ORIGINAL ARTICLE

Oral health–related quality of life changes in

standard, cleft, and surgery patients after
orthodontic treatment
Joseph S. Antoun,a Peter V. Fowler,b Hannah C. Jack,c and Mauro Farellad
Dunedin and Christchurch, New Zealand

Introduction: The purpose of this study was to investigate the effect of orthodontic treatment on oral health–
related quality of life (OHRQoL) in groups of standard patients with severe malocclusions; cleft lip, cleft palate,
or cleft lip and palate patients; and orthognathic surgery patients. Methods: The study sample consisted of 83
consecutive patients undergoing treatment at the orthodontic unit of Christchurch Hospital, Christchurch, New
Zealand, divided into 3 groups: 30 adolescents with severe malocclusions; 24 adolescents with cleft lip, cleft pal-
ate, or cleft lip and palate; and 29 adults with severe skeletal discrepancies requiring both orthognathic surgery
and orthodontic treatment. Each patient completed the Short Form of the Oral Health Impact Profile (OHIP-14)
questionnaire before and after orthodontic treatment. Results: The baseline OHIP-14 subscale scores among
the 3 study groups were significantly different, with the surgery patients having nearly twice the OHIP-14 scores
of the other 2 groups for nearly half of the items (P \0.05). The surgery patients experienced the greatest
reduction in OHIP-14 scores (ie, improvement in OHRQoL), with the largest effect sizes reported for the
psychological discomfort (12.73) and disability (12.65) domains. The group with clefts experienced the
smallest changes in OHIP-14 scores across all 7 domains (
0.03 to 10.63). After adjusting for age and sex,
the surgical patients had a significantly greater reduction in pretreatment OHIP-14 scores than did the
standard and the cleft patients (P \0.01). Conclusions: The effect of orthodontic treatment on OHRQoL varies
for different patient groups even after adjusting for age and sex. The greatest improvement in OHRQoL occurred
in adults with a need for orthognathic surgery, whereas the least improvement seemed to occur in adolescents
with cleft lip, cleft palate, or cleft lip and palate. (Am J Orthod Dentofacial Orthop 2015;148:568-75)

M
alocclusion is a relatively common condition model.2 Most orthodontic patients seek treatment for
that can adversely affect a person's function purely esthetic reasons that often have an underlying
and psychological well-being.1 In contrast to psychological component.3 The importance of these
other medical conditions, however, most orthodontic psychological factors in influencing treatment need
problems do not fit the classical “disease-symptom” and outcome has resulted in a paradigm shift toward
self-report assessment tools and patient-centered
a
Senior lecturer, Discipline of Orthodontics, Department of Oral Sciences, Sir care.4 Oral health–related quality of life (OHRQoL) in-
John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dune-
din, New Zealand. struments are particularly useful in orthodontic popula-
b
Consultant, Orthodontic Department, Christchurch Hospital, Christchurch, New tions because of their ability to tap into a wide range of
Zealand. domains including the functional, psychological, and
c
Professional practice fellow, Discipline of Orthodontics, Department of Oral Sci-
ences, Sir John Walsh Research Institute, Faculty of Dentistry, University of social aspects.5
Otago, Dunedin, New Zealand. The recent use of OHRQoL instruments in general
d
Professor and chair, Discipline of Orthodontics, Department of Oral Sciences, Sir and orthodontic samples has shown that many maloc-
John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dune-
din, New Zealand. clusions have a significant impact on the patient's
All authors have completed and submitted the ICMJE Form for Disclosure of Po- emotional and social well-being.6-9 Children and
tential Conflicts of Interest, and none were reported. adolescents with multiple missing teeth, large overjets,
Address correspondence to: Joseph S. Antoun, 310 Great King St, Discipline of
Orthodontics, Department of Oral Sciences, Faculty of Dentistry, University of and anterior spacing are particularly susceptible to
Otago, Dunedin, New Zealand; e-mail, [email protected]. poor OHRQoL.10-13 In general, there appears to be a
Submitted, July 2014; revised and accepted, March 2015. distinctive gradient in OHRQoL scores across the
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists. categories of malocclusion severity.6 This association
http://dx.doi.org/10.1016/j.ajodo.2015.03.028 between malocclusion and OHRQoL raises an important
568
Antoun et al 569

clinical question: Does the etiology and severity of a treatment. All study participants were treated by an
malocclusion influence the effect of orthodontic treat- author (P.V.F.).
ment on a person's OHRQoL? The study participants were classified as (1) stan-
The degree of improvement in OHRQoL after ortho- dard patients with severe malocclusions warranting
dontic treatment may vary in patients with dentofacial orthodontic treatment (n 5 30, 36.2%), (2) surgery
deformities. For instance, patients with severe jaw-size patients with severe skeletal discrepancies requiring
discrepancies have reported marked improvements in both orthodontic treatment and orthognathic surgery
their general quality of life and OHRQoL after orthodon- (monomaxillary surgery, 14; bimaxillary surgery, 15;
tic treatment and orthognathic surgery.14 By compari- n 5 29, 34.9%), and (3) nonsyndromic CL/P patients
son, cleft lip, cleft palate, or cleft lip and palate (CL/P) with craniofacial deformities requiring orthodontic
patients, who also have severe dentofacial deformities, treatment as part of their multidisciplinary manage-
do not always experience similar improvements in qual- ment (n 5 24, 28.9%). OHRQoL changes in the cleft
ity of life as do those in the normal population.15 This group were mostly assessed after the last stage of or-
lack of improvement in patients with CL/P is further thodontic treatment, with only 3 participants likely to
compounded by a lower baseline OHRQoL in comparison need orthodontic treatment or orthognathic surgery in
with noncleft populations.16 the future.
So far, the impact of orthodontic treatment on Data were collected for the sample's sociodemo-
OHRQoL has been largely investigated in isolated sam- graphic characteristics, treatment duration, DAI
ples, which may not necessarily be comparable. Few values, and baseline and posttreatment scores from
studies have compared the effect of malocclusion and the Short Form of the Oral Health Impact Profile
orthodontic treatment on OHRQoL in a study sample (OHIP-14) questionnaire. This information was ob-
with distinctively different etiologic and clinical back- tained as part of a clinical audit designed to evaluate
grounds. Moreover, the validity of findings from the quality of care delivered by our orthodontic
studies investigating specific types of malocclusion department. All study participants provided consent,
and dentofacial deformities are often limited, since and data were collected in accordance with the Hel-
these studies do not usually include a comparative or sinki Declaration of 1975.
control group. The DAI is a common epidemiologic index used to
The purpose of this study was, therefore, to investi- assess and rank a person's dental appearance on a
gate the changes between baseline and posttreatment continuous scale. The DAI consists of 10 intraoral mea-
OHRQoL scores in groups of standard, orthognathic surements, which are multiplied by a regression coeffi-
surgery, and CL/P patients treated at the same institu- cient to produce a weighted score for each
tion. We hypothesized that different patient groups component.18,19 The overall DAI score is calculated by
would experience varying degrees of change in OHR- adding the scores of the 10 weighted components and
QoL after orthodontic treatment. Based on the findings summing with a constant of 13.20 The DAI score was
of previous research, it was expected that the greatest calculated for each participant before treatment. This
improvement would occur in the patients whose under- score was used to classify the severity of a malocclusion
lying concerns were most addressed by treatment.17 into 4 distinct categories: minor (15-25), definite
(26-31), severe (32-35), and handicapping (greater
than 36).21
MATERIAL AND METHODS The OHIP-14 is a widely used self-report question-
The overall study sample consisted of 83 consecutive naire designed to assess OHRQoL.22 The Short Form
patients who commenced treatment at the orthodontic OHIP-14 consists of 14 items that were derived from
unit of Christchurch Hospital, Christchurch, New the original 49-item OHIP.23 The OHIP-14 items are
Zealand, between 2005 and 2007. Treatment at the or- organized into 7 domains that relate to function, pain,
thodontic department is usually limited to patients with physical disability, psychological discomfort, psycholog-
severe malocclusions. The study sample consisted of pa- ical disability, social disability, and handicap. The partic-
tients who met the orthodontic department's eligibility ipants were asked to complete the OHIP-14 based on
criteria, which included having a severe malocclusion their experiences before and after orthodontic treatment
(dental aesthetic index [DAI] score greater than 32), or- (within a 3-month window). They reported the impact
ofacial clefting, or both. Patients with diagnosed genetic for each item using a 5-point Likert-type scale (coded
syndromes were excluded from the study. Eligible partic- as 4, very often; 3, fairly often; 2, occasionally; 1, hardly
ipants received either single-arch (6%) or double-arch ever; and, 0, never). A subject's overall score ranged from
(94%) fixed appliances as part of their orthodontic 0 to 56, whereas domain scores ranged from 0 to 8. A

American Journal of Orthodontics and Dentofacial Orthopedics October 2015  Vol 148  Issue 4
570 Antoun et al

higher OHIP-14 score indicated a greater impact on

Table I. Sociodemographic characteristics of the study
OHRQoL.
sample
Statistical analysis Standard CL/P Surgery
(n 5 30) (n 5 24) (n 5 29)
The data were analyzed using the Statistical Package Sex
for Social Sciences (version 20.0; IBM, Armonk, NY). Male 17 (56.7%) 14 (58.3%) 15 (51.7%)
Bivariate analysis was carried out using the chi-square Female 13 (43.3%) 10 (41.7%) 14 (48.3%)
test with the alpha level set at 0.05. Nonparametric tests Pretreatment age (y) 14.5 (1.9)* 12.6 (2.8) 19.0 (4.3)
(Kruskal-Wallis and Mann-Whitney U) were used when- Posttreatment age (y) 16.6 (2.0)* 14.4 (2.7) 21.8 (4.0)
Length of treatment (mo) 25.2 (6.4)* 21.7 (9.1) 33.6 (11.9)
ever a continuous variable was not normally distributed. DAIz 45.5 (9.0)y 45.4 (13.4) 56.6 (12.8)
A general linear model was used to assess the changes in
OHIP-14 scores between the 3 study groups after adjust- Values are number (%) or mean (SD).
*P \0.001, Kruskal-Wallis test; yP \0.01, Kruskal-Wallis test.
ing for the effect of age and sex. Bonferroni adjustment z
Missing DAI score for 1 participant.
was used for post hoc multiple tests.
Effect sizes were used to determine the magnitude
of the statistical difference in scores. Effect size was
calculated by dividing the mean change in pretreat- largest effect sizes in the surgery group were noted
ment and posttreatment scores by the pooled standard in the psychological discomfort (12.73) and disability
deviations after correcting for the amount of correla- (12.65) domains. The standard patients also experi-
tion between the 2 scores. Effect sizes less than 0.2 enced significant improvements in the physical pain,
were minimal, 0.2 to 0.49 were small, 0.5 to 0.8 were handicap, psychological discomfort, and psychological
moderate, and greater than 0.8 were large. Accordingly, disability domains. The greatest effect sizes in the stan-
a larger effect size indicated a greater change as a dard group were also noted in the psychological
result of treatment.24 discomfort (11.21) and disability (11.15) domains.
Conversely, the CL/P group experienced no significant
RESULTS changes between baseline and posttreatment mean
The distribution of the sexes was similar across the OHIP-14 scores in any of the 7 subscales. The effect
3 study groups, although the surgery patients were sizes for the CL/P patients ranged from
0.03
generally older than were the CL/P and the standard to 10.63, indicating small-to-moderate changes in
patients (Table I). The surgery patients had longer OHRQoL after treatment. Overall, the surgery and the
treatment periods than the standard and CL/P patients standard patients experienced large improvements in
(P \0.001), with delays often experienced in accessing their total OHIP-14 scores, with effect size means
surgery. The surgery patients also had significantly of 12.59 and 11.11, respectively. In contrast, there
higher DAI scores than their standard and CL/P coun- was a considerably smaller improvement in the CL/P
terparts (P \0.01). group (effect size, 10.52). The post hoc power of
The baseline OHIP-14 scores of the 3 study groups nonsignificant statistical tests in the standard group
were significantly different for nearly half of the 14 ranged from 68.3% for the physical disability domain
items. Surgery patients had nearly twice the baseline to 91.5% for the social disability domain. In the CL/P
OHIP-14 score of the other 2 groups for most of these group, the post hoc power of nonsignificant statistical
items (P \0.05). There were a number of statistically tests was particularly low for the physical pain domain
significant differences among the 3 groups at the post- (5.2%); the remaining tests ranged from 41.2% for the
treatment stage. The CL/P patients had significantly functional limitation domain to 84.0% for the social
higher posttreatment OHIP-14 scores for several disability domain.
items, including “trouble pronouncing words,” “self- Changes in OHIP-14 scores were not influenced by
conscious,” “feeling tense,” “difficulty relaxing,” “irrita- sex (F 5 2.4; P 5 0.124) or age (F 5 0.57;
ble with others,” and “unsatisfying life” (P \0.05). P 5 0.811), but they differed significantly for study
The mean changes in OHIP-14 score after treatment group (F 5 7.92; P 5 0.001). Post hoc tests showed
are presented in Table II. Surgery patients experienced that the surgery patients had a significantly greater
significant improvements in all of the OHIP-14 do- reduction in OHIP-14 scores (ie, improvement) than
mains. For the surgery group, the effect size ranged did both the standard and the CL/P groups (Fig).
from 11.25 to 12.73; this indicated a large and signif- The OHIP-14 scores of the CL/P group were further
icant improvement in OHRQoL after treatment. The analyzed by cleft type (Table III). There were no

October 2015  Vol 148  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Antoun et al 571

statistically significant differences between the sub-

11.36
11.25
12.73
11.58
12.65
11.72
12.01
12.59
Effect
size*
groups in terms of age, sex, or DAI score (P .0.05). Pa-
tients with clefting of both the lip and the palate or of

17.48 (10.21)z
change (SD)
just the lip had similar baseline OHIP-14 scores to those

1.79 (2.19)z
2.24 (2.29)z
4.35 (2.45)z
1.48 (1.70)z
3.69 (2.14)z
1.97 (2.26)z
1.97 (1.50)z
Mean
with cleft palate. Patients with cleft lip and palate, and
cleft lip only, however, experienced a smaller decrease
Surgery (n 5 29)

in their baseline OHIP-14 score after treatment, suggest-

ing less improvement in OHRQoL, whereas those in the
Posttreatment

*Effect size (Cohen d) was calculated based on the pooled standard deviations corrected for the correlation between the pretreatment and posttreatment OHIP-14 scores.
0.24 (0.58)
0.86 (1.27)
0.48 (1.12)
0.10 (0.41)
0.24 (0.58)
0.03 (0.19)
0.07 (0.37)
2.03 (3.13)
cleft palate sample reported a nearly 50% reduction
(SD)

(P .0.05). Patients with clefting of both the lip and

the palate or of just the lip had higher posttreatment
scores for most of the OHIP-14 domains, although this
0.38 (1.50) 10.37 2.03 (2.10)

0.04 (1.83)
0.03 3.10 (1.90)
0.79 (1.74) 10.62 4.83 (2.41)
0.42 (1.14) 10.44 1.59 (1.68)
0.58 (1.91) 10.43 3.93 (1.91)
0.58 (1.67) 10.63 2.00 (2.27)
0.54 (1.29) 10.51 2.03 (1.35)
3.25 (8.50) 10.52 19.52 (9.62)
was not statistically significant (P .0.05). The post
Baseline
(SD)

hoc power of these statistical comparisons, however,

was always below 20%.
Effect
change (SD) size*

DISCUSSION
The evaluation of orthodontic treatment has mostly
Mean

been carried out using clinic-based indexes, although

there is a growing trend of combining these conven-
CL/P (n 5 24)

tional indexes with OHRQoL instruments to better gauge

Posttreatment

a patient's perception of his or her facial appear-

7.25 (7.28)
1.37 (1.21)
1.29 (1.60)
1.75 (1.85)
0.33 (1.09)
1.33 (1.71)
0.58 (0.88)
0.58 (1.14)

ance.25,26 Of these instruments, the OHIP-14 is among

Table II. Mean baseline, posttreatment, and changes in OHIP-14 scores by study group

(SD)

the most widely used to assess the impact of orthodontic

problems27,28 and the effect of treatment on
OHRQoL.14,24,25,29
11.11 10.50 (10.80)
10.47 1.75 (1.68)
10.58 1.25 (1.70)
11.21 2.54 (2.32)
10.46 0.75 (1.29)
11.15 1.92 (2.15)
10.63 1.17 (1.74)
1.1 (1.45)
Baseline

The OHIP-14 was used to measure OHRQoL in our

(SD)

study because of its simplicity and good discriminative

properties in patients with both normal treatment
needs30 and severe dentofacial deformities.31 Moreover,
10.90
Effect
size*

the OHIP has been shown to be valid in younger age

groups.32 It was therefore expected that the OHIP-14,
P \0.05, Wilcoxon signed rank test; zP \0.01, Wilcoxon signed rank test.
7.97 (12.03)z
change (SD)

in conjunction with an epidemiologic index (eg, the

0.83 (2.23)y
2.30 (2.94)z

2.00 (2.67)z

0.97 (1.75)y
0.47 (1.55)

0.50 (1.61)

0.90 (2.22)
Mean

DAI), would provide a useful and valid evaluation of or-

thodontic treatment in our diverse sample of standard,
Standard (n 5 30)

surgical, and cleft patients. It is noteworthy, however,

Posttreatment

that the present study may not have been adequately

0.77 (0.86)
0.67 (1.27)

3.63 (5.04)
0.70 (1.37)
0.23 (0.73)
0.67 (1.16)
0.37 (1.03)
0.23 (0.68)

powered to detect subgroup differences because of

(SD)

the limited sample size. Subgroup comparisons should

therefore be interpreted with caution.
Before treatment, patients in the surgery group
11.60 (10.93)
1.23 (1.50)
1.50 (1.83)
Psychological discomfort 3.00 (2.52)
0.73 (1.60)

1.20 (1.61)
2.67 (2.43)
1.27 (2.16)

reported significantly higher scores than did their peers

Baseline
(SD)

for nearly half of the OHIP-14 items. The highest scores

were found in the domains relating to psychological
discomfort and disability. Although orthognathic
patients are known to suffer from both functional and
Psychological disability
Functional limitation

esthetic problems, there is some evidence that these pa-

Physical disability

tients mainly seek treatment to improve their facial

Social disability
Physical pain

appearance.33 The demand for improved facial esthetics

Handicap

in these patients is believed to stem from their desire for

Overall

better social interactions and psychological func-

tioning.34 Interestingly, surgical patients who are
y

American Journal of Orthodontics and Dentofacial Orthopedics October 2015  Vol 148  Issue 4
572 Antoun et al

Fig. Box plot showing median change in OHIP-14 score by study group. *Adjusted for age and sex.

esthetics and psychological functioning in orthognathic

Table III. Mean baseline, posttreatment, and changes
surgery patients have a stronger influence on OHRQoL
in OHIP-14 scores by cleft type*
than do the functional factors.36 In some patients, how-
Cleft lip only or ever, the motivation for treatment may stem from a
Cleft palate cleft lip and combination of functional and psychological factors.17
only (n 5 9) palate (n 5 15)
In addition to the underlying psychological profiles
Mean overall baseline 10.9 (12.2) 10.3 (10.3)
score (SD) of these patients, a number of other factors may
Functional limitation 2.2 (1.8) 1.5 (1.6) explain the reduced OHRQoL in this group. First, the
Physical pain 1.4 (2.0) 1.1 (1.6) degree of malocclusion severity has been reported to
Psychological discomfort 2.3 (2.2) 2.7 (2.5) play a role in OHRQoL, with more severe malocclusions
Physical disability 0.9 (1.5) 0.7 (1.2)
associated with higher OHRQoL scores.6 The surgical
Psychological disability 1.9 (2.4) 1.9 (2.1)
Social disability 1.2 (1.8) 1.1 (1.8) patients in our sample had significantly greater base-
Handicap 0.9 (1.5) 1.3 (1.4) line DAI scores, indicating relatively greater malocclu-
Mean overall posttreatment 5.2 (6.5) 8.5 (7.7) sion severities than did the other 2 groups. Second,
score (SD) our surgical patients were significantly older than those
Functional limitation 1.1 (1.2) 1.5 (1.2)
in the standard and CL/P groups, and this may have
Physical pain 0.9 (1.2) 1.5 (1.8)
Psychological discomfort 1.3 (1.8) 2.0 (1.9) had some influence on their perceived quality of life.
Physical disability 0.1 (0.3) 0.5 (1.4) Unlike most orthodontic patients, those undergoing or-
Psychological disability 0.9 (1.4) 1.6 (1.9) thognathic surgery are typically nongrowing adults
Social disability 0.3 (0.5) 0.7 (1.0) who may be more self-conscious about their orthodon-
Handicap 0.6 (1.3) 0.6 (1.1)
tic problems and facial appearance. Motivation for
Mean overall OHIP-14 5.7 (11.5) 1.8 (6.1)
change (SD) treatment in these patients is often linked to the
impact of the condition, although other factors (eg,
*No statistical comparison between the groups was significant personality traits and upbringing) may also play a
(P .0.05). role.17 Clinicians treating these patients should there-
fore be aware of any underlying social or psychological
psychologically healthy also report significant and pro- issues, since these can be useful in assessing motivation
gressive reductions in a range of psychopathologic and managing patient expectations. The latter, which
symptoms after surgery.35 Not surprisingly, improved include expectations about physical and nonphysical

October 2015  Vol 148  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Antoun et al 573

changes, seems to influence a patient's satisfaction OHRQoL for children aged 8 to 12 years than those in a
with treatment.37 younger cohort. This age-related change in quality of
After treatment, the surgical patients reported a life is believed to reflect the importance of social rela-
significant reduction in the scores of all the OHIP-14 tionships and self-evaluations in the lives of older chil-
domains, indicating a marked improvement in their dren.45 On the other hand, patients with an isolated cleft
OHRQoL. This expected finding is consistent with those palate often suffer from speech-related problems,46
of previous studies that have also found drastic improve- which may improve with age, especially after speech
ments in the quality of life after orthognathic sur- therapy.45
gery.14,24,36,38 The fact that our participants completed The lack of improvement in OHRQoL of the CL/P
the OHIP-14 after orthodontic treatment, and not group could also be caused by some treatment-related
immediately after surgery, suggests that the beneficial factors. It is well recognized that the outcome of the pri-
effects of surgery on a patient's OHRQoL can be ex- mary cleft surgery, typically carried out in the first year of
pected to persist, at least in the short and middle terms. life, has a strong bearing on the resultant facial esthetics
Marked improvements in OHRQoL and other psycholog- and the need for further surgical treatment.47 Facial
ical parameters have been documented up to 5 years esthetics appears to play a particularly important role
after orthognathic surgery.38 in the quality of life experienced by cleft patients.40,48
Perhaps a more surprising finding was the relatively In New Zealand, the quality of primary surgery in
small change in OHRQoL that occurred in the CL/P children with CL/P has been reported to be worse than
group. By comparison, the standard patients, who had in some European cleft centers, with nearly half of the
similar ages and DAI scores, reported significant im- patients likely to need orthognathic surgery to achieve
provements in OHRQoL after orthodontic treatment. a better outcome.49 However, the sample in that study
One reason for this lack of perceived benefit from ortho- was historical and might not have reflected present-
dontic treatment may be related to the prolonged man- day surgical outcomes in New Zealand. Although we
agement of a cleft patient, which typically extends from did not evaluate patients' satisfaction with treatment,
infancy to early adulthood. During this long process, it is possible that dissatisfaction with facial appearance
cleft patients often receive orthodontic treatment with in the CL/P group may have led to limited improvement
an element of compulsion because it is part of a lengthy in OHRQoL. Clinicians should be aware, however, that
and staged multidisciplinary treatment. In contrast, the cleft patients who are not satisfied with their facial
immediate and often drastic transformation of facial es- appearance do not necessarily request further treat-
thetics in the surgical patients is likely to result in posi- ment.40 Moreover, patient satisfaction with treatment
tive and relatively rapid improvements in psychological does not seem to correlate with the psychological and
well-being and quality of life. social domains of the OHRQoL measures.50 The need
Another important factor is that cleft patients are for further treatment may therefore be better evaluated
likely to be more concerned with the external appear- if both OHRQoL and satisfaction with facial appearance
ance of their nose and lip, especially since these factors are considered.
may convey important social cues.39-41 Visible clefts, The CL/P patients were the youngest group in the
involving both the lip and the palate, are reported to study, and this may have affected their perceived benefit
have an adverse impact on peer interactions, marriage, from treatment. Although a recent review of the litera-
and employment.42,43 Dissatisfaction with the upper ture found that age had little effect on the psychological
lip and nose after treatment is not only limited to cleft well being of cleft patients,51 some authors have re-
patients themselves, but also extends to professionals, ported reduced patient satisfaction52 and health-
parents, and laypeople.44 Interestingly, we found that related quality of life in younger patients.53 Our findings
patients with orofacial clefts involving the lip reported suggest that even after adjusting for demographic fac-
little or no change in OHRQoL after treatment. In tors such as age and sex, the surgical patients still expe-
contrast, patients with intraoral clefting of the palate, rienced significantly greater improvements in OHRQoL
but a normal upper lip, reported some improvement in than did either the cleft or the standard patients. None-
OHRQoL (nonsignificant). The findings of this subgroup theless, future studies should also follow cleft patients to
analysis are based on a relatively small sample of cleft evaluate changes in OHRQoL over time.
patients and should therefore be interpreted with This study has a number of limitations that deserve
caution. Nonetheless, our findings are consistent with consideration. First, our study sample consisted of
those of a larger study that found an interaction be- hospital-treated patients who had more severe maloc-
tween cleft type and quality of life.45 In that study, pa- clusions than those of the average New Zealand
tients with clefting of the lip (6 palate) reported a worse adolescent.54 In turn, our sample had relatively higher

American Journal of Orthodontics and Dentofacial Orthopedics October 2015  Vol 148  Issue 4
574 Antoun et al

OHIP-14 baseline scores than other groups of randomly lip) are involved. The greatest improvement in OHRQoL
selected patients with a normative need for treat- seems to occur in patients whose underlying concerns
ment.55 It is possible that this may limit the generaliz- are addressed by treatment. In surgical patients (and
ability of our findings to populations with more severe standard patients to a lesser extent), these concerns
malocclusions. Second, we did not reassess the DAI are addressed by the improved social and psychological
after orthodontic treatment to determine whether functions that result from the drastic transformation in
clinical outcome may have influenced posttreatment facial appearance. Both quantitative and qualitative
OHRQoL. Although cleft patients are typically more studies are needed to investigate the impact of cleft-
challenging to treat, the same experienced orthodontist specific treatment factors, including the burden of
treated all participants with similar treatment princi- care, on quality of life.
ples. Third, a generic OHRQoL measure was used in
the 3 study groups, even though condition-specific in- REFERENCES
struments have recently been advocated for different 1. Zhang M, McGrath C, H€agg U. The impact of malocclusion and its
patient populations.34 For instance, the OHIP-14 does treatment on quality of life: a literature review. Int J Paediatr Dent
not relate to some specific aspects of cleft patients, 2006;16:381-7.
including nasal deformity, soft-tissue scarring, and 2. Cunningham SJ, Hunt NP. Quality of life and its importance in or-
thodontics. J Orthod 2001;28:152-8.
speech problems.40 Because of the heterogenic nature 3. Tuominen ML, Tuominen RJ. Factors associated with subjective
of our sample, however, we decided that the use of a need for orthodontic treatment among Finnish university appli-
generic measure would permit sufficient discriminative cants. Acta Odontol Scand 1994;52:106-10.
power and facilitate intergroup comparisons.31 None- 4. Sischo L, Broder HL. Oral health-related quality of life: what, why,
theless, authors of future studies should consider using how, and future implications. J Dent Res 2011;90:1264-70.
5. Mehta A, Kaur G. Oral health-related quality of life—the concept,
generic and condition-specific instruments together to its assessment and relevance in dental research and education.
obtain a more informative insight into OHRQoL.55 Indian J Dent 2011;2:26-9.
Fourth, there were significant differences in the mean 6. Foster Page LA, Thomson WM, Jokovic A, Locker D. Validation of
ages of the 3 groups; the cleft group was particularly the child perceptions questionnaire (CPQ 11-14). J Dent Res 2005;
young. Although the OHIP has been validated in young 84:649-52.
7. Kok YV, Mageson P, Harradine NW, Sprod AJ. Comparing a quality
samples, the age discrepancy among the 3 groups is an of life measure and the aesthetic component of the index of ortho-
important limitation.32 To help adjust for these age dif- dontic treatment need (IOTN) in assessing orthodontic treatment
ferences, a general linear model was used. The inclu- need and concern. J Orthod 2004;31:312-8.
sion of a global question in future studies should 8. O'Brien C, Benson PE, Marshman Z. Evaluation of a quality of life
also be used as a concurrent validity check. Finally, measure for children with malocclusion. J Orthod 2007;34:
185-93.
our sample size was relatively small due (in part) to 9. O'Brien K, Wright JL, Conboy F, Macfarlane T, Mandall N. The
the limited number of patients who met the hospital's child perception questionnaire is valid for malocclusions in the
strict clinical eligibility criteria. Although the study had United Kingdom. Am J Orthod Dentofacial Orthop 2006;129:
sufficient power to detect differences in OHRQoL 536-40.
changes among the 3 groups (primary objective), it is 10. Johal A, Cheung MY, Marcene W. The impact of two different
malocclusion traits on quality of life. Br Dent J 2007;202:E2.
likely that subgroup analyses were affected by an in- 11. Locker D, Jokovic A, Prakash P, Tompson B. Oral health-related
flated type II error. Future studies should, therefore, quality of life of children with oligodontia. Int J Paediatr Dent
aim for larger samples with sufficient power to analyze 2010;20:8-14.
different subgroups (eg, cleft types, sex, and age 12. Sardenberg F, Martins MT, Bendo CB, Pordeus IA, Paiva SM,
groups). Moreover, study participants should be fol- Auad SM, et al. Malocclusion and oral health-related quality of
life in Brazilian school children. Angle Orthod 2013;83:83-9.
lowed prospectively to evaluate the stability of OHRQoL 13. Wong AT, McMillan AS, McGrath C. Oral health-related quality of
changes in the different patient groups. life and severe hypodontia. J Oral Rehabil 2006;33:869-73.
14. Choi WS, Lee S, McGrath C, Samman N. Change in quality of life
CONCLUSIONS after combined orthodontic-surgical treatment of dentofacial de-
formities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;
Patients undergoing a combination of orthognathic 109:46-51.
surgery and orthodontic treatment have relatively poor 15. Foo P, Sampson W, Roberts R, Jamieson L, David D. General
baseline OHRQoL, but also benefit the most from treat- health-related quality of life and oral health impact among Austra-
lians with cleft compared with population norms; age and gender
ment in comparison with standard and cleft patients.
differences. Cleft Palate Craniofac J 2012;49:406-13.
On the other hand, cleft patients experience the least 16. Antonarakis GS, Patel RN, Tompson B. Oral health-related quality
change in OHRQoL after orthodontic treatment, espe- of life in non-syndromic cleft lip and/or palate patients: a system-
cially when external structures of the face (eg, the atic review. Community Dent Health 2013;30:189-95.

October 2015  Vol 148  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Antoun et al 575

17. Ryan FS, Barnard M, Cunningham SJ. Impact of dentofacial defor- 38. Motegi E, Hatch JP, Rugh JD, Yamaguchi H. Health-related quality
mity and motivation for treatment: a qualitative study. Am J Or- of life and psychosocial function 5 years after orthognathic
thod Dentofacial Orthop 2012;141:734-42. surgery. Am J Orthod Dentofacial Orthop 2003;124:138-43.
18. Cons NC, Jenny J, Kohout FJ. DAI—the dental aesthetic index. Iowa 39. Oosterkamp BC, Dijkstra PU, Remmelink HJ, van Oort RP,
City: College of Dentistry, University of Iowa; 1986. Goorhuis-Brouwer SM, Sandham A, et al. Satisfaction with treat-
19. Jenny J, Cons NC, Kohout FJ, Frazier PJ. Test of a method to deter- ment outcome in bilateral cleft lip and palate patients. Int J Oral
mine socially acceptable occlusal conditions. Community Dent Maxillofac Surg 2007;36:890-5.
Oral Epidemiol 1980;8:424-33. 40. Sinko K, Jagsch R, Prechtl V, Watzinger F, Hollmann K,
20. Jenny J, Cons NC. Establishing malocclusion severity levels on the Baumann A. Evaluation of esthetic, functional, and quality-of-
dental aesthetic index (DAI) scale. Aust Dent J 1996;41:43-6. life outcome in adult cleft lip and palate patients. Cleft Palate
21. Estioko LJ, Wright FA, Morgan MV. Orthodontic treatment need of Craniofac J 2005;42:355-61.
secondary schoolchildren in Heidelberg, Victoria: an epidemiologic 41. Strauss RP, Broder H, Helms RW. Perceptions of appearance and
study using the dental aesthetic index. Community Dent Health speech by adolescent patients with cleft lip and palate and by their
1994;11:147-51. parents. Cleft Palate J 1988;25:335-42.
22. Slade GD. Derivation and validation of a short-form oral health 42. Ramstad T, Ottem E, Shaw WC. Psychosocial adjustment in Norwe-
impact profile. Community Dent Oral Epidemiol 1997;25:284-90. gian adults who had undergone standardised treatment of complete
23. Slade GD, Spencer AJ. Development and evaluation of the oral cleft lip and palate. II. Self-reported problems and concerns with
health impact profile. Community Dent Health 1994;11:3-11. appearance. Scand J Plast Reconstr Surg Hand Surg 1995;29:329-36.
24. Lee S, McGrath C, Samman N. Impact of orthognathic surgery on 43. Ramstad T, Ottem E, Shaw WC. Psychosocial adjustment in Norwe-
quality of life. J Oral Maxillofac Surg 2008;66:1194-9. gian adults who had undergone standardised treatment of com-
25. de Oliveira CM, Sheiham A. The relationship between normative plete cleft lip and palate. I. Education, employment and
orthodontic treatment need and oral health-related quality of marriage. Scand J Plast Reconstr Surg Hand Surg 1995;29:251-7.
life. Community Dent Oral Epidemiol 2003;31:426-36. 44. Gkantidis N, Papamanou DA, Christou P, Topouzelis N. Aesthetic
26. Tsakos G, Gherunpong S, Sheiham A. Can oral health-related qual- outcome of cleft lip and palate treatment. Perceptions of patients,
ity of life measures substitute for normative needs assessments in families, and health professionals compared to the general public.
11 to 12-year-old children? J Public Health Dent 2006;66:263-8. J Craniomaxillofac Surg 2013;41:e105-10.
27. Frejman MW, Vargas IA, Rosing CK, Closs LQ. Dentofacial defor- 45. Damiano PC, Tyler MC, Romitti PA, Momany ET, Jones MP,
mities are associated with lower degrees of self-esteem and higher Canady JW, et al. Health-related quality of life among preadoles-
impact on oral health-related quality of life: results from an observa- cent children with oral clefts: the mother's perspective. Pediatrics
tional study involving adults. J Oral Maxillofac Surg 2013;71:763-7. 2007;120:e283-90.
28. Rusanen J, Lahti S, Tolvanen M, Pirttiniemi P. Quality of life in pa- 46. Millard T, Richman LC. Different cleft conditions, facial appear-
tients with severe malocclusion before treatment. Eur J Orthod ance, and speech: relationship to psychological variables. Cleft Pal-
2010;32:43-8. ate Craniofac J 2001;38:68-75.
29. Esperao PT, de Oliveira BH, de Oliveira Almeida MA, Kiyak HA, 47. Mars M, Plint DA, Houston WJ, Bergland O, Semb G. The Goslon
Miguel JA. Oral health-related quality of life in orthognathic sur- yardstick: a new system of assessing dental arch relationships in
gery patients. Am J Orthod Dentofacial Orthop 2010;137:790-5. children with unilateral clefts of the lip and palate. Cleft Palate J
30. de Oliveira CM, Sheiham A. Orthodontic treatment and its impact 1987;24:314-22.
on oral health-related quality of life in Brazilian adolescents. J Or- 48. Marcusson A, Paulin G, Ostrup L. Facial appearance in adults who
thod 2004;31:20-7. had cleft lip and palate treated in childhood. Scand J Plast Reconstr
31. Lee S, McGrath C, Samman N. Quality of life in patients with den- Surg Hand Surg 2002;36:16-23.
tofacial deformity: a comparison of measurement approaches. Int 49. Jack HC, Antoun JS, Fowler PV. Evaluation of primary surgical
J Oral Maxillofac Surg 2007;36:488-92. outcomes in New Zealand patients with unilateral clefts of the
32. Broder HL, Slade G, Caine R, Reisine S. Perceived impact of oral lip and palate. Aust Orthod J 2011;27:23-7.
health conditions among minority adolescents. J Public Health 50. Munz SM, Edwards SP, Inglehart MR. Oral health-related quality
Dent 2000;60:189-92. of life, and satisfaction with treatment and treatment outcomes
33. Rivera SM, Hatch JP, Dolce C, Bays RA, Van Sickels JE, Rugh JD. of adolescents/young adults with cleft lip/palate: an exploration.
Patients' own reasons and patient-perceived recommendations Int J Oral Maxillofac Surg 2011;40:790-6.
for orthognathic surgery. Am J Orthod Dentofacial Orthop 2000; 51. Hunt O, Burden D, Hepper P, Johnston C. The psychosocial effects
118:134-41. of cleft lip and palate: a systematic review. Eur J Orthod 2005;27:
34. Hunt OT, Johnston CD, Hepper PG, Burden DJ. The psychosocial 274-85.
impact of orthognathic surgery: a systematic review. Am J Orthod 52. Thomas PT, Turner SR, Rumsey N, Dowell T, Sandy JR. Satisfaction
Dentofacial Orthop 2001;120:490-7. with facial appearance among subjects affected by a cleft. Cleft
35. Hatch JP, Rugh JD, Bays RA, Van Sickels JE, Keeling SD, Palate Craniofac J 1997;34:226-31.
Clark GM. Psychological function in orthognathic surgical pa- 53. Mani M, Carlsson M, Marcusson A. Quality of life varies with
tients before and after bilateral sagittal split osteotomy with rigid gender and age among adults treated for unilateral cleft lip and
and wire fixation. Am J Orthod Dentofacial Orthop 1999;115: palate. Cleft Palate Craniofac J 2010;47:491-8.
536-43. 54. Foster Page LA, Thomson WM. Malocclusion and uptake of ortho-
36. Rustemeyer J, Gregersen J. Quality of life in orthognathic dontic treatment in Taranaki 12-13-year-olds. N Z Dent J 2005;
surgery patients: post-surgical improvements in aesthetics and 101:98-105.
self-confidence. J Craniomaxillofac Surg 2012;40:400-4. 55. Bernabe E, de Oliveira CM, Sheiham A. Comparison of the discrim-
37. Ryan FS, Barnard M, Cunningham SJ. What are orthognathic inative ability of a generic and a condition-specific OHRQoL mea-
patients' expectations of treatment outcome—a qualitative study. sure in adolescents with and without normative need for
J Oral Maxillofac Surg 2012;70:2648-55. orthodontic treatment. Health Qual Life Outcomes 2008;6:64.

American Journal of Orthodontics and Dentofacial Orthopedics October 2015  Vol 148  Issue 4