Zygomatic Complex Fracture Essay
Zygomatic Complex Fracture Essay
Zygomatic complex fracture Type of manuscript- review article Running title- zygomatic complex fracture Swetaa.A Undergraduate student Saveetha Dental College, Saveetha university Chennai, India. Mr. K. Yuvaraj Babu Assistant professor Department of Anatomy Saveetha Dental College Saveetha university, Corresponding author Chennai, India. Corresponding author- Email- [email protected] Telephone number- 9566047924 Author name- Swetaa.A Guide Name- Mr. K. Yuvaraj Babu Telephone number- 9840210597 Year of the study- I BDS 2017-2018 Total no.of words- Abstract- Aim- To create awareness on zygomatic complex fracture. Objective- To review and establish about zygomatic complex fracture. Zygomatic Complex Fracture Essay.
INTRODUCTION
Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation. However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications.
The zygomaticomaxillary complex (ZMC) functions as a buttress for the face and is the cornerstone to a person’s aesthetic appearance, by both setting midfacial width and providing prominence to the cheek. It can best be anatomically described as a “tetrapod” as it maintains four points of articulation with the frontal bone, temporal bone, maxilla, and greater wing of the sphenoid, at the zygomaticofrontal (ZF) suture, zygomaticotemporal (ZT) suture, zygomaticomaxillary buttress (ZMB), and zygomaticosphenoid (ZS) suture. Zygomatic Complex Fracture Essay. This tetrapod configuration then lends itself to complex fractures, as fractures here rarely occur in isolation. Additionally, the zygoma serves as the attachment point for muscles of both mastication and facial animation, but among these, it is the masseter that provides the most significant intrinsic deforming force on the zygomatic body and arch, albeit a small one. The zygoma plays an integral role with the orbit, as it buttresses the orbit and forms the majority of the lateral orbital wall and floor. The cause is usually a direct blow to the Malar eminence of the cheek during assault. The paired zygomas each have two attachments to the cranium, and two attachments to the maxilla, making up the orbital floors and lateral walls. These complexes are referred to as the zygomaticomaxillary complex. The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures. The formerly used ‘tripod fracture’ refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture. There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity.
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Materials and methods- A total of 140 articles were identified through the database searches.Zygomatic Complex Fracture Essay. Data relevant to the demographic profile of the patients such as age and gender, cause of injury, other associated injuries (noncranio-facial), and surgical treatment provided was collected. Only those patients with iZMC fractures without any other facial bone injury were included in this study. Patients who presented with displaced iZMC fractures causing aesthetic or functional problems that needed surgical intervention underwent standard preoperative investigations. All patients were given peri-operative antimicrobial prophylaxis, adjunct . Every article identified checked by one reviewer and subjected to pre-determined inclusion/exclusion criteria. Where abstracts were ambiguous, the article was obtained. These were found to be a review papers, summaries of other studies, or contained no data to inform the research questions.
A total 37 articles were included in the review. Discussion- The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, has four components: the lateral orbital wall ,inferior wall, separation of the maxilla and zygoma along the anterior maxilla , the zygomatic arch, and the orbital floor near the infraorbital. Zygomatic Complex Fracture Essay. BUTTRESS The buttress system of the mid face is formed by strong frontal, maxillary, zygomatic and sphenoid bones and their attachments to one another. The central mid face contains fragile bones.These fragile bones are surrounded by thicker bones of the facial buttress system lending it some strength and stability. Horizontal buttress system- These buttresses interconnect and provide support for the vertical buttresses. They include: 1. Frontal bar 2. Infraorbital rim & nasal bones 3. Hard palate & maxillary alveolus Vertical buttress system- These buttresses are very well developed. They include: 1. Nasomaxillary 2. Zygomaticomaxillay 3. Pterygomaxillay 4. Vertical mandible. Majority of the forces absorbed by midface are masticatory in nature. Hence the vertical buttresses are well developed in humans. CLASSIFICATION-Non displaced,Displaced,Comminuted,Orbital wall fracture,Zygomatic arch fracture Knight & North classification.
CLINICAL FEATURES
- Anaesthesia / Paraesthesia of that side of the face
- Inability to open the mouth
- Flattening of zygomatic area
- Diplopia
- Subconjunctival haemorrhage
- Eye lid oedema
- Periorbital haemorrhage
- Lateral canthal dystopia
- Ipsilateral epistaxis
- Buccal sulcus haematomas
- Enopthalmos in orbital floor fractures.
TREATMENT
Majority of the patients were managed conservatively / Gillie’s procedure. Only few needed open reduction with three point fixation. Zygomatic Complex Fracture Essay.
Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation.
However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications. Zygomatic Complex Fracture Essay. The zygomaticomaxillary complex (ZMC) functions as a buttress for the face and is the cornerstone to a person’s aesthetic appearance, by both setting midfacial width and providing prominence to the cheek. It can best be anatomically described as a “tetrapod” as it maintains four points of articulation with the frontal bone, temporal bone, maxilla, and greater wing of the sphenoid, at the zygomaticofrontal (ZF) suture, zygomaticotemporal (ZT) suture, zygomaticomaxillary buttress (ZMB), and zygomaticosphenoid (ZS) suture. This tetrapod configuration then lends itself to complex fractures, as fractures here rarely occur in isolation.
Additionally, the zygoma serves as the attachment point for muscles of both mastication and facial animation, but among these, it is the masseter that provides the most significant intrinsic deforming force on the zygomatic body and arch, albeit a small one. The zygoma plays an integral role with the orbit, as it buttresses the orbit and forms the majority of the lateral orbital wall and floor. The cause is usually a direct blow to the Malar eminence of the cheek during assault. The paired zygomas each have two attachments to the cranium, and two attachments to the maxilla, making up the orbital floors and lateral walls. These complexes are referred to as the zygomaticomaxillary complex.
The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures. The formerly used ‘tripod fracture’ refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture. There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity.
Evaluate the 1-year treatment outcome of zygomatic complex fractures with surgical or nonsurgical intervention.
Materials and Methods:
One hundred and forty-two consecutive patients with a zygomatic complex fracture were enrolled. Sixty-eight patients underwent surgical intervention and 74 patients nonsurgical intervention. The 1-year examination evaluated cosmetic and functional outcome including malar symmetry, ocular motility, occlusion, mouth opening, neurosensory disturbances, and complications. Zygomatic Complex Fracture Essay.
Results:
Forty-six patients allocated to surgical intervention responded to the 1-year follow-up examination. Satisfying facial contour and malar alignment was observed in 45 patients. All patients presented with identical position of the eye globe without enophthalmos and normal ocular movement. A habitual occlusion was seen in all patients with a mean interincisal mouth opening without pain of 49 mm. One patient presented with minor ectropion. Wound infection occurred in five patients. Persistent infraorbital neurosensory disturbance was described by 19 patients. The 1-year radiographic examination showed adequate fracture alignment in all patients with satisfying facial contour. However, dissimilar position of the orbital floor was seen in three patients having orbital reconstruction. None of the patients were re-operated or needed secondary correction of the zygomatic complex or orbital floor.
Conclusion:
Surgical intervention is an effective treatment modality of depressed zygomatic complex fractures, whereas a nonsurgical approach is often used for nondisplaced fractures. Most zygomatic complex fractures can be treated solely by an intraoral approach and rigid fixation at the zygomaticomaxillary buttress. Further exposure of the zygomaticofrontal junction or inferior orbital rim is necessary for severely displaced fractures, which require additional fixation.
The zygomatic bone defines the anterior and lateral projection of the face and articulates with the frontal, sphenoid, temporal, and maxillary bones. The zygomatic complex is responsible for the protection of the orbital contents and the mid-facial contour. Fracture of the zygomatic complex is one of the most common facial injuries in maxillofacial trauma and predominately appears in young adult males [1-5]. The etiology of zygomatic complex fractures primarily includes road traffic accidents, violent assaults, falls and sports injuries [1-5]. However, there is geographic and sociodemographic variation in the epidemiology of maxillofacial fractures due to socioeconomic, cultural and environmental factors. The main clinical features of zygomatic complex fractures include diplopia, enophthalmos, subconjunctival ecchymosis, extraocular muscle entrapment, cosmetic deformity with depression of the malar eminence, facial widening, malocclusion and neurosensory disturbances of the infraorbital nerve [6]. Diagnosis of zygomatic complex fractures is usually clinical, with confirmation by computed tomography (CT) scan [6].
The integrity of the zygomatic complex is fundamental in maintaining normal facial width and prominence of the cheek. Zygomatic complex fractures with no or minimal displacement are often treated without surgical intervention, whereas fractures with functional or esthetic impairments in the form of diplopia, extraocular muscle entrapment, malocclusion, restricted mouth opening and/or depression of the malar prominence often necessitate surgical intervention. Zygomatic Complex Fracture Essay. Various surgical approaches and treatment strategies have been proposed to obtain successful treatment outcome, including the Gilles temporal approach, coronal, eyebrow, upper eyelid, transconjunctival, infraciliary lower eyelid, and intraoral vestibular approaches [4-7]. The surgical approach for adequate reduction of zygomatic complex fractures must provide maximum necessary exposure of the fractured segments, minimize the potential for injury to facial structures, and ensure a good functional and cosmetic result. The Gilles temporal approach has been a commonly used surgical technique for the reduction of zygomatic complex fractures. However, this surgical approach is associated with a facial scar in the hairline and risk of facial nerve palsy. Moreover, further exposure of the zygomaticofrontal junction or the inferior orbital rim is required for placement of mini-plates fixation in case of an unstable zygomatic complex fracture. Surgical reduction of zygomatic fractures by an intraoral surgical approach was first described in 1909 by Keen [8], and several studies have subsequently documented the treatment outcome after open reduction of zygomatic complex fractures by an intraoral surgical approach [9-17].
The objective of the present retrospective study was to assess the 1-year clinical and radiographic outcome after surgical or nonsurgical treatment of zygomatic complex fractures.
2. MATERIALS AND METHODS
2.1. Patients
One hundred and forty-two consecutive patients (113 males and 29 females) with a zygomatic complex fracture were admitted to the Department of Oral and Maxillofacial Surgery, Aalborg University Hospital, Denmark. The average age of the patients was 42.2 years (range 9-97). The mechanism of injury was accidents at work (4%), sports injuries (12%), bike accidents (15%), assaults or interpersonal violence (21%), road traffic accidents (23%), and falls (25%). The time interval between injury and the initial consultation ranged from 0 to 60 days (mean of 3 days). Six patients were in the intensive care unit at the initial consultation. The zygomatic complex fractures were confirmed by CT-scan. Twenty-nine of the patients had concomitant facial fractures involving the nose (8), mandible (10) and Le Fort I/II/III fractures (11).
2.2. Treatment Strategy
The zygomatic complex fractures were initially classified in nondisplaced and displaced. Sign and symptoms of the patient were evaluated as restricted mouth opening, diplopia, impaired eye vision, occlusal alteration, neurologic disturbance of infraorbital nerve, clinical and radiological asymmetry related to fracture displacement. The zygomatic complex fractures were treated by surgical intervention in 68 patients (48%) and without surgical intervention in 74 patients (52%). Zygomatic Complex Fracture Essay.
Patients treated with nonsurgical intervention presented with insignificant flattening of the cheek (19%), restricted mouth opening (23%), diplopia (7%), malocclusion (7%), diminished eye vision (3%), extraocular muscle entrapment (1%), enophthalmos (1%) and neurosensory disturbances of the infraorbital nerve (36%). One patient with flattening of the cheek refused surgical intervention, due to no cosmetic complaint.
Patients treated with surgical intervention presented with flattening of the cheek (84%), restricted mouth opening (47%), diplopia (13%), malocclusion (19%), diminished eye vision (4%), extraocular muscle entrapment (6%), enophthalmos (1%) and neurosensory disturbances of the infraorbital nerve (66%).
The time interval between injury and surgical intervention ranged from 0 to 11 days (mean of 3.4 days). Open reduction without mini-plate fixation was conducted in 11 patients (16%), while plate fixation with adequate mini-plate osteosynthesis was performed in 57 patients (84%). Two-point fixation involving the zygomaticomaxillary buttress and the zygomaticofrontal junction was used in 7 patients (15%), while the zygomaticomaxillary buttress and infraorbital rim were used in 3 patients (4%). Three-point fixation involving the zygomaticomaxillary buttress, zygomaticofrontal junction and infraorbital rim was used in seven patients (10%). Zygomatic Complex Fracture Essay. Orbital reconstruction using a polydioxanone foil was performed in eight patients (12%). The mean length of hospitalization after surgery was 1.6 days (range 1-5).
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All surgical or nonsurgical treated patients were advised not to apply pressure on the fractured side for a period of six weeks and were followed on a weekly basis for the first four weeks postoperatively, then at three months and 1-year.
2.3. Description of the Surgical Intervention
Surgical treatment of zygomatic complex fractures was performed in general anesthesia with an oral or nasotracheal intubation. The surgical intervention was conducted by different surgeons using a similar surgical technique. Initially, a forced duction test for ocular motility was conducted to determine the presence or absence of extraocular muscle entrapment. After local anesthesia, an upper buccal vestibular incision was made from the canine to the first molar. The mucoperiosteum was reflected exposing the nasomaxillary and zygomaticomaxillary buttresses. The infraorbital nerve was identified and protected. Under direct vision, the depressed zygomatic complex was elevated and manipulated into its proper anatomical alignment by Rowe’s elevator, whilst the contour of the infraorbital rim and the frontozygomatic junction were palpated. Though the fracture reduction was stable and showed adequate anatomic alignment, the zygomatic complex fracture was almost always stabilized with mini-plates fixation at the zygomaticomaxillary buttress. If the fracture reduction was inadequate anatomic aligned or the zygomatic complex was considered unstable, the zygomaticofrontal junction and/or the infraorbital rim was exposed for second or third fixation points. Finally, a forced duction test for ocular motility was conducted to determine the presence or absence of extraocular muscle entrapment. Zygomatic Complex Fracture Essay.
