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ARTICLE IN PRESSG ModelOMSMP-276; No. of Pages 7

Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology

j o ur nal ho me pa ge: www.elsev ier .com/ locate / jomsmp

riginal Research

sychosocial and functional outcomes of orthognathic surgery:omparison with untreated controls

agla Sara, Sidika Sinem Soydanb,∗, Ayca Arman Ozcirpici a, Sina Uckanb

Baskent University, Faculty of Dentistry, Department of Orthodontics, Ankara, TurkeyBaskent University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Ankara, Turkey

r t i c l e i n f o

rticle history:eceived 18 November 2013eceived in revised form 22 January 2014ccepted 3 March 2014vailable online xxx

eywords:rthognathic surgeryentofacial deformitysychological well-beingsychological assessmentatient satisfaction

a b s t r a c t

Objectives: Orthognathic surgery is a procedure for patients with dentofacial deformities and providesdramatical dentofacial and psychological alterations. The aim of this controlled study was to evaluate howorthognathic surgery affects patients’ psychosocial well-being and compare them with patients havingdentofacial discrepancies and with individuals who do not have any skeletal discrepancies.Methods: Hundred and sixty-three adult individuals were included in this study as three groups: patientswho underwent orthognathic surgery, patients having skeletal discrepancies and individuals who donot have any skeletal discrepancies. Patients in all groups were asked to fill out two questionnairesconcerning the psychological and physical status of the patients at that moment and additional questionswere asked to patients in post-surgical phase regarding post-surgical satisfaction. Categorical variableswere statistically evaluated by Fisher Exact and chi-square tests.Results: Patients who were going to seek orthognathic surgery were significantly concerned about theirdentofacial appearance, body image and psychosocial status when compared with patients in the post-surgical phase and the individuals who did not have skeletal discrepancies. The results of the patientswho underwent orthognathic surgery were approximated to the results of non-patient control group andhad high degrees of satisfaction with improvement in appearance brought about by surgery at 6-month

post-operatively.Conclusion: Following orthognathic surgery, patients had better psychosocial status when compared topatients without skeletal deformities. Patients in the pre-surgical phase were not only functionally butalso psychosocially the least satisfied group of individuals.

© 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.�

. Introduction

As adult orthodontic treatment becomes more widely available,here has been an increase in the demand for orthognathic surgeryor cases that cannot be treated by orthodontics alone. In adults,rthognathic surgery procedures lead to rapid alterations not only

Please cite this article in press as: Sar C, et al. Psychosocial and functioncontrols. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/1

n functions, such as chewing, swallowing, speech and respiration,ut also in the appearance of the face. Although the focus is gen-rally on correcting the morphological deformity, assessment and

� Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asianociety of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-gy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japaneseociety of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.∗ Corresponding author at: Maresal Fevzi Cakmak Caddesi, 11 Sokak, No. 26,ahcelievler, Ankara, Turkey. Tel.: +90 3122151336; fax: +90 3122152962.

E-mail address: sdksoydan@yahoo.com (S.S. Soydan).

ttp://dx.doi.org/10.1016/j.ajoms.2014.03.001212-5558/© 2014 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Else

treatment planning should also involve psychosocial aspects of thepatient.

Studies have shown that orthognathic surgery yields positivechanges in psychological well-being and self-concept [1–4]. It hasbeen reported that patients who undergo orthognathic surgery dis-play better social functioning, social adjustment, self-confidence,self-concept, body image, emotional stability, positive life changes,and reduced anxiety [5,6]. Furthermore, studies have revealed thatdissatisfaction in the post-operative phase is not necessarily relatedto the outcome of surgery, but also upon results primarily from alack of communication between the orthodontist, surgical team andthe patient.

In summary, the literature reveals that high satisfaction follow-ing orthognathic surgery has been related to effective preoperative

al outcomes of orthognathic surgery: Comparison with untreated0.1016/j.ajoms.2014.03.001

preparation of the patient, realistic expectations of post-operativediscomfort and recovery, and the outcome of surgery [5]. How-ever, the reasons for dissatisfaction in a minority of the patientsare still unclear. Understanding the patients’ expectations from the

vier Ltd. All rights reserved.�

IN PRESSG ModelJ

2 urgery, Medicine, and Pathology xxx (2014) xxx–xxx

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Table 2Questionnaire 1.

Consider each item listed below and mark in the column that best represents your feelings abo ut you rself at the p resent ti me

(1) very uncomfortable / very much a p roblem (2) unco mfortab le / so mewha t a problem(3) unco mfortab le/so-so(4) relatively comfortable(5) ver y co mfortable / don ’t have any p rob lems

1- Chewing ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )2- Biting into foods ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )3- Fi tting your front t eeth together ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )4- Fi tting your back tee th together ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )5- Speech ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )6- Popping and clic king of jaw joint ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )7- Pain on biting food ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )8- Numbness on your face ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )9- Pai n in front of ear ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )10- Pai n on your face ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )11- He adache ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )12- Pai n while going down the stai rs ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )13- Di fficulty in your daywork ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )14- Appearance of your teeth ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )15- Facial profile ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )16- Ge neral appearance ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )17- Feeli ng nervous ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )18- Feeli ng depres sion ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )19- Feeli ng ashamed ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )20- Ge neral health ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )21- Feeli ngs about self ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )22- Socializi ng with friends/family ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )23- Performance in work or schoo l ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )24- Ha ving your photo ta ken ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )25- Seei ng yourself on the mirror ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )26- Your po sition in the socie ty ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )27- Sati sfacti on from your life ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )28- Sleep ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )29- Your eati ng habit ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )30- Palat al taste ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )31- Smiling ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )32- Gummy smile ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )

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C. Sar et al. / Journal of Oral and Maxillofacial S

reatment should be carefully considered preoperatively in ordero avoid possible unrealistic expectations [7].

Generally, past studies have compared patients who under-ent orthognathic surgery with individuals who have skeletaleformities [8–15]. However, the present study aimed to evalu-te how orthognathic surgery affects psychosocial well-being andunctional improvement of patients with skeletal deformity, andompared same patients to their pre-surgical phase and a healthyontrol group.

. Materials and methods

This study was approved by the Bas kent University Institutionaleview Board and Ethical Committee with project no. D-KA08/02.

Three groups of adult individuals were included in this study.he exclusion criteria were: trauma or previous orthognathicurgery, patients under 18 years of age, syndromic patients, cleftip and palate patients, distraction osteogenesis cases, and patients

ho had undergone isolated genioplasty procedures.Ninety-two consecutive patients who applied to the Bas kent

niversity Faculty of Dentistry Department of Orthodontics withentofacial skeletal discrepancies between the years 2008 and 2011ere included in the study. Out of 92 patients, 10 patients were not

ncluded in the study due to one or more exclusion criteria, and theotal number of 82 patients constituted Group 1 (Class 2 (n = 15),lass 3 (n = 67), mean age: 23.8 yrs). Twenty-five of these patientsere treated with single-jaw surgery, whereas 57 patients were

reated with double-jaw surgery by the same surgical team. Gen-er distribution among groups is shown in Table 1. Patients weresked to complete three questionnaires 6 months after the surgery.re-surgical phase of these 82 patients comprised Group 2 (n = 82,lass 2 (n = 15), Class 3 (n = 67), mean age: 23 yrs). The control groupGroup 3, n = 81, mean age: 24.2 yrs) consisted of 81 individuals whoid not have any skeletal discrepancies. Additionally, these individ-als were not orthodontic patients, but were recruited mostly fromniversity students and an attempt was made to match for age andender.

The first questionnaire (Table 2) aimed to evaluate patients’ per-eptions of their problems in oral function, general health, pain,ppearance, social and inter-personal relationships, body image,nd satisfaction with surgical outcome, with 34 questions that wereodified and adapted from the study of Lazaridou-Terzoudi et al.’s

1]. The second questionnaire (Table 3) was the modified version ofecord and Jourard’s “body cathexis scale” [16] and composed of 26uestions. Patients were questioned regarding their perceptions ofacial and general appearance.

The original questionnaires were translated into Turkish byhree orthodontists who had an advanced level of English, and arofessional translator assessed the translations. This was followedy minor and necessary modifications for the Turkish population. Arofessional translator, who had an equal command of English andurkish, translated the final version of the Turkish questionnairento English. Finally, when the original and the translated ques-

Please cite this article in press as: Sar C, et al. Psychosocial and functioncontrols. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/1

ionnaires were compared, a high level similarity was found andhe questionnaires were approved for use.

All groups completed two questionnaires. In addition, patientsn Group 1 received another questionnaire, which contained

able 1ender distribution between three groups.

Females Males

n % n %

Group 1 (n = 82) 33 40 49 60Group 2 (n = 82) 33 40 49 60Group 3 (n = 81) 34 42 47 58

33- Proble m in breathing ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )34- Pai n inside your mouth ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 )

12 questions designed by the authors to assess their post-surgicalperceptions as follows:

Q1: What was your main intention to undergo orthognathicsurgery? Please mark one of the given answers: My wish-my fam-ily’s wish-pressure from society-my doctor’s advice.Q2: In how many days were you able to return back to your dailylife? Please mark one of the given answers: Less than 7 days-7 to15 days-15 to 30 days-more than 1 month.Q3: Was your stay in the hospital as you expected it to be? (Yes orNo)Q4: Would you undergo surgery if you knew the difficulties of thepost-operative phase? (Yes or No)Q5: Would you recommend the operation to other patients? (Yesor No)Q6: Would you undergo the operation again if it is indicated? (Yesor No)

al outcomes of orthognathic surgery: Comparison with untreated0.1016/j.ajoms.2014.03.001

Q7: Are you satisfied with your healing period? (Yes or No)Q8: In how many days could you go back to your school/work?Please mark one of the given answers: Less than 7 days-7 to 15days-15 to 30 days-more than 1 month.

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Table 3Questionnaire 2: Body Image.

Cons ider each item li sted below a nd mark in the column tha t best rep resents your feelings abo ut you rself at the present ti me1. Strong feelings-wish a change2. Do not li ke but c an put up wit h3. No particu lar feelings one way o r the o ther4. I am s ati sfied 5. Conside r myself very fortun ate

1 2 3 4 51- Height2- Wei ght3- Hair4- Ear5- For ehead6- Eyes7- Nose8- Lips9- Mouth10- Teeth11- Face12- Chin13- Nec k14- Profile15- Shoulders16- Chests/breasts17- Arms18- Hands19- Waist20- Hips21- Legs22- General mu scle tone develop ment23- General facial atracti veness24- Overall upper trunks attracti veness

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25- Overall lower trunks att racti veness26- Overall bo dy appearance

Q9: In how many days/weeks could you do activities that requiredeffort? Please mark one of the given answers: Less than 20 days-20to 30 days-1 to 2 months-more than 2 months.Q10: Are you satisfied with your facial aesthetics? (Yes or No)Q11: Do you get used to your new image? (Yes or No)Q12: Do you have any pain or restrictions in jaw movements(mouth opening and closing)? (Yes or No)

.1. Statistical method

The Statistical Package for the Social Sciences software (ver-ion 18 for Windows; SPSS, Chicago, IL) was used for analyses.he responses (mean ± standard deviation) and the median valueere specified as min–max and interquartile range (IQR). Categor-

cal data were analyzed with Fisher’s exact test and the chi-squareest. The level of significance was set at 0.05 for all analyses.

. Results

All participants were Caucasian. Table 4 demonstrates theesults of Questionnaire 1 in each group and statistical comparisonf groups. Table 5 shows the statistical data regarding Question-aire 2 and comparison of parameters among three groups.

When oral functions such as chewing, biting foods, fitting frontr back teeth together, speech, popping and clicking of the jawoint, and pain when biting food were considered, there was notny statistically significant difference between post-surgical group

Please cite this article in press as: Sar C, et al. Psychosocial and functioncontrols. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/1

nd control group. However, the results in pre-surgical group weretatistically different compared to those in Groups 1 and 3.

Regarding the appearance of the teeth, profile, face, andmiling, patients who underwent orthognathic surgery differed

PRESS, Medicine, and Pathology xxx (2014) xxx–xxx 3

significantly from Group 2, and were similar to the untreatedcontrol group. Answers to the questions related to social andinter-personal relationships were significantly different betweenpre-surgery and post-surgery.

Furthermore, the scores of the daily functions of the patientssuch as sleeping, eating, palatal taste, and breathing demonstratedsignificant difference among Groups 1 and 2, and Groups 2 and 3,whereas no significant differences were seen between Groups 1and 3.

Table 5 displays the distribution of findings of the second ques-tionnaire in the three groups. Thirteen of the 26 parameters did notshow any significant difference when the three groups were com-pared. The results regarding lips, mouth, teeth, face, chin, profile,general facial attractiveness, and overall body appearance were sta-tistically significant between pre-surgical and post-surgical groups.

The results of the third questionnaire given to 82 patients inGroup 1 are presented in Table 6.

4. Discussion

There are many studies in the literature that evaluated theeffects of orthognathic surgery and it is still controversial as whichimprovement is more substantial for the patient: dentofacial defor-mity related functional impediments or psychosocial aspects. It iscrucial to be aware of how surgical outcome effects patients’ emo-tional and functional status in order to satisfy the patient.

The researchers in this field generally used a control group ofpatients with untreated dentofacial deformities. In a systematicreview, it was emphasized that it would be more appropriate to usea control sample of subjects with normal facial and dental appear-ance, as the aim of orthognathic surgery is to bring the patient’sfacial and dental appearance within the normal range [6]. Onlyfew studies used normal individuals as a control group [1,17,18].Therefore, the aim of the current study was to compare patientswith dentofacial deformities and patients who underwent orthog-nathic surgery, with the control group who did not have any skeletaldiscrepancies.

The World Health Organization established a worldwideresearch group in 1993 in order to define personal quality of life[19]. Their results implied that quality of life is mainly subjectiveand cannot be evaluated by others. Personal questionnaires andinterviews allow for personal evaluation [16]. A variety of meth-ods were used to collect data, including questionnaires speciallydesigned by the authors, semi-structured interviews, qualitativeinterviews, and a combination of these methods. In this study weused modifications of the questionnaires of Lazaridou-Terzoudiet al. [1] and Secord and Jourard’s [16], “body cathexis scale”.Lazaridou-Terzoudi et al.’s questionnaire tends towards a compre-hensive evaluation of patients’ perception of self-concept, bodyimage, and function. Body cathexis is defined as the degree of satis-faction or dissatisfaction with the various parts or processes of thebody [14].

The main psychological benefits of orthognathic surgery under-lined in the literature were improved self-esteem, self-confidence,body image, facial attractiveness, desirable changes in personality,social functioning, emotional stability, overall mood, and the abilityto mix socially, as well as decreased self-consciousness and positivelife changes, such as better personal relationships [6].

According to a study conducted by Phillips et al., 28% of thepatients reported that they chewed better and 22% of the patientshad better biting 4–6 weeks after surgery [2]. The percentages were

al outcomes of orthognathic surgery: Comparison with untreated0.1016/j.ajoms.2014.03.001

significantly lower compared to our study, which was evaluated6 months after surgery. The possible reason of this result may bethat when patients were evaluated 4–6 weeks after surgery, mostof the patients would still have some complaints that may have

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Psychosocial

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Table 4Number and percent of patients who marked 1 and 2 (none), 3 (some), 4 and 5 (lot) in Questionnaire 1. Statistical comparison of the parameters among groups. Statistical Significance: p < 0.05. Boldface indicates statisticalsignificance.

Group 1 Group 2 Group 3 p values p

None Some Lot None Some Lot None Some Lot 1–2 2–3 1–3

n % n % n % n % n % n % n % n % n %

1. Chewing 0 0 12 15 70 85 12 14 44 52 26 32 1 1 6 7 74 88 0.000 0.000 0.391 0.0012. Biting into foods 0 0 16 20 66 80 5 6 37 45 40 48 0 0 9 11 72 75 0.000 0.000 0.629 0.0013. Fitting your front teeth together 1 1 12 15 69 84 38 46 33 40 11 13 1 1 17 20 63 77 0.000 0.000 0.697 0.0014. Fitting your back teeth together 0 0 8 10 74 90 12 14 37 45 33 40 0 0 12 14 69 85 0.000 0.000 0.805 0.0015. Speech 0 0 22 27 60 73 14 17 38 46 30 36 1 1 19 23 61 75 0.000 0.000 0.891 0.0016. Popping and clicking of jaw joint 2 2 22 27 58 71 13 15 21 25 48 58 1 1 20 24 60 74 0.000 0.001 0.677 0.0017. Pain on biting food 1 1 15 18 66 80 4 5 27 32 51 62 0 0 50 61 73 90 0.008 0.000 0.411 0.0018. Numbness on your face 2 2 22 27 58 71 1 1 6 7 75 91 0 0 2 2 79 97 0.002 0.033 0.000 0.0019. Pain in front of ear 1 2 10 12 70 85 3 2 9 10 70 85 0 0 14 17 67 82 0.959 0.541 0.616 0.86910. Pain on your face 3 4 9 11 70 85 1 1 7 8 74 90 0 0 7 8 74 91 0.033 0.436 0.272 0.10611. Headache 5 6 6 8 71 86 3 4 17 20 62 75 4 5 33 40 44 54 0.151 0.019 0.000 0.00112. Pain while going down the stairs 1 1 3 4 78 95 0 0 5 6 77 94 1 1 8 9 72 75 0.33 0.598 0.439 0.59113. Difficulty in your daywork 1 1 5 6 76 92 2 2 12 14 68 82 0 0 7 8 74 88 0.032 0.2 0.632 0.15214. Appearance of your teeth 2 2 10 12 70 85 30 36 35 42 17 20 0 0 20 24 61 75 0.000 0.000 0.116 0.00115. Facial profile 2 1 10 12 71 87 26 31 39 47 17 20 0 0 8 9 73 90 0.000 0.000 0.314 0.00116. General appearance 1 1 8 9 73 89 17 20 35 42 30 37 0 1 7 8 73 90 0.000 0.000 0.812 0.00117. Feeling nervous 1 1 11 13 70 85 5 6 28 34 49 60 0 0 16 20 65 80 0.000 0.006 0.159 0.00118. Feeling depression 2 2 5 6 75 91 6 7 16 19 60 73 0 0 19 23 62 76 0.017 0.139 0.002 0.00519. Feeling ashamed 1 1 4 5 77 94 6 7 19 23 57 70 0 1 14 17 66 81 0.033 0.073 0.012 0.00120. General health 0 0 4 5 78 95 1 1 11 13 70 85 0 0 7 8 74 88 0.000 0.498 0.042 0.03721. Feelings about self 0 0 2 2 80 98 4 5 19 23 59 71 0 1 8 9 72 75 0.002 0.036 0.002 0.00122. Socializing with friends/family 1 1 0 0 81 99 5 6 9 10 67 81 0 0 3 4 78 96 0.186 0.013 0.006 0.00123. Performance in work or school 0 0 5 6 77 94 2 2 10 12 70 85 0 2 7 8 72 75 0.000 0.509 0.012 0.09924. Having your photo taken 3 4 9 11 70 85 19 23 36 43 27 32 0 2 12 15 67 82 0.000 0.000 0.142 0.00125. Seeing yourself on the mirror 0 0 9 11 73 89 10 12 32 39 40 49 0 2 7 8 62 76 0.000 0.000 0.037 0.00126. Your position in the society 0 0 1 1 81 99 10 12 10 12 62 75 0 0 6 7 75 92 0.000 0.006 0.176 0.00127. Satisfaction from your life 1 1 6 8 75 91 6 7 11 13 65 79 0 2 14 17 65 80 0.015 0.376 0.127 0.03328. Sleep 1 1 8 10 73 89 8 10 16 20 58 71 0 2 17 20 62 76 0.007 0.01 0.071 0.00129. Your eating habit 1 1 6 8 75 91 5 6 16 20 61 74 0 1 10 12 70 86 0.002 0.171 0.474 0.01430. Palatal taste 0 0 7 8 75 91 1 1 17 21 64 78 0 0 6 7 75 92 0.001 0.012 0.130 0.00231. Smiling 1 1 9 11 72 88 18 22 37 45 27 33 0 0 11 14 70 86 0.000 0.000 0.932 0.00132. Gummy smile 3 4 9 11 70 85 16 20 19 60 47 57 0 0 11 14 70 86 0.002 0.000 0.057 0.00133. Problem in breathing 2 2 10 12 70 85 7 9 22 27 53 65 0 1 14 17 66 81 0.021 0.015 0.805 0.02134. Pain inside your mouth 3 4 15 17 64 78 6 7 19 60 57 70 0 0 6 7 75 92 0.342 0.002 0.016 0.009

Please cite

this

article in

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as: Sar

C,

et al.

Psychosocial

and

fun

ctional

outcom

es of

orthogn

athic

surgery:

Com

parison

with

un

treatedcon

trols. J

Oral

Maxillofac

Surg

Med

Pathol

(2014), h

ttp://d

x.doi.org/10.1016/j.ajom

s.2014.03.001

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5

Table 5Number and percent of patients who marked 1 and 2 (none), 3 (some), 4 and 5 (lot) in Questionnaire 2. Statistical comparison of the parameters among groups. Statistical Significance: p < 0.05. Boldface indicates statisticalsignificance.

Group 1 Group 2 Group 3 p values p

None Some Lot None Some Lot None Some Lot 1–2 2–3 1–3

n % n % n % n % n % n % n % n % n %

1. Height 1 1 9 11 72 88 3 4 6 7 73 89 8 10 12 15 61 75 0.449 0.199 0.093 0.1152. Weight 8 10 9 11 65 79 17 20 13 16 52 63 14 17 20 25 47 58 0.278 0.517 0.034 0.1013. Hair 1 1 6 8 75 91 1 1 5 6 76 93 5 6 9 11 67 83 0.841 0.295 0.123 0.2194. Ear 3 4 4 5 75 91 5 6 7 9 74 90 2 2 3 4 76 94 0.936 0.726 0.759 0.8955. Forehead 0 0 6 8 76 92 1 1 3 4 78 95 3 4 7 9 71 88 0.389 0.572 0.25 0.4036. Eyes 1 1 1 1 80 98 0 0 4 5 78 95 3 4 5 6 73 90 0.584 0.527 0.358 0.5477. Nose 5 6 12 15 65 79 16 20 17 21 49 60 4 5 18 22 59 73 0.063 0.043 0.703 0.0408. Lips 2 2 6 8 74 90 12 15 19 23 51 62 1 1 8 10 72 89 0.001 0.000 0.969 0.0019. Mouth 1 1 5 6 76 93 34 41 21 26 27 33 1 1 9 11 71 88 0.001 0.001 0.717 0.00110. Teeth 1 1 6 8 75 91 51 62 15 18 16 20 5 5 12 15 64 79 0.001 0.001 0.018 0.00111. Face 1 1 6 8 75 91 22 27 14 17 46 56 1 1 5 5 75 93 0.001 0.001 0.226 0.00112. Chin 2 2 7 9 73 89 53 65 12 15 17 21 2 2 4 5 75 93 0.001 0.001 0.242 0.00113. Neck 1 1 3 4 78 95 3 4 8 10 71 87 2 2 2 2 77 95 0.32 0.202 0.336 0.19314. Profile 1 1 7 9 74 90 25 30 15 18 42 51 2 2 9 11 70 86 0.001 0.001 0.123 0.00115. Shoulders 0 0 5 6 77 94 4 5 2 2 76 93 2 2 10 12 69 85 0.068 0.121 0.051 0.02516. Chests/breasts 2 2 3 4 77 94 2 2 5 6 75 91 5 6 12 15 67 83 0.934 0.277 0.079 0.19717. Arms 0 0 4 5 78 95 2 2 3 4 77 94 2 2 9 11 70 86 0.187 0.471 0.111 0.28818. Hands 1 1 3 4 78 95 3 4 3 4 75 91 4 5 9 11 68 84 0.528 0.342 0.049 0.10119. Waist 3 4 4 5 75 91 6 7 3 4 73 89 7 9 13 16 65 80 0.185 0.325 0.173 0.23020. Hips 4 5 7 9 71 86 4 5 5 6 73 89 4 5 18 22 59 73 0.979 0.046 0.109 0.10421. Legs 1 1 6 8 75 91 5 6 8 9 69 84 4 5 12 15 67 83 0.277 0.629 0.317 0.41022. General muscle tone development 1 1 8 10 73 89 5 6 10 12 67 82 5 6 9 11 67 83 0.332 0.946 0.547 0.76123. General facial attractiveness 1 1 9 11 72 88 18 22 17 21 46 56 2 2 10 12 69 85 0.001 0.001 0.957 0.00124. Overall upper trunks attractiveness 0 0 7 9 75 91 7 9 6 7 69 84 5 6 10 12 66 81 0.004 0.719 0.048 0.03325. Overall lower trunks attractiveness 2 2 8 10 72 88 6 7 4 5 72 88 4 5 15 19 62 77 0.213 0.107 0.129 0.07026. Overall body appearance 0 0 3 4 79 96 5 6 9 11 68 83 6 7 7 9 68 84 0.005 0.920 0.003 0.020

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Table 6The results of the third questionnaire (post-surgical perceptions) given to patients in Group 1.

Question Answer

Q1: What was your main intention to undergo orthognathic surgery? My wish: 78.5%My doctor’s advice: 19%My family’s wish: 2.5%

Q2: In how many days were you able to return back to your daily life? More than 1 month: 44%15–30 days: 27.4%7–15 days: 19%Less than 7 days: 9%

Q3: Was your stay in the hospital as you expected it to be? 85.7% of the subjects answered “Yes”Q4: Would you undergo surgery if you knew the difficulties of the post-operative phase? 88.1% of the subjects answered “Yes”Q5: Would you recommend the operation to other patients? 89.3% of the subjects answered “Yes”Q6: Would you undergo the operation again if it is indicated? 69% of the subjects answered “Yes”Q7: Are you satisfied with your healing period? 86.9% of the subjects answered “Yes”

Q8: In how many days could you go back to your school/work? More than 1 month: 41.7%15–30 days: 35.7%7–15 days: 23%Less than 7 days: 0

Q9: In how many days/weeks could you do activities that required effort? More than 2 months: 42.9%1–2 months: 25%20–30 days: 22.6%Less than 20 days: 10%

Q10: Are you satisfied with your facial aesthetics? 97.6% of the subjects answered “Yes”

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Q11: Do you get used to your new image?

Q12: Do you have any pain or restrictions in jaw movements (mouth opening and

ffected the responses. Espeland et al. [5] reported that the greatestmprovements with the surgery were dental and facial appear-nces. Improvement in chewing ability in the post-surgical phasearied from 40% to 80% in the literature, and 85% improvement waseen in chewing in the sixth post-operative month in this study.ther parameters that were above 90% improvement at 6 monthsost-surgically in our study were: difficulty during the day/at work,eeling ashamed, general health, feelings about self, socializing, per-ormance in work or school, position in society, satisfaction fromife, eating habits, and palatal taste. In short, most of the functions

ere improved significantly with the surgery.It was observed that parameters related to facial appearance and

ttractiveness in pre-surgical patients were significant, whereasther parameters related to various parts of the body were neg-igible. This reveals that patients in Group 2 only had complaintsbout their skeletal deformities.

Among 34 parameters in Questionnaire 1, there was no sta-istically significant difference between the responses betweenost-surgical group and control group considering 24 parameters.he most important dissatisfaction was “numbness in the face”n Group 1 (27% uncomfortable/so-so, and 2% very uncomfort-ble/very much a problem), whereas almost all patients were veryomfortable in Group 3 (97% did not have any problems). On thether hand, when “headache, feeling nervous, feeling depression,eeling ashamed, feeling about self, seeing yourself on the mirror,aving your photo taken, socializing, or general health” was con-idered, patients were more satisfied in post-surgical phase whenompared to control group. One of the unexpected results of thistudy was the higher psychosocial satisfaction in Group 1.

With the exception of five parameters (pain in the front of thear, headache, pain while going down the stairs, pain inside theouth, and socializing) in Questionnaire 1, which were mainly

bout pain feelings of the patients, the results were significantlyifferent between pre-surgery and post-surgery. These remarkableifferences between Groups 1 and 2 corroborate the functional

Please cite this article in press as: Sar C, et al. Psychosocial and functioncontrols. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/1

nd emotional improvements in patients following orthognathicurgery.

In 22 out of 26 parameters, no differences were foundetween Groups 1 and 3, whereas the differences were statistically

92.9% of the subjects answered “Yes”ng)? 81% of the subjects answered “No”

significant in parameters related to the maxillofacial regionbetween Groups 1 and 2. The only statistically significant param-eter in the maxillofacial region between Group 1 and 3 was toothappearance (Group 1: 91% lot and Group 3: 79% lot) and generalbody attractiveness was also found significant between Groups 1and 3 (Group 1: 96% lot and Group 3: 84% lot). This result was quiteunexpected, which shows the positivism of patients who under-went orthognathic surgery.

Patients’ satisfaction from the results of orthognathic surgerywas 80–95%, and the improvement of facial appearance was50–90% in previous studies [14,20,21]. In Group 1, 97.6% of thepatients were satisfied with their new facial aesthetics accordingto the results of the present study. Difficulties in adjusting to thenew appearance following the orthognathic surgery were reportedin 60–80% of cases by Frost and Peterson [21]. In the current study,92.9% of the patients adjusted to their new image 6 months aftersurgery. It was also observed that 85% to 89% of the patients weresatisfied with the surgical outcome when the parameters “stay-ing in the hospital, recovery period, and undergoing the operationagain” were considered.

It has been reported that patients who have realistic expecta-tions from the surgery are more satisfied with the outcome [5,6].Patients’ satisfaction with the outcomes of orthognathic surgeryis influenced by their preoperative expectations, anxiety, stress,and psychological well-being. Kiyak et al. [22] reported two basicpredictors of reduced satisfaction in orthognathic surgery patientsas neuroticism and external motivation, such as family pressure.Body dysmorphic disorder (BDD) is another possible mental ill-ness and somatoform disorder that is characterized by extremedissatisfaction and preoccupation of body image in orthognathicsurgery patients [23]. The main features of BDD are obsession withimagined bodily defects in appearance and emotional depression[24,25]. In the present study one of our male patients in Group1 had a slight Class III skeletal deformity and his aesthetic com-plaints increased following the orthognathic surgery. Although

al outcomes of orthognathic surgery: Comparison with untreated0.1016/j.ajoms.2014.03.001

the surgical outcome and aesthetic improvement of the patientwere assumed successful by responsible surgical and orthodon-tic teams, the patient compared his appearance to other people,inspected the feature of concern in a mirror, and his dissatisfaction

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ontinued. According to these clinical signs, the patient may haveDD. Hence, a routine, standardized mental health evaluation pro-ess before elective orthognathic surgery should be a routine partf the preoperative assessment of a patient [2]. Furthermore, Cun-ingham et al. [26] suggested that every patient would be assessedy a psychologist at the initial appointment to understand theirotives for requesting treatment and to determine whether these

oals are realistic. If not patient should be prepared for the real-stic surgical outcomes and/or psychological support should beecommended. Moreover, orthognathic surgery may be cancelledr postpone in border line cases with psychological obstacles.

In the past, it was reported that men were less concerned withppearance than women [27]. Yet, in today’s modern society aes-hetics and appearance are equally important for men and women.here are studies available in the literature that found no genderifferences or even men being more concerned than women withegard to their appearance [12]. Likewise, in this study no genderifferences were found in any of the questions before treatmentnd our results support those of Oland et al. [12] and Ostler andiyak [20], who found no differences between genders in terms ofotives for orthognathic surgery.With regard to post-operative satisfaction with the outcome,

land et al. [12] reported that when satisfaction was analyzed inelation to the resulting facial profile type, Class III male patientsxpressed more satisfaction with their general appearance than didlass III female patients. In other words, men tended to be mostlyatisfied with the overall treatment outcome, whereas womenere mostly satisfied with their resultant facial profile. Further-ore, Ostler and Kiyak [20] found no gender differences in any

f the post-surgical patient satisfaction questionnaire variables 4onths after surgery, and this result was confirmed in a prospec-

ive study 12–36 months after surgery. In our study, no genderifferences were found in any of the questions when patients werevaluated in the post-surgical phase.

. Conclusion

The great improvement of functions such as chewing, biting orpeech, aesthetics such as profile view, face appearance or smiling,nd various daily functions showed the contribution of the orthog-athic surgery to patients’ life. The results of the patients whonderwent orthognathic surgery were approximated to the resultsf individuals who did not have any skeletal discrepancies at 6-onth post-operatively. Following orthognathic surgery, patients

ad better psychosocial status when compared to patients withoutkeletal deformities. Patients in the pre-surgical phase were theeast satisfied group of individuals not only functionally but alsosychosocially.

Please cite this article in press as: Sar C, et al. Psychosocial and functioncontrols. J Oral Maxillofac Surg Med Pathol (2014), http://dx.doi.org/1

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