This study aimed to evaluate the association of esthetic expectations with self-reported personal characteristics, anxiety, depression, self-esteem, oral health–related quality of life, and the Orthognathic Quality of Life Questionnaire (OQLQ) in Chinese adult patients before orthognathic treatment.
This study involved 213 patients with clinically significant skeletal deformity requiring orthognathic surgery for comprehensive treatment. Each patient completed a series of Chinese version scales, including the self-rating anxiety scale, self-rating depression scale, self-esteem scale, the Oral Health Impact Profile-14 questionnaire, and the OQLQ. The patients’ self-reported personal characteristics were also recorded, including facial appearance ratings before and after orthognathic treatment, highest education level, mean monthly income, and enthusiasm toward orthodontic or orthognathic treatment. The Least Absolute Shrinkage and Selection Operator multivariate linear regression model was conducted for the selection of the above factors. The final multivariate linear regression model was built with variables identified under the optimal tuning parameter.
A total of 213 patients (87 men and 126 women) were included in this study. The patients’ esthetic expectation scores were significantly associated with their total scores, which encompassed the education level, mean monthly income, enthusiasm toward orthodontic or orthognathic treatment, self-esteem scale, the Chinese version of the 14-item Oral Health Impact Profile questionnaire, OQLQ, etc. In the multivariate linear regression model, the OQLQ, enthusiasm toward orthognathic treatment, depression, and expected facial appearance score after the treatment were the most important factors to predict esthetic expectation.
High esthetic expectations for orthognathic treatment were mostly associated with higher expected facial appearance scores after the treatment, greater enthusiasm toward orthognathic treatment, worse depression (confusion), and 2 domains ( social aspects of deformity and oral function ) of OQLQ. Therefore, OQLQ, enthusiasm toward orthognathic treatment, and expected facial appearance score after treatment may be used to predict patients’ esthetic expectations before commencing orthognathic treatment in daily clinical practice.
High esthetic expectations were associated with higher expected facial appearance score.
High esthetic expectations related to greater orthognathic enthusiasm, and worse depression.
High esthetic expectations were also associated with orthognathic quality of life.
Orthognathic quality of life and enthusiasm may predict esthetic expectations.
Expected facial appearance may predict patients’ esthetic expectations, too.
Patients with severe skeletal malocclusion often have associated facial deformity, which may negatively affect facial esthetics, oral function, and psychological state. Combined orthodontic-orthognathic treatment is often the only feasible and effective method for treating severe skeletal malocclusion. Patients’ motivations for seeking orthognathic treatment include improvement in esthetics, function, and psychosocial health. , Patients’ motivations are affected by economic, cultural, ethnic, and social aspects. However, orthognathic patients may have different motivations for undergoing treatment depending on their cultural background. Esthetics appear to be the primary motivation in China.
Dissatisfaction with facial esthetics negatively influences patients’ social and quality of life. The most important reason for dissatisfaction among patients who regret undergoing surgery is that there were no apparent facial changes. The psychological and psychiatric status of orthognathic patients encompasses many factors, such as depression, anxiety, and low self-esteem. Orthognathic patients often show significantly higher emotional instability, anxiety, introversion, and unsociability compared with the general population. This may lead to insecurity, reserved personality, and lack of self-esteem and self-confidence. Patients’ psychological or psychiatric status can also be affected by internal factors or their social environment, particularly economical or emotional factors associated with their parental interactions. All the above factors can be associated with differences in patients’ expectations of treatment outcomes. Some patients are willing to undergo surgery, and they look forward to positive changes in their appearance or function. However, others might not be willing to seek surgical treatment.
Esthetic expectations refer to a patient’s idea of how much their appearance might be improved after the treatment. In this study, the value of esthetic expectations is equal to the difference between self-reported facial appearance scores preoperatively and postoperatively. The patient’s esthetic expectations of treatment outcomes are among the key determinants of satisfaction and have been shown to affect recovery. , It can be positively expressed as hopes or dreams about a realistic future identity. It can also be negative, taking the form of unrealistic improvement. Patients with realistic expectations are much more satisfied in the long term. In contrast, unrealistic expectations may play an important role in patients’ dissatisfaction, and it is instrumental in understanding patients’ expectations to improve their satisfaction with health care interventions. , Similar to the theory of possible selves , esthetic expectations can be used as a unifying concept to help predict patient satisfaction.
It is important to explore how maxillofacial surgeons and orthodontists can determine patients’ underlying esthetic expectations before surgery and predict which patients are most likely to be dissatisfied with the outcomes of their treatment. However, to our knowledge, no studies have investigated the associations among esthetic expectations and related factors, such as economics, social aspects, psychological status, and oral health, in different cultural backgrounds.
This study aimed to explore the correlations between esthetic expectations and sociocultural aspects, psychological status, and oral health status in Chinese orthognathic patients and show how relevant characteristics can convey esthetic expectations to orthognathic surgeons.
Material and methods
The present study had a cross-sectional design. Patients were enrolled from January 2012 to December 2015 at the Department of Oral and Cranio-Maxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai, China. The study protocol was approved by the Shanghai Ninth People’s Hospital Institutional Review Board. Informed consent was obtained from each of the patients. The inclusion criteria were as follows: (1) patients aged 18 years or older, (2) patients with facial bony malformation who had accepted a treatment plan of combined orthodontic-orthognathic surgery, (3) patients who had no systematic diseases or psychiatric disorders, and (4) patients who had not undergone any orthognathic or cosmetic surgeries before recruitment.
Patient data were collected to investigate the factors that influenced patients’ expectations of orthognathic surgery. Every adult patient was asked to complete 1 questionnaire and 5 scales before undergoing orthognathic treatment.
The following personal characteristics and relevant background information were collected with the questionnaire: sex, age, whether the patient was the only child in their family, patient’s highest education level, mean monthly family income, enthusiasm toward orthodontic and orthognathic treatment, which were presented as multiple-choice options. Self-rated current facial appearance scores before the treatment and expected facial appearance scores after the treatment were also determined using the questionnaire.
The current facial appearance and the expected facial appearance after surgery were presented as 2 statements, followed by a visual analog scale: (1) from 0 to 10, how do you rate your current facial appearance? (T1); (2) from 0 to 10, how do you rate the facial appearance you expect to achieve after the orthognathic surgery? (T2). The esthetic expectations after surgery were therefore expressed as the T2 − T1.
The Zung self-rating anxiety scale (SAS) was used to measure patient anxiety. The SAS consists of 20 items rated on a 4-point scale (1 = a little of the time; 2 = some of the time; 3 = a good part of the time; 4 = most of the time). Five of the 20 items are worded positively and are reverse-scored. Thus, the total scores range from 20 to 80, with higher scores indicating higher anxiety.
Depression was measured by the Zung self-rating depression scale (SDS). The SDS contains 20 items on the basis of the clinical diagnostic criteria for depressive disorders. Ten items are worded positively (items 2, 5, 6, 11, 12, 14, 16, 17, 18, 20). The other 10 items are worded negatively. Questions are answered according to the same 4-point scale used for the SAS. The scale is scored by totaling the scores for each item after reverse scoring the positively worded items.
The Rosenberg self-esteem scale (RSES) is thought to be a reliable, valid, and widely used instrument to measure global self-esteem. , The RSES consists of 10 items, 5 of which are positively worded (items 1, 3, 4, 7, 10) and the other 5 of which are negatively worded (items 2, 5, 6, 8, 9). Responses are made on a 4-point scale (1 = strongly agree; 2 = agree; 3 = disagree; 4 = strongly disagree). The scale is scored by totaling the scores for each item after reverse scoring the positively worded items. Therefore, total scores ranged from 10 to 40, with higher scores indicating higher self-esteem.
In this study, the Chinese versions of the SAS, SDS, and RSES were used to assess the patients’ self-worth and self-acceptance. The validity and reliability of these questionnaires have been proven to be acceptable.
Oral health–related quality of life (OHRQOL) was measured using the Chinese version of the Oral Health Impact Profile-14 (OHIP-14). As a shortened version of the OHIP-49, the OHIP-14 has good reliability and validity when measuring people’s perceptions of the impact of oral conditions on their well-being. It contains 4 conceptual dimensions of OHRQOL, including functional limitations, pain and discomfort, disability, and handicap. The 14 questions were answered on a 5-point scale (0 = never; 1 = rarely; 2 = occasionally; 3 = fairly often; 4 = very often), with a total score ranging from 0 to 56. Higher scores indicate worse OHRQOL. The Chinese OHIP-14 that we used in the present study has been reported to be valid and reliable.
The Orthognathic Quality of Life Questionnaire (OQLQ) is an instrument used to measure the quality of life of patients with severe dentofacial deformity who seek orthognathic treatment. It shows good reliability, validity, and responsiveness. , The OQLQ consists of 22 items rated on a 4-point scale (1 = it bothers you a little; 4 = it bothers you a lot; 2 and 3 are in between these statements; not applicable [NA] = the statement does not apply to you, or the stated issue does not bother you). These 22 items are divided into 4 domains pertaining to social aspects of deformity, dentofacial esthetics, oral function, and awareness of dentofacial deformity. The OQLQ is scored by summing the individual items within the domains. The total score of the OQLQ ranges from 0 to 88, and each domain is scored separately (social aspects of deformity, 0-32; dentofacial esthetics, 0-20; oral function, 0-20; awareness of dentofacial deformity, 0-16). A higher score indicates a poorer orthognathic quality of life.
For statistical analysis, R software (version 3.4.3; R Development Core Team 2010) was used. Total scores or domain scores obtained from the SAS, SDS, SES, OHIP-14, and OQLQ were expressed as the mean and standard deviation.
Pearson correlation tests were used to assess univariate correlations between demographic characteristics and psychological factors, such as nationality, being an only child, highest education level, mean monthly income, enthusiasm toward orthodontic and orthognathic treatment, SAS score, SDS score, SES score, OHIP and OQLQ domains, and the patient’s esthetic expectations. Differences in these variables were evaluated using independent-sample t tests and analysis of variance analysis.
We constructed Least Absolute Shrinkage and Selection Operator multivariate linear regression model for variable(s) selection and relative importance calculation. The final multivariate linear regression model was built with variables identified under the optimal tuning parameter. A P value of <0.05 was considered significant.
A total of 213 patients (87 men and 126 women) met the inclusion criteria and were included in this study ( Table I ). The mean age of the female patients was 22.53 ± 0.35 years, whereas that of males was 23.54 ± 0.45 years. The patients’ sociodemographic profile, self-reported personal characteristics, and esthetic expectation scores are presented in Table I . The mean esthetic expectation score was 3.06 ± 1.87. The mean values of the highest education level and the mean monthly income were 2.04 ± 1.06 and 2.60 ± 1.066, respectively. In addition, the enthusiasm toward orthodontic or orthognathic treatment was 7.76 ± 2.33 or 7.74 ± 2.14.
|Female||22.53 ± 0.35|
|Male||23.54 ± 0.45|
|Self-reported personal characteristics|
|How do you rate your current facial appearance? (T1)||4.89 ± 1.83|
|How do you rate the facial appearance you expect to have after orthognathic surgery? (T2)||7.98 ± 1.41|
|What is your highest education level?||2.04 ± 1.06|
|Postgraduate degree||84 (39.4)|
|Bachelor’s degree||68 (31.9)|
|Completed high school||30 (14.1)|
|Middle school or below||31 (14.6)|
|How much is the mean monthly income in your family? (RMB) (%)||2.60 ± 1.066|
|Enthusiasm toward orthodontic treatment||7.76 ± 2.33|
|Enthusiasm toward orthognathic treatment||7.74 ± 2.14|
|Patients’ esthetic expectation scores ∗||3.06 ± 1.87|