Subjects

The subjects were 119 patients (38 males and 81 females) in whom jaw deformities were surgically corrected in the oral and maxillofacial surgery clinic of a university medical and dental hospital in Niigata, Japan, between April 2006 and August 2011 ( Table 1 ). The mean age ± standard deviation (SD) at surgery was 25.5 ± 9.4 years (range 16–59 years).

Skeletal morphology was examined with the use of lateral and frontal cephalograms, which were taken simultaneously with the teeth in centric occlusion. Lateral and frontal cephalograms were traced and digitized by translating the points on landmarks. The anteroposterior and vertical relationships between facial skeletal structures were assessed on the lateral cephalogram and the patients were divided into three groups according to the type of anteroposterior skeletal pattern. Eighty-four patients had skeletal class III malocclusions (class III group), 20 patients had skeletal class II malocclusions (class II group), and 15 patients had skeletal class I malocclusions with facial asymmetry and/or open bite (class I group). The mean age ± SD at surgery was 25.4 ± 10.2 years (range 16–59 years) in the class III group, 25.2 ± 6.0 years (range 17–35 years) in the class II group, and 26.8 ± 8.6 years (range 17–44 years) in the class I group. On the frontal cephalogram, the x -axis was the line connecting bilateral latero-orbitales, the y -axis was perpendicular to the x -axis passing through the neck of the crista galli, and asymmetry was assessed with the absolute x -value of the menton. The patients were divided into two groups according to the presence or absence of facial asymmetry, which was diagnosed if the absolute x -value of the menton on a frontal cephalogram was over 4 mm. Fifty-one patients had facial asymmetry (asymmetry group) and 68 patients had no facial asymmetry (symmetry group). The mean age ± SD at surgery was 26.4 ± 10.2 years (range 16–59 years) in the asymmetry group and 24.9 ± 8.8 years (range 16–55 years) in the symmetry group.

A combination of Le Fort I osteotomy and bilateral sagittal split osteotomies and/or other surgeries was used in 81 patients, and bilateral sagittal split osteotomies were performed in 38 patients. Secondary genioplasty was used in 19 patients. No cases of cleft palate or craniofacial syndrome were included. All of the subjects received pre- and postoperative orthodontic treatment, and osteosynthesis was achieved using titanium miniplate and/or resorbable fixation devices. Maxillomandibular fixation was performed 1 day after surgery and maintained for 14 days. The psychological status of each of the patients was assessed using the MMPI before surgery and at more than 6 months after surgery.

The study protocol was approved by the institutional ethics committee and informed consent was obtained from the subjects.

Minnesota Multiphasic Personality Inventory (MMPI)

We used the new Japanese version of the MMPI (The Society for MMPI New Japanese Version, 1993), which is a self-report personality inventory consisting of 550 items that describe feelings or actions that the person is asked to agree with or disagree with. The MMPI is made up of 10 clinical subscales, which are a result of answering certain questions on the test in a specific manner: (1) The Hypochondriasis (Hs) scale measures a person’s perception and preoccupation with their health and health issues. (2) The Depression (D) scale measures a person’s depressive symptoms level. (3) The Hysteria (Hy) scale measures the emotionality of a person. (4) The Psychopathic Deviate (Pd) scale measures general social maladjustment and the absence of strongly pleasant experiences. (5) The Masculinity/Femininity (Mf) scale measures a stereotype of a person and how they compare. (6) The Paranoia (Pa) scale primarily measures interpersonal sensitivity, moral self-righteousness, and suspiciousness. (7) The Psychasthenia (Pt) scale measures a person’s inability to resist specific actions or thoughts, regardless of their maladaptive nature. (8) The Schizophrenia (Sc) scale measures a person’s unusual/odd cognitive, perceptual, and emotional experiences. (9) The Hypomania (Ma) scale measures a person’s energy. (10) The Social Introversion (Si) scale measures the social introversion and extroversion of a person.

Additionally, the MMPI contains four validity scales designed to measure a person’s test-taking attitude and approach to the test: (1) the Cannot say (CNS) scale is the number of items answered “I cannot say either way” and is high in general neurotic patients. (2) The Lie (L) scale is intended to identify individuals who are attempting to place themselves in a good light. (3) The Frequency (F) scale is intended to detect unusual or atypical ways of answering the test items, like if a person were to randomly fill out the test. (4) The Correction (K) scale is intended to identify psychopathologies in people who would otherwise have profiles within the normal range.

These scales are standardized to ensure that the averages are around 50 points, with scores more than 70 points considered high.

Statistical analysis

All MMPI data were compared with standard values calculated from measurements obtained from 114 Japanese men and 86 Japanese women in their twenties. To assess the significance of differences between the groups, the Student’s t -test, one-way repeated measures analysis of variance (ANOVA), or Tukey multiple comparison test was used, as appropriate. Probabilities of less than 0.05 were accepted as significant. Data were analyzed using IBM SPSS Statistics 20 for Windows (IBM Japan, Ltd, Japan).

Comparison of preoperative and postoperative MMPI scores with standard values

The preoperative scores on the D, Hy, Pt, and Si scales were significantly higher than standard values for their generation, and the score on the Ma scale was significantly lower than standard values. The scores on the CNS, D, and Hy scales decreased significantly after surgery. However, the postoperative scores on the D, Pt, and Si scales were significantly higher than standard values, and the postoperative score on the Ma scale was significantly lower than the standard value ( Table 2 ).

Thirty-five of the 119 patients had high scores (>70) on some clinical subscales. In 16 of the 35 patients with high scores before surgery, all scores were within normal ranges after surgery, but the other 19 patients still had high scores on some clinical subscales after surgery.

Five of the patients were diagnosed as having mental diseases before surgery. One patient with atypical autism had high scores on the F, Hs, D, Hy, Pd, Pa, Pt, Sc, and Si scales before and after surgery. A patient with schizophrenia had high scores on the F, Pd, Pa, Pt, and Sc scales before surgery and on the F, D, Hy, Pd, Pa, Pt, and Sc scales after surgery. A patient with depression had a high score on the Pt scale before surgery and high scores on the Pt and Sc scales after surgery, and another patient with depression had a high score on the Sc scale before surgery and high scores on the Sc and Si scales after surgery. A patient with orthostatic disturbance had a high score on the Pa scale before surgery.

Comparison of MMPI scores between male and female patients

With regard to score differences between male and female patients, the Mf scale was significantly higher in male patients than in female patients ( Table 3 ).

Comparison of MMPI scores among types of jaw deformity

The D scale in the skeletal class III group was higher than that in the other skeletal groups, and the D and Hy scales in the skeletal class III group decreased significantly after surgery ( Table 4 ). There was no significant difference in clinical subscales between the asymmetry and symmetry groups, although there was a significant difference in the CNS scale between the two groups, and the Hy scale in the asymmetry group decreased significantly after surgery ( Table 5 ).

Table 4

Comparison of MMPI scores among types of anteroposterior skeletal pattern; mean ± SD.

Scales	Type of jaw deformity, skeletal class	Patients
		Before surgery	After surgery
Cannot say	III	49.88 ± 6.3 a	47.98 ± 5.5 a
	II	47.15 ± 5.7	47.25 ± 6.2
	I	50.8 ± 7.2	49.93 ± 6.7
Lie	III	48.98 ± 9.1	49.38 ± 9.7
	II	45.6 ± 8.1	46.6 ± 10.6
	I	48.07 ± 9.6	51.07 ± 11.0
Frequency	III	52.15 ± 12.3	52.35 ± 15.3
	II	52.05 ± 10.2	52.50 ± 12.6
	I	51.40 ± 16.3	51.80 ± 15.5
Correction	III	50.50 ± 9.9	51.31 ± 10.2
	II	51.15 ± 11.5	52.40 ± 10.8
	I	51.60 ± 10.5	54.07 ± 8.2
Hypochondriasis	III	51.62 ± 10.0	51.40 ± 9.8
	II	52.90 ± 9.4	52.60 ± 8.4
	I	51.33 ± 8.4	53.20 ± 9.1
Depression	III	54.83 ± 12.8 a	52.74 ± 11.8 a
	II	51.80 ± 8.8	50.65 ± 10.1
	I	50.33 ± 9.3	52.47 ± 11.1
Hysteria	III	52.85 ± 9.6 a	50.90 ± 9.5 a
	II	52.40 ± 8.8	53.90 ± 7.9
	I	55.27 ± 6.4	51.73 ± 9.9
Psychopathic deviate	III	52.42 ± 11.4	51.32 ± 9.1
	II	50.90 ± 7.8	53.70 ± 7.8
	I	57.07 ± 14.5	59.8 ± 16.7
Masculinity/femininity	III	51.10 ± 10.1	51.61 ± 10.7
	II	50.45 ± 8.0	50.60 ± 9.0
	I	53.93 ± 12.8	54.67 ± 13.8
Paranoia	III	54.33 ± 11.1	53.23 ± 11.0
	II	56.20 ± 9.7	56.55 ± 9.4
	I	55.00 ± 12.5	56.07 ± 11.0
Psychasthenia	III	54.62 ± 12.8	52.92 ± 12.1
	II	54.40 ± 8.4	57.95 ± 11.8
	I	55.93 ± 9.6	57.13 ± 14.7
Schizophrenia	III	53.82 ± 16.1	53.86 ± 14.9
	II	52.25 ± 8.7	53.20 ± 13.2
	I	54.07 ± 17.2	55.20 ± 17.8
Hypomania	III	47.90 ± 9.7	46.76 ± 9.6
	II	49.95 ± 9.4	46.85 ± 8.4
	I	48.87 ± 10.9	49.67 ± 11.1
Social introversion	III	54.02 ± 11.6	53.52 ± 11.0
	II	52.95 ± 11.9	51.80 ± 9.8
	I	50.60 ± 13.2	51.80 ± 12.4

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