ORIGINAL ARTICLE

Health-related quality of life and depressionin patients with dentofacial deformity

Érica Dorigatti de Ávila & Rafael Scaf de Molon &

Leonor Castro Monteiro Loffredo &

Elaine Maria Sgavioli Massucato &

Eduardo Hochuli-Vieira

Received: 13 April 2012 /Accepted: 16 July 2012 /Published online: 4 September 2012# Springer-Verlag 2012

AbstractIntroduction Patients with dentofacial deformities presentdifficulties at work and in social adaptation. At the sametime, they often appear depressed, and as a consequence, thepsychosocial aspects of surgery play an important role. Theaim of this study was to investigate the effects that depres-sion causes in the quality of life of patients with dentofacialdeformity.Material and methods Filthy patients were recruited 1 yearbefore undergoing orthognathic surgery and correlated oraland general health with the presence and absence of depres-sion. In order to accomplish this, these patients received anadapted questionnaires of quality of life and Beck DepressionInventory to fill out. Fisher's test was applied, with a signifi-cance level of 5 %. Intercooled Stata version 9.0 was used toanalyze data.Results Among the eight domains of quality of life, therewere three associated with depression status: vitality (p<0.001), social aspects (p00.011), and mental health (p00.008).Discussion There is growing interest in the impact of den-tofacial deformity conditions on patients' quality of life. Thescientific literature has discussed the social aspects of these

deformities and showed that untreated patients had low self-esteem and suffered social restrictions before making theorthodontic and surgical treatments. This study concludedthat the depression interferes significantly in vitality, socialaspects of the individual, and mental health and, at the sametime, emphasizes that the orthognathic surgery aims to notonly restore esthetics and function to the patient but alsoimprove the quality of life.

Keywords Orthognathic surgery . Quality of life .

Dentofacial deformity . Depression

Introduction

The World Health Organization defines quality of life as anindividual's perception of their position in life in the contextof the culture and value system in which they live and inrelation to their goals, expectations, standards, and concerns.There is a growing interest in understanding how the orthog-nathic surgery affects the lives of patients with dentofacialdeformities. Most scientific studies aim to evaluate changesin quality of life of patients with dentofacial deformitiesafter orthognathic surgery [1–4] and have suggested signif-icant improvement in quality of life and psychological statusafter surgery. However, there is a dearth of informationabout what to expect from orthognathic surgery effects onpatients during the preoperative phase. That is to say, fewstudies compare the quality of life of patients before surgery,and these data are necessary to enable surgeons to informpatients about what to expect from surgery.

Patients with dentofacial deformities present difficultiesat work and in social adaptation. They often appear de-pressed, which brings negative consequences to their mental

É. D. de Ávila (*) :R. S. de Molon : E. M. S. Massucato :E. Hochuli-VieiraDepartment of Diagnosis and Surgery; Faculdadede Odontologia de Araraquara, Univ Estadual Paulista (UNESP),Rua Humaitá, 1680,14801903 Araraquara, SP, Brazile-mail: erica.fobusp@yahoo.com.br

L. C. M. LoffredoDepartment of Social Dentistry; Faculdade de Odontologiade Araraquara, Univ Estadual Paulista (UNESP),Campus Araraquara, SP, Brazil

Oral Maxillofac Surg (2013) 17:187–191DOI 10.1007/s10006-012-0338-5

health. As a consequence, the psychosocial aspects of sur-gery, such as changes in body image and emotional andcognitive states, improvement of interpersonal relationships,and changes in the reactions of society play an importantrole. It is important to establish and compare the impact ofdifferent dental and dentofacial conditions on patients' qual-ity of life so as to determine and prioritize the need oftreatment, especially since public health resources are lim-ited [1, 5].

Considering that there are few studies associating qualityof life and depressive state in patients with dentofacialdeformities, the aim of this study is to highlight the effectthat depression causes in the quality of life of patientsrecruited 1 year before orthognathic surgery and, at the sametime, to correlate oral and general health with the presenceand absence of depression.

Methods

Study design

A pilot study was performed to validate the adapted ques-tionnaires of quality of life and Beck Depression Inventory(BDI) and to define the population sample size. All patients,scheduled to undergo orthognathic surgery in the Depart-ment of Diagnosis and Surgery, Araraquara Dental School,São Paulo State University, were included in this study.Exclusion criteria for this group were physical disabilityand patients under the age of 18. The group consisted of50 patients with dentofacial deformities, recruited a yearbefore orthognathic surgery.

Data collection and instruments

Each patient was evaluated individually by the researcherusing the adapted questionnaires of quality of life and theBeck Depression Inventory during the preoperative periodfor subsequent analysis of the results. Data collection con-sisted of questionnaires incorporating a generic health-related approach (short form health survey measure) withdemographic information (age, gender, and race), theadapted questionnaires of quality of life, and the BDI.

The adapted questionnaires of quality of life consists of 36items, divided in eight domains, which are then divided intotwo large groups: physical (functional capacity, physicalaspects, pain, and general health status) and mental (mentalhealth, emotional and social aspects, and vitality). The firstcomponent evaluates the presence and extension of limitationsrelated to the functional capacity (FC) and is placed in tenitems. The physical aspects (PA) item assesses how physicalhealth interferes with domestic habits, and it consists of fourquestions. The next component assesses the presence of pain

(P), its intensity, and interference in domestic activities. Thefourth component is the state of general health (SGH), and itassesses the perception that the patient has of his or her ownhealth and expectations for the future. Vitality (V) is the degreeof energy and disposition to perform daily tasks, and it consistsof four items. The sixth component, social aspects (SA), ana-lyzes how much habitual social activities are affected by phys-ical and emotional states. The last two components areemotional aspect (EA), which consist of three items, andmental health (MH), which consists of five. They evaluatethe impact of psychological aspects in the well-being of thepatient and the degree of anxiety, depression, change of be-havior, and psychological well-being, respectively. Theanswers to the questions are scored from 0 to 100, with 0corresponding to the worst health and 100 to the best [6, 7].

The Beck Depression Inventory consists of 21 items,where participants must answer a four-point scale codednever (0), occasionally (1), fairly (2), and often (3). Accord-ing to Beck et al., the selection of the point of adequate cutdepends on the nature of the sample and the objectives ofthe study. The depression was classified in two levels:namely, absent (less than 10) and present (varying from 10to 63). The domains of quality of life had been subdivided,being classified as low for FC<70, PA<75, P<70, SGH<70, V<70, SA<75, EA<70, and MH<70; they had beenclassified as high when they had varied from the lower limitto 100 [5]. Tables of contingency were made according toeach dimension (FC, PA, P, SGH, V, SA, EA, and MH) andpresence of the depression.

Data analysis

Fisher's test was applied with a significance level of 5 %.Intercooled Stata version 9.0 was used to analyze data.

Ethical considerations

Research protocol (25/07) was approved in advance bythe research ethics committee of the Araraquara DentalSchool, Sao Paulo State University, and written in-formed consent was obtained from all subjects beforethe investigation.

Results

A total of 50 patients with dentofacial deformity consentedto participate in the study completed at the first year. Thegroup consisted of 27 women and 23 men, but the studyresults showed no statistically significant difference be-tween the genders. Table 1 shows presence (and lack) ofheadache and temporomandibular joint (TMJ) pain inorthognathic patients.

188 Oral Maxillofac Surg (2013) 17:187–191

Among the 33 patients who had headaches, 25 alsoreported having pain in the temporomandibular joint. Consid-ering the depressive state of these patients, it was observedthat depressive patients are more susceptible to headaches andTMJ pain (p<0.05). The opposite was noticed in patients whodid not have depression (p00.530).

Of the eight domains evaluated by the adaptedquestionnaires of quality of life with the depressive stateof the patients (BDI), three were statistically significant andare presented here: vitality, social aspects, and mentalhealth. It was found that the patients, who did not havedepression, possessed higher vitality (p<0.05), higher ca-pacity to carry out social activities (p00.011), and highmental health (p00.389). The average values for vitality,social aspects, and mental health confirm the correlationbetween dentofacial deformity and reduced quality of life.

Discussion

There is growing interest in the impact of deformityconditions on patients' quality of life, and it reflectsthe need seen in many other health conditions that arenot necessarily fatal but can, nevertheless, cause consid-erable physical, social, and psychological dysfunction[2, 8]. The scientific literature has discussed the socialaspects of dentofacial deformity and showed that un-treated patients had low self-esteem and that their socialreaction is undesirable and suffered social restrictionsbefore making the orthodontic and surgical treatments[9–11]. Similarly, in relation to impact of facial defor-mity in an individual's quality of life, it may affirm thatpeople who have depression have a quality of life thatis worse than those who do not [8].

As mentioned before, 50 patients participated in thisstudy, 27 women and 23 men. The items, which wereevaluated separately in relation to gender, were TMJ pain,headaches, sleep, presence of shortness of breath, presence

of deleterious habits, and appetite. In this context, it wasconcluded that women had a significant percentage overmen in the items: TMJ pain, headaches, shortness of breath,and deleterious habits. Furthermore, there was no significantassociation between these results and the presence of crani-al–facial disharmony.

Although the most common reasons reported by patientssubmitted to the orthognathic surgery are the improvementsof physical appearance and functions, the expectation of thepsychosocial benefits is also an important factor in thisdecision. These benefits include change in personality, im-provement in relationships, and confidence in oneself [2].

Some authors evaluated the impact of the orthognathicsurgery in the rectification of the personality of the patientsand concluded that the personality of the surgical patientshad improved significantly in the course of 2 years follow-ing the surgery [10, 12]. In a study of Motegi et al., theseauthors showed the impact of mandibular advances in classII patients and concluded that there is a significant improve-ment in the quality of life, in general, and buccal health andpsychosocial functions. The psychosocial dimensions arerelated to the individual's social interaction, communication,emotional behavior, and vivacity, and all showed consider-able improvement 2 years after surgery [2]. Unlike theseresults, Cunningham et al. demonstrated improvement in thequality of life of the patients who submitted to orthognathicsurgery 16 years after its completion but affirmed that thelack of preoperative data makes it difficult to define theconclusions about the psychological effect of the orthog-nathic surgery [13].

The quality of life related to health evaluates theeffect that the illnesses and the treatments have on thedaily life and personal satisfaction. The perception ofstigma, of discrimination, rejection, and social isolation;difficulties in relationships (to initiate and to keep aloving relationship); limitations in daily activities; andproblems in work and unemployment have been associ-ated with depressive states, negatively influencing thequality of life of these individuals. Depression is asso-ciated with a significant decrease in the quality of life,including harmed social functionality [14]. Diminishingvitality, concentration, quality of social interactions, andsatisfaction with life may be observed in depressivepatients [14, 15]. In this context, it can be affirmed thatface alterations cause personal dissatisfaction, which, inturn, can be observed by means of the individual'semotional state. Depression drastically causes the de-crease of quality of life of the individual. In this study,it is possible to affirm that the depressive state increasesthe susceptibility for individuals to develop headachesand TMJ pain (Table 1).

Patients with dentofacial deformity should be evaluatedbefore orthognathic surgery in relation to depressive status

Table 1 Headache and temporomandibular joint pain in orthognathicpatients

H TMJ Total

Not Yes

Not 9 8 17

Yes 8 25 33

Total 17 33 50

The association between H and TMJ was statistically significant(p00.042)

T headache, TMJ temporomandibular joint

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because these patients tend to create an esthetic expec-tative that if there was not the wishing esthetic im-provement after surgery, the psychological damagewill be high [16]. For this reason, to avoid surprisesafter surgery, the oral and maxillofacial surgeon has arole of preparing these patients for perioperative proce-dures by providing adequate details regarding impor-tance of positive psychological attitude and care andpossible complications in postoperative such as swell-ing, pain, injection, nasal congestion, possibility ofnausea and vomiting, length of hospital stay, postoper-ative depression, possible weight loss, oral hygiene, andabnormal perception among other. Similarly, the moni-toring of a psychologist is essential as part of preoper-ative preparation [17].

The depressive state of the patients has intervened direct-ly with the domains of quality of life. Statistically significantoutcomes were recorded for three of the eight domainsevaluated in depressive patients. Regarding vitality, signifi-cant association was observed between the degree of energyand disposition to perform daily tasks and absence of de-pression (Table 2).

In the social aspects domains, significant associationswere observed between the absence of depression and highcapacity to carry out social activities. Lovius et al. demon-strated that improvement of facial appearance influencessocial interactions, which is in agreement with the presentinvestigation [18]. In the same way, Lazaridou-Terzoudiobserved significant improvement in social interactionsand reported an increase in self-confidence in interpersonalcontacts, which also agrees with the results of the presentstudy [19]. In this investigation, we prove the effect of theorthognathic surgery in the eight domains of the adaptedquestionnaires of quality of life and the direct influence ofthe depressive state in quality of life (Table 3).

As we analyzed the mental health data, we observed thatfrom the 31 patients who presented a less depressive state,21 admitted tranquility in daily life, confirming the strongrelation of the depressive state in the quality of life (Table 4).

Patients, who are not depressive, were admitted to highvitality, excellent capacity to carry out social activities,and good mental health and, therefore, have improvedquality of life. Garvill et al. (1992) analyzed the psy-chosocial effects of orthognathic surgery and reported adecrease in social anxiety that was related to improve-ment in facial esthetics and body image [20]. Theauthors also emphasized the psychological and destruc-tive potential of facial deformities, which influence thewhole personality of the individual, and this fact justi-fies the goal of this study in correlating quality of lifewith depression and discusses the results.

In conclusion, people with dentofacial deformities anddepression have a poorer quality of life than those without.Depression interferes significantly in vitality, social aspectsof the individual, and mental health. Both the general oralhealth and specific conditions of quality of life are compro-mised in orthognathic patients.

Orthognathic surgery aims to not only restore estheticsand function to the patient but also improve the quality oflife. Future studies will be carried out to determine thesensitivity and responsiveness of the three approaches (vi-tality, social aspects, and mental health) to changes of qual-ity of life in patients after orthognathic surgery.

Table 2 Distribution of vitality according to the presence or not ofdepression

V Depression Total

Absence Presence

Low 8 16 24

High 23 3 26

Total 31 19 50

The association between V and depression was statistically significant(p<0.001)

V velocity

Table 3 Distribution of social aspects according to the presence or notof depression

SA Depression Total

Absence Presence

Low 5 10 15

High 26 9 35

Total 31 19 50

The association between SA and depression was statistically signifi-cant (p00.011)

SA social aspects

Table 4 Distribution of mental health according to the presence or notof depression

MH Depression Total

Absence Presence

Low 10 14 24

High 21 5 26

Total 31 19 50

The association between SA and depression was statistically signifi-cant (p00.008)

MH mental health

190 Oral Maxillofac Surg (2013) 17:187–191

Acknowledgments The authors acknowledge with sincere thanks the“Centro de Pesquisa e Tratamento das Deformidades Buco-Faciais(Cedeface)” of the City of Araraquara. They also record their gratefulappreciation of devotion of psychologist.

Conflict of interest None.

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