Abstract
The aim of this study was to compare the satisfaction of skeletal class III patients following treatment with three different methods of orthognathic surgery. Eighty-two patients were divided into three groups according to the surgical procedure performed to correct their class III dentofacial deformity, and answered a questionnaire designed to determine the patient’s opinion of the aesthetic and functional treatment outcomes. Differences in the patterns of responses to questions in the questionnaire related to satisfaction between the three clinical groups were evaluated by χ 2 and Fisher’s exact tests ( α = 5%). Eighty patients (97.6%) reported being satisfied with the treatment received. There was no significant difference in response patterns among clinical groups when assessing the improvement in facial appearance, chewing, speech, and socialization. Maxillary advancement led to higher levels of improvement in breathing ( P < 0.0003). Class III patients treated by orthognathic surgery had high levels of satisfaction with the aesthetic and functional outcomes of their treatment.
The human face is a complex mosaic of angles, lines, planes, shapes, textures, and colours. The interaction of these elements produces a multitude of variations of form, from an exceptionally balanced aesthetic form to an imbalance of facial elements incompatible with aesthetic standards and functional normality. Knowing that facial appearance greatly influences how society judges an individual and that this may also have a critical impact on self-esteem, patterns of behaviour, and success in interpersonal interactions, facial harmony is a constant concern for most people.
Dentofacial deformities (DFD) affect about 20% of the population. DFD patients show varying degrees of aesthetic and functional impairment, which may be restricted to a single jaw or extend to the entire craniofacial complex. Orthognathic surgery is recommended for the treatment of most of these cases due to the potential to obtain functional occlusion combined with better facial aesthetics, and improved chewing, breathing, and phonation functions and motor development.
Orthognathic surgery has a profound impact on the psychological state of patients undergoing such treatment due to the resulting aesthetic and functional changes. The way the patient perceives the benefits of treatment is a major concern, especially considering the complexity of the treatment.
Patient perceptions of their self-esteem and evaluation of their appearance are closely related to the well-being of the individual; the aesthetic and functional changes associated with orthognathic surgery are related to an improvement in patient self evaluation, with a beneficial influence on self esteem and improvement in patient social relationships. Proper restoration of the occlusal and skeletal pattern and the achievement of aesthetic and functional results are not satisfactory to the surgeon if the patient shows no satisfaction with the results achieved, since the success of surgical orthodontic treatment (SOT) depends not only on perfect tooth alignment and correct bone repositioning through surgery, but also satisfaction of the expectations and motivations that led the patient to seek treatment.
This retrospective study aimed to compare the satisfaction of skeletal class III patients treated by surgery for maxillary advancement, mandibular setback, or a combination of both treatments.
Materials and methods
This research project was submitted to and approved by the ethics committee of the study institution. Patients who agreed to participate in the study read and signed the consent form designed for this purpose.
Skeletal class III patients were considered eligible for the study if they were aged between 18 and 50 years and had undergone SOT comprising mandibular setback, or maxillary advancement, or both procedures. Osteotomies performed in all patients were limited to two bilateral sagittal split osteotomies (BSSO) and Le Fort I osteotomy using rigid internal fixation and no maxillomandibular fixation in the postoperative period. Patients were at least 1 year postoperative when they participated in the study. Those who had suffered an accident during the operative procedures or a postoperative infection were excluded. Patients were from a centre for research and treatment of oral–facial deformities in Araraquara, São Paulo, Brazil.
One hundred and seventy records of skeletal class III patients operated on between 1998 and 2007 were retrieved from the files. Reasons for non-eligibility included infection ( n = 7), age <18 years or >50 years ( n = 8), use of other surgical protocols ( n = 9), postsurgical period less than 1 year ( n = 12), and the use of maxillomandibular fixation ( n = 2). Excluded patients received other SOT modalities, such as vertical mandibular osteotomy, Le Fort II osteotomy, or maxillary segmental osteotomies ( n = 3). Thus 129 potential participants were identified. Among these eligible patients, we were able to contact 115. Eighty-two (71%) of the eligible patients attended the assessment and comprised the final sample. Patients were divided into three groups according to the surgical procedure used, based on clinical assessment: group A ( n = 30) comprised patients who had undergone maxillary advancement combined with mandibular setback; group B ( n = 36) comprised patients who had undergone maxillary advancement; group C ( n = 16) comprised patients who had undergone mandibular setback.
Surgical procedures performed included Le Fort I osteotomy and maxillary advancement in groups A and B, and BSSO of the mandible and mandibular setback in groups A and C. All patients received rigid internal fixation.
Participants answered a questionnaire focusing on satisfaction with the treatment outcome based on one used by Ambrizzi et al., modified for the purposes of this study ( Table 1 ). This questionnaire consisted of 10 questions (Q1–Q10) aimed at determining who initially diagnosed the DFD, the use of previous treatments for the correction of the DFD, and the patient’s opinions about the aesthetic and functional outcomes of the treatment. The patient was considered satisfied with the treatment if responses to Q3–Q8 were all ‘yes’, or if the answer to Q9 or Q10 was ‘yes’. The patient was considered dissatisfied with treatment if there was at least one ‘no’ answer to any of Q3–Q8, or if there was a ‘no’ response to Q9 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment), or if there was a ‘no’ response to Q10 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment).
| 1. | Who first detected the problem and referred it for treatment? You/Dental surgeon/Physician/Relatives/Friends/Other (please specify) |
| 2. | Had you already undergone other orthodontic treatment in an attempt to correct your deformity before you started your treatment at this unit? Yes/No |
| 3. | Do you believe that there was an improvement in your appearance after treatment? Yes/No/Do not know |
| 4. | Do you believe that there was an improvement in your chewing after treatment? Yes/No/Do not know |
| 5. | Do you believe that there was an improvement in your breathing after treatment? Yes/No/Do not know |
| 6. | Do you believe that there was an improvement in your pronunciation of sounds and words after treatment? Yes/No/Do not know |
| 7. | Do you believe that there was an improvement in your social relationships or contact with people after treatment? Yes/No/Do not know |
| 8. | How do you consider your treatment results? Great/Good/Poor/Do not know |
| 9. | Would you undergo the surgery again? Yes/No (please provide reasons) |
| 10. | Would you recommend the surgical treatment to other people? Yes/No (please provide reasons) |
The χ 2 test and Fisher’s exact tests were used to evaluate the differences in patterns of responses among the three clinical groups ( α = 5%).
Results
The total sample consisted of 82 patients; 53.7% (44 patients) were female and 46.3% (38 patients) were male. The average age of patients was 26 years, ranging from 18 to 48 years. Of the 82 patients, 36.6% (30 patients) were in group A, 43.9% (36 patients) in group B, and 19.5% (16 patients) in group C.
Patient satisfaction after treatment was 97.6% (80 patients), with only 2.4% (two patients) being dissatisfied with the results of surgical treatment. Of the two patients who were considered dissatisfied, one answered ‘no’ to Q6 and Q7 and the other replied ‘no’ to Q7; however, these same patients when asked if they would undergo the treatment again answered ‘yes’ and considered the results as ‘good’ and ‘excellent’, respectively. Three patients (3.7%) responded that they would not undergo the treatment again, two of whom reported that the pain in the postoperative period was intense and the other reported being frightened of being admitted to a hospital for any reason. All three patients described treatment results as ‘excellent’ and would recommend the SOT to other patients.
Regarding the initial diagnosis of DFD and recommendation of SOT, most patients, 79.3% ( n = 65), were diagnosed and recommended this treatment by a dentist. Seven patients (2.4%) requested the treatment themselves, and the same number were recommended the treatment by a physician ( n = 7; 8.5%). The recommendation of relatives and friends accounted for 2.4% ( n = 2), and only one patient (1.2%) reported having been recommended this treatment by another route ( Table 2 ).
| Group a | 1 Patient |
2 Dentist |
3 Physician |
4 Relatives/friends |
5 Other |
Number of patients | % of total sample |
|---|---|---|---|---|---|---|---|
| A | 1 (3.3%) | 25 (83.3%) | 3 (10%) | 1 (3.3%) | 0 (0%) | 30 | 36.6% |
| B | 5 (13.9%) | 28 (77.8%) | 2 (5.6%) | 0 (0%) | 1 (2.8%) | 36 | 43.9% |
| C | 1 (6.3%) | 12 (75%) | 2 (12.5%) | 1 (6.3%) | 0 (0%) | 16 | 19.5% |
| Total | 7 (8.5%) | 65 (79.3%) | 7 (8.5%) | 2 (2.4%) | 1 (1.2%) | 82 | 100% |
a Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
The possibility of a difference in diagnosis and recommendations for SOT between the study groups (groups A, B, and C) was evaluated by Fisher’s exact test; no statistically significant difference was found ( P = 0.535), indicating that the referral patterns among the three groups were similar.
Most patients (69.5%, n = 57) had not undergone previous orthodontic treatment (OT) at other clinics for correction of the DFD, however 30.5% ( n = 25) had, without success. There was no significant difference between the three clinical groups regarding the number of patients who had undergone prior orthodontic treatment ( P = 0.436) ( Table 3 ).
| Group a | No | Yes | Number of patients | % of total sample |
|---|---|---|---|---|
| A | 22 (73.3%) | 8 (26.7%) | 30 | 36.6% |
| B | 26 (72.2%) | 10 (27.8%) | 36 | 43.9% |
| C | 9 (56.3%) | 7 (43.8%) | 16 | 19.5% |
| Total | 57 (69.5%) | 25 (30.5%) | 82 | 100% |
a Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
When inquiring about the improvement in facial appearance, 97.6% ( n = 80) of patients reported an improvement and 2.4% ( n = 2) did not know whether they noticed an improvement in their appearance after SOT. No patient reported ‘no improvement’ in facial appearance after treatment. There was no significant difference in the patterns of responses between the three study groups when evaluated by Fisher’s exact test ( P = 0.495) ( Fig. 1 ).
Most patients, 97.6% ( n = 80) reported an improvement in masticatory function following treatment, but 2.4% ( n = 2) did not know if there was an improvement. There was no significant difference among the three study groups regarding the pattern of responses, as evaluated by Fisher’s exact test ( P = 0.485) ( Fig. 2 ).
In assessing the improvement in breathing after treatment, 87.8% ( n = 72) of the total sample answered that breathing had improved and 12.2% ( n = 10) did not know if their breathing had improved. By group, 96.7% ( n = 29) of patients in group A, 94.4% ( n = 34) in group B, and 56.3% ( n = 9) in group C reported an improvement in breathing; yet 3.3% ( n = 1) in group A, 5.6% ( n = 2) in group B, and 43.8% ( n = 7) in group C did not know if their breathing had improved. There was a significant difference in the pattern of responses in the three groups ( P < 0.0003, Fisher’s exact test) ( Fig. 3 ).
Analyzing speech improvement, 86.6% ( n = 71) of patients responded that there was improvement in pronunciation, 12.2% ( n = 10) did not know if there was an improvement, and 1.2% ( n = 1) reported no change. There was no significant difference among responses in groups A, B, and C when evaluated by Fisher’s exact test ( P = 0.195) ( Fig. 4 ).
Most patients, 91.5% ( n = 75), reported an improvement in their socialization after treatment, 2.4% ( n = 2) reported no improvement in interpersonal relationships after SOT, and 6.1% ( n = 5) did not know whether or not there was an improvement ( Fig. 5 ). The difference in the pattern of responses of the three groups comprising the total sample was not significant ( P = 0.374), as analyzed by Fisher’s exact test.
