Assessment of quality of life in patients with surgically treated maxillofacial fractures

Introduction

Maxillofacial trauma and associated injuries can cause severe physical deformity and psychological consequences.¹ Disability following major trauma has gained significant attention due to these related complications.² Poor quality of life in injured patients with a risk of developing psychiatric problems has been observed by some studies.^3–6 In the present era, to evaluate the impact of disease and the efficiency of the treatment, assessment of the quality of life of the patients is of vital importance.¹ Unfortunately, studies that assess the quality of life (QOL) after surgical treatment of maxillofacial fracture surgeries are rare and so we decided to investigate this.

Specific factors that influence the outcomes of trauma are the site of the fracture, the type of fracture, and the patient's age.⁷ An associated fear factor with the treatment of fractures warrants the need to look into the psychological issues related to fracture surgery.^8–10 Though there are many quality of life (QOL) assessment tools in literature, an exclusive QOL assessment tool for maxillofacial fractures is lacking. We have devised an exclusive, first-of-its-kind QOL assessment tool that looks into both physical and psychological aspects following maxillofacial trauma surgery. The ‘Twenty-point Quality of life assessment in facial trauma patients in Indian population' assessment tool was developed and used to determine the QOL in this study. The aim of this study was to assess the QOL following surgical management of maxillofacial trauma patients based on the severity of the injury. The objectives of the study were:

Also, the authors intend to introduce a new assessment tool to determine QOL precisely from a maxillofacial injury perspective.

Methods

Results

The study group comprises 182 subjects (145 males and 37 females) (Table 6). 160 were below 65 years of age (Table 6). The causes of fractures were road traffic accidents (84.3%), violence (5.3%), falls (8.2%), and sports activities (2.2%). In Zone 1, the mean scores for Group A and Group B were 38.6 and 39.26, respectively. In Zone 2, Group B (44.56) had higher mean scores compared to Group A (32.92), and this was statistically significant (p< 0.001) (Table 7). Group B (83.8) had higher mean scores compared to Group A (71.58) when the total of both Zone 1 and Zone 2 were taken into consideration, and this was statistically significant (p<0.001) (Table 7).

In Zone 1, the domains of 'Satisfaction in daily activities' (Question 2) and 'Acceptance of post-trauma facial appearance' (Question 9) had the lowest mean scores in Group A. In Group B, 'the ability to interact with family and friends' (Question 4) domain showed the lowest mean score (Table 8, Figure 1). In Zone 2, the domains of 'aesthetics' (Question 9) and 'mastication' (Question 3) had the lowest mean scores in Group A, and in Group B, the 'aesthetics' domain (Question 9) had the lowest mean score (Table 9, Figure 2). On comparison of individual domains between the two groups in Zone 1, except for domains of 'Quality of sleep,' 'Lack of suicidal tendencies,' and 'Acceptance of post-trauma facial appearance,' all other domains showed statistically significant differences (Table 8). In Zone 2, on comparison of the two groups, all domains showed statistically significant differences (p<0.001) (Table 9).

Figure 1. Mean scores of individual domains in Group A and Group B in Zone 1.

Figure 2. Mean scores of individual domains in Group A and Group B in Zone 2.

In Group A, 9 out of 91 patients had a total score of 81-100. Three patients scored below 60, and the remaining 79 scored in the 61-80 range. Two out of 16 female participants had excellent prognosis and the remaining 14 showed good prognosis. In Group B, 68 patients scored in the 81-100 range, and the remaining 23 scored in the 61-80 range. 14 out of 21 female participants showed excellent prognosis and the remaining seven showed good prognosis (Table 10).

Discussion

The inclusion of assessment of QOL is essential in treating patients with maxillofacial fractures to determine psychological well-being and patient satisfaction.¹² Unfortunately, the evaluation of QOL of people who had been surgically treated for maxillofacial fractures is not practiced routinely.¹³ While assessing QOL in maxillofacial injuries, it is essential to consider the severity of the injury. Maxillofacial injuries occur in various combinations, and individual fractures require specific descriptions. We used the FISS to classify severe and moderate/mild injuries. The FISS is a valuable tool for maxillofacial trauma assessment. This scale can reliably predict the severity of maxillofacial injuries and is easily calculated.¹¹ We consider 4.4 as the average demarcating score to classify severe and moderate/mild injuries based on the study by Bhageri et al.¹¹

Several assessment tools are available to determine the well-being and QOL of patients, but maxillofacial injuries are unique due to the disfigurement and dysfunction they cause. These injuries can lower the person's self-esteem and adversely affect daily activities and social relationships, ultimately affecting QOL.^13,14 We have devised an exclusive QOL assessment tool for facial trauma patients to assess post-surgery patients from a maxillofacial trauma perspective. The new assessment tool determines both the psychosocial and functional and aesthetic impacts due to maxillofacial fracture surgery.

WHO's Quality of Life (WHOQOL-100) and its shorter version, the WHOQOL-BREF, are used in various settings to determine patients' quality of life.¹⁵ The WHOQOL-BREF, more popular among the two, contains four domains: physical health, psychological health, social relationships, and environment.¹³ Mood disorders, body image disorders, and a poor QOL are often exhibited in aesthetic and functional disturbances associated with maxillofacial trauma.¹⁶ A disfiguring maxillofacial injury can make an individual withdraw from social interaction.¹ Also, a lack of support from family and friends affects an individual's physical and emotional well-being.¹⁶ All these observations were considered in the new assessment tool (The Twenty-point Quality of life assessment in facial trauma patients in Indian population), which we devised. The psychosocial impact questionnaire evaluated the patient's satisfaction with their overall physical health, the confidence of the individual in performing daily activities and interacting with family and friends, and the ability to concentrate and sleep well (Zone 1, Questions 1-5) (Table 3). Also, the personal relationships of the patient with people around them, the support by their near and dear ones, suicidal tendencies, if any, ability to accept changes in facial appearance, and satisfaction with medical services provided can be assessed (Zone 1, Questions 6-10). Hence the four domains of the WHOQOL-BREF evaluation tool are given adequate importance in the new assessment tool presented by the authors.

Moreover, we also determined the functional and aesthetic impact on subjects after maxillofacial surgery (Zone 2) (Table 4). The progress of pain, swelling, mouth opening, and paresthesia can be assessed by this questionnaire (Zone 2, Questions 1, 2, 4, and 6). Evaluation of daily activities like eating, swallowing, talking (Zone 2, Questions 3, 7, 8), and discomfort due to the hardware (Zone 2, Question 5) are also evaluated. This assessment tool also considers patient concerns regarding facial appearance and visual disturbances (Zone 2, Questions 9, 10).

Previous studies have documented that patients with facial trauma subsequently exhibit poor QOL outcomes.^17–20 The inflammatory response caused by a facial injury results in increased vascular permeability, vasodilation, and infiltration of monocytes and polymorphonuclear leukocytes in the area of injury. These changes take place within a few days following an injury. Hence an early fracture surgery can lead to an unfavorable outcome due to a lack of initial blood supply.²¹ In our study, most surgical treatment of fractures was done at least 72 hours after injury to achieve favorable outcomes.

Complications in all surgically treated patients accounted for 6.6%. Alcohol abuse, smoking, and plating procedures are some factors significantly associated with complications.²² The findings of our study suggest that adequate reduction and fixation of fractures with high-end titanium miniplates and screw systems (AO Principles of Fracture Management) and efficient management of soft tissue injuries greatly enhance the outcomes of facial trauma patients. Our unit's soft tissue injury management included adequate debridement of devitalized tissue, layered closure of the wounds, and aesthetic reconstruction of soft tissue injuries with tissue loss. By following these measures, the outcomes of the surgical intervention can be significantly enhanced, as shown in our study. Moreover, severe injuries are associated with extensive soft tissue injuries, which can lead to poor QOL. In our study, the mean total scores (Zone 1+ Zone 2) show a good outcome for Group A subjects with severe injuries (71.58) and an excellent outcome for Group B subjects with mild/moderate injuries (83.8) (Table 7). These favorable outcomes in our study can be attributed to the use of state-of-the-art titanium hardware for fixation, excellent soft tissue care, restoring the functional ability of the patient, such as chewing and mouth opening, and adequate control of postoperative pain and edema.

A lack of improvement in QOL after surgery was attributed to appearance, pain, and mood issues in the postoperative period.²³ Also, the primary concern of patients with maxillofacial trauma compared to other types of trauma is their appearance.²⁴ These findings correlate to our study in which the ‘facial appearance’ domain in Zone 1 and the ‘aesthetics’ domain in Zone 2 had low mean scores (Tables 8 and 9). As both these domains are related to the cosmetic appearance of the patient, cosmetic defects can adversely affect QOL in patients. Severe maxillofacial injuries can cause cosmetic defects. Cosmetic defects caused by maxillofacial trauma can, in turn, lead to depression and affect QOL.²⁵ Moreover, trauma leading to difficulty in chewing and functional impairment such as paresthesia and diplopia can also cause depression in individuals.²⁶ Hence, a correlation exists between psychological and aesthetic/functional components resulting from severe maxillofacial trauma. These findings relate to our study wherein the QOL was comparatively better in mild to moderate injuries compared to severe ones. In our study, better QOL was seen in Group B (mild/moderate facial injuries) compared to Group A (severe facial injuries) (Figure 3). There was statistical significance in Zone 2 scores and the combined Zone 1 + Zone 2 scores (Table 7).

Figure 3. Relationship between severity of injury (Group 1 and 2) and quality of life (zones 1 and 2).

Patients who underwent open reduction and internal fixation of fractures recorded higher pain scores post-surgery.^27–29 Pain reduces the QOL of patients, and hence it is essential to employ adequate pain reduction protocols post-surgery to improve QOL.³⁰ Our study also shows the effect of pain on the QOL of the patient. The average mean score for decline in pain (Zone 2, Question 1) was 3.38 and 4.89, respectively, for severe and mild/moderate injuries (Figure 2). As higher scores denote better QOL, it is evident that mild/moderate injuries show better QOL compared to severe injuries. Adequate analgesics are to be prescribed to patients for effective pain control postoperatively. Moreover, we believe that meticulous and gentle handling of soft and hard tissues during the surgical procedure is vital in decreasing postoperative pain, edema, and patient discomfort. Anggayanti et al. reported significant improvement in QOL within 14 days of surgical intervention.³¹ Open reduction and fixation in association with excellent management of postoperative complications restore the normal configuration of anatomic structures, enhance stability, and establishes normal function.³² Efficient surgical management, good postoperative care, and due consideration of facial aesthetics were employed in our unit to obtain favorable outcomes. Both sexes showed excellent outcome in Group B compared to Group A (Table 10). The higher male:female ratio of the participants can be attributed to the fact that motorcycles in India are predominantly driven by males. Due to this higher male:female ratio, only a descriptive analysis based on sex of the individual has been demonstrated.

The study had certain limitations. The stratification of patients in Mild, Moderate and Severe facial trauma, using the FISS, is not statistically validated. The Comprehensive Facial Injury (CFI) score proposed in 2019, exceeded the limits of the FISS from which it derives, while maintaining its simplicity of use.^33–35 Stratification of patients into Mild, Moderate and Severe facial trauma, using CFI score, was yet statistically validated, and published. An assessment of QOL in maxillofacial fracture patients based on the CFI scoring system is desirable. Moreover, as we had used a new diagnostic tool, its credibility could have been enhanced by advocating it to assess the pre-operative QOL and comparing the outcomes with the present findings. Also, comparing postoperative outcomes at different periods could have shed light on the possibility of improvement in the QOL over a period after surgery.

Conclusion

Proper surgical management with adequate care to the hard and soft tissues can improve the QOL by reducing postoperative psychosocial and functional complications. Aesthetic outcomes play an important role in determining the QOL. Mild/Moderate injuries show better QOL compared to severe maxillofacial injuries.