The emotional impact of orthognathic

surgery and conventional otihodontics

H. Awman Klyak, Ph.D.,* R. Wim
Roger A. West, D.M.D.*
Seattle, Wash.

M8Wl1, D.D.S., bl.S.,** and

Previous research by the authors has pointed to depressive reactions among ort~thic
surgery patients during
the fixation-removal stage and up to 9 months later. However, lees is known about emotional shff among
persons who choose to undergo conventional orthodontic treatment after rxm
twfgid orthodontics. In the
current study, a standard measure of mood states was applied to 99 surgical pattents and 66 who had
considered surgery but decided against it. Of these, 33 were undergotng orthodontic treatment and 33 were
having no treatment. The mood scale and measures of personal&y were first apptii before surgery and then
during orthodontic treatment, just after surgery, at fixation removal, and 6 months after surgery. Nonsurgical
respondents completed questionnaires at the same time as their matched surgical respondents. Scores on tension
and fatigue increased significantly among surgical pattents from before sufgery to immadtately after surgery
and dropped to presurgical levels when fixation was removed. Anger-hostfftty incmased at fiiation removal but
declined within 5 months. Postsurgical discomfort, pain, and paresthesta, and i~al
and oral function
problems were correlated with postsurgery emotional state. On the later questtonnabes, whii corresponded to
the later periis of orthodontic treatment, patients who had opted for conventtonal orthodontic treatment
reported that they experienced greater depmseion, anger, and tension. These patMts may be particularly
vulnerable to emotional problems because their orthodontic treatment may be more oomptex and of longer
duration than that of the typical orthodontic patient. These results point to the tmpcKtsnoe of continued psychological
support for both orthodontic and surgical patients throughout their course of treatment.

Key wwds: Treatment effects, psychologicalfactors, emotional impact, pre- and post-treatment moods, depression, patient preparation

cry few studies evaluating the emotional

impact of cosmetic or orthognathic surgery have been
reported in the literature. Most of the available reports
are based on clinical data or on a one-time-only retrospective interview or questionnaire. Systematic longitudinal studies of this phenomenon are rare. In a survey of patients who underwent orthognathic surgery,
Ouellette reported that a majority of patients felt more
self-confident and more appreciated by their friends
following surgery. Rittersma and associates measured
patient satisfaction with surgical outcomes in his study
of 110 patients following orthognathic surgery. The respondents reported generally high satisfaction but believed that they had been insufficiently informed about

From the University of Washington.

This research was supported by Gram ROl-DE-05744
from the National Institute for Dental Research.
*Associate Professor, Depattment of Oral and Maxillofacial Surgery.
**Professor, Department of Orthodontics,
University
of Washington, and
Noahwest Center for t3tbodontics and Facial orthopedics.
***Northwest
Center for Corrective Jaw Surgery.

224

postsurgical adjustment problems. No controls or nonsurgical comparison groups were included in either
study. Simihuly, in a study by Ohlsen and co-workers,
thirty-seven patients who underwent augmentation
mammaplasty were questioned by a psychiatrist 1 to 5
years postoperatively and asked about their emotional
state during that period. Most reported that they felt
greater self-esteem and less sensitivity and depressive
reactions, but the researchers did not follow the course
of those reactions. Goin followed eight patients who
underwent reduction mammaplasty. During face-toface interviews, five of the eight patients reported emotional disturbances, such as a sense of loss or transient
depression, directly related to the operation and lasting
from 3 weeks to 8 months.
The current study represents an attempt to examine
more systematically any changes that take place in patients emotional states following orthognathic surgery.
The Profile of Mood States (POMS)J was used to
evaluate depression, anger, vigor, anxiety, and overall
mood. In our previous study of seventy-four patients
who underwent orthognatbic surgery,6 several persons

Volume 88
Number 3

Emotional impact of orthognathic surgery and conventional orthodontics 225

reported experiencing postoperative depression. These

responses, which were gathered from open-ended patient comments on the final questionnaire (9 months
after surgery), prompted the present longitudinal study
of patients emotional changes using a standardized
measure of moods. In addition, we have introduced two
comparison groups into the current study: persons undergoing conventional orthodontic treatment and persons deciding against treatment altogether. Both comparison groups had consulted with an orthodontist and
oral surgeon regarding the possibility of surgery but
had decided ag,ainst it. By introducing nonsurgical control groups, tbe emotional lability associated with surgery could be c:ompared with the effects of conventional
orthodontic tmatment and no treatment.
Most studies that have dealt with the postsurgical
emotional state of patients have focused primarily on
the relationship between depression, anxiety, and dissatisfaction with the surgical procedure. Satisfaction/
dissatisfaction often represents the only measure of outcome.7-9 The work of George and Scott. is a notable
exception. In their study of 38 patients (18 males and
20 females) who underwent third molar extraction in
an outpatient setting, they examined the relationship
between patients psychological and physiologic characteristics, such as expectations, anxiety, coping behaviors, health locus of control, and postextraction
pain, disability, and healing. Subjects completed questionnaires just before the extraction, for 4 days following treatment, and 2 weeks after extraction. A single
experimenter, who was kept blind to the subjects selfratings, evaluated all data. High expectations of pain,
anxiety, and vigilant coping behaviors before the extraction were ,correlated with greater pain after treatment. High levels of reported pain were also associated
with higher levels of surgical trauma. Even with the
effect of trauma statistically partialed out, however, the
relationship between postextraction pain and pretreatment psychological characteristics was significant. A
regression equation using all the psychological predictors and trauma supported this effect and explained 4 1%
of the variance in overall pain. In a hierarchical regression equation, expectations and anxiety about recovery
accounted for 23% of the variance, suggesting that these
two factors alalne might be the most important psychological variables to consider. It should be noted that
this study did not compare outcomes 4 days after surgery and those: 2 weeks after surgery. The authors do
not make a distinction between these periods in their
description of outcomes.
The current study also attempts to examine outcomes of surgery beyond just satisfaction/dissatisfaction; by applying the PGMS scale, we have been able

to increase the number of psychological parameters that

we can statistically assess. In the current study, we have
evaluated the relationship between negative mood states
postsurgically (anxiety, anger, low vigor, and depression) and problems reported by patients at the same
measurement period, such as facial pain, numbness,
and functional problems, as well as dissatisfaction with
the outcomes of surgery. More specifically, the following research questions were explored in this study: (1)
What changes take place in the emotional state of orthognathic surgery patients from before surgery up to 6
months after surgery? (2) Do males and females report
different emotional states throughout the course of treatment? (3) What is the relationship between personality
characteristics and emotional states before and after
treatment? (4) What is the relationship between emotional states at various stages after surgery and postsurgical problems, such as complaints of facial pain,
numbness, functional problems, and dissatisfaction
with surgical outcomes? (5) Do these patterns in emotional state following surgery differ from the pattern
observed longitudinally among persons undergoing
orthodontic treatment alone and those who decide
against any treatment?
METHOD
Subjects

The research subjects were selected from the files

of the Oral Surgery Clinic at University Hospital. Letters were sent to all patients who had been referred to
the clinic by an orthodontist for consultation regarding
possible orthognathic surgery during the past 3 years
but who had not yet undergone treatment. The patients
were asked to return a postcard indicating whether they
were currently undergoing orthodontic treatment in
preparation for surgery, undergoing orthodontic treatment alone with no plans for surgery, had decided
against treatment altogether, or were still undecided.
Patients who responded in the first three categories and
who fulfilled the research criteria were subsequently
asked to participate in this 3-year prospective (longitudinal) study. The criteria for selecting subjects
were age over 14 years and consultation for treatment
of a developmental dentofacial malrelation not due to
trauma or a congenital deformity.
In this manner, 90,patients who were preparing for
surgery 6 to 12 months later, 33 who had decided to
undergo conventional orthodontic treatment, and 33
who had decided against any treatment were selected
and agreed to participate in the study. This proportion
of surgical cases to orthodontics-only and no-treatment
cases reflects the distribution of these groups in the
clinic population. Approximately two thirds of all pa-

226

Kiyak, McNeill,

Am. J. Orrhod.
September 1985

and West

tients who seek consultation eventually undergo surgery. To the extent possible, each subject in the orthodontics-only and the no-treatment groups was matched
with a surgery patient on the basis of sex, age range,
and diagnosis.
The demographic characteristics of subjects in the
three groups were quite similar. In each group, the
majority of subjects were female (64.6% in the surgery
sample, 66.7% in the orthodontics-only group, and 72%
in the no-treatment group). Patients ranged in age from
14 to 43, with a mean age in the three comparison
groups of 26, 24.5, and 30.3, respectively. Despite our
attempt to match the samples as to age, the no-treatment
group tended to be older than the other two groups
(F = 6.03, df 2,162, P < .05), although the distribution of age was similar across groups. Approximately
75% of all patients were of European descent; fewer
than 10% were black or Pacific Asians. Reflecting on
the age differences between the no-treatment group and
the other two samples, only 21% of the former were
still students, whereas 26% of the surgery sample and
42% of those undergoing orthodontic treatment were in
school at the start of this study. Among those who had
completed their education, more than 75% in each sample had finished high school or beyond.
Procedure

All questionnaires were designed to be self-administered. The first questionnaire (T,), which was the most
extensive because it included questions on demographics, patients problems with oral function, motives for
having or not having surgery, and several personality
scales, was mailed to all respondents after we received
postcards from them stating their decision regarding
surgery and their agreement to participate in the study.
In the case of surgical patients, the first questionnaire
was mailed 6 to 12 months before the anticipated surgery date. Telephone follow-ups were made to determine if the subjects had any questions about the forms
and/or methods of the study and to remind them to
return the forms in the attached envelope within 2
weeks. This approach resulted in a 100% response rate.
The second questionnaire (TJ was designed to ascertain surgical patients psychological status just before (5 to 10 days) their scheduled surgery date. This
was the shortest questionnaire and sought to determine
the patients moods and expectations of surgical outcomes. Of the 90 subjects who completed T1, 12 did
not receive T, in time to complete it before surgery and
seven did not return the questionnaires; thus, there was
a 7.8% refusal rate and a 79% completion rate.
All subjects received TX, which was delivered by
the research assistant to surgical patients in the hospital

on the day after surgery and collected the next day. A

similar questionnaire was maiIed to the comparison
sample subjects at the same time the T3 questionnaire
was given to their matched surgery patient respondents.
All subjects completed the mood scale and a measure
of body image. Surgical patients also were asked questions about their postsurgical experiences and satisfaction with outcomes. Response rates were quite high for
all three groups: 89% of the surgery patients, 96% of
orthodontic patients, and 93% of the no-treatment group
returned their questionnaires within the period just after
surgery or at the comparable time for nonsurgical subjects.
The fourth questionnaire (TJ was mailed only to
subjects in the surgery sample, 4 to 6 weeks after surgery, to coincide with the date of fixation removal. This
questionnaire was similar to T3, although more extensive personality questions were included as follow-ups
to the T, measures. As with T3, 89% of the surgical
patients completed this questionnaire.
The fifth questionnaire was designed to ascertain
the effects of surgical intervention after most of the
healing had taken place (6 months after surgery). Subjects in the two comparison groups also received T,
when the matched surgery subjects received a questionnaire. Response rates remained high even at this
point, 12 to 20 months after our first contact with the
subjects. Thus, 8 1 surgery patients, 30 orthodontic patients, and 29 no-treatment subjects completed the TS
questionnaire (90%, 90%, and 88% response rates, respectively) .
Variables and their rmmmment

As stated above, this longitudinal study examined

several different aspects of personality and psychological adaptation to surgical outcomes. For the purposes
of this presentation, however, we will focus on the
measurement of moods, satisfaction with surgery, and
postsurgical reports of healing progress and functional
problems.
Neuroticism and self-esteem are personality characteristics that may be associated with mood states
following surgery. The former was measured with
Eysencks Personality Inventory* in the T, questionnaire. A person who scores high on the neuroticism
scale tends to be emotionally labile and overresponsive
to environmental cues. Hence, one would expect variations in emotional states during the postsurgical course
among persona who score high on neuroticism, but less
so among those who score low.
Fitts Tennessee Self-Concept S~ale~ was used
to measure self-esteem, defined as an individuals
self-assessment of his/her own interpersonal and per-

Emotional impact of orthognathic surgery and conventional orthodontics 227

v01lo?le 88
Number 3

Below
is a list of words
that descAbe$%elings
people
have.
Please
read each
carefully.
Then circle
ONE number
,&der
the answer
to the right
which
describes
how you have been feeling
du?%J
the last few weeks.

0 =

not at all

I =

A little

2 =

Moderately

Quite

Extremely

a bit

I.

Friendly..

.............

2.

Tense..

..........

3.

Angry..

................

4.

Worn

5.

Unhappy..

out..

one
best

. ....

.............
..........

. ..

Fig. 1. Sample items from Profile of Mood States.

sonal characteristics. Two dimensions of this measure

emerged with alpha coefficients greater than .72. These
are personal self and family self dimensions.
Scores obtained at T, on these two subscales and on
the total self-esteem scale will be correlated with scores
on the mood scale.
Moods were measured longitudinally by administering the 65item Profile of Mood States (POMS) to
all surgery patients at T,, T3, T4, and T5 and to the
comparison samples at T3 and T5. This permitted an
assessment of patients emotional states from just before
surgery to 6 months after surgery. The 65 adjectives
which comprise POMS describe emotional states along
six dimensions: tension-anxiety, depression-dejection,
confusion. anger-hostility, vigor, and fatigue. These
factors were derived and replicated in studies of 2,000
normal and psychiatric patients by Lorr and McNair5
Tension-anxiety refers to heightened musculoskeletal,
somatic tension. Depression/dejection is described as
a sense of personal inadequacy, whereas anger-hostility
is a generalized sense of frustration. Vigor and fatigue
represent opposite emotions. In fact, vigor is the only
positive dimension and suggests energy and ebullience.
Fatigue is described by such terms as weary, listless, and low energy level. Each adjective is accompanied by a five-point response scale (0 = not at
all; 4 = extremely); the individual indicates to what
extent he/she has been feeling that way during the
past few days. The total mood score is obtained by
adding the individuals scores on five dimensions and

subtracting vigor scores from this total. Therefore, the

higher ones total score, the more negative ones mood.
A sample of items is presented in Fig. 1.
Fig. 2 illustrates the four satisfaction questions
asked of surgery patients at T3, T4, and T5. Each item
reflects a different aspect of the individuals satisfaction
or dissatisfaction with surgical outcomes and is accompanied by a seven-point response scale. Tests of internal
consistency reliability at each measurement period
showed a high intercorrelation among these items
(f, = 0.97 at T, and T5, r, = 0.90 at TJ; that is,
these items were found to be measuring the same underlying concept. For this reason, the four items were
combined statistically into a scale of satisfaction at each
measurement period, using the mean score for these
four items. For all analyses that considered satisfaction
as an outcome variable scale scores rather than individual satisfaction items were used.
A set of questions was also asked at T3, T,,, and T5
to determine the level of discomfort currently being
experienced in the areas of pain, swelling, paresthesia,
oral functions (eating, swallowing, speaking), and interpersonal behavior. Each item was accompanied by a
seven-point scale ranging from no discomfort to
much discomfort. Factor analysis of this scale revealed three primary factors, which accounted for more
than 90% of the variance and which represented problems with surgical discomfort, problems with appearance and social function, and probkms with oral function. Tests of internal consistency reliability confirmed

228

Kiyak, McNeill,

41% J. Onhod.
September 1985

and West
For each of the areas below, circle the number which best describes
of satisfaction,
from 1 (not at all satisfied) to 7 (very satisfied):
d

At present,
surgery?
1
Not at all
all satisfied

b)

are you with the extent

Considering
recommend
1
Not at all

Very
satisfied

again, how likely

would you be to undergo this same

Neutral

this was an elective

it to others?
2

VWY
likely

operation,

how

likely

would

Neutral

Considering
1
Not at all
all satisfied

everything,
2

how satisfied
3

are you now with the results

4
Neutral

you now be to

very
like1 y

likely

d)

level

of healing you have had since

Neutral

If you had to make the decision

surgery?
1
Not at all
likely

c)

how satisfied

your present

of surgery?
7
Very

satisfied

Fig. 2. Postsurgical satisfaction questions.

SCALES

T3

T4

Ts

.72

.70

.70

Discomfort

.80

.80

.82

Interpersonal
Relations
Performance
Public
self
Feeling
depressed
General
health
Socializing

.81

.83

.91

Oral Function
Numbness
Swelling
Pain in face
Pain in mouth

Postsurgical
toting
Swallowing
Appetite
Speaking

Fig. 3. Alpha coefficients T, to T,.

these results; alpha coefficients ranged from .70 to .72

for oral function, .80 to .82 for discomfort, and .8 1 to
.93 for interpersonal problems at T3 through T,. Fig. 3
illustrates the items within each dimension and the alpha
coefficients for these dimensions at T, through T,.
Another method of determining postsurgical problems was devised for this study. At each postsurgical
measurement, the patient was given a set of full-face

drawings (Fig. 4), on which he/she was asked to draw

the areas of pain, paresthesia, and swelling which represented the extent of discomfort that he/she was currently experiencing. The total area of the face covered
by the patient at each measurement period was scored
with a grid that divided the lower two thirds of the face
into four regions consistent with areas covered by major
nerves. The extent to which patients filled in each region was scored, so that we could determine longitudinal changes in areas and extent of pain, paresthesia,
and swelling. Two raters independently scored ten faces
for each of the three areas of facial discomfort. Only
after 95% agreement was reached between the two raters on all three dimensions did they proceed to score
the remaining patient self-assessments.
RESULTS

In order to answer the first research question, which

asked what changes take place in surgical patients from
just before surgery to 6 months after surgery, we conducted analysis of variance tests, repeated measures
technique, using time (T2 through TJ as the repeated
factor. Scores on each of the FOMS dimensions and
on total mood scores were compared across measurement periods. Complete data derived from PfXvIS were
available for 57 surgery patients.
As shown in Figs. 5 and 6, significant changes

Vohme 88
Number 3

Emotional

impact of orthognathic

surgery and conventional

On Drowinp #I above, shade in the

areas of ycur face where You am
presently experiencing @&

On Drawing 12 above. shade in the

area of your face vhare you are
presently experiencing MIMBNESS.

On hawing 13 above, shada in the

weas of your face wixwe ycu a,*
pmmtly experirrlng
SWELLING.

If ycu arc not experiencing

pain,checkhere
.

If you are not experiencing

numbneat, chsck here

If you are not ev+wfancing

swelling, check hare

my

229

DRAYINGY3

DRAUINGI 2

DRAWING81

orthodontics

any
.

al7
.

Fig. 4. Self report of postsurgical discomfort, visual technique for female respondents. (Note: Similar
visual representations using male faces were used with male respondents.)

Negative
mood

20.0

Positive
mod

II

T2
(I week
pre)

(I dL:
past)

T4
(4-6 weaks
post)

(6 manA s
post)

Fig. 5. Changes in mood dimensions before and after surgery. 7, High scores indicate high vigor. 2,
High scores indicate more negative mood.

emerged in four of the six dimensions of moods and in

overall mood scores. For the other two dimensions
(depression and confusion), there was a slight tendency
toward increased depression and confusion at the immediate postsurgical stage (T3), but these changes were
nonsignificant. Note that depression does not appear to
be very high in this sample overall, although individual
cases of high depression scores emerged at each measurement period. POMS scores on anger-hostility,
vigor, and fatigue showed the greatest change. Patients
reported a significant reduction in anger-hostility immediately after surgery, with a return to presurgical
levels at fixation removal and 6 months later ( F = 8.3,

df 3,168, P < .05). These changes from T, to T3, T,

to T4 and T4 to T, were significant, but T2 and T5 scores
were not significantly different from each other.* As
one might expect, self-reported fatigue increased significantly just after surgery, remained high at fixation
removal, and dropped below presurgery levels 6 months
later (F = 17.4 df 3,168, P C .OOl). The paired comparisons between Tz and T3, T3 and T4, T4, and TSwere
similar to the pattern observed for anger-hostility. Like*Note that differences

between mans

were tested by the Tukey a, or Honestly

Significant Differences (HSD) method and were considered

differences were greater than a probability of 0.05.

sipificant

if the

230

Kiyak, McNeill,

and West

Am. J. Orthod.

September 1985

Negative

30.0

mead

I
25.0

Positive
Mood

10.0

1
I

T2

T4
(4-6 weeks

(I week
pre)

Fig. 6. Overallchanges in mood

Table

IA.

(6 mobs

post)

scofes

before

post)

and after surgery.

Significant correlations between personality and mood scores (T,)

Overall
Neuroticism

Mood3
Depression-dejection 3
Tension-anxiety 3
Anger-hostility 3
Fatigue 3
Confusion 3
Vigor 3

self-esteem

.40*
.38*
.41*
.28*
.22

.31*
- .21

-.19
-.19
-.14
-.06

-.lO
-.lO
.13

Family

self

Personal

- .20*
- .22*
-.05
- .02
-.08

-.17
-.12
-.17
-.12
-.09

-.12
.12

-.12
.12

self

*P < .os.

wise, T, and T4 were not significantly different from

each other. Vigor decreased just after surgery and continued to improve up to 6 months later (F = 46.1, df
3,168, P C .C@Ol). Paired comparisons on this variable
revealed significant differences between T, and T3, T3
and T4, T4 and Tg , as well as T, and T5, suggesting that
patients perceived themselves to be more vigorous 6
months after surgery than they had felt just before
surgery.
Anticipatory anxiety about surgery
was demonstrated by patients self-reports of tension and anxiery
at the presurgical stage. Scores on this diinsion were
most negative at T, and gradually improved to
their most positive level by T, (F = 9.4, df 3,168,
P < -01). Paired comparisons revealed that T, scores
were &leed signilktntly more negative than at all other
measurement periods.
Overall mood scores were calculated by adding
POMS scores on depression, confusion, tension, fatigue, and anger and subtracting the individuals scores

on the vigor dimension from this set of items. These

scores are graphically presented in Fig. 6, which illustrates the significant improvement from negative mood
states before surgery, immediately after surgery, during
thefixationperiod,to6monthsaftersurgery(F
= 7.2,
df 3,168, P < .Ol). Note that overall mood is lowest
at TS, just after surgery. It may be this overall nqative
affect that leads many patients to describe a generally
depressed mood during the immediate postoperative
stage, even though their scores on the depression scale
alone are not so low. Overall mood improves to its
highest level 6 months after surgery. Pairedcomparisons were sign&ant for each pair, suggest&q a dramatic shiff in overall mood states across these measurement periods associated with stagy of surgery.
Inanattempttoascert&wktherornotsex-differences inil~nce emoknal responses to surgery (research question No. 2), a series of two-way a&y& of
variance tests ah40 was c
(time and sex). No
main effects or interaction &f&% of sex emerged, sug-

Volume 88

Emotional

Number 3

impact

of orthognathic

surgery

and

conventional

231

orthodontics

Table IB. Significant correlations between personality and mood scores (T4)
Overall
self-esteem

Neuroticism

.4.5*
.43*
.45*
.47*
.34*
.31
- .28*

Mood4
Depression-dejectzIon 4
Tension-anxiety 4
Anger-hostility 4
Fatigue 4
Confusion 4
Vigor 4

Family

.30**
.21**
.25**
.31**
.22*
.25*
.15

self

Personal

self

- .45**
-.I7
- .22*
- .20*
- .23*
-.21*
.03

- .30*
-.I7
-.12
- .24*
-.13
- .I9
.21*

*P < .05.
**p < .OOl.

Table IC. Significant correlations between personality and mood scores (T,)

I
Mood5
Depression-dejection 5
Tension-anxiety 5
Anger-hostility 5
Fatigue 5
Confusion 5
Vigor 5

Neuroticism

Overall
self-esteem

.49*
.47*
.40*
.44*
.41*
.38*
- .25*

- .32**
- .28**
-.19
- .29**
- .24*
-.19
.37+*

Family

self

- .24*
- .24*
-.I3
- .22*
-.15
-.lI
.29**

Personal

self

-.19
-.14
-.12
-.I2
-.16
-.ll
.31**

*P < .05.
**p < ,001.

gesting that males and females undergo similar emotional responses to orthognathic surgery.
Research question No. 3 sought to determine the
relationship between two personality characteristics
(neuroticism and self-esteem) and the patients emotional state before and after surgery. This was tested
with a series of Pearson product moment correlations
between POMS scores at T2, T3, T4, T, and scores on
neuroticism and self-esteem for surgical patients. Correlations were also obtained between POMS and the
personality variables for orthodontic patients at T3 and
T5. Results are presented in Table I.
As expected, neuroticism was significantly associated with scores on POMS at all measurement periods.
Particularly with respect to the dimensions of depression, tension, anger, and confusion, the greater the patients neuroticism score, the more likely he/she was
to report negative moods at T3, T4, and T5. It is noteworthy that neuroticism was significantly correlated
with all emotional dimensions measured in this study
at T5, suggesting that these variations in mood states
were most likely to continue among the more neurotic
surgical patients up to 6 months after surgery.
Self-esteem was not generally associated with mood
states at the immediate postsurgical stage but became

a significant correlate at T4 and T5. The individual dimensions of personal self and family self were significantly correlated with overall mood and anger at T4
and with vigor at T,. Overall self-esteem was significantly correlated with all mood dimensions except vigor
at T4 and with all dimensions except tension and confusion at T5. The direction of these results was consistent; the higher the persons self-esteem scores, the
fewer reports of negative emotion at the later stages of
treatment.
In testing research question No. 4, correlations were
obtained between surgical patients mood scores at TJ,
T4, and T5 and their reports of pain, swelling, and
numbness at those periods as indicated on the facial
drawings. In addition, correlations between mood
scores, satisfaction, and self-ratings of surgical discomfort, functional problems, and interpersonal relations at
T3, T4, and T, were obtained.
Tables IIA, IIB, and IIC present the significant correlations among the variables for each measurement
period. Note that this research question was tested with
Pearson product moment correlations, which does not
require assumptions of causality. In the present study,
it would be difficult to assume that mood states result
from postsurgical problems and dissatisfaction or that

232

Am. J. Orthod.
September 1985

Kiyak, McNeilE, and West

Table HA. Significant correlations between moods and surgical outcomes (T,)
Pain

Mood 3
Depression-dejection 3
Tension-anxiety 3
Anger-hostility 3
Fatigue 3
Confusion 3
Vigor 3

.40**
.31**
.34**
.33**
.32**
.31**
-

Numb

Swell

.2.5*
.23*
.28*
-

Surg
Disc

.48*
.41**
.37**
.29*
.43**
- .38**

Functional

.45**
.31**
.49**
.56**
- .31**

Inrerpersonal

.64*
.57**
.44**
.32*
.53**
.23*
- .53**

Satisfaction

- .54**
- .54**
- .36**
- .35**
- .3.5**
-.21*
.34**

*P < .05.
**p < ,001.

Table MB. Significant correlations between moods and surgical outcomes (TJ
Surg
Pain

Mood4
Depression-dejection 4
Tension-anxiety 4
Anger-hostility 4
Fatigue 4
Confusion 4
Vigor 4

.32**
.35**
.33**
.26**
.36**
.34**
- .25*

Numb

Swell

Disc

.38**
.36**
.31*x
.20**
.22*
.21*
- .27*

Functional

.40**
.32**
.31**
.25**
.22*
.30*
- .22*

Interpersonal

.58**
.50**
.53**
.32**
.28**
.49**
- .41**

Satisfaction

.52**
.56**
.46**
.36**
.35**
.45**
.28*

*P < .05.
**p < ,001.

postsurgical problems and dissatisfaction are caused by

negative emotions. Instead, correlation tests will permit
us to conclude that there is some association between
emotional states and surgical outcomes.
At the immediate postsurgical stage (TJ, dissatisfaction was greater among surgical patients who experienced greater depression, anger, tension, confusion, fatigue, and less vigor. Similarly, reports of interpersonal problems and surgical discomfort were
more likely among those who experienced more negative mood states, although confusion was not correlated with surgical discomfort. Problems with oral function (speaking, eating, swallowing) were correlated
with all mood dimensions except anger and confusion.
It is noteworthy that facial drawings indicating extent
of facial swelling (Fig. 4) were not correlated with
mood states; extent of numbness at T, also had generally
low correlations with mood. Only in the area of pain
were facial ratings correlated with emotional states.
Facial ratings of numbness and swelling were not
significantly associated with moods at the fixation stage
(TJ either. However, patients who perceived their emotional states more negatively tended to report a greater
area of facial pain, more surgical discomfort, and more
problems with oral function and with interpersonal relations; they also were more dissatisfied than were pa-

tients who reported generally positive mood states

(Table IIB) .
As shown in Table IIC, the correlations between
mood scores and surgical outcomes are considerably
reduced for all outcomes at T5 except interpersonal relations. That is, the more problems the patient experiences in the area of relationships with other persons
6 months following surgery, the more negative his/her
emotional state. The pattern of significant correlations
between these variables was consistent across T3, T4,
and T,.
Table IIC also reveals several significant correlations between patients ratings of areas of swelling,
numbness, and emotional states. Although these correlations are relatively low, they are noteworthy in that
problems with swelling were not related to moods at
T3 and T4, while problems with numbness were correlated with moods only at T3. The finding of significant
associations at T5 indicates that those few patients who
are still experiencing problems with paresthesia and
swelling 6 months after surgery are most likely to feel
depressed, angry, hostile, tense, and anxious.
The final research question sought to determine the
effects of orthognathic surgery per se on emotional
states, as opposed to conventional orthodontic treatment
alone OF abstinence from treatment. Thus, the first com-

Volume88
Number 3

Emotional

impact of orthognathic

surgery and conventional

orthodontics

2%

Table IIC. Significant correlations between moods and surgical outcomes (T,)

surg
Pain
Mood5
Depression-dejection 5
Tension-anxiety 5
Anger-hostility 5
Fatigue 5
Confusion 5
Vigor 5

-.

-.

Numb

Swell

disc

.24*
.23*
.21*
.20*
- .22*

.25*
.35**
.27*

.24*
.20*
.21
.22*
.26*
-

Functional

.28*
.24*
.21*
.2-P
.25+
- .21*

Inierpersonal
.52**
.51**
.45**
.47*+
.35**
.47**
- ,274

Satisfaction
-

.41**
.36**
.31**
.37**
.33**
.21*
.28*

*P < .05.
**p < ,001.

parison group was used to test the differential effects

of surgery versus orthodontic treatment alone; the second comparison group permitted an examination of the
effects of surgery versus the mere passage of time on
emotional changes. A main effect for the variable of
time (T, versus T5), in a repeated-measures analysis of
variance comparing these three groups would suggest
that a similar pattern of change takes place for all three
groups. A significant interaction of the variables of
time X group would indicate that patients who undergo surgery experience a different pattern of mood
changes over time than do orthodontic patients who, in
turn, may differ from patients who do not undergo any
treatment.
The results suggest that such differential patterns of
change took place in these three samples. A series of
analysis of variance tests across each dimension of
moods revealed a significant interaction effect in total
mood scores (IF = 8.8, df 2,121, P < -02) and in
the individual dimensions of fatigue (F = 19.1, P <
.OOOl), anger-hostility (F = 3.8, P < .OS), depression-dejection (F = 4.0, P < .02), tension-anxiety
(F = 6.2, P <: .OOl), and vigor (F = 25.0, P <
.OOOl). The patiein that emerged across all dimensions
and in total mood scores was such that surgical patients
expressed a significantly more positive mood, less fatigue, more vigor, less depression, less tension-anxiety,
and more anger-hostility at T5 than at T,. Mean mood
scores showed a reverse pattern among orthodontic patients when compared to surgical patients, primarily
because self-reported levels of depression and tensionanxiety increas& significantly among respondents in
this sample from T, to T5. Like the surgical patients,
those undergoing orthodontic treatment only reported
greater anger-hostility at Ts than at T,, but mean scores
differed even more for the latter. Subjects who did not
undergo any treatment showed no significant changes
on any aspect of POMS. The main effect for time was
significant only for anger-hostility, which probably re-

fleets the similar pattern of increasing anger and hostility among surgical and orthodontic patients alike
(F = 3.4,df 1,122,P < .05).Forallotherdimensions
of POMS, the opposite patterns of change reported by
these two groups from T3 to T5, combined with the lack
of significant change among no-treatment respondents,
resulted in a nonsignificant effect for time.
This finding of increased depression and tensionanxiety among conventional orthodontic patients suggested the need to examine the duration of orthodontic
appliance wear and whether or not appliances were still
being worn at T5. Comparisons were made between the
mood scores of those still wearing orthodontic bands
versus those with no appliances at T,; one-way analysis
of variance tests were used for these comparisons. Although mean scores were in the expected direction, no
significant differences emerged. In particular, patients
wearing bands were more likely to report depression,
tension-anxiety, and fatigue than were patients who
were no longer wearing orthodontic appliances.
DISCUSSION

These results point to the potentially significant impact that orthognathic surgery can have on a patients
emotional well-being. The anticipation of surgery results in considerable tension and anxiety. The days immediately following surgery are characterized by fatigue, loss of vigor, moderate levels of tension and
anxiety, and some depression. Yet it appears that the
contrast between their health immediately and 6 months
after surgery is so striking to these patients that their
mood scores improve significantly, even beyond the
presumably normal mood scores reported by persons
who do not undergo surgery. It is noteworthy that angerhostility reaches its lowest level at the immediate postsurgical stage but peaks 4 to 6 weeks later. This is
accompanied by continued tension and anxiety and mild
depression during the stages immediately and 4 to 6
weeks after surgery. This may represent a period of

Am. J. Orthod.
September 1985

234 Kiyak, McNeil& and West

frustration and helplessness in these persons just before

fixation wires are removed. It would be useful to examine more closely the period just before and just after
fixation removal, when so many patients experience
frustration and anticipation.
Our results with respect to the association between
emotional well-being following surgery and reports of
postsurgical problems and dissatisfaction suggest that
the impact of surgery on patients continues long after
they leave the hospital. Patients who report extensive
pain, postsurgical discomfort, and problems with oral
function in the early postsurgical stages are more likely
to report depression, tension, anxiety, anger, hostility,
and fatigue than those without serious surgical sequelae.
Those who report continued problems with numbness
and swelling 6 months after surgery are most likely to
experience these negative mood states. Finally, the consistently high correlations between mood states and
postsurgical problems with interpersonal relations and
dissatisfaction with outcomes suggest that adaptation to
the changes in facial form and oral function produced
by surgery takes much longer than patients expect and
appears to have a dynamic relationship with interpersonal factors such as the individuals relationships with
family, friends, and co-workers as well as his/her performance on the job or in school. Nevertheless, these
results do not imply a particular direction of casuality.
Our findings suggest that undergoing conventional
orthodontic treatment without surgery may be a stressful
event for persons who have initially considered surgical
orthodontics, as revealed by their significant shifts in
mood scores across time. The impact of long-term
orthodontic treatment appears to be one of heightened
tension and frustration in the later stages. Although
emotional status improves after treatment ends,, the patient must be forewarned of these potential problems
before treatment begins. Furthermore, as we have
stressed in previous reports,6,4 it is important that the
surgical-orthodontic team continue to work closely with
patients long after surgery, to assure a successful recovery not only physiologically but emotionally as well.
This appears to be a useful approach also for orthodontists who treat patients who have decided to undergo

conventional orthodontic treatment after considering

surgical orthodontics.
The authors expresstheir appreciationto Ms. P. I. Heaton
for her assistancein collecting the data, to Mr. Jeff Crinean
for performing all the data analyses, and to Ms. Co&en
Donnelly for her editorial assistance.
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Reprint requests to:
Dr. H. Asuman Kiyak
Department
of Oral and Maxillofacial
University
of Washington
Seattle, WA 98 195

Surgery