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Journal of Orthodontics, Vol. 36, No. 1, 61-66, March 2009 doi:10.1179/14653120722923
© 2009 British Orthodontic Society
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Features Section

Orthognathic treatment: see how they feel?

Susan J. Cunningham and Justin Shute

UCL Eastman Dental Institute and Eastman Dental Hospital, UCLH Foundation Trust, London, UK

Address for correspondence: Susan Cunningham, UCL Eastman, Dental Institute, 256 Gray’s Inn Road, WC1X 8LD, London, UK Email: S.Cunningham{at}eastman.ucl.ac.uk

Received 5 April 2008; accepted 7 October 2008


   Abstract
Top
 Abstract
Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
As clinicians we are becoming increasingly careful in our pre-treatment screening processes and in acknowledging the importance of psychological assessment of potential orthognathic patients. However, this does not necessarily guarantee post-treatment satisfaction, even if the clinician thinks the clinical outcome is good. This paper provides the clinician with a schematic framework of those factors which may affect post-treatment outcomes.

Key words: Orthognathic treatment, Outcomes, Psychology, Satisfaction


   Introduction
Top
 Abstract
 Introduction
Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
The management of orthognathic patients involves a number of important aspects including the clinical examination, use of radiographs and other imaging techniques, study models and photographs and, in many cases, surgical predictions using specialist software such as QuickCephTM or DolphinTM. Increasingly, clinicians are also acknowledging the value of considering the patient’s psychological status and placing it on a par with clinical assessment in terms of importance.1Go

The management of patients from a psychological perspective is not a one-off procedure which is undertaken at the initial assessment and can then be forgotten about. It is a continuing process throughout treatment from the very first visit through to the post-debond phase, involving a two-way dialogue between patient and clinician. Some of the methods which are used to obtain information are listed in Table 1Go and what is immediately obvious is the importance of communication and building a rapport with the patient. This then raises the question: If we are increasingly careful in our pre-treatment screening processes, why do we still get patients who are unhappy with the outcomes of treatment?


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  		Table 1 Important elements of patient management
 
In the initial years of research in this area, the belief was very much that if the outcome was technically good, then the patient would be happy. Gradually it became apparent that this was not the whole story and researchers then worked on the theory that two aspects contributed to patient satisfaction: a technically good result and internal patient (‘psychological’) factors and this framework was operational for some years.

In this paper, we propose an extension to this framework and suggest that there are four main aspects which contribute to patient satisfaction (Figure 1Go). There are clearly other contributing issues but we feel these are potentially the four most important influencing factors.


Figure 1
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  		Figure 1 A schematic framework for those factors contributing to patient satisfaction

 

   Technically good result
Top
 Abstract
 Introduction
 Technically good result
Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
This is one area which, as clinicians, we do have control over. That is not to say that we always achieve perfection but the quality of the result is under our control and also, to some extent, under the patient’s control depending on how well they comply with treatment. However, this aspect will not be discussed further as it is not the main subject of this paper.


   Internal patient factors
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
In the cosmetic surgery literature some, but not all, studies have suggested that depression, anxiety, personality disorders and neurosis may be associated with a poorer outcome.2Go–5Go Interestingly, two orthognathic studies have also shown that neuroticism is associated with poorer outcome.6Go,7Go Neuroticism is one of the ‘big five’ personality traits (the others being openness, conscientiousness, extraversion and agreeableness) and can be thought of as ‘the tendency to experience negative emotions such as sadness, anxiety or guilt’.8Go Whilst it is recognized that screening for neuroticism per se is complex, it seems reasonable to conclude that for patients who exhibit a high degree of distress (sadness, anxiety, etc.), a more detailed mental health assessment should be considered prior to any physical intervention.

There has been considerable investigation of the effect of personality traits and mental illnesses on outcomes in cosmetic surgery but ‘only limited rigorous scientific data that help clinicians predict who will fare poorly in psychological terms’.9Go Similar efforts have been made in the narrower field of orthognathic treatment and for both areas, body dysmorphic disorder (BDD) is consistently associated with a poor outcome.9Go,10Go

Body dysmorphic disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders IV11Go as a preoccupation with an imagined or minor defect in appearance which causes significant distress in social, occupational and other important areas of functioning, and is not better accounted for by another mental disorder (e.g. anorexia nervosa). This condition is thought to affect both genders equally and many BDD patients are single and socially isolated, with a significant impact on their psychosocial functioning.12Go,13Go The condition usually starts around the age of 12 to 13 years and patients may vividly recall the first time they worried about their appearance.13Go,14Go Patients may have one or more targets for their concerns but these may also alter over time. These patients have an intense preoccupation with certain aspects of their appearance and there are characteristic behaviours associated with BDD which are rather like compulsions: for example, inspecting the feature of concern in a mirror, comparing their appearance with other people both in their life and in the media (magazines, television, etc.), and fantasizing about how life could be if their appearance was different.

The prevalence of BDD is not well documented. A large study of the general population in the US showed a prevalence of 1.7%1Go but this may be as high as 20% in the cosmetic surgery population.16Go Interestingly, BDD was also identified in 3 out of 40 (7.5%) new adult orthodontic patients17Go and it seems likely that the prevalence in orthognathic patients is somewhere between the orthodontic and cosmetic surgery patients. The subject is included in this paper due to the potentially serious consequences if it goes undetected, rather than due to its prevalence.

What constitutes a ‘minor defect’ in the definition of BDD is not clear, and this presents orthodontists and surgeons with a difficulty. It is clearly easier to identify BDD in patients with no dentofacial abnormality than in those who have some problem. This difficulty is further complicated by the lack of any prospective studies on BDD patients and treatments which change someone’s appearance.10Go However, clinical experience and retrospective studies suggest that physical treatment alone is contraindicated in patients with BDD18Go and that, if any physical intervention is considered, it should be undertaken in conjunction with a psychiatrist/psychologist. Psychological treatment of BDD usually involves cognitive behavioural therapy (CBT).19Go–21Go Cognitive behavioural therapy is a structured and collaborative form of psychotherapy whose core idea is that thoughts, feelings and behaviour are all connected. Cognitive behavioural therapy aims to give patients more choice by helping them to recognize their own patterns of thinking and feeling, and what realistic alternatives might be open to them. Patients can then learn to exercise these choices to gain better control over their thoughts and behaviour leading to more positive emotions. A diary of BDD-related behaviours can be useful as part of this therapy. Table 2Go shows a typical diary which also illustrates the effect that BDD can have on patients’ lives. Although, the content of such diaries has not been looked at in a formal research study, the example shows the debilitating effect of this condition and also highlights why orthognathic treatment on its own is unlikely to solve all of these problems.


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  		Table 2 Example of a diary completed by a patient with BDD
 
Not all patients with BDD have the characteristic associated behaviours or admit to being preoccupied with their appearance and, in some circumstances, it is useful to ask a series of questions so that both the clinician and patient can attempt to anticipate the likelihood of dissatisfaction with the procedure. Firstly, the patient is asked to rate their current appearance on a scale from 0 to 10, where 10 is very attractive and 0 very unattractive. Secondly, they are asked what rating they hope to attain after treatment. The patient is then asked what life would be like if they achieved this level of appearance and this should be explored in some detail. The third and final question is to ask the patient how they would feel if the treatment does not go well and they only achieve perhaps a half or one point increase in their subjective appearance rating. The aim is to achieve a shared understanding of how the patient would cope with a result that falls short of their expectations of psychosocial change (as opposed to the actual physical result). Some patients experience a feeling of anger or extreme frustration when imagining such a scenario and this should suggest to the clinician that physical treatment alone carries a high risk. This form of questioning may also be utilized in other forms of treatment when the clinician is concerned about how realistic a patient’s expectations are (for example, adult orthodontic treatment or combined orthodontic-restorative treatment).

Identifying which patients may have BDD is only the first part of the problem; the second issue is to help the patient to access more appropriate treatment. One can think of this as a three stage process of: engagement,10Go broadening the agenda and then referring on to a more appropriate health professional. The first step is to fully explore the patient’s concerns and to show the patient that you understand how they feel. The next step is to broaden the discussion from the patient’s concerns about appearance to the effect these concerns are having on the rest of his/her life. Once you understand a little about this, the patient should be asked whether they have ever had any help with this distress and suggest that it would be best to refer them to their general medical practitioner (GMP).

In summary, clinicians should be interested in their patients’ psychological state, although psychological problems should not necessarily be viewed as a reason to exclude from orthognathic intervention. Clinicians should also be particularly alert to the possibility of BDD, as physical treatment alone has a clearly increased risk of patient dissatisfaction in this cohort of patients.


   Interaction and communication
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
Interaction and communication, both within the orthognathic team and between the team and the patient, are fundamental to achieving optimum patient satisfaction. The literature states that between 92 and 100% of orthognathic patients are satisfied post-operatively.7Go,22Go–24Go However, only a very small percentage of those who are dissatisfied have psychiatric disorders such as BDD. This means that in the region of 5% are dissatisfied for other reasons. This is usually due to problems in the treatment process rather than the actual outcome and many of these issues stem from poor communication. Cunningham et al.24Go found that the majority of their respondents were happy with the outcomes of treatment and the majority of respondents also felt that the technical aspects of the operation had been well explained. However, almost a quarter felt that the effects following surgery were badly explained and it was concluded that pre-operative counselling and communication needed to be improved. The last decade has seen obvious improvements in information provision, but this aspect of care remains of fundamental importance.

Any patient requesting orthognathic intervention has certain motivating factors, these may be functional, aesthetic or a combination of the two.25Go Associated with these motivating factors, the patient has expectations of both the process and outcome of treatment and it appears to be their experience of the process and outcome, relative to these expectations which influences their ultimate satisfaction (Figure 2Go). An example which supports this theory is the longitudinal study of 74 orthognathic patients undertaken by Kiyak and colleagues26Go which showed that expectations of pain and paraesthesia were the best predictors of post-surgical outcome. The authors stressed the importance of preparing patients against unrealistic expectations if optimum results are to be obtained. Therefore, if we can give sufficient information to ensure that the experience correlates well with expectations (by intervening at the second stage in the flow diagram in Figure 2Go), it seems likely that patient satisfaction should be optimized. These expectations are not static and they do change during treatment, for example as a result of the extended duration of treatment or due to the interaction between the patient and the team. As a result, this process needs to be revisited at times during treatment to ensure that the patient still has realistic expectations.


Figure 2
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  		Figure 2 The relationship between motivation, expectations and satisfaction with orthognathic treatment

 
This can also be looked at as a cyclical process as shown in Figures 3Go and 4Go. Any consultation should start with exploration of the patient’s motivations, progressing on to a discussion of their expectations of treatment. It is then the responsibility of the clinician to explain the likelihood of these expectations being met. Logic may then dictate that consent can be taken prior to starting treatment (Figure 3Go), but the process is not quite as straightforward as this. The discussion between patient and clinician should have influenced the patient’s expectations so the cycle has to start again and the motivations and expectations re-explored. It may take a number of cycles (Figure 4Go) before the clinician feels that the patient is fully informed and can make an informed decision as to whether or not they wish to proceed with treatment and can give truly informed consent. It is also important to allow the patient adequate time between visits to allow them to take onboard all that has been said and to ensure they have considered all necessary factors in making their decision whether or not to proceed with treatment. This clearly has implications in the current climate of the 18 week wait. However, it is important that patient care/safety are not dictated by such agendas and clinicians should ensure that the ‘clock stops’ during this stage and allows the patient adequate time to make the decision as to whether or not they wish to proceed with treatment.


Figure 3
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  		Figure 3 Exploration of motivation and expectations in the informed consent process

 

Figure 4
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  		Figure 4 The cyclical process when exploring motivation and expectations

 

   Factors external to the patient and the team
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
What are the implications...
 Where do we go...
 Other areas of interest
 References
 
This is one of the most difficult areas to deal with as these issues tend to be outside the control of both the patient and the team. There are a number of aspects which may be considered under this heading but perhaps the most important is the influence of family and friends. There is evidence that those patients who have support from family and friends when making treatment decisions and immediately following surgery are those who tend to be most satisfied post-treatment.27Go,28Go Therefore, it seems logical that, if family members or friends could be encouraged to attend certain key appointments with the patient and can be told what to expect and how to help manage the patient, satisfaction levels should be optimized. At the very least, clinicians should ask patients whether they have discussed their treatment with family and friends. Those who have not done so may benefit from more in-depth psychological assessment and support.


   What are the implications of this framework?
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
Where do we go...
 Other areas of interest
 References
 
This framework proposes that there is a great deal more to achieving patient satisfaction than just producing a technically good result and that some of the most important aspects of care are communicating with the patient and showing an interest in them and what they hope to achieve from treatment. It also highlights the importance of being aware of certain complicating factors, such as BDD, and the importance of the team having a care pathway so that they know how to manage a patient about whom they have concerns.


   Where do we go from here?
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
Other areas of interest
 References
 
A recent questionnaire survey of UK consultant orthodontists showed that approximately 70% of consultants felt that at least some of their patients would benefit from referral to a mental health professional. Perhaps, not surprisingly, the main reason for not referring patients was that they had no-one to refer to.29Go There are clearly funding issues associated with this but in many situations there are potential solutions, for example, employing a clinical psychologist or liaison psychiatrist for a small number of sessions initially (perhaps one session a week or less) or linking with other specialities in the trust such as Plastic Surgery or Women’s Health who frequently work with mental health teams. Issues of clinical governance are paramount, however, and the authors believe that it is no longer acceptable to work in an isolated clinical setup without the appropriate members of the multidisciplinary team. A recent report by the National Institute of Clinical Excellence30Go stated that any clinician involved in a specialty where they may see patients suffering from BDD, should have an established referral pathway to a mental health professional experienced in the management of BDD. This is a useful publication to cite in business cases for those units attempting to gain funding for the input of a mental health professional on their orthognathic team.


   Other areas of interest
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
References
 
This article is a summary of a presentation given by the authors at the 2007 BOC and is intended only to provide an overview of this topic. The article is not a comprehensive review of the subject but highlights some of the issues related to personality, decision making, perceptions of control, adherence, communication and information provision. Interested readers may wish to explore some of these areas in more detail.


   References
Top
 Abstract
 Introduction
 Technically good result
 Internal patient factors
 Interaction and communication
 Factors external to the...
 What are the implications...
 Where do we go...
 Other areas of interest
 References
 
1 Morris DO. Improving standards in orthognathic care: the bigger picture (a national and international perspective (Editorial). J Orthod 2006; 33: 149–51.[Free Full Text]

2 Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery. Arch Otolaryngol 1975; 101: 145–51.[Abstract/Free Full Text]

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6 Kiyak HA, McNeill RW, West RA, et al. Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthod 1986; 89: 383–92.[CrossRef][Medline]

7 Finlay PM, Atkinson JM, Moos KF. Orthognathic surgery: patient expectations; psychological profile and satisfaction with outcome. Br J Oral Maxillofac Surg 1995; 33: 9–14.[CrossRef][Medline]

8 Goldberg LR. Language and individual differences: the search for universals in personality lexicons. In Wheeler L (ed.). Review of personality and social psychology. Beverly Hills, CA: Sage, 1981, 141–65.

9 Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg 2004; 113: 1229–37.[CrossRef][Medline]

10 Veale D. Body dysmorphic disorder: a review. Postgrad Med J 2004; 80: 67–71.[Abstract/Free Full Text]

11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edn. Washington DC: American Psychiatric Press, 1994.

12 Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996.

13 Veale D, Boocock A, Gournay K. Body dysmorphic disorder: a survey of fifty cases. Br J Psychiatry 1996; 169: 196–201.[Abstract/Free Full Text]

14 Phillips KA, Menard W, Fay C, et al. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Pyschomatics 2005; 46: 317–25.

15 Rief W, Buhlmann U, Wilhelm S, et al. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36: 877–85.[CrossRef][Medline]

16 Hodgkinson DJ. Identifying the body-dysmorphic patient in aesthetic surgery. Aesthetic Plast Surg 2005; 29: 503–9.[CrossRef][Medline]

17 Hepburn S, Cunningham SJ. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofac Orthop 2006; 130: 569–74.[CrossRef][Medline]

18 Phillips KA, McElroy SL, Keek PE. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150: 302–8.[Abstract/Free Full Text]

19 Rosen JC, Reiter J, Orosan P. Cognitive-behavioural body image therapy for body dysmorphic disorder. J Consult Clin Psychol 1995; 63: 263–9.[CrossRef][Medline]

20 Veale D, Gournay K, Dryden W. Body dysmorphic disorder: a cognitive behavioural model and pilot randomised-controlled trial. Behav Res Ther 1996; 34: 717–29.[CrossRef][Medline]

21 Williams J, Hadjistavropoulos T, Sharpe D. A meta-analysis of psychological and pharmacological treatments for Body Dysmorphic Disorder. Behav Res Ther 2006; 44: 99–111.[CrossRef][Medline]

22 Kiyak HA, Hohl T, West RA, et al. Psychologic changes in orthognathic surgery patients: a 24-month follow up. J Oral Maxillofac Surg 1984; 42: 506–12.[Medline]

23 Flanary CM, Barnwell GM, Jr, Alexander JM. Patient perceptions of orthognathic surgery. Am J Orthod 1985; 88: 137–45.[CrossRef][Medline]

24 Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery. Br J Oral Maxillofac Surg 1996; 34: 210–3.[CrossRef][Medline]

25 Stirling J, Latchford G, Morris DO, et al. Elective orthognathic treatment decision making: a survey of patient reasons and experiences. J Orthod 2007: 34: 113–27.[Abstract/Free Full Text]

26 Kiyak HA, McNeill RW, West RA, et al. Predicting psychologic responses to orthognathic surgery. J Oral Maxillofac Surg 1982; 40: 150–5.[CrossRef][Medline]

27 Holman AR, Brumer S, Ware WH, et al. The impact of interpersonal support on patient satisfaction with orthognathic surgery. J Oral Maxillofac Surg 1995; 53: 1289–97.[CrossRef][Medline]

28 Chen B, Zhang ZK, Wang X. Factors influencing postoperative satisfaction of orthognathic surgery patients. Int J Adult Orthodon Orthognath Surg 2002; 17: 217–22.[Medline]

29 Juggins KJ, Feinmann C, Shute J, et al. Psychological support for orthognathic patients – what do orthodontists want? J Orthod 2006; 33: 107–15.[Abstract/Free Full Text]

30 NICE Guidelines. Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder, available at: http//www.nice.org.uk (accessed 1 November 2005).




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