Sulalman E. S. AlEmran, BDS, MS, PhD
College of Dentistry, King Saud University, Riyadh, Saudi Arabia

The purpose of this study was to characterize the self-perception of facial profile among Saudi patients with dentofacial deformity and to correlate the findings with their educational level, social status, gender, chief complaint, type of dentofacial deformity and with the degree of patients' agreement to undergo orthognathic surgery. One hundred and fifteen Saudi patients with dentofacial deformity participated in the study. Clinical examination, soft tissue cephalometric analysis and patient perception assessment were done on all patients. Findings revealed that most of the patients had university-level education (56.5%) and were unmarried (92.2%) and that more males (58.3%) sought clinic consultation than female patients (41.71%). Majority of the patients were mainly concerned about their facial appearance, which was reflected in the high demand for orthognathic surgery (63.5%). About one third of the study patients (28.7%) were exact in their facial profile self-perception and only 20% of the total samples were far from the right perception. There was positive correlation between high educational level and self-perception of facial profile leading to a higher demand for orthognathic surgery when compared to low education level group. Furthermore, among the different classification of dentofacial deformity, patients with skeletal class III expressed higher demand for surgical correction.

Dentofacial deformity is a severe discrepancy in the size, form and interrelationship of the jaws to the cranial base, which is not normally corrected by orthodontic treatment alone. There is therefore indication for surgical correction in severe skeletal and/or dentoalveolar discrepancy in the jaws that cannot be corrected or camouflaged by teeth movement alone. The face is the main source of vocal and emotional communication and is considered a major concern for physical attractiveness. Improvement of dentofacial appearance has been reported to be a strong motivating factor for many individuals who decide to undergo orthodontic and/or orthognathic treatment.1

The adverse psychological and psychosocial effects caused by dentofacial deformity are considered an integral part of society's overall responsibility towards health care. Physical defects are routinely clinically documented. Its effects on psycho-social aspects, however, are often misinterpreted and not properly documented while managing dentofacial deformity. In the past,  clinicians used  to  ignore  the value of perception of dentofacial disfigurement by the patient or his family and its effect on patients' motivation for orthognathic surgery and patient satisfaction on final result. During the late 1960s, orthodontists began to acknowledge the role of subjective factors such as perception of facial appearance or esthetic satisfaction in determining patient's behavior.2 The importance of dentofacial complex on the development of personality and psychological interaction has been recognized by Story,3 who stated that, "the mouth and face are invested together and used for the expression of many feelings and emotional conflicts outside orthodontics". Boverman et al4 emphasized the great emotional significance of orofacial areas and its relation to self-image and found in their study evidence that women place relatively greater importance on physical attractiveness of facial appearance than men.

Hershon et al5 conducted a study on self-perception of facial profile on forty-two orthodontic patients and on a control non-orthodontic patients group. They concluded that both orthodontic and non-orthodontic groups had under-estimated the position of their lips.

Bell et al6 conducted a study on eighty patients to evaluate the influence of self-perception of facial profiles on the decision to undergo orthognathic surgery. They found that patients who agreed to have surgical correction were well aware of their dentofacial deformity, whereas patients who decided against surgery had to be influenced by others to undergo surgical correction. Bell and colleagues6 concluded therefore that the patient's self-perception was an important factor in the decision to elect surgical correction. They also reported that class III patients had difficulty in differentiating between mandibular prognathism and maxillary retrognathism. Similarly, class II patients also found difficulty in differentiating between retruded mandible and protruded maxilla. Maxwell and Kiyak7 studied the relationship between psychosocial factors and patient's self-perception and found that depressed individuals viewed themselves more negatively than non-depressed individuals despite the absence of differences in the judgments by others to same individuals and that perception of facial defect was important in a patient's willingness to seek treatment. They concluded that the patients' general feeling about their facial appearance revealed some relationship to their willingness for seeking orthodontic treatment.7

It is evident that the amount of soft tissues thickness determines the final facial profile of the patient.8-9 Czamecki et al10 assessed the role of the nose, lips and chin in achieving balanced facial profile and reported that more lip protrusion was accepted for both male and female faces when either a large nose or a large chin was present.

The selection of appropriate treatment plan is not only based on the clinician's assessment of the final result with regard to esthetic function and stability but also on the patient's objectives and perceptions of need. Thus, it is suggested that information regarding the patient's perception of facial profile and its influence on the decision to undergo orthognathic surgery should be taken into consideration during the planning for surgical correction. This might lead to a better prediction of result and to patient's satisfaction on final result. It is also assumed that perception of facial deformity and the decision for orthognathic surgery vary among different populations and even within the same population. Education, socio-economic status, culture and religious background are factors, which may influence a person's perception of facial deformity and demand for orthodontic treatment.

The purpose of this study was to determine the perception of facial profile among Saudi patients with dentofacial deformity and to correlate the findings with the educational level, social status, gender, chief complaint, type of dentofacial deformity and with the degree of patients' agreement to undergo orthognathic surgery.

The study was conducted on 115 patients who attended the orthognathic surgery clinic of the Orthodontic Division in the College of Dentistry, King Saud University, Riyadh. The sample involved all patients, who were screened and listed in the waiting list for orthognathic surgery during the period from 1997 to 1999. All the patients were adult Saudis, with no previous history of orthodontic treatment. Patients with cleft lip and palate or severe genetically disturbances were not included. Patients' personal data, which included name, gender, age, social status, educational level and the chief complaint were registered. Patient's self-perception of facial profile was evaluated using a method developed by Bell et al6. The method (Fig. 1) divided facial discrepancy into four variables: vertical (A), maxillary (B), mandibular
(C),   and   dentoalveolar   (D).      Each   variable consisted of five profiles and the assessment of patient's perception was based on assigned points from one to nine. A patient who was able to identify the four dentofacial variables from A to D correctly, received 4 points, which indicated an exact perception. In the situation where a patient failed to identify some or all variables correctly, the points score was reduced accordingly (Table 1).

The pre-treatment lateral cephalometric radiographs for all patients were digitized using the Dentofacial Planner plus (1.5 software program).* Legan's analysis for soft tissue11 was used to compute measurement for each patient. The measurements which are comprable to Bell's rating scale6 are as follows: G-Sn and SnMe' representing vertical excess/deficiency, Sn-G representing maxillary prognathism/ retrognathism, Pg'-G representing mandibular prognathism/retrognathism and the distance perpendicular from Ls to Sn-Pg' and Li to Sn-Pg' representing dentoalveolar protrusion (Fig. 2). Intra-examiner error of cephalometric measure- ments was determined by applying Pearson correlation and Dahlberg's test on randomly repeated measurements. The two tests showed high degree of correlation (0.984-0.995) with no significant difference between the two observations for all variables using the paired T-test. After assessment of self-perception, patients were briefed in general about the procedures involved in orthodontic treatment and jaw surgical correction. Patient agreement or disagreement for the surgical approach was then registered. For patients who indicated agreement for surgical intervention, the level of their agreement was also determined by requesting the patients to mark the level of their agreement on a given ascending scale from one to ten. To facilitate statistical correlation of patient's demand with other variables, it was reclassified as low, moderate and high demand according to the recorded scores (Table 2).

The obtained data were analyzed using SPSS statistics software program and presented in the form of tables and figures. Mean age and frequency distribution were calculated for all variables. Chi-square test was used to determine the significant relationship between different variables.
 

Gender and age distribution: Gender distribution revealed that 58.3% of the study sample were male and 41.7% were female patients. In addition, majority of the patients were unmarried at 92.2% with 7.8% married. The age range was between 17 and 34 years with a mean of 21.4 years (Table 3). Educational level: Most of the patients (56.5%) had university-level educational background, 35.7% had secondary school level, 5.2% had intermediate school level and only 2.6% had primary school level.

Chief complaint: As explained by the patients themselves, the majority of them were mainly concerned about their facial (49.6%) and dental appearance (25.5%) respectively. Others, 8.7% complained of speech problem, 11.3% suffered from masticatory problem and only 5.2% had TMJ pain.

Patient demand for orthognathic surgery: Most of the patients (63.5%) showed high treatment demand for orthognathic surgery followed by 26.1% who indicated moderate demand and only 10.4% with low demand for orthognathic surgery.

Of the skeletal class III patients, 49.1% expressed high demand for surgery while only 43.8% of class II and 6.8% of class I expressed the same.

Patient self-perception: In our subjects, 34.7% showed an exact perception of their dentofacial deformity while 23.6% were close to the correct perception. Those who were able to perceive half of their dentofacial deformity were 21.7% while 13.9% were far from the correct perception.

It was evident that patients who had their facial appearance as the main chief complaint showed better self-perception of their dentofacial deformity (Fig. 3).

A significant correlation (P<0.05) was found between self-perception and educational level where patients with higher educational level perceived themselves better than others (Fig. 4). Although the frequency distribution of gender indicated more male patients than females, in the present study, female patients were able to reach an exact perception or close to an exact perception better than male patients (Fig. 5).

The findings also revealed that patients with class III skeletal deformity were able to perceive their facial deformity better than class II and class I skeletal deformity patients respectively (Fig. 6).

Patients who were single demanded orthognathic surgery more than married patients and were able to perceive their dentofacial deformity more accurately (Fig. 7).   It   was   evident   from   the present findings that patients with low demand for orthognathic surgery had low perception or were totally unable, to comprehend their dentofacial deformity, whereas, patients with high demand for orthognathic surgery were often able to reach an exact or close to an exact perception of their dentofacial deformity. This difference was significant (P<0.01) (Fig. 8).