Material and methods

This was a qualitative interview study with a cross-sectional design. Ethical approval was obtained from the joint research and ethics committee of The Joint University College London/University College London Hospitals NHS Trust Committees on the Ethics of Human Research, and all participants were treated according to the principles of the Declaration of Helsinki. The subjects were recruited between March and September 2009 from orthognathic clinics. Inclusion criteria were patients with a dentofacial deformity aged 16 years and over, who had not yet commenced orthognathic treatment. Exclusion criteria were patients under the age of 16 years; patients with congenital craniofacial anomalies—eg, due to craniofacial syndromes or clefts of the lip or the palate; patients with acquired facial defects—eg, trauma; and patients who had previously received orthognathic treatment.

Purposive sampling, a common method of sampling in qualitative research, was used in this study, whereby participants were selected to represent key characteristics that enable the researcher to explore and understand the theories and topics under scrutiny. Four subcategories were chosen to reflect the influence of age, sex, ethnicity, and type of deformity, and to ensure that a representative sample was obtained. A minimum of 12 subjects was needed to capture a range of views, as can been seen from the sampling frame ( Table II ).

Data were collected by using semistructured in-depth interviews that were carried out by a trained researcher (F.S.R.), who is widely experienced in conducting qualitative research. A topic guide was used to focus the interviews and ensure that key topics were explored; however, the interviews were exploratory, and the interviewer was free to deviate from the guide if deemed necessary. All topics under investigation were probed fully until the interviewer was satisfied that the perspective of the interviewee was captured in detail. Each interview was digitally recorded and transcribed verbatim on completion, and the transcripts were coded to protect confidentiality.

Results

Eighteen patients (9 male, 9 female) were approached and consented to being interviewed ( Table III ).

The findings from the interviews could be divided into 2 main themes: the impact of the dentofacial deformity and the motivation for treatment, with related subthemes ( Table IV ).

The subjects first became aware of the dentofacial deformity in a variety of ways. There was a general awareness of a problem with the teeth or face, but many subjects were not aware what the problem was attributed to specifically. A number of people had noticed a problem with their teeth but were unaware of the underlying skeletal discrepancy and what the actual problem was until a professional pointed it out to them. Whereas for some, a professional diagnosis simply raised their awareness of the defect, but, for others, it led to a “fixation” on the defect (patients 8-10 and 13).

“It bothers me because once you know about it you can’t help noticing it (patient 13).” “I just thought there was something about my face . . . and I thought it was my nose . . . and then they told me that my lower jaw was growing too far forward. I then . . . realized hang on, no my nose is fine, it’s my lower, it’s this part of my mouth I don’t like, and it just became a kind of fixation (patient 8).”

The nature of the dentofacial problem was closely linked to, and usually the same as, the impact of the problem but is discussed separately as the primary physical cause of the subsequent impacts of dentofacial deformity. The nature of the problem was divided into an exclusively practical problem, an exclusively psychological problem, and a combination.

The practical problem manifested itself in 2 ways: a functional or a structural problem. Functional problems included problems with eating, speech, or other activities. Examples of problems with eating included tiredness when eating (patient 3); only being able to bite with certain teeth (patient 5); not being able to eat the foods wanted or the way the subject liked (patient 15); and eating took a long time and was messy, with spitting and making noise when eating (patients 5 and 13). Problems with speech ranged from not pronouncing certain letters clearly, to lisping when speaking or having a major problem with articulation (patient 13). Other functional problems included not being able to bite clear adhesive tape with the front teeth (patient 5), the tongue getting trapped between the teeth (patient 8), biting the inside of the cheeks (patient 14), and the lower lip getting trapped under the top teeth (patient 17).

Practical structural problems involved people being objectively aware of the physical condition and where the problem was (eg, a vertical gap between the front teeth or the mandible longer than the maxilla). In these subjects, the awareness of the defect and the “ideal” dental and facial appearance were purely objective; they acknowledged the problem as a physical one only (patients 12, 13, and 16), without any apparent psychological consequences.

“I had kids making fun of that (my teeth), I also had kids making fun of my cast arm, I also had kids making fun of my haircuts that my mum used to make me have and to be honest, it never really bothered me because, I never let that sort of thing bother me. I’m more worried about the impact it’s going to have on my eating habits than anything else (patient 13).”

A dentofacial deformity or a malocclusion presented a psychological problem for many. Traditionally, this has been termed psychosocial to encompass the “interrelation of social factors and individual thought and behaviour.” Although a dentofacial deformity has psychosocial impacts, it also has psychological impacts that do not directly relate to the social environment: eg, a feeling of victimization or hopelessness when seeing the reflection in the mirror independently of negative reactions from others.

“Sometimes I get so emotional and just sit down and look at in the mirror and I’m like what’s going on, what happened to me (patient 3).”

In many subjects, there was a combination of both practical and psychological problems as a result of the dentofacial deformity.

The impact of living with a dentofacial deformity or malocclusion followed from the nature of the problem and was often synonymous. The effects on everyday life were divided into impacts on interpersonal relationships, impacts on employment, and psychological impacts.

With regard to interpersonal relationships, the defect had effects on both new and existing relationships. On the extreme end of the spectrum, some patients avoided meeting new people completely and, as children, had avoided making friends, using avoidance tactics such as staying in the library during breaks (patient 11). As adults, they avoided socializing and had not made friends (patient 7). There were senses of paranoia (patient 18) and insecurity (patients 8 and 14), and feeling defensive (patient 1) because of concerns that others were making judgments based on their appearance. Some were bullied as children because of their appearance (patients 11 and 14). Problems forming intimate relationships were also described (patients 9 and 14). Some participants had been teased by siblings in childhood (patients 4, 6, and 18), and this had led to problems with interfamily relationships when they took their frustrations out on those close to them or put up barriers such as avoiding family gatherings (patients 6, 7, 14, and 18).

Negative impacts on employment were described: lack of self-confidence, low self-esteem, and fear of rejection kept people from applying for the jobs they wanted.

“I’m not achieving what I should be, and that’s one of the reasons, I don’t like public standing up and doing public speaking, I find it difficult to voice my opinions in groups (patient 14).”

Others controlled their working environments to minimize contact with others.

“I avoid face-to-face communication with people. I always had a very good salaried paid job, but I moved out from it because I was very uncomfortable . . . there, so now I do work in the warehouse, so I’m always at the back (patient 7).”

There was a sense, and in some cases experience, of being discriminated against due to the visible defect, with adverse impacts on career progression.

“When I’m in an interview say and there’s two girls and me . . . they’re not gonna choose me because of my look. I was gonna be a like presenter and they like said you struggle with your talking and your look doesn’t look on the um on the camera basically very good so they got someone else . . . that was so horrible (patient 3).”

The psychological impacts were wide ranging, with effects on self-image, image projection, and self-confidence, and feelings of victimization. There was anxiety that other people would judge them based on their face or teeth, and people worried that they were not projecting an accurate image of themselves and their personality as a result. Others felt vulnerable and exposed, and that they could not stop people for focusing on their flaw; there was a general sense of wanting to look “normal” and not stand out in a crowd (patients 1, 9, and 13).

“They (people) look at this part of your face when you’re speaking, it’s the most visible and apparent part of you. Sometimes I would actually like to stick a balaclava on or something like that so just my eyes were visible, then I could talk to people without being conscious of it. I’m much happier talking to people on the phone, I don’t particularly like face-to-face contact with people, and your mouth is the . . . I mean, your face, it’s the focus for people isn’t it (patient 1).”

As expected, a dentofacial deformity had negative effects on self-confidence and self-image. This affected people internally (negative self-image) and in social situations, with both new people and existing acquaintances and family. Negative self-image ranged from mild dislike of the appearance of the teeth and face to a sense of self-loathing, with people using expressions such as “deformed,” “freak,” and “damaged inside.” There was a sense of having something wrong with them. In some subjects, the impacts on self-confidence were so strong that they caused a low mood and even depression (patients 6, 7, and 14).

Those who had concerns regarding their teeth and bite alone tended not to have significant impacts on their self-confidence. This was especially true of those whose reasons for treatment were purely functional. These patients mentioned feelings of embarrassment but did not relate the problem to their self-image or confidence (patients 12, 13, and 15). Those whose primary concern was their facial appearance experienced more impacts on self-confidence and self-image.

There was a feeling of victimization, “why me,” of being singled out and punished unfairly, and not knowing why. Some expressed feeling let down and looked down on as a result (patient 6). There was a general feeling that life was more difficult and might have turned out differently if they had not been affected in this way, that they had an additional hurdle to jump or a “millstone” around their neck (patient 14). Those who expressed these feelings tended to have the strongest impacts on their day-to-day lives as a result of their defect.

Two types of coping mechanism were described. Avoidance coping behavior involved avoiding seeing or thinking about the defect, and also preventing others from seeing it. Patterns of behavior included not going out (patient 2), not socializing, not eating in front of people (patient 14), not having photographs taken (patient 14), not smiling (patient 4), not thinking about the problem, not allowing friends or family to discuss it, and not looking in the mirror (patient 6).

An altered coping strategy involved carrying out their normal day-to-day activities but modifying their behavior to minimize the impact of their condition. There was a huge range of altered behaviors that included covering the mouth to hide the teeth, not biting together to hide the bite (patients 4 and 10), not posing for photos straight on (patient 9), keeping the mouth open (patient 17), retracting the jaw (patient 14), mirror checking with posing on their best side to reassure themselves, putting the tongue under the top lip so it looked fuller (patient 14), moving or blinking during photographs so the photo would be ruined and not be put in the album, posturing the jaw forward (patient 11), and positioning strategies so that people were unable to view them in profile (patient 3). These were often described as subconscious and had become part of a learned habit.

There were 4 main triggers for patients to seek orthognathic treatment at a particular time.

• 1.

  Eligibility: people came for treatment at varying ages, and many were still growing; therefore, the trigger for treatment at this point was that they had stopped growing and were now suitable for treatment.

• 2.

  Availability: for a variety of reasons, people had become aware that this treatment was available and an option for them; some had heard about it from friends or relatives, and others were told by their dentist or orthodontist.

“From the moment I heard about it, there was some sort of a light bulb went on up there and I just was happy. It’s, like, you know, you having some sort of illness and finding there’s a cure for it, so that’s the kind of thing. I never knew there was a cure for it, so I was really, really happy about it (patient 13).”

• 3.

  Incident or experience: a particular encounter, experience, or event acted as the trigger for seeking treatment.

“A failed relationship (was a trigger for seeking treatment), and I thought the reasons for it were to do with my self-esteem and my behavior related to this, and I thought I ought to do something about it (patient 14).”

• 4.

  Climax in the effects of the problem: the problem that had been observed for a variable length of time was now becoming critical.

“My facial expression changed in a way because I’m not sure if my lower jaw recessed or what it was but I did notice a massive difference . . . between the lower jaw and the top jaw was a wake-up call (patient 13).”

The same classifications used for the range of impacts could be applied to the motivating factors: exclusively practical motivation (including functional and structural), exclusively psychological motivation (including psychosocial and esthetic), and a combination. Often a person’s motivation was simply to address the problems that the deformity was directly causing, but, for others, the real motivation was to bring about other secondary changes in their lives, such as having more confidence and being able to get on with life without having to worry about the problem.

“I don’t like where I’m going at the moment, and that’s why I’m doing something about it, because I want my life to change, because I want to be out there, I want to be with the outside crowd, I want to go out, I want to talk to people, I want to be friendly with my colleagues and everyone. That’s everything that I want to and, at the moment, the only thing that’s stopping me from doing so is just my teeth (patient 7).”

This research supports the traditional classifications of external and internal motivation but suggests that the 2 categories form a continuum, with purely external motivation at 1 end and purely internal motivation at the other, rather than distinct and separate factors. Motivation is also inextricably linked to the nature and the impact of the problem. For example, 1 subject whose motivation registered on the internal end of the spectrum had become increasingly aware that he was only biting on his back teeth and had always had problems eating certain foods. He wanted the treatment so that he could enjoy food.

“Once it starts interfering with my eating habits which I take religiously, I’m very serious about my, I love to eat, I eat a lot, I’m known for that and you know anything that would have an impact on that will annoy me (patient 13).”

Another subject, whose motivation for treatment was purely external, had been told by a senior colleague that she needed to have the treatment for career progression and admitted, if she had not been told, that she probably would not have had the treatment.