The impact of surgery-first approach on the oral health-related quality of life: a systematic review and meta-analysis

Exploring the relationship between the number of systematic reviews and quality of evidence: an orthognathic surgery-based study

OBJECTIVE

We analyzed the quality and quantity of systematic reviews (SRs) of orthognathic surgery, the most frequently published topic in maxillofacial surgery.

STUDY DESIGN

We searched the PubMed database for SRs of orthognathic surgery with no restriction on the language of publication date. We assessed the certainty of evidence presented according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and the Leiden Manifesto using the Grading of Recommendations Assessment, Development, and Evaluation approach. We analyzed the data using descriptive statistics, Pearson´s correlation test, and linear regression.

RESULTS

Of the 171 SRs evaluated, approximately one fifth presented evidence with a high level of certainty. The number of orthognathic surgery SRs has been increasing, and many SRs were published after very similar topics had already been published. There is no relationship between the impact factor and the certainty of evidence.

CONCLUSIONS

An excessive number of SRs of orthognathic surgery are published, and many SRs are superfluous, simply reporting previous findings. Clinicians should not base treatment decisions solely on the evidence presented in SRs, and journal editors and reviewers should evaluate these SRs more critically, particularly when they address topics that have already been covered in the literature.

Effect of surgery-first approach on quality of life and mental health of orthognathic patients: A systematic review and meta-analysis

Objectives

This study intends to explore the effects of the surgery-first approach (SFA) on quality of life and mental health of patients who undergo orthognathic surgery compared to the conventional three-stage approach (CTA).

Data

The analysis included eight studies with a total of 307 patients, of which one was randomized controlled trial (RCT), one was clinical controlled trial (CCT), and six were non-randomized studies of interventions (NRSIs).

Sources

Electronic databases such as Medline, Embase, Scopus, and Web of Science were searched for eligible trials up to April 2023.

Study selection

RCTs, CCTs, and NRSIs, which compared the quality of life or mental health of orthognathic patients treated with SFA and CTA, were included in this study. The meta-analysis showed that the standardized mean differences (SMD) of Oral Health Impact Profiles-14 (OHIP-14) scores and the Orthognathic Quality of Life Questionnaire (OQLQ) between SFA and CTA were -1.58 (P = 0.05) and -2.99 (P < 0.00001) at the termination of the first-stage treatment, which altered to -0.94 (P = 0.54) and 0.09 (P = 0.65) after total treatment. Two studies applied the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and the Beck Depression Inventory (BDI-II) to examine mental health, resulting in a trend similar to the former scales.

Conclusion

In contrast to the conventional procedure, orthognathic treatment with SFA can instantly enhance the quality of life at the end of the first-stage treatment but has similar effects after the overall treatment. Moreover, SFA has a positive impact on psychological conditions.

Clinical significance

This study first systematically reviewed the effect of SFA on patients' mental well-being. According to our findings, it is better to select SFA if possible. Otherwise, the patient's psychological condition should be monitored appropriately throughout decompensation for better well-being both physically and mentally.

Development of a novel patient-reported outcome measure for orthognathic surgery

OBJECTIVES

This study aimed to develop a new patient-reported outcome measure (PROM) to systematically and scientifically evaluate patients' subjective feelings after orthognathic surgery.

METHODS

A literature review and semi-structured interviews were conducted to construct a conceptual framework and an item pool, followed by expert and patient surveys for measure construction. We conducted a clinical investigation to test the feasibility, reliability, and content validity of this measure.

RESULTS

The conceptual framework included four domains: psychological health, physiological health, social function, and satisfaction, and 33 items were included in the survey. Following the expert analysis, 31 items remained in the draft. The clinical investigation showed a 100% recovery and completion rate and good reliability, with Cronman-Brown formula coefficients of 0.893 and 0.944, respectively.

CONCLUSIONS

A new outcome measure to evaluate patients' subjective feelings after orthognathic surgery was successfully developed, and the clinical investigation demonstrated that the PROM had satisfactory feasibility, reliability, and validity. Further studies are possible based on our PROM, and data on a larger scale may reveal more information on patients' subjective feelings about orthognathic surgery.

CLINICAL SIGNIFICANCE

The novel PROM provides a systematic and scientific way to evaluate the patient's subjective feelings to help surgeons obtain complete patient-reported information after orthognathic surgery. Additionally, standardised multicentre research on patients' subjective feelings using our PROM is possible and could improve the effectiveness of the evaluation and help maintain treatment quality.

Starting a Swedish national quality registry for orthognathic surgery: a tool for auditing fundamentals of care

BACKGROUND

National quality registries (NQRs) provide open data for user-directed acquisition. National Quality Registry (NQR) data are often used to analyze the rates of treatment success and adverse events for studies that aim to improve treatment quality and patient satisfaction. Thus, NQRs promote the goal of achieving evidence-based therapies. However, the scientific literature seldom focuses on the complex process of initiating, designing, and implementing an NQR. Starting an NQR may be particularly challenging in a setting where specialized care is decentralized, such as orthognathic surgery in Sweden. The present study describes the initiation and early phases of a new NQR for orthognathic surgery in Sweden.

METHODS

The initial inventory phase included gaining knowledge on regulations, creating economic plans, and identifying pitfalls in existing NQRs. Next, a crude framework for the registry was achieved. Outcome measures were selected with a nation-wide questionnaire, followed by a Delphi-like process for selecting parameters to include in the NQR. Our inclusive process comprised a stepwise introduction, feedback-based modifications, and preparatory educational efforts. Descriptive data were collected, based on the first 2 years (2018-2019) of registry operation.

RESULTS

Two years after implementation, 862 patients that underwent 1320 procedures were registered. This number corresponded to a 91% coverage rate. Bimaxillary treatments predominated, and the most common were a Le Fort I osteotomy combined with a bilateral sagittal split osteotomy (n = 275). Reoperations were conducted in 32 patients (3.6%), and the rate of patient satisfaction was 95%.

CONCLUSIONS

A National Quality Registry should preferentially be started and maintained by an appointed task force of active clinicians. A collaborative, transparent, inclusive process may be an important factor for achieving credibility and high coverage, particularly in a decentralized setting.

Three-Dimensional Changes in the Mandibular Proximal Segment After Using a Surgery-First Approach in Patients With Class III Malocclusion and Facial Asymmetry

ABSTRACT

This study was performed to evaluate condylar position and angulation after asymmetric mandibular setback between a conventional (CA) and surgery-first approach (SFA) using three-dimensional analysis. The condylar positions of 30 patients with skeletal Class III malocclusion and facial asymmetry who underwent 1-jaw (sagittal split ramus osteotomy) or 2-jaw orthognathic surgery (Le Fort I osteotomy and sagittal split ramus osteotomy) with CA (n = 18) or SFA (n = 12) from 2 university hospitals were studied. The three-dimensional assessment of condylar changes was performed using computed tomography images at the initial time point (T0) and at least 6 months after surgery (T1). Segmentation of condyles and cranial base assessment from cone-beam computed tomography images were performed using ITK-SNAP software (version 3.4.0). Condylar position and angulation changes were calculated using 3D Slicer software (version 4.10.2), and statistical analysis was performed. No significant translational or rotational condylar changes were observed between the deviated and nondeviated sides in each group or between the CA and SFA groups except yaw (P = 0.014). Linear mixed-model analysis and multivariate analysis showed no significant difference between the CA and SFA groups. Surgery-first approach might not be associated with more harmful effects on the condylar position and angulation changes as compared with CA.

Comparison of psychosocial and aesthetic features of class III malocclusion after orthognathic surgery: Conventional approach versus surgery-first approach

The aim of this study is to investigate and compare the changes in psychosocial status, self-esteem, and quality of life in patients treated with conventional and SF approaches. 14 patients (mean age 23.04±3.36; 9 male and 5 female) who met the inclusion criteria were included in the SF group; 18 patients with class III malocclusion (mean age 29.27±3.78; 9 male and 9 female) were included in the COS group. In the research protocol, the first questionnaires were carried out 2 weeks before surgery (T0); second survey approximately 4 weeks after surgery (T1); and the third one was done to patients after the treatment was completed (debonding) (T2). In our study, Orthognathic Quality of Life Questionnaire (OQLQ), Pyschosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), Oral Health Impact Profile (OHIP-14), Beck Depression Inventory second edition (BDI-II) and Rosenberg Self-Esteem Scale (RSES), surveys were conducted. No statistically significant difference was observed in all of the PIDAQ parameters and most of the OQLQ parameters within the COS and SF groups (P>0.05). When the BDI-II results were examined, different trends in scores were observed between the two groups, and this difference was found to be statistically significant (P<0.05). In the SF approach, progressive improvement was detected in the patients in terms of psychosocial and quality of life in the early period of treatment. The greater improvement in psychological and social characteristics in the SF approach compared to conventional orthognathic surgery may also be associated with a shorter treatment time.

The impact of a surgery-first approach on oral health-related quality of life

Orthognathic surgery using a surgery-first approach (SFA) has been shown to result in better quality of life (QoL) throughout the treatment duration; however, the effects of gender, age and type of dentofacial deformity on SFA-related QoL remain unknown. In total, 228 consecutive patients underwent SFA for correction of dentofacial deformities (skeletal class III, bimaxillary protrusion and facial asymmetry). We assessed their QoL before surgery and at 1, 6 and 12 months after surgery using the Orthognathic Quality of Life Questionnaire (OQLQ). The results indicated a significant decrease in the total OQLQ, facial aesthetics and social aspect domain scores 1, 6 and 12 months after surgery. Among all domains, the greatest improvement was noted in the facial aesthetics domain. The oral function scores declined significantly immediately after surgery, but improved significantly 6 and 12 months after surgery; however, the awareness scores remained relatively stable. At each time point, women and the bimaxillary protrusion group exhibited a significantly higher total and specific domain scores. Patients aged 18-22 years exhibited lower total and four specific domain scores than older patients. Thus, QoL improves in all aspects, except awareness domain, by 12 months after SFA, but gender, age, and type of dentofacial deformity affect this improvement.

Surgery-first for a patient with mild hemifacial microsomia: A case report and review of literature

BACKGROUND

Hemifacial microsomia (HFM) is the second most common craniofacial congenital anomaly following cleft lip and palate. Because of the various phenotypic spectra and the severity of the deformity, a wide range of treatment approaches have been proposed. Recently, the surgery-first approach (SFA) was introduced to treat mild to moderate HFM, and it yielded a balanced facial appearance. The SFA not only promotes rapid improvement in facial aesthetics but also considerably reduces the overall treatment time.

CASE SUMMARY

A female patient, aged 25 years old, sought orthodontic treatment with the chief complaint of dental and facial asymmetry. After a comprehensive physical examination and imaging analysis were performed, the patient was diagnosed with mild HFM that was primarily attributed to unilateral abnormal development of the maxilla-mandibular. The SFA was carried out to correct the skeletal deformity. The palatal suture was used as the midline of the maxilla in the surgical plan to center the maxilla, and the chin was also properly positioned to obtain a relatively symmetrical facial appearance. Four weeks after the surgery, the patient was referred for postsurgical orthodontics to decompensate the dentition and stabilize the occlusion. After 20 mo of treatment, all orthodontic appliances were removed. The posttreatment photographs of the patient and her smile confirmed good aesthetic and occlusal results.

CONCLUSION

Mild HFM can be corrected by SFA, which not only promotes rapid improvement in facial aesthetics but also considerably reduces the overall treatment time.

Surgery-first orthognathic approach vs conventional orthognathic approach: A systematic review of systematic reviews

Surgery-first approach (SFA) has been introduced as an alternative for conventional orthognathic approach (COA) in the treatment of patients with dentoskeletal deformities. This review aimed to evaluate skeletal stability, treatment time, surgical complications, and quality of life in SFA and COA. Six databases were accessed up to May 2020 to obtain all systematic reviews (SRs). After title and abstract reading, data extraction was performed from eligible SRs. The methodological quality was calculated for the included SRs using the last version of A Measurement Tool to Assess Systematic Review (AMSTAR-2). Ten SRs were included in this review. A good stability of the jaws was assessed both with SFA and COA by most of low- or critically low-quality SRs. Less treatment time was reported for SFA than COA with a moderate quality level. Slightly higher complications rate was recorded with SFA than COA by SRs with low or moderate quality. A better quality of life with SFA than COA was reported by moderate- or low-quality SRs. SFA may represent a reasonable alternative to COA. However, for the heterogeneity of the included SRs, well-designed studies with a long term follow-up are needed to clarify the findings of this analysis.

Effect of surgery-first orthognathic approach on oral health-related quality of life

OBJECTIVES

To systematically evaluate the effect of the surgery-first approach (SFA) on oral health-related quality of life (OHRQoL) in patients with dentofacial deformities.

MATERIALS AND METHODS

An electronic database search and hand search of selected journals and references were carried out. Studies investigating the OHRQoL of patients receiving SFA with or without a control group were included. The risk of bias was assessed by the Cochrane risk of bias tool in randomized clinical trials (RCTs) and the Newcastle-Ottawa Scale in non-RCTs.

RESULTS

A total of seven articles met the eligible criteria and were included, of which six were cohort studies and one was an RCT, and six assessed the OHRQoL of the SFA with conventional orthodontic-surgical treatment (COST) as a control and one without. A total of 214 patients were examined, with sample sizes in studies ranging from 9 to 50. A total of 3 articles successfully measured the OHRQoL both before and after treatment in both the SFA and conventional orthodontic-surgical treatment groups. A total of six cohort studies were classified as low to moderate risk of bias, and the RCT was classified as high.

CONCLUSIONS

The SFA could improve the OHRQoL of patients with dentofacial deformities similar to conventional orthodontic-surgical treatment at the end of complete treatment. In addition, it increases OHRQoL immediately at the beginning of treatment without a deterioration.

Modern Surgery-First Approach Concept in Cleft-Orthognathic Surgery: A Comparative Cohort Study with 3D Quantitative Analysis of Surgical-Occlusion Setup

Despite the evident benefits of the modern surgery-first orthognathic surgery approach (reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics), the challenge of the surgical-occlusion setup acts as a hindering factor for the widespread and global adoption of this therapeutic modality, especially for the management of cleft-skeletofacial deformity. This is the first study to assess three-dimensional (3D) quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery. This comparative retrospective study was performed on 3D image datasets from consecutive patients with skeletal Class III deformity who had a unilateral cleft lip/palate (cleft cohort, n = 44) or a noncleft dentofacial deformity (noncleft cohort, n = 22) and underwent 3D computer-assisted single-splint two-jaw surgery by a single multidisciplinary team between 2014 and 2018. They received conventional orthodontics-first or surgery-first approaches. 3D quantitative characterization (linear, angular, and positional measurements) of the final surgical-occlusion setup was performed and adopted for comparative analyses. In the cleft cohort, the occlusion setup in the surgery-first approach had a significantly (all p < 0.05) smaller number of anterior teeth contacts and larger incisor overjet compared to the conventional approach. Considering the surgery-first approach, the cleft cohort presented significantly (all p < 0.05) larger (canine lateral overjet parameter) and smaller (incisor overjet, maxillary intercanine distance, maxillary intermolar distance, ratio of intercanine distance, and ratio of intermolar distance parameters) values than the noncleft cohort. This study contributes to the literature by providing 3D quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery, and delivers information that may assist multidisciplinary teams to adopt the surgery-first concept to optimize cleft care.