Zygomatico-orbital Fractures Research Articles

Evaluation of Different Patterns of Zygomaticoorbital Complex Fractures.

Very few studies exist regarding the fracture pattern variability of the zygomaticoorbital (ZMO) complex. The retrospective evaluation of a large series of surgically treated unilateral ZMO fractures would in certain circumstances help intraoperative predictability and define sensitive indicators for open reduction and internal fixation. The aim of this study was to investigate the different fracture patterns after ZMO complex injury regarding the 5 anatomic sutures of the zygoma as well as the concomitance of the paranasal buttress and maxillary sinus wall fracture. The medical records of all patients with unilateral ZMO fractures who underwent surgical intervention in a single trauma center department between April 2015 and June 2020 were retrospectively reviewed. Demographic and anamnesis data, radiologic findings, and surgical reports were evaluated. According to the preoperative radiologic evaluation, ZMO fractures were classified as unisutural, bisutural, trisutural, tetrasutural, and complete based on the number of zygomatic sutures. The prevalence of various fracture patterns was analyzed. The impact of patient's age and trauma etiology on the fracture pattern was evaluated using descriptive statistical analysis. The study included 492 patients with unilateral ZMO fractures, with a mean age of 49.93 years (SD = 20.66) and a male:female ratio of 2.23:1. The most affected age group was 19-44years (41.67%) and tripping falls were the most common etiology (27.24%). Trisutural (57.32%) and unisutural fractures (23.17%) were the most common, followed by tetrasutural (8.94%), bisutural (8.54%), and complete fractures (2.03%). A trisutural fracture involving the zygomaticomaxillary suture, the infraorbital rim, and the zygomaticosphenoidal suture was the most common fracture pattern (52.03%). Most fractures were observed in the zygomaticosphenoidal suture (86.99%), followed by the infraorbital rim (74.59%) and the zygomaticomaxillary suture (68.29%). Fractures of the maxillary sinus wall and the paranasal buttress co-existed in 9.55% and 31.30% of all cases, respectively. No correlation was detected between age and fracture pattern (P = .4111). Tripping falls and bicycle accidents significantly influenced the fracture pattern (P < .0001). According to the results, knowledge of the fracture pattern variability of the ZMO complex could in certain circumstances designate CT or CBCT as mandatory before operating on ZMO fractures. Consequently, unnecessary incisions could be avoided. The high concomitance of paranasal buttress fracture also suggests its intraoperative surgical exploration. Further studies should correlate the clinical findings with indication for surgery and postoperative outcome for the different fracture patterns described.

Subciliary and Subtarsal Incision in Management of Zygomatico-Orbital Fracture, A Study on Scar Assessment

Objective: To evaluate outcome between the subciliary and subtarsal incision in management of zygomatico-orbital fracture in terms of postoperative scar assessment. Subject and Methods: A total 36 patients of either gender, age 21 to 40 years having isolated zygomatico-orbital fracture were selected by consecutive sampling (16 patients in Subciliary and 16 in Sub-tarsal group). Zygomatico-orbital fracture was confirmed by 3D CT scan and Occipitomental view of face. After surgery postoperative scar assessment (Pigmentation, Pliability, Vascularity and height) was performed using Vancouver scar scale. Results: Male participants accounted for 27 (84.4%) of the 32 zygomaticomaxillary complex fractured patients, followed by 5 female patients (15.6% ). With 17 (53.1%) patients, the age group 21-25 years was the most afflicted, followed by 26-30 years with 15 (46.9%) patients and a mean age of 25.59 ± 3.004 years. In all three postoperative weeks, the subtarsal group performed considerably better than the subciliary group in terms of postoperative scar evaluation. Conclusion: Scar formation was higher in subciliary group as compared to subtarsal group Keywords: Subtarsal, Subciliary, Zygomatico-orbital, Fracture,Scar, Assessment

Preliminary outcomes of the surgical navigation system combined with intraoperative three-dimensional C-arm computed tomography for zygomatico-orbital fracture reconstruction

This study analyzed the outcomes of zygomatico-orbital fracture reconstruction using the real-time navigation system with intraoperative three-dimensional (3D) C-arm computed tomography (CT). Fifteen patients with zygomatico-orbital or isolated orbital/zygoma fractures were enrolled in this prospective cohort. For zygoma reduction, the displacement at five key sutures and the differences between preoperative and intraoperative CT images were compared. For orbital reconstruction, the bilateral orbital volume differences in the anterior, middle, and posterior angles over the medial transitional buttress were measured. Two patients required implant adjustment once after the intraoperative 3D C-arm assessment. On comparing the preoperative and postoperative findings for the zygoma, the average sum of displacement was 19.48 (range, 5.1–34.65) vs. 1.96 (0–3.95) mm (P < 0.001) and the deviation index was 13.56 (10–24.35) vs. 2.44 (0.6–4.85) (P < 0.001). For the orbit, the mean preoperative to postoperative bilateral orbital volume difference was 3.93 (0.35–10.95) vs. 1.05 (0.12–3.61) mm3 (P < 0.001). The mean difference in the bilateral angles at the transition buttress was significantly decreased postoperatively at the middle and posterior one-third. There was no significant difference in orbital volume, angle of the transition zone, and the sum of five zygoma distances between post operative results and preoperative virtual planning. The surgical navigation system with the intraoperative 3D C-arm can effectively improve the accuracy of zygomatico-orbital fracture reconstruction and decrease implant adjustment times.

Results of a Clinical Scoring System Regarding Symptoms and Surgical Treatment of Isolated Unilateral Zygomatico-Orbital Fractures: A Single-Centre Retrospective Analysis of 461 Cases.

Systematic assessment of computed tomography (CT) scans and clinical symptoms is necessary to quickly indicate the correct treatment of zygomatico-orbital (ZMO) fractures. For this purpose, a clinical scoring system (=Clinical Score) was developed and correlated with CT scans to analyse its validity. Every operated, isolated, and unilateral ZMO fracture between January 2012 and December 2016 was screened retrospectively, including patient and treatment data. All available CT scans were analysed, and the grade of dislocation was measured for each case and plane. Four hundred and sixty-one cases were included and showed a median surgery time of 66.0 min (5.0–361.0) and a median postoperative hospital stay of three days (0–25). The distribution of gender, aetiologies and age groups was significantly different (each p = 0.001), and the aetiology had a significant influence on the Clinical Score (p = 0.038). The degree of dislocation in the coronary and sagittal planes correlated significantly with the Clinical Score with regard to the orbital involvement (p < 0.001, ρ = 0.566; p < 0.001, ρ = 0.609). The simple, quick, and easy-to-apply Clinical Score showed a significant correlation with the most important planes in CT scans as well as with the clinical course. It may facilitate fast risk stratification of the patient. However, the validity of the proposed score in determining indications must now be evaluated in a prospective setting, including both operated and non-operated fractures.

The Role of Prebent Titanium Mesh with 3D-Printed Model in Reconstruction of Zygomatico-Orbital Fractures

The Role of Prebent Titanium Mesh with 3D-Printed Model in Reconstruction of Zygomatico-Orbital Fractures

Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures.

From 2005 to 2020, the American Board of Plastic Surgery collected data on 20 common plastic surgery operations as part of the Maintenance of Certification process. These data allow the authors to examine national trends in zygomatico-orbital fracture repair over a 15-year period. Tracer data for zygomatico-orbital fracture repair were reviewed in cohorts from 2005 to 2013 and 2014 to 2020. Results were categorized based on their presence in evidence-based medicine articles published during this period. Differences between years were assessed using the t test or chi-square test as appropriate. Four hundred thirty patients were included as of March of 2020. Average age was 37 years (range, 6 to 85 years), and 76 percent were male. Operations took place on average 10 days from injury. There were significant decreases in the use of subciliary (31.9 percent versus 10.0 percent; p < 0.001), gingival buccal (84.3 percent versus 56.4 percent; p < 0.001), and lateral brow (45.2 percent versus 22.3 percent; p < 0.001) incisions, with an increase in lower lid external incisions (15.2 percent versus 30.9 percent; p < 0.001); 2.7 percent of patients had a complication requiring readmission and 4.5 percent required reoperation. The incidence of postoperative diplopia was 7.7 percent, and the infection rate was 1.7 percent. This article reviews the American Board of Plastic Surgery tracer data for zygomatico-orbital fracture repair. The Maintenance of Certification tracer data provide a national database with longer follow-up and more specific information than comparable databases. Analysis of these data over time enables the authors to describe practice trends and gives surgeons the opportunity to compare their outcomes to national norms.

Discussion: Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures.

Discussion: Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures.

Implant malposition and revision surgery in primary orbital fracture reconstructions

The aim of the study was to assess factors leading to revision surgery and implant position of primary orbital fracture reconstructions.A retrospective cohort included patients who underwent orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type, surgery and implant-related variables, and postoperative implant position were analyzed.The overall revision surgery rate was 6.5% (15 of 232 surgeries). The rate was highest in combined midfacial fractures with rim involvement (14.0%), lower in zygomatico-orbital fractures (8.7%), and lowest in isolated blowout fractures (3.8%). Fracture type, orbital rim fixation and implant malposition predicted revision. The best positioning was achieved with patient-specific milled titanium implants (mtPSI) and resorbable materials, whereas the poorest with preformed three-dimensional titanium plates.Combined midfacial fractures with rim involvement in particular have a high risk for orbital revision surgery. Within the limitations of the present study, mtPSIs should be preferred in the reconstruction of primary orbital fractures if possible.

Titanium Nickelide in Midface Fractures Treatment.

Background: The question of reconstruction of human tissues and organs with the use of medical materials is still open, because of the accurate requirements for their biological and physical features. The aim of this study was to prove the efficiency of titanium nickelide constructors in treatment of isolated orbital floor fractures or combination with zygomatico-orbital complex fractures. Methods: Patients with a fracture of zygomatico-orbital complex and/or low orbital floor (n = 44) carried out different treatments: in the first group, osteosynthesis and endoprosthesis with titanium nickelide structures; in the second group, titan mini-plates osteosynthesis; in the third group (‘blow-out’), endoprosthesis with a titanium nickelide mesh; and in the fourth group (‘blow-out’), conservative treatment and monitoring (archive data) (p > 0.05). The paraesthesia, diplopia, enophthalmos and exophthalmos degree were measured in points. Results: In one year, the first and second groups had no differences in level of paraesthesia (p > 0.05). The absence of exophthalmos and differences between first and second groups, and between the third and the fourth groups with positive dynamics inside the groups were proved (p < 0.05). In the first and third groups, enophthalmos was absent, and it increased in the second and fourth groups (p < 0.01, p < 0.11). Diplopia in the first and third groups was absent, and it increased in the second and fourth groups (p < 0.05, p < 0.01). Conclusion: The elasticity and biocompatibility of titanium nickelide make the implant insertion and restoration of the lower orbital wall anatomy easier, with good postoperative clinical results.

Does Intraoperative Computed Tomography Improve the Outcome in Zygomatico-Orbital Complex Fracture Reduction?

Zygomatico-orbital (ZMO) fractures pose considerable difficulty in intraoperative assessment during open reduction and internal fixation (ORIF), and this can be attributed to its three-dimensional complex anatomy and articulations. Recent advancements in the form of intraoperative imaging and navigation have led to an adequate assessment and correct reduction of these fractures minimizing chances of any revision surgery. The purpose of this study was to evaluate the advantage of intraoperative computerized tomography (CT) scan in the management of ZMO/isolated orbital complex fracture and further to develop a protocol for managing such fractures. Twenty-three cases of ZMO/isolated orbital fractures were managed with ORIF, followed by an intraoperative CT scan. The evaluation was focused on the articulations of the zygoma and orbital wall reconstruction. The score of 0 and 1 was given for inadequate and adequate reduction, respectively. Necessary corrections were performed in case of improper reduction followed by a repeat CT scan if required. The reduction score was statistically correlated with number of incisions. In 8 (35%) out of 23 patients, clinical judgment was inaccurate when radiologically assessed with an intraoperative CT scan. In 6 out of 8 cases, a repeat CT scan was done after revision of reduction. The reduction score improved with additional incision and revision in the second CT scan. Intraoperative CT has an important role in assessing the accuracy of reduction and confirming implant position in ZMO/isolated orbital fractures. This can avoid the need for secondary corrective surgery and postoperative imaging. Intraoperative CT is an important tool to improve surgical outcomes in the management of ZMO orbital fractures.

Reoperation in Zygomatico-orbital Trauma: A Review of Patients With Suboptimal Outcomes Following Initial Repair.

Treatment to restore anatomy, function, and aesthetics after trauma should involve as little surgical insult as possible. As such, repeated procedures may suggest failed initial management. To date, no predictive factors for failure of primary surgery have been identified. The aim of this review was to identify factors affecting the requirement for reoperation following treatment of zygomatico-orbital injuries. A retrospective review of patients undergoing surgery for zygomatico-orbital fractures between 2011 and 2019 in a single UK major trauma center was undertaken. All operative notes and imaging were reviewed independently by 2 authors to classify the fracture patterns for both zygomatic and orbital components of the injury. For all cases, the mode of preoperative imaging the grade of operating surgeon, materials used for fixation, and the surgical approaches were recorded. Coding data identified 432 patients who underwent surgery for zygomatico-orbital fractures. In total, 116 cases were treated with closed reduction and 316 with open reduction and internal fixation; 20 cases required reoperation. There were no significant differences identified between cases requiring reoperation and those who did not. A need for repeated surgery is rare. However, this review identified an increased risk of infection of fixation when an intraoral approach was used and highlights the potential benefits that can be achieved by open reduction and internal fixation when more conservative approaches fail to achieve the desired outcome.

Zygomatico-Orbital Fracture-Dislocation in Surgical Treatment: Novel 3-Dimensional Software Automated Analysis

The human capability to detect the degree of zygomatico-orbital (ZMO) fracture-dislocation in surgical treatment is unknown. The aim of this study was to examine the association between ZMO fracture-dislocation and injury etiology and treatment. We implemented a retrospective cross-sectional study, enrolled a sample composed of patients with an isolated unilateral ZMO fracture, and analyzed fracture-dislocation from computed tomography images with an automatic algorithm. The primary predictor variable was mean surface point-to-point dislocation (the mean distance of dislocation for all surface points in isolated ZMO fracture segments between the original position and after virtual repositioning). The primary outcome was the treatment choice (operative vs nonoperative). Other studied variables were gender, age group, injury mechanism, clinical asymmetry, and human-evaluated dislocation on computed tomography images. Descriptive and bivariate statistics were computed, and the threshold for statistical significance was set at P<.05. The sample consisted of 115 patients with a mean age of 66.3years, 66.1% of whom were male patients, and the most common cause of injury was falling on the ground (49.6%). Operative treatment was required in 58 patients (50.4%). A significant association was found between mean dislocation and operative treatment. Mean dislocation of operatively versus nonoperatively treated fractures was 2.39mm versus 1.05mm(P<.001). Mean fracture-dislocation was greatest in injuries caused by assault (2.41mm) and smallest in motor vehicle accidents (1.08mm) and ground-level falls (1.25mm). The threshold of human-eye detection for ZMO fracture-dislocation was 1.97mm. The results of this study demonstrate that the threshold for operative treatment of ZMO fracture-dislocation is over 2mm, which the human eye is able to detect. True dislocation is greater in younger patients than elderly patients and in injuries caused by assault compared with falling.

Coincidence of craniocerebral and craniofacial injuries

PurposeTo determine the incidence of craniocerebral injuries in patients who experienced upper facial or midfacial traumas associated with the disorders of consciousness. To find which types of craniofacial traumas predisposed to craniocerebral injuries. To analyze a relationship between the site of the force application and the type of resultant craniocerebral injury. Materials and methodsThe study included 3,481 patients with upper facial and midfacial traumas. All 425 patients with craniofacial traumas and disorders of consciousness at the time of the event or hospital admission, were qualified for computed tomography (CT) of the head. ResultsIn 85/425 patients (20%), 70 men and 15 women (age 14–71 years), craniofacial trauma coincided with a craniocerebral injury. Upper facial dislocation and zygomatic-orbital-maxillary complex fracture significantly more often co-existed with skull, dura mater or cranial nerve injuries, and zygomatico-orbital fracture with the injuries of the brain. Application of force both centrally and laterally to the horizontal plane predisposed to skull, dura mater and cranial nerve injuries. ConclusionThe recommendation to perform head CT in each patient with craniofacial trauma who experienced the disorders of consciousness is as simple as possible, yet provides high diagnostic sensitivity, facilitating proper management at initial stages post-injury.

Associated Injuries Are Frequent and Severe Among Geriatric Patients With Zygomatico-Orbital Fractures

Associated injuries (AIs) are hypothesized to be frequent in geriatric zygomatico-orbital (ZMO) fractures. The study aim was to determine the relation between ZMO fractures and AIs in geriatric patients compared with younger adult patients. A retrospective case-and-control study was carried out on geriatric patients at least 65years of age (n=93) and younger adult patients 20 to 30years of age (n=68) diagnosed with pure unilateral ZMO fractures. The main exposure was age, the primary outcome was AI outside the face, and the secondary outcomes were type and severity of AI, ocular injuries, restriction of mandibular movement, and ZMO buttress asymmetry. The confounding variables were gender, trauma mechanism, type of ZMO fracture, and dislocation. Statistical analyses included χ2 tests, risk evaluation with 2×2 tables, and logistic regression analysis. AIs outside the face, and particularly brain injuries, were significantly more frequent in the geriatric group than in the control group (P<.001). The significant predictors of AIs outside the face were fall from a height (66.7%), motor vehicle accidents (66.7%), and absence of ZMO dislocation (59.5%; P<.001). The adjusted risk of brain injury was 2.5-fold in the absence of dislocation. The geriatric group had a more than 5-fold higher risk of brain injuries compared with the younger control group (P=.003). AIs in general, and particularly brain injuries, are frequent in geriatric ZMO fractures. Intracranial injuries should be ruled out, particularly in geriatric patients diagnosed with a non-dislocated ZMO fracture.

Role of Intraoperative Computerized Tomographic Scan in the Management of Zygomatico-Orbital Complex Fractures

Role of Intraoperative Computerized Tomographic Scan in the Management of Zygomatico-Orbital Complex Fractures

Did King Philip II of Ancient Macedonia Suffer a Zygomatico-Orbital Fracture? A Maxillofacial Surgeon's Approach.

Philip II, father of Alexander the Great, succeeded his brother, Perdiccas III, to the throne of Macedonia in 360 BC. He has been described by historians as a generous king and military genius who managed to achieve his ambitious plans by expanding the Macedonian city-state over the whole Greek territory and the greater part of the Balkan Peninsula. The aim of our study was to present the evidence with regard to the facial injury of King Philip II of Macedonia and discuss the treatment of the wound by his famous physician, Critobulos. We reviewed the literature for historical, archaeological, and paleopathological evidence of King Philip's facial injury. We include a modern reconstruction of Philip's face based on the evidence of his injury by a team of anatomists and archaeologists from the Universities of Bristol and Manchester. In the light of the archaeological findings by Professor Andronikos and the paleopathological evidence by Musgrave, it can be claimed with confidence that King Philip II suffered a significant injury of his zygomaticomaxillary complex and supraorbital rim caused by an arrow as can be confirmed in many historical sources. To the best of our knowledge, this is the first attempt to present the trauma of King Philip II from a maxillofacial surgeon's point of view.

Comparison of Subciliary, Subtarsal and Transconjunctival Approaches for Management of Zygomaticoorbital Fractures

Comparison of Subciliary, Subtarsal and Transconjunctival Approaches for Management of Zygomaticoorbital Fractures

Substantial CT radiation dose reduction does not affect the preference for CT over direct digital radiography to diagnose isolated zygomatic fractures – A study in human cadavers

IntroductionZygomatic fractures can be diagnosed with either computed tomography (CT) or direct digital radiography (DR). The aim of the present study was to assess the effect of CT dose reduction on the preference for facial CT versus DR for accurate diagnosis of isolated zygomatic fractures. Materials and methodsEight zygomatic fractures were inflicted on four human cadavers with a free fall impactor technique. The cadavers were scanned using eight CT protocols, which were identical except for a systematic decrease in radiation dose per protocol, and one DR protocol. Single axial CT images were displayed alongside a DR image of the same fracture creating a total of 64 dual images for comparison. A total of 54 observers, including radiologists, radiographers and oral and maxillofacial surgeons, made a forced choice for either CT or DR. ResultsForty out of 54 observers (74%) preferred CT over DR (all with P < 0.05). Preference for CT was maintained even when radiation dose reduced from 147.4 μSv to 46.4 μSv (DR dose was 6.9 μSv). Only a single out of all raters preferred DR (P = 0.0003). The remaining 13 observers had no significant preference. ConclusionThis study demonstrates that preference for axial CT over DR is not affected by substantial (∼70%) CT dose reduction for the assessment of zygomatico-orbital fractures.

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.

An Algorithm for the Treatment of Isolated Zygomatico-Orbital Fractures

To present algorithms for the treatment of zygomatico-orbital (ZMO) fractures and to review how many of our patients were treated using each. We have presented 2 algorithms: 1 for when intraoperative computed tomography (CT) scans are not available and 1 for when intraoperative CT scans are available. The data from all patients treated by us for isolated, unilateral ZMO fractures from January 1991 to December 31, 2013 with adequate medical records were retrospectively analyzed. The demographic information and treatment methods were collected and tabulated to determine how these patients' fractures had been classified using the 2 algorithms. Simple descriptive statistics were applied. A total of 883 patients with sufficient records who had undergone treatment of isolated, unilateral ZMO fractures were included. Of these 883 patients, 71 were classified as having high-energy ZMO fractures that had not been treated using 1 of the algorithms. A total of 758 patients with sufficient records to be included in the present study were treated using the algorithm before intraoperative CT scanning was available. Finally, 54 patients were treated using the algorithm after intraoperative CT scanning was available. The patients were similar demographically. The number of patients treated at each point in the algorithms is shown. Overall, only 40% of patients required internal orbital reconstruction. The treatment of most ZMO fractures can be sequential, using an algorithm to avoid unnecessary surgical approaches and procedures that can potentially cause iatrogenic deformities. The use of intraoperative CT scans will allow the surgeon to be less invasive, with greater predictability and precision.