THE PHYSICAL AND PSYCHOLOGICALMAXILLOFACIAL TRAUMA PATIENTS

MORBIDITY IN

SW Au Yong L, Ummu Aiman Y and Rahman ZAA .. Thephysical and psychological morbidity in maxillofacialtrauma patients. Annal Dent Univ Malaya 1999; 6: 8 - 10.

ABSTRACTThe aim of this research is to study how the physicalchanges in the maxillofacial trauma patients affect thempsychologically in patients of different ages, sexes, races,socioeconomic backgrounds, types and severity of injury.The study was conducted by doing a questionnaire survey,which was divided into physical and psychologicalcomponents. In the physical component, the questionswere mainly related to the physical injuries to the patient,which could be visualized clinically and functionally. Thepsychological component consisted of analyzing theimpact of the maxillofacial trauma to the psychologicalprofile. Twenty patients of both sexes and ages, rangedfrom 15 to 62 years old were interviewed. The main causeof trauma was from motor vehicle accidents. This studyappears to show that maxillofacial trauma may have apsychological impact on patients.

Keywords: maxillofacial trauma, physical morbidity, andpsychological morbidity

INTRODUCTIONThe face is usually involved in a host of important rolesand functions. in everyday life. The appearance and'attractiveness' of a person to other people is partlycontributed by the person's face. As a result ofmaxillofacial trauma, the patient may suffer facialdisfigurement, chronic facial pain, anosmia, dysosmia,speech, dental and ophthalmological disabilities. Otherthan the physical aspect of maxillofacial trauma, anotherimportant aspect of maxillofacial trauma that has beenoverlooked in the dental and surgical clinical scenario isthe impact of various injuries in the maxillofacial regionon the patient's psychological makeup.

Facial disfigurement is one of the importantphysical consequence of maxillofacial trauma.Maxillofacial trauma victims often experiences anguishand resentment, and consequently may be emotionallydisabled (1,2). Negative reactions from members of publicand complaints by the victims of being rejected have beenreported in the literature(l). While these negative reactionsand the feelings of the rejection may be the result ofmisperception on the part of the facially disfigured, severalstudies had suggested that the discrimination that occurredwere solely based on appearance and not as a result ofconduct and manner (I).

It has also been noted that the interaction betweenthe level of social skill and disfigurement was significantlyless influential than the level of social skill displayed (3).Similar conclusions were also reported from burn patients,where the importance of personality and social supportrather than the severity of the visible disfigurement werereported (4). It had also been reported that the severity of

SW Au Yong L*, Ummu Aiman y*and Rahman ZAA**

*Year V Undergraduate Student (1999/2000)Faculty of Dentistry, University of Malaya

**Associate ProfessorDepartment of Oral and Maxillofacial SurgeryFaculty of Dentistry, University of Malaya

**Name and address of author to whom requestsfor reprints should be addressed.

a deformity was inversely related to the psychologicalimpact of the patient (5).

Another important physical component ofmaxillofacial trauma is chronic facial pain. The face andscalp have a rich sensory innervation, chiefly frombranches of the trigeminal nerve, and nerve injury is acommon complication of craniomaxillofacial trauma.Victims of nerve injury may complain of numbness,abnormal sensation and discomfort but very few furthercomplained of chronic pain. The formation of a traumaticneuroma was often postulated, and in some cases, thisappeared to be the cause of.pain(l).

Anosmia and dysosmia may also occur aftermaxillofacial trauma. Both disabilities result from damageto the olfactory nerves which is a very important and oftenneglected component of many craniomaxillofacial injuries.If the natural protection via sense of smell was destroyed,this may lead to failure to smell burning or escaping gas,which further endanger the patient, while also deprivingthe patient from the pleasure of eating (I).

Speech disabilities after maxillofacial trauma maydevelop in several ways. These disabilities were dependenton the site of injury, whether there was cerebral injury,damage to the muscles of articulation, nasal obstruction, orimpaired oral or labial sensation (I).

Dental disabilities due to maxillofacial traumamay affect a person functionally as well as aesthetically.Patients might not be able to afford complex andexpensive aesthetic restorative treatment. Provision of anacrylic partial denture might then change taste perceptionand alter eating habits.

Ophthalmological disability such as eyedisfigurement, visual loss and diplopia would havesignificant effects on the victim's interaction with otherpeople. These may result from disturbances of the shape ofthe globe and the eyelids and/or disturbances in the colour,the clarity and the position of the eye (I).

Many patients with oro facial trauma have noother injuries, whereas others have multiple injuriesinvolving several physiological and anatomical systems.Furthermore, some patients with minor injuries may suffer

The physical and psychological morbidity in maxillofacial trauma patients 9

severe psychological problems while some severelyinjured patients may have only minor psychologicalproblems(6). It is therefore necessary that both the overallpsychological impacts of an incident and the specificpsychological problem associated with orofacial injury betaken into account when managing patients withmaxillofacial trauma(7). Thus, the objectives of this studywere to evaluate the physical and psychological morbidityof the maxillofacial trauma patients. Another objective wasto discern and compare the patients' responses tomaxillofacial trauma in relation to their age, sex, race,socioeconomic background and the types and severity oflllJury.

MATERIALS AND METHODThis study consisted of a cross-sectional overview ofpatients with maxillofacial trauma seeking/referred fortreatment in the Oral and Maxillofacial SurgeryDepartment (OMFS), Faculty of Dentistry, University ofMalaya in a period of 4 weeks in March 1999. All patientsregardless of age, sex, race, type and cause of injury andstage of treatment were included in this 4 weeks' survey.

A survey form was devised based on selectedquestions found in existing survey forms, which weretaken from the Brief Disaster Questionnaire (InternationalLiaison Group) (6), and the Late Effect of AccidentalInjury Questionnaire (7). These selected questions weremodified to reflect the objectives of this study.

The survey form was divided into three parts: thebackground information, the physical and psychologicalportions. The background information included therecording of the age, sex, occupation of the patient; thetime period from the occurrence of the injury to the time ofthe interview; the type and cause of injuries and the type oftreatment received.

The physical portion involved recording theclinical observation of the patients' face and mouth, withradiological imaging when appropriate. These include theseverity of the injuries suffered by the patients'. Severityof the injuries was divided into three categories namely,mild, moderate and severe. The mild injury was defined asthose with no obvious deformity, disfigurement, disabilityor dysfunction to the face requiring either elective orconservative treatment only. Those in the moderatecategory would have some form of deformity,disfigurement, disability or dysfunction to the face whilethose with obvious deformity, disfigurement, disability ordysfunction to the face requiring· surgical correction wereplaced into the severe category.

In the psychological portion, the patients wereasked to gauge the level of their selfcconsciousnesstowards their .disfigurement. These induded, thejr"perception and experienc~ or how other pe<?Pl~ react to

, their appearanc,:, how the' actual incident. ,and .tIi~ injury'affected them psychologically and als'o iftherewa's anychange in their social interaction brought about by thesequelae of the injury.

RESULTS _ '"During the one-month period,twcnty maxillo'facial.:traurnapatients attended the OMFS Clinic. There were 1r Malays,

4 Chinese, 3 Indians, 2 foreign (1 Indonesian and 1Bangladeshi) patients. They consisted of 15 males and 5females whose age ranges from 15 to 62 years old. Eightypercent of these patients were between 20 to 30 years ofage.

The distribution of the time period from theoccurrence of the injury to the time of the interview of thepatients was varied. The time period ranged from 14 hoursto 19 months after the associated accidents. At the time ofthe interview, 55% of the patients were discharged fromthe wards/outpatients, 25% were on medical leave andonly 20% were still in the ward.

The most common cause of maxillofacial traumain this study was due to motor vehicle accidents (MVAs),totaling 70%. Other causes included occupation-relatedinjuries (10%), domestic injuries (10%), sport-relatedaccidents (5%) and assault injuries (5%).

Half of the patients in this study who were allmales, suffered permanent physical changes. All 3categories of severity of physical changes were recorded.The mild category recorded was 30%, moderate 40% andthe severe category 30% of all cases. These changes weredental injuries, asymmetry of the nose and blindness. Thedental injuries were crown and root fractures, and toothavulsion.

Many sites in the craniofacial region weresusceptible to trauma. The most susceptible region totrauma was the mandible, most notably fractures of thebody of the mandible, which occurred up to 26% of thecases seen(Table 1). This was followed by injuries to themaxillary complex (18%), dental injuries (18%) and softtissue injuries (32%).

Ninety percent(17) of the patients claimed thatthere were reduced physical function such as eating,speaking and other physical activities. Out of these cases,85% faced difficulties in eating due to tooth loss andfractures, displaced jaws and malocclusion. Sixty fivepercent(13) of the patients reported that their speech wasaffected while fifteen percent(3) claimed reduced physicalactivity due to the maxillofacial trauma.

For the psychological component, 50% of allpatients felt self-conscious of their facial disfigurementand 25% of them tried to conceal their disfigurement. Tenpercent of the patients felt extremely sad/depressed, 25%very sad/depressed, 35% felt a little sad/depressed while30% did not feel sad/depressed after the trauma. Inmost ofthe cases evaluated, the patients did not have a problemgoing out in public.

Table 1 : Location and severity of maxillofacial traumasuffered by the patients..•.:.."'.,}..."i :~ t ",'Mild Moderate

.Severe Total

No.(' %) ,, "lWUldt Ie '2 (20)" 5 ('50) , fO (26)

Maxilla 1 ( 14) 6 ( S6) 7 ( IS)Denlal 2 ( 29) 2 ( 29) 7 ( IS)Eyes 0 ( 0) I (100) I ( 3)Base of skull 0 ( 0) I (100) I ( 3)Soft tis~e 5 ( 42) 6 ( 50) . 12 ( 32),

..•. ~:~:~~ ,:~.t (S) ;:'Ill' (:26) ""T{Jl,aI~'•. 21 ( 55) 3S (100)

10 Annals of Dentist/y, University of Malaya Vol.6 1999

DISCUSSIONMotor vehicle-related accidents were the number onecause of maxillofacial trauma in our study. The region thatbears the brunt of the trauma was usually the mandible.

In most cases the women were self-conscious incomparison to the men, even though their injuries weremuch less severe than the men. In this study, only onequarter of the patients was females. They were all between20 to 30 years old and were single. They only incurredmild to moderate injuries with no permanent physicalchanges. Nonetheless, three of them felt self-conscious oftheir appearance, although they suffered no obvious facialdeformity. Whereas in comparison, only six men out of thefifteen did, and they all suffered obvious deformity. Thiscould be attributed to the fact that women were morepreoccupied with their appearance (8).

There were trends in this study that would suggesta relation between physical and psychological morbiditydue to maxillofacial trauma where 50% of all patients feltself conscious of their facial disfigurement arising from themaxillofacial trauma. However, only 10% of patients feltvery sad or depressed while 35% and 30% felt a little sadand no feeling respectively. Raphael et al (1989)(6)reported that these feelings were apparent within a week ortwo of the injuries. These feelings were probably due tothe pain and discomfort, the changed appearance, thereduced function and the anxiety suffered by the patients.

Feelings of sadness or depression did not seem todepend on the severity of the injuries suffered. Thesefeelings tend to decrease with time, which could be due tothe reduction in active sensation and discomfort. Thepatients reportedly feels comforted in the presence of otherpeople especially their loved ones, denoting the need forpsychological support. These findings concur with otherstudies that remarked that personality traits affect theadjustment of the patients (9).

However the limited sample in this study does notpermit a statistical evaluation of the observations from thisstudy. Thus, this study was unable to dwell deeper into thesignificance of both the physical and .psychologicalmorbidity suffered by the patients. The injuries of differingnature, areas and severity made data comparison andcorrelation difficult. Other factors such as injuries to otherparts of the body would also contribute to the changes inthe quality of life, making it difficult to conclude that thepsychological response was due to the craniofacial region.The wide distribution in the time periods of occurrence ofinjury to the time of interview further made datacomparison and correlation difficult.

It was also not possible to compare the patients'responses to maxillofacial trauma with regards to age, sex,race, socioeconomic background and the types andseverity of injury due to the small number of patients inthis study. Thus, future studies of similar nature requiresthe involvement of a bigger sample and interviews with

the patient should be conducted at the same time periodafteJ; the trauma.

CONCLUSIONIn conclusion, this study appears to show thatmaxillofacial trauma may have a psychological impact onthe patients. Arising from this, it is thus important tounderstand the impact of the maxillofacial trauma to anindividual, physically and psychologically.

Even as busy clinicians, time and effort must begiven to manage these trauma patients with sympathy andempathy. There is no use mending the patients physically,but at same time, neglecting their need for psychologicalsupport, for both the physical and psychologicalcomponents are inseparable.

ACKNOWLEDGEMENTSThis paper was part of a presentation at the 'First DentalStudent Scientific Conference' for the Dental Faculty,University ofM..alaya held on 19 - 20 November 1999. Theauthors wished to thank the Dean of the Dental Faculty forapproving the fund required for this study. The authorsalso wished to thank Ms. Vivien Tuan Hui-wearn and Ms.Nor Azwa Hashim for their assistance.

REFERENCES1. Wood M, Hammerton M. Impairments and

disabilities. In David DJ, Simpson DA ed.Craniomaxillofacial trauma. Churchill Livingstone1995: 649-75.

2. Macgregor Fe. Facial disfigurement: Problems andmanagement of social interaction and implications formental health. Aesthet Plast Surg 1990; 14: 249-257.

3. Rumsey N, Bull R. The effects of facial disfigurementon social interaction. Hum Learn J Prac Res Applens1986; 5: 203-208.

4. Hill e. Psychosocial adjustment of adult burn patients:is it more difficult for people with visible scars? Br ]Occupat Ther 1985; 48: 281-283.

5. Lansdown R, Lloyd J, Hunter J. Facial deformity inchildhood: severity and psychological adjustment.Child Care Health Dev 1991; 17: 165-171.

6. Raphael B, Lundin T, Weisaeth L. A research methodfor the study of psychological and psychiatric aspectsof a disaster. Acta Psychiatr. Scand 1989 (suppl); 80:1, no. 353,1-75.

7. Malt UF, Myhrer T, Blikra G, et al. Psychopathologyand accidental injuries. Acta Psychiatr. Scand 1987;76: 261.

8. Kleck RE, Strenta Ae. Gender and responses todisfigurement in self and others. J Soc Clin Psychol1985; 3: 257-267.

9. Shepherd JP. Strategies for the study of long-termsequelae of oral and facial injuries. J Oral MaxillofacSurg 1992; 50: 390-399.