Zygomaticomaxillary Complex Fractures Research Articles

Right Zygomaticomaxillary Complex Fracture With Rupture Of Internal Maxillary Artery: A Case Report

Background: This case report gives prominence to the risk of delayed, possibly life - threatening bleeding following mid-facial fractures. Methods: A 42-year-old male was involved in an accident during which he suffered from right zygomaticomaxillary complex fractures with massive bleeding. The hemoglobin level was decreased from 11 to 5 g/dL, suspected caused by rupture of internal maxillary artery. Incidence of massive bleeding due to zygomaticomaxillary complex fracture is quite rare. Patient also felt right visual loss due to retrobulbar hematoma compression. He was given nasal tampon and transfusion in referral hospital. The patient had fracture reconstruction (reduction and fixation), ligation of right facial artery and temporary ligation of external carotid artery with Ethiloop for 5 days. Nevertheless, the bleeding still occurred. The patient then underwent Digital Subtraction Angiography (DSA) and coiling procedure from radiologic intervention. Twenty days after last procedure, we ligated the right external carotid artery due to recurrence of bleeding. Results: There are many modalities and procedure for the therapy of massive bleeding on midface fracture, ranging from conservative, minimal invasive to operative surgery. Patient that has gone through DSA procedure can still bleed. After ligation of external carotid artery, no more bleeding occurred. Conclusion: Patient suffering from extensive midfacial fracture, the internal maxillary artery and its branches are at special risk of injury due to their close anatomical relationship to bony structures. Its bleeding is possibly life threatening. Tampon and nasal packing are non-essential initial treatment, but digital pressure procedure can be performed to stop the bleeding temporarily. Ligation of external carotid artery is the best choice of treatment for permanent outcome.

Reduction of Zygomatic Complex Fracture Using Combination of Microplate and Miniplate Osteosynthesis

Zygomaticomaxillary complex (ZMC) fracture is the second most common facial bone fractures after nasal bone and has been extensively described in the literature. Numerous techniques have been described for the reduction of ZMC fracture. This case report presents a 21-year-old man who was involved in a traffic accident and who subsequently presented with a ZMC fracture. The patient was treated through an open reduction and internal fixation procedure using a titanium microplate and miniplate combination.

Reevaluating the Utility of Maxillary Sinus Opacification as a Screening Tool for Facial Bone Fracture a Decade After Its Original Analysis.

In 1997, Lambert and colleagues demonstrated that the absence of sinus fluid on head CT essentially excludes a fracture involving the sinus walls. Our purpose is to reevaluate this association utilizing the current standard of imaging technology. With improved image resolution, we aim to reassess whether the sensitivity and specificity of the “clear sinus sign” are improved or worsened. Furthermore, the current standard of care is to obtain a CT of the facial bones along with a head CT when facial trauma is suspected, so we also analyzed the association of the "clear sinus sign" with nasal bone and mandible fractures. We identified 629 facial bone CT scans performed on adult patients in the emergency department between July 2012 and May 2013. They were retrospectively analyzed by three reviewers for the presence of facial bone fracture and/or fluid opacification of at least one paranasal sinus (as defined by either complete sinus opacification or an air-fluid level - circumferential mucosal thickening was considered the absence of fluid). We found that sinus opacification was 98.8% specific for facial bone fracture but only 44.7% sensitive. However, for complex facial fractures, such as zygomaticomaxillary complex, orbital, and sinus fractures, the lack of sinus fluid is significantly more sensitive at 91%. Therefore, our results for complex facial fractures are congruent with those of the previous studies conducted by Lambert, et al. and Lewandowski, et al. However, we also demonstrate that sinus opacification is not specific for nasal bone or mandibular fractures.

Meta Analysis of Etiology and its Clinical and Radiological Correlation in Cases of Craniomaxillofacial Trauma.

The present study was planned to investigate the etiology of injuries and to analyze correlation between clinical and radiological findings in cases of craniomaxillofacial trauma. An 18months cross-sectional study was done and 325 patients with maxillofacial fractures were analyzed from January 2013 to June 2014 who reported to the department of oral and maxillofacial surgery, Aligarh, Uttar Pradesh. Data was recorded in a preformed case sheet which included: patient's demographic data, cause of injury, type of injury, treatment plan. Out of the 325 patients, 74.4% were males with a male: female ratio of 2.91:1. The 21-30year age group was found to be maximum. Road traffic accidents accounted for 71.3%, followed by fall from height (19%) and assault (9.5%). Most commonly involved vehicles were two wheelers followed by public transport. Mandibular fractures (65%) were most prevalent, followed by zygomaticomaxillary complex (44.27%), parietal bone (48%) and orbital fractures (21.3%). Thirty-seven fractures (7.14%) were missed clinically which were confirmed later by radiographic technique. Maximum were in cranium region (57%) followed by mandible (27%), mid face region (16.21%). Thirty-three fractures (6.37%) were overestimated or suspected clinically which could not be confirmed by radiographic technique. Maximum were in mandible (48.5%) followed by mid face (36.33%) and cranium (15.15%). The idea behind this article is to analyze the various trends and affecting factors and correlation between clinical and radiological findings. A better understanding of the above said would help in future treatment planning and management of facial injuries.

Functional Evaluation of the Behavior of Masticatory Muscles in Zygomaticomaxillary Complex Fracture: A Prospective Study.

The purpose of this study is to functionally evaluate the behavior of the masticatory muscles (masseter and temporalis) following zygomaticomaxillary complex (ZMC) fractures by assessing bite force, electromyography (EMG), and mandibular movements. Group I consisted of 20 patients with unilateral ZMC fractures who were treated surgically with one-, two-, or three-point fixations at the frontozygomatic, infraorbital, or zygomaticomaxillary buttress region as per clinical and radiological assessments. Group II control group included 20 normal patients. The muscle activity was functionally evaluated before and after the surgery for a period of 6 months. The evaluation consisted of bite force measurement, EMG analysis of masseter and temporalis muscles, and measurements of mandibular movements. There was an increase in bite force and EMG activity throughout the evaluated postoperative period, but at the end of 6 months, the values were still below the control levels for majority of the patients. Maximum mouth opening increased considerably after the surgery. According to bite force and EMG, the masticatory musculature returned to near normal levels by the 3rd month after the surgery. Management of fractures of the zygoma by open reduction and fixation raises the question of the location of fixation points owing to the action of masseter and temporalis on the ZMC. This study supports the current clinical concept of minimized fixation in treating ZMC fractures.

Surgical Methods of Zygomaticomaxillary Complex Fracture.

BackgroundZygoma is a major buttress of the midfacial skeleton, which is frequently injured because of its prominent location. Zygoma fractures are classified according to Knight and North based on the direction of anatomic displacement and the pattern created by the fracture. In zygomaticomaxillary complex (ZMC) fracture many incisions (lateral eyebrow, lateral upper blepharoplasty, transconjunctival, subciliary, subtarsal, intraoral, direct percutaneous approach) are useful. We reviewed various approaches for the treatment of ZMC fractures and discussed about incisions and fixation methods.MethodsA retrospective review was conducted of patients with ZMC fracture at a single institution from January 2005 to December 2014. Patients with single zygomatic arch fracture were excluded.ResultsThe identified 694 patients who were admitted for zygomatic fractures from which 192 patients with simple arch fractures were excluded. The remaining 502 patients consisted of 439 males and 63 females, and total 532 zygomatic bone was operated. Orbital fracture was the most common associated fracture. According to the Knight and North classification the most frequent fracture was Group IV. Most fractures were fixated at two points (73%).ConclusionWe reviewed our cases over 10 years according to fracture type and fixation methods. In conclusion, minimal incision, familiar approach and fixation methods of the surgeon are recommended.

Retrospective study of maxillofacial trauma in Alexandria University: Analysis of 177 cases

Purpose The aim of the present study was to analyze retrospectively the age and sex distribution, etiology, and location of mandibular and midface fractures in a sample of patients from the Oral and Maxillofacial Surgery Department, Alexandria University, Egypt. Patients and methods The data for this study were obtained from the medical records of 177 cases treated at the Oral and Maxillofacial Surgery Department, Alexandria University, from April 2010 to August 2011. Results The total number of patients with maxillofacial trauma presenting to the Oral and Maxillofacial Surgery Department, during the period from April 2010 to August 2011 was 177 patients. The male population was more frequently affected compared with the female population, males were more frequently affected than females, where males accounted for 82% (145 patients) and females accounted for 18% (32 patients) of the study population with a ratio of 4.5:1. The ages of the patients in the study population ranged from 1.5 to 75 years, with a mean of 25.56 ΁ 14.04 years. Road traffic accident (RTA) was the most common cause of trauma, accounting for 77.97% (138) of cases. A total of 103 cases had isolated mandibular fractures, 54 cases had midface fractures only, and 20 patients had mandibular fractures associated with midface fractures. The most common site in mandibular fractures was the parasymphysis (40.64%; 63 fractures), and zygomaticomaxillary complex fractures were the most common, accounting for 70.13% (54 fractures) of midface fractures. Most of the fractures were treated by means of open reduction and internal fixation using plates (144 cases; 81.36%), whereas the remaining 33 (18.64%) cases were treated conservatively by means of closed reduction. The duration of hospital stay ranged from 0 to 26 days, with an average of 7.34 ΁ 4.64 days. Conclusion RTAs are the main etiological factor in maxillofacial injuries occurring in Alexandria, with men between 21 and 45 years of age being affected predominantly. Preventive strategies remain the best way to reduce the sequelae of RTAs.

Primary Infraorbital Foramen Decompression for the Zygomaticomaxillary Complex Fracture: Is It Essential?

The frequency of zygomaticomaxillary fracture is second only to nasal bone fracture. Up to 30% to 80% of zygomaticomaxillary fracture patients complain of sensory disturbance results from infraorbital nerve injury. The objective of this study was to detect what factors are related to infraorbital nerve recovery and specifically to investigate decompression of infraorbital foramen improves sensory recovery. A total of 257 patients were assessed with unilateral zygomaticomaxillary complex fracture, treated with open reduction and internal fixation with orbital floor reconstruction. Of these, 166 patients followed up over 6 months were included in this study. The data collected included age, sex, pre, and postoperative sensory score measured by visual analogue scale (range: 0-10). Sensory score was measured at the infraorbital nerve innervation. The impact of decompression operation on the change of sensory score was compared. Statistical analysis was performed using SPSS 18.0 software (SPSS Inc, Chicago, IL). In patients with preoperative hypoesthesia, difference between postoperative and preoperative sensory score was 3.2 (decompression group), 4.4 (nondecompression group), respectively, but not significant (P > 0.05). In patients without preoperative hypoesthesia, difference between postoperative and preoperative sensory score was -0.2 (decompression group), -0.3 (nondecompression group), respectively, and did not show significant association (P > 0.05). Based on this result, in patients with preoperative hypoesthesia, infraorbital decompression operation is not useful for sensory recovery. This result indicates infraorbital sensory disturbance occurs from not only pinched nerve injury at the infraorbital foramen but also traction nerve injury at the other part of the nerve.

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.

Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes.

Maxillofacial fractures in pediatric trauma patients require significant force and frequently are associated with concomitant injuries. The anatomic and developmental differences between the adult and child that impact patterns of injury also affect management and outcomes. The aim of this study was to analyze fracture location, mechanism, concomitant injuries as well as methods of surgical treatment and outcomes, to improve management of this patient population. A retrospective review was conducted of pediatric patients with maxillofacial fractures presenting to a level-1 trauma center during an 8-year span. Only patients requiring surgical intervention, 204, were included in this study. Data pertaining to the location of injury, mechanism, associated injuries, surgical treatment, outcomes, and complications were analyzed. The most common fracture location was the mandible (36.3%), then the nasal bone (35.3%), followed by the tripod fracture (10.8%). A total of 30.7% of patients were involved in motor vehicle accidents, with the next most common mechanisms being sports (24.4%), and assault (13.7%). A total of 46% of the patients sustained concomitant injuries, with the majority involving cerebral trauma (14.7%) or the extremities (9.3%). Total 75.4% of all fractures, excluding the nose, were treated with open reduction and internal fixation (ORIF). Our complication rate was 11.2%. Pediatric craniofacial trauma remains a frequent presentation to the emergency department of trauma centers. Facial fracture patterns and mechanism of trauma observed in the pediatric population presenting to this facility are consistent with incidences reported in the literature. Knowledge of treatment options and potential complications is an important tool in the management of the pediatric trauma patient.

Traumatic Carotid-Cavernous Sinus Fistula in a Patient with Facial Bone Fractures.

Carotid-cavernous sinus fistulas (CCFs) are abnormal connections between the cavernous sinus and the carotid arterial system (the internal carotid artery, external carotid artery, or both). CCFs may be classified as spontaneous or acquired and as direct (high blood flow) or dural (low blood flow) [[1]]. Direct CCFs represent 70% to 90% of all CCFs, and mostly result from head trauma, especially basal skull fractures [[2]]. Patients with CCFs may present with signs and symptoms such as conjunctival chemosis, decreased vision, proptosis, diplopia, orbital pain, audible bruits, headache, and blindness [[2] [3]]. In this report, we present the case of a 49-year-old man with a CCF and ophthalmic symptoms, resulting from a left zygomaticomaxillary complex fracture.

Applications of three-dimensional surface imaging combine with computer-assisted navigation for zygomaticomaxillary complex fractures

Applications of three-dimensional surface imaging combine with computer-assisted navigation for zygomaticomaxillary complex fractures

Pterygoid Plate Fractures: Not Limited to Le Fort Fractures.

Pterygoid plate fractures are often described in the setting of Le Fort fractures. The goal of this study was to define other craniofacial fracture patterns causing injury to the pterygoid plates. A retrospective review of computed tomography (CT) scans obtained on craniofacial trauma patients over a 5-year period revealed 209 patients with pterygoid plate fractures. Pterygoid plate fractures in 78 patients (37.3%) were unrelated to Le Fort fractures. Common causes included sphenotemporal buttress fractures in 26 patients (33.3%), temporal bone fractures in 18 patients (23.1%), zygomaticomaxillary complex fractures in 17 patients (21.8%), and displaced mandible fractures in 14 patients (17.9%). These findings indicate that approximately one third of pterygoid plate fractures do not result from Le Fort pattern injuries and that the craniofacial surgeon should have a broad differential for causes of pterygoid plate fractures when reviewing trauma imaging.

Electromyography assessment in zygomaticomaxillary complex fractures.

The aim of this study was to assess the activity of the masseter and temporalis muscles using surface electromyography (EMG) in patients with zygomaticomaxillary complex (ZMC) fractures. This prospective study was carried out on 25 patients who had ZMC fractures. Fifteen patients were managed by open reduction and rigid fixation (ORIF) using titanium miniplates. This study, using surface electromyography, analyzed the activity of the masseter and temporalis muscles of 25 patients with ZMC fractures; 15 of them were surgically treated under general anesthesia (GA). Evaluations were made before surgery and 6weeks after surgery by recording the mean of muscle contraction of 20 motor unit action potential (MUAP) against resistance, and statistical analyses were performed. A significant EMG difference between the normal and ZMC fracture sides was found (P < 0.0001) for both masseter and temporalis muscles and was significantly improved after ORIF. However, postoperative EMV values of the repaired side was significantly less than measured postoperatively in the normal side (P < 0.0001) for both muscles. ZMC fractures significantly diminish muscular activity of the masseter and temporalis and even though significant recovery of muscle activity was revealed after 6weeks, it is still less than normal activity, highlighting the importance of postoperative rehabilitation.

Ocular Injuries Associated with Midface Fractures: A 5Year Survey.

The aim of this study is retrospective analysis of ocular injuries after maxillofacial trauma reporting to the Department of Oral and Maxillofacial Surgery at V.S. Dental College and Kempegowda Institute of Medical Sciences and Hospital, Bangalore. A retrospective analysis of ocular injuries following facial trauma from 2008 to 2013. Road traffic incident was the most common etiology (55.46%). Zygomaticomaxillary complex fracture was the most common fracture associated with ocular injuries (67.22%). Out of 119 patients, 5 had severe visual impairment and (0.84%) had blindness. Maxillofacial trauma particularly that associated with Lefort II, Lefort III and Zygomatico maxillary complex fracture may lead to opthalmic injuries and even blindness. A thorough opthalmic examination should be carried out for every patient with maxillofacial trauma and suspected cases should be placed under closed observation so that immediate and active treatment can be taken if necessary.

How Can Paresthesia After Zygomaticomaxillary Complex Fracture Be Determined After Long-Term Follow-Up? A New and Quantitative Evaluation Method Using Current Perception Threshold Testing

The aims of the present study were to analyze the effectiveness of current perception threshold (CPT) testing to determine patients' minor paresthesia of the infraorbital region after open reduction and internal fixation (ORIF) for unilateral zygomaticomaxillary bone fracture (UZF) and to clarify which nerve fiber was related to the paresthesia. We conducted a retrospective cohort study of patients who had undergone ORIF after UZF. We also performed neurosensory testing for healthy volunteers who served as the control group. The predictor variables were the period of measurement of Semmes-Weinstein monofilament (S-W) testing and CPT testing (preoperatively and 1 and 5 years postoperatively), measurement side, and disease status (UZF or control). The outcome variables were paresthesia status of the infraorbital nerve region and the results of S-W and CPT testing in both UZF and control groups. The differences in the S-W and CPT values between the affected and unaffected sides in the UZF group and between the UZF and control groups were analyzed by t test (P < .05 was considered significant). The present study included 10 patients (6 males and 4 females), with an average age of 25.0 ± 12.7 years, and 21 controls (10 males and 11 females), with an average age of 24.3 ± 1.7 years. In the control group, the CPT and S-W test results did not show any significant differences between the left and right sides. All 10 patients had paresthesia at 1 and 5 years postoperatively. At 5 years postoperatively, the S-W values in all patients showed normalization. From the results of CPT testing, only the A-β fiber function showed significant improvement at 5 years postoperatively. The CPT test was an effective sensory test for determining minor paresthesia that could not be detected using S-W testing. Paresthesia of the infraorbital nerve region was caused by the damaged A-δ and C fibers.

Risk of Ear-Associated Diseases After Zygomaticomaxillary Complex Fracture.

Investigate the risk of ear-associated diseases after zygomaticomaxillary complex (ZMC) fracture in a population-based retrospective cohort study. This is a retrospective cohort study using Taiwan's National Health Insurance Research Database of reimbursement claims. A total of 1,330 ZMC fracture patients and 5,320 non-ZMC fracture participants were included and newly developed ear-associated disease data were collected. A Poisson regression and multivariate Cox proportion hazard regression were used for data analysis. The ZMC fracture cohort had a higher incidence of tinnitus than non-ZMC fracture cohort (IRR 1.64, 95% CI 1.37-1.96), particularly in younger patients (≤34years of age; IRR 4.05, 95% CI 3.18-5.15) and male patients (IRR 2.08, 95% CI 1.12-3.73). ZMC fracture patients also showed a significantly increased risk of having trigeminal neuralgia [IRR 4.06, 95% CI 3.34-4.94, adjusted HR 4.07 (1.02-16.3)]. For sudden hearing loss and peripheral vertigo, the incidence densities were higher in the ZMC fracture cohort, but these relationships were not significant in the multivariate Cox proportional hazard regression analyses (HR 2.69, 95% CI 0.76-9.53 for risk of sudden hearing loss; HR 1.36, 95% CI 0.77-2.40 for risk of peripheral vertigo). The findings of the study suggest an increased risk of ear-associated diseases among individuals with ZMC fractures, particularly within 2-years follow-ups after injury. We suggest performing detailed examinations for ear-associated diseases in patients with ZMC fractures for early diagnosis and adequate treatment.

Management of tripod fractures (zygomaticomaxillary complex) 1 point and 2 point fixations: A 5-year review.

The zygomaticomaxillary complex (ZMC) plays a key role in the structure, function, and esthetic appearance of the facial skeleton. They can account for approximately 40% of mid-face fractures. They are the second most common facial bone fracture after nasal bone injuries. The fracture complex results from a direct blow to the malar eminence and results in three distinct fracture components that disrupt the anchoring of the zygoma. In addition, the fracture components may result in impingement of the temporalis muscle, trismus (difficulty with mastication) and may compromise the infraorbital foramen/nerve resulting in hypesthesia within its sensory distribution. A 4-year retrospective review of all patients treated with ZMC fractures at oral and maxillofacial surgery department, sree balaji dental college and hospital was performed. Computed tomography scans were reviewed. Demographics, treatment protocols, outcomes, complications, reoperations, and length of follow-up were identified. A total of 245 patients was identified by the Current Procedural Terminology codes for ZMC fractures. Closed or open reduction methods were performed with the goal of treatment being preservation of normal facial structure, sensory function, globe position, and mastication functionality. Unacceptably poor surgical outcomes are uncommon. Significant facial asymmetry requiring surgical revision occurs in 3-4% of patients. Postoperative infection rates are extremely low, and these infections nearly always resolve with oral antibiotics. In general, the long-term prognosis after repair of ZMC fractures is very good.

One point fixation of zygomatic tripod fractures in the zygomatic buttress through Keen's intraoral approach: A review of 30 cases.

For decades, facial beauty and esthetics have been one of the most important quests of the human race. The lateral prominence and convexity of the zygomatic bone makes it the most important bone for providing the aesthetic facial look and sets up the facial width but at the same time this prominence and convexity makes this bone more vulnerable to injury. Zygomatic complex fractures or tripod fractures are the second most common fractures after nasal fractures among facial injuries. Several studies have been undertaken regarding the reduction and fixation of zygomatic fractures with mini plates and screws. In 2002 Fujioka et al in vivo studies successfully proved that one point fixation at the zygomaticomaxillary complex gives three point alignment and sufficient rigidity when the fractures are not comminuted. In this article, 30 cases have been reviewed with one point fixation of zygomatic complex tripod fractures at the zygomatic buttress through Keen's intraoral approach along with advantages and disadvantages.

Infraorbital nerve transpositioning into orbital floor: a modified technique to minimize nerve injury following zygomaticomaxillary complex fractures.

ObjectivesTranspositioning of the inferior alveolar nerve to prevent injury in lower jaw has been advocated for orthognathic, pre-prosthetic and for implant placement procedures. However, the concept of infra-orbital nerve repositioning in cases of mid-face fractures remains unexplored. The infraorbital nerve may be involved in trauma to the zygomatic complex which often results in sensory disturbance of the area innervated by it. Ten patients with infraorbital nerve entrapment were treated in similar way at our maxillofacial surgery centre.Materials and MethodsIn this article we are reporting three cases of zygomatico-maxillary complex fracture in which intra-operative repositioning of infra-orbital nerve into the orbital floor was done. This was done to release the nerve from fractured segments and to reduce the postoperative neural complications, to gain better access to fracture site and ease in plate fixation. This procedure also decompresses the nerve which releases it off the soft tissue entrapment caused due to trauma and the organized clot at the fractured site.ResultsThere was no evidence of sensory disturbance during their three month follow-up in any of the patient.ConclusionInfraorbital nerve transposition is very effective in preventing paresthesia in patients which fracture line involving the infraorbital nerve.