Vol. 119 No. 4 April 2015
Health-related quality of life after surgical treatment of mandibular fracture Leena Kaukola, DDS,a Johanna Snäll, MD, DDS,a Christian Lindqvist, MD, DDS,a Risto Roine, MD, PhD,b Harri Sintonen, PhD,c Jyrki Törnwall, MD, DDS, PhD,a and Hanna Thorén, MD, DDS, PhDa Objectives. We evaluated health-related quality of life (HRQoL) before and after surgical treatment of mandibular fracture and assessed patients’ perceptions of the esthetic and functional outcomes of surgery. Study Design. We established a prospective study of adult patients who were to undergo open reduction and rigid fixation of mandibular fracture. Of the patients, 49 met the inclusion criteria, and of these, 45 agreed to participate. HRQoL was measured with the generic 15-dimensional (15-D) instrument, and patients’ satisfaction was assessed with an additional questionnaire. Results. The average preoperative 15-D score among patients (0.891) was significantly lower than that in the general population (0.964) (P < .01). Patients were worse off on 9 of the 15 dimensions of HRQoL; however, at 3 months following surgery, all dimensions had improved to the level observed in the general population. Conclusions. HRQoL is significantly reduced after mandibular trauma but improves in a few months after surgery. Sensory disturbance is the most significant disadvantage of the surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:402-407)
There is a growing awareness of the psychological and social problems associated with recovery from facial trauma.1-6 Anxiety, depression, and posttraumatic stress disorders are particularly common.1,3,6,7 Moreover, patients with a history of facial trauma show low life satisfaction, disturbed body image, alcoholism, depression, and social problems, such as unemployment and marital conflict.8 Considering that effective and complete recovery from an injury or illness is a top priority of the health care system, we cannot afford to ignore these aspects of recovery that may worsen patients’ health-related quality of life (HRQoL). HRQoL is a concept that aims to define how contented people are with their lives overall in relation to their health. In medicine and dentistry, a change in HRQoL can be used to measure the effectiveness of specific treatments. Yet, to date, we have found only one study that has evaluated the outcomes of facial injuries with the aid of a multidimensional HRQoL instrument.7 Mandibular fractures are commonly observed in patients with facial injuries.9 Patients suffering from mandibular fractures confront several problems that a Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland. b University of Eastern Finland, Research Centre for Comparative Effectiveness and Patient Safety, Department of Health and Social Management, Kuopio, Finland; and Helsinki and Uusimaa Hospital District, Administration/Research and Development, Helsinki, Finland. c Hjelt Institute/Department of Public Health, University of Helsinki, Helsinki, Finland. Received for publication Oct 26, 2014; accepted for publication Nov 17, 2014. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2014.11.018
402
may have a great impact on their HRQoL, including changes in facial appearance, impaired oral and masticatory functions, sensory disturbances, obstacles in daily routines, and interruptions of social and working life due to convalescence. Therefore, we evaluated HRQoL before and after surgical treatment of mandibular fracture with the aid of a 15-dimensional (15-D) measure of HRQoL. A further aim was to clarify patients’ perceptions of the esthetic and functional outcomes with the aid of a structured self-report questionnaire specially designed for this study.
PATIENTS AND METHODS Patient selection Our prospective study included patients who were at least 18 years of age and were to undergo open reduction and fixation of mandibular fracture with titanium miniplates and nonlocking monocortical screws through one or two intraoral approaches. Patients were recruited over a 4-year period and were followed up for 6 months. Fracture types included were (1) a single fracture in the angle, (2) a single fracture in the body, (3) a single fracture in the symphysis or parasymphysis, and (4) a double mandibular fracture (i.e., angle þ body
Statement of Clinical Relevance Our study revealed that mandibular fracture has a negative effect on patients’ health-related quality of life (HrQoL). The most significant problem is impaired facial sensation. Patients should be thoroughly informed about the risk of sensory disturbance before surgery.
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or angle þ symphysis or parasymphysis fracture). Patients with any other mandibular or facial fractures were excluded. Maxillomandibular fixation was not used postoperatively in any patient.
15-D instrument HRQoL was assessed with the 15-D instrument, which is a generic, comprehensive, standardized, selfadministered measure of HRQoL. The 15-D questionnaire is designed for populations aged over 15 years and is available in nearly 30 languages. It is highly reliable, valid, and sensitive in detecting changes in HRQoL, and it has a good discriminatory power.10,11 In most aspects, the 15-D questionnaire compares favorably with other commonly used generic HRQoL measures, such as the NHP, SF-20, SF-6 D, and EQ-5 D.10-14 The 15-D questionnaire can be used as both a profile measure and a single index score measure. The single index number (15-D score) ranges from 0 to 1, with 1 representing full health and 0 being equivalent to death. The valuation system is based on application of the multiattribute utility theory. The 15-D score is calculated from the health state descriptive system by using a set of population-based preference or utility weights, elicited from the Finnish population through a three-stage valuation procedure.10 In the 15D score, an improvement of approximately 0.018 can be considered clinically important in the sense that people can, on average, perceive such a change.15 In self-administered instruments such as the 15-D questionnaire, respondents often leave some questions unanswered. Missing data can be imputed by using linear regression analysis. The missing values for each dimension are predicted and the 15-D score is derived from the existing SPSS algorithm provided that no more than three questions (dimensions) are left unanswered. High completion rates in several previous studies10,16-20 indicate that the 15-D questionnaire is simple and quick for the respondent to complete, as it takes only 5 to 10 minutes to check off the level best describing their health state in the 15 dimensions of the instrument. The dimensions of the 15-D questionnaire comprise mobility, vision, hearing, breathing, sleeping, eating, speech, excretion, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity. Each dimension is further divided into five levelsdfrom no problems of any kind to extreme difficulties. As the 15-D instrument covers the physical, mental, and social aspects of well-being, it can be considered conceptually consistent with the definition of health by the World Health Organization. The 15-D questionnaire was given to patients for self-administration before surgery (on the same day or 1 day before) and again at 1 day, 2 days, 1 week, 1
ORIGINAL ARTICLE Kaukola et al. 403
month, 3 months, and 6 months after surgery. Patients filled in the 15-D questionnaire during their stay in hospital and at clinical follow-up appointments. If the patient did not attend the follow-up visit, the questionnaire remained uncompleted. Additional questionnaire In addition to the 15-D questionnaire, patients’ perceptions of the esthetic and functional outcomes of surgery were evaluated by a structured self-report questionnaire especially designed for this study. This additional questionnaire explored patients’ perceptions of facial appearance, sensation, occlusion, chewing, and overall recovery. For each of these parameters, the respondents chose from the following levels the one that best described their current health status: (1) bad outcome, (2) moderate outcome, and (3) good outcome. This questionnaire was completed 1, 3, and 6 months after surgery. Statistical analysis Data were analyzed using the SPSS algorithm for Windows statistical software version 19.0 (SPSS, Inc., Chicago, IL). The results are given as mean plus standard deviation. The significance of the differences between baseline and follow-up HRQoL scores was analyzed with Student paired sample t test and the differences between patients and the general population with the Mann-Whitney U-test or the Independent Samples t test. P values under .05 were considered significant. Data for the general population were obtained from the National Health 2000 Health Examination Survey covering a sample of the Finnish population aged 30 years and over21 and matched for patient age and gender. Ethical approval The Ethics Committee of the Department of Surgery and the Internal Review Board of the Division of Musculoskeletal Surgery, Helsinki University Central Hospital, Finland, approved the study protocol (Dno 33/E6/06). Informed written consent was obtained from all patients.
RESULTS A total of 49 patients met the inclusion criteria for the study, and 45 agreed to participate. Forty-four patients were men. The mean age at time of surgery was 28 (range 18-50) years. Table I summarizes the types of mandibular fractures. The vast majority of fractures (80%) resulted from assault, the other causes being falls (9%), traffic accidents (4%), and sports-related accidents (4%). One cause remained unclear due to
ORAL AND MAXILLOFACIAL SURGERY 404 Kaukola et al.
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Table I. Site of mandibular fractures in 45 patients Site Mandibular Mandibular Mandibular Mandibular Mandibular Total
angle symphysis or parasymphysis angle þ symphysis or parasymphysis angle þ body body
Number of patients
%
16 13 12 2 2 45
35.6 28.9 26.7 4.4 4.4 100
the patient’s amnesia. Alcohol was involved in 24 cases (53%). The response rate for the 15-D questionnaire varied between 78% (35 patients) and 100% and for the additional questionnaire between 69% (31 patients) and 82% (37 patients) over the 6-month follow-up period. Figure 1 shows the preoperative 15 dimensions relative to the general population. Patients were significantly worse off on 9 of the 15 dimensions. These dimensions were sleeping (P ¼ .02), eating (P < .001), speech (P ¼ .02), usual activities (P < .001), discomfort and symptoms (P < .001), depression (P ¼ .013), distress (P ¼ .02), vitality (P ¼ .01), and sexual activity (P ¼ .012). The average preoperative 15-D score of patients (0.891) was significantly worse than the average score of the age- and gender-matched general population (0.964) (P < .01). One month after the surgery, the 15-D score of patients (0.933) remained significantly lower than that of the general population (P ¼ .007), but the significance disappeared between 1 and 3 months. Three months after surgery, patients did not differ significantly from the general population on any of the 15 dimensions (Figure 2). Figure 3 shows the average 15-D scores at each follow-up appointment relative to the general population. The 15-D score decreased after surgery, with the lowest score attained on the first postoperative day. As shown in Figure 4 (AeE), patients’ perceptions of facial appearance, sensation, occlusion, chewing, and overall recovery improved over time during the follow-up. At the 6-month follow-up appointment, all respondents considered their facial appearance to be good, the corresponding rates regarding overall recovery, occlusion, and chewing being 100%, 96.9%, and 90.9%, respectively. However, sensation was considered good by only 57.6% of patients.
DISCUSSION The primary aim of this study was to establish HRQoL before and after surgical treatment of mandibular fracture with the aid of the 15-D questionnaire. A further aim was to clarify patients’ perceptions of the esthetic
and functional outcomes, with an additional questionnaire designed for this study. The results revealed that the mean 15-D score of patients before surgery was significantly lower than that of the general population, and patients were significantly worse off on 9 of 15 dimensions. Three months after the surgery, all 15 dimensions had normalized. The significance of the difference in 15-D scores between the patients and the general population disappeared between 1 and 3 months. At the 6-month follow-up appointment, the great majority of patients considered their overall recovery to be good. However, sensation was considered good by only 57.6%. Ukpong et al.7 used the World Health Organization QoL-Bref to compare the quality of life in patients with facial fractures, facial soft tissue lacerations, or both with that of healthy controls. At baseline, the scores in all four domains (i.e., physical health, psychological health, social relationships, and environment) were considerably reduced in patients with facial trauma. Similar results were observed preoperatively in the patients in our study. Moreover, the 15-D score decreased further postoperatively, bottoming out on the first and second postoperative days, likely reflecting the pain, swelling, and nausea caused by surgery and general anesthesia. Stress related to the trauma, sleeping problems, diminished vitality, discomfort, depression, and distress were significant psychological problems during recovery. Yet the HRQoL of our patients improved markedly with time after the initial postoperative drop, and all 15 dimensions were at the same level as those of the general population 3 months after surgery. This is in contrast to findings from previous studies that have reported poor improvement of HRQoL after facial injuries over time, particularly in the psychosocial domains. During a 10- to 12-week follow-up, Ukpong et al.7 observed no improvement in the domain scores of psychological health, and the domain scores of social relationships, in fact, deteriorated significantly over time. Lento et al.22 noted that patients who had sustained mandibular fractures were significantly more likely to be depressed and anxious at the 6-month follow-up compared with controls. Potential explanations for the discrepant results between our study and the above-mentioned ones include differences in the general health and sociodemographic characteristics of patients; in the types, severity, and treatment success of facial injuries; and in the degree of psychosocial support provided to patients during recovery. Zazzali et al.23 conducted a survey of surgeons who treat orofacial injuries, aiming to clarify the providers’ awareness of patients’ psychosocial needs as well as perceived barriers to integrated care. Less than half of the respondents believed that patients’ problems with
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ORIGINAL ARTICLE Kaukola et al. 405
Fig. 1. Preoperative 15 dimensions compared with the general population.
Fig. 2. 15 dimensions 3 months postoperatively compared with the general population.
Fig. 3. 15-dimensional scores at each follow-up appointment compared with the general population.
depression, anxiety, or substance abuse were adequately managed at the hospital. The majority perceived a significant need for aftercare programs for patients, and most were of the opinion that adequate
aftercare would also enhance patient compliance. The finding of the present study and previously published papers7,22 indicating that psychological and social problems are frequent in patients recovering from facial
ORAL AND MAXILLOFACIAL SURGERY 406 Kaukola et al.
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Fig. 4. Patients’ perceptions of (A) facial appearance after surgical treatment of mandibular fracture, (B) facial sensation after surgical treatment of mandibular fracture, (C) occlusion after surgical treatment of mandibular fracture, (D) chewing after surgical treatment of mandibular fracture, and (E) overall recovery after surgical treatment of mandibular fracture.
injuries emphasize the importance of multiprofessional collaboration in providing services that support patients’ recovery. At our hospital, trauma patients with obvious socioeconomic problems are routinely referred to the hospital’s social worker for further assistance. Evidence from earlier research suggests a correlation between anxiety and negative body image resulting from facial disfigurement.2,8 This highlights the powerful role of facial appearance in self-perception and mental status. In the present study, facial disfigurement was not a relevant issue 6 months after injury. Moreover, chewing problems and occlusal disturbances were rare, with the exception of the immediate
postoperative period, when swelling and pain likely still had adverse effects on masticatory functions. The findings confirm that surgical treatment of simple mandibular fractures with titanium miniplates using an intraoral approach is the method of choice from the patients’ point of view. However, only 57.6% of patients considered facial sensation to be good 6 months after the surgery. Sensory disturbances are common after mandibular fracture.24-26 Scott and Perry27 recently published a prospective study that included 150 patients undergoing surgical treatment for mandibular fractures passing the nerve canal. One year after treatment, 32%
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had no or only minimal recovery of sensation. However, the important question is to what extent sensory disturbance actually impacts on the patient’s life. Our results revealed that impaired facial sensation was the most significant subjective problem 6 months after surgery. However, sensory recovery can, of course, continue to occur beyond 6 months. Informing patients about the risk of sensory disturbance at an early stage is important and may help those who end up with a permanent disturbance to adapt to the situation.
CONCLUSIONS HRQoL of patients with mandibular fracture deteriorates significantly after trauma compared with the general population. The average 15-D score of the patients is worst immediately after the surgery, followed by fairly rapid improvement until normal levels are reached 3 months postoperatively. The normalized 15-D scores indicate that the negative influence of mandibular trauma on patients’ HRQoL is transient. Recovery from mandibular trauma involves a variety of physical, social, and psychological problems that patients experience. To enable effective recovery and to ensure that patients are provided with sufficient support, effective multiprofessional collaboration is needed. Six months after the surgery, the most significant subjective problem that remains is disturbed facial sensation. Informing patients in advance about the risk of sensory impairment and its nature might help them deal with and more readily adjust to the problem. REFERENCES 1. Islam S, Ahmed M, Walton GM, et al. The prevalence of psychological distress in a sample of facial trauma victims. A comparative cross-sectional study between UK and Australia. J Craniomaxillofac Surg. 2012;40:82-85. 2. Islam S, Ahmed M, Walton GM, et al. The association between depression and anxiety disorders following facial traumada comparative study. Injury. 2010;41:92-96. 3. Roccia F, Dell’Acqua A, Angelini G, Berrone S. Maxillofacial trauma and psychiatric sequelae: post-traumatic stress disorder. J Craniofac Surg. 2005;16:355-360. 4. Islam S, Cole JL, Walton GM, et al. Does attribution of blame influence psychological outcomes in facial trauma victims? J Oral Maxillofac Surg. 2011;70:593-598. 5. Hull AM, Lowe T, Devlin M, et al. Psychological consequences of maxillofacial trauma: a preliminary study. Br J Oral Maxillofac Surg. 2003;41:317-322. 6. Bisson JI, Shepherd JP, Dhutia M. Psychological sequelae of facial trauma. J Trauma. 1997;43:496-500. 7. Ukpong DI, Ugboko VI, Ndukwe KC, Gbolahan OO. Healthrelated quality of life in Nigerian patients with facial trauma and controls: a preliminary survey. Br J Oral Maxillofac Surg. 2008;46:297-300. 8. Levine E, Degutis L, Pruzinsky T, et al. Quality of life and facial traumadpsychological and body image effects. Ann Plast Surg. 2005;54:502-510. 9. Thorén H, Snäll J, Salo J, et al. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg. 2010;68:805-810.
ORIGINAL ARTICLE Kaukola et al. 407 10. Sintonen H. The 15 D instrument of health-related quality of life: properties and applications. Ann Med. 2001;33:328-336. 11. Vainiola T, Pettilä V, Roine R, et al. Comparison of two utility instruments, the EQ-5 D and the 15 D, in the critical care setting. Intens Care Med. 2010;36:2090-2093. 12. Sintonen H, Johansson S, Ohinmaa A, et al. Measuring healthrelated quality of life in women on hormone replacement therapy. Expert Rev Pharmacoecon Outcomes Res. 2003;3:351-361. 13. Hawthorne G, Richardson J, Day NA. A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments. Ann Med. 2001;33:358-370. 14. Stavem K. Reliability, validity and responsiveness of two multiattribute utility measures in patients with chronic obstructive pulmonary disease. Qual Life Res. 1999;8:45-54. 15. Alanne S. Subjectively significant change in the measurement of health-related quality of life. Joensuu, Finland: University of Eastern Finland, Faculty of Social Sciences and Business Studies, Department of Health Policy and Management; 2011. 16. Helmiö M, Salminen P, Sintonen H, et al. A 5-year prospective quality of life analysis following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg. 2011;21:1585-1591. 17. Dahlberg A, Alaranta H, Sintonen H. Health-related quality of life in persons with traumatic spinal cord lesion in Helsinki. J Rehabil Med. 2005;37:312-316. 18. Horneman G, Folkesson P, Sintonen H, et al. Health-related quality of life of adolescents and young adults 10 years after serious traumatic brain injury. Int J Rehabil Res. 2005;28:245-249. 19. Kauppinen-Mäkelin R, Sane T, Sintonen H, et al. Quality of life in treated patients with acromegaly. J Clin Endocrinol Metab. 2006;91:3891-3896. 20. Hytönen ML, Lilja M, Mäkitie AA, et al. Does septoplasty enhance the quality of life in patients? Eur Arch Otorhinolaryngol. 2012;12:2497-2503. 21. Aromaa A, Koskinen S. Health and Functional Capacity in Finland. Baseline Results of the Health 2000 Health Examination Survey. Helsinki, Finland: National Public Health Institute of Finland; 2004. 22. Lento J, Glynn S, Shetty V, et al. Psychological functioning and needs of indigent patients with facial injury: a prospective controlled study. J Oral Maxillofac Surg. 2004;62:925-932. 23. Zazzali JL, Marshall GN, Shetty V, et al. Provider perceptions of patient psychosocial needs after orofacial injury. J Oral Maxillofac Surg. 2007;65:1584-1589. 24. Mayrink G, Moreira RW, Araujo MM. Prospective study of postoperative sensory disturbances after surgical treatment of mandibular fractures. Oral Maxillofac Surg. 2013;17:27-31. 25. Marchena JM, Padwa BL, Kaban LB. Sensory abnormalities associated with mandibular fractures: incidence and natural history. J Oral Maxillofac Surg. 1998;56:822-825. 26. Halpern LR, Kaban LB, Dodson TB. Perioperative neurosensory changes associated with treatment of mandibular fractures. J Oral Maxillofac Surg. 2004;62:576-581. 27. Scott RA, Teo N, Perry M. Displacement of mandibular fractures: is there a correlation with sensory loss and recovery? Int J Oral Maxillofac Surg. 2014;43:555-558.
Reprint requests: Leena Kaukola, DDS Department of Oral and Maxillofacial Diseases Helsinki University Central Hospital P.O. Box 263 HUCH Finland Leena.kaukola@helsinki.fi
Health-related quality of life after surgical treatment of mandibular fracture Leena Kaukola, DDS,a Johanna Snäll, MD, DDS,a Christian Lindqvist, MD, DDS,a Risto Roine, MD, PhD,b Harri Sintonen, PhD,c Jyrki Törnwall, MD, DDS, PhD,a and Hanna Thorén, MD, DDS, PhDa Objectives. We evaluated health-related quality of life (HRQoL) before and after surgical treatment of mandibular fracture and assessed patients’ perceptions of the esthetic and functional outcomes of surgery. Study Design. We established a prospective study of adult patients who were to undergo open reduction and rigid fixation of mandibular fracture. Of the patients, 49 met the inclusion criteria, and of these, 45 agreed to participate. HRQoL was measured with the generic 15-dimensional (15-D) instrument, and patients’ satisfaction was assessed with an additional questionnaire. Results. The average preoperative 15-D score among patients (0.891) was significantly lower than that in the general population (0.964) (P < .01). Patients were worse off on 9 of the 15 dimensions of HRQoL; however, at 3 months following surgery, all dimensions had improved to the level observed in the general population. Conclusions. HRQoL is significantly reduced after mandibular trauma but improves in a few months after surgery. Sensory disturbance is the most significant disadvantage of the surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:402-407)
There is a growing awareness of the psychological and social problems associated with recovery from facial trauma.1-6 Anxiety, depression, and posttraumatic stress disorders are particularly common.1,3,6,7 Moreover, patients with a history of facial trauma show low life satisfaction, disturbed body image, alcoholism, depression, and social problems, such as unemployment and marital conflict.8 Considering that effective and complete recovery from an injury or illness is a top priority of the health care system, we cannot afford to ignore these aspects of recovery that may worsen patients’ health-related quality of life (HRQoL). HRQoL is a concept that aims to define how contented people are with their lives overall in relation to their health. In medicine and dentistry, a change in HRQoL can be used to measure the effectiveness of specific treatments. Yet, to date, we have found only one study that has evaluated the outcomes of facial injuries with the aid of a multidimensional HRQoL instrument.7 Mandibular fractures are commonly observed in patients with facial injuries.9 Patients suffering from mandibular fractures confront several problems that a Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland. b University of Eastern Finland, Research Centre for Comparative Effectiveness and Patient Safety, Department of Health and Social Management, Kuopio, Finland; and Helsinki and Uusimaa Hospital District, Administration/Research and Development, Helsinki, Finland. c Hjelt Institute/Department of Public Health, University of Helsinki, Helsinki, Finland. Received for publication Oct 26, 2014; accepted for publication Nov 17, 2014. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2014.11.018
402
may have a great impact on their HRQoL, including changes in facial appearance, impaired oral and masticatory functions, sensory disturbances, obstacles in daily routines, and interruptions of social and working life due to convalescence. Therefore, we evaluated HRQoL before and after surgical treatment of mandibular fracture with the aid of a 15-dimensional (15-D) measure of HRQoL. A further aim was to clarify patients’ perceptions of the esthetic and functional outcomes with the aid of a structured self-report questionnaire specially designed for this study.
PATIENTS AND METHODS Patient selection Our prospective study included patients who were at least 18 years of age and were to undergo open reduction and fixation of mandibular fracture with titanium miniplates and nonlocking monocortical screws through one or two intraoral approaches. Patients were recruited over a 4-year period and were followed up for 6 months. Fracture types included were (1) a single fracture in the angle, (2) a single fracture in the body, (3) a single fracture in the symphysis or parasymphysis, and (4) a double mandibular fracture (i.e., angle þ body
Statement of Clinical Relevance Our study revealed that mandibular fracture has a negative effect on patients’ health-related quality of life (HrQoL). The most significant problem is impaired facial sensation. Patients should be thoroughly informed about the risk of sensory disturbance before surgery.
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or angle þ symphysis or parasymphysis fracture). Patients with any other mandibular or facial fractures were excluded. Maxillomandibular fixation was not used postoperatively in any patient.
15-D instrument HRQoL was assessed with the 15-D instrument, which is a generic, comprehensive, standardized, selfadministered measure of HRQoL. The 15-D questionnaire is designed for populations aged over 15 years and is available in nearly 30 languages. It is highly reliable, valid, and sensitive in detecting changes in HRQoL, and it has a good discriminatory power.10,11 In most aspects, the 15-D questionnaire compares favorably with other commonly used generic HRQoL measures, such as the NHP, SF-20, SF-6 D, and EQ-5 D.10-14 The 15-D questionnaire can be used as both a profile measure and a single index score measure. The single index number (15-D score) ranges from 0 to 1, with 1 representing full health and 0 being equivalent to death. The valuation system is based on application of the multiattribute utility theory. The 15-D score is calculated from the health state descriptive system by using a set of population-based preference or utility weights, elicited from the Finnish population through a three-stage valuation procedure.10 In the 15D score, an improvement of approximately 0.018 can be considered clinically important in the sense that people can, on average, perceive such a change.15 In self-administered instruments such as the 15-D questionnaire, respondents often leave some questions unanswered. Missing data can be imputed by using linear regression analysis. The missing values for each dimension are predicted and the 15-D score is derived from the existing SPSS algorithm provided that no more than three questions (dimensions) are left unanswered. High completion rates in several previous studies10,16-20 indicate that the 15-D questionnaire is simple and quick for the respondent to complete, as it takes only 5 to 10 minutes to check off the level best describing their health state in the 15 dimensions of the instrument. The dimensions of the 15-D questionnaire comprise mobility, vision, hearing, breathing, sleeping, eating, speech, excretion, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity. Each dimension is further divided into five levelsdfrom no problems of any kind to extreme difficulties. As the 15-D instrument covers the physical, mental, and social aspects of well-being, it can be considered conceptually consistent with the definition of health by the World Health Organization. The 15-D questionnaire was given to patients for self-administration before surgery (on the same day or 1 day before) and again at 1 day, 2 days, 1 week, 1
ORIGINAL ARTICLE Kaukola et al. 403
month, 3 months, and 6 months after surgery. Patients filled in the 15-D questionnaire during their stay in hospital and at clinical follow-up appointments. If the patient did not attend the follow-up visit, the questionnaire remained uncompleted. Additional questionnaire In addition to the 15-D questionnaire, patients’ perceptions of the esthetic and functional outcomes of surgery were evaluated by a structured self-report questionnaire especially designed for this study. This additional questionnaire explored patients’ perceptions of facial appearance, sensation, occlusion, chewing, and overall recovery. For each of these parameters, the respondents chose from the following levels the one that best described their current health status: (1) bad outcome, (2) moderate outcome, and (3) good outcome. This questionnaire was completed 1, 3, and 6 months after surgery. Statistical analysis Data were analyzed using the SPSS algorithm for Windows statistical software version 19.0 (SPSS, Inc., Chicago, IL). The results are given as mean plus standard deviation. The significance of the differences between baseline and follow-up HRQoL scores was analyzed with Student paired sample t test and the differences between patients and the general population with the Mann-Whitney U-test or the Independent Samples t test. P values under .05 were considered significant. Data for the general population were obtained from the National Health 2000 Health Examination Survey covering a sample of the Finnish population aged 30 years and over21 and matched for patient age and gender. Ethical approval The Ethics Committee of the Department of Surgery and the Internal Review Board of the Division of Musculoskeletal Surgery, Helsinki University Central Hospital, Finland, approved the study protocol (Dno 33/E6/06). Informed written consent was obtained from all patients.
RESULTS A total of 49 patients met the inclusion criteria for the study, and 45 agreed to participate. Forty-four patients were men. The mean age at time of surgery was 28 (range 18-50) years. Table I summarizes the types of mandibular fractures. The vast majority of fractures (80%) resulted from assault, the other causes being falls (9%), traffic accidents (4%), and sports-related accidents (4%). One cause remained unclear due to
ORAL AND MAXILLOFACIAL SURGERY 404 Kaukola et al.
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Table I. Site of mandibular fractures in 45 patients Site Mandibular Mandibular Mandibular Mandibular Mandibular Total
angle symphysis or parasymphysis angle þ symphysis or parasymphysis angle þ body body
Number of patients
%
16 13 12 2 2 45
35.6 28.9 26.7 4.4 4.4 100
the patient’s amnesia. Alcohol was involved in 24 cases (53%). The response rate for the 15-D questionnaire varied between 78% (35 patients) and 100% and for the additional questionnaire between 69% (31 patients) and 82% (37 patients) over the 6-month follow-up period. Figure 1 shows the preoperative 15 dimensions relative to the general population. Patients were significantly worse off on 9 of the 15 dimensions. These dimensions were sleeping (P ¼ .02), eating (P < .001), speech (P ¼ .02), usual activities (P < .001), discomfort and symptoms (P < .001), depression (P ¼ .013), distress (P ¼ .02), vitality (P ¼ .01), and sexual activity (P ¼ .012). The average preoperative 15-D score of patients (0.891) was significantly worse than the average score of the age- and gender-matched general population (0.964) (P < .01). One month after the surgery, the 15-D score of patients (0.933) remained significantly lower than that of the general population (P ¼ .007), but the significance disappeared between 1 and 3 months. Three months after surgery, patients did not differ significantly from the general population on any of the 15 dimensions (Figure 2). Figure 3 shows the average 15-D scores at each follow-up appointment relative to the general population. The 15-D score decreased after surgery, with the lowest score attained on the first postoperative day. As shown in Figure 4 (AeE), patients’ perceptions of facial appearance, sensation, occlusion, chewing, and overall recovery improved over time during the follow-up. At the 6-month follow-up appointment, all respondents considered their facial appearance to be good, the corresponding rates regarding overall recovery, occlusion, and chewing being 100%, 96.9%, and 90.9%, respectively. However, sensation was considered good by only 57.6% of patients.
DISCUSSION The primary aim of this study was to establish HRQoL before and after surgical treatment of mandibular fracture with the aid of the 15-D questionnaire. A further aim was to clarify patients’ perceptions of the esthetic
and functional outcomes, with an additional questionnaire designed for this study. The results revealed that the mean 15-D score of patients before surgery was significantly lower than that of the general population, and patients were significantly worse off on 9 of 15 dimensions. Three months after the surgery, all 15 dimensions had normalized. The significance of the difference in 15-D scores between the patients and the general population disappeared between 1 and 3 months. At the 6-month follow-up appointment, the great majority of patients considered their overall recovery to be good. However, sensation was considered good by only 57.6%. Ukpong et al.7 used the World Health Organization QoL-Bref to compare the quality of life in patients with facial fractures, facial soft tissue lacerations, or both with that of healthy controls. At baseline, the scores in all four domains (i.e., physical health, psychological health, social relationships, and environment) were considerably reduced in patients with facial trauma. Similar results were observed preoperatively in the patients in our study. Moreover, the 15-D score decreased further postoperatively, bottoming out on the first and second postoperative days, likely reflecting the pain, swelling, and nausea caused by surgery and general anesthesia. Stress related to the trauma, sleeping problems, diminished vitality, discomfort, depression, and distress were significant psychological problems during recovery. Yet the HRQoL of our patients improved markedly with time after the initial postoperative drop, and all 15 dimensions were at the same level as those of the general population 3 months after surgery. This is in contrast to findings from previous studies that have reported poor improvement of HRQoL after facial injuries over time, particularly in the psychosocial domains. During a 10- to 12-week follow-up, Ukpong et al.7 observed no improvement in the domain scores of psychological health, and the domain scores of social relationships, in fact, deteriorated significantly over time. Lento et al.22 noted that patients who had sustained mandibular fractures were significantly more likely to be depressed and anxious at the 6-month follow-up compared with controls. Potential explanations for the discrepant results between our study and the above-mentioned ones include differences in the general health and sociodemographic characteristics of patients; in the types, severity, and treatment success of facial injuries; and in the degree of psychosocial support provided to patients during recovery. Zazzali et al.23 conducted a survey of surgeons who treat orofacial injuries, aiming to clarify the providers’ awareness of patients’ psychosocial needs as well as perceived barriers to integrated care. Less than half of the respondents believed that patients’ problems with
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ORIGINAL ARTICLE Kaukola et al. 405
Fig. 1. Preoperative 15 dimensions compared with the general population.
Fig. 2. 15 dimensions 3 months postoperatively compared with the general population.
Fig. 3. 15-dimensional scores at each follow-up appointment compared with the general population.
depression, anxiety, or substance abuse were adequately managed at the hospital. The majority perceived a significant need for aftercare programs for patients, and most were of the opinion that adequate
aftercare would also enhance patient compliance. The finding of the present study and previously published papers7,22 indicating that psychological and social problems are frequent in patients recovering from facial
ORAL AND MAXILLOFACIAL SURGERY 406 Kaukola et al.
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Fig. 4. Patients’ perceptions of (A) facial appearance after surgical treatment of mandibular fracture, (B) facial sensation after surgical treatment of mandibular fracture, (C) occlusion after surgical treatment of mandibular fracture, (D) chewing after surgical treatment of mandibular fracture, and (E) overall recovery after surgical treatment of mandibular fracture.
injuries emphasize the importance of multiprofessional collaboration in providing services that support patients’ recovery. At our hospital, trauma patients with obvious socioeconomic problems are routinely referred to the hospital’s social worker for further assistance. Evidence from earlier research suggests a correlation between anxiety and negative body image resulting from facial disfigurement.2,8 This highlights the powerful role of facial appearance in self-perception and mental status. In the present study, facial disfigurement was not a relevant issue 6 months after injury. Moreover, chewing problems and occlusal disturbances were rare, with the exception of the immediate
postoperative period, when swelling and pain likely still had adverse effects on masticatory functions. The findings confirm that surgical treatment of simple mandibular fractures with titanium miniplates using an intraoral approach is the method of choice from the patients’ point of view. However, only 57.6% of patients considered facial sensation to be good 6 months after the surgery. Sensory disturbances are common after mandibular fracture.24-26 Scott and Perry27 recently published a prospective study that included 150 patients undergoing surgical treatment for mandibular fractures passing the nerve canal. One year after treatment, 32%
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had no or only minimal recovery of sensation. However, the important question is to what extent sensory disturbance actually impacts on the patient’s life. Our results revealed that impaired facial sensation was the most significant subjective problem 6 months after surgery. However, sensory recovery can, of course, continue to occur beyond 6 months. Informing patients about the risk of sensory disturbance at an early stage is important and may help those who end up with a permanent disturbance to adapt to the situation.
CONCLUSIONS HRQoL of patients with mandibular fracture deteriorates significantly after trauma compared with the general population. The average 15-D score of the patients is worst immediately after the surgery, followed by fairly rapid improvement until normal levels are reached 3 months postoperatively. The normalized 15-D scores indicate that the negative influence of mandibular trauma on patients’ HRQoL is transient. Recovery from mandibular trauma involves a variety of physical, social, and psychological problems that patients experience. To enable effective recovery and to ensure that patients are provided with sufficient support, effective multiprofessional collaboration is needed. Six months after the surgery, the most significant subjective problem that remains is disturbed facial sensation. Informing patients in advance about the risk of sensory impairment and its nature might help them deal with and more readily adjust to the problem. REFERENCES 1. Islam S, Ahmed M, Walton GM, et al. The prevalence of psychological distress in a sample of facial trauma victims. A comparative cross-sectional study between UK and Australia. J Craniomaxillofac Surg. 2012;40:82-85. 2. Islam S, Ahmed M, Walton GM, et al. The association between depression and anxiety disorders following facial traumada comparative study. Injury. 2010;41:92-96. 3. Roccia F, Dell’Acqua A, Angelini G, Berrone S. Maxillofacial trauma and psychiatric sequelae: post-traumatic stress disorder. J Craniofac Surg. 2005;16:355-360. 4. Islam S, Cole JL, Walton GM, et al. Does attribution of blame influence psychological outcomes in facial trauma victims? J Oral Maxillofac Surg. 2011;70:593-598. 5. Hull AM, Lowe T, Devlin M, et al. Psychological consequences of maxillofacial trauma: a preliminary study. Br J Oral Maxillofac Surg. 2003;41:317-322. 6. Bisson JI, Shepherd JP, Dhutia M. Psychological sequelae of facial trauma. J Trauma. 1997;43:496-500. 7. Ukpong DI, Ugboko VI, Ndukwe KC, Gbolahan OO. Healthrelated quality of life in Nigerian patients with facial trauma and controls: a preliminary survey. Br J Oral Maxillofac Surg. 2008;46:297-300. 8. Levine E, Degutis L, Pruzinsky T, et al. Quality of life and facial traumadpsychological and body image effects. Ann Plast Surg. 2005;54:502-510. 9. Thorén H, Snäll J, Salo J, et al. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg. 2010;68:805-810.
ORIGINAL ARTICLE Kaukola et al. 407 10. Sintonen H. The 15 D instrument of health-related quality of life: properties and applications. Ann Med. 2001;33:328-336. 11. Vainiola T, Pettilä V, Roine R, et al. Comparison of two utility instruments, the EQ-5 D and the 15 D, in the critical care setting. Intens Care Med. 2010;36:2090-2093. 12. Sintonen H, Johansson S, Ohinmaa A, et al. Measuring healthrelated quality of life in women on hormone replacement therapy. Expert Rev Pharmacoecon Outcomes Res. 2003;3:351-361. 13. Hawthorne G, Richardson J, Day NA. A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments. Ann Med. 2001;33:358-370. 14. Stavem K. Reliability, validity and responsiveness of two multiattribute utility measures in patients with chronic obstructive pulmonary disease. Qual Life Res. 1999;8:45-54. 15. Alanne S. Subjectively significant change in the measurement of health-related quality of life. Joensuu, Finland: University of Eastern Finland, Faculty of Social Sciences and Business Studies, Department of Health Policy and Management; 2011. 16. Helmiö M, Salminen P, Sintonen H, et al. A 5-year prospective quality of life analysis following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg. 2011;21:1585-1591. 17. Dahlberg A, Alaranta H, Sintonen H. Health-related quality of life in persons with traumatic spinal cord lesion in Helsinki. J Rehabil Med. 2005;37:312-316. 18. Horneman G, Folkesson P, Sintonen H, et al. Health-related quality of life of adolescents and young adults 10 years after serious traumatic brain injury. Int J Rehabil Res. 2005;28:245-249. 19. Kauppinen-Mäkelin R, Sane T, Sintonen H, et al. Quality of life in treated patients with acromegaly. J Clin Endocrinol Metab. 2006;91:3891-3896. 20. Hytönen ML, Lilja M, Mäkitie AA, et al. Does septoplasty enhance the quality of life in patients? Eur Arch Otorhinolaryngol. 2012;12:2497-2503. 21. Aromaa A, Koskinen S. Health and Functional Capacity in Finland. Baseline Results of the Health 2000 Health Examination Survey. Helsinki, Finland: National Public Health Institute of Finland; 2004. 22. Lento J, Glynn S, Shetty V, et al. Psychological functioning and needs of indigent patients with facial injury: a prospective controlled study. J Oral Maxillofac Surg. 2004;62:925-932. 23. Zazzali JL, Marshall GN, Shetty V, et al. Provider perceptions of patient psychosocial needs after orofacial injury. J Oral Maxillofac Surg. 2007;65:1584-1589. 24. Mayrink G, Moreira RW, Araujo MM. Prospective study of postoperative sensory disturbances after surgical treatment of mandibular fractures. Oral Maxillofac Surg. 2013;17:27-31. 25. Marchena JM, Padwa BL, Kaban LB. Sensory abnormalities associated with mandibular fractures: incidence and natural history. J Oral Maxillofac Surg. 1998;56:822-825. 26. Halpern LR, Kaban LB, Dodson TB. Perioperative neurosensory changes associated with treatment of mandibular fractures. J Oral Maxillofac Surg. 2004;62:576-581. 27. Scott RA, Teo N, Perry M. Displacement of mandibular fractures: is there a correlation with sensory loss and recovery? Int J Oral Maxillofac Surg. 2014;43:555-558.
Reprint requests: Leena Kaukola, DDS Department of Oral and Maxillofacial Diseases Helsinki University Central Hospital P.O. Box 263 HUCH Finland Leena.kaukola@helsinki.fi
