LEFT TO RIGHT: SHAHID R. AZIZ, DMD, MD; ROBERT N. FEMMINELLA, MS, MS;
SUSAN GOULD FOGERITE, PHD; AND NATHAN WUEBBLES, DMD, MD
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rthognathic surgery, which is usually done for people between the ages of 15 and 35, is surgery to correct dentofacial deformities of the maxilla and mandible (upper and lower jaw). These deformities can consist of skeletal malocclusions such as “open bites,” “underbites,” or “overbites,” which are not correctable by conventional orthodontics (such as braces) alone, but rather require surgical intervention to correct. Orthognathic surgery requires planning and preparation on the part of the patient, patient’s family, orthodontist, and surgeon. Most patients have a natural anxiety in the days prior to surgery. This anxiety is generally addressed in the form of reassurance and education by the surgeon, or having the patient speak to former patients who have undergone similar procedures. Immediately after the surgery, these patients often require maxillomandibular fixation (wiring the teeth together) for 3-4 weeks to stabilize the jaw while it heals. They need to deal with seeing their face significantly changed and swollen after surgery, concerns about postoperative pain management, and fears about breathing adequately and the inability to eat solids or speak properly while the teeth are wired.
FIGURE 1. 3-DIMENSIONAL CT SCAN OF ORTHOGNATHIC SURGERY PATIENT IMMEDIATELY FOLLOWING MAXILLARY AND MANDIBULAR ADVANCEMENT SURGERY
Guided imagery, breathing and relaxation
We believe that conventional medical/surgical techniques may not address these pre- and post-surgical issues in an optimal way. We would like to find out whether certain complementary and alternative medicine (CAM) techniques within mind/body medicine can be used to help the mind act as a positive force in decreasing anxiety and pain, and facilitating postoperative healing in orthognathic surgery. Guided imagery helps the listener get into a relaxed state and suggestions are made relating to desired outcomes. In the case of preparing for surgery, these could include staying calm and having positive expectations about the surgery and about the postoperative healing. Physically, imagery has the ability to directly influence the autonomic nervous system, and the power of imagination can be recruited to promote specific physiological changes as an aid to healing. Studies indicate that certain imagery techniques may stimulate immune and endocrine (hormonal) responses, which can accelerate the healing process. In addition to guided imagery, yoga also has breathing and relaxation techniques that can help a person calm down and be less affected by stressful
situations.
The clinical trial
One of the best ways to investigate the effects of a change in medical practice is to do a randomized clinical trial. Patients who are eligible and interested in participating are randomly assigned to one of two or more groups being studied. Comparisons can be made within a group over time and between groups. This pilot randomized clinical trial, which is currently recruiting subjects, is supported partially by a seed grant from the UMDNJ Foundation through the UMDNJ-New Jersey Dental School (NJDS). The goal of this study is to compare the use of guided imagery (GI) and relaxation techniques to listening to music in helping to prepare patients for orthognathic surgery and improving post surgery recovery. Twenty six orthognathic surgery patients, ages 15 to 35, treated at the dental school, will be randomized into either a “guided imagery” or a “music” group. Both groups will be given education and reassurances about the surgery, a portable MP3 player, earphones and a journal. The guided imagery subjects will be given an MP3 download of a guided imagery program called “Successful Surgery,” written and recorded by Belleruth Naparstek, LISW, which has been shown to be safe and effective in improving outcomes in other clinical trials. It contains specially designed background music, guided relaxation, auto-suggestions and reassurances about the surgical experience and recovery. In addition, GI subjects will be personally taught diaphragmatic breathing and progressive relaxation techniques prior to surgery. The music group subjects will be asked to listen to music of their choosing for the same amount of time pre- and post-surgery as the GI program will be listened to by the other group. All subjects will record their listening time and either their music choices or their practice time in their journal.
Recovery will be evaluated, including weight loss, swelling, and nerve function. Mouth opening will be measured and chewing function assessed at baseline and all time points after wires restricting jaw movement are removed. Pain and anxiety will be quantified using the most commonly used and well validated visual scales and questionnaires. All subjects will be given questionnaires to determine how well they felt they were prepared for surgery, to what degree they felt that the guided imagery, relaxation and breathing techniques, or the music, made the pre-surgical and post-surgical phases less stressful, and whether they would recommend this program be made available to future patients. Biochemical markers of stress, inflammation and tissue damage will be measured in the ICAM research lab on subjects’ blood samples to help characterize emotional stress and the rate and extent of healing post surgery.
As co-principal investigators, Dr. Aziz will be performing all the orthognathic surgeries and Dr. Gould Fogerite will be teaching the relaxation and breathing practices to the guided imagery subjects in this trial. Co-investigators include Nathan Wuebbles, DMD, MD, chief resident, NJDS Department of Oral/Maxillofacial Surgery, who will be assisting with surgeries, doing many of the assessments, and serving as study coordinator; Malvin Janal, PhD, senior research associate, UMDNJ-New Jersey Medical School (NJMS) Department of Psychiatry, will serve as chief statistician; and Robert Femminella, MS, MS, will be assisting with the laboratory analysis, relaxation training and literature research in partial fulfillment of the requirements for his PhD in Health Sciences at UMDNJ-School of Health Related Professions (SHRP). NJMS student Charles Tyshkov also helped with some of the preparation for the study.
Shahid R. Aziz, DMD, MD, is an associate professor in the Department of Oral & Maxillofacial Surgery at UMDNJ-New Jersey Dental School and the Division of Plastic and Reconstructive Surgery in the Department of Surgery at UMDNJ-New Jersey Medical School. Dr. Aziz received his DMD from Harvard University School of Dental Medicine, his MD from Columbia University College of Physicians and Surgeons, and completed surgical training at Columbia Presbyterian Medical Center. He practices the full scope of oral and maxillofacial surgery, including orthognathic, facial trauma, and cleft lip and palate surgery.
Susan Gould Fogerite, PhD, is Director of Research for the Institute for Complementary and Alternative Medicine and associate professor in the Departments of Primary Care and Clinical Laboratory Sciences at UMDNJ-School of Health Related Professions. She earned her PhD in microbiology and immunology from Albany Medical School of BioMedical Sciences, and her BS from Albany Medical School of Medical Technology and SUNY at Albany. She teaches mind/body practices, and microbiology and immunology, and leads research on the biochemistry and immunology of stress and relaxation.
You can access additional information about the surgery, the clinical trial or complementary and alternative medicine at ICAM on these Websites: http://dentalschool.umdnj.edu/depts/oral-surgery/faculty-practice.htm or http://umdnj.edu/icam.
