Zygomatic fractures managed by closed reduction: an analysis with postoperative computed tomography follow-up evaluating the degree of reduction and remaining dislocation

Evaluation of Zygomaticomaxillary Complex Fractures with Gillies Approach in Al-Baha Region of Saudi Arabia: A Cohort Study

Background

The aim of this study was to evaluate the accuracy of the degree of fracture reduction after open reduction and internal fixation of Zygomaticomaxillary Complex (ZMC) fractures in the Saudi population of the Al-Baha region, using Gillies approach. Further comparison with preoperative and postoperative standardized computed tomography (CT) views with the calculation of residual deformity percentage, which remained after the ZMC rehabilitation.

Methods

A 5-year retrospective CT-based study on preoperative and postoperative axial CT scans of 46 male patients with ZMC fractures. The CT measurements were made (in millimeters) at the fracture site of maximum displacement through the anterior orbital rim and orbital floor, posterolateral wall of the maxillary sinus, zygomatic arch, and zygomaticofrontal suture. For the zygomatic arch, measurements were made (in mm) by drawing a tangent to the fractured arch segments and dropping a perpendicular to the inward displaced fractured arch. The total difference in all measured parts between preoperative and postoperative displacement was calculated in percentages.

Results

Upon comparison of preoperative and postoperative zygomaticomaxillary complex CTs, three-point fixation at the regions of infraorbital rim, frontozygomatic suture, and posterolateral wall of the maxilla results in a reduction of the fracture sites in the range of 72.85% to 85%. Maximum reduction was noted at the zygomatic arch, that is, 85%, and minimum at the infraorbital rim, that is, 72.85%. The reduction obtained at all four sites was statistically significant, with P values ranging from .011 to .039.

Conclusion

Gillies temporal approach and three-point fixation at the regions of the infraorbital rim, frontozygomatic suture, and posterolateral wall of the maxilla results in satisfactory treatment of ZMC fractures and improves patients oral health and quality of life.

Role of Intraoperative Imaging in Improving Closed Reduction of Zygomatic Arch Fractures: A Systematic Review and Meta-analysis

PURPOSE

The use of intraoperative imaging (IOI) to improve the reduction adequacy of zygomatic arch (ZMA) fractures has been reported, but few systematic reviews have examined this topic. The aim of this review was to investigate and compare the value of IOI with conventional methods without IOI (N-IOI) for the closed reduction of ZMA fractures.

METHODS

Electronic retrieval of MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, and citation search until December 2, 2022, was used to identify controlled clinical trials that employed IOI for improving adequacy in closed reduction of ZMA fractures. The predictor variable was the use of IOI-yes/no (IOI vs N-IOI). The covariates included imaging technique (ultrasound, C-arm, and cone beam computed tomography) and ZMA fracture type (M-shape fracture, mechanistic force in 1 direction; variable fracture, mechanistic force in 2 directions). The primary outcome variables were the reduction adequacy of ZMA fractures (the remaining cortical step and dislocation angle) compared with the ideal mirrored position. Weighted or mean differences, risk ratios, and corresponding 95% confidence intervals were calculated, where P >.05 and I2＜50% fixed effect model was adopted, and a vice versa random effect model was adopted.

RESULTS

A total of 1250 studies were identified, of which 6 studies with 259 participants were included. The meta-analysis results indicated that compared with N-IOI, IOI yielded fewer cortical steps (-1.76 [-2.42, 1.10], P ＜.00001, fixed model) and dislocation angles (-5.60 [-8.08, 3.12], P＜.00001, fixed model) in patients with variable ZMA fractures, while no significant difference was detected in the M-shape ZMA fracture (-0.72, [-2.93, 1.48], P = .52; -1.48, [-3.51, 0.55], P = .15). Although there was no significant difference in postoperative correction (0.35, [0.06, 2.01] P = .24, fixed model), all secondary revision cases occurred in the N-IOI group. Descriptive analysis showed that IOI yielded better symmetry and appearance satisfaction.

CONCLUSION

IOI improved the adequacy of the procedure and led to a better postoperative appearance, especially for patients with variable ZMA fractures. Furthermore, the use of IOI avoided the risk of secondary surgery. In future studies, researchers should standardize the scale and outcomes to facilitate the intuitive evaluation of reduction adequacy.

Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study

The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.

The Volume Difference Along the External Surface of the Zygomatic Bone: A Novel Method of Measuring Zygomatic Bone Asymmetry

ABSTRACT

This study introduced the volume difference along the external surface (VDAES) of the zygomatic bone as a novel approach to assess zygomatic bone asymmetry and was the first to describe a distinctive, 4-step method of measuring it. VDAES has a potential to be used as an objective tool to evaluate dislocation and can assist surgeons in predicting risks of long-term cosmetic complications in patients with zygomaticomaxillary complex fractures. After having measured 100 healthy study participants, the observed median VDAES was 1.48 cm3 for all study participants, 2.02 cm3 for males, and 1.09 cm3 for females, with the gender difference being significant (P = 0.003). Additional studies are needed to test the hypothesis of whether VDAES is more relevant than conventional methods of clinically evaluating zygomatic bone asymmetry.

Unilateral Zygomatic Complex Fracture - A Comparison Between non Surgical Treatment and Surgical Treatment

BACKGROUND

Medical advances have enabled zygomatic complex (ZMC) fractures to be treated by various approaches. This study aim to analyse the demographics and treatment outcomes of unilateral ZMC fractures, treated non-surgically or surgically.

METHODS

This 5 year non-randomized prospective study had included 65 cases of unilateral ZMC fractures from October 2014 until December 2019. Patients were treated and divided into non-surgical and surgically treated group. Treatment outcomes in terms of step deformities, malar depression, diplopia, infraorbital hypoaesthesia and mouth opening were evaluated up to 6 months post trauma/intervention.

RESULTS

Road traffic accident (96.9%) was the main cause, with predominant male involvement (80%) and median age of 28 years. Significant improvements (p<0.05) were observed for step deformities and malar depression among the surgically treated group at postoperative day 1 and week 1. Throughout the 6 months review, infraorbital hypoesthesia and diplopia showed no significant differences between both groups, (p>0.05). Besides, all patients showed significant mouth opening improvement (p < 0.05) over 6 months period.

CONCLUSION

We found that infraorbital hypoaesthesia and limited of mouth opening should not be the absolute indications for surgical treatment of ZMC fractures. Non-surgical treatment that included early jaw exercise and symptomatic treatment had potential value for satisfactory functional gain.

Low-Dose Computed Tomographic Scans for Postoperative Evaluation of Craniomaxillofacial Fractures: A Pilot Clinical Study

Computed tomographic scans are frequently obtained following craniomaxillofacial fracture reconstruction. The additive radiation from such scans is not trivial; cumulative radiation exposure poses stochastic health risks. In this article, the authors postulate that a low-dose computed tomography protocol provides adequate image quality for postoperative evaluation of reconstructed craniomaxillofacial fractures. This study included patients for whom a computed tomographic scan was indicated following craniomaxillofacial fracture repair at a Level I trauma center. Postoperative craniomaxillofacial computed tomography was performed using a low-dose protocol, rather than standard protocols. A craniomaxillofacial surgeon and a radiologist interpreted the images to determine whether they were of sufficient quality. It was decided a priori that any inadequate low-dose computed tomography would require repeated scanning using standard protocols. The primary endpoint was the need for repeated computed tomography. In addition, the clarity of clinically significant anatomical landmarks on the images was graded on a five-point Likert scale. Twenty patients were scanned postoperatively using the low-dose protocol. Mean radiation dose (total dose-length product) from the low-dose protocol was 71 mGy · cm versus 532 mGy · cm for the preoperative computed tomographic scans that were obtained using conventional protocols (p < 0.001). All 20 low-dose computed tomographic scans were determined to provide satisfactory image quality. No patients required repeated computed tomography secondary to poor image quality. Low-dose computed tomography received high image-quality scores. A low-dose computed tomography protocol that delivers approximately 7.5-fold less radiation than the standard protocols was found to be adequate for postoperative evaluation of craniomaxillofacial fractures. Larger prospective studies may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Outcome of Different Treatment Modalities of Fracture Zygoma

OBJECTIVES

This study aimed to determine the pattern of fractured zygoma, different treatment modalities, and complications of the treatment in our center. It also aimed to determine the association between the treatment modalities and complication of treatment, and association between number of fixation and complication.

METHODOLOGY

A retrospective review was conducted from January 2008 until December 2011. All patients diagnosed with zygomatic complex fractured that met the inclusion and exclusion criteria were included in the study. Zingg's Classification was used in the study.

RESULTS

The median age was 23.5. Type A was the most common fracture type made up 26.6%. About 90.8% of the injury was caused by road traffic accident. Forty-four patients were treated with open reduction and internal fixation and 4 patients were treated with close reduction only. Fifty patients were treated conservatively. Gillies approach in combination with fixation is the most common procedure accounted for 50%. Three-point fixation at infraorbital, maxillary buttress, frontozygomatic suture, and zygomatic arch was the most common site. However, there were no significant associations between the number of fixation and the occurrence of the complication (P = 0.307). About 29.2% in the treatment group and 66% in the conservative group had complications. About 35.7% of patients in treatment group had complications, while 66% had trismus in conservative group.

CONCLUSION

There was a significant association between types of treatment and the occurrence of complication (P = 0.001). However, there were no significant association between number of fixation and the occurrence of complications (P = 0.307).

Use of C-Arm to Assess Reduction of Zygomatic Complex Fractures: A Comparative Study

The aim of this study was to analyze the use of C-arm and its significance in accurate reduction of zygomaticomaxillary complex (ZMC) fractures. Orbital volume is used as parameter to compared pre- and postoperative volumes of injured orbit. Differences in orbital volume calculated in cases done with intraoperative imaging and in controls treated without the use of intraoperative imaging were evaluated using Student t-test. C-arm is definitively an effective tool in the armamentarium of oral and maxillofacial surgery in assessment of reduction of ZMC fracture.

Surgical treatment of unilateral zygomaticomaxillary complex fractures: A 7-year observational study assessing treatment outcome in 153 cases

This study investigates treatment outcome in zygomaticomaxillary complex (ZMC) fracture repair.

METHODS

The medical records and CT-images of patients that received treatment for a unilateral ZMC fracture in 2005-2011 were studied. ZMC fractures were categorised as incomplete (type A), tetrapod (type B) or comminuted (type C). The incidence of sequelae, wound infection and secondary surgical interventions was analysed per fracture category.

RESULTS

A total of 153 patients were treated in the selected period. Persisting sensory disturbances in the area innervated by the infraorbital nerve were observed in 50 cases (37%), facial asymmetry in 19 cases (14%), enophthalmos in 10 cases (7%) and persisting diplopia in 9 cases (7%). Wound infection occurred in 6 cases (4%). Secondary surgical procedures of the ZMC, orbital floor, and/or extraocular muscles were performed in 14 cases (9%). C-type fractures were associated with more secondary corrections for ZMC malreduction (12%, p = 0.03), more secondary reconstructions of the orbital floor (10%, p < 0.01), and more functional corrections of diplopia by extraocular muscle correction (5%, p = 0.02).

CONCLUSION

Treatment outcome in C-type ZMC fractures is less favourable than treatment outcome in A-type and B-type fractures. Intraoperative imaging, surgical navigation devices and 3D-planning software may improve treatment outcome in C-type ZMC fractures.

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

Objectives

In 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 Methods

Subjects 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.

Results

The 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).

Conclusion

When 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.

Assessment for treatment of tripod fractures of the zygoma with microcompressive screws

PURPOSE

The present prospective study sought to evaluate a new rigid internal fixation device called a "neck screw," which was applied to patients presenting with a tripod fracture of the zygomaticomaxillary complex.

PATIENTS AND METHODS

Seventeen patients with tripod fractures received surgical treatment from 2007 to 2010, and had their zygomaticomaxillary complex monofragments fixed using the neck screw protocol. The adequacy of fracture reduction, stability of the zygomatic monofragment after fixation, cosmetic outcomes, and postoperative complications were used to determine the efficacy of this protocol. The stability provided by the neck screw was evaluated by computed tomography (CT) scans by comparing the immediate postoperative distances between the fractured bone segments (control group) with those distances measured on CT scans obtained 5 weeks later (late group).

RESULTS

The average distance observed between the fractured ends on the immediate postoperative CT scan was less than 0.58 mm, demonstrating adequate fracture reduction. No significant changes were seen in these postoperative values after 5 weeks (Wilcoxon test, P = 1.0000), demonstrating no displacement of the zygomaticomaxillary complex monofragment after fixation using the neck screw.

CONCLUSIONS

The proposed surgical treatment proved efficient in 17 patients. The fixation stability provided by the neck screw was confirmed by subsequent CT scan measurements, statistical analysis, and clinical follow-up during the postoperative period, in which patients showed no significant associated complications, facial asymmetry, enophthalmos, or diplopia.

A retrospective study of zygomatico-orbital complex and/or zygomatic arch fractures over a 71-month period

BACKGROUND/AIM

The aim of this retrospective study was to evaluate the epidemiology, treatment, and complications of zygomatico-orbital complex (ZOC) and/or zygomatic arch (ZA) fractures either associated with other facial fractures or not over a 71-month period.

MATERIAL AND METHODS

This survey was performed in three hospitals of Ribeirao Preto in Sao Paulo, Brazil, from August 2002 to July 2008. The records of 1575 patients with facial trauma were reviewed. There were 140 cases of ZOC and ZA fractures either associated with other facial fractures or not. Data regarding gender, age, race, addictions, day of trauma, etiology, signs and symptoms, oral hygiene condition, day of initial evaluation, hospital admission, day of surgery, surgery approach, pattern of fractures, treatment performed, post-operative antibiotic therapy, day of hospital discharge, and post-operative complications were collected. The data were subjected to descriptive statistical analyses.

RESULTS

The most frequent fractures affected Caucasian men and occurred during the fourth decade of life. The most frequent etiology was traffic accident, and symptoms and signs included pain and edema. Type I fractures were the main injury observed, and the treatment of choice was always rigid internal fixation. Post-operative antibiotic therapy was solely employed when there was an indication. Complications were observed in 13.1% of the cases.

CONCLUSIONS

The treatment protocol yielded suitable post-operative results and also showed success rates comparable to published data around the world.