Introduction
Many studies have found lower oral health-related quality of life (OHRQoL) in patients with dentofacial deformities [
1‐
7]. Patients with dentofacial deformities are characterized by various irregularities of the face and dental bone structures, such as hyperplasia, hypoplasia, and asymmetries of the maxilla, mandible, or chin. An abnormal position of the jaws can manifest in the dentition as a class II or III malocclusion and cause esthetic and functional problems, including difficulty chewing, sleeping, breathing, speaking, or overall oral health problems [
8]. Some patients experience psychological and emotional problems [
9].
Orthognathic surgery is a common treatment for dentofacial deformities. The procedure involves repositioning of the maxilla, mandible, or both, sometimes in combination with correction of the chin. The functional and esthetic goals are to achieve a class I dental occlusion and facial balance and proportion. Traditionally, orthognathic surgery involves preoperative and postoperative orthodontics to achieve dentofacial correction by aligning the dental arches. The main surgical techniques are Le Fort I osteotomy, bilateral sagittal split osteotomy (BSSO), and bimaxillary osteotomy (BIMAX), which are sometimes combined with an osseous genioplasty.
Patients seek orthognathic surgery for various reasons. Their primary motivations are esthetic concerns and improved QoL [
10,
11]. Some studies have found that oral function, including bite, pain, smile, and speech, is a primary motivation [
12‐
14]. A recent systematic review showed physiological and psychological improvement in QoL following orthognathic surgery [
15]. A study with a 5-year follow-up found significant improvement and stabilization after 2–5 years in regard to the general health-related QoL, OHRQoL, and psychosocial function after BSSO [
16].
The Oral Health Impact Profile (OHIP-14) is a standardized questionnaire that measures the OHRQoL. The questionnaire is a short version of the OHIP-49 that includes 14 questions representing 7 domains [
17,
18]. The Dutch version of the questionnaire, OHIP-14NL, was reported in 2011 to be a reliable and valid questionnaire for measuring the impact of oral health on QoL [
19]. Other validated questionnaires commonly used in orthognathic studies are the Orthognathic Quality of Life Questionnaire (OQLQ) and the Short Form Health Survey (SF-36) [
15].
It is important to provide patients with realistic and accurate information prior to the start of orthognathic treatment. The temporary discomfort in the initial postoperative period, such as problems related to oral function, pain, numbness of the lower lip and chin, and postoperative bleeding and swelling, should be explained to patients prior to the treatment, and they should also be given a realistic idea of the final facial appearance [
20‐
22]. This knowledge would lead to greater satisfaction after surgery [
12,
23,
24].
The aim of this study was to evaluate the impact of orthognathic surgery on the QoL of patients with various dentofacial deformities in the immediate postoperative period and during at least 1 year of follow-up using the OHIP-14 questionnaire. The hypothesis is that the QoL of patients with different dentofacial deformities improves with orthognathic surgery. This knowledge would be useful in improving preoperative, perioperative, and postoperative care and could lead to greater satisfaction for patients.
Discussion
The aim of this study was to investigate the impact of orthognathic surgery on OHRQoL in the immediate postoperative period until at least 1 year, as measured by the OHIP-14NL questionnaire. The OQLQ is another commonly used questionnaire in orthognathic studies. A comparison of the OQLQ with the OHIP-14NL has shown that both tools are able to discriminate differences in QoL over time and between patient groups. The OQLQ is more specific for orthognathic surgery [
25]. The English version of the OQLQ was developed in 2000 and validated in 2002 [
6,
25‐
27]. However, the current study did not use the OQLQ because the Dutch version has not yet been validated. The SF-36 is also used in some orthognathic studies, but it focuses more on one’s physical and mental status [
25]. The SF-36 was not used in this study because this questionnaire is not restricted to the orofacial area.
Previous studies have reported a lower QoL in patients with dental facial deformities compared to a control group [
28‐
30]. The present study did not have a control group. The preoperative OHIP score in this study was higher than the OHIP scores of control groups in other studies. Thus, in general, one can conclude that the OHRQoL of persons with dentofacial deformities is worse overall than in patients without a dentofacial deformity.
The current study found significant deterioration of the OHRQoL 1 day after surgery compared to baseline. However, the OHRQoL improved significantly in the first week. The OHRQoL was still significantly lower after 4 weeks but after 6 months had improved. Comparable results after orthognathic surgery have been reported in other studies [
8,
27‐
33]. Deterioration in the immediate postoperative period has also been described in patients who suffer from pain, swelling, limited mouth opening, reduced masticatory efficiency, and numbness of the lower lip [
28,
34,
35]. The answers to the additional questions in our study indicate that a high proportion of patients experience discomfort and need more self-care in the immediate postoperative period. This study also found a significant positive correlation between duration of surgery and OHIP score for the first 7 days after surgery. There was no significant correlation between OHIP score and age or gender.
Some studies have described female patients experiencing better improvement in self-esteem and a greater reduction in depression after orthognathic surgery compared to male patients [
3,
28,
29]. Corso et al. found, in both the dentofacial deformities group and control group, a lower perception of QoL by women compared to men [
28]. However, some studies did not find a difference in OHIP score between men and women [
31,
32,
34]. The present study also found no difference in OHIP score between men and women.
This study found no difference in regard to the type of surgery. However, some investigators have found better improvement in patients who underwent BIMAX compared to single jaw surgery (Le Fort I or BSSO) [
29]. Another study evaluated whether a combination of BIMAX and genioplasty for females with prognathism and maxillary hypoplasia has a greater positive impact on QoL than BIMAX alone; genioplasty led to significantly greater QoL after surgery [
36].
The current study did not find a significant difference between indications for surgery. Some other studies also found no significant association between the indication for surgery and OHIP-14 scores [
28,
34]. However, other studies have found that skeletal class III patients had more positive effects form surgery than class I and class II patients [
29,
32]. Baherimoghaddam et al. found an improvement in both class II and class III patients, but the pattern of change was different; class II patients experience deterioration in QoL during the preoperative stage and improvement in function rather late in the postoperative stage [
8]. Class III patients exhibited more significant changes in the domains concerning appearance and psychological issues.
Another finding in this study was that the OHIP score for every question was significantly lower at least 1 year after the operation compared to baseline, except for question 14, which refers to total oral dysfunction. The fact that the OHIP score for question 14 was only 0.4 at baseline indicates that people with various dentofacial deformities do not or hardly suffer from total oral dysfunction. This could explain why no improvement was noted after 1 year. The patients recruited for this study may have more problems with their facial appearance psychologically than with function.
The pain score significantly decreased after day 5 and was very low after 4 weeks. In the first week, a high percentage of patients said that they had taken painkillers. This could influence the perceived pain, so the actual pain score may have been higher. There was a significant positive correlation between pain scores and OHIP scores for every time point except 6 months, but no association was found between pain and age, gender, blood loss, time of surgery, indication for surgery, or type of surgery.
A major limitation of this study is that only 22 of the 85 patients completed all the questionnaires. A paper version of the questionnaires was used only in the first 6 months of this study. After that, the questionnaire was sent by email; patients may have perceived the questionnaires received by email as less important, despite the reminders that were sent. Consequently, the number of patients was too low for all 11 time points (T0–T10). Therefore, we applied the Friedman test for only the first 7 days after surgery and separately tested the later time points using the Wilcoxon signed rank test.
In this study, some patients mentioned numbness of the lower lip in the comments to the questionnaire, though numbness of the lower lip after surgery was not specifically requested. There may have been more patients who suffered from this complication. Damage of the inferior alveolar nerve is a common postoperative complication [
34‐
36]. There is broad variation in the incidence of inferior alveolar nerve injury [
37,
38], which could influence patient satisfaction [
39]. However, some studies that report a high incidence of lip paresthesia in patients following orthognathic surgery have shown no effect on patient satisfaction [
9,
40,
41]. Most patients, especially in the younger age group, seem to adapt to this complication [
40].
Another limitation of this study was that the first questionnaire was completed before surgery, but this was not the baseline for orthodontic treatment. Patients already had orthodontic braces for a few months, which can influence the OHRQoL when they filled out the first questionnaire. Huang et al. compared surgery-first and orthodontic-first treatments. The orthodontic-first group experienced deterioration before surgery and suggested that pre-orthodontics could worsen the facial deformity [
42]. Therefore, our last evaluation was 1–3 years after surgery. Not every patient had finished the orthodontic treatment. Choi et al. suggested that the best time for evaluating OHRQoL is 1 year after debonding [
34].
Notably, we did not take into account a possible second operation that may have been required as a follow-up of the first surgery due to complications or a relapse. A second surgery could result in more discomfort and lower OHRQoL, influencing the answers to the questionnaire.
Another point that could influence the answers is that the consultation and surgeries were done by different oral maxillofacial surgeons of the Amsterdam UMC. This creates variation in preoperative preparations, provided information, manner of operation, and postoperative support.
Further long-term clinical studies should investigate the impact of orthognathic surgery on psychological well-being and OHRQoL in patients. This could lead to better preoperative and postoperative guidance for patients who undergo orthognathic surgery.
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