To determine the psychosocial effects of a facial skeletal mal-relationship with its subsequent surgical correction in a group of patients treated using surgical orthodontics compared with a matched group of nontreated controls.
This study was approved by The Ohio State University Institutional Review Board. Subjects were patients presenting with facial skeletal mal-relationships whose proposed treatment plans included orthognathic surgery. This study used valid and reliable questionnaires: Orthognathic Quality of Life Questionnaire (OQLQ), Beck Depression Inventory II (Children’s Depression Inventory – 2), Satisfaction with Life Scale, and State Trait Anxiety Inventory (State Trait Anxiety Inventory for Children), administered at 3 different stages of treatment (time 1 = initial pretreatment, time 2 = before oral surgery, and time 3 = at completion of treatment). Matched controls recruited at each time point completed the same questionnaires.
A total of 267 subjects were recruited to participate in this study. There were no significant differences between treatment and control groups in age, sex, education level, or employment status at any of the 3 time points. The randomization test was used to compare values for all outcome variables between groups at the 3 stages of treatment. For the pretreatment period, T 1 , there were significant differences between patients and controls in domains 1 ( P = 0.0126), 2 ( P = 0.0000), and 3 ( P = 0.0000) of the OQLQ (social aspects, facial esthetics, and oral function, respectively) as well as total OQLQ ( P = 0.0000). For the presurgery period, T 2 , there were significant differences between patients and controls in domains 2 ( P = 0.0136) and 3 ( P = 0.0001) of the OQLQ (facial esthetics and oral function) as well as total OQLQ ( P = 0.0291). Finally, for the posttreatment period, T 3, there was a significant difference between patients and controls only in domain 3 ( P = 0.0196) of the OQLQ (oral function).
The psychosocial profile of patients with a facial skeletal mal-relationship does not differ from the general population in depression, anxiety, and overall satisfaction with life. However, these patients do report a reduced quality of life based on condition-specific measures in social aspects, facial esthetics, and oral function. Concerns about oral function remain even up to 2 years after treatment is completed.
The psychosocial profile of patients with facial skeletal mal-relationships was studied.
Quality of life (QoL) was assessed by a questionnaire before and after orthognathic surgery.
Topics included depression, anxiety, overall satisfaction with life, and orthognathic QoL.
Before surgery, patients and controls differed with regard to orthognathic QoL.
After surgery, patients and controls differed only in oral function.
A facial skeletal mal-relationship exists when a patient exhibits deviations from normal facial proportions and dental relationships caused by an underlying skeletal discrepancy. According to Proffit et al, these deviations can be so severe that they are thought to be handicapping and are then referred to as a dentofacial deformity. Jaw function, speech, and social interactions are often compromised within this population of patients.
Treatment for these patients requires a combined orthodontic and orthognathic surgical approach because of the severity of the mal-relationship in which orthodontics or growth modification alone cannot provide an ideal result. Although functional impairments such as difficulty in chewing food, discomfort, and pain from temporomandibular joint dysfunction are important reasons for treatment, it is generally accepted that most of these patients are seeking treatment because of concerns about their dentofacial esthetics and are motivated by self-image and social well-being. It has been shown that the more the patient perceives his or her problem as outside of normal, the more likely they are to seek treatment. ,
Facial esthetics can strongly affect a person’s quality of life (QoL) and therefore have a psychological impact on the individual that includes making them feel inadequate or discontented because of their appearance. Cunningham et al reported that there are differences in the psychological profile of an orthognathic patient compared with the general population: specifically, higher levels of anxiety, a greater number of people in their social support network, lower body and facial images, and borderline lower self-esteem. Other investigators, however, have reported no differences in regards to psychosocial parameters , and therefore do not recommend psychological screening of patients requiring orthognathic surgery. It has been suggested that most dentofacial patients have coping skills that keep them within the normal range on psychological testing, and this may conceal the true extent of their psychosocial distress.
A longitudinal study by Kiyak et al , confirmed that most patients with facial skeletal mal-relationships benefit psychologically after orthognathic treatment, demonstrating improved facial and dental appearance and an associated increase in self-confidence. The patients reported high levels of satisfaction after surgery and that they perceived considerable improvements in their facial appearance and body image, viewing themselves more positively after surgery. Some patients did report depression and dissatisfaction with the surgical outcome. However, most of this was attributable to prolonged time in orthodontics after surgery. Flanary et al also found high levels of postoperative satisfaction and a healthy psychological adjustment and concluded that orthognathic treatment appears to have a positive impact on QoL. Positive effects were seen for self-concept including self-esteem, self-satisfaction, self-identity, physical self, social self, and total self-conflict. It is possible that a portion of this satisfaction could result from the time, discomfort, and expense of treatment creating cognitive dissonance with an unsatisfactory outcome.
There has been a paradigm shift in the focus of health care, which now includes health-related quality of life (HRQoL) and evaluation of treatment based on its impact on the patient’s feelings and perceptions of treatment. According to the World Health Organization, QoL can be defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.” More specifically, HRQoL refers to the effect that a disease, condition, or treatment has on a patient’s ability to carry out the physical and social tasks of daily life and has been used as an outcome measure in clinical trials.
Flood et al reported that patient expectations can affect treatment outcomes, therefore managing realistic patient expectations is critical for successful outcomes. It is important to build rapport with patients and communicate with them throughout treatment so that they understand what is happening and why. QoL issues are strong underlying motivators in the decision for a patient to accept treatment that includes orthognathic surgery. Both the clinician and the patient require a thorough understanding of the effects of treatment on HRQoL to anticipate the changes that occur and to allow this type of treatment to be compared with other procedures. This information allows clinicians to be able to give clear and accurate information to patients as to what to anticipate the impact of surgical treatment will have on their QoL.
A systematic review conducted by Hunt et al identified an urgent need for well-controlled longitudinal studies to be conducted to confirm the psychosocial benefits after orthognathic surgery. The authors noted both a lack of high-level evidence and a lack of consistency in the methods used to measure psychosocial status, which resulted in an inability to show a clear and precise psychosocial benefit.
This study aimed to determine the psychosocial effects of a facial skeletal mal-relationship and its surgical correction compared with a matched group of nontreated controls.
Material and methods
This study was approved by The Ohio State University Institutional Review Board (protocol no. 20111H0195) and was mixed cross-sectional and longitudinal.
Subjects were patients presenting to The Ohio State University College of Dentistry graduate orthodontic clinic and the college’s dental faculty practice whose proposed treatment plan included orthognathic surgery to correct a facial skeletal mal-relationship. To reduce selection bias, all treatment subjects who were eligible to participate were consecutively recruited into the study from August 2011 to November 2015. The criteria for inclusion were treatment subjects had to be at least 12 years old, be accompanied by a parent or a guardian if younger than 18 years, not have any developmental disabilities or urgent medical conditions, be able to communicate in English, and have been offered a combined orthodontic and surgical treatment plan that was not a result of cleft lip or palate, trauma, or a developmental syndrome. A convenience sample of nonsurgical controls matched to age and sex of the treatment subjects was recruited from The Ohio State University College of Dentistry Hygiene Department, Pediatric Department, and The Ohio State University main campus. This group of patients was chosen to reflect the general population, and exclusion criteria included the presence of orthodontic fixed appliances or a marked dentofacial abnormality.
The questionnaires used in this study were the following:
Orthognathic Quality of Life Questionnaire (OQLQ) , : A condition-specific QoL measure developed in 2000 by Cunningham et al to be used in studies investigating the outcome of orthognathic treatment. The OQLQ consists of 22 statements relating to the impact that a facial skeletal mal-relationship has on a patient’s QoL. These statements can be subdivided into 4 domains: social aspects of the deformity, facial esthetics, oral function, and awareness of facial deformities. Responses range from 0 to 4 points making a minimum possible score of 0 and a maximum of 88, with a higher score indicating a reduced QoL.
Satisfaction with Life Scale (SWLS) : A scale to measure global life satisfaction as a cognitive-judgmental process developed in 1985 by Diener et al. The SWLS consists of 5 items with a Likert-type scale ranging from 1 to 7 making a minimum possible score of 5 and a maximum of 35, with a higher score indicating higher life satisfaction.
Beck Depression Inventory II (BDI-II) : A widely used instrument to assess the severity of depression first developed by Beck et al in 1961. The BDI consists of 21 items scored from 0 to 3 with a minimum possible score of 0 and a maximum of 63.
Children’s Depression Inventory – 2 : A 27-item assessment that rates the severity of symptoms related to depression in children and adolescents. Scores range from 0 to 2 with a minimum possible score of 0 and a maximum of 56.
With both inventories, a higher score indicates more severe depressive symptoms.
State Trait Anxiety Inventory (STAI-Y) : An inventory developed in 1973 by Spielberger et al to investigate how strong a person’s feelings of anxiety are. The STAI-Y consists of 40 statements scored from 1 to 4 with a minimum possible score of 40 and a maximum of 160.
State Trait Anxiety Inventory for Children (STAI-C) : For subjects younger than 18 years. The STAI-C consists of 40 statements scored from 1 to 3 with a minimum possible score of 40 and a maximum of 120.
With both inventories, a higher score indicates a greater amount of anxiety.
All questionnaires had previously been shown to be valid and reliable. ,
These questionnaires were administered at 3 different stages of treatment:
T 1 : Pretreatment – Before initiation of orthodontic appliances. This stage of treatment was chosen to compare QoL parameters of untreated patients who possessed a facial skeletal mal-relationship with controls representing the general population.
T 2 : Presurgery – At completion of presurgical orthodontics, just before orthognathic surgery. This stage of treatment was included to evaluate if making the malocclusion worse by removing dental compensations affected QoL.
T 3 : Posttreatment – 6 months to 2 years after orthodontic appliances have been removed. This stage of treatment was chosen to evaluate if correction by surgical orthodontics makes QoL parameters of treatment subjects comparable with the general population. The time interval was selected to allow enough time to pass after removal of appliances so that responses were not a reflection of elation from being finished with treatment and short enough so that other life events had not intervened and become the primary determinants of psychological state.
Control subjects were recruited during each period. They were matched for sex, age, education level, and employment status.
Questionnaires were either administered at the time of appointment or mailed to subjects who would return the questionnaires by mail or bring them to the following appointment. Demographic information including age, sex, education level, and employment status was recorded for all participants. Subjects and controls were given a $10 gift certificate as compensation for the time required to respond.
Sample size determination was based on the dependent variable instrument with the highest variability, the OQLQ. With an alpha risk of 0.05, a sample size of 35 subjects per period was required to demonstrate a difference of ± 15 units with a power of 0.86. Descriptive statistics and inferential analyses were used to compare the independent variables (group and treatment stage) with the dependent variables (questionnaires). Tests included the independent-samples t test, chi-square test, Wilcoxon test, and randomization test (SAS Institute Inc, Cary, NC). Statistical significance for all tests was set at P <0.05. Calculations were done using the Statistical Analysis System (version 9.3; SAS Institute Inc).
A total of 267 subjects were recruited to participate in this study. The demographic information of the groups is presented in Table I along with the statistical analysis for comparison. There were no significant differences between the treatment subjects and control subjects in age, sex, education level, or employment status at all 3 stages of treatment indicating that the groups were well matched.
|Treatment stage||Age, y mean (±SD)||Independent t test, P value||Sex n (%)||Chi-square test, P value||Education level ∗ n, ED level (%)||Wilcoxon test, P value||Employment status, n (%)||Chi-square test, P value|
|Treatment subjects||Control subjects||Treatment subjects||Control subjects||Treatment subjects||Control subjects||Treatment subjects||Control subjects|
|Initial, T 1||19.6 (6.7)||19.7 (7.0)||0.9079||0.5162||42 ED 1 (59.2)||47 ED 1 (62.7)||0.9181||0.0675|
|35 females (49.3)||41 females (54.7)||8 ED 2 (11.3)||5 ED 2 (6.7)||20 Yes (28.2%)||32 Yes (42.7%)|
|36 males (50.7)||34 males (45.3)||13 ED 3 (18.3)||12 ED 3 (16.0)||51 No (71.8%)||43 No (57.3%)|
|5 ED 4 (7.0)||5 ED 4 (6.7)|
|Total = 71||Total = 75||3 ED 5 (4.2)||6 ED 5 (8.0)|
|Presurgery, T 2||20.8 (5.1)||20.9 (5.2)||0.9192||0.6466||7 ED 1 (31.8)||5 ED 1 (26.3)||0.5865||0.4757|
|12 females (54.5)||9 females (47.4)||6 ED 2 (27.3)||3 ED 2 (15.8)||14 Yes (63.6%)||10 Yes (52.6%)|
|10 males (45.5)||10 males (52.6)||5 ED 3 (22.7)||9 ED 3 (47.4)||8 No (36.4%)||9 No (47.4%)|
|2 ED 4 (9.1)||0 ED 4 (0.00)|
|Total = 22||Total = 19||2 ED 5 (9.1)||2 ED 5 (10.5)|
|Posttreatment, T 3||25.9 (11.1)||25.2 (10.6)||0.7843||0.7604||9 ED 1 (24.3)||5 ED 1 (11.6)||0.7562||0.6236|
|22 females (59.5)||27 females (62.8)||7 ED 2 (18.9)||7 ED 2 (16.3)||26 Yes (70.2%)||28 Yes (65.1%)|
|15 males (40.5)||16 males (37.2)||8 ED 3 (21.6)||21 ED 3 (48.8)||11 No (29.7%)||15 No (34.9%)|
|10 ED 4 (27.0)||9 ED 4 (20.9)|
|Total = 37||Total = 43||3 ED 5 (8.11)||1 ED 5 (2.3)|