Improving Standards in Orthognathic Care: The Bigger Picture (a National and International Perspective)

There can be no doubt that improvement of facial aesthetics and its psychosocial impact are dominant factors that define the perceived treatment benefit of combined surgical-orthodontics. Indeed, it is likely that psychological factors, rather than the actual severity of the malocclusion, actually determines the demand for orthognathic treatment. However, despite professionals being seemingly in agreement on this point, there are currently few psychometric instruments either available or regularly used to assess objectively the impact of orthognathic treatment on our patients’ well-being. It almost seems as if we have chosen to ignore this aspect of our treatment outcome, focusing instead on solely clinical, provider-based outcomes, e.g. cephalometric analyses and occlusal indices (e.g. Peer Assessment Rating (PAR)) scores. Such outcome measurements are relatively meaningless to patients no matter where in the world. Are we therefore doing ourselves an injustice with this approach? In the UK, a minimum dataset for orthognathic patients was jointly agreed between the British Orthodontic Society (BOS) and the British Association of Oral and Maxillofacial Surgeons (BAOMS) in 2005. This document is an initial attempt to rationalize and justify our record collection strategy. It has been widely circulated and is available on the web sites of both specialities. Ethical approval is not required in order to follow the advice from the dataset document. However, if a local or regional orthognathic database is to be developed in conjunction with the minimum dataset, then Central Office for Research Ethics Committees (COREC) approval should be sought as usual. An earlier development to assist with the assessment of orthognathic treatment outcome has been the surgicalorthodontic cephalometric analysis sheet developed by Chris Johnston in Belfast. This document evolved from a 1999 national audit of consecutively treated orthognathic cases and enables a relatively quick assessment of the complexity of orthognathic caseload against a national standard. Both documents are available to BOS members from either the Members Download section or the Consultant Orthodontist Group (COG) section of the BOS web site (www.bos.org.uk). Internationally, there is an ever-increasing interest in consumer-centred outcomes of dental treatment. In addition to our routine clinically based outcome measures, we too need to concentrate our attention on more subjective patient-based measures to allow us to distinguish between patient and provider viewpoints and serve as a means of documenting the true benefits of orthognathic treatment in health policy discussions. Patient-centred research can influence and ultimately improve clinical practice. Currently, there is a lack of qualitative, scientific research into this aspect of our orthognathic treatment. Some UK-based individuals are trying to address this issue by developing specific consumer questionnaires based on face-to-face interviews and focus group analysis. The orthognathic patient satisfaction questionnaire has been our most recent nationally-based outcome project. The Clinical Effectiveness Committee of the BOS is supporting this national survey. Questionnaires were distributed at the end of 2005 and the findings should be available later this year. It is to be hoped that soon this specific questionnaire will be used prospectively as part of routine record-collection procedures for orthognathic patients. An improvement in the quality of life of our orthognathic patients is an important patient-outcome measure and can be a strong motive for surgicalorthodontic treatment. Recently, there has been increased involvement of clinical psychology services within the field of cosmetic surgery. However, surveys have shown that lack of funding and manpower has severely limited the role of psychologists as part of the orthognathic team. Clinical psychologists could potentially contribute to the assessment of suitability for surgery, assist with patient decision-making and provide therapeutic interventions. I carried out an unpublished informal survey in 1999 with the aim of establishing whether orthognathic teams within the UK had access Journal of Orthodontics, Vol. 33, 2006, 149–151