Year : 2008 | Volume
: 19 | Issue : 1 | Page : 12--16
Self-assessment of facial form oral function and psychosocial function before and after orthognathic surgery: A retrospective study
Vinod Narayanan, Shankar Guhan, K Sreekumar, Ashok Ramadorai
Department of Oral and Maxillofacial Surgery, Saveetha University, 162, P. H. Road, Velappanchavadi, Chennai - 600 077, India
Department of Oral and Maxillofacial Surgery, Saveetha University, 162, P. H. Road, Velappanchavadi, Chennai - 600 077
Orthognathic surgery is a well-accepted treatment for patients with skeletal discrepancies. The primary motivation of many patients who seek orthognathic surgery is esthetics and not for correction of functional disability. The treatment is incomplete if the surgeon attempts to correct the physical deformity alone without adequate understanding and regard for the emotional framework. The purpose of this study is aimed at patient«SQ»s self-perceptions of facial form oral function and psychosocial function before and after orthognathic surgery. Fifty patients were included in the study, of which 21 were used as control. Twenty-two questions were asked to evaluate the problem in all four areas as mentioned earlier. Each question takes a score from one to five. In group I, the internal consistency of each scale indicates moderate to high internal reliability, ranging from α = 0.71 for general health to α = 0.88 for psychosocial problem. In group II, except for functional problems, the internal consistency of each scale has moderate to high reliability. The psychological wellbeing of an orthognathic surgery patient is enhanced by careful preoperative counseling regarding the expected surgical treatment objectives, the operative course, and the expected postoperative sequelae. Patients who undergo orthognathic surgery readily accept the changes in their postoperative appearance and are satisfied with achieved results.
|How to cite this article:|
Narayanan V, Guhan S, Sreekumar K, Ramadorai A. Self-assessment of facial form oral function and psychosocial function before and after orthognathic surgery: A retrospective study.Indian J Dent Res 2008;19:12-16
|How to cite this URL:|
Narayanan V, Guhan S, Sreekumar K, Ramadorai A. Self-assessment of facial form oral function and psychosocial function before and after orthognathic surgery: A retrospective study. Indian J Dent Res [serial online] 2008 [cited 2021 Mar 3 ];19:12-16
Available from: https://www.ijdr.in/text.asp?2008/19/1/12/38925
The human face can tell us about personal attributes, the sex, race, age, physical fitness, as well as changes in emotion and his or her self-concept. Facial anomalies may negatively affect body image and self-concept. Orthognathic surgery is well accepted for patients with skeletal discrepancies.  The goal of treatment is to maximize patient benefit, and hence the clinician must know what is really important to the patient. A clinician's effectiveness in providing the human side of treatment depends on understanding a variety of personal factors, such as personal history, family and cultural background, values, bias, attitudes, and emotional responses. Dentofacial defects are extremely prominent and, unlike other physical handicaps, cannot be easily disguised.  The primary motivation of many patients seeking orthognathic surgery is esthetics and not correction of functional disability. ,, The treatment is incomplete if the surgeon attempts to correct the physical deformity alone without adequate understanding and regard for the emotional framework. 
School is one of the stages where teachers rate attractive children more favorably, and children's preferences for each other are associated with physical attractiveness. , Legal interactions, dating, and marriage are found to be influenced by physical appearance of the involved persons. ,, Literature supports that the improvement in appearance brought about by maxillofacial surgery is associated with improvement in psychosocial adjustment.  The postoperative dissatisfaction is not necessarily related to the surgical skill of the surgeon; it results primarily from failure of communication between the surgeon and patient. , Accordingly, in order to minimize the risk of unwanted outcome and maximize the benefit of orthognathic surgery, it is important that the goals and expectations of the patient are realistic and achievable.
The purpose of this study is aimed at patient's self-perceptions of facial form, oral function and psychosocial function before and after orthognathic surgery. These values are compared with those of the non-patient controls.
Materials and Methods
The addresses of 50 patients who were operated during the period 2002-2003 were collected, and they were called for a review and for filling the questionnaire [Figure 1]. Out of 50 patients, 19 patients came in person to fill the questionnaire. For the rest of the patients, the questionnaire was sent through post. Totally 21 patients filled the questionnaire and belonged to group I category.
The control group was used to compare the patient's responses. The control group consisted of comparably aged adults who have moderate to severe skeletal deformity and were not seeking surgical correction for various reasons. Most of the patients in this group opted for orthodontics. Totally 21 patients were used as control and belonged to group II category.
Out of 21 patients in group I, 8 patients were below 20 years of age and 13 were above 20 years. In group II category, 10 patients were 20 years or below, and 11 patients were above 20 years. There are 7 male patients and 14 female patients in group I, and 11 male and 10 female patients in group II controls.
In group I, only few patients underwent presurgical orthodontics, and most of them were in post-surgical orthodontic phase. The questionnaire was designed to assess patient's perceptions of their problems in four areas (i.e., oral function, general health, appearance, and inter-personal relationships) before and after surgery. This questionnaire for this study was adapted from Prof. H. Asuman Kiyak, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA, USA.
Twenty-two questions were asked to evaluate the problem in all four areas as mentioned earlier. Each question takes a score from one to five. One denotes the more negative part and five denotes the more positive part. Key was given at the bottom of the questionnaire. The questionnaire was adapted to ask the patient to recall how he or she feels before and after orthognathic surgery.
The first stage in the statistical analysis of data was to test the internal consistency and reliability of questionnaire subscales using Cronbach's alpha.
In group I, the internal consistency of each scale indicates moderate to high internal reliability, ranging from α = 0.71 for general health to α = 0.88 for psychosocial problems, with an exception that general health score for after-surgery group was α = 0.43 [Table 1]a
In group II, except for functional problems, the internal consistency of each scale has moderate to high reliability [Table 1]b.
The mean and standard deviation were estimated from the sample for each study group. Using either Student's paired t -test or Student's independent t -test, the mean values were compared appropriately. In the present study, P et al . compared the morphology and function of patients with combined vertical maxillary excess (VME) and mandibular retrognathia with those of the controls. They confirmed that VME and retrognathic patients suffer from substantial deficiencies in their oro-motor function. 
The results from the "problems questionnaire" indicate a perceived improvement from the period before surgery to the present in all the four areas examined (oral function, health, appearance, and interpersonal relationship) [Table 2]. Kiyak et al . reported improved mastication and occlusion in patients who underwent the surgery. Most patients continued to experience minor TMJ problems long after surgery, but this did not affect their satisfaction with outcomes.  The level of satisfaction among patients was higher than the control groups. Vallino concluded in his study that there is improved sound production particularly in 's' and 'z' after surgery. Orthognathic defects do not appear to be associated with voice disorders. Orthognathic surgery does not affect voice quality or pitch.  In consideration that surgical patients start from a level lower than that of the control groups on the appearance and interpersonal subscales, the benefit of treatment on their perceptions about their psychological and physical characteristics can be clearly seen [Table 3],[Table 4]. Heldt concluded in his study that improvement in appearance was by far the most important motivating factor in patients who sought orthognathic surgery.  Even if the subjectively evaluated improvement regarding function and health is not consistent with the objective physical changes, the influence of positive thinking regarding these factors is equally important in comparing these results with that reported in the literature. We see higher levels of perceived improvement in the current patient sample. Hiyak concluded that fatigue, loss of vigor, moderate level of tension, and depression are seen immediately following surgery. Anger and hostility reaches its lowest levels in the immediate postsurgical stage and reaches its peak level after 4-6 weeks.  Kobayashi et al . evaluated masticatory efficiency spectrophotometrically. The mean masticatory efficiency of the preoperative group was approximately half that of control group, and the value for the postoperative group was slightly higher, but there was no statistical difference between the two groups. 
In group I (before treatment), patients below 20 years had more negative feeling as compared to the patients above 20 years in all problem areas. Postsurgically, both groups faired equally [Table 5],[Table 6]. Statistically, the differences were less significant. Presurgically, the male patients worried much about their appearance [Table 7],[Table 8]. Frost in his study explored the motivation levels and problems shared by adult orthognathic surgery patients over the age of 25. Women had depression more often than men but were more enthusiastic about the final results of the procedure. He concluded that patients who were more positive toward the procedure and more satisfied with the results were those who were better informed and who thought they had a good system of communication with the orthodontist, surgeon, and their respective staffs.  In group II controls, the patients between 15 and 20 years felt that they have more functional and health problems as compared with the patients above 20 years but the difference in values were insignificant. The patients above 20 years had more negative feelings about their appearance and faired less psychologically as compared with patients below the age of 20 years [Table 9]. Statistically, the value does not show any significance between male and female patients in problem areas, such as function and general health. Psychologically, females faired better than males. Male patients had more negative feelings about their appearance [Table 10].
Perceived support for patient's decision to orthognathic surgery would affect patient satisfaction or a function of whoever providing the support. Patients who were more satisfied with orthognathic surgery would perceive others to have favorable opinions of their postoperative appearance.
General support is important in the immediate postoperative period, while the reactions of significant others to the patient's postoperative appearance influence the early and late postoperative stages. Spouse and close relatives are the most critical to general support, whereas the reactions of additional subgroups, such as relatives, are significant when considering reaction to postoperative appearance. From our study, we understood that patient's mental attitude about his or her postoperative appearance may be influenced by patient's postoperative support network. Holman conducted a prospective longitudinal study to examine the relationship between interpersonal support and patient satisfaction with orthognathic surgery and found that the reactions of the patient's support group to his or her postoperative appearance was found to be highly related to the satisfaction in both the early and late postoperative stages.  Flanony in her study reported that the leading factor in patient dissatisfaction with surgery is the patient's experience of postoperative "surprises". 
In this study, significant self-concept and personality improvements have been found in almost all personality dimensions assessed. Hunt, in all his studies, reported that orthognathic patients experience psychosocial benefits as a result of orthognathic surgery, including improved self-confidence, body and facial image, and social adjustment.  Terzoudi concludes that orthognathic surgery resulted in the subjective estimation of function, appearance, health and interpersonal relationship that was higher than that among pretreatment and non-treatment control groups. 
The findings of this study were also supported by Hutton, Kiyak, Crowell and Laufer. , They found that a majority of patients have good chance in developing personality, self-confidence, boldness, self-consciousness and had improved relationship with opposite sex postsurgically. Modiq et al . conclude that patients' perceptions after orthognathic operations were generally favorable, but there is a need for improved information to patients during the treatment. 
The psychological wellbeing of the orthognathic surgery patients is enhanced by careful preoperative counseling regarding the expected treatment objectives, the operative course, and the expected postoperative sequelae. Informed postoperative psychological and emotional support, if required, generally leads to a satisfactory result for most patients.
Most of the patients who undergo orthognathic surgery readily accept changes in their postoperative appearance and are satisfied with the achieved results. Although most patients report satisfaction with treatment results, unexpected psychological experiences can occur, and further research is required to gain additional insight into this complex area.
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