Eligibility Criteria

The following inclusion criteria were used:

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  The study evaluated factors associated with patient satisfaction after the conclusion of an orthodontic treatment combined with an orthognathic surgery.

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  Orthognathic surgical procedures were undertaken after completion of craniofacial growth.

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  Any satisfaction psychometric tool was considered.

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  Neither language nor publication year set as limitations.

The following exclusion criteria were applied:

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  Reviews, letters, case reports, conference papers, and personal opinion publications

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  Evaluation of individuals with severe craniofacial syndromes

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  Orthognathic surgery related to obstructive sleep apnea therapy

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  Treatment involving other major dental specialty work

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  Cases that simultaneously underwent minor esthetic/cosmetic surgery (ie, genioplasty, septoplasty)

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  Studies that did not assess participants’ expectations after completion of the entire treatment.

Information Sources

A computerized systematic search was conducted in MEDLINE, PubMed, EBM Reviews, Web of Science, EMBASE, LILACS, and Scopus. The references cited in the selected articles were also hand searched for additional relevant studies that could have been missed in the electronic searches. A limited gray-literature search was explored in Google Scholar by restricting the search by the first 100 most relevant hits.

Search Strategy

Details of the key words and word truncation for each database are presented in Appendix 1. All electronic searches were conducted from their earliest records up to September 30, 2014 and updated until March 28, 2015.

Study Selection

Eligibility of the selected articles was determined in two phases. In phase one, two reviewers independently screened titles and abstracts of studies identified in all electronic databases. In phase two, the two reviewers assessed the selected full-text articles applying the same inclusion and exclusion criteria to confirm their final eligibility. The reviewers were not blinded to the authors and the full text of the study. Disagreements between reviewers were resolved through discussion until consensus; a third reviewer was involved when this attempt failed to make a final decision.

Data Collection Process and Data Items

Three reviewers were involved in a standardized data extraction process based on the Cochrane Consumers and Communication Review¹³ template. One reviewer collected the required information from the selected articles. Two reviewers cross-checked all the retrieved information. Again, disagreements were resolved by discussion and mutual agreement between the reviewers. An additional reviewer was involved, when required, to make a final decision.

The data extracted included sample size of selected studies, timing of assessment, methodology, psychological tool elected to assess patients’ satisfaction, orthognathic surgery type, response rate of studies, statistical test, and findings of the included articles. If the reviewers deemed any article to be unclear after full evaluation, they contacted the authors of the study for clarification.

Risk of Bias in Individual Studies

The Newcastle-Ottawa Scale,^14,15 modified for cross-sectional studies,^16,17 was applied. This scale addresses three domains (selection, comparability, and outcome), and the selected studies could be awarded one check for each factor in the two first categories (sum of five checks) and two checks for each factor in the comparability domain. The sum of the checks, a maximum of seven, reflects the overall quality rating of the study.

Two reviewers assessed the risk of bias of the selected studies. Disagreements were resolved by attempting to achieve consensus between reviewers. A third reviewer was involved when needed to make a final decision.

Summary Measures and Synthesis of Results

Any quantified/qualified factor that was identified as affecting a patient’s satisfaction after the completion of orthodontic treatment combined with orthognathic surgery was accepted.

Risk of Bias Across Studies and Additional Analyses

It was decided a priori that if the data from different studies were sufficiently homogeneous and that the combination of the collected data was justifiable a meta-analysis would be carried out. Additional analysis, such as risk of bias across studies or publication bias, would be calculated only if a meta-analysis was completed.

Study Selection

Eight articles satisfied the inclusion criteria of this systematic review. A flow chart of the selection process is outlined in Figure 1. A list of articles excluded during the second selection phase and the reasons for their exclusion is presented in Appendix 2.

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Study Characteristics

The included studies showed large variation in sample size, age, distinct psychological evaluation tools, and time elapsed between the satisfaction assessment and treatment. Most samples included patients from university hospitals.^4,18–22 A summary of the studies’ characteristics is provided in Table 1.

Table 1. Summary of Descriptive Characteristics of the Included Articles^a

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Table 1. Extended

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Table 1. Continued

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Table 1. Extended

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Studies applied different tools to assess satisfaction: questionnaires filled out during a follow-up consultation,^22–24 questionnaires mailed after treatment,⁴ structured interview after the follow-up consultation,²¹ or both questionnaires (interview and questionnaires)^19,20 and structured interview by phone.¹⁸ Two studies reported that patients were first interviewed by telephone and the satisfaction evaluation was conducted later.^4,23

The author of one initially selected study was contacted to clarify missing information by e-mail.²⁵ Because of the provided information, the study was later excluded from the review.

Risk of Bias Within Studies

Most of the studies (five of eight) had high risk of bias. The main risk of bias limitations were related to sample-size calculation and sample power calculation, which were not presented in any of the selected studies. However, some retrospective studies^22–24 defined timing and selected consecutive patients, thereby improving the selection methodology. None of the studies indicated use of blinded interviewers or questionnaire/interview evaluators. Finally, half of the studies did not apply previously validated questionnaires or interviews to assess satisfaction after treatment. Specific description and items of the Newcastle-Ottawa Scale quality assessment is presented in Table 2.

Table 2. Newcastle-Ottawa Quality Assessment Adapted for Cross-Sectional Studies^a

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Summary Description of the Individual Studies

Synthesis of Results

Because of the limitations of the identified available evidence, only a list of the factors associated with or without patient’s satisfaction can be presented.

The following factors were associated with satisfaction.

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  Final esthetic outcome^22,24

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  Perceived social benefits from the outcome²²

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  Type of orthognathic surgery^20,22

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  Sex (female patients were more likely to link dental appearance and satisfaction with treatment outcome)^18,22

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  Changes in patient self-concept after treatment^19,20

The following factors were associated with dissatisfaction:

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  Treatment length²¹

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  Sensation of functional impairment and dysfunction after surgery^18,22,23

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  Information about the risks of surgery was not providced⁴

Risk of Bias Across Studies and Additional Analysis

Included data were not homogeneous enough to justify a meta-analysis.

Limitations

A clear limitation of this study is related to the different timing of the satisfaction assessment as the time frame could influence perception of satisfaction. Memory bias should be considered when assessing patients within a 9-year interval after treatment completion.²⁴ Also, the interpretation of results could differ when the results derive from face-to-face interview, mailed questionnaire or structured interview by phone. Two studies^4,21 only presented descriptive statistics, which hampers comparison with statistically significant results.

There is need to develop surgical outcomes questionnaires with confirmed standard psychometric properties, such as validity and reliability.³⁵