J Oral Maxillofac 49:594-602,
Surg
1991
Attitude
Variables of Den tofacial Deformity Patients:
Demographic
Characteristics
and Associations
KATHLEEN
H. MAYO, DDS, MS,* KATHERINE DRYLAND VIG, BDS, MS, DORTH, FDSRCSJ PETER S. VIG, BDS, PHD, DORTH, FDSRCS,$ AND CHARLES J. KOWALSKI, PHD§
For patients to obtain satisfaction from surgical orthodontic treatment, a concordance needs to exist between the patients’ concerns and expectations and the clinician’s outcome measures of success. In this study, 231 patients 16 years or older were analyzed to define attributes of treatment that relate to patient satisfaction with outcome. The most prevalent patient concerns were related to facial and dental esthetics, and the effect of the dentofacial deformity on the quality of life was associated with a significantly higher motivation for surgical treatment.
A combination of orthodontics and orthognathic surgery is the contemporary approach for the treatment of patients with dentofacial deformities. For patients to achieve optimal satisfaction from treatment, most clinicians would agree that the selection of the appropriate procedure must not only be based on the clinician’s anticipated objectives with regard to esthetics, function, and stability, but also on the patients’ objectives, expectations, and their perceived needs. Dissatisfaction with treatment is seldom related to the technical skill of the surgeon, but may result from an unfavorable interpersonal relationship between the clinician and patient. This may arise from a failure to identify and deal appropriately with those patients who may become displeased with the
outcome of treatment even if the results are excellent. This situation may pose a significant problem. Patient discontent may manifest in an emotional crisis, legal action, verbal complaints to the surgeon, refusal to pay the fee for service, and even occasioning physical harm to the doctor.’ Treatment goals should, therefore, address the patients’ perceived needs as well as the clinicians’ diagnostic criteria for recommending treatment. The needs of patients and the concordance between patients’ and providers’ expectations for treatment outcomes are not well understood. The purpose of this study was to characterize a dentofacial patient population with respect to the frequency distribution of demographic variables and features that pertain to patients’ concerns, desires, and expectations.
* Lecturer, Department of Oral and Maxillofacial Surgery, The University of Michigan, Ann Arbor. t Associate Professor and Chairman, Department of Orthodontics. The University of Pittsburgh, Pittsburgh, PA. j: Professor, Associate Dean for Research, The University of Pittsburgh, Pittsburgh, PA. 5 Professor, Department of Biologic and Materials Sciences, The University of Michigan, Ann Arbor. This research was supported in part by grant DE 06881 and DE 09883. Address correspondence and reprint requests to Dr Katherine Dryland Vig: Department of Orthodontics, School of Dental Medicine, The University of Pittsburgh, Pittsburgh, PA 15261.
Literature Review
0 1991 American geons
Association
of Oral and Maxillofacial
PATIENT MOTIVATION FACTORS
In an effort to predict postsurgical satisfaction, various motivational factors for seeking treatment have been investigated. Functional improvement has been studied as a motivation factor for patients who decide to have orthognathic surgery. In the study by Olson and Laskin,2 all patients were satisfied with the functional change and 92% with the esthetic change. Kiyak and coworkers3 reported that neither the severity of problems nor the needs
Sur-
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of the patients can predict the likelihood of success or failure of psychosocial adaptation postsurgically. These authors emphasize the importance of establishing what is expected from surgery before treatment. They conclude that if a patient is primarily concerned with esthetics, which can be corrected, then a successful outcome from treatment will occur. However, if an improvement in esthetics is unlikely, the patient will probably be dissatisfied with the outcome. Esthetic improvement has also been reported to be a strong motivational factor for many patients who decide on orthognathic surgery.4 In 1985, Bell and coworkers’ reported that in spite of surgery being recommended by dental professionals, and the dentofacial deformity confirmed by cephalometric or morphologic parameters, patients’ self-perception of their facial profile may be the most important factor in the decision to elect surgical correction. In recommending treatment alternatives to patients, it is important for orthodontists and surgeons to establish that their evaluation of facial esthetics is in agreement with the concerns of the patient.’ Other investigators have also stated that esthetic considerations influence the decision of patients to have orthognathic surgery. A report of a study by Wictorin and coworkers6 showed that 62% of postsurgical patients stated a desire for changes in appearance as a motive for electing surgical treatment, whereas 76% desired an improvement in dental function. These results are similar to those published by Laufer and colleagues,7 who reported that 56% of postsurgical patients claimed that esthetic concerns were their primary motive for seeking treatment. Kiyak and coworkers4 found that 53% of the females and 41% of the males in their study reported esthetic appearance as the major reason for considering orthognathic surgery. PSYCHOLOGICAL ASSESSMENT
The need to assess psychological characteristics as a predictor of patient satisfaction has recently been recognized.‘.“” Peterson and Topazian’ examined body image as a predictor of satisfaction. Prior to surgery, patients were asked to state the nature, duration, and degree of their deformity, as well as their motives for surgery and expectations from treatment. The results of Peterson and Topazian’ suggest that an increase in the number of positive responses may be a predictor of postoperative patient satisfaction. Patients who had developed a good body image despite their objective deformity were more likely to have realistic expectations of corrective procedures than those with a
poor body image. The patients’ state of social adjustment also affected treatment. Those patients who were aggressive and overdemanding were not likely to be satisfied with the results of treatment. Regarding the role of deformity in personality structure, Peterson and Topazian’ wrote, “The aim of well-adjusted patients is to get rid of self-conscious preoccupations with the deformity as a way of freeing themselves of emotional barriers. They are seeking a primary gain; for example, getting a better job or improving their interpersonal relationships.” In addition, the patient with a major deformity generally is psychologically a more favorable candidate for surgery than one with a minor defect. Oulette” studied postsurgical patients and specifically asked if they were reticent about treatment and attempted to elicit the cause. Fear of cost deterred most patients initially, even though they were unhappy with their appearance or they had been strongly advised to begin treatment by their dentists or physicians. More than half the patients in this study were happy with the results immediately after treatment was completed. In the longterm, the number increased to 93%. Oulette” stated that the results of this preliminary study indicated that the psychological needs of patients may be more fundamentally important than the morphologic aspects of treatment. In a study of cosmetic surgery patients, Lewis and coworkers’ administered an open-ended questionnaire to obtain self-assessments of attractiveness, anxiety, fear, and expectation in an attempt to predict satisfaction. Kiyak and colleagues’” suggested that patients who were planning to undergo surgery were significantly more dissatisfied with their facial appearance than those patients who were not contemplating surgery. The results indicated that surgery improved self-esteem and body image, particularly the patient’s evaluation of facial attractiveness. The importance attached to physical features, patients’ self-esteem, body image, and degree of extroversion were unrelated to postsurgical satisfaction. The only personality variable that was found to be associated with surgical outcomes was neuroticism, which correlated positively with satisfaction. Considerations of the patient’s self-concept and neuroticism should be taken into account when planning surgical treatment or conventional orthodontic treatment. GENDER DIFFERENCES
Gender differences in establishing motives for rhinoplasty have been described by SchultzCoulon.” Men seeking rhinoplasty gave an equal number of functional and appearance motives,
596
ATTITUDE
whereas women gave a greater number of reasons for esthetic rather than functional motives. HayI reported that women thought cosmetic surgery would give them a new start on life, whereas men more often believed it would improve their career prospects. These findings support the traditional gender role stereotypes, that women are more concerned with appearance and men are more concerned with achievement. DEVELOPMENTOF SURVEYINSTRUMENTS
The literature indicates that a number of attempts have been made to create survey instruments to assess the goals of treatment and the patients’ expectations and perceptions of attained objectives. A more valid instrument is needed to derive utility scales to weight the relative importance of treatment procedures and outcome variables and to quantify patient and clinician preferences to establish the efficacy of treatment. The need to incorporate preferences and values into clinical decisions has received more attention in the medical than the dental literature.14 Currently, there is no explicit quantitative estimation of the effects of the intervention on health outcomes with regard to orthodontic/orthognathic surgery. Clinical and administrative decisions are typically based on qualitative subjective estimates of risk/benefit. However, the rising cost and patterns of delivery of health care have resulted in greater involvement of patients and consumer groups in treatment decisions. The increase in malpractice claims where expert opinion is, of necessity, given on the basis of subjective judgments, and the pressure for quantitative estimates of a technology’s effects, require a quantitative assessment method.r5 Decision analysts state that the value judgments underlying clinical decisions can and ought to be considered systematically and explicitly. Utility analysis defines values based on a decision maker’s preference for various treatment outcomes.r6 According to Cochrane,” preliminary steps and definitions are essential before a cost/benefit approach becomes a practical possibility. He refers to efficacy as the decision that a particular treatment actually alters the natural history of a particular disease for the better. This comparison is made against no treatment or against a placebo. Ej@+ncy also implies that a given treatment works better or worse than some other active form of treatment. The comparison is against a standard treatment the efficacy of which is well demonstrated or generally accepted. This is not yet available for either orthodontics or surgery. Effectiveness, however, refers not
VARIABLES
OF DENTOFAClAL
PATIENTS
to a comparison, but rather to the impact of a therapeutic agent in the community. Although a treatment may be both efficacious and efficient in clinical trials, the treatment may be ineffective when introduced into the community because it is so inconvenient, uncomfortable, or expensive that patient compliance becomes a problem. An important aspect of a utility assessment is the identification of a suitable health outcome by which to evaluate a treatment intervention. Our present preliminary study reconciles patient needs and expectations. Using patient need and expectations as a reference, the efficacy of conventional procedures may be evaluated. How well any procedure fulfills a patient’s needs depends how satisfied a patient is with the treatment results. Methods and Materials Questionnaires of 231 patients of 16 years and older were analyzed. The 23 1 patients ranged in age from 16 to 65 years, with a mean age of 26.7 years and a female/male ratio of 3 to 2. This subset of patients was part of a larger sample of patients referred to the University of Michigan dentofacial program during 1984 to 1988. Approximately 70 orthodontic-surgical patients are referred annually to the dentofacial program both from within the School of Dentistry and from general dentists, orthodontists, and by self-referral. These patients are not in the category of craniofacial anomalies or dysmorphic syndromes, but may be regarded as extremes or normal biological variation of craniofacial morphology. The initial records of these dentofacial patients were examined retrospectively. They included the patient interview questionnaire, which was either administered by an oral surgery or orthodontic resident who had received instructions in how to report the demographic data and attitude variables (Fig 1). The residents were all instructed in how to administer the questionnaire, and the interpreter agreement was verified by both an oral and maxillofacial surgeon and orthodontic faculty on the same day. The chief complaint was expressed in terms of dental and/or facial esthetic concerns and functional terms related to the bite or occlusal relationship. The frequency distribution of patients attitudes to their dentofacial appearance, function, and demographic variables were determined. Contingency analysis was used and the x2 test was applied to compare orthodontic motivation, surgical motivation, and concerns with demographic and attitudinal variables. The 231 patients were divided by gender
597
MAYOETAL
FIGURE 1. The interview questionnaire that was administered to patients at their first appointment in the dentofacial program.
to compare differences between males and females with respect to demographic and attitudinal variables. Results REASONS FOR SEEKING TREATMENT
The duration of concern was trimodally distributed, with 38% of patients having concerns for 1 to 3 years before seeking treatment, 30% having concerns for 3 to 9 years, and, surprisingly, almost a third of the sample (32%) having waited 9 to 11 years before seeking treatment. When questioned as to what prompted the decision to seek treatment, only 7% of the patients cited insurance and 10% of the patients cited savings. As the financial cost of orthognathic surgery is considerable, the influence of financial coverage for treatment was expected to be a prime factor in the decision-making process. Encouragement from a “significant other” was the reason for 12% of patients deciding on treatment now. The majority of patients (71%) responded that “other” reasons prompted them to seek treatment.
PAST HISTORY
About one half of the patients (51%) reported a history of previous treatment for their deformity. In our sample 28% had received orthodontic treatment only, 15% had bite appliance therapy, 20% had “other” nonspecified treatment, 4% had surgical treatment, and less than 1% received both orthodontics and surgery. Approximately one fourth (28%) of the patients claimed to have a history of previous facial trauma as a reason for treatment. Less than one half (40%) of the patients reported a family history of a dentofacial deformity. Of those patients, there was an almost equal distribution between a maternal and paternal history. PERSONAL HISTORY
Most patients interviewed were single (68%). Twenty-five percent of the patients were married, 10% were divorced, and less than 1% were separated. Most patients had no children (70%). Of these patients, 34% lived with their parents. Others
598
ATTITUDE VARIABLES OF DENTOFACIAL PATIENTS
lived with their spouse (28%), with their children (17%), alone (19%), or with “other” (5%). When asked about their dating pattern, 44% of the patients stated they did not date, 25% stated they dated regularly, and 14% stated they dated occasionally. Nearly one half of the patients admitted to recent or anticipated major life events, which included the death of a friend or relative (30%), job change (26%), promotion (15%), separation or divorce (13%), birth of a child (6%), and “other” (10%). Most patients experienced a good (86%) or average (12%) relationship with their family. REFERRAL PATTERN
The majority of patients (89%) were referred for one or more reasons. Dental esthetics (50%) was the reason most frequently given for referral. Dental function (51%), facial esthetics (25%), temporomandibular disorder (TMD) symptoms (27%), and “other” (6%) were additional reasons. Patients with dental esthetic and dental function concerns were more frequently referred than patients who were concerned about facial esthetics, TMD symptoms, and “other.” ATTITUDE VARIABLES
Orthodontic
Motivation
Median motivation rating for orthodontic treatment on a lo-point scale was 9. No association was found between orthodontic motivation and age (Fig 2). However, a highly significant association between motivation for orthodontics and motivation for surgery (I’ < .OOOl)was shown by x2 analysis of coded data. Patients who were highly motivated for orthodontic treatment tended to be highly motivated for surgical treatment. Reasons given for seeking treatment at that time included “significant other,” savings, insurance, or “other.” The patients most highly motivated for orthodontic treatment gave the reason for seeking treatment at that time as “other” (73%). The remaining reasons, “significant other” (13%), savings (lo%), and insurance (5%), were given less often. No statistically significant associations existed between orthodontic motivation and frequency of referral, patient concerns, reason for seeking treatment, history or previous trauma, history of previous treatment, effect of deformity on life, family history of deformity, or expectations of treatment.
Age FIGURE 2. Distribution of motivation for orthodontic treatment by age. W, Motivation 1 to 3; q, motivation 4 to 6; cl, motivation 7 to 10.
tween surgical motivation and age (Fig 3). The chief complaint or reason for seeking treatment at that time, and the effect of the dentofacial deformity on their life were also associated with motivation for surgery. Patients over the age of 41 years tended to be less motivated for surgery (P = .Ol) than the younger adults or teenagers (Fig 3). Patients who sought treatment for dental esthetic complaints (59%) were significantly more motivated for surgery than those without such complaints (P = .034). The 60
0 16-20
21-30
31-40
>41
Surgical Motivation Median motivation rating for surgical treatment was 8 on a IO-point scale. Associations existed be-
Age FIGURE 3. Distribution of motivation for surgery by age. n , Motivation 1 to 3; q, motivation 4 to 6; Cl, motivation 7 to 10.
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MAYO ET AL
other complaints that prompted patients to seek treatment, namely, facial esthetics (34%), TMD (33%), dental function (61%), and “other reasons” (7%), were not significantly associated with the level of motivation that patients had for surgical treatment. Patients who claimed that their deformity had an effect on their life (44%) were more highly motivated for surgery than those who did not (P = .029). No significant associations existed between surgical motivation and frequency of referral, patient concerns, history of previous trauma, or history of previous treatment.
60
JO
20
Patient Concerns 0
The rank order of concerns (Fig 4) was dental esthetics (31%), dental function (27%), facial esthetic (22%), TMD symptoms (17%), and other (3%). No discernable association existed between patient concerns and reason for seeking treatment at that particular time or a history of previous trauma. The relationship between patient concerns and treatment expectations, reason for referral, or reason for seeking treatment could not be tested with the x2 test as there were multiple responses in all categories.
Dent. Est
Dent. Funct
Face Est. TMJ
Other Physical
Expectations -Desired Outcomes FIGURE 5. Frequency distribution of expectations ment by gender. H, Males; H. females.
from treat-
facial esthetics, TMD symptoms, and in the “other” category appeared to be more highly motivated than patients who expected improvements in dental function and dental esthetics. GENDER DIFFERENCES
Patient Expectations Patient expectations corresponded closely with concerns and reasons for seeking treatment. Psychological and/or economic benefits from treatment were expected. Expectations from treatment (Fig 5) included improvements in dental esthetics, dental function, facial esthetics, TMD symptoms, and “other.” Patients who expected improvements in 100
The female/male ratio was 3 to 2. Using xz significant gender differences were found with regard to patient age (Fig 6). A history of trauma and also a history of previous treatment (Fig 7). and motivation for surgery (Fig 8) were strongly associated. 60
SO
80
40
60
30
-IO
20
20
IO
0
0 Dent Est. Dent. Funct. Face Est.
TMJ
Olher Physical
16-20
21-30
Concerns
Age
FIGURE 4. Ranked order of patients’ concerns by gender. W, Males; H, females.
FIGURE 6. Gender distribution in the sample when ranked by age. W. Males; q, females.
ATTITUDE VARIABLES
OF DENTOFACIAL
PATIENTS
symptoms than did males. Females complained of and sought treatment for TMD symptoms twice as often as males. Females also tended to seek treatment more often than males for facial esthetic reasons (Fig 4). No associations existed between gender and incidence of referral, reason for seeking treatment at that particular time, effect of deformity on life, family history of deformity, or motivation for orthodontic treatment. Discussion
Ortho
Surgery
Bitesplint
Other
Previous Treatment
FIGURE 7. Distribution of patients’ previous history of treatment before referral to the dentofacial program. n , Males; E?J, females.
There were twice as many females than males over the age of 30 (P = .004). More females (80%) reported a history of trauma than did males (69%) (P = .038). Three times as many females had previous bite appliance therapy (Fig 7), and males more often expressed a high rating for surgery (P = JOI). Improvement in dental esthetics, dental function, facial esthetics, and “other” was expected equally regardless of gender (Fig 5). However, twice as many females expected improvement in TMD
no
60
(l-3)
Surgical
(J-6) Motivation
(7-10) Rating
FIGURE 8. Motivation for surgery among males and females in the sample. W, Males; q females.
The mean age of the patients in this study was similar to that reported by Oulette.” However, the female to male ratio was lower than reported in previous studies in which there were two to three times as many females in the sample.“*‘* In 1981, Kiyak and coworkers4 concluded that motives of patients for seeking orthognathic surgery are different from those seeking cosmetic surgery. In Kiyak’s opinion, orthognathic surgery patients are frequently referred by a general dentist or orthodontist for a functional problem, with esthetic appearance having a secondary role. In contrast, individuals seeking cosmetic surgery do so primarily for reasons of appearance. The most frequent reason for referral in our patient sample was related to dental esthetics, although this might be biased by the referral being made to a dental school. However, esthetic improvement has been reported as a strong motivational factor for many patients who seek orthognathic surgery.6*7 In 1976, Laufer and colleagues7 administered a questionnaire to patients who had previously had surgical correction of mandibular prognathism. Fifty-six percent of this group reported that esthetic concerns were their primary motive. Dental function was the second most common reason given by our patients for referral, and ranked second among patient concerns. This is consistent with Laufer,6 who also reported that difftculty in chewing was the second most common primary reason for seeking surgery. In a report by Oulette,” fear of cost deterred most people initially from seeking treatment, even though they were unhappy with their appearance or they had been strongly urged to begin treatment by their dentists or physicians. Surprisingly, in our study, financial concerns played only a minor role with regard to seeking treatment. When questioned as to what prompted the patient to seek treatment at that particular time, only a few patients cited insurance or savings as the reason for seeking treatment. “Other” reasons were most likely to prompt patients to seek treatment when they did.
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MAYO ET AL
The majority of patients in our study were single; only one fourth of the patients were married. A small proportion were separated or divorced. In a report by Oulette, ” the rank order of marital status was similar; there was a nearly equal distribution of married and single people, and a smaller number were divorced. Improvement in dental esthetics, dental function, facial esthetics, and “other” were equally distributed expectations from treatment, regardless of gender. However, male and female dentofacial deformity patients differed significantly in the distribution of concerns, motivation, and expectations regarding treatment. In a study by Kiyak,4 there were no significant gender differences regarding reasons for seeking surgical treatment. In that study, esthetic appearance was an important consideration for both genders, second only to the advice of professionals as a motive. Contrary to gender role stereotypes, Kiyak4 suggests that it appears that both men and women seeking orthognathic surgery are concerned about their appearance and that functional and health motives were equally important for men and women. In our study, more females complained of and sought treatment for TMD symptoms than did males, and expected improvement in TMD symptoms. They also had more frequent previous bite appliance therapy. This is consistent with reports by Kiyak and colleagues,3 who found females had TMD problems nearly five times more frequently than did men. Externul Influences A report by Kiyak and Beach” suggests that influences from friends, family, and other relatives may be more significant in contributing to the decision to pursue treatment than the advice of dental experts, expectation of functional improvement, esthetic enhancement, or financial considerations. If family and friends think surgery will be beneficial, and support the decision to proceed with orthognathic surgery, then a patient is more inclined to proceed. In our study, young adults tended to be highly motivated for both surgical and orthodontic treatment, regardless of parental influence. Patients who claimed that their deformity had an effect on their life were also more highly motivated for surgery than those who did not, and very few patients stated that their family or significant others influenced their decision to seek treatment. Patients who sought treatment for dental esthetic reasons were also more highly motivated for surgery than patients who sought treatment for facial esthetic or dental function. Those patients who were highly
motivated for orthodontic treatment also tended to be highly motivated for surgical treatment. According to Bell and coworkers5 dental specialists should be aware of the potential for exaggeration of perceived needs developed during training, and which may not be concordant with the patients’ perceived need for treatment. Patients’ perceptions of facial esthetics and need or desires for treatment should be of primary concern when a therapeutic alteration of facial esthetics is contemplated. Treatment planning should not be based solely on the morphologic deviations from “norms” or from technically attainable “ideals.” The patient’s rather than clinician’s utility for the various outcomes should be established and incorporated into the decision. ” Utility assessment of treatment should partition outcome variables to permit cost-benefit assessment from the patients’ perspective; specifically, in terms of the degree to which expectations are met and especially in view of the elective nature of the treatment. Summary and Conclusions In this study, the two most common and equally prevalent patient concerns were facial and dental esthetics, which corresponded closely with patient expectations. No associations existed between orthodontic motivation and the incidence of referral or patient concerns. Likewise, no associations were demonstrated between surgical motivation and age. The effect of dentofacial deformity on the quality of life was, however, associated with a significantly higher motivation for surgical treatment. There was a female/male ratio of 3 to 2 and significant gender differences occurred regarding age and previous TMD history in females. This preliminary study defines attributes of treatment that relate to patients’ and clinicians’ expectations from treatments and their respective degrees of satisfaction with outcomes. Survey instruments based on such findings should be developed to assess the goals of treatment and the patients’ expectations and perceptions of the attained objective. It should be possible to derive utility scales to weight the relative importance of the many treatment processes and outcome variables, and thereby to quantify patient and clinician preferences and to establish key parameters that provide valid measures of efficacy. Through the development of such methods, it may be possible to test if significant differences exist between populations derived from private practices as opposed to university clinics, and thereby to design criteria that may be applied to improve both prospective and retrospective clinical studies.
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ATTITUDE VARIABLES
References I. Peterson LJ, Topazian R: Psychological consideration in corrective maxillary and midfacial surgery. J Oral Surg 34: 157, 1976 2. Olson RE, La&in DM: Expectations of patients from orthognathic surgery. J Oral Surg 38:283, 1980 3. Kiyak HA, Hohl T, West RA, et al: Psychologic changes in orthognathic surgery patients: A 24-month follow up. J Oral Surg 42:506, 1984 4. Kiyak HA, Hohl T, Sherrick RA, et al: Sex differences in motives for and outcomes of orthognathic surgery. J Oral Surg 39:757, 1981 5. 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 6. Wictorin L, Hillerstrom K, Sorensen S: Biological and psychosocial factors in patients with malformations of the jaws. Stand J Plast Reconstr Surg 3: 138, 1969 7. Laufer D, Glick D, Gutman D, et al: Patient motivation and response to surgical correction of prognathism. Oral Surg Oral Med Oral Pathol41:309, 1976 8. Lewis C, Lavell S, Simpson M: Patient selection and patient satisfaction. Clin Plast Surg 10:321, 1983 9. Sachs RH: Assessment of readiness in patients desiring
10.
11.
12. 13. 14.
15.
16. 17.
18.
OF DENTOFACIAL
PATIENTS
treatment of dentofacial anomalies. J Oral Surg 39:113, 1981 Kiyak HA, McNeil1 RW, West RA, et al: Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthod 89:383, 1986 Oulette PL: Psychological ramifications of facial change in relation to orthodontic treatment and orthognathic surgery. J Oral Surg 36:787, 1978 Schultz-Cot&on JH: Rhinoplasty-mainly aesthetic or functional operation? Laryngol Rhinolotol Otol 56:233, 1977 Hay GD: Dysmorphobia. Br J Psychiatry 116:399, 1970 Antczak-Bouckoms AA, Weinstein MC: Cost-effectiveness analysis of periodontal disease control. J Dent Res 66: 1630, 1987 Tulloch JFC, Antczak-Bouckoms AA: Decision analysis in the evaluation of clinical strategies for the management of mandibular third molars. J Dent Educ 51:652, 1987 Weinstein MC, Feinberg HV: Clinical Decision Analysis. Philadelphia, PA, Saunders, 1980 Cochrane AL: Effectiveness and Efficiency: Random Reflections on Health Services. London, Nuffteld Provincial Hospitals Trust, 1972 Kiyak HA, Beach LR: Intrinsic motives in the decision to seek orthognathic surgery. J Dent Res 63:750, 1984
Surg
1991
Attitude
Variables of Den tofacial Deformity Patients:
Demographic
Characteristics
and Associations
KATHLEEN
H. MAYO, DDS, MS,* KATHERINE DRYLAND VIG, BDS, MS, DORTH, FDSRCSJ PETER S. VIG, BDS, PHD, DORTH, FDSRCS,$ AND CHARLES J. KOWALSKI, PHD§
For patients to obtain satisfaction from surgical orthodontic treatment, a concordance needs to exist between the patients’ concerns and expectations and the clinician’s outcome measures of success. In this study, 231 patients 16 years or older were analyzed to define attributes of treatment that relate to patient satisfaction with outcome. The most prevalent patient concerns were related to facial and dental esthetics, and the effect of the dentofacial deformity on the quality of life was associated with a significantly higher motivation for surgical treatment.
A combination of orthodontics and orthognathic surgery is the contemporary approach for the treatment of patients with dentofacial deformities. For patients to achieve optimal satisfaction from treatment, most clinicians would agree that the selection of the appropriate procedure must not only be based on the clinician’s anticipated objectives with regard to esthetics, function, and stability, but also on the patients’ objectives, expectations, and their perceived needs. Dissatisfaction with treatment is seldom related to the technical skill of the surgeon, but may result from an unfavorable interpersonal relationship between the clinician and patient. This may arise from a failure to identify and deal appropriately with those patients who may become displeased with the
outcome of treatment even if the results are excellent. This situation may pose a significant problem. Patient discontent may manifest in an emotional crisis, legal action, verbal complaints to the surgeon, refusal to pay the fee for service, and even occasioning physical harm to the doctor.’ Treatment goals should, therefore, address the patients’ perceived needs as well as the clinicians’ diagnostic criteria for recommending treatment. The needs of patients and the concordance between patients’ and providers’ expectations for treatment outcomes are not well understood. The purpose of this study was to characterize a dentofacial patient population with respect to the frequency distribution of demographic variables and features that pertain to patients’ concerns, desires, and expectations.
* Lecturer, Department of Oral and Maxillofacial Surgery, The University of Michigan, Ann Arbor. t Associate Professor and Chairman, Department of Orthodontics. The University of Pittsburgh, Pittsburgh, PA. j: Professor, Associate Dean for Research, The University of Pittsburgh, Pittsburgh, PA. 5 Professor, Department of Biologic and Materials Sciences, The University of Michigan, Ann Arbor. This research was supported in part by grant DE 06881 and DE 09883. Address correspondence and reprint requests to Dr Katherine Dryland Vig: Department of Orthodontics, School of Dental Medicine, The University of Pittsburgh, Pittsburgh, PA 15261.
Literature Review
0 1991 American geons
Association
of Oral and Maxillofacial
PATIENT MOTIVATION FACTORS
In an effort to predict postsurgical satisfaction, various motivational factors for seeking treatment have been investigated. Functional improvement has been studied as a motivation factor for patients who decide to have orthognathic surgery. In the study by Olson and Laskin,2 all patients were satisfied with the functional change and 92% with the esthetic change. Kiyak and coworkers3 reported that neither the severity of problems nor the needs
Sur-
0278-2391/91/4906-0007$3.00/O
594
595
MAYO ET AL
of the patients can predict the likelihood of success or failure of psychosocial adaptation postsurgically. These authors emphasize the importance of establishing what is expected from surgery before treatment. They conclude that if a patient is primarily concerned with esthetics, which can be corrected, then a successful outcome from treatment will occur. However, if an improvement in esthetics is unlikely, the patient will probably be dissatisfied with the outcome. Esthetic improvement has also been reported to be a strong motivational factor for many patients who decide on orthognathic surgery.4 In 1985, Bell and coworkers’ reported that in spite of surgery being recommended by dental professionals, and the dentofacial deformity confirmed by cephalometric or morphologic parameters, patients’ self-perception of their facial profile may be the most important factor in the decision to elect surgical correction. In recommending treatment alternatives to patients, it is important for orthodontists and surgeons to establish that their evaluation of facial esthetics is in agreement with the concerns of the patient.’ Other investigators have also stated that esthetic considerations influence the decision of patients to have orthognathic surgery. A report of a study by Wictorin and coworkers6 showed that 62% of postsurgical patients stated a desire for changes in appearance as a motive for electing surgical treatment, whereas 76% desired an improvement in dental function. These results are similar to those published by Laufer and colleagues,7 who reported that 56% of postsurgical patients claimed that esthetic concerns were their primary motive for seeking treatment. Kiyak and coworkers4 found that 53% of the females and 41% of the males in their study reported esthetic appearance as the major reason for considering orthognathic surgery. PSYCHOLOGICAL ASSESSMENT
The need to assess psychological characteristics as a predictor of patient satisfaction has recently been recognized.‘.“” Peterson and Topazian’ examined body image as a predictor of satisfaction. Prior to surgery, patients were asked to state the nature, duration, and degree of their deformity, as well as their motives for surgery and expectations from treatment. The results of Peterson and Topazian’ suggest that an increase in the number of positive responses may be a predictor of postoperative patient satisfaction. Patients who had developed a good body image despite their objective deformity were more likely to have realistic expectations of corrective procedures than those with a
poor body image. The patients’ state of social adjustment also affected treatment. Those patients who were aggressive and overdemanding were not likely to be satisfied with the results of treatment. Regarding the role of deformity in personality structure, Peterson and Topazian’ wrote, “The aim of well-adjusted patients is to get rid of self-conscious preoccupations with the deformity as a way of freeing themselves of emotional barriers. They are seeking a primary gain; for example, getting a better job or improving their interpersonal relationships.” In addition, the patient with a major deformity generally is psychologically a more favorable candidate for surgery than one with a minor defect. Oulette” studied postsurgical patients and specifically asked if they were reticent about treatment and attempted to elicit the cause. Fear of cost deterred most patients initially, even though they were unhappy with their appearance or they had been strongly advised to begin treatment by their dentists or physicians. More than half the patients in this study were happy with the results immediately after treatment was completed. In the longterm, the number increased to 93%. Oulette” stated that the results of this preliminary study indicated that the psychological needs of patients may be more fundamentally important than the morphologic aspects of treatment. In a study of cosmetic surgery patients, Lewis and coworkers’ administered an open-ended questionnaire to obtain self-assessments of attractiveness, anxiety, fear, and expectation in an attempt to predict satisfaction. Kiyak and colleagues’” suggested that patients who were planning to undergo surgery were significantly more dissatisfied with their facial appearance than those patients who were not contemplating surgery. The results indicated that surgery improved self-esteem and body image, particularly the patient’s evaluation of facial attractiveness. The importance attached to physical features, patients’ self-esteem, body image, and degree of extroversion were unrelated to postsurgical satisfaction. The only personality variable that was found to be associated with surgical outcomes was neuroticism, which correlated positively with satisfaction. Considerations of the patient’s self-concept and neuroticism should be taken into account when planning surgical treatment or conventional orthodontic treatment. GENDER DIFFERENCES
Gender differences in establishing motives for rhinoplasty have been described by SchultzCoulon.” Men seeking rhinoplasty gave an equal number of functional and appearance motives,
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ATTITUDE
whereas women gave a greater number of reasons for esthetic rather than functional motives. HayI reported that women thought cosmetic surgery would give them a new start on life, whereas men more often believed it would improve their career prospects. These findings support the traditional gender role stereotypes, that women are more concerned with appearance and men are more concerned with achievement. DEVELOPMENTOF SURVEYINSTRUMENTS
The literature indicates that a number of attempts have been made to create survey instruments to assess the goals of treatment and the patients’ expectations and perceptions of attained objectives. A more valid instrument is needed to derive utility scales to weight the relative importance of treatment procedures and outcome variables and to quantify patient and clinician preferences to establish the efficacy of treatment. The need to incorporate preferences and values into clinical decisions has received more attention in the medical than the dental literature.14 Currently, there is no explicit quantitative estimation of the effects of the intervention on health outcomes with regard to orthodontic/orthognathic surgery. Clinical and administrative decisions are typically based on qualitative subjective estimates of risk/benefit. However, the rising cost and patterns of delivery of health care have resulted in greater involvement of patients and consumer groups in treatment decisions. The increase in malpractice claims where expert opinion is, of necessity, given on the basis of subjective judgments, and the pressure for quantitative estimates of a technology’s effects, require a quantitative assessment method.r5 Decision analysts state that the value judgments underlying clinical decisions can and ought to be considered systematically and explicitly. Utility analysis defines values based on a decision maker’s preference for various treatment outcomes.r6 According to Cochrane,” preliminary steps and definitions are essential before a cost/benefit approach becomes a practical possibility. He refers to efficacy as the decision that a particular treatment actually alters the natural history of a particular disease for the better. This comparison is made against no treatment or against a placebo. Ej@+ncy also implies that a given treatment works better or worse than some other active form of treatment. The comparison is against a standard treatment the efficacy of which is well demonstrated or generally accepted. This is not yet available for either orthodontics or surgery. Effectiveness, however, refers not
VARIABLES
OF DENTOFAClAL
PATIENTS
to a comparison, but rather to the impact of a therapeutic agent in the community. Although a treatment may be both efficacious and efficient in clinical trials, the treatment may be ineffective when introduced into the community because it is so inconvenient, uncomfortable, or expensive that patient compliance becomes a problem. An important aspect of a utility assessment is the identification of a suitable health outcome by which to evaluate a treatment intervention. Our present preliminary study reconciles patient needs and expectations. Using patient need and expectations as a reference, the efficacy of conventional procedures may be evaluated. How well any procedure fulfills a patient’s needs depends how satisfied a patient is with the treatment results. Methods and Materials Questionnaires of 231 patients of 16 years and older were analyzed. The 23 1 patients ranged in age from 16 to 65 years, with a mean age of 26.7 years and a female/male ratio of 3 to 2. This subset of patients was part of a larger sample of patients referred to the University of Michigan dentofacial program during 1984 to 1988. Approximately 70 orthodontic-surgical patients are referred annually to the dentofacial program both from within the School of Dentistry and from general dentists, orthodontists, and by self-referral. These patients are not in the category of craniofacial anomalies or dysmorphic syndromes, but may be regarded as extremes or normal biological variation of craniofacial morphology. The initial records of these dentofacial patients were examined retrospectively. They included the patient interview questionnaire, which was either administered by an oral surgery or orthodontic resident who had received instructions in how to report the demographic data and attitude variables (Fig 1). The residents were all instructed in how to administer the questionnaire, and the interpreter agreement was verified by both an oral and maxillofacial surgeon and orthodontic faculty on the same day. The chief complaint was expressed in terms of dental and/or facial esthetic concerns and functional terms related to the bite or occlusal relationship. The frequency distribution of patients attitudes to their dentofacial appearance, function, and demographic variables were determined. Contingency analysis was used and the x2 test was applied to compare orthodontic motivation, surgical motivation, and concerns with demographic and attitudinal variables. The 231 patients were divided by gender
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MAYOETAL
FIGURE 1. The interview questionnaire that was administered to patients at their first appointment in the dentofacial program.
to compare differences between males and females with respect to demographic and attitudinal variables. Results REASONS FOR SEEKING TREATMENT
The duration of concern was trimodally distributed, with 38% of patients having concerns for 1 to 3 years before seeking treatment, 30% having concerns for 3 to 9 years, and, surprisingly, almost a third of the sample (32%) having waited 9 to 11 years before seeking treatment. When questioned as to what prompted the decision to seek treatment, only 7% of the patients cited insurance and 10% of the patients cited savings. As the financial cost of orthognathic surgery is considerable, the influence of financial coverage for treatment was expected to be a prime factor in the decision-making process. Encouragement from a “significant other” was the reason for 12% of patients deciding on treatment now. The majority of patients (71%) responded that “other” reasons prompted them to seek treatment.
PAST HISTORY
About one half of the patients (51%) reported a history of previous treatment for their deformity. In our sample 28% had received orthodontic treatment only, 15% had bite appliance therapy, 20% had “other” nonspecified treatment, 4% had surgical treatment, and less than 1% received both orthodontics and surgery. Approximately one fourth (28%) of the patients claimed to have a history of previous facial trauma as a reason for treatment. Less than one half (40%) of the patients reported a family history of a dentofacial deformity. Of those patients, there was an almost equal distribution between a maternal and paternal history. PERSONAL HISTORY
Most patients interviewed were single (68%). Twenty-five percent of the patients were married, 10% were divorced, and less than 1% were separated. Most patients had no children (70%). Of these patients, 34% lived with their parents. Others
598
ATTITUDE VARIABLES OF DENTOFACIAL PATIENTS
lived with their spouse (28%), with their children (17%), alone (19%), or with “other” (5%). When asked about their dating pattern, 44% of the patients stated they did not date, 25% stated they dated regularly, and 14% stated they dated occasionally. Nearly one half of the patients admitted to recent or anticipated major life events, which included the death of a friend or relative (30%), job change (26%), promotion (15%), separation or divorce (13%), birth of a child (6%), and “other” (10%). Most patients experienced a good (86%) or average (12%) relationship with their family. REFERRAL PATTERN
The majority of patients (89%) were referred for one or more reasons. Dental esthetics (50%) was the reason most frequently given for referral. Dental function (51%), facial esthetics (25%), temporomandibular disorder (TMD) symptoms (27%), and “other” (6%) were additional reasons. Patients with dental esthetic and dental function concerns were more frequently referred than patients who were concerned about facial esthetics, TMD symptoms, and “other.” ATTITUDE VARIABLES
Orthodontic
Motivation
Median motivation rating for orthodontic treatment on a lo-point scale was 9. No association was found between orthodontic motivation and age (Fig 2). However, a highly significant association between motivation for orthodontics and motivation for surgery (I’ < .OOOl)was shown by x2 analysis of coded data. Patients who were highly motivated for orthodontic treatment tended to be highly motivated for surgical treatment. Reasons given for seeking treatment at that time included “significant other,” savings, insurance, or “other.” The patients most highly motivated for orthodontic treatment gave the reason for seeking treatment at that time as “other” (73%). The remaining reasons, “significant other” (13%), savings (lo%), and insurance (5%), were given less often. No statistically significant associations existed between orthodontic motivation and frequency of referral, patient concerns, reason for seeking treatment, history or previous trauma, history of previous treatment, effect of deformity on life, family history of deformity, or expectations of treatment.
Age FIGURE 2. Distribution of motivation for orthodontic treatment by age. W, Motivation 1 to 3; q, motivation 4 to 6; cl, motivation 7 to 10.
tween surgical motivation and age (Fig 3). The chief complaint or reason for seeking treatment at that time, and the effect of the dentofacial deformity on their life were also associated with motivation for surgery. Patients over the age of 41 years tended to be less motivated for surgery (P = .Ol) than the younger adults or teenagers (Fig 3). Patients who sought treatment for dental esthetic complaints (59%) were significantly more motivated for surgery than those without such complaints (P = .034). The 60
0 16-20
21-30
31-40
>41
Surgical Motivation Median motivation rating for surgical treatment was 8 on a IO-point scale. Associations existed be-
Age FIGURE 3. Distribution of motivation for surgery by age. n , Motivation 1 to 3; q, motivation 4 to 6; Cl, motivation 7 to 10.
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other complaints that prompted patients to seek treatment, namely, facial esthetics (34%), TMD (33%), dental function (61%), and “other reasons” (7%), were not significantly associated with the level of motivation that patients had for surgical treatment. Patients who claimed that their deformity had an effect on their life (44%) were more highly motivated for surgery than those who did not (P = .029). No significant associations existed between surgical motivation and frequency of referral, patient concerns, history of previous trauma, or history of previous treatment.
60
JO
20
Patient Concerns 0
The rank order of concerns (Fig 4) was dental esthetics (31%), dental function (27%), facial esthetic (22%), TMD symptoms (17%), and other (3%). No discernable association existed between patient concerns and reason for seeking treatment at that particular time or a history of previous trauma. The relationship between patient concerns and treatment expectations, reason for referral, or reason for seeking treatment could not be tested with the x2 test as there were multiple responses in all categories.
Dent. Est
Dent. Funct
Face Est. TMJ
Other Physical
Expectations -Desired Outcomes FIGURE 5. Frequency distribution of expectations ment by gender. H, Males; H. females.
from treat-
facial esthetics, TMD symptoms, and in the “other” category appeared to be more highly motivated than patients who expected improvements in dental function and dental esthetics. GENDER DIFFERENCES
Patient Expectations Patient expectations corresponded closely with concerns and reasons for seeking treatment. Psychological and/or economic benefits from treatment were expected. Expectations from treatment (Fig 5) included improvements in dental esthetics, dental function, facial esthetics, TMD symptoms, and “other.” Patients who expected improvements in 100
The female/male ratio was 3 to 2. Using xz significant gender differences were found with regard to patient age (Fig 6). A history of trauma and also a history of previous treatment (Fig 7). and motivation for surgery (Fig 8) were strongly associated. 60
SO
80
40
60
30
-IO
20
20
IO
0
0 Dent Est. Dent. Funct. Face Est.
TMJ
Olher Physical
16-20
21-30
Concerns
Age
FIGURE 4. Ranked order of patients’ concerns by gender. W, Males; H, females.
FIGURE 6. Gender distribution in the sample when ranked by age. W. Males; q, females.
ATTITUDE VARIABLES
OF DENTOFACIAL
PATIENTS
symptoms than did males. Females complained of and sought treatment for TMD symptoms twice as often as males. Females also tended to seek treatment more often than males for facial esthetic reasons (Fig 4). No associations existed between gender and incidence of referral, reason for seeking treatment at that particular time, effect of deformity on life, family history of deformity, or motivation for orthodontic treatment. Discussion
Ortho
Surgery
Bitesplint
Other
Previous Treatment
FIGURE 7. Distribution of patients’ previous history of treatment before referral to the dentofacial program. n , Males; E?J, females.
There were twice as many females than males over the age of 30 (P = .004). More females (80%) reported a history of trauma than did males (69%) (P = .038). Three times as many females had previous bite appliance therapy (Fig 7), and males more often expressed a high rating for surgery (P = JOI). Improvement in dental esthetics, dental function, facial esthetics, and “other” was expected equally regardless of gender (Fig 5). However, twice as many females expected improvement in TMD
no
60
(l-3)
Surgical
(J-6) Motivation
(7-10) Rating
FIGURE 8. Motivation for surgery among males and females in the sample. W, Males; q females.
The mean age of the patients in this study was similar to that reported by Oulette.” However, the female to male ratio was lower than reported in previous studies in which there were two to three times as many females in the sample.“*‘* In 1981, Kiyak and coworkers4 concluded that motives of patients for seeking orthognathic surgery are different from those seeking cosmetic surgery. In Kiyak’s opinion, orthognathic surgery patients are frequently referred by a general dentist or orthodontist for a functional problem, with esthetic appearance having a secondary role. In contrast, individuals seeking cosmetic surgery do so primarily for reasons of appearance. The most frequent reason for referral in our patient sample was related to dental esthetics, although this might be biased by the referral being made to a dental school. However, esthetic improvement has been reported as a strong motivational factor for many patients who seek orthognathic surgery.6*7 In 1976, Laufer and colleagues7 administered a questionnaire to patients who had previously had surgical correction of mandibular prognathism. Fifty-six percent of this group reported that esthetic concerns were their primary motive. Dental function was the second most common reason given by our patients for referral, and ranked second among patient concerns. This is consistent with Laufer,6 who also reported that difftculty in chewing was the second most common primary reason for seeking surgery. In a report by Oulette,” fear of cost deterred most people initially from seeking treatment, even though they were unhappy with their appearance or they had been strongly urged to begin treatment by their dentists or physicians. Surprisingly, in our study, financial concerns played only a minor role with regard to seeking treatment. When questioned as to what prompted the patient to seek treatment at that particular time, only a few patients cited insurance or savings as the reason for seeking treatment. “Other” reasons were most likely to prompt patients to seek treatment when they did.
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The majority of patients in our study were single; only one fourth of the patients were married. A small proportion were separated or divorced. In a report by Oulette, ” the rank order of marital status was similar; there was a nearly equal distribution of married and single people, and a smaller number were divorced. Improvement in dental esthetics, dental function, facial esthetics, and “other” were equally distributed expectations from treatment, regardless of gender. However, male and female dentofacial deformity patients differed significantly in the distribution of concerns, motivation, and expectations regarding treatment. In a study by Kiyak,4 there were no significant gender differences regarding reasons for seeking surgical treatment. In that study, esthetic appearance was an important consideration for both genders, second only to the advice of professionals as a motive. Contrary to gender role stereotypes, Kiyak4 suggests that it appears that both men and women seeking orthognathic surgery are concerned about their appearance and that functional and health motives were equally important for men and women. In our study, more females complained of and sought treatment for TMD symptoms than did males, and expected improvement in TMD symptoms. They also had more frequent previous bite appliance therapy. This is consistent with reports by Kiyak and colleagues,3 who found females had TMD problems nearly five times more frequently than did men. Externul Influences A report by Kiyak and Beach” suggests that influences from friends, family, and other relatives may be more significant in contributing to the decision to pursue treatment than the advice of dental experts, expectation of functional improvement, esthetic enhancement, or financial considerations. If family and friends think surgery will be beneficial, and support the decision to proceed with orthognathic surgery, then a patient is more inclined to proceed. In our study, young adults tended to be highly motivated for both surgical and orthodontic treatment, regardless of parental influence. Patients who claimed that their deformity had an effect on their life were also more highly motivated for surgery than those who did not, and very few patients stated that their family or significant others influenced their decision to seek treatment. Patients who sought treatment for dental esthetic reasons were also more highly motivated for surgery than patients who sought treatment for facial esthetic or dental function. Those patients who were highly
motivated for orthodontic treatment also tended to be highly motivated for surgical treatment. According to Bell and coworkers5 dental specialists should be aware of the potential for exaggeration of perceived needs developed during training, and which may not be concordant with the patients’ perceived need for treatment. Patients’ perceptions of facial esthetics and need or desires for treatment should be of primary concern when a therapeutic alteration of facial esthetics is contemplated. Treatment planning should not be based solely on the morphologic deviations from “norms” or from technically attainable “ideals.” The patient’s rather than clinician’s utility for the various outcomes should be established and incorporated into the decision. ” Utility assessment of treatment should partition outcome variables to permit cost-benefit assessment from the patients’ perspective; specifically, in terms of the degree to which expectations are met and especially in view of the elective nature of the treatment. Summary and Conclusions In this study, the two most common and equally prevalent patient concerns were facial and dental esthetics, which corresponded closely with patient expectations. No associations existed between orthodontic motivation and the incidence of referral or patient concerns. Likewise, no associations were demonstrated between surgical motivation and age. The effect of dentofacial deformity on the quality of life was, however, associated with a significantly higher motivation for surgical treatment. There was a female/male ratio of 3 to 2 and significant gender differences occurred regarding age and previous TMD history in females. This preliminary study defines attributes of treatment that relate to patients’ and clinicians’ expectations from treatments and their respective degrees of satisfaction with outcomes. Survey instruments based on such findings should be developed to assess the goals of treatment and the patients’ expectations and perceptions of the attained objective. It should be possible to derive utility scales to weight the relative importance of the many treatment processes and outcome variables, and thereby to quantify patient and clinician preferences and to establish key parameters that provide valid measures of efficacy. Through the development of such methods, it may be possible to test if significant differences exist between populations derived from private practices as opposed to university clinics, and thereby to design criteria that may be applied to improve both prospective and retrospective clinical studies.
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References I. Peterson LJ, Topazian R: Psychological consideration in corrective maxillary and midfacial surgery. J Oral Surg 34: 157, 1976 2. Olson RE, La&in DM: Expectations of patients from orthognathic surgery. J Oral Surg 38:283, 1980 3. Kiyak HA, Hohl T, West RA, et al: Psychologic changes in orthognathic surgery patients: A 24-month follow up. J Oral Surg 42:506, 1984 4. Kiyak HA, Hohl T, Sherrick RA, et al: Sex differences in motives for and outcomes of orthognathic surgery. J Oral Surg 39:757, 1981 5. 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 6. Wictorin L, Hillerstrom K, Sorensen S: Biological and psychosocial factors in patients with malformations of the jaws. Stand J Plast Reconstr Surg 3: 138, 1969 7. Laufer D, Glick D, Gutman D, et al: Patient motivation and response to surgical correction of prognathism. Oral Surg Oral Med Oral Pathol41:309, 1976 8. Lewis C, Lavell S, Simpson M: Patient selection and patient satisfaction. Clin Plast Surg 10:321, 1983 9. Sachs RH: Assessment of readiness in patients desiring
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PATIENTS
treatment of dentofacial anomalies. J Oral Surg 39:113, 1981 Kiyak HA, McNeil1 RW, West RA, et al: Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthod 89:383, 1986 Oulette PL: Psychological ramifications of facial change in relation to orthodontic treatment and orthognathic surgery. J Oral Surg 36:787, 1978 Schultz-Cot&on JH: Rhinoplasty-mainly aesthetic or functional operation? Laryngol Rhinolotol Otol 56:233, 1977 Hay GD: Dysmorphobia. Br J Psychiatry 116:399, 1970 Antczak-Bouckoms AA, Weinstein MC: Cost-effectiveness analysis of periodontal disease control. J Dent Res 66: 1630, 1987 Tulloch JFC, Antczak-Bouckoms AA: Decision analysis in the evaluation of clinical strategies for the management of mandibular third molars. J Dent Educ 51:652, 1987 Weinstein MC, Feinberg HV: Clinical Decision Analysis. Philadelphia, PA, Saunders, 1980 Cochrane AL: Effectiveness and Efficiency: Random Reflections on Health Services. London, Nuffteld Provincial Hospitals Trust, 1972 Kiyak HA, Beach LR: Intrinsic motives in the decision to seek orthognathic surgery. J Dent Res 63:750, 1984
