Bimaxillary orthognathic surgery with a conventional saw compared with the piezoelectric technique: a longitudinal clinical study

The only cutting technique used for osteotomies in orthognathic surgery for many years has been a saw, but recently piezoelectric surgery has been introduced as a possible alternative. The aim of this study was to find out if piezoelectric surgery can be more comfortable for patients having orthognathic surgery. A total of 25 patients with dentofacial deformities (seven male and 18 female), were treated from January 2016 to September 2017. In 11 patients, osteotomies were made using a conventional saw, while in 14 a piezoelectric device was used. The variables assessed were: operating time, postoperative swelling, postoperative pain, and cutaneous sensitivity of the upper and lower lips. The duration of operation for the piezosurgery group was significantly longer than that for controls, but the patients had less swelling at all follow-up visits, and the difference was significant at the 30-day follow-up (p = 0.045). Those who had piezosurgery had significantly less pain at the three-day follow up (p = 0.035). There was a significant difference in cutaneous sensitivity only for the right side of the upper lip and only at the one-day follow-up. We conclude that piezoelectric surgery offers some advantages in lessening swelling and the perception of pain after orthognathic surgery, but further investigations are required.     

Effects of the preoperative administration of Yunnan Baiyao capsules on intraoperative blood loss in bimaxillary orthognathic surgery: A prospective,randomized, double-blind,placebo-controlled study

Yunnan Baiyao is a well-known Chinese herbal medicine that has been used as a haemostatic drug for nearly 100 years. The aim of this clinical trial was to evaluate the efficacy and safety of Yunan Baiyao capsules on the reduction of blood loss in bimaxillary orthognathic surgery. 87 consecutive patients scheduled for simultaneous maxillary Le Fort I osteotomies and bilateral sagittal split ramus osteotomies (BSSRO) were enrolled in a prospective, randomized, double-blind, placebo-controlled clinical trial. Patients were administered Yunnan Baiyao capsules or placebo capsules, orally for 3 days before surgery. Intraoperative blood loss was estimated and the safety of Yunnan Baiyao capsules was evaluated. The total blood loss in the Yunnan Baiyao group (mean, 330.5 ± 134.4 ml) was significantly lower than in the control group (mean, 420.3 ± 175.9 ml). No allergic reactions, thromboembolic events or other side effects were recorded in this trial. It can be concluded that the preoperative use of Yunnan Baiyao capsules, in combination with hypotension anaesthesia, results in a reduction in intraoperative blood loss in bimaxillary orthognathic surgery. Yunnan Baiyao capsules are an effective and safe haemostatic Chinese medicine.     

Survey of patient experiences of orthognathic surgery: health-related quality of life and satisfaction

The objective of this study was to assess changes in patient quality of life (QoL) after orthognathic surgery at the Kuwait University Dental Clinic. A self-administered Arabic version of the Orthognathic Quality of Life Questionnaire (OQLQ) and two different visual analogue scales (VAS) were used. Sixty-six patients participated (63.6% female). The deformities were corrected by bimaxillary jaw surgery (83.3%), Le Fort I (9.1%), and bilateral sagittal split osteotomy (7.6%). The most important reasons given for undertaking the surgery were facial aesthetics (80.3%) and bite correction (75.8%). Of the patients who had reported moderate to high levels of problems pre-surgery, the majority reported improvements in facial appearance (91.3%), appearance of the teeth (97.0%), biting (96.3%), chewing (92.3%), and eating function (76.5%). Overall, 93.9% of patients reported better conditions after surgery, and the satisfaction level was very high (VAS 91.6%). The VAS score for QoL increased significantly from pre-surgery (73.0%) to post-surgery (93.6%) (P = 0.0001). The OQLQ score was also significantly decreased after surgery, reflecting improvements in the ‘social aspects of dentofacial deformity’, ‘facial aesthetics’, ‘oral function’, and ‘awareness of dentofacial aesthetics’ domains (P = 0.0001). Overall, the patients who underwent orthognathic surgery were satisfied and had improved QoL. The satisfaction rate in the present study reflects successful treatment with orthognathic surgery.     

Comparative study of skeletal stability between bicortical resorbable and titanium screw fixation after sagittal split ramus osteotomy for mandibular prognathism

IntroductionResorbable screw fixation for orthognathic surgery is widely used in oral and maxillofacial surgery and has several advantages. However, surgeons are concerned about using resorbable screws in orthognathic surgery because of possible postoperative complications such as relapse, screw fracture, and infection. The purpose of this study was to evaluate the skeletal stability of bicortical resorbable screw fixation after sagittal split ramus osteotomies for mandibular prognathism.Materials and methodsThis study included 25 patients who underwent mandibular setback surgery fixed with resorbable screws after sagittal split osteotomy at the Department of Oral and Maxillofacial Surgery at Seoul National University Dental Hospital. Five resorbable screws (Inion CPS^®, Inion Ltd., Finland) were applied bicortically at each osteotomy site via a transbuccal approach. No rigid intermaxillary fixation was applied on the first postoperative day. Passive mouth opening exercises were allowed, using two light, rubber elastics for guidance. The control group was 25 patients fixed with four titanium screws. The follow-up period was 12–22 months (mean 17.8 months). Postoperative skeletal changes on lateral cephalometric radiographs were analyzed and compared between the two groups preoperatively, immediately postoperatively, and 6 months postoperatively.ResultsThe average setback was 6.9 mm and no major intraoperative complications occurred. One patient experienced infection immediately after surgery that was controlled uneventfully. The data did not demonstrate any significant difference in postoperative skeletal stability between the two groups. Differences between the immediate postoperative state and 6 months after surgery were not significant. In earlier cases, especially for patients with severe mandibular prognathism, immediate postoperative elastic traction was needed for stable occlusal guidance.ConclusionsThe results of this study indicate that bicortical resorbable screws offer a clinically stable outcome for the fixation of mandibular sagittal split osteotomies in mandibular prognathism. However the resorbable screws showed less stable results vertically than the titanium screws.     

What are the defining characteristics of the most cited publications in orthognathic surgery?

The purpose of this study was to identify the characteristics associated with highly cited papers in orthognathic surgery. This was a cohort study of articles published in the English-language literature from 1900 to 2017. Citation databases were searched for papers related to orthognathic surgery and the most frequently cited papers were identified. For each paper, the following variables were collected: region of origin, time-period of publication, corresponding author specialty, journal of publication, topic area, study design, and number of citations. The outcome variable was the citation index (citations per year). North American investigators published 70% of the 100 most-cited articles in orthognathic surgery. The majority of papers were from oral and maxillofacial surgeons. Frequent content areas were diagnosis, virtual planning, fixation/stability, and complications. The majority (54%) of studies were cohort or case report/series. The mean number of citations was 235.0 ± 126.5; the mean citation index was 9.9 ± 6.1 citations per year. Time-period, content area, and study design were associated with the citation index (all P < 0.001). Time-period, content area, and study design predicted the citation index (all P ≤ 0.009). Among frequently cited papers in orthognathic surgery, oral and maxillofacial surgeons had the highest volume of contributions. Diagnosis, treatment planning, and complications were the most common topics studied.     

Numbness of the lower lip does not adversely affect quality of life or patients’ satisfaction after mandibular orthognathic surgery

Measures of patient-reported quality of life (QoL) are increasingly being used to tailor services that are funded by Clinical Commissioning Groups (CCG) in England. Mandibular osteotomies may result in altered sensation of the lower lip, but we know of limited evidence about the resulting effect on QoL. The modified Bristol orthognathic patient outcomes questionnaire was given to patients who had mandibular osteotomies at the Queen Elizabeth Hospital, Birmingham, between March 2006 and April 2016. Questionnaires were collected at the final orthognathic postoperative appointment. The significance of the difference in QoL between those who had altered sensation of the lower lip and those who did not was compared using a two-tailed t test. During this period 170 patients had mandibular orthognathic operations. Completed questionnaires were received from 117 of those patients (69%) during this period, after a follow up of about six months. We found no significant difference between the perceived benefits of treatment between the 41 who had altered sensation and the 74 who did not (p = 0.30). Only 5/41 who reported residual numbness six months postoperatively stated that they would not choose to have the same treatment again. In conclusion, orthognathic surgery results in an appreciable improvement in QoL and should continue to be funded by CCG in England. Contrary to the perception of some clinicians, those patients with residual numbness of the lip did not have significantly poorer QoL. Future interpretation of the data will be improved if they are collected both before and after the operation.     

Variation between natural head orientation and Frankfort horizontal planes in orthognathic surgery patients: 187 consecutive cases

The purpose of this study was to assess the relationship between the Frankfort horizontal (FH) and natural head orientation (NHO), their correlation between patients’ malocclusion, and the impact of counterclockwise rotation (CCW) on the FH-NHO angle variation after orthognathic surgery. An evaluation of 187 consecutive patients was performed at the Maxillofacial Institute (Teknon Medical Center, Barcelona). FH-NHO° was measured pre- and postoperatively at 1 and 12 months, after three-dimensional (3D) superimposition using a software (Dolphin®). Patients were classified as follows: 3.2%, 48.7% and 48.1%, class I, II and III, respectively. Baseline FH-NHO° was significantly positive for patients with dentofacial deformities (2.73° ± 4.19 (2.12–3.33°, P < 0.001). The impact of orthognathic surgery in FH-NHO° was greater in class II when compared with class III patients, with a variation of 2.04° ± 4.79 (P < 0.001) and −1.20° ± 3.03 (P < 0.001), respectively. FH-NHO° increased when CCW rotational movements were performed (P = 0.006). The results of this study suggest that pre- and postoperative NHO differs from FH in orthognathic patients. The angle between FH and NHO is significantly larger in class III than in class II patients at baseline, which converges after orthognathic surgery when CCW rotation is performed. Therefore, NHO should be used as the real horizontal plane when planning for orthognathic surgery.     

Minimally invasive orthognathic surgery: a systematic review

Minimally invasive techniques are currently applied in many oral and maxillofacial surgical procedures, including orthognathic surgery. A systematic review on the application of potentially minimally invasive procedures in orthognathic surgery was performed to provide a clear overview of the relevant published data. Articles in English on minimally invasive orthognathic procedures, published in the scientific literature, were obtained from the PubMed, Embase, and Cochrane Library databases, and an additional manual search (revised 31 December 2016). After screening the abstracts and applying the eligibility criteria, 403 articles were identified. All articles reporting the potential for minimally invasive orthognathic surgery were included (n = 44). The full papers were evaluated in detail and categorized as articles on a minimally invasive surgical approach (n = 4), endoscopically assisted orthognathic procedures (n = 17), or the use of a piezoelectric device in orthognathic surgery (n = 25); two articles were each included in two categories. Although a small incision and minimal dissection is the basic principle of a minimally invasive technique, most articles (90.9%) reported the endoscope and piezoelectric instrument as important tools in minimally invasive orthognathic surgery. Evidence from available studies suggests that patients undergoing minimally invasive orthognathic surgery have less morbidity and make a faster recovery. Further research should aim to obtain higher levels of evidence.     

Stability of intraoral vertical ramus osteotomies for mandibular setback: a longitudinal study

This study aimed to investigate the postoperative longitudinal skeletal changes and stability following intraoral vertical ramus osteotomies (IVRO) for orthognathic mandibular setback, and the possible risk factors that might affect the stability. A retrospective cohort study was conducted. Lateral cephalograms were analyzed for the predictor (magnitude of setback and adjunctive procedures) and outcome (stability of vertical and horizontal dimensions) variables at six time points. A total of 152 patients (mean age 24.2 years) were included in the study. Following IVRO, the mandible measured at B-point had moved a mean 0.50 mm posteriorly at 1 week after the removal of intermaxillary fixation (7 weeks postoperative); this was followed by progressive small anterior relapse. At 2 years postoperative, the mean relapse of the mandible after IVRO measured at B-point was 0.05 mm (standard deviation 1.14 mm), representing 0.7% of the mean surgical movement. Large setback (>8 mm) showed significantly higher relapse compared to small setback (<4 mm) at 2 years after surgery (P = 0.021). Patients who underwent adjunctive mandibular surgeries other than IVRO showed no significant differences in relapse compared to those who underwent IVRO alone. In conclusion, IVRO for mandibular setback is a stable procedure in the long term, with small relapse of 0.05 mm after 2 years.     

Applying artificial intelligence to assess the impact of orthognathic treatment on facial attractiveness and estimated age

This observational study aimed to use artificial intelligence to describe the impact of orthognathic treatment on facial attractiveness and age appearance. Pre- and post-treatment photographs (n = 2164) of 146 consecutive orthognathic patients were collected for this longitudinal retrospective single-centre study. Every image was annotated with patient-related data (age; sex; malocclusion; performed surgery). For every image, facial attractiveness (score: 0–100) and apparent age were established with dedicated convolutional neural networks trained on >0.5 million images for age estimation and with >17 million ratings for attractiveness. Results for pre- and post-treatment photographs were averaged for every patient separately, and apparent age compared to real age (appearance). Changes in appearance and facial attractiveness were statistically examined. Analyses were performed on the entire sample and subgroups (sex; malocclusion; performed surgery). According to the algorithms, most patients’ appearance improved with treatment (66.4%), resulting in younger appearance of nearly 1 year [mean change: ?0.93 years (95% confidence interval (CI): ?1.50; ?0.36); p = 0.002), especially after profile-altering surgery. Orthognathic treatment had similarly a beneficial effect on attractiveness in 74.7% [mean difference: 1.22 (95% CI: 0.81; 1.63); p < 0.001], especially after lower jaw surgery. This investigation illustrates that artificial intelligence might be considered to score facial attractiveness and apparent age in orthognathic patients.     

The efficacy of tranexamic acid for orthognathic surgery: a meta-analysis of randomized controlled trials

The efficacy of tranexamic acid in orthognathic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on blood loss for orthognathic surgery.We performed a search of PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through October 2017 for randomized controlled trials (RCTs) assessing the effects of tranexamic acid versus placebo on orthognathic surgery. Meta-analysis was performed using the random-effects model.Six RCTs were included in the meta-analysis. Overall, compared with placebo in orthognathic surgery, tranexamic acid administration results in significantly decreased blood loss [mean difference (MD) = −159.73; 95% confidence interval (CI) = −236.42 to −83.03; P < 0.0001], and higher postoperative haemoglobin (MD = 0.71; 95% CI = 0.11 to 1.31; P = 0.02), but has no remarkable impact on postoperative haematocrit (MD = 1.23; 95% CI = −1.22 to 3.69; P = 0.33) and operation time (MD = −2.35; 95% CI = −18.05 to 13.36; P = 0.77). In addition, patients with orthognathic surgery need decreased amounts of irrigant fluid (MD = −229.23; 95% CI = −399.63 to −58.83; P = 0.008) after using tranexamic acid.We concluded that tranexamic acid promotes the bleeding control in orthognathic surgery.     

Does the use of amoxicillin/amoxicillin–clavulanic acid in third molar surgery reduce the risk of postoperative infection? A systematic review with meta-analysis

The objectives of this systematic review were to investigate the efficacy of amoxicillin/amoxicillin–clavulanic acid for reducing the risk of postoperative infection after third molar surgery and to evaluate the adverse outcomes in these patients, as well as in healthy volunteers. A systematic search of four databases was performed on May 26, 2017. Eleven studies qualified for the qualitative analysis and eight were found suitable for meta-analysis. The results suggest that both amoxicillin–clavulanic acid and amoxicillin significantly reduce the risk of infection after third molar extraction (overall relative risk (RR) 0.25, P < 0.001). However, with the exclusion of randomized controlled trials with a split-mouth design (due to an inadequate crossover period after antibiotic treatment), only amoxicillin–clavulanic acid was found to be effective (RR 0.21, P < 0.001). The risk of adverse effects was significantly higher in the amoxicillin–clavulanic acid group (RR = 4.12, P = 0.023) than in the amoxicillin group (RR 1.57, P = 0.405). In conclusion, amoxicillin–clavulanic acid and amoxicillin may significantly reduce the risk of infection after third molar extraction. However, their use in third molar surgery should be viewed with caution, as recent clinical trials on healthy volunteers have shown evidence of the negative impact of amoxicillin use on bacterial diversity and antibiotic resistance.     

Aesthetic outcomes and morphological changes in chin parameters after mandibular distraction and subsequent advancement genioplasty in patients with mandibular micrognathia

Despite the wide uses of mandibular distraction osteogenesis (MDO), no study appears to have evaluated the use of MDO and subsequent advancement genioplasty. This study addressed lower facial third aesthetics in a consecutive series of subjects with micrognathia who underwent MDO and subsequent advancement genioplasty. Standard cephalometric measurements were performed pre-MDO, at the end of consolidation, and at 1 week, 6 months, and 12 months after genioplasty. At the end of follow-up, questionnaires were given to measure patient satisfaction. Forty patients were included, 33 of whom underwent genioplasty. The mean patient age was 22.35 ± 1.12 years. Pre-genioplasty cephalometric measurements showed that all patients had a deficient chin position and projection; they were dissatisfied with their facial aesthetics. Post-genioplasty cephalometric measurements showed that the hard and soft tissue pogonion had moved significantly: 8.4 ± 2.3 mm and 11.0 ± 2.11 mm, respectively. According to the questionnaire, the patients were satisfied with the final results. The MDO reduced the amount of chin advancement and minimized relapses; the soft tissue response of the lower facial third was more sensitive to genioplasty than isolated MDO. MDO and genioplasty lead to a modest horizontal chin movement that achieves the preferred pogonion position and projection.     

Precision of maxillary repositioning during orthognathic surgery: A prospective study

The purpose of this study was to evaluate the accuracy of surgical splints and an external reference point to reposition the maxilla during orthognathic surgery. Before surgery, a radiological marker was inserted inside the orthodontic bracket of the first right maxillary molar. A surgical splint was utilized to reposition the maxilla in the sagittal and coronal planes after the osteotomy. The vertical position was established by measuring the distance between a Kirschner wire inserted at bony nasion and the orthodontic wire. Preoperative and postoperative cephalometric radiographs were obtained and manually traced. The radiological marker and the tip of the right maxillary incisor were used as specific landmarks. Their displacement on the pre- and postoperative radiographs was measured. The actual surgical movement of the maxilla was compared to the initial surgical planning. 23 patients met the inclusion criteria to participate in the study. The mean difference between the planned and executed movements of the maxilla was 0.1 mm (p = 0.71). The difference was not statistically significant for any given movements of the maxilla. The use of surgical splints made from model surgery combined with an external reference point at bony nasion is accurate methods for repositioning the maxilla during orthognathic surgery.     

Incidence and treatment of complications in patients who had third molars or other teeth extracted

The aim of this study was to compare the incidence of complications after extraction of third molars (M3) or other teeth, and to describe their management. We made a retrospective cohort study of patients having M3 or other teeth extracted, and recorded complications up to two years’ follow-up. A total of 142 complications developed after 2355 procedures (6%) – 7% after extraction of M3 compared with 5% after extractions of other teeth (p = 0.024). The three most common complications were wound infection (2%), pain without apparent cause (<1%), and oroantral communication (<1%). Patients who had M3 extracted were at increased risk of complications compared with those who had other teeth extracted (Odds ratio (OR) 1.5, p = 0.024), particularly for infection (OR 5.9, p < 0.001) and hypoaesthesia (OR 8.4, p = 0.027). Half of all patients with a complication were treated with antibiotics orally. The incidence of postoperative bleeding was 0.6% as a result of suboptimal management of antithrombotic drugs in extractions of teeth other than M3. Finally, optimal treatment of the complications was compared with the available evidence. Prevention and treatment of these complications could reduce the incidence, particularly of bleeding.     

Does a learning curve exist for accuracy in three-dimensional planning for maxillary positioning in bimaxillary orthognathic surgery?

The purpose of this study was to investigate the influence of time, and experience, on the accuracy of maxillary repositioning in bimaxillary orthognathic surgery performed using virtual surgical planning (VSP). Patients who had undergone bimaxillary orthognathic surgery were reviewed. Maxillary position on pre- and postoperative computed tomography scans was compared. The patients were divided into groups according to the year in which VSP was performed and surgery completed. Linear distances between upper jaw reference landmarks were measured in all three planes of space to determine accuracy between the preoperative VSP and the surgical outcome at various time points. One hundred subjects met the eligibility criteria for assessment and were allocated to groups: 2013 (n = 10), 2014 (n = 17), 2015 (n = 39), 2016 (n = 20), and 2017 (n = 14). Overall, the results demonstrated improved precision in maxillary position over the years, with more accurate results in patients who underwent surgery in 2015, 2016, and 2017. Mean linear differences between planned and obtained results demonstrated more accurate results in the horizontal direction, followed by transverse and vertical directions. An overall average difference within 1 mm was observed for 51.3% of the measurements included in the sample group. Time, and surgeon experience, can influence the accuracy of maxillary positioning in bimaxillary orthognathic surgery.     

TMD before and after correction of dentofacial deformities by orthodontic and orthognathic treatment

The aims of the study were to investigate the alteration of temporomandibular disorders (TMD) after correction of dentofacial deformities by orthodontic treatment in conjunction with orthognathic surgery; and to compare the frequency of TMD in patients with dentofacial deformities with an age and gender matched control group. TMD were evaluated in 121 consecutive patients (treatment group), referred for orthognathic surgery, by a questionnaire and a clinical examination. 18 months after treatment, 81% of the patients completed a follow-up examination. The control group comprised 56 age and gender matched subjects, of whom 68% presented for follow-up examination. TMD were diagnosed according to research diagnostic criteria for TMD. At baseline examination, the treatment group had a higher frequency of myofascial pain (P = .035) and arthralgia (P = .040) than the control group. At follow-up, the frequencies of myofascial pain, arthralgia and disc displacement had decreased in the treatment group (P = .050, P = .004, P = .041, respectively). The frequency of TMD was comparable in the two groups at follow-up. Patients with dentofacial deformities, corrected by orthodontic treatment in conjunction with orthognathic surgery, seem to have a positive treatment outcome in respect of TMD pain.     

Submental intubation in oral and maxillofacial surgery: a systematic review 1986–2018

Submental intubation is a low-risk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. To improve the selection of patients and clinical outcomes we have explored published papers on submental intubation in oral and maxillofacial surgery, and included a proposal for a decision pathway. Systematic searches of PubMed, Scopus, and Cochrane databases for papers published between 1986 and 2018 yielded 116 eligible articles (one randomised controlled trial, 61 case series, 40 case reports, six surgical techniques, and eight letters) that included 2 229 patients. Measured outcomes were the indications, techniques, devices used, time taken to complete the procedure, and complications. Indications were trauma (81%), orthognathic surgery (15%), disease (2%), and cosmetic surgery (1%). Technical preferences were for a one-tube (84%) over a two-tube technique (6%), and a paramedian (52%) over a median incision (33%). The preferred device was a reinforced endotracheal tube (85%). The mean (range) intubation time was 10 (2–37) minutes. The complication rate was 7% (n = 152), the most common being superficial skin infection (n = 54), hypertrophic scarring (n = 18), and damage to the tube apparatus (n = 15). Submental intubation has minimal complications, takes a short time to do, and it is a useful alternative to tracheostomy in some oral and maxillofacial operations. More robust evidence regarding the selection of patients, modifications to the technique, and a comparison of risk with that of tracheostomy, are needed for further evaluation of its feasibility.     

Efficient in-house 3D printing of an orthognathic splint for single-jaw cases

The purpose of this paper is to outline a simple and effective digital protocol for in-house 3D-printing of orthognathic splints for use during single-jaw orthognathic surgery. Using this protocol, an intraoral scanner, and virtual planning software, computer-designed splints were fabricated by a rapid prototyping machine in-house. The protocol was utilized for 35 consecutive patients requiring single-jaw orthognathic surgery between January 2019 and March 2020. The total time from initial scan to splint fabrication for each case was between 5 and 9 hours, including 3 minutes for scanning of models, 4.5 minutes for development of the splint, and 4–8 hours for rapid prototyping and post-processing. This time varied based on the complexity of the design and the number of splints printed simultaneously. The average cost of raw materials for each splint was $0.73 Canadian dollars.     

Is there a difference in judgement of facial appearance depending on ethnic background? Photographic evaluation of facial appearance in orthognathic surgery

Is there a variation in facial ideals depending on ethnic background that affects judgements of outcome in orthognathic surgery? How does the evaluation correlate with patient-reported outcome measures? Two evaluation panels, Singaporean and Swedish, judged photographs of patients undergoing orthognathic surgery taken before and after operation. Improvement in facial aesthetics was calculated between the two ratings. The result was compared between the panels and correlated with health-related quality of life (QoL) measures. Thirty male and 27 female patients aged between 18 and 28 years (mean 21) were included, and 52 subjects were eligible for comparison of health-related QoL. The photographic evaluation showed that both panels judged there to be significant improvement in facial aesthetics after treatment (p < 0.001). The Singaporean panel rated the overall facial appearance higher than the Swedish panel when evaluating photographs both before (p = 0.025) and after (p = 0.032) operation. Improvement of the overall facial appearance showed no significant difference between the panels (p > 0.30). No correlation between health-related QoL and improvement of facial appearance was found by either panel. Subjective evaluation of facial aesthetics in orthognathic surgery is unaffected by the observer’s ethnic origin. Independently of their ethnicity, the evaluation juries found that facial aesthetics improved after orthognathic surgery. Improvement reported by the juries corresponded to that reported by patients.