Evaluation of medium and long-term psychological effects

of orthognathic surgery vs orthodontic treatment. Scoping

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review.

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N. Cenzato 1,2

A. Manti 1,2+

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F. Di Vito 1,2

G. Di Iasio 1,2

C. N. Maspero 1,2

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1-Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122, Milan, Italy.

2-Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
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* corrisponding author: email: antonino.manti@studenti.unimi.it Indirizzo postale: 20124 tel. number:
3463877172
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 ABSTRACT

OBJECTIVE:

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The research aims to determine the positive impacts of malocclusion correction through ortho-

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dontic therapy and orthognathic surgery on individuals' quality of life.

MATERIALS AND METHODS

A systematic review was conducted, which included 15 clinical trials involving patients undergo-
ing orthodontic-surgical and/or orthognathic-surgical treatments. These trials assessed Oral

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Health-Related Quality of Life (OHRQoL) before and after surgery. A narrative summary was pro-
vided, outlining the key outcomes from all studies that met the inclusion criteria. Our assess-
ment considered factors such as the risk of bias in included studies, timeliness of evidence, con-
sistency of results, precision of estimates, potential publication bias, and the magnitude of the
observed effects.

RESULTS

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Out of the 15 articles, 3 indicate an improvement in patients' quality of life following orthog-
nathic therapy. Another 3 articles generally suggest that both therapies are beneficial for en-
hancing quality of life. Among these, 4 articles favor orthodontic therapy as superior to orthog-
nathic therapy. Additionally, 1 article notes a negative trend in quality of life during orthodontic
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therapy, primarily due to pain, which peaks during the initial 2 days.

CONCLUSIONS
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Orthognathic surgery and orthodontic therapy make it possible to improve the quality of life of
people undergoing treatment and thus offer a positive impact in the medium and long term from
a psychological point of view.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 INTRODUCTION

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The stomatognathic apparatus may have morphological alterations from birth, resulting in a
three-dimensional position of the bony bases that is not compatible with stomatognathic multi-

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function. Thus, masticatory and digestive functions are impaired; phonation can also be affect-
ed, and despite the remarkable adaptive capacities displayed by the organism, it is sometimes
structurally difficult for the subject to be able to articulate certain categories of sounds, with
repercussions on social life as well. In addition, some malocclusions can predispose to medium to
severe respiratory problems, such as obstructive sleep apnea syndrome (OSAS), with repercus-

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sions on the cardiovascular and respiratory systems. The temporomandibular joint (TMJ) may
also be affected, causing pain and dysfunction that only with the restoration of occlusal stability
will joint efficiency be restored. Postural alterations with scoliotic, kyphoscoliotic and lordotic
attitudes can also occur at the vertebral level (1,2,3). The causes of dento-skeletal alterations
and malocclusions may be genetic, first and foremost, without neglecting environmental factors,
which, in the orthognathic/orthodontic matter play a relevant role (4-6). Treatment of these

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malocclusions is carried out with interceptive, functional orthodontics or fixed appliances; when
the technologies existing to date do not allow a satisfactory result to be achieved or when inter-
vention is postponed due to diagnostic delay, orthognathic surgery is used. Both therapies have
been shown to improve vital function and quality of life (QoL) in people with dentofacial defor-
mities and malocclusions (1-7). er
Orthodontic and orthognathic therapy therefore constitute any measure performed to correct a
developing malocclusion or to simplify subsequent orthodontic treatment (6,7). A branch of den-
tistry that embraces subjects of all ages, including adults (4,8,9-13).
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A pleasant face exerts a positive effect from many points of view: in the area of confidence,
self-esteem, thus creates psychological repercussions and influence on the awareness of one's
own value and personality development. So the first motivation for patients to seek orthodontic
consultation is aesthetic appearance, as an unattractive face often conditions the subject in his
relationship with himself and society, leading to depressive syndromes, altered states of emo-
tionality, character disorders, and behavioral alterations. The goal is to aim for the concept of
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normality, eugnathia, a Greek term (the Greek prefix eu means "good, beautiful" and gnathos
means "jaw") expression of a morphological-functional harmony of the various stomatognathic
components. In the presence of severe malocclusions, the treatment of choice, orthodontic-sur-
gical treatment, is resorted to, through which the skeletal gap in the three planes of space can
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be recomposed. In fact, growth phase is exhausted and orthopedic results are null, orthodontical
it is only possible to modify the vertical dimension through dental extrusion and exploit the state
of fibrous synarthrosis, present in some maxillary sutures.
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Orthodontic-surgical treatment, on the other hand, is an alternative option to reharmonize the

skeletal components to correct jaw discrepancies, consistent with the subject's range of neuro-
muscular tolerance in a functional key, so that a stable result can be achieved over
time(3,10,12,13-15).
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The studies of Fleming PS and those of Katrin Bakes et al. show an improvement in quality of life
with orthodontics (11), the same again through orthognathic surgery. Thinking about the data,
the degree of change in Oral health related quality of life (OHRQoL) may differ for patients in
relation to oral sociodemographic distribution and oral health impact profile(1).
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- The selection criteria for orthodontic and orthodontic surgical treatment are based on timing
(4,8,12,13). Orthodontic treatment can be divided according to the following criteria: the first
period (4-6 years) in deciduous dentition. This is orthodontic therapy designed to stimulate the
maxilla three-dimensionally; the second period (6-10 years): early mixed dentition. Here the
goal is to correct harmful habits and modify growth through speech and myofunctional reedu-

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 cation is functional therapy. The most frequent situations of bad oral habits are: sucking of
fingers, hickey or other objects and lip interposition; oral breathing; atypical swallowing (4,
41-43) . In the third one (10-12 years): late mixed teething. It allows to: take advantage of "lee

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way space"; place first molars; achieve incisor guidance and prevent ectopic eruption of ca-
nines. Therapy for this period is fixed orthodontics with utility arches (4). In the fourth period

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(12-18 years): early permanent dentition. At this timing it is impossible to: harmonize the
shape of the arches, solve space problems (crowding and diastemas) and achieve good occlusal
function through the use of fixed orthodontics with full arches (4).

- In the fifth period (over 18 years): adulthood orthodontic or surgical orthodontic treatment can
be chosen according to the motivations for treatment aesthetic or functional (12).

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The basic criteria for clinician's choice and success of orthodontic and orthognathic-surgical
therapy (15,16,36-42) can be summarized as: achievement of physiological static and dynamic
occlusion that satisfies the six keys to optimal occlusion described by Andrews with mutually
protected occlusion pattern and correct and well-coordinated arch forms; periodontal health;
TMJ health. Condyles should be well positioned in the glenoid fossae with correct range of mo-
tion without interference; achievement of harmonious facial proportions; stability of the results

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chief compliant (3,15,16,17, 42-50).

Therefore, the aim of this research is to identify the benefits in relation to Quality of life (QoL)
related to orthodontic and orthodontic-surgical therapy in relation to dentofacial changes and
malocclusions. er
MATERIALS AND METHODS

A systematic review was carried out in adherence to the Cochrane Handbook for Systematic Re-
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view of Interventions and reported in accordance with the preferred reporting elements for sys-
tematic reviews and meta-analyses guidelines. Employing the PICO method (Patient, Interven-
tion, Comparison, Outcome), our research question focused on assessing the impact of orthodon-
tic and orthognathic therapy on the quality of life of patients. The eligibility criteria were as-
sessed, with randomized clinical trials with or without a control group and no-randomized clini-
cal trials with or without control group being included in the inclusion criteria. Of these studies
patients underwent orthodontic-surgical and/or orthognathic-surgical treatment that measured
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OHRQoL before and after surgery. The instrumental tests used to monitor OHRQoL were validat-
ed. On the other hand, studies concerning patients with congenital abnormalities, such as cran-
iofacial syndrome or cleft lip-palate, studies related to sequelae for maxillofacial trauma,studies
using generic instruments to assess HRQoL, case reports or case series, and studies that were not
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primary were considered as exclusion criteria

With regard to information sources and the search strategy adopted, searches for eligible arti-
cles were conducted in the following databases: PubMed, google scholar, MEDLINE, EMBASE,
Psychinfo, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) from their in-
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ception until February 2023.The following terms were used in the search: "orthognathic treat-
ment and psychological impact," "orthodontic treatment and psychological impact," and "quality
of life." A date limit was added to the searches regarding orthodontic treatment, where we con-
sidered reviews and randomized clinical trials from the last 10 years. Details of the search strat-
egy used in each database are listed in the supplementary data (Table search strategy mesh
terms). The literature was explored by reviewing reference lists of primary studies and published
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systematic reviews.

The process of article selection, and thus systematic review, followed three steps. In the first
phase, the title and abstract were screened, in the second phase we performed a full-text re-
view with data extraction, and in the third phase a review of references listed in the articles
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was conducted.

Considering these, based on the previously established inclusion and exclusion criteria, step (1)
was performed independently by two reviewers from the study group (FD and AM); disagreement

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 was resolved by consensus or by a third reviewer (NC). Subsequently, all selected articles were
reviewed to full text independently by two reviewers (FD and AM).

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All selected articles were reviewed to full text.

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Information extracted from the included studies was publication data, study design, country in
which the study was conducted, sample size, patient characteristics, type of treatment, OHRQoL
instrument used, time of follow-up data collection, and results obtained by each group evaluat-
ed (mean and standard deviation of global and domain scores). Several searches were conduct-
ed, based on appropriate keywords, where different filters were made in each.

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The keywords were "orthodontic therapy and quality of life" with 826 total articles, "orthodontic
treatment and psychological impact" and 300 articles were found, "orthodontic treatment" 68
articles were found in total, "orthognathic treatment and quality of life" and 301 articles were
found, "orthognathic treatment and psychological impact" and 95 articles were found, "orthog-
nathic treatment" a total of 34 articles were identified. From these identified articles there was
an initial skimming based on the time frame an annual range of 10 years ranging from 2013 to
2023.

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From the total, the following were identified: 587 articles from the first search, 230 articles
from the second search, 23 articles from the third search, 58 articles from the fourth search,
and, finally, ; the type of study carried out was assessed, determining to include randomized
clinical trials and free systematic reviews, in order to analyze the articles in their entirety.
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considering the relevant title 40 articles were selected for orthodontic treatment and 12 for or-
thognathic treatment. regarding the type of study performed (being part of the inclusion crite-
ria: randomized clinical trials and systematic reviews). These included: 131 articles in the first
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search, 26 articles for the second search, 9 articles for the third search, and 5 articles for the
fourth search.

Recruitment of free articles was necessary in order to read them accessively in their entirety: 54
studies in the first search, 14 studies in the second, 32 studies in the third, 2 in the fourth, and 5
in the fifth search.A narrative description was performed using the main outcome characteristics
of all studies that met the inclusion criteria. Most studies assessed OHRQoL immediately before
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surgery (with presurgical orthodontic treatment) and several months after surgery. The change
between these temporal assessments was selected as the main outcome of interest.To assess the
overall quality of evidence for comparison and outcome, we used the Grading of Recommenda-
tions Assessment, Development, and Evaluation (GRADE) system. The GRADE approach assesses
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the quality of a body of evidence based on the extent to which one can be confident that an es-
timate of effect or association reflects the evaluated outcome. We assessed the quality of the
body of evidence with reference to the overall risk of bias of included studies, immediacy of ev-
idence, inconsistency of results, precision of estimates, risk of publication bias, and magnitude
of effect.
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RESULTS

A total of 15 articles were chosen. The characteristics of the studies reviewed are summarized in
Table 1.
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The most relevant recent articles ranging from 2015 to 2023 were considered: 6 studies were
from European countries (Italy, Sweden, Norway, Romania, Poland, Spain), 2 studies from the
United Kingdom, 2 from the U.S.A., 2 from Brazil, 1 from Saudi Arabia, 1 from China, and 1 from
India.
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Regarding the type of study: 3 are randomized controlled trials, 8 systematic reviews, 2 observa-
tional studies, 1 longitudinal study, 1 cross-sectional study. For articles concerning orthodontic
therapy, a total of 2135 patients were recruited. While for the articles concerning orthognathic
therapy, 5504 patients were enrolled.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 Regarding systematic reviews related to orthodontic therapy consider 799 articles, while those
related to orthognathic therapy, 40 articles. As evaluation methods, studies using validated
questionnaires: OHRQoL questionnaire, Oral Health Impact Profile questionnaire, OHIP-14 ques-

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tionnaire and OQL questionnaire were considered.

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Of the 15 articles: 3 report that patients' quality of life improves with orthognathic therapy; 3
articles generally describe that both therapies are good for improving quality of life; again re-
garding the latter, 4 articles call orthodontic therapy better than orthognathic therapy. 1 article
reports that quality of life during orthodontic therapy has a negative trend initially because of
pain, maximum in the first 2 days. This fades over time, promoting patient acceptance of thera-
py.All authors declare that they have no conflicts of interest.

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DISCUSSION

The psychological aspect related to the two types of approaches is a widely discussed topic in
the literature. Several questionnaires are used to understand the impact of these therapies.
Among the articles analyzed (Table numbers 20,21,22,23,24,26,27,28,29,30,32,34), the most ac-
credited questionnaire for conducting this type of research is the OHRQoL (Oral Health-Related

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Quality of Life), which is an integral part of general health and well-being and is recognized by
the World Health Organization (WHO) as an important segment of the Global Oral Health Pro-
gram (2003). As for the specific questionnaire for orthognathic therapy, the OHIP (Oral Health
Impact Profile) is commonly used.
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A review of articles in the literature shows that both orthodontic and orthognathic therapy gen-
erally lead to an improvement in quality of life. This improvement encompasses social aspects,
facial aesthetics, and oral function across all age groups, from children to adolescents and
adults (10,11). Out of the articles identified, four were not reviews: 2 observational studies, 1
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longitudinal study, and 1 cross-sectional study. These studies, with their different designs, con-
firm the results mentioned earlier.

Regarding these treatments, it's important to acknowledge that there may be some initial pain
and negative emotions, as highlighted in the study conducted by Meazzini MC et al. (33). Howev-
er, it's also clear that orthognathic therapy offers positive effects compared to orthodontic ther-
apy in terms of treatment duration. According to all the authors of the articles analyzed in this
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review, orthodontic therapy is generally longer in duration, and its timing can be adjusted for
better occlusion. Specifically, orthognathic surgical therapy, as explained by Pelo in his article,
can have a negative impact on patients' perception of quality of life. Surgeons should consider
an initial surgical approach to mitigate this, as suggested by Ke Yao (24), who reports that Surgi-
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cally Facilitated Accelerated Orthodontics (SFA) could improve the OHRQoL of patients with
dentofacial deformities similar to conventional orthodontic-surgical treatment at the end of full
treatment. SFA also leads to an immediate increase in OHRQoL at the beginning of treatment
without worsening it.
An important aspect discussed in the article by Zamboni et al. (22) is that the psychological im-
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pact is influenced by the information provided by professionals before surgery. Properly in-
formed patients tend to be more accepting of treatment and more compliant with therapy, re-
sulting in a better overall outcome in terms of healing, psychological impact, and social life.
The positive impact of orthognathic surgery on the improvement of social and psychological
quality of life is also emphasized in the article by Leck R. (23). However, the article by Lancaster
L. (25) reports that concerns about the recovery of oral function can persist up to 2 years after
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the completion of treatment.

Regarding orthodontic therapy, most articles agree on the negative impact it can have on the
psychological and social aspects of patients in the initial stages of treatment. This is due to the
pain that patients may experience initially, the enamel anesthetics that orthodontic therapy may
cause on the enamel, and the social stigma associated with orthodontic appliances. However,
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the psychological and social impact tends to improve over time. As A. González-Sáez (34) reports
in his article, patients using fixed multi-bracket orthodontics experience lower oral health-relat-
ed quality of life, primarily due to the pain experienced in the first weeks of therapy. Meazzini
MC's article (33) also suggests that aligners could be a viable alternative to traditional orthodon-

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
 tic therapy for patients with craniofacial anomalies, as they are transparent and less visible to
others, potentially improving social quality of life and psychological impact.
The heterogeneous nature of these studies does not exempt us from potential biases. Common

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weaknesses include inconsistencies in sample size calculations, variations in the questionnaires
used (OHIP-14, OQLQ, OHRQoL), differences in the timing of questionnaire administration (some

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before, some after, some both before and after treatment), and the lack of blinding during data
analysis. Small sample sizes in many studies can significantly affect the reliability of the results.
Another potential source of bias is the timing of data collection after surgery. In two table items
(S. Pelo et al. (20) and Zamboni R. et al. (22)), the questionnaires were not administered consis-
tently in terms of the time interval from surgery, which could influence patient satisfaction and
quality of life results.

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CONCLUSIONS
Orthognathic surgery and orthodontic therapy can significantly enhance the quality of life for
individuals receiving these treatments, providing a lasting and favorable psychological impact.
They contribute to the improvement of self-esteem, bolstering confidence, enhancing self-
awareness, and fostering personal development. It would be intriguing to explore further the

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specific personalities and personality traits that are most conducive to undergoing orthognathic
surgery and/or orthodontic therapy.

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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4680855