Treatment of zygomatic fractures: internal wiring-antral-packing-reposition without fixation

Recovery of the Infraorbital Nerve Following Open Reduction and Fixation Surgery of Zygomaticomaxillary Complex Fractures-A Prospective Cohort Study Based on Quantitative Sensory Testing

This study aimed to assess the sensory function of the infraorbital nerve in patients with fractures of the zygomatic complex who underwent open reduction and internal fixation at different time points using quantitative sensory testing, which was established by the German Neuropathic Pain Research Network, comprising a 7-item mechanical and thermal sensory test. A total of 21 patients (age range 17-46 y, 14 males) with unilateral zygomatic complex fractures were included. Quantitative sensory testing was conducted before the operation and at 1 week, 3 months, and 6 months operatively, with cold detection threshold, warmth detection threshold, cold pain threshold, heat pain threshold, mechanical detection threshold, mechanical pain threshold, pressure pain threshold, and vibration detection threshold being measured in bilateral infraorbital regions. Notable changes in sensitivity were observed in all values except for the mechanical pain threshold. In the majority of patients with zygomaticomaxillary complex fractures, infraorbital hypoesthesia was significantly improved within 3 months postoperatively, and almost complete recovery could be achieved by 6 months postoperatively.

Neurosensory Assessment of Infraorbital Nerve Injury Following Unilateral Zygomaticomaxillary Complex Fracture – A Prospective Study

Background:

This study aimed to assess the difference in the recovery pattern of branches of infraorbital nerve paraesthesia after zygomaticomaxillary complex (ZMC) fracture in both surgically and non-surgically managed patients.

Materials & Methods:

A prospective, observational study involving 31 patients with unilateral ZMC fracture - 15 in the surgical group (Group A) and 16 in the non-surgical group (Group B) was evaluated. These patients were assessed at the time of injury, 3-months follow-up, and 6-months follow-up for the sensory function of the infraorbital nerve. The assessment of paraesthesia by cotton wisp test, light touch monofilament test, and the cold thermal test was subjected to intra-group and inter-group correlation by McNemar test and Fischer's exact test. Repeated Measures ANOVA with post-hoc Bonferroni test for intra-group correlation and independent sample t-test for inter-group correlation were used for two-point discrimination.

Results:

A statistically significant improvement was noted on both 3 and 6 months follow-up in the malar region in group A. Other statistically significant improvements were noted only on 6 months follow-up in the infraorbital region in group A. On the 2-point discrimination test, all the facial regions showed significant improvement in both the groups over 3 months and 6 months of follow-up.

Conclusion:

There was a significant improvement in the infraorbital nerve sensory function following ZMC fracture over 6 months; however, the surgical intervention showed no statistical significance. Further, it can also be concluded that the inferior palpebral branch of the infraorbital nerve shows maximum functional disruption resulting in a higher incidence of paraesthesia in the infraorbital and malar region.

Introduction of pulsed radiofrequency cautery in infraorbital nerve block method for postoperative pain management of trauma-induced zygomaticomaxillary complex fracture reduction

Although various cases of neuralgia and its treatments have been reported, not enough evidence is present to recommend a single type of treatment as the most effective. The patient we have dealt with experienced significant interferences in his daily life due to chronic allodynia, but the symptom could not be resolved via previously reported treatments. We report a case of which a patient who presented infraorbital neuralgia after trauma was successfully treated by a novel treatment strategy. The patient was treated by applying infraorbital nerve block and pulsed radiofrequency cautery side by side. Through this report, we evaluate proper prevention and treatment strategies for patients who develop infraorbital neuralgia through similar etiologies.

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Prospective blind comparative clinical study of two point fixation of zygomatic complex fracture using wire and mini plates

BACKGROUND

The zygomatic maxillary complex (ZMC) fractures are one of the most frequent injuries of the facial skeleton due to its position and facial contour. Assaults, road traffic accidents and falls are the principal etiologic factors that may cause fractures of zygomatic bone. The different fixation methods are applied to treat the zygomatic bone fractures, with many more classifications which have been described in the literature for the ease of management. The type of the fracture, its severity and associated facial fractures usually interferes the treatment modality.

PURPOSE OF STUDY

The aim of this paper is to show the results of 18yrs prospective blind comparative study using wire and plate osteosynthesis which needed open reduction and internal fixation involving Type II to Type IV Spissel and Schroll ZMC fractures.

MATERIALS AND METHODS

Total 80 cases included in the study out of 1780 ZMC cases which were treated using wire and plate osteosynthesis over a period of 18 yrs, involving only Type II to Type IV Spissel and Schroll ZMC fractures. Other types excluded from study to prevent observer bias. All the fixations carried out through Standard Dingman's incision using stainless steel 26 gauze wire and titanium 1.5 mm mini plate system under general anesthesia by single maxillofacial surgeon and evaluated by another maxillofacial surgeon who is blinded for surgical procedure after 2 and 4 wks of follow-up for facial symmetry, wound healing, functional assessment (mouth opening, diplopia), and sensory disturbance. All the data tabulated in Excel software (Microsoft) for statistical analysis. P-value calculated to know the Significance of treatment modality in all aspects.

RESULTS

Result shows no significant p-values indicating both the operating techniques are equally efficient in the surgical management of ZMC fracture.

CONCLUSION

Osteosynthesis by mini plates is simple, logical and effective treatment compared to wire osteosynthesis in regard to stability of fracture fragments. Wire osteosynthesis will be helpful in emergency surgeries or where the mini plates are not available. Even though the wire osteosynthesis is economical compared to mini plate fixation; but the time and skill is required for fixation of wires.

Neurosensory changes in the infraorbital nerve following zygomatic fractures

OBJECTIVE

To document the neurosensory changes in the infraorbital nerve following zygomatic fractures managed in various ways.

STUDY DESIGN

Twenty-five patients were included in the study. Neurosensory function was assessed with calibrated nylon monofilaments, electrical stimulation, heat detection thresholds and response to pin prick in the infraorbital, supraorbital, and mental nerve regions. Patients were seen immediately post-trauma, then 1 and 6 months following surgery.

RESULTS

Nine fractures were caused by traffic accidents (TAs), 8 by falls, and 8 by a local blow in a physical dispute. The fractures consisted of 15 displaced and 10 minimally or nondisplaced zygomatic complex fractures, and were left surgically untreated in 7 cases (None group), reduced but not fixed in 8 cases (Reduction group), and fixed with plates in 10 cases (Plates group). Plates were employed significantly more often in displaced fractures (chi-squared P = .0006). At 6 months significantly improved infraorbital nerve function was found in the Plate and None groups relative to the Reduction group (ANOVA P = .006). Only 1 case of chronic neuropathic pain was found.

CONCLUSIONS

This study concurs with previous studies in finding that plate fixation allows for significantly better restoration of infraorbital nerve function. Chronic neuropathic pain following zygomatic fractures is rare.

Infraorbital Nerve Injury Associated with Zygoma Fractures: Documentation with Neurosensory Testing

Persistent sensibility abnormalities after correction of zygoma fractures indicate injury to the infraorbital nerve and may produce pain. To investigate this, a retrospective study of 25 patients who had undergone surgical correction of a zygoma fracture was performed. Bilateral neurosensory measurements were obtained with the Pressure-Specified Sensory Device (Sensory Management Services, Baltimore, Md.). Seven of the 25 patients had required orbital floor reconstruction. Each patient had undergone fracture correction at least 6 months earlier and was interviewed, at the time of sensibility testing, regarding symptoms related to the fracture. The data were evaluated by a blinded examiner, from a separate clinical facility, who attempted to predict the side of the fracture and the degree of zygoma displacement on the basis of measurements of sensibility of the paranasal, upper lip, and zygomaticotemporal areas. Seventy-six percent of patients demonstrated abnormal sensibility on the side of the zygoma fracture, compared with the contralateral side. Sensibility was abnormal for 100 percent of the patients who required orbital floor reconstruction. Seventy-four percent of patients with abnormal sensibility reported symptoms related to the fracture. Eighty percent of the zygoma fractures were correctly identified, with respect to the side of the fracture, by the blinded examiner on the basis of the neurosensory measurements alone (p < 0.005). Predictions proved correct for 91 percent of the patients with widely displaced fractures and none of the patients with nondisplaced fractures. The results of this study suggest that neurosensory testing is an important clinical adjunct for the evaluation of patients with facial pain or dysesthesia after facial fracture reconstruction. The results suggest the need to develop algorithms for the diagnosis and treatment of trigeminal nerve injuries after craniofacial trauma. This approach could also be applicable to dysesthesia or pain after aesthetic facial surgical procedures.

Early and delayed repair of orbitozygomatic complex fractures

PURPOSE

The goal of this study was to review experience with early and delayed repair of orbitozygomatic complex fractures and develop guidelines for repair based on timing and extent of injury.

PATIENTS AND METHODS

Records of patients with orbitozygomatic complex fractures over a 10-year period were reviewed for cause of injury, signs and symptoms, length of time from injury to repair, and method of repair. Results were evaluated by office examination and telephone interviews at least 6 months to 10 years after surgery.

RESULTS

Seventy-eight patients who had undergone 81 surgical procedures were analyzed. The series consisted of 49 primary repairs (1 to 22 days postinjury), 10 delayed repairs using osteotomies at 21 days to 5 months postinjury, and 22 delayed repairs requiring onlay bone grafting from 4 months to 16 years postinjury. Forty patients (43 procedures) were available for follow-up. Early surgical intervention dramatically improved esthetic and functional outcomes, whereas late repair was less satisfactory. Hypoesthesia was not improved by surgery. Osteotomy and onlay grafting techniques were necessary for delayed treatment.

CONCLUSION

Orbitozygomatic fractures can be repaired up to 21 days postinjury using primary reduction and fixation techniques. Osteotomies are required after 21 days and can be used successfully up to 4 months postinjury. After 4 months, successful repair requires onlay bone grafting.

Evaluation of results with three-point visualization of zygomaticomaxillary complex fractures

OBJECTIVE

To retrospectively evaluate the results of three-point visualization and liberal rigid fixation for the treatment of unilateral zygomaticomaxillary fractures by assessing the incidence and severity of complications.

STUDY DESIGN

Fourteen patients were examined an average of 19 months after 3-point visualization with multiple points of rigid fixation for their unilateral zygomaticomaxillary fractures. Patients were evaluated for asymmetry in globe position, superior tarsal fold size, diplopia, lateral canthus height, and malar projection.

RESULTS

The following were found: two patients with significant changes in globe position, none with diplopia in direct gaze, two with diplopia in extreme gazes, two with severe tarsal fold asymmetry, five with mild tarsal fold asymmetry, and two with noticeable malar asymmetry.

CONCLUSION

Three-point visualization and liberal rigid fixation for zygomaticomaxillary fracture treatment results in a low incidence of complications that are proportional in severity to the trauma sustained.

Morbidity of the infraorbital nerve following orbitozygomatic complex fractures

Acute sensory disturbances in the distribution of the infraorbital nerve are recognised signs present in patients with orbitozygomatic complex fractures. Fifty consecutive patients with unilateral orbitozygomatic complex fractures were evaluated with regard to the long-term infraorbital nerve sensory function. The highest incidence of long-term neurosensory deficits occurred in fractures with an undistracted frontozygomatic suture. This is in complete agreement with the distribution of long-term neurosensory deficits regarding the method of treatment for orbitozygomatic complex fractures. In our series slightly more than one-third of the patients had third or fourth degree nerve injuries, according to Sunderland's classification, to the infraorbital nerve following orbitozygomatic complex fractures. This outcome should influence the management of orbitozygomatic complex fractures. With regard to fixation of unstable malar fractures in relation to sensory recovery of the infraorbital nerve, miniplate osteosynthesis is recommended as opposed to wire fixation in all unstable bone fractures when there is displacement. Furthermore, open reduction and fixation of an orbitozygomatic complex fracture offer a better prognosis for complete recovery of the infraorbital nerve function than elevation only with or without Kirschner wire fixation.

Recovery of the infraorbital nerve after zygomatic complex fractures: a preliminary study of different treatment methods

The infraorbital nerve (ION) is often involved in trauma to the zygomatic complex (ZC), resulting in sensory disturbance of the area innervated by it. The purpose of the study was to compare the incidence of persistent sensory disturbance after recovery from isolated simple fractures of the ZC, with four treatment methods: 1) closed reduction via subcutaneous approach without fixation; 2) open reduction via subcutaneous approach without fixation; 3) open reduction via oroantral approach and support of the complex by an intraantral Foley catheter; and 4) open reduction via Gillies approach with fixation of the frontozygomatic (FZ) fracture with wire osteosynthesis, and open reduction via Gillies approach with fixation of the FZ fracture with miniplate osteosynthesis. Analysis revealed that patients treated with miniplate osteosynthesis exhibited a trend for higher recovery rate of the (ION) than with the other three methods. No significant differences were found among the other three methods.

The characteristics of midfacial fractures and the association with ocular injury: a prospective study

Ocular injuries commonly occur in patients with facial fractures. This prospective study was set up to determine the incidence of ocular injuries, as assessed by an ophthalmologist, in patients who had sustained midfacial fractures. Over a 2-year period, a study of 363 patients who had sustained midfacial trauma sufficient to lead to a facial bone fracture (438 fractures) was undertaken and patients received a comprehensive examination by an ophthalmologist and an orthoptist within 1 week of injury. The characteristics of the eye injuries sustained were related to the aetiology of the fracture, the type of fracture, and the sex and age of each patient. Ninety percent of patients sustained ocular injuries of various severities. Sixty three percent of patients sustained only minor or transient ocular injuries, 16% suffered moderately severe ocular injury and 12% experienced severe eye injuries. Road traffic accident was associated with the highest incidence of severe ocular disorder (9/45 = 20%) whilst assaults had the second highest incidence at 11% (20/181). One third of all patients with comminuted malar fracture suffered a severe ocular disorder (9/27) whilst blow-out fracture came second at 16.7% (6/36). Fifty six patients (15.4%) had a decrease in their visual acuity and 9 patients (2.5%) had significant traumatic optic neuropathy. Decrease in visual acuity was the main clinical finding accompanying the majority of significant eye injuries. When ocular injuries were related to aetiology, it was apparent that road traffic accidents and assaults associated with alcohol abuse showed the highest incidence of major ocular dysfunction. It is suggested that all patients sustaining midfacial fracture associated with a significant decrease in visual acuity either pre- or postoperatively should have an early ophthalmological review.

Zygomatico-maxillary fractures. Late results after traction-hook reduction

A simple, closed method for zygomatico-maxillary fracture treatment is described i.e. replacement by the use of a traction bone-hook. After X-ray and clinical examination had excluded undisplaced fractures, blow out fractures and comminuted fractures, the postreduction stability was assessed peroperatively and again one week after. Sophisticated preoperative fracture-classifications predicting postoperative stability appeared redundant. In the present study, this procedure could be performed in 55.4% of the total fractures which needed to be reduced. At re-evaluation, two to eight years later, the results remained satisfactory. The method appeared, in addition to its simplicity, to require less complicated postoperative care and, therefore, a short hospitalization.

Paraesthesia of the infraorbital nerve following fracture of the zygomatic complex

68 patients with fractures of the zygomatic complex were studied. Of these, 56 had sensory disturbances of the infraorbital nerve. 50 patients were operated on and in 42% (21) some degree of persisting hypesthesia was found. No significant difference in outcome was found between the different methods of indirect reduction used. However, in 10 out of 12 patients in which direct fixation with transosseous wiring of the infraorbital margin was performed, persisting hypesthesia was encountered. In 3 out of 4 patients where the nerve was also explored primarily, the sensation returned totally. A secondary nerve deliberation was also found to be beneficial in 4 out of 5 patients with persisting total loss of sensation.

An analysis of 2,067 cases of zygomatico-orbital fracture

A ten-year review of 2,067 cases of zygomatico-orbital fractures is presented. The age and sex distribution, anatomical types of fractures, associated maxillofacial and nonmaxillofacial trauma, and causes of the injuries are described. The majority of fractures were sustained by males and resulted from trauma inflicted in altercations. The most common associated facial fractures were mandibular; the most common associated nonmaxillofacial trauma was extremity fractures. Motorcycle accidents caused the most significant amount of associated trauma, followed by motor vehicle accidents in which no seat restraint was used by the victim. Treatment, when indicated, consisted of elevation via a temporal approach followed by fixation where necessary. The fixation methods used are presented and discussed.

Fractures of the orbital floor: indications for exploration and for the use of a floor implant

Fractures of the orbital floor are frequently treated by exploratory surgery and by the insertion of a floor implant, because of the possibility of late diplopia and enophthalmos. The findings of this study would suggest that this fear is not justified and that there is no indication for an early diagnostic exploration of the fractured orbital floor, if there are no clinical or radiological signs of orbital floor fracture within 14 days of the accident. The significance of the status of the periorbita in the method of treatment of the fractured orbital floor is stressed. The suggestion is made, contrary to what is generally found in the literature, that a linear or a comminuted floor fracture and an orbital floor with a defect do not require a floor implant, if the periorbita is intact.

Proplast augmentation for posttraumatic zygomatic deficiency

Facial deformities following fractures of the zygomatic complex are common. Included in this article are the indications, work-up, and surgical technique for placement of Proplast implant material to correct the deformity of the malunited zygomatic complex. Three cases are presented to illustrate this approach.

Late treatment of malunited malar fractures

Malunited malar fractures are considered from the points of view of pathophysiology and anatomy. Clinical and radiographic approaches to assessment are described. Surgical techniques are presented in detail. Four representative cases are reported.

The trans-nasal Kirschner wire as a method of fixation of the unstable fracture of the zygomatic complex

A technique for the fixation of the unstable zygomatic complex is described and compared with other methods currently available.

The use of a single fronto-zygomatic osteosynthesis plate and a sinus balloon in the repair of fractures of the lateral middle third of the face

In certain orbito-zygomatic fractures, a fronto-zygomatic screwed plate and a sinus balloon permit, at the expense of a single eyebrow incision, the repositioning of the cheekbone and the alignment of the other fracture sites; the other fractures sites consolidate and remodel themselves spontaneously due to the action of the adjacent soft tissues. The plate is malleable so that correct reduction can occur during the course of surgical repair; the plate should align the cheekbone perfectly. Neglect of the stability offered by reduction after exposure of the bone fragments may seem exaggerated, in simple cases; the orbital approach is without risk and limited. This argument - which also depends on the experience of the surgeon - does not apply in the case with a comminution of the orbital rim; closed fracture site reduction and distant osteosynthesis offer an alternative to the classical repair which requires a wide cutaneous incision and significant periosteal stripping with the subsequent risk of eyelid distortion.