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Psychiatric morbidity is common in orthognathic surgery patients – a retrospective study

Open AccessPublished:September 21, 2022DOI:https://doi.org/10.1016/j.oooo.2022.09.009

      HIGHLIGHTS

      • This study emphasizes the need for structured psychiatric evaluation of OS patients in all units providing orthognathic treatment.
      • Detection of psychiatric symptoms during orthodontic and surgical treatment is important in predicting patients’ postoperative psychiatric illness to allocate psychiatric support.
      • Patients with preceding psychiatric morbidity are common; 24% of patients have a history of psychiatric morbidity before OS.
      • Patients' postoperative morbidity is substantially predicted by pre-existing psychiatric disorders.
      • Disorders may be exacerbated by OS or new diagnoses may emerge.
      • High-dose dexamethasone should be used with caution due to its potential impact on mental health.

      ABSTRACT

      Objective

      : The study aimed to clarify psychiatric morbidity in orthognathic surgery (OS) patients pre- and postoperatively.

      Study design

      : Patients 18 years or older undergoing OS were included in this retrospective study. The outcome variable was the incidence of new mild, moderate, or severe psychiatric morbidity or exacerbation of pre-existing psychiatric morbidity postoperatively. Surgery and patient-related background variables for outcome were analysed (SPSS for Macintosh, version 27).

      Results

      : Of 182 patients, 44 (24%) had preceding psychiatric morbidity. It was associated significantly with history of alcohol abuse (P < .001) and smoking (P = .046) and was more common in older patients (P = .042). During the postoperative phase new psychiatric morbidity or exacerbation of a pre-existing psychiatric condition was found in 12 patients (7%). Preceding psychiatric history (OR 8.88, P = .004) and high-dose perioperative dexamethasone (OR 9.81, P = .036) were independent predictors for postoperative psychiatric morbidity. No other evaluated variables were associated with outcome.

      Conclusions

      : Psychiatric conditions are common among OS patients. Treatment planning should consider the patient's mental health to minimize the risk of exacerbating psychiatric conditions, and collaboration with psychiatric professionals is recommended. Perioperative high-dose dexamethasone should be used with caution considering possible adverse psychiatric effects.

      INTRODUCTION

      Orthognathic surgery (OS) alters the patient's facial profile, and it warrants discussion whether these alterations in facial structures can occasionally contribute negatively to the patient's mental health. Little is known about whether this burden can exacerbate previous psychiatric conditions or lead to new psychiatric morbidity. The lengthy treatment process (1), risks entailed by the surgery, peri- and postoperative complications, and adjustment to changes in physical appearance can strain the patient mentally during treatment.
      It has previously been proposed that OS patients have a unique psychiatric profile relative to the general population. A study by Phillips et al. (2) suggested that 25% of OS patients qualify for a psychiatric diagnosis at the beginning of treatment. It is unclear which factors contribute to this phenomenon. One factor could be that patients seeking OS are predisposed to bullying during childhood and adolescence due to deviations in dentofacial features and not fitting the general standards of normal occlusion (3). Studies focusing on the connection between psychological profiles and severity of maxillofacial deformity suggest that a subgroup of patients with severe facial deformities is more prone to psychological distress than patients whose deformities are classified as mild or moderate (4, 5). These severe facial deformities might affect psychiatric health, predisposing the patients to distress, depression, and adverse psychological reactions (4), and patients with more severe deformities may be more aware of their own facial and dental appearance (6).
      The findings regarding psychiatric epidemiology in OS populations are somewhat contradictory. Some previous studies have shown that overall OS patients do not suffer more often from psychiatric symptoms than the general population (7, 8). Cunningham et al. (9) reported that patients in the preoperative treatment phase do not meet the criteria for depression more often than controls when screened using the Beck's Depression Index (BDI) scale. However, opposite results have also been presented. OS patients seem to show more depressive symptoms (10-12) and post-traumatic stress disorder symptoms than controls (13) and high levels of social anxiety (14) and trait anxiety on stress (15) during the preoperative treatment phase. In addition, the rates of such psychiatric disorders as obsessive-compulsive disorder (OCD) (11) and body dysmorphic disorder (11, 16) may be high among OS patients. Recently, Sebastiani et al. (12) made the alarming discovery that the occurrence of severe depression is five times higher in individuals seeking OS than in controls.
      The purpose of our study was to investigate psychiatric morbidity in OS patients during phases preceding surgery and postoperatively. We hypothesized that patients with psychiatric morbidity during the postoperative treatment phase could be identified based on background variables, such as preceding psychiatric morbidity, allowing us to improve comprehensive patient care processes.

      MATERIALS AND METHODS

      Study design

      A retrospective single-centre study of patients undergoing OS was designed and implemented at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland. Electronic medical records of all patients undergoing OS from 2017 to 2019 were reviewed from the hospital database.

      Inclusion and exclusion criteria

      Patients 18 years or older who received Bilateral Sagittal Split Osteotomy (BSSO), Le Fort I, or Bimaxillary–osteotomy with postoperative follow-up of at least six months were included in the study. Patients with oral cancer, developmental disability, mental retardation, or secondary surgery for previous facial fracture, BSSO, or Le Fort osteotomy were excluded.

      Study variables

      The main outcome variable was incidence of new psychiatric morbidity or exacerbation of pre-existing psychiatric conditions within a 12-month follow-up after surgery.
      The primary predictor variable was psychiatric morbidity before surgery, i.e. history of morbidity or current morbidity during preoperative orthodontic treatment.
      Surgery-related predictor variables were perioperative dexamethasone administration grouped as 10 mg or less or no dexamethasone and more than 10 mg of dexamethasone and major surgery-related complications, including reoperations for surgical complications and severe complications requiring intensive care.
      Explanatory variables were age, sex, smoking, history of alcohol and/or substance abuse, skeletal type categorized as I, II, or III, Surgically Assisted Rapid Maxillary Expansion (SARME) preceding surgery, surgical procedures classified as BSSO, Le Fort I, or a combination of the two, and preoperative psychiatric consultation. Alcohol abuse history was determined according to the Finnish Current Care Guidelines (17).

      Ethical considerations

      The study protocol was approved by the Internal Review Board of the Head and Neck Center, Helsinki University Hospital, Finland (HUS/141/2020). Principles outlined in the Declaration of Helsinki were followed.

      Statistical analysis

      All statistical analyses were performed with a statistical software package (SPSS for Macintosh, version 27). Categorical explanatory and predictor variables were cross-tabulated with the outcome variables and analysed with Pearson's Chi-square test to determine levels of association. Student's t-test was used to compare differences between study groups in continuous variables. Effect sizes were estimated with Φ for the Chi-square test and with Cohen's d for the t-test. Binary logistic regression was selected for multivariate analysis of the main outcome variable. P values < .05 were considered significant throughout the study.

      RESULTS

      Of the 232 patients evaluated, 182 (42% men, 58% women) were included in the final analyses. Patients' perioperative age ranged from 19 to 61 years (mean 33 years) (Table 1). The most common surgery type was BSSO exclusively (42%), followed by Le Fort I (35%) and bimaxillary surgery (23%).
      TABLE 1Descriptive characteristics of 182 patients receiving orthognathic surgery
      CharacteristicAll, N = 182 (100%)
      Age

      Range

      Mean

      Median


      19 – 61

      33

      30
      Sex
      Male76 (42%)
      Female106 (58%)
      Smoking
      Yes35 (19%)
      No147 (81%)
      Alcohol abuse history
      Yes5 (3%)
      No177 (97%)
      Substance abuse history
      Yes3 (2%)
      No179 (98%)
      Skeletal class
      I10 (6%)
      II93 (51%)
      III79 (43%)
      Preoperative psychiatric consultation
      Yes17 (9%)
      No165 (91%)
      Major surgery related complication
      Yes6 (3%)
      No176 (97%)
      Perioperative dexamethasone administration
      10 mg or less or no dexamethasone85 (47%)
      0mg7 (4%)
      5mg4 (2%)
      7,5mg7 (4%)
      10mg67 (37%)
      More than 10 mg of dexamethasone97 (53%)
      15mg12 (7%)
      20mg20 (11%)
      25mg47 (26%)
      30mg17 (9%)
      40mg1 (<1%)
      New or exacerbated psychiatric morbidity after orthognathic surgery
      Yes12 (7%)
      No170 (93%)
      Surgery type
      Bilateral Sagittal Split Osteotomy77 (42%)
      Le Fort I63 (35%)
      Bimaxillary42 (23%)
      SARME as preceding surgery
      Yes9 (5%)
      No173 (95%)
      SARME, Surgically Assisted Rapid Maxillary Expansion
      A major surgical or surgery-related complication was observed in six patients (3%). Reoperation was required in five patients. Indications for the reoperation were suboptimal primary surgery, relapse during healing, and mobility of the maxilla with inadequate osteosynthesis during long-term follow-up. In one patient, increased septum deviation after Le Fort I osteotomy required surgical treatment. In addition, one patient had severe aspiration pneumonia and pulmonary embolism, requiring intensive care.
      Variations in psychiatric diagnoses and the severity of morbidity during treatment phases are presented in Table 2. Morbidity was determined by psychiatric history and psychiatric medication documented by medical professionals and self-reported mental health status. Severity of the psychiatric disorder was evaluated based on the functional limitation of the mental illness (18). The ICD-10 classification of mental and behavioural disorders was used to further categorize the diseases (19).
      TABLE 2Descriptive statistics of psychiatric morbidity in 182 patients: ICD10–classification of mental and behavioral disorders
      N = number of patientsPsychiatric morbidity before orthodontic treatment,N = 32Current psychiatric morbidity during orthodontic treatmentN = 32Postoperative new or exacerbated psychiatric morbidityN = 12
      n = number of diagnoses
      None of the patients had intellectual disabilities (F70-F79) or other unspecified mental disorders (F99).
      ,
      Patients can have simultaneous comorbidities (for instance mood disorders, and behavioral disorders) in the table, and the severity of the disorder may vary during the treatment phase. This causes the total number of diagnoses not to match the total number of patients with psychiatric morbidity.
      n% of 182n% of 182n% of 182
      F00–F09 Organic, including symptomatic, mental disorders00%00%21%
      F10–F19 Mental and behavioral disorders due to psychoactive substance use32%21%21%
      F20–F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders1<1%00%00%
      F30–F39 Mood [affective] disorders2011%2815%74%
      F40–F48 Anxiety, dissociative, stress-related, somatoform, and other nonpsychotic mental disorders158%127%63%
      F50–F59 Behavioral syndromes associated with physiological disturbances and physical factors00%1<1%1<1%
      F60–F69 Disorders of adult personality and behavior21%1<1%00%
      F80–F89 Pervasive and specific developmental disorders21%0<1%00%
      F90–F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence21%1<1%32%
      Psychiatric morbidity
      Patients can have simultaneous comorbidities (for instance mood disorders, and behavioral disorders) in the table, and the severity of the disorder may vary during the treatment phase. This causes the total number of diagnoses not to match the total number of patients with psychiatric morbidity.
      Mild or moderate psychiatric morbidity2212%3218%84%
      Neuropsychiatric disorder21%21%31%
      Severe psychiatric morbidity95%21%31%
      Suicidal ideation95%42%21%
      Suicide attempts42%21%1<1%
      a None of the patients had intellectual disabilities (F70-F79) or other unspecified mental disorders (F99).
      b Patients can have simultaneous comorbidities (for instance mood disorders, and behavioral disorders) in the table, and the severity of the disorder may vary during the treatment phase. This causes the total number of diagnoses not to match the total number of patients with psychiatric morbidity.
      Patients with psychiatric morbidity before surgery were slightly older than those without (P = .042, Cohen's d = .354) (Table 3). History of smoking was more frequent in patients with preceding psychiatric morbidity (P = .046). In total, 17 patients (9%) had a psychiatric consultation during the preoperative treatment phase. Psychiatric consultations concentrated significantly on patients with preceding psychiatric morbidity (P < .001).
      TABLE 3Associations between explanatory variables, surgery-related predictor variables, and preceding psychiatric morbidity.
      N = Number of patientsPatients with preceding psychiatric morbidityN = 44 (24% of 182)Patients without preceding psychiatric morbidityN = 138 (76% of 182)P value*
      Age:

      Range

      Mean

      Median


      19 – 61

      37

      35



      20 – 61

      33

      30

      .042
      Characteristicn% of n
      Such as all patients receiving LeFort I-surgery
      % of 44n% of n
      Such as all patients receiving LeFort I-surgery
      % of 138
      Sexn.s.
      Male1520%34%6180%44%
      Female2927%66%7773%56%
      Smoking.046
      Yes1337%29,5%2263%16%
      No3121%70,5%11679%84%
      Alcohol abuse history<0.001
      Yes5100%11%00%0%
      No3922%89%13878%100%
      Substance abuse historyn.s.
      Yes267%4,5%133%1%
      No4223,5%95,5%13776,5%99%
      Skeletal classn.s.
      I330%7%770%5%
      II2426%54,5%6974%50%
      III1721,5%38,5%6278,5%45%
      Preoperative psychiatric consultation<0.001
      Yes1694%36%16%1%
      No2817%64%13783%99%
      Major surgery-related complicationn.s.
      Yes117%2%583%4%
      No4324%98%13376%96%
      Perioperative dexamethasone administrationn.s.
      10 mg or less or no dexamethasone1821%41%6779%49%
      More than 10 mg of dexamethasone2627%59%7173%51%
      Surgery typen.s.
      Bilateral Sagittal Split Osteotomy1823%41%5977%43%
      Le Fort I1524%34%4876%35%
      Bimaxillary1126%25%3174%23%
      SARME as preceding surgeryn.s.
      Yes111%2%889%6%
      No4325 %98%13075%94%
      * To ascertain the degrees of independence, categorical variables were tested with Pearson's chi-square analysis. Student's t-test was used to compare differences between study groups in age. N.s., non-significant, P value > 0.05.
      SARME, Surgically Assisted Rapid Maxillary Expansion
      a Such as all patients receiving LeFort I-surgery
      New psychiatric morbidity or exacerbation of pre-existing psychiatric conditions during the postoperative treatment phase occurred in 12 patients (7%) (Table 4). Preceding psychiatric morbidity was associated significantly with exacerbation of pre-existing or new postoperative psychiatric morbidity (P < .001). Nine of 12 patients with new or exacerbated psychiatric morbidity had a preceding psychiatric condition. Six of 12 patients underwent a preoperative psychiatric consultation. History of smoking (P = .041) and alcohol abuse (P = .002) were also significantly more frequent in patients with postoperative psychiatric morbidity. In addition, high perioperative dexamethasone administration was associated significantly with postoperative psychiatric morbidity (P = .006).
      TABLE 4Associations between explanatory variables, surgery related predictors and new or exacerbated psychiatric morbidity after orthognathic surgery.
      Patients with new or exacerbated psychiatric morbidity, N=12 (7% of 182): mild or moderate n=8, severe n=3Patients without new or exacerbated psychiatric morbidity, N=170 (93% of 182)P value*
      Age

      Range

      Mean

      Median


      21 – 52

      34

      38



      19 – 61

      33

      30

      n.s.
      Characteristicn% of n
      Such as all patients receiving Le Fort I–surgery
      % of 12n% of n
      Such as all patients receiving Le Fort I–surgery
      % of 170
      Sexn.s.
      Male45%33%7295%42%
      Female87,5%67%9892,5%58%
      Smoking.041
      Yes514%42%3086%18%
      No75%58%14095%82%
      Alcohol abuse history.002
      Yes240%17%360%2%
      No106%83%16794%98%
      Substance abuse historyn.s.
      Yes133%8%267%1%
      No116%92%16894%99%
      Skeletal classn.s.
      I110%8%990%5%
      II55%42%8895%52%
      III68%50%7392%43%
      Preceding psychiatric disorder: severe n=5, mild or moderate n=4<0.001
      Yes920,5%75%3579,5%21%
      No32%25%13598%79%
      Preoperative psychiatric consultation<0.001
      Yes635%50%1165%6,5%
      No64%50%15996%93,5%
      Major surgery related complicationn.s.
      Yes117%8%583%3%
      No116%92%16594%97%
      Perioperative dexamethasone administration.006
      10 mg or less or no dexamethasone11%8%8499%49%
      More than 10 mg of dexamethasone1111%92%8689%51%
      Surgery typen.s.
      Bilateral Sagittal Split Osteotomy45%33%7395%43%
      Le Fort I46%33%5994%35%
      Bimaxillary49,5%33%3890,5%22%
      SARME as preceding surgeryn.s.
      Yes00%0%9100%5%
      No127%100%16193%95%
      * To ascertain the degrees of independence, categorical variables were tested with Pearson's chi-square analysis. Student's t-test was used to compare differences between study groups in age. N.s., non-significant, P value > 0.05.
      SARME, Surgically Assisted Rapid Maxillary Expansion
      a Such as all patients receiving Le Fort I–surgery
      A new or exacerbated postoperative psychiatric morbidity was nine times more likely to occur in patients with a previous psychiatric history than in those without (OR 8.88, P = .004 [CI 2.023 – 38.966]) in logistic regression analyses (Table 5). In addition, high-dose perioperative dexamethasone predicted postoperative psychiatric outcome independently (OR 4.411, P = .036 [CI 1.165 – 82.680]).
      TABLE 5Multivariate logistic regression for postoperative new or exacerbated psychiatric morbidity after orthognathic surgery.
      PredictorBSEWaldP valueOdds Ratio95% CI
      Age0.0070.0340.042.8381.0070.942 to 1.076
      Smoking0.6390.7470.731.3931.8940.438 to 8.192
      History of alcohol and/or substance abuse0.5501.1300.236.6271.7320.189 to 15.886
      Preceding psychiatric morbidity2.1840.7558.372.0048.8782.023 to 38.966
      More than 10 mg of dexamethasone2.2841.0874.411.0369.8131.165 to 82.680
      Constant-5,8221.66312.251<0.001<0.003
      SE, standard error, CI, confidence interval

      DISCUSSION

      This study aimed to clarify psychiatric morbidity in OS patients during phases preceding surgery and postoperatively. We hypothesized that patients with new or exacerbated psychiatric morbidity during the postoperative treatment phase could be identified based on background variables. The results supported our hypothesis. Preceding psychiatric conditions strongly predicted patients´ postoperative morbidity. Psychiatric illness worsened postoperatively in 21% of patients with a preceding psychiatric condition (Table 4).
      Previous studies have reported that 20−25% of patients seeking OS might meet the criteria for a psychiatric condition (2, 20, 21). The findings here are consistent with earlier research, as up to 24% of our patients had a history of a psychiatric condition or current morbidity during preoperative orthodontic treatment (Table 3). While it has been stated that OS patients do not experience psychological symptoms to a greater degree than others (22) and that they do not seem to suffer from psychological distress in general (7), our findings indicate that preceding psychiatric morbidity must be carefully considered in OS patients. These diseases may be exacerbated by surgery, although signs of mental distress and psychiatric episodes were also seen in patients with no preceding psychiatric history.
      To be able to identify patients in need of more intensive psychiatric evaluation and treatment, it is appropriate to recognize the severity of psychiatric illnesses. In the present study, severe morbidity was observed both before and after surgery (Table 2). These severe conditions included suicidal ideation and attempts, severe depression, and psychosis. Of patients, 5% had severe morbidity before orthodontic treatment. This is less than previously reported by Sebastiani et al. (12) who found that 18% of patients seeking OS had severe depression. Despite the lower prevalence of severe psychiatric diseases in our study, these conditions must not be disregarded and should be evaluated accordingly.
      Recognition of the spectrum of psychiatric disorders is also important in treatment processes since mental health conditions are known to have a negative impact on postoperative oral health-related quality of life (23). According to our results, specifically mood disorders (ICD-10 Clinical Modification code range F30-F39), e.g. depressive disorders and bipolar disorder, were common (Table 2). Up to 15% of patients had an affective mood disorder during orthodontic treatment. Exacerbations of these affective disorders were also common postoperatively, and thus, special attention should be paid to patients with these disorders.
      Preceding psychiatric morbidity was associated significantly with postoperative morbidity (P < .001), and 12 patients (7%) had a new or an exacerbation of a previous psychiatric disease after surgery (Table 4). Earlier research has reported varying results for postoperative symptoms in OS patients. Psychiatric symptoms have been presented to improve when comparing preoperative with postoperative symptoms in anxiety (10, 15, 24), depression (10), OCD (10, 25), and psychoticism (10). However, the evolution of symptoms at an individual level could be dependent on the severity of the psychiatric disease. Brunault et al. (1) demonstrated a decrease in depressive symptoms, although more than two-thirds of patients who were depressed at the start of the study still had substantial depression 12 months after surgery. Häberle et al. (25) found no changes in anxiety and depressive symptoms when comparing pre- and postoperative symptom scores.
      In addition to exacerbations of preceding diseases, we also observed an increase in neuropsychiatric conditions (Table 2). While these disorders can be detected and diagnosed in adults, it is important to note that neuropsychiatric disorders, such as Attention-Deficit / Hyperactivity Disorder, have an onset in childhood (26). Patients' increased interest in general health after surgery could explain the rising occurrence of these conditions.
      Patients with different malocclusions (27) and dentofacial deformities (25) have been described to have significantly different psychiatric profiles. Here, we found no association between skeletal class discrepancies and preceding or postoperative morbidity, postoperative major complications, or type of surgery. Previous prospective research supports these findings, with patients who received bimaxillary, Le Fort I, or BSSO surgery feeling similarly about their post-surgical recovery one month after surgery (28). Additionally, it appears that there is no difference in treatment lengths between patients with and without self-reported mental health problems (29). However, we found that high dexamethasone administration was associated significantly with postoperative psychiatric morbidity (Table 4).
      Glucocorticoid use is very common in OS (30), and the benefits on peri- and postoperative recovery include the prevention of nausea (31) and reduction of pain and swelling specifically in OS patients (32). However, glucocorticoids have side effects (32), and research regarding OS is incomplete (33). Here, the overall distribution between low (10 mg or less or no dexamethasone) and high (more than 10 mg of dexamethasone) total glucocorticoid dose was equal in the studied patients (Table 1). Up to 92% of patients with an exacerbation or a new psychiatric disorder received a high dose of dexamethasone during surgery. Dexamethasone is known to have adverse psychiatric effects on mood changes, including depression, anxiety, mania, and even psychosis (34). However, due to the small sample size of our study and the lack of previous research on psychiatric effects in OS patients, further investigations are required to confirm this association. Based on the present finding, caution should be exercised in the use of high-dose dexamethasone in this patient group. It must be emphasized that the benefits of glucocorticoids can be achieved with small single doses (31, 35).
      Only 16 (36%) of the 44 patients with a previous history of psychiatric morbidity (Table 3) had a psychiatric consultation before surgery. Again, no psychiatric evaluation was performed in 50% of the patients with a new or exacerbated postoperative psychiatric disorder. This highlights the need for structured evaluation of OS patients in all units providing orthognathic treatment. Preventing psychiatric morbidity in patients receiving OS care and bringing psychiatric care closer to the patients should be the main objectives. Before beginning OS treatment, it would be optimal if patients were evaluated by a mental health professional who can identify and assess patients with severe psychiatric morbidities or unstable mental health. These patients are more likely to require psychiatric support throughout their OS care, so close psychiatric support must also be allocated to these patients pre- and post-operatively. In addition, patients whose mental health is regarded as good could also benefit from a structured discussion that considers the impact of OS on the psyche to prepare them for extensive surgery. As suggested by earlier studies by Kiyak et al, OS patients should have realistic expectations regarding OS and be aware of potential negative psychiatric and physiological side effects (36, 37).
      Due to the retrospective nature of this study, some variables might have been incompletely reported in patient records. Some psychiatric diseases or exacerbations may not have been registered due to the lack of systematic evaluation of psychiatric status. This could cause an underestimation of these diseases. The 12-month follow-up period has been in standard use in previous studies investigating the psychological and psychiatric status of OS patients. However, longer effects of OS were not reported. The use of standardized questionnaires to evaluate the psychiatric status of patients during pre- and postoperative treatment phases could bring additional value to OS care and research.
      Our findings emphasize the importance of evaluation of current and past psychiatric health during overall OS care. As shown in this study (Table 2), a wide range of psychiatric diseases should be considered in this patient population. Orthodontists and surgeons should understand the fundamentals of mental health disorders to be able to provide proper orthognathic treatment. As stated by Juggins et al. (38), both professionals and OS patients would benefit from collaboration between clinicians and mental health teams.

      STATEMENT OF CLINICAL RELEVANCE

      Patients and professionals would benefit from collaboration between clinicians and mental health teams. Psychiatric illnesses can be exacerbated by orthognathic surgery, thus emphasizing the need to carry out a thorough evaluation of current and past psychiatric history preceding the surgery.

      Additional information

      This study was accepted and presented in the session “Free Papers – Orthognathic surgery / TMJ disorders” as an oral presentation in the Face Ahead Summit held in Barcelona, Spain, 5-7 May 2022.

      Funding

      S.K. and J.S. were funded by the Helsinki University Hospital Fund.

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      Declaration of interest

      The authors have no conflicts of interest to declare.