Management Of Zygomaticomaxillary Complex Fractures Research Articles

A clinical prospective study on the surgical management of zygomatico-maxillary complex fractures using two-point fixation

The ZMC fractures are one of the most frequently occurring maxillofacial injuries due to its prominence and facial contour. The ZMC forms a principle buttress of face and helps transmit occlusal forces to skull base. Fracture of zygomatic bone leads aesthetic and functional deformity. Restoration to premorbid condition is most predictable by ORIF. In this study was to evaluate efficacy of two-point internal fixation using conventional miniplates and screws for ZMC fractures. 35 patients with established unilateral isolated ZMC fractures were operated using two-point fixation method i.e. the maxillary buttress and the fronto-zygomatic suture, followed up for 3 months. Patients were assessed clinically and radiographically at different follow up intervals. Charts of patients were reviewed for age, gender, etiology, malar height analysis and vertical dystopia. 35 patients in this study, underwent ORIF under GA with two-point fixation. Preoperatively, mean malar height of the patients recorded was 66.55 ± 3.02. There was a significant increase in malar height postoperatively (P < 0.0001). 70.24 ± 2.05, at 1st week, and 69.87 ± 1.98. in 3rd and 6th weeks. Preoperatively, mean vertical dystopia of patients was 2.24 ± 0.71. Postoperative resolution of vertical dystopia was statistically significant (P<0.0001), with value of 0.52 ± 0.52.Integrity of ZMC is important in maintenance of normal facial width and prominence of cheek. Two‑point fixation shows satisfactory results functionally, esthetically and also provides additional advantage by eliminating another surgical site. Thus we conclude that our study provides a basis for further research.

‘Y’ Modification of the cutaneous incision of the preseptal transconjunctival approach for the management of zygomatico-maxillary complex fractures: A prospective clinical study

AimThe purpose of this clinical study was to evaluate the efficacy of the preseptal transconjunctival approach with Y modification of the cutaneous extension for the management of zygomaticomaxillary complex (ZMC) fractures. MethodsThis prospective interventional study was conducted at our institute from 2012 to 2020. The study included patients aged 15–65 years with displaced ZMC fractures. Patients with uncontrolled systemic conditions, infected and/or comminuted fractures were excluded. The variables evaluated were age, gender, mechanism of injury, fracture side, clinical features, surgical exposure time, adequacy of exposure, complications, scar evaluation scores and cosmetic outcomes. The parameters for comparison were operated versus non operated side Eye Fissure Index (EFI) and surgical exposure time was compared with respect to the types of scars. ResultsA total of 49 patients were included in this study. The average exposure time was 18.87 ± 1.92 min. The exposure of fracture site was excellent in 73.5 % and satisfactory in 26.5 %. The mean EFI of operated side was 34.2 ± 5.04 mm while that of non-operated side was 34.22 ± 5 mm. On comparison of the same there was no significant difference. Invisible scars were noted in 71.4 % and barely visible scars in 22.4 %. The comparison of exposure time with type of scars showed a significant association (p = 0.02). The complications noted were chemosis, lower eyelid edema, conjunctival granuloma and entropion. Cosmetic outcomes were fairly satisfactory. ConclusionThe Y modification of the transconjunctival approach can provide excellent surgical exposure without the need for a second incision. Although this approach is technique sensitive and requires experience, the advantages outweigh the learning curve. Since this approach has been widely studied, a systematized review is recommended to further substantiate its reliability and advantages.

Refining Operative Indications for Zygomaticomaxillary Complex Fracture Repair

Study Design Case-control. Objective Although zygomaticomaxillary complex (ZMC) fractures are among the most common facial injuries, the optimal approach to management remains controversial. This study analyzes the relationship between displacement measures derived from pre-operative CT imaging and clinical symptomatology to enhance surgeon understanding of the need for operative intervention. Methods A retrospective analysis was conducted on 95 patients with ZMC fractures seen at a single institution between 2015 and 2020. Patient demographics, CT characteristics, and symptoms prompting surgery were recorded from the medical record. Statistical analysis was conducted to determine relationships between radiographic characteristics, symptomatology, and need for operative intervention. Results Malar flattening or facial asymmetry was significantly predicted by lateral maxillary wall impaction (OR = 1.36 , P < .001) and anterior-posterior displacement (OR = 1.18, P = .01). Infraorbital rim step-off was significantly associated with lateral maxillary wall impaction (OR = 1.23, P < .01). Vertical displacement predicted complaint of malocclusion (OR = 1.47, P = .03). Moreover, fractures with posterior displacement greater than 2.5 mm (OR = 14.3, P < .001) or lateral maxillary wall impaction greater than 4.5 mm (OR = 12.0, P < .001) were significantly more likely to be considered operative. Fractures displaced less than 15 mm total in all directions (OR = 16.0, P < .001) were less likely to require surgery. Conclusions CT characteristics of ZMC fractures reliably predict a patient’s likelihood of developing symptoms, indicating surgical intervention. We hope these findings will aid in surgical decision-making regarding the management of ZMC fractures.

A comparison of one point versus two point fixation in the management of zygomatico-maxillary complex fractures

The zygomaticomaxillary complex (ZMC) fractures are highly frequent injuries. There is a variety of operative techniques for fixation of ZMC fractures, with no consensus about the best technique. We aim to compare one-point versus two-point fixation of tripodal zygomatic fractures. This study was carried out on 34 patients admitted to the trauma unit in Sanjay Gandhi Institute of Trauma and Orthopaedics in the period from September 2022 to August 2023. Patients were divided into two groups (group 1; one-point fixation, and group 2; two- point fixation). When compared to the one-point fixation group, only 14 patients had substantial stability with a P-value of <0.05 being statistically significant. In contrast, nearly all patients in the two-point fixation group had higher stability. In the two-point fixation group, nearly all patients had a post-operative scar; in the one-point fixation group, however, only two patients had the same scar, and the mouth opening was also improved. In two-point fixation, paraesthesia was observed in nearly seven patients, while in one-point fixation, it was present in only two patients.The one-point fixation technique for tripodal ZMC fractures is considered effective as the two-point fixation technique; and it offers advantages of scarless operation, reduced operation time, fewer complications, and lower cost.

Outcomes of Non-surgical Management of Zygomaticomaxillary Complex Fractures

IntroductionWith little evidence available in the literature, this study tries to clinically determine the efficiency and outcomes of non-surgical management of post-traumatic Zygomaticomaxillary complex (ZMC) fractures.Materials and MethodsOne hundred and three patients with post-traumatic isolated ZMC fractures managed conservatively for various reasons were identified. The patients were classified based on the Zingg et al. criteria into Types A, B, and C. We evaluated the resolution of signs and symptoms of six standard parameters over 6 months—persistent pain, restriction in mouth opening, infraorbital nerve (ION) paresthesia, aesthetic deformity, infraorbital step deformity with associated tenderness on palpation, and ophthalmic status. The study variables were then statistically analyzed using Cochran’s Q test with an associated confidence interval of 95%.ResultsA six-month follow-up revealed persisting residual deformities for all three groups. However, Type A and Type B showed significant improvement in pain reduction, mouth opening, and infraorbital nerve (ION) paresthesia. No significant improvement was noted in any of the groups for aesthetic deformity, infraorbital step deformity, and ophthalmic status. Type C, which had comminuted fracture patterns, exhibited significant defects in all the parameters. Significant inter-variable relationship between certain paired parameters was also observed.ConclusionThe Type A group is most suited for non-surgical management. Type B with a mono-bloc fracture is a crucial group that demands broader, long-term studies to extract a proper treatment protocol. Type C with severe fracture displacement validates surgical correction.

Post-operative Scar Comparison With Supraorbital Eyebrow and Upper Blepharoplasty Approach in the Management of Zygomaticomaxillary Complex Fractures.

A prospective randomized comparative study was conducted to evaluate the postsurgical scar with Supraorbital Eyebrow (SE) Approach and Upper Blepharoplasty (UB) Approach used for open reduction and internal fixation (ORIF) of zygomaticomaxillary complex (ZMC) fractures. To evaluate and compare the post-operative scar using Vancouver Scar Scale (VSS) following ORIF of ZMC fractures with SE and UB approaches. In this study, 88 patients with ZMC fractures requiring ORIF and meeting the inclusion criteria were recruited between 2019 and 2020. Patients were randomly divided into SE and UB group, 44 patients in each. Clinical and radiological assessment was done preoperatively and post-operative scar evaluation was carried out at different intervals over a period of 6 months using VSS. A blinded observer rated the scar. The results showed that after 6 months of surgery, all the 44 (100%) patients in UB group had a mild scar (VSS score 1-5), while in the SE group 34 (77.3%) patients had a mild scar (VSS score 1-5) and 10 (22.7%) had a moderate scar (VSS score 6-10). The difference between the 2 groups was statistically significant (P-value = .001). The UB approach has been established to be superior to SE approach in terms of post-operative scar as the results were statistically significant. This study can be used to advocate more frequent use of UB approach as compared to the previously popular SE approach for the management of ZMC fractures.

Contemporary Management of Zygomaticomaxillary Complex Fractures.

Zygomaticomaxillary complex fracture is one of the most commonly treated facial fractures. Accurate reduction and stable fixation of the zygoma are required to restore facial symmetry and projection and avoid functional sequalae from changes in orbital volume. Achieving optimal outcome is challenging due to the complex three-dimensional anatomy and limited visualization of all affected articulations of the zygoma. This article provides an updated overview of the evaluation and management of zygomaticomaxillary complex fractures based on available evidence and clinical experience at our center. The importance of soft tissue management is emphasized, and approaches to internal orbital reconstruction are discussed. While evidence remain limited, intraoperative imaging and navigation may prove to be useful adjuncts in the treatment of zygomaticomaxillary fractures.

Two-Point versus Three-Point Fixation in the Management of Zygomaticomaxillary Complex Fractures: A Comparative Study.

Introduction:The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore, zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements that require a protocol for management and long-term follow-up. The objectives of this study were to compare the efficacy of zygomatic bone after treatment with open reduction internal fixation (ORIF) using two-point fixation and ORIF using three-point fixation and compare the outcome of two procedures.Materials and Methods:Twenty patients were randomly divided equally into two groups. In Group A, ten patients were treated by ORIF using two-point fixation by miniplates and in Group B, ten patients were treated by ORIF using three-point fixation by miniplates. They were evaluated with their advantages and disadvantages and the difference between the two groups was observed.Results:We found that postoperative facial and neurological complications are minimum in two-point fixation group. Based on this study, open reduction and internal fixation using two-point fixation by miniplates is sufficient and the best available treatment of choice for the management of zygomaticomaxillary complex fractures.Discussion:Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Two-point interosseous fixation at the “buttress” fracture and the frontozygomatic (FZ) fracture is suitable for routine surgery. The results of these studies confirm with the present study that two-point fixation provided better stability in patients with clinical and radiological evidence of fracture in FZ and zygomaticomaxillary buttress area.

Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol

Utilization of technology to aid in the assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Limited data exist regarding the implication of intraoperative CT/3-Dimensional imaging on decision making in the management of zygomaticomaxillary complex (ZMC) fractures. This study characterizes the utilization of the intraoperative CT scanner for ZMC fracture surgery and analyzes the impact of the intraoperative CT scanner on fracture management. Using these findings, we sought to propose an algorithm to guide the appropriate utilization of intraoperative 3-Dimensional imaging in ZMC fracture surgery. This retrospective case series evaluates the use of the intraoperative CT scanner for orbitozygomatic trauma surgery at a level 1 trauma center from February 2011 to September 2016. We evaluated the preoperative CT images assessing for the number of displaced sutures, the presence of adjacent fractures requiring fixation, the presence of comminution of the zygomaticomaxillary buttress or body of the zygoma, as well as the number of axes displaced ≥ 5mm. This information was evaluated to provide guidance on the appropriate utilization of the intraoperative scanner in ZMC fracture management. A total of 71 patients were identified to have intraoperative facial CT scans and surgery for ZMC fractures over the study time period. There was a 23.9% (17/71) CT directed revision rate. There was a significantly increased likelihood of CT directed revision for fractures with adjacent fractures requiring fixation, and those with ≥ 2 axes displaced ≥ 5mm. Using these findings, we proposed the ZYGOMAS algorithm outlining the indications for use of intraoperative CT in management of ZMC fractures. If available, intraoperative CT/3-Dimensional imaging should be utilized in the management of ZMC fractures with the requirement for orbital floor reconstruction, where adjacent fractures require fixation and/or when ≥ 2 axes are displaced ≥ 5mm.

Surgical Management of Zygomatico-Maxillary Complex Fractures with Two Point Fixation- A Clinical Case Presentation & Review of Literature

&Background: Zygomatico-maxillary complex fractures are the most common mid face among all craniofacial fractures. Various surgical approaches and their complications can be done to check the outcome measurement for displaced type of Zygomatico-Maxillary Complex (ZMC) fractures & long term follow up. &Objectives: This case presentation are to check the treatment outcome of zygomatic fractures after treatment with Open Reduction Internal Fixation (ORIF) using 2 point fixation technique. &Case Report: Patient reported to the Department of Oral & Maxillofacial Surgery at Swargiya Dadasaheb Kalmegh Smruti Dental College & Hospital, Nagpur with chief complaints of pain & swelling over right side of face with Periorbital edema & Subconjuctival hemorrhage. On investigation it was diagnosed as Unilateral Displaced ZMC Fractured which was treated with Open Reduction Internal Fixation (ORIF) using two-point fixation technique. &Conclusion: We found that postoperative facial & neurological complications are minimum in two point fixation technique. Open reduction and internal fixation using two-point fixation by miniplates is sufficient for reduction of fracture & postoperative stability at the fracture site and minimize the chance of postoperative complications.

Comparison of infraorbital nerve recovery after open and closed reduction of zygomaticomaxillary complex fractures

<p class="abstract"><strong>Background:</strong> Zygomaticomaxillary complex (ZMC) fracture is quite commonly seen fracture in the road side accidents (RTA). It is the second most common fracture after nasal bone fractures. Infraorbital nerve is almost always involved with ZMC fractures which can be treated with open reduction and internal fixation or closed reduction.</p><p class="abstract"><strong>Methods:</strong> The aim of this study was to compare the recovery of infraorbital nerve paresthesia following open reduction and internal fixation verses closed reduction in the management of ZMC fractures. </p><p class="abstract"><strong>Results:</strong> Two groups with n=50 patients each, qualifying our inclusion criteria were selected, examined, reduced by open and closed reduction respectively and followed up.</p><p class="abstract"><strong>Conclusions:</strong> The functional infraorbital nerve recovery was found among 74% patients those who underwent open reduction and internal fixation. While the patients treated with closed reduction the functional nerve recovery was seen in 52%.</p>

Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review.

Despite the prevalence of zygomaticomaxillary complex (ZMC) fractures, there is no consensus regarding the best approach to management. The aim of this study is to determine differences in ZMC fracture treatment among various surgical specialties. A survey was conducted regarding treatment of patients with different ZMC fractures that included a minimally displaced fracture (Case 1), a displaced fracture without diplopia (Case 2), a displaced fracture with diplopia (Case 3), and a complex comminuted fracture (Case 4). The survey was distributed to members of plastic surgery, oral maxillofacial surgery, and otolaryngology societies. The rates of surgical treatment, exploration of the orbital floor, and plating three or more buttresses were analyzed among the specialties. A total of 173 surgeons participated (46 plastic and reconstructive surgeons, 25 oral and maxillofacial surgeons, and 102 otolaryngologists). In Case 1, a significantly higher percentage of plastic surgeons recommend an operation (p < 0.01) compared with other specialties. More than 90% of surgeons would perform an operation on Case 2. Plastic surgeons explored the orbital floor (p < 0.01) and also fixated three or more buttresses more frequently (p < 0.01). More than 93% of surgeons would operate on Case 3, with plastic surgeons having the greatest proportion who fixed three or more buttresses (p < 0.01). In Case 4, there was no difference in treatment patterns between specialties. Across the specialties, more fixation was placed by surgeons with fewer years in practice (<10 years). Conclusion There is no consensus on standard treatment of ZMC fractures, as made evident by the survey. Significant variability in fracture type warrants an individualized approach to management. A thorough review on ZMC fracture management is provided.

Does Training Background Influence Decision-Making in the Management of Zygomaticomaxillary Complex Fractures?

Management of zygomaticomaxillary complex (ZMC) fractures should be based on injury patterns and not on training background. This study assessed management decisions for ZMC injuries among surgeons with different training backgrounds. This was a cross-sectional study of surgeons who evaluated 5 ZMC injury cases. The primary predictor variable was training background: plastic and reconstructive surgeons (PRSs), craniofacial PRSs (c-PRSs), and oral and maxillofacial surgeons (OMSs). Other variables were years in practice, fellowship training, practice scope, and comfort with managing facial injuries. The primary outcome variable was management of the ZMC and orbital floor (operative vs nonoperative). Secondary outcome measurements were related to surgical approaches and fixation. Descriptive, bivariate, and regression statistics were computed. Twenty-one surgeons (7 PRSs, 7 c-PRSs, and 7 OMSs) with an average of 14.4 ± 12.6years of experience provided a total of 105 treatment plans. There was significant agreement between c-PRSs and OMSs for management of ZMC and orbital floor injuries (rs= 0.70 and 0.76, respectively; P ≤ .001). PRSs did not have substantial agreement with c-PRSs or OMSs with regard to ZMC fractures (rs= 0.39 and 0.49, respectively; P ≤ .06), but significant agreement with regard to orbital floor injuries (rs= 0.70 and 0.76, respectively; P < .001). In a regression model, injury pattern was the only factor associated with operative management (P ≤ .001). There is substantial agreement between OMSs and c-PRSs regarding the management of ZMC fractures and associated orbital floor injuries.

Clinical Evaluation of Neurosensory Changes in the Infraorbital Nerve Following Surgical Management of Zygomatico-Maxillary Complex Fractures.

Zygomatico-orbital fractures are the second most common facial injuries. Trauma to mid-facial region can lead to an alteration or loss of sensation in the facial region which sometimes requires early surgical intervention to aid in an early recovery. To evaluate the different neurosensory changes in the infraorbital nerve function following common treatment modalities used in the management of zygomatico-maxillary complex fractures. Thirteen patients selected for the study had unilateral zygomatic complex fracture with altered sensation in the region of distribution of the infraorbital nerve. The fractures were managed either by reduction followed by internal fixation with mini-plates (Group A), reduction alone (Group B) or conservatively (Group C). Infraorbital nerve function tests were done by mechanical, heat and pain threshold detection. Evaluation was done on 1(st), 3(rd), 7(th) day, one month, three months and six months interval in a manner similar to that done at the beginning of the study (Day0). A male predominance with male:female ratio of 5.5:1 and an age range of 21 to 50 years was found with the right side mostly affected. Road traffic accident was the most common aetiology. Most common clinical presentations were sub-conjunctival haemorrhage (84.61%), flattening of the malar prominence (69.23%) with deficit in neurosensory function of infra orbital nerve. Recovery in the infraorbital nerve function was relatively complete in 76.92% cases with partial recovery in 23.07% of the patients. Marked improvement in the neurosensory function of the infraorbital nerve was found when some form of treatment either in the form of Open Reduction and Internal Fixation (ORIF) or approach through Gillie's temporal or Keen's intraoral approach were applied as compared to when conservative treatment was provided. In zygomatic complex fractures, any form of treatment employed brought about decompression of the infraorbital nerve which aided in the recovery of the nerve within a span of 1-6 months, except when no treatment was applied.

Optimizing the Surgical Management of Zygomaticomaxillary Complex Fractures

Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation. However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications. The goal of this article is to provide an overview of ZMC fractures and discuss treatment options, with an emphasis on providing surgical pearls to optimize outcomes.

A statistical analysis and review of management of zygomaticomaxillary complex fractures

Purpose: To evaluate the aetiology, incidence, clinical findings, radiographic findings, demographic and treatment data of unilateral zygomaticomaxillary complex fracture (ZMCF) managed during period of 2 years. Patients and methods: A total of 25 patients with ZMCF were treated and reviewed. Patients with isolated orbital fracture were excluded. Demographic data was retrospectively analysed and reviewed with respect to age, gender, aetiology, clinical findings, radiographic findings, treatment and postoperative complications. All the patients were assessed and operated by same team of surgeons. Results: Majority of fractures were sustained between the age groups of 20–40 years by males (88%), resulting from two wheeler accidents (80%). Isolated ZMCFs were present in 19 cases (76%). Most common clinical finding was paraesthesia of cheek (56%), while the commonest radiographic findings were fracture of zygomaticofrontal and zygomaticomaxillary suture. Surgical treatment included was Gillie's approach (56%) and open reduction with fixation (88%) and without fixation (12%). Postoperative complication encountered was persistent paraesthesia (8%). Conclusion: Main aetiological factor was two wheeler accidents. Treatment done with/without plates showed satisfactory results with adequate aesthetic and function with very low complication rate.

Etiology and management of zygomaticomaxillary complex fractures in the Armed Forces

Background: The nature of duties in the Armed Forces predisposes its personnel to various kinds of injuries. The rise in violence coupled with an exponential increase in motorized population has contributed towards maxillofacial injuries. The aim of this study was to determine the incidence, cause and pattern of various injuries resulting in fracture of the zygomaticomaxillary complex in Armed Forces personnel and their families. Methods: A study was conducted between January 2001 – December 2002 in maxillofacial surgical wing of an Army Dental Centre with specific regard to age, sex, location and etiology of zygomaticomaxillary complex fracture. Out of 201 maxillofacial injuries received, 87 individuals were treated for zygomaticomaxillary fractures. Majority of the individuals were in their third decade of life and road traffic accident was the leading cause of the fractures. Results: Uneventful recovery was there in 81 individuals (93.10%). Six patients (6.89%) had post operative complications in the form of enophthalmos, hypophthalmos, paraesthesia, diplopia and facial asymmetry. These complications were subsequently treated successfully as a secondary procedure for all the patients. Conclusion: Facial bones, especially of the middle third of the face, are composed of a network of fragile bones which give way in case of force to a lesser extent than other parts of the body. It is imperative to educate people regarding the importance of restraints and use of protective headgears/use of seat belts while travelling in motorized transport.