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Quality of life assessment in patients with dentofacial deformity undergoing orthognathic surgery—A systematic review
Int. J. Oral Maxillofac. Surg. 2013; 42: 974–980 http://dx.doi.org/10.1016/j.ijom.2013.03.023, available online at http://www.sciencedirect.com
Systematic Review Orthognathic Surgery
Quality of life assessment in patients with dentofacial deformity undergoing orthognathic surgery—A systematic review
C. L. Soh, V. Narayanan Saveetha University, Vellappanchavadi, Chennai, India
C. L. Soh, V. Narayanan: Quality of life assessment in patients with dentofacial deformity undergoing orthognathic surgery—A systematic review. Int. J. Oral Maxillofac. Surg. 2013; 42: 974–980. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of this systematic review was to evaluate the benefits of orthognathic surgery to quality of life, the different motivations and perceptions of patients towards orthognathic surgery, and the various methods that have been used to analyze these changes, in patients who undergo orthognathic surgery for dentofacial deformities. A review of the literature was carried out, and articles published from 2001 to June of 2012 that satisfied the inclusion criteria were included in the review. A total of 21 articles were included. The results indicate that orthognathic patients experience an improvement in quality of life after surgery. Each individual patient has different motivations and expectations from the treatment. Also the use of validated instruments helped in quantifying results. Further research should be aimed at higher levels of evidence in study design, quantifying the changes for different types of dentofacial deformities and surgeries, and have a longer follow-up duration.
Introduction
Patients with dentofacial deformities are at a disadvantage in society due to low self-esteem and decreased levels of confidence, as well as associated physiological problems. Indeed such deformities interfere not only with oral health and function, but also adversely affect mental well-being, thus affecting the entire spectrum that constitutes quality of life. 0901-5027/080974 + 07 $36.00/0
Orthognathic surgery is recognized as the mainstay of treatment for dentofacial deformities. While most published articles have placed an emphasis on the techniques for performing such surgeries, it is also necessary to give importance to the effects of such surgical interventions on the psyche of the patient. Over the years, research has shown that most patients desire correction of dentofacial deformities to improve the aesthetics of the facial and
Key words: orthognathic surgery; dentofacial deformity; quality of life. Accepted for publication 6 March 2013 Available online 21 May 2013
dental components.1 There are also certain studies that have reported the primary motivation to be bite function rather than appearance.2,3 As such interventions affect the patient’s appearance directly over an almost immediate period of time, it is also of paramount importance to quantify the psychological impact of the surgery. The earliest reports of patient satisfaction4 indicated good responses to orthognathic
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Quality of life assessment in orthognathic surgery surgery, and this has since been substantiated by other authors.5–10 However the lack of comparable quantifiable data to denote the extent of improvement has been one of the shortcomings in the past literature. This has mainly been due to the lack of consensus among the various scales and tools used to measure such a change. The onus is now not only on treating the aesthetic component of dentofacial deformity, but also on restoring the patient’s psychosocial component as well. It is easy to assume that the two go hand in hand, but the motivations, perceptions, and expectations of the individual play a significant role in determining not only the surgical success, but also the psychosocial success; all of these contribute to the overall quality of life of the individual. Thus the aim of this systematic review was to evaluate the motivations and perceptions of patients and the benefits of orthognathic surgery to quality of life, as well as the various methods and tools that have been used to analyze quality of life and psychosocial changes in patients who undergo orthognathic surgery for dentofacial deformities.
cleft lip and palate have a different set of complaints, perceptions, and expectations, hence were not included in this review. Variables of interest included study design, sample size, duration of followup, number of times findings were recorded, types of instruments used, motivational factors, perception of patients towards orthognathic surgery, and quality of life changes. Results
The search was carried out in the following manner (Fig. 1): the search terms ‘orthognathic surgery’ and ‘dentofacial deformity’ were grouped together and the option ‘OR’ was used. This revealed a total of 3317 articles. The terms ‘quality of life’ and ‘psychosocial’ were grouped together, again with the option ‘OR’. This revealed 236,016 articles. When both groups were cross-checked with one another using the option ‘AND’, a final 97 articles were identified. Limits were then applied to the search, in which only articles from 2001 to the end of June 2012 were included; this revealed 67 articles. After discussions between the authors, 48 articles were excluded from the initial
search for the following reasons: 12 were papers on cleft lip and palate or syndromes; six were case reports; 12 were not related to the topic directly; two were short-term studies; seven articles were not in English; two papers focused on temporomandibular joint changes; two were orthodontic articles; four articles could not be obtained; and one was a review article. The final search yielded 19 articles. Two papers were then added from a hand search of various orthodontic and surgical journals. Finally 21 articles were included in this review. The review of the literature revealed a variety of study designs used to evaluate quality of life and psychosocial changes following orthognathic surgery. There was one randomized controlled trial, ten cohort studies, four case-control studies, five cross-sectional studies, and one retrospective study (Table 1). The highest level of evidence in this review was a randomized controlled trial done by Motegi et al.12 This was the study with the longest follow-up of all subjects (5 years), and recorded data seven times, although only results at 2 and 5 years were published. The authors reported an improvement in general quality of life,
Materials and methods
An online database search was carried out. The search was conducted in PubMed with the use of medical subheadings to include all studies from 2001 to June of 2012. The limiting year was chosen based on a previous systematic review on the same topic in an indexed journal by Hunt et al. in 2001.11 Search key words included: ‘orthognathic surgery’, ‘dentofacial deformity’, ‘psychosocial’, and ‘quality of life’. Various maxillofacial surgery and orthodontic journals were also hand searched and suitable articles identified for inclusion. Articles that assessed motivations, perceptions, or postsurgical changes in quality of life were included in this review. Articles that used both qualitative and quantitative measures were included. The rationale behind the inclusion of all articles was to objectively assess all methods of evaluation of quality of life. The authors feel that there is still scope for qualitative assessments regarding patient perception and postoperative changes. Exclusion criteria included articles that assessed quality of life changes in patients with syndrome-associated deformities and patients with cleft lip and palate. Such studies were excluded as we wished to limit out review to only classic dentofacial deformity. Patients with syndromes and
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Fig. 1. Flow chart of systematic article selection.
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Table 1. Hierarchy and summary of included study designs. Type of study Randomized clinical trial with controls Randomized clinical trial without controls Prospective cohort with controls Prospective cohort without controls
Case-control studies
Cross-sectional study with controls Cross-sectional study without controls
Retrospective study with controls Retrospective study without controls
oral health-related quality of life, psychological function, and overall patient satisfaction. The results were statistically significant at 5 years, while remaining stable from 2 to 5 years. Although this study had the highest level of evidence, several concerns exist. Firstly, the size of the two study groups was not balanced. Also there was no control group to compare the results with. Further, the results were reported as a combination of both of the groups. Although reported as a clinical trial, the trial was to do with the method of fixation and not quality of life. There were three prospective cohorts utilizing controls included in this review. Khadka et al.8 attempted to compare the changes in quality of life between patients with dentofacial deformities involving occlusion and those whose deformity did not include occlusion (prominent zygoma). The results revealed a significant difference preoperatively between the two groups in the physical role, bodily pain, facial aesthetics, and oral function. Postoperatively, there was an overall improvement in quality of life, with only oral function showing a significant difference between the two groups. Kim et al.13 compared 34 patients with 30 dental students preoperatively and postoperatively. They reported an improvement in the psychological profile of the subjects postoperatively, and the score difference with the control group was not statistically significant postoperatively. There was a significant change in
Studies included Nil Motegi et al.12 Khadka et al.8 Kim et al.13 Oland et al.14 Murphy et al.6 Rustemeyer and Gregersen7 Choi et al.10 Lee et al.15 Turker et al.16 Nicodemo et al.17 Modig et al.18 Al-Ahmad et al.19 Narayanan et al.20 Smith and Cunningham22 Lazaridou-Terzoudi et al. 21 Lee et al.26 Ryan et al.24 Esperao et al.9 Bock et al.23 Posnick and Wallace25 Nil Proothi et al.3
No. of data collection times
Methods of data collection
93 115 + 43 34 + 30 118 + 47 62 50 32 36 30 29 32 143 + 37 39 + 21 88 + 100 117 + 131 76 + 76 18 117 50 42
3 2 2 2 2 2 4 3 2 2 2 1 1 1 1 1 1 1 1 1
e, h, i, k, o a, c e, g d, n a, f b a, b, c a, b, c d, j c b, o a, c d o d, l, m a, b, c o b a o
501
1
o
Sample size
personality characteristics after orthognathic surgery. Oland et al.14 attempted to discover the motives for seeking treatment, and how satisfaction of the primary motive correlated with patient satisfaction. Most patients cited function and appearance as the main reasons for seeking treatment, with social reasons and the wish to prevent disease as other reasons. After a follow-up at an average of 1 year after surgery, the authors reported that fulfilment of motive was a significant factor for patient satisfaction. Self-concept and social interaction were associated with higher satisfaction. The authors concluded that patients who seek treatment for a functional motive express a lower degree of satisfaction than others. Most of the other prospective studies without controls assessed preoperative scores that were compared to postoperative scores 6 months to 1 year after surgery, using a variety of epidemiological tools to evaluate the change in quality of life. Murphy et al.6 evaluated quality of life using the Orthognathic Quality of Life Questionnaire (OQLQ), and reported a statistically significant improvements in appearance (93%), chewing function (64%), comfort (60%), and speech (32%). The biggest change was in the aesthetics domain. Rustemeyer and Gregersen7 used the Oral Health Impact Profile 14 (OHIP-14) and came to the conclusion that the biggest change was seen in the aesthetics domain, with
significant changes in psychological discomfort and social disability scores. Choi et al.10 and Lee et al.15 evaluated patients using three questionnaires: the Short Form Health Survey (SF-36), OHIP-14, and OQLQ, with the former concluding their last follow-up at 1 year, and the latter at 6 months. They both reported a significant improvement in the mental health and physical health component of the SF-36. With the more generic OHIP-14 for oral health, a larger effect size was revealed. Likewise, with the use of the condition-specific questionnaire OQLQ, the magnitude of statistical change was larger. Both sets of authors reported an improvement in overall quality of life. Turker et al.16 reported that 76% of patients were very satisfied with the surgical result, with 90% of patients expressing complete correction and improvement in their postoperative image. Sixty-three percent of patients reported an absolute improvement in self-confidence and 40% an improvement in social adjustment. Nicodemo et al.17 conducted a study on 29 patients with a Class III malocclusion using the SF-36 questionnaire. They reported an improvement in physical and social aspects, while an improvement in emotional aspects was higher in females after surgery. Modig et al.18 used both quantitative and qualitative measures. They reported that 72% of patients had an improvement in aesthetics and social
Quality of life assessment in orthognathic surgery security, while 91% and 19% reported an improvement in chewing and speech, respectively. They also gave an insight into the reasons why patients seek orthognathic surgery, with 55% of patients desiring an improvement in bite function and 30% desiring an improvement in appearance. Four case-control studies were included in this review. Al-Ahmad et al.,19 Narayanan et al.,20 and Lazaridou-Terzoudi et al.21 all reported a significant improvement in quality of life postoperatively compared to their selected controls. Smith and Cunningham22 evaluated willingnessto-pay for orthognathic surgery, and came to the conclusion that patients with a dentofacial deformity are willing to spend more than normal controls, and consider surgery as a good option in terms of cost– benefit. Out of the cross-sectional and retrospective studies, Proothi et al.3 and Bock et al.23 sought to understand the motivation and reasons behind seeking orthognathic surgical treatment. Proothi et al. concluded that it was bite function rather than appearance that motivated patients (36% versus 15% out of 201 patients reviewed). Bock et al. reported that 50.4% desired treatment due to functional impairment and 43% due to aesthetic impairment. Ryan et al.24 conducted a qualitative study to assess patient expectations from surgery. They concluded that patients have both physical and non-physical expectations and it is important to understand both before proceeding with treatment. Esperao et al.9 and Posnick and Wallace25 aimed to assess the impact of orthognathic surgery on patients. Their results revealed that the majority of patients are satisfied with the treatment and report an overall improvement in quality of life. Lee et al.26 conducted a study to assess changes in quality of life by all three measures using 76 patients with concurrent controls. Their results indicated that there is no correlation between SF-36 and the other two questionnaires. The generic oral health and condition-specific questionnaires are able to discriminate between patients with and without dentofacial deformities, and have a value in determining the impact of such deformities on quality of life.
Fig. 2. Summation of results for articles quantifying QOL using OQLQ.
standardized questionnaires makes it possible to quantify the extent of improvement as well. For studies that employed the OQLQ, the biggest change was seen in the aesthetics and social domains6,8,10,15,19 (Fig. 2). For studies that used the OHIP14, the most significant change was seen in psychological discomfort the domain7,10,15 (Fig. 3). For studies that employed the SF-36, the largest effect size differed among the different studies, with some reporting a maximal change in the mental health domain,8,19 some in the emotional role domain,10,17 and some in the vitality domain15,26 (Fig. 4). When compared to the previous systematic review by Hunt et al.,11 the results
of both systemic reviews are almost synonymous, with overall data pointing towards an improvement in quality of life and psychosocial components. Compared to earlier studies on the topic, the introduction of validated condition and oral health-specific questionnaires has greatly affected the design and instruments for newer trials. Earlier studies used a variety of instruments for recording psychosocial benefits, most of which were designed for general psychology instead of psychosocial changes specific to orthognathic surgery. Table 2 provides a summary of the Hunt et al. review, showing the numerous analyses on psychosocial impact. However none of
Fig. 3. Summation of results for articles quantifying QOL using OHIP.
Discussion
All the studies concluded that orthognathic surgery resulted in an improved quality of life. The employment of
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Fig. 4. Summation of results for articles quantifying QOL using SF-36.
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Table 2. Summary of Hunt et al.11 Total number of studies, N = 29 1 Prospective cohort 16 prospective study with no controls 10 retrospective study with no controls 2 cross-sectional study with no controls Types of questionnaires included a. Body Cathexis Scale b. Body Satisfaction Scale c. Eysenck Personality Inventory d. 16-Factor Personality Questionnaire e. Goal Attainment Scale f. General Health Questionnaire g. Health Opinion Survey h. Impact Message Inventory i. Millon Behavioural Health Inventory j. Profile of Mood States k. Rotter’s Internality/Externality Scale l. Rosenberg Self-Esteem Scale m. Surgical Audit n. Social Avoidance and Distress/Fear of Negative Evaluation Scales o. Symptom Checklist Revised (SCL-90-R) p. Tennessee Self-Concept Scale q. Ward Adjustment Scale r. Hospital Anxiety and Depression Scale s. Yatabe-Guilford Personality Inventory t. State-Trait Anxiety Inventory u. Beck Depression Inventory v. Short Form Social Support Questionnaire w. Derogatis Stress Profile x. Introspectiveness Inventory y. Self-Esteem Inventory z. Zung Anxiety Inventory aa. Zung Depression Inventory bb. Minnesota Multiphasic Personality Inventory cc. Family Environment Scale dd. Questionnaire devised by authors or unvalidated measure
the methods are validated for orthognathic surgery. Also lower levels of evidence are evident among the study designs in earlier papers. The studies included in this review showed an emerging trend in the utilization of standard tested and proven questionnaires as the tool of choice for assessing changes in quality of life. These include three questionnaires: first, the generic health-related questionnaire Short Form Health survey (SF-36)27; second, a generic oral health-related questionnaire Oral Health Impact Profile 14 (OHIP14)28–30; and third, a condition-specific questionnaire Orthognathic Quality of Life Questionnaire (OQLQ)31,32 (Table 3). The SF-36 is a 36-item questionnaire corresponding to eight health domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotion, and mental health. These domains can then be summarized into a physical component and mental component. The scores range from 0 to
Table 3. Types of questionnaires used. Questionnaire type a. b. c. d. e. f. g. h. i. j. k. l. m. n o.
Orthognathic Quality of Life Questionnaire (OQLQ) Oral Health Impact Profile (OHIP) Short Form Health Survey (SF-36) Kiyak’s Internal Assessment/Personal Inventory Symptom Checklist 90 Revised Global Transition Scale Minnesota Multiphasic Personality Inventory (MMPI) Sickness Impact Profile Psychosocial Dimension Oral Health Status Questionnaire Maslach Burnout Inventory Eysenck Personality Inventory Body Cathexis Scale Fitts Tennessee Department of Mental Health Self-Concept Scale Motives for Surgical-Orthodontic Treatment Questionnaire devised by author or invalidated measure
100, with 0 being the worst possible health and 100 the best.26,27 The OHIP-14 is a 14-item questionnaire, spread over seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Scoring is made over a 4-point Likert scale, with overall scores ranging from 0 (worst) to 56 (best). Individual domains consist of two questions each, with scores from 0 to 8 per domain.27–30 The OQLQ has 22 items divided into four domains: facial aesthetics, oral function, awareness of deformity, and social aspects of the deformity. Items are rated over a 4-point Likert scale. The total score ranges from 0 to 88, from lower quality of life to better quality of life.26,31,32 The generic health questionnaire, oral health-related questionnaire, and condition-specific questionnaire have been presented and validated by various authors. Most of the questionnaires have also been translated into other languages.33–36 What are the common patient motivations?
Three articles in this series emphasized patient motivation and reasons. In the study with the largest series of patients by Proothi et al.,3 and also papers by Oland et al.14 and Modig et al.,18 the primary motivating factor was identified as bite rather than appearance. Other reasons included pain, smile, and speech. This is consistent with earlier studies as well,36 although the majority of studies have reported that aesthetic concerns are the primary reason.23,37–41 Most of the studies in this review concluded their research at 6 months postoperatively. The longest postoperative assessment was made by Motegi et al.,12
No. of studies 7 6 6 4 2 1 1 1 1 1 1 1 1 1 6
for a duration of 5 years. According to that study, the psychosocial benefits obtained were stable after 2 years. However several issues like the lack of a control group and the timing of the baseline score evaluation necessitates further controlled prospective trials of a longer follow-up duration to confirm the long-term benefits. This is synonymous with the results obtained earlier by Kiyak et al.42 and Flanary et al.43 Which patients are most at risk of being dissatisfied?
A very small percentage of patients in all studies reported dissatisfaction with the treatment outcomes. Using the Global Transition Scale adapted by Murphy et al.,6 the authors reported that 7% of patients had deterioration in function, 15% in overall comfort attributed to postsurgical side effects, and 4% in speech. Other authors reported almost similar figures among their study samples.10,16,25 This is attributed mainly to the lack of postsurgical orthodontics and the timing of follow-up. Permanent effects of facial changes should be evaluated after 2–5 years to allow the patient’s personality to accept and incorporate the new features into their psychology and function.12,21,44,45 This could be a reason for the dissatisfaction in treatment outcomes, as most of the studies only followed up the patients for a duration of 6 months. Kim et al.13 reported that 15% of patients were dissatisfied with the surgery. The authors attributed this to the high cost of the treatment, which was not covered by health insurance. A qualitative study by Ryan et al.24 stated that patients have expectations from both a physical and non-physical point of view, and that patient satisfaction can be increased by understanding them. Turker et al.16 stated that adequate psychological
Quality of life assessment in orthognathic surgery preparation helps to prepare the patient for the postoperative image. This can be achieved by the surgeon giving sufficient explanations, or by speaking to previous patients who have undergone orthognathic surgery. Also, in the study by Smith and Cunningham,22 the fact that patients and the general public are willing to put a price on orthognathic surgery shows the positive perception towards the procedure as a treatment modality for dentofacial deformity. Improvements in trials since 2001 have been a higher level of evidence in study design and the use of better validated quantifiable instruments. The ability to justify earlier observations and results is proof enough that orthognathic surgery improves the quality of life of patients with dentofacial deformities. It is important to consider the implications of surgeries that are elective and for a primarily cosmetic purpose, like orthognathic surgery, from the psychological perspective of the patient. Failing to do so, even though the surgical outcomes may be ideal, may result in dissatisfaction on the part of the patient. From this systematic review, it can be concluded that orthognathic surgery is of significant benefit to patients with a dentofacial deformity. However, further longterm studies with quantification using standardized, validated questionnaires are required to further substantiate the results. Also the motivations and perceptions of each individual patient are important in determining treatment success, in restoring not only the aesthetic and functional problems, but also the psychosocial problems as well. The use of standardized tools has helped to achieve consistent comparable results in this area of orthognathic research, which is an improvement on older studies. Further research in study design should include comparable groups, more randomized clinical trials, and more thorough analysis of the different types of dentofacial deformities as well as the different types of surgical procedures.
Funding
Self-funded.
Competing interests
None.
Ethical approval
Institutional Review Board.
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Address: Chen Loong Soh Saveetha University No. 162 Poonamallee High Road Vellappanchavadi Chennai 600077 India Tel.: +91 99 40690089 E-mail: [email protected]
Systematic Review Orthognathic Surgery
Quality of life assessment in patients with dentofacial deformity undergoing orthognathic surgery—A systematic review
C. L. Soh, V. Narayanan Saveetha University, Vellappanchavadi, Chennai, India
C. L. Soh, V. Narayanan: Quality of life assessment in patients with dentofacial deformity undergoing orthognathic surgery—A systematic review. Int. J. Oral Maxillofac. Surg. 2013; 42: 974–980. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of this systematic review was to evaluate the benefits of orthognathic surgery to quality of life, the different motivations and perceptions of patients towards orthognathic surgery, and the various methods that have been used to analyze these changes, in patients who undergo orthognathic surgery for dentofacial deformities. A review of the literature was carried out, and articles published from 2001 to June of 2012 that satisfied the inclusion criteria were included in the review. A total of 21 articles were included. The results indicate that orthognathic patients experience an improvement in quality of life after surgery. Each individual patient has different motivations and expectations from the treatment. Also the use of validated instruments helped in quantifying results. Further research should be aimed at higher levels of evidence in study design, quantifying the changes for different types of dentofacial deformities and surgeries, and have a longer follow-up duration.
Introduction
Patients with dentofacial deformities are at a disadvantage in society due to low self-esteem and decreased levels of confidence, as well as associated physiological problems. Indeed such deformities interfere not only with oral health and function, but also adversely affect mental well-being, thus affecting the entire spectrum that constitutes quality of life. 0901-5027/080974 + 07 $36.00/0
Orthognathic surgery is recognized as the mainstay of treatment for dentofacial deformities. While most published articles have placed an emphasis on the techniques for performing such surgeries, it is also necessary to give importance to the effects of such surgical interventions on the psyche of the patient. Over the years, research has shown that most patients desire correction of dentofacial deformities to improve the aesthetics of the facial and
Key words: orthognathic surgery; dentofacial deformity; quality of life. Accepted for publication 6 March 2013 Available online 21 May 2013
dental components.1 There are also certain studies that have reported the primary motivation to be bite function rather than appearance.2,3 As such interventions affect the patient’s appearance directly over an almost immediate period of time, it is also of paramount importance to quantify the psychological impact of the surgery. The earliest reports of patient satisfaction4 indicated good responses to orthognathic
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Quality of life assessment in orthognathic surgery surgery, and this has since been substantiated by other authors.5–10 However the lack of comparable quantifiable data to denote the extent of improvement has been one of the shortcomings in the past literature. This has mainly been due to the lack of consensus among the various scales and tools used to measure such a change. The onus is now not only on treating the aesthetic component of dentofacial deformity, but also on restoring the patient’s psychosocial component as well. It is easy to assume that the two go hand in hand, but the motivations, perceptions, and expectations of the individual play a significant role in determining not only the surgical success, but also the psychosocial success; all of these contribute to the overall quality of life of the individual. Thus the aim of this systematic review was to evaluate the motivations and perceptions of patients and the benefits of orthognathic surgery to quality of life, as well as the various methods and tools that have been used to analyze quality of life and psychosocial changes in patients who undergo orthognathic surgery for dentofacial deformities.
cleft lip and palate have a different set of complaints, perceptions, and expectations, hence were not included in this review. Variables of interest included study design, sample size, duration of followup, number of times findings were recorded, types of instruments used, motivational factors, perception of patients towards orthognathic surgery, and quality of life changes. Results
The search was carried out in the following manner (Fig. 1): the search terms ‘orthognathic surgery’ and ‘dentofacial deformity’ were grouped together and the option ‘OR’ was used. This revealed a total of 3317 articles. The terms ‘quality of life’ and ‘psychosocial’ were grouped together, again with the option ‘OR’. This revealed 236,016 articles. When both groups were cross-checked with one another using the option ‘AND’, a final 97 articles were identified. Limits were then applied to the search, in which only articles from 2001 to the end of June 2012 were included; this revealed 67 articles. After discussions between the authors, 48 articles were excluded from the initial
search for the following reasons: 12 were papers on cleft lip and palate or syndromes; six were case reports; 12 were not related to the topic directly; two were short-term studies; seven articles were not in English; two papers focused on temporomandibular joint changes; two were orthodontic articles; four articles could not be obtained; and one was a review article. The final search yielded 19 articles. Two papers were then added from a hand search of various orthodontic and surgical journals. Finally 21 articles were included in this review. The review of the literature revealed a variety of study designs used to evaluate quality of life and psychosocial changes following orthognathic surgery. There was one randomized controlled trial, ten cohort studies, four case-control studies, five cross-sectional studies, and one retrospective study (Table 1). The highest level of evidence in this review was a randomized controlled trial done by Motegi et al.12 This was the study with the longest follow-up of all subjects (5 years), and recorded data seven times, although only results at 2 and 5 years were published. The authors reported an improvement in general quality of life,
Materials and methods
An online database search was carried out. The search was conducted in PubMed with the use of medical subheadings to include all studies from 2001 to June of 2012. The limiting year was chosen based on a previous systematic review on the same topic in an indexed journal by Hunt et al. in 2001.11 Search key words included: ‘orthognathic surgery’, ‘dentofacial deformity’, ‘psychosocial’, and ‘quality of life’. Various maxillofacial surgery and orthodontic journals were also hand searched and suitable articles identified for inclusion. Articles that assessed motivations, perceptions, or postsurgical changes in quality of life were included in this review. Articles that used both qualitative and quantitative measures were included. The rationale behind the inclusion of all articles was to objectively assess all methods of evaluation of quality of life. The authors feel that there is still scope for qualitative assessments regarding patient perception and postoperative changes. Exclusion criteria included articles that assessed quality of life changes in patients with syndrome-associated deformities and patients with cleft lip and palate. Such studies were excluded as we wished to limit out review to only classic dentofacial deformity. Patients with syndromes and
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Fig. 1. Flow chart of systematic article selection.
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Table 1. Hierarchy and summary of included study designs. Type of study Randomized clinical trial with controls Randomized clinical trial without controls Prospective cohort with controls Prospective cohort without controls
Case-control studies
Cross-sectional study with controls Cross-sectional study without controls
Retrospective study with controls Retrospective study without controls
oral health-related quality of life, psychological function, and overall patient satisfaction. The results were statistically significant at 5 years, while remaining stable from 2 to 5 years. Although this study had the highest level of evidence, several concerns exist. Firstly, the size of the two study groups was not balanced. Also there was no control group to compare the results with. Further, the results were reported as a combination of both of the groups. Although reported as a clinical trial, the trial was to do with the method of fixation and not quality of life. There were three prospective cohorts utilizing controls included in this review. Khadka et al.8 attempted to compare the changes in quality of life between patients with dentofacial deformities involving occlusion and those whose deformity did not include occlusion (prominent zygoma). The results revealed a significant difference preoperatively between the two groups in the physical role, bodily pain, facial aesthetics, and oral function. Postoperatively, there was an overall improvement in quality of life, with only oral function showing a significant difference between the two groups. Kim et al.13 compared 34 patients with 30 dental students preoperatively and postoperatively. They reported an improvement in the psychological profile of the subjects postoperatively, and the score difference with the control group was not statistically significant postoperatively. There was a significant change in
Studies included Nil Motegi et al.12 Khadka et al.8 Kim et al.13 Oland et al.14 Murphy et al.6 Rustemeyer and Gregersen7 Choi et al.10 Lee et al.15 Turker et al.16 Nicodemo et al.17 Modig et al.18 Al-Ahmad et al.19 Narayanan et al.20 Smith and Cunningham22 Lazaridou-Terzoudi et al. 21 Lee et al.26 Ryan et al.24 Esperao et al.9 Bock et al.23 Posnick and Wallace25 Nil Proothi et al.3
No. of data collection times
Methods of data collection
93 115 + 43 34 + 30 118 + 47 62 50 32 36 30 29 32 143 + 37 39 + 21 88 + 100 117 + 131 76 + 76 18 117 50 42
3 2 2 2 2 2 4 3 2 2 2 1 1 1 1 1 1 1 1 1
e, h, i, k, o a, c e, g d, n a, f b a, b, c a, b, c d, j c b, o a, c d o d, l, m a, b, c o b a o
501
1
o
Sample size
personality characteristics after orthognathic surgery. Oland et al.14 attempted to discover the motives for seeking treatment, and how satisfaction of the primary motive correlated with patient satisfaction. Most patients cited function and appearance as the main reasons for seeking treatment, with social reasons and the wish to prevent disease as other reasons. After a follow-up at an average of 1 year after surgery, the authors reported that fulfilment of motive was a significant factor for patient satisfaction. Self-concept and social interaction were associated with higher satisfaction. The authors concluded that patients who seek treatment for a functional motive express a lower degree of satisfaction than others. Most of the other prospective studies without controls assessed preoperative scores that were compared to postoperative scores 6 months to 1 year after surgery, using a variety of epidemiological tools to evaluate the change in quality of life. Murphy et al.6 evaluated quality of life using the Orthognathic Quality of Life Questionnaire (OQLQ), and reported a statistically significant improvements in appearance (93%), chewing function (64%), comfort (60%), and speech (32%). The biggest change was in the aesthetics domain. Rustemeyer and Gregersen7 used the Oral Health Impact Profile 14 (OHIP-14) and came to the conclusion that the biggest change was seen in the aesthetics domain, with
significant changes in psychological discomfort and social disability scores. Choi et al.10 and Lee et al.15 evaluated patients using three questionnaires: the Short Form Health Survey (SF-36), OHIP-14, and OQLQ, with the former concluding their last follow-up at 1 year, and the latter at 6 months. They both reported a significant improvement in the mental health and physical health component of the SF-36. With the more generic OHIP-14 for oral health, a larger effect size was revealed. Likewise, with the use of the condition-specific questionnaire OQLQ, the magnitude of statistical change was larger. Both sets of authors reported an improvement in overall quality of life. Turker et al.16 reported that 76% of patients were very satisfied with the surgical result, with 90% of patients expressing complete correction and improvement in their postoperative image. Sixty-three percent of patients reported an absolute improvement in self-confidence and 40% an improvement in social adjustment. Nicodemo et al.17 conducted a study on 29 patients with a Class III malocclusion using the SF-36 questionnaire. They reported an improvement in physical and social aspects, while an improvement in emotional aspects was higher in females after surgery. Modig et al.18 used both quantitative and qualitative measures. They reported that 72% of patients had an improvement in aesthetics and social
Quality of life assessment in orthognathic surgery security, while 91% and 19% reported an improvement in chewing and speech, respectively. They also gave an insight into the reasons why patients seek orthognathic surgery, with 55% of patients desiring an improvement in bite function and 30% desiring an improvement in appearance. Four case-control studies were included in this review. Al-Ahmad et al.,19 Narayanan et al.,20 and Lazaridou-Terzoudi et al.21 all reported a significant improvement in quality of life postoperatively compared to their selected controls. Smith and Cunningham22 evaluated willingnessto-pay for orthognathic surgery, and came to the conclusion that patients with a dentofacial deformity are willing to spend more than normal controls, and consider surgery as a good option in terms of cost– benefit. Out of the cross-sectional and retrospective studies, Proothi et al.3 and Bock et al.23 sought to understand the motivation and reasons behind seeking orthognathic surgical treatment. Proothi et al. concluded that it was bite function rather than appearance that motivated patients (36% versus 15% out of 201 patients reviewed). Bock et al. reported that 50.4% desired treatment due to functional impairment and 43% due to aesthetic impairment. Ryan et al.24 conducted a qualitative study to assess patient expectations from surgery. They concluded that patients have both physical and non-physical expectations and it is important to understand both before proceeding with treatment. Esperao et al.9 and Posnick and Wallace25 aimed to assess the impact of orthognathic surgery on patients. Their results revealed that the majority of patients are satisfied with the treatment and report an overall improvement in quality of life. Lee et al.26 conducted a study to assess changes in quality of life by all three measures using 76 patients with concurrent controls. Their results indicated that there is no correlation between SF-36 and the other two questionnaires. The generic oral health and condition-specific questionnaires are able to discriminate between patients with and without dentofacial deformities, and have a value in determining the impact of such deformities on quality of life.
Fig. 2. Summation of results for articles quantifying QOL using OQLQ.
standardized questionnaires makes it possible to quantify the extent of improvement as well. For studies that employed the OQLQ, the biggest change was seen in the aesthetics and social domains6,8,10,15,19 (Fig. 2). For studies that used the OHIP14, the most significant change was seen in psychological discomfort the domain7,10,15 (Fig. 3). For studies that employed the SF-36, the largest effect size differed among the different studies, with some reporting a maximal change in the mental health domain,8,19 some in the emotional role domain,10,17 and some in the vitality domain15,26 (Fig. 4). When compared to the previous systematic review by Hunt et al.,11 the results
of both systemic reviews are almost synonymous, with overall data pointing towards an improvement in quality of life and psychosocial components. Compared to earlier studies on the topic, the introduction of validated condition and oral health-specific questionnaires has greatly affected the design and instruments for newer trials. Earlier studies used a variety of instruments for recording psychosocial benefits, most of which were designed for general psychology instead of psychosocial changes specific to orthognathic surgery. Table 2 provides a summary of the Hunt et al. review, showing the numerous analyses on psychosocial impact. However none of
Fig. 3. Summation of results for articles quantifying QOL using OHIP.
Discussion
All the studies concluded that orthognathic surgery resulted in an improved quality of life. The employment of
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Fig. 4. Summation of results for articles quantifying QOL using SF-36.
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Table 2. Summary of Hunt et al.11 Total number of studies, N = 29 1 Prospective cohort 16 prospective study with no controls 10 retrospective study with no controls 2 cross-sectional study with no controls Types of questionnaires included a. Body Cathexis Scale b. Body Satisfaction Scale c. Eysenck Personality Inventory d. 16-Factor Personality Questionnaire e. Goal Attainment Scale f. General Health Questionnaire g. Health Opinion Survey h. Impact Message Inventory i. Millon Behavioural Health Inventory j. Profile of Mood States k. Rotter’s Internality/Externality Scale l. Rosenberg Self-Esteem Scale m. Surgical Audit n. Social Avoidance and Distress/Fear of Negative Evaluation Scales o. Symptom Checklist Revised (SCL-90-R) p. Tennessee Self-Concept Scale q. Ward Adjustment Scale r. Hospital Anxiety and Depression Scale s. Yatabe-Guilford Personality Inventory t. State-Trait Anxiety Inventory u. Beck Depression Inventory v. Short Form Social Support Questionnaire w. Derogatis Stress Profile x. Introspectiveness Inventory y. Self-Esteem Inventory z. Zung Anxiety Inventory aa. Zung Depression Inventory bb. Minnesota Multiphasic Personality Inventory cc. Family Environment Scale dd. Questionnaire devised by authors or unvalidated measure
the methods are validated for orthognathic surgery. Also lower levels of evidence are evident among the study designs in earlier papers. The studies included in this review showed an emerging trend in the utilization of standard tested and proven questionnaires as the tool of choice for assessing changes in quality of life. These include three questionnaires: first, the generic health-related questionnaire Short Form Health survey (SF-36)27; second, a generic oral health-related questionnaire Oral Health Impact Profile 14 (OHIP14)28–30; and third, a condition-specific questionnaire Orthognathic Quality of Life Questionnaire (OQLQ)31,32 (Table 3). The SF-36 is a 36-item questionnaire corresponding to eight health domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotion, and mental health. These domains can then be summarized into a physical component and mental component. The scores range from 0 to
Table 3. Types of questionnaires used. Questionnaire type a. b. c. d. e. f. g. h. i. j. k. l. m. n o.
Orthognathic Quality of Life Questionnaire (OQLQ) Oral Health Impact Profile (OHIP) Short Form Health Survey (SF-36) Kiyak’s Internal Assessment/Personal Inventory Symptom Checklist 90 Revised Global Transition Scale Minnesota Multiphasic Personality Inventory (MMPI) Sickness Impact Profile Psychosocial Dimension Oral Health Status Questionnaire Maslach Burnout Inventory Eysenck Personality Inventory Body Cathexis Scale Fitts Tennessee Department of Mental Health Self-Concept Scale Motives for Surgical-Orthodontic Treatment Questionnaire devised by author or invalidated measure
100, with 0 being the worst possible health and 100 the best.26,27 The OHIP-14 is a 14-item questionnaire, spread over seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Scoring is made over a 4-point Likert scale, with overall scores ranging from 0 (worst) to 56 (best). Individual domains consist of two questions each, with scores from 0 to 8 per domain.27–30 The OQLQ has 22 items divided into four domains: facial aesthetics, oral function, awareness of deformity, and social aspects of the deformity. Items are rated over a 4-point Likert scale. The total score ranges from 0 to 88, from lower quality of life to better quality of life.26,31,32 The generic health questionnaire, oral health-related questionnaire, and condition-specific questionnaire have been presented and validated by various authors. Most of the questionnaires have also been translated into other languages.33–36 What are the common patient motivations?
Three articles in this series emphasized patient motivation and reasons. In the study with the largest series of patients by Proothi et al.,3 and also papers by Oland et al.14 and Modig et al.,18 the primary motivating factor was identified as bite rather than appearance. Other reasons included pain, smile, and speech. This is consistent with earlier studies as well,36 although the majority of studies have reported that aesthetic concerns are the primary reason.23,37–41 Most of the studies in this review concluded their research at 6 months postoperatively. The longest postoperative assessment was made by Motegi et al.,12
No. of studies 7 6 6 4 2 1 1 1 1 1 1 1 1 1 6
for a duration of 5 years. According to that study, the psychosocial benefits obtained were stable after 2 years. However several issues like the lack of a control group and the timing of the baseline score evaluation necessitates further controlled prospective trials of a longer follow-up duration to confirm the long-term benefits. This is synonymous with the results obtained earlier by Kiyak et al.42 and Flanary et al.43 Which patients are most at risk of being dissatisfied?
A very small percentage of patients in all studies reported dissatisfaction with the treatment outcomes. Using the Global Transition Scale adapted by Murphy et al.,6 the authors reported that 7% of patients had deterioration in function, 15% in overall comfort attributed to postsurgical side effects, and 4% in speech. Other authors reported almost similar figures among their study samples.10,16,25 This is attributed mainly to the lack of postsurgical orthodontics and the timing of follow-up. Permanent effects of facial changes should be evaluated after 2–5 years to allow the patient’s personality to accept and incorporate the new features into their psychology and function.12,21,44,45 This could be a reason for the dissatisfaction in treatment outcomes, as most of the studies only followed up the patients for a duration of 6 months. Kim et al.13 reported that 15% of patients were dissatisfied with the surgery. The authors attributed this to the high cost of the treatment, which was not covered by health insurance. A qualitative study by Ryan et al.24 stated that patients have expectations from both a physical and non-physical point of view, and that patient satisfaction can be increased by understanding them. Turker et al.16 stated that adequate psychological
Quality of life assessment in orthognathic surgery preparation helps to prepare the patient for the postoperative image. This can be achieved by the surgeon giving sufficient explanations, or by speaking to previous patients who have undergone orthognathic surgery. Also, in the study by Smith and Cunningham,22 the fact that patients and the general public are willing to put a price on orthognathic surgery shows the positive perception towards the procedure as a treatment modality for dentofacial deformity. Improvements in trials since 2001 have been a higher level of evidence in study design and the use of better validated quantifiable instruments. The ability to justify earlier observations and results is proof enough that orthognathic surgery improves the quality of life of patients with dentofacial deformities. It is important to consider the implications of surgeries that are elective and for a primarily cosmetic purpose, like orthognathic surgery, from the psychological perspective of the patient. Failing to do so, even though the surgical outcomes may be ideal, may result in dissatisfaction on the part of the patient. From this systematic review, it can be concluded that orthognathic surgery is of significant benefit to patients with a dentofacial deformity. However, further longterm studies with quantification using standardized, validated questionnaires are required to further substantiate the results. Also the motivations and perceptions of each individual patient are important in determining treatment success, in restoring not only the aesthetic and functional problems, but also the psychosocial problems as well. The use of standardized tools has helped to achieve consistent comparable results in this area of orthognathic research, which is an improvement on older studies. Further research in study design should include comparable groups, more randomized clinical trials, and more thorough analysis of the different types of dentofacial deformities as well as the different types of surgical procedures.
Funding
Self-funded.
Competing interests
None.
Ethical approval
Institutional Review Board.
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Address: Chen Loong Soh Saveetha University No. 162 Poonamallee High Road Vellappanchavadi Chennai 600077 India Tel.: +91 99 40690089 E-mail: [email protected]