Int. J. Oral Maxillofac. Surg.

2013; 42: 974–980

http://dx.doi.org/10.1016/j.ijom.2013.03.023, available online at http://www.sciencedirect.com

Systematic Review
Orthognathic Surgery

Quality of life assessment in C. L. Soh, V. Narayanan

Saveetha University, Vellappanchavadi,
Chennai, India

patients with dentofacial

deformity undergoing
orthognathic surgery—A
systematic review
C. L. Soh, V. Narayanan: Quality of life assessment in patients with dentofacial
deformity undergoing orthognathic surgery—A systematic review. Int. J. Oral
Maxillofac. Surg. 2013; 42: 974–980. # 2013 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this systematic review was to evaluate the benefits of
orthognathic surgery to quality of life, the different motivations and perceptions of
patients towards orthognathic surgery, and the various methods that have been used
to analyze these changes, in patients who undergo orthognathic surgery for
dentofacial deformities. A review of the literature was carried out, and articles
published from 2001 to June of 2012 that satisfied the inclusion criteria were
included in the review. A total of 21 articles were included. The results indicate that
orthognathic patients experience an improvement in quality of life after surgery.
Each individual patient has different motivations and expectations from the
Key words: orthognathic surgery; dentofacial
treatment. Also the use of validated instruments helped in quantifying results. deformity; quality of life.
Further research should be aimed at higher levels of evidence in study design,
quantifying the changes for different types of dentofacial deformities and surgeries, Accepted for publication 6 March 2013
and have a longer follow-up duration. Available online 21 May 2013

Introduction
Patients with dentofacial deformities are
at a disadvantage in society due to low
self-esteem and decreased levels of con-
fidence, as well as associated physiologi-
cal problems. Indeed such deformities
interfere not only with oral health and
function, but also adversely affect mental
well-being, thus affecting the entire spec-
trum that constitutes quality of life.
Orthognathic surgery is recognized as
the mainstay of treatment for dentofacial
deformities. While most published articles
have placed an emphasis on the techniques
for performing such surgeries, it is also
necessary to give importance to the effects
of such surgical interventions on the psy-
che of the patient. Over the years, research
has shown that most patients desire cor-
rection of dentofacial deformities to
improve the aesthetics of the facial and
dental components.1 There are also certain
studies that have reported the primary
motivation to be bite function rather than
appearance.2,3
As such interventions affect the
patient’s appearance directly over an
almost immediate period of time, it is also
of paramount importance to quantify the
psychological impact of the surgery. The
earliest reports of patient satisfaction4
indicated good responses to orthognathic

0901-5027/080974 + 07 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Quality of life assessment in orthognathic surgery 975

surgery, and this has since been substan- cleft lip and palate have a different set of search for the following reasons: 12 were
tiated by other authors.5–10 However the complaints, perceptions, and expectations, papers on cleft lip and palate or syn-
lack of comparable quantifiable data to hence were not included in this review. dromes; six were case reports; 12 were
denote the extent of improvement has Variables of interest included study not related to the topic directly; two were
been one of the shortcomings in the past design, sample size, duration of follow- short-term studies; seven articles were not
literature. This has mainly been due to the up, number of times findings were in English; two papers focused on tempor-
lack of consensus among the various recorded, types of instruments used, moti- omandibular joint changes; two were
scales and tools used to measure such a vational factors, perception of patients orthodontic articles; four articles could
change. towards orthognathic surgery, and quality not be obtained; and one was a review
The onus is now not only on treating the of life changes. article. The final search yielded 19 arti-
aesthetic component of dentofacial defor- cles. Two papers were then added from a
mity, but also on restoring the patient’s hand search of various orthodontic and
Results
psychosocial component as well. It is easy surgical journals. Finally 21 articles were
to assume that the two go hand in hand, but The search was carried out in the follow- included in this review.
the motivations, perceptions, and expecta- ing manner (Fig. 1): the search terms The review of the literature revealed a
tions of the individual play a significant ‘orthognathic surgery’ and ‘dentofacial variety of study designs used to evaluate
role in determining not only the surgical deformity’ were grouped together and quality of life and psychosocial changes
success, but also the psychosocial success; the option ‘OR’ was used. This revealed following orthognathic surgery. There was
all of these contribute to the overall quality a total of 3317 articles. The terms ‘quality one randomized controlled trial, ten cohort
of life of the individual. of life’ and ‘psychosocial’ were grouped studies, four case-control studies, five
Thus the aim of this systematic review together, again with the option ‘OR’. This cross-sectional studies, and one retrospec-
was to evaluate the motivations and per- revealed 236,016 articles. When both tive study (Table 1).
ceptions of patients and the benefits of groups were cross-checked with one The highest level of evidence in this
orthognathic surgery to quality of life, another using the option ‘AND’, a final review was a randomized controlled trial
as well as the various methods and tools 97 articles were identified. Limits were done by Motegi et al.12 This was the study
that have been used to analyze quality of then applied to the search, in which only with the longest follow-up of all subjects
life and psychosocial changes in patients articles from 2001 to the end of June 2012 (5 years), and recorded data seven times,
who undergo orthognathic surgery for were included; this revealed 67 articles. although only results at 2 and 5 years were
dentofacial deformities. After discussions between the authors, 48 published. The authors reported an
articles were excluded from the initial improvement in general quality of life,
Materials and methods
An online database search was carried out.
The search was conducted in PubMed with
the use of medical subheadings to include
all studies from 2001 to June of 2012. The
limiting year was chosen based on a pre-
vious systematic review on the same topic
in an indexed journal by Hunt et al. in
2001.11 Search key words included:
‘orthognathic surgery’, ‘dentofacial defor-
mity’, ‘psychosocial’, and ‘quality of life’.
Various maxillofacial surgery and ortho-
dontic journals were also hand searched
and suitable articles identified for inclu-
sion.
Articles that assessed motivations, per-
ceptions, or postsurgical changes in qual-
ity of life were included in this review.
Articles that used both qualitative and
quantitative measures were included.
The rationale behind the inclusion of all
articles was to objectively assess all meth-
ods of evaluation of quality of life. The
authors feel that there is still scope for
qualitative assessments regarding patient
perception and postoperative changes.
Exclusion criteria included articles that
assessed quality of life changes in patients
with syndrome-associated deformities and
patients with cleft lip and palate. Such
studies were excluded as we wished to
limit out review to only classic dentofacial
Fig. 1. Flow chart of systematic article selection.
deformity. Patients with syndromes and
976 Soh and Narayanan

Table 1. Hierarchy and summary of included study designs.

No. of data Methods of
Type of study Studies included Sample size collection times data collection
Randomized clinical trial with controls Nil
Randomized clinical trial without controls Motegi et al.12 93 3 e, h, i, k, o
Prospective cohort with controls Khadka et al.8 115 + 43 2 a, c
Kim et al.13 34 + 30 2 e, g
Oland et al.14 118 + 47 2 d, n
Prospective cohort without controls Murphy et al.6 62 2 a, f
Rustemeyer and Gregersen7 50 2 b
Choi et al.10 32 4 a, b, c
Lee et al.15 36 3 a, b, c
Turker et al.16 30 2 d, j
Nicodemo et al.17 29 2 c
Modig et al.18 32 2 b, o
Case-control studies Al-Ahmad et al.19 143 + 37 1 a, c
Narayanan et al.20 39 + 21 1 d
Smith and Cunningham22 88 + 100 1 o
Lazaridou-Terzoudi et al. 21 117 + 131 1 d, l, m
Cross-sectional study with controls Lee et al.26 76 + 76 1 a, b, c
Cross-sectional study without controls Ryan et al.24 18 1 o
Esperao et al.9 117 1 b
Bock et al.23 50 1 a
Posnick and Wallace25 42 1 o
Retrospective study with controls Nil
Retrospective study without controls Proothi et al.3 501 1 o

oral health-related quality of life, psycho-
logical function, and overall patient satis-
faction. The results were statistically
significant at 5 years, while remaining
stable from 2 to 5 years. Although this
study had the highest level of evidence,
several concerns exist. Firstly, the size of
the two study groups was not balanced.
Also there was no control group to com-
pare the results with. Further, the results
were reported as a combination of both of
the groups. Although reported as a clinical
trial, the trial was to do with the method of
fixation and not quality of life.
There were three prospective cohorts
utilizing controls included in this review.
Khadka et al.8 attempted to compare the
changes in quality of life between patients
with dentofacial deformities involving
occlusion and those whose deformity did
not include occlusion (prominent
zygoma). The results revealed a signifi-
cant difference preoperatively between the
two groups in the physical role, bodily
pain, facial aesthetics, and oral function.
Postoperatively, there was an overall
improvement in quality of life, with only
oral function showing a significant differ-
ence between the two groups.
Kim et al.13 compared 34 patients with
30 dental students preoperatively and
postoperatively. They reported an
improvement in the psychological profile
of the subjects postoperatively, and the
score difference with the control group
was not statistically significant postopera-
tively. There was a significant change in
personality characteristics after orthog-
nathic surgery.
Oland et al.14 attempted to discover the
motives for seeking treatment, and how
satisfaction of the primary motive corre-
lated with patient satisfaction. Most
patients cited function and appearance
as the main reasons for seeking treatment,
with social reasons and the wish to prevent
disease as other reasons. After a follow-up
at an average of 1 year after surgery, the
authors reported that fulfilment of motive
was a significant factor for patient satis-
faction. Self-concept and social interac-
tion were associated with higher
satisfaction. The authors concluded that
patients who seek treatment for a func-
tional motive express a lower degree of
satisfaction than others.
Most of the other prospective studies
without controls assessed preoperative
scores that were compared to postopera-
tive scores 6 months to 1 year after sur-
gery, using a variety of epidemiological
tools to evaluate the change in quality of
life. Murphy et al.6 evaluated quality of
life using the Orthognathic Quality of Life
Questionnaire (OQLQ), and reported a
statistically significant improvements in
appearance (93%), chewing function
(64%), comfort (60%), and speech
(32%). The biggest change was in the
aesthetics domain. Rustemeyer and Gre-
gersen7 used the Oral Health Impact Pro-
file 14 (OHIP-14) and came to the
conclusion that the biggest change was
seen in the aesthetics domain, with
significant changes in psychological dis-
comfort and social disability scores.
Choi et al.10 and Lee et al.15 evaluated
patients using three questionnaires: the
Short Form Health Survey (SF-36),
OHIP-14, and OQLQ, with the former
concluding their last follow-up at 1 year,
and the latter at 6 months. They both
reported a significant improvement in
the mental health and physical health
component of the SF-36. With the more
generic OHIP-14 for oral health, a larger
effect size was revealed. Likewise, with
the use of the condition-specific question-
naire OQLQ, the magnitude of statistical
change was larger. Both sets of authors
reported an improvement in overall qual-
ity of life.
Turker et al.16 reported that 76% of
patients were very satisfied with the sur-
gical result, with 90% of patients expres-
sing complete correction and
improvement in their postoperative image.
Sixty-three percent of patients reported an
absolute improvement in self-confidence
and 40% an improvement in social adjust-
ment.
Nicodemo et al.17 conducted a study on
29 patients with a Class III malocclusion
using the SF-36 questionnaire. They
reported an improvement in physical
and social aspects, while an improvement
in emotional aspects was higher in females
after surgery. Modig et al.18 used both
quantitative and qualitative measures.
They reported that 72% of patients had
an improvement in aesthetics and social
 Quality of life assessment in orthognathic surgery 977

security, while 91% and 19% reported an

improvement in chewing and speech,
respectively. They also gave an insight
into the reasons why patients seek orthog-
nathic surgery, with 55% of patients desir-
ing an improvement in bite function and
30% desiring an improvement in appear-
ance.
Four case-control studies were included
in this review. Al-Ahmad et al.,19 Naraya-
nan et al.,20 and Lazaridou-Terzoudi
et al.21 all reported a significant improve-
ment in quality of life postoperatively
compared to their selected controls. Smith
and Cunningham22 evaluated willingness-
Fig. 2. Summation of results for articles quantifying QOL using OQLQ.
to-pay for orthognathic surgery, and came
to the conclusion that patients with a
dentofacial deformity are willing to spend standardized questionnaires makes it pos- of both systemic reviews are almost
more than normal controls, and consider sible to quantify the extent of improve- synonymous, with overall data pointing
surgery as a good option in terms of cost– ment as well. For studies that employed towards an improvement in quality of life
benefit. the OQLQ, the biggest change was seen in and psychosocial components.
Out of the cross-sectional and retrospec- the aesthetics and social domains6,8,10,15,19 Compared to earlier studies on the
tive studies, Proothi et al.3 and Bock (Fig. 2). For studies that used the OHIP- topic, the introduction of validated condi-
et al.23 sought to understand the motiva- 14, the most significant change was seen in tion and oral health-specific question-
tion and reasons behind seeking orthog- the psychological discomfort naires has greatly affected the design
nathic surgical treatment. Proothi et al. domain7,10,15 (Fig. 3). For studies that and instruments for newer trials. Earlier
concluded that it was bite function rather employed the SF-36, the largest effect size studies used a variety of instruments for
than appearance that motivated patients differed among the different studies, with recording psychosocial benefits, most of
(36% versus 15% out of 201 patients some reporting a maximal change in the which were designed for general psychol-
reviewed). Bock et al. reported that mental health domain,8,19 some in the ogy instead of psychosocial changes spe-
50.4% desired treatment due to functional emotional role domain,10,17 and some in cific to orthognathic surgery. Table 2
impairment and 43% due to aesthetic the vitality domain15,26 (Fig. 4). provides a summary of the Hunt et al.
impairment. When compared to the previous sys- review, showing the numerous analyses
Ryan et al.24 conducted a qualitative tematic review by Hunt et al.,11 the results on psychosocial impact. However none of
study to assess patient expectations from
surgery. They concluded that patients
have both physical and non-physical
expectations and it is important to under-
stand both before proceeding with treat-
ment. Esperao et al.9 and Posnick and
Wallace25 aimed to assess the impact of
orthognathic surgery on patients. Their
results revealed that the majority of
patients are satisfied with the treatment
and report an overall improvement in
quality of life.
Lee et al.26 conducted a study to assess
changes in quality of life by all three
Fig. 3. Summation of results for articles quantifying QOL using OHIP.
measures using 76 patients with concur-
rent controls. Their results indicated that
there is no correlation between SF-36 and
the other two questionnaires. The generic
oral health and condition-specific ques-
tionnaires are able to discriminate
between patients with and without dento-
facial deformities, and have a value in
determining the impact of such deformi-
ties on quality of life.

Discussion
All the studies concluded that orthog-
nathic surgery resulted in an improved
quality of life. The employment of Fig. 4. Summation of results for articles quantifying QOL using SF-36.
978 Soh and Narayanan
Table 2. Summary of Hunt et al.11
Total number of studies, N = 29
1 Prospective cohort
16 prospective study with no controls
10 retrospective study with no controls
2 cross-sectional study with no controls
Types of questionnaires included
a. Body Cathexis Scale
b. Body Satisfaction Scale
c. Eysenck Personality Inventory
d. 16-Factor Personality Questionnaire
e. Goal Attainment Scale
f. General Health Questionnaire
g. Health Opinion Survey
h. Impact Message Inventory
i. Millon Behavioural Health Inventory
j. Profile of Mood States
k. Rotter’s Internality/Externality Scale
l. Rosenberg Self-Esteem Scale
m. Surgical Audit
n. Social Avoidance and Distress/Fear of
Negative Evaluation Scales
o. Symptom Checklist Revised (SCL-90-R)
p. Tennessee Self-Concept Scale
q. Ward Adjustment Scale
r. Hospital Anxiety and Depression Scale
s. Yatabe-Guilford Personality Inventory
t. State-Trait Anxiety Inventory
u. Beck Depression Inventory
v. Short Form Social Support Questionnaire
w. Derogatis Stress Profile
x. Introspectiveness Inventory
y. Self-Esteem Inventory
z. Zung Anxiety Inventory
aa. Zung Depression Inventory
bb. Minnesota Multiphasic Personality
Inventory
cc. Family Environment Scale
dd. Questionnaire devised by authors or
unvalidated measure
the methods are validated for orthognathic
surgery. Also lower levels of evidence are
evident among the study designs in earlier
papers.
The studies included in this review
showed an emerging trend in the utiliza-
tion of standard tested and proven ques-
tionnaires as the tool of choice for
assessing changes in quality of life. These
include three questionnaires: first, the gen-
eric health-related questionnaire Short
Form Health survey (SF-36)27; second, a
generic oral health-related questionnaire
Oral Health Impact Profile 14 (OHIP-
14)28–30; and third, a condition-specific
questionnaire Orthognathic Quality of
Life Questionnaire (OQLQ)31,32 (Table 3).
The SF-36 is a 36-item questionnaire
corresponding to eight health domains:
physical functioning, role physical, bodily
pain, general health, vitality, social func-
tioning, role emotion, and mental health.
These domains can then be summarized
into a physical component and mental
component. The scores range from 0 to
Table 3. Types of questionnaires used.
Questionnaire type No. of studies
a. Orthognathic Quality of Life Questionnaire (OQLQ) 7
b. Oral Health Impact Profile (OHIP) 6
c. Short Form Health Survey (SF-36) 6
d. Kiyak’s Internal Assessment/Personal Inventory 4
e. Symptom Checklist 90 Revised 2
f. Global Transition Scale 1
g. Minnesota Multiphasic Personality Inventory (MMPI) 1
h. Sickness Impact Profile Psychosocial Dimension 1
i. Oral Health Status Questionnaire 1
j. Maslach Burnout Inventory 1
k. Eysenck Personality Inventory 1
l. Body Cathexis Scale 1
m. Fitts Tennessee Department of Mental Health Self-Concept Scale 1
n Motives for Surgical-Orthodontic Treatment 1
o. Questionnaire devised by author or invalidated measure 6
100, with 0 being the worst possible health for a duration of 5 years. According to that
and 100 the best.26,27 study, the psychosocial benefits obtained
The OHIP-14 is a 14-item question- were stable after 2 years. However several
naire, spread over seven domains: issues like the lack of a control group and
functional limitation, physical pain, the timing of the baseline score evaluation
psychological discomfort, physical dis- necessitates further controlled prospective
ability, psychological disability, social trials of a longer follow-up duration to
disability, and handicap. Scoring is made confirm the long-term benefits. This is
over a 4-point Likert scale, with overall synonymous with the results obtained ear-
scores ranging from 0 (worst) to 56 (best). lier by Kiyak et al.42 and Flanary et al.43
Individual domains consist of two ques-
tions each, with scores from 0 to 8 per
Which patients are most at risk of being
domain.27–30
dissatisfied?
The OQLQ has 22 items divided into
four domains: facial aesthetics, oral func- A very small percentage of patients in all
tion, awareness of deformity, and social studies reported dissatisfaction with the
aspects of the deformity. Items are rated treatment outcomes. Using the Global
over a 4-point Likert scale. The total score Transition Scale adapted by Murphy
ranges from 0 to 88, from lower quality of et al.,6 the authors reported that 7% of
life to better quality of life.26,31,32 patients had deterioration in function, 15%
The generic health questionnaire, oral in overall comfort attributed to postsurgi-
health-related questionnaire, and condi- cal side effects, and 4% in speech. Other
tion-specific questionnaire have been pre- authors reported almost similar figures
sented and validated by various authors. among their study samples.10,16,25 This
Most of the questionnaires have also been is attributed mainly to the lack of post-
translated into other languages.33–36 surgical orthodontics and the timing of
follow-up. Permanent effects of facial
changes should be evaluated after 2–5
What are the common patient
years to allow the patient’s personality
motivations?
to accept and incorporate the new
Three articles in this series emphasized features into their psychology and func-
patient motivation and reasons. In the tion.12,21,44,45 This could be a reason for
study with the largest series of patients the dissatisfaction in treatment outcomes,
by Proothi et al.,3 and also papers by as most of the studies only followed up the
Oland et al.14 and Modig et al.,18 the patients for a duration of 6 months.
primary motivating factor was identified Kim et al.13 reported that 15% of
as bite rather than appearance. Other rea- patients were dissatisfied with the surgery.
sons included pain, smile, and speech. The authors attributed this to the high cost
This is consistent with earlier studies as of the treatment, which was not covered by
well,36 although the majority of studies health insurance.
have reported that aesthetic concerns are A qualitative study by Ryan et al.24
the primary reason.23,37–41 stated that patients have expectations from
Most of the studies in this review con- both a physical and non-physical point of
cluded their research at 6 months post- view, and that patient satisfaction can be
operatively. The longest postoperative increased by understanding them. Turker
assessment was made by Motegi et al.,12 et al.16 stated that adequate psychological

preparation helps to prepare the patient for
the postoperative image. This can be
achieved by the surgeon giving sufficient
explanations, or by speaking to previous
patients who have undergone orthognathic
surgery. Also, in the study by Smith and
Cunningham,22 the fact that patients and
the general public are willing to put a price
on orthognathic surgery shows the
positive perception towards the procedure
as a treatment modality for dentofacial
deformity.
Improvements in trials since 2001 have
been a higher level of evidence in study
design and the use of better validated
quantifiable instruments. The ability to
justify earlier observations and results is
proof enough that orthognathic surgery
improves the quality of life of patients
with dentofacial deformities.
It is important to consider the implica-
tions of surgeries that are elective and for a
primarily cosmetic purpose, like orthog-
nathic surgery, from the psychological
perspective of the patient. Failing to do
so, even though the surgical outcomes
may be ideal, may result in dissatisfaction
on the part of the patient.
From this systematic review, it can be
concluded that orthognathic surgery is of
significant benefit to patients with a dento-
facial deformity. However, further long-
term studies with quantification using stan-
dardized, validated questionnaires are
required to further substantiate the results.
Also the motivations and perceptions of
each individual patient are important in
determining treatment success, in restoring
not only the aesthetic and functional pro-
blems, but also the psychosocial problems
as well. The use of standardized tools has
helped to achieve consistent comparable
results in this area of orthognathic research,
which is an improvement on older studies.
Further research in study design should
include comparable groups, more rando-
mized clinical trials, and more thorough
analysis of the different types of dentofacial
deformities as well as the different types of
surgical procedures.
Funding
Self-funded.
Competing interests
None.
Ethical approval
Institutional Review Board.
Quality of life assessment in orthognathic surgery
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