Psychological factors in orthognathic surgery J6rgan Garvill 1, Helena Garvill 2, Karl-Erik Kahnberg a, Stefan Lundgren ~
1Departments of Psychology (Head: Prof. L.-G. Nilsson, PhD), 2Applied Psychology (Head: Prof. S. S. Bergstr6m, PhD), 4 Oral and Maxillofacial Surgery (Head: Prof. K.-E. Kahnberg, DDS, Dr Odont), University of Umedt and aDepartment of Oral and Maxillofacial Surgery (Head: Prof. J. Rosenquist, DDS, Dr Odont), University of Gdteborg, Sweden.
S U M M A R Y . 27 patients subjected to various orthognathic surgery procedures were studied preoperatively and during a period of 18 months postoperatively by a team of psychologists to evaluate the patients' own opinions concerning the indication for surgery, information about the surgical procedure, the postoperative period and the long-term aesthetic and functional results. The patients were interviewed 5 times: 2 days before surgery, 2 days after surgery and 2, 6 and 18 months after surgery. The decision to undergo surgery was taken after a long period of time, 4 years on average, and half of the patients were influenced by their family or dentist before they made their decision. 60 % gave three or more reasons for surgery, 85 % mentioned functional problems, 74 % facial appearance and 59 % craniomandibular symptoms. 63 % indicated that the facial appearance problems had negatively influenced their personal fife and 44 % their social fife. Women experienced this problem more often than men. The results showed that the overall majority of patients were relieved of their presurgical problems. The aesthetic improvement was better than expected. It was found that improvements in facial features had a beneficial influence on the patients as individuals and also on their social fife situation.
KEY W O R D S : Psychological factors- Orthognathic surgery
deformed children undergoing major reconstructive surgery go through 4 phases in the modification of their body image: (1) the decision to undergo surgery; (2) the experience of surgery, (3) the immediate postoperative period and (4) the reintegration phase. They also stated that an objective slight deformity may be of equivalent psychological importance as a deformity that is more obviously disfiguring (Murray et al., 1975). The aim of this study was to examine which factors govern the patient's decision to undergo surgical orthodontic treatment for correcting a dentofacial deformity and to evaluate the patient's estimation of the immediate and late postoperative phases, and overall satisfaction with the results in terms of quality of life.
INTRODUCTION In contrast to the steady and even dramatic progress made in orthognathic surgery, our knowledge of the social and psychological aspects of functional and aesthetic deviations is limited. Kiyak and co-workers investigated patients' motives for requesting orthognathic surgery by identifying the personality patterns of those individuals who made such requests and relating them to the patients' personal satisfaction with the alterations after they had been made (Kiyak et al., 1984, Kiyak and Zeitler, 1988). Facial alterations that enhance the patient's physical attractiveness may not only affect the individual's self-esteem but also his or her social value to others. Physical attractiveness was found to receive preferential social treatment in virtually every social situation examined thus far (Berscheid and Waister, 1974). It may very well be that the fact that the media in recent years have so emphasized physical beauty and set standards so high is an important factor responsible for the increasing demand for orthognathic surgery. However, functional problems associated with the dento-facial deformity are the dominating reason for the demand for orthognathic surgery, mostly combined with increased facial aesthetics (Lovius et al., 1990, Hutton 1967, Crowell et al., 1970). Murray and co-workers found that congenitally
MATERIAL AND M E T H O D S Patients
The group studied consisted of all patients who underwent orthognathic surgery in combination with orthodontic treatment in 1987. There were 17 women and 10 men between 17 and 56 years of age, with a median age of 28. The indications for surgery were: mandibular prognathism, 10 patients; mandibular prognathism in combination with maxillary retrognathism, 1 patient; mandibular retrognathism, 11 patients; maxillary retrognathism, 3 patients; and 28
Psychological factors in orthognathic surgery
open bite, 2 patients. The consecutive group of patients was intact throughout the 18-month period.
Procedure The patients were interviewed 5 times, 2 days before surgery, 2 days after surgery and 2, 6 and 18 months after surgery. The first interview, performed 2 days before the operation, focussed on the patient's decision to undergo surgical treatment and on the reasons for seeking surgical treatment. They were further asked if these factors had affected them as individuals and/or their social relations. All patients were also requested to rate how satisfied or dissatisfied they were with their facial appearance. Finally, they were asked how well informed they felt concerning the proposed surgery and what kinds of problems they expected in the immediate postsurgical period. The second interview was conducted 2 days after surgery and focussed on the patients' experiences in the immediate postsurgical period. The third interview was held 2 months after surgery. The patients were asked about postsurgical problems and if they had experienced any change in their facial appearance. The patients were asked to rate their satisfaction/dissatisfaction with the result. They were also asked if the result of the surgery had influenced them and/or their social relations. Finally, they were asked if they would undergo the same treatment again if they were in the same situation as before the surgery. The fourth interview was conducted 6 months after surgery and focussed on what functional, personal and social changes they experienced in relation to the problems they had had before surgery. Also, the patients rated their satisfaction/dissatisfaction with their facial appearance. The fifth interview was held 18 months after surgery and the patients were asked to evaluate the functional, personal and social changes they had experienced in relation to their preoperative problems. They also rated their facial appearance and finally gave a total evaluation of how satisfied or dissatisfied they were with the total experience starting 24 months before surgery and ending 18 months after surgery. The interviews were structured, with added follow-up questions. Some questions required 'yes' or 'no' answers, some ratings on quantitative scales, and some verbal answers freely expressed. The interviews were conducted by one female or one male psychologist. The female and male patients were approximately equally distributed among the interviewers. The length of the interviews varied between 30 and 60 min.
RESULTS
Decision to undergo surgical treatment It was found that the possibility of surgical treatment had been known to the patients from 1-30 years before the decision, with a median of 4 years. They had thought seriously about surgery, as a possibility,
29
for 1-9 years, with a median of 3 years, and they had made their decision 1-2 years before the operation. 51% of the patients had, at the time for their decision, felt uncertain about what would be the best decision and 3 % said that they had not really had enough information to reach a decision. 22% rated the decision as 'rather difficult' or 'very difficult' on a 5point rating scale, ranging from 'not difficult at all' (1) to 'very difficult' (5), with an intermediate level of 'rather difficult' (3). 30% of the patients said that they questioned their decision once or several times during the preoperative period. 52 % said that they had reached the decision on their own while 48 % said that they were influenced by their family and/or professionals. Although some patients felt uncertain at the time of decision, 82 % of the women and 50 % of the men said that reaching a decision made them feel more confident. Two days before surgery, nobody thought that a wrong decision had been made.
Types of problems In the first interview, the patients were asked to give their own reasons for undergoing surgical treatment. The reasons given were classified in 5 categories: (1) functional problems connected with chewing and biting; (2) craniomandibular symptoms, i.e. TMJ problems; (3) facial appearance; (4) phonetic problems, and (5) gastro-intestinal problems. Of the total group, 11% gave only one reason while 60% gave three or more reasons for undergoing surgery. 85 % mentioned functional problems, 59 % craniomandibular symptoms, 74 % facial appearance as a reason while phonetic and gastro-intestinal problems were each mentioned by 27% of the patients. Comparing men to women with respect to type of problem, craniomandibular symptoms were more frequent among the female patients than among the males (71% vs. 40%). Dividing the patients into one group of younger patients (29 years or less, n = 15) and one group of older patients (30 years or more, n = 12), we found that functional problems were mentioned by 100 % vs. 73 % and craniomandibular problems by 83 % vs. 40 %, thus more frequently by the older patients than by the younger ones. There was no difference between women and men or between younger and older patients with respect to facial appearance as a reason for surgical treatment. The patients were also asked to state the most important problem. 44 % indicated functional problems as the most important, 33% facial appearance and 22% craniomandibular symptoms. There were no differences regarding the patient's most important problem between women and men or between younger and older patients except for facial appearance, where the younger patients more often mentioned this problem as the most important (younger, 47 % vs. older, 17 %). When asked if the problems had influenced them as individuals and/or their social relations, 63 % stated that they had been negatively influenced as individuals and 44% that their social life had been impaired. Women had experienced personal and social problems more often than men (women, 76 % vs. men, 40 % and
30
Journal of Cranio-Maxillo-Facial Surgery
women, 59 % vs. men, 20 % for personal and social problems, respectively). The problems mentioned were of the following kind: ' I do not speak when with other people' ;' I always keep one of my hands in front of my mouth', 'I avoid social gatherings ; 'I do not like to be photographed, especially not in profile'; I avoid eating among other people' ;' I have become shy and inhibited'; 'I am constantly aware of my facial appearance'; 'I feel other people look at me'.
Information When asked 2 days before surgery how well informed they felt about the expected effects the surgery would have on their problems, 69 % of the patients felt well informed with regard to the effects on the functional problems, 81% felt well informed about the effects on craniomandibular symptoms, 50 % thought they were well informed concerning the effects on their facial appearance and 33 % and 20 %, respectively, said that they were well informed about the effects on gastrointestinal and speech problems. Further, 67 % said that they were 'poorly' or 'very poorly' informed about the proposed surgery and 74 % said they were 'poorly' or 'very poorly' informed about the postsurgical period. This rating was done on a 5-point rating scale, ranging from 'very poorly informed' ( - 2 ) to 'very well informed' (+2), with an intermediate level at 'neither poorly nor well informed' (0). Two days after surgery, the patients were asked if there was any information they had not been given before the surgery which they thought they should have had. 30 % of the patients stated that there was some information missing, mostly concerning the surgery and recovery after surgery. In the third interview they were asked how well informed they thought they had been concerning the 2-month period after surgery. 33 % of the patients said they had been 'poorly' or ' very poorly' informed.
Expected and perceived problems The patients were asked to list what kinds of problems they expected the days immediately after the surgery and in the second interview, 2 days after the operation, they were asked to list what kinds of problems they were actually experiencing. The percentages of the total group expecting and actually experiencing the different kinds of problems are given in Table 1. Two months after surgery, the patients were asked
to indicate which problems, from a given list of possible ones, they had experienced and also to rate the degree of distress on a 5-point rating scale, ranging from 'no trouble at all' (1) to 'very distressing' (5), with an intermediate level of 'rather distressing' (3). The percentages of patients indicating different kinds of problems as well as the mean ratings for each kind of problem are given in Table 2. In answer to the question whether the 2 months in the immediate postsurgical period, as a whole, had been ' better', ' as expected' or ' worse than expected ', 67 % said it had been better than expected, 15 % as expected and 18 % worse than expected.
Evaluation of the effects of surgery The interviews conducted 2, 6 and 18 months after surgery focussed on the patients' subjective evaluations of the effects of the surgery and on the problems they had given as reasons for treatment before surgery. Two months after surgery, 81% thought that their facial appearance had changed 'somewhat' or 'very much'. The rating was done on a 5-point rating scale, ranging from 'no change' (1) to 'very much' (5) with an intermediate level of' somewhat' (3). 15 % thought the change was less than expected, 59 % said it was as expected and 26 % said the change was bigger than expected. In the fourth and fifth interview, the patients were asked to rate the effects of the surgery with regard to the kinds of preoperative problems they had experienced. The rating was done on a 7-point rating scale, ranging from 'much worse' ( - 3 ) to 'much better' (+ 3), with an intermediate level at' no change' (0). The percentage of patients perceiving their problems as 'worse', 'unchanged' and 'better' as well as the mean ratings 6 months and 18 months after surgery are given in Tables 3 and 4. The patients were further asked if they felt free from their presurgical problems. At the 6 months interview 39 % answered ' yes' and at 18 months 77 % answered ' yes'. The patients also rated how satisfied or dissatisfied they were with their facial appearance. These ratings were done before surgery and 2 months, 6 months and 18 months after surgery. The ratings were done for full face and in profile on a 11-point rating scale
Table 2 . - Percentage of patients experiencing different kinds of J problems during the 2-month period after surgery and mean ratings of how distressing the problems had been
Table 1 . - Comparison of expected problems actually experienced
Type of problem
% Patients expecting different kinds of problems
% Patients actually experiencing problems
Pain Eating problems Swelling Intermaxillary fixation Speech difficulties Only able to drink Tiredness Breathing difficulties
78 59 37 33 30 15 11 0
26 45 41 23 52 0 12 30
Kind of problem
% Patients experiencing the problem
Mean rating
Intermaxillary fixation Pain Swelling Breathing difficulties Eating difficulties Only able to drink Speech difficulties Loss of sensitivity Tiredness Depression
77 19 74 41 70 74 63 52 48 41
3.24 2.40 2.85 3-46 3-25 2.85 3.12 2'79 2.79 3'25
Psychological factors in orthognathic surgery
Table 3. - Evaluation of the effects of surgery after 6 months.
100
Percentage of patients experiencing the problems as worse, unchanged or better. Mean ratings of the effects of surgery
~
90-
Pre~qurgery Enface
80-
Preoperative type of problem
Worse
No change
Better
Mean rating
N1
Functional Craniomandibular Facial appearance Gastrointestinal Speech
4 0 5 0 0
17 8 17 75 20
79 92 78 25 80
+ 2-04 +2'31 + 1.79 + 1'20 + 1"60
23 16 20 7 7
70-
60'E 0
5040-
a_
30"
1 Number of subjects indicating each kind of problem before surgery 10Table 4. - Evaluation of the effects of surgery after 18 months.
Percentage of patients experiencing the problems as worse, unchanged or better. Mean ratings of the effects of surgery Preoperative type of problem
Worse
Functional 0 Craniomandibular 0 Facial appearance 0 Gastrointestinal 0 Speech 33
0
-5
m -4
Lm n ! -3
=
-2 ' -1 ~ 0 ' +1 ' +2' +3 ' +4 ~ +5
Very
Very
dissatisfied
No change
Better
Mean rating
N1
5 18 17 33 0
95 82 83 67 67
+ 2.70 +2-27 + 1.83 + 2.25 + 1'00
23 16 20 7 7
1 Number of subjects indicating each kind of problems before surgery.
Table 5. - Mean ratings of satisfaction/dissatisfaction with facial
appearance, before surgery and 2 months, 6 months and 18 months after surgery
Full-face Profile
31
Before surgery
2 months
After surgery 6 months
18 months
-1.07 a - 2.07 ~
+2.15 + 2-07
+2.52 + 2.33
+2.50 + 2.23
J- The differences between ratings before and after surgery are
satisfied
Rating Scale
Fig. 1 -Comparison of patients' pre-surgery rating of facial appearance with non-patients' ratings. Table 6. - Percentage of patients reporting positive personal and
social effects of surgery1 Effects
2 months
6 months
18 months
Personal Social Reaction from others
48 26 78
59 48 78
55 46 45
t No patients reported any negative personal or social effects of surgery 10o
90-J ~ 80-
Post-Surgepj:18monthEnface
I Non-patients
70-
significant, p < 0.1, oneway ANOVA
ranging, from 'very dissatisfied' ( - 5 ) to 'very satisfied' ( + 5), with intermediate levels at 'rather dissatisfied' ( - 3 ) , 'neither satisfied, nor dissatisfied' (0) and 'rather satisfied' ( + 3). The mean ratings are given in Table 5. As can be seen in Table 5, a significant increase in the patients' satisfaction (p < 0.01) with their facial appearance from before surgery to the 18-month postsurgical interview was found. In order to evaluate the distribution of the satisfaction or dissatisfaction with facial appearance, a comparison with a nonpatient group was made. 22 students at the University of Ume~, 11 women and 10 men, age-matched with the patient group, were asked to rate how satisfied or dissatisfied they were with their facial appearance on the same rating scale as the patients used. The mean rating in the non-patient group was full face +2.91 and for in profile +2.05. Thus, before surgery, the patients with dentofacial deformities as a group were more dissatisfied with their facial appearance than a non-patient group. However, after orthognathic surgery, the patients did not differ from a non-patient group with regard to satisfaction with facial appearance (Fig. 1).
50
1
-5
-4
-3
-2
-1
0
+1 +2 +3 +4 +5
Vet-/
dissatisfied
Rating Scale
Very satisfied
Fig. 2 - Comparison of patients' post-surgery ratings of facial
appearance with non-patients' ratings.
The patients wee also questioned about the effects of the surgery regarding their psychological and social situation. They were asked if they had had any reactions such as comments from persons in their surroundings, if the effects of surgery had or had not influenced them as individuals and if their social relations had or had not been influenced. The percentages of patients reporting positive effects of surgery are given in Table 6. No patient reported any negative effects in these areas.
32
Journal of Cranio-Maxillo-Facial Surgery
The following phrases are examples of the kinds of psychological and social changes the patients experienced : ' I feel more confident'; ' I am not afraid to open my mouth and to laugh'; 'I am not ashamed of my appearance any more'; 'I am not afraid to approach other persons'; 'I am in a better mood and I enjoy being with people'. When asked if they would undergo the same kind of surgical treatment again, should they have similar problems, 70% of the patients answered 'yes' 2 months after surgery, 78 % said 'yes' 6 months after surgery and after 18 months 82 % answered 'yes'. Finally, the patients were asked to rate how satisfied or dissatisfied they were with the total experience from 24 months before surgery to 18 months after surgery. This rating was done on the same kind of 11-point rating scale as was used for the ratings of facial appearance. The mean rating for the total group was +3.5, with 4.5% of the patients indicating dissatisfaction, 4.5% indicating 'neither satisfied nor dissatisfied' and 91% of the patients being 'rather satisfied' or 'very satisfied'. DISCUSSION AND CONCLUSIONS We found that the decision to undergo surgical treatment was a decision taken after a long period of time, 4 years on average, and that half of the patients were influenced by others, i.e. their family or dentist, before they made their final decision. We also found that 100 % of the patients felt they had made the right decision when interviewed 2 days before surgery. 60 % of the patients gave three or more reasons for undergoing surgery. 85 % mentioned functional problems, 74 % facial appearance and 59 % craniomandibular symptoms as reasons for their demand for treatment. Most of the patients thus have a multicausal background for treatment. Among the patients, 63 % indicated that the facial appearance problem had negatively influenced their personal life and 44 % their social life. Women experienced this problem more often than men, which might explain why women more often than men seek orthognathic surgery treatment. The results correspond to the results in studies where physical attractiveness affected both the subjects' self-esteem and their social value to others (Bercheidand Waister, 1974, Kiyak et al., 1984, Kiyak and Zeitler, 1988, Lovins et al., 1990). The patients rated their facial appearance before surgery and 2 months, 6 months and 18 months after surgery. The rating was done on a bi-polar rating scale ranging from - 5 (very dissatisfied) to +5 (very satisfied). The mean value for the presurgical rating (full face) was -1"07 and increased to + 2"50 after 18 months. In a study among a non-patient group (students), we found a mean value for facial appearance on the same level as for the treated patient group (Table 5, Fig. 1). Thus, the surgical treatment moved the majority of the patients from the negative side of the scale to the positive side and to a level comparable to a non-surgical group. Furthermore (see table 6) all of the patients said that the effects of
the surgery had influenced them as individuals, as well as their social relations, in a positive way. This result corresponds well to results found in other studies (Kiyak et al., 1982, 1984, Kiyak and Zeitler, 1988, Lovins et al., 1990, Crowell et al., 1970, Hutton 1967). Our results in this longitudinal study showed that the majority of the patients were relieved of their presurgical problems, and facial appearance seemed to be a major factor for the patients' estimation of the postsurgical result, which was stable over the investigation period. The aesthetic improvements in facial attractiveness were better than expected presurgically, and the satisfaction was high regardless of functional problems. It was also found that improvements in facial features influenced the patients as individuals and their social relations (Reich, 1975). Facial disfigurements due to dentofacial deformities are a psychological and social handicap (Belfer et al., 1982). The patients who had made their decision to undergo surgical orthodontic treatment for their dentofacial deformity were very determined in their decision and the decision per se raised their feeling of confidence. The difference in this group of patients compared to the patients with dentofacial deformities who do not ask for treatment or refrain from treatment after they had been informed is a question which will be the subject of further investigations. The preoperative information given to the patients regarding effects of surgery on functional problems seemed, in the majority of patients, to have been received satisfactorily while information on the surgical procedure, complications and the postoperative period seemed to have failed in many of the patients. This finding may be due to the oral surgeon's inability to present the information adequately or on the patients' inability to receive the information correctly preoperatively (in order not to have second thoughts about having the surgery). The value to the patients of written information regarding such items as general anaesthesia, postoperative diet, weight loss, absence from work, loss of sensibility or possible damage to the dentition has been discussed in papers by Rittersma et al. (1980) and Rittersma (1989). However, the personal contact between surgeon and patient was considered most important. The long term overall positive attitude postoperatively, however, encourages further efforts to treat this category of patients and thus enhance their social life situation and their confidence in themselves.
References Berseheid, E., E. Waister : Physical attractiveness. In: Berkowitz
(ed): Advances in experimental social psychology. Academic Press, New York 1974, vol 7 Belfer, M. L., A. M. Harrison, F. C. Pillemar, J. E. Murray:
Appearance and the influence of reconstructive surgery on body image. Clin. Plast. Surg. 9 (1982) 307 Crowell, N. T., H. J. Sazima, S. T. Elder: Survey of patients' attitudes after surgical correction of prognathism: Study of 33 patients. J. Oral Surg. 28 (1970) 818 Hutton, C. E, : Patients' evaluation of surgical correction of prognathism. J. Oral Surg. 25 (1967) 225
Psychological factors in orthognathic surgery
33
Kiyak, H. S., T. Hohl, R. A. West, R. W. McNeill: Psychologic
Rittersma, J..' Patient information and patient preparation in
changes in orthognathic surgery patients: A 24-month follow up. J. Oral Maxillofac. Surg. 42 (1984) 506 Kiyak, H. A., R. A. West, T. Hohl, R. W. McNeil: The psychological impact of orthognathic surgery: a 9 month follow-up. Am. J. Orthod. 81 (1982) 404 Kiyak, H. A., D. L. Zeitler : Self assessment of profile and body image among ortbognathic surgery patients before and two years after surgery. J. Oral Maxillofac. Surg. 46 (1988) 365
orthognathic surgery. The role of an information brochure. A medical audit study. J Cranio-Max-Fac. Surg. 17 (1989) 278 Rittersma, J., A. F. Carparie, E. Reerink : Patient information and patient preparation in orthognathic surgery. J. Max-Fac. Surg. 8 (1980) 206
Lovius, B. B. J., R. B. Jones, O. A. Pospisil, D. Reid, P. D. Slade, T. H. M. Wynne: The specific psychosocial effects of
orthognathic surgery. J. Cranio-Max-Fac. Surg. 18 (1990) 339 Murray, J. E., L. T. Swanson, R. D. Strand, G. M. Hrieko :
Evaluation of craniofacial surgery in the treatment of facial deformities. Ann. Surg. 182 (1975) 240 Reich, 9".: Factors influencing patient's satisfaction with the results of aesthetic plastic surgery. Plast. Reconstr. Surg. 55 (1975) 5
K.-E. Kahnberg, DDS, Odont, dr Department of Oral and Maxillofacial Surgery Faculty of Odontology University of G6teborg S-40033 G6teborg Sweden Paper received 4 March 1991 Accepted 7 October 1991
1Departments of Psychology (Head: Prof. L.-G. Nilsson, PhD), 2Applied Psychology (Head: Prof. S. S. Bergstr6m, PhD), 4 Oral and Maxillofacial Surgery (Head: Prof. K.-E. Kahnberg, DDS, Dr Odont), University of Umedt and aDepartment of Oral and Maxillofacial Surgery (Head: Prof. J. Rosenquist, DDS, Dr Odont), University of Gdteborg, Sweden.
S U M M A R Y . 27 patients subjected to various orthognathic surgery procedures were studied preoperatively and during a period of 18 months postoperatively by a team of psychologists to evaluate the patients' own opinions concerning the indication for surgery, information about the surgical procedure, the postoperative period and the long-term aesthetic and functional results. The patients were interviewed 5 times: 2 days before surgery, 2 days after surgery and 2, 6 and 18 months after surgery. The decision to undergo surgery was taken after a long period of time, 4 years on average, and half of the patients were influenced by their family or dentist before they made their decision. 60 % gave three or more reasons for surgery, 85 % mentioned functional problems, 74 % facial appearance and 59 % craniomandibular symptoms. 63 % indicated that the facial appearance problems had negatively influenced their personal fife and 44 % their social fife. Women experienced this problem more often than men. The results showed that the overall majority of patients were relieved of their presurgical problems. The aesthetic improvement was better than expected. It was found that improvements in facial features had a beneficial influence on the patients as individuals and also on their social fife situation.
KEY W O R D S : Psychological factors- Orthognathic surgery
deformed children undergoing major reconstructive surgery go through 4 phases in the modification of their body image: (1) the decision to undergo surgery; (2) the experience of surgery, (3) the immediate postoperative period and (4) the reintegration phase. They also stated that an objective slight deformity may be of equivalent psychological importance as a deformity that is more obviously disfiguring (Murray et al., 1975). The aim of this study was to examine which factors govern the patient's decision to undergo surgical orthodontic treatment for correcting a dentofacial deformity and to evaluate the patient's estimation of the immediate and late postoperative phases, and overall satisfaction with the results in terms of quality of life.
INTRODUCTION In contrast to the steady and even dramatic progress made in orthognathic surgery, our knowledge of the social and psychological aspects of functional and aesthetic deviations is limited. Kiyak and co-workers investigated patients' motives for requesting orthognathic surgery by identifying the personality patterns of those individuals who made such requests and relating them to the patients' personal satisfaction with the alterations after they had been made (Kiyak et al., 1984, Kiyak and Zeitler, 1988). Facial alterations that enhance the patient's physical attractiveness may not only affect the individual's self-esteem but also his or her social value to others. Physical attractiveness was found to receive preferential social treatment in virtually every social situation examined thus far (Berscheid and Waister, 1974). It may very well be that the fact that the media in recent years have so emphasized physical beauty and set standards so high is an important factor responsible for the increasing demand for orthognathic surgery. However, functional problems associated with the dento-facial deformity are the dominating reason for the demand for orthognathic surgery, mostly combined with increased facial aesthetics (Lovius et al., 1990, Hutton 1967, Crowell et al., 1970). Murray and co-workers found that congenitally
MATERIAL AND M E T H O D S Patients
The group studied consisted of all patients who underwent orthognathic surgery in combination with orthodontic treatment in 1987. There were 17 women and 10 men between 17 and 56 years of age, with a median age of 28. The indications for surgery were: mandibular prognathism, 10 patients; mandibular prognathism in combination with maxillary retrognathism, 1 patient; mandibular retrognathism, 11 patients; maxillary retrognathism, 3 patients; and 28
Psychological factors in orthognathic surgery
open bite, 2 patients. The consecutive group of patients was intact throughout the 18-month period.
Procedure The patients were interviewed 5 times, 2 days before surgery, 2 days after surgery and 2, 6 and 18 months after surgery. The first interview, performed 2 days before the operation, focussed on the patient's decision to undergo surgical treatment and on the reasons for seeking surgical treatment. They were further asked if these factors had affected them as individuals and/or their social relations. All patients were also requested to rate how satisfied or dissatisfied they were with their facial appearance. Finally, they were asked how well informed they felt concerning the proposed surgery and what kinds of problems they expected in the immediate postsurgical period. The second interview was conducted 2 days after surgery and focussed on the patients' experiences in the immediate postsurgical period. The third interview was held 2 months after surgery. The patients were asked about postsurgical problems and if they had experienced any change in their facial appearance. The patients were asked to rate their satisfaction/dissatisfaction with the result. They were also asked if the result of the surgery had influenced them and/or their social relations. Finally, they were asked if they would undergo the same treatment again if they were in the same situation as before the surgery. The fourth interview was conducted 6 months after surgery and focussed on what functional, personal and social changes they experienced in relation to the problems they had had before surgery. Also, the patients rated their satisfaction/dissatisfaction with their facial appearance. The fifth interview was held 18 months after surgery and the patients were asked to evaluate the functional, personal and social changes they had experienced in relation to their preoperative problems. They also rated their facial appearance and finally gave a total evaluation of how satisfied or dissatisfied they were with the total experience starting 24 months before surgery and ending 18 months after surgery. The interviews were structured, with added follow-up questions. Some questions required 'yes' or 'no' answers, some ratings on quantitative scales, and some verbal answers freely expressed. The interviews were conducted by one female or one male psychologist. The female and male patients were approximately equally distributed among the interviewers. The length of the interviews varied between 30 and 60 min.
RESULTS
Decision to undergo surgical treatment It was found that the possibility of surgical treatment had been known to the patients from 1-30 years before the decision, with a median of 4 years. They had thought seriously about surgery, as a possibility,
29
for 1-9 years, with a median of 3 years, and they had made their decision 1-2 years before the operation. 51% of the patients had, at the time for their decision, felt uncertain about what would be the best decision and 3 % said that they had not really had enough information to reach a decision. 22% rated the decision as 'rather difficult' or 'very difficult' on a 5point rating scale, ranging from 'not difficult at all' (1) to 'very difficult' (5), with an intermediate level of 'rather difficult' (3). 30% of the patients said that they questioned their decision once or several times during the preoperative period. 52 % said that they had reached the decision on their own while 48 % said that they were influenced by their family and/or professionals. Although some patients felt uncertain at the time of decision, 82 % of the women and 50 % of the men said that reaching a decision made them feel more confident. Two days before surgery, nobody thought that a wrong decision had been made.
Types of problems In the first interview, the patients were asked to give their own reasons for undergoing surgical treatment. The reasons given were classified in 5 categories: (1) functional problems connected with chewing and biting; (2) craniomandibular symptoms, i.e. TMJ problems; (3) facial appearance; (4) phonetic problems, and (5) gastro-intestinal problems. Of the total group, 11% gave only one reason while 60% gave three or more reasons for undergoing surgery. 85 % mentioned functional problems, 59 % craniomandibular symptoms, 74 % facial appearance as a reason while phonetic and gastro-intestinal problems were each mentioned by 27% of the patients. Comparing men to women with respect to type of problem, craniomandibular symptoms were more frequent among the female patients than among the males (71% vs. 40%). Dividing the patients into one group of younger patients (29 years or less, n = 15) and one group of older patients (30 years or more, n = 12), we found that functional problems were mentioned by 100 % vs. 73 % and craniomandibular problems by 83 % vs. 40 %, thus more frequently by the older patients than by the younger ones. There was no difference between women and men or between younger and older patients with respect to facial appearance as a reason for surgical treatment. The patients were also asked to state the most important problem. 44 % indicated functional problems as the most important, 33% facial appearance and 22% craniomandibular symptoms. There were no differences regarding the patient's most important problem between women and men or between younger and older patients except for facial appearance, where the younger patients more often mentioned this problem as the most important (younger, 47 % vs. older, 17 %). When asked if the problems had influenced them as individuals and/or their social relations, 63 % stated that they had been negatively influenced as individuals and 44% that their social life had been impaired. Women had experienced personal and social problems more often than men (women, 76 % vs. men, 40 % and
30
Journal of Cranio-Maxillo-Facial Surgery
women, 59 % vs. men, 20 % for personal and social problems, respectively). The problems mentioned were of the following kind: ' I do not speak when with other people' ;' I always keep one of my hands in front of my mouth', 'I avoid social gatherings ; 'I do not like to be photographed, especially not in profile'; I avoid eating among other people' ;' I have become shy and inhibited'; 'I am constantly aware of my facial appearance'; 'I feel other people look at me'.
Information When asked 2 days before surgery how well informed they felt about the expected effects the surgery would have on their problems, 69 % of the patients felt well informed with regard to the effects on the functional problems, 81% felt well informed about the effects on craniomandibular symptoms, 50 % thought they were well informed concerning the effects on their facial appearance and 33 % and 20 %, respectively, said that they were well informed about the effects on gastrointestinal and speech problems. Further, 67 % said that they were 'poorly' or 'very poorly' informed about the proposed surgery and 74 % said they were 'poorly' or 'very poorly' informed about the postsurgical period. This rating was done on a 5-point rating scale, ranging from 'very poorly informed' ( - 2 ) to 'very well informed' (+2), with an intermediate level at 'neither poorly nor well informed' (0). Two days after surgery, the patients were asked if there was any information they had not been given before the surgery which they thought they should have had. 30 % of the patients stated that there was some information missing, mostly concerning the surgery and recovery after surgery. In the third interview they were asked how well informed they thought they had been concerning the 2-month period after surgery. 33 % of the patients said they had been 'poorly' or ' very poorly' informed.
Expected and perceived problems The patients were asked to list what kinds of problems they expected the days immediately after the surgery and in the second interview, 2 days after the operation, they were asked to list what kinds of problems they were actually experiencing. The percentages of the total group expecting and actually experiencing the different kinds of problems are given in Table 1. Two months after surgery, the patients were asked
to indicate which problems, from a given list of possible ones, they had experienced and also to rate the degree of distress on a 5-point rating scale, ranging from 'no trouble at all' (1) to 'very distressing' (5), with an intermediate level of 'rather distressing' (3). The percentages of patients indicating different kinds of problems as well as the mean ratings for each kind of problem are given in Table 2. In answer to the question whether the 2 months in the immediate postsurgical period, as a whole, had been ' better', ' as expected' or ' worse than expected ', 67 % said it had been better than expected, 15 % as expected and 18 % worse than expected.
Evaluation of the effects of surgery The interviews conducted 2, 6 and 18 months after surgery focussed on the patients' subjective evaluations of the effects of the surgery and on the problems they had given as reasons for treatment before surgery. Two months after surgery, 81% thought that their facial appearance had changed 'somewhat' or 'very much'. The rating was done on a 5-point rating scale, ranging from 'no change' (1) to 'very much' (5) with an intermediate level of' somewhat' (3). 15 % thought the change was less than expected, 59 % said it was as expected and 26 % said the change was bigger than expected. In the fourth and fifth interview, the patients were asked to rate the effects of the surgery with regard to the kinds of preoperative problems they had experienced. The rating was done on a 7-point rating scale, ranging from 'much worse' ( - 3 ) to 'much better' (+ 3), with an intermediate level at' no change' (0). The percentage of patients perceiving their problems as 'worse', 'unchanged' and 'better' as well as the mean ratings 6 months and 18 months after surgery are given in Tables 3 and 4. The patients were further asked if they felt free from their presurgical problems. At the 6 months interview 39 % answered ' yes' and at 18 months 77 % answered ' yes'. The patients also rated how satisfied or dissatisfied they were with their facial appearance. These ratings were done before surgery and 2 months, 6 months and 18 months after surgery. The ratings were done for full face and in profile on a 11-point rating scale
Table 2 . - Percentage of patients experiencing different kinds of J problems during the 2-month period after surgery and mean ratings of how distressing the problems had been
Table 1 . - Comparison of expected problems actually experienced
Type of problem
% Patients expecting different kinds of problems
% Patients actually experiencing problems
Pain Eating problems Swelling Intermaxillary fixation Speech difficulties Only able to drink Tiredness Breathing difficulties
78 59 37 33 30 15 11 0
26 45 41 23 52 0 12 30
Kind of problem
% Patients experiencing the problem
Mean rating
Intermaxillary fixation Pain Swelling Breathing difficulties Eating difficulties Only able to drink Speech difficulties Loss of sensitivity Tiredness Depression
77 19 74 41 70 74 63 52 48 41
3.24 2.40 2.85 3-46 3-25 2.85 3.12 2'79 2.79 3'25
Psychological factors in orthognathic surgery
Table 3. - Evaluation of the effects of surgery after 6 months.
100
Percentage of patients experiencing the problems as worse, unchanged or better. Mean ratings of the effects of surgery
~
90-
Pre~qurgery Enface
80-
Preoperative type of problem
Worse
No change
Better
Mean rating
N1
Functional Craniomandibular Facial appearance Gastrointestinal Speech
4 0 5 0 0
17 8 17 75 20
79 92 78 25 80
+ 2-04 +2'31 + 1.79 + 1'20 + 1"60
23 16 20 7 7
70-
60'E 0
5040-
a_
30"
1 Number of subjects indicating each kind of problem before surgery 10Table 4. - Evaluation of the effects of surgery after 18 months.
Percentage of patients experiencing the problems as worse, unchanged or better. Mean ratings of the effects of surgery Preoperative type of problem
Worse
Functional 0 Craniomandibular 0 Facial appearance 0 Gastrointestinal 0 Speech 33
0
-5
m -4
Lm n ! -3
=
-2 ' -1 ~ 0 ' +1 ' +2' +3 ' +4 ~ +5
Very
Very
dissatisfied
No change
Better
Mean rating
N1
5 18 17 33 0
95 82 83 67 67
+ 2.70 +2-27 + 1.83 + 2.25 + 1'00
23 16 20 7 7
1 Number of subjects indicating each kind of problems before surgery.
Table 5. - Mean ratings of satisfaction/dissatisfaction with facial
appearance, before surgery and 2 months, 6 months and 18 months after surgery
Full-face Profile
31
Before surgery
2 months
After surgery 6 months
18 months
-1.07 a - 2.07 ~
+2.15 + 2-07
+2.52 + 2.33
+2.50 + 2.23
J- The differences between ratings before and after surgery are
satisfied
Rating Scale
Fig. 1 -Comparison of patients' pre-surgery rating of facial appearance with non-patients' ratings. Table 6. - Percentage of patients reporting positive personal and
social effects of surgery1 Effects
2 months
6 months
18 months
Personal Social Reaction from others
48 26 78
59 48 78
55 46 45
t No patients reported any negative personal or social effects of surgery 10o
90-J ~ 80-
Post-Surgepj:18monthEnface
I Non-patients
70-
significant, p < 0.1, oneway ANOVA
ranging, from 'very dissatisfied' ( - 5 ) to 'very satisfied' ( + 5), with intermediate levels at 'rather dissatisfied' ( - 3 ) , 'neither satisfied, nor dissatisfied' (0) and 'rather satisfied' ( + 3). The mean ratings are given in Table 5. As can be seen in Table 5, a significant increase in the patients' satisfaction (p < 0.01) with their facial appearance from before surgery to the 18-month postsurgical interview was found. In order to evaluate the distribution of the satisfaction or dissatisfaction with facial appearance, a comparison with a nonpatient group was made. 22 students at the University of Ume~, 11 women and 10 men, age-matched with the patient group, were asked to rate how satisfied or dissatisfied they were with their facial appearance on the same rating scale as the patients used. The mean rating in the non-patient group was full face +2.91 and for in profile +2.05. Thus, before surgery, the patients with dentofacial deformities as a group were more dissatisfied with their facial appearance than a non-patient group. However, after orthognathic surgery, the patients did not differ from a non-patient group with regard to satisfaction with facial appearance (Fig. 1).
50
1
-5
-4
-3
-2
-1
0
+1 +2 +3 +4 +5
Vet-/
dissatisfied
Rating Scale
Very satisfied
Fig. 2 - Comparison of patients' post-surgery ratings of facial
appearance with non-patients' ratings.
The patients wee also questioned about the effects of the surgery regarding their psychological and social situation. They were asked if they had had any reactions such as comments from persons in their surroundings, if the effects of surgery had or had not influenced them as individuals and if their social relations had or had not been influenced. The percentages of patients reporting positive effects of surgery are given in Table 6. No patient reported any negative effects in these areas.
32
Journal of Cranio-Maxillo-Facial Surgery
The following phrases are examples of the kinds of psychological and social changes the patients experienced : ' I feel more confident'; ' I am not afraid to open my mouth and to laugh'; 'I am not ashamed of my appearance any more'; 'I am not afraid to approach other persons'; 'I am in a better mood and I enjoy being with people'. When asked if they would undergo the same kind of surgical treatment again, should they have similar problems, 70% of the patients answered 'yes' 2 months after surgery, 78 % said 'yes' 6 months after surgery and after 18 months 82 % answered 'yes'. Finally, the patients were asked to rate how satisfied or dissatisfied they were with the total experience from 24 months before surgery to 18 months after surgery. This rating was done on the same kind of 11-point rating scale as was used for the ratings of facial appearance. The mean rating for the total group was +3.5, with 4.5% of the patients indicating dissatisfaction, 4.5% indicating 'neither satisfied nor dissatisfied' and 91% of the patients being 'rather satisfied' or 'very satisfied'. DISCUSSION AND CONCLUSIONS We found that the decision to undergo surgical treatment was a decision taken after a long period of time, 4 years on average, and that half of the patients were influenced by others, i.e. their family or dentist, before they made their final decision. We also found that 100 % of the patients felt they had made the right decision when interviewed 2 days before surgery. 60 % of the patients gave three or more reasons for undergoing surgery. 85 % mentioned functional problems, 74 % facial appearance and 59 % craniomandibular symptoms as reasons for their demand for treatment. Most of the patients thus have a multicausal background for treatment. Among the patients, 63 % indicated that the facial appearance problem had negatively influenced their personal life and 44 % their social life. Women experienced this problem more often than men, which might explain why women more often than men seek orthognathic surgery treatment. The results correspond to the results in studies where physical attractiveness affected both the subjects' self-esteem and their social value to others (Bercheidand Waister, 1974, Kiyak et al., 1984, Kiyak and Zeitler, 1988, Lovins et al., 1990). The patients rated their facial appearance before surgery and 2 months, 6 months and 18 months after surgery. The rating was done on a bi-polar rating scale ranging from - 5 (very dissatisfied) to +5 (very satisfied). The mean value for the presurgical rating (full face) was -1"07 and increased to + 2"50 after 18 months. In a study among a non-patient group (students), we found a mean value for facial appearance on the same level as for the treated patient group (Table 5, Fig. 1). Thus, the surgical treatment moved the majority of the patients from the negative side of the scale to the positive side and to a level comparable to a non-surgical group. Furthermore (see table 6) all of the patients said that the effects of
the surgery had influenced them as individuals, as well as their social relations, in a positive way. This result corresponds well to results found in other studies (Kiyak et al., 1982, 1984, Kiyak and Zeitler, 1988, Lovins et al., 1990, Crowell et al., 1970, Hutton 1967). Our results in this longitudinal study showed that the majority of the patients were relieved of their presurgical problems, and facial appearance seemed to be a major factor for the patients' estimation of the postsurgical result, which was stable over the investigation period. The aesthetic improvements in facial attractiveness were better than expected presurgically, and the satisfaction was high regardless of functional problems. It was also found that improvements in facial features influenced the patients as individuals and their social relations (Reich, 1975). Facial disfigurements due to dentofacial deformities are a psychological and social handicap (Belfer et al., 1982). The patients who had made their decision to undergo surgical orthodontic treatment for their dentofacial deformity were very determined in their decision and the decision per se raised their feeling of confidence. The difference in this group of patients compared to the patients with dentofacial deformities who do not ask for treatment or refrain from treatment after they had been informed is a question which will be the subject of further investigations. The preoperative information given to the patients regarding effects of surgery on functional problems seemed, in the majority of patients, to have been received satisfactorily while information on the surgical procedure, complications and the postoperative period seemed to have failed in many of the patients. This finding may be due to the oral surgeon's inability to present the information adequately or on the patients' inability to receive the information correctly preoperatively (in order not to have second thoughts about having the surgery). The value to the patients of written information regarding such items as general anaesthesia, postoperative diet, weight loss, absence from work, loss of sensibility or possible damage to the dentition has been discussed in papers by Rittersma et al. (1980) and Rittersma (1989). However, the personal contact between surgeon and patient was considered most important. The long term overall positive attitude postoperatively, however, encourages further efforts to treat this category of patients and thus enhance their social life situation and their confidence in themselves.
References Berseheid, E., E. Waister : Physical attractiveness. In: Berkowitz
(ed): Advances in experimental social psychology. Academic Press, New York 1974, vol 7 Belfer, M. L., A. M. Harrison, F. C. Pillemar, J. E. Murray:
Appearance and the influence of reconstructive surgery on body image. Clin. Plast. Surg. 9 (1982) 307 Crowell, N. T., H. J. Sazima, S. T. Elder: Survey of patients' attitudes after surgical correction of prognathism: Study of 33 patients. J. Oral Surg. 28 (1970) 818 Hutton, C. E, : Patients' evaluation of surgical correction of prognathism. J. Oral Surg. 25 (1967) 225
Psychological factors in orthognathic surgery
33
Kiyak, H. S., T. Hohl, R. A. West, R. W. McNeill: Psychologic
Rittersma, J..' Patient information and patient preparation in
changes in orthognathic surgery patients: A 24-month follow up. J. Oral Maxillofac. Surg. 42 (1984) 506 Kiyak, H. A., R. A. West, T. Hohl, R. W. McNeil: The psychological impact of orthognathic surgery: a 9 month follow-up. Am. J. Orthod. 81 (1982) 404 Kiyak, H. A., D. L. Zeitler : Self assessment of profile and body image among ortbognathic surgery patients before and two years after surgery. J. Oral Maxillofac. Surg. 46 (1988) 365
orthognathic surgery. The role of an information brochure. A medical audit study. J Cranio-Max-Fac. Surg. 17 (1989) 278 Rittersma, J., A. F. Carparie, E. Reerink : Patient information and patient preparation in orthognathic surgery. J. Max-Fac. Surg. 8 (1980) 206
Lovius, B. B. J., R. B. Jones, O. A. Pospisil, D. Reid, P. D. Slade, T. H. M. Wynne: The specific psychosocial effects of
orthognathic surgery. J. Cranio-Max-Fac. Surg. 18 (1990) 339 Murray, J. E., L. T. Swanson, R. D. Strand, G. M. Hrieko :
Evaluation of craniofacial surgery in the treatment of facial deformities. Ann. Surg. 182 (1975) 240 Reich, 9".: Factors influencing patient's satisfaction with the results of aesthetic plastic surgery. Plast. Reconstr. Surg. 55 (1975) 5
K.-E. Kahnberg, DDS, Odont, dr Department of Oral and Maxillofacial Surgery Faculty of Odontology University of G6teborg S-40033 G6teborg Sweden Paper received 4 March 1991 Accepted 7 October 1991
