Patients’ perceptions of improvements after bilateral sagittal split osteotomy advancement surgery: 10 to 14 years of follow-up


The aims of this study were to determine reasons for orthodontic-surgical treatment, to quantify the perceptions of possible improvement 10 to 14 years after treatment, and to assess factors that affect treatment satisfaction and socio-dental impacts on quality of life.


The participation rate was 36 of 78 patients; their mean age was 45.7 years (SD, 10.7 years; range, 29-62 years). The presurgical anatomic occlusions were measured on dental casts. Visual analog scales allowed the participants to rate their perceived treatment outcome on 7 oral health-related items. A 3-point scale rated satisfaction with orthodontic-surgical treatment. The oral impact of daily performances index was included to assess socio-dental impacts on quality of life.


Most responders reported improvements on the 7 items. The most significant change was reported for chewing. “Very satisfied” with the treatment was reported by 13 responders; 19 of 36 persons were “reasonably satisfied.” Reporting “very satisfied with treatment” was 8 times more likely when peers had noticed a changed in the participant’s appearance after surgery. Sex was significantly associated with quality of life.


The most frequently reported reason for treatment was to improve chewing, and the item that showed the most pronounced improvement was also chewing. Most responders were only reasonably satisfied with the treatment. Whether peers noticed a change in appearance after treatment was a significant factor affecting both treatment satisfaction and reporting a good quality of life.

Studies have repeatedly shown that facial attractiveness affects interpersonal success, particularly in school and employment settings. Whereas the influence of malocclusion on periodontal health is fairly minor, there is disagreement on whether malocclusion per se can cause psychological problems, lack of social competence, low self-esteem, or more impacts on oral health-related quality of life. In 1993, a worldwide research group organized by the World Health Organization defined quality of life as persons’ perceptions of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. The definition implies that quality of life is fundamentally subjective and cannot be evaluated by others.

In adults, skeletal Angle Class II relationships are frequently treated by a combination of preorthodontic treatment and sagittal split osteotomy surgery to correct the occlusion and the mandibular position, improve the soft-tissue profile, and obtain a normal condyle position after surgery. The sagittal split osteotomy technique involves splitting the mandible at the inferior border and providing controlled replacement of the proximal segment. Although it has definite advantages, the sagittal split osteotomy also has some challenges; nerve injuries might be a complication, and relapse has been noted, especially with greater skeletal moves and complex facial patterns. The professional objective of dental treatment is to improve mastication and esthetics. In addition to such clinical challenges, there is a need for studies that evaluate treatment over time by inquiring whether the treatment the patients received had actually improved their quality of life. The aims of this investigation were to determine the reasons for seeking orthodontic-surgical treatment, to quantify the perceived possible improvement after surgical intervention with bilateral sagittal split osteotomy by means of visual analog scales reporting oral status before orthodontic surgical-treatment and 10 to 14 years after treatment, and to assess factors that affect treatment satisfaction and socio-dental impacts on quality of life.

Material and methods

During the years 1995 to 1998, 78 patients with Angle Class II malocclusions, all with pronounced mandibular retrognathia, referred from private and public orthodontists, were surgically treated with sagittal split osteotomy advancement surgery at the Department of Oral and Maxillofacial Surgery, Haukeland University Hospital, Bergen, Norway. An oral and maxillofacial surgeon (K.T.) and a specialist in orthodontics (P.J.W.) prepared the treatment plan for each patient. The inclusion criteria for the follow-up study were as follows: (1) patients had combined orthodontic-surgical treatment by sagittal split osteotomy surgery or genioplasty combined with sagittal split osteotomy, (2) they did not need major dental restorations including crowns and bridges in the frontal area during the follow-up period, and (3) they were not syndromic or medically compromised. From 78 potential participants, 4 responding subjects did not meet the inclusion criteria and were excluded. Thirty-six subjects agreed to participate in this retrospective cohort study 10 to 14 years after their orthodontic-surgical treatment, signed written consent forms, had a clinical examination, and completed a structured self-administered questionnaire. Regarding the nonparticipants, 2 had moved abroad, 1 was pregnant, 7 did not have time, 9 refused to participate for unknown reasons, and 19 could not be contacted. There were no significant differences between responders and nonresponders regarding sex, age, years since treatment, or the distribution of domiciles.

The participants had mean ages of 32.7 years (SD, 11.2 years; range, 16-50 years) when treated and 45.7 years at the time of the study (SD, 10.7 years; range, 29-62 years). Approval was obtained from the ethical research committee in Norway in 2008.

A surgical technique described by Messer et al and slightly modified by Leira and Gilhuus-Moe was used in all patients. All participants had bilateral sagittal split osteotomies as the sole surgery with miniplate fixation (Gebrüder Martin Gmbh & Co, Tuttlingen, Germany) or customized occlusal splints. Fixations were performed with a miniplate system including 5-mm monocortical screws in 30 patients. Customized occlusal splints were used in 22 patients. Wire fixation and intermaxillary fixation was performed in 6 patients. There was a corresponding distribution of miniplate and wire fixation in the nonresponders.

The clinical examinations, including impressions for study casts and wax recordings of centric occlusion, were performed by an author (K.M.). Anatomic occlusion was measured on dental casts and controlled by clinical measurements on 5 occasions (at baseline, T0; after presurgical orthodontic treatment, T1; 8 weeks after surgery, T2; 1 year after surgery, T3; and 10-14 years after surgery, T4). Maxillary overjet was measured as the greatest distance from the labial-incisal edge of the most protruded maxillary incisor to the labial surface of the corresponding mandibular incisor. Sensory impairment was measured by using a battery of neurosensory tests (light touch test, 2-point discrimination, localization sensibility, sharp-blunt differentiation, pin-prick sensibility, and thermal stimuli) according to the method of Leira and Gilhuus-Moe. All participants had presurgical orthodontic treatment with fixed appliances.

The participants provided information about their demographic characteristics such as sex, age, and education. The reasons for undergoing the surgical treatment included yes or no to 9 specific problems (mastication, appearance, speech, sinuses/bronchia, headache, temporomandibular joint disorder, palatal ulcer, other reasons). Two questions about recollection of pain were recorded: “did you experience pain during the orthodontic treatment?” and “did you experience pain after surgery?” Both questions were rated on a 4-point scale: severe pain, only minor pain, no pain, or do not remember. The duration of numbness in the lips or jaws after the sagittal split osteotomy surgery was rated on a 4-point scale from numbness after surgery to continued numbness.

Two visual analog scales allowed the participants to rate their perceived treatment outcome from T0 to T4 on 7 oral health-related items concerning oral function and appearance. The visual analog scale was presented as a 10-cm line, with clearly defined anchors at each end: left side, “no problem”; right side,”big problems.” The questionnaire included detailed instructions on how to record their answers. A 3-point ordinal scale (very satisfied, relatively satisfied, and not satisfied) allowed the participants to rate their present overall satisfaction with the orthodontic-surgical treatment. For the purpose of analyses, this variable was dichotomized to “very and less satisfied.” The latter was the combination of responses in the categories “relatively satisfied” and “not satisfied.”

The oral impact of daily performances (OIDP) index was included to assess information on socio-dental impacts on quality of life during the last 6 months. The reliability and validity of the OIDP has previously been established. The OIDP index covers limitations in eating and enjoying food, speech, cleaning the mouth, relaxing, smiling, working, emotions, and social contacts because of disorders of the teeth or jaws. The OIDP was scored by adding the responses of 8 items, each rated on 5-point scales from 1 (never or less than once a month) to 5 (more often than 3 or 4 times a week) (range, 1-40). Higher OIDP scores expressed frequent episodes of negative impacts from oral health on perceived quality of life and a poorer oral health status. The variables expressing the extent of oral impacts were calculated as 0, no impacts (including the original category 1), and 1, impacts (including the original categories 2-5) (range, 0-8).

The Statistical Package for the Social Sciences software (version 15.0.1 for Windows; SPSS, Chicago, Ill) was used for the analyses. Differences in demographic and background variables were tested by using chi-square tests, t tests, and Mann-Whitney U tests for continuous and nonparametric variables, respectively. The intrarater correlation coefficient (ICC) was used to assess consistency between different oral health items (visual analog scale questions). For analyses of associations, multiple logistic regression models were used. Quantitative variables were dichotomized by using the median as the cutoff point, and qualitative variables according to characteristics or categories as described. All potential confounders that had an association with the outcome variables in the simple regression at the 5% level were included in the model: sex, age, educational level, follow-up period after surgery, self-concerns about appearance, and pain recollection during or after treatment. Odds ratios and 95% confidence intervals were calculated. The reported changes in the extent of problems related to oral function and appearance were examined graphically with box plots, which are a convenient way to depict groups, with minimum, first quartile, median, third quartile, maximum, and outliers for each group. P <0.05 was considered to be statistically significant.


The participation rate was 46% (36 of 78); there were 20 women and 16 men. The main reasons for nonparticipation were no contact (50%), refusals (24%), and no time (18%). Table I shows the responders’ motivations for treatment. The most frequent motivations were “to improve mastication” (56%; 20 of 36) and “to improve appearance” (36%; 13 of 36). In most cases, the dentist was the initiator for treatment. In this respect, there were no sex or age differences, or no differences in reasons for seeking treatment when initiated by the patients or their dentists ( P >0.05). Most responders regarded themselves as normally engaged in their appearance. Equal proportions of participants reported pain during the orthodontic treatment and surgery (25%; 9 of 36), and 9 persons (25%) still experienced numbness in the lip 10 to 14 years after treatment. Sensory impairment was confirmed clinically in 4 persons; only 2 had a history of preoperational complications. Recordings from the dental casts are shown in Table II . A statistically significant sex difference in mean maxillary overjet was recorded after presurgical orthodontic treatment only (T0-T1) ( P = 0.003). No different outcomes across age were discerned.

Table I
Percentage distribution of reasons for having surgical treatment (n = 36)
Initiator of treatment, % (n)
Patient Dentist All
To improve mastication 50 (5) 60 (15) 55.6 (20)
To improve appearance 60 (6) 28 (7) 36.1 (13)
Other reasons 30 (3) 24 (6) 27.8 (10)
To eliminate TMD 30 (3) 24 (6) 25.0 (9)
To eliminate palatal ulcer 10 (1) 16 (4) 13.9 (5)
TMD , Temporomandibular joint disorder.

Table II
Subject characteristics by sex for anatomic occlusions on dental models at 5 times (n = 36)
Maxillary overjet Mean maxillary overjet in millimeters (SD)
Male Female Range (all)
At baseline (T0) 7.9 (4.0) 7.8 (2.9) 1-15
After presurgerical orthodontic treatment (T1) 8.8 (3.5) 7.3 (1.5) 4-16
8 weeks after surgery (T2) 2.3 (1.5) 2.4 (1.2) 0-6
1 year after surgery (T3) 1.9 (0.9) 2.5 (1.4) 0-6
10-14 years after surgery (T4) 3.8 (2.4) 4.2 (1.7) 0-9

P <0.05.

More than two thirds of the responders reported improvements in the 7 oral health-related items measured on the visual analog scales (chewing, digestion, headache, speech, appearance, bullying, and self-confidence), compared with recordings before treatment (T0-T4). The Figure gives the box plots side by side for each item. The most evident change was in regard to chewing (median, 4.03). Appearance had a median of 1.56, self-confidence a median of 0.26, and bullying a median of 0.13. Digestion, headache, and the ability to speak did not change significantly for most participants. The overall intrarater reliability on the 7 items was high for men and relatively high for women ( Table III ).

Table III
Intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) of the 7-item visual analog scale questions on change after treatment (n = 36)
Variable n ICC 95% CI
Overall 36 0.694 0.51-0.83
Men 16 0.846 0.69-0.92
Women 18 0.518 0.08-0.79

“Very satisfied” with the treatment was reported by 36% (13 of 36) of the responders; 53% (19 of 36) were “reasonably satisfied,” and 8% (3 of 36) were not satisfied. Table IV depicts the associations between the covariates and the level of satisfaction with treatment in retrospect (Nagelkerke R 2 , .330). The logistic regression analysis showed that reporting “very satisfied with treatment” was nearly 8 times more likely when friends and family had noticed a change in the participant’s appearance, compared with those whose friends and family had not. Sex added no significant independent contribution to the analysis. The results were adjusted for sex, age, education, follow-up period after surgery, self-concerns about appearance, and recollection of pain during or after treatment.

Table IV
Association between covariates and satisfaction with treatment (reported 10-14 years in retrospect) and results from multiple logistic regression (dependent variable: relatively or not satisfied, very satisfied ); Nagelkerke R 2 0.330, degrees of freedom 7. Results were adjusted for gender, age, level of education and follow-up period after surgery
Covariables Satisfied, % (n) Less than satisfied, % (n) P OR 95% CI interval for OR
Concerned about appearance
Normal or less than average 41.9 (13) 58.1 (18)
More than average 20.0 (1) 80.0 (4) 0.628 0.40 (0.0-8.8)
Friends noticed changed appearance
No 16.7 (3) 83.3 (15)
Yes 61.1 (11) 38.9 (7) 0.015 7.70 (1.2-50.6)
Pain during or after treatment
No 34.8 (8) 62.2 (15)
Yes 46.2 (6) 53.8 (7) 0.501 1.56 (0.2-11.2)
OR , Odds ratio; CI , confidence interval.

Fisher exact test (2-sided).

The mean sum score of the OIDP was 10.27 (SD, 5.4; range, 8-36); the scores were 9.44 in the men (95% CI, 7.5-11.3) and 11.06 in the women (95% CI, 7.6-14.5) ( P = 0.398). The OIDP sum score and satisfaction with treatment were not significantly associated (Spearman rho, .329; P = 0.213). A total of 36% (13 of 36; 95% CI, 22.0-57.0) of the responders reported at least 1 socio-dental impact on quality of life during the past 6 months. The mean number of items affected was 1.1 (SD, 1.9; range, 0-7). The proportion of subjects reporting impacts varied across the different OIDP items. Table V also presents comparable results from a national random survey in 2003 (mean age, 43.4 years; range, 16-79 years; 50.5% men). The patients in our study most frequently reported impacts related to smiling (22.9%, 8 of 35) and sleeping (20%, 7 of 35). Eating and enjoying food was the third most frequently reported item (17.1%, 6 of 35). Cleaning the teeth, speaking, and social contact showed similar results: 14.3%, 14.3%, and 14.3%, respectively (5/35); aspects such as carrying out work (3 persons) and emotional stability (2 persons) were reported less frequently. Problems with cleaning the teeth were most frequently reported among subjects who were very satisfied with their treatment (23%, 3 of 13), and problems with smiling were most frequently reported by those who were less satisfied with their treatment (27%, 6 of 22). Impacts on quality of life at T4 did not depend on the level of satisfaction with orthognathic surgery and orthodontic treatment at T4 ( P >0.05) for any OIDP item. Table VI depicts the association between the covariates and the OIDP scores (Nagelkerke R 2 , 0.523). Sex and whether friends and family had noticed a change in the participant’s appearance after surgery were significantly associated with the T4 report on the impacts on quality of life. The results were adjusted for age, education, self-concerns about appearance, and recollections of pain during or after treatment.

Table V
Percentage distribution of the OIDP items causing an impact on quality of life by satisfaction with treatment 10 to 14 years in retrospect (n = 35)
OIDP item Very satisfied with treatment, % (n) n = 13 Less satisfied with treatment, % (n) n = 22 All, % (n) n = 35 Nonpatient prevalence rate,
all, % (n) n = 1297
At least 1 oral impact 39.4 (13) 18.3 (237)
Smiling 15.4 (2) 27.3 (6) 22.9 (8) 4.6 (60)
Sleeping 15.4 (2) 22.7 (5) 20.0 (7) 3.9 (50)
Eating and enjoying food 7.7 (1) 22.7 (5) 17.1 (6) 11.3 (147)
Cleaning teeth 23.1 (3) 9.1 (2) 14.3 (5) 5.4 (70)
Speaking 15.4 (2) 13.6 (3) 14.3 (5) 3.0 (39)
Social contact 7.7 (1) 18.2 (4) 13.9 (5) 2.1 (26)
Work 7.7 (1) 9.1 (2) 8.3 (3) 4.4 (57)
Emotional stability – (-) 9.5 (2) 5.9 (2) 3.5 (46)

National random survey in 2003, 16-79 years (mean, 43.4 years; 50.5% men).

Table VI
Association between covariates and reported OHQoL and results from multiple logistic regression (dependent variable: no impact, one or more impacts ); Nagelkerke R 2 0.523, degrees of freedom 6
Covariables No impact,
% (n)
At least 1 oral impact,
% (n)
P OR 95% CI interval for OR
Male 77.8 (14) 22.2 (4)
Female 43.8 (7) 56.3 (9) 0.076 18.12 (1.2-284.4)
Age during treatment (y)
Young (<32) 52.9 (9) 47.1 (8)
Old (≥32) 70.6 (12) 29.4 (5) 0.290 0.42 (0.1-3.5)
Less education 62.5 (10) 37.5 (6)
College or university 61.1 (11) 38.9 (7) 0.934 1.34 (0.2-11.4)
Concerned about appearance
Normal or less than average 69.0 (20) 31.0 (9)
More than average 20.0 (1) 80.0 (4) 0.059 6.42 (0.4-109.8)
Friends noticed changed appearance
No 47.1 (8) 52.9 (9)
Yes 76.5 (13) 23.5 (4) 0.157 0.05 (0.0-0.9)
Pain during or after treatment
No 73.9 (17) 26.1 (6)
Yes 36.4 (4) 63.3 (7) 0.060 3.01 (0.4-24.7)
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Apr 8, 2017 | Posted by in Orthodontics | Comments Off on Patients’ perceptions of improvements after bilateral sagittal split osteotomy advancement surgery: 10 to 14 years of follow-up
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