recreational and social activities of orthognathic surgery patients

Recreational and social activities of orthognathic surge? patients

Tony Lam, Ph.C.,* H. Asuman Kiyak, Ph.D.,** Thomas Hohl, D.D.S.,*** Roger A. West, D.M.D.,*** and R. William McNeill, D.D.S., M.S.*** Seattle, Wash.

The present study examined changes in recreational and social activities after orthognathic surgery. Because this is often an expectation of patients seeking surgery, it was hypothesized that activity levels would increase gradually after surgery, particularly for patients who become more extroverted and for unmarried patients. Information on the frequencies of recreational and social activities, and the persons with whom these activities were performed, were obtained from 53 patients in a self-administered questionnaire administered at least 2 days before surgery and again 3 weeks, 4 months, and 9 months after surgery. In addition, patients were assessed on introversion-extroversion before and after surgery. The results indicated that (1) for both married and single patients, recreational and social activities dropped immediately after surgery and gradually increased to a level similar to that prior to surgery at nine months after surgery; (2) contrary to expectations, the single patients over age 15 did not increase their recreational and social activities with friends of the opposite sex after surgery; and (3) the degree of change in introversion-extroversion after surgery was not associated with the degree of change in recreational and social activities performed with others. Implications for postsurgical adjustment of orthognathic patients and recommendations for future research are discussed.

T he number of individuals undergoing orthognathic surgery for the correction of malocclusion and oral function and for the improvement of facial esthetics has increased over the last decade. Ortho- gnathic surgery can produce significant improvements in oral functioning (e.g., mastication and speech), as well as improve facial appearance. A review of the literature reveals that the psychosocial effects associated with these physiologic and morphologic changes have been studied by a few investigators and consistent results have been found.

In a long-term follow-up of 32 patients (6 months to 16 years) by Hutton,’ 16 (50%) of the patients re- sponded positively to a question about whether their personality had changed as a result of the operation. These 16 respondents’ comments seem to indicate that they have gained self-confidence, have less fear in meeting and talking with people, enjoy being seen in public, and, in general, have become more sociable. Crowell and associates2 modified Hutton’s questionnaire and used it in their study of prognathic patients 3 months to 3% years after surgery. They found that 18 of the 33 patients claiming a change in personality re-

From the University of Washington School of Dentistry. Supported by BRSG Grant RR-05346 from the School of Dentistry. *Department of Educational Psychology. **Department of Community Dentistry. ***Department of Oral and Maxillofacial Surgery. ****Department of Orthodontics.

0002-9416/83/020143+ 10$01.00/0 0 1983 The C.V. Mosby Co.

ported improved self-confidence and decreased shyness and self-consciousness. In a study of 49 patients 12 months after treatment, Hillerstrlim and associates3 found that most patients reported they had gained greater self-assurance, felt happier and more self-confident, and had improved relations with the opposite sex. Similarly, 17 of the 25 patients examined by Laufer and co-workers4 2 to 6 years after surgery mentioned that “their personality had improved. ”

The studies described above have been concerned primarily with patients’ subjective evaluations of their overall psychologic and social well-being at one point after surgery. No measures of behavioral change, subjective or observed, were obtained. As part of a larger investigation of orthognathic surgery,5 the present re- port describes the pattern of recreational and social activity changes at various times after surgery.

HYPOTHESES

The following three hypotheses were proposed and tested in this study:

1. After surgery, the frequency of recreational and social activities will show a gradual increase, with the lowest activity levels immediately after surgery and the greatest number of activities 9 months later. The frequency at 9 months after surgery will be greater than before surgery.

2. For unmarried patients, the postsurgical frequency of recreational and social activities with friends

143

144 Lam et al. Am. J. Orthod. February 1983

Table I. Demographic characteristics of sample completing activities questionnaire (N = 53)

Marital status:

Sex:

Never married Married Separated No response

Females Males

33 16

2 2

36 17

Age: 12-15 6 16-19 13 20-29 21 30-39 11 40-47 2 Mean age 23.5 Standard deviation 7.7

of the opposite sex will gradually increase to levels greater than before surgery.

3. For those patients who have become more extroverted, their recreational and social activities performed with others will also increase after surgery. In contrast, those who have become more introverted will reduce their level of recreational and social activities with others.

The first two hypotheses are derived from the findings of previous researchers who have indicated the following. (1) Esthetic complaints are often as critical a reason for patients to seek surgery as are complaints of oral function.4, 6, 7 This implies that social motives play a significant role in surgery decisions. (2) In general, all the research reviewed indicates that patients were satisfied with their new appearance.le3 (3) From the follow-up studies of orthognathic surgery discussed earlier, increased self-confidence was reported for over half of the sample in each study. It may therefore be argued that the patients’ desire to improve their appearance is related to a desire to be accepted socially. If surgery is successful in enhancing one’s perceived appearance and self-confidence, interpersonal contacts should be increased through increased recreational or social activities after surgery.

The third hypothesis is an extension of a previous finding on the same subjects used in the current study.j The results showed a significant increase in extroversion 9 months after surgery. An extrovert is operation- ally defined by Eysenck’s Personality Inventory8 as one who “is sociable, has many friends, needs people to talk to, craves excitement, and is generally impulsive. ’ ’ It is therefore reasonable to conjecture that as a patient becomes more extroverted after surgery, he or she will tend to do more recreational and social activities with someone than alone.

It has been found that a patient’s satisfaction with the results of orthognathic surgery is not necessarily

related to the skills of the surgeon; rather it is often determined by characteristics of the patient and the communication between the surgeon and the patient .9 In order to increase the probability of a patient being satisfied with the results of treatment, these individual differences should be detected by the surgeon to use either as a basis for selecting patients or in consulting with them prior to surgery. One of these factors listed by Peterson and Topazian is what the patient expects as a result of surgery. A patient with realistic expectations is likely to be happier after surgery than one with unrealistic expectations. The current study was an at- tempt to determine what behavioral changes can be expected in these persons after surgery by examining their postoperative activities in recreation and social functioning. The results can be used to educate prospective patients in establishing their expectations re- alistically before surgery so that they will be more likely to be satisfied with the outcomes.

METHODS Subjects

The respondents were selected from the pool of all orthognathic surgery patients treated by two of the au- thors (R. A. W. and R. W. M.) at the University of Washington hospital between June 15 and Oct. 15, 1979. The major selection criteria were (1) age over 12 years, (2) ability to complete a series of self-administered questionnaires, (3) willingness to participate in a longitudinal study, and (4) a deformity that was devel- opmental and not due to trauma or a congenital defect. Of the 87 patients scheduled to undergo surgery within this period, five did not fulfill study criteria, eight chose not to participate, and 21 did not complete all questionnaires at various times. Some demographic characteristics of the 53 remaining subjects are illustrated in Table I.

Variables and their measurement

A checklist of recreational and social activities was developed, based on earlier interviews with other persons who had undergone orthognathic surgery. The checklist was included in a larger self-administered questionnaire that was mailed or personally delivered to patients at five time intervals during a lo-month period before and after surgery. It was administered to patients at least 2 days before surgery (T,) and again 3 weeks (T3), 4 months (T4) and 9 months (T,) after surgery. The T, questionnaire was administered in the hospital within the first 2 days after surgery and did not include an activities checklist. The section on activities com- prised a list of 12 recreational activities (e.g., hiking, swimming) and 12 social activities (e.g., going to movies). Table II lists these activities. Respondents

Volume 83 Number 2

Recreational and social activities of orthognathic surgery patients 145

A.- Pre-Surgical Ouestionnalres

ACPIVITIES: FOR THE ACTIVITIES LOW aE INDICATE HOW OFTEN

FREQUENCY: DO YOU DO THIS: YOU PARTICIPATE IN EACH ONE AND WHETHER YOU DO IT ALONE OR WITH OTHERS. PLEASE HAKE SURE YOU MARK BOTH COLUMNS.

Swimning

Horseback Riding

Walking/Hiking

B. Post-Surqical Questionnaires

ACTIVITIES: FOR EACH ACTIVITY LISTED BELOW, PLEASE INDICATE HOW OFTEN YOU NOW PARTICIPATE IN EACH ONE AND WHETHER YOU DO IT ALONE OR WITH OTHERS. PLEASE MAKE SURE YOU MARK BOTH COLUMNS.

FREQUENCY: I

Swimaing I I I I

Horseback Riding

Walking/Hiking

Fig. 1. Format of activity questionnaire.

Table II. Activities listed on questionnaires

Recreational activities Swimming Horseback riding Walking/biking Golf Sailing Bicycling Skiing

Jogging Fishing Bowling Participating in group sport (e.g., basketball, football, Tennis/racquetball, other net sports

Social activities Going to spectator sports (e.g., football games) Going to movies, concerts, ballet, theater Going to parties Taking lessons (nonphysical) Working as a volunteer Attending church/synagogue Attending organizational meetings (e.g., bridge club, Lions Club) Working on hobbies (e.g., sewing, woodwork) Watching TV Reading or writing letters Entertaining/visiting with friends Going out to eat at a restaurant

were asked to indicate with whom they had performed each activity (friends of same sex, friends of opposite sex, alone, or in a group). At the presurgical assessment, they were asked how ofen they performed the activity (none, little, some, regularly). No specific time frame was presented, so that respondents could de- scribe their general behavior without seasonal or other variations. The frequency columns were revised in the postsurgical questionnaires to “more than before surgery, ” “same as before surgery, ” and “less than before surgery.” Fig. 1 illustrates the format for the presurgical and postsurgical versions.

The dependent measures were (1) total number of checks summed across all recreational activities, and

(2) total number of checks summed across all social activities. Analyses were performed separately for the frequency data at T,, T,, T5, and the interpersonal or “with whom” data at T1, TS, T4 and T,.*

In addition, repeated measures-trend tests with un- equal intervals (BMDP-P2V)‘O were performed on these data. This technique of data analysis was chosen because multiple measures were obtained from the same individual over time.” Results from this statistical procedure enable conclusions to be made about how recreational and social activities are related to other

*Because frequency at T, was the referent for subsequent questionnaires, data from T, were not included in the analyses of frequency.


Table III. Frequency distribution for recreational and social activities as compared to frequency before surgery

All respondents Unmarried respondents Married respondents (N = 53) (N = 35) (N = 16)

Time after surgery: weeks months months weeks months months weeks months months

Recreational activities More than 17 0.70* 1.02 0.34 0.63 1.06 0.40 0.69 0.63 0.19

S.D. 0.87 1.38 0.65 0.77 1.30 0.74 0.95 0.96 0.40 Same as f 3.58 4.70 4.02 3.74 4.77 4.09 3.13 4.75 3.69

S.D. 3.68 3.97 3.67 3.76 3.85 3.85 3.42 4.52 3.18 Less than

Al. 2.91 0.68 0.26 2.83 0.83 0.26 2.75 0.19 0.19 3.26 1.74 0.62 3.24 1.98 0.61 2.84 0.75 0.54

Social activities More than x 1.51 1.74 0.47 1.63 1.86 0.69 1.19 1.25 0.06

S.D. 1.09 2.17 1.14 1.00 2.07 1.35 1.28 2.24 0.25 Same as x 3.53 6.04 4.83 3.57 5.71 4.31 3.56 6.94 5.56

S.D. 2.67 2.63 3.30 2.86 2.58 3.27 2.45 2.57 3.29 Less than f 2.72 0.55 0.32 2.31 0.71 0.31 3.50 0.25 0.25

S.D. 2.48 1.10 0.64 2.42 1.27 0.63 2.31 0.58 0.58

*Mean scores indicate average number of activities reportedly performed by patient.

Table IV. Means and standard deviations of change in recreation and social activity levels

All respondents Unmarried respondents Married respondents (N = 51) (N = 35) (N = 16)

Recreational activities f -2.21* 0.34t 0.08 -2.20 0.23 0.14 -2.06 0.44 O.OO$ S.D. 3.55 2.25 0.76 3.51 2.39 0.77 3.13 1.31 0.73

Social activities x -1.21 1.19 0.15 -0.69 1.14 0.37 -2.31 1.00 -0.19 S.D. 2.67 2.43 1.23 2.51 2.41 1.37 2.13 2.39 0.66

*Negative scores indicate less activity compared to presurgical activity levels. TPositive scores indicate more activity compared to presurgical activity levels. #Zero or close to zero indicates no change in activity level compared to presurgical levels.

changes in the passage of time. If a significant linear trend is detected, it implies a constant rate of change of activity (either increasing or decreasing) across time. If, on the other hand, the quadratic or curvilinear trend is significant, it implies that activity level increases up to a certain time period and then starts to decline, or vice versa. Finally, if both linear and quadratic trends are significant, it suggests an overall unidirectional increase or decrease in activity across time but with cy- clical (up and down) changes along the way.

The trend analysis technique will determine how the relationship between activity and time should be characterized: linear, quadratic, or both. *

*The trend analysis performed here tested the significance of the linear and quadratic components.

Introversion-extroversion was measured with Eys- enck’s Personality Inventory presurgically (T,) and 9 months after surgery (T,). An extroversion change score was computed for each patient by subtracting the preoperative extroversion score from the score at 9 months after surgery. A positive difference reflects a change toward extroversion; a negative difference indicates a change toward introversion.

In order to obtain some measures of change in activities performed with others from T, to T,, two steps were taken. First, the frequencies of recreational and social activities with friends of the same sex, with friends of the opposite sex, and in a group were aver- aged separately for T, and T,. Second, the average number of group activities at T1 was subtracted from

Volume 83 Number 2


. . . . . . . . . . . . ..CIARRIEO --------OVERALL

- - - - - - -SINGLE

-2.50 ' t

3 Weeks 4 Months 9 Months Post-Surgery Post-Surgery Post-Surgery

Fig. 2. Changes in frequency of recreational activities.

1.50 -

0.50 --

-0.50 --

-1.50 l *

. . . . . . . . . . . ..fingle Bverall --.------+hrried

-2.50 ' : b

3 Weeks 4 Months 9 Month5 Post-Surgery Post-Surgery Post-Surgery

Fig. 3. Changes in frequency of social activities.

the average number at T, for both recreational and social activities. A positive change score therefore implies an increase in number of activities performed with others, and a negative change score indicates a decrease in such activities. Pearson product-moment correlations were calculated between the extroversion change scores and the recreational and social group activities change scores.

RESULTS Analysis of activity frequencies

All 12 social activities were summed together, as were the 12 recreational activities. Within these two types, means and standard deviations of the categories (“more than before surgery, ” “same as before surgery,” and “less than before surgery”) were computed for each assessment period (3 weeks, 4 months, and 9

148 Lam et al. Am. .I. Orthod. Februarv 1983

Table V. Means and standard deviations of recreational and social activities for each “with whom” category (unmarried respondents only)*

Before urger):

Recreational activities (N = 31) Social activities (N = 31)

With friends With friends of With friends With friends of of same sex opposite sex Alone In group of same sex opposite sex Alone In group

2.391‘ 1.23 0.90 0.90 1.68 0.87 1.03 0.61 x

S.D. 1.28 0.96 0.79 1.08 1.25 1.09 1.28 I .05 After surgev

3 weeks 2.23 0.77$ 0.65 0.65 1.00 0.48 0.48 0.26 ic

S.D. 1.50 0.88 0.71 0.96 1.29 1.00 0.68 0.44 4 months 2.39 1.13 0.61 0.61 1.35 0.65 0.52 0.16

x S.D. 1.82 1.36 0.88 0.84 1.60 1.33 0.89 0.37

9 months 2.13 1.06 0.35 0.74 1.32 0.87 0.61 0.45

S.D. 1.52 1.36 0.61 1.03 1.40 1.36 0.92 0.85

*All unmarried respondents were older than 15 years of age. thtdicates that, on average, patients performed 2.39 recreational activities with friends of same sex before surgery. $Indicates that, on average, patients performed 0.7 recreational activities with friends of opposite sex 3 weeks after surgery.

months after surgery). Results were obtained for both recreational and social activities for all respondents, then separately for unmarried and married respondents over age 15. These means and standard deviations are summarized in Table III. The first number indicates the mean number of activities performed more than, less than, or equal to presurgical numbers by patients at each measurement period (e.g., 3.58 recreational activities were performed just as often at 3 weeks as they had been before surgery).

A simple transformation on the frequency data was made by subtracting the number of activities performed “less than before surgery” from the number of activities performed “more than before surgery. ” These scores were computed first for the total sample, then separately for unmarried and married respondents. A positive mean difference score implies more activities after surgery than before surgery. A negative mean difference score implies fewer activities after surgery. A zero or close to zero mean difference may be interpreted as no change in activity level after surgery. Table IV illustrates the means and standard deviations of these differences for recreational and social activities at the three postsurgery measurements.

As expected, patients reported fewer activities at 3 weeks than before surgery. However, their activity frequency increased to a much higher level than the presurgery one at 4 months, especially their social activities. By 9 months after surgery, these frequencies were only slightly greater than the presurgery levels.

Graphic representations of these means are shown in Figs. 2 and 3.

Results from tests for trend indicate the following. (1) For recreational activities, the linear and quadratic trends were significant (p < 0.05) for unmarried patients, married patients, and the two groups combined. (2) For social activities, only the quadratic component was significant (p < 0.05) for the unmarried group, whereas both the linear and quadratic trends were significant (p < 0.05) for the married patients and for the whole sample. These results suggest that there was a significant decline in recreational and social activities 3 weeks after surgery for both single and married patients. Not surprisingly, the frequency of recreational and social activities gradually increased for both groups, peaked at 4 months after surgery, and gradually declined toward presurgical levels 9 months after surgery . These trends are illustrated in Figs. 2 and 3. For recreational activities (Fig. 2)) the differences between single and married patients were negligible for all three measurement periods. At 4 and 9 months after the operation, although the average differences were positive (i.e., generally more activities than before surgery), they were very close to zero. This indicates a steady level of activity during the early postoperative stage.

Turning to social activities, we observe in Fig. 3 that unmarried patients tended to have more positive difference scores than married patients, especially at 3 weeks and 9 months. This implies that, relative to their presurgical activity levels, unmarried patients partici-

Volume 83 Number 2


B 3.00 - z : 2 P ? g 2.M) -- 4 ; t

1 '; 1.00 *.

%

: e ti 4

------ - - With friends same Sex

With friends opposite Sex -_-- With group or family -.---- - A,o"e

4% ._-4--- -4-c

-0------------- -_____ ---

I Prc- 3 Nets 4 Pbnths 9 knths

surgery Post-surgery Post-Surgery Post-Surgery

Fig. 4. Changes in extent of “with whom” recreational activities.

3.00

2.00

T

_- ---- -__-- With friends same sex -.-..---_-. Alone

With friends opposite sex ---- - With group or family

\ \ '. \

l.W 8,-d'

I?7

-e-----------m -m---I_ ----- C-

z - '\

'\ <L-.-.-.-

.-.-.-.-.--.-

--v---c #M-c-

Pre- 3 Ueeks 4 Months 9 Months Surgery Post-Surgery Post-Surgery Post-Surgery

Fig. 5. Changes in extent of “with whom” social activities.

pated in more social activities than did married patients after surgery.

The degree of change in recreational activities may be compared to the degree of change in social activities by examining Figs. 2 and 3 simultaneously. It can be seen that patients participated in more social activities than recreational activities at 4 months after surgery. However, they reported similar levels of social and recreational activities at 9 months after surgery. Fur- thermore, activity levels at 9 months were similar to those prior to surgery (as suggested by mean difference scores close to zero).

Analysis of interpersonal (“with whom”) data

Another analysis was performed only on data gathered from unmarried respondents older than 15 years of age to test the second hypothesis, i.e., that

single patients will increase their recreational and social activities with members of the opposite sex after surgery. The mean number of checks and their standard deviations across all recreational and all social activities were computed for each interpersonal (“with whom”) category before surgery (T,) and after surgery (T3, Tq, TJ. These results are summarized in Table V and graphically represented in Figs. 4 and 5.

As seen in the table and figures, the average number of recreational and social activities performed with friends of the same sex was consistently higher at all four measurements than with friends of opposite sex, alone, or in groups. The mean number of activities performed with opposite-sex friends, alone, or in groups showed small and unsystematic differences across the measurement periods. Repeated measures- trend analysis showed (1) a significant linear decreas-


ing trend (p < 0.05) in recreational activities performed alone and (2) significant quadratic trends (p < 0.05) in social activities performed alone and in groups. However, there were no signi&znt increasing linear trends detected for either recreational or social activities performed with members of the opposite sex, as had been predicted by the hypothesis.

Analysis of changes in extroversion and activities

No significant correlations were obtained between degree of change in extroversion and amount of change in recreational activities performed with others (r = 0.04, p = 0.20, N = 56); or between extroversion change and change in social group activities (r = -0.01, p = 0.35, N = 56). Although the magnitude of the correlation coefficients is probably reduced somewhat by the typical problem of unreliability of change scores, the values of the correlations were so low that the likelihood of a true relationship between these variables in the population was very low.

SUMMARY AND DISCUSSION

The results presented above may be summarized as follows:

1. Shortly after surgery, both recreational and social activities were reduced, although the reduction in social activity for single patients was not as great as that for married patients.

2. Even four months after surgery, recreational activities gradually increased to a level slightly higher than before surgery. In contrast, before-after surgery differences in social activities were greater, with postsurgical social activity at 4 months significantly higher than presurgery levels.

3. Both recreational and social activities started to decline after the 4 months postsurgical level. Nine months after surgery, the level of recreational activity for both married and single patients had returned to presurgery levels. The same was true of social activities of married patients. The rate of decline for the unmarried subjects was slower. At 9 months after surgery, their average social activity level was still slightly higher than before surgery.

4. No significant association was found between increased extroversion in some patients and their level of social or recreational activities.

In order to support the first hypothesis, that patients ’ recreational and social activity frequencies will be greater after surgery than before, significant linear trends should be observed. The results obtained do not coincide with such a prediction; therefore the hypothesis proposed cannot be supported. The postoperative

enhancement effect of orthognathic surgery on the frequencies of recreational and social activities seems to be temporary. These changes tend to fade away 9 months after surgery when activity levels return to their presurgical levels.

The pattern of results obtained is consistent with other data reported by Kiyak and associates5 from this study. In examining the psychologic and functional outcomes of orthognathic surgery, it was found that measures of satisfaction with outcomes, self-esteem, and body image all peaked at 4 months after surgery and then showed a significant decline at 9 months. It was suggested that at the intermediate postsurgical periods, patients were still anticipating long-term improvements and believed that a better facial profile would resolve most of their personal problems. How- ever, when structural changes had stabilized at 9 months after surgery, some patients with unrealistic expectations may have been disappointed. Further- more, other parts of the body may now have become more salient in their self-concept. Extending this explanation further to account for the findings in the current study, one may expect that at 4 months after surgery, patients are still optimistic and feel confident about potential outcomes and for having undergone a major operation. As a result, they are inclined to participate in more recreational or social activities. How- ever, at 9 months after surgery, patients with unrealistic expectations may express their disappointment by re- ducing their activity levels. It may also be that in the earlier stages after surgery, considerable support and encouragement are received from the clinician. This support declines with time, probably because there is less frequent contact between patient and clinician in the later stages. The reader must be cautioned that these are only speculations; we do not have data to assess the degree of realism in patients’ expectations.

With respect to the second hypothesis, that unmarried patients will engage in more recreational and social activities with friends of the opposite sex after surgery, the analyses of “with whom” data have failed to support it. Unmarried patients mostly spent their time with friends of the same sex both before and after surgery. There was no evidence to suggest that their recreational and social activities with opposite-sex friends increased over time postoperatively.

As for the third hypothesis, which suggested an association between extroversion and activities, it is interesting that we found no significant correlations. This seems contrary to the clinical observations of many orthodontists and surgeons who find that some patients become much more outgoing and socially ac-

Volume 83 Number 2


tive after treatment. Indeed, in examining individual cases in this study, we also found two patients who had increased in extroversion as well as in their social activity levels. But these were the exceptions, not the rule. It may be that patients who become more extroverted cannot find an outlet for their extroversion. It may also be that the quality of patients’ social and recreational activities improves after surgery, but not the quantity. We did not examine quality of relation- ships or activities in this study.

The results obtained from this present study seem to be in accordance with the speculations made by Jen- senl* and Peterson and Topazian.g After reviewing the literature on the psychosocial dimensions of oral and maxillofacial surgery, Jensen noted that “the patient’s actual social behavior and experiences with others, however, may not always improve postoperatively. ” An explanation was offered by Peterson. One possible source of external motivation to seek surgery, accord- ing to Peterson, is “ . . . the desire to remove obstruc- tions to personal, career or social ambitions. However, this may be a realistic goal if the patient has the other attributes necessary to achieve that ambition.. . . If the patient lacks the necessary talent to fulfill his ambition, the correction of the deformity will not aid him in reaching the goal.” Although a significant increase in extroversion was found 9 months after surgery,j indi- cating a positive change in attitudes toward doing recreational and social activities with others, this desire can be realized only if the necessary social skills are present. The correction of facial deformity may not be a major determinant of success in social life. Another possible explanation is the lag between attitudes and behavior. The actual social and behavioral change may require more time than attitudinal change.

One of the major motives for an individual to undergo orthognathic surgery is to gain social approval and thereby increase social contacts either through recreational or social activities. The lack of evidence for a continued increase in recreational and social activities after surgery seems to question whether such motives for surgery are justifiable. However, before it can be decided that such a motive is unrealistic, one must also consider the length of the postoperative adaptation period. Nine months after surgery may not be long enough to detect the full effects of orthognathic surgery, especially in regard to social outcomes. Further longitudinal research is therefore needed that will follow patients beyond 9 months, preferably over several years’ span. Other issues that need to be addressed in future research are the questionnaire format and a control population of nonsurgery respondents. The present

investigators have recently begun a 4-year study that will compare persons who elect surgery with those who reject it.

It is difficult, if not impossible, to build into the experimental design a control group that matches well with the experimental group in certain important attributes such as dentofacial anomalies. However, without such a control group, results must be interpreted cau- tiously in light of rival hypotheses or factors (e.g., psychologic or biologic maturation) that may be re- sponsible for the patients’ behavior and personality changes.13 Another problem with the approach used to obtain activity data is our reliance on respondents’ memory of their activity levels before surgery. One may ask how well an individual can recall activity levels 9 months later, but the use of a comparison technique may have alleviated this problem. Nevertheless, it would be more accurate to specify frequency along a numerical scale (e.g., once a week, twice a month).

Despite these problems, the results of this study provide some insights into the behavior of persons who undergo orthognathic surgery. It appears that their recreational and social activities decrease during the first few weeks after surgery, increase significantly at 4 months, but return to presurgical levels by 9 months. By then, both the recreational and social activity levels are similar to those before surgery. The surgery does not seem to increase single patients’ recreational and social activities with friends of the opposite sex during the first 9 months after the operation. Finally, how much a patient changes in introversion-extroversion is not related to his or her change in recreational and social activities up to 9 months after surgery.

These results suggest an additional caution in selecting and counseling prospective patients. Patients who have high expectations of improving their social functioning and increasing their recreational activities after surgery are likely to be disappointed. Therefore, in interviewing and counseling prospective patients prior to surgery, one must emphasize that surgery cannot by itself improve the individual’s psychologic and social functioning. If self-esteem and self-confidence improve as a result of surgery, then psychosocial function may be enhanced.

REFERENCES 1. Hutton, C. E.: Patients’ evaluation of surgical correction of

prognathism: Survey of 32 patients, J. Oral Surg. 25: 225-228, 1967.

2. Crowell, N. J., Sazima, M. J., and Elder, S. T.: Survey of Patients’ attitudes after surgical correction of prognathism: Study of 33 patients, J. Oral Surg. 28: 818-822, 1970.

3. Hillerstriim, K., Sijrensen, S., and Wictorin, L.: Biological and


psycho-social factors in patients with malformations of the jaws, Stand. J. Plast. Reconstr. Surg. 5: 34-40, 1971.

4. Laufer, D., Glick, D., Gutman, D., and Sharon, A.: Patients’ motivation and response to surgical correction of prognathism, Oral Surg. 41: 309, 1976.

5. Kiyak, H. A., Hohl, T., West, R. A., and McNeil& R. W.: The psychological impact of orthognathic surgery: A g-month follow-up, AM. J. ORTHOD. 81: 404-412, 1982.

6. Picard, C. F.: Surgical correction of mandibular prognathism, Dent. Surg. 40: 35, 1964.

7. Wictorin, L., Hillerstriim, K., and Siirensen, S.: Biological and psycho-social factors in patients with malformations of the jaws, Stand. J. Plast. Reconstr. Surg. 3: 138-143, 1969.

8. Eysenck, H. J.: Manual for the Eysenck Personality Inventory, San Diego, 1968, EDITS, p. 5.

9. Peterson, L. J., and Topazian, R. G.: The preoperative interview and psychological evaluation of the orthognathic surgery patient, J. Oral Surg. 32: 583-588, 1974.

10. Dixon, W. J., and Brown, M. B., editors: Biomedical compu- ter programs P-series, Berkeley 1979, University of California Press.

11. Winer, B. J.: Statistical principles in experimental design, ed. 2, New York, 1971, McGraw-Hill Book Co.

12. Jensen, S. H.: The psychosocial dimensions of oral and maxillofacial surgery: A critical review of the literature, J. Oral Surg. 36: 447-453, 1978.

13. Campbell, D. T., and Stanley, J. C.: Experimental and quasi- experimental designs in research, Chicago, 1966, Rand McNally & co.

recreational and social activities of orthognathic surgery patients

Documents