Int. J. Oral Maxillofac. Surg. 2015; 44: 195–202 http://dx.doi.org/10.1016/j.ijom.2014.09.015, available online at http://www.sciencedirect.com
Clinical Paper Orthognathic Surgery
Satisfaction of skeletal class III patients treated with different types of orthognathic surgery J.F.C. Dantas, J.N.N. Neto, S.H.G. de Carvalho, I.M.C.L.deB. Martins, R.F. de Souza, V.A. Sarmento: Satisfaction of skeletal class III patients treated with different types of orthognathic surgery. Int. J. Oral Maxillofac. Surg. 2015; 44: 195–202. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to compare the satisfaction of skeletal class III patients following treatment with three different methods of orthognathic surgery. Eighty-two patients were divided into three groups according to the surgical procedure performed to correct their class III dentofacial deformity, and answered a questionnaire designed to determine the patient’s opinion of the aesthetic and functional treatment outcomes. Differences in the patterns of responses to questions in the questionnaire related to satisfaction between the three clinical groups were evaluated by x2 and Fisher’s exact tests (a = 5%). Eighty patients (97.6%) reported being satisfied with the treatment received. There was no significant difference in response patterns among clinical groups when assessing the improvement in facial appearance, chewing, speech, and socialization. Maxillary advancement led to higher levels of improvement in breathing (P < 0.0003). Class III patients treated by orthognathic surgery had high levels of satisfaction with the aesthetic and functional outcomes of their treatment.
The human face is a complex mosaic of angles, lines, planes, shapes, textures, and colours. The interaction of these elements produces a multitude of variations of form, from an exceptionally balanced aesthetic form to an imbalance of facial elements incompatible with aesthetic standards and functional normality. Knowing that facial appearance greatly influences how society judges an individual and that this may also have a critical impact on self-esteem, patterns of behaviour, and success in interpersonal interactions, facial harmony is a constant concern for most people. 0901-5027/020195 + 08
Dentofacial deformities (DFD) affect about 20% of the population. DFD patients show varying degrees of aesthetic and functional impairment, which may be restricted to a single jaw or extend to the entire craniofacial complex. Orthognathic surgery is recommended for the treatment of most of these cases due to the potential to obtain functional occlusion combined with better facial aesthetics,1 and improved chewing, breathing, and phonation functions and motor development.2 Orthognathic surgery has a profound impact on the psychological state of
J. F. C. Dantas1, J. N. N. Neto2, S. H. G. de Carvalho2, I. M. C. L. deB.Martins3, R. F. de Souza4, V. A. Sarmento5 1
Department of Oral and Maxillofacial Surgery, Portuguese Hospital, Salvador, Bahia, Brazil; 2Department of Propaedeutics, Dental School at Araruna, State University of Paraı´ba, Araruna, Paraı´ba, Brazil; 3Health Science Centre, Federal University of Paraiba, Joa˜o Pessoa, Paraı´ba, Brazil; 4Department of Dental Materials and Prosthodontics, Ribeira˜o Preto Dental School, University of Sa˜o Paulo, Ribeira˜o Preto, SP, Brazil; 5Department of Propaedeutics and Integrated Clinic, Dental School of the Federal University of Bahia, Salvador, Bahia, Brazil
Key words: skeletal class III; orthognathic surgery; aesthetics; dentofacial deformity; satisfaction. Accepted for publication 22 September 2014 Available online 14 October 2014
patients undergoing such treatment due to the resulting aesthetic and functional changes.3,4 The way the patient perceives the benefits of treatment is a major concern, especially considering the complexity of the treatment. Patient perceptions of their self-esteem and evaluation of their appearance are closely related to the well-being of the individual; the aesthetic and functional changes associated with orthognathic surgery are related to an improvement in patient self evaluation, with a beneficial influence on self esteem and improvement
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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in patient social relationships.5,6 Proper restoration of the occlusal and skeletal pattern and the achievement of aesthetic and functional results are not satisfactory to the surgeon if the patient shows no satisfaction with the results achieved, since the success of surgical orthodontic treatment (SOT) depends not only on perfect tooth alignment and correct bone repositioning through surgery, but also satisfaction of the expectations and motivations that led the patient to seek treatment.7–9 This retrospective study aimed to compare the satisfaction of skeletal class III patients treated by surgery for maxillary advancement, mandibular setback, or a combination of both treatments. Materials and methods
This research project was submitted to and approved by the ethics committee of the study institution. Patients who agreed to participate in the study read and signed the consent form designed for this purpose. Skeletal class III patients were considered eligible for the study if they were aged between 18 and 50 years and had undergone SOT comprising mandibular setback, or maxillary advancement, or both procedures. Osteotomies performed in all patients were limited to two bilateral sagittal split osteotomies (BSSO) and Le Fort I osteotomy using rigid internal fixation and no maxillomandibular fixation in the postoperative period. Patients were at least 1 year postoperative when they participated in the study. Those who had suffered an accident during the operative procedures or a postoperative infection were excluded. Patients were from a centre for research and treatment of oral– facial deformities in Araraquara, Sa˜o Paulo, Brazil. One hundred and seventy records of skeletal class III patients operated on between 1998 and 2007 were retrieved from the files. Reasons for non-eligibility included infection (n = 7), age 50 years (n = 8), use of other surgical protocols (n = 9), postsurgical period less than 1 year (n = 12), and the use of maxillomandibular fixation (n = 2). Excluded patients received other SOT modalities, such as vertical mandibular osteotomy, Le Fort II osteotomy, or maxillary segmental osteotomies (n = 3). Thus 129 potential participants were identified. Among these eligible patients, we were able to contact 115. Eighty-two (71%) of the eligible patients attended the assessment and comprised the final sample. Patients were divided into three groups
according to the surgical procedure used, based on clinical assessment: group A (n = 30) comprised patients who had undergone maxillary advancement combined with mandibular setback; group B (n = 36) comprised patients who had undergone maxillary advancement; group C (n = 16) comprised patients who had undergone mandibular setback. Surgical procedures performed included Le Fort I osteotomy and maxillary advancement in groups A and B, and BSSO of the mandible and mandibular setback in groups A and C. All patients received rigid internal fixation. Participants answered a questionnaire focusing on satisfaction with the treatment outcome based on one used by Ambrizzi et al.,10 modified for the purposes of this study (Table 1). This questionnaire consisted of 10 questions (Q1–Q10) aimed at determining who initially diagnosed the DFD, the use of previous treatments for the correction of the DFD, and the patient’s opinions about the aesthetic and functional outcomes of the treatment. The patient was considered satisfied with the treatment if responses to Q3–Q8 were all ‘yes’, or if the answer to Q9 or Q10 was ‘yes’. The patient was considered dissatisfied with treatment if there was at least one ‘no’ answer to any of Q3–Q8, or if there was a ‘no’ response to Q9 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment), or if there was a ‘no’ response to Q10 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment). The x2 test and Fisher’s exact tests were used to evaluate the differences in patterns
of responses among the three clinical groups (a = 5%). Results
The total sample consisted of 82 patients; 53.7% (44 patients) were female and 46.3% (38 patients) were male. The average age of patients was 26 years, ranging from 18 to 48 years. Of the 82 patients, 36.6% (30 patients) were in group A, 43.9% (36 patients) in group B, and 19.5% (16 patients) in group C. Patient satisfaction after treatment was 97.6% (80 patients), with only 2.4% (two patients) being dissatisfied with the results of surgical treatment. Of the two patients who were considered dissatisfied, one answered ‘no’ to Q6 and Q7 and the other replied ‘no’ to Q7; however, these same patients when asked if they would undergo the treatment again answered ‘yes’ and considered the results as ‘good’ and ‘excellent’, respectively. Three patients (3.7%) responded that they would not undergo the treatment again, two of whom reported that the pain in the postoperative period was intense and the other reported being frightened of being admitted to a hospital for any reason. All three patients described treatment results as ‘excellent’ and would recommend the SOT to other patients. Regarding the initial diagnosis of DFD and recommendation of SOT, most patients, 79.3% (n = 65), were diagnosed and recommended this treatment by a dentist. Seven patients (2.4%) requested the treatment themselves, and the same number were recommended the treatment
Table 1. Clinical questionnaire. 1. Who first detected the problem and referred it for treatment? You/Dental surgeon/Physician/Relatives/Friends/Other (please specify) 2. Had you already undergone other orthodontic treatment in an attempt to correct your deformity before you started your treatment at this unit? Yes/No 3. Do you believe that there was an improvement in your appearance after treatment? Yes/No/Do not know 4. Do you believe that there was an improvement in your chewing after treatment? Yes/No/Do not know 5. Do you believe that there was an improvement in your breathing after treatment? Yes/No/Do not know 6. Do you believe that there was an improvement in your pronunciation of sounds and words after treatment? Yes/No/Do not know 7. Do you believe that there was an improvement in your social relationships or contact with people after treatment? Yes/No/Do not know 8. How do you consider your treatment results? Great/Good/Poor/Do not know 9. Would you undergo the surgery again? Yes/No (please provide reasons) 10. Would you recommend the surgical treatment to other people? Yes/No (please provide reasons)
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Table 2. Frequency of answers regarding the person who initially detected the problem and referred the patient for treatment.
Groupa
1 Patient
2 Dentist
3 Physician
4 Relatives/ friends
5 Other
Number of patients
A B C
1 (3.3%) 5 (13.9%) 1 (6.3%)
25 (83.3%) 28 (77.8%) 12 (75%)
3 (10%) 2 (5.6%) 2 (12.5%)
1 (3.3%) 0 (0%) 1 (6.3%)
0 (0%) 1 (2.8%) 0 (0%)
30 36 16
7 (8.5%)
65 (79.3%)
7 (8.5%)
2 (2.4%)
1 (1.2%)
82
Total
% of total sample 36.6% 43.9% 19.5% 100%
a
Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
Table 3. Sample distribution regarding whether the patient had undergone previous orthodontic treatment(s) in an attempt to correct the dentofacial deformity. Groupa
No
Yes
Number of patients
A B C
22 (73.3%) 26 (72.2%) 9 (56.3%)
8 (26.7%) 10 (27.8%) 7 (43.8%)
30 36 16
57 (69.5%)
25 (30.5%)
82
Total
% of total sample 36.6% 43.9% 19.5% 100%
a
Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
by a physician (n = 7; 8.5%). The recommendation of relatives and friends accounted for 2.4% (n = 2), and only one patient (1.2%) reported having been recommended this treatment by another route (Table 2). The possibility of a difference in diagnosis and recommendations for SOT between the study groups (groups A, B, and C) was evaluated by Fisher’s exact test; no statistically significant difference was found (P = 0.535), indicating that the referral patterns among the three groups were similar. Most patients (69.5%, n = 57) had not undergone previous orthodontic treatment (OT) at other clinics for correction of the DFD, however 30.5% (n = 25) had, without success. There was no significant difference between the three clinical groups regarding the number of patients who had undergone prior orthodontic treatment (P = 0.436) (Table 3). When inquiring about the improvement in facial appearance, 97.6% (n = 80) of patients reported an improvement and 2.4% (n = 2) did not know whether they noticed an improvement in their appearance after SOT. No patient reported ‘no improvement’ in facial appearance after treatment. There was no significant difference in the patterns of responses between the three study groups when evaluated by Fisher’s exact test (P = 0.495) (Fig. 1). Most patients, 97.6% (n = 80) reported an improvement in masticatory function following treatment, but 2.4% (n = 2) did not know if there was an improvement.
There was no significant difference among the three study groups regarding the pattern of responses, as evaluated by Fisher’s exact test (P = 0.485) (Fig. 2). In assessing the improvement in breathing after treatment, 87.8% (n = 72) of the total sample answered that breathing had improved and 12.2% (n = 10) did not know if their breathing had improved. By group, 96.7% (n = 29) of patients in group A, 94.4% (n = 34) in group B, and 56.3% (n = 9) in group C reported an improvement in breathing; yet 3.3% (n = 1) in group A, 5.6% (n = 2) in group B, and 43.8% (n = 7) in group C did not know if their breathing had improved. There was a significant differ-
ence in the pattern of responses in the three groups (P < 0.0003, Fisher’s exact test) (Fig. 3). Analyzing speech improvement, 86.6% (n = 71) of patients responded that there was improvement in pronunciation, 12.2% (n = 10) did not know if there was an improvement, and 1.2% (n = 1) reported no change. There was no significant difference among responses in groups A, B, and C when evaluated by Fisher’s exact test (P = 0.195) (Fig. 4). Most patients, 91.5% (n = 75), reported an improvement in their socialization after treatment, 2.4% (n = 2) reported no improvement in interpersonal relationships after SOT, and 6.1% (n = 5) did not know whether or not there was an improvement (Fig. 5). The difference in the pattern of responses of the three groups comprising the total sample was not significant (P = 0.374), as analyzed by Fisher’s exact test. All patients in the sample responded that the treatment results were good (20.7%; n = 17) or excellent (79.3%; n = 65); no patient considered the treatment results to be poor (Fig. 6). There was no significant difference in response patterns among the three groups of patients, as tested by x2 test (P = 0.183).
35 35 30 30 25 20
Yes
15
Do not know
15 10 5
1
1
0 0 GA
GB
GC
Fig. 1. Sample distribution for the question on perceived improvement in appearance after treatment (GA, group A; GB, group B; GC, group C).
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Dantas et al. 35
35 30 30 25 20
Yes
15
Do not know
15 10 5
1
1
0 0 GA
GB
GC
Fig. 2. Sample distribution for the question on perceived improvement in chewing after treatment (GA, group A; GB, group B; GC, group C).
34 35 29 30 25 20
Yes Do not know
15 9 10
7
5
2
1
0 GA
GB
GC
Fig. 3. Sample distribution for the question on perceived improvement in breathing after treatment (GA, group A; GB, group B; GC, group C).
33
35 30
26
25 Yes
20
No 15
12
Do not know
10 4
5 0
4 1
2 0
0 GA
GB
GC
Fig. 4. Sample distribution for the question on perceived improvement in pronunciation of sounds and words after treatment (GA, group A; GB, group B; GC, group C).
Just over 96% of patients reported that they would undergo the treatment again. Only 3.7% reported that they would not undergo the treatment again, two of whom explained that the pain in the postoperative period was very intense and the other stating a terror of being admitted to hospital for any reason (Fig. 7). The difference in response patterns among the three groups was tested by Fisher’s exact test and no significant difference was found (P = 1). All patients reported that they would recommend the treatment that they had undergone to other people who had a similar condition. Discussion
In the present survey, patients classified with the same pattern of malocclusion were selected, with the aim of limiting the analysis to only one class of deformity, providing more uniformity to the sample. Class III patients were chosen for this study as their issues are more complicated and challenging than class II patients, and orthognathic surgery is the key to treatment success for a large number of individuals with class III issues.11 A minimum age of 18 years has been established for this treatment due to the decreasing rate of growth at this stage, providing more stability to the surgical results.11,12 The age limit for patients included in this evaluation was 50 years due to this age being the average reference point for the beginning of menopause, a period during which hormonal changes promote a series of physiological changes in women’s bodies including bone weight loss, which may increase the likelihood of complications due to delayed bone healing.13 A postoperative period of 1 year was established for the evaluation of satisfaction, due to the possibility of dissatisfaction with the treatment outcome by over-valuation of discomfort in the early postoperative period potentially negating the benefits of the aesthetic and functional results of SOT. Victims of intraoperative accidents and postoperative infection were ineligible for the study due to the possibility of such accidents and complications interfering with the assessment of patient satisfaction. The relationship between dissatisfaction with treatment and the occurrence of unexpected events in the postoperative period is clear; however, even if advised of the possibility of complications as a result of treatment, patients have reported emotional unpreparedness
Satisfaction with orthognathic surgery 33
35 30
29
25 Yes
20
No 13
15
Do not know
10 5 0
1
2
1
2
1
0 GA
GB
GC
Fig. 5. Sample distribution for the question on perceived improvement in social relationships or contact with people after treatment (GA, group A; GB, group B; GC, group C).
30 30 25 25 20 Good 15
Excellent
10 10
6
5
6
5 0 GA
GB
GC
Fig. 6. Sample distribution for the evaluation of treatment results (GA, group A; GB, group B; GC, group C).
34 35 29 30 25 20
Yes
16
No
15 10 5
2
1
0
0 GA
GB
GC
Fig. 7. Sample distribution for the question on whether the patient would undergo the surgery again (GA, group A; GB, group B; GC, group C).
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to deal with the complications after surgery.14 Surgical procedures in all patients were limited to two techniques, BSSO and Le Fort I osteotomy – most cases of DFD can be addressed through these two osteotomies for the treatment of jaw deformities.15 The distribution of patients by gender was similar: 53.7% of the sample were females and 46.3% were males. Other studies have also shown a greater number of women than men.16–19 Thirty patients were grouped in group A, 36 in group B, and 16 in group C. The lower number of patients in group C, who underwent mandibular setback, is due to this movement being avoided in orthognathic surgery due to the negative aesthetic changes promoted in the patient’s profile11 in addition to the greater stability of surgical movements resulting from maxillary advancement in relation to surgical movements resulting from mandibular setback.20 In addition, maxillary advancement or a combination of techniques results in a lower long-term relapse, even in growing patients.21 Additionally, setback movements of the maxilla and mandible are considered less predictable in terms of the final conformation of the soft tissue.22 Among patients in the total sample, 97.6% reported satisfaction with the treatment carried out, with only 2.4% being dissatisfied with the methodology used. High satisfaction scores in studies assessing satisfaction with SOT are common.6,17,23–25 The high rate of patient satisfaction can be explained by the impact of DFD class III correction on a patient’s life, since this deformity is reported to be the most disabling and for a large number of individuals the required result of DFD treatment can only be achieved through orthognathic surgery.11 Feelings of satisfaction with the results of SOT provide subjective data and can be difficult to assess by the patient, since in addition to their own opinion, the patient is influenced by several external factors including the impact of the results in their social circle, family expectations of the SOT, and impact of treatment on their professional and private lives. Usually, the assessment of SOT success is determined by whether expectations were met8,9 and how the treatment and outcome was received by the patient’s social circle.10 Ouellette17 reported that more than half of patients felt satisfied with the results during the early postoperative period, whereas 93% of patients were satisfied with the results later in the postoperative period. The change in
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satisfaction between the early and later postoperative period can be explained by a positive change in the evaluation of the treatment results once the unpleasant memories of the immediate postoperative period are replaced by an understanding of the overall beneficial results.23 The percentage of variation in satisfaction with the SOT results varies from study to study depending on the time elapsed between surgery and evaluation, but overall satisfaction increases over time.14 Most patients in this study were recommended for SOT by a dentist (Table 2), which is consistent with other studies.10,18,24,26,27 Patient self-referral was reported for 8.5%. There was no significant difference between the clinical groups in the response pattern regarding SOT recommendation (P = 0.535). Many patients know of the existence of their DFD, but most are unaware of the treatment options available to correct their problems until they are alerted to these by health professionals, especially dentists.2,14,19 The use of orthodontic treatment in an attempt to compensate for the DFD prior to SOT was reported by 30.5% of the total sample of patients. Group C had the highest percentage of patients (43.8%) who had undergone a prior treatment in an attempt to repair the DFD (Table 3). However, there was no difference among the three clinical groups regarding the number of patients seeking prior orthodontic treatment (P = 0.436). Several reasons can lead patients to seek orthodontic treatment for the correction of a DFD, even when their case should be approached surgically. Concerns about the cost of SOT, fear of surgery, or a concern about discomfort in the postoperative period are cited as factors that may influence the selection of orthodontic treatment over SOT.20 Knowing that orthodontists usually recommend SOT,2 when an orthodontist does prefer to treat the DFD through orthodontic treatment instead of SOT, this can result in SOT not even being offered as a therapeutic option for the patient, even in cases where SOT would more effectively address the major complaints and wishes of the patient.14 Regarding the change in facial appearance, 97.6% of patients reported an improvement (Fig. 1). There was no significant difference in the patterns of responses among groups A, B, and C (P = 0.485). Ambrizzi et al.10 reported that an improvement in facial aesthetics was the main motivation for seeking SOT by class III patients, with treatment results being considered excellent or good by 95.6% of those in their sample. Facial
appearance has a great influence on how individuals judge themselves and on how society looks at the individual, and has a major impact on self-esteem. The wish for aesthetic improvement by patients undergoing DFD correction is substantial, and even when patients report functional motivations for seeking treatment, they may actually be seeking aesthetic changes when reporting the desire for functional changes, as such changes would more easily justify the SOT treatment.10,23,25 Most patients studied, 97.6%, reported an improvement in chewing (Fig. 2). There was no significant difference among the three study groups regarding the pattern of responses (P = 0.485). The correct maxillomandibular positioning promoting an occlusion in class I, with normal overbite and overjet, is mentioned as one of the goals of orthognathic surgery for class III patients.28 The maxillomandibular repositioning by orthognathic surgery promotes increased strength and improved masticatory efficiency of chewing cycles in class III patients.29 In assessing the improvement in breathing after treatment, 87.8% of the total sample responded that there was improvement and 12.2% could not answer whether there was improvement or not (Fig. 3). There was a significant difference in the pattern of responses among the three groups (P < 0.0003). Nearly 44% of patients in group C did not know if there was an improvement or worsening of respiratory function after treatment. The pharyngeal space is narrowed in patients undergoing mandibular setback surgery.30 This narrowing is due to the posterior movement of the hyoid bone and tongue after mandibular setback, however there is a tendency for the positioning of these two structures to relapse to their original position. Nevertheless, the pharyngeal airway space remains smaller than its length before surgery.30 Class III patients who undergo mandibular setback surgery associated with maxillary advancement have increased upper respiratory resistance with a decrease in oxygen saturation after surgery, but the decline in respiratory function is not represented at the pathological level, probably due to physiological adaptations by compensatory mechanisms.31 Despite the tendency of the pharyngeal space to decrease with a consequent impairment in respiratory function, no patient in this study complained of a worsening in breathing after surgery. The absence of complaints does not, however, exclude the possibility of a worsening of respiratory function in
these patients, which needs to be evaluated more accurately but is beyond the scope of the present study. Analyzing the improvement in phonation, 86.6% of patients reported an improvement (Fig. 4). There was no significant difference among responses in groups A, B, and C (P = 0.195). Phonetic articulation errors are common in patients with DFD, most commonly in the pronunciation of sibilant sounds (‘c’, ‘s’, and ‘z’), and these are more frequent in class III patients.32 In the early postoperative period there is an increase in phonetic errors, and these errors then gradually decline from the third to the twelfth month postoperative, with a significant reduction or elimination of the number of phonetic errors in patients submitted to SOT.33 Many patients report feeling more able to do their work and happier at work after orthognathic surgery17; the improvement in appearance obtained with the SOT is associated with an improvement in the patient’s psychosocial condition.5 Barbosa et al.23 reported that 63% of patients in their sample denied social adjustment problems caused by the DFD; 25.4% reported mild problems and 12.2% reported severe problems in their social adjustment caused by the DFD. The high incidence of patients who reported no problems related to socialization may be due to the patient’s wish to mask their psychological problems from the surgeon, or to not having knowledge of the magnitude of the negative impact of the DFD on their mental development. With regard to the improvement in social relationships or socializing with other people after treatment, 91.5% of the total sample of patients reported an improvement and 6.1% did not know whether or not there was an improvement (Fig. 5). There was no significant difference in the pattern of responses in groups A, B, and C (P = 0.374). All patients in the sample responded that the treatment results were good or very good (Fig. 6). No patient reported the treatment results as being poor. When asked if they would undergo treatment again, 96.3% of patients responded ‘yes’ and only 3.7% said ‘no’ (Fig. 7). Of these latter patients, two explained that the pain in the postoperative period was intense and the other reported being frightened of being admitted to a hospital for any reason. However, all patients including those who responded that they would not undergo the treatment again reported that they would recommend SOT to people who had the same DFD. Ambrizzi et al.10 reported that 95.6% of class III
Satisfaction with orthognathic surgery patients in the sample reported considered the treatment outcome to be good or excellent, and that all patients in the sample would recommend the treatment to other people with the same condition. SOT provides psychologically beneficial results to patients with DFD27; orthognathic surgery should also be offered to patients due to the improved psychological state it promotes.5 Due to the retrospective design used in this study, there are potential limitations that must be considered. This study enrolled 71% of eligible participants, which is a higher percentage than that reported in other studies.26 This indicates that our response rate was favourable and, considering that eligible participants had no serious complication during the longterm postsurgical period, it is likely that reasons for non-response were not associated with SOT. Therefore, selection bias may not be a significant issue, i.e. the study groups are representative of treated patients. Regarding the outcome reported by participants, the results are representative of post-treatment satisfaction and highlight the positive results of SOT. Patients who comprised the sample had a high degree of satisfaction with the treatment performed, showing improvements in psychosocial and functional criteria, indicating that treatment based on clinical diagnosis is an effective way to treat skeletal class III patients. Funding
None. Competing interests
None declared. Ethical approval
The research protocol was submitted to the Ethics Committee for Research of the College of Dentistry, Federal University of Bahia, and was approved (FR – 216192, CAAE: 0030.368.000-08). Patient consent
Not required. Acknowledgements. We thank Dr Roberto Della Coletta, President of CEDEFACE, and Dr Mario Gabrielli, Professor of Oral and Maxillofacial Surgery, Dental School at Araraquara, UNESP, for the support given to this work.
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1st ed. Philadelphia: WB Saunders; 2000. p. 506–34. Tucker MR. Correction of dentofacial deformities. In: Ellis III E, Hupp JR, Tucker MR, editors. Contemporary oral and maxillofacial surgery. 5th ed. St. Louis: Mosby; 2009. p. 25. Johnston C, Burden D, Kennedy D, Harradine N, Stevenson M. Class III surgical-orthodontic treatment: a cephalometric study. Am J Orthod Dentofac Orthop 2006;130:300–9. Ouellette PL. Psychological ramifications of facial change in relation to orthodontic treatment and orthognathic surgery. J Oral Surg 1978;36:787–90. Phillips C, Broder HL, Bennett ME. Dentofacial disharmony: motivations for seeking treatment. Int J Adult Orthodon Orthognath Surg 1997;12:7–15. Zhou Y, Ha¨gg U, Rabie AB. Severity of dentofacial deformity, the motivations and the outcome of surgery in skeletal class III patients. Chin Med J (Engl) 2002;115: 1031–4. Proffit WR, Phillips C. Respostas fisiolo´gicas aos tratamentos e estabilidade po´s-ciru´rgica. In: Proffit WR, White Jr RP, Sarver DM, editors. Tratamento contemporaˆneo de deformidades dentofaciais. 1st ed. Porto Alegre: Artemed; 2005. p. 682–715. Bayley LJ, Phillips C, Proffit WR. Longterm outcome of surgical class III correction as a function of age at surgery. Am J Orthod Dentofac Orthop 2008;133:365–70. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast Surg 2007;34: 437–45. Barbosa AL, Marcantonio E, Barbosa CE, Gabrielli MF, Gabrielli MA. Psychological evaluation of patients scheduled for orthognathic surgery. J Nihon Univ Sch Dent 1993;35:1–9. Laufer D, Glick D, Gutman D, Sharon A. Patient motivation and response to surgical correction of prognathism. Oral Surg Oral Med Oral Pathol 1976;41:309–13. Olson RE, Laskin DM. Expectations of patients from orthognathic surgery. J Oral Surg 1980;38:283–5. Ek E, Persson J, Lundgren S. Surgical correction of dentofacial anomalies: an evaluation of two patient groups with the aid of a questionnaire. Swed Dent J 1997;21: 101–10. Garvill J, Garvill H, Kahnberg KE, Lundgren S. Psychological factors in orthognathic surgery. J Craniomaxillofac Surg 1992;20: 28–33. Park JU, Baik SH. Classification of Angle class III malocclusion and its treatment modalities. Int J Adult Orthodon Orthognath Surg 2001;16:19–29. Thronckmorton GS, Ellis III E. Functional outcomes following orthognathic surgery. In: Fonseca RJ, editor. Oral and maxillofacial surgery. 1st ed. Philadelphia: WB Saunders; 2000. p. 2.
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30. Kim JS, Kim JK, Hong SC, Cho JH. Pharyngeal airway changes after sagittal split ramus osteotomy of the mandible: a comparison between genders. J Oral Maxillofac Surg 2010;68:1802–6. 31. Folta´n R, Hoffmannova´ J, Donev F, Vlk M, Sedy´ J, Kufa R, et al. The impact of Le Fort I advancement and bilateral sagittal split osteotomy setback on ventilation during sleep. Int J Oral Maxillofac Surg 2009;38:1036–40. 32. Ruscello DM, Tekieli ME, Jakomis T, Cook L, Van Sickels JE. The effects of orthognathic
surgery on speech production. Am J Orthod 1986;89:237–41. 33. Vallino LD. Speech, velopharyngeal function, and hearing before and after orthognathic surgery. J Oral Maxillofac Surg 1990;48:1274–81.
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Clinical Paper Orthognathic Surgery
Satisfaction of skeletal class III patients treated with different types of orthognathic surgery J.F.C. Dantas, J.N.N. Neto, S.H.G. de Carvalho, I.M.C.L.deB. Martins, R.F. de Souza, V.A. Sarmento: Satisfaction of skeletal class III patients treated with different types of orthognathic surgery. Int. J. Oral Maxillofac. Surg. 2015; 44: 195–202. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to compare the satisfaction of skeletal class III patients following treatment with three different methods of orthognathic surgery. Eighty-two patients were divided into three groups according to the surgical procedure performed to correct their class III dentofacial deformity, and answered a questionnaire designed to determine the patient’s opinion of the aesthetic and functional treatment outcomes. Differences in the patterns of responses to questions in the questionnaire related to satisfaction between the three clinical groups were evaluated by x2 and Fisher’s exact tests (a = 5%). Eighty patients (97.6%) reported being satisfied with the treatment received. There was no significant difference in response patterns among clinical groups when assessing the improvement in facial appearance, chewing, speech, and socialization. Maxillary advancement led to higher levels of improvement in breathing (P < 0.0003). Class III patients treated by orthognathic surgery had high levels of satisfaction with the aesthetic and functional outcomes of their treatment.
The human face is a complex mosaic of angles, lines, planes, shapes, textures, and colours. The interaction of these elements produces a multitude of variations of form, from an exceptionally balanced aesthetic form to an imbalance of facial elements incompatible with aesthetic standards and functional normality. Knowing that facial appearance greatly influences how society judges an individual and that this may also have a critical impact on self-esteem, patterns of behaviour, and success in interpersonal interactions, facial harmony is a constant concern for most people. 0901-5027/020195 + 08
Dentofacial deformities (DFD) affect about 20% of the population. DFD patients show varying degrees of aesthetic and functional impairment, which may be restricted to a single jaw or extend to the entire craniofacial complex. Orthognathic surgery is recommended for the treatment of most of these cases due to the potential to obtain functional occlusion combined with better facial aesthetics,1 and improved chewing, breathing, and phonation functions and motor development.2 Orthognathic surgery has a profound impact on the psychological state of
J. F. C. Dantas1, J. N. N. Neto2, S. H. G. de Carvalho2, I. M. C. L. deB.Martins3, R. F. de Souza4, V. A. Sarmento5 1
Department of Oral and Maxillofacial Surgery, Portuguese Hospital, Salvador, Bahia, Brazil; 2Department of Propaedeutics, Dental School at Araruna, State University of Paraı´ba, Araruna, Paraı´ba, Brazil; 3Health Science Centre, Federal University of Paraiba, Joa˜o Pessoa, Paraı´ba, Brazil; 4Department of Dental Materials and Prosthodontics, Ribeira˜o Preto Dental School, University of Sa˜o Paulo, Ribeira˜o Preto, SP, Brazil; 5Department of Propaedeutics and Integrated Clinic, Dental School of the Federal University of Bahia, Salvador, Bahia, Brazil
Key words: skeletal class III; orthognathic surgery; aesthetics; dentofacial deformity; satisfaction. Accepted for publication 22 September 2014 Available online 14 October 2014
patients undergoing such treatment due to the resulting aesthetic and functional changes.3,4 The way the patient perceives the benefits of treatment is a major concern, especially considering the complexity of the treatment. Patient perceptions of their self-esteem and evaluation of their appearance are closely related to the well-being of the individual; the aesthetic and functional changes associated with orthognathic surgery are related to an improvement in patient self evaluation, with a beneficial influence on self esteem and improvement
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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in patient social relationships.5,6 Proper restoration of the occlusal and skeletal pattern and the achievement of aesthetic and functional results are not satisfactory to the surgeon if the patient shows no satisfaction with the results achieved, since the success of surgical orthodontic treatment (SOT) depends not only on perfect tooth alignment and correct bone repositioning through surgery, but also satisfaction of the expectations and motivations that led the patient to seek treatment.7–9 This retrospective study aimed to compare the satisfaction of skeletal class III patients treated by surgery for maxillary advancement, mandibular setback, or a combination of both treatments. Materials and methods
This research project was submitted to and approved by the ethics committee of the study institution. Patients who agreed to participate in the study read and signed the consent form designed for this purpose. Skeletal class III patients were considered eligible for the study if they were aged between 18 and 50 years and had undergone SOT comprising mandibular setback, or maxillary advancement, or both procedures. Osteotomies performed in all patients were limited to two bilateral sagittal split osteotomies (BSSO) and Le Fort I osteotomy using rigid internal fixation and no maxillomandibular fixation in the postoperative period. Patients were at least 1 year postoperative when they participated in the study. Those who had suffered an accident during the operative procedures or a postoperative infection were excluded. Patients were from a centre for research and treatment of oral– facial deformities in Araraquara, Sa˜o Paulo, Brazil. One hundred and seventy records of skeletal class III patients operated on between 1998 and 2007 were retrieved from the files. Reasons for non-eligibility included infection (n = 7), age 50 years (n = 8), use of other surgical protocols (n = 9), postsurgical period less than 1 year (n = 12), and the use of maxillomandibular fixation (n = 2). Excluded patients received other SOT modalities, such as vertical mandibular osteotomy, Le Fort II osteotomy, or maxillary segmental osteotomies (n = 3). Thus 129 potential participants were identified. Among these eligible patients, we were able to contact 115. Eighty-two (71%) of the eligible patients attended the assessment and comprised the final sample. Patients were divided into three groups
according to the surgical procedure used, based on clinical assessment: group A (n = 30) comprised patients who had undergone maxillary advancement combined with mandibular setback; group B (n = 36) comprised patients who had undergone maxillary advancement; group C (n = 16) comprised patients who had undergone mandibular setback. Surgical procedures performed included Le Fort I osteotomy and maxillary advancement in groups A and B, and BSSO of the mandible and mandibular setback in groups A and C. All patients received rigid internal fixation. Participants answered a questionnaire focusing on satisfaction with the treatment outcome based on one used by Ambrizzi et al.,10 modified for the purposes of this study (Table 1). This questionnaire consisted of 10 questions (Q1–Q10) aimed at determining who initially diagnosed the DFD, the use of previous treatments for the correction of the DFD, and the patient’s opinions about the aesthetic and functional outcomes of the treatment. The patient was considered satisfied with the treatment if responses to Q3–Q8 were all ‘yes’, or if the answer to Q9 or Q10 was ‘yes’. The patient was considered dissatisfied with treatment if there was at least one ‘no’ answer to any of Q3–Q8, or if there was a ‘no’ response to Q9 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment), or if there was a ‘no’ response to Q10 (only if the answer was justified by dissatisfaction with the results obtained with surgical treatment). The x2 test and Fisher’s exact tests were used to evaluate the differences in patterns
of responses among the three clinical groups (a = 5%). Results
The total sample consisted of 82 patients; 53.7% (44 patients) were female and 46.3% (38 patients) were male. The average age of patients was 26 years, ranging from 18 to 48 years. Of the 82 patients, 36.6% (30 patients) were in group A, 43.9% (36 patients) in group B, and 19.5% (16 patients) in group C. Patient satisfaction after treatment was 97.6% (80 patients), with only 2.4% (two patients) being dissatisfied with the results of surgical treatment. Of the two patients who were considered dissatisfied, one answered ‘no’ to Q6 and Q7 and the other replied ‘no’ to Q7; however, these same patients when asked if they would undergo the treatment again answered ‘yes’ and considered the results as ‘good’ and ‘excellent’, respectively. Three patients (3.7%) responded that they would not undergo the treatment again, two of whom reported that the pain in the postoperative period was intense and the other reported being frightened of being admitted to a hospital for any reason. All three patients described treatment results as ‘excellent’ and would recommend the SOT to other patients. Regarding the initial diagnosis of DFD and recommendation of SOT, most patients, 79.3% (n = 65), were diagnosed and recommended this treatment by a dentist. Seven patients (2.4%) requested the treatment themselves, and the same number were recommended the treatment
Table 1. Clinical questionnaire. 1. Who first detected the problem and referred it for treatment? You/Dental surgeon/Physician/Relatives/Friends/Other (please specify) 2. Had you already undergone other orthodontic treatment in an attempt to correct your deformity before you started your treatment at this unit? Yes/No 3. Do you believe that there was an improvement in your appearance after treatment? Yes/No/Do not know 4. Do you believe that there was an improvement in your chewing after treatment? Yes/No/Do not know 5. Do you believe that there was an improvement in your breathing after treatment? Yes/No/Do not know 6. Do you believe that there was an improvement in your pronunciation of sounds and words after treatment? Yes/No/Do not know 7. Do you believe that there was an improvement in your social relationships or contact with people after treatment? Yes/No/Do not know 8. How do you consider your treatment results? Great/Good/Poor/Do not know 9. Would you undergo the surgery again? Yes/No (please provide reasons) 10. Would you recommend the surgical treatment to other people? Yes/No (please provide reasons)
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Table 2. Frequency of answers regarding the person who initially detected the problem and referred the patient for treatment.
Groupa
1 Patient
2 Dentist
3 Physician
4 Relatives/ friends
5 Other
Number of patients
A B C
1 (3.3%) 5 (13.9%) 1 (6.3%)
25 (83.3%) 28 (77.8%) 12 (75%)
3 (10%) 2 (5.6%) 2 (12.5%)
1 (3.3%) 0 (0%) 1 (6.3%)
0 (0%) 1 (2.8%) 0 (0%)
30 36 16
7 (8.5%)
65 (79.3%)
7 (8.5%)
2 (2.4%)
1 (1.2%)
82
Total
% of total sample 36.6% 43.9% 19.5% 100%
a
Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
Table 3. Sample distribution regarding whether the patient had undergone previous orthodontic treatment(s) in an attempt to correct the dentofacial deformity. Groupa
No
Yes
Number of patients
A B C
22 (73.3%) 26 (72.2%) 9 (56.3%)
8 (26.7%) 10 (27.8%) 7 (43.8%)
30 36 16
57 (69.5%)
25 (30.5%)
82
Total
% of total sample 36.6% 43.9% 19.5% 100%
a
Group A: patients who had undergone maxillary advancement combined with mandibular setback; group B: patients who had undergone maxillary advancement; group C: patients who had undergone mandibular setback.
by a physician (n = 7; 8.5%). The recommendation of relatives and friends accounted for 2.4% (n = 2), and only one patient (1.2%) reported having been recommended this treatment by another route (Table 2). The possibility of a difference in diagnosis and recommendations for SOT between the study groups (groups A, B, and C) was evaluated by Fisher’s exact test; no statistically significant difference was found (P = 0.535), indicating that the referral patterns among the three groups were similar. Most patients (69.5%, n = 57) had not undergone previous orthodontic treatment (OT) at other clinics for correction of the DFD, however 30.5% (n = 25) had, without success. There was no significant difference between the three clinical groups regarding the number of patients who had undergone prior orthodontic treatment (P = 0.436) (Table 3). When inquiring about the improvement in facial appearance, 97.6% (n = 80) of patients reported an improvement and 2.4% (n = 2) did not know whether they noticed an improvement in their appearance after SOT. No patient reported ‘no improvement’ in facial appearance after treatment. There was no significant difference in the patterns of responses between the three study groups when evaluated by Fisher’s exact test (P = 0.495) (Fig. 1). Most patients, 97.6% (n = 80) reported an improvement in masticatory function following treatment, but 2.4% (n = 2) did not know if there was an improvement.
There was no significant difference among the three study groups regarding the pattern of responses, as evaluated by Fisher’s exact test (P = 0.485) (Fig. 2). In assessing the improvement in breathing after treatment, 87.8% (n = 72) of the total sample answered that breathing had improved and 12.2% (n = 10) did not know if their breathing had improved. By group, 96.7% (n = 29) of patients in group A, 94.4% (n = 34) in group B, and 56.3% (n = 9) in group C reported an improvement in breathing; yet 3.3% (n = 1) in group A, 5.6% (n = 2) in group B, and 43.8% (n = 7) in group C did not know if their breathing had improved. There was a significant differ-
ence in the pattern of responses in the three groups (P < 0.0003, Fisher’s exact test) (Fig. 3). Analyzing speech improvement, 86.6% (n = 71) of patients responded that there was improvement in pronunciation, 12.2% (n = 10) did not know if there was an improvement, and 1.2% (n = 1) reported no change. There was no significant difference among responses in groups A, B, and C when evaluated by Fisher’s exact test (P = 0.195) (Fig. 4). Most patients, 91.5% (n = 75), reported an improvement in their socialization after treatment, 2.4% (n = 2) reported no improvement in interpersonal relationships after SOT, and 6.1% (n = 5) did not know whether or not there was an improvement (Fig. 5). The difference in the pattern of responses of the three groups comprising the total sample was not significant (P = 0.374), as analyzed by Fisher’s exact test. All patients in the sample responded that the treatment results were good (20.7%; n = 17) or excellent (79.3%; n = 65); no patient considered the treatment results to be poor (Fig. 6). There was no significant difference in response patterns among the three groups of patients, as tested by x2 test (P = 0.183).
35 35 30 30 25 20
Yes
15
Do not know
15 10 5
1
1
0 0 GA
GB
GC
Fig. 1. Sample distribution for the question on perceived improvement in appearance after treatment (GA, group A; GB, group B; GC, group C).
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35 30 30 25 20
Yes
15
Do not know
15 10 5
1
1
0 0 GA
GB
GC
Fig. 2. Sample distribution for the question on perceived improvement in chewing after treatment (GA, group A; GB, group B; GC, group C).
34 35 29 30 25 20
Yes Do not know
15 9 10
7
5
2
1
0 GA
GB
GC
Fig. 3. Sample distribution for the question on perceived improvement in breathing after treatment (GA, group A; GB, group B; GC, group C).
33
35 30
26
25 Yes
20
No 15
12
Do not know
10 4
5 0
4 1
2 0
0 GA
GB
GC
Fig. 4. Sample distribution for the question on perceived improvement in pronunciation of sounds and words after treatment (GA, group A; GB, group B; GC, group C).
Just over 96% of patients reported that they would undergo the treatment again. Only 3.7% reported that they would not undergo the treatment again, two of whom explained that the pain in the postoperative period was very intense and the other stating a terror of being admitted to hospital for any reason (Fig. 7). The difference in response patterns among the three groups was tested by Fisher’s exact test and no significant difference was found (P = 1). All patients reported that they would recommend the treatment that they had undergone to other people who had a similar condition. Discussion
In the present survey, patients classified with the same pattern of malocclusion were selected, with the aim of limiting the analysis to only one class of deformity, providing more uniformity to the sample. Class III patients were chosen for this study as their issues are more complicated and challenging than class II patients, and orthognathic surgery is the key to treatment success for a large number of individuals with class III issues.11 A minimum age of 18 years has been established for this treatment due to the decreasing rate of growth at this stage, providing more stability to the surgical results.11,12 The age limit for patients included in this evaluation was 50 years due to this age being the average reference point for the beginning of menopause, a period during which hormonal changes promote a series of physiological changes in women’s bodies including bone weight loss, which may increase the likelihood of complications due to delayed bone healing.13 A postoperative period of 1 year was established for the evaluation of satisfaction, due to the possibility of dissatisfaction with the treatment outcome by over-valuation of discomfort in the early postoperative period potentially negating the benefits of the aesthetic and functional results of SOT. Victims of intraoperative accidents and postoperative infection were ineligible for the study due to the possibility of such accidents and complications interfering with the assessment of patient satisfaction. The relationship between dissatisfaction with treatment and the occurrence of unexpected events in the postoperative period is clear; however, even if advised of the possibility of complications as a result of treatment, patients have reported emotional unpreparedness
Satisfaction with orthognathic surgery 33
35 30
29
25 Yes
20
No 13
15
Do not know
10 5 0
1
2
1
2
1
0 GA
GB
GC
Fig. 5. Sample distribution for the question on perceived improvement in social relationships or contact with people after treatment (GA, group A; GB, group B; GC, group C).
30 30 25 25 20 Good 15
Excellent
10 10
6
5
6
5 0 GA
GB
GC
Fig. 6. Sample distribution for the evaluation of treatment results (GA, group A; GB, group B; GC, group C).
34 35 29 30 25 20
Yes
16
No
15 10 5
2
1
0
0 GA
GB
GC
Fig. 7. Sample distribution for the question on whether the patient would undergo the surgery again (GA, group A; GB, group B; GC, group C).
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to deal with the complications after surgery.14 Surgical procedures in all patients were limited to two techniques, BSSO and Le Fort I osteotomy – most cases of DFD can be addressed through these two osteotomies for the treatment of jaw deformities.15 The distribution of patients by gender was similar: 53.7% of the sample were females and 46.3% were males. Other studies have also shown a greater number of women than men.16–19 Thirty patients were grouped in group A, 36 in group B, and 16 in group C. The lower number of patients in group C, who underwent mandibular setback, is due to this movement being avoided in orthognathic surgery due to the negative aesthetic changes promoted in the patient’s profile11 in addition to the greater stability of surgical movements resulting from maxillary advancement in relation to surgical movements resulting from mandibular setback.20 In addition, maxillary advancement or a combination of techniques results in a lower long-term relapse, even in growing patients.21 Additionally, setback movements of the maxilla and mandible are considered less predictable in terms of the final conformation of the soft tissue.22 Among patients in the total sample, 97.6% reported satisfaction with the treatment carried out, with only 2.4% being dissatisfied with the methodology used. High satisfaction scores in studies assessing satisfaction with SOT are common.6,17,23–25 The high rate of patient satisfaction can be explained by the impact of DFD class III correction on a patient’s life, since this deformity is reported to be the most disabling and for a large number of individuals the required result of DFD treatment can only be achieved through orthognathic surgery.11 Feelings of satisfaction with the results of SOT provide subjective data and can be difficult to assess by the patient, since in addition to their own opinion, the patient is influenced by several external factors including the impact of the results in their social circle, family expectations of the SOT, and impact of treatment on their professional and private lives. Usually, the assessment of SOT success is determined by whether expectations were met8,9 and how the treatment and outcome was received by the patient’s social circle.10 Ouellette17 reported that more than half of patients felt satisfied with the results during the early postoperative period, whereas 93% of patients were satisfied with the results later in the postoperative period. The change in
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satisfaction between the early and later postoperative period can be explained by a positive change in the evaluation of the treatment results once the unpleasant memories of the immediate postoperative period are replaced by an understanding of the overall beneficial results.23 The percentage of variation in satisfaction with the SOT results varies from study to study depending on the time elapsed between surgery and evaluation, but overall satisfaction increases over time.14 Most patients in this study were recommended for SOT by a dentist (Table 2), which is consistent with other studies.10,18,24,26,27 Patient self-referral was reported for 8.5%. There was no significant difference between the clinical groups in the response pattern regarding SOT recommendation (P = 0.535). Many patients know of the existence of their DFD, but most are unaware of the treatment options available to correct their problems until they are alerted to these by health professionals, especially dentists.2,14,19 The use of orthodontic treatment in an attempt to compensate for the DFD prior to SOT was reported by 30.5% of the total sample of patients. Group C had the highest percentage of patients (43.8%) who had undergone a prior treatment in an attempt to repair the DFD (Table 3). However, there was no difference among the three clinical groups regarding the number of patients seeking prior orthodontic treatment (P = 0.436). Several reasons can lead patients to seek orthodontic treatment for the correction of a DFD, even when their case should be approached surgically. Concerns about the cost of SOT, fear of surgery, or a concern about discomfort in the postoperative period are cited as factors that may influence the selection of orthodontic treatment over SOT.20 Knowing that orthodontists usually recommend SOT,2 when an orthodontist does prefer to treat the DFD through orthodontic treatment instead of SOT, this can result in SOT not even being offered as a therapeutic option for the patient, even in cases where SOT would more effectively address the major complaints and wishes of the patient.14 Regarding the change in facial appearance, 97.6% of patients reported an improvement (Fig. 1). There was no significant difference in the patterns of responses among groups A, B, and C (P = 0.485). Ambrizzi et al.10 reported that an improvement in facial aesthetics was the main motivation for seeking SOT by class III patients, with treatment results being considered excellent or good by 95.6% of those in their sample. Facial
appearance has a great influence on how individuals judge themselves and on how society looks at the individual, and has a major impact on self-esteem. The wish for aesthetic improvement by patients undergoing DFD correction is substantial, and even when patients report functional motivations for seeking treatment, they may actually be seeking aesthetic changes when reporting the desire for functional changes, as such changes would more easily justify the SOT treatment.10,23,25 Most patients studied, 97.6%, reported an improvement in chewing (Fig. 2). There was no significant difference among the three study groups regarding the pattern of responses (P = 0.485). The correct maxillomandibular positioning promoting an occlusion in class I, with normal overbite and overjet, is mentioned as one of the goals of orthognathic surgery for class III patients.28 The maxillomandibular repositioning by orthognathic surgery promotes increased strength and improved masticatory efficiency of chewing cycles in class III patients.29 In assessing the improvement in breathing after treatment, 87.8% of the total sample responded that there was improvement and 12.2% could not answer whether there was improvement or not (Fig. 3). There was a significant difference in the pattern of responses among the three groups (P < 0.0003). Nearly 44% of patients in group C did not know if there was an improvement or worsening of respiratory function after treatment. The pharyngeal space is narrowed in patients undergoing mandibular setback surgery.30 This narrowing is due to the posterior movement of the hyoid bone and tongue after mandibular setback, however there is a tendency for the positioning of these two structures to relapse to their original position. Nevertheless, the pharyngeal airway space remains smaller than its length before surgery.30 Class III patients who undergo mandibular setback surgery associated with maxillary advancement have increased upper respiratory resistance with a decrease in oxygen saturation after surgery, but the decline in respiratory function is not represented at the pathological level, probably due to physiological adaptations by compensatory mechanisms.31 Despite the tendency of the pharyngeal space to decrease with a consequent impairment in respiratory function, no patient in this study complained of a worsening in breathing after surgery. The absence of complaints does not, however, exclude the possibility of a worsening of respiratory function in
these patients, which needs to be evaluated more accurately but is beyond the scope of the present study. Analyzing the improvement in phonation, 86.6% of patients reported an improvement (Fig. 4). There was no significant difference among responses in groups A, B, and C (P = 0.195). Phonetic articulation errors are common in patients with DFD, most commonly in the pronunciation of sibilant sounds (‘c’, ‘s’, and ‘z’), and these are more frequent in class III patients.32 In the early postoperative period there is an increase in phonetic errors, and these errors then gradually decline from the third to the twelfth month postoperative, with a significant reduction or elimination of the number of phonetic errors in patients submitted to SOT.33 Many patients report feeling more able to do their work and happier at work after orthognathic surgery17; the improvement in appearance obtained with the SOT is associated with an improvement in the patient’s psychosocial condition.5 Barbosa et al.23 reported that 63% of patients in their sample denied social adjustment problems caused by the DFD; 25.4% reported mild problems and 12.2% reported severe problems in their social adjustment caused by the DFD. The high incidence of patients who reported no problems related to socialization may be due to the patient’s wish to mask their psychological problems from the surgeon, or to not having knowledge of the magnitude of the negative impact of the DFD on their mental development. With regard to the improvement in social relationships or socializing with other people after treatment, 91.5% of the total sample of patients reported an improvement and 6.1% did not know whether or not there was an improvement (Fig. 5). There was no significant difference in the pattern of responses in groups A, B, and C (P = 0.374). All patients in the sample responded that the treatment results were good or very good (Fig. 6). No patient reported the treatment results as being poor. When asked if they would undergo treatment again, 96.3% of patients responded ‘yes’ and only 3.7% said ‘no’ (Fig. 7). Of these latter patients, two explained that the pain in the postoperative period was intense and the other reported being frightened of being admitted to a hospital for any reason. However, all patients including those who responded that they would not undergo the treatment again reported that they would recommend SOT to people who had the same DFD. Ambrizzi et al.10 reported that 95.6% of class III
Satisfaction with orthognathic surgery patients in the sample reported considered the treatment outcome to be good or excellent, and that all patients in the sample would recommend the treatment to other people with the same condition. SOT provides psychologically beneficial results to patients with DFD27; orthognathic surgery should also be offered to patients due to the improved psychological state it promotes.5 Due to the retrospective design used in this study, there are potential limitations that must be considered. This study enrolled 71% of eligible participants, which is a higher percentage than that reported in other studies.26 This indicates that our response rate was favourable and, considering that eligible participants had no serious complication during the longterm postsurgical period, it is likely that reasons for non-response were not associated with SOT. Therefore, selection bias may not be a significant issue, i.e. the study groups are representative of treated patients. Regarding the outcome reported by participants, the results are representative of post-treatment satisfaction and highlight the positive results of SOT. Patients who comprised the sample had a high degree of satisfaction with the treatment performed, showing improvements in psychosocial and functional criteria, indicating that treatment based on clinical diagnosis is an effective way to treat skeletal class III patients. Funding
None. Competing interests
None declared. Ethical approval
The research protocol was submitted to the Ethics Committee for Research of the College of Dentistry, Federal University of Bahia, and was approved (FR – 216192, CAAE: 0030.368.000-08). Patient consent
Not required. Acknowledgements. We thank Dr Roberto Della Coletta, President of CEDEFACE, and Dr Mario Gabrielli, Professor of Oral and Maxillofacial Surgery, Dental School at Araraquara, UNESP, for the support given to this work.
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