J Oral Maxillofac Surg61:545-552, 2003

Long-Term Assessment of PsychologicOutcomes of Orthognathic Surgery

Theodora Lazaridou-Terzoudi, DDS, MS,*

H. Asuman Kiyak, MA, PhD,† Rod Moore, DDS, PhD,‡

Athanasios E. Athanasiou, DDS, MSD, Dr Dent,§

and Birte Melsen, DDS, Dr Odont�

Purpose: This long-term study of post–orthognathic surgery patients aimed at assessing perceptions ofproblems with physical and psychologic functioning, self-concept, body image, and satisfaction with thesurgical outcome based on subjective evaluations. In addition, the patient’s perception of self-concept,body image, and function was compared with the perception of pretreatment patients and controls withno treatment need.

Patients and Methods: One hundred seventeen patients who underwent orthognathic surgery 10 to14 years earlier and participated in a psychologic study 10 years earlier received questionnaires that werecomposed of 4 instruments designed to assess these factors. A sample of 92 persons representing a populationwithout treatment need and 39 patients requesting treatment for a malocclusion served as control groups.

Results: The findings of this study support the hypothesis that improvement in appearance broughtabout by orthognathic surgery is associated with improvement in psychosocial adjustment. Orthognathicsurgery resulted in subjective estimation of function, appearance, health, and interpersonal relationshipsthat was higher than that among pretreatment and no-treatment control groups. The level of body imageand self-esteem approximated but did not reach that of a nonpatient population.

Conclusions: In view of the current psychologic and social environment, patients should be offeredthe appropriate treatment to correct a disfigurement if it is subjectively perceived by them as a handicap,in part to improve the psychologic outcome.© 2003 American Association of Oral and Maxillofacial SurgeonsJ Oral Maxillofac Surg 61:545-552, 2003

The dilemma of whether to proceed to orthognathicsurgery is not trivial, as it may have major public

health policy implications, as well as a significantimpact on individuals seeking treatment. It is impor-tant to understand the effects of treatment on a long-term basis, but most studies have followed patientsfor only the short term.1 The answers to many ques-tions related to the need and demand for orthognathicsurgery treatment appear to lie in a better understand-ing of the psychosocial meaning of dentofacial ap-pearance. The association among appearance, familyand/or social acceptance, and psychologic adjustmentis by no means clearly delineated.

Numerous investigations have examined the phys-ical attractiveness stereotype across several contexts.Research evidence suggests that this stereotype isseldom mediated by the environmental contexts, andphysically attractive persons are favored over theirless attractive peers across a variety of experiencesand throughout the life cycle. School is one of thesestages where teachers consistently rate attractive chil-dren more favorably and children’s preferences foreach other are associated with physical attractive-ness.2-6 Outside of the school setting, within the fam-ily, it is reported that family members also may be

*Private Practice, Alexandroupolis, Greece; Clinical Assistant

Professor, Department of Orthodontics, Faculty of Health Sciences,

University of Aarhus, Aarhus, Denmark.

†Professor, Department of Oral and Maxillofacial Surgery,

School of Dentistry, University of Washington, Seattle, WA.

‡Research Associate Professor, Department of Oral Medicine,

University of Washington, Seattle, WA; Associate Professor, Faculty

of Health Science, Department of Oral Epidemiology and Public

Health, University of Aarhus, Aarhus, Denmark.

§Professor and Program Director, Department of Orthodontics,

Vice Dean, School of Dentistry, Aristotle University of Thessaloniki,

Thessaloniki, Greece.

�Professor and Chairman, Department of Orthodontics, Faculty

of Health Science, University of Aarhus, Aarhus, Denmark.

Address correspondence and reprint requests to Dr Melsen:

Department of Orthodontics, Faculty of Health Science, University

of Aarhus, DK-8000 C, Denmark; e-mail: orthodpt@odont.au.dk

© 2003 American Association of Oral and Maxillofacial Surgeons

0278-2391/03/6105-0003$30.00/0

doi:10.1053/joms.2003.50107

545

influenced by attractiveness.6,7 In competence-perfor-mance settings, a physical attractiveness stereotypeeffect has also been found in situations where indi-viduals of varying degrees of attractiveness wereviewed as differing in their level of task performanceaccording to their appearance.2,8 The related findingsregarding physical appearance can be summarized:“Not only what is beautiful is good, but what is beau-tiful is also responsible for what is good (success), andwhat is not beautiful is responsible for what is notgood (failure).” Legal interactions,9 dating, and mar-riage10-13 have also been found to be influenced by thephysical appearance of the involved persons.

Only recently was it recognized that facial alter-ations that significantly change the individual’s facialattractiveness (whether for better or worse andwhether those alterations were deliberately under-taken or occurred inadvertently) may change the in-dividual’s life in many ways.14 Because orthognathicsurgery generally results in significant objective im-provements in facial appearance, a better understand-ing of the psychosocial meaning of dentofacial ap-pearance is necessary when a decision has to be maderegarding which individuals should be treated withorthodontics or orthognathic surgery.

Surgery produces sudden and often dramaticchanges, thereby placing immediate demands on thepatient’s adaptive skills. The literature supports thecontention that improvement in appearance broughtabout by craniofacial surgery is associated with im-provement in psychosocial adjustment.15 Quality oflife has been found to improve for the post–facialsurgery patient because of increased self-esteem andconfidence, which frees them to overcome socialbarriers. This may explain why orthognathic surgerypatients have reported high rates of satisfaction. Mostresearchers have found that great majorities of orthog-nathic patients are generally satisfied with the re-sults.1,16-21

Few studies have examined orthognathic surgerypatients several years after their surgery with stan-dardized instruments to assess the long-term effect oftreatment. In one study, the impact of surgical orth-odontics on patients’ personality and perceptions oforal function was tested by examining 74 patientslongitudinally. Patients completed 5 questionnairesduring the course of treatment, from 1 month beforeto 24 months after surgery. Satisfaction peaked at 4months but declined at 9 months postsurgically, asdid self-esteem and facial body image. However,scores improved on all psychologic and satisfactionmeasures by the time of the 24-month assessment.22,23

Changes in self-esteem and body image resulting fromorthognathic surgery and conventional orthodontics,and the association between personality characteris-tics and postoperative reports of pain, paresthesia,

swelling, and satisfaction, were investigated among90 patients who underwent surgical orthodontics. Itwas found that surgery is more effective than orth-odontics alone in enhancing body image. Self-esteemalso improved among surgery patients toward themiddle-to-high range.22

Purpose of Study

In reviewing the existing literature in orthognathicsurgery, it could be concluded that this treatmentappears to have an impact on the patients’ personalitycharacteristics and lead to major changes in theirlives. However, no studies have followed patientsbeyond the first years of orthognathic surgery. There-fore, the primary question was to evaluate whetherthese patients at 10 to 14 years after treatment dif-fered from those anticipating treatment and a nonpa-tient control group in their self-assessments of currentoral function, general health, and psychosocial func-tioning. The second question addressed the issue ofpsychologic well-being after treatment (ie, body im-age and self-concept in comparison with pretreat-ment and nonpatient controls).

Changes associated with treatment may vary acrosscountries because of cultural differences and the ex-isting health care systems; this knowledge can beused in the selection of patients for this type oftreatment and for assisting them with each postsurgi-cal stage.24 The third question was therefore howorthognathic surgery patients in Denmark perceive achange in their oral function, overall health, bodyimage and self-esteem, and personal and social life upto 14 years after their treatment.

Materials and Methods

The initial study sample comprised all 152 peoplein Denmark who had undergone orthognathic surgeryat the Aarhus University Hospital from 1982 to 1986and participated in a previous retrospective psycho-logic study of the impact of orthognathic surgery.1

The addresses of 134 of the original 152 patients werefound, and questionnaires were mailed. These werecompleted and returned by 117 patients (87.3% re-sponse rate). The respondents did not differ from theoriginal sample with respect to gender distributionand surgical intervention.

Two control groups were used to compare withpatients’ responses. The first control group consistedof future patients, those on the waiting list of theDepartment of Orthodontics, Aarhus University, Den-mark. These patients represented a population whoperceived a need for orthodontics or combined orth-odontic/orthognathic surgery treatment. Of the 74persons contacted, 39 returned the questionnaires

546 LONG-TERM PSYCHOLOGIC OUTCOME OF SURGERY

(52.7% response rate). The second control sampleconsisted of comparably aged adults who were notseeking treatment. Of the 150 questionnaires distrib-uted, 92 were returned (61.3%). A comparison ofthese 3 groups by gender and age is given (Table 1).The patient sample included a larger proportion ofmen than the 2 control groups (41% versus 25% and32%, P � .05). On average, the patient group wasyounger at the time of assessment (mean age, 36.8versus 39.2 and 40.7 years, P � .05).

PSYCHOLOGIC EVALUATION

Patients completed 3 questionnaires to assess theirperceptions of problems with physical and psycho-logic functioning, self-concept, and body image andsatisfaction with surgical outcome. Each question-naire was accompanied by detailed instructions aboutthe measures and their response scales.25

The first questionnaire was designed to assess pa-tients’ perceptions of their problems in 4 areas, be-fore and after surgery. It was adapted for this researchfrom a previous study by Kiyak et al22 with Americanpatients. It is composed of 19 questions designed tomeasure problems with oral function, general health,appearance, and interpersonal relationships. Thequestionnaire was adapted to ask the patient to recallhow he or she felt about these items before surgeryand just after surgery, as well as their current feelings(Table 2). This was done to assess their comparativeperception of changes versus stability in each area ofproblems. The control groups reported only theircurrent feelings.

The second questionnaire was the shortened FittsTennessee Department of Mental Health Self-ConceptScale (26 items); it was used to measure the individ-ual’s current self-assessment of their personal and

Table 1. DISTRIBUTION ACCORDING TO AGE OF PATIENTS AND CONTROL GROUPS

Patients (n � 117)

Control 1: ThoseSeeking Treatment

(n � 39)

Control 2: ThoseNot SeekingTreatment(n � 92)

Age (yr), mean (SD) (range) 36.8, (7.77) (28–69) 39.2, (9.89) (25–66) 40.7, (7.58) (29–61)

Table 2. QUESTIONNAIRE 1: PROBLEMS BEFORE AND AFTER JAW SURGERY

Whenever we undergo any medical or dental treatment, we often experience some changes in our physical and emotionalhealth. These changes may be good or bad.

You have probably also experienced some changes in some aspects of your life since your jaw surgery and orthodontics.For each of the areas listed below, place a number from 1 to 5, where 1 � “very much a problem” to 5 � “very easy,”in each column to indicate how you felt before your surgery and orthodontics, how you felt just after, and how youfeel now in each of these areas:

BeforeSurgery

Just afterSurgery Now

1. Chewing 1 2 3 4 5 1 2 3 4 5 1 2 3 4 52. Biting into foods 1 2 3 4 5 1 2 3 4 5 1 2 3 4 53. Fitting your back teeth together 1 2 3 4 5 1 2 3 4 5 1 2 3 4 54. Fitting your front teeth together 1 2 3 4 5 1 2 3 4 5 1 2 3 4 55. Speech 1 2 3 4 5 1 2 3 4 5 1 2 3 4 56. Popping and clicking of jaw joint 1 2 3 4 5 1 2 3 4 5 1 2 3 4 57. Pain and soreness in front of ear 1 2 3 4 5 1 2 3 4 5 1 2 3 4 58. Sinus problems 1 2 3 4 5 1 2 3 4 5 1 2 3 4 59. Appearance of teeth 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

10. Facial profile 1 2 3 4 5 1 2 3 4 5 1 2 3 4 511. General appearance 1 2 3 4 5 1 2 3 4 5 1 2 3 4 512. General health 1 2 3 4 5 1 2 3 4 5 1 2 3 4 513. Feelings about self 1 2 3 4 5 1 2 3 4 5 1 2 3 4 514. Socializing with friends/family 1 2 3 4 5 1 2 3 4 5 1 2 3 4 515. Performance in work or school 1 2 3 4 5 1 2 3 4 5 1 2 3 4 516. Being out in public 1 2 3 4 5 1 2 3 4 5 1 2 3 4 517. Headaches 1 2 3 4 5 1 2 3 4 5 1 2 3 4 518. Sleeping 1 2 3 4 5 1 2 3 4 5 1 2 3 4 519. Appetite 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

NOTE. Scale: 1, very much a problem; 2, somewhat; 3, so-so; 4, relatively easy; 5, very easy.

LAZARIDOU-TERZOUDI ET AL 547

social self and their interactions with family.26 The 26items reflect 5 aspects of an individual’s self-concept,namely the physical, social, personal, family self, andself-criticism.

The third questionnaire, “body image,” was a mod-ified version of Secord and Jourard’s27 body cathexisscale. The original scale included several items relatedto general self-concept rather than body image per se.The modifications were made by Kiyak et al22 toinclude more body parts, especially those related tofacial features (Table 3).

Patients were asked to complete Questionnaires 2and 3 with their current appearance in mind.

The 2 control groups received all 3 questionnaires.The questionnaires were designed to be self-adminis-tered. In addition, the surgery patients received aquestionnaire that included 5 of the questions theyhad been asked 10 years ago.1 Respondents returnedthem in an enclosed stamped and addressed envelopeto the first author at the Department of Orthodontics,Aarhus University.

Statistical Evaluation

The first step in the statistical analysis of the datawas to test the internal consistency reliability of ques-tionnaire subscales using Cronbach’s �. Descriptivestatistics were performed for each subscale withineach of the 3 questionnaires; in relation to Question-naire 1, scores on the problem checklist were calcu-lated for each time point for the surgical patients.Statistical analyses were conducted separately for the3 groups, and group comparisons on relevant mea-sures were made with 1-way analysis of variance(ANOVA) tests.

Patients’ mean scores were calculated for the satis-faction questions. Correlation tests were conductedbetween the 4 “problem” subscores of Questionnaire1, all body image subscales (Questionnaire 3), and allself-concept subscales (Questionnaire 2). Within eachof the 4 subscales of the “problems” questionnaire, arepeated measures ANOVA was performed across the3 time points to assess perceived changes within

Table 3. QUESTIONNAIRE 3: BODY IMAGE

Images of yourself: Consider each item listed below and place a circle in the column that best represents your feelingsabout yourself at the present time.

StrongFeelings—Wish

a Change

Do Not LikeBut Can Put

Up With

No ParticularFeelings OneWay or the

OtherI Am

Satisfied

ConsiderMyself VeryFortunate

1. Height 1 2 3 4 52. Weight 1 2 3 4 53. Hair 1 2 3 4 54. Ears 1 2 3 4 55. Forehead 1 2 3 4 56. Eyes 1 2 3 4 57. Nose 1 2 3 4 58. Lips 1 2 3 4 59. Mouth 1 2 3 4 5

10. Teeth 1 2 3 4 511. Facial complexion 1 2 3 4 512. Chin 1 2 3 4 513. Neck 1 2 3 4 514. Profile 1 2 3 4 515. Shoulders 1 2 3 4 516. Chest (males)/breasts (females) 1 2 3 4 517. Arms 1 2 3 4 518. Hands 1 2 3 4 519. Waist 1 2 3 4 520. Hips 1 2 3 4 521. Thighs 1 2 3 4 522. Legs 1 2 3 4 523. General muscle tone development 1 2 3 4 524. Overall facial attractiveness 1 2 3 4 525. Overall upper trunk attractiveness 1 2 3 4 526. Overall lower trunk attractiveness 1 2 3 4 527. Overall body appearance 1 2 3 4 5

Data from Secord and Jourard.27

548 LONG-TERM PSYCHOLOGIC OUTCOME OF SURGERY

patients on these dimensions. One-way ANOVA testswere performed to evaluate the influence of genderand age.

Results

Evaluation of the internal consistency of each scaleindicated moderate to high internal reliability, rangingfrom � � .71 for the “pretreatment oral functionproblems” checklist to � � .95 for the “current inter-personal problems” checklist (Table 4). Not surpris-ingly, patients rated current feelings in the 4 domainsof problems more consistently than they did in ratingthemselves before treatment. Body image had highinternal consistency reliability for both the overallscale (� � .92) and on the facial image subscale (� �.81).

The validity of the answers related to the questionson the patients’ perception 10 years ago was evalu-ated by comparing answers given at that time andnow to the same question. Apart from the motive forseeking treatment, assigning more weight to theaesthetics retrospectively than at the time of sur-gery the other answers did not differ significantly(Table 5).

The first question explored in this study was,“Among patients who undergo orthognathic surgery,what changes do they perceive in their oral function,health, appearance, and interpersonal relationships?”A series of repeated measures ANOVA tests wereconducted to answer this question. The results from

the “problems” questionnaire appear in Figure 1. Alinear improvement in all 4 subscales is evident, frombefore treatment to right after treatment and from theimmediate posttreatment phase to the present (allP � .001). That is, patients today perceive their oralfunction, health, appearance, and interpersonal well-being to be significantly better now than before orjust after surgery. They also perceive significant im-provements from presurgery to immediate postsur-gery.

The second question was related to patients’ per-ceptions of problems in these 4 areas currently com-pared with those of the 2 control groups. To assessdifferences between treated patients and the 2 con-trol groups, a 1-way ANOVA was carried out. Theresults, shown in Figure 2, generally indicated higherscores for postsurgical patients even when comparedwith nonpatient controls. Patients’ reports of currentfunctioning in these areas were slightly better thanthe scores of nonpatient controls and much betterthan the scores of patients who were anticipatingtreatment (P � .001 for oral function, health, andappearance; P � .01 for interpersonal skills).

The third questionnaire focused on the patients’current self-concept and body image and on whether

Table 4. RESULTS OF CRONBACH TEST

Subscale �

Problem TotalBefore treatment .8806Right after treatment .9253Currently .9634

FunctionBefore treatment .7077Right after treatment .8011Currently .9065

HealthBefore treatment .8714Right after treatment .8691Currently .9130

AppearanceBefore treatment .7469Right after treatment .8691Currently .8240

InterpersonalBefore treatment .8483Right after treatment .9123Currently .9460

Self-feelings Total (excluding questions 9 and 18) .7355Body image Facial .8095

Total body image .9162

Table 5. RESULTS FROM THE QUESTIONS ASKED IN1986 AND CURRENTLY

Question*

PairedDifferences

t Test SignificanceMean SD

1a �0.12 0.54 �1.28 .211b �0.13 0.41 �2.97 .0042 �0.07 1.17 �0.6 .563 0.03 0.66 0.45 .664 �0.12 0.88 1.36 .18

NOTES. Questions 1a and 1b were about hesitation towards sur-gery. Question 2 was about the impact of aesthetics or function onindications for surgery. Questions 3 and 4 were about concern inrelation to surgery and decision making.

Data from Athanasiou et al.1

FIGURE 1. Perceived problems before surgery, after surgery, andcurrently (aF � 29.65, P � .001; bF � 12.17, P � .001; cF �79.62, P � .001; dF � 22.87, P � .001, repeated measuresanalysis of variance).

LAZARIDOU-TERZOUDI ET AL 549

differences exist between the posttreatment patientsand the 2 control groups. Responses to this question-naire by the 3 groups were analyzed by means of1-way ANOVA and indicate a significant differencebetween patients and nonpatient controls (Fig 3).Although all groups scored in the intermediate range,the 2 patient samples scored lowest, whereas nonpa-tients scored highest on overall self-concept (F �2.99, P � .05).

Body image scores were also evaluated in relationto the 2 control groups (Fig 4). The results suggestthat perceptions of facial profile are higher amongpatients after orthognathic surgery than among thoseanticipating it but not as high as self-ratings amongnonpatient controls (F � 4.80, P � .01). Mean scoreson the 9 items comprising facial body image werehighest in the normal control group and lowest in thepretreatment control group (F � 5.08, P � .01).Generalized body image, however, was equally highin all 3 groups.

The influence of age on orthognathic surgery pa-tients’ responses on the “problems” questionnairewas analyzed by dividing patients into 3 groups basedon current age: 26 to 32, 32 to 36, and 36 to 68 (Table6). Statistically significant age differences emerged onthe subscale of perceived problems with appearanceafter treatment (P � .05) and on interpersonal prob-

lems before treatment (P � .05). No age differencesemerged in the body image and self-concept mea-sures. The highest scores were achieved in all 3 areasby patients in their mid-30s (who would have been 20to 26 years old at the time of surgery), such that theywere least concerned with their appearance and in-terpersonal status and most satisfied with treatmentoutcomes. The youngest group (who would havebeen 14 to 20 at the time of surgery) was most criticalof their current appearance and least satisfied of all 3age groups.

Results of the influence of gender on patients’ re-sponses found that men were less concerned withappearance (P � .05) and reported a more favorableoverall body image (P � .05) than did women (Table7). However, gender differences did not emerge onother “problem” subscores, on subscales of body im-age, or on self-concept.

FIGURE 4. “Body image” for patients versus controls (aF � 4.8, P �.01; bF � 5.08, P � .01; cNS).

Table 6. EFFECTS OF AGE ON PROBLEMS

Problems Subscale

Patients’ Age at Time of Interview(yr)

26–32(n � 41)

32–36(n � 33)

36–68(n � 37)

AppearanceMean 3.20 3.77 3.32SD 0.99 0.82 1.08

InterpersonalMean 3.60 3.81 3.59SD 0.99 0.96 1.09

SatisfactionMean 5.41 6.61 6.11SD 1.73 0.79 1.70

NOTE. Mean values of scores. Appearance and interpersonal: sub-scale can range from 1 (serious problems) to 5 (very easy, noproblems). Satisfaction: subscale scores range from 1 (not satisfied)to 7 (very satisfied). Appearance: F � 3.36, df � 2/108, P � .05.Interpersonal: F � 3.95, df � 2/108, P � .05. Satisfaction: F � 5.90,df � 2/108, P � .01.

FIGURE 2. “Problems” for patients versus controls (aF � 16.78, P �.001; bF � 7.03, P � .001; cF � 7.08, P � .001; dF � 4.25, P �.001, comparison of current status across groups).

FIGURE 3. “Self-concept” for patients versus controls (F � 2.99, P �.05).

550 LONG-TERM PSYCHOLOGIC OUTCOME OF SURGERY

Discussion

This study aimed to assess the psychologic impactof orthognathic surgery on patients with maxilloman-dibular discrepancies and in particular to identify anypsychologic benefits from such surgery. Only after 2to 5 years should one take as permanent the effect offacial change, because this time is necessary for thepersonality to accept and incorporate the new fea-tures.21,22 The long-term impact of treatment for adentofacial malformation on patients’ self-concepthas, however, been addressed in only a few stud-ies.22,28 The current project surveyed a large numberof patients (n � 117) who had undergone all types oforthognathic surgery 10 to 14 years earlier. The psy-chologic instruments used were developed by re-search psychologists and have already been used andtested in several studies with orthognathic surgeryand orthodontic patients.1,22,26,27 For this reason, re-sults could be compared with those of the previousstudies. Furthermore, the Cronbach � tests confirmedthe internal consistency reliability of the measure-ments adapted from previous studies.

The repetition of the same questions as asked 10years earlier1 ensured the validity of the questionrelated to the perception 10 years earlier. The changein the motive for seeking treatment could well berelated to the influence of time because it was con-sidered less legitimate to seek treatment for aestheticsthan for functional problems.

The results from the “problems” questionnaire in-dicate a perceived improvement from the period be-fore surgery to the postsurgery time and up to thepresent in all 4 areas examined (oral function, health,appearance, and interpersonal relationships) (Fig 1).The level of satisfaction among patients is higher thanthat among nonpatient controls, and even more sothan that of the prospective patients control group(Fig 2). In consideration that surgical patients startedfrom a level lower than the prospective orthodonticpatients control group on the appearance and inter-

personal subscales, the benefits of treatment on theirperceptions about these psychologic and physicalcharacteristics can be clearly seen. Even if the subjec-tively evaluated improvement regarding function andhealth is not consistent with the objective physicalchanges,25 the influence of positive thinking regard-ing these factors is equally important. In comparingthese results with what is reported in the literaturefrom a previous study,28 we see higher levels of per-ceived improvement in the current patient sample.

Nevertheless, it should be emphasized that askingpatients to recall their problems before surgery andimmediately after surgery may create a situation ofcognitive dissonance and, therefore, a tendency toexaggerate differences between one’s past and cur-rent well-being. That is, if a patient believes that he orshe has undergone significant improvements, even ifit is not true, it may result in an artificial inflation ofhis or her current well-being. It may also result inconvincing oneself that the experience was worthone’s efforts and pain. It seems that the surgical treat-ment acts as a self-fulfilling prophecy, proving oncemore the theorem set forth by Thomas and Thomas29:“If men define situations as real, they are real in theirconsequences.”

The influence of age on the factors examined bythe “problems” questionnaire was not surprising; thefinding that patients in their 30s are more satisfiedwith the effects of surgery on their appearance andinterpersonal relationships is normal and has beenpreviously reported.30 The influence of gender on theappearance subscale was also an expected finding.The high correlation between perceived health andappearance and between the health and interpersonalsubscales of the “problems” questionnaire is an indi-cation of the close relationship between the physicaland psychologic well-being of an individual.

Two questions involved the “body image” and “self-concept” measures. 1) Are positive changes in self-concept and body image realized after corrections ofdentofacial deformities by orthognathic surgery? 2)What is the level of self-concept and body image ofpersons having been treated by orthognathic surgerycompared with that of a nonpatient population andprospective patients? In comparing these findingswith those of previous studies,1,22,31 significant differ-ences emerged between patients and nonpatient re-spondents. It appears that people who seek orthog-nathic surgery have a lower self-concept and are morecritical of their facial features than are nonpatientcontrols, even 10 years after undergoing surgery.Thus, despite reporting few problems with their ap-pearance and interpersonal relationships in anotherquestionnaire, these people have not achieved thehigh level of self-confidence about their facial andbody appearance or about their psychosocial well-

Table 7. ESTIMATION OF APPEARANCE AND TOTALBODY IMAGE BY MALES AND FEMALES

Subscale Male (n � 46) Female (n � 64)

AppearanceMean 2.64 2.26SD 1.07 1.03

Total body imageMean 3.75 3.43SD 0.51 0.65

NOTE. Mean values of scores. Appearance: subscale scores canrange from 1 (serious problems) to 5 (no problems). Total bodyimage: subscale scores can range from 1 (wish a change) to 5 (veryfortunate). Appearance: t value � �1.91, df � 108, P � .05. Totalbody image: t value � �2.86, df � 107, P � .05.

LAZARIDOU-TERZOUDI ET AL 551

being that is found in a population that has not soughttreatment. Nevertheless, they report very high levelsof satisfaction. This research supports evidence fromearlier studies that body image and self-concept doimprove with orthognathic surgery.

The findings of this study support the hypothesisthat improvement in appearance brought about byorthognathic surgery is associated with improvementin psychosocial adjustment. It is controversialwhether psychosocial and functional problems areconsidered legitimate reasons from a cost-benefitpoint of view for orthognathic surgery. The commu-nity-perceived importance of “straight teeth and anice smile” was recently confirmed by Coyne et al,32

and the present study suggests that a relief of thenegative impact of a person’s disfiguration may leadto an improvement in the patient’s self-concept. Be-cause dissatisfaction would have an adverse impacton the occupational and professional life of the indi-vidual, patients should appropriately be offered theappropriate treatment to correct a disfigurementwhen they subjectively perceived a handicap. Orthog-nathic surgery may, in that case, lead to an improve-ment in the quality of these patients’ lives.

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