Abstract
Objective
This study sought to evaluate the quality of life in patients with class III malocclusion and dentofacial deformity undergoing orthognathic surgery.
Materials and Methods
This study evaluated 25 patients with Angle’s class III malocclusion submitted to orthognathic surgery through the application of the B-OQLQ questionnaire, over two periods: 30 days before surgery (T0) and 6 months after surgery (T1). The B-OQLQ is a specific questionnaire to assess quality of life in patients with dentofacial deformities.
Results
The average age for women was 26.11 years and for men 31.13 years. The dental discrepancy between the incisors (overjet) was on average 2.55 ± 4.36 mm. There was no correlation between overjet and the level of satisfaction after surgery. There was no statistically significant relationship between patient satisfaction and the type of surgery performed. The results revealed statistically significant differences, showing improvement in the quality of life in the postoperative period of 6 months (p < 0.05), with a positive effect in all four domains of the questionnaire.
Conclusion
Orthognathic surgery significantly improved the quality of life of patients, and the type of questionnaire used (B-OQLQ) proved to be appropriate for the proposed analysis.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12663-022-01771-w.
Keywords: Orthognathic surgery, Malocclusion, Lifestyle
Introduction
Quality of life can be defined as the individual's perception of his position in life, within the context of the culture and value systems in which he is inserted, and in relation to his goals, expectations, standards and concerns. [1] Individuals who have difficulties accepting their facial appearance, or who aren't happy with the shape of their face, may have low self-esteem, which may harm their daily routine and therefore decrease the quality of life [2, 3].
The class III dentoskeletal deformity is the result of a mandibular prognathism and/or maxillary deficiency. It is generally characterized by patients who have an aesthetic and functional complaint. One of the goals of orthosurgical treatment is the improvement of facial aesthetics, with a consequent impact on interpersonal relationships. Studies on the quality of life of patients with dentoskeletal deformities, and the evaluation of the influence of treatment, are of notable importance because of the psychosocial alterations, in addition to the potential challenges regarding adaptation, acceptance of the new image, changes in emotional states and the way of interacting with society [4, 5].
Some questionnaires have been used to assess the quality of life in orthosurgical patients, but there is still no consensus on the most appropriate method [6]. Cunningham et al. [7] drafted a condition-specific questionnaire for orthosurgical patients entitled “Orthognathic Quality of Life Questionnaire” (OQLQ), in order to enable a specific and reliable evaluation of patients with dentoskeletal deformities. The specificity of this instrument is revealed by the fact it focuses its questions on domains that are closely related to dentoskeletal deformities, which enables it to evaluate the quality of life in this type of patients. After the development of the condition-specific OQLQ questionnaire, other studies have used this methodology and demonstrated positive results in the improvement of the quality of life of patients submitted to orthosurgical treatment [6–13].
Araújo et al. [13] performed a cross-cultural adaptation and translation to the Portuguese language of the OQLQ questionnaire. The Brazilian version of the OQLQ, entitled Questionário de Qualidade de Vida para pacientes Ortocirúrgicos (B-OQLQ), can be considered as an appropriate instrument to assess the impact of dentalskeletal deformities on the quality of life of patients in need of orthosurgical treatment.
With the aforementioned facts in mind, this study seeks to evaluate the quality of life in patients with mandibular prognathism and dentofacial deformity undergoing orthognathic surgery.
Materials and Methods
The research project that led to this study was submitted to the Research Ethics Committee of the General Hospital “Dr. José Pangella” in Vila Penteado (CAAE: 42406815.0.0000.5446), where it was reviewed and approved.
Subjects
Twenty-five patients with class III dentoskeletal deformities undergoing orthognathic surgery during the year 2018 were prospectively evaluated. These patients were submitted to preoperative orthodontics and all were operated by the same surgeon. The inclusion of patients was based on the following criteria: (a) adult patients (18–60 years); (b) Patients with mandibular prognathism; (c) Surgical mandibular setback and/or maxillary advancement. Patients who were syndromic, had labiopalatine cleft, missed a significant number of teeth, had previous orthognathic surgery and with physical disabilities, were excluded. The patients received and were instructed in how to answer the B-OQLQ, filling it out in two periods: one month before surgery (T0) and six months after surgery (T1).
The B-OQLQ is a specific questionnaire for the assessment of quality of life in patients with dentoskeletal deformities, and it is based on a 4-point scale, where 1 means that the item bothers the patient very little, 4 means that the item bothers him very much, and 2 and 3 are in between the two concepts. An option “does not apply to me” exists for those who are not affected by some question. The 22 items of the questionnaire are divided into four domains: (a) facial aesthetics (items 1, 7, 10, 11 and 14); (b) function (items 2 and 6); (c) awareness of the deformity (items 8, 9, 12 and 13) and (d) social aspects of the dentoskeletal deformity (items 15 to 22), totaling a score of 0 to 88, with a lower score meaning less discomfort of the patient in relation to the deformity and a higher score meaning more discomfort.
Statistical Analysis
The software Microsoft Excel® (Microsoft Inc., USA) and MATLAB (Version 5.3 The Math Works Inc., Natick, MA) were used for the tabulation and statistical and descriptive analysis of the data. The paired t test was used to check if there was a difference between the pre- and postoperative scores of each domain and the total pre- and postoperative score of the B-OQLQ questionnaires. To find out which was the most influential domain in the B-OQLQ questionnaire, the analysis of variance (ANOVA) test was applied in the domains of the preoperative scores to analyze the means, complemented with Tukey’s Post Hoc test and Residual Analysis for validation of the model.
A new variable named Spread was created, which was used to measure the improvement that the surgery brought to patients. Spread is the post-surgery B-OQLQ score minus the pre-surgery score, and it therefore measures the drop in scores between the evaluations. The Spread variable was used and the type of surgery that was performed on the patients was classified for a comparative analysis in order to observe whether there was significant evidence to suggest that the type of surgery was of influence on the level of the patient satisfaction. The statistical method used to identify whether there was a significant difference between the three methods of surgery, was the Kruskal–Wallis test, since this study deals with small samples.
To confirm the assumption that patients with a greater dental discrepancy (overjet) tend to be more satisfied after corrective surgery, a correlation study was performed using Spearman's Rho methodology, since it is a nonparametric method, which does not require the assumption of normality and presents a good fit to nonlinear data. A statistical significance level of 5% was adopted for decision-making [14].
Results
Of the 25 patients studied, 15 (60%) were female and 10 (40%) were male. The average age for women was 26.11 years (18–35) and for men 31.13 years (21–59). The mean dental discrepancy (overjet) was 4.36 mm ± 2.55.
According to the Spread x overjet scatterplot (Fig. 1), there was no correlation between the overjet and the level of satisfaction (Spearman p = −0.371), and the p value = 0.068 indicates that there is no evidence that this result is the product of random errors.
Fig. 1.
Correlation between the overjet and level of satisfaction (Spearman p = −0.371 and p-value = 0.068)
Ten patients were submitted to surgery of the maxilla, nine to bimaxillary surgery and six were only submitted to mandibular setback. There was no statistically significant evidence to support a relationship between the satisfaction of patients and the type of surgery performed (Table 1).
Table 1.
Correlation between the type of surgery and the improvement in quality of life, using the Kruskal–Wallis analysis
| Type of surgery | N | Median | p Value |
|---|---|---|---|
| Mandible | 6 | − 42.5 | 0.41 |
| Maxilla | 10 | − 37.5 | 0.41 |
| Maxilla and Mandible | 9 | − 44 | 0.41 |
When the pre (T0) and post-surgery (T1) periods are compared, a statistically significant difference could be observed, showing an improvement in the quality of life of the patients under study in the postoperative period of six months (p < 0.05) (Table 2). Positive effect was observed in all questionnaire’s domains (Table 2). Comparing women and men satisfaction in T0 and T1, there is statistically significant difference between then, showing that female patients are less satisfy before and after six months of the surgery (p < 0.05) (Table 3).
Table 2.
Evaluation of the improvement of the quality of life in the preoperative period (T0) and in the postoperative period (T1), using Student's T test
| T0 | T1 | Difference | t Statistics | p Value | Effect | |
|---|---|---|---|---|---|---|
| B-OQLQ | 46.52 [16, 89] | 4.00 [4, 73] | 42.52 [16, 24] | 13.09 | < 0.001 | 2.62 |
| Facial Aesthetics | 3.02 [0, 84] | 0.22 [0, 35] | 2.79 [0, 80] | 17.47 | < 0.001 | 3.49 |
| Function | 1.94 [0, 85] | 0.12 [0, 18] | 1.81 [0, 84] | 10.75 | < 0.001 | 2.15 |
| Awareness of the deformity | 1.50 [0, 92] | 0.25 [0, 33] | 1.26 [0, 83] | 7.57 | < 0.001 | 1.51 |
| Social aspects of the deformity | 1.78 [1, 01] | 0.13 [0, 20] | 1.65 [1, 00] | 8.20 | < 0.001 | 1.64 |
Table 3.
Evaluation of the improvement of the quality of life in the preoperative period (T0) and in the postoperative period (T1) compering different genders, using Student's T test
| Female | Male | t Statistics | p Value | |
|---|---|---|---|---|
| T0 | 47.8 [16, 8] | 44.6 [17, 8] | 0.5 | 0.7 |
| T1 | 5.3 [4, 7] | 2 [3, 3] | 1.8 | 0.08 |
After the Analysis of Variance (ANOVA), it was possible to see that the means of the domains differed among themselves (Table 4). Through the analysis of Tukey's Post-hoc simultaneous comparisons, one can see that only the domain "facial aesthetics" showed a statistically significant difference when the domains are compared with each other.
Table 4.
Evaluation between the four domains: facial aesthetics, function, awareness of the deformity and social aspects of the deformity, using the ANOVA test
| GL | Sum of squares | Medium square | F Statistics | p Value | |
|---|---|---|---|---|---|
| Factors | 3 | 32.92 | 10.97 | 13.36 | < 0.001* |
| Error | 96 | 78.88 | 0.82 | ||
| Total | 99 | 111.80 |
*Statistical significance for α = 0.05
Discussion
The gender and age sampling characteristics of the present study were similar to several other studies [5, 10–12, 15–18], but it differed from the one performed by Motegi et al. [19], where from the 93 patients sampled, 71% were women and only 29% were men. One can see that female patients are more prevalent in percentage than male patients. Since this concerns a functional and aesthetic treatment, women are usually more likely to go looking for this type of surgical procedure.
When the type of procedure performed is concerned, this study presented nine patients who were submitted to combined surgery (36%), ten maxillary advancement surgeries (40%) and six mandibular setback surgeries (24%). These totals differ from the study by Murphy et al. [11], who treated class III patients only with mandibular setback or bimaxillary procedures, but they are quite similar to the work done by Modig et al. [25], where 33% of the investigated patients underwent bimaxillary surgeries, 43% underwent surgery of the maxilla and 24% surgery of the mandible. The vast majority of patients with class III dentoskeletal deformities are currently treated with maxillary advancement or combined surgeries, with mandibular setback surgery only being applied in some specific cases [17]. The question whether the type of surgery performed on patients was of influence on the pattern of responses in the B-OQLQ questionnaires was assessed, but no statistically significant difference was found in the results. It is believed that the size of the sample (25 patients) and the fact that the evaluation was performed only six months after the surgery, may have influenced this result, given that the postoperative period is more uncomfortable in patients submitted to mandibular surgeries when compared to those submitted to surgery in the maxilla.
Lee et al. [22] and Choi et al. [10] used the generic health questionnaire (SF-36), the generic oral health questionnaire (OHIP-14) and the condition-specific questionnaire (OQLQ) to evaluate patients in the pre- and post-surgery period. The authors observed an improvement in results with the SF-36, but the scores of questionnaires OHIP-14 and OQLQ were lower, with the results evolving as the postoperative time increased. The adoption of only one type of assessment instrument in the present study (B-OQLQ) can be justified because it is a questionnaire focused on the specific condition (dentoskeletal deformity), and with several positive results in the assessment of the quality of life of patients with this deformity. The application of generic questionnaires doesn't add important information to the results achieved. [8, 10, 11, 21–23] According to what has been observed in the literature, one could say that the use of specific questionnaires for assessing dentoskeletal deformities is the most sensitive method to capture the changes resulting from the dentoskeletal deformities and the improvement in the quality of life of patients.
Nicodemo et al. [5] evaluated patients 30 days before surgery and six months after, analogous to the period used in this study. The sample characteristics were similar, with the sample being composed of 29 patients (55% women and 45% men), but they used the SF-36 questionnaire to measure the changes. Only four of the eight domains of the questionnaire showed a statistically significant difference, which differs from the present study, in which all domains of the B-OQLQ showed a remarkable improvement. The authors evaluated the overjet and did not obtain a statistically significant difference in the results when correlating it with the satisfaction of patients, similar to what was observed in this study. It could be inferred that the sample size and the fact that few patients had a dental discrepancy (overjet) greater than 6 mm, may have influenced the lack of correlation of improvement in the quality of life with overjet.
In relation to the four domains assessed in the study, the highest score of the questionnaire was obtained in the domain “facial aesthetics,” followed by “function” and “social aspects.” “Awareness of the deformity” represented the domain with the lowest score. In the studies carried out by Al-Ahmad et al. [8] and Choi et al. [10], Lee et al. [22], aesthetics proved to be the most important domain. Bock et al. [9] observed that in the population under study, the greatest discomfort was observed in the “social aspects,” followed by “function” and with “aesthetics” as third placed factor. Cunningham et al. [24] obtained “social aspects” as main factor evaluated by patients, followed by “facial aesthetics” and “function.” Modig et al. [25] found that the functional problems were the main complaint of the patients in the preoperative period, which differs from the results observed in this study and in other studies, in which facial aesthetics was the factor that bothered the evaluated patients most. It is believed that the dissatisfaction with facial aesthetics is characterized as the main complaint of patients with dentoskeletal deformities as a result of the mandibular prognathism [26]. It also reflects the great demand for aesthetic procedures that can be seen in the medical and dental fields of Brazilian society. This study and other studies reveal that the awareness of the deformity was the domain that caused less discomfort in the population, probably because of the lack of information and access that patients have in relation to dentoskeletal deformities. Perhaps an early diagnosis of the deformity, with explanations on the forms of treatment from de very beginning by orthodontists and surgeons, would allow for a better understanding of the problem.
Lee et al. [22] conducted a study with 36 patients, evaluating them over three periods. Women accounted for 69.4% of the sample and men for 30.6%. The social factor was the domain that bothered the evaluated patients most, with aesthetics in second and function in third place. Awareness of the deformity was once again the factor that least affected patients. There was a statistically significant improvement in the quality of life of patients, only differing from this study where the effect of domains is concerned: the social factor was less important than aesthetics and function.
Choi et al. [10] evaluated 32 patients using the SF-36, OHIP-14 and OQLQ questionnaires in the preoperative period and six weeks and six months after surgery. The results showed that patients had an improvement in quality of life when the period of six weeks was compared with six months. It is possible that the period of six weeks is too short to evaluate the improvement of the domains and the quality of life in the postoperative period because the patient still has edema, which can lead to asymmetries in the soft tissue, difficulties and limitations in chewing, the presence of elastics to improve intercuspation and phonation difficulties. Taking these factors into account, the questionnaire was not applied in the early postoperative phase because it is believed that this would not reflect the improvement in the quality of life observed in patients submitted to orthognathic surgery.
Murphy et al. [11] analyzed 62 patients with the OQLQ questionnaire. The patients were evaluated at the preoperative and postoperative period of six months. The highest OQLQ score was for the factor “facial aesthetics,” followed by “function,” “social aspects” and “awareness of the deformity.” In the reviewed literature, this was the only study whose results were similar to those presented here when the domains are concerned. Patients with class II and class III dentoskeletal deformities were assessed, which diverged from this work that only considered patients with mandibular prognathism. It is believed that the standardization of the kind of deformity allows one to get a clearer and more specific profile of the type of deformity and its main complaints.
Conclusion
The results show the importance of a full assessment of the individual and not just the technical factors of the procedure, since orthognathic surgery will result in changes in the patient's life, including the way he interacts with society.
Supplementary Information
Below is the link to the electronic supplementary material.
Author’s Contribution
Larissa M. Vicente contributed to writing—original draft, resources and formal analysis. Amanda F. Araujo contributed to writing—review and editing and visualization. Lucas M. Castro-Silva contributed to conceptualization, methodology and supervision.
Funding
No funding was provided to this research.
Declarations
Conflict of Interest
No conflict of interest.
Ethical Approval
This research was approved by the Research Ethics Committee of the General Hospital “Dr. José Pangella” in Vila Penteado (CAAE: 42406815.0.0000.5446).
Consent to Participate
All the patients agreed to participate of this research.
Consent for Publication
All authors agreed with the publication of the research.
Footnotes
Publisher's Note
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Contributor Information
Larissa M. Vicente, Email: larissa_martini@outlook.com
Amanda Farhat de Araujo, Email: amandafarhat.araujo@gmail.com.
Lucas M. Castro-Silva, Email: prof.lucassilva@saojudas.br
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