Orthognathic Surgery

Asuman H. Kiyak MA, PhD

Orthognathic surgery, also known as surgical orthodontic treatment, is designed to correct skeletal discrepancies in the orofacial region that orthodontics alone cannot modify. Although this procedure is intended primarily to improve severe dentofacial malrelations and their impact on mastication, speech, and mouth opening, most patients who seek orthognathic surgery do so in order to improve their dental and facial appearance. Indeed, the dramatic changes in appearance have significant preoperative and postoperative implications worthy of discussion.

The majority of patients in Western countries undergo orthognathic surgery for mandibular retrognathia (sometimes including a genioplasty), followed by bimaxillary procedures to correct maxillary prognathia. However, other skeletal problems are also treated through a combination of facial surgery and orthodontics. Occlusal function is less of an incentive than aesthetics for patients who are referred for this type of surgery than for the orthodontists and surgeons who treat them. Unlike most plastic surgical procedures, the surgical component is just one part in the sequence of treatment; the orthodontic phase of treatment can take up to 2 years presurgery and postsurgery. Therefore, patients’ psychological responses to their posttreatment changes in appearance and function evolve over significant periods of time.

This chapter begins by reviewing the influence of dental malocclusion on judgments of physical attractiveness and the role of body image and subjective wellbeing in understanding patient motivations for orthognathic procedures. Subsequently, the psychological benefits of orthognathic surgery, as well as the potential adverse effects of surgical procedures on physical and psychological functioning, are discussed. Specific clinical management recommendations are provided, including the use of a brief questionnaire to assess treatment expectations of patients and their significant other.

MALOCCLUSION AND JUDGMENTS OF ATTRACTIVENESS

The face is one of the areas of the body that produces the greatest concern among most people regarding their physical attractiveness. During social interaction, it is the individual’s focal point and the source of vocal and emotional communication. In one of the first large-scale surveys of body image and its association with specific body parts, Berscheid et al. (1) found that people who were satisfied with their facial features expressed greater self-confidence overall. Perhaps the most extreme examples of this are children with cleft lip and palate, who have been found to demonstrate lower self-concept and introversion than children without this condition (2, 3). (This research is reviewed in detail in Chapter 5.) Even in less severe conditions, such as malocclusion, persons are rated as less attractive than those with normal occlusion. Such ratings are often associated with negative judgments regarding the
intelligence level of these individuals, as well as their social desirability (4, 5). Helm et al. (4) found that self-ratings were particularly negative among young adults with extreme overjet (i.e., upper front teeth protruding outward), deep bite (upper teeth covering most of the lower teeth), or crowding.

Gender differences also have been found; in most cases body image is lower among women with malocclusion than among men (4,6, 7, 8). Women score lower on self-evaluations of body image, particularly on items describing the face. However, men who undergo orthognathic surgery often report lower facial body image satisfaction than women within the first few months after surgery; it appears that it takes longer for men to adapt to changes in their physical appearance.

Body Image, Self-esteem, and Psychological Well-being

The two psychological variables explored most often among those with malocclusion are body image and self-esteem. When compared to the general population that has not been referred for orthodontic or surgical correction of a dentofacial disharmony, preoperative patients report significantly lower overall body image, as well as heightened dissatisfaction with their facial appearance (9, 10). Differences are particularly striking between females in the pretreatment and no treatment groups. Members of minority groups who seek surgical orthodontic treatment generally report a more positive body image than their Caucasian counterparts; the most favorable scores were reported by Black respondents in a study of patients and age-matched nonpatients in London (10).

It is instructive to compare people with similar levels of malocclusion who do and do not seek treatment (orthodontics only or combined orthodontic and surgical procedures). An individual who is objectively judged to have a dentofacial skeletal discrepancy severe enough to recommend surgical intervention may not seek treatment because of higher levels of body image satisfaction and self-esteem. Such psychological strengths may serve as a protective barrier against external pressure to undergo treatment. In some cases, they may undergo orthodontics alone, recognizing that it will not correct the skeletal problem (11, 12). In contrast, those who undergo orthognathic surgery have been found to score lower on measures of body image, but this is focused primarily on their facial appearance and profile (7, 8). This finding is consistent with studies of body image concerns among cosmetic surgery patients. As reviewed in Chapter 15, women undergoing breast augmentation surgery report greater dissatisfaction with their breasts than physically similar women who are not interested in surgery.

At least one study has found differences in body image as a function of the specific type of dentofacial or skeletal discrepancy. Among patients in the Netherlands, Hakman (13) found greater dissatisfaction with facial features in individuals with mandibular retrognathia than in those with a prognathic mandible. Patients who presented with an increased lower anterior face height (“long face”), with lip incompetence and exposed maxillary incisors, reported more teasing by their peers and lower body image. Surgical treatment of patients with anterior open bite may reduce their lower facial height, and indirectly improve their satisfaction with their facial appearance (13, 14).

The combined orthodontic-surgical procedure results in improvements in facial appearance, more than the changes observed for patients who elect orthodontics only, despite the benefits of surgical orthodontics for their condition. Since the early work of Kiyak et al. (7,15, 16), who expanded the Secord and Jourard Body Cathexis Scale (17) to include more items describing the face, orthodontic researchers have utilized this measure to assess body image. When the items are classified as facial, profile, and general body image, facial and profile image scores show significant improvement after both surgery and orthodontics have been completed. In one study, pretreatment patients were compared with patients who had completed treatment 9 to 12 years earlier, and with a control group who did not need any
orthodontic treatment. Facial profile and facial body image were lowest among the pretreatment group, higher in the posttreatment, and highest in the nonpatient control group (8). Overall body image satisfaction has been shown to remain relatively high in these studies and does not show significant changes following surgery (7, 8,18, 19). It is noteworthy that improvements in body image typically do not emerge fully until postsurgical orthodontics is completed. That is, surgery alone is insufficient to change patients’ facial and profile images.

Despite earlier studies that demonstrated significantly lower levels of self-esteem among people with severe malocclusion, subsequent research has generally found scores in the normal range on measures of self-esteem (20, 21). Using various measures, researchers have found few or no differences between patients and control groups not seeking orthognathic surgery, or between preoperative and postoperative patients (9,22). Even when changes are observed in the same patient population over time, improvements in self-esteem are modest and not clinically significant (23, 24, 25). Although surgical orthodontics does not dramatically improve the individual’s self-esteem, this variable may be a significant predictor of postoperative outcomes. Van Steenbergen et al. (26) tested whether postoperative satisfaction with facial appearance could be predicted by self-esteem, psychological distress, demographic variables, or orthodontists’ ratings of the patient’s lateral and frontal facial disharmony. Although all these variables showed significant correlations with satisfaction in the bivariate analyses, the only significant predictor of patients’ postoperative satisfaction with their appearance was self-esteem scores, accounting for 15% of the variance in this outcome. Those who had high self-esteem before undergoing treatment demonstrated the highest satisfaction with their facial appearance following their combined surgical and orthodontic procedures.

A sizable minority of orthognathic surgery patients may experience psychological distress. In particular, young adults anticipating treatment were found to experience slightly higher levels of distress than a group of age-matched nonpatient controls, as observed on three of the ten dimensions of the Symptom Checklist (SCL-90-R), a widely used measure of psychological symptomotology (27). The scales on which pretreatment patients scored worse than nonpatients were interpersonal sensitivity, obsessive-compulsiveness, and psychoticism. A mild elevation of distress was found for 15% to 25% of patients on these dimensions in a study of 194 adults seeking surgical orthodontic treatment in a university medical center (21). These researchers found that almost 19% of patients had an elevated Global Severity Index (GSI) score, and almost 25% met the criteria for a psychiatric diagnosis. In addition, men seeking orthognathic surgery scored higher than population norms on the phobic anxiety dimension of the SCL-90-R; women scored higher on the paranoid ideation dimension.

The authors caution clinicians that these symptoms should not disqualify a potential patient from undergoing surgical orthodontic treatment. Underscoring the recommendations of Pogrel and Scott (28), they suggest that patients with excessive symptoms and inadequate support systems should be referred for counseling between the time they initiate orthodontics and before undergoing surgery. This was subsequently echoed by Phillips et al. (29), in which a computerized treatment planning simulation was found to create more discomfort in patients with elevated scores on the SCL-90-R measure of generalized psychological distress. To date, no studies have investigated the rate of formal psychopathology, such as mood or anxiety disorders, among these patients.

MOTIVES FOR SURGICAL ORTHODONTICS

Despite gender differences in attention to and dissatisfaction with body image as a result of severe malocclusion, both men and women report that improved aesthetics is a major reason for seeking treatment. Some researchers have used an open-ended technique, asking patients to describe their primary motives for surgery. Not
surprisingly, 76% to 89% of patients reported that improved appearance was a central motivation (30, 31). Improved aesthetics and self-concept were more commonly expressed as motives, as compared to functional changes, in a sample of patients undergoing treatment at a university medical center (32). At least one study, however, has suggested that, for some patients, appearance concerns may not be the primary motivation for surgery. In a retrospective examination of patients who had undergone orthognathic surgery to correct an open bite, Hoppenreijs et al. (14) asked patients to list their reasons for seeking treatment. They found that the most commonly recalled motive was a desire to improve biting and chewing (61%), followed by concerns with facial appearance (47%), and temporomandibular dysfunction (TMD, 36%). The retrospective nature of this study, where patients were able to truly appreciate the postoperative improvements in biting and chewing, may account for this finding. It may also be that patients who are asked to list their motives in an open-ended manner feel compelled to give more practical motives for treatment.

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