Evaluation of the psycho-social impact of distraction osteogenesis of the mandible with extra-oral appliance

Name:Age: Sex: Serial No:

Ortho No:

Filled by: self / parent / doctor

Part 1: Pre-distraction Phase

Have you understood the treatment procedure

  1. yes
  2. no
  3. not completely

What are your reasons for seeking surgery

  1. esthetics (appearance of your face / teeth)
  2. function ( chewing / speech / breathing )
  3. other reasons -

Specify the most important reason or give rank according to importance

What is the major motivating factor for your seeking this treatment

  1. self motivated
  2. on the advice of doctor/dentist/orthodontist
  3. on advice or pressure from family
  4. on advice or pressure from friends
  5. other reasons –

Specify the most important reason or give rank according to importance

Do you feel that surgery will change any aspect of your life

  1. yes
  2. no
  3. don’t know

Have you understood the other treatment modalities

  1. yes
  2. no
  3. not sure

What do you think about the distraction device / your reaction to the distraction device on a patient

  1. unaesthetic / bulky
  2. acceptable
  3. not sure

Part 2: Distraction Phase

Does the distraction appliance meet your expectations

  1. yes
  2. no
  3. if no, why

Do you have any of the following complaints

  1. pain/discomfort
  2. functional impairment (specify)
  3. numbness
  4. abnormal sensation
  5. any other

Do people in your day to day life comment about this device

  1. always
  2. never
  3. sometimes

If yes, then are these comments

  1. encouraging
  2. discouraging
  3. neutral
  4. not sure

If these comments are disturbing to you, do you feel

  1. irritated or annoyed
  2. angry
  3. ashamed
  4. ignore the comments

Do you think you are being made to suffer in any way because of this treatment

  1. yes
  2. no
  3. not sure

Do you think you made the right decision in going in for this sort of treatment

  1. yes
  2. no
  3. can’t say at this stage

Part 3: Post distraction phase

How do you feel about the results of your surgery

  1. totally satisfied
  2. satisfied
  3. unsatisfied
  4. totally unsatisfied
  5. don’t know

Do you feel a change in any of the following

  1. the appearance of your face

yes / no / can’t say : if yes, better or worse

  1. speech

yes / no / can’t say : if yes, better or worse

  1. breathing

yes / no / can’t say : if yes, better or worse

  1. chewing

yes / no / can’t say : if yes, better or worse

Which of the above is the most important change

Do you think the treatment was justifiable or worth it

  1. yes
  2. no
  3. can’t say

Do you think the treatment was worth the problems (if any) that you faced during the procedure

  1. yes
  2. no
  3. not sure

(Specify problems if possible)

Now that you know about the procedure, would you go through this operation again

  1. yes, no hesitation
  2. yes, some hesitation
  3. don’t know
  4. probably not
  5. certainly not

Would you recommend this operation to other patients who require treatment

  1. yes, no hesitation
  2. yes, some hesitation
  3. don’t know
  4. probably not
  5. certainly not