Handbook of Orthognathic Treatment

A Team Approach

Ashraf Ayoub, Balvinder Khambay, Philip Benington, Lyndia Green, Khursheed Moos, Fraser Walker

• Publisher: Wiley
• Year: 2013
• Print ISBN: 9780470659052
• eBook ISBN: 9781118709498
• Edition: 1
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

This handbook provides a short, contemporary text on the management of dentofacial deformities. The importance of a well organised, inter-disciplinary approach is emphasised throughout and the following key areas are presented:

• A detailed account of the role of the psychologist, from initial assessment through to post-operative support.
• A systematic approach to dentofacial assessment, including a section on diagnostic records and an overview of cephalometry.
• A logical step-by-step approach to treatment planning, emphasising the interactive thought process required when setting orthodontic and surgical objectives.
• The fundamentals of surgical orthodontics, with the scope and limitations of orthodontic appliances clearly explained for each phase of treatment.
• A description of orthognathic technical procedures and how potential errors can be minimised in order to improve the accuracy of model surgery.
• An account of how to carry out photo-cephalometric profile prediction planning, including a critique of the method.
• A detailed description of the full range of mandibular and maxillary orthognathic surgical procedures, including indications and complications.
• A chapter on higher-level osteotomies for the treatment of more severe craniofacial abnormalities is included for completeness.
• A series of six contrasting case studies.

There is an emphasis on the technological advances that are rapidly enabling the global paradigm shift from 2D to 3D planning.

1

Psychological considerations for the orthognathic patient

---

Chapter overview

Intended learning outcomes

1.1 Psychological issues associated with facial appearance

1.2 Psychological assessment

1.2.1 Patient perception of the presenting clinical problem

1.2.2 Patient expectation of treatment

1.2.3 Patient motivation for treatment

1.2.4 Patient's psychological status

1.2.5 Outcome from psychological assessment

1.3 Advice on management of patients following assessment

1.4 Red flag and amber flag patients

1.4.1 Red flags

1.4.2 Amber flags

1.5 Psychological therapeutic input to patients during treatment

1.5.1 Pre-surgical orthodontics

1.5.2 Surgical planning stage – patient preparation for surgery

1.5.3 Psychological input following surgery

1.6 Conclusion

1.7 References

---

---

Intended learning outcomes

By the end of this chapter the reader should:

• Understand the role of a clinical psychologist in an Orthognathic Service.
• Be able to explain the psychological impact of dentofacial anomalies.
• Be able to identify factors which may impact on patient satisfaction with treatment.
• Be able to identify psychological conditions which may not be helped by orthognathic treatment.

---

This chapter describes the role of a clinical psychologist, as an integral part of the multi-disciplinary team, in a dentofacial planning clinic. It covers:

• Psychological issues in facial appearance.
• Psychological assessment.
• Advice on the management of patients' psychological issues.
• Identification of patients with psychological problems which impact treatment.
• Psychological therapeutic input within this setting.

1.1 Psychological issues associated with facial appearance

A person's face is the most visible aspect of their appearance and is what other people focus on, during social interaction. Those with severe malocclusions may have been stared at, bullied, discriminated against most of their lives. Even when their condition may evoke a sympathetic response there may be an unintentional, negative non-verbal response from others which may be difficult for those people to suppress. As a result of these negative experiences, people with a facial deformity may go on to exhibit shyness and defensiveness in social situations, which compounds their social difficulties. Even those with more minor physical problems may be seen as less attractive, less socially competent and they may also have been subjected to teasing with resulting impact on their body image and self-esteem. MacGregor (1970) suggests that people with a minor anomaly such as “buck teeth” may evoke amusement, be a target of jokes and experience more actual direct comments about their appearance than those with more severe problems. Bull and Rumsey (1988) have conducted a number of experiments, in real life situations, which demonstrate the negative responses of others to a minor facial anomaly. Having an atypical facial appearance can therefore constitute a severe handicap in a wide range of situations and can affect social acceptance and social functioning in addition to the associated physical problems.

In addition to the objective features of the face, with its social implications, the psychological aspects of appearance also include the concept of body image. This is the person's subjective representation of their bodily experience and appearance. Cash (2006) has described body image as a multi-dimensional construct, encompassing both an individual's perception of and attitude towards their appearance. This involves their thoughts, feelings and behaviour in relation to their appearance. Their body image evaluation influences their level of satisfaction with appearance and will be influenced by cultural, ethnic and gender issues. The salience of attractive appearance, for that person, will also influence their associated distress with an objective or perceived anomaly. This helps explain why there is not a linear relationship between degrees of facial deformity and associated psychological disturbance.

Dental appearance plays an important part in body image assessment both in adolescence and adulthood. It is only one aspect of someone's face but it can independently influence how attractive a person is perceived to be. Both the individual themselves and other people rate someone with severe malocclusion as less popular and less sociable. Cunningham et al. (2000) found that orthognathic patients had poorer body image and facial body image than a matched non-clinical control group. Those most dissatisfied with their dental appearance are reported to be firstly those having an extreme overjet, secondly, an extreme deep bite and thirdly, space abnormalities (Helm et al., 1985). Combined orthodontic and orthognathic surgical treatment is now more readily available and there is more awareness of it. The majority of people undergo such treatment in order to improve function, but it also has an impact on the aesthetic appearance of their face. Indeed many people presenting for treatment in clinics do not have a severe malformation and are seeking treatment primarily for aesthetic reasons. In this situation, surgery is being carried out with the objective of improving the individual's body image. Even for those people who report a clear physical reason for undergoing orthognathic treatment, in a majority of cases, it is the aesthetic outcome from treatment that will determine their satisfaction with treatment.

Patients' expectation of orthognathic treatment is that it will improve both physical problems and their appearance, with resulting improvement in their body image, self-esteem and social functioning. In some cases the change in appearance can be quite marked, whereas in others the changes may be more subtle. Patients have to adapt to the change in their appearance and to deal with the response of others, or conversely the lack of response, to these changes. Most patients cope well with the treatment process and are happy with the outcome; for a minority however, treatment appears to have some negative psychological effects. Equally, psychological factors have an impact on physical response to treatment and to patients' level of satisfaction with it. There is therefore a complex interaction between oral functional and aesthetic factors in orthognathic treatment and between the physical and psychological aspects of treatment.

1.2 Psychological assessment

The psychological assessment takes place within the dentofacial planning clinic, before the patient is seen by the rest of the multi-disciplinary team. It is conducted in a one to one setting, in order to maximise the information obtained, as patients are much more likely to disclose information in that situation. The assessment does require a clinical psychologist with considerable experience of both psychological problems associated with appearance and also of the issues relating to the transitional period from late adolescence to adulthood (as the majority of patients seen are in this age group). It is a brief, focused psychological assessment covering the areas known to be relevant to patient satisfaction with the process and outcome of orthognathic treatment. The kind of information provided to the multi-disciplinary team includes:

• Patient's perception of the presenting problem and associated functional impact.
• Patient's motivation for and expectation of treatment.
• Patient's current psychological status and early identification of those patients who may need psychological support during treatment.
• Identification of those whose perceived problem is unlikely to be resolved by treatment.
• Assessment of risk factors predicting dissatisfaction with treatment.

1.2.1 Patient perception of the presenting clinical problem

Assessment of the patient's perception of the presenting clinical problem seeks to identify what exactly bothers them, how severe they perceive it to be and the impact it is having on their everyday life.

Patient's view of the clinical problem

It is important, at this initial stage, to understand what the patient thinks about the referred problem because a patient's perceived need for treatment may not always match the clinician's view. They may have a relatively uninformed view of the problem or they may be quite knowledgeable. Initially they are asked, irrespective of what they have been told or heard or read, what exactly bothers them and why. A more structured format follows the initial open ended questions in order to cover the relevant areas.

Functional and aesthetic concerns

It is important to understand the relative importance of physical functional problems and aesthetic concerns for the patient, associated with the malocclusion they present with. Patients may find it easier to discuss the functional concerns but may feel that their aesthetic concerns will be considered to be less important by clinicians. Jensen (1978) maintains that the evidence suggests that many patients conceal their aesthetic motivation for surgery. It may therefore be necessary to encourage patients to describe the aesthetic aspect of their concern. The relative importance of the functional and aesthetic concern, for the patient, is important when decisions are being made to proceed with treatment. If for example, the patient is primarily interested in aesthetic change and the team concludes that there is little chance of noticeable aesthetic change or the possibility of a negative effect then clearly the patient's concerns will not be met and they are likely to be dissatisfied with the outcome.

Perception of severity

The need to proceed with treatment is also influenced by the perceived severity of the problem both by the clinicians and the patient. The use of a Visual Analogue Scale, with defining markers at each pole, can be helpful in assessing the degree of concern a patient feels both about how severe they feel that the physical problem is and also the degree of distress they experience associated with the problem. There is no linear relationship between the degree of objective physical deformity and the severity of psychological disturbance associated with appearance reported by patients. So that someone presenting with marked facial problems may report little aesthetic concern, whereas others with some minor anomaly, which clinicians may consider to be within a normal range, may present with significant aesthetic concern. This latter group may require further more detailed assessment from a psychological perspective.

Not all patients who are offered surgery will accept this approach. In a study of patients with an equal objective need for surgery Bell et al. (1985) found that the patient's own perception of their face was a more important determinant of whether or not they accepted treatment. In general, lay people are more likely to judge a face as normal compared to surgeons and orthodontists. The authors of the study suggest that the patient's perception of their facial aesthetics should be of primary concern when alteration of facial aesthetics is being considered.

Impact on life

The reported impact that concern about appearance is having on the patient's everyday life is also assessed. This may require careful assessment in order to gain a realistic picture and to avoid both under-reporting and over-reporting of associated difficulties. Information about the onset of their concern, when this happened and if there were any particular triggers for it. Occasionally, patients may be referred who have not been aware of problems with their facial appearance prior to initial referral, but when the problem has been identified and named, may begin to become more self-conscious about their appearance. Equally, there may be patients who have been concerned about their facial appearance from an early age and this may have had a significant impact on their social and emotional development. The reported impact of the perceived problem is therefore assessed both in the past and on their current functioning.

Patients are asked if they have consulted anyone else in the past about the problem or had any previous treatment for it. A more general assessment of their body image is also made, asking for example, if there are other aspects of their face or body that they dislike and have considered changing by surgery or some other means. A history of any previous cosmetic type procedures undergone is also noted and this should include cosmetic dentistry.

In addition to the patient's description of the impact of their concern about their appearance, the psychologist will also observe their behaviour. For example, observing a patient automatically cover their mouth with their hand when smiling, gives important information about the behavioural aspects of their body image concern. Again, if a patient has problems establishing or maintaining eye contact then this may indicate a severe body image problem or a psychological condition such as social anxiety.

The assessment of the patient's perception of the presenting clinical problem is important for the team discussion and comparisons made with the clinical view of the problem, in order to avoid problems associated with disproportionate concern about appearance and dissatisfaction ultimately with treatment outcome.

1.2.2 Patient expectation of treatment

A second main area of the psychological assessment involves looking at the patient's expectation of treatment both from a physical and a psychological ...

Table of contents

• Cover
• Title page
• Copyright page
• List of authors
• Foreword
• Preface
• 1: Psychological considerations for the orthognathic patient
• 2: Dentofacial assessment
• 3: The treatment planning process
• 4: The role of orthodontics
• 5: Orthognathic technical procedures
• 6: Prediction planning
• 7: Basic orthognathic surgical procedures
• 8: High level osteotomies
• 9: Case reports
• Index