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Psychosocial Factors ssociated W ith

Orthodontic and Orthognathic

Surgical Treatment

SemiUa M. Rivera John P. Hatch and John D. Rugh

Recognition of the potential repercussions associated with malocclusion

has encouraged investigations aimed at understanding the psychosocial

outcomes associated with orthodontics and orthognathic surgery. Of par-

ticular interest are the benefits of treatment on judgements of self-image

and interpersonal relationships. This article examines patients adjus tmen t

to dentofacial malrelations in an attempt to assess their psychologic well-

being before treatm ent. This discussion is followed by a review of the

psychosocial benefits and negative effects associated with orthodontics and

orthognathic surgery. Although dentofacial deviations can have some social

disadvantages, candidates for corrective treatment appear to be well-ad-

justed before treatment. Long-term benefits in self-concept, body image,

and interpersonal relations after treatment are variable, with larger psycho-

social changes generally reported by orthognathic surgery patients than by

patients who receive orthodontic treatment alone. (Semin Orthod 2000;6:

259-269.)

Co p y r i g h t © 2 0 0 0 b y W B S a u n d e r s C om p a n y

s t h e n u m b e r o f o r t h o d o n t i c a n d s u r g i ca l

p r o c e d u r e s p e r f o r m e d t o c o r r e c t d e n t o f a -

c i al m a l r e l a t i o n s r is e s, t h e r e i s a g r o w i n g n e e d t o

a s se ss t h e p s y c h o l o g i c w e l l - b e i n g o f p a t i e n t s a f t e r

t r e a t m e n t . C h a n g e s i n f u n c t i o n a n d f a c i a l e s -

t h e ti c s m a y b e a c c o m p a n i e d b y i m p r o v e m e n t s i n

s e l f - im a g e a n d s o c ia l re l a t i o n s . M u c h o f t h e p a s t

l i t e ra t u r e h a s f o c u s ed o n t h e f u n c t i o n a l a n d

s t r u ct u r a l p r o b l e m s i n h e r e n t i n m a l o c cl u s i o n .

M o r e r e c e n t l y , r e s e a r c h e r s h a v e r e c o g n i z e d t h e

n e e d t o u n d e r s t a n d t h e s o c i a l a n d p s y c h o l o g i c

i m p l i c a t i o n s a s s o c i a t e d w i t h m a l o c c l u s i o n a n d

c o r r e c t i v e t r e a t m e n t . A f l o u r i s h i n g b o d y o f l i te r -

a t u r e h a s e m e r g e d i n t h i s a r e a . H o w e v e r , s t u d y

r e s u l t s a r e o f t e n q u e s t i o n a b l e d u e t o t h e i r r e t r o -

s p e ct i ve n a t u r e , l a c k o f p r o p e r c o m p a r i s o n

From the Department o f Orthodontics, The University of Texas

Health Science Center, Sa n Antonio, TX.

Supported by NIDCR grant DE0 9630.

Address co~esDondence o Semilla M. Rivera, BA, Department of

Orthodontics, The University of Texas Health Science Center; 7703

Floyd Curl Dr, San Antonio, TX 78284-7910.

Copyright © 200 0 by W.B. Saunders Company

1073-8746/00/0604-0009510. 00/0

doi: 10.1053/sodo.2000.19074

g r o u p s , o r f a i l u r e t o u s e s t a n d a r d i z e d m e a s u r e s .

F u r t h e r m o r e , m a n y s t u d i es f o c u s o n p a t i e n t s a t-

i s f a c t i o n w i t h o u t p r o v i d i n g i n f o r m a t i o n o n

c h a n g e s i n s p e c i f i c a re a s o f p e r s o n a l i t y a n d s o -

c ia l re la t ions .

P r e v i o u s r e v i e w s h a v e d i s c u s s e d t h e p s y c h o -

l o g i c a s p e c t s o f c r a n i o f a c i a l d i s f i g u r e m e n t , 1 m a l -

occ lu s ion in pa r t i cu la r . 2,3 O th e r rev iews have

e x a m i n e d t h e p s y c h o l o g ic c h a n g e s e x p e r i e n c e d

b y p a t i e n ts w h o r e c e i ve o r t h o d o n t i c t r e a t m e n t

a n d o r t h o g n a t h i c s u r g e r y . 4-6 H o w e v e r , t h e s p e -

c i fi c e ff e c t s o f t r e a t m e n t a r e o f t e n d i f f i cu l t t o

as ses s due to the s ca rc i ty o f sys tem a t ic , con-

t r o l l e d , p r o s p e c t i v e s t u d i e s t h a t e x a m i n e t h e

c h a n g e s o f t r e a t m e n t o v e r t i m e . W i t h t h e s e

p o i n t s i n m i n d , t h e f i rs t p a r t o f t h is a r t ic l e s e e k s

t o i d e n t i f y t h e e f f e c t s o f d e n t o f a c i a l m a l r e l a t i o n

o n p a t i e n t s p s y c h o l o g i c w e l l - b e i n g a n d i n t e r p e r -

sona l re la t ions . Th i s f i r s t s ec t ion e s tab l i shes a

f o u n d a t i o n b y w h i c h t o c o m p a r e t h e p s y c h ol o g i c

c h a n g e s a n d b e n e f i t s a s s o c i a t e d w i t h o r t h o d o n -

t i c a n d s u r g i c a l t r e a t m e n t , w h i c h i s t h e f o c u s o f

t h e s e c o n d p a r t o f t hi s a r ti c le . G i v e n t h e l i m i t a-

t i o n o f c a s e r e p o r t s , t h is r e v i e w f o c u se s p r i m a r i l y

o n l o n g i t u d i n a l p r o s p e c t i v e a n d w h e n a v a i l a b l e ,

Seminars in Orthodontics , Vol 6, No 4 December) , 200 0: pp 25 9-2 69 2 5 9

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260 Rivera Hatch and Rugh

controlled studies that permit assessment of

treatment effects.

Psychosocial mpact of M alocclus ion

Malocclusion has been broadly defined as phys-

ical deviations from ideal occlusal relations. 7

Malocclusions are often differentiated from

more severe forms of dentofacial malrelations

such as cleft lip and palate or severe facial injury.

Appro ximat ely 70% to 75% of the pop ulat ion is

affected by some for m o f malocclusion, s How-

ever, the psychologic and social repercussions of

these conditions are diverse and vary across

individuals and their culture. The impact of

malocclusion on psychosocial factors can be

understood in the context of 2 interrelated

processes.Z.3,9,mThe first deals with social ju dg e-

ment and responses of others to malocclusion.

The second process involves patients' selt:adjust-

ment to malocclusion. These 2 components are

discussed in turn.

S o c ia l J u d g e m e n t s o f M a l o c c l u s i on

Dental characteristics are fundamental determi-

nants of facial appearance, an impor tant factor

in personal identification and nonverbal com-

munication. 6 Nume rous studies have examine d

the effects of physical attractiveness on social

ju dg em en t a nd social relations. Hq5 Unattractive

individuals are perceived to be less liked, less

friendly, less intelligent, less successful, and less

co mpe te nt as dates and marria ge partners. H-~3

Some studies have found physical attractiveness

to be significantly associated with teachers' ex-

pectations about intelligence, popularity, and

success . /4 15 Many of these studies focus on what

Shaw16 terms bac kgr ound attractiveness whereb y

judgement of attractiveness is based on total facial

appearance.

There is reason to believe that specific facial

deviations, including malocclusion, give rise to

similar social stereotypes. Normal incisor rela-

tionships are associated with higher levels of

friendliness, social class, popularity, attractive-

ness, and lower levels of aggressiveness when

compared with prominent incisors, crowded in-

cisors, and absenc e of lateral inc isor ) v,ls

S e l f A d j u s tm e n t t o M a l o c c l u s i o n

It is suggested that patients with severe forms of

craniofacial deformities, such as cleft lip and

cleft palate are likely to internalize the negative

react ion of others, m However, findings across

studies are mixed as to the impac t of these neg-

ative responses on self-concept. Some studies

show that craniofacial patients score significantly

lower on self-concept and body image when

com par ed with a cont rol group. 2°,21 Perts chuk 22

found that although craniofacial patients scored

significantly lower on self-concept when com-

pared with a control group, scores remained

within the normative range. Furthermore, Pope

and Ward 2~ rep ort ed that craniofacial patients

scored low on global self-esteem but had no

probl ems in othe r areas of self-concept. Of par-

ticular concern is whether the social stigma at-

tached to less extreme conditions such as mal-

occlusion yields similar effects on individuals'

self-image.

Self-image relates to the implications and

problems associated with self-concept and body

image.1 Several investigators have examined the

relationship between malocclusion and self-im-

age. Most studies show that patients with maloc-

clusions have a p ositive sel f-concept ~°,24-2s an d

self-es teem. 27,29,3°-~ Wit h few exc ept ion s, 27 stud-

ies also reveal that patients with malocclusion

typically report a positive body image that is

co mpa ra ble with the gen era l p opu lat ion , m,30,3~

Several investigators have also studied the re-

lationship between malocclusion and personal-

ity characteristics in an attempt to determine if

patients seeking treatment show personality dis-

turbances. In contrast to an earlier study in

which patients reported several psychosocial

problemsy more recent research indicates that

patie nts have well a djus ted pers onal itie s2 5-27,34

Patients are comparable to the general popula-

tion on several personality characteristics includ-

ing neu rot ici sm, 4,%,27,3~ locu s of con tro l, 24 in-

troversion and extroversion2<27,30 Similarly,

presurgical scores on the symptom checklist 90

(SCL-90)fl 5 the revis ed SCL-90 (SCL-90-R), 34

and the general health questionnaire :~ indicate

that patients score near general population

norms on several dimensions of psychopathol-

ogy. The extent of psychosocial problems re-

ported in the earlier study33 may reflect a time

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Psychosocial actors and Orthodontie~

2 6 1

w h e n m a l o c c l u s i o n a n d t r e a t m e n t w e r e l es s a c -

c e p t e d . T o d a y , t h e r e is g r e a t e r a c c e p t a n c e o f a

w i d e r v a r ie t y o f oc c l u s al d e r a n g e m e n t s a n d l es s

s t i g m a p l a c e d o n c o r r e c t i v e t r e a t m e n t , s,-~ ; A l -

t h o u g h r e c e n t s t u d i e s s h o w t h a t s o m e i n d i -

v i d ua l s s c o re o u t s i d e o f t h e n o r m a t i v e r a n g e o n

s e v e r a l p e r s o n a l i t y c h a r a c t e r i s t i c s 26,34 a n e x a m i -

n a t i o n o f t h e r a n g e o f t he s e o u t l yi n g s c o r e s re -

v e a l s t h a t t h e s e s u b g r o u p s a r e o n l y s li g h tl y w o r s e

o f f t h a n t h e g e n e r a l p o p u l a t i o n .

I n g e n e r a l , t h e s e s t u d i e s o f f e r s e v e r a l c o n c l u -

s i o n s . F i r s t , d e v i a t i o n s f r o m t h e i d e a l o c c l u s i o n

c a n p r e s e n t s o m e d i s a d v a n t a g e s i n s o c i a l i n t e r -

a c t i o n s a n d i n t e r p e r s o n a l r e l a t i o n s h i p s . A m o n g

y o u n g a d u l t s a n d c h i l d r e n , i n d i v i d u a l s w i t h d e n -

t a l a n o m a l i e s a r e a t t r i b u t e d l e ss s oc i a ll y d e s i r -

a b l e p e r s o n a l i t y t r a i t s . S o m e i n d i v i d u a l s r e p o r t

b e i n g t e a s e d o r n i c k n a m e d a n d r e p o r t f e e li n gs

o f d i s t r e s s a n d a g i t a t i o n . :~7 I n t e r e s t i n g l y , s o c i a l

r e s p o n s e t o m a l o c c l u s i o n d o e s n o t a p p e a r t o

s i g n i f ic a n t l y a f f e c t a n i n d i v i d u a l s s e l f - im a g e .

T h e m a j o r i t y o f p a t i e n t s s e e k i n g o r t h o d o n t i c

t r e a t m e n t a n d o r t h o g n a t h i c s u r g e r y a r e w e ll a d -

j u s t e d . I n d i v i d u a l s w i t h m a l o c c l u s i o n r e p o r t le v -

e l s o f s e l f - c o n c e p t , b o d y i m a g e , a n d p e r s o n a l i t y

c h a r a c te r i s ti c s t h a t a r e c o m p a r a b l e w i t h t h e g e n -

e r a l p o p u l a t i o n . O t h e r i n v e s ti g a to r s h a v e d r a w n

s im i l a r co n c lu s io n s , m , :4 s

O n e e x p l a n a t i o n f o r t h e l a c k o f a s t r o n g r e -

l a t i o n s h i p b e t w e e n m a l o c c l u s i o n a n d p s y c h o s o -

c ia l p r o b l e m s i s t h a t p e o p l e a r e m o t i v a t e d t o

p r o t e c t a n d e n h a n c e t h e s e l f. 1 P a t i e n t s w i t h m a l -

o c c l u s i on m a y d e v e l o p d i f f e r e n t c o p i n g m e c h a -

n i s m s a s a d e f e n s e a g a i n s t n e g a t i v e s o c i a l j u d g e -

m e n t . A n e f f o r t m i g h t b e m a d e t o o v e r c o m e

s o c i a l s t i g m a b y d i s m i s s i n g t h o s e w h o a r e c r i ti c a l ,

o r p a t ie n t s m a y a c c o m m o d a t e f o r t h e d e v i a ti o n

b y e m p h a s i z i n g o t h e r s t r e n g th s . A s e c o n d p o ss i -

b i li t y i s t h a t t h e p e r c e i v e d s e v e r i ty o f m a l o c c l u -

s i o n i s s u b j e c t i v e . A n i n d i v i d u a l w i t h a m i l d f a c i a l

d i s f i g ur e m e n t m a y b e a f f ec t e d m o r e p r o f o u n d l y

t h a n s o m e o n e w i th a m o r e s e v e r e d e v i a t io n . 3s

F u r t h e r m o r e , m a n y p a ti e n t s w i t h m a l o c c l u s i o n

s e e k t r e a t m e n t f o r c o n g e n i t a l d e v i a t io n s r a t h e r

t h a n o n e s t h a t a r e a c q u i r e d b y i n j ur y . F o r th e

m a j o r i t y o f p a t i e n t s w i t h m a l o c c l u s i o n , p h y s i c a l

a p p e a r a n c e b e c o m e s a n i n t e g r a l p a r t o f s e lf -

i m a g e a t a v e r y y o u n g a g e , le s s e n i n g t h e i m p a c t

o f t h e se d e v i a ti o n s o n j u d g e m e n t o f s el f- w o rt h .

T h i s d o e s n o t e x c l u d e t h e p o s s i bi l it y th a t s o m e

i n d i v i d u a l s e x p e r i e n c e p e r s o n a l a d j u s t m e n t

p r o b l e m s . H o w e v e r , m o r e s e v e r e f o r m s o f f ac i a l

m a l t o r m a t i o n m a y h a v e g r e a t e r a d v e r s e e f f ec t s

o n s e l f- i m a g e t h a n d o e s m a l o c c l u s i o n .

S e v e r i ty o f a l o c c l u s i o n

T h e r e l a t i o n s h i p b e t w e e n t h e o b j e c t iv e s e ve r it y

o f a m a l o c c l u s i o n a n d p a t i e n t s p s y c h o l o g ic a d-

j u s t m e n t t o t h e d e v i a ti o n r e m a i n s u n c l e a r . M o r e

s e v e r e ca s e s o f m a l o c c l u s i o n m i g h t b e e x p e c t e d

t o p r e s e n t t h e g r e a t e s t p s y c h o l o g i c d i st r e ss . R e -

s e a r c h , h o w e v e r , s u g g e s t s t h a t i t is th e p e r c e i v e d

d e g r e e o f d i s f i g u r e m e n t a n d n o t t h e o b j e ct i ve

s e v e r i ty o f m a l o c c l u s i o n t h a t p r o v i d e s t h e g r e a t -

e s t i n f o r m a t i o n a b o u t p r e s u r g i c a l l e v e l s o f s e lf -

co n cep t , ~ °,2s an d m o r e sp ec i f i ca l l y , s e l f - e s t eem . 29,39

T h e s e v e r i t y o f m a l o c c l u s i o n i s a s s o c i a t e d w i t h

a l o w e r j u d g e m e n t o f p h y s i c a l a t t r a c ti v e n e s s , i s

F o r e x a m p l e , o v e r j e t in e x c e s s o f 9 m m l o w e r e d

c h i l d r e n s g e n e r a l a t t ra c t i v en e s s a s j u d g e d b y

o t h e r s a n d b y th e m s e l v e s , b u t d i d n o t a f f e c t

s e l f - e s t e e m o r t e a c h e r p e r c e p t i o n s . -~s R e s e a r c h

a l s o s h o w s n o s i g n i f i c a n t r e l a t i o n s h i p b e t w e e n

t h e t y p e o r o b j e c t i v e s e v e r it y o f m a l o c c l u s i o n

a n d b o d y i m a g e 7,1°,27,~9 o r p s y c h o s o c i a l d i s c o m -

f o r t . 4 ° A s s u g g e s t e d b y A l b i n o a n d T e d e s c o , ~s

t h e s e s t u di e s i n d i c a t e t h e i m p o r t a n c e o f e v a lu a t -

i n g n o t o n l y o b j e c t iv e c l in i c a l d i m e n s i o n s b u t

a l s o t h e s u b j e c t i v e p e r c e p t i o n s a n d t h e m e a n i n g

o f t h e d i s f i g u r e m e n t t o t h e p a t i e n t . T h i s wi ll

e n a b l e a m o r e c o m p r e h e n s i v e a s s e s sm e n t o f t h e

p a t i e n t s p s y c h o l o g i c a d j u s t m e n t t o m a l o c c l u -

s io n .

ulllmary

T h e r e i s l it tl e d i r e c t e v i d e n c e t h a t u n f a v o r a b l e

s t e r e o t y p i n g o p e r a t e s a g a i n s t i n d i v i d u a l s w i t h

v i s ib l e d e n t o f a c i a l m a l o c c l u s i o n s o r t h a t i t i n t e r -

f e r e s w i t h p e r s o n a l i t y d e v e l o p m e n t . 4 A l t h o u g h

i n d iv i d u a ls w i th m a l o c c l u s i o n m a y r e p o r t f e e l-

i n g n e g a t i v e l y i m p a c t e d a n d s o c i al l y d i s a d v a n -

t a g e d , 4~ t h e s e c i r c u m s t a n c e d o n o t h a v e l a r g e

n e g a t i v e r e p e r c u s s i o n s o n p a t i e n t s p s y c h o l o g ic

w e l l - b e i n g . F o r t h e m o s t p a r t , i n d i v i d u a l s w i t h

m a l o c c l u s i o n r e p o r t a p o s it i ve s e l f - c o n c e p t a n d

b o d y i m a g e t h a t is c o m p a r a b l e w i t h t h e g e n e r a l

p o p u l a t i o n . I n a d d i t i o n , f e w p a t ie n t s s h o w p e r -

s o n a l i t y d i s t u r b a n c e s . A l s o , t h e o b j e c t i v e s e v e r i t y

o f th e m a l o c c l u s i o n d o e s n o t s e e m t o b e a ss o ci -

a t e d w i th s e l f - ju d g m e n t s o f s e lf : e s te e m o r b o d y

i m a g e . P e r h a p s , a s K l i m a e t a l m s u g g e s t, t h e

p s y c h o l o g i c i m p a c t o f m a l o c c l u s i o n h a s b e e n

o v e r e s t i m a t e d . G i v e n t h a t p a t i e n t s a r e w e ll a d -

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2 6 2 Rivera Hatch and Rugh

j u s t e d b e f o r e t r e a t m e n t , i t is i m p o r t a n t t o e x a m -

i n e t h e i n f l u e n c e s o f t r e a t m e n t o n p s y c h o s o c ia l

c h a r a c t e r i s t i c s .

P s y c h o s o c i a l E f f e ct s of T r e a t m e n t

P a t i e n t E x p e c t a t i o n s

R e s e a r c h s h o w s t h a t p a t i e n t s w i t h m a l o c c l u s i o n

a r e m o t i v a t e d t o u n d e r g o c o r re c t iv e t r e a t m e n t

p r i m a r i l y f o r e s t h e t i c 42-44 a n d f u n c t i o n a l r e a -

s o n s . 41,45,46 T h e r e i s a l s o e v i d e n c e t h a t p a t i e n t s

e x p e c t c e r t a i n p s y c h o s o c i a l b e n e f i t s a f t e r t r e a t -

m e n t . F o r e x a m p l e , p a t i e n t s h o p e t h a t t r e a t -

m e n t w il l p o s i ti v e l y i n f l u e n c e i n t e r p e r s o n a l r e l a -

t i o n s h i p s a n d p s y c h o l o g i c w e l l - b e i n g 46 a s w e l l a s

i m p r o v e s e l f - c o n f i d e n c e a n d s e l f - i m a g e . 3~,4:~ I n

a d d i t i o n , p a t i e n t s e x p e c t t h a t t h e i r l i f e w i ll i m -

p r o v e i n s o m e w a y b e c a u s e o f t r e a t m e n t , a I n a n

a f o r e m e n t i o n e d s t ud y , W i c t o r in e t a 13 3 r e p o r t

t h a t 6 0 o f p a t i e n t s b e l i e v e d t h a t s e l f- c o n fi -

d e n c e w o u l d i n c r e a s e i n r e l a t i o n t o th e o p p o s i t e

s e x, a n d 5 4 b e l i e v e d t h e y w o u l d b e h a p p i e r i f

t h e i r m a l o c c l u s i o n w a s c o r r e c t e d . I t i s u n c l e a r

t h e e x t e n t t o w h i c h c o r r e c t i v e t r e a t m e n t c o n t r i b -

u t e s t o i n c r e a s e d l e v el s o f s e l f - c o n c e p t a n d s o c i a l

i n t e r a c ti o n s . T h e p h y s ic a l r e su l ts o f t r e a t m e n t

a r e u su a l ly f a v o r a b le , p r o d u c i n g i m p r o v e m e n t s

i n o c c l u s io n , f u n c t i o n , a n d f a c ia l a p p e a r a n c e .

T h e p s y c h o l o g i c im p l i c a t i o n s o f th e s e c h a n g e s

a r e le s s a p p a r e n t b u t o f e q u a l i m p o r t a n c e i n

a s s es s in g t h e i m p a c t o f t r e a t m e n t . T h e f o l lo w i n g

s e c t io n s c h a r a c t e r i z e t h e p s y c h o l o g i c c h a n g e s

t h a t f o l lo w o r t h o d o n t i c a n d o r t h o g n a t h i c t r e at -

m e n t . T h e i s s u e s a r e d i s c u s s e d s e p a r a t e l y f o r

o r t h o d o n t i c t r e a t m e n t a n d o r t h o g n a t h i c s u r-

g e ry .

O r t h o d o n t i c T r e a t m e n t

S e l f c o n c e p t .

S e l f - c o n c e p t is c o m p o s e d o f s e lf -

i m p r e s s i o n s a n d p e r s o n a l e v a l u a t io n s o f o n e ' s

s e l f - a d e q u a c y. 47 S e l f - c o n c e p t i s m u l t i d i m e n -

s i o n a l i n n a t u r e . T h e s e d i m e n s i o n s i n c l u d e s e l f -

e f f i c a c y ( i e , o n e ' s p e r c e i v e d a b i l i t y t o a c h i e v e

g o a l s t h r o u g h o n e ' s o w n e f f o r t s ) , 4 s s e l f- e v a lu a -

t i o n o f i n t e l l i g e n c e , s t r e n g t h s a n d w e a k n e s s e s ,

s e l f - e s t e e m , a n d s e l f - p e r c e p t i o n s o f p h y s i c a l a p-

p e a r a n c e ( ie , b o d y i m a g e ) .

O r t h o d o n t i c t r e a t m e n t , w h i c h o f t e n p r o -

d u c e s p o s i t i v e c h a n g e s i n f a c i a l a p p e a r a n c e , i s

a s s u m e d t o i m p r o v e s e l f - c o n c e p t ? ° A r e v i e w o f

t h e l i t e r a t u r e , h o w e v e r , p r o v i d e s l i t t l e e v i d e n c e

t o s u g g e st t h a t s e l f - c o n c e p t is e n h a n c e d a f t e r

o r t h o d o n t i c t r e a t m e n t . F o r in s t a n c e , a d u l t pa -

t i e n t s w i th m i l d - t o - s e v e r e d e g r e e s o f m a l o c c l u -

s i on , u n d e r g o i n g f i x e d - a p p l i a n c e o r t h o d o n t i c

t r e a t m e n t , s h o w n o s i g n if i c a nt d i f f e r e n c e s i n

s e l f - c o n c e p t f r o m p r e t r e a t m e n t t o 6 m o n t h s a f-

t e r t h e s t a r t o f t r e a t m e n t o r 1 to 4 w e e k s a f t e r t h e

e n d o f t r e a t m e n t Y 7 S i m il a rl y , a c o m p a r i s o n o f

o r t h o d o n t i c p a t i e n t s 1 5 m o n t h s a f t e r th e s t a r t o f

t r e a t m e n C s a n d 1 y e a r a f t e r th e c o m p l e t i o n o f

a c t i v e t r e a t m e n t 7 i n d i c a t e s t h a t s e l f - c o n c e p t i s

c o m p a r a b l e w i t h t h a t o f a g r o u p r e c e i v i n g n o

t r e a t m e n t . F u r t h e r m o r e , s e l f - c o n c e p t is n o t s i g-

n i f i c a n t ly d i f f e r e n t i n t h o s e p a t i e n t s w h o p r e s e n t

f o r t r e a t m e n t , t h o s e w h o a r e s ti ll i n r e t a i n e r s , o r

t h o s e w h o h a v e c o m p l e t e d t r e a t m e n t . 1°,49 T h u s ,

t h e l i t e r a t u r e s u g g e s t s t h a t s e l f - c o n c e p t u n d e r -

g o e s l it tl e c h a n g e o v e r t h e c o u r s e o f o r t h o d o n t i c

t r e a t m e n t a n d r e m a i n s s t a b l e a f t e r a c t i v e t r e a t -

m e n t is c o m p l e t e d .

S e v e ra l e x p l a n a t i o n s c a n b e o f f e r e d f o r t h e s e

f i n d i n g s . F i r s t , b e c a u s e t h e r e s e a r c h s h o w s t h a t

p a t i e n t s a r e c o m p a r a b l e w i th t h e g e n e r a l p o p u -

l a t i on i n r e g a r d t o s e l f- c o n c e p t b e f o r e o r t h o d o n -

t ic t r e a t m e n t , s e l f - c o n c e p t sc o r e s a f t e r t r e a t m e n t

m a y n o t s h o w l ar g e s u b s e q u e n t i m p r o v e m e n t .

S e c o n d l y, o r t h o d o n t i c t r e a t m e n t m a y n o t p r o -

d u c e s u f f i c i e n t c h a n g e s i n t o ta l fa c i a l a p p e a r -

a n c e t o s i g n if i c a n t ly i m p a c t t h e p h y s i c a l a p p e a r -

a n c e d i m e n s i o n o f s e l f -c o n c e p t. F u r t h e r m o r e ,

o r t h o d o n t i c s r e q u i r e s t h a t p a t i e n t s w e a r a p p li -

a n c e s t h r o u g h o u t t h e c o u r s e o f t r e a t m e n t . P a -

t i e n t s m a y p e r c e i v e t h e a p p l i a n c e s a s u n a t t r a c -

t iv e . T h e r e f o r e , s e l f - c o n c e p t m a y n o t h a v e a

c h a n c e t o c h a n g e v e ry m u c h d u r i n g t r e a t m e n t .

L a s t, e v e n w it h i m p r o v e m e n t s i n d e n t o f a c i a l a p -

p e a r a n c e , o t h e r d i m e n s i o n s o f s e l f - c o n c e p t m a y

h a v e a g r e a t e r i n fl u e n c e o n j u d g e m e n t s a n d

p e r c e p t i o n s o f s e l f - w o r t h t h a n d o e s t h e p h y s i c a l

a t t ra c t i v en e s s d i m e n s i o n . I t a p p e a r s t h a t i m -

p r o v e m e n t s i n d e n t a l a p p e a r a n c e f o l l o w i n g

o r t h o d o n t i c t r e a t m e n t d o n o t n e c e s sa r i ly tr a n s -

l a t e t o c h a n g e s i n s e l f - c o n c e p t .

Body image.

B o d y i m a g e i s t h e d e g r e e t o

w h i c h o n e f e e l s s a t is f i e d o r d i s s a t i sf i e d w i t h v a r-

i o u s p a r t s o r p r o c e s s e s o f t h e b o d y . 5° T h i s t e r m

is d i s ti n g u i s h a b le f r o m g e n e r a l s e l f - c o n c e p t i n

t h a t i t c o n c e r n s p e r c e p t i o n s s p e c if i ca l ly r e l a te d

t o p h y s i c a l a s p e c t s o f th e b o d y . F e w l o n g i t u d i n a l

s t u d ie s h a v e c o n s i d e r e d t h e c h a n g e s i n p a t ie n t s '

b o d y i m a g e a f t e r o r t h o d o n t i c t r e a t m e n t . S t u di e s

t h a t h a v e e x a m i n e d t h i s r e l a t i o n s h i p h a v e pro

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Psychosocial Factors and Orthodontics 963

d u c e d l i m i t e d s u p p o r t f o r su s t a in a b l e l o n g - t e r m

b e n e f i t s i n g e n e r a l b o d y i m a g e . F o r i n s t a n c e,

o n e s t u d y s h o w e d t h a t g e n e r a l b o d y a n d f a c i a l

i m a g e s i g n i fi c a nt l y i n c r e a s e d f r o m p r e t r e a t m e n t

l evel s wh en as sessed 4 weeks fo l lowing the com-

ple t io n o f ac t ive t rea tm ent . 7 A t 1 yea r fo l lowing

the co mp le t io n of ac tive t rea tm ent , s e lf -eva lua-

t ions of den to fac ia l a t t rac t ivenes s in ado lescen t s

s i g ni f ic a n tl y i m p r o v e d w h e n c o m p a r e d w i t h p r e -

t r e a t m e n t l ev e ls . 7 H o w e v e r , t h e s e i m p r o v e m e n t s

d id no t gene ra l i ze to o the r fac i a l cha rac te r i s t i c s

o r t o g e n e r a l p e r c e p t i o n s o f t h e f a c e.

Based on these s tud ies , i t can be in fe r red tha t

a t t he ea r ly s t ages fo l lowing remova l o f o r th -

o d o n t i c a p p l i a n c e s , p a t i e n t s e x p e r i e n c e a

h e i g h t e n e d p e r c e p t i o n o f o v e r a ll b o d y a n d f a ci a l

i m a g e . M t h o u g h p a t i e n t s c o n t i n u e t o m a i n t a i n

p o s it i ve p e r c e p t i o n s o f t h e i r d e n t o f a c i a l a p p e a r -

a n c e 1 y e a r a f t e r c o m p l e t i o n o f ac t iv e t r e a t m e n t ,

h e i g h t e n e d p e r c e p t i o n s r e l a t e d t o o t h e r b o d y

p a r ts o r g e n e r a l b o d y im a g e d i m i n i s h . O n e e x -

p l a n a t i o n i s t h a t i m p r o v e m e n t s t o a n y p h y s i c a l

c h a r a ct e r is t ic s m a y p r o d u c e a f al se p e r c e p t i o n

t h a t o t h e r a s p e c ts o f t h e b o d y h a v e e n h a n c e d ,

s imi l a r t o the fee l ing one ge t s a f t e r a makeover .

However , ove r t ime , t he spec i f i c changes to den-

t al f ea t u r e s b e c o m e i n c o r p o r a t e d i n t o o n e ' s s e lf -

c o n c e p t a n d t h e e n t h u s i a s m a s s o c ia t e d wi t h a

new look dec reases . Pa t i en t s may con t inu e to

b e s a t i s f i e d w i t h t h e e s t h e t i c c h a n g e s p r o d u c e d

i n d e n t o f a c i a l f e a t u r e s . H o w e v e r , a t t e n t i o n m a y

b e r e f o c u s e d o n i m p e r f e c t i o n s o f o t h e r b o d y

par t s , l ower ing prev ious ly he ld s e l f -pe rcep t ions

o f g e n e r a l b o d y i m a g e .

Social interpersonal relations

A c o m m o n a s -

s u m p t i o n o f p a t ie n t s w i t h m a l o c c l u s i o n is t h a t

improvement s in den tofac ia l a t t rac t ivenes s w i l l

evoke more favorab le soc ia l r e sponse and , i n

turn , f ac i l it a t e socia l behavior . Very few prospec -

t ive s tud ies have exam ine d the chan ges to spe -

c i f i c a t t i t udes and behaviors o f soc ia l func t ion-

i n g a f t e r o r t h o d o n t i c t r e a t m e n t . A l b i n o a n d

T e d e s c o 7 e x a m i n e d j u d g m e n t s o f d e n t a l a t tr a c -

t i v e n e s s i n a d o l e s c e n t s r e c e i v i n g o r t h o d o n t i c

t r e a t m e n t . P a r e n t a n d p e e r p o s t t r e a t m e n t r a t -

ings of these ad olescen t s w ere s ign i f i can t ly

h i g h e r t h a n p r e t r e a t m e n t r a t i n g s a n d h i g h e r

t h a n r a t i n g s o f a d e l a y e d t r e a t m e n t c o n t r o l

g r o u p . H o w e v e r , p a r e n t a n d s e l f - e v a l u a t i o n s o f

soc ia l goa l s and soc ial comp e ten cy d id no t d i f fe r

1 y e a r a f t e r t r e a t m e n t . 7 P a t i en t s w h o u n d e r g o

o r t h o d o n t i c t r e a t m e n t d o n o t r e p o r t m a j o r

p r o b l e m s s o c i a li z in g b e f o r e t r e a t m e n t . T h e r e -

fore , de t e c t ion of l a rge changes in soc ia l func -

t ion a f t e r t r ea tment may be d i f f i cu l t . Pa t i en t s

w h o e x p e r i e n c e s o c i a l s t i g m a r e l a t e d e i t h e r t o

t h e i r m a l o c c l u s i o n o r t o t h e i r o r t h o d o n t i c a p p li -

a n c e s m a y c o m p e n s a t e b y e m p h a s i zi n g o t h e r

pe rsona l i ty cha rac te r i s t i c s . Thus , soc ia l compe-

t e n c y d o e s n o t b e c o m e p r o b l e m a t i c . T h e r e -

s e a r c h e x a m i n i n g s o c i a l i n t e r a c t i o n f o l l o w i n g

o r t h o d o n t i c t r e a t m e n t i s l i m i t e d . H o w e v e r ,

based o n th e few chan ges ob se rved in s e l f-con-

c e p t a n d b o d y i m a g e a f t e r t r e a t m e n t , o n e c a n

infe r t ha t soc ia l behavior and soc ia l goa l s w i l l

g e n e r a l l y r e m a i n s t a b l e f o l l o w i n g o r t h o d o n t i c

t r e a t m e n t . H o w e v e r , f u r t h e r i n v e s t i g a t i o n i n t o

this i ssue is warranted.

dverse

effects Few psycholog ica l ly adve rse e f -

f e c ts a r e r e p o r t e d f o l l o w in g o r t h o d o n t i c t r ea t -

ment . Mos t d i s comfor t i s phys ica l and i s expe r i -

e n c e d d u r i n g t h e i n i ti a l 4 w e e k s o f t r e a t m e n t

an d du rin g a pp l ian ce ad jus tm en t vis its. 51,52 How-

e v e r , t h e s e p r o b l e m s a p p e a r t o b e s h o r t l i v e d

a n d d o n o t c a u s e a l a r g e a m o u n t o f di st re ss .

S e v e r a l s t u d i e s h a v e r e p o r t e d o n m i n o r p s y c h o -

soc ia l d i s comfor t s a s soc ia t ed wi th or thodont i c

t r e a t m e n t t h a t a r e w o r t h n o t i n g . F o r i n s t a n c e ,

ind iv idua l s wear ing braces have been t a rge t s o f

n i c k n a m i n g ; h o w e v e r , p a t i e n t s d o n o t g e n e r a l l y

rep or t be in g s e r ious ly upse t. ~7 Teas ing abo ut

den ta l app l i ances , h owever , causes anxie ty in

s o m e p a t ie n t s . 53 F u r t h e r m o r e , o n e s t u d y f o u n d

t h a t p a t i e n t s w h o i n it ia l ly c o n s i d e r e d s u r g e r y b u t

c h o s e o r t h o d o n t i c t r e a t m e n t o n l y , e x p e r i e n c e d

g r e a t e r l ev e ls o f d e p r e s s i o n , t e n s i o n , a n d a n g e r

a f t e r t r ea tm ent than d id surg ica l pa t i en t s. 54 Thi s

sugges t s t ha t t hose who an t i c ipa ted l a rge e s -

the t i c changes a f t e r surge ry may be d i s ap-

po in t ed by the l es s d ram at i c fac i a l change s pro-

d u c e d b y o r t h o d o n t i c - o n l y t r e a tm e n t . O t h e r

p r o b l e m s e x p r e s s e d i n c l u d e f e a r a n d w o r r y o v e r

b e i n g e x c l u d e d f r o m s o c i a l g r o u p s a n d s t r e s s

re l a t ed to t rea tm ent . 5~,55 In gene ra l , however ,

o r t h o d o n t i c t r e a t m e n t p r o d u c e s f e w a d v e r se r e -

ac t ions . Any advers i t i e s expe r i enced by pa t i en t s

a r e t e m p o r a r y a n d d o n o t p o s e a g r e a t t h r e a t t o

pa t i en t s ' psycholog ic we l l -be ing .

Summary O r t h o d o n t i c t r e a t m e n t d o e s n o t

s ign i f i can t ly inc rease or dec rease s e l f -concept .

H e i g h t e n e d p e r c e p t i o n s o f o v e r al l b o d y a n d f a -

c i a l image em erg e a t t he ea r ly s t ages fo l lowing

a c ti v e t r e a t m e n t . A l t h o u g h d e n t o f a c i a l i m a g e r e -

ma ins h igh , i n i t i al impro vem ent s in ove ra l l bod y

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2 6 4

Rivera Hatch and Rugh

i m a g e d e c l i n e o v e r t i m e . T h i s i m p l i e s t h a t o r -

t h o g n a t h i c t r e a t m e n t i s a b l e t o i m p r o v e s e l f -

p e r c e p t i o n s o f th e s p e c i f ic a r e a t r o u b l i n g t h e

p a t i e n t b u t m a y n o t h a v e a l a s t i n g i m p a c t o n

g e n e r a l b o d y i m a g e . T h e l i m i t ed d a t a c o n c e r n -

i n g s o c i a l b e h a v i o r f o l l o w i n g t r e a t m e n t s u g g e s t

t h a t f e w c h a n g e s o c c u r i n s o c i a l g o a l s o r s o c i a l

c o m p e t e n c y . F i n a l l y , t h e p s y c h o s o c i a l p r o b l e m s

e x p e r i e n c e d d u r i n g a n d a f t e r t r e a t m e n t a r e m i-

n o r a n d g e n e r a l ly d e c li n e o v e r t h e c o u r s e o f

t r e a t m e n t .

O r t h o g n a t h i c urgery

Self-concept.

O r t h o g n a t h i c s u r g e r y in v o lv e s

t h e u s e o f p r e o p e r a t i v e o r t h o d o n t i c a p p l i a n c e s

t o p o s i t i o n t h e t e e t h a n d s u r g i c a l p r o c e d u r e s t o

m a n i p u l a t e t h e u p p e r a n d / o r l o w e r j aw s . 56 T h e

o u t c o m e s o f t r e a t m e n t a r e o f t e n m a n i f e s t e d b y

i m p r o v e m e n t s i n o c cl u s i o n , e s th e t i cs , a n d f u n c -

t iona l ab i l i ty . Les s d i s ce rnab le a re the psycho-

l o g i c b e n e f i t s a s s o c i a t e d w i t h o r t h o g n a t h i c s u r -

g e r y , p a r t i c u l a r l y t h e c h a n g e s t h a t e m e r g e i n

s e l f - c o n c e p t . R e s e a r c h s h o w s t h a t f o l l o w i n g s u r -

g e r y , d i m e n s i o n s o f s e l f - c o n c e p t s i g n i f ic a n t ly i n -

cre ase fr om pre sur gic al levels 26,41,46,57 an d re-

m a in h igh a t 1 yea r 32 and 2 yea rs a f t e r su rge ry . 96

P a t i e n t s o f t e n r e p o r t p o s i t i v e p e r s o n a l b e n e f i t s ,

inc reased fac ia l s e l f - judgem ent , s e l f -e s teem , s e l f -

c o n f i d e n c e , a n d l o w e r l e v el s o f s e lf - c o n sc i o u s-

nes s . F in lay e t a142 a l so fou nd a t ren d towa rd

i n c r e a s e d l e ve l s o f s e lf - e s t e e m a t 6 m o n t h s a n d 1

y e a r a f te r s u r g e ry w h e n c o m p a r e d w i th b a s e l i ne ,

h o w e v e r t h e s e d i f f e r e n c e s w e r e n o t s i g n i f i c a n t .

I n c o n t r a s t , o t h e r s t u d i e s s h o w t h a t l e v e l s o f

s e l f - co n c e p t u n d e r g o p e r i o d s o f v ac i ll a ti o n a f t e r

surge ry . 29,5s In these l a t t e r s tud ie s , pa t i en t s '

o v e r a l l s e l f - c o n c e p t s h o w e d s o m e i m p r o v e m e n t

4 m o n t h s a f t e r s u r g e r y . H o w e v e r , al l d i m e n s i o n s

o f s e l f - c o n c e p t si g n i f ic a n t l y d e c l i n e d a t 9 m o n t h s

to l eve ls be lo w base l ine . 29 Two yea rs a f t e r su r -

g e r y , s e l f - c o n c e p t s c o r e s s i g n i f i c a n t l y i n c r e a s e d

f r o m s c o r e s at 9 m o n t h s , b u t r e m a i n e d a t o r

s ign i f i can t ly be lo w presu rg ica l l evel s . 58 Th e au-

t h o r s a t t r i b u t e d t h e d e c l i n e a t 9 m o n t h s t o f ee l -

i n gs o f d i s a p p o i n t m e n t e x p e r i e n c e d b y p a ti e n t s

w h o m a y h a v e o v e r e s t i m a t e d t h e p h y s i c a l , p s y-

c h o l o g i c , a n d s o c ia l b e n e f i t s o f s u r g e r y o r t o

p a t i e n t s w h o s e o r t h o d o n t i c b a n d s w e r e s t i l l i n

p l a c e . T h e s u b s e q u e n t i n c r e a s e a t 2 y e a r s p o s t -

su rge ry was a t t r i bu t ed to a s t ab i l i za t ion o f s e lf -

c o n c e p t o n c e a c t i v e t r e a t m e n t w a s c o m p l e t e d .

Kiyak e t a l 3° rep or ted s im i la r f luc tua t io ns in a

l a t e r s t u d y s u c h t h a t o v e r a l l s e l f - e s t e e m a n d i n

p a r t i c u l a r , p e r s o n a l s e l f - e st e e m s i g n i fi c a n tl y i m -

p r o v e d f r o m p r e s u r g i c a l l e v e l s a t f i x a t i o n r e -

m o v a l ( 6 w e e k s p o s t s u r g e r y ) b u t d e c l i n e d a t 6

m o n t h s t o l e v el s sl i g ht l y b e l o w b a s e l i n e .

U n l i k e o r t h o d o n t i c t r e a t m e n t , w h i c h p r o -

d u c e s p r i m a r i l y d e n t a l c h a n g e s , o r t h o g n a t h i c

s u r g e r y i s g e n e r a l l y a s s o c i a t e d w i t h s i g n i f i c a n t

i m p r o v e m e n t s i n s e l f - c o n c e p t a n d p e r s o n a l w e ll -

b e i n g . H o w e v e r , a s s o m e s t u d i e s s u g g e s t , p a -

t i e n t s w h o p e r c e i v e t h a t t h e o u t c o m e s o f s u r g e r y

f a ll s h o r t o f t h e i r p r e s u r g i c a l e x p e c t a t i o n s m a y

e x p e r i e n c e a p e r i o d o f d i s a p p o i n t m e n t . A s a

r e s u l t , l e v e l s o f s e l f - c o n c e p t m a y n o t m a n i f e s t

l a r g e l o n g - t e r m g a i n s .

Body image. T h e e s t h e t i c c h a n g e s a s s o c i a t e d

w i t h o r t h o g n a t h i c s u r g e r y c a n h a v e a m a j o r i m -

p a c t o n b o d y i m a g e . I n v e s t i g a t o r s h a v e b e e n

p a r t i c u l a r l y i n t e r e s t e d i n t h e d e g r e e t o w h i c h

c h a n g e s i n d e n t o f a c i a l c o m p o s i t i o n l e a d t o i m -

p r o v e d l e v el s o f g e n e r a l b o d y i m a g e . I t is su g -

g e s t e d t h a t f o l l o w i n g s u r g e r y , p a t i e n t s e x p e r i -

e n c e a h a l o e f f e c t s u c h t h a t i m p r o v e m e n t s i n

o n e a r e a o f t h e b o d y a r e g e n e r a l i z e d t o o t h e r

p a r t s o f t h e b o d y Y S o m e s t u d ie s s h o w s u p p o r t

fo r th i s no t io n . Kiyak e t a l so fo un d a l a rge im -

p r o v e m e n t i n a l l m e a s u r e s o f b o d y i m a g e b e g i n -

n i n g i m m e d i a t e l y a f t e r s u r g e r y a n d c o n t i n u i n g

u p t o 6 m o n t h s a f t e r su r g e r y . I n a d d i t i o n , t h e

i m p o r t a n c e a t t r i b u t e d t o f a c ia l a n d o t h e r p h y s i -

c a l f e a t u r e s i n c r e a s e d o v e r 6 m o n t h s . ~° S i m i l a r

i m p r o v e m e n t s i n d e n t a l , f ac i a l, a n d g e n e r a l a p -

p e a r a n c e w e r e r e p o r t e d 1 y e a r ~2 a n d 2 y e a r s 59

fo l lowing surge ry .

O t h e r s t u d i e s s h o w t h a t t h e p r i m a r y g a i n s i n

b o d y i m a g e r e l a te s p e c if i ca l ly t o j u d g e m e n t s o f

t h e f a c e a n d d o n o t n e c e s s a r i l y g e n e r a l i z e t o

o t h e r b o d y f e a t u r e s w h e n a s s e ss e d 6

mo nt hs , - ,46

9 m o n t h s , 29 a n d 2 4 m o n t h s f o l l o w i n g s u r g e ry . ~s

I t is c l e ar t h a t a f t e r o r t h o g n a t h i c s u r g e r y , le v e ls

o f b o d y i m a g e r i se . H o w e v e r , t h e r o l e t h a t s u r -

g e r y h as i n i m p r o v i n g g e n e r a l b o d y i m a g e i s

o p e n t o d e b a t e . I t is s u g g e s t e d t h a t f o l l o w i n g

s u r ge r y , p a t i e n ts m a y e x p e r i e n c e a p e r i o d o f

cogn i t ive d i s son ance . ''m ,:~ 2 This theo ry s t a te s

t h a t p e o p l e a r e m o t i v a t e d t o v ie w t h e o u t c o m e s

of a s i tua t ion t ha t i s h igh in cos t s o r r i sks in a

f a v o r a b l e w a y . T h i s m a y e x p l a i n w h y p a t i e n t s

e x p e r i e n c e f e e l i n g s o f b l is s w i t h o t h e r p a r t s o f

t h e i r b o d y . O v e r t i m e , h o w e v e r , p a t i e n t s b e g i n

t o f o c u s a t t e n t i o n o n o t h e r p h y s i c a l i m p e r f e c -

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Psychosocial Factors and Orthodon tics 2 6 5

t i o n s , a n d f e e l i n g s a s s o c i a t e d w i t h t h e h a l o e f-

f e c t m a y f a d e . A d d i t i o n a l i n v e s t i g a t i o n s a r e

n e e d e d t o f u r t h e r u n d e r s t a n d t h e l on g - t e r m

c h a n g e s i n b o d y i m a g e a f t e r o r t h o g n a t h i c s u r-

g e ry .

S o c i a l ~ i n t e r p e r s o n a l r e l a t i o n s A c o m m o n b e -

l i e f o f p a t i e n t s u n d e r g o i n g o r t h o g n a t h i c s u r g e r y

i s t h a t i n t e r p e r s o n a l r e l a t i o n s h i p s , p a r t i c u l a r l y

t h o s e w i t h t h e o p p o s i t e s e x , w il l i m p r o v e . W i t h

e n h a n c e d p e r c e p t i o n s o f se l f -c o n c e pt a n d b o d y

i m a g e , i t c a n b e h y p o t h e s i z e d t h a t p a t i e n t s w i l l

e n g a g e i n g r e a t e r s o c i a l a c t iv i ty a f t e r s u r g e r y .

S e v e ra l in v e s ti g a to r s h a v e e x a m i n e d t h e c h a n g e s

i n so c i a l r e l a t i o n s a f t e r o r t h o g n a t h i c s u r g e r y .

S t u d i e s s h o w t h a t f o l l o w i n g a d e c l i n e i n s o c i a l

a c t iv i ty d u r i n g t h e e a r l y w e e k s a f t e r s u r g e r y ,

t h e r e is a g r a d u a l i n c r e a s e i n r e c r e a t i o n a l a n d

s o c i a l a c t iv i ti e s a t 4 m o n t h s 6° a n d i n c r e a s e d l e v-

e l s o f s o c i a l p o t e n c y a n d s o c i a l r e s p o n s i v e n e s s a t

6 m o n t h s p o s t s u r g e r y . 46 P a t i e n t s a l s o r e p o r t l e ss

i n h i b i t i o n s w h e n k i s si n g , f e w e r d i s a d v a n t a g e s r e -

l a t e d t o p h y s i c a l a p p e a r a n c e , l e s s t e a s i n g , a n d

p e r c e i v e a g r e a t e r c a p a b i l i t y o f e s t a b l i s h i n g l o n g -

t e r m r e l a t i o n s h i p s . 46 T h e d e c l i n e i n s o c i a l a c t iv -

i t i e s i m m e d i a t e l y a f t e r s u r g e r y i s l i k e l y d u e t o

p o s t s u r gi c a l s w e l li n g a n d / o r m a x i l l o m a n d i b u l a r

f i x a t io n . H a t c h e t a l 4° f o u n d s i m i l a r s i g n i f i c a n t

i m p r o v e m e n t s o n t h e p s y c h os o c ia l d i m e n s i o n

s c o r e s o f t h e S i c k n e s s I m p a c t P r o f il e . S o c i a l in -

t e r a c t io n , c o m m u n i c a t i o n , e m o t i o n a l b e h a v i o r ,

a n d a l e r t ne s s b e h a v i o r p r o g r e ss i v e l y i m p r o v e d

f r o m p r e s u r g i c a l b a s e l i n e w h e n a s s e ss e d 8 w e e k s ,

6 m o n t h s , 1 2 m o n t h s , a n d 2 4 m o n t h s a f t e r s u r-

g e r y .

S o m e s t u d i e s s u g g e s t t h a t t h e s o c i a l b e n e f i t s

o b t a i n e d f r o m o r t h o g n a t h i c s u r g e r y d e c l i n e

o v e r t im e . F o r e x a m p l e , L a m e t a l 6° e x a m i n e d 5 3

p a t i e n t s ( a v e r a g e a g e = 2 3 . 5 ) , 9 m o n t h s p o s t s u r -

g e r y a n d f o u n d t h a t s o c i a l a c ti v it y l e v e ls d e c l i n e d

t o n e a r p r e s u r g i c a l l e v e l s . S i m i l a r r e s u l t s w e r e

f o u n d i n a n o t h e r

s t u d y 4 1

T h e p e r c e n t a g e o f

p a t i e n t s r e p o r t i n g p o s i ti v e c o m m e n t s f r o m o t h -

e r s i n c r e a s e d f r o m 2 t o 6 m o n t h s a f t e r s u r g e r y

b u t t h e n d e c l i n e d w h e n a s s e s s e d 18 m o n t h s f ol -

l o w in g su rg e ry . 41

S o c i a l a c t iv i t ie s w i th t h e o p p o s i t e s e x h a v e

a ls o b e e n e x a m i n e d i n u n m a r r i e d p a t ie n t s ( a ge

> 1 5 y e a r s ) f o l l o w i n g o r t h o g n a t h i c s u r g e r y . 6°

S i g n i f i c a n t i n c r e a s e s i n r e c r e a t i o n a l a n d s o c i a l

a c ti vi ti es o c c u r r e d w i t h m e m b e r s o f th e s a m e s e x

b u t d i d n o t o c c u r w it h m e m b e r s o f t h e o p p o s i t e

sex . 60

I n g e n e r a l , s o c i a l a c t iv i ty a n d i n t e r p e r s o n a l

r e l a t i o n s i m p r o v e a f t e r o r t h o g n a t h i c s u r g e r y .

S o m e s t u d i e s s u g g e s t t h a t t h e s e i m p r o v e m e n t s

d e c l i n e o v e r t i m e . O n e e x p l a n a t i o n is t h a t a f t e r

s u r ge r y , p a t ie n t s r e c e i v e a n a b u n d a n c e o f po s i-

t iv e f e e d b a c k f r o m f a n fi ly , f r i e n d s , a n d t h e i r c l i -

n i c ia n s . T h i s f e e d b a c k e n c o u r a g e s p a t i e n t s t o

e n g a g e i n g r e a t e r d e g r e e s o f s o c ia l a ct iv i ty . O v e r

t i m e , f a c i a l c h a n g e s a n d l e v e ls o f s e l f - c o n f i d e n c e

s t a bi l iz e , a n d t h e s a l i e n c e o f th e f a c i a l c h a n g e s

t o o t h e r s a s w e l l a s t o t h e s e l f d i m i n i s h e s . T h i s

m a y e x p l a i n t h e d e c l i n e i n s o c i a l a c t iv i ty a n d

p o s it i ve s o c ia l f e e d b a c k r e p o r t e d i n s o m e s t u d -

i es . T h i s d e c l i n e d o e s n o t n e c e s s a r i l y m e a n t h a t

t h e s o c i a l b e n e f i t s o b t a i n e d f r o m s u r g e r y a r e

l o st . T h i s m e r e l y s u g g e s t s t h a t p a t i e n t s a d j u s t t o

t h e i r n e w l o o k , a n d t h e e x h i l a r a t i o n f e l t i n t h e

e a r l y m o n t h s f o l lo w i n g s u r g e r y w a n e s .

T h e s e f i n d i n g s a l s o s u g g e s t t h a t c h a n g e s i n

s o c ia l b e h a v i o r w i t h r e s p e c t t o t h e o p p o s i t e s e x

o c c u r a t a s lo w e r p a c e . A n t i c i p a t i o n o f i m p r o v e -

m e n t s i n t h is a r e a o f so c i a l i z a ti o n , a n d r e a li z a -

t i o n t h a t i m p r o v e m e n t s h a v e n o t y e t o c c u r r e d

m a y p a r t l y e x p l a i n t h e d e c l i n e i n s o c ia l a c ti v it y

o b s e r v e d i n s o m e p a t i e n t s . A d d i t i o n a l t i m e m a y

b e n e e d e d b e f o r e c h a n g e s i n h e t e r o s e x u a l i n t e r -

a c t i o n s a r e o b s e r v e d .

E m o t i o n a l i m p a c t F e w st u d ie s h a v e e x a m i n e d

t h e e m o t i o n a l s t a t e o f p a t i e n t s a f t e r o r t h o g -

n a t h i c s u r g e r y . B e f o r e t r e a t m e n t , p a t i e n t s m a y

e x p e r i e n c e s o m e a n t i c i p a t o r y a n x i e ty a n d t e n -

s i o n . -~4 I n s u r g i c a l c a s e s , a n x i e t y m a y b e a s s o c i -

a t e d w i t h a p a t i e n t ' s f e a r o f s e n s o r y l o s s, s w el l-

i n g , p a i n , t h e s u r g i c a l p r o c e d u r e i ts e lf , a n d t h e

p h y s i c a l c h a n g e s a f t e r t r e a t m e n t . 46 H o w e v e r ,

t h e s e f e a r s a r e t e m p o r a r y . A f t e r s u r g e r y , r e -

s e a r c h s h o w s t h a t p a t i e n t s e x p e r i e n c e p o s i t i v e

m o o d s t a te s . O n e s t u d y f o u n d t h a t p a ti e n t s

s h o w e d i n c r e a s e d v i g o r a n d l o w e r l e ve l s o f t e n-

s i o n a n x i e t y 6 m o n t h s a f t e r s u r g e r y . ~4 I n a d d i -

t i o n , p o s i t iv e m o o d s t a t e s a n d l o w e r l e v el s o f

f a t i g ue a n d d e p r e s s i o n w e r e o b s e r v e d . 54 O t h e r

s t u d i e s f o u n d s i m i l a r r e s u lt s r e p o r t i n g l e ss s o c i a l

a n x i e t y , -~5 l o w e r l e v e l s o f d e p r e s s i o n , a n d i n -

c r e a s e d l e v el s o f w e l l - b e i n g a t 6 m o n t h s 46 a n d

g r e a t e r f e e l i n g s o f h a p p i n e s s , 1 y e a r f o l l o w i n g

s u r g e r y . 57 A l t h o u g h t h e s e s t u d i e s s u g g e s t t h a t

p a t i e n t s ' e m o t i o n a l s t a t e s a f t e r s u r g e r y a r e p o si -

t iv e , f u r t h e r r e s e a r c h i s n e e d e d o n t h is i ss u e .

d v e r s e

effects As f o u n d i n o r t h o d o n t i c t r ea t -

m e n t , p a t i e n t s r e p o r t f e w a d v e r s e p s y c h o l o g ic

e f f e c t s f o l l o w i n g s u r g e r y . T h e m o s t d i f f i c u lt p e -

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2 6 6 Rivera Hatch and Rugh

r i o d a p p e a r s t o b e i m m e d i a t e l y a f t e r s u r g e r y .

D u r i n g t h i s p e r i o d , p a t i e n t s r e p o r t i n c r e a s e d

level s o f fa t igue , l os s o f v igor , mo de ra t e l evel s o f

t ens ion and anxie ty , and on ly a s ligh t i nc rease in

depres s ion . 54 The se n ega t ive m oo d s t a te s gene r -

a l ly la s t fo r o n ly abo ut 4 to 6 weeks . Pa t i en t s who

repor t phys ica l pos t surg ica l p rob lems , such a s

p a i n , n u m b n e s s , a n d o r a l f u n c t i o n a l p r o b l e m s

a r e m o r e l ik e ly t o r e p o r t n e g a t i v e m o o d s ta t es a t

these ea r ly s tages. How ever , t hese phys ica l p rob-

l e m s d o n o t i n f l u e n c e s e l f - e s t e e m , b o d y i m a g e ,

or s a t i s fac t ion when as ses sed 9 months and 2

yea rs a f t e r surge ry . 29 Oth e rs have f ou nd no ad-

verse psyc holo gic effects fo l lowin g su rgery. 34,41

Th e d egr ee o f psycholog ic d if f i cu lt i e s expe r i -

e n c e d a f t e r s u r g e r y h a s b e e n r e l a t e d t o p a t ie n t s

co pin g s t ra tegies . K iyak e t a161 sugge s t t hat vigi-

l a n t c o p e r s ( t h o s e w h o a n t i c i p a t e m o r e p r o b -

l e m s ) m a y e x p e r i e n c e m o r e u n n e c e s s a r y a n x i e t y

t h a n d o a v o i d e r s ( t h o s e w h o e x p e c t f e w p r o b -

l e m s ) . A n t i c ip a t i o n o f p r o b l e m s m a y r e s u l t in a

se l f- fu l fi l li ng prop hecy . Thi s occ urs whe n an in i -

t ia l f a l se de f in i t ion o f a s itua t ion evokes behavio r

that con fi rm s th e fa lse bel ief . 62 In 1 s tudy, ex-

p e c t a t i o n s o f i n t e r p e r s o n a l p r o b l e m s s ig n if i-

c a n t ly i n f l u e n c e d p a t i e n t s r e p o r t s o f i n t e r p e r -

sona l re l a t ions immedia t e ly a f t e r , 4 to 6 weeks ,

and 6 mo nth s fo l lowing surge ry . 6~ In gene ra l ,

h o w e v e r , p a t ie n t s r e p o r t f e w l o n g - t e r m a d v e r s e

psycholog ic e f fec t s fo l lowing surge ry .

Summary.

O r t h o g n a t h i c s u r g e r y is a ss o c i at e d

w i th i m p r o v e d s e l f- c o n c ep t , b o d y i m a g e , a n d s o-

c i al ac tiv it i es . Howev er , t he long- t e rm benef i t s i n

t h e s e a r e a s n e e d f u r t h e r e x a m i n a t i o n . S o m e

s tud ies show tha t t hese bene f i t s dec l ine ove r

t i m e as p a t i e n t s o u t c o m e s b e c o m e s t a b il i ze d

a n d a t t e n t i o n is r e f o c u s e d o n o t h e r p h y s i c a l i m -

pe r fec t ions . Resea rch a l so shows tha t pa t i en t s

r e p o r t n e g a t i v e m o o d s t a t e s i m m e d i a t e l y a f t e r

surge ry . However , t hese s t a t e s appea r to be t em-

p o r a r y a n d i m p r o v e o v e r t i m e .

M a t u r a t i o n a l

F act ors

A d o l e s c e n c e i s a c c o m p a n i e d b y s u d d e n g r o w t h

spur t s , changes in fac i a l f ea tures , emot iona l and

h o r m o n a l c h a n g e s , a n d a g r e a t e r e m p h a s i s o n

p e e r o p i n i o n s . I t is al so a p e r i o d o f h e i g h t e n e d

levels of insec uri ty an d sel f-cr it ic ism. For individ-

ua l s w i th den tofac ia l dev ia t ions adolescence can

be d i f f i cu l t . No t on ly may pee rs be m ore c r i t ica l

of phys ica l dev ia t ions a t t h i s pe r io d b u t a l so ,

ind iv idua l s a re l i ke ly to be more s ens i t ive to

cri t ic ism. Even the smal les t phys ical deviat ions

may be magni f i ed and re su l t i n g rea te r d i s t re s s .

C o r r e c t i v e t r e a t m e n t f o r m a l o c c l u s i o n s c a n

b e v e r y i m p o r t a n t t o t h e a d o l e s c e n t . E a r ly t re a t-

m e n t m a y p r e v e n t th e d e v e l o p m e n t o f a p o o r

se l f -concept . 28 Because of the i r s t age o f deve lop-

m e n t , a d o l e s c e n t s m a y a ls o h av e m o r e p r o b l e m s

a d j u s t i n g t o t r e a t m e n t . F o r e x a m p l e , a d o l e s c e n t

pa t i en t s r ep or t h igh e r l eve ls o f pa in a f t e r a ll

p h a s e s o f o r t h o d o n t i c t r e a t m e n t , p a r t ic u l a r ly a f-

t e r d e b a n d i n g , a n d s h o w m o r e a d v e r s e p sy c h o -

l o g ic e f fe c t s t h a n d o a d u l ts a n d p r e a d o l e s c e n t

pat ien ts. 52

M a t u r a t i o n m a y a l so i n f l u e n c e t h e w a y i n

w h i c h a d o l e s c e n t s r e s p o n d t o t r e a t m e n t . I t is

sugges ted tha t s e l f - image wi l l dec rease f rom

e a r l y t o m i d d l e a d o l e s c e n c e a n d t h e n i n c r e a se t o

prev iou s l eve l s in the t een age yea rs . 63 Fur the r -

m o r e , m a t u r a t i o n m a y i m p a c t s o c i al i n t e r a c t i o n

pa t t e rns , pa r t i cu la r ly w ith the op pos i t e s ex .

C h a n g e s a t t r i b u t e d t o c o r r e c t i v e t r e a t m e n t m a y

b e i n f l u e n c e d b y m a t u r a t i o n . O n e s t u d y t h a t

c o m p a r e d p a t i e n t s w h o r e c e i v e d o r t h o d o n t i c

t r e a t m e n t w i t h a n u n t r e a t e d c o n t r o l g r o u p

found tha t s e l f -e s t eem, soc ia l goa l s , and soc ia l

c o m p e t e n c y s i g n if i ca n t ly i m p r o v e d o v e r t i m e f o r

bo th groups . 7 O t he r inves t iga tors have cau-

t i o n e d t h a t p s y c h o l o g i c c h a n g e s a f t e r t r e a t m e n t

may be influenced by maturation.97,sl,40.52

T h e r e f o r e , p a t i e n t s m a y r e p o r t f e e l i n g b e t t e r

a b o u t t h e i r a p p e a r a n c e a n d h a v e m o r e p o s i t i v e

l eve l s o f s e l f -concept and s e l f -e s t eem rega rd les s

of t rea tme nt e f fect s . I t i s neces sa ry tha t c l in i c ians

a n d r e s e a r c h e r s u n d e r s t a n d t h e i n f l u e n c e s o f

m a t u r a t i o n o n p s y c h o l o g i c a d j u s t m e n t t o m a l o c-

c l u s io n a n d t h e e f f e c ts o f m a t u r a t i o n o n t r ea t -

m e n t o u t c o m e s . I n t h e a b s e n ce o f a n u n t r e a t e d

c o n t r o l g r o u p , i n t e r p r e t i n g p s y c h o s o c i a l

changes a s d i rec t re su l t s o f t r ea tment i s i nadvi s -

able .

G e n e r a l o n c l u s i o n s

A p r i m a r y o b j e ct i v e o f o r t h o d o n t i c s a n d o r t h o g -

na th ic su rge ry i s t o improve pa t i en t s qua l i ty o f

l i fe . Thi s inc ludes cor rec t ing func t iona l de f i -

c i e n c ie s a n d i m p r o v i n g f a c i al a p p e a r a n c e s o t h a t

ind iv idua l s f ind re l i e f f ro m the phys ical dev ia -

t ions tha t d i s t ingui sh them f rom o the rs . Pa t i en t s

a r e m o t i v a t e d t o s e e k t r e a t m e n t , h o w e v e r , n o t

o n l y t o c o r r e c t f u n c t i o n a l a n d e s t h e t i c l i m i t a -

7/17/2019 1-s2.0-S1073874600800535-main


Psychosocial actors an d Orthodontics 2 6 7

t ions ; t hey a l so have psycholog ic and soc ia l

g o al s. A n u n d e r s t a n d i n g o f t h e p s y c h o s o c i a l e f-

fec t s o f ma lo cc lus io n a s we l l a s the psych osoc ia l

bene f i t s a s soc ia t ed wi th t rea tment i s e s sen t i a l .

A l t h o u g h d e n t o f a c i a l d e v i a t i o n s h a v e b e e n

his torical ly associa ted with in crea sed r isks of psy-

cholog ic ma lad jus tment and nega t ive soc ia l s t e -

r e o t y p i n g , m o d e r n r e s e a r c h s h o w s t h a t p a t i e n t s

a re gen e ra l ly ab le to ad jus t t o these dev ia t ions

and rep or t r e l a tive ly few psychosoc ia l d i f f i cu lt i e s

be fore t rea tment . S t i l l , bo th pa t i en t s and c l in i -

c i a n s e x p e c t t h a t o r t h o d o n t i c a n d o r t h o g n a t h i c

surg ica l t r ea tment s w i l l r e su l t i n improved psy-

c h o s o c i a l f u n c t i o n . C l i n i c a l e x p e r i e n c e c l e a r l y

s u p p o r t s t h e s e e x p e c t a t i o n s . P a t i e n t r e p o r t s t o

c l in i c i ans and of f i ce s t a f f fo l lowing t rea tm en t

a re mos t o f t en s t rongly pos i t ive . I t may surpr i s e

m a n y c l in i c ia n s t h a t r e s e a r c h s ho w s f ew m a r k e d

c h a n g e s i n p a t ie n t s s e l f - c o n c ep t a f t e r o r t h o d o n -

t ic t r e a t m e n t a n d o n l y t ra n s i e n t b e n e f i t s i n o v e r-

a ll b o d y i m a g e . E x c e p t w h e n p a t i e n t s r e q u i r e

o r t h o g n a t h i c s u r g e r y d u e t o f u n c t i o n a l l i m it a -

t ions or s eve re de formi t i e s , r e s ea rch has no t

shown s ign i f i can t l ong- t e rm psychosoc ia l im-

p r o v e m e n t s f o l l o w i n g c o r r e c t i o n o f m a l o c c lu -

sions.

G i v e n t h e o f t e n d r a m a t i c i m p r o v e m e n t s i n

es the t i c s , pa r t i cu la r ly fo l lowing or thogna th ic

surge ry , and pa t i en t - repor t ed s a t i s fac t ion wi th

o u t c o m e s , h o w c a n i t b e t h a t n e a r l y 3 0 y e ar s o f

r e s e a r c h p r o d u c e s o n l y li m i t e d e v i d e n c e s u p -

por t ing s ign i f i can t l ong l a s t ing psychosoc ia l ben-

e f it s? The re a re 2 pos s ib l e exp lana t ions . F i rs t, i t

i s pos s ib l e tha t t he psychosoc ia l impac t i s , i n

fac t, no t a s s ign i f ican t a s c l in i ca l obse rv a t ion has

l ed us to be l i eve . Thi s m ay be pa r t ly t rue . Jus t a s

p a t i e n t s m a y e x a g g e r a t e t h e b e n e f i t s o f t re a t -

m e n t s h o r t ly a f t e r c o m p l e t i o n , c l in i c ia n s m a y b e

subject to a s imilar halo effect . Al ternat ively, i t

m a y b e t h a t c u r r e n t r e s e a r c h m e t h o d s a r e s im p l y

inade qua te ; i e , t he r e a re s ign i f i can t psychosoc ia l

c h a n g e s , b u t t h e r e s e a r c h m e t h o d o l o g y to d a t e

h a s b e e n i n a d e q u a t e t o d o c u m e n t t h e p s y c h o s -

o c i a l c h a n g e s . T h e r e s e a r c h e x a m i n e d i n t h i s

rev iew shows tha t mos t pa t i en t s t r ea t ed for ma l -

occ lus ions a re psychosoc ia l ly hea l th y be for e

t r e a t m e n t . T h e y h a v e u su a l ly a d a p t e d t o t h e i r

ma locc lus ion , have good coping sk i l l s , have

pos i t ive se l f-concepts , and have pos i t ive socia l

suppor t sys t ems . In such a gene ra l ly hea l thy

popula t ion , i t i s d i f f i cu l t t o show fur the r im-

provement , i e , a ce i l i ng e f fec t , and bo th pos s i -

b i l it i es should b e addre s sed by fu ture re sea rch .

F u t u r e r e s e a r c h m a y b e a b l e t o m o r e c l e ar l y

d o c u m e n t p o s i t iv e p s y c h o s o c ia l c h a n g e s b y c a r e -

f u l l y c o n t r o l l i n g f o r t h e e f f e c t s o f m a t u r a t i o n ,

t h e p a t i e n t s a g e a t t r e a t m e n t , t h e t y p e a n d d e -

gree of ma locc lus ion , t he p a t i en t s cop ing sk il ls ,

t h e t i m e o f a ss e s sm e n t a f t e r t r e a t m e n t , t h e p a -

t i en t s p e r c e p t i o n o f h i s / h e r m a l o c cl u s io n , a n d

the im pac t o f fami ly and s ign i f i can t o the rs .

There is a lso the need to re-evaluate the assess-

ment me thodology . I t i s pos s ib l e tha t t he psycho-

soc ia l a s ses sment s used to da te a re no t de tec t ing

the psychosoc ia l changes tha t a re obse rved c l in -

i ca l ly . These fac tors have no t been we l l con-

t r o l l e d i n m a n y o f t h e r e s e a r c h r e p o r t s t o d a te .

P r o s p e c t i v e s t u d i e s w i t h a p p r o p r i a t e c o n t r o l

group s , ca l ib ra t ed exa mine rs , and ca re fu l ly s e-

l e c t e d p a t i e n t r e l e v a n t o u t c o m e m e a s u r e s a r e

n e e d e d .

cknowledgment

The authors thank Annie Rugh for he r technical and biblio-

graphic assistance in the preparation of this article.

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