Transsinus reduction and one-point fixation of malar fractures

OBJECTIVE

To describe and evaluate transsinus reduction and one-point miniplate fixation of the zygomaticomaxillary buttress for the treatment of tripod malar fractures.

DESIGN

A consecutive case series.

SETTING

Private otolaryngology practice.

PATIENTS

A consecutive sample of 17 patients presenting with isolated tripod malar fractures over a 42-month period.

INTERVENTION

A gingivobuccal sulcus incision is made. Access into the maxillary sinus was obtained through an invariably comminuted inferior fracture line. The zygoma was reduced by applying lateral and anterior traction force to the zygomatic recess of the maxillary sinus. Miniplate fixation of the zygomaticomaxillary buttress area was then performed bridging over an area of bone loss and comminution.

MAIN OUTCOME MEASURES

Clinical assessment of facial symmetry by patients, physician, and roentgenographic studies.

RESULTS

All patients presenting with no comminution of the orbital rim had complete restoration of their premorbid facial symmetry. One of the two patients presenting with comminuted orbital rim had poor results.

CONCLUSIONS

This technique is simple, limited, and successful in treating most malar fractures. The lack of comminution of the orbital rim is crucial for the stability of the reduced zygoma. A simple and clinically relevant classification of malar fractures is proposed.

The skull base in plagiocephaly

Between 1975 and 1992, 426 children with craniofacial malformations were treated in the Department of Pediatric Neurosurgery at the Hôpital des Enfants de la Timone in Marseille. Plagiocephaly was present in 71 (16.6%). The authors present a reproducible analysis of the skull base in plagiocephaly based on these 71 patients. A control group of Mediterranean children (n = 20) was used for comparison. Clinical anthropometric patterns were analyzed in all cases. Comparison with the control group showed a difference only in the nasion-lambda distance. Data obtained from clinical anthropometry were compared for the involved and the uninvolved sides. A three-dimensional reconstruction was possible in 20 cases. The statistical correlation between the basal angles (nasion-pterional, nasion-petrosal, nasion-clino-basion, and zygomatic angles) of the involved and uninvolved sides allows a new nosographic identification of this complex malformation.

Apert syndrome: quantitative assessment by CT scan of presenting deformity and surgical results after first-stage reconstruction

We reviewed our experience with eight infants or young children (less than 2 years of age) who presented sequentially with Apert syndrome. Using a method of 14 measurements taken from the cranio-orbitozygomatic region in preoperative and postoperative CT scans of these patients, we documented their presenting skeletal morphology and the results of surgical correction at least 1 year after surgery. Significant preoperative findings included a wide anterior cranial vault at 110 percent of normal, a maximum cranial length that averaged only 90 percent of normal, a substantially widened anterior interorbital distance of 117 percent of normal, an increased lateral interorbital distance (112 percent of normal), and a widened bitemporal width at 122 percent of normal. Globe protrusion was significant at 121 percent of normal, and the medial orbital wall distance (length) was less than normal at 92 percent. In the upper midface (zygomatic) region, both the distance between the zygomatic buttresses and the interarch distance were found to be increased at 109 percent of normal, while the zygomatic arch lengths were substantially shortened at 79 percent of normal. Results of surgical correction, as documented by CT scan measurements, showed that more than a year after surgery, skeletal morphology had changed from preoperative measurements but that none of the craniofacial measurements had significantly improved (p < 0.05) in comparison with those of age-matched controls. Quantitative measurement of CT scans of the cranio-orbitozygomatic region confirmed clinically observed findings in these patients before cranio-orbital reconstruction in infancy and early childhood and proved useful in assessing the surgical results over time.

The use of ultrasound to determine the position of the mandibular condyle

A randomized, single blind study of 20 patients examined the accuracy of ultrasound in establishing the position of the mandibular condyle in relation to the glenoid fossa. The sonographic technique is described. The temporomandibular joint was imaged sonographically with the patients in an open- and a closed-mouth position as a model for condylar sag and proper condylar seating, respectively, during mandibular ramus osteotomy procedures. One radiologist identified condylar position correctly in 38 of 40 still ultrasound images, with a sensitivity and a specificity of 95%. During real time ultrasound examination, it is possible to visualize varying degrees of condylar movement in relation to the glenoid fossa. The results of this study support the potential use of ultrasound as an adjunct to mandibular orthognathic surgery.

Case report 786: Ewing's sarcoma of the left zygoma

We present a relatively common tumor, Ewing's sarcoma, in an exceptionally rare site, the zygomatic bone, wherein the only symptom was swelling in the cheek despite intracranial extension. Ewing's sarcoma is not an uncommon tumor in the Asian Indian as it is in the African American. It appear to occur as frequently in the subcontinent as it does in Europe and in Americans of European descent.

[Fractures of the zygomatic bone]

Under study were 248 patients with fractures of the upper and middle zone of face including injury of the zygomatic bone. The examination performed has revealed a joint character of the injury of the zygomatic bone and the maxillary sinus walls. The rational grouping of fractures of the zygomatic bone includes isolated fractures of its processes and lower edge of the orbit as well as fractures of the zygomatic-maxillary complex. The panorama zonography is an effective method of diagnosing fractures of the zygomatic bone and the zygomatic-maxillary complex.

Comparative evaluation of different radiographic projections of zygomatic complex fractures

Diagnosis of zygomaticomaxillary fractures is a major problem in radiographic interpretation. The purpose of the present study was to evaluate several radiographic examinations performed in an emergency room to diagnose zygomatic complex (ZC) fractures, in order to determine which is the single best radiographic projection for this purpose. Radiographs of 160 patients with ZC fractures were evaluated retrospectively. The modified P-A projection (10 degrees-20 degrees) provided a clear image of the frontozygomatic, infra-orbital rim and temporozygomatic fracture lines in all cases. In half the cases, the modified P-A projection also clearly demonstrated the fracture line in the zygomatic maxillary buttress. On the other hand, the Water's view demonstrated the fracture line in the zygomatic maxillary buttress and the temporozygomatic bone in all cases, but in only 65% of the cases was the fracture line in the infra-orbital rim and the frontozygomatic bones shown. The modified P-A projection was found to be the single best radiographic examination that should be performed in the emergency room to diagnose ZC fractures.

Craniofacial skeletal measurements based on computed tomography: Part II. Normal values and growth trends

Current diagnosis and surgical correction of craniofacial anomalies would benefit from accurate quantitative and standardized points of reference. A retrospective study was undertaken to define normal values for a series of craniofacial measurements and to evaluate the growth patterns of the craniofacial complex through axial computed tomography (CT). Fifteen measurements were taken from 542 CT scan series of skeletally normal subjects. The measurement values were then divided into 1-year age categories from 1 to 17 years, and into four age groups for those under 1 year of age. The normal range and growth pattern of measurement values for the cranial vault, orbital region, and upper midface are presented. The overall size of the cranio-orbito-zygomatic skeleton reaches more than 85 percent of adult size by age 5 years. The cranial vault grows rapidly in the first year of life but growth levels off early. The upper midface grows at a slower rate in infancy, but continues to grow later in childhood and early adolescence. Knowledge of the differential growth patterns and normal measurement values in the craniofacial region will help improve diagnostic accuracy, staging of reconstruction, precision of corrective surgery, and follow-up of patients.

Cranio-orbito-zygomatic measurements from standard CT scans in unoperated Crouzon and Apert infants: comparison with normal controls

Cranio-orbito-zygomatic measurements taken from standard axial computed tomographic (CT) scans of unoperated patients with Crouzon syndrome (6 males, 14 females) and Apert syndrome (6 males, 10 females) under 1 year of age were compared to each other and to normal controls (40 males, 35 females). Fifteen cranio-orbito-zygomatic variables were measured and repeated. Means and standard deviations were computed for each sex, and means were pooled since they were not significantly different. Correlation coefficients for repeat measures (intra-observer error) of each variable showed good reproducibility. Only the lateral orbital wall angle differed between the syndromes (p = .034), suggesting that upper facial differences (as measured by these variables) do not manifest themselves at this young age. All measurements for both syndromes, except one, were outside the 95 percent confidence range for age-matched controls. Measurements taken from standard CT scans provide an objective comparison between specific syndromes and the normal population.

Craniofacial skeletal measurements based on computed tomography: Part I. Accuracy and reproducibility

Computed tomography (CT) is a useful modality for the management of craniofacial anomalies. A study was undertaken to assess whether CT measurements of the upper craniofacial skeleton accurately represent the bony region imaged. Measurements taken directly from five dry skulls (approximate ages: adults, over 18 years; child, 4 years; infant, 6 months) were compared to those from axial CT scans of these skulls. Excellent agreement was found between the direct (dry skull) and indirect (CT) measurements. The effect of head tilt on the accuracy of these measurements was investigated. The error was within clinically acceptable limits (less than 5 percent) if the angle was no more than +/- 4 degrees from baseline (0 degrees). Objective standardized information gained from CT should complement the subjective clinical data usually collected for the treatment of craniofacial deformities.

Infections of the infratemporal fossa: imaging/clinical correlations

While infections of the infratemporal fossa are occasionally documented in the otolaryngologic literature, a recent computer literature search failed to identify any significant series of cases describing this potentially fatal infection. This presentation focuses attention on the joint clinical/imaging experience of 11 cases of infratemporal fossa infection, as seen at the Soroka Medical Center of the Ben Gurion University of the Negev, in Beer-Sheva, Israel, and the Mount Sinai Hospital, of the University of Toronto, in Toronto, Canada. This manuscript reviews our experience, with particular emphasis on the effective role and accuracy of CT scanning in identifying the correct anatomic and pathologic diagnosis, as well as in the planning of treatment.

[Nodular fasciitis: a case at the level of the zygomatic arch]

The case of a man who developed a nodular fasciitis at the zygomatic arch after a minor facial trauma is presented. Nodular fasciitis is a benign fibroblastic proliferation with unknown etiology; in a number of cases, a recent trauma is mentioned as the triggering cause. The CT characteristics are discussed and the recent literature is reviewed.

Lymphoma of the zygoma: an unusual cause of unilateral facial swelling

Primary lymphoma of bone is a rare clinicopathological entity, but accurate diagnosis is important as the tumor is usually radiosensitive and associated with a good prognosis when locally eradicated. To our knowledge primary non-Hodgkin's lymphoma of the zygoma has not been previously reported. We describe a case in which the radiographic appearances were misleading and computed tomography (CT) was important in diagnosing a malignant lesion. The differential diagnosis is discussed.

Ultrasonographic evaluation during reduction of zygomatic arch fractures

Ultrasonography was utilized in three cases of zygomatic arch fracture to confirm the position of the fragments during surgery. Ultrasonography revealed the nature of the fracture clearly and real-time imaging aided its reduction. Accordingly, ultrasonography is considered to be useful to confirm the position of fragments of the zygomatic arch during reduction.

A cephalometric analysis of patients with coronoid process enlargement and locking

Two patient groups with radiographically verified coronoid process locking were cephalometrically examined. In eight patients the locking was of congenital origin, and in eight patients the locking had developed as a result of internal derangement of the temporomandibular joint. When compared with that in a control group, the height of the coronoid process was statistically significantly greater in both patient groups, but there was no difference on condylar height between any of the groups. Neither were there any differences between groups regarding the upper face height, which, if present, could have been expected to contribute to the development of coronoid process locking. In the group with congenital enlargement, the mandibular configuration was strikingly square-shaped, which was expressed by a statistically significantly smaller gonion angle than was present in the other two groups. The finding was interpreted as a growth effect due to the mandibular locking.

The infratemporal fossa: a trial clarification

The contents of the infratemporal fossa have been studied using CT scans, anatomical dissections and radiography of the anatomical specimens. On the strength of this, 3 distinct regions are discernable: the anterior part of the fossa contains the fat pad of the cheek and this area corresponds to the retromaxillo-zygomatic region; the region of the pterygoid m. contains vascular structures and lies behind the preceding region; the pterygopalatine fossa, formerly considered the deepest part, extends the infratemporal fossa superiorly and medially. These anatomical and radiographic findings could serve as a guide to maxillo-facial surgeons dealing with expanding lesions within the infratemporal fossa, or invading it from adjacent regions.

[Fibrous dysplasia of the jaws. The literature and a presentation of 2 cases]

After an analysis of the literature, the clinical, roentgenographic, anatomopathologic and therapeutic features of fibrous dysplasia of the jaws have been described. Two cases have been presented: a fifteen-year-old boy affected by a monostotic form of the right maxilla and a nineteen-year-old girl affected by a craniofacial variety, restricted to the right zygomatic and maxilla bones.

Use of three-dimensional computerized tomography in the diagnosis of an obstructed coronoid process

The principles of three-dimensional computerized tomography are discussed. An unusual case of an iatrogenically induced coronoid obstruction is presented with the three-dimensional computerized tomograph as an integral tool in its diagnosis.

Facial musculoskeletal asymmetry in hemifacial microsomia

Computer-assisted medical imaging--transaxial computed tomography (CT) scans and three-dimensional surface reconstructions--was used to study the muscles of mastication and their osseous origins and insertions in 24 patients with untreated unilateral hemifacial microsomia (HFM). The relationship between the volume of a muscle of mastication and the shape and size of its origin and insertion in such patients varies widely. Comparison of mean volumes of specific muscles documents a statistically significant decrease among patients who have moderate to marked mandibular dysmorphology as compared with those with minimally dysmorphic mandibles. This study supports the hypothesis that the shape and size of the mandible are related to the muscles that originate and insert upon it. However, the variation among individual patients means that assumptions regarding muscle mass and, in turn, function cannot be made regarding an individual patient on the basis of osseous dysmorphology that has been demonstrated on skull radiographs alone.

[Study on renal osteodystrophy using 2-compartment model analysis of bone scintigraphy. 1. Clinical significance of K Index]

The dynamic analyses of bone scintigraphy were performed in 30 cases of hemodialysed patients. The regression analyses between biochemical data or duration and K indexes obtained from the 2-compartment model analysis in the maxillofacial region were carried out. The obtained results were as follows. 1) The duration and K indexes were significantly correlated with 1 or 2% of significance level in the parietal bone and the zygomatic bone. 2) Serum Ca and K indexes were highly correlated in every settled ROI. The correlation coefficients were distributed from 0.58 to 0.79. In the cranial bone the correlation were more higher than in maxilla and mandibular bone. 3) Serum ALP and K indexes have more higher significant level of correlation than the results of Ca. The correlation coefficients were distributed from 0.48 to 0.83. The level of significance were changed by location. The highest correlation coefficient was 0.83 in the parietal bone. 4) Serum c-PTH and K indexes have significant correlation in every settled ROI with the correlation coefficient from 0.59 to 0.69. The significance level were nearly equal in every location. 5) In the case of subtotal parathyroidoectomy the K indexes which were abnormally high in preoperation showed the tendancy to decrease toward normal range in postoperation. These results indicated that K indexes reflected the bone change caused by renal osteodystrophy. And the K indexes considered to be usefull to estimate the bone improvement.