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Self-assessment of profile and body image among orthognathic surgery patients before and two years after surgery
J
Oral Maxlllofac
46:36&371,
Surg
1966
Self-Assessment of Profile and Body Image Among Orthognathic Surgery Patients Before and Two Years After Surgery H. ASUMAN
KIYAK,
PHD* AND
DEBORAH
L. ZEITLER,
DDS, MST
Ninety patients undergoing surgery at two major university hospitals completed self-ratings of their profile, perceived deviations from the ideal profile, and a measure of body image. Identical measures were obtained presurgically and two years following surgery. Patients diagnosed with mandibular hypoplasia perceived themsetves significantly more prognathic on the maxillary dimension and most retrognathic on the mandibular dimension; their self-drawings reflected a shorter vertical dimension. These perceptions approached the normal range at the postsurgical assessment. Patients treated for maxillary hypoplasia, however, rated themselves in the mandibular prognathic range both before and after surgery. These patients were also more likely to perceive other deviations from the ideal in their facial features 2 years after surgical correction. Body image did not differentiate among diagnostic categories, but showed overall improvements for all patients from presurgery to postsurgery. Profile drawings appear to be the most statistically and clinically useful method of determining patients’ self-assessments of deviations from normal, and their perceptions of treatment needs.
A number of researchers have commented on the negative social and psychological effects of objectively definable facial abnormalities. Belfer and colleagues’ have noted a wide range of associated problems, including limited ability to interact successfully with the parent during infancy, failure to gain a sense of mastery and competence, limited peer interactions, development of pathologic de-
fenses, and damaged self-esteem. In a comparison of 43 children undergoing surgical treatment for craniofacial malformations with a group of matched controls, Pertschuk and Whitake? found the patients to be significantly more anxious, introverted, and hyperactive; and to have poorer self-concepts, more negative social experiences, and poorer classroom behavior than children in the control group. Although the majority of subjects in the preceding studies had more severe deformities, Helm and associates3 concluded that certain malocclusions, especially conspicuous occlusal and space anomalies, may also negatively affect body image and selfconcept. Given the documented association of attractiveness with positive social outcomes, it is not surprising that esthetic considerations have been cited in many studies as a major reason for facial surgery.M Patients’ self assessments of attractiveness have been found to differ significantly from those of professionals and untrained raters, however.7-‘0 Bell
* Associate Professor, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle. I’ Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Iowa, Iowa City, Iowa. This research was supported by Grant No. 1 ROl DE05744 from the National Institute for Dental Research. This paper was presented at meetings of the IADR, Chicago, March 1987. ** Address correspondence and reprint requests to Dr. Kiyak: Department of Oral and Maxillofacial Surgery, SB-24, University of Washington, Seattle, WA 98195. 0 1988 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391188
$0.00 + .25
365
366 and associates’ concluded that self-perceptions of profile were, in fact, more important than professional recommendations and cephalometric measurements in determining whether or not individuals elect surgical correction. Noting that patients’ self-ratings were lower than these other two groups, Albino and associates” determined that patients’ self-perceptions of attractiveness and their concern about malocclusion best predicted patients’ decisions about surgery. Other predictors were an objective dental facial appearance scale (DFA) and a treatment priority index, completed by untrained observers and professionals, respectively. Evidence of whether surgical correction actually does improve self-concept and social achievements is mixed. Although an earlier study12 failed to demonstrate such gains, Arndt and colleagues” found significant positive changes among children and adolescents with mild and more severe craniofacial abnormalities after surgery. Patients’ selfperceptions of attractiveness increased dramatically when evaluated 6 months and 2 years after surgery, as did their scores on the Piers Harris selfconcept scale. Results of these studies must be viewed with caution. Belfer and associates’ point out that body image is a complex and relatively stable psychological phenomenon. The associated defense system that, in severe cases especially, includes massive denial, can be modified only slowly. These researchers conclude that surgical intervention facilitates but does not by itself produce changes in self-concept and social interaction. Furthermore, just as patients often differ from professionals in their preoperative self-perceptions, they may also express dissatisfaction with surgical results that are technically adequate. Macgregor13 has catalogued a variety of factors that may contribute to this outcome, including those attributable to patients (e.g., unrealistic expectations), to the surgeon (e.g., alterations of features that the patient does not consider deformed), and interactions between the surgeon and the patient (e.g., poor communication). A variety of instruments have been designed by these researchers to assess the perceptions of patients and others. Albino and colleagues”*‘4 used drawings to represent ideal occlusion; crowding; excess spacing; maxillary, mandibular, and bimaxillary protrusion; midline deviation; and open bite; in addition to the DFA cited earlier. Arndt and colleagues” administered Hay’s Rating Scale to patients, parents, and untrained raters. Bell and colleagues’ used profile sketches representing a nine-point rating scale along each of four dimensions (vertical, maxillary, mandibular, and dentoalveolar), and compared the ratings of patients and
SELF-ASSESSMENTS
OF ORTHOGNATHIC
PATIENTS
untrained observers on this measure with cephalometric analyses. The purpose of this report is to describe the results of a study aimed at comparing self-perceptions of facial form, malocclusion and body image among patients undergoing orthognathic surgery. Objective assessments of each patient’s maxiliofacial abnormalities by his or her oral and maxillofacial surgeon and orthodontist were used to categorize these patients. Comparisons were made between patient types; the relationship between diagnosed abnormalities and patients’ self-assessments before surgery and two years following surgery was examined. Materials and Methods SUBJECTS
Ninety patients were selected from the files of the Oral and Maxillofacial Clinic at University Hospital in Seattle who were in preparation for orthognathic surgery for a developmental maxillofacial abnormality. A comparable sample of 30 surgical patients was obtained at the University of Iowa. Diagnostic data were available for 69 Seattle and 21 Iowa patients. All baseline comparisons of demographic distributions, personality characteristics, and diagnostic categories between the Seattle and Iowa samples were nonsignificant. Therefore, all subsequent analyses pooled the data obtained for the two groups. Diagnostic categories and the distribution of patients in each category are illustrated in Table 1. Mandibular hypoplasia was the diagnosis in 63% of all cases. VARIABLES AND THEIR MEASUREMENT
Patients were asked to rate themselves on four profile dimensions (Fig. 1). These profile ratings were identical to those used by Bell et al.’ Each set Table 1.
Diagnosisof OentofacialMairelation Percentage of total (%)
Diagnosis
Seattle
Iowa
Mandibular hypoplasia Mandibular hyperplasia Maxillary hyperplasia Maxillary hypoplasia Combined a + c Apertognathia
45 1 2 9 11 1
12 0 2 3 3 1
63.3 1.1 4.4 13.4 15.6 2.2
21
100.0
-
69
-
367
KIYAK AND ZEITLER
of profiles consisted of a nine-point rating scale representing a different dimension of dental or skeletal disharmony: 1) vertical deficiency-vertical excess; 2) maxillary hyperplasia-hypoplasia; 3) mandibular hypoplasia-hyperplasia; and 4) dentoalveolar protrusion-retrusion. The extremes of each rating scale (1, 2, 3 and 7, 8, 9) represented dentofacial disharmony, and a midpoint rating of 5 represented an “ideal” profile (with ideal occlusion and skeletal harmony). A method was also devised to obtain selfperceptions of facial profile (Fig. 2). Male patients were given a drawing of a male profile with ideal occlusion and skeletal harmony. Female patients
i
I
B.1
2
D. 1
2
FIGURE
were administered a comparable drawing of a female profile. They were asked to sketch their profile, indicating how it differed from the drawing at any point from the forehead to the neck. A millimeter grid was later applied to the lower half of the face to measure deviations from ideal in the maxilla, the mandible, and the vertical dimension. Ten measurement points were obtained; the first seven were horizontal, and the last three were vertical measures. A factor analysis revealed that the first two points represented the maxillary dimension; points 4 through 6 the mandibular, and points 8 through 10 the vertical dimension. Scores on each of these three measures were combined, with positive
I.
3
3
4
4
5
6
7
8
Self-ratings of facial profile. A, vertical: B. maxillary; C, mandibular: and D. dentoalveolar.
9
368
SELF-ASSESSMENTS
OF ORTHOGNATHIC
PATIENTS
Point 1 Point 2 ;:I:: 4' Point 5 Point 6 Point 7 Point 8 Point 9 Point 10
FIGURE 2.
Self-assessments
of facial profile. Left, drawing for male patients. Right, drawing for female patients.
scores indicating prognathism and negative scores representing retrognathism. The individual thereby received a total self-assessment score for each of the three dimensions. In addition, self-perceptions of deviations from the ideal in the forehead region, the eyes, and the nose were noted. Body image, defined as the individual’s selfconcept of his or her physical being, was assessed with a modified version of Secord and Jourard’s body cathexis scale. l5 In our previous research, we found that the scale included several items related to general self-concept rather than body image per se. Therefore, the scale was modified to include more body parts, especially those related to facial features. This permitted the development of a subscale composed of facial body image, as well as an overall body image score. Each respondent was asked to rate his or her satisfaction with each body part on a five-point response scale, from “strong feelings, wish a change” (l), to “consider myself fortunate (5).” Research by Rosen and ROSS’~suggests that the measurement of body image may be refined by considering the subjective importance attributed to specific items by the individual. Thus, the person who reports dissatisfaction with a body part, but does not consider that body part important for his or her self-concept may have a different body image from one who is dissatisfied and rates that body part as important. In the current study, we administered a parallel list of body parts, for which the individual was asked to rate the importance of the body part to himself or herself on a 6-point response scale. Thus, we could obtain scores on body and facial image, and the importance attributed to each. The multi-
plicative outcome of body and facial image by importance (ie, C {body parti X importancei}) could then be calculated. The two body image questionnaires were administered at all five measurement periods, T, through Ts. The items that made up each body image scale were then tested for internal consistency reliability at each measurement period. Alpha coefficients ranged from 0.80 to 0.97 on the facial image cathexis scale, from 0.91 to 0.99 on overall body image-cathexis, 0.89 to 0.98 on the multiplicative outcome of importance by cathexis of facial features, and 0.96 to 0.99 on importance by cathexis of body parts. PROCEDURE
All questionnaires were designed to be selfadministered. The first questionnaire (T,), which was the most extensive because it included questions on demographics, patients’ problems with oral function, motives for having or not having surgery, and several personality scales, was mailed to all respondents after we received postcards from them stating their decision regarding surgical treatment and their agreement to participate in the study. Of the 252 patients contacted, 181 (or 72%) fit the study criteria and agreed to participate. In the case of the surgical patients, the first questionnaire was mailed 6 to 12 months before the anticipated surgery date. Telephone follow-ups were made to determine if the subjects had any questions about the forms and/or methods of the study, and to remind them to return the forms in the attached envelope within 2 weeks. This approach resulted in a 100% response rate. The final questionnaires were mailed
369
KIYAK AND ZEITLER
to all patients two years after their surgery date. (Although questionnaires were also provided to the patients at 1 day, 4 to 6 weeks, and 6 months after surgery, these data are not included in this report.) This resulted in a completion rate of 80% for the Seattle sample and 84% for Iowa patients. These represent excellent completion rates for a longitudinal study. Comparisons of patients who returned their questionnaires with those who did not revealed no significant differences in age, sex, motives for surgery, and diagnosis. Results The first analyses compared self-ratings on the four facial dimensions (Fig. 2) across the six diagnostic categories. A series of x2 tests of association were conducted between each nine-point rating scale and the six categories at the presurgical assessment and at the 2-year postsurgical follow-up. At the initial measurement, significant associations emerged on all four dimensions. For example, those with mandibular hyperplasia and those in the combined category rated themselves with the greatest vertical excess, and patients with maxillary hyperplasia or hypoplasia reported vertical deficiency (x2 = 46.18, p < 0.05). Patients with mandibular hypoplasia and those in the combined category perceived themselves to be most prognathic in the maxillary (x2 = 79.53, p < 0.0001) and most deficient in the mandibular dimensions (x2 = 72.02, p < 0.0001). Conversely, patients with mandibular hyperplasia and those with maxillary hypoplasia perceived the most maxillary deficiency (x2 = 79.53, p < 0.0001) and the most mandibular excess (x2 = 72.02, p < 0.0001). Patients with mandibular hypoplasia, including those with combined maxillary hyperplasia and mandibular hypoplasia, rated themselves with the greatest bimaxillary prognathism. On the other hand, those with mandibular hyperplasia or maxillary hypoplasia rated themselves as most retrusive on this dimension (x2 = 65.05, p < 0.0005). Significant associations between diagnostic categories and self-ratings persisted on two dimensions at the 2-year follow-up, despite the fact that surgery had corrected the patients’ presurgical dentofacial malrelation. Patients who had had surgery to correct retrognathic maxillas continued to rate themselves most deficient on the maxillary dimension (x2 = 44.84, p < O.Ol), and rated themselves in the mandibular prognathic range at Time 6 (x2 = 46.32, p < 0.004). Significant differences also emerged among the six diagnostic categories on self-drawing of facial profile. Thus, patients with mandibular hypoplasia
drew their profiles significantly more retrognathic than those with mandibular hyperplasia or maxillary hypoplasia at the presurgical assessment (F = 9.21, p < 0.0001). The former also drew themselves with a shorter vertical dimension than did the latter (F = 6.02, p < 0.0004). In examining selfassessments of “other perceived deviations from normal” at the initial assessment, only 18.7% of the total sample drew deviations from the ideal profile in their nose, forehead, or upper facial region. Such perceptions were more frequent among patients with mandibular hyperplasia (33%) and mandibular hypoplasia (21%). Overall group differences were not significant. The maxillary dimension did not differ significantly among the six diagnostic categories at the presurgical assessment, but it was the only self-assessment dimension that showed significant differences at the 2-year follow-up (F = 2.46, p < 0.05). This was consistent with our finding of significant differences on the ratings of maxillary and bimaxillary dimensions at this same measurement. A notable minority of patients with maxillary hypoplasia (43%) continued to evaluate themselves as deviating from the ideal in other facial features at the final assessment. Patients who had been treated for a combined maxillary hypoplasia and mandibular hyperplasia (100%) also perceived other facial deviations at this final assessment, as did those with a combined maxillary hyperplasia and apertognathia (67%). Note that these groups had shown little likelihood of such perceptions at the presurgical stage. Patients with maxillary hypoplasia were slightly more likely to rate themselves as deviating from the ideal in other facial features at this postsurgical assessment than at the presurgical(25% vs 21%). These changes resulted in slightly more (24.6%) patients at T6 rating themselves in this manner. The second series of analyses compared presurgical patients who had been diagnosed as prognathic with those who were retrognathic and those who had a combined prognathic maxilla and a retrognathic mandible. Consistent with the comparisons across all six diagnostic categories, significant differences emerged on two of the three facial selfdrawing dimensions; the mandibular (F = 5.5 1, p < 0.006) and the vertical (F = 5.72, p < 0.005) dimensions. Prognathic patients drew their profiles to be most prognathic and long-faced. Those with combined maxillary hyperplasia and mandibular hypoplasia perceived themselves in the most retrognathic range on the mandibular dimension, as one would expect. A comparison of patients who had a maxillary malrelation with those who had a mandibular problem revealed differences only on the profile draw-
SELF-ASSESSMENTS
370
ings. Body image and the 9-point rating scales showed no differences between the two groups; this finding was consistent with the comparisons of prognathic and retrognathic patients. At the presurgical assessment, patients with mandibular problems drew their profiles most differently from maxillary patients on the mandibular (F = 3.40, p < 0.001) and the vertical dimension (F = 3.07, p < 0.003). These differences were no longer significant at Time 6. Instead, these same patients 2 years after surgery rated themselves most differently on the maxillary dimension (F = 3.19, p < 0.002). Although surgery patients generally evaluated their body image negatively at the pre-assessment, scores did not differ among the six diagnostic categories. They also did not differ at the postassessment for the overall sample, but a significant change did occur from T, to T,. Facial body image was significantly different at Time 6 for the Seattle sample (F = 3.09, p < 0.02), with the greatest differences emerging between those with maxillary hyperplasia and the combined categories. Discussion The self ratings of facial profile on the four facial dimensions (vertical, maxillary, mandibular, and dentoalveolar) at the pretreatment evaluation revealed many findings that follow logically from the diagnostic groupings. For example, patients with mandibular hypoplasia tended to choose profiles with mandibular deficiency and patients with maxillary hyperplasia combined with mandibular hypoplasia chose profiles with vertical excess, maxillary prognathism, and mandibular deficiency. Some of the profiles chosen actually correlated with a deformity in the more normal jaw, however, in the opposite direction of the actual diagnosis. Patients with maxillary hypoplasia, for example, chose profiles with mandibular prognathism. The choice of profiles in the dentoalveolar group seemed to be more related to the relative chin prominence of the profile than the degree of bimaxillary protrusion or retrusion. For example, patients with mandibular hypoplasia tended to select profiles with dentoalveolar protrusion, which has an appearance of chin deficiency. Patients tended to select profiles in the abnormal range in several or all four rating scales, even when the diagnosis of dentofacial deformity was limited to a single dimension. The self drawings of facial profiles showed some findings similar to the profile ratings. In particular, patients with mandibular deformities were able to accurately draw profiles consistent with the diagnostic categories of their dentofacial deformity. Patients with maxillary deformities, however, tended
OF ORTHOGNATHIC
PATIENTS
to draw facial profiles depicting a deformity in the mandible in the opposite direction of the maxillary diagnosis. For example, patients with maxillary hypoplasia tended to draw profiles with mandibular hyperplasia. At the 2-year postsurgery follow-up, most patients tended to choose profiles and produce drawings in the normal range; however, one category of patients, those with maxillary hypoplasia, persisted in the perception of dentofacial deformity. We propose the following explanation for this. Patients with maxillary hypoplasia may have a component of vertical deficiency with a flat mandibular plane and a prominent chin. If the surgical correction of this deformity involves correction of the sagittal problem only, the prominent chin will persist and may lead the patient to feel that a discrepancy still remains. Considering that few of the patients in this study had bone grafts, this is the most likely explanation. This is also consistent with the manner in which patients chose profiles in the dentoalveolar rating group. Analyses grouping patients by the jaw involved and by the direction of the deformity showed findings similar to the analysis by each diagnostic category. The findings strengthen the conclusion that patients can characterize mandibular and vertical deformities best and tend to characterize maxillary deformities as a mandibular deformity in the opposite direction. The higher incidence of perceived deviations in other facial features at the 2-year follow-up indicates a transfer of attention from major dentofacial abnormalities to more minor deviations. This may explain why patients with maxillary hypoplasia who tended to persist in perceptions of dentofacial abnormalities noted fewer other facial deviations than did patients with other dentofacial diagnoses. In general, body image did not differ among the diagnostic categories. This indicates that no particular group could be expected to have a better or worse body image than another diagnostic category, and that this instrument is not useful in distinguishing perceptions of various diagnostic groups. These findings indicate that body image is not a useful measure to differentiate among patients with different dentofacial deformities. Both profile ratings and profile drawings provide useful information regarding the patient’s perception of his or her dentofacial deformity. More errors seemed to be made in the choice of profiles in the four rating scales. In particular, the rating of the dentoalveolar dimension seemed to be based on relative chin prominence rather than bimaxillary protrusion or retrusion. Profile drawings were accurate for mandibular and vertical dimensions. In both methods,
371
KIYAK AND ZEITLER
patients with maxillary deformities perceived their deviation along the mandibular dimension rather than the maxillary and depicted this accordingly. Profile drawings had the additional value of allowing the patient to illustrate other areas of deviation (in nose or neck profiles, for example) from the ideal profile. Based on these findings, we recommend the use of a quick self-drawing that patients may use to illustrate how they perceive themselves to differ from a normal facial profile. By supplying a simple line drawing, the artistic skill of the patient does not influence his or her ability to depict the perceived deformity. Summary The treatment of dentofacial deformities generally results in a high degree of satisfaction for patient and doctor. This study indicates that, although patients are satisfied with the end result, the perception of facial profile by the patient is not necessarily consistent with the diagnosis. If patients perceive most deformities as mandibular in nature, care should be taken in explaining the reasons for maxillary surgery. Similarly, if chin contour is a primary focus of the patient, postsurgical expectations of change need to be addressed. Body image ratings do not appear to be a useful method for differentiating among surgical patients. A method of profile evaluation, however, can differentiate among diagnostic categories. In particular, the profile drawings may be a useful instrument for evaluating patients’ perception of their profile, and their expectations of the surgical result. In using this instrument, the patient’s tendency to overlook maxillary and dentoalveolar deformities, and to emphasize mandibular and chin profiles should be recognized.
References 1. Belfer ML, Harrison AM, Pillemer FC, et al: Appearance and the influence of reconstructive surgery on body image. Clin Plast Surg 9:307, 1982 2. Pertschuk MJ, Whitaker LA: Psychosocial adjustment and craniofacial malformations in childhood. Plast Reconstr Surg 75: 177, 1985 3. Helm S, Kreiborg S. Solow B: Psychosocial implications of malocclusion: A 15year follow-up study in 30-year-old Danes. Am J Orthod 87: 110. 1985 4. Laufer D, Glick D, Gutman D, et al: Patient motivation and response to surgical correction of prognathism. Oral Surg Oral Med Oral Pathol 41:309, 1976 5. Kiyak HA, Hohl T, Shenick RA, et al: Sex differences in motives for and outcomes of orthognathic surgery. J Oral Surg 39:757, 1981 6. Wictorin L, Hillerstrom K, Sorenson S: Biological and psychosocial factors in patients with malformation of the jaws. Stand J Plast Reconstr Surg 3: 138, 1969 7. Bell R, Kiyak HA, Joondeph DR. et al: Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod 88:323. 1985 8. ShawWC, Lewis HG, Robertson NRE: Perception of malocclusion. Br Dent J 138:225. 1975 9. Albino JE, Lewis EA, Wu TH, et al: Comparisons of professional and public assessments of malocclusion. J Dent Res 58:375, 1979 (abstr) 10. Arndt EM, Travis F, Lefebvre A, et al: Beauty and the eye of the beholder: Social consequences and personal adjustments for facial patients. Br J Plast Surg 39:81, 1986 11. Albino JE, Tedesco LA. Conny DJ: Patient perceptions of dental-facial esthetics: Shared concerns in orthodontics and prosthodontics. J Prosthet Dent 52:9, 1984 12. Rutzen SR: The social importance of orthodontic rehabilitation: Report of a five year follow-up study. J Health Sot Behav 14:233. 1973 13. Macgregor FC: Patient dissatisfaction with results of technically satisfactory surgery. Aesthetic Plast Surg 527, 1981 14. Albino JE, Cunat JJ, Fox RN, et al: Variables discriminating individuals who seek orthodontic treatment. J Dent Res 60: 1661, 1981 15. Secord PF, Jourard SM: The appraisal of body cathexis: Body cathexis and the self. J Consult Psycho1 17:343. 1953 16. Rosen G. Ross A: Relationship of body image to selfconcept. J Consult Clin Psycho1 32:100, 1969
Oral Maxlllofac
46:36&371,
Surg
1966
Self-Assessment of Profile and Body Image Among Orthognathic Surgery Patients Before and Two Years After Surgery H. ASUMAN
KIYAK,
PHD* AND
DEBORAH
L. ZEITLER,
DDS, MST
Ninety patients undergoing surgery at two major university hospitals completed self-ratings of their profile, perceived deviations from the ideal profile, and a measure of body image. Identical measures were obtained presurgically and two years following surgery. Patients diagnosed with mandibular hypoplasia perceived themsetves significantly more prognathic on the maxillary dimension and most retrognathic on the mandibular dimension; their self-drawings reflected a shorter vertical dimension. These perceptions approached the normal range at the postsurgical assessment. Patients treated for maxillary hypoplasia, however, rated themselves in the mandibular prognathic range both before and after surgery. These patients were also more likely to perceive other deviations from the ideal in their facial features 2 years after surgical correction. Body image did not differentiate among diagnostic categories, but showed overall improvements for all patients from presurgery to postsurgery. Profile drawings appear to be the most statistically and clinically useful method of determining patients’ self-assessments of deviations from normal, and their perceptions of treatment needs.
A number of researchers have commented on the negative social and psychological effects of objectively definable facial abnormalities. Belfer and colleagues’ have noted a wide range of associated problems, including limited ability to interact successfully with the parent during infancy, failure to gain a sense of mastery and competence, limited peer interactions, development of pathologic de-
fenses, and damaged self-esteem. In a comparison of 43 children undergoing surgical treatment for craniofacial malformations with a group of matched controls, Pertschuk and Whitake? found the patients to be significantly more anxious, introverted, and hyperactive; and to have poorer self-concepts, more negative social experiences, and poorer classroom behavior than children in the control group. Although the majority of subjects in the preceding studies had more severe deformities, Helm and associates3 concluded that certain malocclusions, especially conspicuous occlusal and space anomalies, may also negatively affect body image and selfconcept. Given the documented association of attractiveness with positive social outcomes, it is not surprising that esthetic considerations have been cited in many studies as a major reason for facial surgery.M Patients’ self assessments of attractiveness have been found to differ significantly from those of professionals and untrained raters, however.7-‘0 Bell
* Associate Professor, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle. I’ Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Iowa, Iowa City, Iowa. This research was supported by Grant No. 1 ROl DE05744 from the National Institute for Dental Research. This paper was presented at meetings of the IADR, Chicago, March 1987. ** Address correspondence and reprint requests to Dr. Kiyak: Department of Oral and Maxillofacial Surgery, SB-24, University of Washington, Seattle, WA 98195. 0 1988 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391188
$0.00 + .25
365
366 and associates’ concluded that self-perceptions of profile were, in fact, more important than professional recommendations and cephalometric measurements in determining whether or not individuals elect surgical correction. Noting that patients’ self-ratings were lower than these other two groups, Albino and associates” determined that patients’ self-perceptions of attractiveness and their concern about malocclusion best predicted patients’ decisions about surgery. Other predictors were an objective dental facial appearance scale (DFA) and a treatment priority index, completed by untrained observers and professionals, respectively. Evidence of whether surgical correction actually does improve self-concept and social achievements is mixed. Although an earlier study12 failed to demonstrate such gains, Arndt and colleagues” found significant positive changes among children and adolescents with mild and more severe craniofacial abnormalities after surgery. Patients’ selfperceptions of attractiveness increased dramatically when evaluated 6 months and 2 years after surgery, as did their scores on the Piers Harris selfconcept scale. Results of these studies must be viewed with caution. Belfer and associates’ point out that body image is a complex and relatively stable psychological phenomenon. The associated defense system that, in severe cases especially, includes massive denial, can be modified only slowly. These researchers conclude that surgical intervention facilitates but does not by itself produce changes in self-concept and social interaction. Furthermore, just as patients often differ from professionals in their preoperative self-perceptions, they may also express dissatisfaction with surgical results that are technically adequate. Macgregor13 has catalogued a variety of factors that may contribute to this outcome, including those attributable to patients (e.g., unrealistic expectations), to the surgeon (e.g., alterations of features that the patient does not consider deformed), and interactions between the surgeon and the patient (e.g., poor communication). A variety of instruments have been designed by these researchers to assess the perceptions of patients and others. Albino and colleagues”*‘4 used drawings to represent ideal occlusion; crowding; excess spacing; maxillary, mandibular, and bimaxillary protrusion; midline deviation; and open bite; in addition to the DFA cited earlier. Arndt and colleagues” administered Hay’s Rating Scale to patients, parents, and untrained raters. Bell and colleagues’ used profile sketches representing a nine-point rating scale along each of four dimensions (vertical, maxillary, mandibular, and dentoalveolar), and compared the ratings of patients and
SELF-ASSESSMENTS
OF ORTHOGNATHIC
PATIENTS
untrained observers on this measure with cephalometric analyses. The purpose of this report is to describe the results of a study aimed at comparing self-perceptions of facial form, malocclusion and body image among patients undergoing orthognathic surgery. Objective assessments of each patient’s maxiliofacial abnormalities by his or her oral and maxillofacial surgeon and orthodontist were used to categorize these patients. Comparisons were made between patient types; the relationship between diagnosed abnormalities and patients’ self-assessments before surgery and two years following surgery was examined. Materials and Methods SUBJECTS
Ninety patients were selected from the files of the Oral and Maxillofacial Clinic at University Hospital in Seattle who were in preparation for orthognathic surgery for a developmental maxillofacial abnormality. A comparable sample of 30 surgical patients was obtained at the University of Iowa. Diagnostic data were available for 69 Seattle and 21 Iowa patients. All baseline comparisons of demographic distributions, personality characteristics, and diagnostic categories between the Seattle and Iowa samples were nonsignificant. Therefore, all subsequent analyses pooled the data obtained for the two groups. Diagnostic categories and the distribution of patients in each category are illustrated in Table 1. Mandibular hypoplasia was the diagnosis in 63% of all cases. VARIABLES AND THEIR MEASUREMENT
Patients were asked to rate themselves on four profile dimensions (Fig. 1). These profile ratings were identical to those used by Bell et al.’ Each set Table 1.
Diagnosisof OentofacialMairelation Percentage of total (%)
Diagnosis
Seattle
Iowa
Mandibular hypoplasia Mandibular hyperplasia Maxillary hyperplasia Maxillary hypoplasia Combined a + c Apertognathia
45 1 2 9 11 1
12 0 2 3 3 1
63.3 1.1 4.4 13.4 15.6 2.2
21
100.0
-
69
-
367
KIYAK AND ZEITLER
of profiles consisted of a nine-point rating scale representing a different dimension of dental or skeletal disharmony: 1) vertical deficiency-vertical excess; 2) maxillary hyperplasia-hypoplasia; 3) mandibular hypoplasia-hyperplasia; and 4) dentoalveolar protrusion-retrusion. The extremes of each rating scale (1, 2, 3 and 7, 8, 9) represented dentofacial disharmony, and a midpoint rating of 5 represented an “ideal” profile (with ideal occlusion and skeletal harmony). A method was also devised to obtain selfperceptions of facial profile (Fig. 2). Male patients were given a drawing of a male profile with ideal occlusion and skeletal harmony. Female patients
i
I
B.1
2
D. 1
2
FIGURE
were administered a comparable drawing of a female profile. They were asked to sketch their profile, indicating how it differed from the drawing at any point from the forehead to the neck. A millimeter grid was later applied to the lower half of the face to measure deviations from ideal in the maxilla, the mandible, and the vertical dimension. Ten measurement points were obtained; the first seven were horizontal, and the last three were vertical measures. A factor analysis revealed that the first two points represented the maxillary dimension; points 4 through 6 the mandibular, and points 8 through 10 the vertical dimension. Scores on each of these three measures were combined, with positive
I.
3
3
4
4
5
6
7
8
Self-ratings of facial profile. A, vertical: B. maxillary; C, mandibular: and D. dentoalveolar.
9
368
SELF-ASSESSMENTS
OF ORTHOGNATHIC
PATIENTS
Point 1 Point 2 ;:I:: 4' Point 5 Point 6 Point 7 Point 8 Point 9 Point 10
FIGURE 2.
Self-assessments
of facial profile. Left, drawing for male patients. Right, drawing for female patients.
scores indicating prognathism and negative scores representing retrognathism. The individual thereby received a total self-assessment score for each of the three dimensions. In addition, self-perceptions of deviations from the ideal in the forehead region, the eyes, and the nose were noted. Body image, defined as the individual’s selfconcept of his or her physical being, was assessed with a modified version of Secord and Jourard’s body cathexis scale. l5 In our previous research, we found that the scale included several items related to general self-concept rather than body image per se. Therefore, the scale was modified to include more body parts, especially those related to facial features. This permitted the development of a subscale composed of facial body image, as well as an overall body image score. Each respondent was asked to rate his or her satisfaction with each body part on a five-point response scale, from “strong feelings, wish a change” (l), to “consider myself fortunate (5).” Research by Rosen and ROSS’~suggests that the measurement of body image may be refined by considering the subjective importance attributed to specific items by the individual. Thus, the person who reports dissatisfaction with a body part, but does not consider that body part important for his or her self-concept may have a different body image from one who is dissatisfied and rates that body part as important. In the current study, we administered a parallel list of body parts, for which the individual was asked to rate the importance of the body part to himself or herself on a 6-point response scale. Thus, we could obtain scores on body and facial image, and the importance attributed to each. The multi-
plicative outcome of body and facial image by importance (ie, C {body parti X importancei}) could then be calculated. The two body image questionnaires were administered at all five measurement periods, T, through Ts. The items that made up each body image scale were then tested for internal consistency reliability at each measurement period. Alpha coefficients ranged from 0.80 to 0.97 on the facial image cathexis scale, from 0.91 to 0.99 on overall body image-cathexis, 0.89 to 0.98 on the multiplicative outcome of importance by cathexis of facial features, and 0.96 to 0.99 on importance by cathexis of body parts. PROCEDURE
All questionnaires were designed to be selfadministered. The first questionnaire (T,), which was the most extensive because it included questions on demographics, patients’ problems with oral function, motives for having or not having surgery, and several personality scales, was mailed to all respondents after we received postcards from them stating their decision regarding surgical treatment and their agreement to participate in the study. Of the 252 patients contacted, 181 (or 72%) fit the study criteria and agreed to participate. In the case of the surgical patients, the first questionnaire was mailed 6 to 12 months before the anticipated surgery date. Telephone follow-ups were made to determine if the subjects had any questions about the forms and/or methods of the study, and to remind them to return the forms in the attached envelope within 2 weeks. This approach resulted in a 100% response rate. The final questionnaires were mailed
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to all patients two years after their surgery date. (Although questionnaires were also provided to the patients at 1 day, 4 to 6 weeks, and 6 months after surgery, these data are not included in this report.) This resulted in a completion rate of 80% for the Seattle sample and 84% for Iowa patients. These represent excellent completion rates for a longitudinal study. Comparisons of patients who returned their questionnaires with those who did not revealed no significant differences in age, sex, motives for surgery, and diagnosis. Results The first analyses compared self-ratings on the four facial dimensions (Fig. 2) across the six diagnostic categories. A series of x2 tests of association were conducted between each nine-point rating scale and the six categories at the presurgical assessment and at the 2-year postsurgical follow-up. At the initial measurement, significant associations emerged on all four dimensions. For example, those with mandibular hyperplasia and those in the combined category rated themselves with the greatest vertical excess, and patients with maxillary hyperplasia or hypoplasia reported vertical deficiency (x2 = 46.18, p < 0.05). Patients with mandibular hypoplasia and those in the combined category perceived themselves to be most prognathic in the maxillary (x2 = 79.53, p < 0.0001) and most deficient in the mandibular dimensions (x2 = 72.02, p < 0.0001). Conversely, patients with mandibular hyperplasia and those with maxillary hypoplasia perceived the most maxillary deficiency (x2 = 79.53, p < 0.0001) and the most mandibular excess (x2 = 72.02, p < 0.0001). Patients with mandibular hypoplasia, including those with combined maxillary hyperplasia and mandibular hypoplasia, rated themselves with the greatest bimaxillary prognathism. On the other hand, those with mandibular hyperplasia or maxillary hypoplasia rated themselves as most retrusive on this dimension (x2 = 65.05, p < 0.0005). Significant associations between diagnostic categories and self-ratings persisted on two dimensions at the 2-year follow-up, despite the fact that surgery had corrected the patients’ presurgical dentofacial malrelation. Patients who had had surgery to correct retrognathic maxillas continued to rate themselves most deficient on the maxillary dimension (x2 = 44.84, p < O.Ol), and rated themselves in the mandibular prognathic range at Time 6 (x2 = 46.32, p < 0.004). Significant differences also emerged among the six diagnostic categories on self-drawing of facial profile. Thus, patients with mandibular hypoplasia
drew their profiles significantly more retrognathic than those with mandibular hyperplasia or maxillary hypoplasia at the presurgical assessment (F = 9.21, p < 0.0001). The former also drew themselves with a shorter vertical dimension than did the latter (F = 6.02, p < 0.0004). In examining selfassessments of “other perceived deviations from normal” at the initial assessment, only 18.7% of the total sample drew deviations from the ideal profile in their nose, forehead, or upper facial region. Such perceptions were more frequent among patients with mandibular hyperplasia (33%) and mandibular hypoplasia (21%). Overall group differences were not significant. The maxillary dimension did not differ significantly among the six diagnostic categories at the presurgical assessment, but it was the only self-assessment dimension that showed significant differences at the 2-year follow-up (F = 2.46, p < 0.05). This was consistent with our finding of significant differences on the ratings of maxillary and bimaxillary dimensions at this same measurement. A notable minority of patients with maxillary hypoplasia (43%) continued to evaluate themselves as deviating from the ideal in other facial features at the final assessment. Patients who had been treated for a combined maxillary hypoplasia and mandibular hyperplasia (100%) also perceived other facial deviations at this final assessment, as did those with a combined maxillary hyperplasia and apertognathia (67%). Note that these groups had shown little likelihood of such perceptions at the presurgical stage. Patients with maxillary hypoplasia were slightly more likely to rate themselves as deviating from the ideal in other facial features at this postsurgical assessment than at the presurgical(25% vs 21%). These changes resulted in slightly more (24.6%) patients at T6 rating themselves in this manner. The second series of analyses compared presurgical patients who had been diagnosed as prognathic with those who were retrognathic and those who had a combined prognathic maxilla and a retrognathic mandible. Consistent with the comparisons across all six diagnostic categories, significant differences emerged on two of the three facial selfdrawing dimensions; the mandibular (F = 5.5 1, p < 0.006) and the vertical (F = 5.72, p < 0.005) dimensions. Prognathic patients drew their profiles to be most prognathic and long-faced. Those with combined maxillary hyperplasia and mandibular hypoplasia perceived themselves in the most retrognathic range on the mandibular dimension, as one would expect. A comparison of patients who had a maxillary malrelation with those who had a mandibular problem revealed differences only on the profile draw-
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ings. Body image and the 9-point rating scales showed no differences between the two groups; this finding was consistent with the comparisons of prognathic and retrognathic patients. At the presurgical assessment, patients with mandibular problems drew their profiles most differently from maxillary patients on the mandibular (F = 3.40, p < 0.001) and the vertical dimension (F = 3.07, p < 0.003). These differences were no longer significant at Time 6. Instead, these same patients 2 years after surgery rated themselves most differently on the maxillary dimension (F = 3.19, p < 0.002). Although surgery patients generally evaluated their body image negatively at the pre-assessment, scores did not differ among the six diagnostic categories. They also did not differ at the postassessment for the overall sample, but a significant change did occur from T, to T,. Facial body image was significantly different at Time 6 for the Seattle sample (F = 3.09, p < 0.02), with the greatest differences emerging between those with maxillary hyperplasia and the combined categories. Discussion The self ratings of facial profile on the four facial dimensions (vertical, maxillary, mandibular, and dentoalveolar) at the pretreatment evaluation revealed many findings that follow logically from the diagnostic groupings. For example, patients with mandibular hypoplasia tended to choose profiles with mandibular deficiency and patients with maxillary hyperplasia combined with mandibular hypoplasia chose profiles with vertical excess, maxillary prognathism, and mandibular deficiency. Some of the profiles chosen actually correlated with a deformity in the more normal jaw, however, in the opposite direction of the actual diagnosis. Patients with maxillary hypoplasia, for example, chose profiles with mandibular prognathism. The choice of profiles in the dentoalveolar group seemed to be more related to the relative chin prominence of the profile than the degree of bimaxillary protrusion or retrusion. For example, patients with mandibular hypoplasia tended to select profiles with dentoalveolar protrusion, which has an appearance of chin deficiency. Patients tended to select profiles in the abnormal range in several or all four rating scales, even when the diagnosis of dentofacial deformity was limited to a single dimension. The self drawings of facial profiles showed some findings similar to the profile ratings. In particular, patients with mandibular deformities were able to accurately draw profiles consistent with the diagnostic categories of their dentofacial deformity. Patients with maxillary deformities, however, tended
OF ORTHOGNATHIC
PATIENTS
to draw facial profiles depicting a deformity in the mandible in the opposite direction of the maxillary diagnosis. For example, patients with maxillary hypoplasia tended to draw profiles with mandibular hyperplasia. At the 2-year postsurgery follow-up, most patients tended to choose profiles and produce drawings in the normal range; however, one category of patients, those with maxillary hypoplasia, persisted in the perception of dentofacial deformity. We propose the following explanation for this. Patients with maxillary hypoplasia may have a component of vertical deficiency with a flat mandibular plane and a prominent chin. If the surgical correction of this deformity involves correction of the sagittal problem only, the prominent chin will persist and may lead the patient to feel that a discrepancy still remains. Considering that few of the patients in this study had bone grafts, this is the most likely explanation. This is also consistent with the manner in which patients chose profiles in the dentoalveolar rating group. Analyses grouping patients by the jaw involved and by the direction of the deformity showed findings similar to the analysis by each diagnostic category. The findings strengthen the conclusion that patients can characterize mandibular and vertical deformities best and tend to characterize maxillary deformities as a mandibular deformity in the opposite direction. The higher incidence of perceived deviations in other facial features at the 2-year follow-up indicates a transfer of attention from major dentofacial abnormalities to more minor deviations. This may explain why patients with maxillary hypoplasia who tended to persist in perceptions of dentofacial abnormalities noted fewer other facial deviations than did patients with other dentofacial diagnoses. In general, body image did not differ among the diagnostic categories. This indicates that no particular group could be expected to have a better or worse body image than another diagnostic category, and that this instrument is not useful in distinguishing perceptions of various diagnostic groups. These findings indicate that body image is not a useful measure to differentiate among patients with different dentofacial deformities. Both profile ratings and profile drawings provide useful information regarding the patient’s perception of his or her dentofacial deformity. More errors seemed to be made in the choice of profiles in the four rating scales. In particular, the rating of the dentoalveolar dimension seemed to be based on relative chin prominence rather than bimaxillary protrusion or retrusion. Profile drawings were accurate for mandibular and vertical dimensions. In both methods,
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patients with maxillary deformities perceived their deviation along the mandibular dimension rather than the maxillary and depicted this accordingly. Profile drawings had the additional value of allowing the patient to illustrate other areas of deviation (in nose or neck profiles, for example) from the ideal profile. Based on these findings, we recommend the use of a quick self-drawing that patients may use to illustrate how they perceive themselves to differ from a normal facial profile. By supplying a simple line drawing, the artistic skill of the patient does not influence his or her ability to depict the perceived deformity. Summary The treatment of dentofacial deformities generally results in a high degree of satisfaction for patient and doctor. This study indicates that, although patients are satisfied with the end result, the perception of facial profile by the patient is not necessarily consistent with the diagnosis. If patients perceive most deformities as mandibular in nature, care should be taken in explaining the reasons for maxillary surgery. Similarly, if chin contour is a primary focus of the patient, postsurgical expectations of change need to be addressed. Body image ratings do not appear to be a useful method for differentiating among surgical patients. A method of profile evaluation, however, can differentiate among diagnostic categories. In particular, the profile drawings may be a useful instrument for evaluating patients’ perception of their profile, and their expectations of the surgical result. In using this instrument, the patient’s tendency to overlook maxillary and dentoalveolar deformities, and to emphasize mandibular and chin profiles should be recognized.
References 1. Belfer ML, Harrison AM, Pillemer FC, et al: Appearance and the influence of reconstructive surgery on body image. Clin Plast Surg 9:307, 1982 2. Pertschuk MJ, Whitaker LA: Psychosocial adjustment and craniofacial malformations in childhood. Plast Reconstr Surg 75: 177, 1985 3. Helm S, Kreiborg S. Solow B: Psychosocial implications of malocclusion: A 15year follow-up study in 30-year-old Danes. Am J Orthod 87: 110. 1985 4. Laufer D, Glick D, Gutman D, et al: Patient motivation and response to surgical correction of prognathism. Oral Surg Oral Med Oral Pathol 41:309, 1976 5. Kiyak HA, Hohl T, Shenick RA, et al: Sex differences in motives for and outcomes of orthognathic surgery. J Oral Surg 39:757, 1981 6. Wictorin L, Hillerstrom K, Sorenson S: Biological and psychosocial factors in patients with malformation of the jaws. Stand J Plast Reconstr Surg 3: 138, 1969 7. Bell R, Kiyak HA, Joondeph DR. et al: Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod 88:323. 1985 8. ShawWC, Lewis HG, Robertson NRE: Perception of malocclusion. Br Dent J 138:225. 1975 9. Albino JE, Lewis EA, Wu TH, et al: Comparisons of professional and public assessments of malocclusion. J Dent Res 58:375, 1979 (abstr) 10. Arndt EM, Travis F, Lefebvre A, et al: Beauty and the eye of the beholder: Social consequences and personal adjustments for facial patients. Br J Plast Surg 39:81, 1986 11. Albino JE, Tedesco LA. Conny DJ: Patient perceptions of dental-facial esthetics: Shared concerns in orthodontics and prosthodontics. J Prosthet Dent 52:9, 1984 12. Rutzen SR: The social importance of orthodontic rehabilitation: Report of a five year follow-up study. J Health Sot Behav 14:233. 1973 13. Macgregor FC: Patient dissatisfaction with results of technically satisfactory surgery. Aesthetic Plast Surg 527, 1981 14. Albino JE, Cunat JJ, Fox RN, et al: Variables discriminating individuals who seek orthodontic treatment. J Dent Res 60: 1661, 1981 15. Secord PF, Jourard SM: The appraisal of body cathexis: Body cathexis and the self. J Consult Psycho1 17:343. 1953 16. Rosen G. Ross A: Relationship of body image to selfconcept. J Consult Clin Psycho1 32:100, 1969