Psychological aspects of orthognathic surgery and its effect ...
150 La Revue de Santé de la Méditerranée orientale, Vol. 13, No 1, 2007 50Psychological aspects of 98 89 96 92orthognathic surgery and its effect on quality of life in Egyptian patientsPsychological aspects of orthognathic surgery and its effect on quality of life inH. Sadek1 and G. Salem 2 33 11 120 2004 1998 95 85ABSTRACT A study was made of 120 patients aged 11–33 years who underwent various types of orthognathic surgery in a Cairo hospital between 1998 and 2004. Patients answered a standardized Determinants and causes of son preference among women delivering inquestionnaire to identify motives for seeking surgery, the degree of satisfaction with the outcome and its effect on quality of life. Preoperatively, aesthetic reasons were the primary motive for seeking surgery in 95% of patients. Postoperatively, 85% of the patients were positive about the outcome of surgery as well as its effect on their quality of life. Postoperative improvement of facial aesthetics of the patients was associated with improvement of their quality of life in all aspects tested.Aspects psychologiques de la chirurgie orthognatique et son effet sur la qualité de vie de patients égyptiens 1.4 400RÉSUMÉ Une étude a été menée auprès de 120 patients, âgés de 11 à 33 ans, ayant subi divers sses formes de chirurgie orthognathique dans un hôpital du Caire entre 1998 et 2004. Ces patients 496ont répondu à un questionnaire standardisé visant à identifier les motifs de demande d’intervention chirurgicale, le degré de satisfaction quant au résultat de l’intervention et son influence sur la qualité de vie. Au stade préopératoire, les raisons esthétiques constituaient le motif principal de la demande d’intervention pour 95 % des patients. En postopératoire, 85 % des patients se déclaraient satisfaits du résultat de lintervention et quant à son effet sur leur qualité de vie. Lamélioration postopératoire de lesthétique faciale des patients est apparue associée à une amélioration de la qualité de vie pour tous les aspects considérés. 1 Egyptian Air Force Dental Corps, Department of Maxillofacial Surgery, Air Force General Hospital, Cairo, Egypt (Correspondence to H. Sadek: email@example.com). 2 Private medical practice, Cairo, Egypt. Received: 08/03/05; accepted: 26/06/05
Eastern Mediterranean Health Journal, Vol. 13, No. 1, 2007 151Introduction factors which greatly affect the need and demand for treatment. Desire for aestheticOrthognathic surgery refers to a group of improvement has been expressed as the mat tcorrective bone operations that involve jor reason for seeking orthognathic surgerymovement of the jawbones completely or in in several studies [12–18].parts . Orthognathic surgery is indicated The motivations of orthognathic surgerywhen there are severe dentofacial deformit t candidates to seek treatment have beenties that cannot be managed by orthodontic studied by Edgerton and Knorr , whotreatment alone, especially in adulthood, described 2 types of motivations, externalwhen the natural growth forces have ceased and internal. External motivations include. Dentofacial deformities are described the need to please others, “paranoid” ideasas deformities that affect primarily the jaws and beliefs that one’s career or social ambittand dentition. They may be limited to one tions are being thwarted by physical appeart tjaw or may extend to multiple craniofacial ance. These motivations require a change instructures . the patients’ personal environment rather The history of orthognathic surgery than surgery to solve the problem .dates back to the 19th century, when Le Internal motivation is usually a more validFort described the classic lines of maxillary form of motivation and includes longtstandt tfracture. Wassmund, in 1927, was the first ing inner feelings about deficiencies insurgeon to use an osteotomy line on Le Fort one’s appearance. These individuals areI level for the correction of malocclusion. better candidates for surgery [12,20].Le Fort I osteotomy was popularized by Considering the psychological aspects,Obwegeser in the midt20th century as a neuroticism may have a negative effectstandard procedure in maxillofacial surgery on the early postoperative phase but notto correct dentofacial deformities [4,5]. The on the longtterm outcome . Althoughmodern history of orthognathic surgery patients with dysmorphophobia (feelingstarted in the 1970s, as it gradually became unattractive despite having almost normala routine choice, with benefits such as imt t appearance) may benefit from surgery, theprovement of mastication and reduction of initial treatment should be psychiatric ratherfacial pain and more stable results even in than surgical . Pogrel and Scott severe discrepancies [6,7]. concluded that most orthognathic surgery The prevalence of dentofacial deformit t patients are psychologically normal, andties has been estimated as 20% of the poput t routine preoperative psychological evalut tlation worldwide . Data gathered from ation is not indicated. A cornerstone of athe United States of America points to a successful outcome is a thorough evaluationprevalence of approximately 20% of the US of the patient’s expectations and carefulpopulation, of which 2% warrant surgery preoperative information about the surgical. In Scandinavia, it has been estimated process.that 10% of young people are in need of Human biophysiology phenomena areorthodontic treatment . In the Netht t similar throughout the world, but psychot terlands, it has been found that 39% of the social responses may differ considerablypopulation needs orthodontic treatment between different cultures. Dentofacial. Indications for orthognathic surgery, deformities requiring orthognathic surgeryother than the purely anatomical ones, int t involve both psychosocial and biologit tclude the psychosocial and biophysiologic cal considerations. Although orthognathic
152 La Revue de Santé de la Méditerranée orientale, Vol. 13, No 1, 2007surgery has been widely practised in Egypt he or she was scheduled for operation. Thefor some time, data about the psychological patients were asked to answer the 1st partaspects of treatment are still lacking. of a standard questionnaire to identify their The aim of this study was to assess the symptoms and problems, their motives formotivation for surgery of a group of patients seeking surgery and their expectations fromundergoing orthognathic surgery in a Cairo it.hospital, the degree of their satisfactionwith the outcome of surgery and its effect Postoperative assessmenton the quality of their lives. After a period of 6 months to 1 year postt t operatively, the patients were requested to answer the 2nd part of the questionnaireMethods to assess the postsurgical outcome and the degree of the patient’s satisfaction with thePatients results as well as its effect on her/his qualityA total of 120 patients (48 male and 72 fett of life. Visual analogue scales based on themale) with dentofacial deformities indicated method documented by Philips et al. for orthognathic surgery in the Department were used to measure the patient’s satisfact tof Maxillofacial Surgery, Air Force General tion with the result. All patients gave a clearHospital, Cairo, were studied between the written consent for participation.years 1998 and 2004. The hospital treats AirForce personnel, including those in the actt Questionnaires and measurementstive service and retired pensioners, as well The 2 parts of the questionnaire were develt tas their dependents. oped by the authors with reference to other investigators [14,17,22–26]. The questiont tPreoperative assessment naire included both qualitative and quantit tA lateral cephalogram as well as frontal and tative data by multipletchoice answers on alateral photographs with the lips at rest were numerical scale ranked from 0 to 4 [0 not attaken for each patient. ANB angle was the all, 1 a little, 2 moderately (good), 3 markttparameter used as a representative of severt t edly (very good), and 4 extremely (excelt tity of class III malocclusion. ANB angle lent)]. The quality of life was assessed usingis the difference between SNA and SNB the Derriford Appearance Scale (DAS59)angles which demonstrates the sagittal dist t [24,25], adjusted for individuals below thecrepancy between the upper and the lower age of 16 years and a reading level of the 6thjaws in both class II division I and class grade of general education. Only 3 factorialIII malocclusions. In class II division I, the subscales were used in this study: generalseverity of anteroposterior discrepancy is selftconsciousness of appearance, socialdetermined by ANB angle measurements selftconsciousness of appearance and negat tgreater than 2 degrees. In class I division II tive selftconcept.the ANB angle is less than 0 degrees. The The questionnaires were translated intomore negative the ANB angle the more set t Arabic separately by 2 translators. The 2vere the skeletal discrepancy in the sagittal versions were combined and revised anddirection. then back translated into English by a 3rd The type of surgery and its expected translator. The translation was refined afteroutcome were explained to each patient back translation until agreement was obt twith the help of diagrams, photos and study tained among the 3 translators. A group of 4models, and consent was obtained before
Eastern Mediterranean Health Journal, Vol. 13, No. 1, 2007 153bilingual experts (Arabic speaking) includt t Table 2 Clinical diagnosis of the study grouping a clinical psychologist examined the 2 Clinical diagnosis No. of % versions of the questionnaire for content patientsand construct validity and agreed upon it.The marking of the scale was examined and Class II division 1 malocclusion 44 36.7the weighting of the scores discussed. The translation was then piloted for Class III malocclusion 17 14.2comprehension and ease of administration Retrognathia 21 17.5on 13 patients (7 males and 6 females) not Anterior open bite 36 30.0participating in this study. Minor adjusttt Mandibular asymmetry 2 1.7ments were made to the questionnaire to Total 120 100.0improve clarity but no major changes werejudged necessary.Statistical analysis ancies constituted 69.4% of the dentofacialA statistical analysis system (SAS, version deformities, open bite 30.0%, and mant t7) was used. The tests used were tttest for dibular asymmetry 1.7%. Class II division 1differences and the Pearson correlation cot t malocclusion constituted 36.7% of the casesefficient (r). with a mean ANB angle of 7.0 (SD 0.74) degrees (Table 3). Class III malocclusion constituted 14.2% of the cases with a meanResults ANB angle of –7.0 (SD 2.5) degrees.The age and sex distribution of the patientsare summarized in Table 1. The age range Operations performed and was 11–33 years; mean age 21.0 years outcomes of surgery[standard deviation (SD) = 4.1]. Table 3 shows a comparison between the measurements of ANB angle before andInitial diagnoses after surgery. A mean difference of 3.6The clinical diagnosis of the patients is degrees (SD 0.54) in ANB angle measuret tshown in Table 2. Anteroposterior discrept t ments were achieved postoperatively in class II division I, and 8.3 (SD 1.0) degrees in class III cases. The difference between the pret and postoperative ANB angle meat tTable 1 Age and sex distribution of the study surement in class II division I cases weregroup statistically significant (t = 32.7; P < 0.01)Age (years) Male Female Total as well as in class III cases (t = 24.4; P < No. No. No. 0.01).11–15 1 0 1 Motives for treatment16–20 30 40 70 The motives for seeking treatment among21–25 15 27 42 the study group are listed in Table 4. In26–30 1 4 5 114 patients (95%) improvement of facial31–35 1 1 2 aesthetics was the primary reason for seekt tTotal 48 72 120 ing treatment, and most of them were free
154 La Revue de Santé de la Méditerranée orientale, Vol. 13, No 1, 2007 Table 3 Comparison between preoperative and postoperative ANB angle measurements in patients with class II division I and class III malocclusion Type of malocclusion ANB angle measurements (degrees) Preoperative Postoperative Class II division 1 (n = 44) Minimum 5 1 Maximum 14 4 Mean (SD) 7.0 (0.74) 2.4 (0.6) Class III (n = 17) Minimum –5 0 Maximum –21 2 Mean (SD)* –7.0 (2.5) 1.0 (0.94) SD = standard deviation.from symptoms or functional problems. The Satisfaction with outcomeremaining 6 patients (5%) cited functional Out of the 120 patients who underwentproblems and speech defects in addition orthognathic surgery in this study, 101to aesthetic reasons for seeking treatment. patients (84.2%) were satisfied with theSome of the patients with the anterior open outcome of surgery (Table 5). The degreebite deformity cited their functional probt t of satisfaction of the patients with the postt tlems as secondary to their aesthetic probtt operative results varied between very goodlems. (score 3) (16 patients) and excellent (score 4) (85 patients). The mean group score was 3.4 (SD 0.6). Correlation analysis was made using theTable 4 Primary motives for seeking coefficient of correlation (r) (Pearson) intreatment among the study group order to detect the relationship between theMotives for seeking No. of % outcome of surgery and the degree of thetreatment patientsAesthetic motives Improvement in facial Table 5 Postoperative degree of satisfaction appearance 114 95.0 with the outcome of surgery among the Functional motives study group Improvement of Degree of satisfaction No. of % temporomandibular patients joint problem 0 0 Improvement in chewing Not at all 9 7.5 ability 2 1.7 A little 0 0 Improvement in speaking Moderate 0 0 ability 4 3.3 Very good 26 21.7 Improvement in breathing 0 0 Excellent 85 70.8Total 120 100.0Modified from Ostler and Kiyak . Total 120 100.0
Eastern Mediterranean Health Journal, Vol. 13, No. 1, 2007 155patients’ postoperative satisfaction with the patients have been retrospective and/orresults. A strong positive correlation existed based on recollection of patients’ preoperat tbetween the patients’ satisfaction scores tive expectations only after the surgery hasand the preoperative measurements of ANB been performed [15,17–28], in addition toangle in patients with class II division 1 problems due to droptout of patients durt tmalocclusion (r = 1.0, P < 0.01). A strong ing followtup. Although in some studiesnegative correlation was found between patients were assessed before and afterthe patients’ postoperative satisfaction and surgery, rarely have standardized questiont tthe preoperative measurements of ANB naires been used [17,21]. No similar studiesangle (r = –1.0, P < 0.01). Sex differences from Egypt or from other parts of the Eastt twere not significant in either posttsurgical ern Mediterranean Region are available forsatisfaction or selftreported pain. comparison. Until replicated, this study will stand alone.Quality of life In this study, the limitations of previousThe quality of life questionnaire revealed studies (small patient sample, retrospectivethat 101 patients (84.2%) reported positive study and high droptout rate) were avoidedchanges in the quality of their lives after as far as possible by using a prospectivesurgery. The percentage of change in the study design, a study sample of 120 patientsDAS59 factorial subscale scores was 70% with a mean followtup of 4 years. Since thisimprovement for the general selftconscioust t study was performed in a military hospital,ness of appearance, 58% for the social selft it was easy to recall the patients regularlyconsciousness of appearance, and 43% for for postoperative checktup, and hence, nothe negative selftconcept. There was also a droptout of patients was reported. Standt tsignificant difference between the preoperatt ardized questionnaires were meticulouslytive and postoperative mean group scores of translated into Arabic to achieve precisionthe DAS59 factorial subtscales tested in this of data and the numerical scale rankedstudy (Table 6). answers facilitated the comparison. In this study, the patients’ demand for orthognathic surgery seemed to be largelyDiscussion driven by desire to improve their appeart t ance. Previous studies have revealed thatMany previous studies on the psychologit t patients’ motives for seeking treatmentcal profiles of the orthognathic surgery Table 6 Preoperative and postoperative mean scores on the Derriford Appearance Scale (DAS59) factorial subsscales for the study group (n = 120 patients) Diagnosis Preoperative Postoperative % change tsvaluea Mean score SD Mean score SD General selfsconsciousness of appearance 48.2 (13.6) 14.2 (11.9) –70 t = 12.2 Social selfsconsciousness of appearance 29.5 (15.6) 12.3 (10.9) –58 t = 5.4 Negative selfsconcept 17.2 (4.1) 9.7 (3.5) –43 t = 9.0 a P < 0.0001.
156 La Revue de Santé de la Méditerranée orientale, Vol. 13, No 1, 2007were primarily related to appearance/self complaints among their motives for seekingimage rather than functional issues [12–18]. treatment. Such patients probably had pretIn some studies up to 89% of patients were surgery trouble sustaining social problemsreported to have aesthetic motives for seekt t which they considered more important thaning treatment [17,22]. However, in a study functional problems.by Frost and Peterson the number of pat t In this study 85% of the patients reportedtients with aesthetic motives was as low as improvement of their facial appearance and4% . In 2 studies from Sweden [29,30], satisfaction with the postoperative aestheticaesthetic motives for seeking treatment changes. This was unlikely to be achievedwere found to be slightly less important unless the defects were actually corrected.than functional motives. In a study from The degree of patient’s satisfaction with theDenmark , functional reasons were outcome of surgery seems to be associatedcited more often than aesthetic reasons. with the severity of their deformities, sinceHowever in a study by Ostler and Kiyak 50% of the patients in this study had class, selftconcept problems were found to II division I or class III skeletal deformit tbe as equally serious as functional probt t ties. This is in agreement with previouslems. The motives for improving aesthetics studies which suggest that class I skeletalin this study varied among individuals. In patterns are perceived to be more attractivesome patients, the motive was the improvet t than class II and class III patterns .ment of physical attractiveness, regardless Furthermore, measures of anteroposteriorof the severity of the deformity. Some otht t dental discrepancy, especially incisal overt ters felt aesthetically impaired to the degree jet, seem to be related to the perceptionof having a social handicap. Improvement of facial attractiveness since the subjectsof facial aesthetics after surgery was associt t having the greater anteroposterior discrept tated with improvement of social acceptance. ancy are more likely to be considered lessStill others were the victims of ridicule, as attractive . Selftperception of profilein an 11tyeartold boy, who was given by was important in the patients’ decision tohis schoolmates the nickname “Boogy”, seek surgery in the present study. In thisa cartoon character on Egyptian TV. The study, an improvement of facial aestheticschild felt embarrassed to the degree that was seen after orthognathic surgery as thehe refused to go school. The surgery had measure of anteroposterior discrepancya positive influence on the relationships decreased, in agreement with earlier reportswith his schoolmates. Interestingly in this [27–31].study, some patients reported postoperative The Derriford Scale (DAS59) selectedimprovement of facial aesthetics more than for use in this study is a conditiontspecificthey reported such improvement as their measure that assesses appearancetrelatedmotive for seeking treatment. Frost and quality of life. According to the results ofPeterson  also reported satisfaction this questionnaire a majority of patients hadwith the postsurgical aesthetic changes of positive changes in all aspects of qualitytheir patients although they listed functional of life after surgery. They showed a rise inproblems as patients’ motivation for seekt t morale, selftcontentment, and selftesteeming treatment. Another interesting finding and change in lifestyle as a result of surgery,in this study was that some patients reported as in 2 patients who stated that they lookedpostoperative improvement of function alt t younger after surgery. These findings supt tthough they did not mention functional
Eastern Mediterranean Health Journal, Vol. 13, No. 1, 2007 157port the impression that patients seeking hospital following orthognathic surgery hadorthognathic surgery are psychologically decreased significantly over a few years.stable. On the whole, the patients in this They concluded that this was due to the usestudy seemed to have had realistic expectat t of internal rigid fixation method, which, ontions. This was evident in the high degree of the other hand increases the expenses ofcorrelation between the aim of the surgery orthognathic surgery. However, there seemand the outcome that led to the satisfaction to be no comprehensive reports on the costswith the treatment. and cost factors of the whole process of In this study, focusing on the surgical orthognathic surgery.phase of orthognathic surgery, only groupfindings have been reported, and manyclinical and cephalometric factors need to Conclusionsbe considered in the future when planningtreatment for each individual patient. It may Aesthetic reasons were the primary motivebe, for instance, reasonable to provide some for seeking orthognathic surgery regardlessform of attempted growthtmodification of age or sex.treatment for those patients for whom there The degree of patients’ postoperativeis doubt about the ultimate choice of the satisfaction with the outcome of the surgerytreatment method. Orthodontic treatment correlated with the severity of their preopt tthat followed orthognathic surgery for some erative dentofacial deformities.patients in this study was not included in The postoperative improvement of fat tthis report. cial aesthetics of the patients was associated Little has been written about the costs with a similar improvement in the qualityof orthognathic surgery compared with of their lives in all the aspects tested in thisother health services in all fields. Dolan study.and White  found that the time spent in References1. Wolford L M, Fields RT. Surgical planning. 5. Drommer RB. The history of “Le Fort I oss s In: Booth PW, Schendel SA, Hausamen teotomy”. Journal of maxillofacial surgery, JE, eds. Maxillofacial surgery. London, 1986, 14:119–22. Churchill Livingstone, 1999:1205–57. 6. The need for surgical orthodontic treatss2. Proffit WR, White RP Jr. Who needs surs s ment. In: Proffit WR, White RP Jr, eds. gical orthodontic treatment? International Surgical orthodontic treatment. Mosby, St journal of adult orthodontics and orthogs s Louis, 1991:2–23. nathic surgery, 1990, 5:81–9. 7. Proffit WR, Turvey TA, Phillips C. Orthogs s3. Ong MAD. Spectrum of dentofacial defors s nathic surgery: a hierarchy of stability. mities. Annals of the Academy of Medis s International journal of adult orthodontics cine, Singapore, 2004, 33:239–42. and orthognathic surgery, 1996, 11:191– 204. 4. Steinhauser EM. Historical development of orthognathic surgery. Journal of cranios 8. Woldorf LM, Fields RT. Surgical planning. maxillosfacial surgery, 1996, 24:195–204. In: Booth PW, Schendel SA, Hausamen
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