Introduction
This study aimed to assess state-trait anxiety level changes in Chinese patients with dentofacial discrepancies before and after orthognathic surgery and to explore the feasibility of developing a reference index for the preoperative screening of postoperative patients with high anxiety.
Methods
A total of 96 Chinese patients with dentofacial discrepancies who underwent orthognathic surgery were included in this study. Data were collected before orthognathic surgery and at 2 weeks (T2), 3 months, and 6 months (T4) after surgery using the State-Trait Anxiety Inventory. Receiver operating characteristic and linear regression analyses were performed to screen for preoperative indicators of postoperative high-state anxiety.
Results
State-trait anxiety levels in patients with dentofacial discrepancies decreased after surgery ( F = 18.95, P <0.01; F = 6.90, P <0.01). Trait Anxiety Inventory can be used to screen patients with high-state anxiety from T2 to T4 (area under cover 95% confidence interval: T2, 0.74 [0.62-0.86]; 3 months, 0.79 [0.69-0.90]; T4, 0.77 [0.66-0.87], P <0.01), corresponding to cutoff values of 48.5, 46.5, and 45.5, respectively.
Conclusions
All participants’ state-trait anxiety levels improved after surgery compared with their preoperative levels. Preoperative trait anxiety levels can be used as a reference indicator to screen patients who may have high-state anxiety levels after orthognathic surgery. The creation of a screening scale will assist health care professionals to more pertinently help patients with high anxiety.
Highlights
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Preoperative trait anxiety level can predict postoperative state anxiety level.
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State-Trait Anxiety Inventory can be used for screening patients with high-state anxiety.
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Orthognathic surgery is associated with long-term psychological improvements.
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The trait anxiety level of patients may change after orthognathic surgery.
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State-trait anxiety levels decreased after orthognathic surgery.
Dentofacial deformities refer to significant deviations from the normal proportions of the maxillomandibular complex, which negatively affect the relationship of the teeth within each arch and the relationship of the arches with one another (occlusion). Some affected patients may exhibit varying degrees of compromise in head and neck functions related to breathing, swallowing, speech articulation, chewing, lip closure, or posture. In addition, the temporomandibular joint, the periodontium, and the teeth themselves may also be affected. This study considered the term “dentofacial discrepancies” to be more appropriate for characterizing the examined patients. This term was employed because their shared characteristic is a discernible distinction in maxillofacial appearance compared with a population with normal occlusion. Patients with these discrepancies often experience heightened social pressure because of esthetic concerns, resulting in higher anxiety and social anxiety levels than those of the general population. Orthognathic surgery is an important treatment for addressing such discrepancies. ,
However, not all patients undergoing orthognathic surgery exhibit amelioration of anxiety or depression after the procedure. Despite achieving a return to normal occlusion, some patients reported elevated levels of anxiety in the postoperative period. , This discontent stemmed from dissatisfaction with the esthetics of their teeth and jaws, impacting their overall quality of life. Possible reasons include surgery-induced body dysmorphic disorder, unrealistic motivation for treatment, and long-term dissatisfaction with appearance. , ,
Therefore, it is crucial to identify an appropriate reference indicator, such as trait anxiety, for the preoperative screening of patients with dentofacial discrepancies who may be at risk of experiencing high levels of postoperative anxiety. Neuroticism and external motivation are significant predictors of reduced satisfaction, and trait anxiety is a type of neuroticism. ,
This study aimed to verify the feasibility of using preoperative trait anxiety levels as a screening tool for patients with postoperative high anxiety. Particularly, it aimed to establish screening criteria for identifying patients predisposed to experiencing elevated state anxiety levels during the perioperative period. The importance of this study lies in its potential to facilitate the implementation of targeted interventions during the perioperative period in a screened population. This proactive approach aimed to reduce postoperative anxiety levels, enhance patient satisfaction, and mitigate health care consumption.
However, limited research has been conducted on trait anxiety, particularly in the orthognathic surgery context. Most studies in this field have predominantly assessed patients’ anxiety levels before and after a procedure.
According to Spielberger, anxiety can be divided into states and traits; state anxiety was defined as a conscious, subjective perception of uneasiness and tension that accompanies or co-occurs with a level of arousal or arousal induced by perception and the autonomic nervous system, which describes unpleasant emotional states, including nervousness, neuroticism, and apprehension. Conversely, trait anxiety was defined as a part of the personality, a motivational or acquired behavioral tendency that predisposes patients to perceive objective nonhazardous situations as threatening or to develop excessively intense state anxiety reactions to objectively dangerous situations. Thus, state anxiety reflects transient psychological and physiological reactions that are directly relevant in a given moment, with a short duration and poor stability, such as patients’ tendency to experience nervousness and sweaty palms when confronted with an examination, followed by the disappearance of the symptoms after the examination is concluded. In contrast, trait anxiety refers to a personality trait that describes patient differences associated with the tendency to present the current state of anxiety. It is a preemptive reaction to a dangerous situation with a long duration and a high degree of stability, such as the tendency to experience prolonged emotional apprehension and irritability, as patients exhibit when dealing with daily life events. Trait anxiety reflects patient differences in the frequency and intensity of past anxious states and predicts the likelihood of experiencing state anxiety in future circumstances. Notably, the stronger a patient’s trait anxiety, the more likely they are to experience heightened state anxiety in threatening situations.
The State-Trait Anxiety Inventory (STAI) is a well-known measure of state and trait anxiety. The State Anxiety Scale evaluates a patient’s perception of anxiety at any given time, whereas the Trait Anxiety Scale evaluates the severity of perceived daily anxiety. , The STAI is highly regarded because of its advantages, including high internal consistency and ease of application, scaling, and interpretation. In addition, it demonstrates sensitivity to various levels of anxiety.
The hypotheses of the study were as follows: (1) state anxiety levels of patients with dentofacial discrepancies are reduced after orthognathic surgery, and (2) preoperative trait anxiety levels can be used as a screening indicator, and an effective cutoff value can be determined to identify patients who are likely to experience a high-state anxiety level after orthognathic surgery.
Material and methods
Informed consent was obtained from the participants with dentofacial discrepancies who were admitted to Peking University School and Hospital of Stomatology for orthognathic surgery between September 2019 and March 2021. The inclusion criteria were as follows: (1) aged ≥18 years, (2) proposed bimaxillary orthognathic surgery, (3) junior high school education or above, and (4) completed preoperative orthodontics.
The exclusion criteria were as follows: (1) diagnosed psychiatric disorders or (2) cleft lip and palate, various syndromes with associated jaw discrepancies, or acquired secondary discrepancies.
This study was approved by the Biomedical Institutional Review Board (PKUSSIRB-201947096) of Peking University, School of Stomatology, China.
All eligible participants were required to complete the STAI at 4 key time points.
- 1.
At admission (T1): at this stage, anxiety primarily arises from the anticipation of the upcoming surgery, enabling better control of variables and minimizing the influence of other life events.
- 2.
Two weeks postoperative (T2): at this stage, the initial postoperative review was conducted; assessments are particularly advantageous because most patients can attend, contributing to a reduction in the lost visit rate. Because patients often experience facial swelling, pain, and lower oral function and have high expectations regarding facial appearance during this period, evaluating anxiety levels is crucial.
- 3.
Three months postoperatively (T3): at this stage, patients typically exhibit improved occlusal function with largely resolved facial swelling and pain. Consequently, patients’ primary concerns shift toward facial appearance. These sequential assessments provide a comprehensive understanding of the participants’ evolving psychological states during the different phases of the orthognathic surgery recovery process.
- 4.
Six months postoperatively (T4): at this stage, patients’ functional aspects and facial appearance typically achieve stability, as indicated by previous studies highlighting a steady psychological state in patients beyond 6 months after surgery. This period offers valuable insights into the prolonged and stable effects of orthognathic surgery on patients’ well-being ( Fig 1 ).
Fig 1
Flowchart of research procedures. OGS , orthognathic surgery; 2W , 2 weeks postoperative; 3M , 3 months postoperative; 6M , 6 months postoperative.
Informed consent was obtained from all participants, and comprehensive instructions on completing the questionnaire were provided. To optimize patient adherence and minimize bias, the researchers distributed the necessary scale to eligible patients and inquired about their postoperative recovery experiences. Patients were requested to complete the scale contemporaneously, ensuring real-time input and enhancing the data accuracy. All data were collected by the same researcher, and the patients were informed that their questionnaire responses would not be disclosed to their attending doctors, nor would they have any impact on their ongoing treatment.
Demographic and clinical characteristics were assessed at baseline. Participants provided basic demographic information such as age, sex, and educational level. Diagnoses of dentofacial discrepancies were also recorded.
The STAI, produced by Spielberger, was used in this study. The scale comprises 40 items:
- 1.
Items 1-20 comprise the State Anxiety Inventory (SAI), which assesses feelings at a specific time in the recent past, such as worry, nervousness, suspicion, or anticipated feelings in a specific or hypothetical situation that may be encountered in the future.
- 2.
Items 21-40 comprise the Trait Anxiety Inventory (TAI), which assesses a patient’s habitual anxiety level. The scale is a 4-point scale ranging from 1 (almost never) to 4 (always), with higher scores indicating higher levels of anxiety. Based on previous studies, a score exceeding 45 on the SAI scale is regarded as indicative of a high-state anxiety level, whereas a score exceeding 45 on the TAI scale signifies a high trait anxiety level.
The scores on the 2 scales were computed independently. , Cronbach’s α reliabilities for the state and trait anxiety subscales were 0.91 and 0.92, respectively. The 2-week test-retest reliabilities for the state and trait anxiety subscales were 0.76 and 0.91, respectively.
Sample size calculation was performed using the G∗ Power analysis software (version 3.1.9.7; Franz Faul University, Kiel, Germany), considering similar studies in the literature regarding sample sizes and measurement instruments. As a result of the power analysis, the minimum required sample size was 58 participants for an effect size of (f) 0.25, α = 0.05, and 1 – β = 0.9.
Statistical analyses
Descriptive statistics for the baseline characteristics and outcome measures at each time point were calculated. Repeated measures analysis of variance, t test, Pearson correlation analysis, receiver operating characteristic (ROC) analysis, and linear regression analyses were performed.
ROC analysis is a statistical method used to evaluate the diagnostic accuracy of tests or measurements. It is commonly used to determine the optimal cutoff value for a diagnostic test on the basis of its sensitivity and specificity. The horizontal coordinate of the ROC curve is the false positive rate, also expressed as 1-specificity, and the vertical coordinate is the true positive rate. This study defined a false positive rate as the probability that a normal anxiety level was misdiagnosed as a high-state anxiety level. Conversely, a true positive rate was defined as the probability that a high-state anxiety level was correctly determined. The area under the curve (AUC) was used to indicate the prediction accuracy; the higher the AUC value (the larger the AUC), the higher the prediction accuracy.
An α level of P <0.05 was applied for statistical significance tests. All statistical analyses were performed using SPSS software (version 26.0; IBM, Armonk, NY).
Results
A total of 96 patients with dentofacial discrepancies participated in the study (70 female and 26 male patients, resulting in a female-to-male ratio of 2.7:1.0). The participants were aged 18-42 years, with a mean of 26.02 ± 0.59 years ( Table I ).
| Variables | Mean ± standard deviation or n (%) |
|---|---|
| Age, y | |
| Mean ± SD | 26.02 ± 5.75 |
| Range | 18-42 |
| Sex | |
| Male | 26 (0.27) |
| Female | 70 (0.73) |
| Income † | |
| ≤2500 ‡ | 3 (0.03) |
| 2500-5500 | 30 (0.31) |
| >5500 § | 63 (0.66) |
| Bony classification | |
| Bony Class III (without asymmetry) | 34 (0.35) |
| Bony Class II (without asymmetry) | 22 (0.23) |
| Skewed discrepancies and facial asymmetry | 40 (0.42) |
| Educational level | |
| ≤ Senior high school | 1 (0.01) |
| Junior college | 12 (0.13) |
| Bachelor’s degree | 66 (0.69) |
| ≥ Master’s degree | 17 (0.18) |
| State anxiety level | |
| High-state anxiety group || | 59(0.61) |
| Normal group ¶ | 37(0.39) |
| Trait anxiety level | |
| High trait anxiety group # | 53 (0.55) |
| Normal group †† | 43 (0.45) |
† Monthly income is based on the 2020 China National Resident Income Standard Report.
‡ low-income group: a monthly per capita household income <2500 yuan.
§ High-income group: >5500 yuan.
|| high-state anxiety group: STAI scores >45.
¶ normal group: STAI scores ≤45.
# high trait anxiety group: TAI scores >45.
No significant differences were found among the groups, including bony classification when analyzing the different demographic characteristics ( P >0.05) ( Table II ).
| Classification | SAI | TAI | ||||||
|---|---|---|---|---|---|---|---|---|
| T1 | T2 | T3 | T4 | T1 | T2 | T3 | T4 | |
| Sex | ||||||||
| Male | 39.77 ± 10.86 | 37.23 ± 13.24 | 35.27 ± 11.67 | 34.19 ± 11.69 | 41.88 ± 9.46 | 41.5 ± 13.98 | 39.12 ± 9.86 | 37.62 ± 11.13 |
| Female | 40.81 ± 8.50 | 36.60 ± 8.77 | 35.39 ± 9.43 | 34.31 ± 9.68 | 42.69 ± 9.66 | 40.67 ± 7.70 | 39.56 ± 9.34 | 39.60 ± 10.04 |
| t value | −0.44 | 0.23 | −0.05 | −0.05 | −0.36 | 0.29 | −0.20 | −0.84 |
| P value | 0.66 | 0.82 | 0.96 | 0.96 | 0.72 | 0.78 | 0.84 | 0.41 |
| Educational level | ||||||||
| ≤ Junior college | 38.92 ± 8.40 | 36.46 ± 8.49 | 38.23 ± 10.80 | 35.69 ± 8.85 | 41.69 ± 9.19 | 42.23 ± 7.03 | 43.15 ± 8.79 | 40.00 ± 8.48 |
| Bachelor’s degree | 40.55 ± 9.19 | 37.68 ± 10.35 | 34.89 ± 10.00 | 34.77 ± 10.84 | 42.74 ± 9.62 | 41.39 ± 10.36 | 39.03 ± 9.82 | 38.94 ± 10.8 |
| ≥ Master’s degree | 41.71 ± 9.86 | 33.47 ± 10.09 | 34.94 ± 9.72 | 31.29 ± 8.33 | 42 ± 10.14 | 37.94 ± 8.76 | 38.18 ± 8.02 | 38.82 ± 10.22 |
| F value | 0.34 | 1.19 | 0.62 | 0.93 | 0.09 | 0.99 | 1.23 | 0.06 |
| P value | 0.72 | 0.31 | 0.54 | 0.40 | 0.92 | 0.37 | 0.30 | 0.94 |
| Age, y | ||||||||
| <25 | 40.70 ± 10.24 | 35.28 ± 9.10 | 34.35 ± 10.12 | 33.17 ± 9.94 | 41.93 ± 10.23 | 39.65 ± 10.67 | 38.67 ± 9.80 | 37.7 ± 10.21 |
| ≥25 | 40.38 ± 8.12 | 38.14 ± 10.86 | 36.28 ± 9.94 | 35.30 ± 10.43 | 42.96 ± 8.99 | 42.04 ± 8.73 | 40.14 ± 9.12 | 40.32 ± 10.37 |
| t value | 0.17 | −1.39 | −0.94 | −1.02 | −0.52 | −1.20 | −0.76 | −1.25 |
| P value | 0.87 | 0.17 | 0.35 | 0.31 | 0.60 | 0.23 | 0.45 | 0.22 |
| Income | ||||||||
| ≤2500 | 40.00 ± 4.58 | 36.67 ± 3.06 | 41.33 ± 10.12 | 35.00 ± 3.00 | 38.33 ± 1.53 | 37.33 ± 6.35 | 44.00 ± 10.58 | 38.33 ± 3.51 |
| 2500-5500 | 39.43 ± 9.19 | 36.13 ± 8.48 | 34.23 ± 9.19 | 34.27 ± 10.1 | 42.07 ± 9.34 | 41.50 ± 11.06 | 38.3 ± 9.04 | 38.2 ± 10.17 |
| 5500 | 41.08 ± 9.33 | 37.08 ± 11.05 | 35.60 ± 10.42 | 34.25 ± 10.56 | 42.86 ± 9.92 | 40.78 ± 9.26 | 39.76 ± 9.62 | 39.51 ± 10.67 |
| F value | 0.33 | 0.09 | 0.74 | 0.01 | 0.35 | 0.26 | 0.60 | 0.17 |
| P value | 0.72 | 0.92 | 0.48 | 0.99 | 0.70 | 0.77 | 0.55 | 0.85 |
| Bony classification | ||||||||
| Bony Class III | 39.12 ± 8.69 | 37.00 ± 11.66 | 34.00 ± 9.55 | 34.65 ± 10.00 | 41.76 ± 9.65 | 39.91 ± 9.34 | 38.97 ± 8.74 | 39.41 ± 9.42 |
| Bony Class II | 41.41 ± 6.81 | 38.05 ± 9.17 | 37.95 ± 9.03 | 37.14 ± 10.58 | 45.00 ± 8.15 | 42.09 ± 8.37 | 40.95 ± 10.17 | 41.05 ± 11.55 |
| Facial asymmetry | 41.25 ± 10.59 | 35.88 ± 9.30 | 35.08 ± 10.86 | 32.40 ± 10.01 | 41.68 ± 10.18 | 41.08 ± 10.83 | 39 ± 9.72 | 37.68 ± 10.41 |
| F value | 0.63 | 0.34 | 1.07 | 1.58 | 1.00 | 0.34 | 0.37 | 0.78 |
| P value | 0.54 | 0.72 | 0.35 | 0.21 | 0.37 | 0.71 | 0.70 | 0.46 |
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