J. Cranio-Max.-Fac. Surg. i8 (1990) J. Cranio-Max.-Fac.Surg. 18 (1990) 339-342 © GeorgThiemeVerlagStuttgart • New York
The Specific Psychosocial Effects of Orthognathic Surgery Barry B. J. Lovius i, R. Barrie Jones e, Oldrich A. Pospisil s, Danny Reid 4, Peter D. Slade 4, Thomas H. M. Wynne s Departmentof Orthodontics(Head:Mr. B, B.J. LoviusM.D.S.,F.D.S., D. Orth.) Departmentof ClinicalDentalSciences,Universityof Liverpool 2Departmentof Psychology,SouthSeftonHealthAuthority 3ConsultantMaxillofacialSurgeon,WaltonHospital,Liverpool 4Departmentof ClinicalPsychology(Head: ProfessorP. D. Slade,B.A., M. Phil PhD., F.B.Ps.S.)Universityof Liverpool sConsultantOrthodontist,LiverpoolDentalHospital Submitted 4.4. 1990; accepted 26. 6. 1990
339
Summary This study was to test the validity of patients' opinions and provide a more accurate method than previously reported of assessing the specific psycho-social effects of orthognathic surgery. Questionnaires were used preoperatively and postoperatively providing a longitudinal sample, while those patients who only completed questionnaires either before or after surgery provided cross-sectional samples. Different questionnaires were used to provide data on a 'Body Satisfaction Scale', 'Fear of Negative Evaluation', 'Social Avoidance and Distress', and a 'General Health Questionnaire'. The results indicate that surgery produced an improvement in body image, particularly in the evaluation of facial attractiveness.
Key words Orthognathic Psychology
Introduction
Method
Among the general population there exist individuals whose facial morphology differs from the norm to such an extent that they seek treatment in order to make themselves more acceptable to others. There are also those who have malocclusions, which cannot be satisfactorily treated by orthodontic means alone. Both these groups of patients can be helped with orthognathic surgery, which frequently needs orthodontic treatment prior to surgery in order to move the teeth into optimal position so that at surgery the best possible result can be achieved. Following surgery, orthodontic treatment also is often required to improve final tooth position. There has been an increased awareness of the psychological implications of orthognatbic surgery. Crowell et al. (1970) reported on patients' attitudes following surgery. He used a questionnaire based on one that Hutton had developed for a study reported in 1967. The questionnaires were based on the patients' own evaluations, and comprised 16 questions, with little attempt to look at psychosocial attitudes except by using leading questions such as, question three, 'Are you pleased with the results of the surgery?' Hillerstrom et al. (1970), wrote a paper on the psychosocial factors in patients with malformations of the jaws and later Oullette (1978), on the psychological ramifications of facial change in relation to orthodontic treatment and orthognathic surgery. More recently Kiyak et al. (1982, 1985, 1986, 1988) investigated in detail some psychological effects of orthognathic surgery and reported on body image perception, personality characteristics and other psychological attributes. The majority of studies apart from those by Kiyak et al. were carried out following surgery and there appeared a need for further work in this field in order to examine patients' attitudes both prior to and following surgery, to provide a method of assessing the specific psychosocial effects of orthognathic surgery.
Procedure
surgery -
Psycho-social effects
At a combined clinic run by orthodontists and a maxillofacial surgeon, patients were seen if it was felt by either of the orthodontists or the maxillofacial surgeon, that orthognathic surgery would be needed in order to correct the malocclusion or to treat the facial disharmony by surgical means. If it was decided that surgery was indicated, then the patients were asked as part of their initial evaluation, to complete some questionnaires, the contents of which would be kept completely confidential. Thus some of the patients were brought to the clinic by the orthodontists and some by the maxillofacial surgeon. These were not segregated into two groups. In planning the patients' treatment, in most cases it was found that orthodontic treatment was initially needed to align the teeth and to correlate the arch dimensions, prior to surgical intervention. The questionnaires were usually completed on the initial visit to the combined clinic. When they were not completed on the initial visit, they were completed on one of the later visits, prior to surgery. Thus the period prior to surgery was variable and never less than three months, but possibly up to one year. Patients also completed the questionnaires following surgery, so that 'before' and 'after' assessments were obtained. A number of patients completed questionnaires only after surgery. The post-surgery assessments were carried out when patients attended for follow-up appointments and the majority completed the questionnaires in the three to six months period following surgery. It was again carefully explained to the patients that the questionnaires would be examined anonymously so that their personal details would not be revealed. The patients were usually able to complete the questionnaires in about 20 minutes. In a few cases, where there were difficulties concerned with catching trains etc., to return home, the questionnaires were given to the patients who posted them back.
340
J. Cranio-Max.-Fac.Surg. 18 (1990)
B.B.J. Lovius et al. Each of the sixteen body parts has to be rated according to degree of satisfaction/dissatisfaction felt with that part. A seven point scale is used in which 1 represents 'very satisfied' and 7 represents 'very dissatisfied'. Thus low scores indicate satisfaction with the body parts and high scores indicate dissatisfaction. In addition to an overall body satisfaction score derived from the ratings of all sixteen body parts, separate scores for head parts and body parts can be derived. For this study a score for 'teeth' and 'jaw' parts was also calculated, taking the average of both scores.
Thus a number of patients in the study had only completed questionnaires prior to surgery and a number only following surgery, providing cross-sectional groups. In addition, there was a longitudinal group who had completed questionnaires both prior to and following surgery.
Subjects Questionnaires were completed by patients who formed two kinds of sample: a) a longitudinal/prospective sample which comprised 41 patients who were assessed both before and after surgery, and b) cross-sectional samples who completed the questionnaires at only one point in time, namely either before surgery (N = 54) or after surgery (N = 58). The longitudinal sample consists of 6 male and 35 female subjects with an average age of 20.6 (SD 5.2). In the crosssectional samples, the sex distribution of those assessed preoperatively was 25 male and 29 female with an average age of 22.0 (SD 5.6), while the sex distribution of those assessed postoperatively was 25 male and 37 female subjects with an average age of 22.6 (SD 8.7). Patients who had congenital abnormalities such as clefts of the lip and palate, or other congenital deformities requiring surgery, were excluded from the study,
Assessments Assessment instruments were selected to test whether psychological effects would be confined to improvements in body image, particularly involving facial appearance, or whether there would be more general psychological changes. As well as a test of satisfaction/dissatisfaction with body image, three further questionnaires were administered. One was included to detect the presence of general psychological disturbance and the others to assess aspects of social anxiety which it was hypothesised may well be a consequence of facial malformation. The following assessments were given to the participating subjects:
ii) Social Avoidance and Distress (SAD) and Fear of Negative Evaluation (FNE) Scales (Watson and Friend 1969) SAD and FNE scales were developed to provide measures of social anxiety. They have been used widely in studies of social anxiety and have been shown to be sensitive to emotional distress (Turner et al., 1987). The SAD scale contains items concerned with subjective distress, feeling ill at ease socially and the tendency to avoid social situations. The FNE scale was designed to assess apprehension about others' evaluations, distress caused by their negative evaluations, avoidance of evaluation and the expectation of being evaluated negatively. iii) General Health Questionnaire (GHQ) (Goldberg 1978) The GHQ is a self-administered screening test aimed at detecting psychological disturbance amongst respondents in such settings as primary care or general medical outpatients. The 28-item version was used which yields an overall score together with scores on four sub-scales representing somatic symptoms, anxiety and insomnia, social dysfunction and severe depression.
Results The results obtained using each of the above questionnaires will be considered in turn for both the longitudinal and cross-sectional samples.
i) Body Satisfaction Scale (Slade et al., 1990) This is a simple rating scale designed to assess satisfaction/dissatisfaction with sixteen body parts, ranging from head to feet. It can be completed quickly and has been demonstrated to have both acceptable internal consistency and to correlate positively with the Body Shape Questionnaire (Cooper et al., 1987).
Table 1
i) Body Satisfaction Scale The findings from this questionnaire are presented in Table 1. Taking the longitudinal sample first it can be seen that this group reports a significant change in the direction of greater satisfaction following surgery on the three out of the four indices. These were the 'general', 'head' parts and 'teeth and jaw' measures. There was no significant change on the 'body parts' measure. This sug-
Means and standard deviations for Body Satisfaction Scale.
General dissatisfaction Dissatisfaction 'Body' parts Dissatisfaction 'Head' parts Dissatisfaction 'Teeth' & 'Jaw'
Longitudinal Sample (N=40) Pre-treat Post-treat
t
Cross-sectional Sample (N pre=52; N post=58) Pre-treat Post-treat t
41.3 (10.8) 14.0 (5.9)
31.2 (11.9) 13.9 (5.8)
4.99* 1.15
43.1 (13.5) 14.7 (7.3)
31.2 (11.5) 14.2 (6.5)
4.90* 0,39
24.6 (7.6)
14,4 (7.8)
6.7*
26.0 (8.1)
14,9 (8.3)
7,10"
5.4 (2.3)
1.9 (1.7)
9.66*
5,4 (1.6)
2.2 (1.7)
10.4"
*p
The Specific Psychosocial Effects of Orthognathic Surgery Barry B. J. Lovius i, R. Barrie Jones e, Oldrich A. Pospisil s, Danny Reid 4, Peter D. Slade 4, Thomas H. M. Wynne s Departmentof Orthodontics(Head:Mr. B, B.J. LoviusM.D.S.,F.D.S., D. Orth.) Departmentof ClinicalDentalSciences,Universityof Liverpool 2Departmentof Psychology,SouthSeftonHealthAuthority 3ConsultantMaxillofacialSurgeon,WaltonHospital,Liverpool 4Departmentof ClinicalPsychology(Head: ProfessorP. D. Slade,B.A., M. Phil PhD., F.B.Ps.S.)Universityof Liverpool sConsultantOrthodontist,LiverpoolDentalHospital Submitted 4.4. 1990; accepted 26. 6. 1990
339
Summary This study was to test the validity of patients' opinions and provide a more accurate method than previously reported of assessing the specific psycho-social effects of orthognathic surgery. Questionnaires were used preoperatively and postoperatively providing a longitudinal sample, while those patients who only completed questionnaires either before or after surgery provided cross-sectional samples. Different questionnaires were used to provide data on a 'Body Satisfaction Scale', 'Fear of Negative Evaluation', 'Social Avoidance and Distress', and a 'General Health Questionnaire'. The results indicate that surgery produced an improvement in body image, particularly in the evaluation of facial attractiveness.
Key words Orthognathic Psychology
Introduction
Method
Among the general population there exist individuals whose facial morphology differs from the norm to such an extent that they seek treatment in order to make themselves more acceptable to others. There are also those who have malocclusions, which cannot be satisfactorily treated by orthodontic means alone. Both these groups of patients can be helped with orthognathic surgery, which frequently needs orthodontic treatment prior to surgery in order to move the teeth into optimal position so that at surgery the best possible result can be achieved. Following surgery, orthodontic treatment also is often required to improve final tooth position. There has been an increased awareness of the psychological implications of orthognatbic surgery. Crowell et al. (1970) reported on patients' attitudes following surgery. He used a questionnaire based on one that Hutton had developed for a study reported in 1967. The questionnaires were based on the patients' own evaluations, and comprised 16 questions, with little attempt to look at psychosocial attitudes except by using leading questions such as, question three, 'Are you pleased with the results of the surgery?' Hillerstrom et al. (1970), wrote a paper on the psychosocial factors in patients with malformations of the jaws and later Oullette (1978), on the psychological ramifications of facial change in relation to orthodontic treatment and orthognathic surgery. More recently Kiyak et al. (1982, 1985, 1986, 1988) investigated in detail some psychological effects of orthognathic surgery and reported on body image perception, personality characteristics and other psychological attributes. The majority of studies apart from those by Kiyak et al. were carried out following surgery and there appeared a need for further work in this field in order to examine patients' attitudes both prior to and following surgery, to provide a method of assessing the specific psychosocial effects of orthognathic surgery.
Procedure
surgery -
Psycho-social effects
At a combined clinic run by orthodontists and a maxillofacial surgeon, patients were seen if it was felt by either of the orthodontists or the maxillofacial surgeon, that orthognathic surgery would be needed in order to correct the malocclusion or to treat the facial disharmony by surgical means. If it was decided that surgery was indicated, then the patients were asked as part of their initial evaluation, to complete some questionnaires, the contents of which would be kept completely confidential. Thus some of the patients were brought to the clinic by the orthodontists and some by the maxillofacial surgeon. These were not segregated into two groups. In planning the patients' treatment, in most cases it was found that orthodontic treatment was initially needed to align the teeth and to correlate the arch dimensions, prior to surgical intervention. The questionnaires were usually completed on the initial visit to the combined clinic. When they were not completed on the initial visit, they were completed on one of the later visits, prior to surgery. Thus the period prior to surgery was variable and never less than three months, but possibly up to one year. Patients also completed the questionnaires following surgery, so that 'before' and 'after' assessments were obtained. A number of patients completed questionnaires only after surgery. The post-surgery assessments were carried out when patients attended for follow-up appointments and the majority completed the questionnaires in the three to six months period following surgery. It was again carefully explained to the patients that the questionnaires would be examined anonymously so that their personal details would not be revealed. The patients were usually able to complete the questionnaires in about 20 minutes. In a few cases, where there were difficulties concerned with catching trains etc., to return home, the questionnaires were given to the patients who posted them back.
340
J. Cranio-Max.-Fac.Surg. 18 (1990)
B.B.J. Lovius et al. Each of the sixteen body parts has to be rated according to degree of satisfaction/dissatisfaction felt with that part. A seven point scale is used in which 1 represents 'very satisfied' and 7 represents 'very dissatisfied'. Thus low scores indicate satisfaction with the body parts and high scores indicate dissatisfaction. In addition to an overall body satisfaction score derived from the ratings of all sixteen body parts, separate scores for head parts and body parts can be derived. For this study a score for 'teeth' and 'jaw' parts was also calculated, taking the average of both scores.
Thus a number of patients in the study had only completed questionnaires prior to surgery and a number only following surgery, providing cross-sectional groups. In addition, there was a longitudinal group who had completed questionnaires both prior to and following surgery.
Subjects Questionnaires were completed by patients who formed two kinds of sample: a) a longitudinal/prospective sample which comprised 41 patients who were assessed both before and after surgery, and b) cross-sectional samples who completed the questionnaires at only one point in time, namely either before surgery (N = 54) or after surgery (N = 58). The longitudinal sample consists of 6 male and 35 female subjects with an average age of 20.6 (SD 5.2). In the crosssectional samples, the sex distribution of those assessed preoperatively was 25 male and 29 female with an average age of 22.0 (SD 5.6), while the sex distribution of those assessed postoperatively was 25 male and 37 female subjects with an average age of 22.6 (SD 8.7). Patients who had congenital abnormalities such as clefts of the lip and palate, or other congenital deformities requiring surgery, were excluded from the study,
Assessments Assessment instruments were selected to test whether psychological effects would be confined to improvements in body image, particularly involving facial appearance, or whether there would be more general psychological changes. As well as a test of satisfaction/dissatisfaction with body image, three further questionnaires were administered. One was included to detect the presence of general psychological disturbance and the others to assess aspects of social anxiety which it was hypothesised may well be a consequence of facial malformation. The following assessments were given to the participating subjects:
ii) Social Avoidance and Distress (SAD) and Fear of Negative Evaluation (FNE) Scales (Watson and Friend 1969) SAD and FNE scales were developed to provide measures of social anxiety. They have been used widely in studies of social anxiety and have been shown to be sensitive to emotional distress (Turner et al., 1987). The SAD scale contains items concerned with subjective distress, feeling ill at ease socially and the tendency to avoid social situations. The FNE scale was designed to assess apprehension about others' evaluations, distress caused by their negative evaluations, avoidance of evaluation and the expectation of being evaluated negatively. iii) General Health Questionnaire (GHQ) (Goldberg 1978) The GHQ is a self-administered screening test aimed at detecting psychological disturbance amongst respondents in such settings as primary care or general medical outpatients. The 28-item version was used which yields an overall score together with scores on four sub-scales representing somatic symptoms, anxiety and insomnia, social dysfunction and severe depression.
Results The results obtained using each of the above questionnaires will be considered in turn for both the longitudinal and cross-sectional samples.
i) Body Satisfaction Scale (Slade et al., 1990) This is a simple rating scale designed to assess satisfaction/dissatisfaction with sixteen body parts, ranging from head to feet. It can be completed quickly and has been demonstrated to have both acceptable internal consistency and to correlate positively with the Body Shape Questionnaire (Cooper et al., 1987).
Table 1
i) Body Satisfaction Scale The findings from this questionnaire are presented in Table 1. Taking the longitudinal sample first it can be seen that this group reports a significant change in the direction of greater satisfaction following surgery on the three out of the four indices. These were the 'general', 'head' parts and 'teeth and jaw' measures. There was no significant change on the 'body parts' measure. This sug-
Means and standard deviations for Body Satisfaction Scale.
General dissatisfaction Dissatisfaction 'Body' parts Dissatisfaction 'Head' parts Dissatisfaction 'Teeth' & 'Jaw'
Longitudinal Sample (N=40) Pre-treat Post-treat
t
Cross-sectional Sample (N pre=52; N post=58) Pre-treat Post-treat t
41.3 (10.8) 14.0 (5.9)
31.2 (11.9) 13.9 (5.8)
4.99* 1.15
43.1 (13.5) 14.7 (7.3)
31.2 (11.5) 14.2 (6.5)
4.90* 0,39
24.6 (7.6)
14,4 (7.8)
6.7*
26.0 (8.1)
14,9 (8.3)
7,10"
5.4 (2.3)
1.9 (1.7)
9.66*
5,4 (1.6)
2.2 (1.7)
10.4"
*p
