Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities

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Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities

Individuals who present with dentofacial deformities do not comprise a monolithic group. They may arrive for evaluation during childhood, adolescence, early adulthood, or it may be later in life. The etiology of the jaw deformity may be congenital, developmental, or posttraumatic, or it may have occurred after tumor resection that required radiation therapy. A combination of orthodontic treatment and orthognathic surgery—often in conjunction with additional dental rehabilitation—may be required to correct the skeletal deformities, to improve head and neck function (i.e., chewing, breathing, speech, swallowing, lip control), to enhance facial aesthetics, and to restore the dentition.

The initial discussion regarding the need for orthognathic surgery may come as a surprise to the patient and his or her family. This is especially true for the individual whose jaw dysmorphology occurred gradually during facial development, without special attention being drawn to it all of a sudden as would occur from a traumatic event, a birth defect, or after tumor resection.9,10,37,68,71,80,81,101,103 Although they have typically been aware of the malocclusion and the associated facial characteristics for at least several years, the patient and his or her family generally assume that orthodontics alone or some other minimally invasive approach is all that will be required for treatment.87 The orthodontist may have already exhausted the patient and his or her family’s energy and resources with several years of treatment to “avoid surgery” before finally “giving up.” The family may have inaccurate preconceived ideas about the surgery and the patient’s expected convalescence. The decision-making role of the parents and the compliance (i.e., the attitude) of the adolescent patient will also be important. Any dysfunctional family interactions involving the mother, the father, the patient, or the patient’s siblings, stepparents, or grandparents at this moment of stress (i.e., when a decision is needed) may also come into play. From the adolescent’s point of view, social interactions with his or her peers and concerns about the interpretation (by others) of any change in his or her appearance—as well as his or her evolving self-image and identity—will also have an impact on the situation in ways that are ongoing and somewhat unpredictable.

Frequently, the treating clinicians (i.e., the surgeon, the orthodontist, the restorative dentist, and the general physician) judge success or failure according to specific anatomic or numeric benchmarks, such as achieving a Class I occlusion, normative cephalometric radiographic measurements, and successful wound healing. Although patients and their families do consider stable occlusion and a lack of wound healing complications to be important aspects of success, there are likely to be other motives and objectives that cannot be overlooked if patient satisfaction is to be achieved. It is not uncommon for an orthognathic surgical result to be labeled as suboptimal by the surgeon, the orthodontist, or the restorative dentist as a result of an imperfect occlusion, whereas the patient’s satisfaction rating will be more favorable. It is just as likely that the treating clinicians may feel that a successful outcome has been achieved (i.e., satisfactory occlusion and uncomplicated wound healing), whereas the patient may feel that the aesthetic objectives have not been fully met.

Research confirms a correlation between an adolescent’s self-reporting of improved appearance ratings and a decrease in social, physical, and psychological problems after successful reconstruction.58,67,73,78 Patel and Kapp-Simon prospectively studied 70 teenagers who were slated to undergo orthognathic surgery.69 Before surgery, 78% stated that a functional reason was their primary motivation for undergoing orthognathic surgery. Not surprisingly, before surgery, the adolescents rated their appearance significantly less favorable than their parents did. Two years after surgery, the adolescents reported significantly increased self-confidence, and a majority (58%) felt that they had achieved improvements in their facial appearance as a result of surgery. They stated that improvements in their facial appearance would be a motivating factor for them to undergo similar surgery again. It would appear that, when all is said and done, adolescents—like adults—rate the enhancement of their facial appearance as a high priority when measuring the success or failure of their orthognathic procedures. Experience confirms it is better to openly discuss facial aesthetic aspects before surgery. This encourages the clinician to set realistic objectives, and it forces the patient and the family to confront their outcome expectations in advance.

Both adolescents and adults undergoing orthognathic surgery should be screened to assess emotional baseline functioning as well as psychological readiness for surgery. The pre-surgical mental health screening should clarify any past or current symptoms of depression, anxiety disorders, panic attacks, aggression, drug/alcohol use, eating disorders, school-related problems, family or social (peer) dysfunctional relationships.4

Psychosocial Aspects to Consider Before Surgery

Personal Motivation

The individual’s personal motivation to seek the correction of a dentofacial deformity is an important factor for clinicians to consider (Figs. 7-1 through 7-5).* In 2000, Rivera and colleagues surveyed 142 patients regarding their reasons for choosing to undergo orthognathic surgery.86 Seventy-one percent indicated facial aesthetic concerns, 47% stated functional issues, and 28% confirmed temporomandibular disorders as their reasons for seeking treatment. In 2007, Narayanan and colleagues surveyed 50 patients who sought orthognathic surgery and found that, for the majority, facial aesthetics rather than the correction of their occlusions was the primary motivating factor.59 In 2007, Stirling and colleagues conducted a questionnaire and interview survey of individuals who had undergone orthognathic surgery. The 46 interviewed patients stated that their primary motivations generally included both “improvement of the occlusion and to gain a more normal facial appearance.”97 More recently, Proothi, Drew, and Sachs completed a retrospective survey of 501 individuals who underwent orthognathic surgery to determine why they sought the procedures.83 The survey group was 43% male and 57% female, and the individuals ranged in age from 12 to 45 years. Seventy-six percent stated that facial appearance was negatively affected by their pretreatment jaw condition, but only 15% claimed that their appearance was their primary motivation for undergoing surgical evaluation. Thirty-six percent stated that their occlusion was the primary motivating force. Interestingly, 33% admitted to having significant speech difficulties, and 15% complained of swallowing problems that resulted from their presenting jaw deformity.

All adolescents more or less struggle with issues related to self-identity, social acceptance, and physical appearance. The added factor of a dentofacial deformity with impaired head and neck function and negative effects on physical appearance—coupled with the need to make a decision for or against surgical correction—may compound these psychological issues. If the individual already has baseline depression, anxiety, poor self-confidence, or other social issues, the presence of a dentofacial deformity with the need for surgical correction is likely to exacerbate these symptoms. The extent to which an exacerbation of baseline symptoms occurs may depend on how much the lack of self-confidence and social problems relate to the dentofacial deformity.

A typical sequence of events is a pre-adolescent individual being referred by his or her general dentist to an orthodontist for the correction of a malocclusion. The orthodontist may have then attempted growth-modification techniques followed by a camouflage approach to “improve” the occlusion for a period of time that ranges from 2 to 8 years before finally “giving up” and suggesting a surgical referral. The adolescent and his or her family may also have pushed for a surgical referral in response to concerns about facial aesthetics and a lack of progress with regard to the full correction of the malocclusion by the orthodontist who initially felt that he or she could solve the problem with orthodontics alone. With today’s evidence-based thinking, knowledgeable clinicians should recognize the need for a surgical approach from the outset.

The adolescent and his or her parents’ motivation for correction may be clearly stated to the surgeon at the initial introduction, or it may be only indirectly discussed. The patients’ and their families’ perceptions of the surgical outcomes will be important to achieving a smooth recovery and a favorable outcome. The results—both functional and aesthetic—should be clearly and realistically articulated by the surgeon, openly discussed, and agreed to by all parties before proceeding.

Baseline Mental Health

Individuals who do not have sufficient preoperative psychological or emotional stability are more likely to experience depression, anxiety, or panic attacks and to demonstrate difficulty complying with treatment demands during the early postoperative phase.16,17,21,27 They will also have greater difficulty with an outcome that does not meet their preconceived and often incompletely articulated expectations. If so, after surgery, they may become easily frustrated and then angry, and this may involve a loss of confidence in the surgeon. They may break off communication and seek additional opinions to justify their concerns. Some may even resort to litigation should a perceived complication or suboptimal outcome occur. Recognizing and addressing these patient-specific tendencies before surgery is the best way to limit or mitigate problems after surgery.

After an initial screening examination, a more in-depth psychological evaluation may be beneficial.8,18,24,96 The patient and his or her family’s motivation and the patient’s readiness for surgery should also be assessed. Unless a sufficient support system is in place, the stress of the necessary convalescence is likely to worsen any premorbid conditions in the patient. An initial screening that results in red flags for potential emotional problems is best followed up with a more focused psychological evaluation. The patient’s therapist should give clearance that the individual is considered emotionally stable enough to undergo the proposed treatment. When the treating clinicians (i.e., the surgeon, the orthodontist, and the general physician) have knowledge of the patient’s premorbid tendencies, coping strategies can be instituted proactively to minimize postoperative stress. The treating mental health professional should be available to the patient, the family, and the surgical team during hospitalization, after discharge, and throughout the patient’s convalescence.

Baseline Eating Disorders

Clinical studies indicate that between 0.5% and 1.0% of late adolescent and young adult women meet the criteria for anorexia nervosa, and between 1% and 3% meet the criteria for bulimia nervosa.92 Eating disorders are multi-determined problems, and they are most commonly recognized among female adolescents. Risk factors may include a perfectionist personality type, a family history of an eating disorder, a history of trauma, a tendency toward feelings of inadequacy, and low self-esteem despite external accomplishments. Patients with eating disorders often exhibit rigid cognitive patterns that are characterized by an all-or-nothing way of thinking.

Orthognathic procedures will significantly alter the diet (i.e., liquids only) and appetite level, with an expected change in nutritional intake for at least 5 weeks. Significant weight loss during the initial 2 weeks of recovery is to be expected, even among healthy individuals. The question is raised as to whether or not these dietary and postsurgical metabolic changes will tend to exacerbate a baseline eating disorder. Maine and Goldberg completed a study to determine if an elective dental manipulation—which, by necessity, results in eating discomfort and dietary restrictions—would likely influence the recovery of or result in a relapse for an individual with a baseline eating disorder.54 Three questions concerning dental and maxillofacial procedures were added to a standard questionnaire assessment of a consecutive series of 97 individuals who were entering an eating disorder therapy program. The additional questions were designed to determine the influence of dental and maxillofacial interventions on individuals with baseline eating disorders. All 97 study subjects complied with the questionnaire; 75 of the study patients were 25 years old or younger, and 53 were diagnosed with anorexia nervosa.

Interestingly, 9.3% of the study patients who had undergone either significant orthodontic therapy or the removal of the wisdom teeth in the past indicated that the dental procedure—which, by necessity, caused eating discomfort and diet alterations—had either exacerbated or resulted in a relapse of their baseline eating disorders. This study confirms that a history of an eating disorder should alert the orthodontist and the orthognathic surgeon to potential postoperative difficulties. With an awareness of the individual’s baseline conditions, the orthodontist, the surgeon, the primary care physician, and members of the psychosocial team may establish guidelines for postoperative behavioral and nutritional objectives to closely monitor to ensure a smooth recovery.

Social Interaction Issues

Ongoing family or social peer conflicts or greater-than-average worries expressed by the individual or his or her family regarding the surgery, the preparation for the surgery, or the anticipated recovery period are red flags.1,29,33,41 When considering the timing of surgery for the adolescent or young adult, the family should take into account the anticipated impact on the patient’s everyday school and social activities, including examination schedules, college applications and interviews, and participation in sports activities. The surgeon’s ability to provide a clear picture of the expected recovery time and the patient’s ability to return to partial and regular activities is important and will vary according to the patient’s age and stage in life (e.g., adolescent, college or graduate student, middle-aged adult with family and work commitments). Clarifying anticipated postoperative limitations in physical, cognitive, and emotional activities is important to setting the stage for a successful outcome.

Body Dysmorphic Disorder

It is estimated that more than 5% of individuals who are seeking cosmetic surgery consults have body dysmorphic disorder (BDD).14,19,65,91 BDD is a somatoform disorder that involves a preoccupation with a slight or imagined defect in some aspect of the individual’s physical appearance that leads to a significant disruption of daily functions. It is important to distinguish an individual with a legitimate cosmetic or functional concern from one who is hyperconcerned about minor imperfections of some aspect of his or her face.

Cunningham and colleagues documented that a percentage of individuals who request orthognathic surgery will have underlying BDD.19 A surgical procedure to improve facial aesthetics typically does not change or fully satisfy the appearance concerns of these individuals. Orthognathic procedures may even exacerbate these symptoms, despite the clinician’s accurate assessment of the presenting deformity and the likelihood of the achievement of a favorable morphologic and functional result. No matter how skilled the surgeon and how perfect the end result, dissatisfaction should be expected when treating a patient with BDD; therefore, surgery should be avoided unless extensive counseling is performed before the proposed procedure. The development of an effective psychosocial screening interview method or the use of a self-reporting assessment survey to help identify individuals with BDD is needed in clinical practice.

Psychological Functioning in the Individual With a Facial Deformity

A spectrum of studies report that individuals with facial deformities have a higher prevalence of psychological problems that may interfere with the ability of these individuals to function socially. The psychological problems described include (1) a reduced quality of life; (2) a tendency to internalize behavior; (3) low self-esteem; (4) an increased tendency toward depression; and (5) anxiety.13,100 Interestingly, studies confirm that it is the patient’s satisfaction with his or her own appearance rather than an objective standard of the severity of the deformity that influences these psychological problems. The individual’s personal dissatisfaction with his or her facial appearance seems to be a better predictor of higher rates of anxiety and depression and lower rates of favorable quality of life and self-esteem as compared with the clinician’s impression of how the individual looks.

Versnel and colleagues conducted research that involved adults with facial disfigurement and confirmed that a subset of these individuals demonstrated psychological dysfunctions: 11% had anxiety; 6% had depression; 10% had externalized problems; and 25% had a tendency to internalize problems.100 The authors clarified that either an actual or a perceived facial deformity can be a significant stressor in life to which the affected individual must adapt.13,55,72,84,89,93 The study also looked at differences between congenital and acquired facial deformities. Many of the study patients that acquired their facial deformities later in life (i.e., those that were related to trauma or tumors) had a more difficult time, which implied that a significant percentage of those with congenital conditions had eventually adapted to their physical problems. The authors surmised that, because the congenital patients had no knowledge of how life would have been without facial disfigurement, their adaptation was different and often more complete.

An individual’s fear of a negative facial appearance evaluation by others during their everyday life is considered a good predictor of psychological functioning. Therefore, psychological support for the individual with either an obvious facial deformity that cannot be further improved or a perceived facial disfigurement should focus on educating the individual to rely less on the opinions of others. From another perspective, surgery carried out for the purpose of enhancing facial appearance must reach or at least approximate the individual’s self-perceived expectations. This is the reason why surgery to improve facial aesthetics in the individual with BDD will not result in patient satisfaction; the unrealistic expectations of these patients can never be fully reached.

Patient and Family Decision for or Against the Correction of a Dentofacial Deformity

The patient and the family members or significant others that comprise his or her immediate social network need a clear and consistent explanation of the following:

• The surgical objectives, anticipated treatment outcomes, and limitations with regard to predicting exact results

• How the surgery will fit in with the overall treatment plan (e.g., orthodontics, dental rehabilitation, speech therapy, airway management)

• The potential risks, complications, and limitations of each planned procedure

• What to expect during hospitalization (e.g., discomfort, swelling, hygiene needs, limitations in activity and diet, limitations in mouth opening and lip seal control, difficulties with speech and communication)

• What to expect after discharge from the hospital (i.e., ongoing convalescence needs)

• What the patient and the family must do to maximize a favorable outcome

• When the patient can expect to resume a more normal routine

• The expected time required for full healing

Information should be provided in a number of different ways, which may include (1) verbal discussion; (2) a demonstration of surgical technique on a model skull; (3) showing similar patients’ before and after photographs to demonstrate the potential range of results; (4) reviewing and discussing the patient’s own photographs, dental models, and radiographs; and (5) providing reinforcement with detailed and readable written material.32,66 The option of discussing details with another patient of the same approximate age and sex who has undergone similar surgery may also be helpful.

Patient and Family Education Regarding Convalescence After Orthognathic Surgery

Early after surgery, while in hospital, the individual who (1) appears to be more irritable and non-communicative; (2) complains of greater-than-expected levels of pain with demands for continued narcotics; and (3) is having more-than-average difficulty complying with personal care needs (i.e., achieving hydration and caloric requirements, oral and body hygiene requirements, and adequate ambulation) may be a candidate for a demanding convalescence.77,79 The adolescent may comply just enough (e.g., ambulation, fluid intake) to get out of the hospital. After he or she gets home, unless the parents are able to remain firm concerning patient care needs, the adolescent’s feeling of self-consciousness or uncertainty about temporary levels of facial swelling, drooling, loss of appetite, and difficulty with breathing and speech can lead to further social withdrawal and non-compliance. This may also lead to overreliance on narcotic medication with the assumption that pain is the problem. Unless this type of patient is closely monitored, dehydration, hypoglycemia, and depression will set in. Even if this phase of convalescence is managed, some adolescents express unwillingness to return to school within the expected time frame as a result of concern about the reactions of their peers. Many will lose this reluctance when a friend is invited to their home to break the ice. As the recovering patient perceives positive affirmation from their family and friends regarding the changes brought about by surgery, their social hesitation generally subsides.

The clinicians (i.e., the surgeon, the orthodontist, and the treating dentist) often judge success on the basis of measurable standards of (1) an “improved” profile; (2) achieving normative cephalometric radiograph measurements; (3) a corrected occlusion; and (4) achieving specific wound-healing parameters. Discussions with the patient and family should not overlook psychosocial aspects. Individuals with baseline evidence of mental health issues are likely to have a greater-than-average need for positive reinforcement, and they may also require more formal psychological support throughout the perioperative process. The success of treatment should not be thought of solely in terms of improving head and neck function or the achievement of strict numerical parameters. The potential for orthognathic procedures to have profound effects on the individual’s psychosocial health—whether positive or negative—should not be underestimated (see Figs. 7-1 through 7-5). During convalescence and after the return to school or work, the clinician should ask the patient about his or her interactions with others regarding the recent surgery to determine if a more in-depth discussion is required.

Patient-Centered Assessment of Surgical and Orthodontic Outcomes

Many public health experts believe that the ultimate determination of a treatment’s quality and success is its effectiveness for producing not just physical health as judged by clinicians but also for resulting in the individual’s personal satisfaction.5,22,23,38,44,45,51,56,57,59,82,94,95,98 Traditional surgical outcome measurements such as mortality and improvement in physiologic parameters (e.g., blood pressure) find limited application in the treatment of dentofacial deformities. At the same time, traditional orthodontic parameters of accomplishing specific change in millimeter distances or degrees of angulation at standard anatomic sites do not necessarily correlate with patient satisfaction. Despite the importance of satisfaction as a proxy for quality, the concept of patient-perceived well-being can be difficult to define. When developing a patient questionnaire for use as a self-administered survey after orthognathic surgery, consideration should be given to the features of care that influence the patient’s satisfaction. These features may be categorized into one of the following domains: (1) aesthetic outcomes; (2) functional outcomes; or (3) psychological outcomes. A review of the literature concerning patient-centered outcome assessments after orthognathic surgery sheds light on the issue of how to achieve patient-based satisfaction after treatment.

Orthognathic Surgery and Health-Related Quality of Life: Review of Study

Posnick and colleagues reported on data from a health-related quality-of-life survey that was completed postoperatively by a consecutive series of patients who had undergone bimaxillary orthognathic surgery in combination with intranasal and other adjunctive procedures. The survey was filled out by each study patient only after recovery from surgery and after all orthodontic therapy and dental rehabilitation was complete (i.e., a minimum of 6 months after surgery).82

A postsurgical patient satisfaction questionnaire was designed by the authors to assess each patient’s overall satisfaction with the procedures that he or she underwent, patient-perceived functional improvements, and patient-perceived negative effects. The self-assessment survey was mailed to a consecutive series of 42 individuals who underwent bimaxillary orthognathic surgery (i.e., Le Fort I osteotomy and sagittal split ramus osteotomies of the mandible) in combination with intranasal (i.e., septoplasty and inferior turbinate reduction) and other patient-specific procedures by a single surgeon (Posnick) at one institution during a 12-month time frame. Patients who underwent orthognathic surgery for the correction of a syndrome, a cleft, or a posttraumatic deformity during the same time frame were excluded from the study. The study group included 15 males and 27 females. The mean age was 25 years, and patient ages ranged from 15 to 55 years. Seven of the 42 patients were less than 18 years old: four were 15 years old, 1 was 16 years old, and two were 17 years old. The most frequent pattern of jaw deformity that was identified in the study group was a long face growth pattern (17 out of 42 patients [40%]), which was characterized as vertical maxillary excess combined with mandibular deficiency. This was followed by primary mandibular deficiency (9 out of 42 patients [21%]). Simultaneous maxillofacial procedures that were completed in addition to those listed previously varied in accordance with patient-specific needs. Thirty-eight percent of the patients (16 out of 42) underwent the simultaneous removal of wisdom teeth. Seventeen percent of the patients (7 out of 42) also underwent suction-assisted lipectomy of the neck. Eighty-six percent of the patients (36 out of 42) underwent osseous genioplasty. The postsurgical patient satisfaction questionnaire made use of a 7-point Likert scale for the respondents to rate their levels of satisfaction or acceptance for each of nine questions that were asked.

To assess overall patient satisfaction three questions were asked. The first question was phrased as follows: “If you had to make the decision again, how likely would you be to undergo this same surgery?” Eighty-three percent (35 out of 42 patients) responded positively to this question; 12% (5 out of 42 patients) were neutral, and 5% (2 out of 42 patients) reported that they would not have undergone orthognathic surgery if they had to do it all over again. The second question was written as follows: “How likely would you be to recommend the same surgery to others?” Two individuals (5%) stated that they would not recommend the same surgery to others. One of the 42 patients (2%) was neutral, whereas 93% of the patients (39 out of 42) stated that they would recommend the same surgery to others. The patients were then asked the following question: “Considering everything, how satisfied are you now with the results of surgery?” Eighty-eight percent (37 out of 42 patients) were satisfied; 1 patient (2%) was neutral, and 4 patients (10%) had at least some degree of uncertainty. These results showed that more than 70% of subjects gave a positive response to all three global satisfaction questions. According to the survey, only 2 out of the 42 consecutive patients (5%) who were treated were dissatisfied (i.e., they answered negatively to all three global satisfaction questions). Interestingly, one of the two dissatisfied patients was judged by the three treating clinicians (i.e., the surgeon, the orthodontist, and the restorative dentist) to have a satisfactory result (i.e., an acceptable occlusion, an improved upper airway, and enhanced facial aesthetics). The second dissatisfied patient developed idiopathic condylar resorption approximately 3 months after surgery, with a resulting residual malocclusion.

The Pearson correlation coefficient highlights several points related to this study group. The global satisfaction questions within the survey (question nos. 1, 2, and 3) all correlate highly with each other. Of the three global satisfaction questions asked, question no. 3 correlates closest with the specific head and neck function questions (question nos. 4 through 9). Of the specific function questions that were asked (question nos. 4 through 9), the perceived residual lip and chin region numbness (question no. 9) had the weakest correlation with overall patient satisfaction. In other words, most individuals were overall satisfied with the results of their orthodontics and orthognathic procedures, despite the fact that they would have preferred a greater return of lip and chin region sensation.

The following question was also asked: “Overall, how satisfied are you with your current bite?” At the completion of treatment, 5 out of 42 patients (12%) were not entirely satisfied with their occlusion, whereas 2% (1 out of 42 patients) gave a neutral response to this question. The majority of patients (36 out of 42 [86%]) expressed satisfaction with their occlusal result after the completion of treatment.

Speech articulation issues are not generally considered a major factor in a patient’s decision to undergo jaw surgery. The following question about this issue was asked: “Overall, how satisfied are you with your current speech articulation?” The data suggests that 34 out of 42 patients (80%) were satisfied with their postoperative speech articulation. Nine percent (4 out of 42 patients) had no strong feelings, whereas 4 out of 42 patients (9%) were not completely satisfied with their speech at the completion of treatment.

Patients in this study group were also asked the following: “Overall, how satisfied are you with your current lip posture and lip closure?” Eighty-six percent (36 out of 42) of the patients were satisfied with static lip posture and their ability to actively close their lips. Twelve percent (5 out of 42 patients) were not entirely satisfied; they apparently felt that their ability to control their lips was not completely normal.

The patients were then asked this question: “Overall, how satisfied are you with your current breathing?” Eighty-one percent (38 out of 42 patients) were overall satisfied with their breathing after treatment. Five percent (2 out of 42) were neutral with regard to their assessment of their own breathing, whereas 2 out of 42 patients (5%) remained dissatisfied with at least some aspects of their breathing.

Each patient was asked the following question: “Overall, how accepting are you with your current level of TMJ [temporomandibular joint] function/facial pain?” Eighty-eight percent (37 out of 42 patients) were accepting of their current TMJ function and of any degree of facial pain that they may have. Five percent (2 out of 42 patients) were neutral about this issue, whereas 3 out of 42 patients (7%) were not completely accepting of their level of TMJ dysfunction or facial pain after treatment.

Patients were asked to respond to the following question: “Overall, how accepting are you with your current level of lower lip/chin sensation?” This question registered the highest level of patient dissatisfaction. Twenty-one percent of patients (9 out of 42) wished that their postsurgical sensory loss was not as much. Twenty-four percent of patients (10 out of 42) were neutral on this issue, whereas 23 out of 42 (55%) were accepting of their level of lower lip and chin region sensory return after treatment.

Controversies Surrounding “Successful” Orthognathic Outcomes

Interestingly, although 5 out of 42 (12%) of the patients studied by Posnick and colleagues were not completely satisfied with their occlusions, only 2 out of 42 (5%) of the patients were dissatisfied with the overall experience of having undergone the orthognathic procedures and the orthodontic treatment. Therefore, it is apparent that the occlusion achieved is not the only and not even the most important factor when a patient is judging surgical success or failure. Posnick’s study group data also showed that, despite the fact that 21% (9 out of 42) of the patients were not entirely comfortable with the degree of sensory return to the lower lip and chin region, only 5% (2 out of 42) were dissatisfied with the postoperative surgical results overall.

Not surprisingly, orthognathic surgery patients’ self-verification needs (i.e., the need to feel accepted) are generally an important factor in their judgment of successful treatment. This need cannot be overlooked if a favorable result is to be achieved.* For example, patients who undergo orthognathic procedures may expect to draw attention to their new appearance. If orthodontic treatment and orthognathic surgery result in positive and praising feedback from those in their social circles, self-verification is fulfilled, and they are likely to be satisfied. Some orthognathic patients may have realistic expectations but do not have a supportive social network of family and friends to fulfill their self-verification needs. Negative appearance–related commentary (e.g., teasing by peers at school, or more subtle forms of negative feedback by adults) has been shown to significantly affect body image and psychosocial functioning after surgery. If the comments of others are not positive or do not meet personal expectations (which can be unrealistically high), self-verification needs are not fulfilled, and the patient is likely to be dissatisfied. One concrete self-verification need after orthognathic surgery is a “normal” occlusion. The feedback that an individual receives from his or her treating clinicians (i.e., the orthodontist, the restorative dentist, and the surgeon) about his or her occlusion would be expected to influence that individual’s level of satisfaction.

Kiyak and colleagues completed a study that evaluated the psychological changes in patients who were undergoing orthognathic surgery.46–51 They used a standardized questionnaire before and at intervals that extended for 2 years after surgery. The data for all six measurement periods (2 weeks preoperatively, in the hospital, and 2 weeks, 4 months, 8 months, and 2 years postoperatively) were available for 46 patients. Several important findings from this research included the following:

1. Complaints of functional head and neck problems decreased significantly from before surgery to 24 months after surgery.

2. A significant percentage of patients (49%) continued to report lip paresthesia 2 years after surgery.

3. The incidence of early postsurgical problems or complaints (i.e., at 2 weeks) had no consistent effect on the satisfaction expressed with longer-term surgical outcomes (i.e., at 2 years).

4. The satisfaction expressed by patients with surgical outcomes at 4 months remained high throughout the postoperative course (i.e., at 2 years).

5. Self-esteem appeared to rise in anticipation of surgery (i.e., at 2 weeks preoperatively) but to decline at 8 months after surgery. The patients’ self-esteem then rose again as documented at 24 months after surgery. Interestingly, on average, self-esteem never reached the high expectations of the surgical outcome that the patients had expressed at 2 weeks before surgery.

6. Body image showed a decline at 9 months after surgery as compared with its highest point. Fortunately, the overall body image at 2 years after surgery was significantly more positive than it was at 2 weeks before surgery.

On the basis of this data, Kiyak’s group suggests that, if feasible, clinicians should maintain periodic contact with their orthognathic surgery patients for at least 2 years after surgery.46–51 Although clinician interactions with the patient immediately after surgery generally fall to the surgeon (i.e., at 0 to 5 weeks), during the intermediate stage after surgery (i.e., 1 to 12 months), clinician feedback primarily falls to the orthodontist and the general dentist. According to the study, at 6 to 12 months after surgery, psychological unevenness for the patient is not uncommon. The patient and the orthodontist may experience conflict regarding the importance of “finishing the bite” and the timing of the completion of treatment. The patient may become adamant that the braces be removed for a specific social event (e.g., graduation, yearbook photographs), whereas the orthodontist may wish to continue detailing the bite. The orthodontist may focus on dental aspects that are considered to be of less immediate importance from the patient’s perspective. At the same time, the patient may have concern about persistent paresthesia (i.e., of the inferior alveolar and infraorbital nerves) and whether this is a complication or an expected consequence of the jaw surgery. If accurate information was given before surgery and if the lines of communication remain open between the patient and the surgeon, a favorable resolution of this issue is likely. The orthodontist should be aware of the expected progression of sensory recovery and suggest a return visit to the surgeon if he or she perceives a potential conflict. If instead the orthodontist, the restorative dentist, or the office personnel (e.g., the hygienist, the dental assistant) make off-the-cuff disparaging remarks about the patient’s facial aesthetics, occlusion, or incomplete facial sensory return, then the patient may assume the worst.

At the conclusion of their study (i.e., 24 months after surgery), Kiyak and colleagues found that a majority of patients had achieved their personal dental (occlusal) or jaw function objectives.46–51 Nevertheless, a minority of the subjects continued to have lingering concerns. If the patient perceived that the facial aesthetic improvements did meet his or her personal expectations, then overall satisfaction was high, regardless of any residual functional complaints (e.g., paresthesia, dysesthesia, temporomandibular disorder, occlusal imperfection). The majority of the orthognathic patients in the study by Kiyak and colleagues did in fact perceive facial aesthetic improvements and were therefore pleased.

The authors made several suggestions. First, it is helpful to prepare patients thoroughly before surgery and to explain not just the temporary functional impairment that they will experience soon after surgery but also the psychological changes toward themselves and toward others that are to be expected throughout recovery. Second, it is important to emphasize that these changes will likely continue to evolve for as long as 2 years after surgery. Third, if the patient is unprepared for the anticipated facial aesthetic changes, then dissatisfaction is also more likely. For these reasons, both the surgeon and the orthodontist should maintain open lines of communication with the patient and each other long after primary skeletal healing has occurred. Anticipating the persistence of lower lip and chin paresthesia as a consequence of the mandibular osteotomies should be communicated clearly during the preoperative discussion and then reinforced at several postoperative intervals.

Lee and colleagues completed a study to evaluate the patient-centered assessment of health at 6 weeks and then 6 months after orthognathic surgery.53 Their 36 study patients were evaluated at intervals that included baseline/presurgery; 6 weeks postoperatively; and 6 months postoperatively. A standardized health-related survey was given at each time interval. The results of this study demonstrated a significant deterioration in both the physical and mental health of the patients soon after surgery (at 6 weeks) as compared with baseline. This matches the expected signs and symptoms that are typically observed soon after surgery. At 6 months after surgery, there was a statistical return to baseline levels in combination with significant improvements in several of the parameters that were measured. The authors concluded that significant positive changes in quality of life occurred after orthognathic surgery in the majority of patients when their healing was complete. There was a marked but transient deterioration in many aspects related to physical and emotional well-being during the early postoperative period (i.e., the first 6 weeks after surgery). This was followed by significant improvements that were documented by 6 months after surgery.

In a discussion of their results, Lee and colleagues stated that patients who report unexpected negative effects after surgery are more likely to be dissatisfied with their overall treatment. Soon after surgery, Lee’s group documented difficulties with the orthognathic patient’s ability to carry out daily physical activities, work performance, and social activities with friends and family. Patients experienced moderate degrees of pain, tiredness or lack of energy, and emotional impairment during the early recovery period. All of these changes are predictable and temporary, and they should be explained to the patient and the patient’s family before surgery and then reinforced during the postoperative visits. It was found that, even during the early recovery period (i.e., the initial 6 weeks), as long as reasonable preoperative education was provided, there is generally improvement in the patient’s psychological status. The authors believe that this is a reflection of the patient’s perceived improvements in both occlusion and facial appearance meeting his or her personal expectations despite difficulties experienced as part of the normal healing process. By 6 months after orthognathic surgery, there was a trend toward further improvements in emotional well-being. By then, the overall study group consciously experienced marked improvements in facial aesthetics, oral and jaw function, and social abilities.

Conclusions

A review of the literature regarding patient satisfaction after orthognathic surgery confirms the need for the following: (1) careful preoperative patient selection; (2) clear communication of realistic and agreed-upon objectives; and (3) including the family or the immediate social network and all collaborating clinicians in the process. Although the majority of patients and their families will be pleased with the results that are achieved, a small percentage will be dissatisfied, despite the clinician’s perception that the results achieved were at least an improvement and even when no specific complications occurred. In addition, as with any form of treatment or surgery, complications may occur despite the best of care. Until the science of patient selection parallels clinical realities, anticipating a small percentage of dissatisfied patients and families remains the norm. The meticulous documentation of the interactions between the patient and the doctor as well as the maintenance of open lines of communication between the patient and all treating clinicians beyond the initial healing period remain essential components of patient management when performing orthognathic procedures.

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