Objective: To investigate differences in quality of life in subjects with and without skeletal malocclusions and factors influencing patients' decision to accept orthognathic surgery. Materials and methods: DESIGN: Cross-sectional with stratified sampling. Settings and sample population: 190 Caucasian subjects (65% females), aged 17-46 years. 95 subjects were consecutive patients referred to University Dental Clinic for skeletal malocclusion treatment of which 58 subjects accepted suggested surgery, 37 refused. The other 95 were age-and sex-matched controls, without malocclusions, recruited from the pool of students and employees of local high schools and university. Main outcome measures: Psychosocial and functional issues were evaluated by Orthognathic Quality of Life Questionnaire. Complexity of malocclusion and treatment need was assessed by the Index of Orthognathic Functional Treatment Need. Results: Discriminant analysis demonstrated that in quality of life, three groups differed mostly in facial aesthetic concern, followed by altered oral function, then by social interactions which were the highest in the group that accepted surgery. When controlling for age, sex, oral function impairment, awareness of facial deformity and inhibitions in social contacts in a multiple logistic regression analysis, only IOFTN and facial aesthetic concern were significant predictors of orthognathic surgery acceptance, increasing the odds for acceptance by 2.9x and 4.7x, respectively (P ≤ .045). Conclusion: Facial aesthetic concern is very important factor in patients' decision-making process for accepting orthognathic treatment for skeletal malocclusions, with greater importance than high normative need for functional orthognathic treatment.