Patient satisfaction after orthodontic treatment combined with orthognathic surgery: A systematic review

The online attention analysis on orthognathic surgery research

OBJECTIVES

Altmetrics is one of the fields of bibliometrics that seeks to assess the impact and interest of a given subject through Internet users. The aim of this study is to make an altmetric analysis of the orthognathic surgery literature.

METHODS

A literature search was conducted using Dimensions app up to December 2023. A list of the 100 most mentioned articles on the topic was compiled. A Google Trends search was performed with same strategy to visualize important data regarding internet search. Charts and tables were created using Microsoft Excel and VOSviewer software to allow bibliometric visualization.

RESULTS

There was a very poor correlation between the number of mentions and the number of citations (r = 0.0202). Most articles discussed on technical innovations associated to orthognathic surgery, majority related to virtual planning (n = 26). Other topics considered interesting to internet readers were complications (n = 18), surgical technique (n = 14), and psychological aspects/quality of life (n = 13).

CONCLUSION

Online interest in orthognathic surgery closely aligns with the level of academic interest but is also influenced by factors such as location and economic status. The internet is a powerful tool for disseminating scientific research to a broad audience, making it more accessible and engaging than traditional academic channels.

Patients' satisfaction with oral health care provided at the University Dental clinic in Tanzania: A cross-sectional analytical study

Background

Patients' satisfaction with health services is considered an essential element for hospital setup as it measures its performance and quality of care. Thus, evaluation of patients' satisfaction has become a basic concern of clinical practice. This study aimed to assess the satisfaction of patients with the oral health care provided at the University Dental Clinic in Tanzania.

Methods

This analytical cross-sectional study targeted all adult patients who sought treatment at the Muhimbili University of Health and Allied Sciences (MUHAS) dental clinic, between December 2019 and August 2020. It utilized a Dental Satisfaction Questionnaire (DSQ) to collect relevant information for this study.

Results

A total of 302 patients participated in this study with male to female ratio of 1:1.54. Their mean age was 35.95 ± (SD = 14.19) years. The mean scores for various domains of satisfaction were; 9.42 ± 2.09 for pain management, 8.11 ± 2.84 for the quality of services, 16.08 ± 2.27 for the cost of service, 7.49 ± 1.94 for satisfaction with accessibility/convenience, and 8.93 ± 2.17 for satisfaction with access to care. The overall mean satisfaction score was 50.03 ± 6.53. Only the education level of the participant was significantly associated with overall satisfaction, with the odds of participants with an education level of less than college, being satisfied with dental service 38% more than those with a college education.

Conclusion

Most of the participants had moderate overall satisfaction with the oral health care provided at the University dental clinic. The level of satisfaction was not determined by the sociodemographic characteristics of the participants.

Patient or Public Contribution

Patients with oral health problems and staff of the university dental clinic were consulted on the design, delivery, and reporting of the research.

The surgical outcomes of anterior segmental osteotomy in Asian skeletal class II patients

PURPOSE

Anterior segmental osteotomy (ASO) following the surgery-first approach is a long-established treatment modality to resolve lip protrusion in patients with skeletal class II patterns. However, the indications and effectiveness of ASO still remain uncertain. The objective of this study is to investigate the effectiveness of ASO in Asian skeletal class II patients by evaluating the skeletal and soft tissue changes and analyzing pre-treatment variables that determine successful outcomes in occlusal as well as esthetic aspects.

METHODS

The lateral cephalograms of 44 skeletal class II patients who underwent ASO and orthodontic treatment for resolving lip protrusion were retrospectively collected. Hard and soft tissue variables of two groups, normalized (NG) and unnormalized (UNG) ANB after treatment were compared and analyzed. The rotational effect of the anterior segment on the hard and soft tissue was also investigated.

RESULTS

ASO was successful in correcting the skeletal class II relationship and lip protrusion (ΔANB - 2.3°, 4-5 mm lips retraction) in most cases. However, for patients with severely camouflaged skeletal class II incisors involving a large ANB and SNA, a large ANB still remained post-treatment. The study also found that rotation of the upper and lower anterior segments further augmented the amount of lip retraction.

CONCLUSIONS

ASO was found to successfully correct ANB of skeletal class II patients under the following conditions (ANB 5.3° ± 1.5°, SNB 77.3° ± 4.5°, U1 to FH 115° ± 7.5, L1 to FH 48.0° ± 4.6). However, patients with larger ANB and SNA values may require bi-maxillary surgery. In addition, ASO has limitations in correcting gummy smile in cases of extreme maxillary excess. For patients requiring a large amount of lip retraction, rotation of the anterior segment may be beneficial in conjunction with bi-maxillary surgery.

Exploring the relationship between the number of systematic reviews and quality of evidence: an orthognathic surgery-based study

OBJECTIVE

We analyzed the quality and quantity of systematic reviews (SRs) of orthognathic surgery, the most frequently published topic in maxillofacial surgery.

STUDY DESIGN

We searched the PubMed database for SRs of orthognathic surgery with no restriction on the language of publication date. We assessed the certainty of evidence presented according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and the Leiden Manifesto using the Grading of Recommendations Assessment, Development, and Evaluation approach. We analyzed the data using descriptive statistics, Pearson´s correlation test, and linear regression.

RESULTS

Of the 171 SRs evaluated, approximately one fifth presented evidence with a high level of certainty. The number of orthognathic surgery SRs has been increasing, and many SRs were published after very similar topics had already been published. There is no relationship between the impact factor and the certainty of evidence.

CONCLUSIONS

An excessive number of SRs of orthognathic surgery are published, and many SRs are superfluous, simply reporting previous findings. Clinicians should not base treatment decisions solely on the evidence presented in SRs, and journal editors and reviewers should evaluate these SRs more critically, particularly when they address topics that have already been covered in the literature.

Risk Factors for Hardware Removal Following Bimaxillary Surgery: A National Database Analysis

Orthognathic surgery typically relies on the rigid fixation of fracture fragments using metal hardware. Though hardware is usually intended to be implanted permanently, the removal of hardware (ROH) is sometimes indicated for a variety of reasons. The authors sought to identify risk factors for ROH following orthognathic surgery. The authors conducted a retrospective analysis of the Merative MarketScan Research Databases, 2007-2021 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and ICD-10) codes to identify patients who underwent an index Le Fort 1 osteotomy and bilateral sagittal split osteotomy operation on the same day. Statistical analysis involved χ2, Shapiro-Wilk, Wilcoxon-Mann-Whitney, Poisson regression, and multivariable logistic regression tests. 4698 patients met the inclusion criteria. The mean age at surgery was 25 years, and 57% were female. ROH occurred in 5.9% of patients. The mean time to hardware removal was 190.5±172.4 days. In a multivariate logistic regression, increased odds of ROH were associated with older patient age [OR: 1.02 (1.01-1.03), P=0.046], sleep apnea [OR: 1.62 (1.13-2.32), P=0.018], and craniofacial syndrome and/or cleft diagnoses [OR: 1.88 (1.14-2.55), P<0.001]. In the same model, postoperative oral antibiotic prophylaxis was not associated with ROH (P=0.494). The incidence of all-cause complications [IRR: 1.03 (1.01-1.05), P<0.001] rose over the study period, while the incidence of ROH did not change significantly (P=0.281). Patients at elevated risk should be counseled on the increased possibility of a second operation for ROH before having orthognathic surgery to ensure expectations and health care utilization decisions align with the evidence.

Thematic Analysis of Parental Experiences of Patients' Orthognathic Surgery

Orthognathic surgery often requires extensive orthodontic preparation and a prolonged postoperative recovery that can be stressful for patients and their families. Parents are a primary source of support for patients; accordingly, a better understanding of the parents' experience of orthognathic surgery can help inform clinical care. Using a prospective cross-sectional qualitative study design, 4 focus groups (2 English and 2 Spanish; mean length 65 min) were held with parents of patients who had completed orthognathic surgery for class II/III malocclusion. Thematic content analysis of the group transcriptions was conducted. Participants were 10 mothers and 3 fathers of 12 children (50% with cleft lip/palate) ages 17 to 23 who completed LeFort I (41.7%), LeFort I with bilateral sagittal split osteotomy (BSSO; 41.7%), or BSSO (16.7%) within the prior 3 to 16 months. Themes fit within a chronological framework: (1) Preparing for Surgery included their larger health context, anticipating surgery, surgery preparation by team and family, and religious faith; (2) Challenges after Surgery consisted of complications, pain, frustration, nutritional challenges, parental anxiety, activity changes, sleep, breathing issues, swelling, and unanticipated aspects of surgery; and (3) Supports after Surgery were nutritional support, appreciation of medical team, postoperative improvements, appearance changes, communicating, supporting patient, and patient coping. Parents also offered advice for families and medical teams. Surgeons and other providers who are part of orthognathic surgical preparation can implement recommendations based on parental experiences to increase patient and family readiness for surgery by providing early education, assisting with advocacy, focusing on nutrition, and supporting coping.

Perceived Effects of Orthognathic Surgery versus Orthodontic Camouflage Treatment of Convex Facial Profile Patients

Increased facial profile convexity has a common occurrence in the population and is a primary reason for seeking orthodontic treatment. The present study aimed to compare the perceived changes in facial profile appearance between patients treated with combined orthognathic/orthodontic treatment versus only orthodontic camouflage treatment. For this reason, 18 pairs of before- and after-treatment facial profile photos per treatment group (n = 36 patients) were presented to four types of assessors (surgeons, orthodontists, patients, laypeople). Ratings were recorded on 100 mm visual analogue scales depicted in previously validated questionnaires. All rater groups identified minor positive changes in the facial profile appearance after exclusively orthodontic treatment, in contrast to substantial positive changes (14% to 18%) following combined orthodontic and orthognathic surgery. The differences between the two treatment approaches were slightly larger in the lower face and the chin than in the lips. The combined orthodontic and orthognathic surgery interventions were efficient in improving the facial appearance of patients with convex profile, whereas orthodontic treatment alone was not. Given the significant influence of facial aesthetics on various life aspects and its pivotal role in treatment demand and patient satisfaction, healthcare providers should take these findings into account when consulting adult patients with a convex facial profile.

Virtual Surgical Planning for Patients with Skeletal-Dental and Obstructive Sleep Apnea Syndrome

The integration of virtual surgical planning (VSP) for the treatment of skeletal, dental, and facial abnormalities and obstructive sleep apnea (OSA) with maxillofacial surgery has catapulted surgical planning. Although reported for treating skeletal-dental abnormalities and dental implant surgery, a paucity of knowledge existed reporting the feasibility and resultant outcome measures when VSP was employed for planning maxillary and mandibular surgery for OSA patients. The surgery-first approach is at the forefront of advancing maxillofacial surgery. Case series reporting success with the surgery-first approach for patients with skeletal-dental and sleep apnea patients have been reported. In sleep apnea patients, clinically significant reductions in apnea-hypopnea index and improvement of low oxyhemoglobin saturation have been achieved. More so, significant improvement in the posterior airway space at the occlusal and mandibular planes were achieved, while preserving aesthetic norms as measured by tooth to lip measurements. VSP is a feasible tool used for predicting surgical outcome measures in maxillomandibular advancement surgery for patients with skeletal, dental, facial, and OSA derangements.

Early Outcomes and Risk Factors in Orthognathic Surgery for Mandibular and Maxillary Hypo- and Hyperplasia: A 13-Year Analysis of a Multi-Institutional Database

BACKGROUND

Orthognathic surgery (OS) is a frequently performed procedure for the correction of dentofacial deformities and malocclusion. Research on OS is mostly limited to single-surgeon experience or single-institutional reports. We, therefore, retrospectively analyzed a multi-institutional database to investigate outcomes of OS and identify risk factors for peri- and postoperative complications.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2020) to identify patients who underwent OS for mandibular and maxillary hypo- and hyperplasia. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. We also evaluated risk factors for complications.

RESULTS

The study population included 674 patients, 48% of whom underwent single jaw surgery, 40% double jaw surgery, and 5.5% triple jaw surgery. The average age was 29 ± 11 years, with an equal gender distribution (females: n = 336; 50%, males: n = 338; 50%). Adverse events were relatively rare, with a total of 29 (4.3%) complications reported. The most common surgical complication was superficial incisional infection (n = 14; 2.1%). While the multivariable analysis revealed isolated single lower jaw surgery (p = 0.03) to be independently associated with surgical complication occurrence, it also identified an association between the outpatient setting and the frequency of surgical complications (p = 0.03) and readmissions (p = 0.02). In addition, Asian ethnicity was identified as a risk factor for bleeding (p = 0.003) and readmission (p = 0.0009).

CONCLUSION

Based on the information recorded by the ACS-NSQIP database, our analysis underscored the positive (short-term) safety profile of OS. We found OS of the mandible to be associated with higher complication rates. The calculated risk role of OS in the outpatient setting warrants further investigation. A significant correlation between Asian OS patients and postoperative adverse events was found. Implementation of these novel risk factors into the surgical workflow may help facial surgeons refine their patient selection and improve patient outcomes. Future studies are needed to investigate the causal relationships of the observed statistical correlations.

"Surgery First" vs "Traditional Sequence" Surgery: A Qualitative Study of Health Experiences in 46 Bimaxillary Orthognathic Patients

Introduction

Orthognathic patients are advocating an active role in selecting their appropriate ortho-surgical treatment, between the surgery first (SF) and the traditional sequence (TS) approaches. The aim of this study was to evaluate, through qualitative analysis, the subjective perceptions of the outcomes of each protocol.

Methods

In-depth interviews were conducted with 46 (10 male and 36 female) orthognathic patients (23 SF and 23 TS) treated with bimaxillary orthognathic surgery by the same surgeon, between 2013 and 2015. Average treatment duration was 6.5 months for SF and 12 months for TS. Inclusion criteria were: the presence of Class III or Class II asymmetries and open bite. Patients were excluded if they refused interviews or stopped attending post-treatment follow-up. Investigated health experiences included overall satisfaction with appearance, self-confidence after surgery, perceived treatment time, functional recovery, and diet restrictions.

Results

All SF and TS patients showed overall satisfaction with their appearance (though TS showed more enthusiastic tones) and approved their degree of functional recovery after surgery. Class III SF patients had earlier improvements in self-confidence after surgery. Orthodontics was considered enduring by both SF and TS patients.

Conclusions

SF patients expressed a higher degree of satisfaction with the reduction in overall treatment time and with the early psychological benefit deriving therefrom. Both SF and TS patients completely approved of the aesthetic outcomes and the functional recovery from which they benefitted due to the entire procedure.

Patients Satisfaction and Nasal Morphologic Change after Orthognathic Surgery

Background:

Patients’ attitudes about their nose changes after orthognathic surgeries. We aimed to evaluate the patient’s opinion about nasal change and morphologic changes following orthognathic surgery.

Methods:

This was a cross-sectional study. The sample was derived from the population of patients who underwent orthognathic surgery in the Oral and Maxillofacial Surgery Department of Shahid Beheshti University of Medical Sciences, Tehran, Iran between 2017 and 2019. Subjects who underwent orthognathic surgery were studied. Subjects filled a modified nose evaluation form before and nine months after orthognathic surgery. For objective assessment, the nasolabial angle, nasofrontal angle, nasofacial angle, tip projection, and tip deviation and alar width were evaluated. Sixty-two patients were studied.

Results:

Forty (64.5%) patients did not absolutely like their nose before orthognathic surgeries, two (3.2 %) expressed a little satisfaction, 17(27.4%) answered they liked more or less, and three liked very much. Nine months after orthognathic surgeries, 4 (6.5%) patients did not like their nose, nine patients (14.5%) liked a little, 30 (48.4%) liked more or less, and 19 liked very much. Analysis of the data demonstrated a significant difference in patients’ satisfaction with their noses before and nine months after orthognathic surgeries (P<0.001). Patients’ satisfaction nine months after orthognathic surgery was not affected by nasal morphologic changes.

Conclusion:

It seems, patients’ satisfaction with their nose improved after orthognathic surgeries. Patients’ attitude was not associated with nasal morphologic changes.

Current Trends in Skeletal Borderline Patients: Surgical versus Orthodontic Treatment Decisions—What Is the Evidence?

Background: The aim is to assess the current evidence-based knowledge about treatment decisions for skeletal malocclusion in adult borderline patients. Methods: A literature search was conducted through three databases. Inclusion criteria were restricted to systematic reviews, prospective, retrospective, and control studies. Only articles comparing orthodontic camouflage and orthognathic surgical treatment for Class II and Class III malocclusions in adult patients were selected to be reviewed. Results: Seven articles concerning Class II and nine concerning Class III met the inclusion criteria. Scientific evidence was poor due to low methodological quality. Conclusions: Surgical treatment was found to better improve skeletal and soft-tissue cephalometric values, whereas camouflage treatment mainly involved dentoalveolar movements. Aesthetic changes, as perceived by the patient, were not significantly different in the two groups. Recently improved surgical techniques, differing from those described in the analyzed articles, may provide similar or more stable outcomes compared with orthodontic-only treatment. Although some cephalometric variables can be helpful, the most important parameters for treatment selection are the patient’s presenting complaint and their self-image perception. Further studies with larger sample sizes and similar pretreatment conditions, and considering patient self-evaluation of esthetics and function, should be undertaken.

Superimposition of serial 3-dimensional facial photographs to assess changes over time: A systematic review

INTRODUCTION

Superimpositions of 3-dimensional photographs enable a thorough and risk-free assessment of facial changes over time. However, the available methods and the evidence supporting them have not been assessed systematically. The paper summarizes and assesses the current evidence on superimposition methods of serial 3-dimensional facial photographs available in the literature.

METHODS

The following databases were searched without time restriction (last updated December 2020): MEDLINE via PubMed, EMBASE, Cochrane Library, and Google Scholar. Unpublished literature was searched on Open Grey and Grey Literature Report. Authors were contacted if necessary, and reference lists of relevant papers were screened. All studies with sample size ≥6 that tested the accuracy or precision of a superimposition technique, or agreement between different techniques regarding facial surface changes, were considered. The 2 authors performed data extraction independently using predefined forms. The risk of bias was assessed through the Quality Assessment and Diagnostic Accuracy Tool 2 tool.

RESULTS

Eight studies fulfilled the inclusion criteria. The total risk of bias of 7 studies was high and of 1 low. Seven studies had high total applicability concerns, and 1 was unclear. There was high heterogeneity among studies, which tested constructed planes through manually selected landmarks, a configuration of 9 landmarks, various surface areas, and the entire facial surface as superimposition references. A small rectangular area on the forehead combined with one on the middle part of the nose and the lower wall of the orbital foramen showed promising results.

CONCLUSIONS

The limited available evidence suggests that surface-based registration is superior to landmark-based registration. Further research in the field is mandatory.

Do the stages of orthodontic-surgical treatment affect patients' quality of life and self-esteem?

The orthodontic-surgical treatment comprises different stages from diagnosis to final soft tissue accommodation, but there are no data regarding the patient's perception during these phases. This study aimed to investigate the impact of these stages on quality of life and self-esteem of patients with dentofacial deformity. Patients were divided into 4 groups according to the treatment stage: initial orthodontic pre-treatment (1), one week before surgery (2), three months after surgery (3), and after the removal of the orthodontic appliance (4) (n = 20 / group). They filled the following questionnaires: Oral Health Impact Profile (OHIP-14), Orthognathic Quality of Life Questionnaire (OQLQ) and Rosenberg Self-Esteem Scale (RSES). Data were evaluated by Kruskal-Wallis test. Differences among groups were noticed in all evaluated scales (p = 0.001 for all). No statistically significant differences between patients in groups 1 and 2 (OHIP, OQLQ, and RSES, p >0.05 for all), while patients at group 4 presented different scores in all questionnaires compared to 1, 2, and 3 (p < 0.05 for all), irrespective of the type of dentofacial deformity (p > 0.05). The results indicate that dental decompensation stage did not negatively affect patient's confidence and well-being. Despite the improvement noticed few months after the orthognathic surgery, the main impact on patient's quality of life and self-esteem was evidenced after the removal of the orthodontic appliance. We highlight the important role of counselling patients to discuss all the treatment stages to clarify patients' subjective expectations before any intervention is carried out.

Recent Trends in Orthognathic Surgery in Asia

Anatomy and standards of beauty are different between Asians and Westerners. Unlike Westerners, Asians have a wide and prominent jaw shape but prefer a slim and soft face shape. To achieve this goal, maxillary setback and/or posterior impaction surgeries are popular among upper jaw surgery, and various adjuvant surgeries are performed simultaneously on the mandible to obtain the so-called oval shape or V-line face. In addition, according to the development of virtual surgery software and orthodontic treatment techniques, the surgery-first approach is now accepted as a reliable option for orthognathic surgery if it is indicated.

Valid 3D surface superimposition references to assess facial changes during growth

Currently, the primary techniques applied for the assessment of facial changes over time utilize 2D images. However, this approach has important limitations related to the dimensional reduction and the accuracy of the used data. 3D facial photography has been recently introduced as a risk-free alternative that overcomes these limitations. However, the proper reference areas that should be used to superimpose serial 3D facial images of growing individuals are not yet known. Here, we tested various 3D facial photo superimposition reference areas and compared their outcomes to those of a standard anterior cranial base superimposition technique. We found that a small rectangular area on the forehead plus an area including the middle part of the nose and the lower wall of the orbital foramen provided comparable results to the standard technique and showed adequate reproducibility. Other reference areas that have been used so far in the literature were less reliable. Within the limitations of the study, a valid superimposition reference area for serial 3D facial images of growing individuals is suggested. The method has potential to greatly expand the possibilities of this highly informative, risk free, and easily obtained 3D tool for the assessment of facial changes in growing individuals.

Patient satisfaction after orthognathic surgery: a 3 year follow-up of 60 high-angle Class II individuals

BACKGROUND AND OBJECTIVES

High-angle Class II malocclusion is considered challenging to treat to a stable result and, although studies report treatment outcome in terms of morphology, patient satisfaction has not been addressed. The objectives of the present study were to examine patients' motives for treatment and satisfaction with the results.

MATERIAL AND METHODS

A structured questionnaire was distributed 3 years post-operatively to 93 consecutively treated patients with an initial diagnosis of mandibular-plane angle (ML/NSL) ≥34.0 degrees and ANB angle ≥4.0 degrees. Three surgical subsamples were defined: one-piece Le Fort I, bilateral sagittal split osteotomy, or a combination of the two (Bimax). Lateral cephalometric radiographs were used to assess morphological characteristics and post-treatment changes.

RESULTS

Questionnaire participation was 69.8 per cent. The most frequently reported motives for seeking treatment were to improve oral function (85.0 per cent) and dental appearance (71.7 per cent). Thirty per cent were very satisfied, 53.3 per cent were satisfied, and 16.7 per cent were dissatisfied with the overall treatment result. Dissatisfaction was associated with a persisting post-treatment anterior open bite (AOB), horizontal relapse at B point, and with sensory impairment.

CONCLUSIONS AND IMPLICATIONS

A higher rate of dissatisfaction was found than what has usually been reported for othognathic surgical patients, and this was associated with a persisting AOB. In addition, mandibular relapse and impaired sensory function were related to dissatisfaction and are associated with mandibular surgery. Prospective high-angle Class II patients should be comprehensively informed about the unpredictability of treatment outcomes in terms of occlusion and facial appearance.

Patient experience and satisfaction of surgically assisted rapid maxillary expansion and mandibular midline distraction

Little is known regarding patient experience and satisfaction with surgically assisted rapid maxillary expansion (SARME) and mandibular midline distraction (MMD). This study therefore aimed to assess patient experience and satisfaction with these techniques in two different groups. The first group answered the post-surgical patient satisfaction questionnaire on a 7-point Likert scale during a long-term follow-up recall. The second group answered a visual analogue scale questionnaire (range: 0-10) with different questions regarding experience and satisfaction, at different time points during the first year of treatment. In both groups, 17 patients were included. Regarding the post-surgical patient satisfaction questionnaire, a mean satisfaction rate of 6.4 (range: 4-7) was reported, with a mean follow-up of 6.5 years post-operatively. In the visual analogue scale group, the mean satisfaction rate was 8.0 and did not significantly differ from the expectations pre-operative (P = 0.96). Both procedures showed relatively low pain scores, although a significant higher score was observed in MMD post-operatively (P = 0.00051). Regarding hindrance, the scores were moderate; the bone-borne distractor in the mandible gained higher scores than the tooth-borne distractor in the mandible. In conclusion, both SARME and MMD gain high satisfaction rates.

Smile dimensions affect self-perceived smile attractiveness

Facial expressions play a leading role in human interactions because they provide signaling information of emotion and create social perceptions of an individuals’ physical and personality traits. Smiling increases socially perceived attractiveness and is considered a signal of trustworthiness and intelligence. Despite the ample information regarding the social importance of an attractive smile, little is known about the association between smile characteristics and self-assessed smile attractiveness. Here we investigate the effect of smile dimensions on ratings of self-perceived smile attractiveness, in a group of 613 young adults using 3D facial imaging. We show a significant effect of proportional smile width (ratio of smile width to facial width) on self-perceived smile attractiveness. In fact, for every 10% increase in proportional smile width, self-perceived attractiveness ratings increased by 10.26%. In the present sample, this association was primarily evident in females. Our results indicate that objective characteristics of the smile influence self-perception of smile attractiveness. The increased strength of the effect in females provides support to the notion that females are overall more aware of their smile and the impact it has on their public image.

The National Dental Practice-Based Research Network Adult Anterior Open Bite Study: Patient satisfaction with treatment

INTRODUCTION

This article evaluates and reports on the satisfaction of adult patients across the United States who received orthodontic treatment for anterior open bite malocclusion. The factors that influence satisfaction are also described.

METHODS

Practitioners were recruited from the National Dental Practice-Based Research Network. On joining the Network, practitioner demographics and information on their practices were acquired. Practitioners enrolled their adult patients in active treatment for anterior open bite. Patient demographics, patient dentofacial characteristics, and details regarding previous and current treatment were collected through questionnaires at enrollment (T1). Pretreatment lateral cephalograms and intraoral frontal photographs were submitted. Treatment performed, and details related to treatment outcome were recorded through questionnaires at the end of active treatment (T2). Posttreatment lateral cephalograms and intraoral frontal photographs were submitted. Patient satisfaction at T2 was assessed using a 5-point Likert-type scale and open-ended responses. Predictive univariate models were developed to evaluate the factors that affect patient satisfaction. Open-ended responses were reviewed for general trends.

RESULTS

T2 data were received for 260 patients, and 248 of these patients completed and returned the patient satisfaction questionnaires. High levels of satisfaction were found in this sample of adult patients receiving treatment for anterior open bite malocclusion. Specifically, 96% of the sample reported being very or somewhat satisfied. Only 10 patients (4%) were not satisfied with the treatment provided or an element of the final result. Successful open bite closure, treatment modality, and certain patient characteristics may affect patient satisfaction. However, there was insufficient power to demonstrate statistical significance because of the very low number of dissatisfied patients. Open-ended responses directly associated with patient satisfaction were received from 23 patients (9%). They relayed positive, neutral, and negative feelings about the treatment received and final results. Additional responses regarding the orthodontic treatment in general, but not specifically linked to patient satisfaction, were received from 119 patients (48%). These comments depict an overwhelmingly positive experience.

CONCLUSIONS

Adult patients who received orthodontic treatment for anterior open bite malocclusion were generally satisfied with the treatment provided, as well as the final esthetic and functional results.

Cephalometric and Anthropometric Changes and Their Relation to Patients' Satisfaction After Orthognathic Surgery

OBJECTIVE

The aim of this prospective study was to evaluate the correlation between cephalometric and anthropometric facial changes and satisfaction level of class III patients after bimaxillary orthognathic surgery.

METHODS AND MATERIALS

Totally, 29 class III patients (mean age = 24.23 ± 4.2) undergoing one-piece Lefort 1 osteotomy and mandibular setback were included. Pre- and postoperative lateral cephalograms were taken. Thirteen cephalometric and 17 anthropometric facial measurements were evaluated. A 6-item questionnaire of Rustemeyer's study was used to assess patient's satisfaction after surgery. The Wilcoxon signed-rank test, paired sample t test and Spearman's correlation analysis were used as statistical analysis.

RESULTS

Facial aesthetic and masticatory improvement was highly significant (P < 0.001), while opinion differences between patients and relatives/friends were not significant (P = 0.334). Increased upper lip length (P = 0.037) and decreased nasal tip protrusion-nose height index (P = 0.017) correlated positively with aesthetic improvements after surgery.

CONCLUSION

Although the association between parameters and satisfaction questionnaire was found, other influential factors should be considered before surgery as well.

Evaluation of effectiveness and stability of aligner treatments using the Peer Assessment Rating Index

AIMS

The aims of this study were to measure treatment effects of aligner treatments in adult patients directly after treatment and the stability of these effects after a short-term retention period using the Peer Assessment Rating (PAR) Index.

METHODS

This double-center trial consecutively screened 98 adult patients of whom 33 patients were treated according to predefined inclusion and exclusion criteria. The study sample was shown to be representative for adult orthodontic reality with regard to gender, age, and distribution of malocclusion type. Malocclusion severity was rated by using the PAR Index measured at baseline (T0), after finishing orthodontic treatment with Invisalign® (T1; Align Technology Inc., Santa Clara, CA, USA) and after a mean retention period of 10 months (T2). Furthermore, to better understand the observed treatment modality, specific treatment characteristics were recorded and analyzed.

RESULTS

The average PAR score at T0 was 22.18 (standard deviation [SD] ± 8.68). Posttreatment PAR score was 4.64 (SD ± 4.23) at T1 and was stable after a retention period of 10.07 months at T2 (SD ± 126.80 days; PAR 4.36, SD ± 3.93). All of the study cases showed a significant reduction of the total PAR score between T0 and T1 (p < 0.001), but no further difference between T1 and T2 (PAR 4.64 vs. 4.36). Cases were either classified 'improved' (n = 23) or 'greatly improved' (n = 10); no case was classified into the third PAR Index category 'worse or no different'. On average, 72 aligners (SD ± 22) with 12 attachments per treatment (SD ± 4) were used to align teeth. Six patients needed a case refinement with a mean of 23 (SD ± 8) further aligners. The maximum number of needed ClinCheck® (Align Technology Inc., Santa Clara, CA, USA) treatment plan revisions was 18 (mean 7, SD ± 4).

CONCLUSION

The detected improvement rate indicated a good standard of orthodontic treatment using aligners. Treatment effects were stable throughout a short-term retention period using a specific retention protocol. Effectiveness and stability were equally achieved in mild, moderate, and rather severe cases within this consecutive sample. A critical focus should be placed on accurate treatment planning in order to make tooth movements predictable, realistic, and stable.

Patients' narratives of orthognathic treatment for facial asymmetry: a qualitative study

To explore patients' experiences of orthognathic treatment for facial asymmetry and their adaptation to facial changes after surgery, we did a qualitative, cross-sectional study of patients after treatment for non-cleft asymmetry at two UK sites. A total of 15 patients aged 19-40 years were approached after being identified using patient databases and clinical notes. Individual and photo-elicitation interviews were conducted covering experiences prior to treatment, during treatment, and after surgery. Interviews were transcribed and thematic narrative analysis undertaken. Participants were largely positive about their orthognathic treatment. The following themes were identified: preoperative (becoming aware, negative impacts of asymmetry, committing to treatment, establishing expectations), pre-surgery orthodontics and inpatient experiences (challenges and coping strategies, preparedness, support, and shared experiences); and postoperative (surgery as 'worth it', positive impacts of treatment, adapting to facial change). Undergoing orthognathic surgery was portrayed as a journey involving recognisable narratives (treatment unfinished, threat of liminality, treatment as resolution, and treatment as transformation). Patients' experiences of facial asymmetry are associated with feeling 'abnormal', and negative impacts, and orthognathic treatment for facial asymmetry is worthwhile. Having the feeling that something is 'wrong' legitimised by clinicians allows patients access to a recognisable treatment narrative (resolution). Orthognathic treatment is also described as transformation from 'normal abnormality' to being 'normal'. Nevertheless, the associated challenges can be frustrating, particularly if resolution is hard to envisage. Further psychological input could help patients cope with these challenges and the complex process of adapting to facial change.

Assent for Orthognathic Surgery: Features, Challenges, and Benefits

The ideal age to undergo orthognathic surgery approximates the age of majority, and as a result a considerable portion of the patient population undergoing orthognathic surgery are legal minors. When a patient cannot legally provide consent, assent is often sought. Assent for surgical orthodontics is complicated by particular changes in cognitive variables during adolescence, the multiphased and multi-provider treatment course, and the intervention's elective nature. Ultimately, inclusion of a high-quality assent process can help identify patients most likely to benefit from orthognathic surgery and increase patient satisfaction.

Recent advances in orthognathic surgery

PURPOSE OF REVIEW

The aim of this article is to review the recent literature on orthognathic surgery for treatment of malocclusion and obstructive sleep apnea (OSA). The discussion outlines the refinements of the procedure and advances in technology.

RECENT FINDINGS

Maxillomandibular advancement (MMA) may be performed for complex malocclusion and OSA. Although orthodontic management followed by MMA has been the gold standard in managing complex cases, the surgery first approach for treatment of malocclusion has increased in popularity because of decreased treatment time and improved patient quality of life. MMA continues to be the gold-standard for treatment of refractory sleep apnea. Technological advancements, including 3D printing and virtual surgical planning, have enhanced the patient experience and provided more efficiency to this surgery.

SUMMARY

First introduced in the 19th century, orthognathic surgery has continuously been refined. Over the last few decades, there has been increasing support for a surgery first approach in the treatment of malocclusion. MMA has revolutionized the surgical treatment of OSA and provides the best opportunity for success or cure in patients with complex obstructive patterns. Technology has enhanced the surgical process and created more efficiency for the surgeon and patient. VIDEO ABSTRACT: http://links.lww.com/COOH/A40.

Clinical, esthetic, and quality of life outcomes after telegnathic surgery in Caucasian OSAS patients

OBJECTIVE

To carry out both an objective and subjective assessment of the facial esthetics, clinical outcome, and quality of life evaluation in 25 OSAS patients treated with telegnathic surgery.

METHODS

Patients were analyzed using AHI, Legan and Burstone and airway cephalometric analysis for the objective study together with youthful and esthetic perception and SF-36 health surveys for the subjective part.

RESULTS

Facial convexity, nasolabial and lower face-throat angle, upper lip protrusion, and vertical height-depth ratio improved the facial and neck esthetics, while the maxillary and mandibular prognathism increased. Eighty-eight percent considered an esthetic change on their facial profile and 52% a more youthful profile. FS-36 survey (pre- 48.86 and post-surgery 71.74) and AHI (pre- 41.32 and post-surgery 7.80) scores improved significantly.

DISCUSSION

Results after telegnathic surgery were both esthetically and clinically satisfactory. The FS-36 survey should be considered for monitoring treatment in OSAS patients.

Patient- and 3D morphometry-based nose outcomes after skeletofacial reconstruction

Patient satisfaction with the shape and appearance of their nose after orthognathic surgery-based skeletofacial reconstruction is an important, but often overlooked, outcome. We assessed the nose-related outcomes through a recently developed patient-reported outcome instrument and a widely adopted 3D computer-based objective outcome instrument, to verify any correlation in the results produced by these tools. We collected FACE-Q nose appearance reports (2 scales) and 3D nasal morphometry (10 parameters) from patients with class III skeletal pattern and congenital cleft lip palate deformity (n = 23) or developmental dentofacial deformity (n = 23) after (>12 months) skeletofacial reconstruction. The cleft and dentofacial cohorts demonstrated significantly (p < 0.001) poorer satisfaction scores with regard to the FACE-Q nostrils scale than the normal age-, gender-, and ethnicity-matched subjects (n = 107), without any significant difference in FACE-Q nose scale. The cleft cohort had significantly (p < 0.001) smaller nasal length, nasal tip projection, and columellar angle and greater nasal protrusion, alar width, and columellar-labial angle values than the dentofacial and normal cohorts; however, there were no significant differences between the dentofacial versus normal cohorts. The FACE-Q nose and nostrils scales were significantly (p < 0.001; r = -0.26-0.27) correlated to the results of the 3D morphometric analysis, with regard to nasal length, alar width, columella angle, and columellar-labial angle parameters. This study revealed differences in satisfaction with the appearance of the nose according to the type of underlying deformity, and demonstrated a significant correlation (low correlation coefficients) between the patient-reports and 3D image-based outcome measure tools, which has implications for multidisciplinary-centered research, auditing, and clinical care.

Measuring patient-reported outcomes in orthognathic surgery: Linguistic and psychometric validation of the Mandarin Chinese version of FACE-Q instrument

Background

Orthognathic surgery is useful for correction of dental malocclusion and improvement of facial appearance. The FACE-Q is a patient-reported outcome instrument for evaluation of surgical and psychosocial effect. The purposes of this study were to conduct a linguistic validation of all FACE-Q scales to Mandarin Chinese, to test the orthognathic surgery-related scales for reliability and validity, and to evaluate the effect of orthognathic surgery.

Methods

All FACE-Q scales and checklists were translated from English to Mandarin Chinese according to international recommendations: forward translations, backward translation, and cognitive interviews. Psychometric testing of orthognathic surgery-related scales of translated version was administered to patients with facial deformities and history of orthognathic surgery (n = 53; 17 scales) or no history of orthognathic surgery (n = 44; 11 scales), and control subjects (n = 57; 11 scales).

Results

All FACE-Q scales and checklists were linguistically validated into Mandarin Chinese. The contents were confirmed valid among Mandarin Chinese-speaking population. The FACE-Q scales had excellent internal consistency (Cronbach's alpha >0.70) and discriminated (p < 0.05) well between patients before and after orthognathic surgeries and normal subjects.

Conclusions

This study discovered significant benefit of orthognathic surgery on improving facial appearance and psychosocial function, as compared with the non-surgical patients and normal controls.

Patient-centered evaluation of alignment changes during the first stage of orthodontic treatment: A longitudinal observational study

Background. The aim of this longitudinal observational study was to evaluate patients’ perceptions of alignment changes during the first stage of fixed orthodontic treatment. Methods. Ninety-three non-extraction patients (mean age: 17.6 years) who were scheduled to undergo fixed-appliance treatment in the first author's private office were included. Patients assessed the alignment of their teeth subjectively using visual analogue scale at the bonding session and four, eight and 12 weeks later. The amount of Little's irregularity index at each session was calculated on stone casts. Freidman test was used to compare the "alignment changes" between different intervals. Correlation coefficients were calculated using Spearman test between Little’s irregularity indices and alignment scores reported by the patients in each session. Results. No patients reported regression in alignment changes during three-month course of treatment. The final changes (from bonding session to the 12th-week visit) were smaller than the sum of the three intervals, which indicated that patients became more perceptive as the treatment progressed. Comparison of two scores reported for each session (in the same session and in the next session) revealed that patients could not recall their previous situation well. Patients do not perceive alignment changes in the same way as clinicians. Furthermore, patients who were 16 or older perceived smaller alignment changes during the first four-week period and smaller final alignment changes. Conclusion. To obtain better patient compliance and improve their motivation throughout orthodontic treatment, patientspecific measures should be undertaken, including reminding them about their initial conditions and highlighting the changes as the treatment progresses.

Satisfaction with Orthodontic Care Provided in a University Orthodontic Clinic

Objective:

To evaluate patients’ satisfaction with their orthodontic care at the Department of Orthodontics of University of Athens.

Materials and Methods:

The study sample comprised of 100 individuals whose orthodontic treatment had been completed during the period May to October 2010. A questionnaire was designed and piloted before the telephone interviews were carried out. Questions concerned socio-demographic characteristics, reason for seeking care at the Dental School, level of satisfaction with treatment outcome, fees paid for treatment, and various aspects of organisation of care provision, assessed on 1-very dissatisfied to 5-very satisfied Likert type items.

Results:

Satisfaction score was particularly high as far as treatment outcome (53% were “very satisfied” and 31% were “satisfied”), dentist’s response to an emergency (81% were “very satisfied”), and personnel’s behavior at initial examination (81% were “very satisfied”) were concerned. Factors appearing to require improvement were the waiting time from initial examination to the beginning of treatment, the waiting room and the duration of treatment. Overall satisfaction was found to be significantly associated with total duration of treatment, fees paid by patients, treatment outcome, the behaviour of personnel who conducted first clinical examination, and dentist’s response to an emergency. Overall satisfaction was confirmed as the vast majority of patients (97%) would recommend the Orthodontic Clinic.

Conclusion:

While the Orthodontics Clinic enjoys overall highly satisfied patients, there is scope for improvement of organizational aspects of care provision like the waiting time between the initial examination and the beginning of treatment, the waiting room and the duration of treatment.

Transcultural adaptation and validation of the Spanish language version of the questionnaire OQLQ for the assessment of quality of life in orthognathic patients

Background

Orthognathic surgery is the cornerstone of the treatment of dentofacial deformities, which have a great psychological and social impact on the life of the patient. Patient satisfaction and the impact on quality of life have recently become clinical parameters of growing importance. The aim of this study was to undertake a transcultural adaptation, translation to Spanish and validation of this version of the questionnaire OQLQ, used to measure quality of life in the context of Spanish culture.

Material and Methods

Validation of the OQLQ questionnaire to the Spanish language was carried out through the methodology of translation and back translation, conceptual equivalence and piloting. The Spanish version was applied through a cross-sectional study to a total of 50 patients undergoing orthognathic surgery.

Results

The adapted and validated version showed adequate metric properties of reliability, change sensitivity and validity. In this study, a positive impact of orthognathic surgery on the specific quality of life was evident in 96% of patients, with an average improvement of 58% with respect to the initial score.

Conclusions

Dentofacial deformities have a marked negative impact on the lives of patients, with orthognathic surgery being a therapeutic tool of great value in improving the quality of life in social, functional and aesthetic terms. The pilot test of this Spanish language version of the OQLQ proved valid for the assessment of quality of life in Spanish-speaking orthognathic patients or those with a Spanish culture. Key words:Orthognathic surgery, quality of life, validation studies, dentofacial deformities, patient satisfaction, treatment outcome.

Patient satisfaction and quality of life changes after Invisalign treatment

INTRODUCTION

Our objective was to assess patient satisfaction and changes in oral health-related quality of life immediately after orthodontic treatment using the Invisalign system (Align Technology, Santa Clara, Calif).

METHODS

Adult patients were recruited from private practices in Canada and surveyed using a combination of 2 validated questionnaires: Dental Impact of Daily Living and Patient Satisfaction Questionnaire. This 94-question assessment focused on various dimensions of satisfaction and changes in quality of life. Multivariate analysis of variance, regression analysis, and canonical correlation analysis were applied in the data analysis.

RESULTS

A total of 81 patients, 29.6% men and 70.4% women, exclusively treated with the Invisalign system participated. The most significant improvements were seen in the appearance and eating and chewing categories, with patients responding positively to more than 70% of the questions in those categories. Food packing between teeth, affecting 24% of the participants, and pain affecting 16% were the most common sources of dissatisfaction. However, these negative experiences were not strong enough to reduce the overall positive experience that patients reported. Appearance and dentofacial improvement were strongly correlated. Canonical correlation of the Patient Satisfaction Questionnaire factors showed that doctor-patient relationship had a significant correlation with situational aspects, dentofacial improvement, and the residual category. Phrases from the doctor-patient relationship category such as "the orthodontist treated me with respect" and "carefully explained what treatment would be like" were associated with higher patient satisfaction.

CONCLUSIONS

Although positive changes in appearance and eating categories were linked with patient satisfaction, doctor-patient relationship was the factor that correlated better with multiple aspects of patient satisfaction.

Evaluation of the Post Orthognathic Surgery Satisfaction: a Comparative Cross-Sectional Study of Patients Class II and III

The aim of this study was to analyze the degree of postoperative satisfaction regarding facial and dental esthetics, masticatory and respiratory function, and psychosocial factors in patients with dentofacial deformity Class II compared with Class III. The patients were divided into 2 groups with 50 patients in Group 1 (Class II) and 30 patients in Group 2 (Class III). Assessing the degree of postoperative satisfaction, the authors did not observe a significant difference between the groups in terms of improvements in the aesthetic and functional aspects and the psychological impact of the treatment. It can be concluded that regardless of the type of dentofacial changes, the treatment well indicated and conducted, results in significant positive effects on patients lives, both aesthetically and in the function, and psychosocial great benefit.

The Medical Legal Aspects of Surgery First and a New Model of Consent Form

The introduction of "surgery first" has resulted in a new requirement to compare and resolve medical legal problems which previously did not exist in traditional orthognathic surgery. The first issue relates to the relationship between the doctor and the patient and, in particular, the need to create a new informed consent form for surgery first. The second problem that has arisen with the arrival of surgery first concerns the relationship between health workers, namely the surgeon, and the orthodontist. The authors of this article propose a new template for informed consent specifically created for surgery first and also a model for the new working relationship between surgeons and orthodontists which will facilitate and improve co-operation between them. This will improve results, and guarantee a greater level of protection for the surgeon. It will also enable the identification the individual responsibilities of each person.

Precision of Le Fort I osteotomy: planning versus outcome. A multi-centre retrospective study

INTRODUCTION

The purpose of this study was to evaluate the accuracy of Le Fort I surgery by comparing planned surgical movements with actual outcomes.

MATERIALS AND METHODS

A minimum number of seven consecutive cases that had undergone a Le Fort I osteotomy procedure alone or in combination with a mandibular osteotomy from six different hospital units in the East of England between 2009 and 2010 were identified. A total of 56 cases met the inclusion criteria where surgical splints were used and model surgery had been performed. Pre- and post-operative lateral cephalograms were digitised using Dolphin^© imaging software (Version 10.0) and three cephalometric points were assessed to measure precision of surgical movements: A point (A-pt); Upper incisor tip (U1 tip); and Upper first molar occlusal point (U6 occ). The final position of the maxilla was compared to the planned position.

RESULTS

In 71% of cases surgical movements were within 2 mm and 20% of this group were within 1 mm of the predicted position. The mean accuracy was 1.39 mm (SD 0.92 mm) for the former and 0.78 mm (SD 0.58 mm) for the latter. Accuracy correlated negatively with increased surgical complexity, particularly posterior differential impactions of the maxilla. There was no statistically significant difference between centres.

CONCLUSIONS

Pre-operative surgical planning of Le Fort I osteotomies was generally accurate. This study demonstrates that different operators across six centres produced consistent surgical outcomes and this confirms previously reported data.

Informed consent comprehension and recollection in adult dental patients: A systematic review

BACKGROUND

Patients' ability to recollect and comprehend treatment information plays a fundamental role in their decision making.

TYPES OF STUDIES REVIEWED

The authors considered original studies assessing recollection or comprehension of dental informed consent in adults. The authors searched 6 electronic databases and partial gray literature and hand searched and cross-checked reference lists published through April 2015. The authors assessed the risk of bias in the included studies via different validated tools according to the study design.

RESULTS

Nineteen studies were included: 5 randomized clinical trials, 8 cross-sectional studies, 3 qualitative studies, 2 mixed-methods studies, and 1 case series. Conventional informed consent processes yielded comprehension results of 27% to 85% and recollection of 20% to 86%, whereas informed consent processes enhanced by additional media ranged from 44% to 93% for comprehension and from 30% to 94% for recollection. Patient self-reported understanding ranged positively, with most patients feeling that they understood all or almost all the information presented. Results of qualitative data analyses indicated that patients did not always understand explanations, although dentists thought they did. Some patients firmly stated that they did not receive any related information. Only a few patients were able to remember complications related to their treatment options.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Results of this systematic review should alert dentists that although patients in general report that they understand information given to them, they may have limited comprehension. Additional media may improve conventional informed consent processes in dentistry in a meaningful way.