Zygomaticomaxillary Complex Fractures Research Articles

Computed tomography scan evaluation of adequacy for reduction of zygomatic arch fracture using Gillie's temporal approach

Aim: The zygomatic bone is the key component of the structural facial aesthetics as it constitutes the prominence of the cheek bone. Also, the most frequent clinical findings in zygomatic arch fracture includes limitation of jaw movement and flattening of cheek. So it is necessary to elevate the arch precisely. Therefore, a prospective study was conducted toevaluate adequacy for reduction of zygomatic arch fracture using Gillie’s temporal approach with the help of pre-operative and post-operative CT scan. Materials & methods: 4 patients, who received surgical treatment of zygomatico-maxillary complex (ZMC) fractures at the Department of Oral and Maxillofacial Surgery were examined for displacement of zygomatic arch pre-operatively with CT scan then re-evaluated the same site post-operatively. Results: The pre-operative mean displacement at the zygomatic arch, in millimetres (mm), was M = 2.8, SD = 3.011. After reduction, the post-operative displacement was M = 0.4, SD = 0.699. The percentage of reduction was M = 85, SD = 24.15. Conclusion: Gillie’s temporal approach for zygomatic arch fracture reduction is precisely considerable due to its simple and effective method and cosmetically more acceptable. Keywords: Zygomatic fractures, Zygomatico-maxillary complex, Fracture

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.

The Retrospective Study of Closed Reduction of Nasal Bone Fracture.

Purpose:This study was conducted in order to investigate the therapeutic effect of closed reduction according to a classification in patients with nasal bone fracture.Methods:The study was conducted retrospectively on 186 patients with a mean age of 38 years (range: 7 to 80 years). All patients were diagnosed by clinical and radiologic examination, and then classified according to Hwang’s classification by computed tomography. The patients were further classified by their age, gender, causes of fracture, operation timing after fracture, concurrent facial bone fracture, and complications. All patients underwent the same reduction and treatment protocol and were then followed up regularly for at least three months.Results:The cause of the fracture was slip down, and the highest prevalence was shown in the 20s. The mean operation timing after fracture was 4.1 days (range: 1 to 14 days), and it tended to be longer in the case of defected septal bone or more severe fracture. The most common concurrent facial bone fracture was orbital blow-out fracture, and zygomaticomaxillary complex and maxillary fracture occured frequently. The largest number of complications occurred in class III and IIBs patients, and the main complication was postoperative pain.Conclusion:Results of nasal bone closed reduction on the 186 patients showed that serious complications rarely occurred. Closed reduction is generally an effective treatment for nasal bone fracture. However, in the case of severe concurrent septal bone fracture or comminuted fracture with depression, open reduction should be considered. Further study with a larger number of patients and further classification is required.

Intimate partner violence: an underappreciated etiology of orbital floor fractures.

To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence-associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non-IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Facial Fractures Secondary to Bicycle Accidents

Objectives: (1) Determine the incidence of facial fractures. (2) Characterize the type of craniofacial injuries due to bicycle trauma. Methods: Using CPT codes, we completed a query of facial fractures treated at a tertiary medical center between 1999 and 2012. Individual chart review of 1108 patients revealed 28 patients who were treated for facial fractures secondary to bicycle accidents. Results: Of the 28 patients identified, 86% (n = 24) were male and 14% (n = 4) were female. The median age was 27.5 with a range from 4 to 78 years. Male patients between the ages of 13 and 39 showed the highest incidence of injury. Alcohol was involved in 18% (n = 5) of cases. A total of 18 (64%) patients were hospitalized, with 28% (n = 5) of hospitalized patients admitted to the intensive care unit. The most common injury type was nasal fracture (46%, n = 13), and the craniofacial region most commonly injured was the mid-face (50%, n = 14), with tripod fractures (36%, n = 5) and Le Fort I fractures (29%, n = 4) as the most likely injuries. Ejection from the bicycle was the most common mechanism of injury cited (50%, n = 14). Though only 18% (n = 15) of patients were involved in a collision with a motorized vehicle, all of these patients required hospitalization. Complex surgery was required in 54% (n = 15) of patients. Nine patients (32%) required closed reduction of a fracture and 4 (14%) underwent maxillomandibular fixation. Conclusions: Bicycle accidents can cause significant craniofacial injuries with many patients requiring hospitalization and surgery, especially when a motor vehicle is involved.

Intraoperative imaging for the repair of zygomaticomaxillary complex fractures: A comprehensive review of the literature

IntroductionIntraoperative imaging seems to be the next step to improve surgical outcome in the treatment of zygomaticomaxillary complex (ZMC) fractures. Many publications have appeared on intraoperative imaging for trauma surgery, but in most hospitals intraoperative imaging is not routinely performed for ZMC fracture repair. The goal of this review was to assess the value of intraoperative imaging in ZMC fracture repair. Material and methodsThe literature was reviewed with focus on the effects of intraoperative imaging on facial symmetry, fracture reduction and the frequency of additional reduction after intraoperative imaging in ZMC fractures. ResultsSix publications were found on the frequency of additional reduction after intraoperative imaging in ZMC fracture repair. Revision of the reduction of the zygoma was performed in 18% (95% CI 10.5%–29.0%), revision of the orbital floor was performed in 9% (95% CI 3.6%–17.2%). No publications were found on the effects of intraoperative imaging on facial symmetry or on the accuracy of fracture reduction. ConclusionsInformation obtained from intraoperative imaging often has consequences on the surgical management of ZMC fractures. However, the effect on restoration of facial symmetry and fracture reduction is yet to be established.

Comparison of efficacy of mandible and iliac bone as autogenous bone graft for orbital floor reconstruction.

This study evaluated and compared the efficacy of mandible and iliac bone as autogenous bone graft for correction of orbital floor fractures. Twenty patients who suffered orbital floor fractures took part in the study. The subjects enrolled in the study sustained both isolated orbital floor fracture and orbital floor fracture associated with fracture of zygomatico-maxillary complex. Each inferior orbital wall was reconstructed using either a mandible bone graft or an iliac graft. Mandibular symphysis was opted as a donor site for graft harvest from mandible and anterior iliac crest for the iliac group. CT scans were taken before the operation. Inclusion criteria consisted of at least 2months postsurgical follow-up, pre- and post-surgical photographic documentation, and complete medical records regarding inpatient and outpatient data. To describe the distribution of complications and facilitate statistical analysis, we categorized our findings into diplopia, enophthalmos, and restriction of ocular movements before and after treatment. We also considered the time required for the harvest of the grafts and the donor site complications. A comparative study was carried out using Chi square test and student t test. We considered P value <0.05 to be statistically significant. Ten iliac crest grafts and ten mandible bone grafts were placed. The mean age of the patients was 33.1years. 80% of the patients were males. The most common complication of orbital floor fracture was diplopia, followed by enophthalmos and restriction of ocular movements. The post operative results were compared after 2months of the surgery. In iliac crest group, diplopia got corrected in six out of seven patients (85%), enophthalmos in four out of five patients (80%) and restricted ocular movement showed 100% correction. While in mandible group, diplopia and ocular movement showed 100% correction and enophthalmos got corrected in five out of six patients (83%). No statistically significant differences were found between the two groups on comparing these variables. On the other hand the mean time required for the harvest of iliac graft and mandible graft was 30.2±3.52min and 16.8±1.75min respectively. The difference was statistically significant. There is no difference in the ability of mandible and anterior iliac crest bone grafts to correct post-traumatic diplopia, enophthalmos and restricted ocular movements. But the time and ease of harvest of the graft from mandible was comparatively less and easy especially when the treating doctor was an oral and maxillofacial surgeon. Secondly the post-operative morbidity was low and the quality and contour of the bone graft was very adaptable for the reconstruction of the orbital floor.

Fixation of Fractured Anterior Wall of Maxillary Sinus Using Fibrin Glue in a Zygomaticomaxillary Complex Fracture

Zygomaticomaxillary complex (ZMC) fracture occurs commonly, and restorations of facial shape and symmetry by 3-dimensional reduction and ridged fixation are important. A severe ZMC fracture is accompanied by fractures to the anterior wall of maxillary sinus; thus, various complications can occur without appropriate restoration by surgery. Of the patients with ZMC fracture from January 2008 to December 2012, 328 patients underwent surgery. Among them, 234 patients with severe fractures to the anterior wall of the maxillary sinus underwent restoration using fibrin glue (Tisseel; Baxter Healthcare, Norfolk, UK). There were no major side effects in any of the 234 patients in whom Tisseel was used, and the bone fragments were fixed well in their original places according to postoperative CT findings. Grafted bone fragments can be maintained in their original places by fibrin clot layers with Tisseel. Using Tisseel, operation time is reduced, and the bleeding tendency is decreased by reduced shearing force with surrounding tissues and the hemostatic reaction of fibrin. Therefore, it can be concluded that using Tisseel is one effective method for the restoration of fractures on the anterior wall of the maxillary sinus.

Radiographic and Clinical Evaluations of the Zygomatico-maxillary Complex Fractures Treated by 2.0 Miniplates System

Las fracturas del complejo cigomaticomaxilar son las segundas mas frecuente del territorio facial. De acuerdo con la complejidad anatomica, existen muchos informes en la literatura sobre este trauma, principalmente relacionadas con el tratamiento de estas fracturas. El proposito de esta investigacion fue evaluar clinica y radiograficamente la estabilidad de las fracturas cigomaticas unilaterales tratadas por reduccion quirurgica y fijadas en dos puntos por fijacion interna estable. Veinte pacientes con fracturas cigomaticas fueron evaluados y comparados con veinte pacientes sin fracturas. En el grupo experimental, los resultados mostraron que no hubo diferencias estadisticamente significativas entre los datos obtenidos del perimetro y el area de los lados tratados y contralaterales. Al comparar estos datos con el grupo de control las diferencias no fueron estadisticamente significativas. Tambien se realizo una comparacion de la distancia entre el hueso nasal y la prominencia cigomatica en todos los grupos, estos resultados tambien fueron satisfactorios.

Evaluation of intra ocular pressure in zygomatico maxillary complex fractures.

To study effects of zygomatico maxillary fractures and fracture reduction on intra ocular pressure (IOP). IOPs of 20 patients with unilateral zygomatico-maxillary complex (ZMC) fractures (divided into 2 groups of 10 undisplaced, 10 displaced) were measured at various time intervals. The relationship between IOPs between the two groups at various time intervals was recorded and evaluated using independent T-tests. 20 subjects were divided into two equal groups (10 each of displaced and undisplaced fractures). Mean age of patients was 33.8years with 90% males and 10% females. The change in IOP at the time of reporting, after 24h and 7days for patients with undisplaced ZMC fractures (Group I) was recorded and was found to be significant. The change in IOP at the time of reporting, before and after surgery, after 24h and 7days for patients with displaced ZMC fractures (Group II) was recorded and was also found to be significant. The IOPs of the two groups was compared at various time intervals and was found to be significant. Also, a significant increase in IOP was noted just after fracture reduction, which could be attributed to oculocardiac reflex, which has been proven to cause bradycardia, and in some cases, even death. A cautious eye needs to be kept over IOP while reducing ZMC fractures at regular intervals and the anaesthetist has to be informed to look for any bradycardia that can occur. Tonometers should be a part of standard armamentarium while reducing and fixing ZMC fractures.

Management of isolated zygomaticomaxillary complex fractures with an individualized approach: a retrospective study

Aim: Fractures of the zygomatico maxillary complex (ZMC) are commonly seen after traumatic injuries to the facial skeleton. The aim of the study was to review the outcome of individualized treatment approach in the management of isolated ZMC fractures. Methods: A retrospective analysis of 25 patients was conducted to assess the outcomes of isolated ZMC (iZMC) fracture treatment at a multi specialty hospital (Punjab, India) over a 3-year period. Results: Out of the 25 patients reviewed, 4 patients required no surgical intervention and 21 patients underwent surgical reduction via the buccal sulcus approach. An individualized treatment plan was formulated for each patient to decide mini plate fixation at one- two- or three-point with or without orbital rim exploration. Two patients required removal of mini plates from the buttress area on postoperative follow up. Conclusion: Our review shows that an individualized treatment approach produces the most favorable results in the management of iZMC fractures.

Evaluation of soft tissue asymmetry using cone-beam computed tomography after open reduction and internal fixation of zygomaticomaxillary complex fracture.

ObjectivesIn this study, we assessed soft tissue asymmetry that occurred after open reduction of unilateral zygomaticomaxillary complex (ZMC) fractures. We proposed a simple method to assess soft tissue asymmetry after reduction surgery by evaluating the symmetry between the affected and the unaffected sides. The factors affecting soft tissue contour after surgery were also analyzed.Materials and MethodsSubjects included patients admitted to Wonkwang University Dental Hospital from 2008 to 2013. Cone-beam computed tomography (CBCT) images of asymmetric patients who underwent open reduction at least 3 months prior were compared with healthy patients.ResultsThe degree of asymmetry was measured in both the open reduction and control groups. Landmarks that showed a statistically significant difference between the two groups were zygion (1.73±0.24 mm), bucclae (1.08±0.26 mm), point of cheek (2.05±0.33 mm) and frontozygomatic point (1.30±0.31 mm).ConclusionWhen compared with the normal group, asymmetry can occur in the affected side, which usually shows depression of overlying soft tissue and is statistically significantly different. Evaluation of soft tissue asymmetry with CBCT images after open reduction of ZMC fracture is useful.

Corrigendum: Evaluation of soft tissue asymmetry using cone-beam computed tomography after open reduction and internal fixation of zygomaticomaxillary complex fracture

Corrigendum: Evaluation of soft tissue asymmetry using cone-beam computed tomography after open reduction and internal fixation of zygomaticomaxillary complex fracture

Repair of a Facial Zygomaticomaxillary Complex Fracture

Repair of facial trauma such as that sustained during a high-speed motor vehicle accident, as described in this patient report, can be functionally and esthetically challenging. Here, successful post-surgical management of wound breakdown following a zygomaticomaxillary complex fracture repair included use of a self-adhesive hydrogel wound dressing.

The role of multi detector computerized tomography in evaluation of maxillofacial fractures

ObjectiveThe purpose of our study was to assess the role of multi-detector CT in the evaluation of maxillofacial fractures. Subjects and methodsThe study included 30 patients complaining from facial trauma with suspected facial fractures referred from the emergency unit of the El-Minia University Hospital. All patients subjected to non contrast MDCT in axial cuts and images are transferred to workstation then they underwent coronal, sagittal reconstructed images and 3-D volume rendering that are of benefit in final diagnosis. ResultsA total of 30 patients were included (their mean age 26years). It was found that the nasal bone is most common to be fractured (found in 19 cases), followed by maxillary bone (17 cases), zygomatic bone (10 cases), mandibular bone (8 cases) and the pterygoid plates are least frequent to be fractured (6 cases). Also, concerning the complex facial fractures; the orbital wall fractures are the most frequent (found in 22 cases), followed by zygomatico-maxillary complex fractures (8 cases), the naso-orbito-ethmoid fractures (6 cases), and lastly comes the Le Forte fractures (found in 4 cases). ConclusionThe use of MDCT is mandatory for the accurate classification of maxillo-facial fractures and so the management decision.

Parestesi pada fraktur kompleks zigomatikomaksilaris Paresthesia in zygomaticomaxillary complex fractures

Head trauma cases can involve os.zygoma and maxilla. Injury to the nerves is one of the complications that can beencountered as a result of the fracture fragments shift. This paper reported one case of n.infraorbitalis paresthesiafollowing zygomaticomaxillary complex fracture. A 30 years old man was referred to the Department of Oral Surgery,Dr.Sardjito Hospital with a history of traffic accident two weeks before admission. The patient complained of rightcheek area feels numbness, bite changed and there was a protrusion of bone under his right eye. Clinical examinationfound paresthesias of right n.infraorbitalis, left posterior open bite, and bone displace at right infraorbital rim. At theWater's x-ray and 3D CT scan visualized fractures involving the right maxillary and infraorbital rim. Open reductioninternal fixation (ORIF) zygomaticomaxillary complex fracture, with miniplate supported by arch bar as a device toachieve individually normal occlusions, was performed under general anesthesia. Postoperative follow up indicateparesthesia symptoms gradually decreased and totally recover within 5 months. Prognosis for this case was bonam. Itwas concluded that ORIF with miniplate, combined with mounting arch bar can support paresthesia correction due tothe displacing of fracture fragment zygomaticomaxillary complex.

Not only “nurture”, but also “nature”, influence the outcome of zygoma repair

The present study aims to elucidate the relationship between preoperative deviation patterns of fractured zygomas and treatment outcomes. Forty-five randomly selected patients with tri-pod type zygoma fractures were classified into a medial rotation group and a lateral rotation group, depending on preoperative deviation patterns. A minimum of 6 months after the operation, symmetry of the cheek was evaluated by three plastic surgeons using a VAS system. The evaluated scores were compared between the two groups. Furthermore, simulation of postoperative secondary deformity was performed by applying hypothetically defined relapse forces on CAD models produced by referring to the CT data of 20 patients. The deviation values obtained by the simulation were compared between the two groups. The results demonstrate that VAS scores were higher for the lateral rotation group than for the medial rotation group and that the deviation values were higher for the medial rotation group than for the lateral rotation group. It is concluded that treatment outcomes of zygoma fractures are affected by preoperative deviation patterns. Cases with medial rotation are likely to present poorer outcomes than those with lateral rotation.

Buccal Fat Pad Lifting: An Alternative Open Technique for Malar Augmentation

The purpose of the study was to introduce a novel technique for malar augmentation using buccal fat pad pedicle flaps and to evaluate the long-term results and complications of the technique. The investigators designed and conducted a prospective clinical trial. Patients underwent unilateral malar augmentation surgery using buccal fat pad pedicle flaps from June 2011 through June 2012. Patients underwent surgery for esthetic reasons or for trauma with severely comminuted or old zygomaticomaxillary complex fractures that could not be reduced precisely. The primary predictor variable was the buccal fat pad pedicle flap technique. The primary outcome variables included the amount of augmentation and resorption (which was estimated by comparing pre- with postsurgical photographic views), pain, edema, bruising, and nerve and parotid duct injuries. Thirteen patients (8 men and 5 women) underwent malar augmentation in the cheekbone area using the buccal fat pad pedicle flap technique. One year after surgery, the average amount of resorption was 0.376 mm. Other major complications, such as prolonged bruising, massive hematoma, intense pain, asymmetry, and parotid duct injury, were not observed. These results indicate that this new open-access technique should be considered an alternative method for the management of mild to moderate malar depression in patients undergoing esthetic and post-trauma surgery.

Management of zygomaticomaxillary complex fracture without infraorbital rim fixation

Purpose: The purpose of this study was to evaluate the adequacy of reduction and stability of fixation of isolated unilateral zygomatico-maxillary complex (ZMC) fracture without infraorbital rim fixation and also to formulate an operative strategy that will achieve the surgical objective of stable fixation while minimizing the morbidity of procedure.

Management of Fractures of the Zygomaticomaxillary Complex

The zygomaticomaxillary complex (ZMC) has important aesthetic, structural, and functional roles that need to be preserved and/or restored during treatment of facial fractures. Surgical treatment of ZMC fractures is indicated when there is displacement of the bony fragments, and open reduction and internal fixation is the treatment of choice in cases of comminution or fracture instability. The surgical approaches used for fracture reduction as well as the type, number, and location of the fixation will be determined by the pattern of the fracture and the surgeon's preference. This article discusses the main points of the management of ZMC fractures.