Treatment of Sagittal Fracture of the Zygomatic Arch Root Assisted by Surgical Navigation Technology

Enhancing Surgical Approach: Breakthrough Markerless Surface Registration With Augmented Reality for Zygomatic Complex Fracture Surgeries

BACKGROUND

Innovative technologies with surgical navigation have been used for enhancing surgical accuracies for zygomaticomaxillary complex (ZMC) fractures and offers advantages in precision, accuracy, effectiveness, predictability, and symmetry improvement. Moreover, augmented reality (AR) navigation technology combines virtual reality, 3-dimensional (3D) reconstruction, and real-time interaction, making it ideal for bone tissue operations. Our study explored the usefulness and clinical efficacy of AR technology in intraoperative guidance for reducing ZMC fractures.

METHODS

We retrospectively studied 35 patients with zygomatic complex fractures, comparing outcomes of AR-guided and conventional methods. Furthermore, the AR system provided real-time visualization and guidance. The evaluation included reduction accuracy using root mean square (RMS) value and symmetry analysis using a mirror image of 3D models. Results demonstrated the feasibility and effectiveness of the AR-guided method in improving outcomes and patient satisfaction.

RESULTS

In 35 patients (25 males, 10 females), AR-guided (n = 19) and conventional (n = 16) approaches were compared. Age, sex, and fracture type exhibited no significant differences between groups. No complications occurred, and postoperative RMS error significantly decreased ( P < 0.001). The AR group had a lower postoperative RMS error ( P = 0.034).

CONCLUSIONS

Augmented reality-guided surgery improved accuracy and outcomes in zygomatic complex fractures. Real-time visualization enhanced precision during reduction and fixation. This innovative approach promises enhanced surgical accuracy and patient outcomes in craniofacial surgery.

Treatment of Sagittal Fracture of the Zygomatic Arch Root

A sagittal fracture at the temporal root of the zygomatic arch (ZAR) often occurs as a component of zygomaticomaxillary complex (ZMC) fractures. However, this area is difficult to access, and anchorage is limited due to the unstable structure around it. Therefore, a preauricular approach using single-screw fixation is proposed, and this study reports its results and usefulness. Forty-four patients with sagittal fractures of ZAR occurring with ZMC fractures were evaluated from 2012 to 2021. Open reduction and internal fixation were performed on all patients with ZMC fractures. Closed reduction using Dingman incision and external finger pressure in group A (indirect approach; 30 patients) and single-screw fixation using a preauricular approach in group B (direct approach; 14 patients) were performed to address sagittal fractures in ZAR. For single-screw fixation, the additional mean operation time was 11.34±3.25 minutes. On postoperative 3-dimensional computed tomography and plain radiographs, group B showed more accurate reduction and less deformity and trismus ( P <0.05). Moreover, a normal diet was initiated more quickly in group B than in group A ( P <0.05). Some cases in group A showed nonunion or malunion. This study revealed that a direct approach (group B) toward sagittal fractures of ZAR is recommended due to more accurate results and fewer complications than those observed with the indirect approach (group A). Moreover, the total operation time and complications may be lesser than those with the bicoronal approach.

Assessment of clinical outcome of surgically managed panfacial fractures with or without ancillary procedures. A 10-year retrospective study

Purpose

The aim of this retrospective study is to analyze the demographic factors, different patterns, complications, and clinical outcomes based on various ancillary surgical procedures performed during the management of panfacial fractures.

Materials and methods

Patients diagnosed with panfacial fractures, who underwent surgical management from 2011 to 2020 were included. The predictor variable was five ancillary surgical procedures, orbital reconstruction with autogenous bone graft, primary nasal bone grafting, open reduction and internal fixation or custom-made palatal splint for palatal fractures, ORIF for zygomatic arch fractures, and reattachment of Medical Canthal Ligament. The outcome variable was post-operative complications. Age, sex, etiology of trauma and pattern of panfacial fractures were the co-variates for the study. The incidence of complications with or without performing ancillary surgical procedures was analyzed.

Results

A total of 1028 patients were treated for various maxillofacial trauma from 2011 to 2020.103 patients were diagnosed with panfacial fractures. 27 of 103 patients were excluded, 76 patients were included in the study with strict adherence to the inclusion criteria. Statistical Analysis was done using SPSS software version 23.0. Chi-Square test was performed to analyze the incidence of complication and fracture pattern. The results were statistically significant for three procedures which included orbital reconstruction, primary nasal bone grafting, and ORIF for palatal fractures with p-value, 0.032, 0.022, and 0.012 respectively.

Conclusion

The results suggested that performing ancillary procedures in the management of panfacial fractures significantly reduces the incidence of postoperative complications and improves the clinical outcome.

Image-Guided Surgery in Complex Skull Base and Facial Fractures: Initial Experience on the Role of Intra-Operative Computer Tomography

Surgery of fractures involving the skull base and the facial skeleton often presents challenges that should be addressed to prevent secondary brain injuries (i.e., cerebro-spinal fluid leak), preserve visual functioning, and guarantee a good esthetic result. Complex craniofacial reconstruction can be aided by navigation and pre-operative planning. In recent years, computerized planning of surgical reconstruction drastically increased the safety and efficacy of surgery, but the impact of intraoperative high quality image devices such as an intraoperative computed tomography (CT) scan has not been investigated yet. This case-control study reports the institutional preliminary experience of using intraoperative CT scans in the surgical management of complex cranio-facial fractures. The results in terms of accuracy of bony reconstruction and neurological or surgical complications have been analyzed in 12 consecutive patients treated with (6 cases) or without (6 cases) i-CT. Comparative analysis demonstrated a greater accuracy of reconstruction in patients treated with the assistance of i-CT. Intraoperative CT is a useful tool with a promising role in a multidisciplinary surgical approach to complex cranio-facial surgery.

Computer-assisted preoperative planning of bone fracture fixation surgery: A state-of-the-art review

Background: Bone fracture fixation surgery is one of the most commonly performed surgical procedures in the orthopedic field. However, fracture healing complications occur frequently, and the choice of the most optimal surgical approach often remains challenging. In the last years, computational tools have been developed with the aim to assist preoperative planning procedures of bone fracture fixation surgery.

Objectives: The aims of this review are 1) to provide a comprehensive overview of the state-of-the-art in computer-assisted preoperative planning of bone fracture fixation surgery, 2) to assess the clinical feasibility of the existing virtual planning approaches, and 3) to assess their clinical efficacy in terms of clinical outcomes as compared to conventional planning methods.

Methods: A literature search was performed in the MEDLINE-PubMed, Ovid-EMBASE, Ovid-EMCARE, Web of Science, and Cochrane libraries to identify articles reporting on the clinical use of computer-assisted preoperative planning of bone fracture fixation.

Results: 79 articles were included to provide an overview of the state-of-the art in virtual planning. While patient-specific geometrical model construction, virtual bone fracture reduction, and virtual fixation planning are routinely applied in virtual planning, biomechanical analysis is rarely included in the planning framework. 21 of the included studies were used to assess the feasibility and efficacy of computer-assisted planning methods. The reported total mean planning duration ranged from 22 to 258 min in different studies. Computer-assisted planning resulted in reduced operation time (Standardized Mean Difference (SMD): -2.19; 95% Confidence Interval (CI): -2.87, -1.50), less blood loss (SMD: -1.99; 95% CI: -2.75, -1.24), decreased frequency of fluoroscopy (SMD: -2.18; 95% CI: -2.74, -1.61), shortened fracture healing times (SMD: -0.51; 95% CI: -0.97, -0.05) and less postoperative complications (Risk Ratio (RR): 0.64, 95% CI: 0.46, 0.90). No significant differences were found in hospitalization duration. Some studies reported improvements in reduction quality and functional outcomes but these results were not pooled for meta-analysis, since the reported outcome measures were too heterogeneous.

Conclusion: Current computer-assisted planning approaches are feasible to be used in clinical practice and have been shown to improve clinical outcomes. Including biomechanical analysis into the framework has the potential to further improve clinical outcome.

Application of Computer-Aided Design and Individualized Templates for Bilateral Zygomaticomaxillary Complex Fractures

PURPOSE

Reduction of the bilateral zygomaticomaxillary complex (ZMC) fracture with individualized templates based on computer- aided surgical simulation system. To evaluate the practicality and accuracy of this approach in the treatment of bilateral ZMC fracture.

METHODS

Sixteen patients with bilateral ZMC fractures were collected to create a study model. The authors reconstruct the ZMC on one side via the three-dimensional (3D) model, and then mirrored to the opposite side. Multiple individualized templates were made based on the 3D model, and used as intraoperative guidance to reduce fractures. After surgery, the facial symmetry and the position of zygoma were observed. The mouth opening, pupil level, and sensation of infraorbital nerve were evaluated. Some mark points on zygoma were measured and the postoperative horizontal asymmetry rate (H) was calculated. Besides, orbital height and width were measured.

RESULTS

For all patients, the position of bilateral ZMC was basically restored. The patients with restriction of mouth opening all recovered to normal. The H values were less than 3.0% at all mark points. There was almost no difference in bilateral orbital width and height. Meanwhile, there was no significant difference between the preoperative measurements of the ideal virtual 3D model and the postoperative measurements of patients.

CONCLUSIONS

The study proves that application of computer-aided design and individualized templates can accurately guide the reduction operation of ZMC fracture, restore the ideal shape of ZMC, and obtain good facial symmetry.

Interrelation between facial soft tissue lessions, underlying fracture patterns and treatment of zygomatic bone trauma: a 10 year retrospective study

Background

The pattern of zygomatic bone fractures varies in the literature, their features being frequently masked by the presence of associated soft tissue lesions. In this context the clinical diagnosis and the therapeutic indications can be difficult. The aim of this study was to evaluate the clinical features of zygomatic bone fractures and their interrelation with concomitant overlying soft tissue injuries, as well as to assess the type of treatment methods applied depending on the fracture pattern and the results achieved depending on the incidence rate of postoperative complications. We will use these results in order to improve the diagnosis and the establishment of correct treatment of this pathology.

Methods

A 10-year retrospective evaluation of midface fractures was performed in patients diagnosed and treated in a tertiary Clinic of Oral and Maxillofacial Surgery. Statistical analysis was performed with the MedCalc Statistical Software version 19.2 (MedCalc Software bvba, Ostend, Belgium; 53 https://www.medcalc.org; 2020). Nominal data were expressed as frequency and percentage. The comparisons of the frequencies of a nominal variable among the categories of another nominal variable were made using the chi-square test. Multivariate logistic regressions were used in order to establish the independent association between variables and lacerations/excoriations. After using the Bonferroni correction for multiple comparisons, a value of p < 0.025 was considered statistically significant.

Results

The study included 242 patients with zygomatic bone fractures. The majority of the fractures were displaced n = 179 (73.9%), closed n = 179 (73.9%) and complete n = 219 (90.5%). Hematoma was the most frequent associated soft tissue lesion n = 102 (42.1%) regardless of the fracture pattern (p = 1.000). Complete zygomatic fracture (OR – 2.68; p = 0.035) and fractures with displacement (OR – 3.66; p = 0.012) were independently associated with the presence of laceration. Fractures with displacement (OR – 7.1; p = 0.003) were independently associated with the presence of excoriation. The most frequent type of treatment applied was Gillies reduction (61.9%), followed by ORIF (30.9%). The most frequent postoperative complication was malunion secondary to Gillies treatment (4,6%).

Conclusions

Patients presenting lacerations and excoriations on clinical soft tissue examination will most frequently have an underlying complete, displaced or comminuted zygomatic fracture. In the case of displaced, open or comminuted fractures we achieved the best results secondary to ORIF treatment method, while in the case of non-displaced and closed fractures, the best results achieved were secondary to conservative treatment.

An Exploration of Multidisciplinary Team Care With Digital Technology for Complicated Cranio-Maxillofacial Bone Defects and Fractures

OBJECTIVE

Early treatment of fractures of the cranio-maxillofacial complex (CMFC) is challenging and likely to result in craniofacial deformity. Multidisciplinary team (MDT) care has developed very rapidly and has recently been accepted in cancer treatment. Therefore, the authors explored the application of MDT care with digital technology in CMFC fractures.

STUDY DESIGN

A 29-year-old man presented for treatment of CMFC fractures and bone defects. An MDT of oral surgeons, ophthalmic surgeons, neurological surgeons, and other experts was convened. After CT scan and three-dimensional reconstruction, the authors performed personalized surgery that included 9 specialists over an 8-hour period.

RESULTS

The operation was successful and all fractures achieved clinical stability. At 1-month follow-up, appropriate appearance and functional recovery had been achieved.

CONCLUSION

In this study, MDT care with digital technology was very effective and had low associated costs. The involvement of more disciplines in MDT care may result in fewer complications.

Surgical navigation improves reductions accuracy of unilateral complicated zygomaticomaxillary complex fractures: a randomized controlled trial

Accurate reduction is the key to successful treatment of bone fractures. Complicated zygomaticomaxillary complex fracture, known as one of the most challenging facial bone fractures, is often hard to achieve an accurate reduction, thus leading to facial deformity. In this study, twenty patients with unilateral complicated zygomaticomaxillary complex fractures were included and randomly divided into experimental and control groups, which is with and without the aid of surgical navigation, respectively. The pre- and postoperative imaging data were collected and then analysed using Geomagic Studio 11 software and Brainlab iPlan CMF 3.0. A more precise reduction was showed in the experimental group according to the measurement results of both software programmes than in the control group. In conclusion, surgical navigation showed great value in performing accurate reductions of complicated zygomaticomaxillary complex fractures and restoring facial contour.