CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Perceptions of Young Adults Having Undergone Combined Orthodontic and Orthognathic Surgical Treatment: A Grounded Theory Approach Zahra Sadat-Marashi, BA,* Paolo Scolozzi, MD, DMD,y and Gregory S. Antonarakis, BSc, DDS, MSc, PhDz Purpose:
The present qualitative study aimed to explore the subjective perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity.
Materials and Methods:
Ten participants (5 women and 5 men; 20 to 25 yr of age) whose combined orthodontic and orthognathic surgical treatment had been terminated 1 to 3 years before undertaking the present study were selected. Open in-depth interviews, of approximately 30 minutes’ duration, were digitally recorded and transcribed verbatim. The interviews were analyzed using procedures inherent to the grounded theory approach, a qualitative approach to collecting and analyzing data that aims to develop a theoretical proposition grounded in real-world observations.
Results:
A core category was identified describing the participants’ satisfaction with treatment outcome despite the difficult experiences that they lived through during the orthodontic and orthognathic surgical treatment. In association to the core category, 6 other categories emerged: experiences shared by those already having undergone similar treatment; shock for family and close friends at the hospital; difficulty eating; pain caused by orthodontic treatment; fears caused by swelling and complications; and smiling with self-confidence.
Conclusion:
A better understanding of patients’ views on combined orthodontic and orthognathic surgical treatment can assist health care professionals in properly counseling patients and their families and providing better patient-centered care. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-8, 2015
Treatment for dentofacial deformity using a combined orthodontic and orthognathic surgical approach is well established. Despite recent advances in surgical and orthodontic expertise, there does not appear to have been similar progress in the understanding of patients’ perceived benefits derived from this treatment. It has been established that orthognathic surgery has beneficial psychological effects, but further evidence is required.1
For elective surgical procedures with associated risks, shared decision making between the clinician and the patient is crucial.2 These two parties need to understand each other’s perceptions to plan future therapy. On the one hand, patients must be well informed to make an educated decision. On the other, clinicians must be aware of the patient’s perspectives of normality and desire for change. The focus is shifting toward the patients’ own perceptions rather
*Dental Student, School of Dental Medicine, University of Geneva,
Address correspondence and reprint requests to Dr Antonarakis:
Geneva, Switzerland.
Division of Orthodontics, University of Geneva, 19 Rue Barthelemy-
yProfessor and Head, Division of Oral and Maxillofacial Surgery, Department of Surgery, University Hospitals of Geneva and Faculty
Menn, 1205 Geneva, Switzerland; e-mail: [email protected] Received April 2 2015
of Medicine, University of Geneva, Geneva, Switzerland.
Accepted May 8 2015
zOrthodontist, Department of Orthodontics, University Clinic of
Ó 2015 American Association of Oral and Maxillofacial Surgeons
Dental Medicine, Geneva, Switzerland.
0278-2391/15/00599-6
Drs Scolozzi and Antonarakis contributed equally to the present
http://dx.doi.org/10.1016/j.joms.2015.05.015
work.
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than a professional evaluation of morphology and treatment,3 although research outcomes continue to focus on morphologic changes.4 These objective measurements do not fully capture the impact of a particular treatment, and subjective assessment of this impact is paramount. Using traditional quantifiable research methodologies, such as questionnaires, to investigate patients’ perspectives do not favor the emergence of new perspectives owing to their deductive approach. The construction of questions or hypotheses is initially based on an existing theory, which narrows the research topic. When used improperly, these techniques can lead to misinterpretation and oversimplification of data. To investigate patients’ views about dentofacial deformities and subsequent corrective treatment, qualitative methods are ideal because they are suited to explore complex phenomena or areas not amenable to quantitative research owing to a lack of previous research on the subject. The strength of qualitative methodology is that it enables the researcher to grasp the patient’s point of view in unbiased ways.5 Qualitative methods, although gaining widespread use in medicine, have been used infrequently in the discipline of dentofacial deformity. Only a handful of studies have examined aspects, such as malocclusion,6 cleft lip and palate,7 dentofacial normality,8 motivation for treatment, and expectations of treatment outcome.9,10 The present study aimed to develop a theory to gain a deeper understanding of subjective perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity.
Materials and Methods GROUNDED THEORY
A qualitative study was conducted using the grounded theory approach, which is an inductive approach used to study social processes and structures.11,12 This approach to collecting and analyzing qualitative data aims to develop a theory or a theoretical proposition grounded in real-world observations to explain existing phenomena, rather than testing a hypothesis derived from an existing theory. According to Glaser and Strauss,11 when using a grounded theory approach, the theory will emerge by itself without being affected by the researchers’ objectiveness. It is particularly valuable for studying areas in which little is known or in which a deeper understanding of an incompletely explored area is desired. Grounded theory was the most suitable research methodology for the present study because the particular area of interest has not been adequately studied
using qualitative research methodology and because it allows a better understanding of the social processes creating the framework of a combined orthodontic and orthognathic surgical treatment. This study followed the Declaration of Helsinki on medical protocol and ethics and owing to its nature was granted exemption from the regional ethical review board. STUDY GROUP AND INTERVIEW PROCEDURE
Participants were eligible for inclusion if they spoke French, lived in Geneva, Switzerland, were 20 to 25 years old, and had been treated with a combined orthodontic and orthognathic surgical approach at the University Hospitals of Geneva, with treatment having been terminated at least 1 year, but not more than 3 years before the study. Exclusion criteria were patients with clefts or craniofacial syndromes, history of maxillofacial trauma or juvenile idiopathic arthritis, history of temporomandibular disorders or myoarthropathy of the masticatory system, history of poor dental health, hypodontia of more than 1 tooth per quadrant, any previous orthodontic treatment, or any form of previous maxillofacial or facial plastic surgery. The notion of purposive sampling was used to strategically select the population in question from the records at the University Hospitals of Geneva based on an a priori judgment about which participants would be most representative or informative. A heterogeneous sample was desired to amplify the field of experiences in the group studied.11 Ten participants were contacted, 5 women and 5 men, half of whom were students and the other half young professionals. Selected participants had different deviations from normal occlusion according to guidelines based on the Index of Orthodontic Treatment Need.13 Four had treatment to correct a Class III malocclusion, 2 to correct a Class II malocclusion, 2 for transverse problems, and 2 for vertical skeletal discrepancies (Table 1). Participants were initially contacted and informed about the study by telephone, providing information and answering questions as needed. Once a participant was willing and agreed to participate in the study, an appointment was made to conduct the interview. The setting of the interview was agreed to by the participant and the interviewer to make it as informal as possible and to make the participant feel comfortable, thereby decreasing bias. An establishment (usually a local cafe) close to the participant’s home, workplace, or university was chosen, making it convenient for the participant to attend. One participant requested an initial meeting with the interviewer to be more comfortable and confident for the actual interview.
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Table 1. DEMOGRAPHIC VARIABLES OF PARTICIPANT SAMPLE
Participant Number 1 2 3 4 5 6 7 8 9 10
Gender
Age (yr)
Professional Status
Malocclusion
Orthognathic Surgery
F F M F M M M F M F
21 22 20 25 22 21 24 23 22 23
Student Student Student Employed Employed Employed Student Employed Student Employed
Open bite Class III Class III Class II Deep bite Transverse deficiency Class II Class III Class III Asymmetry
Bimaxillary Maxillary Bimaxillary Mandibular Bimaxillary Maxillary Mandibular Bimaxillary Maxillary Bimaxillary
Abbreviations: F, female; M, male. Sadat-Marashi, Scolozzi, and Antonarakis. Perceptions of Surgical Orthodontic Treatment. J Oral Maxillofac Surg 2015.
All one-to-one interviews were conducted by the same interviewer. To decrease bias, this interviewer was not known to the participants, had not been involved in any way in the treatment of any of the participants, and would not be involved in the future care of any of these patients. The interviews, approximately 30 minute’s duration, were digitally recorded with the participant’s consent. Anonymity was guaranteed to protect participant confidentiality, and participants were assured that they could stop the interview at any time. At the outset of the interviews, the same general open-ended question was asked, ‘‘How did you experience the treatment for your teeth and jaws?’’ Each participant was given the opportunity to discuss freely and raise any topics or themes they judged appropriate. The interviewer, when necessary, posed additional questions for probing and clarification to understand the experiences of the participant. An interview guide (flexible and evolving) was used to cover the participants’ experiences, thoughts, and feelings about their treatment. Themes that were covered in the interviews included participant motivation, pain, satisfaction, social interactions, impact (with regard to school, work, and daily life), and outlook toward the future. If required, the interview was reinforced with further questioning in a conversational way. Data collection and analysis were conducted simultaneously, adhering to the principle of constant comparisons,14 and continued until saturation (no additional information emerging from new data) was reached. DATA COLLECTION AND ANALYSIS
Each interview was transcribed verbatim and then checked for accuracy against the original recordings. The interviews were analyzed strategically using a coding process. Two researchers, with different clinical backgrounds, independently analyzed and coded the
data to ensure that any emerging theory was robust and valid.15 Three types of coding were used, namely open, axial, and selective.16 Data from the interviews were initially coded using open coding. Open coding implies that the data are read, sentence by sentence, and the meaning of a particular sentence or what it expresses is defined. Then, these codes are clustered into categories (axial coding). By this means, the substance of the data was segmented into substantive codes and given concrete labels. Codes with similar content were clustered into summarizing categories. Then, a core category was established, along with its relation to other categories, and further refinement of the categories was carried out (selective coding).
Results The core category and 6 other related categories were identified (Fig 1). The core category described the participants’ satisfaction with treatment outcome despite their difficult experiences during the orthodontic and orthognathic surgical treatment. The 6 other categories identified were experiences shared by those already having undergone similar treatment; shock for family and close friends at the hospital; difficulty eating; pain caused by orthodontic treatment; fears caused by swelling and complications; and smiling with self-confidence. All patients were satisfied with the outcome of treatment and believed that it was worthwhile despite their difficult experiences during the treatment. Difficulties concerned the orthodontic treatment and the orthognathic surgical treatment. The worst part of the orthodontic treatment was the pain after many of the appointments. The worst part of the orthognathic surgical treatment was postoperative facial swelling, which also shocked family and friends, and caused difficulty eating. The greatest satisfaction described by the participants was the ability to smile with
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asking myself, why did I do this?! . I have had so much pain! Some participants also brought up whether they would pursue this treatment knowing what they knew about the pain and difficulties. They decided they would because of the final outcome and satisfaction with their face and smile. If I could go back in time then I wouldn’t change my mind. I would do it again. Yes, clearly! . Even my mom was very happy! EXPERIENCES SHARED BY THOSE ALREADY HAVING UNDERGONE SIMILAR TREATMENT
FIGURE 1. Relation between the core category and the 6 other categories concerning the perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity. Sadat-Marashi, Scolozzi, and Antonarakis. Perceptions of Surgical Orthodontic Treatment. J Oral Maxillofac Surg 2015.
confidence. Talking to patients who had already undergone similar treatments could have been beneficial to many of the participants. The following sections describe each of these categories in more detail. The categories also are illustrated with quotations from the interviewees. SATISFACTION WITH TREATMENT OUTCOME DESPITE THE DIFFICULT EXPERIENCE
The core category identified shows that participants were generally very satisfied with the outcome of the treatment. During the duration of the orthodontic treatment and the period surrounding the orthognathic surgical procedure (pre- and postoperatively), participants were faced with several difficulties and their experiences were somewhat negative with regard to pain and complications during treatment. Participants reported a combination of positive and negative thoughts immediately after orthognathic surgery with the expectation that the final treatment outcome would be as they had hoped, but with certain fears. These fears were mainly in relation to postoperative swelling and some comments received from family and friends. However, the universal remark common to the participants was that the final outcome outweighed the difficult experiences during the process. Today I’m really very happy. However, just after the surgery and until 1 or 2 months ago I was
Participants trusted the medical professionals and were satisfied with the information given to them by the orthodontist and maxillofacial surgeon concerning their treatment and possible side-effects and complications. However, a common desire, in hindsight, was to have been able to speak with a patient who had undergone a similar treatment. Participants believed that this would have better prepared them for what was to come. Hearing someone’s experiences firsthand was deemed to be more useful than just being given a list of possible complications by the health professional. Information coming from someone not in the medical profession appears to be desirable. Also, participants would have been more at ease about asking questions and discussing personal experiences with a peer who was more familiar with the process. This category shows the importance of being briefed by someone who has had the same treatment. Patients trust medical professionals, but they want to be informed by someone who is not included in the medical team and who has lived the experiences. Some participants had this desire before undergoing surgery, and some realized at the hospital that they wanted to speak to someone with the same condition. [B]ecause I was afraid of having a 6-hour surgery and not being able to eat. Before my surgery I should have asked the doctors if they knew someone who already had this surgery in order to ask some questions. I think it would have been useful. Especially another girl so I could feel more at ease! SHOCK FOR FAMILY AND CLOSE FRIENDS AT THE HOSPITAL
Most participants brought up the shock of their family and close friends when coming for the first time to the hospital after the orthognathic surgery. Sometimes, the family would even cry or at least show with their facial expressions that something was wrong. Participants reported that some family
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members mentioned that they were unsure whether what they were seeing, especially the swelling, was normal and that they were afraid that a mistake had been made during surgery. My mother told me that she didn’t recognize me because of the swelling.
[M]y family was crying in front of me and I was wondering what was happening. DIFFICULTY EATING
After orthognathic surgery, most participants believed themselves very limited by what they could or could not eat. They mentioned that they could eat only soups for the first weeks or up to 2 months. A soft diet followed that for the next month or so. A surprising number (approximately half) of participants mentioned how much they had wanted to eat a burger but could not. [A]fter all, it’s my favorite food! I was only able to eat a cheeseburger 4 months after surgery! I had missed crunching into a cheeseburger so much, and even after 4 months my teeth were still a bit sensitive. It had seemed like forever. Participants also brought up an element of fear. Because they were advised to not bite hard into any food after orthognathic surgery to avoid complications, some were extra vigilant, not wanting to compromise the final result after all their efforts and sacrifices. A limited mouth opening also was mentioned as one of the reasons that the participants had difficulty eating. After orthodontic appointments, eating also was difficult for some for a few days. Most participants mentioned that they were informed that they would lose weight after surgery. This seemed to have occurred to most participants. I lost a lot of weight. In the very beginning I could eat only liquids because if I closed my mouth even for swallowing my saliva, I felt pressure on my stitches. However, 1 participant reported that despite difficulties eating, she had not lost any weight because she had found a solution. [A]nd that was because I discovered that I could eat Nutella [a sweetened hazelnut chocolate spread] because it was soft! PAIN CAUSED BY ORTHODONTIC TREATMENT
All participants mentioned the pain they had experienced caused by the orthodontic part of the treatment. This was mainly subsequent to orthodontic
appointments and to the ‘‘tightening of the braces’’ in particular. One participant mentioned that the day after she had received her orthodontic appliances, she experienced the ‘‘the worse pain of my life.’’ All participants were in agreement that the orthodontic treatment was perhaps the most painful, even more than the surgery, and the fact that they still had orthodontic appliances in place after the surgery did not facilitate the situation and made it more difficult for them to ‘‘face the real word’’ just after their orthognathic surgery. The duration of orthodontic treatment was another factor that aggravated their experience because of the pain after almost every appointment. Participants also experienced other difficulties with the orthodontic treatment, but mostly after the initial appointment to bond the fixed appliance. However, pain seemed to be the worst problem because it was perceived intermittently throughout treatment. I had a brace with metallic bars which crossed the roof of my mouth, and some other braces all around the other teeth and I couldn’t stand them at first. I wore them for 3 days and then I went back to ask the dentist to take everything off because of the pain! It caused pain and I had difficulty to speak because of the bars inside. I had difficulty speaking and this bothered me a lot when I was with others. But most of all, I couldn’t stand the pain! FEARS CAUSED BY SWELLING AND COMPLICATIONS
The interviews showed how bad the patients felt when they woke up after their orthognathic surgery. A common question they asked their surgeons immediately postoperatively was whether their faces would stay swollen forever and whether they would be able to speak and eat as before. Some participants even doubted having chosen this treatment option and regretted this decision. There was mention of wanting to go back and undo what was done. Despite adequate information given by the surgeon and the medical team before the orthognathic surgery, most participants were still shocked by the swelling, difficulty eating, and difficulty speaking and, more importantly, feared these difficulties would remain for the long term. [W]hen I saw my face . I had the impression that I had just been run over by a truck. It wasn’t my face at all. I was suddenly afraid this would last forever. Some participants discussed their muscular pain after orthognathic surgery. In most cases, this pain was present before commencing treatment, but for
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some reason there was the common misconception that it would disappear with treatment. Disappointment that the pain persisted and the fear it would get worse were discussed. Limited jaw opening was brought up by some participants, as was the fear that this would last and prevent them from being able to eat as before and the fear of its becoming locked. When I yawned I would force myself to stop because I thought that if I let it go, my jaw would get locked in that position. Hypoesthesia was reported by some participants and discussed, although it was mostly transient. This was commonly near the chin area. One participant mentioned that this had not gone away and this participant was afraid it would become permanent. [A] year and a half has gone by after the surgery and it still tickles.
SMILING WITH SELF-CONFIDENCE
The smile was pointed out in many interviews as being the reason why the participants wanted to have some form of treatment performed and what they liked most about the final outcome. Having a dentofacial deformity caused patients to develop different habits or tactics to hide the smile that they did not find attractive. This included putting a hand in front of the mouth when smiling, smiling and keeping the lips together to avoid showing the teeth, putting the tongue between the teeth when smiling, avoiding smiling altogether, or putting the facial emphasis elsewhere with the application of large quantities of makeup around the eyes or with noticeable hair styles. Smiling was impossible! I was hiding my teeth so much and also because I had a large jaw, I tried to compensate for it by putting on so much eye shadow so that people around were attracted to my eyes and didn’t pay much attention to my mouth! Once treatment was finished, participants were very pleased with the fact that they could smile without shame and without trying to conceal their smile. This seemed to improve their self-reported confidence and self-esteem and made them more comfortable socially. Professional and personal social interactions were improved in some cases as a consequence. Today I don’t use makeup as before, and my smile is here, always here! Look! I have no more shame when I show my teeth, and it is much easier to talk to boys! It changed my life.
Discussion There is an increasing need to fully understand how patients with dentofacial deformity experience the impact of a combined orthodontic and orthognathic surgical treatment on their lives. Using the grounded theory approach allowed the authors to develop a theory revolving around different themes disclosed by the participants through the analysis of their interviews. A core category was generated in addition to 6 other categories. The core category was defined as the satisfaction of the participants with the treatment outcome despite their difficult experiences during treatment. The other categories identified were experiences shared by those already having undergone similar treatment, shock for family and close friends at the hospital, difficulty eating, pain caused by orthodontic treatment, fears caused by swelling and complications, and smiling with self-confidence. The core category identified was the satisfaction of participants having undergone a combined orthodontic and orthognathic surgical treatment. Satisfaction has been found from previous questionnaire-based studies to be high, ranging from 87 to nearly 100% of patients.17-20 The degree of satisfaction has been found to be unrelated to gender, age, diagnosis, or procedure.18,20 If satisfaction is measured only a few months after orthognathic surgery, then some dissatisfaction is reported, possibly owing to the lingering side-effects; however, with increased time, satisfaction improves and has been found to be high 1 year after surgery.18,21 The desire to have the opportunity to speak with someone having undergone a similar treatment was identified as another category. People are afraid of the unknown, which makes them seek out further specific explanations to better understand what they will go through. A previous study has found that patients undergoing orthognathic surgery look to the Internet for supplemental information regarding their proposed treatment.22 This could suggest a possible gap in the provision of information by health care professionals. However, it is clear that patients use Internet forums to seek additional information, support, and reassurance from peers undergoing similar treatment. Therefore, there is a need for clinicians to ensure that patients have access and are guided to appropriate and relevant Internet resources.22 Another identified category was the initial shock for family and close friends at the hospital. It has been found that approximately half of patients are influenced by their family or dentist before deciding to undergo a combined orthodontic and orthognathic surgery treatment.23 It also has been observed that the opinions of friends and family affect patient satisfaction, and those who receive comfort from their
SADAT-MARASHI, SCOLOZZI, AND ANTONARAKIS
entourage present better psychological health status.21,24,25 However, friends and family also could have problems getting used to or accepting the new appearance of the patient.25,26 Reaction of the patient’s entourage to his or her postoperative appearance has been found to correlate with satisfaction.27 Difficulty eating is commonly experienced by patients undergoing a combined orthodontic and orthognathic surgical treatment and was another identified category. Based on a previous study using a mail-in questionnaire, many patients reported that difficulty eating immediately postoperatively was worse than expected.28 The category of pain caused by the orthodontic treatment was of particular interest. Although the orthognathic surgical procedure is more invasive, the patients reported that the worst pain was in relation to the orthodontic treatment. This also has been brought to light in a previous questionnaire-based study that found that most patients experienced the orthodontic treatment as painful and the most unpleasant part of the entire treatment.19 The category of fears caused by the presence of swelling and complications is one that is relevant to the first few weeks after orthognathic surgery. The intervention is traumatic, and swelling is inevitable. Approximately 50% of the swelling has been found to decrease after the third postoperative week, whereas only 20% remains after 3 months.29 Despite being well informed, this still causes patients a certain amount of fear. Many patients, based on a previous mail-in questionnaire study, reported that the pain and swelling experienced immediately postoperatively were worse than expected.28 Moreover, another study of 118 patients found that one third of patients reported that it took them longer to recover from the intervention than anticipated.30 The ability to smile with self-confidence once treatment was completed was a category that was central to the participants’ everyday experiences. A systematic review has found an improvement in self-confidence after a combined orthodontic and orthognathic surgical treatment.1 A more recent study using a questionnaire also has found that an important outcome of treatment is improved self-concept.30 Moreover, post-treatment satisfaction improved as self-concept improved. METHODOLOGIC ISSUES
In qualitative studies such as the present one, understanding a certain phenomenon is favored over its distribution in the population or intergroup comparisons. The unit of comparison in grounded theory is events and stories, rather than individual participants.7
7 For this reason, sampling is fundamentally different than in quantitative studies. To maximize the generalizability of the findings, heterogeneous nonprobability purposive sampling is carried out to choose participants providing an array of experiences for in-depth study. One can use analogic reasoning to generalize the results of this study to other populations with similar characteristics. The authors did not aim to investigate gender-specific issues or issues related to a particular dentofacial deformity over another or a different orthognathic surgical procedure over another. The number of participants, being limited, can be seen as a weakness, but this type of research does not require an adequate sample to detect statistical importance, but one that reaches saturation. Saturation occurs after a period of data collection, when a point is reached at which no new data result from including new participants and the collection of additional data. The choice of the sample, namely French-speaking residents of Geneva 20 to 25 years old, was rather selective. This could limit the generalizability of the present findings with regard to age and location and culture. Any single-center study has inherent limitations for generalizability, because all participants are selected from a single center and a single geographic location. Age could be a factor that determines in part the subjective perceptions and values of individuals having undergone combined orthodontic and orthognathic surgical treatment, but this was beyond the realms of the present study. A sample of young adults was desired because this population represents patients who had appropriately timed treatment rather than delayed treatment. All interviews were conducted by 1 person who was not involved with any previous or current treatment of the participants. Thus, there was no conflict of the interviewer having a bias toward the participants or vice versa, and this helped the participants be more comfortable sharing positive and negative experiences and be as honest as possible. The interviews also were conducted in an environment where the participant was at ease and comfortable. Thus, the risk of a participant not sharing the truth with the interviewer was decreased. Nonetheless, bias is always a factor to consider in faceto-face interviews. The interviewer is a human being who brings an unknown agenda to the process composed of his own life experiences and biases, and one has a limited ability to understand how these biases affect the collection of data and the interpretation of results. Participants were included who had terminated their treatment at least 1 year but not more than 3 years before the study, so that postoperative difficulties and complications would not negatively influence the participant’s testimony and the recollection of events would be as accurate as possible without experiences becoming diluted with the passage of time.
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The analysis of the transcribed interviews was carried out by 2 individuals who were involved in the data management and explanatory analysis. The procedure was kept as transparent as possible so that the conclusions could be traced to the individual interviews and to ensure that the findings were supported by evidence. Cross-checks were carried out where necessary. The 2 individuals carrying out the analysis discussed their findings and reached a consensus. CLINICAL IMPLICATIONS
Understanding how patients experience the impact of their treatment on their lives is pivotal to counseling patients and families adequately before commencing orthodontic treatment or undertaking orthognathic surgical procedures. If one knows about the experiences of young adults with dentofacial deformity who have undergone combined orthodontic and orthognathic surgical treatment, then one can provide better care and advice during orthodontic treatment and pre- and postoperatively. Clinicians also can help prospective patients and their families make better informed decisions about whether to undergo this modality of treatment. This will help orthodontists and maxillofacial surgeons meet the psychological needs of their patients. The authors investigated how patients view their combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity. A core category and 6 other related categories emerged: satisfaction with treatment outcome despite the difficult experiences of the treatment, experiences shared by those already having undergone similar treatment, shock for family and close friends at the hospital, difficulty eating, pain caused by orthodontic treatment, fears caused by swelling and complications, and smiling with self-confidence. A better understanding of patients’ views on this combined treatment modality can assist health care professionals in properly counseling patients and their families and providing better patient-centered care.
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Acknowledgments The authors thank the participants for taking part and for sharing their experiences, thoughts, and emotions.
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controlled trials involving children. Am J Orthod Dentofacial Orthop 146:279, 2014 Hallberg LR: The ‘ core category’’ of grounded theory: Making constant comparisons. Int J Qual Stud Health Well-being 1: 141, 2006 Taghavi Bayat J, Hallberg U, Lindblad F, et al: Daily life impact of malocclusion in Swedish adolescents: A grounded theory study. Acta Odontol Scand 71:792, 2013 Chetpakdeechit W, Hallberg U, Hagberg C, et al: Social life aspects of young adults with cleft lip and palate: Grounded theory approach. Acta Odontol Scand 67:122, 2009 Stanford ND, Ip TB, Durham J: Adult orthodontic patients’ views regarding dentofacial normality: A qualitative study. Am J Orthod Dentofacial Orthop 145:287, 2014 Ryan FS, Barnard M, Cunningham SJ: What are orthognathic patients’ expectations of treatment outcome—A qualitative study. J Oral Maxillofac Surg 70:2648, 2012 Ryan FS, Barnard M, Cunningham SJ: Impact of dentofacial deformity and motivation for treatment: A qualitative study. Am J Orthod Dentofacial Orthop 141:734, 2012 Glaser BG, Strauss AL: The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL, Aldine, 1967 Rich M, Ginsburg KR: The reason and rhyme of qualitative research: Why, when, and how to use qualitative methods in the study of adolescent health. J Adolesc Health 25:371, 1999 Brook PH, Shaw WC: The development of an index of orthodontic treatment priority. Eur J Orthod 11:309, 1989 Glaser BG: The constant comparative method of qualitative analysis. Soc Probl 12:436, 1965 Spencer L: Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence. London, UK, TSO, 2003 Strauss AL, Corbin JM: Basics of Qualitative Research. Grounded Theory Procedures and Techniques. Thousand Oaks, CA, Sage, 2001 Rittersma J, Casparie AF, Reerink E: Patient information and patient preparation in orthognathic surgery: A medical audit study. J Maxillofac Surg 8:206, 1980 Finlay PM, Atkinson JM, Moos KF: Orthognathic surgery: Patient expectations; psychological profile and satisfaction with outcome. Br J Oral Maxillofac Surg 33:9, 1995 Nurminen L, Pietil€a T, Vinkka-Puhakka H: Motivation for and satisfaction with orthodontic-surgical treatment: A retrospective study of 28 patients. Eur J Orthod 21:79, 1999 Bock JJ, Maurer P, Fuhrmann RA: The importance of temporomandibular function for patient satisfaction following orthognathic surgery. J Orofac Orthop 68:299, 2007 Chen B, Zhang ZK, Wang X: Factors influencing postoperative satisfaction of orthognathic surgery patients. Int J Adult Orthodon Orthognath Surg 17:217, 2002 Bhamrah G, Ahmad S, NiMhurchadha S: Internet discussion forums, an information and support resource for orthognathic patients. Am J Orthod Dentofacial Orthop 147:89, 2015 Garvill J, Garvill H, Kahnberg KE, et al: Psychological factors in orthognathic surgery. J Craniomaxillofac Surg 20:28, 1992 Yao S, Zhou J, Li Z: Psychologic health status of patients undergoing orthognathic surgery. J Craniofac Surg 25:e540, 2014 Rustemeyer J, Eke Z, Bremerich A: Perception of improvement after orthognathic surgery: The important variables affecting patient satisfaction. Oral Maxillofac Surg 14:155, 2010 G€ uzel MZ, Sarac¸ M, Arslan H, et al: A new face by combined surgery for patients with complex dentofacial deformity. Aesthetic Plast Surg 31:32, 2007 Holman AR, Brumer S, Ware WH, et al: The impact of interpersonal support on patient satisfaction with orthognathic surgery. J Oral Maxillofac Surg 53:1289, 1995 Williams RW, Travess HC, Williams AC: Patients’ experiences after undergoing orthognathic surgery at NHS hospitals in the south west of England. Br J Oral Maxillofac Surg 42:419, 2004 van der Vlis M, Dentino KM, Vervloet B, et al: Postoperative swelling after orthognathic surgery: A prospective volumetric analysis. J Oral Maxillofac Surg 72:2241, 2014 Oland J, Jensen J, Elklit A, et al: Motives for surgical-orthodontic treatment and effect of treatment on psychosocial well-being and satisfaction: A prospective study of 118 patients. J Oral Maxillofac Surg 69:104, 2011
Perceptions of Young Adults Having Undergone Combined Orthodontic and Orthognathic Surgical Treatment: A Grounded Theory Approach Zahra Sadat-Marashi, BA,* Paolo Scolozzi, MD, DMD,y and Gregory S. Antonarakis, BSc, DDS, MSc, PhDz Purpose:
The present qualitative study aimed to explore the subjective perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity.
Materials and Methods:
Ten participants (5 women and 5 men; 20 to 25 yr of age) whose combined orthodontic and orthognathic surgical treatment had been terminated 1 to 3 years before undertaking the present study were selected. Open in-depth interviews, of approximately 30 minutes’ duration, were digitally recorded and transcribed verbatim. The interviews were analyzed using procedures inherent to the grounded theory approach, a qualitative approach to collecting and analyzing data that aims to develop a theoretical proposition grounded in real-world observations.
Results:
A core category was identified describing the participants’ satisfaction with treatment outcome despite the difficult experiences that they lived through during the orthodontic and orthognathic surgical treatment. In association to the core category, 6 other categories emerged: experiences shared by those already having undergone similar treatment; shock for family and close friends at the hospital; difficulty eating; pain caused by orthodontic treatment; fears caused by swelling and complications; and smiling with self-confidence.
Conclusion:
A better understanding of patients’ views on combined orthodontic and orthognathic surgical treatment can assist health care professionals in properly counseling patients and their families and providing better patient-centered care. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-8, 2015
Treatment for dentofacial deformity using a combined orthodontic and orthognathic surgical approach is well established. Despite recent advances in surgical and orthodontic expertise, there does not appear to have been similar progress in the understanding of patients’ perceived benefits derived from this treatment. It has been established that orthognathic surgery has beneficial psychological effects, but further evidence is required.1
For elective surgical procedures with associated risks, shared decision making between the clinician and the patient is crucial.2 These two parties need to understand each other’s perceptions to plan future therapy. On the one hand, patients must be well informed to make an educated decision. On the other, clinicians must be aware of the patient’s perspectives of normality and desire for change. The focus is shifting toward the patients’ own perceptions rather
*Dental Student, School of Dental Medicine, University of Geneva,
Address correspondence and reprint requests to Dr Antonarakis:
Geneva, Switzerland.
Division of Orthodontics, University of Geneva, 19 Rue Barthelemy-
yProfessor and Head, Division of Oral and Maxillofacial Surgery, Department of Surgery, University Hospitals of Geneva and Faculty
Menn, 1205 Geneva, Switzerland; e-mail: [email protected] Received April 2 2015
of Medicine, University of Geneva, Geneva, Switzerland.
Accepted May 8 2015
zOrthodontist, Department of Orthodontics, University Clinic of
Ó 2015 American Association of Oral and Maxillofacial Surgeons
Dental Medicine, Geneva, Switzerland.
0278-2391/15/00599-6
Drs Scolozzi and Antonarakis contributed equally to the present
http://dx.doi.org/10.1016/j.joms.2015.05.015
work.
1
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than a professional evaluation of morphology and treatment,3 although research outcomes continue to focus on morphologic changes.4 These objective measurements do not fully capture the impact of a particular treatment, and subjective assessment of this impact is paramount. Using traditional quantifiable research methodologies, such as questionnaires, to investigate patients’ perspectives do not favor the emergence of new perspectives owing to their deductive approach. The construction of questions or hypotheses is initially based on an existing theory, which narrows the research topic. When used improperly, these techniques can lead to misinterpretation and oversimplification of data. To investigate patients’ views about dentofacial deformities and subsequent corrective treatment, qualitative methods are ideal because they are suited to explore complex phenomena or areas not amenable to quantitative research owing to a lack of previous research on the subject. The strength of qualitative methodology is that it enables the researcher to grasp the patient’s point of view in unbiased ways.5 Qualitative methods, although gaining widespread use in medicine, have been used infrequently in the discipline of dentofacial deformity. Only a handful of studies have examined aspects, such as malocclusion,6 cleft lip and palate,7 dentofacial normality,8 motivation for treatment, and expectations of treatment outcome.9,10 The present study aimed to develop a theory to gain a deeper understanding of subjective perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity.
Materials and Methods GROUNDED THEORY
A qualitative study was conducted using the grounded theory approach, which is an inductive approach used to study social processes and structures.11,12 This approach to collecting and analyzing qualitative data aims to develop a theory or a theoretical proposition grounded in real-world observations to explain existing phenomena, rather than testing a hypothesis derived from an existing theory. According to Glaser and Strauss,11 when using a grounded theory approach, the theory will emerge by itself without being affected by the researchers’ objectiveness. It is particularly valuable for studying areas in which little is known or in which a deeper understanding of an incompletely explored area is desired. Grounded theory was the most suitable research methodology for the present study because the particular area of interest has not been adequately studied
using qualitative research methodology and because it allows a better understanding of the social processes creating the framework of a combined orthodontic and orthognathic surgical treatment. This study followed the Declaration of Helsinki on medical protocol and ethics and owing to its nature was granted exemption from the regional ethical review board. STUDY GROUP AND INTERVIEW PROCEDURE
Participants were eligible for inclusion if they spoke French, lived in Geneva, Switzerland, were 20 to 25 years old, and had been treated with a combined orthodontic and orthognathic surgical approach at the University Hospitals of Geneva, with treatment having been terminated at least 1 year, but not more than 3 years before the study. Exclusion criteria were patients with clefts or craniofacial syndromes, history of maxillofacial trauma or juvenile idiopathic arthritis, history of temporomandibular disorders or myoarthropathy of the masticatory system, history of poor dental health, hypodontia of more than 1 tooth per quadrant, any previous orthodontic treatment, or any form of previous maxillofacial or facial plastic surgery. The notion of purposive sampling was used to strategically select the population in question from the records at the University Hospitals of Geneva based on an a priori judgment about which participants would be most representative or informative. A heterogeneous sample was desired to amplify the field of experiences in the group studied.11 Ten participants were contacted, 5 women and 5 men, half of whom were students and the other half young professionals. Selected participants had different deviations from normal occlusion according to guidelines based on the Index of Orthodontic Treatment Need.13 Four had treatment to correct a Class III malocclusion, 2 to correct a Class II malocclusion, 2 for transverse problems, and 2 for vertical skeletal discrepancies (Table 1). Participants were initially contacted and informed about the study by telephone, providing information and answering questions as needed. Once a participant was willing and agreed to participate in the study, an appointment was made to conduct the interview. The setting of the interview was agreed to by the participant and the interviewer to make it as informal as possible and to make the participant feel comfortable, thereby decreasing bias. An establishment (usually a local cafe) close to the participant’s home, workplace, or university was chosen, making it convenient for the participant to attend. One participant requested an initial meeting with the interviewer to be more comfortable and confident for the actual interview.
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Table 1. DEMOGRAPHIC VARIABLES OF PARTICIPANT SAMPLE
Participant Number 1 2 3 4 5 6 7 8 9 10
Gender
Age (yr)
Professional Status
Malocclusion
Orthognathic Surgery
F F M F M M M F M F
21 22 20 25 22 21 24 23 22 23
Student Student Student Employed Employed Employed Student Employed Student Employed
Open bite Class III Class III Class II Deep bite Transverse deficiency Class II Class III Class III Asymmetry
Bimaxillary Maxillary Bimaxillary Mandibular Bimaxillary Maxillary Mandibular Bimaxillary Maxillary Bimaxillary
Abbreviations: F, female; M, male. Sadat-Marashi, Scolozzi, and Antonarakis. Perceptions of Surgical Orthodontic Treatment. J Oral Maxillofac Surg 2015.
All one-to-one interviews were conducted by the same interviewer. To decrease bias, this interviewer was not known to the participants, had not been involved in any way in the treatment of any of the participants, and would not be involved in the future care of any of these patients. The interviews, approximately 30 minute’s duration, were digitally recorded with the participant’s consent. Anonymity was guaranteed to protect participant confidentiality, and participants were assured that they could stop the interview at any time. At the outset of the interviews, the same general open-ended question was asked, ‘‘How did you experience the treatment for your teeth and jaws?’’ Each participant was given the opportunity to discuss freely and raise any topics or themes they judged appropriate. The interviewer, when necessary, posed additional questions for probing and clarification to understand the experiences of the participant. An interview guide (flexible and evolving) was used to cover the participants’ experiences, thoughts, and feelings about their treatment. Themes that were covered in the interviews included participant motivation, pain, satisfaction, social interactions, impact (with regard to school, work, and daily life), and outlook toward the future. If required, the interview was reinforced with further questioning in a conversational way. Data collection and analysis were conducted simultaneously, adhering to the principle of constant comparisons,14 and continued until saturation (no additional information emerging from new data) was reached. DATA COLLECTION AND ANALYSIS
Each interview was transcribed verbatim and then checked for accuracy against the original recordings. The interviews were analyzed strategically using a coding process. Two researchers, with different clinical backgrounds, independently analyzed and coded the
data to ensure that any emerging theory was robust and valid.15 Three types of coding were used, namely open, axial, and selective.16 Data from the interviews were initially coded using open coding. Open coding implies that the data are read, sentence by sentence, and the meaning of a particular sentence or what it expresses is defined. Then, these codes are clustered into categories (axial coding). By this means, the substance of the data was segmented into substantive codes and given concrete labels. Codes with similar content were clustered into summarizing categories. Then, a core category was established, along with its relation to other categories, and further refinement of the categories was carried out (selective coding).
Results The core category and 6 other related categories were identified (Fig 1). The core category described the participants’ satisfaction with treatment outcome despite their difficult experiences during the orthodontic and orthognathic surgical treatment. The 6 other categories identified were experiences shared by those already having undergone similar treatment; shock for family and close friends at the hospital; difficulty eating; pain caused by orthodontic treatment; fears caused by swelling and complications; and smiling with self-confidence. All patients were satisfied with the outcome of treatment and believed that it was worthwhile despite their difficult experiences during the treatment. Difficulties concerned the orthodontic treatment and the orthognathic surgical treatment. The worst part of the orthodontic treatment was the pain after many of the appointments. The worst part of the orthognathic surgical treatment was postoperative facial swelling, which also shocked family and friends, and caused difficulty eating. The greatest satisfaction described by the participants was the ability to smile with
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asking myself, why did I do this?! . I have had so much pain! Some participants also brought up whether they would pursue this treatment knowing what they knew about the pain and difficulties. They decided they would because of the final outcome and satisfaction with their face and smile. If I could go back in time then I wouldn’t change my mind. I would do it again. Yes, clearly! . Even my mom was very happy! EXPERIENCES SHARED BY THOSE ALREADY HAVING UNDERGONE SIMILAR TREATMENT
FIGURE 1. Relation between the core category and the 6 other categories concerning the perceptions and values of young adults having undergone combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity. Sadat-Marashi, Scolozzi, and Antonarakis. Perceptions of Surgical Orthodontic Treatment. J Oral Maxillofac Surg 2015.
confidence. Talking to patients who had already undergone similar treatments could have been beneficial to many of the participants. The following sections describe each of these categories in more detail. The categories also are illustrated with quotations from the interviewees. SATISFACTION WITH TREATMENT OUTCOME DESPITE THE DIFFICULT EXPERIENCE
The core category identified shows that participants were generally very satisfied with the outcome of the treatment. During the duration of the orthodontic treatment and the period surrounding the orthognathic surgical procedure (pre- and postoperatively), participants were faced with several difficulties and their experiences were somewhat negative with regard to pain and complications during treatment. Participants reported a combination of positive and negative thoughts immediately after orthognathic surgery with the expectation that the final treatment outcome would be as they had hoped, but with certain fears. These fears were mainly in relation to postoperative swelling and some comments received from family and friends. However, the universal remark common to the participants was that the final outcome outweighed the difficult experiences during the process. Today I’m really very happy. However, just after the surgery and until 1 or 2 months ago I was
Participants trusted the medical professionals and were satisfied with the information given to them by the orthodontist and maxillofacial surgeon concerning their treatment and possible side-effects and complications. However, a common desire, in hindsight, was to have been able to speak with a patient who had undergone a similar treatment. Participants believed that this would have better prepared them for what was to come. Hearing someone’s experiences firsthand was deemed to be more useful than just being given a list of possible complications by the health professional. Information coming from someone not in the medical profession appears to be desirable. Also, participants would have been more at ease about asking questions and discussing personal experiences with a peer who was more familiar with the process. This category shows the importance of being briefed by someone who has had the same treatment. Patients trust medical professionals, but they want to be informed by someone who is not included in the medical team and who has lived the experiences. Some participants had this desire before undergoing surgery, and some realized at the hospital that they wanted to speak to someone with the same condition. [B]ecause I was afraid of having a 6-hour surgery and not being able to eat. Before my surgery I should have asked the doctors if they knew someone who already had this surgery in order to ask some questions. I think it would have been useful. Especially another girl so I could feel more at ease! SHOCK FOR FAMILY AND CLOSE FRIENDS AT THE HOSPITAL
Most participants brought up the shock of their family and close friends when coming for the first time to the hospital after the orthognathic surgery. Sometimes, the family would even cry or at least show with their facial expressions that something was wrong. Participants reported that some family
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members mentioned that they were unsure whether what they were seeing, especially the swelling, was normal and that they were afraid that a mistake had been made during surgery. My mother told me that she didn’t recognize me because of the swelling.
[M]y family was crying in front of me and I was wondering what was happening. DIFFICULTY EATING
After orthognathic surgery, most participants believed themselves very limited by what they could or could not eat. They mentioned that they could eat only soups for the first weeks or up to 2 months. A soft diet followed that for the next month or so. A surprising number (approximately half) of participants mentioned how much they had wanted to eat a burger but could not. [A]fter all, it’s my favorite food! I was only able to eat a cheeseburger 4 months after surgery! I had missed crunching into a cheeseburger so much, and even after 4 months my teeth were still a bit sensitive. It had seemed like forever. Participants also brought up an element of fear. Because they were advised to not bite hard into any food after orthognathic surgery to avoid complications, some were extra vigilant, not wanting to compromise the final result after all their efforts and sacrifices. A limited mouth opening also was mentioned as one of the reasons that the participants had difficulty eating. After orthodontic appointments, eating also was difficult for some for a few days. Most participants mentioned that they were informed that they would lose weight after surgery. This seemed to have occurred to most participants. I lost a lot of weight. In the very beginning I could eat only liquids because if I closed my mouth even for swallowing my saliva, I felt pressure on my stitches. However, 1 participant reported that despite difficulties eating, she had not lost any weight because she had found a solution. [A]nd that was because I discovered that I could eat Nutella [a sweetened hazelnut chocolate spread] because it was soft! PAIN CAUSED BY ORTHODONTIC TREATMENT
All participants mentioned the pain they had experienced caused by the orthodontic part of the treatment. This was mainly subsequent to orthodontic
appointments and to the ‘‘tightening of the braces’’ in particular. One participant mentioned that the day after she had received her orthodontic appliances, she experienced the ‘‘the worse pain of my life.’’ All participants were in agreement that the orthodontic treatment was perhaps the most painful, even more than the surgery, and the fact that they still had orthodontic appliances in place after the surgery did not facilitate the situation and made it more difficult for them to ‘‘face the real word’’ just after their orthognathic surgery. The duration of orthodontic treatment was another factor that aggravated their experience because of the pain after almost every appointment. Participants also experienced other difficulties with the orthodontic treatment, but mostly after the initial appointment to bond the fixed appliance. However, pain seemed to be the worst problem because it was perceived intermittently throughout treatment. I had a brace with metallic bars which crossed the roof of my mouth, and some other braces all around the other teeth and I couldn’t stand them at first. I wore them for 3 days and then I went back to ask the dentist to take everything off because of the pain! It caused pain and I had difficulty to speak because of the bars inside. I had difficulty speaking and this bothered me a lot when I was with others. But most of all, I couldn’t stand the pain! FEARS CAUSED BY SWELLING AND COMPLICATIONS
The interviews showed how bad the patients felt when they woke up after their orthognathic surgery. A common question they asked their surgeons immediately postoperatively was whether their faces would stay swollen forever and whether they would be able to speak and eat as before. Some participants even doubted having chosen this treatment option and regretted this decision. There was mention of wanting to go back and undo what was done. Despite adequate information given by the surgeon and the medical team before the orthognathic surgery, most participants were still shocked by the swelling, difficulty eating, and difficulty speaking and, more importantly, feared these difficulties would remain for the long term. [W]hen I saw my face . I had the impression that I had just been run over by a truck. It wasn’t my face at all. I was suddenly afraid this would last forever. Some participants discussed their muscular pain after orthognathic surgery. In most cases, this pain was present before commencing treatment, but for
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some reason there was the common misconception that it would disappear with treatment. Disappointment that the pain persisted and the fear it would get worse were discussed. Limited jaw opening was brought up by some participants, as was the fear that this would last and prevent them from being able to eat as before and the fear of its becoming locked. When I yawned I would force myself to stop because I thought that if I let it go, my jaw would get locked in that position. Hypoesthesia was reported by some participants and discussed, although it was mostly transient. This was commonly near the chin area. One participant mentioned that this had not gone away and this participant was afraid it would become permanent. [A] year and a half has gone by after the surgery and it still tickles.
SMILING WITH SELF-CONFIDENCE
The smile was pointed out in many interviews as being the reason why the participants wanted to have some form of treatment performed and what they liked most about the final outcome. Having a dentofacial deformity caused patients to develop different habits or tactics to hide the smile that they did not find attractive. This included putting a hand in front of the mouth when smiling, smiling and keeping the lips together to avoid showing the teeth, putting the tongue between the teeth when smiling, avoiding smiling altogether, or putting the facial emphasis elsewhere with the application of large quantities of makeup around the eyes or with noticeable hair styles. Smiling was impossible! I was hiding my teeth so much and also because I had a large jaw, I tried to compensate for it by putting on so much eye shadow so that people around were attracted to my eyes and didn’t pay much attention to my mouth! Once treatment was finished, participants were very pleased with the fact that they could smile without shame and without trying to conceal their smile. This seemed to improve their self-reported confidence and self-esteem and made them more comfortable socially. Professional and personal social interactions were improved in some cases as a consequence. Today I don’t use makeup as before, and my smile is here, always here! Look! I have no more shame when I show my teeth, and it is much easier to talk to boys! It changed my life.
Discussion There is an increasing need to fully understand how patients with dentofacial deformity experience the impact of a combined orthodontic and orthognathic surgical treatment on their lives. Using the grounded theory approach allowed the authors to develop a theory revolving around different themes disclosed by the participants through the analysis of their interviews. A core category was generated in addition to 6 other categories. The core category was defined as the satisfaction of the participants with the treatment outcome despite their difficult experiences during treatment. The other categories identified were experiences shared by those already having undergone similar treatment, shock for family and close friends at the hospital, difficulty eating, pain caused by orthodontic treatment, fears caused by swelling and complications, and smiling with self-confidence. The core category identified was the satisfaction of participants having undergone a combined orthodontic and orthognathic surgical treatment. Satisfaction has been found from previous questionnaire-based studies to be high, ranging from 87 to nearly 100% of patients.17-20 The degree of satisfaction has been found to be unrelated to gender, age, diagnosis, or procedure.18,20 If satisfaction is measured only a few months after orthognathic surgery, then some dissatisfaction is reported, possibly owing to the lingering side-effects; however, with increased time, satisfaction improves and has been found to be high 1 year after surgery.18,21 The desire to have the opportunity to speak with someone having undergone a similar treatment was identified as another category. People are afraid of the unknown, which makes them seek out further specific explanations to better understand what they will go through. A previous study has found that patients undergoing orthognathic surgery look to the Internet for supplemental information regarding their proposed treatment.22 This could suggest a possible gap in the provision of information by health care professionals. However, it is clear that patients use Internet forums to seek additional information, support, and reassurance from peers undergoing similar treatment. Therefore, there is a need for clinicians to ensure that patients have access and are guided to appropriate and relevant Internet resources.22 Another identified category was the initial shock for family and close friends at the hospital. It has been found that approximately half of patients are influenced by their family or dentist before deciding to undergo a combined orthodontic and orthognathic surgery treatment.23 It also has been observed that the opinions of friends and family affect patient satisfaction, and those who receive comfort from their
SADAT-MARASHI, SCOLOZZI, AND ANTONARAKIS
entourage present better psychological health status.21,24,25 However, friends and family also could have problems getting used to or accepting the new appearance of the patient.25,26 Reaction of the patient’s entourage to his or her postoperative appearance has been found to correlate with satisfaction.27 Difficulty eating is commonly experienced by patients undergoing a combined orthodontic and orthognathic surgical treatment and was another identified category. Based on a previous study using a mail-in questionnaire, many patients reported that difficulty eating immediately postoperatively was worse than expected.28 The category of pain caused by the orthodontic treatment was of particular interest. Although the orthognathic surgical procedure is more invasive, the patients reported that the worst pain was in relation to the orthodontic treatment. This also has been brought to light in a previous questionnaire-based study that found that most patients experienced the orthodontic treatment as painful and the most unpleasant part of the entire treatment.19 The category of fears caused by the presence of swelling and complications is one that is relevant to the first few weeks after orthognathic surgery. The intervention is traumatic, and swelling is inevitable. Approximately 50% of the swelling has been found to decrease after the third postoperative week, whereas only 20% remains after 3 months.29 Despite being well informed, this still causes patients a certain amount of fear. Many patients, based on a previous mail-in questionnaire study, reported that the pain and swelling experienced immediately postoperatively were worse than expected.28 Moreover, another study of 118 patients found that one third of patients reported that it took them longer to recover from the intervention than anticipated.30 The ability to smile with self-confidence once treatment was completed was a category that was central to the participants’ everyday experiences. A systematic review has found an improvement in self-confidence after a combined orthodontic and orthognathic surgical treatment.1 A more recent study using a questionnaire also has found that an important outcome of treatment is improved self-concept.30 Moreover, post-treatment satisfaction improved as self-concept improved. METHODOLOGIC ISSUES
In qualitative studies such as the present one, understanding a certain phenomenon is favored over its distribution in the population or intergroup comparisons. The unit of comparison in grounded theory is events and stories, rather than individual participants.7
7 For this reason, sampling is fundamentally different than in quantitative studies. To maximize the generalizability of the findings, heterogeneous nonprobability purposive sampling is carried out to choose participants providing an array of experiences for in-depth study. One can use analogic reasoning to generalize the results of this study to other populations with similar characteristics. The authors did not aim to investigate gender-specific issues or issues related to a particular dentofacial deformity over another or a different orthognathic surgical procedure over another. The number of participants, being limited, can be seen as a weakness, but this type of research does not require an adequate sample to detect statistical importance, but one that reaches saturation. Saturation occurs after a period of data collection, when a point is reached at which no new data result from including new participants and the collection of additional data. The choice of the sample, namely French-speaking residents of Geneva 20 to 25 years old, was rather selective. This could limit the generalizability of the present findings with regard to age and location and culture. Any single-center study has inherent limitations for generalizability, because all participants are selected from a single center and a single geographic location. Age could be a factor that determines in part the subjective perceptions and values of individuals having undergone combined orthodontic and orthognathic surgical treatment, but this was beyond the realms of the present study. A sample of young adults was desired because this population represents patients who had appropriately timed treatment rather than delayed treatment. All interviews were conducted by 1 person who was not involved with any previous or current treatment of the participants. Thus, there was no conflict of the interviewer having a bias toward the participants or vice versa, and this helped the participants be more comfortable sharing positive and negative experiences and be as honest as possible. The interviews also were conducted in an environment where the participant was at ease and comfortable. Thus, the risk of a participant not sharing the truth with the interviewer was decreased. Nonetheless, bias is always a factor to consider in faceto-face interviews. The interviewer is a human being who brings an unknown agenda to the process composed of his own life experiences and biases, and one has a limited ability to understand how these biases affect the collection of data and the interpretation of results. Participants were included who had terminated their treatment at least 1 year but not more than 3 years before the study, so that postoperative difficulties and complications would not negatively influence the participant’s testimony and the recollection of events would be as accurate as possible without experiences becoming diluted with the passage of time.
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The analysis of the transcribed interviews was carried out by 2 individuals who were involved in the data management and explanatory analysis. The procedure was kept as transparent as possible so that the conclusions could be traced to the individual interviews and to ensure that the findings were supported by evidence. Cross-checks were carried out where necessary. The 2 individuals carrying out the analysis discussed their findings and reached a consensus. CLINICAL IMPLICATIONS
Understanding how patients experience the impact of their treatment on their lives is pivotal to counseling patients and families adequately before commencing orthodontic treatment or undertaking orthognathic surgical procedures. If one knows about the experiences of young adults with dentofacial deformity who have undergone combined orthodontic and orthognathic surgical treatment, then one can provide better care and advice during orthodontic treatment and pre- and postoperatively. Clinicians also can help prospective patients and their families make better informed decisions about whether to undergo this modality of treatment. This will help orthodontists and maxillofacial surgeons meet the psychological needs of their patients. The authors investigated how patients view their combined orthodontic and orthognathic surgical treatment to resolve their dentofacial deformity. A core category and 6 other related categories emerged: satisfaction with treatment outcome despite the difficult experiences of the treatment, experiences shared by those already having undergone similar treatment, shock for family and close friends at the hospital, difficulty eating, pain caused by orthodontic treatment, fears caused by swelling and complications, and smiling with self-confidence. A better understanding of patients’ views on this combined treatment modality can assist health care professionals in properly counseling patients and their families and providing better patient-centered care.
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Acknowledgments The authors thank the participants for taking part and for sharing their experiences, thoughts, and emotions.
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