Psychosocial Factors Associated With Orthodontic and ...€¦ · Psychosocial Effects of Treatment Patient Expectations Research shows that patients with malocclusion are motivated

Psychosocial Factors Associated With 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 particular interest are the benefits of treatment on judgements of self-image and interpersonal relationships. This article examines patients" adjustment to dentofacial malrelations in an attempt to assess their psychologic well- being before treatment. 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-adjusted before treatment. Long-term benefits in self-concept, body image, and interpersonal relations after treatment are variable, with larger psychosocial changes generally reported by orthognathic surgery patients than by patients who receive orthodontic treatment alone. (Semin Orthod 2000;6: 259-269.) Copyright © 2000 by W.B. Saunders Company

A s the n u m b e r of or thodont ic and surgical procedures pe r fo rmed to correct dentofa-

cial malrelations rises, there is a growing need to assess the psychologic well-being of patients after treatment. Changes in function and facial esthetics may be accompanied by improvements in self-image and social relations. Much of the past li terature has focused on the functional and structural problems inheren t in malocclusion. More recently, researchers have recognized the need to unders tand the social and psychologic implications associated with malocclusion and corrective treatment. A flourishing body of literature has emerged in this area. However, study results are often questionable due to their retro- spective nature, lack of p rope r compar ison

From the Department of Orthodontics, The University of Texas Health Science Center, San Antonio, TX.

Supported by NIDCR grant DE09630. Address co~esDondence to Semilla M. Rivera, BA, Department of

Orthodontics, The University of Texas Health Science Center; 7703 Floyd Curl Dr, San Antonio, TX 78284-7910.

Copyright © 2000 by W.B. Saunders Company 1073-8746/00/0604-0009510. 00/0 doi: 10.1053/sodo.2000.19074

groups, or failure to use standardized measures. Fur thermore , many studies focus on pat ient satisfaction without providing information on changes in specific areas of personality and social relations.

Previous reviews have discussed the psychologic aspects of craniofacial disfigurement, 1 malocclusion in particular. 2,3 Other reviews have examined the psychologic changes exper ienced by patients who receive or thodont ic t rea tment and or thognathic surgery. 4-6 However, the specific effects of t rea tment are often difficult to assess due to the scarcity of systematic, controlled, prospective studies that examine the changes of t rea tment over time. With these points in mind, the first par t of this article seeks to identify the effects of dentofacial malrelat ion on patients ' psychologic well-being and interpersonal relations. This first section establishes a foundat ion by which to compare the psychologic changes and benefits associated with or thodontic and surgical t reatment , which is the focus of the second par t of this article. Given the limita- tion of case reports, this review focuses primarily on longitudinal prospective and when available,

Seminars in Orthodontics, Vol 6, No 4 (December), 2000: pp 259-269 2 5 9

260 Rivera, Hatch, and Rugh

controlled studies that permit assessment of treatment effects.

Psychosocial Impact of Malocclusion

Malocclusion has been broadly defined as physical 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. Approximately 70% to 75% of the population is affected by some form of 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 judgement and responses of others to malocclusion. The second process involves patients' selt:adjustment to malocclusion. These 2 components are discussed in turn.

Social Judgements of Malocclusion

Dental characteristics are fundamental determi- nants of facial appearance, an important factor in personal identification and nonverbal com- munication. 6 Numerous studies have examined the effects of physical attractiveness on social j udgement and social relations. Hq5 Unattractive individuals are perceived to be less liked, less friendly, less intelligent, less successful, and less competent as dates and marriage partners. H-~3 Some studies have found physical attractiveness to be significantly associated with teachers' expectations about intelligence, popularity, and success./4,15 Many of these studies focus on what Shaw 16 terms "background attractiveness" whereby 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 relationships are associated with higher levels of friendliness, social class, popularity, attractiveness, and lower levels of aggressiveness when compared with prominent incisors, crowded incisors, and absence of lateral incisor) v,ls

Self-Adjustment to Malocclusion

It is suggested that patients with severe forms of craniofacial deformities, such as cleft lip and cleft palate are likely to internalize the negative reaction of others, m However, findings across studies are mixed as to the impact of these negative responses on self-concept. Some studies show that craniofacial patients score significantly lower on self-concept and body image when compared with a control group. 2°,21 Pertschuk 22 found that al though craniofacial patients scored significantly lower on self-concept when compared with a control group, scores remained within the normative range. Furthermore, Pope and Ward 2~ reported that craniofacial patients scored low on global self-esteem but had no problems in other areas of self-concept. Of particular concern is whether the social stigma at- tached to less extreme conditions such as malocclusion 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-image. Most studies show that patients with malocclusions have a positive self-concept ~°,24-2s and self-esteem. 27,29,3°-~ With few exceptions, 27 studies also reveal that patients with malocclusion typically report a positive body image that is comparable with the general population, m,30,3~

Several investigators have also studied the relationship between malocclusion and personality characteristics in an attempt to determine if patients seeking treatment show personality disturbances. In contrast to an earlier study in which patients reported several psychosocial p r o b l e m s y more recent research indicates that patients have well adjusted personalities2 5-27,34 Patients are comparable to the general population on several personality characteristics including neuroticism, "4,%,27,3~ locus of control, 24 in- troversion and extroversion2<27,30 Similarly, presurgical scores on the symptom checklist 90 (SCL-90)fl 5 the revised 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 reported in the earlier study 33 may reflect a time

Psychosocial Factors and Orthodontie~ 261

when malocclusion and t rea tment were less ac- cepted. Today, there is greater acceptance of a wider variety of occlusal derangements and less stigma placed on corrective treatment, s,-~; Al- though recent studies show that some individuals score outside of the normative range on several personality characteristics 26,34 an examination of the range of these outlying scores re- veals that these subgroups are only slightly worse off than the general populat ion.

In general, these studies offer several conclusions. First, deviations f rom the ideal occlusion can present some disadvantages in social interactions and interpersonal relationships. Among young adults and children, individuals with dental anomalies are at tr ibuted less socially desir- able personality traits. Some individuals repor t being teased or n icknamed and repor t feelings of distress and agitation. :~7 Interestingly, social response to malocclusion does not appear to significantly affect an individual 's self-image. The majority of patients seeking or thodont ic t rea tment and or thognathic surgery are well adjusted. Individuals with malocclusion repor t levels of self-concept, body image, and personality characteristics that are comparable with the general populat ion. Other investigators have drawn similar conclusions, m,:4s

One explanat ion for the lack of a strong relationship between malocclusion and psychosocial problems is that people are motivated to protect and enhance the self. 1 Patients with malocclusion may develop different coping mecha- nisms as a defense against negative social judgement. An effort might be made to overcome social stigma by dismissing those who are critical, or patients may accommoda te for the deviation by emphasizing o ther strengths. A second possibility is that the perceived severity of malocclusion is subjective. An individual with a mild facial disf igurement may be affected more profoundly than someone with a more severe deviation. 3s Fur thermore , many patients with malocclusion seek t rea tment for congenital deviations ra ther than ones that are acquired by injury. For the majority of patients with malocclusion, physical appearance becomes an integral part of self- image at a very young age, lessening the impact of these deviations on j u d g e m e n t of self-worth. This does not exclude the possibility that some individuals exper ience personal adjus tment problems. However, more severe forms of facial

mal tormat ion may have greater adverse effects on self-image than does malocclusion.

Severity of Malocclusion

The relationship between the objective severity of a malocclusion and patients ' psychologic adjus tment to the deviation remains unclear. More severe cases of malocclusion might be expected to present the greatest psychologic distress. Re- search, however, suggests that it is the perceived degree of disf igurement and not the objective severity of malocclusion that provides the greatest informat ion about presurgical levels of self- concept, ~°,2s and more specifically, self-esteem. 29,39

The severity of malocclusion is associated with a lower j u d g e m e n t of physical attractiveness, is For example, overjet in excess of 9 m m lowered chi ldren 's general attractiveness as j udged by others and by themselves, but did not affect self-esteem or teacher perceptions. -~s Research also shows no significant relationship between the type or objective severity of malocclusion and body image 7,1°,27,~9 or psychosocial discomfort. 4° As suggested by Albino and Tedesco, ~s these studies indicate the impor tance of evaluat- ing not only objective clinical dimensions but also the subjective percept ions and the meaning of the disf igurement to the patient. This will enable a more comprehensive assessment of the pat ient 's psychologic adjustment to malocclusion.

Sulllmary

There is little direct evidence that unfavorable stereotyping operates against individuals with visible dentofacial malocclusions or that it inter- feres with personality development . 4 Although individuals with malocclusion may repor t feeling negatively impacted and socially disadvan- taged, 4~ these circumstance do not have large negative repercussions on patients ' psychologic well-being. For the most part, individuals with malocclusion repor t a positive self-concept and body image that is comparab le with the general populat ion. In addition, few patients show personality disturbances. Also, the objective severity of the malocclusion does not seem to be associated with self-judgments of self:esteem or body image. Perhaps, as Klima et al m suggest, the psychologic impact of malocclusion has been overestimated. Given that patients are well ad-


justed before t reatment , it is impor tan t to examine the influences of t rea tment on psychosocial characteristics.

Psychosocia l Effects of Treatment

Patient Expectations

Research shows that patients with malocclusion are motivated to undergo corrective t rea tment primarily for esthetic 42-44 and functional rea- sons. 41,45,46 There is also evidence that patients expect certain psychosocial benefits after treatment . For example, patients hope that treat- men t will positively influence interpersonal relationships and psychologic well-being 46 as well as improve self-confidence and self-image. 3~,4:~ In addition, patients expect that their life will improve in some way because of t reatment, a In an a forement ioned study, Wictorin et a133 repor t that 60% of patients believed that self-confidence would increase in relation to the opposite sex, and 54% believed they would be happier if their malocclusion was corrected. It is unclear the extent to which corrective t rea tment contrib- utes to increased levels of self-concept and social interactions. The physical results of t rea tment are usually favorable, p roducing improvements in occlusion, function, and facial appearance. The psychologic implications of these changes are less apparen t but of equal impor tance in assessing the impact of t reatment . The following sections characterize the psychologic changes that follow or thodont ic and or thognathic treatment . The issues are discussed separately for or thodont ic t rea tment and or thognathic surgery.

Orthodontic Treatment

Self-concept. Self-concept is composed of self- impressions and personal evaluations of one ' s self-adequacy. 47 Self-concept is mult idimen- sional in nature. These dimensions include self- efficacy (ie, one ' s perceived ability to achieve goals through one ' s own efforts), 4s self-evalua- tion of intelligence, strengths and weaknesses, self-esteem, and self-perceptions of physical appearance (ie, body image).

Or thodont ic t reatment, which often produces positive changes in facial appearance, is assumed to improve self-concept? ° A review of the literature, however, provides little evidence

to suggest that self-concept is enhanced after or thodont ic t reatment. For instance, adult patients with mild-to-severe degrees of malocclusion, undergoing fixed-appliance or thodont ic t reatment , show no significant differences in self-concept f rom pre t rea tment to 6 months after the start of t rea tment or 1 to 4 weeks after the end of treatmentY 7 Similarly, a comparison of or thodont ic patients 15 months after the start of t rea tmenC s and 1 year after the complet ion of active t rea tment 7 indicates that self-concept is comparable with that of a g roup receiving no treatment. Fur thermore , self-concept is not significantly different in those patients who present for t reatment, those who are still in retainers, or those who have comple ted treatment. 1°,49 Thus, the li terature suggests that self-concept under- goes little change over the course of or thodontic t rea tment and remains stable after active treat- m e n t is completed.

Several explanations can be offered for these findings. First, because the research shows that patients are comparable with the general population in regard to self-concept before or thodontic t reatment , self-concept scores after t rea tment may not show large subsequent improvement . Secondly, or thodont ic t rea tment may not produce sufficient changes in total facial appearance to significantly impact the physical appearance dimension of self-concept. Fur thermore , or thodontics requires that patients wear appliances th roughout the course of t reatment. Pa- tients may perceive the appliances as unattractive. Therefore , self-concept may not have a chance to change very much dur ing treatment. Last, even with improvements in dentofacial appearance, o ther dimensions of self-concept may have a greater influence on judgements and percept ions of self-worth than does the physical attractiveness dimension. It appears that improvements in dental appearance following or thodont ic t rea tment do not necessarily trans- late to changes in self-concept.

Body image. Body image is the degree to which one feels satisfied or dissatisfied with var- ious parts or processes of the body. 5° This term is distinguishable f rom general self-concept in that it concerns percept ions specifically related to physical aspects of the body. Few longitudinal studies have considered the changes in patients ' body image after or thodont ic t reatment. Studies that have examined this relationship have pro-

Psychosocial Factors and Orthodontics 963

duced limited support for sustainable long-term benefits in general body image. For instance, one study showed that general body and facial image significantly increased from pre t rea tment levels when assessed 4 weeks following the completion of active treatment. "7 At 1 year following the complet ion of active treatment, self-evaluations of dentofacial attractiveness in adolescents significantly improved when compared with pre- t reatment levels. 7 However, these improvements did not generalize to o ther facial characteristics or to general perceptions of the face.

Based on these studies, it can be inferred that at the early stages following removal of orthodontic appliances, patients experience a heightened percept ion of overall body and facial image. Mthough patients continue to maintain positive perceptions of their dentofacial appearance 1 year after complet ion of active treatment, heightened perceptions related to o ther body parts or general body image diminish. One ex- planation is that improvements to any physical characteristics may produce a false percept ion that other aspects of the body have enhanced, similar to the feeling one gets after a makeover. However, over time, the specific changes to dental features become incorporated into one's self- concept and the enthusiasm associated with a "new look" decreases. Patients may continue to be satisfied with the esthetic changes produced in dentofacial features. However, attention may be refocused on imperfections of o ther body parts, lowering previously held self-perceptions of general body image.

Social interpersonal relations. A common as- sumption of patients with malocclusion is that improvements in dentofacial attractiveness will evoke more favorable social response and, in turn, facilitate social behavior. Very few prospective studies have examined the changes to specific attitudes and behaviors of social functioning after or thodontic treatment. Albino and Tedesco 7 examined judgments of dental attractiveness in adolescents receiving or thodont ic treatment. Parent and peer post treatment ratings of these adolescents were significantly higher than pre t reatment ratings and higher than ratings of a delayed t reatment control group. However, parent and self-evaluations of social goals and social competency did not differ 1 year after treatment. 7 Patients who undergo orthodontic t reatment do not repor t major

problems socializing before treatment. There- fore, detection of large changes in social function after t reatment may be difficult. Patients who experience social stigma related ei ther to their malocclusion or to their or thodont ic appliances may compensate by emphasizing other personality characteristics. Thus, social competency does not become problematic. The research examining social interaction following or thodont ic t reatment is limited. However, based on the few changes observed in self-concept and body image after treatment, one can infer that social behavior and social goals will generally remain stable following or thodont ic treatment. However, fur ther investigation into this issue is warranted.

Adverse effects. Few psychologically adverse effects are repor ted following orthodontic treatment. Most discomfort is physical and is experi- enced during the initial 4 weeks of t reatment and during appliance adjustment visits. 51,52 How- ever, these problems appear to be short lived and do not cause a large amount of distress. Several studies have repor ted on minor psychosocial discomforts associated with or thodont ic t reatment that are worth noting. For instance, individuals wearing braces have been targets of nicknaming; however, patients do not generally repor t being seriously upset. ~7 Teasing about dental appliances, however, causes anxiety in some patients. 53 Furthermore, one study found that patients who initially considered surgery but chose or thodont ic t reatment only, exper ienced greater levels of depression, tension, and anger after t reatment than did surgical patients. 54 This suggests that those who anticipated large esthetic changes after surgery may be disap- pointed by the less dramatic facial changes produced by orthodontic-only treatment. Other problems expressed include fear and worry over being excluded from social groups and stress related to treatment. 5~,55 In general, however, or thodont ic t reatment produces few adverse re- actions. Any adversities exper ienced by patients are temporary and do not pose a great threat to patients' psychologic well-being.

Summary. Orthodont ic t reatment does not significantly increase or decrease self-concept. Heightened perceptions of overall body and facial image emerge at the early stages following active treatment. Although dentofacial image remains high, initial improvements in overall body


image decline over time. This implies that orthognathic t rea tment is able to improve self- percept ions of the specific area troubling the pat ient but may not have a lasting impact on general body image. The limited data concern- ing social behavior following t rea tment suggest that few changes occur in social goals or social competency. Finally, the psychosocial problems exper ienced during and after t rea tment are mi- nor and generally decline over the course of t reatment.

Orthognathic Surgery

Self-concept. Orthognath ic surgery involves the use of preoperat ive or thodont ic appliances to position the teeth and surgical procedures to manipulate the uppe r a n d / o r lower jaws. 56 The outcomes of t rea tment are often manifested by improvements in occlusion, esthetics, and functional ability. Less discernable are the psychologic benefits associated with or thognathic surgery, particularly the changes that emerge in self-concept. Research shows that following surgery, dimensions of self-concept significantly increase f rom presurgical levels 26,41,46,57 and remain high at 1 year 32 and 2 years after surgery. 96 Patients often repor t positive personal benefits, increased facial self-judgement, self-esteem, self- confidence, and lower levels of self-conscious- ness. Finlay et a142 also found a t rend toward increased levels of self-esteem at 6 months and 1 year after surgery when compared with baseline, however these differences were not significant.

In contrast, o ther studies show that levels of self-concept undergo periods of vacillation after surgery. 29,5s In these latter studies, patients ' overall self-concept showed some improvemen t 4 months after surgery. However, all dimensions of self-concept significantly declined at 9 months to levels below baseline. 29 Two years after surgery, self-concept scores significantly increased f rom scores at 9 months, but remained at or significantly below presurgical levels. 58 The authors attr ibuted the decline at 9 months to feelings of d isappoin tment exper ienced by patients who may have overest imated the physical, psychologic, and social benefits of surgery or to patients whose or thodont ic bands were still in place. The subsequent increase at 2 years postsurgery was attr ibuted to a stabilization of self- concept once active t rea tment was completed.

Kiyak et al 3° repor ted similar fluctuations in a later study such that overall self-esteem and in particular, personal self-esteem significantly improved f rom presurgical levels at fixation removal (6 weeks postsurgery) but declined at 6 months to levels slightly below baseline.

Unlike or thodont ic t reatment , which produces primarily dental changes, or thognathic surgery is generally associated with significant improvements in self-concept and personal well- being. However, as some studies suggest, patients who perceive that the outcomes of surgery fall short of their presurgical expectat ions may exper ience a per iod of disappointment . As a result, levels of self-concept may not manifest large long-term gains.

Body image. The esthetic changes associated with or thognathic surgery can have a major impact on body image. Investigators have been particularly interested in the degree to which changes in dentofacial composi t ion lead to improved levels of general body image. It is suggested that following surgery, patients experience a "halo effect" such that improvements in one area of the body are generalized to other parts of the b o d y Y Some studies show suppor t for this notion. Kiyak et al so found a large im- p rovement in all measures of body image begin- ning immediately after surgery and cont inuing up to 6 months after surgery. In addition, the impor tance attr ibuted to facial and o ther physical features increased over 6 months. ~° Similar improvements in dental, facial, and general appearance were repor ted 1 year ~2 and 2 years 59 following surgery.

Other studies show that the pr imary gains in body image relate specifically to judgements of the face and do not necessarily generalize to o ther body features when assessed 6 months , -%,46 9 months, 29 and 24 months following surgery. ~s It is clear that after or thognathic surgery, levels of body image rise. However, the role that surgery has in improving general body image is open to debate. It is suggested that following surgery, patients may exper ience a per iod of "cognitive dissonance. ''m,:~2 This theory states that people are motivated to view the outcomes of a situation that is high in costs or risks in a favorable way. This may explain why patients exper ience feelings of bliss with o ther parts of their body. Over time, however, patients begin to focus at tention on other physical imperfec-


tions, and feelings associated with the "halo effect" may fade. Additional investigations are needed to fur ther unders tand the long-term changes in body image after or thognathic sur-

gery. Social~interpersonal relations. A c o m m o n be-

lief of patients undergoing or thognathic surgery is that interpersonal relationships, particularly those with the opposite sex, will improve. With enhanced percept ions of self-concept and body image, it can be hypothesized that patients will engage in greater social activity after surgery. Several investigators have examined the changes in social relations after or thognathic surgery. Studies show that following a decline in social activity dur ing the early weeks after surgery, there is a gradual increase in recreational and social activities at 4 months 6° and increased levels of social potency and social responsiveness at 6 months postsurgery. 46 Patients also repor t less inhibitions when kissing, fewer disadvantages related to physical appearance, less teasing, and perceive a greater capability of establishing long- term relationships. 46 The decline in social activities immediately after surgery is likely due to postsurgical swelling a n d / o r maxi l lomandibular fixation. Hatch et al 4° found similar significant improvements on the psychosocial dimension scores of the Sickness Impac t Profile. Social interaction, communicat ion, emot ional behavior, and alertness behavior progressively improved f rom presurgical baseline when assessed 8 weeks, 6 months, 12 months, and 24 months after surgery.

Some studies suggest that the social benefits obta ined f rom orthognathic surgery decline over time. For example, Lam et al 6° examined 53 patients (average age = 23.5), 9 months postsurgery and found that social activity levels declined to near presurgical levels. Similar results were found in another study. 41 The percentage of patients repor t ing positive comments f rom others increased f rom 2 to 6 months after surgery but then declined when assessed 18 months following surgery. 41

Social activities with the opposite sex have also been examined in unmar r i ed patients (age >15 years) following or thognathic surgery. 6° Significant increases in recreational and social activities occurred with member s of the same sex but did not occur with member s of the opposite sex. 60

In general, social activity and interpersonal relations improve after or thognathic surgery. Some studies suggest that these improvements decline over time. One explanat ion is that after surgery, patients receive an abundance of positive feedback f rom fanfily, friends, and their clinicians. This feedback encourages patients to engage in greater degrees of social activity. Over time, facial changes and levels of self-confidence stabilize, and the salience of the facial changes to others as well as to the self diminishes. This may explain the decline in social activity and positive social feedback repor ted in some studies. This decline does not necessarily mean that the social benefits obta ined f rom surgery are lost. This merely suggests that patients adjust to their new look, and the exhilaration felt in the early months following surgery wanes.

These findings also suggest that changes in social behavior with respect to the opposite sex occur at a slower pace. Anticipation of improvements in this area of socialization, and realiza- tion that improvements have not yet occurred may partly explain the decline in social activity observed in some patients. Additional t ime may be needed before changes in heterosexual interactions are observed.

Emotional impact. Few studies have examined the emot ional state of patients after orthognathic surgery. Before treatment, patients may exper ience some anticipatory anxiety and tension. -~4 In surgical cases, anxiety may be associated with a pat ient 's fear of sensory loss, swelling, pain, the surgical p rocedure itself, and the physical changes after t reatment. 46 However, these fears are temporary. After surgery, research shows that patients experience positive m o o d states. One study found that patients showed increased vigor and lower levels of tension anxiety 6 months after surgery. ~4 In addition, positive m o o d states and lower levels of fatigue and depression were observed. 54 Other studies found similar results repor t ing less social anxiety, -~5 lower levels of depression, and increased levels of well-being at 6 months 46 and greater feelings of happiness, 1 year following surgery. 57 Although these studies suggest that patients ' emot ional states after surgery are positive, fur ther research is needed on this issue.

Adverse effects. As found in or thodont ic treatment , patients repor t few adverse psychologic effects following surgery. The most difficult pe-


riod appears to be immediately after surgery. During this period, patients repor t increased levels of fatigue, loss of vigor, moderate levels of tension and anxiety, and only a slight increase in depression. 54 These negative mood states generally last for only about 4 to 6 weeks. Patients who repor t physical postsurgical problems, such as pain, numbness, and oral functional problems are more likely to repor t negative mood states at these early stages. However, these physical problems do not influence self-esteem, body image, or satisfaction when assessed 9 months and 2 years after surgery. 29 Others have found no adverse psychologic effects following surgery. 34,41

The degree of psychologic difficulties experi- enced after surgery has been related to patients' coping strategies. Kiyak et a161 suggest that vigi- lant copers (those who anticipate more problems) may experience more unnecessary anxiety than do avoiders (those who expect few problems). Anticipation of problems may result in a self-fulfilling prophecy. This occurs when an initial false definition of a situation evokes behavior that confirms the false belief. 62 In 1 study, expectations of interpersonal problems significantly inf luenced patients' reports of interpersonal relations immediately after, 4 to 6 weeks, and 6 months following surgery. 6~ In general, however, patients repor t few long-term adverse psychologic effects following surgery.

Summary. Orthognathic surgery is associated with improved self-concept, body image, and social activities. However, the long-term benefits in these areas need fur ther examination. Some studies show that these benefits decline over time as patients' outcomes become stabilized and attention is refocused on other physical imperfections. Research also shows that patients repor t negative mood states immediately after surgery. However, these states appear to be temporary and improve over time.

Maturational Factors

Adolescence is accompanied by sudden growth spurts, changes in facial features, emotional and hormonal changes, and a greater emphasis on peer opinions. It is also a period of heightened levels of insecurity and self-criticism. For individuals with dentofacial deviations adolescence can be difficult. Not only may peers be more critical of physical deviations at this period but also,

individuals are likely to be more sensitive to criticism. Even the smallest physical deviations may be magnified and result in greater distress.

Corrective t reatment for malocclusions can be very important to the adolescent. Early treatment may prevent the development of a poor self-concept. 28 Because of their stage of development, adolescents may also have more problems adjusting to treatment. For example, adolescent patients repor t higher levels of pain after all phases of or thodont ic treatment, particularly after debanding, and show more adverse psychologic effects than do adults and preadolescent patients. 52

Maturation may also influence the way in which adolescents respond to treatment. It is suggested that self-image will decrease from early to middle adolescence and then increase to previous levels in the teenage years. 63 Further- more, maturat ion may impact social interaction patterns, particularly with the opposite sex. Changes attributed to corrective t reatment may be influenced by maturation. One study that compared patients who received or thodont ic t reatment with an untreated control group found that self-esteem, social goals, and social competency significantly improved over time for both groups. 7 Other investigators have cau- t ioned that psychologic changes after t reatment may be influenced by maturation.97,sl,40.52 Therefore , patients may repor t feeling bet ter about their appearance and have more positive levels of self-concept and self-esteem regardless of t reatment effects. It is necessary that clinicians and researchers unders tand the influences of maturat ion on psychologic adjustment to malocclusion and the effects of maturat ion on treatment outcomes. In the absence of an untreated control group, interpret ing psychosocial changes as direct results of t reatment is inadvis- able.

General Conclusions

A primary objective of orthodontics and orthognathic surgery is to improve patients' quality of life. This includes correcting functional defi- ciencies and improving facial appearance so that individuals find relief f rom the physical deviations that distinguish them from others. Patients are motivated to seek treatment, however, not only to correct functional and esthetic limita-


tions; they also have psychologic and social goals. An understanding of the psychosocial effects of malocclusion as well as the psychosocial benefits associated with t reatment is essential.

Although dentofacial deviations have been historically associated with increased risks of psychologic maladjustment and negative social stereotyping, modern research shows that patients are generally able to adjust to these deviations and repor t relatively few psychosocial difficulties before treatment. Still, both patients and clinicians expect that or thodont ic and orthognathic surgical treatments will result in improved psychosocial function. Clinical experience clearly supports these expectations. Patient reports to clinicians and office staff following t reatment are most often strongly positive. It may surprise many clinicians that research shows few marked changes in patients' self-concept after or thodontic t reatment and only transient benefits in overall body image. Except when patients require orthognathic surgery due to functional limita- tions or severe deformities, research has not shown significant long-term psychosocial improvements following correction of malocclusions.

Given the often dramatic improvements in esthetics, particularly following orthognathic surgery, and patient-reported satisfaction with outcomes, how can it be that nearly 30 years of research produces only limited evidence sup- porting significant long lasting psychosocial benefits? There are 2 possible explanations. First, it is possible that the psychosocial impact is, in fact, not as significant as clinical observation has led us to believe. This may be partly true. Just as patients may exaggerate the benefits of treatment shortly after completion, clinicians may be subject to a similar halo effect. Alternatively, it may be that current research methods are simply inadequate; ie, there are significant psychosocial changes, but the research methodology to date has been inadequate to document the psychosocial changes. The research examined in this review shows that most patients treated for malocclusions are psychosocially healthy before treatment. They have usually adapted to their malocclusion, have good coping skills, have positive self-concepts, and have positive social support systems. In such a generally healthy population, it is difficult to show fur ther im-

provement, ie, a ceiling effect, and both possi- bilities should be addressed by future research. Future research may be able to more clearly document positive psychosocial changes by carefully controll ing for the effects of maturation, the patient 's age at treatment, the type and degree of malocclusion, the patient 's coping skills, the time of assessment after treatment, the patient's percept ion of h i s /he r malocclusion, and the impact of family and significant others. There is also the need to re-evaluate the assessment methodology. It is possible that the psychosocial assessments used to date are not detecting the psychosocial changes that are observed clin- ically. These factors have not been well controlled in many of the research reports to date. Prospective studies with appropriate control groups, calibrated examiners, and carefully se- lected patient relevant outcome measures are needed.

Acknowledgment The authors thank Annie Rugh for her technical and biblio- graphic assistance in the preparation of this article.

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