The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality

*Takako Sato, Ryota Nakamura, Akio Himejima, Akemi Kusano, Serim Kang, Saori Ohtani, Kentarou Yamada, Kanako Yamagata, Hiroaki Azaki, Junya Aoki, Keiichi Yanagawa, Keiji Shinozuka, Takeya Yamada and Morio Tonogi*

## **Abstract**

Maxillomandibular advancement (MMA) using a standardized surgical procedure consisting of a LeFort I osteotomy and bilateral sagittal split ramus osteotomy and genioglossus advancement (GA) using a genioplasty improve airway volume, oxygen desaturation, and the AHI in patients with OSA. However, there are few reports on changes in sleep quality following MMA and GA. We assessed the effects of MMA and GA on sleep quality by comparing oxygen desaturation, AHI, and sleep architecture before and after surgery. Methods: Eight patients underwent polysomnography (PSG) and CT scan before and after surgery. Conclusions: Our study finds that %TST and %REM were both increased, while %S1 and NA both decreased. Based on these results, it appears that both the quality and quantity of sleep were improved. MMA and GA improve sleep respiratory disturbance and can also improve sleep quality.

**Keywords:** maxillomandibular advancement, sleep quality, genioplasty, respiratory disturbance

## **1. Introduction**

Obstructive sleep apnea (OSA) is a disorder characterized by intermittent and recurrent episodes of partial or complete upper airway obstruction during sleep. Obesity, a narrow nasopharynx and oropharynx, large soft palate, large tonsils, large tongue, tongue retroposition, micrognathia, mandibular retrognathia, and maxillary retrusion can all cause upper airway obstruction [1–8].

Maxillomandibular advancement (MMA) and genioglossus advancement (GA) improve airway volume, oxygen desaturation, and the apnea-hypopnea index (AHI) in patients with OSA. However, there are few reports on changes in sleep quality and architecture following MMA and GA [9]. Therefore, we assessed the

effects of MMA and GA on sleep quality by comparing oxygen desaturation, AHI, and sleep architecture before and after MMA and GA.

## **2. Materials and methods**

Nine OSA patients who had MMA and GA underwent polysomnography (PSG) before and after surgery, which was assessed using the same scoring criteria. One subject was excluded because computed tomography (CT) data were not collected, neither before nor after surgery. Our study included a total of eight subjects (six males and two females). The average age and body mass index (BMI) of the participants were 43.75 ± 8.17 years and 21.8 ± 1.8 kg/m2, respectively.

### **2.1 Surgical procedure**

All patients underwent MMA using a standardized surgical procedure consisting of a LeFort I osteotomy and bilateral sagittal split ramus osteotomy and GA using a genioplasty to pull the genioglossus and geniohyoid muscles. The amount of maxillary advancement was routinely set at a minimum of 5 mm or more in consideration for unavoidable change in facial appearance. The mandibular jaw was advanced to match the maxilla, to restore the preoperative jaw relationship. The average amount of mandibular advancement was 13.2 mm. The average amount of skeletal advancement in GA was 6.3 mm. All patients were informed regarding the study protocol and provided consent.

#### **2.2 Morphological evaluation**

The lateral cephalometric radiograph were taken and calculated with manual hand-tracing.

The CT evaluation (1-mm slices) was performed with the aid of an Asteion device (TSX-021B/4; Toshiba, Tokyo, Japan), before and at 1 year after surgery. For standard reproducibility the patient was placed in the supine position, with the head and neck positioned on a pillow to maintain the Frankfurt plane at right angles to the floor. CT scans were performed during inspiration at rest, without swallowing. The upper airway area was measured in three regions: the superior posterior airway space (SPAS), which is the airway region at the midpoint between the inferior tip of the soft palate (P point) and the posterior nasal spine (PNS) point, parallel to the line from the gonion point to the point at the deepest midline concavity on the mandibular alveolus between the infradentale and pogonion (B point) (GO-B line); the middle airway space (MAS), which is the airway region on the P point parallel to the GO-B line; and the inferior airway space (IAS), which is the airway region on the GO-B line [10] (**Figures 1** and **2**).

The volume between PNS and Eb was also measured (**Figure 3**).

All data analyses were performed using Mimics software (Materialize, Leuven, Belgium).

#### **2.3 Physiological evaluation (polysomnography)**

Polysomnographic recordings were performed before and within 1 year after surgery. We used a 16-channel PSG instrument (Alice 5; Philips Respironics, Murrysville, PA, USA) with continuous monitoring performed by a technician.

**125**

**Figure 3.**

**Figure 1.**

**Figure 2.**

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality*

*Scheme of each of the measurement regions (anteroposterior dimension). SPAS, superior posterior airway* 

*Scheme of each of the measurement regions (cross-sectional area). SPAS, Superior posterior airway space;* 

The measures taken included electroencephalography (EEG), electrooculogram (EOG), electromyogram (EMG), electrocardiogram (ECG), snore, thermocouple airflow, nasal pressure, chest and abdominal movement, pulse oximetry, and body

*Scheme of the measurement regions (volume). PNS, Posterior nasal spine; Eb, Epiglottal base.*

*DOI: http://dx.doi.org/10.5772/intechopen.89296*

*space; MAS: Middle airway space; IAS: Inferior airway space.*

*MAS, Middle airway space; IAS, Inferior airway space.*

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality DOI: http://dx.doi.org/10.5772/intechopen.89296*

#### **Figure 1.**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

pants were 43.75 ± 8.17 years and 21.8 ± 1.8 kg/m2, respectively.

and sleep architecture before and after MMA and GA.

**2. Materials and methods**

**2.1 Surgical procedure**

and provided consent.

hand-tracing.

(**Figures 1** and **2**).

Belgium).

**2.2 Morphological evaluation**

effects of MMA and GA on sleep quality by comparing oxygen desaturation, AHI,

Nine OSA patients who had MMA and GA underwent polysomnography (PSG) before and after surgery, which was assessed using the same scoring criteria. One subject was excluded because computed tomography (CT) data were not collected, neither before nor after surgery. Our study included a total of eight subjects (six males and two females). The average age and body mass index (BMI) of the partici-

All patients underwent MMA using a standardized surgical procedure consisting of a LeFort I osteotomy and bilateral sagittal split ramus osteotomy and GA using a genioplasty to pull the genioglossus and geniohyoid muscles. The amount of maxillary advancement was routinely set at a minimum of 5 mm or more in consideration for unavoidable change in facial appearance. The mandibular jaw was advanced to match the maxilla, to restore the preoperative jaw relationship. The average amount of mandibular advancement was 13.2 mm. The average amount of skeletal advancement in GA was 6.3 mm. All patients were informed regarding the study protocol

The lateral cephalometric radiograph were taken and calculated with manual

The CT evaluation (1-mm slices) was performed with the aid of an Asteion device (TSX-021B/4; Toshiba, Tokyo, Japan), before and at 1 year after surgery. For standard reproducibility the patient was placed in the supine position, with the head and neck positioned on a pillow to maintain the Frankfurt plane at right angles to the floor. CT scans were performed during inspiration at rest, without swallowing. The upper airway area was measured in three regions: the superior posterior airway space (SPAS), which is the airway region at the midpoint between the inferior tip of the soft palate (P point) and the posterior nasal spine (PNS) point, parallel to the line from the gonion point to the point at the deepest midline concavity on the mandibular alveolus between the infradentale and pogonion (B point) (GO-B line); the middle airway space (MAS), which is the airway region on the P point parallel to the GO-B line; and the inferior

airway space (IAS), which is the airway region on the GO-B line [10]

The volume between PNS and Eb was also measured (**Figure 3**).

**2.3 Physiological evaluation (polysomnography)**

All data analyses were performed using Mimics software (Materialize, Leuven,

Polysomnographic recordings were performed before and within 1 year after surgery. We used a 16-channel PSG instrument (Alice 5; Philips Respironics, Murrysville, PA, USA) with continuous monitoring performed by a technician.

**124**

*Scheme of each of the measurement regions (anteroposterior dimension). SPAS, superior posterior airway space; MAS: Middle airway space; IAS: Inferior airway space.*

#### **Figure 2.**

*Scheme of each of the measurement regions (cross-sectional area). SPAS, Superior posterior airway space; MAS, Middle airway space; IAS, Inferior airway space.*

#### **Figure 3.**

*Scheme of the measurement regions (volume). PNS, Posterior nasal spine; Eb, Epiglottal base.*

The measures taken included electroencephalography (EEG), electrooculogram (EOG), electromyogram (EMG), electrocardiogram (ECG), snore, thermocouple airflow, nasal pressure, chest and abdominal movement, pulse oximetry, and body position. Polysomnographic analyses were performed according to the American Academy of Sleep Medicine guidelines. Apnea was defined as complete cessation of airflow for more than 10 seconds. Hypopnea was defined as a decrease in airflow of 90% or more from the baseline, as measured by an oronasal thermistor for at least 10 seconds, a 30% or greater reduction in respiratory airflow lasting for more than 10 seconds, or at least a 3% decrease in oxygen saturation (SpO2) from the pre-event baseline. The 3% oxygen desaturation index (ODI) represents the average number of times per hour that the blood oxygen level drops by 3% from the baseline during sleep [9].

Arousal was defined as a sudden change in EEG frequency. We collected data on AHI, apnea index (AI), hypopnea index (HI), 3% ODI, lowest SpO2, percentage at which SpO2 was <90% of TST (%SpO2 < 90%), total sleep time (TST), sleep efficiency (SE: TST/time in bed [TIB]), number of awakenings (NA), percentage of nonrapid eye movement sleep stage 1 (NREM1) of TST (%S1), percentage of NREM2 of TST (%S2), percentage of NREM3 of TST (%S3), percentage of rapid eye movement (REM) sleep of TST (%REM), wakefulness after sleep onset (WASO), WASO as a proportion of sleep period time (SPT) (%WASO), sleep latency, and REM latency.

All data were analyzed using the Wilcoxon t-test, with a value of p < 0.05 considered statistically significant.

## **3. Results**

#### **3.1 Change in the airway before versus after MMA and GA**

The mean anteroposterior dimension of the SPAS, MAS, and IAS increased from 9.8 ± 3.24, 7.3 ± 2.93, and 9.6 ± 2.47 to 15.7 ± 3.67 (p < 0.005), 12.6 ± 2.94 (p < 0.005), and 15.4 ± 3.73 (p < 0.005), respectively (**Figure 4**).

The mean cross-sectional area of the SPAS, MAS, and IAS increased from 171.3 ± 104.6, 221.3 ± 66.6, and 200.9 ± 70.2 to 317.1 ± 141.7 (p < 0.005), 335.0 ± 132.8 (p < 0.01), and 316.9 ± 140.4 (p < 0.01), respectively. The mean enlargement factor of SPAS, MAS, and IAS was 213.0 ± 70.6%, 152.1 ± 47.3%, and 160.9 ± 54.8%, respectively. The mean volume between PNS and Eb increased from 13664.2 ± 5458.6 to 18647.0 ± 8456.0 (p < 0.01). The mean volume expansion rate was 136.5 ± 30.2% (p < 0.01) (**Figure 5**).

**127**

**Figure 7.**

**Figure 5.**

**Figure 6.**

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality*

*Change in each cross-sectional area and volume of airway before and after MMA and GA.*

**3.2 Changes in PSG parameters in subjects before versus after MMA and GA**

*Change in polysomnography parameter before and after MMA and GA (sleep-disordered breathing).*

The mean AHI decreased from 28.0 ± 24.6 to 7.4 ± 6.9 events/hour (p < 0.005), the AI decreased from 19.0 ± 25.4 to 2.3 ± 2.4 (p < 0.008), the

*Change in polysomnography parameter before and after MMA and GA (sleep stage).*

*DOI: http://dx.doi.org/10.5772/intechopen.89296*

**Figure 4.** *Change in each anteroposterior dimension of airway before and after MMA and GA.*

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality DOI: http://dx.doi.org/10.5772/intechopen.89296*

**Figure 5.** *Change in each cross-sectional area and volume of airway before and after MMA and GA.*

**Figure 7.** *Change in polysomnography parameter before and after MMA and GA (sleep stage).*

## **3.2 Changes in PSG parameters in subjects before versus after MMA and GA**

The mean AHI decreased from 28.0 ± 24.6 to 7.4 ± 6.9 events/hour (p < 0.005), the AI decreased from 19.0 ± 25.4 to 2.3 ± 2.4 (p < 0.008), the

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

position. Polysomnographic analyses were performed according to the American Academy of Sleep Medicine guidelines. Apnea was defined as complete cessation of airflow for more than 10 seconds. Hypopnea was defined as a decrease in airflow of 90% or more from the baseline, as measured by an oronasal thermistor for at least 10 seconds, a 30% or greater reduction in respiratory airflow lasting for more than 10 seconds, or at least a 3% decrease in oxygen saturation (SpO2) from the pre-event baseline. The 3% oxygen desaturation index (ODI) represents the average number of times per hour that the blood oxygen level drops by 3% from the baseline during

Arousal was defined as a sudden change in EEG frequency. We collected data on AHI, apnea index (AI), hypopnea index (HI), 3% ODI, lowest SpO2, percentage at which SpO2 was <90% of TST (%SpO2 < 90%), total sleep time (TST), sleep efficiency (SE: TST/time in bed [TIB]), number of awakenings (NA), percentage of nonrapid eye movement sleep stage 1 (NREM1) of TST (%S1), percentage of NREM2 of TST (%S2), percentage of NREM3 of TST (%S3), percentage of rapid eye movement (REM) sleep of TST (%REM), wakefulness after sleep onset (WASO), WASO as a proportion of sleep period time (SPT) (%WASO), sleep

All data were analyzed using the Wilcoxon t-test, with a value of p < 0.05

The mean anteroposterior dimension of the SPAS, MAS, and IAS increased from 9.8 ± 3.24, 7.3 ± 2.93, and 9.6 ± 2.47 to 15.7 ± 3.67 (p < 0.005), 12.6 ± 2.94 (p < 0.005),

The mean cross-sectional area of the SPAS, MAS, and IAS increased from 171.3 ± 104.6, 221.3 ± 66.6, and 200.9 ± 70.2 to 317.1 ± 141.7 (p < 0.005), 335.0 ± 132.8 (p < 0.01), and 316.9 ± 140.4 (p < 0.01), respectively. The mean enlargement factor of SPAS, MAS, and IAS was 213.0 ± 70.6%, 152.1 ± 47.3%, and 160.9 ± 54.8%, respectively. The mean volume between PNS and Eb increased from 13664.2 ± 5458.6 to 18647.0 ± 8456.0 (p < 0.01). The mean volume expansion rate

**3.1 Change in the airway before versus after MMA and GA**

*Change in each anteroposterior dimension of airway before and after MMA and GA.*

and 15.4 ± 3.73 (p < 0.005), respectively (**Figure 4**).

was 136.5 ± 30.2% (p < 0.01) (**Figure 5**).

**126**

**Figure 4.**

sleep [9].

**3. Results**

latency, and REM latency.

considered statistically significant.

ODI decreased from 20.5 ± 19.9 to 6.5 ± 5.9 (p < 0.008), and the %SpO2 < 90% decreased from 2.1 ± 4.0 to 0.2 ± 0.4 (p < 0.02), while the mean lowest SpO2 increased from 83.3 ± 9.5% to 88.3 ± 6.4% (p < 0.02) (**Figure 6**).

The mean SE increased from 81.2 ± 12.8 to 86.2 ± 7.7 (p < 0.03), and %REM increased from 15.4 ± 5.7% to 19.0 ± 3.6% (p < 0.02); meanwhile, the mean %S1 and NA decreased from 27.7 ± 21.2% to 15.3 ± 7.6% (p < 0.01) and 184.7 ± 108.4 to 119.5 ± 40.7 (p < 0.008), respectively (**Figure 7**).

## **4. Discussion**

In this study, we divided airway space into retropalatal and retroglossal spaces: SPAS and MAS corresponded to retropalatal, while IAS corresponded to retroglossal. We found an increase in anteroposterior dimension and cross-sectional area of both the retropalatal and retroglossal spaces following MMA and GA, consistent with previous studies. The volume of airway space was also increased.

The retropalatal space is influenced by the position of the maxilla, soft palate, and tonsils, while the retroglossal space is influenced by the mandibular position and glossal shape and position [11–13]. The soft palate is comprised of the musculus uvulae, tensor veli palatini, levator veli palatini, and palatoglossus. The former three muscles are attached to the maxilla, while the latter is attached to the mandible. The genioglossus and geniohyoid muscles are attached to the mental spine and hyoid bone [14]. Airway enlargement is primarily caused by elevation of the tissues attached to the jaw and hyoid bone. Therefore, the most effective surgical approach to resolve this issue is to move both the upper and lower jaw.

Surgical success of MMA is defined as an AHI with less than 20 events/hour or an AHI showing a greater than 50% reduction after surgery. Meanwhile, surgical cure is defined as an AHI with less than five events/hour following surgery [15].

In this study, all patients were in the surgical success category, and 50% of patients were also classified as surgical cure.

The ODI and %SpO2 < 90% both decreased, while the lowest SpO2 increased; these results are consistent with previous reports [16]. These findings indicate that although achieving complete cure is difficult, MMA remains an effective method for treating sleep-disordered breathing. Furthermore, improvements in the lowest SpO2 and %SpO2 < 90% levels prevent the development of oxygen-desaturationrelated diseases. A number of previous studies demonstrated that hypoxia-induced oxidative stress, sympathetic activation, and inflammatory responses increase the long-term risk of multiple comorbidities, including hypertension, heart attack, stroke, and diabetes [17–22].

The sleep architecture was also altered after MMA. There is currently no consensus on how "better sleep" should be quantitatively and qualitatively defined [9]. However, some researchers have suggested that decreased SE, TST, and percentage of slow-wave sleep (SWS) of TST (%SWS) and increased WASO are indicators of poor sleep quality [23–25]. Others believe that improved sleep quality is reflected by the increases in %REM and %SWS, based on prior CPAP treatment data [26]. Our study did not find any decrease in WASO. However, TST and %REM were both increased, while %S1 and NA both decreased. Furthermore, there is no significant difference, but SWS tends to increase. Based on these results, it appears that both the quality and quantity of sleep were improved.

OSA interrupts the normal sleep cycle: REM sleep disappears or becomes irregular, while SWS disappears. In our study, some subjects exhibited a REM pattern similar to that of healthy subjects, while in others no therapeutic effect of MMA was observed, despite sufficient airway expansion. Given the small number of subjects

**129**

study.

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality*

in our study, it was not possible to identify factors affecting the therapeutic efficacy. However, the most common causative factors of OSA include poor upper airway anatomy (collapsibility), weak upper airway dilator muscle responsiveness, a low respiratory arousal threshold, and an unstable ventilatory control system (loop gain) [27–30]. Taken together, we consider that oxygen inhalation and sleeping medication, for example, may prove therapeutic for patients with symptoms not

MMA and GA cannot provide equal effect for every patient. The airway expan-

MMA and GA can increase the anteroposterior dimension, cross-sectional area, and volume of the retropalatal and retroglossal spaces, consistent with previous

MMA and GA may be able to improve not only sleep respiratory disturbance but

This study was supported by the Sato Fund, Nihon University School of Dentistry; a grant from the Dental Research Center, Nihon University School of

Data herein have been previously applied to Nichidai Shigaku (in Japanese) by

This study was performed with the approval of the Ethics Committee of Nihon

Informed consent was obtained from all individual participants included in the

Dentistry; and the Uemura Fund, Nihon University School of Dentistry.

sion is affected by the amount of jaw movement. However, even if the airway expansion is made bigger, it does not necessarily improve the quality of sleep. So, I

must further explore other factors involved in affecting sleep quality.

*DOI: http://dx.doi.org/10.5772/intechopen.89296*

improved by surgical intervention alone.

**5. Conclusion**

also improve sleep quality.

**Acknowledgements**

Ryota Nakamura.

**Conflict of interest**

**Ethical approval**

**Informed consent**

University School of Dentistry.

The authors declare no conflict of interest.

studies.

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality DOI: http://dx.doi.org/10.5772/intechopen.89296*

in our study, it was not possible to identify factors affecting the therapeutic efficacy. However, the most common causative factors of OSA include poor upper airway anatomy (collapsibility), weak upper airway dilator muscle responsiveness, a low respiratory arousal threshold, and an unstable ventilatory control system (loop gain) [27–30]. Taken together, we consider that oxygen inhalation and sleeping medication, for example, may prove therapeutic for patients with symptoms not improved by surgical intervention alone.

MMA and GA cannot provide equal effect for every patient. The airway expansion is affected by the amount of jaw movement. However, even if the airway expansion is made bigger, it does not necessarily improve the quality of sleep. So, I must further explore other factors involved in affecting sleep quality.

## **5. Conclusion**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

increased from 83.3 ± 9.5% to 88.3 ± 6.4% (p < 0.02) (**Figure 6**).

with previous studies. The volume of airway space was also increased.

to resolve this issue is to move both the upper and lower jaw.

patients were also classified as surgical cure.

the quality and quantity of sleep were improved.

stroke, and diabetes [17–22].

119.5 ± 40.7 (p < 0.008), respectively (**Figure 7**).

**4. Discussion**

ODI decreased from 20.5 ± 19.9 to 6.5 ± 5.9 (p < 0.008), and the %SpO2 < 90% decreased from 2.1 ± 4.0 to 0.2 ± 0.4 (p < 0.02), while the mean lowest SpO2

The mean SE increased from 81.2 ± 12.8 to 86.2 ± 7.7 (p < 0.03), and %REM increased from 15.4 ± 5.7% to 19.0 ± 3.6% (p < 0.02); meanwhile, the mean %S1 and NA decreased from 27.7 ± 21.2% to 15.3 ± 7.6% (p < 0.01) and 184.7 ± 108.4 to

In this study, we divided airway space into retropalatal and retroglossal spaces: SPAS and MAS corresponded to retropalatal, while IAS corresponded to retroglossal. We found an increase in anteroposterior dimension and cross-sectional area of both the retropalatal and retroglossal spaces following MMA and GA, consistent

The retropalatal space is influenced by the position of the maxilla, soft palate, and tonsils, while the retroglossal space is influenced by the mandibular position and glossal shape and position [11–13]. The soft palate is comprised of the musculus uvulae, tensor veli palatini, levator veli palatini, and palatoglossus. The former three muscles are attached to the maxilla, while the latter is attached to the mandible. The genioglossus and geniohyoid muscles are attached to the mental spine and hyoid bone [14]. Airway enlargement is primarily caused by elevation of the tissues attached to the jaw and hyoid bone. Therefore, the most effective surgical approach

Surgical success of MMA is defined as an AHI with less than 20 events/hour or an AHI showing a greater than 50% reduction after surgery. Meanwhile, surgical cure is defined as an AHI with less than five events/hour following surgery [15]. In this study, all patients were in the surgical success category, and 50% of

The ODI and %SpO2 < 90% both decreased, while the lowest SpO2 increased; these results are consistent with previous reports [16]. These findings indicate that although achieving complete cure is difficult, MMA remains an effective method for treating sleep-disordered breathing. Furthermore, improvements in the lowest SpO2 and %SpO2 < 90% levels prevent the development of oxygen-desaturationrelated diseases. A number of previous studies demonstrated that hypoxia-induced oxidative stress, sympathetic activation, and inflammatory responses increase the long-term risk of multiple comorbidities, including hypertension, heart attack,

The sleep architecture was also altered after MMA. There is currently no consensus on how "better sleep" should be quantitatively and qualitatively defined [9]. However, some researchers have suggested that decreased SE, TST, and percentage of slow-wave sleep (SWS) of TST (%SWS) and increased WASO are indicators of poor sleep quality [23–25]. Others believe that improved sleep quality is reflected by the increases in %REM and %SWS, based on prior CPAP treatment data [26]. Our study did not find any decrease in WASO. However, TST and %REM were both increased, while %S1 and NA both decreased. Furthermore, there is no significant difference, but SWS tends to increase. Based on these results, it appears that both

OSA interrupts the normal sleep cycle: REM sleep disappears or becomes irregular, while SWS disappears. In our study, some subjects exhibited a REM pattern similar to that of healthy subjects, while in others no therapeutic effect of MMA was observed, despite sufficient airway expansion. Given the small number of subjects

**128**

MMA and GA can increase the anteroposterior dimension, cross-sectional area, and volume of the retropalatal and retroglossal spaces, consistent with previous studies.

MMA and GA may be able to improve not only sleep respiratory disturbance but also improve sleep quality.

### **Acknowledgements**

This study was supported by the Sato Fund, Nihon University School of Dentistry; a grant from the Dental Research Center, Nihon University School of Dentistry; and the Uemura Fund, Nihon University School of Dentistry.

Data herein have been previously applied to Nichidai Shigaku (in Japanese) by Ryota Nakamura.

#### **Conflict of interest**

The authors declare no conflict of interest.

## **Ethical approval**

This study was performed with the approval of the Ethics Committee of Nihon University School of Dentistry.

#### **Informed consent**

Informed consent was obtained from all individual participants included in the study.

## **Author details**

Takako Sato1 \*, Ryota Nakamura1 , Akio Himejima1 , Akemi Kusano1 , Serim Kang1 , Saori Ohtani1 , Kentarou Yamada1 , Kanako Yamagata1 , Hiroaki Azaki1 , Junya Aoki1 , Keiichi Yanagawa1 , Keiji Shinozuka1 , Takeya Yamada2 and Morio Tonogi1

1 Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, Tokyo, Japan

2 Hikone Municipal Hospital, Hikone, Japan

\*Address all correspondence to: sato.takako@nihon-u.ac.jp

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[7] Tsai WH, Remmers JE, Brant R, Flemons WW, Davies J, Macarthur C. A decision rule for diagnostic testing in obstructive sleep apnea. American Journal of Respiratory and Critical Care

Medicine. 2003;**167**:1427-1432

[8] Riley RW, Powell N, Guilleminault C. Current surgical concepts for treating

**References**

*The Effects of Maxillomandibular Advancement and Genioglossus Advancement on Sleep Quality DOI: http://dx.doi.org/10.5772/intechopen.89296*

## **References**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

**130**

**Author details**

Keiichi Yanagawa1

Dentistry, Tokyo, Japan

\*, Ryota Nakamura1

2 Hikone Municipal Hospital, Hikone, Japan

provided the original work is properly cited.

, Kentarou Yamada1

, Keiji Shinozuka1

\*Address all correspondence to: sato.takako@nihon-u.ac.jp

, Akio Himejima1

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Department of Oral and Maxillofacial Surgery, Nihon University School of

, Kanako Yamagata1

, Takeya Yamada2

, Akemi Kusano1

, Hiroaki Azaki1

and Morio Tonogi1

, Serim Kang1

, Junya Aoki1

,

,

Takako Sato1

Saori Ohtani1

[1] Yagi H, Nakata S, Tsuge H, Yasuma F, Noda A, Morinaga M, et al. Morphological examination of upper airway in obstructive sleep apnea. Auris Nasus Larynx. 2009;**36**:444-449

[2] Hudgel DW, Hendricks C. Palate and hypopharynx—Sites of inspiratory narrowing of the upper airway during sleep. The American Review of Respiratory Disease. 1988;**138**:1542-1547

[3] Trudo FJ, Gefter WB, Welch KC, Gupta KB, Maislin G, Schwab RJ. Staterelated changes in upper airway caliber and surrounding soft-tissue structures in normal subjects. American Journal of Respiratory and Critical Care Medicine. 1998;**158**:1259-1270

[4] Zonato AI, Bittencourt LR, Martinho FL, Junior JF, Gregorio LC, Tufik S. Association of systematic head and neck physical examination with severity of obstructive sleep apnea– hypopnea syndrome. Laryngoscope. 2003;**113**:973-980

[5] Schellenberg JB, Maislin G, Schwab RJ. Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures. American Journal of Respiratory and Critical Care Medicine. 2000;**162**:740-748

[6] Petrou-Amerikanou C, Belazi MA, Daskalopoulou E, Vlachoyiannis E, Daniilidou NV, Papanayiotou PC. Oral findings in patients with obstructive sleep apnea syndrome. Quintessence International. 2005;**36**:293-298

[7] Tsai WH, Remmers JE, Brant R, Flemons WW, Davies J, Macarthur C. A decision rule for diagnostic testing in obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine. 2003;**167**:1427-1432

[8] Riley RW, Powell N, Guilleminault C. Current surgical concepts for treating

obstructive sleep apnea syndrome. Journal of Oral and Maxillofacial Surgery. 1987;**45**:149-157

[9] Liu SY-C, Huon L-K, Ruoff C, Riley RW, Strohl KP, Peng Z. Restoration of sleep architecture after maxillomandibular advancement: Pp beyond the apnea –hypopnea index. International Journal of Oral and Maxillofacial Surgery. 2017;**46**:1533-1538

[10] Furuhashi A, Yamada S, Shiomi T, Sasanabe R, Aoki Y, Yamada Y, et al. Effective three-dimensional evaluation analysis of upper airway form during oral appliance therapy in patients with obstructive sleep apnoea. Journal of Oral Rehabilitation. 2013;**40**:582-589

[11] Schendel SA, Broujerdi JA, Jacobson RL. Three-dimensional upperairway changes with maxillomandibular advancement for obstructive sleep apnea treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 2014;**146**(3):385-393

[12] Powell NB, Mihaescu M, Mylavarapu G, Weaver EM, Guilleminault C, Gutmark E. Patterns in pharyngeal airflow associated with sleep-disordered breathing. Sleep Medicine. 2011;**12**:966-974

[13] Stephen S, Powell N, Jacobson R. Maxillary, mandibular, and chin advancement: Treatment planning based on airway anatomy in obstructive sleep apnea. Journal of Oral and Maxillofacial Surgery. 2011;**69**:663-676

[14] Okushi T, Tonogi M, Arisaka T, Kobayashi S, Tsukamoto Y, Morishita H, et al. Effect of maxillomandibular advancement on morphology of velopharyngeal space. Journal of Oral and Maxillofacial Surgery. 2011;**69**:877-884

[15] Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;**19**:156-177

[16] Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: A systematic review and metaanalysis. Sleep Medicine Reviews. 2010;**14**:287-297

[17] Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: A systematic review of the literature. Journal of Clinical Sleep Medicine. 2012;**8**:199-207

[18] Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. The New England Journal of Medicine. 2000;**342**:1378-1384

[19] Tasali E, Mokhlesi B, Van Cauter E. Obstructive sleep apnea and type 2 diabetes: Interacting epidemics. Chest. 2008;**133**:496-506

[20] Sharma B, Owens R, Malhotra A. Sleep in congestive heart failure. The Medical Clinics of North America. 2010;**94**:447-464

[21] Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. The New England Journal of Medicine. 2005;**353**:2034-2041

[22] Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet. 2005;**365**:1046-1053

[23] Means MK, Edinger JD, Glenn DM, Fins AI. Accuracy of sleep perceptions

among insomnia sufferers and normal sleepers. Sleep Medicine. 2003;**4**:285-296

[24] Coaters TJ, Killen JD, George J, Marchini E, Silverman S, Thoresen C. Estimating sleep parameters: A multitrait-multimethod analysis. Journal of Consulting and Clinical Psychology. 1982;**50**:345-352

[25] Perlis ML, Smith MT, Andrews PJ, Orff H, Giles DE. Beta/gamma EEG activity in patients with primary and secondary insomnia. Journal of Psychosomatic Research. 2009;**66**:59-65

[26] Riley RW, Powell NB, Guilleminault C. Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome. Chest. 1990;**98**:1421-1425

[27] Eckert DJ, Owens RL, Kehlmann GB, Wellman A, Rahangdale S, Yim-Yeh S, et al. Eszopiclone increases the respiratory arousal threshold and lowers the apnoea/hypopnoea index in obstructive sleep apnoea patients with a low arousal threshold. Clinical Science (London). 2011;**120**:505-514

[28] Heinzer RC, White DP, Jordan AS, Lo YL, Dover L, Stevenson K, et al. Trazodone increases arousal threshold in obstructive sleep apnea. The European Respiratory Journal. 2008;**31**:1308-1312

[29] Wellman A, Malhotra A, Jordan AS, Stevenson KE, Gautam S, White DP. Effect of oxygen in obstructive sleep apnea: Role of loop gain. Respiratory Physiology & Neurobiology. 2008;**162**:144-151

[30] Edwards BA, Sands SA, Eckert DJ, White DP, Butler JP, Owens RL, et al. Acetazolamide improves loop gain but not the other physiological traits causing obstructive sleep apnoea. The Journal of Physiology. 2012;**590**:1199-1211

**133**

**Chapter 10**

*Türker Yücesoy*

**Abstract**

psychiatry

**1.1 History**

**1. Description**

Body Dysmorphic Disorder in

Oral and Maxillofacial Surgery

Body dysmorphic disorder (BDD) may be related to the appearance of a body part or may sometimes arise from concerns about a body function. Currently, this disorder was included in contemporary classification systems with DSM-5. The majority of BDD patients first consult dermatologists, surgeons, and more often plastic surgeons, rather than psychiatrists. Therefore, it is difficult to determine the prevalence of this disorder in the psychiatric society. The oral and maxillofacial region is highly associated with face deformities, and the patients with BDD are applying to those clinics even without self-awareness of their disorders. It has been reported that most of the orthognathic surgical patients are associated with the facial appearance of surgical motivations and will have similar psychological motivations to cosmetic surgery patients. Moreover, the orthodontics, prosthetic and restorative dentistry are the branches of dentistry that mostly the patients come with esthetic complaints. Studies on BDD have not yet received the value they deserve concerning the prevalence and severity. Researches in dentistry and oral and maxillofacial surgery are much less, and the individuals suffering from BDD are not well-known among dentists/oral and maxillofacial surgeons; therefore, the frequency of BDD patients is not noticed and treated properly.

**Keywords:** body dysmorphic disorder, maxillofacial surgery, esthetics, dentistry,

Most people are not completely satisfied with their appearance. But some individuals are very concerned about a slight or imaginary flaw in their appearance. These individuals could have a "problem" not only physically but also psychiatrically.

Body dysmorphic disorder (BDD) is a condition not only in which a person overestimates and exaggerates a body defect but also one may believe in the existence even if there is not a body defect. This engagement can lead to significant unrest or impaired functionality. BDD is a severe illness and relatively common which often presents to both mental health professionals and nonpsychiatric physicians [1].

The disorder was defined as "compulsive neurosis" in the first place. After, it was called "obsession with shame of the body" and "dysmorphophobia," respectively. Dysmorphophobia is preferred to explain the sudden emergence and continuation of the idea of a deformity; it is defined as an individual's fear of the occurrence of

this deformity and feeling the anxiety of this awareness considerably [2].

## **Chapter 10**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

among insomnia sufferers and normal sleepers. Sleep Medicine.

George J, Marchini E, Silverman S, Thoresen C. Estimating sleep parameters: A multitrait-multimethod analysis. Journal of Consulting and Clinical Psychology. 1982;**50**:345-352

[25] Perlis ML, Smith MT, Andrews PJ, Orff H, Giles DE. Beta/gamma EEG activity in patients with primary and secondary insomnia. Journal of Psychosomatic Research.

Guilleminault C. Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome. Chest. 1990;**98**:1421-1425

[27] Eckert DJ, Owens RL, Kehlmann GB, Wellman A, Rahangdale S, Yim-Yeh S, et al. Eszopiclone increases the respiratory arousal threshold and lowers the apnoea/hypopnoea index in obstructive sleep apnoea patients with a low arousal threshold. Clinical Science

[28] Heinzer RC, White DP, Jordan AS, Lo YL, Dover L, Stevenson K, et al. Trazodone increases arousal threshold in obstructive sleep apnea. The European Respiratory Journal.

(London). 2011;**120**:505-514

[29] Wellman A, Malhotra A,

Jordan AS, Stevenson KE, Gautam S, White DP. Effect of oxygen in obstructive sleep apnea: Role of loop gain. Respiratory Physiology & Neurobiology. 2008;**162**:144-151

[30] Edwards BA, Sands SA, Eckert DJ, White DP, Butler JP, Owens RL, et al. Acetazolamide improves loop gain but not the other physiological traits causing obstructive sleep apnoea. The Journal of

Physiology. 2012;**590**:1199-1211

2008;**31**:1308-1312

[24] Coaters TJ, Killen JD,

2003;**4**:285-296

2009;**66**:59-65

[26] Riley RW, Powell NB,

[15] Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;**19**:156-177

[16] Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: A systematic review and metaanalysis. Sleep Medicine Reviews.

[17] Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: A systematic review of the literature. Journal of Clinical Sleep Medicine.

[18] Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. The New England Journal of Medicine.

[19] Tasali E, Mokhlesi B, Van Cauter E. Obstructive sleep apnea and type 2 diabetes: Interacting epidemics. Chest.

[20] Sharma B, Owens R, Malhotra A. Sleep in congestive heart failure. The Medical Clinics of North America.

[21] Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. The New England Journal of Medicine.

[22] Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet. 2005;**365**:1046-1053

[23] Means MK, Edinger JD, Glenn DM, Fins AI. Accuracy of sleep perceptions

2010;**14**:287-297

2012;**8**:199-207

2000;**342**:1378-1384

2008;**133**:496-506

2010;**94**:447-464

2005;**353**:2034-2041

**132**

## Body Dysmorphic Disorder in Oral and Maxillofacial Surgery

*Türker Yücesoy*

## **Abstract**

Body dysmorphic disorder (BDD) may be related to the appearance of a body part or may sometimes arise from concerns about a body function. Currently, this disorder was included in contemporary classification systems with DSM-5. The majority of BDD patients first consult dermatologists, surgeons, and more often plastic surgeons, rather than psychiatrists. Therefore, it is difficult to determine the prevalence of this disorder in the psychiatric society. The oral and maxillofacial region is highly associated with face deformities, and the patients with BDD are applying to those clinics even without self-awareness of their disorders. It has been reported that most of the orthognathic surgical patients are associated with the facial appearance of surgical motivations and will have similar psychological motivations to cosmetic surgery patients. Moreover, the orthodontics, prosthetic and restorative dentistry are the branches of dentistry that mostly the patients come with esthetic complaints. Studies on BDD have not yet received the value they deserve concerning the prevalence and severity. Researches in dentistry and oral and maxillofacial surgery are much less, and the individuals suffering from BDD are not well-known among dentists/oral and maxillofacial surgeons; therefore, the frequency of BDD patients is not noticed and treated properly.

**Keywords:** body dysmorphic disorder, maxillofacial surgery, esthetics, dentistry, psychiatry

### **1. Description**

Most people are not completely satisfied with their appearance. But some individuals are very concerned about a slight or imaginary flaw in their appearance. These individuals could have a "problem" not only physically but also psychiatrically.

Body dysmorphic disorder (BDD) is a condition not only in which a person overestimates and exaggerates a body defect but also one may believe in the existence even if there is not a body defect. This engagement can lead to significant unrest or impaired functionality. BDD is a severe illness and relatively common which often presents to both mental health professionals and nonpsychiatric physicians [1].

#### **1.1 History**

The disorder was defined as "compulsive neurosis" in the first place. After, it was called "obsession with shame of the body" and "dysmorphophobia," respectively. Dysmorphophobia is preferred to explain the sudden emergence and continuation of the idea of a deformity; it is defined as an individual's fear of the occurrence of this deformity and feeling the anxiety of this awareness considerably [2].

Body dysmorphic disorder was first shown in the DSM-IV in 1980 and described as an atypical somatoform disorder [3]. The American Psychiatric Association (APA) classified this "problem" as a distinct somatoform disorder in 1987, and since then it has gained popularity in the media and in clinical researches [4]. Currently, BDD is included in contemporary classification systems with DSM-5 (the *Diagnostic and Statistical Manual of Mental Disorders, 5th Edition*), the classification system of the APA [5].

## **1.2 Diagnosis**

The changes between DSM 4 and DSM 5 criteria for diagnosing BDD are shown in **Figure 1**. On the other hand, many tests have been established to diagnose BDD or measure its severity. However, some tests are performed more frequently for specific reasons, such as easy application and providing more effective results, for example, the Body Image Disturbance Questionnaire (BIDQ ) [6], Yale-Brown Obsessive–Compulsive Scale Modified for BDD (BDD-YBOCS) and Body Dysmorphic Disorder Questionnaire (BDDQ ) [7], the Cosmetic Procedure Screening (COPS) questionnaire [8], the Appearance Anxiety Inventory (AAI) [9], BDD Dimensional Scale (BDD-D) [10], the Body Image Disturbance Questionnaire (BIQLI) [11], and the Dysmorphic Concern Questionnaire (DCQ ) [12].

## **1.3 Epidemiology**

BDD is a relatively common disorder. Despite its prevalence and severity, the diagnosis can be missed in clinical settings [13]. The majority of BDD patients first consult dermatologists, internists, surgeons, and more often plastic surgeons, rather than psychiatrists. Therefore, it is difficult to determine the prevalence of this disorder in the psychiatric society. Although the studies in the general population range from 0.7 to 5.3% [14–18], clinical studies reveal higher rates: 8.8 to 12% [19, 20] among dermatology patients; 7% in cosmetic surgery patients [21]; 14–42% in patients with atypical major depression [22–24]; 11–13% in patients with social anxiety [25, 26]; 8–37% in patients with obsessive–compulsive disorder [26–28]; and 39% in patients with anorexia nervosa [29].


**135**

*Body Dysmorphic Disorder in Oral and Maxillofacial Surgery*

ages of 15 and 20, with an average age of 16–18 [31].

suicidal tendencies and especially poor quality of life [35].

Despite the presence of BDD cases beginning in adulthood or childhood, symptoms often begin in adolescence or young adulthood [30]. In particular, men and young people do not want to report their complaints because of humiliation and embarrassment or do not see them as a mental problem. Although the age of onset goes down to 6 years, in many studies the age of onset is reported to be between the

The main cognitive feature of BDD is the belief that extreme anxiety and imagined defect represent a personal disability. One's quality of life can vary considerably. Many people can at least limit their social functions and resort to avoidance in order to prevent their imperfections from appearing fully in the public sphere. These avoidance strategies may include camouflage by wearing makeup or concealed clothing. Some individuals may never leave the house. Phillips et al. reported that men with BDD had a higher rate of single or single living than women, whereas another study found that 30% of BDD patients were individuals who could not leave their homes at least 1 week before the study [32, 33]. Other compulsive behaviors are to examine, heal, or conceal the perceived defects and include excessive mirror control, excessive care, styling hair, camouflaging the defect, comparing oneself with others, picking skin, and trying to convince the ugliness of the defect to others [34]. Therefore, psychosocial functioning of BDD is associated with

Although BDD was classified as a somatoform disorder in DSM-IV, it is currently accepted as a disorder of the obsessive–compulsive spectrum disorders (OCSD) group because of its overlapping aspects with OCSD in DSM-V. However, it is frequently emphasized that BDD not only is a clinical variant of OCSD but is

also associated with mood disorders, social anxiety disorders, and eating

The main clinical features of BDD are disproportionately dealing with an imaginary or mild physical defect, which leads to significant clinical distress or a significant loss of functionality in work, private, and social life. It is known that most patients with BDD do not consult with psychiatrists and apply to nonpsychiatric physicians, such as esthetic surgeons, to eliminate the perceived physical defects. Sixty eight to ninety-eight percent of BDD patients experience concerns about

BDD may be related to the appearance of a body part or may sometimes arise from concerns about a body function. Sweating and related thoughts about the secretion of bad odor can be given as an example. Concerns of BDD cases become more apparent in social settings. Avoidance behaviors such as being unable to go out of the house or going out in the dark only, not being able to enter social environments due to concerns, and leaving school or work are common symptoms. Most of the patients believe that their physical defects are seen and noticed by others, and therefore they look at the mirror in excessive levels or try to stay away from the objects that reflect the mirror image as much as possible, make use of makeup material, and make dress changes in order to hide the areas that they

*DOI: http://dx.doi.org/10.5772/intechopen.90541*

**1.4 Quality of life and functionality**

**1.5 Classification**

disorders [36].

**1.6 Clinical symptoms**

multiple body regions [32, 37].

believe to be defective.

### **Figure 1.**

*DSM-IV to DSM-V body dysmorphic disorder comparison.*

Despite the presence of BDD cases beginning in adulthood or childhood, symptoms often begin in adolescence or young adulthood [30]. In particular, men and young people do not want to report their complaints because of humiliation and embarrassment or do not see them as a mental problem. Although the age of onset goes down to 6 years, in many studies the age of onset is reported to be between the ages of 15 and 20, with an average age of 16–18 [31].

## **1.4 Quality of life and functionality**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

the APA [5].

**1.2 Diagnosis**

Questionnaire (DCQ ) [12].

and 39% in patients with anorexia nervosa [29].

*DSM-IV to DSM-V body dysmorphic disorder comparison.*

**1.3 Epidemiology**

Body dysmorphic disorder was first shown in the DSM-IV in 1980 and described as an atypical somatoform disorder [3]. The American Psychiatric Association (APA) classified this "problem" as a distinct somatoform disorder in 1987, and since then it has gained popularity in the media and in clinical researches [4]. Currently, BDD is included in contemporary classification systems with DSM-5 (the *Diagnostic and Statistical Manual of Mental Disorders, 5th Edition*), the classification system of

The changes between DSM 4 and DSM 5 criteria for diagnosing BDD are shown in **Figure 1**. On the other hand, many tests have been established to diagnose BDD or measure its severity. However, some tests are performed more frequently for specific reasons, such as easy application and providing more effective results, for example, the Body Image Disturbance Questionnaire (BIDQ ) [6], Yale-Brown Obsessive–Compulsive Scale Modified for BDD (BDD-YBOCS) and Body Dysmorphic Disorder Questionnaire (BDDQ ) [7], the Cosmetic Procedure Screening (COPS) questionnaire [8], the Appearance Anxiety Inventory (AAI) [9], BDD Dimensional Scale (BDD-D) [10], the Body Image Disturbance Questionnaire (BIQLI) [11], and the Dysmorphic Concern

BDD is a relatively common disorder. Despite its prevalence and severity, the diagnosis can be missed in clinical settings [13]. The majority of BDD patients first consult dermatologists, internists, surgeons, and more often plastic surgeons, rather than psychiatrists. Therefore, it is difficult to determine the prevalence of this disorder in the psychiatric society. Although the studies in the general population range from 0.7 to 5.3% [14–18], clinical studies reveal higher rates: 8.8 to 12% [19, 20] among dermatology patients; 7% in cosmetic surgery patients [21]; 14–42% in patients with atypical major depression [22–24]; 11–13% in patients with social anxiety [25, 26]; 8–37% in patients with obsessive–compulsive disorder [26–28];

**134**

**Figure 1.**

The main cognitive feature of BDD is the belief that extreme anxiety and imagined defect represent a personal disability. One's quality of life can vary considerably. Many people can at least limit their social functions and resort to avoidance in order to prevent their imperfections from appearing fully in the public sphere. These avoidance strategies may include camouflage by wearing makeup or concealed clothing. Some individuals may never leave the house. Phillips et al. reported that men with BDD had a higher rate of single or single living than women, whereas another study found that 30% of BDD patients were individuals who could not leave their homes at least 1 week before the study [32, 33]. Other compulsive behaviors are to examine, heal, or conceal the perceived defects and include excessive mirror control, excessive care, styling hair, camouflaging the defect, comparing oneself with others, picking skin, and trying to convince the ugliness of the defect to others [34]. Therefore, psychosocial functioning of BDD is associated with suicidal tendencies and especially poor quality of life [35].

## **1.5 Classification**

Although BDD was classified as a somatoform disorder in DSM-IV, it is currently accepted as a disorder of the obsessive–compulsive spectrum disorders (OCSD) group because of its overlapping aspects with OCSD in DSM-V. However, it is frequently emphasized that BDD not only is a clinical variant of OCSD but is also associated with mood disorders, social anxiety disorders, and eating disorders [36].

## **1.6 Clinical symptoms**

The main clinical features of BDD are disproportionately dealing with an imaginary or mild physical defect, which leads to significant clinical distress or a significant loss of functionality in work, private, and social life. It is known that most patients with BDD do not consult with psychiatrists and apply to nonpsychiatric physicians, such as esthetic surgeons, to eliminate the perceived physical defects. Sixty eight to ninety-eight percent of BDD patients experience concerns about multiple body regions [32, 37].

BDD may be related to the appearance of a body part or may sometimes arise from concerns about a body function. Sweating and related thoughts about the secretion of bad odor can be given as an example. Concerns of BDD cases become more apparent in social settings. Avoidance behaviors such as being unable to go out of the house or going out in the dark only, not being able to enter social environments due to concerns, and leaving school or work are common symptoms. Most of the patients believe that their physical defects are seen and noticed by others, and therefore they look at the mirror in excessive levels or try to stay away from the objects that reflect the mirror image as much as possible, make use of makeup material, and make dress changes in order to hide the areas that they believe to be defective.

## **1.7 Co-diagnosis**

The most common comorbid diagnoses in BDD are major depression, social phobia, drug addictions, and OCD [38]. Phillips et al. showed that the frequency of OCD was 37% among 100 cases [39], and similarly the incidence of OCD was found to be 39% of the study of 50 cases by Hollander et al. [37].

## **1.8 Differential diagnosis**

Because BDD and OCD have similar features in many respects, BDD is often accepted as an OCD [40–42]. However, poorer insight than OCD, higher suicide rates, and higher comorbidity of depression differentiate the two disorders [41, 43, 44]. A significant proportion of patients diagnosed with BDD show avoidance behaviors in social settings. This situation evokes the avoidance behaviors of social phobic patients [43]. Social phobia cases are comfortable as long as they stay away from crowded environments that cause anxiety for them.

Social phobia patients also know that their concerns are meaningless, but they cannot resist their anxiety. While individuals with BDD do not think their concerns are meaningless, staying away from social settings does not reduce the anxiety of such patients. Also, in social phobia, the reason for staying away from the social environment is not usually exaggerated physical defects [13, 35].

## **1.9 Treatment**

Many individuals with BDD resort to nonpsychiatric medical and surgical treatments to correct perceived defects in their physical appearance. Dermatological treatment is the most desirable and applied treatment (mostly acne agents). It is followed by surgical treatment, most commonly rhinoplasty. In a study in which 12% of subjects received isotretinoin, treatment rarely increased BDD. Therefore, nonpsychiatric medical treatments do not seem to be effective in the treatment of body dysmorphic disorder. Crerand et al. stated that individuals were also evaluated, and the results reported that individuals who refused psychiatric treatment did not observe any change and their condition worsened [45]. The somatic subtype of delusional disorder needs to be distinguished from BDD. The somatic subtype of delusional disorder provides more benefits than antipsychotic medication; BDD patients benefit from treatment with selective serotonin reuptake inhibitors (SSRIs) [38, 41]. The general opinion is that the use of high-dose SSRIs in BDD will be beneficial [46, 47]. The use of SSRI is considered to be the ideal treatment when the highest dose recommended by the manufacturer for 12 weeks or more is used. Daily fluvoxamine 150 mg, fluoxetine 40 mg, paroxetine 40 mg, sertraline 150 mg, citalopram 40 mg, and escitalopram 20 mg SSRI doses are considered as the minimum and adequate doses [48]. Any treatment of "defect" in patients with BDD is controversial. However, the general idea is that surgical treatments should be performed if only these individuals still need surgery after psychiatric treatment [49].

### **1.10 Translation of the scales and questionnaires**

Due to almost all the scales being prepared in English, the translation of those forms into other languages and validity and reliability studies should be performed, and it must be proven that it is equivalent to the original language. For example, the translation of the YBOCS-BDD scale into Brazilian Portuguese was performed among 93 selected rhinoplasty patients of both sexes. Also, the test–retest method was used for reliability at 1-week intervals, and statistical analysis was performed

**137**

**Figure 2.**

*Body Dysmorphic Disorder in Oral and Maxillofacial Surgery*

population of BDD, which is between 6 and 16% [60].

*Nonpsychiatric departments where body dysmorphic disorder patients generally apply to.*

using correlation coefficient and intraclass correlation coefficient (ICC) [50]. It has also been translated into Persian, German, French, and Italian, and these studies have shown significant results [51, 52]. In the German reliability and validity study of the BIDQ-S scale, which is a modification of the BIDQ scale for scoliosis patients,

The developed scales have been mentioned in many studies in the world, includ-

259 patients with idiopathic scoliosis were included in the study [53].

**2. Body dysmorphic disorder in oral and maxillofacial surgery**

ing esthetics such as dermatology, esthetic surgery, maxillofacial surgery, and orthodontics, and have been used to detect individuals with BDD (**Figure 2**). But the maxillofacial region is highly associated with face deformities, and the patients with BDD are applying to those clinics even without self-awareness of their disorders. Particularly, orthognathic surgery, also known as corrective jaw surgery, is considered functional surgery in the treatment of maxillomandibular dysfunction. However, the correction of maxillomandibular deformity creates highly esthetic and satisfactory results. In the studies in the literature, it has been reported that 52–74% of orthognathic surgical patients are associated with the facial appearance of surgical motivations and will have similar psychological motivations to cosmetic surgery patients. After this type of surgery, satisfaction with the outcome is as high as 92%, resulting in improved quality of life [54–56]. In a small number of patients (<10%) who are not satisfied with the surgical outcome, the underlying cause may be a psychological condition experienced by the individual rather than a failed surgical procedure. The underlying psychological condition may be BDD, which is believed to be increased in patients seeking orthognathic surgery [56]. It was found that 10% of orthognathic surgery patients met significantly higher BDD criteria than reported rates (between 0.7 and 4.0%) in the general adult population [15, 57–59]. This rate is similar to the prevalence of cosmetic surgery and dermatology patient

*DOI: http://dx.doi.org/10.5772/intechopen.90541*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

to be 39% of the study of 50 cases by Hollander et al. [37].

from crowded environments that cause anxiety for them.

environment is not usually exaggerated physical defects [13, 35].

only these individuals still need surgery after psychiatric treatment [49].

Due to almost all the scales being prepared in English, the translation of those forms into other languages and validity and reliability studies should be performed, and it must be proven that it is equivalent to the original language. For example, the translation of the YBOCS-BDD scale into Brazilian Portuguese was performed among 93 selected rhinoplasty patients of both sexes. Also, the test–retest method was used for reliability at 1-week intervals, and statistical analysis was performed

**1.10 Translation of the scales and questionnaires**

The most common comorbid diagnoses in BDD are major depression, social phobia, drug addictions, and OCD [38]. Phillips et al. showed that the frequency of OCD was 37% among 100 cases [39], and similarly the incidence of OCD was found

Because BDD and OCD have similar features in many respects, BDD is often accepted as an OCD [40–42]. However, poorer insight than OCD, higher suicide rates, and higher comorbidity of depression differentiate the two disorders [41, 43, 44]. A significant proportion of patients diagnosed with BDD show avoidance behaviors in social settings. This situation evokes the avoidance behaviors of social phobic patients [43]. Social phobia cases are comfortable as long as they stay away

Social phobia patients also know that their concerns are meaningless, but they cannot resist their anxiety. While individuals with BDD do not think their concerns are meaningless, staying away from social settings does not reduce the anxiety of such patients. Also, in social phobia, the reason for staying away from the social

Many individuals with BDD resort to nonpsychiatric medical and surgical treatments to correct perceived defects in their physical appearance. Dermatological treatment is the most desirable and applied treatment (mostly acne agents). It is followed by surgical treatment, most commonly rhinoplasty. In a study in which 12% of subjects received isotretinoin, treatment rarely increased BDD. Therefore, nonpsychiatric medical treatments do not seem to be effective in the treatment of body dysmorphic disorder. Crerand et al. stated that individuals were also evaluated, and the results reported that individuals who refused psychiatric treatment did not observe any change and their condition worsened [45]. The somatic subtype of delusional disorder needs to be distinguished from BDD. The somatic subtype of delusional disorder provides more benefits than antipsychotic medication; BDD patients benefit from treatment with selective serotonin reuptake inhibitors (SSRIs) [38, 41]. The general opinion is that the use of high-dose SSRIs in BDD will be beneficial [46, 47]. The use of SSRI is considered to be the ideal treatment when the highest dose recommended by the manufacturer for 12 weeks or more is used. Daily fluvoxamine 150 mg, fluoxetine 40 mg, paroxetine 40 mg, sertraline 150 mg, citalopram 40 mg, and escitalopram 20 mg SSRI doses are considered as the minimum and adequate doses [48]. Any treatment of "defect" in patients with BDD is controversial. However, the general idea is that surgical treatments should be performed if

**1.7 Co-diagnosis**

**1.9 Treatment**

**1.8 Differential diagnosis**

**136**

using correlation coefficient and intraclass correlation coefficient (ICC) [50]. It has also been translated into Persian, German, French, and Italian, and these studies have shown significant results [51, 52]. In the German reliability and validity study of the BIDQ-S scale, which is a modification of the BIDQ scale for scoliosis patients, 259 patients with idiopathic scoliosis were included in the study [53].

## **2. Body dysmorphic disorder in oral and maxillofacial surgery**

The developed scales have been mentioned in many studies in the world, including esthetics such as dermatology, esthetic surgery, maxillofacial surgery, and orthodontics, and have been used to detect individuals with BDD (**Figure 2**). But the maxillofacial region is highly associated with face deformities, and the patients with BDD are applying to those clinics even without self-awareness of their disorders. Particularly, orthognathic surgery, also known as corrective jaw surgery, is considered functional surgery in the treatment of maxillomandibular dysfunction. However, the correction of maxillomandibular deformity creates highly esthetic and satisfactory results. In the studies in the literature, it has been reported that 52–74% of orthognathic surgical patients are associated with the facial appearance of surgical motivations and will have similar psychological motivations to cosmetic surgery patients. After this type of surgery, satisfaction with the outcome is as high as 92%, resulting in improved quality of life [54–56]. In a small number of patients (<10%) who are not satisfied with the surgical outcome, the underlying cause may be a psychological condition experienced by the individual rather than a failed surgical procedure. The underlying psychological condition may be BDD, which is believed to be increased in patients seeking orthognathic surgery [56]. It was found that 10% of orthognathic surgery patients met significantly higher BDD criteria than reported rates (between 0.7 and 4.0%) in the general adult population [15, 57–59]. This rate is similar to the prevalence of cosmetic surgery and dermatology patient population of BDD, which is between 6 and 16% [60].

**Figure 2.** *Nonpsychiatric departments where body dysmorphic disorder patients generally apply to.*

Although researches on BDD and dental treatment are relatively rare, published case reports showed the BDD patients involved in general dentistry and maxillofacial surgery. Some authors applied a questionnaire to 40 adult patients who participated in orthodontic treatment and estimated the prevalence of BDD to be 7.5%, suggesting that individuals with BDD had a high demand for orthodontic treatment [34]. De Jongh et al. reported the frequency of occupation of individuals with a defect in their appearance and stated that the rate of whitening and orthodontic treatment of those who reported that they were engaged in such defect was nine times higher [60]. These studies have shown that clinicians working in esthetic dentistry are likely to be visited by BDD patients and therefore need to be aware of the condition of such patients and to know how to evaluate and manage patients suspected of having BDD [49].

In addition to areas such as plastic surgery and dermatology, another important part where the patient comes with esthetic complaints is dentistry. Maxillofacial surgery, orthodontics, prosthetic, and restorative dental treatment, which is a branch of dentistry, are among the important parts that patients come with esthetic complaints. The inability to detect individuals with possible BDD in these departments and to try to eliminate the esthetic complaint before the treatment of psychiatric disorder adversely affects the success of the treatment.

Eventually, all of those studies show that the prevalence of BDD among dentist individuals is much more severe than the general population. Moreover, the incidence of BDD patients among individuals who apply to clinics is unknown. To increase the success rate of the treatment by increasing the satisfaction rate obtained as a result of the esthetic treatments, further studies should be planned to identify the individuals with BDD. The importance of informing the patients preoperatively in dentistry/maxillofacial surgery must be well-known. The studies should aim to increase the frequency of application of the tests for BDD in dentistry to determine the real epidemiology of this disease among this field.

## **3. Conclusion**


**139**

**Author details**

Türker Yücesoy

Vakif University, Istanbul, Turkey

provided the original work is properly cited.

\*Address all correspondence to: dt.yucesoy@hotmail.com

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Body Dysmorphic Disorder in Oral and Maxillofacial Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.90541*

## **Conflict of interest**

None.

*Body Dysmorphic Disorder in Oral and Maxillofacial Surgery DOI: http://dx.doi.org/10.5772/intechopen.90541*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

atric disorder adversely affects the success of the treatment.

to determine the real epidemiology of this disease among this field.

surgery that provide esthetic treatment to a large extent.

ing the prevalence and severity of the disease.

BDD patients is not noticed.

**Conflict of interest**

None.

suspected of having BDD [49].

**3. Conclusion**

logical disorder.

Although researches on BDD and dental treatment are relatively rare, published

In addition to areas such as plastic surgery and dermatology, another important part where the patient comes with esthetic complaints is dentistry. Maxillofacial surgery, orthodontics, prosthetic, and restorative dental treatment, which is a branch of dentistry, are among the important parts that patients come with esthetic complaints. The inability to detect individuals with possible BDD in these departments and to try to eliminate the esthetic complaint before the treatment of psychi-

Eventually, all of those studies show that the prevalence of BDD among dentist individuals is much more severe than the general population. Moreover, the incidence of BDD patients among individuals who apply to clinics is unknown. To increase the success rate of the treatment by increasing the satisfaction rate obtained as a result of the esthetic treatments, further studies should be planned to identify the individuals with BDD. The importance of informing the patients preoperatively in dentistry/maxillofacial surgery must be well-known. The studies should aim to increase the frequency of application of the tests for BDD in dentistry

• The patients with BDD apply to all clinics to relieve their esthetic concerns which are the main complaint despite the lack of self-awareness of the psycho-

• These clinics may be dental, maxillofacial surgery, dermatology, and esthetic

• Worldwide research on BDD has not yet received the value it deserves concern-

• Researches in dentistry and oral and maxillofacial surgery are much less than in other departments. Individuals suffering from BDD are not well-known among dentists/oral and maxillofacial surgeons; therefore, the frequency of

case reports showed the BDD patients involved in general dentistry and maxillofacial surgery. Some authors applied a questionnaire to 40 adult patients who participated in orthodontic treatment and estimated the prevalence of BDD to be 7.5%, suggesting that individuals with BDD had a high demand for orthodontic treatment [34]. De Jongh et al. reported the frequency of occupation of individuals with a defect in their appearance and stated that the rate of whitening and orthodontic treatment of those who reported that they were engaged in such defect was nine times higher [60]. These studies have shown that clinicians working in esthetic dentistry are likely to be visited by BDD patients and therefore need to be aware of the condition of such patients and to know how to evaluate and manage patients

**138**

## **Author details**

Türker Yücesoy

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif University, Istanbul, Turkey

\*Address all correspondence to: dt.yucesoy@hotmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[18] Sarwer DB, Cash TF, Magee L, Williams EF, Thompson JK, Roehrig M, et al. Female college students and cosmetic surgery: An investigation of experiences, attitudes, and body image. Plastic and Reconstructive Surgery. 2005;**115**(3):931-938

[19] Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. Journal of the American Academy of Dermatology. 2000;**42**(3):436-441

[20] Uzun Ö, Başoğlu C, Akar A, Cansever A, Özşahin A, Çetin M, et al. Body dysmorphic disorder in patients with acne. Comprehensive Psychiatry. 2003;**44**(5):415-419

[21] Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plastic and Reconstructive Surgery. 1998;**101**(6):1644-1649

[22] Nierenberg AA, Phillips KA, Petersen TJ, Kelly KE, Alpert JE, Worthington JJ, et al. Body dysmorphic disorder in outpatients with major depression. Journal of Affective Disorders. 2002;**69**(1-3):141-148

[23] Perugi G, Akiskal H, Lattanzi L, Cecconi D, Mastrocinque C, Patronelli A, et al. The high prevalence of "soft" bipolar (II) features in atypical depression. Comprehensive Psychiatry. 1998;**39**(2):63-71

[24] Phillips KA, Nierenberg AA, Brendel G, Fava M. Prevalence and clinical features of body dysmorphic disorder in atypical major depression. The Journal of Nervous and Mental Disease. 1996;**184**(2):125-129

[25] Brawman-Mintzer O, Lydiard RB, Phillips KA, Morton A, Czepowicz V, Emmanuel N, et al. Body dysmorphic disorder in patients with anxiety disorders and major depression: A comorbidity study. The American Journal of Psychiatry. 1995;**152**(11):1665-1667. Available from: https://doi.org/10.1176/ajp.152.11.1665

[26] Wilhelm S, Otto MW, Zucker BG, Pollack MH. Prevalence of body dysmorphic disorder in patients with anxiety disorders. Journal of Anxiety Disorders. 1997;**11**(5):499-502

[27] Pigott TA, L'Heureux F, Dubbert B, Bernstein S, Murphy DL. Obsessive compulsive disorder: comorbid conditions. The Journal of Clinical Psychiatry. 1994;**55**:15-27. discussion 28-32

[28] Simeon D, Hollander E, Stein DJ, Cohen L, Aronowitz B. Body dysmorphic disorder in the DSM-IV field trial for obsessive-compulsive disorder. The American Journal of Psychiatry. 1995;**152**(8):1207-1209

[29] Grant JE, Kim SW, Eckert ED. Body dysmorphic disorder in patients with anorexia nervosa: Prevalence, clinical features, and delusionality of body image. International Journal of Eating Disorders. 2002;**32**(3):291-300

[30] Hollander E, Aronowitz BR. Comorbid social anxiety and body dysmorphic disorder: Managing the complicated patient. The Journal of Clinical Psychiatry. 1999;**60**:27-31

[31] Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder: A survey

**140**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

appearance anxiety inventory: Validation of a process measure in the treatment of body dysmorphic disorder. Behavioural and Cognitive Psychotherapy. 2014;**42**(5):605-616

[10] LeBeau RT, Mischel ER, Simpson HB, Mataix-Cols D,

Phillips KA, Stein DJ, et al. Preliminary assessment of obsessive–compulsive spectrum disorder scales for DSM-5. Journal of Obsessive-Compulsive and Related Disorders. 2013;**2**(2):114-118

[11] Hrabosky JI, Cash TF, Veale D, Neziroglu F, Soll EA, Garner DM, et al. Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: A multisite study.

Body Image. 2009;**6**(3):155-163

[12] Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic concern questionnaire: A screening measure for body dysmorphic disorder. The Australian and New Zealand Journal of

Psychiatry. 2010;**44**(6):535-542

Phillips KA. Body dysmorphic disorder. Dialogues in Clinical Neuroscience.

[15] Bohne A, Keuthen NJ, Wilhelm S, Deckersbach T, Jenike MA. Prevalence of symptoms of body dysmorphic disorder and its correlates: A crosscultural comparison. Psychosomatics.

[16] Cansever A, Uzun Ö, Dönmez E, Özşahin A. The prevalence and clinical

[13] Bjornsson AS, Didie ER,

[14] Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang K-Y, Cullen BA, et al. The relationship of obsessive–compulsive disorder to possible spectrum disorders: Results from a family study. Biological Psychiatry. 2000;**48**(4):287-293

2010;**12**(2):221

2002;**43**(6):486-490

[1] Phillips KA. The presentation of body dysmorphic disorder in medical settings. Primary Psychiatry.

[2] Fava GA. Morselli's Legacyi:

[3] Crerand CE, Franklin ME,

and cosmetic surgery. Plastic and Reconstructive Surgery. 2006;**118**(7):167e-180e

2008;**78**(2):217-224

2004;**1**(4):363-372

1997;**33**(1):17

[7] Phillips KA, Hollander E,

rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown obsessive compulsive scale. Psychopharmacology Bulletin.

[8] Veale D, Ellison N, Werner TG, Dodhia R, Serfaty M, Clarke A. Development of a cosmetic procedure screening questionnaire (COPS) for body dysmorphic disorder. Journal of Plastic, Reconstructive & Aesthetic

Surgery. 2012;**65**(4):530-532

[9] Veale D, Eshkevari E, Kanakam N, Ellison N, Costa A, Werner T. The

Rasmussen SA, Aronowitz BR. A severity

Dysmorphophobia. Psychotherapy and Psychosomatics. 1992;**58**(3-4):117-118

Sarwer DB. Body dysmorphic disorder

[4] Hunt TJ, Thienhaus O, Ellwood A. The mirror lies: Body dysmorphic disorder. American Family Physician.

[5] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). USA: American Psychiatric Publishing; 2013

[6] Cash TF, Phillips KA, Santos MT, Hrabosky JI. Measuring "negative body image": Validation of the body image disturbance questionnaire in a nonclinical population. Body Image.

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*Body Dysmorphic Disorder in Oral and Maxillofacial Surgery DOI: http://dx.doi.org/10.5772/intechopen.90541*

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*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

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**145**

**Chapter 11**

**Abstract**

prevalence rate of 25%.

**1. Introduction**

post-traumatic stress disorder

*and Kizito Chioma Ndukwe*

Psychosocial and Health-Related

Oral and Maxillofacial Trauma

*Ramat Oyebunmi Braimah, Dominic Ignatius Ukpong* 

Quality of Life (HRQoL) Aspect of

Psychosocial and health-related quality of life following oral and maxillofacial injuries is an often neglected aspect of patients' management. It has been noted that patients with maxillofacial trauma were more likely to be depressed, anxious with low self-esteem and poor health-related quality of life and possibility of post-traumatic stress disorder (PTSD). Depression and anxiety associated with facial trauma are often coupled with worries regarding recovery. Following trauma, there may be physical dysfunction especially facial disfigurement which may adversely affect the patients' ability to undertake daily activities and lower their mood and self-esteem leading to overall poor health-related quality of life. Focusing on these psychosocial factors, this chapter also elaborated on the immediate and long term effects of these factors if not incorporated into patient's care. In a study of 80 maxillofacial injured patients' in Sub-Saharan Africa using hospital anxiety and depression scale (HADS) questionnaire, the HADS detected 42 (52.5%) cases of depression and 56 (70.0%) cases of anxiety at baseline. Rosenberg's self-esteem questionnaire detected 33 (41.3%) patients with low self-esteem at baseline. WHO HRQoL-Bref questionnaire showed poor Quality of life in all the domains of the instrument with lowest in the physical and psychological domains. Similarly, the trauma screening questionnaire (TSQ ) for PTSD detected 19 patients had symptoms of PTSD at Time 1 with a

**Keywords:** anxiety, depression, injury, maxillofacial, self-esteem, quality of life,

Following maxillofacial trauma, the psychosomatic requirements of patients are distinctive and very important. Studies have shown that individuals with maxillofacial trauma often presents with signs of depression/sadness, worry/ anxiety and aggression/hostility over 1 year period after such traumatic conditions as compared to equaled control group [1]. Similarly, several authors have documented that 10–70% of maxillofacial trauma patients showed signs of sadness and worry [1]. Often, these patients have other psychosocial troubles such as joblessness, illiteracy and poor societal support [2]. Many times these symptoms are sub-threshold and might not meet the diagnostic benchmarks for a psychiatric

## **Chapter 11**
