Long-term functional and subjective outcomes after facial fracture surgery

BACKGROUND AND PURPOSE Facial injury and surgical treatment of facial fractures may cause aesthetic and functional disadvantages that affect patients´ health-related quality of life (HRQoL). The aims of this study were to investigate the long-term occurrences and characteristics of temporomandibular disorder (TMD) and lower eyelid malposition (LEM) and to evaluate HRQoL after surgical treatment of facial fractures. PATIENTS AND METHODS This study comprises three prospective studies (I, II and IV) and one retrospective study (III). Study I included patients with fractures of the zygomatic complex (ZC) (n=45), Study II patients with fractures of the non-condylar mandible (n=31), Study III patients with facial fractures extending to the orbit (n=174) and Study IV patients with isolated orbital fractures (n=26). In Studies I and II, the outcome variables were the anamnestic index Ai and the clinical index Di according to the Helkimo dysfunction indices. In Study III, the primary outcome variables were ectropion and entropion, and the primary predictor variable was age. In Study IV, the outcome variable was HRQoL, which was measured with the multidimensional, generic 15D instrument, and was compared with that of the general population. A complementary questionnaire about patients´ perceptions of recovery was also administered. RESULTS The occurrence of TMD symptoms (Ai) six months after surgical treatment of ZC fractures was 13.3% and after non-condylar mandibular fractures 12.9%. Clinical findings of TMD (Di) were observed in 84.4% and 80.6% of patients, respectively. The subjective symptoms of TMD did not correlate with the clinical findings of TMD. The occurrence of LEM following surgical reconstruction of orbital fracture was 7.5%, with ectropion in 5.7% and entropion in 1.7% of patients. Older age, complex fractures and reconstructions, traumatic lower lid wound, transcutaneous approaches, preformed orbital implants, orbital lower rim fixation and screw fixation of orbital implant were associated significantly with LEM. Of all patients, 3.4% required surgical correction of LEM. Six (46.2%) of the 13 patients who developed LEM, required surgical correction. HRQoL was significantly reduced immediately after facial injury and further reduced after operative treatment of orbital fracture. After one month, the significant difference compared with the control population in the median scores of HRQoL had disappeared. Six months postoperatively, the main disadvantages reported by patients were deficiencies in facial sensation (34.6%) and in aesthetics (30.8%) and diplopia (19.2%). CONCLUSIONS TMD is common after surgically treated fractures of the ZC and non-condylar mandible and should be evaluated after all facial fractures. Patients with symptoms of TMD should be referred to specialists for further diagnosis and treatment. LEM is fairly common sequela after orbital fracture reconstruction surgery. Older patients with complex facial fractures are at particular risk for developing LEM and, when possible, should be treated with patient-specific implants via transconjunctival approaches. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic. HRQoL is significantly reduced after orbital fractures and their operative treatment. However, the negative impact is only transient. The main long-term disadvantages reported by the patients are deficiencies in facial sensation and in aesthetics and diplopia. Patients with psychological or social challenges should be identified and offered assistance early on during facial injury recovery.