Improving standards in orthognathic care: the bigger picture (a national and international perspective)

Systematic Review and Meta-Analysis of the Index of Orthognathic Functional Treatment Need for Detecting Subjects with Great Need for Orthognathic Surgery

Index of Orthognathic Functional Treatment Need (IOFTN) Identifies patients with greatest need for orthognathic surgery. This systematic review looks into the available evidence on prevalence of patients with great treatment need (IOFTN 4&5) who had orthognathic surgery in previous studies. Literature search of the major electronic databases was carried out for articles published between 2014 and September 2023, looking for "Index of Orthognathic Functional Treatment Need","Orthognathic Surgery","IOFTN", "Epidemiology" and "Dentofacial Deformity". The prevalence of patients identified with IOFTN grades of 4&5 was calculated. A random-effect model was employed and the Forest and Galbraith plots were produced. The pooled prevalence estimate for subjects with IOFTN scores of 4&5 was calculated. The heterogeneity among studies was assessed with the I2 statistics. In total, 14 retrospective studies conducted between 2015 and 2019 in 7 countries (UK, New Zealand, Iran, Pakistan, Turkey, Malaysia, Japan) were included, reporting on 1339 orthognathic patients. The sample sizes ranged from 30 to 200. Only 7 studies reported on the subcategories of the IOFTN for grades 1, 2&3. The prevalence of orthognathic patients with IOFTN scores of 4 & 5 ranged from 79% to 100%. The heterogeneity I2 statistics was high (76%, random effects model) for 14 studies, but after removing 3 outlier studies reduced to zero. The pooled prevalence estimate for subjects with IOFTN scores of 4&5 was 93% (95% CI, 0.91-0.94%). According to this meta-analysis, IOFTN successfully identified 93% of patients who underwent orthognathic surgery with a great need for treatment (Grade 4 & 5). To enhance the identification of patients with well-compensated malocclusions, previous orthodontic treatment, or extreme occlusal deviations (e.g., proclination or retroclination of incisors), it would be advantageous to employ additional means alongside IOFTN for assessing orthognathic need in this group.

Characteristics of orthognathic multidisciplinary team clinics in England. Part 2: A qualitative study

OBJECTIVE

The aim of the study was to explore the orthodontist's perspective of the strengths and weaknesses of their current multidisciplinary team (MDT) design for orthognathic treatment.

PARTICIPANTS AND METHODS

This was a qualitative study using online interviews of orthodontic consultants across England. The data were analysed using thematic analysis. This was the second part of a two-part study, where the first part, an online questionnaire survey, identified the variation in design of orthognathic MDTs across England and was the source of the 19 participants for this study.

RESULTS

Seven themes were identified that influenced the design of orthognathic MDTs across England. Close working relationship with the team, access to closed surgery space to conduct the MDT and access to 3D planning were identified as definite strengths of some MDT clinics. Lack of a team psychologist and long waiting lists were identified as weaknesses of some orthognathic MDTs. Teaching and training within MDT clinics were highlighted as a strength of MDTs where surgery spaces were not restricted due to the pandemic. Finally, there was general agreement about revising the orthognathic minimum dataset for records collection as it was not thought to be in the patient's best interest.

CONCLUSION

This study was able to identify key areas considered to be determinants of a successful orthognathic MDT design from the orthodontic consultant's perspective. Orthodontic consultants across England prioritised the need for a psychologist in the orthognathic MDT to improve the effectiveness of these clinics.

Characteristics of orthognathic multidisciplinary team clinics in England. Part 1: A questionnaire survey

BACKGROUND

Orthognathic clinics across England are currently run in a multidisciplinary team (MDT) format. It is, however, likely that there is a large variation in the style of these clinics and care pathways for orthognathic patients across the country. This was a cross-sectional, online questionnaire with a primary aim to obtain information on the way orthognathic care is currently delivered throughout England. The secondary objectives were to determine the compliance to the minimum dataset for record collection. The questionnaire, disseminated to orthodontic consultants, detailed 27 items split into waiting lists for new patients, mechanics of the clinic, support for patients and record collection.

RESULTS

A total of 36 participants responded (one was excluded) to give a total of 35 questionnaire responses. Descriptive statistics were used to analyse the data. Of the participants, 34% followed up their patients as per the commissioning guidelines at 1, 2 and 5 years after treatment. Of the participants, 20% said patients' mental health would be screened before adding them to a waiting list, with 26% of participants stating screening was not undertaken for all patients. Of the participants, 11% had available access to psychological support during the MDT meeting and 20% recorded the minimum dataset at the follow-up intervals.

CONCLUSION

There are inconsistencies in the orthognathic MDT design across England. Acceptance criteria, support services available and records collected for patients showed substantial variation, highlighting the limited guidance offered by the commissioning guidelines and the potential need to revise the minimum dataset.

Young Adults’ Experience of Appearance-Altering Orthognathic Surgery

Objective:

To gain an experiential account of the processes of change associated specifically with orthognathic surgery. Design: A qualitative design was used. Semistructured interviews were carried out with 7 participants approximately 1 week before and 6-8 weeks after surgery. The data were analyzed using interpretative phenomenologic analysis (IPA).

Setting:

Participants were recruited from a NHS Dental Hospital. Participants: Patients aged 16 to 25 years scheduled to undergo orthognathic surgery on both the upper and lower jaws were purposively sought to participate. Seven participants aged between 18 and 25 years and who had undergone a bimaxillary osteotomy completed interviews (5 females and 2 males).

Results:

Themes were identified in connection with the overall journey of treatment being a rite of passage; the treatment’s role in raising awareness about the anomalies in appearance; the initial shock at the changes that followed surgery; the uncertainty about treatment; the impact of actual negative reactions of others; and the role of significant others in the decision-making process.

Conclusions:

Participants described undergoing a much more complex process of adjustment to change in appearance than has been identified elsewhere within the literature, and the study highlights the nuanced fashion in which both medical and parental communication influence patient expectation and experience of surgery. There is a need to improve communication between clinicians, families, and young adults seeking orthognathic surgery. Further studies are needed to investigate the processes associated with seeking to change facial appearance resulting from other forms of dentofacial condition.

Elective orthognathic treatment decision making: a survey of patient reasons and experiences

OBJECTIVE

Few studies have explored decisions about orthognathic treatment (OGT) from the patient's perspective. This study describes the factors associated with the patient's decision to have or not have orthognathic treatment, and assesses whether the process can be considered to be informed decision making.

DESIGN

A cross-sectional survey employing both interview and questionnaire methods, conducted in four OGT services in Yorkshire.

SAMPLE

Participants were patients aged over 16 years, either making an OGT decision over a 6-month period or had made their treatment choice 18-42 months prior to the study start date in 2003.

MEASURES

Questionnaires assessed patient demographics, dental history and psychopathology (anxiety, satisfaction with self, body satisfaction, facial appearance); interviews explored patients' reasons for, and experiences of, orthognathic treatment.

RESULTS

Of 138 patients approached, 61 participated (mean age 25 years, 66% female). Psychopathology scores were within the normal range. The thematic content analysis of interview transcripts found: reasons given for having OGT were to improve the 'bite', as well as gaining a more normal facial appearance; most patients reported the service information was satisfactory, but about half made negative comments, with some reporting staff communications made them feel worse; knowledge of OGT risks and benefits was poor; patients had strong emotions about their facial appearance and the orthognathic treatment they received, which did not seem to be addressed by current practice.

CONCLUSIONS

Some OGT patients do not appear to be making informed decisions about their treatment. They seem to have unmet needs in relation to support for their decision making, and managing the emotional effects of undergoing and adjusting to treatment. The implications for information provision, assessment and support during treatment are discussed.