Patient Satisfaction Following Orthognathic Surgery: A Systematic Review

Abstract

Objective

This study is intended to review data pertaining to patient satisfaction following orthognathic surgery through a systematic literature survey.

Methods and Materials

An electronic search was done on Medline, EMBASE and CENTRAL databases. The inclusion criteria considered were as follows: (1) assessment of patients' satisfaction, (2) one-stage orthognathic surgery, and (3) follow-up period of 8 weeks or more in English literature. The exclusion criteria considered were as follows: (1) presence of craniofacial syndromes, cleft lip and palate or traumatic injuries, (2) previous facial surgery, and (3) psychological problems before surgery. The data were extracted and analyzed under three categories: function, esthetics and overall satisfaction.

Results

Eighteen studies met the inclusion criteria. Esthetic and function were improved in majority of patients; however, it was not possible to assess the overall satisfaction levels statistically. Overall satisfaction analysis revealed that 70–87% of patients were satisfied, while nearly 15% of patients were dissatisfied with the treatment outcome.

Conclusion

Most of the patients were satisfied with the surgical outcome. However, satisfaction seemed to be multifactorial and it was not possible to predict satisfaction prior to the surgery.

Introduction

It is a well-known fact that facial esthetics is an important aspect of human interactions [1]. Orthognathic surgery is mainly performed to enhance facial esthetics primarily by repositioning the bony facial skeleton particularly the jaws and thus the soft tissues of the face [2]. Establishment of an optimal maxillomandibular skeletal relationship in conjunction with a good dental occlusion and balancing the cephalometric parameters is generally considered to be the gold standard for defining the success of orthognathic surgery by the surgeon [3]. However, in many a case, this may not seem to be true from the patients perspective [4] although the operator may be satisfied with the outcome while the patient may not and vice versa [3].

The literature reveals that the postoperative dissatisfaction pertaining to the preoperative expectations of orthognathic surgery and postoperative outcome are a result of failure of communication between the surgeon and the patient [5–7]. This imbalance is not necessarily related to the skill of the surgeon [5]. Understanding the factors that govern the satisfaction and dissatisfaction of the patient following orthognathic surgery and attempting to address these factors would be of great clinical importance to both patient and surgeon. A great disparity exists in the literature pertaining to patient’s satisfaction following orthognathic surgery with some studies revealing high rates of patient satisfaction while some studies revealing a high rate of dissatisfaction [8–11]. Hence, this study is intended to review data pertaining to patient satisfaction following orthognathic surgery through a systematic literature survey.

Materials and Methods

This systematic review was conducted by following the reporting checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For this study, a comprehensive literature search was undertaken to identify papers published until the end of April 2023 in dental and oral and maxillofacial surgery journals. A protocol was developed in advance to document the analysis method and inclusion criteria. We utilized Scopus, Google Scholar, Emerald, ProQuest, PubMed, and in some cases the website of the journals to search for articles published in the selected journals containing the terms “orthognathic surgery,” “patient satisfaction” and “patient dissatisfaction” in their titles, abstracts, and/or keywords with only English being the preferred language.

The title, abstract, keywords, authors names and affiliations, journal name, and year of publication of the identified records were exported to an MS Excel spreadsheet. Two independent authors screened the titles and abstracts of the records independently and those articles that clearly were not specific to the topic were discarded. Then, the two authors performed eligibility assessment by carefully screening the full texts of the remaining papers independently. During this phase, disagreements between the authors were discussed and resolved by consensus. If no agreement could be reached, the views of a third author were taken into consideration.

The MS Excel spreadsheet was modified by adding the items for which data were sought for data management. More specifically, the bibliographic details of the included studies, the essential items of PRISMA checklist with some extensions, and an item to address reporting the PRISMA flowchart were added to the data management spreadsheet. One author extracted the data from the included papers and the second author checked the extracted data. Disagreements were resolved by discussion between the two reviewers. Subsequently, all the included papers were carefully reviewed to extract and code the data.

The inclusion criteria were as follows: (1) studies which have assessed patients' satisfaction, (2) one-stage orthognathic surgery, (3) follow-up period of 6 months or more, and (4) articles in English language only. The exclusion criteria were studies that included patients with: (1) craniofacial syndromes, cleft lip and palate and traumatic injuries in facial skeleton, (2) history of previous surgery in craniofacial region, and (3) psychological problems diagnosed prior to surgery.

The main intention of this study is to ascertain the incidence of satisfaction and dissatisfaction in patient’s following orthognathic surgery and to evaluate the variables that may influence the patients' satisfaction and dissatisfaction levels following orthognathic surgery. Descriptive data from all the carefully chosen articles were selected and gathered in tables. Function, esthetic appearance and overall satisfaction were assessed separately. For quantitative analysis, the total numbers of patients which were satisfied and dissatisfied were extracted from each study and the numbers were summed and overall percentage was calculated. All the data were summarized, and the overall result was categorized in 2 groups: "satisfied" and "unsatisfied".

Results

The current study reviewed 18 articles. The study selection process is summarized in Figs. 1 and 2. While the literature search against the databases and search engines resulted in 1892 records, 1557 were screened and 1290 were eliminated and 267 articles were assessed for eligibility. Systematic reviews, articles involving patients who were operated congenital defects or for sleep apnea, articles involving patients treated for orthognathic surgery coupled with other esthetic procedures and articles whose full texts were not available were excluded. The full texts of the remaining 249 articles were carefully evaluated and only those articles involving patients treated for orthognathic surgery and were evaluated subsequently for patients satisfaction alone were included. Finally, 18 articles were considered for this study (Table 1).

Fig. 1.

The PRISMA flow diagram

Fig. 2.

Flowchart of study selection process

Table 1.

Summary of descriptive characteristics of the included articles

S. no	Author (year)	Sample size	Patient satisfaction levels	Reason for dissatisfaction
1	Holman et al. [35]	55 patients were included	90% of the patients were satisfied with the treatment outcome	Reactions of the patient's support group to his or her postoperative appearance was found to be highly related to satisfaction in both the early and late postoperative stages
2	Cheng et al. [27]	165 patients were included	84% of the patients were satisfied with the treatment outcome	Orthognathic surgery should not mainly focus on the esthetic aspects alone but should lay emphasis on functional aspects also equally in order to enhance the patients satisfaction following orthognathic surgery
3	Chen et al. [8]	108 patients were included	85% of the patients were satisfied with the treatment outcome	Insufficient support or passive acceptance of the surgical outcome by the family and relatives of the patient in the early postoperative period has a significant correlation with the patient dissatisfaction
4	Philips [10]	126 patients were included	Percentage not quantified but the article states that majority were satisfied	Postoperative satisfaction or dissatisfaction depended on the preoperative psychological distress of the patient
5	Posnick et al. [3]	42 patients were included	89% of the patients were satisfied with the treatment outcome	Adjunctive esthetic procedure could aid in enhancing the patient satisfaction levels
6	Al-Ahmad [11]	38 patients were included	82% of the patients were satisfied with the treatment outcome	Lack of information pertaining to the possible limitations and difficulties related to the surgical procedure and the postoperative morbidities greatly influence the patient satisfaction level
7	Rustemeyer [5]	77 patients were included	77.9% of the patients were satisfied with the treatment outcome	Dysmorphophobia and over dependence on cephalometric values with little importance to facial proportions in the correction of dentofacial deformity is the cause for patient dissatisfaction
8	AlKharafi et al. [20]	74 patient were included	94% of the patients were satisfied with the treatment outcome	Increased information concerning discomfort and surgical risks increased the level of patient satisfaction
9	Kufta et al. [18]	37 patients were included	80% of the patients were satisfied with the treatment outcome	Significance of preoperative operator and patient communication in achieving high patient satisfaction levels following orthognathic surgery
10	Mohanty [26]	19 patients were included	81.81% of the patients were satisfied with the treatment outcome	The timing of treatment and immediate results are important factors governing patient satisfaction
11	Al-Asfour et al. [15]	66 patients were included	93.9% of the patients were satisfied and 6.1% patients were dissatisfied	Unrealistic expectations are the cause for dissatisfaction
12	Raffaini et al. [36]	70 patients were included	91.4% of the patients were satisfied with the treatment outcome	Adjunctive esthetic procedures like facial lipofilling in most cases led to satisfactory esthetic outcomes
13	Al-Hadi [32]	118 patients were included	90.7% of the patients were satisfied with the treatment outcome	The overall patient satisfaction was significantly associated with the presence of an ongoing problem. Improved esthetics and function are not the only predictors of patient satisfaction. Thus comprehensive assessment of patient management throughout the treatment journey is essential in assessing the post-treatment esthetic and functional outcomes
14	Duhduh [16]	50 patients were included	80% of patients were satisfied with the treatment outcome	Lack of motivated with long-standing inner feelings of their esthetic problem
15	Thiem [28]	119 patients were included	85.4% of patients were satisfied, and 14.6% of the patients were dissatisfied	Significance of preoperative patient education in achieving high patient satisfaction levels following orthognathic surgery
16	Kamarainena [19]	57 patients were included	96% of the patients were satisfied with the treatment outcome	Psychosocial factors play a role in long term post-treatment outcome
17	Torgersbraten [34]	60 patients were included	83.3% of the patients were satisfied with the treatment outcome	Persistent anterior open bite, mandibular relapse and impaired sensory function were related to dissatisfaction and these are associated with mandibular surgery more than maxillary surgeries
18	Keefe [31]	40 patients were included	85% of the patients were satisfied with the treatment outcome	Unrealistic expectations and lack of information pertaining the possible postoperative morbidities are the cause for dissatisfaction

There was a large variation noted in sample size, age, distinct psychological evaluation tools, and time elapsed between the satisfaction assessment and treatment among all the studies that were included. The authors applied various tools to assess patients satisfaction in the form of questionnaires filled during a follow-up consultation, questionnaires mailed after treatment or a structured interview after the follow-up consultation.

Following a thorough literature search, it was evident that nearly 70 to 87% of the patients seeking orthognathic surgery for the correction of their dentofacial deformity were satisfied with their treatment outcome. However, around 15 to 20% of the patients were unsatisfied with their final outcome. Considering the fact that the existing prevalence of dissatisfaction level among patients undergoing orthognathic surgery are still high this systematic review was undertaken to identify the factors contributing for dissatisfaction. The factors contributing to patients satisfaction/dissatisfaction following orthognathic surgery are listed in Fig. 3.

Fig. 3.

Factors contributing to patient satisfaction/dissatisfaction following orthognathic surgery

Discussion

It is a well-established fact that performing orthognathic surgery in a patient with dentofacial deformity would invariably improve musculoskeletal function in addition to improving quality of life and psychosocial well-being [1, 12]. Majority of the previous studies reported high patient satisfaction levels ranging from 70 to 87% due to improvement in esthetics or function, or both [5, 13–15]. It was observed that those patients who were highly motivated with long-standing inner feelings of their esthetic problems expressed a high satisfaction level following orthognathic surgery [16].

Studies revealed that males expressed a more satisfaction level following orthognathic surgery than females especially in the three domains of facial esthetics, oral function, and awareness of dentofacial esthetics [13, 17]. This could be attributed to the fact that females are more concerned about their appearance than males [15, 18]. Previous studies have revealed that patients experienced a better satisfaction levels following bijaw surgeries that single jaw procedures [15]. Hence, the type of surgical procedure coupled with the severity of the dentofacial deformity would have a bearing on the postoperative satisfaction levels of the patients [4, 8]. However, the literature reveals that age and marital status do not play a role in the patients satisfaction following orthognathic surgery [4, 19].

Esthetic expectations were better fulfilled with orthognathic surgery than functional expectations. Therefore, it was observed that postoperative satisfaction following orthognathic surgery would be high when esthetic needs were met, regardless of possible residual functional problems [18, 19]. Furthermore, it was observed that patients with lower educational level were more often satisfied with the surgical outcome than patients with higher educational level, due to their low levels of expectations [8, 19, 20].

Dysmorphophobia

The literature reveals that the most common cause for patient dissatisfaction following orthognathic surgery may be due to dysmorphophobia experienced by the individual rather than a failed surgical procedure [16, 21, 22]. Nearly 10% of the patients undergoing orthognathic surgery encounter dysmorphophobia. It is essential for the operator to determine whether or not a patient has body dysmorphic disorder (BDD) based on interactions with the patient in the preoperative phase and clinical intuition [23]. Since it adversely affects the quality of life and is associated with depression and obsessive compulsive disorder, it is critical to understand the expectations and also if the patient has been previously treated [24].

Lack of Proper Preoperative Counselling

The root cause for dissatisfaction among patients following orthognathic surgery is unrealistic patient expectations [25]. It is well‑known that patient satisfaction and the perception of surgical outcome depend on the preoperative expectations and the degree to which the procedure is explained by the operator [26]. The literature reveals that the information provided by the operator in the preoperative period pertaining to the possible limitations and difficulties related to the surgical procedure would greatly influence the levels of patient satisfaction in the postoperative period [5–7, 20, 27–30]. Lack of proper counselling by the operator could be considered as one of the key factors that can influence the patient satisfaction level. Hence, the attention paid by the operator to the preoperative counselling plays a pivotal role in determining patients' satisfaction following orthognathic surgery in the postoperative period. A recent study stated that the duration of time required from initial consideration of treatment to having the actual surgery should be at least 18 months or more [31].

Timing of Patient Satisfaction Evaluation in the Postoperative Period

Another possible reason for the evident high rate of dissatisfaction noted in the literature could be attributed to the bias in data collection after surgery [28]. In order to get optimal patient responses, it is advisable to assess patient satisfaction levels in the late postoperative phase than in the early postoperative phase. This could be attributed to a much more adverse and morbid condition in the early postoperative phase [4, 8, 32–34]. However, another recent study stated that postoperative morbidities had no overall effect on patient satisfaction levels following orthognathic surgery [25]. The primary factor that governed patient satisfaction following orthognathic surgery was determined by the patient’s perception of the esthetic outcome. If the esthetic outcome was significantly improved, the satisfaction levels was high regardless of functional problems [25]. However, it is also important to note that insufficient support or passive acceptance of the surgical outcome by the family and relatives of the patient in the early postoperative period has a significant correlation with the patient dissatisfaction [5, 8, 35]. In addition to this, the data obtained from retrospective studies may not be reliable contributing to a bias in the results obtained. Since many studies available in the literature pertaining to patient satisfaction following orthognathic surgery are retrospective, reliability of the results is questionable [28].

Future Thought Processes

Previous studies reported that enhanced levels of patient satisfaction may be accomplished with simultaneous procedures like septoplasty or liposuction in addition to orthognathic surgery [3, 36]. In order to accomplish the best clinical outcome following orthognathic surgery, it is essential to consider facial balance, beauty, and harmony in addition to dental occlusion. The ability to combine adjunctive esthetic procedures with orthognathic planning and surgery may enhance patient satisfaction [36, 37]. Hence, it is advocated that adjunctive esthetic procedures should become an integral part of the overall diagnosis and treatment planning of orthognathic surgery and the possibility of incorporating these procedures as an inclusive treatment plan should be proposed to the patient in the correction of the dentofacial deformities. A recent study evaluated the factors which affect patient satisfaction following surgery first approach and conventional orthognathic surgery [26]. It stated that the most important factor for patient satisfaction following surgery first approach and conventional orthognathic surgery was facial esthetics. However, masticatory function and psychological aspects should be considered equally when planning surgery. They found that the patient satisfaction was more in surgery first approach than conventional orthognathic surgery. They concluded that the timing of treatment and immediate results are important factors toward patient satisfaction [26].

Even though the assessment of facial beauty is subjective, the assessment of facial proportions is predominantly objective. It is generally comprehended that disproportionate human faces are unattractive, while optimal facial proportions render acceptable features, even if not always attractive [38]. Hence, one needs to understand that if the treatment plan is designed dictated primarily by cephalometric values alone, it can result in inadequate correction of the dentofacial deformity leading to patient dissatisfaction. Soft-tissue changes following skeletal repositioning should be pre-empted and cephalometric indications should be compared with esthetic clinical indications [39, 40]. Dentofacial deformities must be corrected based on the esthetic needs in order to accomplish both esthetic and functional outcomes simultaneously.

Conclusion

The interpretations obtained from the current systematic review are deemed to have many useful implications for future clinical care. The data obtained from this literature review therefore give a better insight into various aspects of the patient’s experience before, during, and after surgery which invariably has a greater bearing on their satisfaction levels following orthognathic surgery.