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

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.

Novel Surgical Technique for Repair of Zygomatic Fractures: Lever Technique

Background

Zygoma is a very crucial component for the anteroposterior positioning of the midface and for the maintenance of facial contours. Zygomatic fractures are considered as the second most common type of facial fractures following nasal fractures. We have developed a new reduction technique called "lever," which is based on the application of lifting force as an alternative to the methods in which the pulling force is applied.

Patients

Over a 12-year period, 90 patients were treated with minimal access approach and 130 patients were treated with open reduction internal fixation (ORIF), using the lever technique.

Results

In the follow-up period, no complications occurred in any of the patients who underwent minimal access approach. Miniplate removal operation was performed in 3 of the patients. Enophthalmos developed in one patient. Since 4 of the 7 suboptimal reduction patients did not experience any functional or cosmetic problems, no treatment was necessary and the remaining 3 patients underwent fat graft due to the presence of malar depression.

Conclusion

This minimally invasive surgical procedure we have developed can be successfully used both in the minimal access approach and in ORIF, especially in delayed cases. We recommend this method due to the reasons that it is safe to conduct, easy to learn, fast to apply, simple to perform, and also economical to deploy.

Patient Perspective in the Management of Zygomatic Fractures

BACKGROUND

A clinical study was undertaken on the management of zygomatic complex fractures using various surgical approaches in the Department of Oral and Maxillofacial surgery during the past 3 years.

AIMS

The aim of this study is to evaluate the versatility of various surgical approaches.

MATERIALS AND METHODS

A total of 15 cases were selected following a clinical and radiological examination of fractures of the zygomatic complex. A standard pro forma was used to record the case history and findings. These cases were treated by mini plate or micro plate osteosynthesis. Reduction techniques used were Gillie's temporal approach, Dingman's lateral eyebrow approach, upper buccal sulcus approach, and inferior orbital approach. Fixations were done either by mini plate or micro plate osteosynthesis. To compare the effectiveness of the reduction and fixation techniques the following parameters were assessed: facial symmetry-corrected/unaltered, wound healing-good/impaired, mouth opening good/restricted, diplopia-present/absent, infraorbital nerve - present/absent.

RESULTS AND CONCLUSION

Successful surgical treatment of the zygomatic complex fracture is influenced by its geometry. Whether the alignment may be successfully achieved or not by open reduction at single or multiple locations, can vary with the individual surgeon's experience.

Facial Fractures

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Demonstrate an understanding of some of the changes in aspects of facial fracture management. 2. Assess a patient presenting with facial fractures. 3. Understand indications and timing of surgery. 4. Recognize exposures of the craniomaxillofacial skeleton. 5. Identify methods for repair of typical facial fracture patterns. 6. Discuss the common complications seen with facial fractures.

SUMMARY

Restoration of the facial skeleton and associated soft tissues after trauma involves accurate clinical and radiologic assessment to effectively plan a management approach for these injuries. When surgical intervention is necessary, timing, exposure, sequencing, and execution of repair are all integral to achieving the best long-term outcomes for these patients.

Zygomaticomaxillary Complex Fractures: A Review of 101 Cases

AIM

ZMC fractures are the common facial injuries. The main causes of fractures are trauma due to RTAs, assaults, falls, sports related injuries, and the civilian warfares. This study is to evaluate and review the etiology, incidence, clinical findings and treatment of ZMC fractures. A sincere effort has been put forward in the management of ZMC fractures and their efficacy is evaluated in the larger interest of the patients.

MATERIALS AND METHODS

In this study 101 patients having displaced ZMC fractures with insignificant medical history were reviewed to evaluate the versatility of its management, with the main emphasis on post operative stability, restoration of mouth opening, wound healing, esthetic restoration of the prominence of cheek and the complications encountered.

RESULTS

A total of 101 patients were reviewed for the management of ZMC fractures. All the cases included were managed during the period from August 2007 to August 2009 in the Department of Oral and Maxillofacial Surgery, Mamata Dental College and Hospital, Khammam. The extremes of ages in this study ranged from 17 to 60 years with the mean of 43. RTA was the most common cause of injury. Seventy-eight patients (77 %) were managed with surgical treatment.

CONCLUSION

Attention should be paid to improvement in automobile safety devices and compliance by motor vehicle occupants in addition to the improvement of the rules and regulations in sporting activities.

"Roller coaster maneuver via lateral orbital approach" for reduction of isolated zygomatic arch fractures

Numerous techniques have been reported for the reduction of zygomatic arch fractures. In this article, we aimed to describe a technique we named as "roller coaster maneuver via lateral orbital approach" to closed reduction of the isolated-type zygomatic arch fractures. Surgical outcomes of 14 patients treated with this method were outlined.

Reoperative midface trauma

Reoperative midface surgery can be challenging. Although well-established surgical principles are still the basis of surgical approaches and techniques, the advent of new materials and technologies brings about opportunities to achieve the best possible outcomes with bony reconstruction and more precise results. Soft tissue deformities continue to be some of the most challenging, especially as they relate to the orbit, but continually evolving techniques offer improved results for volume corrections to treat enophthalmos and diplopia. Conventional orthognathic and reconstructive rhinoplasty techniques can also be applied to great effect and with satisfying results to treat posttraumatic malocclusions and nasal deformities.

Temporal miniplates in the frontozygomatic area--an anatomical study

PURPOSE

The advantages of rigid fixation over wire osteosynthesis are well established for the management of facial trauma. Miniplates in the frontozygomatic area are traditionally applied to the lateral face of the orbital rim, but with some undesirable effects, such as palpability, visibility, and risk of penetration into the anterior cranial fossa. The aim of this study was to perform an anatomical study to validate the use of miniplates on the temporal face of the frontozygomatic region.

METHODS

Osseous thickness measurements were performed in 30 skulls, on four points above and four below the suture, at 3-mm intervals, perpendicular to the bone surface.

RESULTS

There is enough bone thickness to apply the screws, ranging between 4 and 6.5 mm. The first hole over the frontozygomatic suture should receive the smallest screws and the other areas can receive screws up to 6 mm. All drillings are made from the temporal fossa to the orbit, and its contents should therefore be protected during the perforations. At the measured points there is no risk of anterior cranial fossa penetration.

CONCLUSION

This study suggests that it is possible to use miniplates at the temporal aspect of the frontozygomatic suture.

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

PURPOSE

To evaluate possible associations between the degree of reduction, remaining dislocation (mm), fracture type, and the sequelae from which the patient may suffer postoperatively in patients with zygomaticomaxillary fracture managed by closed reduction.

MATERIAL AND METHODS

A 3-year retrospective audit was undertaken to identify all patients who had sustained a fractured zygoma and were operated on by closed reduction at the Ear, Nose, and Throat Department, Karolinska University Hospital, Huddinge, Sweden. Patients were followed up by mail questionnaire and postoperative computed tomography (CT).

RESULTS

The odds of having symptoms (odds ratio [OR] 4.26, confidence interval [CI] 1.09-18.44) was significantly higher in the group with a reduction less than 100% (n = 34) compared with the group with 100% reduction (n = 17) (P = .035). The odds of having symptoms (OR 9.91, CI 0.89->500) was higher in the group with remaining dislocation 6 to 10 mm compared with the group with no remaining dislocation (P = .069). The type of fracture (A, B, or C) also influenced the patients' postoperative symptoms. The odds of having symptoms was 48.40 (CI 4.60->500) times higher having fracture C compared with fracture A (P < .001).

CONCLUSIONS

The degree of reduction and remaining dislocation of zygomaticomaxillary fractures is important to achieve a good postoperative result, that is, reducing the patient's postoperative symptoms. Furthermore, the type of fracture also influences the patient's long-term sequelae.

A Retrospective Analysis of 101 Zygomatico-Orbital Fractures

A 5-year review of 101 cases of zygomatico-orbital fractures is presented. The epidemiology, fracture patterns, treatment modalities, and complications were evaluated in this retrospective study. A majority of fractures were sustained by males and resulted from trauma inflicted during altercations and traffic accidents. The most common fracture pattern was tripod fracture and the most common associated facial fractures were mandibular fractures. Open reduction and rigid fixation was the most frequently employed treatment modality. Depending on the stability of reduced zygoma, one, two and three-point fixations were applied. Orbital floor exploration was performed in 41 cases. Ten out of 16 orbital floor bone defects required reconstruction. In these cases orbital floor was reconstructed with 1.5-mm porous polyethylene implant. Although we encountered a few complications related to the incisions for open reduction, the rate of complication in which correction was difficult (e.g. facial asymmetry) was lower with this approach when compared with the literature.

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.

Changing trends in the treatment of zygomaticomaxillary complex fractures: a 12-year evaluation of methods used

PURPOSE

The efficacy of the current methods for the treatment of fractures of the zygomaticomaxillary complex was evaluated.

PATIENTS AND METHODS

One thousand two hundred seventy-seven patients with fracture of the zygomaticomaxillary complex and 196 patients with fractures of the zygomatic arch that were admitted between 1984 and 1995 were evaluated. One thousand one hundred fifty surgical procedures were performed, and in 401 cases, no operative treatment was considered necessary. The Gillie's approach was used in 514 cases, intraosseous wiring in 89 cases, bone plate osteosynthesis in 322 cases, Roger-Anderson pins in 180 cases, antral packing in 17 cases, and elevation with a hook in 28 cases.

RESULTS

The best results were achieved with the use of semirigid fixation with miniplates applied at one or more sites of the fractured complex, occasionally used in combination with other methods such as Roger-Anderson pins.

CONCLUSIONS

Semirigid fixation with miniplates offers the most reliable method available today for the treatment of zygomatico-orbital complex fractures and has practically replaced every other method in our institution. The increased cost and occasionally the necessity to remove the hardware are the main disadvantages of the method.

Analysis of treatment for isolated zygomaticomaxillary complex fractures

PURPOSE

The purpose of this study was to evaluate the adequacy of reduction and stability of fixation of isolated zygomaticomaxillary complex (ZMC) fractures treated by various methods over a 5-year period.

PATIENTS AND METHODS

Forty-eight patients with isolated, unilateral ZMC fractures that had at least 6 weeks' clinical follow-up were studied. Demographic information and methods of treatment were obtained from the medical records. Quality of reduction was assessed by examination of postoperative images. Stability of the repositioned ZMC was assessed by comparing immediate postoperative images with those obtained at least 5 weeks later. Cosmetic outcomes were assessed by clinical assessment and examination of photographs.

RESULTS

A variety of surgical approaches and fixation sites were used in the sample. All patients but five had satisfactory reductions performed during surgery. In two of the latter, no noticeable facial deformity was apparent. No patient showed postsurgical change in position of the reduced ZMC. Three patients showed postsurgical enophthalmos at longest follow-up. Approximately 20% of those having lower eyelid incisions had some amount of scleral show at longest follow-up.

CONCLUSIONS

A variety of techniques can be used to produce a satisfactory outcome. Based on the results and a review of the literature, recommendations for treatment are proposed.

Classification and treatment of zygomatic fractures: a review of 1,025 cases

The treatment of zygomatic fractures varies among surgeons, and the cosmetic and functional results are frequently less than optimal. A treatment guideline based on a simple classification of zygomatic fractures is presented. The emphasis is placed on the indications for closed and open reduction, consistent methods of three-dimensional alignment and fixation, and the management of concomitant infraorbital rim and orbital floor fractures. Postoperative results with regard to infraorbital nerve and maxillary sinus dysfunction, malar asymmetry, and orbital complications in the treatment of 1,025 consecutive zygomatic fractures are presented.