Int. J. Oral Maxillofac. Surg.

2016; 45: 476–485

http://dx.doi.org/10.1016/j.ijom.2015.10.019, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Assessment of the changes in T. Baherimoghaddam1, R. Tabrizi2,

N. Naseri3, A. Pouzesh4, M. Oshagh5,
S. Torkan6

quality of life of patients with

1
Department of Orthodontics, School of
Dentistry, Yasuj University of Medical
Sciences, Yasuj, Iran; 2Department of
Craniomaxillofacial Surgery, Shiraz University

class II and III deformities of Medical Sciences, Shiraz, Iran;

3
Department of Orthodontics, School of
Dentistry, Azad University of Medical
Sciences, Shiraz, Iran; 4Department of
during and after orthodontic– Craniomaxillofacial Surgery, School of
Dentistry, Yasuj University of Medical
Sciences, Yasuj, Iran; 5Private Practice,

surgical treatment Tehran, Iran; 6Orthodontic Research Centre,

Shiraz University of Medical Sciences, Shiraz,
Iran

T. Baherimoghaddam, R. Tabrizi, N. Naseri, A. Pouzesh, M. Oshagh, S. Torkan:

Assessment of the changes in quality of life of patients with class II and III deformities
during and after orthodontic–surgical treatment. Int. J. Oral Maxillofac. Surg. 2016;
45: 476–485. # 2015 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this longitudinal study was to assess and compare the oral
health-related quality of life (OHRQoL) of patients with class II and III deformities
during and after orthodontic–surgical treatment. Thirty class III and 28 class II
patients were evaluated at baseline (T0), just prior to surgery (T1), at 6 months after
surgery (T2), and at 12 months after debonding (T3). OHRQoL was assessed using
the Oral Health Impact Profile (OHIP-14). Friedman two-way analysis of variance
and the Wilcoxon signed-rank test were performed to compare the relative changes
in OHRQoL during treatment. Significant changes in the overall OHIP-14 scores
were observed during and after orthodontic–surgical treatment in both groups.
During the pre-surgical stage, psychological discomfort and psychological
disability decreased in class III patients, and class II patients experienced a
significant deterioration in psychological discomfort during the same period. Six
Key words: oral health-related quality of life;
months after surgery, patients in both groups showed improvements in
orthognathic surgery; OHIP index; dentofacial
psychological discomfort, social disability, and handicap. Physical disability and deformity.
functional limitation showed further improvement at 12 months after debonding in
class II patients. This study reaffirms that orthodontic–surgical treatment has a Accepted for publication 21 October 2015
significant effect on the OHRQoL of class III and class II patients. Available online 18 November 2015

Previous studies have indicated that treatment.1 The results of many studies other hand, some studies have reported
patients hope to improve their oral have shown that the primary motivation that certain patients prefer to improve bite
health-related quality of life (OHRQoL) for the correction of dentofacial deformity function rather than aesthetics.3,4 Several
by undergoing orthodontic–surgical is to improve facial aesthetics.2 On the studies have described the psychological

0901-5027/040476 + 010 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

advantages of orthodontic–surgical treat-
ment.5,6 These include changes in person-
ality, improvements in self-esteem, and
positive changes in lifestyle, such as
improvements in personal relation-
ships.7–9
The evaluation of OHRQoL during or-
thodontic–surgical treatment helps clini-
cians to understand what patients have to
endure during treatment and to consider
this when recommending treatment
options.10 Many studies have shown a
correlation between objective orthodontic
indices and patient perceptions of their
own appearance and oral health condi-
tion.11,12 OHRQoL is a multifactorial in-
dex and is thus difficult to measure
objectively.13 Tools for the measurement
of OHRQoL should be selected based on
the physical, social, and psychological
domains.14 Condition-specific and generic
measures have been used to evaluate the
impact of orthodontic–surgical treatment
on patient OHRQoL. Lee et al. reported
that generic health questionnaires like the
short-form of the 36-item health survey
(SF-36) are not sensitive to the changes in
OHRQoL and are not helpful in detecting
differences in OHRQoL between individ-
uals with and without dentofacial defor-
mity.15
Condition-specific measures can be
helpful in evaluating disease-related attri-
butes and are more sensitive to small but
clinically important changes.16 One of
these disease-specific measures is the Oral
Health Impact Profile (OHIP). Slade and
Spencer introduced the original 49-item
OHIP based on Locker’s conceptual mod-
el, derived from the World Health Orga-
nization International Classification of
Impairments, Disabilities, and Handicaps
.17 Today, the short form of OHIP (OHIP-
14) is used widely and can be employed in
order to measure dysfunction, discomfort,
and disability related to oral conditions.17
The validity of the Persian version of the
OHIP-14 was reported by Ravaghi et al.18
Some longitudinal studies have assessed
the effects of orthodontic–surgical treat-
ment on patient OHRQoL using SF-36 and
OHIP-14.2,15,19–21
Although, the negative impacts of mal-
occlusion might not be related to its sever-
ity,22,23 the negative impacts of deformity
seem to be related to the type of maloc-
clusion. There appear to be no reported
studies that have examined the effects of
the type of deformity or Angle classifica-
tion of malocclusion on OHRQoL using
OHIP-14. The aim of this longitudinal
study was to compare changes in OHR-
QoL in young adults with class II and III
deformities undergoing bimaxillary
QoL and orthodontic–surgical treatment
osteotomies for the correction of skeletal
deformities using OHIP-14 at four time
points: prior to treatment, just before sur-
gery, post-surgery, and after debonding.
Materials and methods
Fifty-eight patients participated in this
prospective longitudinal study (28 class
II and 30 class III patients). Ethical ap-
proval for the study was granted by the
relevant ethics committee. Patients with
4 mm or more reverse overjet were cat-
egorized as class III and those with
+10 mm or more overjet were categorized
as class II. Inclusion criteria were the
following: the patient received orthodon-
tic treatment prior to surgery via the same
technique (standard edge-wise, 022 slot
brackets); the patient was scheduled for
a combination of a standard one-piece Le
Fort I osteotomy and bilateral sagittal split
ramus osteotomy (BSSRO) with rigid fix-
ation; condylar positioning devices were
not to be applied; an inter-occlusal splint
was scheduled to be used for 2 weeks.
Exclusion criteria were the presence of
craniofacial syndromes, cleft lip/palate,
and having been scheduled to receive
any of the following treatments: distrac-
tion osteogenesis therapy, genioplasty, or
maxillary impaction. Patients who had a
postoperative infection, malunion with
poor occlusion, or a nerve injury were
also excluded.
OHRQoL was evaluated at four time
points: prior to treatment (T0), just before
surgery (T1), at 6 months after surgery
(T2), and at 12 months after debonding
(T3). The initial evaluation (T0) was car-
ried out when the patient was referred to
the orthodontic department, before any
treatment was received. In the pre-surgical
stage (T1), patients were examined just
before surgery (within an average period
of 0.9 years (standard deviation 0.5 years)
after their treatment had been started). In
the post-surgical stage (T2), patients were
examined at least 6 months after surgery in
order to minimize the effects of post-sur-
gical complications (oedema, swelling,
and pain) on the results. In the post-treat-
ment stage (T3), patients were evaluated
12 months after removal of the orthodontic
appliances.
To evaluate OHRQoL, the Persian ver-
sion of the OHIP-14 questionnaire,18
which also included items related to the
socio-demographic status of the partici-
pants, was used. OHIP-14 includes seven
domains (two items per domain): func-
tional limitation, physical pain, psycho-
logical discomfort, physical disability,
psychological disability, social disability,
477
and handicap. The questionnaire is
designed based on a five-point scale, as
follows: never (0), hardly ever (1), occa-
sionally (2), fairly often (3), and very often
(4). Each domain score can range from 0
to 8 and can be calculated by summating
the responses to the items within a domain.
The overall OHIP-14 score has a range of
0 to 56, where 0 indicates the best OHR-
QoL and 56 indicates the worst impact of
oral condition on OHRQoL. Before an-
swering the questionnaire, an orthodontist
provided the patient with some informa-
tion about the study and instructions on
how to complete the questionnaire and
helped the participant if they had ques-
tions. Participants were asked to answer
all 14 questions in 30 min in a quiet class-
room.
Statistical analysis
The Kolmogorov–Smirnov normality test
was performed to determine if the samples
conformed to a normal distribution. Fried-
man two-way analysis of variance
(ANOVA) was employed to compare
changes in OHIP-14 scores at T0, T1,
T2, and T3 in each group. The Wilcoxon
signed-rank test was used to compare
changes in OHRQoL between the time
points T0, T1, T2, and T3. The Wilcoxon
signed-rank test was also used to identify
the direction and amount of change during
the treatment stages by comparing the
level of OHRQoL at T0, T1, T2, and T3
in each group. A two-tailed Student t-test
was used to compare the means of vari-
ables between class II and class III patients
at the four predefined time points (T0, T1,
T2, and T3).
The magnitude of the statistical differ-
ence was assessed by calculating effect
sizes. The effect size was calculated by
dividing the mean change by the standard
deviation; the larger the effect size, the
greater the magnitude of the change as a
result of treatment. An effect size of <0.2
was considered minimal, of 0.2–0.49 as
small, of 0.5–0.8 as moderate, and of >0.8
as large. The level of significance was set
at P < 0.05; a high level of significance
was indicated by P < 0.001.
Results
Of the 75 adult patients who took part in
the study, 28 class II and 30 class III
patients completed the OHIP-14 question-
naire at all four time points and were
eligible for analysis following the appli-
cation of the inclusion and exclusion cri-
teria. Patients in the class III malocclusion
group (mean age 21.3  2.7 years)
478 Baherimoghaddam et al.

Table 1. Demographic characteristics of the study patients (N = 58).
Class II, n (%)
Sex
Female
Male
Education
Primary/secondary
Tertiary/university
Age, years, mean  SD
SD, standard deviation.
were significantly younger than the
patients in the class II group (mean age
25.1  3.4 years) (P = 0.04). However,
there was no significant difference be-
tween the two groups regarding the sex
of the participants (P = 0.543) or their
educational level (P = 0.763). Patient de-
mographic data are given in Table 1. Sex
and educational level had no significant
effect on the results of the study. Changes
in the OHIP domain scores during ortho-
dontic–surgical treatment in class II and
class III patients can be seen in Tables 2
and 3, respectively.
Changes in physical pain score
Class III, n (%) The increase in physical pain score during
T0–T1 was not significant for either class II
16 (57.1) 11 (36.7) patients or class III patients. The physical
12 (42.9) 19 (63.3) pain score decreased significantly during
T0–T2 and highly significantly during T0–
17 (60.7) 16 (53.3)
T3 in class II patients (Table 4). A signifi-
11 (39.3) 14 (46.7)
25.1  3.4 21.3  2.7 cant decrease was observed during T0–T2
and T0–T3 in class III patients (Table 5).
Also, class II patients showed a significant
improvement during T2–T3. Differences
were significant between class II and class
III patients at T0 (P = 0.013), T1
Changes in the functional limitation
(P = 0.024), and T3 (P = 0.021) (Fig. 2).
score
A significant increase in the functional
Changes in psychological discomfort
limitation score, indicating a worsening,
score
was observed during T0–T1 in class II
patients (Table 4) and a significant de- Changes in the psychological discomfort
crease was found during T0–T2 in class score showed a highly significant decrease
II patients and during T0–T2 and T0–T3 in during T0–T2 and T0–T3 in class II
class III patients (Table 5). There was also patients (Table 4) and during T0–T1,
a highly significant decrease during T0– T0–T2, and T0–T3 in class III patients
T3 in class II patients. Changes in the (Table 5). Class II and class III patients
mean OHRQoL in class II and class III showed significant differences at T0
patients are shown in Fig. 1. (P = 0.017) and T2 (P = 0.039) (Fig. 3).

Table 2. Comparisons of the mean overall and domain scores during orthodontic–surgical treatment at four time points in class II patients.
T0 T1 T2 T3
OHIP-14 domain P-value
Mean SD Mean SD Mean SD Mean SD
Functional limitation 1.82 1.25 2.61 1.16 0.87 1.01 0.85 0.82 0.014a
Physical pain 2.86 1.18 3.57 1.07 1.61 1.07 1.11 0.95 <0.001b
Psychological discomfort 3.07 2.09 3.81 1.24 1.07 0.82 1.18 1.02 <0.001b
Physical disability 3.15 1.79 3.75 1.07 1.46 1.10 0.86 0.71 0.007b
Psychological disability 2.75 1.51 3.85 1.17 1.24 1.51 0.90 0.89 0.004b
Social disability 3.07 1.53 3.00 1.02 1.25 0.97 1.04 0.88 <0.001c
Handicap 2.46 1.35 2.25 1.23 1.14 0.65 0.93 0.72 0.011a
Overall OHIP-14 19.18 2.97 22.84 3.40 8.64 3.21 6.87 2.11 <0.001c
OHIP, Oral Health Impact Profile; SD, standard deviation; T0, baseline; T1, just before surgery; T2, 6 months after surgery; T3, 12 months after
debonding.
a
Significant at the level P < 0.05 (Friedman two-way ANOVA).
b
Significant at the level P < 0.01.
c
Highly significant at the level P < 0.001.

Table 3. Comparisons of the mean overall and domain scores during orthodontic–surgical treatment at four time points in class III patients.
T0 T1 T2 T3
OHIP-14 domain P-value
Mean SD Mean SD Mean SD Mean SD
Functional limitation 1.53 0.82 2.13 1.33 0.80 0.83 0.81 0.78 0.005b
Physical pain 1.47 0.86 1.70 1.06 0.83 0.65 0.80 0.66 0.040a
Psychological discomfort 5.23 1.07 3.23 1.01 1.00 0.95 0.93 0.87 <0.001c
Physical disability 1.30 0.75 2.07 1.01 0.80 0.71 0.77 0.75 0.020a
Psychological disability 4.33 0.88 3.63 0.96 1.01 0.88 0.97 1.03 <0.001c
Social disability 3.03 1.13 2.50 1.48 1.07 0.83 0.93 0.74 <0.001c
Handicap 2.97 1.07 2.37 0.75 1.20 0.81 1.03 0.85 <0.001c
Overall OHIP-14 19.86 2.57 17.63 3.83 6.71 2.45 6.24 2.66 <0.001c
OHIP, Oral Health Impact Profile; SD, standard deviation; T0, baseline; T1, just before surgery; T2, 6 months after surgery; T3, 12 months after
debonding.
a
Significant at the level P < 0.05 (Friedman two-way ANOVA).
b
Significant at the level P < 0.01.
c
Highly significant at the level P < 0.001.
 QoL and orthodontic–surgical treatment 479

Table 4. Comparisons of oral health-related quality of life from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2), and 12 months after
debonding (T3) in class II patients.
OHIP-14 T0–T1 T0–T2 T0–T3 T2–T3
domain
Effect Effect Effect Effect
Mean SD P-value size Mean SD P-value size Mean SD P-value size Mean SD P-value size
Functional +0.78 1.75 0.024a 0.45 0.96 1.50 0.004b 0.64 0.97 1.25 <0.001c 0.8 0.02 0.98 0.808 0.40
limitation
b c b
Physical pain +0.91 1.86 0.050 0.39 1.25 1.65 0.001 0.75 2.04 1.75 <0.001 1.17 0.50 1.17 0.003 0.67
Psychological +0.64 2.47 0.182 0.26 2.00 2.24 <0.001c 0.89 1.89 2.11 <0.001c 0.90 +0.11 1.47 0.853 0.07
discomfort
Physical +0.86 2.21 0.044a 0.31 1.43 2.10 0.002b 0.68 2.04 1.89 <0.001c 1.08 0.61 1.37 0.028a 0.45
disability
a b c
Psychological +1.10 1.87 0.010 0.53 1.51 2.50 0.001 0.64 1.85 1.61 <0.001 1.13 0.34 1.69 0.631 0.12
disability
Social +0.07 1.90 0.828 0.03 1.83 1.66 <0.001c 1.10 2.04 1.80 <0.001c 1.13 0.21 1.17 0.365 0.18
disability
Handicap +0.21 1.34 0.384 0.17 1.32 1.44 <0.001c 0.91 1.54 1.35 <0.001c 1.14 0.21 0.83 0.175 0.25
Overall +3.71 4.32 0.002b 0.86 10.40 6.43 <0.001c 1.62 12.36 5.57 <0.001c 2.21 1.99 3.99 0.942 0.49
OHIP-14
OHIP, Oral Health Impact Profile; SD, standard deviation.
a
Significant at the level P < 0.05 (Wilcoxon signed-rank test).
b
Significant at the level P < 0.01.
c
Highly significant at the level P < 0.001.

Table 5. Comparisons of oral health-related quality of life from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2), and 12 months after
debonding (T3) in class III patients.
OHIP-14 T0–T1 T0–T2 T0–T3 T2–T3
domains
Effect Effect Effect Effect
Mean SD P-value size Mean SD P-value size Mean SD P-value size Mean SD P-value size
Functional +0.60 1.52 0.044 0.39 0.73 1.21 0.005b 0.05 0.80 1.21 0.002b 0.66 0.01 1.06 0.960 0.09
limitation
Physical pain +0.23 1.41 0.435 0.16 0.63 1.16 0.011a 0.54 0.67 0.96 0.001b 0.69 0.03 0.85 0.855 0.03
Psychological 2.00 1.51 <0.001c 1.32 4.23 3.45 <0.001c 1.22 4.30 3.37 <0.001c 1.27 0.07 1.26 0.668 0.05
discomfort
Physical +0.77 1.48 0.013a 0.52 0.50 0.97 0.010a 0.51 0.53 1.14 0.013a 0.46 0.03 0.56 0.739 0.05
disability
Psychological 0.70 1.37 0.014a 0.51 3.32 2.85 <0.001c 1.13 3.36 2.98 <0.001c 1.15 0.20 1.27 0.950 0.16
disability
c c
Social 0.53 1.90 0.121 0.27 1.97 1.80 <0.001 1.06 2.10 1.44 <0.001 1.46 0.13 1.01 0.572 0.13
disability
Handicap 0.40 1.40 0.127 0.29 1.77 1.59 <0.001c 1.11 1.93 1.28 <0.001c 1.50 0.17 0.95 0.325 0.18
Overall 2.03 4.85 0.029a 0.44 13.03 10.25 <0.001c 1.27 13.76 7.87 <0.001c 1.98 0.73 3.04 0.227 0.24
OHIP-14
OHIP, Oral Health Impact Profile; SD, standard deviation.
a
Significant at the level P < 0.05 (Wilcoxon signed-rank test).
b
Significant at the level P < 0.01.
c
Highly significant at the level P < 0.001.

Changes in physical disability score
A significant increase in physical dis-
ability score was observed during T0–
T1 in class II and class III patients.
During T0–T2 and T0–T3, physical
disability scores decreased significantly
in both class II and class III patients
(Tables 4 and 5). Significantly higher
physical disability scores were found
at T0 (P = 0.004), T1 (P = 0.029),
and T3 (P = 0.044) in class II
patients compared to class III patients
(Fig. 4).
Changes in psychological disability
score
A significant increase in psychological
disability score during T0–T1 and a sig-
nificant decrease during T0–T2 and T0–
T3 were recorded in class II patients (Ta-
ble 4). Class III patients showed a constant
decrease during treatment, which was sig-
nificant during T0–T1 and highly signifi-
cant during T0–T2 and T0–T3 (Table 5).
Significantly higher scores were recorded
at T0 in class III patients (P = 0.031)
(Fig. 5).
Changes in social disability score
Class II patients showed an increase in
social disability score during T0–T1 but it
was not significant. They also showed a
highly significant decrease during T0–T2
and T0–T3 (Table 4). In contrast, during
orthodontic–surgical treatment in class III
patients, a non-significant decrease was
observed during T0–T1 and a highly sig-
nificant decrease during T0–T2 and T0–
T3 (Table 5). The difference was signifi-
cant between class III and class II patients
at T1 (P = 0.024) (Fig. 6).
480 Baherimoghaddam et al.

Fig. 1. Changes in the functional limitation score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery
(T2), and 12 months after debonding (T3).

Changes in handicap score
The handicap score remained relatively
unchanged during T0–T1 in both groups;
however, a highly significant decrease was
recorded during T0–T2 and T0–T3 in both
class II and class III patients (Table 4 and
5). A significantly higher score was found
at T0 in class III patients compared to class
II patients (P = 0.018) (Fig. 7).
Changes in overall score
Both class III and class II patients
showed a decrease in the overall
score following orthodontic–surgical

Fig. 2. Changes in the physical pain score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2), and
12 months after debonding (T3).
 QoL and orthodontic–surgical treatment 481

Fig. 3. Changes in the psychological discomfort score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after
surgery (T2), and 12 months after debonding (T3).

treatment. However, class II patients stage in class III patients. Changes (Tables 4 and 5). Differences between
showed a significant increase in the over- in the overall score showed a highly class II and class III were significant at
all score during T0–T1; in contrast, significant decrease during T0–T2 and T1 (P = 0.003) and T2 (P = 0.008)
the overall score decreased during this T0–T3 in class II and class III patients (Fig. 8).

Fig. 4. Changes in the physical disability score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2),
and 12 months after debonding (T3).
482 Baherimoghaddam et al.

Fig. 5. Changes in the psychological disability score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery
(T2), and 12 months after debonding (T3).

Discussion
Aesthetic and functional improvements are
not the only aims of orthodontic–surgical
treatment; the patient’s psychological
health should be taken into consideration
as well.7–9 It is important to evaluate the
impact of different stages of orthodontic–
surgical treatment on patient OHRQoL
in order to educate patients regarding the
possible effects of treatment on their quality
of life during and after treatment.
In the present study, class III patients
were younger than class II patients. The
lower mean age of the class III patients

Fig. 6. Changes in the social disability score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2),
and 12 months after debonding (T3).
 QoL and orthodontic–surgical treatment 483

Fig. 7. Changes in the handicap score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2), and 12
months after debonding (T3).

might be due to the psychosocial pressure
of this type of malocclusion, which neces-
sitates earlier treatment seeking. Patients
with class III malocclusion have been
shown to be significantly less happy with
their appearance compared to class II
patients.24 The results of the present study
did not show any significant differences in
the results obtained from all approaches
between the two sexes; this finding is
consistent with those of other studies
that have found no association between
sex and OHRQoL.19,25,26 However,
Nicodemo et al. observed that male
patients showed greater improvement in

Fig. 8. Changes in the overall score in class II and class III patients from baseline (T0) to pre-surgery (T1), 6 months after surgery (T2), and 12
months after debonding (T3).
484 Baherimoghaddam et al.
the vitality domain of the SF-36 and
females showed greater improvement in
the emotional domain.20
The present data showed significant
improvements in all seven domains of
the OHIP-14 in both groups after ortho-
dontic–surgical treatment. These results
are in agreement with those of other stud-
ies showing that orthodontic–surgical
treatment does have functional, aesthetic,
and psychological benefits.19,20 In con-
trast, Rustemeyer and Gregersen reported
that physical limitation, pain, and chewing
function did not change after surgery, and
improvements in psychological and aes-
thetics aspects were higher than the func-
tional aspect following surgery.2
Although significant improvements in
OHRQoL were observed in both groups
during and after orthodontic–surgical
treatment, the pattern of change was dif-
ferent in the two groups. The psychologi-
cal and personality profiles of skeletal
class II and class III patients and how they
are perceived by their relatives and friends
are different.20 Class III deformity engen-
ders more psychological and inter-person-
al problems due to the alterations in soft
tissue aesthetics.10,27 Although, Choi et al.
claimed that no significant difference was
observed in the level of OHRQoL among
patients with different deformities during
treatment,19 Gerzanic et al. reported that
patients with class II and class III maloc-
clusion showed significant differences in
preoperative psychological profile and the
postoperative changes in that profile.24
Patients in both groups showed a wors-
ening of functional limitation and physical
disability during the pre-surgical stage;
improvements in these domains were
recorded in both groups following surgery.
This might have occurred due to the pre-
surgical preparation followed by aggrava-
tion of the anteroposterior discrepancy,
which makes the occlusion between the
arches difficult.
Ironically, class III patients attained a
significant reduction in psychological dis-
comfort and psychological disability at the
pre-surgical stage. In contrast, class II
patients experienced a significant deterio-
ration in the psychological domains before
surgery. Marked differences between class
II and class III patients in the preoperative
and postoperative psychological profile
have been reported in a previous study.24
The required pre-surgical decompensa-
tions had a negative impact on the psy-
chological profile of class II patients; the
opposite impact was recorded in class III
patients. A higher percentage of patients
with class III deformity are handicapped
by their deformity more than their class II
counterparts among whites.28 Some defor-
mities may be less troublesome due to
their higher incidence in society; approxi-
mately 15% of untreated adolescents in
the USA have a class II malocclusion.
Class II deformities are more prevalent
in white populations than class III, thus
they might impose less of a social burden
on the individual because of the appear-
ance. In class III patients, although the
required pre-surgical decompensations
have more untoward side-effects on the
appearance, the mere presence of the or-
thodontic brackets on the teeth is evidence
of ongoing treatment and can help the
patient to overcome their psychological
problems.28
In the post-surgical stage, both groups
experienced significant improvements in
all seven domains of the OHIP-14. How-
ever, those with a class III deformity
showed more significant changes in the
domains concerning appearance and psy-
chological issues, such as psychological
discomfort, psychological disability, and
social disability, rather than the domains
related to functional limitation and physi-
cal pain. The results of this study are
consistent with the findings of Nicodemo
et al., who showed that vitality, social
function, and emotional function changed
more significantly than physical health
after surgery in class III patients.20
In this study, the changes in OHRQoL
were evaluated 1 year after the completion
of orthodontic treatment; this time frame
is in accordance with that of Choi et al.,
who suggested the best time for OHRQoL
evaluation is 1 year after debonding.19
Hatch et al. reported no further improve-
ment in OHRQoL from 1 to 2 years after
surgery.29 With regards to class II patients,
improvements in the functional limitation
and physical pain domains continued for a
year after debonding. In class III patients,
the evaluation of long-term OHRQoL
changes revealed no further improvement.
These data show that class II patients
attain an improvement in functional limi-
tation and physical pain domains rather
late in the post-treatment stage.
The data presented here showed that
class II and class III patients experienced
significant improvements in the OHIP-14
domains; however, changes were marked-
ly different between patients with class II
and class III malocclusion. The greatest
differences between the two groups were
recorded in the pre-surgical and the post-
treatment stages. Class II patients need
to be aware that they may experience
deterioration in their QoL during the
pre-surgical stage and improvement in
their functional domain rather late in the
postoperative stage. These findings are
especially useful for educating patients
about what to expect in the pre-surgical
and post-surgical stages of treatment and
to help them overcome the negative tem-
porary effects of treatment.
Funding
All authors disclose no financial or per-
sonal relationships with other people or
organizations that could inappropriately
have influenced their work.
Competing interests
No competing interests exist.
Ethical approval
Ethical approval was obtained from the
Ethics Committee of Shiraz University of
Medical Sciences (#90-01-03-3887).
Patient consent
Not required.
Acknowledgements. The authors appreci-
ate the cooperation of Dr Mehrdad
Vosough for his help with the statistical
analyses.
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Address:
Tahereh Baherimoghaddam
Department of Orthodontics
Faculty of Dentistry
Yasuj University of Medical Sciences
Yasuj
Iran
Tel: +98 91 24190940; Fax: +98 74 33226929
E-mail: T_baheri@yahoo.com