This study was designed to assess the relationship between postsurgical cephalometric changes and quality of life and satisfaction after orthognathic surgery.
Sample size consisted of 30 patients with class III and 25 patients with class II malocclusion treated with bilateral sagittal split osteotomy and Le Fort I osteotomy. Profile convexity, lower facial height proportion, lip position and length, nose, and chin position were measured on pre and post-treatment cephalograms. To assess the patients’ satisfaction and quality of life (QoL) after surgery, the questionnaire of the Rustemeyer’s study and Oral Health Impact Profile (OHIP) questionnaire were used, respectively. The paired-sample t-test, Spearman correlation analysis and Pearson correlation analysis was used in SPSS statistical software.
In class III malocclusion patients, decrease in facial angle, convexity angle, mentolabial angle, and increase in upper lip protrusion had the most positive impact on QoL. Decrease in facial angle and increase in upper lip protrusion were correlated positively with satisfaction questionnaires. In class II malocclusion patients, increase in convexity angle, facial angle and mentolabial angle had the most positive impact on satisfaction and QoL.
Consideration both subjective and objective parameters affecting on the patients’ satisfaction and their quality of life is essential.
Skeletal and dentofacial discrepancies may adversely influence the quality of life (QoL) of patients through affecting their facial appearance, oral function or both [
Nowadays, orthognathic surgeries are commonly used for patients with severe skeletal discrepancies [
Despite equipment improvements and technical progress that have made the orthognathic surgeries much faster and simpler than they used to be, patients’ dissatisfaction with the outcomes is still a common issue [
Even in the most successful cases, patients’ preoperative expectations of orthognathic surgery and postoperative outcome could offer discrepancies if they are not well informed and clarified about the outcomes and possible postsurgical discomforts. Therefore, patients may experience physical or psychological dissatisfaction, and express such dissatisfaction through formal or informal complaints [
Orthodontic surgical treatments are planned and conducted based on objective criteria and normative values, these may differ from patients’ perception of improvement and QoL which are affected by subjective parameters [
Several questionnaires have been developed in order to assess the impact of dental conditions on the QoL [
Hence, the aim of this study was to assess relationships between oral health-related quality of life and satisfaction with cephalometric changes in hard and soft tissues variables. The results of this study may help clinicians to improve patients’ quality of life and satisfaction following orthognathic surgery by considering effective soft and hard tissue variables. The research hypothesis was that there are soft and hard tissue variables which are more effective in patients’ level of satisfaction and quality of life.
A cohort study of orthodontic patients whose treatment plan included an orthognathic surgery was designed. Ethical permission was obtained from the ethical committee of Shiraz University of Medical Sciences. All patients who were referred to maxillofacial departments of any private or public hospitals of the city of Shiraz for orthognathic surgery by their orthodontists during March 2010 - July 2011 were invited into the study. The 25 class II and 30 class III malocclusion patients who met the specific criteria were recruited. The inclusion criteria were: to have received presurgical orthodontic treatment with the same protocol (0.022 inch standard edge wise bracket), were scheduled for a combination of a standard one-piece Le Fort I osteotomy and bilateral sagittal split ramus osteotomy (BSSRO) with rigid fixation, condylar positioning devices were not used, inter-occlusal splint were applied for two weeks. For all patients, pre- and postsurgical cephalograms were available, and all patients filled the questionnaires. Those who did not go under surgery for any reason (e.g. financial or general health issues), and who had cleft lip/palate, craniofacial syndrome, posttraumatic deformity, tempromandibular diseases, facial asymmetry, or mandibular border asymmetry were not recruited for the study. Moreover, among recruited ones, those who had a postoperative infection, mal-union with poor occlusion, or nerve injury, and those who refused to fill the questionnaires in full were excluded from final analysis.
Pre- and postsurgical cephalograms were taken with head in natural position, teeth in centric occlusion, and lips in response. The distance between film and X-ray tube was 150 cm and the distance between the film and mid sagittal plane of the patient’s head was 18 cm. The horizontal reference line used in this study was the line with 7 degrees of difference to the sella-nasion line. Soft and hard tissue landmarks were shown in
Soft and hard tissue cephalometric landmarks used in the study.
S = sella; A = point A; B = point B; N = nasion; Go = gonion; Me = menton; Po = pogonion; G = glabella; SN = subnasale; Ls = labralesuperius; Li = labraleinferius; Stms = stomionsuperius; Stmi = stomioninferius; Pg’ = soft tissue pogonion; Si = labiomental sulcus; N’ = soft tissue nasion.
Soft and hard tissue measurement: 1 = Nasolabial angle; 2 = Facial angle; 3 = Mentolabial angle; 4 = Convexity angle; 5 = Upper lip protrusion; 6 = Lower lip protrusion; 7 = Upper lip length; 8 = Lower lip length.
The Persian version of the short form (14 itemed) of the Oral Health Impact Profile questionnaire (OHIP-14) [
A short six-item form of the Rustemeyer’s questionnaire [
Rustemeyer's questionnaire about patients' satisfaction after surgery
Questions | |
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1. How would you assess your facial aesthetics before surgery? | 0–1–2–3–4–5–6–7–8–9–10 |
2. How would you assess your facial aesthetics after surgery? | 0–1–2–3–4–5–6–7–8–9–10 |
3. How would you assess your chewing function before surgery? | 0–1–2–3–4–5–6–7–8–9–10 |
4. How would you assess your chewing function today? | 0–1–2–3–4–5–6–7–8–9–10 |
5. How do you feel exactly about the surgical outcome of your operation? | 0–1–2–3–4–5–6–7–8–9–10 |
6. How do your relatives and friends feel in total about the surgical outcome of your operation? | 0–1–2–3–4–5–6–7–8–9–10 |
Patients’ socio-demographic information was obtained when consented to participate. Participants were then guided through the process of the study. They were provided with the researchers’ phone number and were encouraged to ask any question they had at any point until the end of study.
SPSS statistical software (version 18.0) was used for data manipulation. Kolmogorov-Smirnov normality test was used to determine whether the quantitative variables were normally distributed. Paired t-test was used to evaluate the difference of QoL/satisfaction outcomes in sexes and educational level.
Paired t-tests were used to assess changes before and after surgery. Pearson correlation analysis was performed to determine the degree of correlation between QoL and satisfaction scores with chephalometric changes. The reproducibility of the measurements was determined by randomly selecting 15 cephalograms and repeating the tracing by the same examiner, one month after the initial tracing. No significant difference was found when the t-test was performed to evaluate the repeated measurements. The intra examiner correlation (Pearson correlation) of obtained data was 0.82.
The results and data were expressed as means and standard deviations (M [SD]).
The study took three and a half years to complete. Data from 30 class III (22.77 [3.78] years, 11 females and 19 males) and 25 class II malocclusion patients (25.12 [4.47] years, 14 females and 11 males) were used in the final analysis.
No significant relationship was found between OHRQoL with gender (P = 0.743) or educational levels (P = 0.534). Therefore, gender and educational level were not considered further. Patients’ responses to questions which evaluate their information about treatment are shown in
Patients’ information about treatment
Questions | Sufficiently | Reasonably | Far too little |
---|---|---|---|
Were the difference treatment relatives explained to you clearly before surgery? | 52 | 2 | 1 |
Were you given adequate information about different procedure before surgery? | 47 | 5 | 3 |
Did you talk about your expectations and motivation with your surgeon? | 45 | 9 | 1 |
A significant decrease was detected post operatively in the soft tissue parameters: nasolabial angle (P = 0.038), facial angle (P ≤ 0.001), convexity angle (P ≤ 0.001), mentolabial angle (P ≤ 0.001), and lower lip protrusion (P ≤ 0.001); in the hard tissue parameters: SNB (P = 0.002). A significant increase was found in the soft tissue parameters: upper lip protrusion (P ≤ 0.001), upper lip length (P ≤ 0.003); in the hard tissue parameters: Jaraback index (P = 0.028), ANB angle (P ≤ 0.001), SNA angle (P ≤ 0.003) and Wits appraisal (P ≤ 0.001). On the other hand, no significant change was found in lower lip length (P = 0.712) (
Cephalometric changes before and 1.6 (0.7) years after surgery
Parameters | Type of deformity |
Presurgery |
Postsurgery | P value |
---|---|---|---|---|
Median |
Median |
|||
SNA | Cl III | 82.4 (5.14) | 85.18 (3.86) | 0.003a |
Cl II | 83.7 (5.38) | 85.9 (7.88) | 0.008a | |
SNB | Cl III | 84.63 (4.68) | 81.98 (3.64) | 0.002a |
Cl II | 75.4 (5.13) | 81.5 (7.93) | < 0.001b | |
ANB | Cl III | -0.57 (3.7) | 2.47 (2.15) | < 0.001b |
Cl II | 8.3 (4.08) | 4.4 (2.7) | < 0.001b | |
Wits appraisal | Cl III | -7.07 (4.58) | -0.39 (3.06) | < 0.001b |
Cl II | 6.12 (3.84) | 2.88 (2.84) | < 0.001b | |
Jaraback index | Cl III | 61.23 (10.62) | 64.87 (7.99) | 0.028a |
Cl II | 63.36 (8.7) | 62.76 (6.41) | 0.578 | |
Upper lip length | Cl III | 21.95 (3.3) | 23.3 (3.04) | 0.003a |
Cl II | 24.52 (3.56) | 22.58 (3.92) | 0.001a | |
Lower lip length | Cl III | 54.43 (7.03) | 54.03 (5.87) | 0.712 |
Cl II | 48.56 (5.77) | 45.64 (5.17) | 0.004 | |
Nasolabial angle | Cl III | 92.13 (4.45) | 90.07 (5.54) | 0.038a |
Cl II | 110.64 (10.93) | 109.16 (11.44) | 0.559 | |
Facial angle | Cl III | 92.3 (3.4) | 87.27 (3.85) | < 0.001b |
Cl II | 85.56 (6.73) | 90.2 (4.97) | < 0.001b | |
Convexity angle | Cl III | 176.37 (3.79) | 170.5 (3.05) | < 0.001b |
Cl II | 162.08 (5.07) | 167.52 (4.62) | < 0.001b | |
Mentolabial angle | Cl III | 138.26 (13.02) | 120.03 (15.16) | < 0.001b |
Cl II | 117.64 (18.98) | 122.8 (17.19) | < 0.001b | |
Upper lip protrusion | Cl III | 2.45 (1.57) | 4.98 (2.27) | < 0.001b |
Cl II | 7 (2.3) | 5.26 (2.27) | < 0.001b | |
Lower lip protrusion | Cl III | 5.75 (2.42) | 3.87 (2.78) | < 0.001b |
Cl II | 5.12 (2.29) | 3.88 (3.48) | 0.004a |
aStatistically significant (Paired t-test, P < 0.05).
bStatistically highly significant (Paired t-test, P < 0.001).
SD = standard deviation.
A significant increase was shown post operatively in the soft tissue parameters: Facial angle (P ≤ 0.001), convexity angle (P ≤ 0.001), and mentolabial angle (P ≤ 0.001); in the hard tissue parameters: SNB (P ≤ 0.001). A significant decrease was found in the soft tissue parameters: upper lip protrusion (P ≤ 0.001), upper lip length (P ≤ 0.001), lower lip protrusion (P ≤ 0.004), and lower lip length (P ≤ 0.004); in the hard tissue parameters: ANB (P ≤ 0.001), SNA (P = 0.008) and Wits appraisal (P ≤ 0.001). Nevertheless, no significant change was found in Jaraback index (P = 0.578), nasolabial angle (P = 0.559) (
Several cephalometric variables were significantly correlated with OHRQoL and satisfaction levels in class III malocclusion patients. Facial angle, convexity angle, mentolabial angle, nasolabial angle, and upper lip protrusion had the most significant correlations with questionnaires items. Reduction in mentolabial angle, facial angle, and convexity angle was correlated positively with functional limitation (OH-2), psychological discomfort (OH-5; OH-6), psychological disability (OH-9), and handicap (facial angle with OH-13 and OH-14, mentolabial angle just with OH-13, and convexity angle just with OH-14). In contrast, reduction in nasolabial angle and increase in upper lip protrusion were correlated negatively with functional limitation (OH-1), psychological discomfort (OH-5; OH-6), psychological disability (OH-9), and handicap (OH-13, OH-14). The changes in Wits appraisal and ANB angle revealed positive correlation with changes in scores of OH-3 (functional limitation) and OH-4 (physical pain) (
Correlations between changes in cephalometric variables and Oral Health Impact Profile questionnaire (OHIP) items in class III malocclusion patients
Parameters | OH-1 | OH-3 | OH-4 | OH-5 | OH-6 | OH-7 | OH-9 | OH-10 | OH-11 | OH-12 | OH-13 | OH-14 |
---|---|---|---|---|---|---|---|---|---|---|---|---|
SNA | n.s | 0.442a | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
SNB | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
ANB | n.s | 0.475a | n.s | n.s | n.s | n.s | n.s | -0.429a | -0.465b | n.s | n.s | n.s |
Wits appraisal | n.s | 0.51a | -0.537b | n.s | n.s | -0.403a | n.s | n.s | -0.503b | n.s | n.s | n.s |
Upper lip length | n.s | n.s | n.s | n.s | 0.364a | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Lower lip length | n.s | n.s | 0.372a | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Nasolabial angle | -0.417a | n.s | n.s | -0.43a | -0.472a | n.s | -0.412a | n.s | n.s | n.s | n.s | n.s |
Facial angle | 0.556b | n.s | n.s | 0.599b | 0.499b | n.s | 0.517b | n.s | n.s | 0.489b | 0.545b | 0.424a |
Convexity angle | 0.464b | n.s | n.s | 0.499b | 0.425a | n.s | 0.381a | n.s | n.s | n.s | n.s | 0.37a |
Mentolabial angle | 0.447a | n.s | n.s | 0.5b | 0.429a | n.s | 0.541a | n.s | n.s | n.s | 0.382a | n.s |
Upper lip protrusion | -0.529b | n.s | n.s | -0.656b | -0.567b | n.s | -0.44a | n.s | n.s | n.s | -0.535b | -0.433a |
Lower lip protrusion | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Jaraback index | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
aStatistically significant (Pearson correlations, P < 0.05).
bStatistically highly significant (Pearson correlations, P < 0.001).
n.s = Statistically non significant (Pearson correlations, P > 0.05).
Also, upper lip protrusion, facial angle, mentolabial angle, and nasolabial angle was significantly correlated with overall satisfaction (Q5) (
In class II malocclusion patients, convexity angle, facial angle, lower lip protrusion, and mentolabial angle were correlated negatively with the changes in OHIP-14 scores involving psychological discomfort (OH-5), physical disability (OH-7), psychological disability (OH-9), and handicaps (OH-13; OH-14). The changes in Wits appraisal revealed positive correlation with OH-3 (functional limitation) (
Correlations between cephalometricchanges and Oral Health Impact Profile questionnaire (OHIP) items in class II malocclusion patients
Parameters | OH-3 | OH-4 | OH-5 | OH-6 | OH-7 | OH-9 | OH-10 | OH-11 | OH-13 | OH-14 |
---|---|---|---|---|---|---|---|---|---|---|
SNA | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
SNB | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
ANB | n.s | n.s | n.s | n.s | 0.488a | n.s | 0.67b | 0.678b | n.s | n.s |
Wits appraisal | -0.517b | n.s | 0.417a | n.s | 0.636b | n.s | n.s | n.s | 0.539b | n.s |
Upper lip length | n.s | n.s | n.s | n.s | n.s | n.s | -0.438a | -0.4a | n.s | n.s |
Lower lip length | n.s | n.s | n.s | n.s | n.s | n.s | -0.456a | -0.407a | n.s | n.s |
Nasolabial angle | n.s | -0.429a | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Facial angle | n.s | n.s | -0.453a | -0.446a | n.s | n.s | n.s | n.s | -0.508a | -0.415a |
Convexity angle | n.s | n.s | -0.578b | n.s | 0a | -0.599b | -0.461a | -0.45a | -0.678b | -0.581b |
Mentolabial angle | n.s | n.s | -0.448a | -0.479a | -0.507b | -0.531b | n.s | n.s | -0.695b | -0.574b |
Upper lip protrusion | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Lower lip protrusion | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | 0.645b | 0.525b |
Jaraback index | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
aStatistically significant (Pearson correlations, P < 0.05).
bStatistically highly significant (Pearson correlations, P < 0.001).
n.s = Statistically non significant (Pearson correlations, P > 0.05).
Correlations between cephalometric changes and satisfaction questions in class III and II malocclusion patients
Parameters | Class III |
Class II | ||||||
---|---|---|---|---|---|---|---|---|
Q 2-1a | Q 4-3a | Q5 | Q6 | Q 2-1 | Q 4-3 | Q5 | Q6 | |
SNA | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
SNB | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
ANB | n.s | n.s | n.s | n.s | n.s | n.s | -0.58b | |
Wits appraisal | n.s | n.s | n.s | 0.458a | -0.445a | -0.449a | -0.49a | -0.668b |
Upper lip length | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Lower lip length | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
Nasolabial angle | n.s | n.s | 0.398a | n.s | n.s | n.s | n.s | n.s |
Facial angle | n.s | -0.431a | -0.697b | n.s | 0.563b | 0.604b | 0.928b | n.s |
Convexity angle | n.s | n.s | n.s | n.s | 0.478a | 0.498a | 0.846b | n.s |
Mentolabial angle | n.s | n.s | -0.426a | n.s | 0.521b | 0.559b | 0.844b | n.s |
Upper lip protrusion | n.s | n.s | 0.488b | n.s | n.s | n.s | n.s | n.s |
Lower lip protrusion | n.s | n.s | n.s | n.s | 0.498b | 0.551b | n.s | n.s |
Jaraback index | n.s | n.s | n.s | n.s | n.s | n.s | n.s | n.s |
aStatistically significant (Pearson correlations, P < 0.05).
bStatistically highly significant (Pearson correlations, P < 0.001).
n.s = Statistically non significant (Pearson correlations, P > 0.05); Q 2-1 = difference between Q2 and Q1; Q 4-3 = difference between Q4 and Q3.
Patient centred evaluation has been valuable in defining patients’ perception and expectation of treatment. It can provide an overall picture of patients’ expectation which determine treatment effectiveness [
Facial disproportionate, in contrast with facial conformity (symmetry), is unattractive, and unacceptable [
Differences between predicted and postsurgical outcomes could be measured with a range of 1 - 2° for SNA, SNB, and ArGoMe in cases of bimaxillary osteotomy, cephalometric prediction remains an accurate tool for treatment planning [
Various factors may affect postsurgical satisfaction in a positive direction [
In the present study, patients with postoperative infections, mal-union with poor occlusions and nerve injury were excluded. It has been shown that patients who experienced unexpected problems such as of postoperative infections, mal-union with poor occlusions and nerve injury following surgery were more likely to be dissatisfied with the treatment [
No significant differences was observed in the result obtained from all approaches between two genders, this finding is consistent with those studies which did not find any association between gender and QoL outcomes [
As in many studies in this field, we observed significant changes in the hard and soft tissue parameters after orthodontic surgical treatment. However, lower lip length in class III and nasolabial angle and Jaraback index in class II malocclusion showed no significant changes after surgery. Chew et al. [
Findings from this study showed that some objective changes of cephalometric variable are effective in improving the patients’ QoL and satisfaction. Correction of sagittal aspect of deformity by improving facial angle and convexity angle compared with Jaraback index which used to determine changes in vertical aspect of deformity, played an important role in increasing QoL and patients’ satisfaction in both groups. This is in great agreement with other studies which have shown that the most important affecting factor on facial attractiveness is the anteroposterior dimension [
A number of studies have shown that increase in lower facial height is more acceptable while other studies claim the opposite [
As reported by Rustemeyer et al. [
Present study showed that increasing the upper lip prominence had significant impact on QoL of class III malocclusion patients. Also, changes in lower lip prominence, in class II malocclusion patients, was significantly correlated with patients’ satisfaction and QoL. Chew et al. [
As a good increase in the QoL is expected from orthognathic surgeries [
In class III malocclusion patients, changes in mentolabial angle, convexity angle, facial angle, and upper lip protrusion were significantly correlated with improvements in patient’ satisfaction and QoL.
In class II malocclusion patients, changes in facial angle, convexity angle, lower lip protrusion, and mentolabial angle were significantly correlated with improvements in patient’ satisfaction and QoL.
Although some variables had significant correlation with patients’ satisfaction and quality of life, it seemed that the associations were moderate.
It is undeniable that considering the subjective and objective parameters during preparing the patients to their new appearance are necessary.
The authors report no conflicts of interest related to this study.