ORIGINAL ARTICLE

Effects of orthognathic surgery on

quality of life compared with nonsurgical
controls in an American population
Lydia Lancaster,a Rashelle D. Salaita,b Charu Swamy,c Shiva Shanker,d Kelly S. Kennedy,e F. Michael Beck,f
William M. Johnston,g and Allen R. Firestoned
Dayton and Columbus, Ohio, and Boston, Mass

Introduction: To determine the psychosocial effects of a facial skeletal mal-relationship with its subsequent
surgical correction in a group of patients treated using surgical orthodontics compared with a matched group
of nontreated controls. Methods: This study was approved by The Ohio State University Institutional Review
Board. Subjects were patients presenting with facial skeletal mal-relationships whose proposed treatment
plans included orthognathic surgery. This study used valid and reliable questionnaires: Orthognathic Quality
of Life Questionnaire (OQLQ), Beck Depression Inventory II (Children's Depression Inventory – 2),
Satisfaction with Life Scale, and State Trait Anxiety Inventory (State Trait Anxiety Inventory for Children),
administered at 3 different stages of treatment (time 1 5 initial pretreatment, time 2 5 before oral surgery,
and time 3 5 at completion of treatment). Matched controls recruited at each time point completed the same
questionnaires. Results: A total of 267 subjects were recruited to participate in this study. There were no signif-
icant differences between treatment and control groups in age, sex, education level, or employment status at any
of the 3 time points. The randomization test was used to compare values for all outcome variables between
groups at the 3 stages of treatment. For the pretreatment period, T1, there were significant differences between
patients and controls in domains 1 (P 5 0.0126), 2 (P 5 0.0000), and 3 (P 5 0.0000) of the OQLQ (social as-
pects, facial esthetics, and oral function, respectively) as well as total OQLQ (P 5 0.0000). For the presurgery
period, T2, there were significant differences between patients and controls in domains 2 (P 5 0.0136) and 3
(P 5 0.0001) of the OQLQ (facial esthetics and oral function) as well as total OQLQ (P 5 0.0291). Finally, for
the posttreatment period, T3, there was a significant difference between patients and controls only in domain
3 (P 5 0.0196) of the OQLQ (oral function). Conclusions: The psychosocial profile of patients with a facial skel-
etal mal-relationship does not differ from the general population in depression, anxiety, and overall satisfaction
with life. However, these patients do report a reduced quality of life based on condition-specific measures in
social aspects, facial esthetics, and oral function. Concerns about oral function remain even up to 2 years
after treatment is completed. (Am J Orthod Dentofacial Orthop 2020;-:---)

A
facial skeletal mal-relationship exists when a pa-
tient exhibits deviations from normal facial pro-
portions and dental relationships caused by an
underlying skeletal discrepancy. According to Proffit
et al,1 these deviations can be so severe that they are
thought to be handicapping and are then referred to
a g
Formerly, Division of Orthodontics, College of Dentistry, The Ohio State University,
Columbus, Ohio; Currently, Private Practice, Dayton, Ohio.
b
Formerly, Division of Orthodontics, College of Dentistry, The Ohio State University,
Columbus, Ohio; Currently, Private Practice, Columbus, Ohio.
c
Formerly, Division of Orthodontics, College of Dentistry, The Ohio State University,
Columbus, Ohio; Currently, Private Practice, Boston, Mass.
d
Division of Orthodontics, College of Dentistry, The Ohio State University,
Columbus, Ohio.
e
Division of Oral & Maxillofacial Surgery and Dental Anesthesiology, College of
Dentistry, The Ohio State University, Columbus, Ohio.
f
Division of Biosciences, College of Dentistry, The Ohio State University, Columbus,
Ohio.
as a dentofacial deformity. Jaw function, speech, and
social interactions are often compromised within this
population of patients.
Treatment for these patients requires a combined or-
thodontic and orthognathic surgical approach because
of the severity of the mal-relationship in which
Emeritus, Division of Restorative and Prosthetic Dentistry, College of Dentistry,
The Ohio State University, Columbus, Ohio.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Approval received by The Ohio State University's Institutional Review Board, proto-
col no. 2011H0195. Financial support provided in part by Delta Dental Foundation.
Address correspondence to: Allen R. Firestone, Division of Orthodontics, College
of Dentistry, The Ohio State University, Rm 4088 Postle Hall, 305 W 12th Ave,
Columbus, OH 43210; e-mail, firestone@dentistry.dent.ohio-state.edu.
Submitted, May 2015; revised and accepted, September 2019.
0889-5406/$36.00
Ó 2020.
https://doi.org/10.1016/j.ajodo.2019.09.020

1
2 Lancaster et al
orthodontics or growth modification alone cannot pro-
vide an ideal result. Although functional impairments
such as difficulty in chewing food, discomfort, and
pain from temporomandibular joint dysfunction are
important reasons for treatment, it is generally accepted
that most of these patients are seeking treatment
because of concerns about their dentofacial esthetics
and are motivated by self-image and social well-be-
ing.2-4 It has been shown that the more the patient
perceives his or her problem as outside of normal, the
more likely they are to seek treatment.5,6
Facial esthetics can strongly affect a person's quality
of life (QoL) and therefore have a psychological impact
on the individual that includes making them feel inade-
quate or discontented because of their appearance. Cun-
ningham et al7 reported that there are differences in the
psychological profile of an orthognathic patient
compared with the general population: specifically,
higher levels of anxiety, a greater number of people in
their social support network, lower body and facial im-
ages, and borderline lower self-esteem. Other investiga-
tors, however, have reported no differences in regards to
psychosocial parameters8,9 and therefore do not recom-
mend psychological screening of patients requiring or-
thognathic surgery.9 It has been suggested that most
dentofacial patients have coping skills that keep them
within the normal range on psychological testing, and
this may conceal the true extent of their psychosocial
distress.1
A longitudinal study by Kiyak et al10,11 confirmed
that most patients with facial skeletal mal-
relationships benefit psychologically after orthognathic
treatment, demonstrating improved facial and dental
appearance and an associated increase in self-
confidence. The patients reported high levels of satisfac-
tion after surgery and that they perceived considerable
improvements in their facial appearance and body im-
age, viewing themselves more positively after surgery.
Some patients did report depression and dissatisfaction
with the surgical outcome. However, most of this was
attributable to prolonged time in orthodontics after sur-
gery.10 Flanary et al12 also found high levels of postop-
erative satisfaction and a healthy psychological
adjustment and concluded that orthognathic treatment
appears to have a positive impact on QoL. Positive ef-
fects were seen for self-concept including self-esteem,
self-satisfaction, self-identity, physical self, social self,
and total self-conflict.12 It is possible that a portion of
this satisfaction could result from the time, discomfort,
and expense of treatment creating cognitive dissonance
with an unsatisfactory outcome.
There has been a paradigm shift in the focus of health
care, which now includes health-related quality of life
- 2020  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
(HRQoL) and evaluation of treatment based on its
impact on the patient's feelings and perceptions of
treatment. According to the World Health Organization,
QoL can be defined as “an individual's perception of
their position in life in the context of the culture and
value systems in which they live and in relation to their
goals, expectations, standards, and concerns.”13 More
specifically, HRQoL refers to the effect that a disease,
condition, or treatment has on a patient's ability to carry
out the physical and social tasks of daily life14 and has
been used as an outcome measure in clinical trials.
Flood et al15 reported that patient expectations can
affect treatment outcomes, therefore managing realistic
patient expectations is critical for successful outcomes.
It is important to build rapport with patients and
communicate with them throughout treatment so that
they understand what is happening and why. QoL issues
are strong underlying motivators in the decision for a
patient to accept treatment that includes orthognathic
surgery. Both the clinician and the patient require a
thorough understanding of the effects of treatment on
HRQoL to anticipate the changes that occur and to allow
this type of treatment to be compared with other pro-
cedures.16 This information allows clinicians to be able
to give clear and accurate information to patients as to
what to anticipate the impact of surgical treatment
will have on their QoL.
A systematic review conducted by Hunt et al17 iden-
tified an urgent need for well-controlled longitudinal
studies to be conducted to confirm the psychosocial
benefits after orthognathic surgery. The authors noted
both a lack of high-level evidence and a lack of consis-
tency in the methods used to measure psychosocial sta-
tus, which resulted in an inability to show a clear and
precise psychosocial benefit.17
This study aimed to determine the psychosocial ef-
fects of a facial skeletal mal-relationship and its surgical
correction compared with a matched group of non-
treated controls.
MATERIAL AND METHODS
This study was approved by The Ohio State University
Institutional Review Board (protocol no. 20111H0195)
and was mixed cross-sectional and longitudinal.
Subjects were patients presenting to The Ohio State
University College of Dentistry graduate orthodontic
clinic and the college's dental faculty practice whose
proposed treatment plan included orthognathic surgery
to correct a facial skeletal mal-relationship. To reduce
selection bias, all treatment subjects who were eligible
to participate were consecutively recruited into the study
from August 2011 to November 2015. The criteria for
Lancaster et al 3

inclusion were treatment subjects had to be at least (4) State Trait Anxiety Inventory (STAI-Y)25: An inven-
12 years old, be accompanied by a parent or a guardian tory developed in 1973 by Spielberger et al25 to
if younger than 18 years, not have any developmental investigate how strong a person's feelings of anxi-
disabilities or urgent medical conditions, be able to ety are. The STAI-Y consists of 40 statements
communicate in English, and have been offered a com- scored from 1 to 4 with a minimum possible score
bined orthodontic and surgical treatment plan that was of 40 and a maximum of 160.
not a result of cleft lip or palate, trauma, or a develop-
a. State Trait Anxiety Inventory for Children
mental syndrome. A convenience sample of nonsurgical
(STAI-C)26: For subjects younger than 18 years.
controls matched to age and sex of the treatment sub-
The STAI-C consists of 40 statements scored
jects was recruited from The Ohio State University Col-
from 1 to 3 with a minimum possible score
lege of Dentistry Hygiene Department, Pediatric
of 40 and a maximum of 120.
Department, and The Ohio State University main
campus. This group of patients was chosen to reflect With both inventories, a higher score indicates a
the general population, and exclusion criteria included greater amount of anxiety.
the presence of orthodontic fixed appliances or a marked All questionnaires had previously been shown to be
dentofacial abnormality. valid and reliable.18-20,27-29
The questionnaires used in this study were the These questionnaires were administered at 3 different
following: stages of treatment:
 T1: Pretreatment – Before initiation of orthodontic
(1) Orthognathic Quality of Life Questionnaire
appliances. This stage of treatment was chosen to
(OQLQ)18,19: A condition-specific QoL measure
compare QoL parameters of untreated patients who
developed in 2000 by Cunningham et al18 to be
possessed a facial skeletal mal-relationship with con-
used in studies investigating the outcome of or-
trols representing the general population.
thognathic treatment. The OQLQ consists of 22
 T2: Presurgery – At completion of presurgical ortho-
statements relating to the impact that a facial skel-
dontics, just before orthognathic surgery. This stage
etal mal-relationship has on a patient's QoL. These
of treatment was included to evaluate if making the
statements can be subdivided into 4 domains: social
malocclusion worse by removing dental compensa-
aspects of the deformity, facial esthetics, oral func-
tions affected QoL.
tion, and awareness of facial deformities. Responses
 T3: Posttreatment – 6 months to 2 years after ortho-
range from 0 to 4 points making a minimum
dontic appliances have been removed. This stage of
possible score of 0 and a maximum of 88, with a
treatment was chosen to evaluate if correction by sur-
higher score indicating a reduced QoL.
gical orthodontics makes QoL parameters of treat-
(2) Satisfaction with Life Scale (SWLS)20: A scale to mea-
ment subjects comparable with the general
sure global life satisfaction as a cognitive-
population. The time interval was selected to allow
judgmental process developed in 1985 by Diener
enough time to pass after removal of appliances so
et al.20 The SWLS consists of 5 items with a Likert-
that responses were not a reflection of elation from
type scale ranging from 1 to 7 making a minimum
being finished with treatment and short enough so
possible score of 5 and a maximum of 35, with a
that other life events had not intervened and become
higher score indicating higher life satisfaction.
the primary determinants of psychological state.
(3) Beck Depression Inventory II (BDI-II)21: A widely
used instrument to assess the severity of depression
Control subjects were recruited during each period.
first developed by Beck et al22 in 1961. The BDI
They were matched for sex, age, education level, and
consists of 21 items scored from 0 to 3 with a min-
employment status.
imum possible score of 0 and a maximum of 63.
Questionnaires were either administered at the
a. Children's Depression Inventory – 223: A 27-item time of appointment or mailed to subjects who would
assessment that rates the severity of symptoms return the questionnaires by mail or bring them to
related to depression in children and adoles- the following appointment. Demographic information
cents.24 Scores range from 0 to 2 with a mini- including age, sex, education level, and employment
mum possible score of 0 and a maximum of 56. status was recorded for all participants. Subjects and
controls were given a $10 gift certificate as compensa-
With both inventories, a higher score indicates more
tion for the time required to respond.
severe depressive symptoms.

American Journal of Orthodontics and Dentofacial Orthopedics - 2020  Vol -  Issue -

4 Lancaster et al
Sample size determination was based on the depen-
dent variable instrument with the highest variability,
the OQLQ. With an alpha risk of 0.05, a sample size of
35 subjects per period was required to demonstrate a dif-
ference of 6 15 units with a power of 0.86.30 Descriptive
statistics and inferential analyses were used to compare
the independent variables (group and treatment stage)
with the dependent variables (questionnaires). Tests
included the independent-samples t test, chi-square
test, Wilcoxon test, and randomization test (SAS Institute
Inc, Cary, NC). Statistical significance for all tests was set
at P \0.05. Calculations were done using the Statistical
Analysis System (version 9.3; SAS Institute Inc).
RESULTS
A total of 267 subjects were recruited to participate in
this study. The demographic information of the groups is
presented in Table I along with the statistical analysis for
comparison. There were no significant differences be-
tween the treatment subjects and control subjects in
age, sex, education level, or employment status at all 3
stages of treatment indicating that the groups were
well matched.
Summarized in Table II are the mean, median, and
range of values for all outcome variables. The randomi-
zation test was used to compare treatment subjects with
controls at all 3 stages of treatment. The Figure illus-
trates significant differences noted between the treat-
ment and control groups within the condition-specific
OQLQ instrument. At the pretreatment period, T1, there
were significant differences between patients and con-
trols in domains 1, 2, and 3, social aspects, facial es-
thetics, and oral function, respectively, of the OQLQ as
well as total OQLQ. At the presurgery period, T2, there
were significant differences between patients and con-
trols in domains 2 and 3, facial esthetics and oral func-
tion, respectively, as well as total OQLQ. Finally, for the
posttreatment period, T3, there was a significant differ-
ence between patients and controls only in domain 3,
oral function, of the OQLQ.
DISCUSSION
This study aimed to evaluate the psychologic well-
being and QoL of patients who possess a facial skeletal
mal-relationship before, during, and after correction
with orthognathic surgery in comparison with a control
group that represented the general population.
Care was taken to ensure that the control groups
matched the treatment groups for age, sex, education
level, and employment status. Similar to previous
studies,4,5,9,19,31-33 there was a wide age range of the
treatment subjects with most of the patients being
- 2020  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
young adults. Sex distribution of the treatment
subjects in the present study was similar between
female and male patients, whereas, other studies have
reported higher percentages of females.4,5,8,9,12,19,31-33
There were no significant differences in the measures
of depression, anxiety, or overall satisfaction with life in
patients with a facial skeletal mal-relationship compared
with matched controls reflecting the general population
at any of the 3 stages of treatment indicating that these
patients are psychologically well adjusted. However, sig-
nificant differences were noted between subjects and
controls in condition-specific QoL as measured by the
OQLQ instrument. The number of these differences
decreased at each stage of treatment that was sampled.
Before the initiation of treatment, differences were pre-
sent for total OQLQ, specifically in the domains of social
aspects, facial esthetics, and oral function. Just before
surgery, however, the social aspect domain of the
OQLQ for the treatment subjects was no longer signifi-
cantly different compared with the controls. One hy-
pothesis for this change could be the patients'
acceptance in social situations once they were in braces
and clearly seeking treatment. At the completion of
treatment, the only difference noted between groups
was decreased QoL related to oral function within the
treatment group. Why this difference persisted even after
6-24 months posttreatment is unknown. The oral func-
tion domain of the OQLQ includes statements related to
difficulties with biting or chewing as well as facial and
jaw pain. Lip paresthesia has been reported as a common
postsurgical complication among orthognathic patients
but as having no effect on overall satisfaction with sur-
gical outcomes, which are typically high.11,34,35 We hy-
pothesize that persistent lip paresthesia was a potential
reason for the subjects indicating functional problems.
However, we have no data that would clarify why oral
function remained a problem after treatment. One of
the advantages of using a condition-specific HRQoL in-
strument such as the OQLQ is that it is responsive and
sensitive to problems that may not be registered on a
more general survey of satisfaction with a medical pro-
cedure.
When examining the Figure, there are trends seen in
the domains of the OQLQ for treatment subjects within
the different stages of treatment. There seems to be an
increase in OQLQ scores and thus, a decrease in QoL
for subjects just before surgery. After treatment, the
OQLQ scores are decreased indicating an improvement
in QoL. Examining specifically the oral function domain,
there seems to be an improvement in function of sub-
jects after treatment (T1 vs T3) even though the oral
function scores at T3 are increased for the treatment
group compared with the control group. Another
 American Journal of Orthodontics and Dentofacial Orthopedics

Lancaster et al
Table I. Demographic characteristics of treatment subjects vs control subjects
Education level* n, ED level
Age, y mean (6SD) Sex n (%) (%) Employment status, n (%)
Independent Wilcoxon
Treatment Treatment Control t test, P Treatment Control Chi-square Treatment Control test, P Treatment Control Chi-square
stage subjects subjects value subjects subjects test, P value subjects subjects value subjects subjects test, P value
Initial, T1 19.6 (6.7) 19.7 (7.0) 0.9079 0.5162 42 ED 1 (59.2) 47 ED 1 0.9181 0.0675
(62.7)
35 females 41 females 8 ED 2 (11.3) 5 ED 2 (6.7) 20 Yes (28.2%) 32 Yes
(49.3) (54.7) (42.7%)
36 males (50.7) 34 males 13 ED 3 (18.3) 12 ED 3 51 No (71.8%) 43 No
(45.3) (16.0) (57.3%)
5 ED 4 (7.0) 5 ED 4 (6.7)
Total 5 71 Total 5 75 3 ED 5 (4.2) 6 ED 5 (8.0)
Presurgery, T2 20.8 (5.1) 20.9 (5.2) 0.9192 0.6466 7 ED 1 (31.8) 5 ED 1 (26.3) 0.5865 0.4757
12 females 9 females 6 ED 2 (27.3) 3 ED 2 (15.8) 14 Yes (63.6%) 10 Yes
(54.5) (47.4) (52.6%)
10 males (45.5) 10 males 5 ED 3 (22.7) 9 ED 3 (47.4) 8 No (36.4%) 9 No (47.4%)
(52.6)
2 ED 4 (9.1) 0 ED 4 (0.00)
Total 5 22 Total 5 19 2 ED 5 (9.1) 2 ED 5 (10.5)
Posttreatment, 25.9 (11.1) 25.2 (10.6) 0.7843 0.7604 9 ED 1 (24.3) 5 ED 1 (11.6) 0.7562 0.6236
T3
22 females 27 females 7 ED 2 (18.9) 7 ED 2 (16.3) 26 Yes (70.2%) 28 Yes
(59.5) (62.8) (65.1%)
15 males (40.5) 16 males 8 ED 3 (21.6) 21 ED 3 11 No (29.7%) 15 No
(37.2) (48.8) (34.9%)
10 ED 4 (27.0) 9 ED 4 (20.9)
Total 5 37 Total 5 43 3 ED 5 (8.11) 1 ED 5 (2.3)

Note. No significant difference between treatment subjects and control subjects in regard to age, sex, education level, or employment status at all 3 stages of treatment.
ED, education.
*1 5 0-12th grade; 2 5 completed high school/equivalent; 3 5 some college; 4 5 completed college; 5 5 graduate education.
- 2020  Vol -  Issue -

5
6 Lancaster et al

Table II. Outcome variables: treatment subjects vs controls

Sample size Mean (6SD) Median Min-Max

Treatment Control Treatment Control Treatment Control Treatment Control Randomization

Treatment stage Variable subjects subjects subjects subjects subjects subjects subjects subjects test, P value
Initial, T1 OQLQ (total) 71 75 37.8 (20.2) 25.7 (16.8) 35 26 2-87 0-60 0.0000*
OQLQ 1 71 75 12.3 (8.6) 9.1 (7.1) 11 8 0-32 0-27 0.0126*
OQLQ 2 71 75 10.6 (6.0) 6.8 (4.8) 10 6 2-22 0-20 0.0000*
OQLQ 3 71 75 8.9 (5.5) 4.9 (3.9) 8 5 0-25 0-18 0.0000*
OQLQ 4 71 75 6.3 (4.4) 5.1 (4.1) 5 4 0-16 0-15 0.1031
SWLS 71 75 25.3 (6.9) 26.7 (6.2) 26 28 9-35 9-42 0.2027
BDI 26 28 7.8 (8.2) 5.4 (7.0) 6 3 0-25 0-24 0.2503
CDI (total) 45 47 8.0 (6.7) 8.6 (7.8) 7 7 0-35 0-44 0.7352
CDI-E 45 47 4.1 (3.9) 4.2 (4.5) 3 3 0-18 0-24 0.9809
CDI-F 45 47 3.9 (3.6) 4.4 (3.8) 3 4 0-17 0-20 0.5396
STAI-Y 26 28 69.3 (22.4) 68.0 (21.0) 65.5 65.5 22-109 40-114 0.8308
STAI-C 45 47 62.0 (11.3) 59.9 (9.3) 60 59 32-87 39-80 0.3428
Presurgery, T2 OQLQ (total) 22 19 38.6 (17.3) 26.7 (15.9) 38 26 4-75 3-60 0.0291*
OQLQ 1 22 19 10.9 (6.8) 9.9 (6.9) 11 8 0-28 0-25 0.6469
OQLQ 2 22 19 11.3 (5.2) 7.3 (4.8) 12 6 0-20 0-12 0.0136*
OQLQ 3 22 19 10.2 (4.4) 4.2 (3.0) 10 5 2-18 0-12 0.0001*
OQLQ 4 22 19 6.2 (3.7) 5.4 (3.5) 6.5 6 0-15 0-12 0.5190
SWLS 22 19 25.1 (5.7) 22.4 (7.3) 25 23 10-33 10-35 0.1982
BDI 15 13 5.0 (6.0) 8.2 (9.3) 2 5 0-18 0-28 0.2861
CDI (total) 7 6 9.3 (7.4) 10.3 (7.0) 7 10.5 2-22 1-21 0.8160
CDI-E 7 6 4.1 (4.3) 5.3 (4.5) 3 5 0-10 0-12 0.6681
CDI-F 7 6 5.1 (3.4) 5.0 (2.8) 4 5.5 2-12 1-9 1.0000
STAI-Y 15 13 67.9 (19.8) 72.3 (17.7) 65 69 44-122 46-108 0.5566
STAI-C 7 6 66.1 (8.6) 62.2 (10.9) 67 60 56-77 47-78 0.4817
Posttreatment, T3 OQLQ (total) 37 43 23.6 (16.5) 20.3 (15.5) 26 16 0-54 0-53 0.3498
OQLQ 1 37 43 7.6 (6.4) 6.4 (6.6) 8 5 0-21 0-26 0.4298
OQLQ 2 37 43 6.1 (4.9) 6.1 (4.3) 5 6 0-14 0-15 0.9629
OQLQ 3 37 43 5.1 (4.9) 2.9 (3.3) 4 1 0-18 0-14 0.0196*
OQLQ 4 37 43 4.8 (4.3) 4.8 (4.58) 4 4 0-16 0-16 1.0000
SWLS 37 43 27.3 (5.8) 25.7 (6.1) 28 27 9-35 8-35 0.2188
BDI 38 38 4.9 (6.2) 6.9 (8.5) 2.5 4 0-23 0-36 0.2647
CDI (total) 7 5 6.6 (4.6) 11.4 (8.4) 5 9 3-14 1-21 0.3059
CDI-E 7 5 2.8 (2.0) 5.0 (3.7) 3 4 1-6 0-10 0.3149
CDI-F 7 5 3.8 (3.5) 6.4 (4.9) 2 5 0-8 1-12 0.3949
STAI-Y 38 38 63.1 (16.8) 70.5 (20.5) 58.5 69.5 33-104 41-118 0.1030
STAI-C 7 5 59.0 (9.5) 66.0 (23.0) 57 70 50-75 43-99 0.5886
Note. OQLQ 1, social aspects; OQLQ 2, facial esthetics; OQLQ 3, oral function; OQLQ 4, awareness; CDI-E, emotional; CDI-F, functional.
CDI, Children's Depression Inventory.
*Statistically significant results (P \0.05).

explanation for the posttreatment difference for oral
function between subjects and controls could be due
to age as a confounding variable. Oral function scores
improved in both the treatment group and the control
group from T1 to T3. The scores for the treatment sub-
jects at T3 were lower than those of the subjects at T1,
at a level similar to that of the control subjects at T1,
whereas the control subjects' scores for oral function
at T3 had also decreased further suggesting that age
could be a confounding variable with oral function
that is, it seems to improve with age.
Interpretation and comparison of previous research
in this area is difficult because of the wide variety of psy-
chological measures used. Studies done by Cunning-
ham7 in 2000 and Burden9 in 2010 used the same
instruments as this study to evaluate symptoms of
depression and anxiety in an orthognathic patient pop-
ulation compared with controls, (ie, the BDI and STAI).
Consistent with the current study, Burden9 found no dif-
ferences in depression or anxiety between the groups,
whereas Cunningham7 reported significantly higher
anxiety levels in the surgical group but found no

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Lancaster et al
40
35
30
25
20
15
10
0
Total* 1* 2* 3* 4 Total*
*Stascally significant results (p<0.05)
Domains: 1 – Social Aspects; 2 – Facial Esthecs; 3 – Oral Funcon; 4 – Awareness
Fig. Orthognathic QoL: treatment subjects vs controls. Domains: 1, social aspects; 2, facial esthetics;
3, oral function; 4, awareness. *Statistically significant results (P \0.05).
differences in regards to depression. However, neither
study took place in the United States, and both studies
only looked at patients at 1 time point, before initiation
of treatment, whereas this study confirmed no difference
within the entire process of treatment as well as after
treatment was complete.
In reviewing the literature, this study seems to be the
first to use the SWLS instrument to evaluate overall
satisfaction with life in an orthognathic population. Un-
like other scales, the SWLS leaves the respondent free to
weight various domains, such as health or material
wealth, and various feeling states in whatever way he
or she chooses.20 The SWLS has been used in previous
studies to show the influence that illnesses such as car-
diovascular disease or eating disorders have on overall
life satisfaction.36,37 However, in the current study
patients with facial skeletal mal-relationships do not
seem to be affected in their overall satisfaction with
life compared with controls.
The OQLQ is a condition-specific instrument that has
been used in previous studies to examine the effect that
an orthognathic condition has on a patient's QoL as well
as to determine changes in QoL after surgical orthodon-
tic treatment in patients with facial skeletal mal-rela-
tionships.19,33,38,39 These studies, however, have all
taken place outside of the United States (England, Jor-
dan, Hong Kong) and therefore differ from the present
American Journal of Orthodontics and Dentofacial Orthopedics
7
T1 Subjects
T1 Controls
T2 Subjects
T2 Controls
T3 Subjects
T3 Controls
1 2* 3* 4 Total 1 2 3* 4
study evaluating an American population. In comparing
the pretreatment group, the current study appears to
have similar mean scores in the OQLQ as a Chinese pop-
ulation,38 whereas both British and Jordanian popula-
tions were reported to have greater mean values and
thus lower condition-specific QoL.19,33 Heterogeneous
methodologies complicate comparison of the current re-
sults with these previous studies. The longitudinal study
done by Cunningham et al19 did not have a control
group for comparison but instead looked at changes
within the subjects between stages of treatment. In
line with the current study, when comparing pretreat-
ment subjects with controls, Lee et al38 reported signif-
icant differences in the overall OQLQ as well as social
aspects, facial esthetics, and oral function. They also re-
ported a significant difference in domain 4, awareness of
facial deformity, which was not found in the current
study.
In their systematic review, Hunt et al17 noted a
consistent methodologic flaw within most previous
studies in this field whereby control groups used were
those who required orthognathic treatment and declined
it. In the current study, the well-matched control group
reflected the general population of patients who do not
have severe skeletal discrepancies. This control group
added value to the study design by considering secular
changes that occur with time.
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8 Lancaster et al
The cross-sectional study design was a limitation of
the current study in which the control subjects were
not compared throughout the 3 stages of treatment.
The difficulties of maintaining a matched control group
over the period of the study precluded using a longitu-
dinal control sample. Furthermore, both treatment and
control groups represented a convenience sample re-
cruited at and around a large Midwestern university.
This limited the ability to generalize from the results
from this study to other locations and populations.
The sample size of the presurgery group was smaller
than indicated by the power analysis and therefore
another limitation of the study. Although significant dif-
ferences were reported for this period, failure to find
more differences may have been attributable to the
reduced statistical power of the small sample size.
It has been shown that cultural influences may affect
the impact that an oral condition has on QoL.40-42
Although we evaluated an American population, the
study could be strengthened to include ethnicity when
collecting the demographic data for both treatment
subjects and controls to account for cultural
differences and allow the study of any existing ethnic
effects, which were not evaluated in this study.
CONCLUSIONS
(1) The psychosocial profile of patients with or who had
initially possessed facial skeletal mal-relationships
did not differ from the general population in depres-
sion, anxiety, and overall satisfaction with life.
(2) Compared with the control group, patients with a
facial skeletal mal-relationship reported a reduced
QoL based on condition-specific measures in social
aspects, facial esthetics, and oral function.
(3) After completion of treatment, there were no differ-
ences in condition-specific QoL except for “oral
function” between patients and matched controls.
ACKNOWLEDGEMENTS
The authors wish to acknowledge Allison Bui, Andrea
Tsatalis and Jenna Zhu for their essential assistance in
data collection and organization. The authors also
wish to acknowledge the Delta Dental Foundation Mas-
ter's Thesis Award Program for its financial support of
this research.
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