Zygomatic fractures. II. A follow-up study of 137 patients

Frequency of Diplopia in Zygomatic Complex Fractures-A Cross-Sectional Descriptive Study

Background

The zygomatic complex is the second most common fracture of the facial bones after the nasal bone. The prominent convex shape of the zygoma makes it vulnerable to traumatic injury. Diplopia is one of the serious complications of zygomatic complex fracture and is a common subjective complaint.

Objective

To determine the frequency of diplopia in zygomatic complex fractures. Methodology. A cross-sectional descriptive study was conducted at the Oral and Maxillofacial Surgery Ward, Civil Hospital, Karachi, Pakistan. The duration of the study was 1 year (March 1, 2021 to February 28, 2022). A total of 126 patients having zygomatic complex fractures were included in this study. After recording the patient's complete history, like demographic details and cause for fracture, diplopia was examined clinically. If, during the examination, the patient complained of double vision, this was labeled as diplopia positive (Yes) and negative (No) if the patient did not have any such complain. Data were statistically analyzed.

Results

The mean (±SD) age of patients was 33.42 (±9.27), with 91 (72.2%) male patients and 35 (27.8%) female patients. The frequency of diplopia in zygomatic complex fractures was observed in 52 (41.3%) patients. The rate of diplopia was significantly high in patients aged between 31 and 40 years (P-value=0.0005).

Conclusion

The frequency of diplopia among patients having zygomatic complex fractures was high in this study. Thus, forming a strategy to properly diagnose and treat it and to prevent persistent morbidity to improve patient's quality of life is recommended.

Radiographic evaluation of percutaneous transfacial wiring versus open internal fixation for surgical treatment of unstable zygomatic bone fractures

Introduction

The fixation of unstable zygomaticomaxillary complex (ZMC) fractures can be achieved by open reduction with rigid internal fixation (ORIF) and/or by closed reduction with percutaneous transfacial Kirschner wire fixation (CRWF). The aim of this study was to tomographically assess the symmetry and the protrusion of the cheekbone with unstable ZMC fractures that had been treated by ORIF vs. CRWF.

Materials and methods

Sixty patients exhibiting a surgically unstable tetrapodal ZMC fracture were included in this multicenter retrospective study. The coordinates of 5 landmarks representing the zygomatic protrusion were comparatively studied on the healthy and on the broken side using preoperative and postoperative tridimensional computed tomography (CT) scans or cone beam CT.

Results

No significant difference was found in the zygomatic protrusion irrespective of the surgical technique that was used. The zygomatico-maxillary ansa was found to be the most complicated area to reduce, particularly in the frontal plane with both the CRWF and the ORIF technique (p₁ = 0.001 and p₂ = 0.0009, respectively). There was no difference in terms of the level of complications, while the mean duration of the surgery was significantly less for the CRWF group.

Conclusion

With good postoperative radiographic outcomes, the CRWF can be proposed as an alternative or in association with the ORIF technique for fixation of tetrapodal fractures of the ZMC.

Evaluation of intra ocular pressure in zygomatico maxillary complex fractures

PURPOSE

To study effects of zygomatico maxillary fractures and fracture reduction on intra ocular pressure (IOP).

MATERIALS AND METHODS

IOPs of 20 patients with unilateral zygomatico-maxillary complex (ZMC) fractures (divided into 2 groups of 10 undisplaced, 10 displaced) were measured at various time intervals. The relationship between IOPs between the two groups at various time intervals was recorded and evaluated using independent T-tests.

RESULTS

20 subjects were divided into two equal groups (10 each of displaced and undisplaced fractures). Mean age of patients was 33.8 years with 90 % males and 10 % females. The change in IOP at the time of reporting, after 24 h and 7 days for patients with undisplaced ZMC fractures (Group I) was recorded and was found to be significant. The change in IOP at the time of reporting, before and after surgery, after 24 h and 7 days for patients with displaced ZMC fractures (Group II) was recorded and was also found to be significant. The IOPs of the two groups was compared at various time intervals and was found to be significant. Also, a significant increase in IOP was noted just after fracture reduction, which could be attributed to oculocardiac reflex, which has been proven to cause bradycardia, and in some cases, even death.

CONCLUSION

A cautious eye needs to be kept over IOP while reducing ZMC fractures at regular intervals and the anaesthetist has to be informed to look for any bradycardia that can occur. Tonometers should be a part of standard armamentarium while reducing and fixing ZMC fractures.

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 New Proposal of Classification of Zygomatic Arch Fractures

PURPOSE

Among facial fractures, zygomatic arch fractures occur rather frequently. Facial fractures have recently been classified in fine detail according to computed tomographic findings. Nevertheless, there exists no classification of the zygomatic arch fracture, which has a physiognomically important place, to provide guidance for treatment. We aimed to make a detailed classification of zygomatic fractures in various shapes, which does not exist in the literature, and to form an algorithm for treatment.

PATIENTS AND METHODS

A total of 451 patients with zygomatic arch fractures treated in our clinic from 1987 through 2004 were assessed retrospectively from the treatment viewpoint together with radiological and clinical findings.

RESULTS

At the end of this assessment, arch fractures were divided into 2 groups: 1) isolated fractures in which the zygomatic arch alone broke, and 2) combined fractures in which the zygomatic arch broke together with the other facial bones. Isolated fractures were also divided into 2 subgroups as A) 2 fractures in the arch, and B) more than 2. Isolated arch fractures with more than 2 fracture lines were also classified as V-shaped fractures where fragments are partially reduced and those where fragments are displaced. As for combined fractures, they were subgrouped as A) single fracture in the arch, and B) plural. Plural fractures were further classified within their own group, also according to whether fragments were displaced or not.

CONCLUSION

In the 2 fractures and V-shaped fracture subgroups of isolated fractures, preservation of fragments in reduced position was satisfactory during the closed reduction and afterwards. As for those with more than 2 fractures of isolated arch fractures, they required open reduction and internal rigid fixation. The same treatment was used in combined zygomatic arch fractures where there were more than one displaced fractures. In addition to classification, we formed an algorithm to guide us in treatment based on our series.

Treatment of Noncomminuted Zygomatic Fractures With Percutaneous Screw Reduction and Fixation

The standard treatment modality of zygomatic fractures is open reduction and rigid fixation of the fractured segments. Although most of the zygomatic fractures deserve this attentive surgical manipulation to prevent late residual asymmetry, minimally depressed noncomminuted zygomatic fractures can be reduced and fixed percutaneously. Percutaneous intervention causes minimal scarring and morbidity than open techniques and it is possible to align fragments precisely by using high-quality three-dimensional computed tomography (3-D CT) imaging. Six patients with noncomminuted fractures of the zygomaticomaxillary skeleton were evaluated with plain radiographs of facial bones, axial, coronal and 3-D CT. Reduction of the displaced bone segments were achieved by traction of percutaneously applied screw. Either reduced segments were not fixated at all or one of the two new fixation techniques, described in detail in the article, were used for stabilization of reduced segments. In all patients, accurate reduction was obtained. None of the patients showed any recurrent displacement or infection during the follow-up period of six months. The screws were removed in the clinical settings without difficulty. Although percutaneous reduction and external fixation of noncomminuted zygomatic fractures has limited indications, it has its own advantages over open techniques. This method is a less invasive technique and can be performed without any problem in selected cases. Our technique is not suitable for complex zygomatic and periorbital fractures.

A comparison of combinations of titanium and resorbable plating systems for repair of isolated zygomatic fractures in the adult: a quantitative biomechanical study

Multiple studies have sought to determine the postreduction stability of internal fixation in zygomaticomaxillary complex (ZMC) fractures. Three-point fixation with titanium miniplates is increasingly recommended to repair these injuries. Use of bioresorbable plates has been suggested to eliminate potential postoperative hardware complications. By quantitatively comparing different combinations of titanium and resorbable plating systems, this study attempts to demonstrate which combinations will provide stable fixation of the fractured ZMC. Osteotomies were performed on 40 zygomas in 20 fresh-frozen cadaver skulls, simulating noncomminuted ZMC fractures. The control group (group 0) consisted of titanium plates at the zygomaticofrontal (ZF) suture, infraorbital rim (IOR), and zygomaticomaxillary buttress (ZMB). Group 1 consisted of titanium plates at the ZF and IOR, and a resorbable plate at the ZMB. Group 2 used a titanium plate at the ZF, and resorbable plates at the IOR and ZMB. Group 3 consisted of resorbable plates at the ZF, IOR, and ZMB. A mechanical test system was used to apply loads in the vectorial direction of the masseter. Critical forces and patterns of hardware failure were recorded. Group 0 failed at a mean force of 589 +/- 146 N (60 kg). Group 1 failed at a mean force of 507 +/- 124 N (52 kg). No statistically significant differences between groups 0 and 1 were found. The mean force required for failure in groups 2 and 3 was lower. Differences in the force required for failure between groups 2 and 3 and the control group was significant (P <0.05). Failure patterns were analyzed. The ZF plate tended to stretch predominantly in groups 1, 2, and 3, whereas it tended to break in group 0 (P = 0.005). The IOR plate demonstrated predictable screw failure in groups 2 and 3 (P = 0.007). For group 0, the ZF was the site of the majority of critical failures. For groups 2 and 3, the IOR was almost invariably the site of critical failure (P = 0.004). At the ZMB, there was no significant association between failure modes and it was rarely the site of critical failure, regardless of the method of fixation. However, the strength of fixation was proportional to the number of titanium plates used. Overall, the method of fixation significantly affected the force required for mechanical failure of ZMC fractures (P <0.0001). The presence of teeth significantly increases the force required for implant failure in ZMC fracture fixation when combinations of plates are used (P = 0.038). All combinations of titanium and resorbable plates may be sufficient to overcome the displacing forces produced by the masseter and may be used for internal fixation of isolated ZMC fractures in the adult.

Quantitative Comparison of Open Reduction and Internal Fixation versus the Gillies Method in the Treatment of Orbitozygomatic Complex Fractures

BACKGROUND

Precise repair of orbitozygomatic complex fractures is essential for proper re-establishment of facial symmetry, ocular globe position, and infraorbital nerve function. Controversy regarding the optimal treatment method remains.

METHODS

To compare uniform study groups, only patients without previous craniofacial injuries or operations who had sustained moderate-energy orbitozygomatic complex fractures, based on preoperative computed tomography scans, and who were treated using the Gillies repair or open reduction and internal fixation were selected. Quantifiable end-points, including orbitozygomatic complex position, ocular globe projection, and infraorbital nerve function, were measured to objectively compare the accuracy of repair produced by the Gillies procedure and open reduction and internal fixation. Negative sequelae resulting from cutaneous access were tabulated.

RESULTS

Overall, 12 patients treated using the Gillies repair and 12 treated with open reduction and internal fixation were examined. The results demonstrated that the open reduction and internal fixation technique produces superior realignment of the orbitozygomatic complex, that is, a smaller difference in the position of the orbitozygomatic complex between the injured and noninjured sides of the face. The differences in orbitozygomatic complex projection, height, and lateral position were 1.4 mm, 1.4 mm, and 1.6 mm, respectively, in the open reduction and internal fixation group and 7.5 mm, 5.6 mm, and 4.1 mm in the Gillies group. The p values were 0.0003, 0.01, and 0.06, respectively. Visible cutaneous scarring was present in four patients and lower lid shortening was seen in three patients treated using open reduction and internal fixation.

CONCLUSIONS

To the authors' knowledge, this is the first study to objectively show that the open reduction and internal fixation technique results in superior positioning of the orbitozygomatic complex in moderate-energy orbitozygomatic complex fractures compared with the Gillies repair. Although negative sequelae from surgical access were substantial, recently introduced transconjunctival and upper lid blepharoplasty incisions will minimize these drawbacks.

Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions

Orbital skeletal injuries are frequently associated with other significant injuries and require a substantial surgical effort to correct. The use of a unified classification of orbital injury may better predict the surgical effort required to correct such injuries and help with future comparisons of results. In an attempt to summarize the principles of reconstruction of the orbital skeleton following trauma and introduce a unified classification system for orbital injuries, a retrospective review of all consecutive orbital reconstructions in a tertiary care teaching hospital was conducted. The nasoethmoidal region was involved in 32%, the zygomatic complex in 50%, and the frontal region in 28% of orbital fractures. Of the orbital walls, four walls were involved in 5%, three walls in 17%, two walls in 30%, and one wall in 53%. Associated ocular and neurologic injury was encountered in 33% and 57% of patients, respectively. Regions of fixation ranged from one to eight. Bone grafts were used in 20% and titanium mesh in 34% of the orbits. In general, the authors recommend an aggressive approach to orbital injuries, addressing all associated injuries simultaneously.

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.

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.

Temporal approach for reduction of zygomatic fractures. Clinical results and advantages of the technique

We have used closed reduction based on Gillies' method using an original Y-shaped zygomatic elevator in 50 cases after radiographic evaluation of the displacement by three directional radiography. No patients had residual restriction of mandibular motion, double vision or facial asymmetry. Radiography showed poor reduction in two cases, and displacement of the initial reduction in three. In all other cases, satisfactory results were achieved.

The Gillies method for fractured zygomas: an analysis of 105 cases

This prospective study analyzed 105 cases treated using the Gillies temporal approach for fractures of the zygoma. In 97 cases (92%) this was sufficient. Only eight cases required open reduction. It is suggested that the Gillies method be used more frequently, because it is associated with minimal morbidity and a short duration of general anesthesia.

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.

Zygomatic fractures: classification and complications

A retrospective study of zygomatic fractures is presented in order to analyse late complications and to evaluate the different radiographic classifications. The study comprises 109 patients with 111 zygomatic fractures. The aetiology was violence in 39% and traffic accidents in 28%. Associated fractures of the craniofacial skeleton occurred in 42% of the patients. Seventy-two patients were available for the follow-up study. Malar flattening was found in 16% of the patients operated on. Thirty-four per cent of the patients had sensory disturbances, 6% had enophthalmos, and 1% had diplopia. Classifications of zygomatic fractures are reviewed. The fractures in the current study were grouped in accordance with the classifications of Knight & North and Larsen & Thomsen. Neither of these classifications was found to be useful in the preoperative evaluation of the postreductive fracture stability. The most reliable method of evaluating this stability is the preoperative evaluation, but CT classification systems may in the future demonstrate their value.

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.

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.

Treatment of zygomatic fractures: a follow-up study of 105 patients

One hundred and five patients with zygomatic fractures are presented. The main cause of the fracture was violence, followed by traffic accidents, fall and sport. In more than 25% of the cases, the fractures were accompanied by another fracture of the facial skeleton, viz maxillary, mandibular and nasal fractures. In severe cases of traffic accidents there were associated fractures in more than half of the cases. The follow-up study showed visible asymmetry of the face in 17 patients and sensory disturbances in 37 patients. We did not find the X-ray subdivision by Knight & North useful in the evaluation of the stability of the fractures. As a method of choice in cases of dislocated zygomatic fractures, we used reposition by the method of Gillies and in cases of instability this reposition was combined with internal wiring, reconstruction of the orbital floor and antral packing. An active attitude towards reconstruction of the orbital floor is recommended.

Facial fractures: a review of 922 cases with special reference to incidence and aetiology

During a 10 year period (1969-1978) 922 patients with facial fractures were hospitalized at the Department of Otolaryngology, Jönköping Central County Hospital, Sweden. Eighty percent were men. The peak incidence occurred at the age of 21-30 years. The yearly number of facial fractures was doubled between 1969 and 1974, after which no marked increase was noted. The aetiologies of the fractures were fights (28%), traffic accidents (23.5%), sport activities (17.4%). There was a comparatively low number of work related facial fractures in this study (8.1%). Front seat passengers, car drivers and cyclists represented a great portion of the traffic injury group. The number of fractures caused by traffic accidents decreased after 1974, a fact that may be due to the safety-belt law.