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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.
“ EVALUATION OF VARIOUS SURGICAL APPROACHES TO
THE
FRACTURED ZYGOMATICO-MAXILLARY COMPLEX ”
By
Dr. SHEERAZ BADAL
Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment of the requirements for the degree of
MASTER OF DENTAL SURGERY
In the speciality of
ORAL AND MAXILLOFACIAL SURGERY
Under the Guidance of
Dr. UMASHANKAR K.V Associate Professor
Department of Cranio Maxillofacial Plastic and Reconstructive Surgery
COLLEGE OF DENTAL SCIENCES DAVANGERE-577 004, KARNATAKA, INDIA.
2006 - 2009
DDeeddiiccaatteedd ttoo
MMyy PPaarreennttss wwhhoossee BBlleessssiinnggss,,
LLoovvee aanndd SSaaccrriiffiicceess hhaavvee mmaaddee
TThhiiss wwoorrkk aa rreeaalliittyy……
ACKNOWLEDGEMENT
To begin with, I would like to bow my head and thank the most merciful and
compassionate, The Almighty God for his blessings on me, without which no
endeavour would ever be success.
I consider it my utmost privilege and honour to express my deep sense of
gratitude, appreciation and indebtedness to my respected teacher and Guide Dr. Uma
Shankar K.V, Associate Professor, Department of Cranio Maxillofacial Plastic and
Reconstructive Surgery, Davangere, for his efficacious guidance, altruistic co-
operation and support during the preparation of this Dissertation and throughout my
post graduation course. I am indeed deeply indebted for his kindness, courtesy,
untiring patience and meticulous care in correcting my mistakes during the course of
this study. This dissertation could not have been written without him, who not only
served as my supervisor but also encouraged and challenged me throughout my
academic program.
With gratitude and humbleness, I sincerely thank Dr. David P Tauro,
Professor and Head, Department of Cranio Maxillofacial Plastic and Reconstructive
Surgery, College Of Dental Sciences, Davangere for his supportive encouragement,
co-operation and support during my post graduation course. As his student, I have
not only inculcated knowledge in the art and science of Oral and Maxillofacial
Surgery, but also in other humane qualities of life. His abstruse knowledge,
proficiency in the subject, sincerity and dedication will always be a source of
inspiration to strive for excellence.
I take this opportunity to express my heartfelt gratitude to Dr. Rajendra
Desai, Professor, Department of Cranio Maxillofacial Plastic and Reconstructive
Surgery, College of Dental Sciences, Davangere, He is excellence personified with the
VI
highest of ideals and the deepest of convictions, which have been truly inspirational
for me and will continue to be in future
I wish to express my sincere appreciation and heart felt gratitude to
Dr. Shiv Bharani, Professor, Department of Cranio Maxillofacial Plastic and
Reconstructive Surgery, College of Dental Sciences, Davangere, for ushering me
towards academic & clinical excellence. His constant support and valuable advice
kept me motivated always.
I sincerely thank Dr. Manjunath, Professor, Department of Cranio
Maxillofacial Plastic and Reconstructive Surgery, College of Dental Sciences,
Davangere, for his constant support and indispensable suggestions.
It is with a humble sense of gratitude and heartfelt appreciation that I express
my sincere thanks to Dr. Shubha Lakshmi, Associate Professor, Department of
Cranio Maxillofacial Plastic and Reconstructive Surgery, College of Dental Sciences,
Davangere, for her professional guidance and whole hearted support throughout my
post-graduate course.
My sincere and warm gratitude to Dr. Kiran Neswi, Anaesthetist, Department
of Cranio Maxillofacial Plastic and Reconstructive Surgery, College of Dental
Sciences, Davangere,Reader, for her overwhelming encouragement, unflinching
support.
This is a great opportunity to express my respect to the other faculty members,
Dr. Yeshvanth, Assistant professor, Dr. Raya A.D. Kamath, Assistant professor and
Dr. Kiran H.Y, Assistant professor, I thank them all , for there overwhelming
encouragement and support during my study.
VII
My deepest gratitude goes to Dr. V.V. Subba Reddy, Principal, and Sri.
Shamanur Shivashankarappa, Hon. Secretary, for providing the kind of atmosphere,
fully equipped with near latest technologies.
I acknowledge Dr.Sudhanashu Saxena, for helping me in carrying out the
statistical analysis of this study.
Heartfelt thanks to my senior Dr.Rohit for his constant support, love and
encouragement throughout my course. I am thankful to My Batchmates, My Juniors
and the non-teaching Staff Members for their support and co-operation during my
study.
I am thankful to all My Patients who participated in the study and without
whom the study would have been incomplete.
This acknowledgement would be incomplete without the mention of My
Parents, My Sisters and My Friends for their innumerable sacrifices, support and
encouragement throughout my life. Indeed, without them this effort would not have
been possible.
Date : Signature of Candidate
Place : DAVANGERE Dr. SHEERAZ BADAL
VIII
LIST OF ABBREVATIONS
HRS HOURS
MINS MINUTES
PREOP POST OPERATIVE
POSTOP POST OPERATIVE
RTA ROAD TRAFFIC ACCIDENT
SD STANDARD DEVIATION
ZMC ZYGOMATIC COMPLEX
PNS PARANASAL SINUS RADIOGRAPH
SMV SUBMENTOVERTEX RADIOGRAPH
df DEGREE OF FREEDOM
IX
ABSTRACT
Background and Objectives: The “zygomaticomaxillary complex” forms a key
component of structural facial aesthetics. The surgical treatment of zygoma fracture
varies from surgeon to surgeon and also depending on the type of fracture and
circumstances. Objectives of this study are to assess the efficacy of various surgical
approaches to the treatment of fractured zygomaticomaxillary complex fractures with
the main emphasis on the adequate exposure, post operative stability achieved and
improvement in the functional and esthetic restoration.
Methods: Twenty five patients with displaced zygomaticomaxillary complex
fractures who reported to the Department of Cranio Maxillofacial Plastic and
Reconstructive Surgery, College of Dental Sciences, Davanagere were included in the
study to evaluate the efficacy of various surgical approaches to the treatment of
fractured zygomaticomaxillary complex fractures under General Anesthesia. Follow
up period for the study was six months. Stability was assessed by adequate reduction,
approximation of the fractured fragments and by return of normal contour of
prominence of cheek and infraorbital rim, which was determined by the inspection
and palpation.
Results: A variety of surgical approaches were used to gain access to the fractured
zygomaticomaxillary complex. Gradual resolution of infraorbital paresthesia was
seen, and by sixth month follow up it was completely resolved in all the patients.
One patient (4%) where combination of lateral eyebrow and infraorbital
approach was used complained of burning sensation, One patient (4%) where
combination of Coronal and Infraorbital approach was used complained of epiphora,
another patient (4%) had developed pre-auricular and temporal infection with pus
X
discharge which lead to sutural abscess. Two patients (8%) where intra-oral maxillary
vestibular approach was used developed post-op infection. Diplopia was not recorded
at the last follow up visit.
Interpretation and conclusion: Combination of Lateral eyebrow and Infra orbital
approaches are the simple, easy and effective approaches to be used in means of
treating fractures of zygomaticomaxillary complex with adequate access to the
fractured segments and minimal complications. The esthetic result were not superior
with the infraorbital approach as compared to the studies which claims that the
Transconjunctival, Subciliary and Blepharoplasty approaches have superior esthetics
results with inconspicuous scar. The intra-oral maxillary vestibular approach is a
simple, easy and effective means of treating fractures of zygomaticomaxillary
complex fractures but is associated with increase risk of postoperative infection. For
late reconstruction, maximum exposure and treatment of comminuted fractures of the
zygomaticomaxillary complex a coronal approach or an extended pre auricular
approach is preferable.
Key Words: Zygomaticomaxillary complex fractures, Lateral eyebrow approach,
Infraorbital approach, Coronal approach, Extended Preauricular approach, Maxillary
vestibular approach, Gillies temporal approach.
XI
TABLE OF CONTENTS
Page No.
1. Introduction 01
2. Objectives 04
3. Surgical Anatomy 05
4. Review of Literature 09
5. Methodology 21
6. Results 30
7. Discussion 43
8. Conclusion 61
9. Summary 63
10. Bibliography 66
11. Annexures
Proforma 74
Master Chart 77
Key to master chart 79
XII
LIST OF TABLES
SL. NO. TITLE PAGE
NO.
TABLE 1 AGE DISTRIBUTION OF THE STUDY POPULATION 33
TABLE 2 GENDER DISTRIBUTION OF THE STUDY POPULATION 33
TABLE 3 OCCUPATION WISE DISTRIBUTION OF THE STUDY POPULATION 33
TABLE 4 ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION 34
TABLE 5 DISTRIBUTION OF TYPE OF FRACTURE IN THE STUDY POPULATION 34
TABLE 6 DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE STUDY POPULATION 34
TABLE 7 DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE AMONG THE STUDY POPULATION
35
TABLE 8
DISTRIBUTION OF PRESENCE OF INFRAORBITAL NERVE PARESTHESIA AND SUBCONJUNCTIVAL HEMORRHAGE DURING SIX MONTH STUDY PERIOD AMONG THE STUDY POPULATION
35
TABLE 9 DISTRIBUTION OF STABILITY OF INFRAORBITAL RIM CONTOUR DURING SIX WEEK STUDY PERIOD AMONG THE STUDY POPULATION
35
TABLE 10 DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY POPULATION
36
TABLE 11 DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH USED AMONG THE STUDY POPULATION
36
TABLE 12 DISTRIBUTION OF TIME TAKEN FOR THE SURGERY IN HOURS AMONG THE STUDY POPULATION
37
TABLE 13 ADDITION PROCEDURES REQUIRED AFTER INITIAL TREATMENT AMONG THE STUDY POPULATION AND IN CASES REQUIRING ADDITIONAL PROCEDURES FOR STABILITY
37
XIII
LIST OF GRAPHS
SL. NO. TITLE PAGE
NO.
GRAPH 1
AGE DISTRIBUTION OF THE STUDY POPULATION 38
GRAPH 2
GENDER DISTRIBUTION OF THE STUDY POPULATION 38
GRAPH 3
OCCUPATION WISE DISTRIBUTION OF THE STUDY POPULATION 39
GRAPH 4
ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION 39
GRAPH 5
DISTRIBUTION OF TYPE OF FRACTURE IN THE STUDY POPULATION
40
GRAPH 6
DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE STUDY POPULATION 40
GRAPH 7
DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE AMONG THE STUDY POPULATION
41
GRAPH 8
DISTRIBUTION OF RESTRICTED MANDIBULAR MOVEMENTS AMONG THE STUDY POPULATION
41
GRAPH 9
DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY POPULATION 42
GRAPH 10
DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH USED AMONG THE STUDY POPULATION
42
XIV
LIST OF FIGURES
SL. NO. TITLE PAGE
NO.
FIGURE 1 FRONTAL VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 2 LATERAL VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 3 OBLIQUE VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 4 BASALVIEW OF FRACTURE PATTERNS OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 5
TEMPORO-POSTERIOR VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 6 INFERIOR VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX
8
FIGURE 7 VARIOUS SURGICAL APPROACHES 50
FIGURE 8 GILLIES TEMPORAL APPROACH
50
FIGURE 9 CORONAL APPROACH 50
FIGURE 10 LATERAL EYEBROW APPROACH 50
XV
LIST OF PHOTOGRAPHS
SL. NO. TITLE PAGE NO.
PHOTOGRAPH 1 ARMAMENTARIUM 25
PHOTOGRAPH 2 PRE-OP FRONTAL VIEW OF PATIENT 25
PHOTOGRAPH 3 PRE-OP OBLIQUE VIEW OF PATIENT 25
PHOTOGRAPH 4 PRE-OP RADIOGRAPH- PNS VIEW 26
PHOTOGRAPH 5 PRE-OP RADIOGRAPH- SMV VIEW 26
PHOTOGRAPH 6 POST-OP RADIOGRAPH- PNS VIEW 27
PHOTOGRAPH 7 GILLIES TEMPORAL APPROACH 27
PHOTOGRAPH 8 CORONAL APPROACH 28
PHOTOGRAPH 9 INFRAORBITAL APPROACH 28
PHOTOGRAPH 10 LATREAL EYEBROW APPROACH 29
PHOTOGRAPH 11 MAXILLARY VESTIBULAR APPROACH 29
XVI
Introduction
Introduction
1
INTRODUCTION
The zygoma, a major buttress of the facial skeleton, is the principle structure
of the lateral midface. A thick, strong bone, the zygoma is roughly quadrilateral in
shape, with an outer convex (cheek) surface and an inner concave (temporal) surface.
The convexity on the outer surface of the zygomatic body forms the point of greatest
prominence of the cheek. Therefore zygomas place a major role in facial contour. It
has temporal, orbital, maxillary and frontal processes, and articulates with four bones-
the frontal, sphenoid, maxillary and temporal bones1.
It has an important role in protecting the eye, and participates in the formation
of orbital cavity, the maxillary sinus, the temporal fossa, and the zygomatic arch. The
convex shape and protrusion of the zygoma, in addition to giving contour to the
cheek, also makes this area of the midface more vulnerable to injury or fracture2.
Zygomaticomaxillary complex fractures are the common facial injuries after
maxillofacial trauma3. The main causes of fractures are trauma due to road traffic
accidents, assaults, falls, sports related injuries, and the civilian warfares3. The
prominent location of the zygoma exposes it to frequent trauma4.
The zygomatic arch, a laterally positioned element of the craniofacial skeleton
comprised of the zygoma and temporal bone, is susceptible to local trauma. Isolated
zygomatic arch fractures comprise about 10% of all zygomatic fractures and results in
noticeable depression at the arch fracture site. There may be impingement of the
fractured arch on the coronoid process, resulting in limited mouth opening5.
When not treated properly, the arch fractures may lead not only to various
cosmetic deformities related to skeletal structure of the face, but also to function
Introduction
2
disorders resulting from the pressure on the coronoid process or ankylose with the
mandible6.
The zygomatic complex injury, by definition, includes orbital involvement and
the possibility of associated ocular damage. Anatomic reduction of the lateral and
inferior orbital rims and orbital floor are necessary to reestablish facial symmetry and
the position of the globe, and to restore the normal sensations to the structures
innervated by the infraorbital nerve7.
Precise repair of fractures of the orbital zygomatic complex requires four
essential features: a through understanding of the regional anatomy; an accurate and
precise diagnosis; an unimpeded exposure; and a rigid fixation of fracture to restore
premorbid form. Although the zygomatic arch may be fractured in isolation, more
commonly it is associated with complex orbital maxillary zygomatic (OMZ) and
midface fractures. If the horizontal and vertical buttress of the orbital
zygomaticomaxillary complex and orbital floor are not properly aligned, a variety of
sequelae can occur, including enophthalmus, diplopia, rotational zygomatic
displacement, orbital dystopia and midface widening. All of these conditions are
difficult to address with revision8.
Fractures of the face and mandible have been recognized for a long time, and
attempts to treat such fractures have been recorded as far back as 25-30 centuries BC.
Zygomatic fractures were not brought to the spotlight in the literature again until
1751, when du Verney described the anatomy, type of fractures of the zygoma
observed, and his approach to reduction in two case reports. Recognizing the
importance of reduction for proper healing, Du Verney took advantage of the
Introduction
3
mechanical forces of the masseter and temporalis muscles on the zygoma in a unique
approach to closed reduction techniques.
In 1906, Lothrop was the first to describe an antrostomy approach in which he
reached the fractured zygoma through the Highmore antrum below the inferior
turbinate. He then was able to rotate the fractured zygoma upward and outward for a
proper reduction. In 1909, Keen categorized zygomatic fractures as those of the arch,
the body, or the sutural disjunction. He was the first to describe an intraoral approach
to the zygomatic arch in which an incision is made in the gingivobuccal sulcus.
In 1927, Gillies described an original approach to reduce a depressed malar
bone. He was the first to reach the malar bone through an incision made behind the
hairline and over the temporal muscle. Gillies further described the use of a small,
thin elevator that is slid under the depressed bone, thus enabling the surgeon to use the
leverage of the elevator to reduce the fracture9.
The ideal surgical approach to treat the maxillofacial injuries should provide
maximum exposure of the fractured fragments, ensure less potential for injury to the
facial structures, and allow for good cosmetic results. Limited access to the fracture
site, lack of adequate exposure, and subsequent facial scars are among the list of
objections to most of these techniques.10
Various methods for the repair of zygomatic complex fractures have been
advocated, and in this study with emphasis to the different surgical approaches. After
reviewing the advantages and limitations of various surgical approaches, a sincere
effort has been made in the form of a prospective clinical study to manage
zygomaticomaxillary complex fractures with these techniques and there efficacy is
evaluated in the larger interest of the patients.
Objectives
Objectives
4
OBJECTIVES
To assess the efficacy of various surgical approaches used for reduction of
zygomaticomaxillary complex fractures with the main emphasis on the post operative
stability achieved and improvement in the functional and esthetic restoration with
minimal complications.
Need for the study:
Zygomaticomaxillary complex fractures are the most common facial injuries
after maxillofacial trauma. Anatomic reduction of the Zygomaticomaxillary complex
is necessary to reestablish facial symmetry, position of the globe and to restore normal
sensations to the structures innerveted by the infraorbital nerve1. Displaced fractures
are treated by open reduction and internal fixation. Adequate surgical exposure is
necessary for proper reduction and fixation of the fractured fragments, requiring
various surgical approaches.
An ideal surgical approach should provide maximum necessary exposure of
the fractured segments and minimize potential for further injury to facial structures
and enable good cosmetic results. Properly placed incisions offers excellent access
with minimal morbidity and scarring. This determines the need for the study.
Surgical Anatomy
SURGICAL ANATOMY
The zygoma is a thick strong bone roughly quadrilateral in shape. The
convexity on the outer surface of the zygomatic body forms the point of greatest
prominence of the cheek. The term "trimalar" fracture actually is a misnomer as the
zygoma, having four projections, is more nearly quadrangular in shape. The frontal
process forms the superior projection; the temporal process forms the posterior
projection; the lateral portion of the infraorbital rim and part of the articulation with
the maxilla forms the inferior projection and the buttress, palpable in the buccal
sulcus, forms the medial projection.
The zygoma articulates with four bones: the frontal, temporal, maxilla and the
greater wing of the sphenoid. The zygomas inheritent architectural strength all to
withstand blows of great force without fracturing. Fractures of the zygomatic
complex, therefore, usually occur near the suture lines.
Two neurovascular bundles course through this bone first the infraorbital
nerve, and second the zygomaticofacial nerve (zygomaticotemporal nerve may course
through the zygomaticofrontal suture area). The muscles attached to it are the
zygomaticus, quadratus labii superioris, orbicularis oculi and the masseter. The
temporalis muscle and the fascia are closely associated with it.
FRACTURE PATTERNS:
When a vector forcibly comes in contact with the prominent and sturdy forces
tend to be transmitted to its four weaker articulating surfaces, the frontozygomatic,
zygomaticomaxillary, zygomatico-sphenoid and zygomaticotemporal sutures as well
as to the weaker bones that articulate with the zygoma. The zygoma is much stronger
5
Surgical Anatomy
6
than the bones with which it articulates, that it is rare to find a fracture of the body of
zygoma itself.
Edward Ellis mentioned the inferior orbital fissure is the key to remembering
the usual lines of zygomaticomaxillary complex fractures. Three lines of fracture
extending from the infraorbital fissure in an anteriomedial, a superiolateral and an
inferior direction (Fig.1- Fig6). One fracture extends anteromedially along the orbital
floor mostly through the orbital process of the maxilla, toward the infraorbital rim, the
orbital floor and the medial are often comminuted, creating multiple lines of fracture
within the internal orbit. The infraorbital canal is usually crossed by the fracture line
or lines because the fracture frequently extends through the infraorbital rim to the
facial surface of maxilla above or even slightly medial to the infraorbital foramen.
The fracture extends from the infraorbital rim in the maxilla laterally and inferiorly
under the zygomatic buttress of the maxilla.
A second fracture line extends from the inferior orbital fissure inferiorly
through the infratemporal aspect of the maxilla and joins the previously mentioned
fracture under the zygomaticomaxillary buttress.
The third fracture line extends superiorly from the inferior orbital fissure along
the lateral orbital wall posterior to the rim, usually separating the zygomaticosphenoid
suture. Extending superiorly, laterally and anteriorly towards the lateral orbital rim,
the fracture frequently separates the frontozygomatic suture, at the lateral orbital rim.
A zygomaticomaxillary complex fracture that follows this pattern usually has
one additional fracture line through the zygomatic arch. Since the point of least
resistance to fracture is not at the zygomatico temporal suture, but approximately
1.5cm more posteriorly, the point of fracture when a single fracture exists is usually in
Surgical Anatomy
7
the approximate middle of the zygomatic arch, in the zygomatic process of the
temporal bone. Frequently however, three fractures exist through the arch, producing
two free segments when the fractures are complete. These segments can be displaced
by associated muscle pull or may be pushed medially into the infratemporal fossa.
Often the fractures are incomplete or greenstick fractures, producing a medial or
lateral warping of the zygomatic arch without notable upward or downward
displacement. The variability of these fractures is great, owing to the differences in
the magnitude and direction of the force, the amount of soft tissues covering the
zygoma and the density of the adjacent bones.
It should be understood that all fractures of the zygomatic complex involve the
floor of the orbit. However, linear fractures of the floor of orbit without herniation or
entrapment of orbital contents, or both, need to be treated only if there is interference
with binocular vision or extraocular muscle function. On the other hand, isolated
fractures of the floor of the orbit can occur secondary to direct trauma to the globe.
The floor of the orbit, which along with the ethmoid bone is one of the weakest
portions of the bony orbit, may be "blown out" as force is applied to the
incompressible soft tissue contents of the rigid orbit.
Surgical Anatomy Surgical Anatomy
8
8
Review of Literature
Review of literature
9
REVIEW OF LITERATURE
In this study 85 patients with depressed fractures of zygomaticomaxillary
complex during the period from July 1, 1969, through June 30, 1972, were treated by
the oral surgical service at the Massachutsetts General Hospital, Boston. 77 fractures
required surgical intervention. The predominant approach was via the lateral eyebrow
and 16 of 17 zygomatic arch fractures were treated by the Gillies approach and left
one was treated by Tracheal hook reduction. In this study, various surgical approaches
to the fractured zygomatic complex were discussed. Data illustrated that a great many
of these fractures are unstable after reduction. For this reason, lateral eyebrow
approach, with internal wire fixation if necessary was used as the initial surgical
approach in the management of zygomatic complex fractures 24.
A technique for reduction of fractures of the zygomatic arch with the use of a
more direct anatomical approach was presented. This lateral coronoid approach
obviates the potential difficulty of coronoid interposition and elevation of an isolated
fragment encountered with the use of old keen approach. This technique provided a
more direct approach to the fractured zygomatic arch. This technique has the
advantage of elevating both the fractured segments of the arch simultaneously rather
than individually which is seen with keens approach, as with this only the anterior
fragment may be elevated alone26.
This paper reviews the morbidity of the procedure in 24 patients in whom
Bicoronal flaps were raised for access to mid and upper facial skeleton. Study was
carried out in Cannes Bur Hospital, Glassgow. 6 patients had post-operative sensory
disturbances. Ptosis was seen in patients operated for craniostenotic syndromes.
Epiphora was seen unilaterally in the patient undergoing enopthalmus correction and
Review of literature
10
probably followed trauma to the nasolacrimal duct. In no case did infection of the flap
occurred. It was found that low incidence of infection of the flap was due to its
profuse blood supply aided by the absence of hematoma formation which is achieved
by the suturing of the galea, suction drainage and pressure dressing. It was concluded
that Bicoronal flap was found to be useful in management of trauma and deformity of
the mid and upper facial skeleton. It provides good access for surgery of
Temperomandibular joint and zygomatic arch60.
In this study 77 patients who were treated in Brigham and Womens
Hospital, during the four and half period from july 1979 to December 1984 for the
fractures of zygomaticomaxillary complex and arch were studied. Various surgical
approaches were used to treat the fractured zygomaticomaxillary complex. Buccal
sulcus and Gillies temporal incisions were used to treat isolated zygomatic arch
fractures. The Gillies incision was used in conjunction with eyelid incisions in four
cases to provide greater leverage. The coronal flap was used in one case of severe
craniomaxillofacial trauma. Lower eyelid incisions were necessary for stabilization at
the infraorbital rims in this case. 28 cases were approached through lateral eyebrow
and lower eyelid incisions. Upper eyelid incision was the method of choice for initial
access to the zygomatic complex fractures and for late reconstruction coronal incision
was preferred. 3 patients had minor wound infections, 2 with in the lower eyelid
incision and 1 with an eyebrow incision7.
A study was conducted on 50 patients, whom the procedure Lower
blepharoplasty was performed and were followed up for 66 weeks at Walton Hospital,
Liverpool.. Ectropion was seen in 10 cases. It was transient in 8 cases and permanent
in 2 cases. It was found that the extension of the Lower blepharoplasty incision did
not increase the incidence of the ectropion. It was concluded that the Lower
Review of literature
11
blepharoplasty, post orbicularis approach offers an excellent exposure to the lower
half of the orbit and is therefore recommended for complicated wiring or plating
procedures and it was observed to be esthetically pleasing and associated with
minimal complications72.
A study was carried out on 68 patients, from January 1984 to June 1985, with
fractures of zygomaticomaxillary complex, who were diagnosed and treated at the
Department of Maxillofacial Surgery University of Central Hospital, Helsinki,
Finland. Follow up time was ranged from 2 weeks to 4 years. Surgical approaches like
Gillies temporal, Lateral eyebrow, Percutaneous, Buccal sulcus approach were used.
A total of 81% of the patients had paraesthesia of the infraorbital nerve, and the
figure was higher in the group of the patients with fractures requiring operative
treatment (94%). Although a regeneration was evident in a majority of cases, some
degree of hypoesthesia was found in 21(42%) out of 52 patients. However in 10 out
of 12 patients in which direct fixation with transosseous wiring of the infraorbital
margin was performed, persisting hypoesthesia was encountered. In 3 out of 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. No significant differences were found between
the different methods of indirect reduction used. In majority of cases, regeneration
took place during the 1st postoperative week. It was observed that full recovery of the
nerve was achieved by 5 months45.
A study was conducted in which 16 cases of the facial bone fractures
including the malar arch treated in Hamamatsu University School of Medicine,
Hamamatsu, Japan. And the usefulness of the “Preauricular Tragus skin incision
elongated to the haired temporal region” was presented. It was concluded that
Review of literature
12
extension of Preauricular Tragus skin incision was carried out to improve the
visibility and safety to the malar arch during surgery. Facial nerve palsy, that is to say
inability of wrinkling unilateral forehead was observed in four patients, however this
complication disappeared over a 3 to 4 months period.
A retrospective study on the use of Bicoronal approach in treatment of
craniomaxillofacial trauma was carried out in 28 patients treated at Presbyterian
University Hospital, Pittsburg. Bilateral Lefort III with zygomaticomaxillary complex
fractures and combination of Lefort II and Lefort I. A Bicoronal flap with subciliary
and maxillary vestibular incisions were used. This study showed that this technique
provides optimum exposure of fractured site allowing for accurate anatomic reduction
and fixation of the fractured segments and good cosmetic results. Follow up period
was ranged from 3 months to 3 years. Both Bicoronal and Hemicoronal approach
allowed accurate anatomic results. Sensory nerve deficit was reported in 5 patients
which returned normal in 6 weeks. 2 patients developed hematoma in temporal
regionon 9th and 10th post-operative day. It was concluded that with an adequate
knowledge of the surgical anatomy, a coronal approach will provide an exposure that
facilitates accurate reduction and fixation of the fractures and will allow superior
cosmetic results with minimal or no complications48.
A study was conducted in 48 patients who had undergone open reduction and
internal fixation of malar fractures during 1988 at the University Of Southern
California School Of Medicine, Los Angeles. 8 of these accompanied Lefort fractures,
they were considered to be malar fractures because the zygomatic complex was truly
displaced as an intact unit.43 of the malar fractures were treated using a variable
combination of Lateral eyebrow, Subciliary and Gingivobuccal incisions to obtain a
three point reduction. In the remaining 5 patients either a coronal or hemicoronal
Review of literature
13
incision was used to expose the Zygomatic arch for use a fourth point of reduction. 3
of these patients had accompanied Lefort fractures, and concluded that complications
appeared to be more related to the severity of the injury than to the technique itself.
The observations justify the use of this extended access approach in selected patients
severe injuries of the Zygomatic complex15.
This prospective study analyzed 105 cases treated with Gillies temporal
approach for fractures of zygoma in Dundee Hospital and School, Scotland from 1987
to 1989. Eight of these cases required open reduction. This study suggested that
Gillies method offers the best advantage of being quick, decreasing the possibility of
facial nerve damage or direct trauma to the Globe by the instruments inserted to
protect the eye, associated with minimal complications and not being represented with
a visible scar28.
1025 consecutive zygomatic fractures managed by the Department of
Craniomaxillofacial surgery at the University Hospital in Bern, Switzerland during
1978 – 1989, were reviewed retrospectively. Zygomatic arch were reduced with ‘J’
shaped, curved hook elevator. Lateral orbital rim fractures were reduced and fixed
through Lateral Eyebrow incision. Infra-orbital rim fractures are mostly associated
with orbital floor fractures. Transconjunctival route without lateral canthotomy was
used exclusively & it was observed that this approach gives optimal exposure of the
fractured area without any cutaneous scars and causes fewer complications than the
standard approaches.
Tetrapod fractures were reduced by closed reduction, performed with a ‘J’
shaped curved hook elevator inserted through an intra oral incision and open
reduction was indicated if there was instability following reduction. For
Review of literature
14
multifragment zygomatic fractures combination of Lateral Eyebrow and a Buccal
Sulcus incision combined with the Transconjunctival approach avoiding a Lateral
Canthotomy were used. A Coronal flap was used only if there were concomitant skull
base fractures and or craniofacial fractures. Follow up period was 2-5 years with
average of 18 months.
Infraorbital nerve dysfunction was noted in 23.9% cases treated with open
reduction. Maxillary nerve dysfunction in the form of clinical or subclinical sinusitis
and oro-antral fistula was very low about 8.4%.
Enopthalmos with Diplopia was found in 40 patients in 3.9%. Complications
related to the Transconjunctival approach were mainly Entropion in 0.4%, Extropion
in 0.7% and Corneal abrasion in 0.1% cases38.
A study was conducted in a group consisting of 183 patients with isolated
simple Zygomatic Complex fractures treated at the Department of Oral and
Maxillofacial Surgery, Chaim, Sheba Medical Center, Israel, between 1985 and 1990.
Follow up period was ranging 6 to 12 months. The purpose of the study was to
compare the incidence of persistant sensory disturbances after recovery from isolated
simple fracture of zygomatic complex with four treatment methods. Closed reduction
via subcutaneous approach, open reduction via oroantral approach, closed reduction
via Gillies and lastly open reduction and fixation of the frontozygomatic fracture by
lateral eyebrow approach. Analysis revealved that patients treated with miniplate
osteosynthesis exhibiting a trend for higher recovery rate of infraoabital nerve than
with others. It can be explained by the fact that fixation with a miniplate provides the
best rigidity to the complex because of the three dimensional stability that can be
achieved by it. In addition it also provides the complete decompression of the
Review of literature
15
infraorbital nerve which is incompletely achieved by the wire osteosynthesis which
provides two dimensional stability to the bone39.
Seventeen patients with zygomatic complex fractures were treated from
December 1989 to December 1991 at Louisana University Medical Center and Shreve
Port or University of Kansas Medical Center, Kanas City. Patients had three to six
months follow up. All patients underwent a Transconjunctival approach with Lateral
canthotomy, seven subjects also had associated Sublabial flaps. Five patients required
Hemicoronal or Coronal approach. Seven minor complications were noted. Two
patients had prolonged conjunctival edema. This was believed to be secondary to
interruption of the orbital lymphatic system. Two patients had frontal nerve weakness,
both of theses were patients with Hemicoronal flap. Management of the trimalar
complex fractures was greatly facilitated by application of these approaches. 93% of
patients surveyed were either very satisfied or satisfied with their functional and
cosmetic results8.
A variety of surgical approaches were used in 48 patients with isolated
unilateral Zygomatic Complex fractures in patients who were treated at Parkland
Memorial Hospital, University of Texas, by the same staff surgeon from January 1st ,
1989 until December 31st . Most of the patients had satisfactory result with no facial
deformity. In this study maxillary vestibular incision was commonly used either alone
or in combination with other approaches. Approximately 20% of those having lower
eyelid incisions, had some amount of sclera show at the longest follow up. It was
concluded that the first area of surgical exposure, if necessary for reduction and
fixation is an intraoral approach. An incision in the lower eyelid is avoided, if
possible, to minimize the chance of postoperative scleral show. A coronal approach
was used in cases with displacement of the Zygomatic Complex posteriorly and
Review of literature
16
laterally and comminution of the arch and also associated medial orbital wall
fractures2.
An experience of an author with transconjunctival approach to access the
orbital floor, infraorbital rim and zygomatic frontal and zygomatic temporal sutures in
40 patients with fractures in the orbital and zygomatic region in Santa Casa Medical
Hospital, Sao Paulo, Brazil was presented. The preseptal and the retroseptal approach
were used. Ectropion was present in one patient and intropion in others. One patient
had a corneal ulcer caused by laceration during operative procedure. It was concluded
that despite the complication rate of 12.5% the esthetic results and simultaneously
visualization of infraorbital rim and lateralorbital rim supports the use of the
Transconjunctival approach because of the esthetic results and the direct and
simultaneous access to the orbital rim and the zygomatico frontal region70.
78 patients who had undergone 81 surgical procedures for fractures of
Orbitozygomatic complex over a period of 10 years were analysed during 1997, at
Department of Otolaryngology – Head and Neck Surgery, Wayne State University,
Detroit. The series consisted of 49 primary repairs (1 to 22 days postinjury), 10
delayed repairs using osteotomies at 21 days to 5 months post injury, and 22 delayed
repairs requiring onlay bone grafting from 4 months to 16 years post injury. 43
patients 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. And it was concluded that Orbitozygomatic
fractures can be repaired upto 21 days post injury using primary reduction and
fixation techniques. Osteotomies are required after 21 days and can be used
Review of literature
17
successfully up to 4 months post injury. After 4 months, successful repair requires
onlay bone grafting4.
1277 patients with fracture of zygomaticomaxillary complex fractures and 196
patients with arch fractures treated between 1984 & 1995 were evaluated at Oral and
Maxillofacial Clinic of K.A.T Hospital, Greece. In 514 cases Gillies temporal
approach was used to reduce fractures of zygomaticomaxillary complex. And
concluded that theGillies temporal approach method was not always successful,
because postoperative reduction was occasionally insufficient and the zygomatic
complex was not always elevated. Post operative radiographic examination showed
inadequate elevation, and in two cases arch fracture reoperation was necessary. Others
were treated with open reduction and internal fixation using various approaches. Intra
oral Buccal sulcus approach with antral packing was used in comminuted fractured
cases, but this was also found to be of less satisfaction because of risk of collapse
after removal of the pack and more chances of intra oral infection. Elevation of the
lateral orbital rim through the Lateral eyebrow approach and reduction of the
fractured fragments through the same approach was the method of choice, as its
associated with limited morbidity and improved functions68.
A retrospectively study was conducted in 50 patients with Zygomatic
Complex reduced by upper buccal sulcus approach. In 13 cases the arch alone was
fractured, in 31 cases the left zygomatic complex was fractured and one case
presented with isolated bilateral fractures of zygomatic complex. Mean follow up
period was 6 weeks. 38 patients were treated by simple elevation, 8 pateints were
treated with plating at zygomatic buttress and 4 patients with extra-oral placement of
bone plates. There was minimal morbidity, one case had mild diplopia, trismus and
swelling all of which setteled spontaneously. It was concluded that the upper buccal
Review of literature
18
sulcus approach is a safe, rapid and effective technique for the reduction of zygomatic
body and arch fractures22.
68 patients who were treated with Bicoronal flap were retrospectively
analysed between January 1991 and December 1996 in Queen Victoria Hospital, East
Grinsted, United Kingdom. 5 year follow up showed that the incidence of permanent
morbidity was low. 24 patients experienced some form of sensory abnormality
immediately after the operation. This persisted for longer than two years in one.
Complete motor recovery occurred by one year in 15 patients who developed frontal
nerve weakness. 3 patients developed male pattern baldness post-operatively, which
resulted in exposure of scar and poor cosmosis. They found that the pivotal point of
the bi-coronal flap was found to lie at its most inferior aspect, by extending the
incision into the skin crease in front of the lobe of the ear, it was possible to adjust the
anteroposterior position of the bicoronal incision without limiting access to facial
skeleton. They advocated the use of this type of flap in patients who are prone to male
pattern baldness53.
A series of 11 patients with comminuted zygomatic complex fractures and one
patient with comminuted malar arch fracture were treated with endoscopically
assisted fracture repair. Subciliary incision was used to access the orbital floor and
infraorbital rim. A Lateral Eyebrow incision gave access to the zygomatic frontal
buttress via the upper buccal sulcus incision the zygomatico-maxillary buttress was
reduced. The zygomatic arch was primarily approached endoscopically in all patients
via the upper buccal sulcus. In four patients an additional pre-auricular incision
extending 1.5cms above the auricle, it was necessary in order to visualize the
proximal stump of the arch. Post-operative the frontal branch of facial nerve was
intact in all patients. Scarring was minimal in 3patients plating of arch resulted in arch
Review of literature
19
necrosis and resorption in long term follow up. Operating time was remarkably longer
than in conventional procedures due to difficult technique33.
911 patients who were treated between 1989 and 2000 for fractures of the
zygoma were investigated in Eppendorf University Hospital, Hamburg, Germany. A
standardized interview was completed with 410 of these 911 patients in order to
collect self reports on treatment results and residual damages. The bone was exposed
via an infraorbital approach, following external reduction and osteosynthesis with
miniplates. Follow up revealed sensory disturbances in 25.6% (severe in 7.2%). The
patients reported impaired eye mobility in 1%, reduction of visual acuity in 3.9%, an
ectropion in 1%, hypersensitivity of the affected eye in 6.8%, and tear dropping in
5.8%. The patient assessed their face as asymmetry following trauma in 2.2% and
reported that the maxillary sinus caused complaints in 3.7%. And concluded that the
rate of complaints following the zygomatic complex fractures (attributable to trauma)
is in the range of other reports. The infraorbital approach is a safe technique and is
particularly preferred approach for training of young surgeons16.
A study was conducted in between January 1998 and January 2003 in Wuhan
University, Wuhan city, Peoples Republic of china, in which coronal incision was
carried out on 69 of 83 patients with zygomaticomaxillary complex fractures, the rest
14 patients were treated by various approaches. In early postoperative period, 5
patients suffered from by haemorrhage, 2 had infections, 24 patients reported with
immediate postoperative anaesthesia and paresthesia affecting the supraorbital region.
6 patients had signs and symptoms of facial nerve injury and it was explained that this
coronal approach offers advantages such as extensive site exposure and had
disadvantage of obvious scar, long operating time, infections, haemorrhage,
Review of literature
20
paresthesia and facial nerve palsy and therefore indicated that coronal incisions
should be strictly applied and should not be overused5.
40 Patients with isolated zygomatic arch fractures were analysed clinically in
Department of Oral and Maxillofacial Surgery, Nara Medical University, Japan in a
12 year period between January 1993 and December 2004. Gillies method was the
method of choice, because the procedure can be performed consistently and the
results are satisfactory. It was concluded that good functional and radiological
outcomes were obtained in isolated zygomatic arch fractures and the reduction status
was not influenced by either the fracture type or the interval between reduction and
injury. And the recovery achieved was excellent6.
A retrospective study was conducted in patients treated in the Department of
Oral and Maxillofacial Surgery at Jordan University Hospital between 2000 and 2006,
only cases where Subtarsal approach was used to explore the orbital floor were
included with a follow up of maximum 72 months. The study group compressed of 12
patients. All examined patients expressed their satisfaction regarding the incision both
esthetically and functionally. One patient suffered from Scleral show, one patient had
mild lid edema and one patient had keratoconjunctivitis. And concluded that subtarsal
approach when used to expose the inferior orbit in patients with isolated and
combined fractures of orbital floor produced nominal postoperative complications and
led to good surgical results, especially in terms of esthetics and ophthalmologic
outcomes71.
Methodology
Methodology
21
MATERIALS AND METHOD
SOURCE OF DATA:
This study is a prospective clinical study involving twenty five patients having
displaced zygomaticomaxillary complex fractures with insignificant medical history
to evaluate the versatility of various surgical approaches, its management, with the
main emphasis on the wound healing, post operative stability, functional restoration in
the form of mouth opening, esthetic restoration of the prominence of cheek and the
complications encountered. This study was conducted in the Department of Cranio
Maxillofacial Plastic and Reconstructive Surgery, at the College of Dental Sciences
Davanagere. The study was done under the topic “Evaluation of Various Surgical
Approaches To The fractured Zygomatico-Maxillary Complex”.
INCLUSION CRITERIA:
1. Patients reporting with zygomaticomaxillary complex fractures.
2. Patients reporting with isolated zygomatic arch fractures.
EXCLUSION CRITERIA:
1. Patients suffering with uncontrolled systemic diseases.
2. Patients not willing for the treatment.
METHOD OF STUDY:
The criteria used to determine the need for the surgical correction consisted of
a both clinical and radiologic assessment. Radiographic evidence of displacement and
combination of one or more of the following clinical signs and symptoms, restricted
Methodology
22
mandibular movements, infraorbital dysesthesia, palpable step deformity of the orbital
rim, tenderness at the fractured points, subconjunctival or periorbital ecchymosis,
diplopia and visible depression of the prominence of the cheek. A proforma was
completed for each patient requiring surgical treatment, detailing the name, age, sex,
date of injury, etiology, medical history, site of injury, involved side of the face, type
of fracture, clinical signs and symptoms, surgical approach used, duration of the
surgery, and postoperative evaluation in the form of assessment of wound healing,
functional stability, esthetic appearance and associated complications were recorded
in a exclusively designed proforma. The water’s view and submento-vertex view
radiographs were taken for the patients preoperatively and postoperatively. The latter
reviewed and post-operative assessment carried out during the immediate
postoperative period, after one week, one month, three months and six months.
SURGICAL PROCEDURE:
All the patients were treated on an inpatient basis under general anesthesia. A
variety of surgical approaches were used. The approaches used for the
zygomaticomaxillary complex were the Lateral eyebrow approach, Infraorbital
approach, Coronal approach, the Maxillary vestibular approach and the Gillies
temporal approach.
Access was gained to the particular fracture site with its corresponding
surgical approach. Stability was determined by reduction of the fractured segment and
return to normal contour of the orbital rim as assessed by palpation and proper
approximation & fixation of the fractured fragments. The incision wound was closed
with sutures using 3.0 vicryl for muscle and mucosa and 3.0 black silk for skin.
Subcuticular suturing was done using 5.0 prolene for Infraorbital approaches.
Methodology
23
All patients were administered antibiotics and analgesic. Patients were
instructed not to sleep on the side of injury and take soft diet orally. And eye cap was
placed over the zygoma for one week. This was to ensure that no pressure is exerts
upon the fractured site and to avoid unintentional trauma to the fractured site, to
contribute towards proper clinical union. Post-operative evaluation was done during
the immediate postoperative period, after one week, one month, three months and six
months, during which the assessment of wound healing, functional stability, esthetic
appearance and associated complications were recorded.
EVALUATION CRITERIA:
Wound Healing: Approximation of the incision was assessed visually and the
process of healing was noted for any tendency towards potential complications.
1. Functional Disturbances:
A) Stability of reduction:
Intraoperatively
- Reduction of the fractured fragments
- Proper approximation of the fractured fragments
Postoperatively
- Visible improvement in prominence of cheek when viewed.
- Return of normal contour of cheek and orbital rim as assessed by palpation.
- Postoperative radiographs.
Methodology
24
B) Improvement in Mouth Opening:
The improvement in mandibular movement is assessed by measuring the
interincisal distance between the maxillary and mandibular central incisors.
2. Esthethic Appearance :
It was judged according with the perception of the operator and the patient as
Acceptable or Unacceptable.
3. Complications:
Complications like Persisting pain, Infection, Wound dehiscence, Plate
exposure, Infraorbital Nerve Paresthesia, Step deformity and Depression over
the cheek, Malformed fractures, Non Union, Epiphora, Ectropion and Diplopia
were recorded.
Method of statistical analysis:
For discrete data, frequency and percentages; and for continuous data mean
and standard deviation were calculated. Further data analysis was done using Chi
square test wherever applicable. Data analysis was carried out using Statistical
Package for Social Science (SPSS, V 16) package. P value< 0.05 was considered
statistically significant.
Results are presented in Tables and Graphs.
Photographs
Photographs
25
Photographs
26
Photographs
27
Photographs
28
Photographs
29
Results
Results
30
RESULTS
A total of twenty five patients underwent the treatment of zygomatic complex
fractures. All the cases included were treated during the period from September 2006
to May 2008 in the Department of Oral and Maxillofacial surgery, College of Dental
Sciences, Davangere. The extremes of ages in this study ranged from 17-55 years
with the mean of 33.52±10.43 years. (Table-1, Graph-1) The peak incidence was seen
in the second and third decade of life. Out of the total twenty five patients selected for
the study 20(80%) were males and 5(20%) were females (Table-2, Graph-2).
Occupation wise 10 patients 12 (48%) were agriculturist making the largest group
among the study population (Table-3, Graph-3).
According to the distribution of the cause of injury of the twenty five patients,
selected in the study group road traffic accident (RTA) being the most common cause
of the injury 23 (92%) patients while only 2 (8%) patients of the study population
reported the history of Assault(Table-4 ,Graph-4). Isolated arch fracture has the least
incidence in the study with only 1 (4%) of the total 25 patients reporting arch fracture.
zygomatic complex fracture has the maximum with 24 (96%) patients (Table-5,
Graph-5).
Average reporting day after the injury to the centre was 6.6 days with
maximum of 5 patients (25%) reported the next day of injury itself. Maximum delay
between the injury day and the day of reporting was 14 days which includes 3 (12%)
patients (Table-6, Graph-6). Majority of the patients were treated two days after their
reporting. This constitutes 5 patients (20%) and 1 patient (4%) was treated on the next
day itself, 1 patient (4%) on the third day, 2 patients (8%) on the fifth day, 2 patients
(8%) on the sixth day, 4 patients (16%) were treated on the eight day, 2 patients (8%)
Results
31
on the ninth day, 4 patients (16%) on the tenth day, 1 patient (4%) on the eleventh
day, 3 patients (12%) on the 15th day.
Among the preoperative clinical findings, isolated arch fractures are
associated with the lowest signs and symptoms. Subconjunctival hemorrhage was a
significant finding with 15(60%) of the total 25 patients. Infra-orbital paresthesia was
present in 3(12%) patients. Restricted mandibular movements and reduced mouth
opening has been reported by 10(40%) patients. Depression over the prominence of
cheek can be appreciated in all of the patients of the study (100%). Step deformity
was reported by all 25(100%) of the patients. Incidence of diplopia was nil reported
among the inclusion criteria taken for this study. (Table-7-10, Graph-7&8).
Resolution of subconjunctival hemorrhage after one week was evident in
100% of the cases (Table-7,Graph-7) There was gradual improvement in the status of
infra orbital paresthesia with eventual restoration of normal sensation in 5 patients
(20%) out of which 3 (12%) patients had pre-operative infra orbital paresthesia and 2
(4%) patients had developed it post-operatively. At the end of first week infraorbital
paresthesia completely resolves in one patient, who had developed it post-operatively.
In one more patient it resolved by 3rd month and at sixth month follow u it was
completely resolved in all then patients (Table-7). Depression of cheek was corrected
in 100% of the cases with relapse recorded in only one patient (4 %) at follow up of
third month. At the end of 6th month all the 25 patients were stable with maintenance
of cheek contour. There was a drastic improvement in the mouth opening at the
immediate postoperative period. Significant limitation of mandibular movement was
seen in 10(40%) patients (Table -8, Graph-8). There was complete restoration of step
deformity in all the patients (100%) which was consistent at the end of 6th month
follow up period (Table-8).
Results
32
Observed difference for subconjunctival hemorrhage between different time
duration was statistically found significant ( χ2 =75.000, df= 5, p= < 0.001), and for
infraorbital paraesthsia between different time duration was statistically found not
significant. ( χ2 =5.364, df= 5, p= 0.373).
According to the side of the face involved, 16(64%) patients reported injury to
the right side of face, 6 (24%) had injury to the left side, and remaining 3(12%)
patients had bilateral involvement (Table-10, Graph-9). In twenty four patients (96%)
of the series the reduction and fixation obtained were stable according to the criteria
used for this study. Out of 25 patients, only 1 patient (4%) required additional
procedure for stability after 3 months.
Uneventful recovery was achieved in all the individuals (100%). One patient
(4%) where combination of Coronal and Infraorbital approach was used complained
of epiphora on 18th follow up day. One patient (4%) where combination of lateral
eyebrow and infraorbital approach was used complained of burning sensation in eye
on 20th day follow up. One patient (4%) where combination of Coronal and
infraorbital approach was used had developed pre-auricular and temporal infection
with pus discharge, which lead to sutural abscess by 40th post-op day. Two patients
(8%) where intra-oral maxillary vestibular approach was used developed infection,
one on 1st month follow up another on 3rd month follow up and they required plate
removal. One patient (4%) where combination of lateral eyebrow and infraorbital
approach was used complained of burning sensation in eye on 20th day follow up. In
this case on 3rd month follow up patient reported back to our unit with a complaint of
pain over the operated site and inability to open mouth (Table-11, Graph-10).
Graphs and Table
Results
30
TABLE 1: AGE DISTRIBUTION OF THE STUDY POPULATION
MEAN 33.52
MEDIAN 30.00
MODE 25
STD. DEVIATION 10.43
RANGE 38
MINIMUM 17
MAXIMUM 55
TABLE 2: GENDER DISTRIBUTION OF THE STUDY POPULATION
GENDER FREQUENCY PERCENTAGE
MALE 20 80.0
FEMALE 5 20.0
TOTAL 25 100.0
TABLE 3: DISTRIBUTION OF THE STUDY SUBJECTS BASED ON
OCCUPATION
Results
34
OCCUPATION FREQUENCY PERCENTAGE
AGRICULTURIST 12 48.0
LABOURER 4 16.0
BUSINESSMAN 3 12.0
HOUSEWIFE 3 12.0
SERVICE 2 8.0
STUDENT 1 4.0
TOTAL 25 100.0
TABLE 4: ETIOLOGY FOR FRACTURE AMONG THE STUDY
POPULATION
ETIOLOGY FREQUENCY PERCENTAGE
ROAD TRAFFIC ACCIDENT 23 92.0
SELF FALL 2 8.0
TOTAL 25 100.0 TABLE 5: DISTRIBUTION OF TYPE OF FRACTURE AMONG STUDY
POPULATION
TYPE OF FRACTURE FREQUENCY PERCENTAGE
ZYGOMATIC BODY FRACTURE 21 84
ZYGOMATIC ARCH FRACTURE 1 4
BOTH 3 12
TOTAL 25 100.0
Results
35
TABLE 6: DISTRIBUTION OF REPORTING DAY AFTER INJURY AMONG
THE STUDY POPULATION
N MEAN MEDIAN MODE SD MIN MAX
Reporting Day After Injury
25 6.60 7 2 4.02 1 14
TABLE 7: DISTRIBUTION OF STATUS OF PRESENCE INFRAORBITAL
NERVE PARESTHESIA AND SUBCONJUNCTIVAL HEMORRHAGE
DURING SIX MONTH STUDY PERIOD AMONG THE STUDY
POPULATION
Time of
Admission Immediate
Postop 7th day
1st month
3rd month
6th month
p-value
IOP 3 5 4 4 3 0 0.373 SCH 15 15 0 0 0 0 0.001
TABLE 8: DISTRIBUTION OF RESTRICTED MANDIBULAR
MOVEMENTS AMONG THE STUDY POPULATION
RESTRICTED MANDIBULAR MOVEMENT FREQUENCY PERCENTAGE
Yes 10 40.0
No 15 60.0
Total 25 100.0
Results
36
TABLE 9: DISTRIBUTION OF STABILITY OF INFRAORBITAL RIM
CONTOUR DURING SIX WEEK STUDY PERIOD AMONG THE STUDY
POPULATION
Time of Admission
Immediate Postop
7th day
1st month
3rd month
6th month
YES 0 25 25 25 25 25 No 25 0 0 0 0 0
TABLE 10: DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY
POPULATION
FREQUENCY PERCENTAGE
RIGHT 16 64 LEFT 6 24
BILATERAL 3 12
TOTAL 25 100
TABLE 11: DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH
USED AMONG THE STUDY POPULATION
SURGICAL APPROACH FREQUENCY PERCENTAGE
COMBINATION OF LATERAL EYEBROW AND INFRAORBITAL APPROACH
15 60.0
LATERAL EYEBROW APPROACH 2 8.0
GILLIES TEMPORAL APPROACH 2 8.0
Results
37
COMBINATION OF CORONAL AND INFRAORBITAL APPROACH 2 8.0
COMBINATION OF LATERAL EYEBROW, INFRAORBITAL AND MAXILLARY VESTIBULAR APPROACH
2 8.0
COMBINATION OF LATERAL EYEBROW AND MAXILLARY VESTIBULAR APPROACH
1 4.0
INFRAORBITAL APPROACH 1 4.0
TOTAL 25 100.00
TABLE 12: DISTRIBUTION OF TIME TAKEN FOR THE SURGERY IN
HOURS AMONG THE STUDY POPULATION.
SURGICAL APPROACH
Time Taken In Hrs Frequency
2 11 COMBINATION OF LATERAL EYEBROW AND INFRAORBITAL APPROACH 2.5 5
1 1 LATERAL EYEBROW APPROACH
2 1
GILLIES TEMPORAL APPROACH 1 2
3 1 COMBINATION OF CORONAL AND INFRAORBITAL APPROACH
3.5 1
COMBINATION OF LATERAL EYEBROW, INFRAORBITAL AND MAXILLARY VESTIBULAR APPROACH
2 2
COMBINATION OF LATERAL EYEBROW AND MAXILLARY VESTIBULAR APPROACH
2.5 1
INFRAORBITAL APPROACH 1 1
Results
38
TABLE 13: ADDITION PROCEDURES REQUIRED AFTER INITIAL
TREATMENT AMONG THE STUDY POPULATION.
Additional Procedure Frequency Percent
REQUIRED 1 4.0
NOT REQUIRED 24 96.0
TOTAL 25 100.0
GRAPH 1: AGE DISTRIBUTION OF THE STUDY POPULATION
Results
39
GRAPH 2: GENDER DISTRIBUTION OF THE STUDY POPULATION
GRAPH 3: DISTRIBUTION OF THE STUDY SUBJECTS BASED ON
OCCUPATION
Results
40
GRAPH 4: ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION
GRAPH5: DISTRIBUTION OF TYPE OF FRACTURE AMONG STUDY
POPULATION
Results
41
GRAPH 6: DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE
STUDY POPULATION
GRAPH 7: DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE
AMONG THE STUDY POPULATION
Results
42
GRAPH 8: DISTRIBUTION OF RESTRICTED MANDIBULAR
MOVEMENTS AMONG THE STUDY POPULATION
GRAPH 9: DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY
POPULATION
Results
43
GRAPH 10: DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH
USED AMONG THE STUDY POPULATION
Discussion
DISCUSSION
Various Surgical Approaches for the treatment of fractured Zygomatico-
Maxillary Complex are mainly categorized as:
- REDUCTION APPROACHES
- FIXATION APPROACHES
REDUCTION APPROACHES
1. Extra Oral Approaches
a) Gillies Temporal Approach
b) Percutaneous Approach
c) Lateral Eyebrow Approach
Discussion
44
2. Intra Oral Approaches
a) Buccal Sulcus Approach
b) Lateral Coronoid Approach
c) Intranasal Transoral Approach
FIXATION APPROACHES:
EXTRA ORAL APPROACHES
a) Lateral Eyebrow Approach
b) Infra Orbital Approach
c) Lateral Coronal Approach
d) Transconjunctival Approach
e) Subciliary Approach (Lower Blepharoplasty Approach)
f) Lateral Upper Lid Blepharoplasty Approach
g) Crows foot Approach
h) Through Existing Laceration
INTRA ORAL APPROACHES:
Discussion
45
a) Maxillary Vestibular Approach
REDUCTION APPROACHES:
1. BUCCAL SULCUS APPROACH
This technique has been in use since the beginning of the century and it was
discussed in detail by Balasubramaniam in 1967. Incision about 1cm in length
placed at the reflection of the upper buccal sulcus immediately behind the zygomatic
buttress, so that a pointed curved elevator can be passed upwards supraperiosteally to
contact the deep or infra temporal surface of the zygomatic bone and thus an
upward, forward and outward pressure can be exerted to elevate the depressed
zygoma.
2. GILLIES TEMPORAL APPROACH
Described by Gillies, in 1927. A 2-cm incision placed behind the temporal
hairline approximately 6 cm above the zygoma. The incision is carried through the
skin, temporoparietal fascia (superficial temporal fascia) and temporalis muscle fascia
(deep temporal fascia). A tunnel is dissected superficial to the temporalis muscle and
deep to the zygomatic arch. Dissection is limited around the fracture site to minimize
the risk of fracture destabilization. Once the dissection is beneath the zygomatic arch,
Elevator is inserted and lateral pressure is applied to reduce the bone fragments. Care
must be taken to avoid using the parietal scalp as a fulcrum for these instruments. This
can result in a parietal skull fracture.
Discussion
46
OPEN REDUCTION AND FIXATION APPROACHES
1. MAXILLARY VESTIBULAR APPROACH
The maxillary vestibular approach provides access to the entire midface
skeleton from the zygomatic arch, to the infraorbital rim, to the frontal process of the
maxilla, which can be achieved in a safe manner. The greatest advantage is the hidden
intraoral scar that results. The incision is placed approximately 3-5mm superior to
mucogingival junction and extended as far as possible posteriorly as necessary to
provide exposure usually to the first molar tooth and traverses mucosa, submucosa,
facial muscles and periosteum. Subperiosteal dissection is carried out to expose the
fractured site and care is taken to preserve neurovascular bundle above and posterior
superior alveolar vessels along the posterior maxilla, which infrequently causes
bleeding.
2. LATERAL BROW APPROACH
The incision is placed within or just below the lateral brow and carried it onto
the frontozygomatic buttress. The advantage of this approach is that the fracture of the
frontozygomatic region can be visualized directly and fixed and simultaneously
allows the reduction of the zygoma as well. Once exposure has been accomplished, a
heavy instrument is inserted posterior to the zygoma along its temporal surface, the
instrument is then used to lift the zygoma anteriorly, laterally, and superiorly while
one hand palpates along the infraorbital rim and body of the zygoma and
simultaneously allows fixation of the frontozygomatic fracture.
3. INFRA ORBITAL APPROACH
Discussion
47
A 3-4cm incision is positioned directly over the bony orbital rim
approximately 1.5-2.0 cm below the lower lid margin. The incision is carried directly
through the skin, orbicularis oculi muscle, subcutaneous tissue and periosteum. While
this approach is faster than eyelid incisions and is associated with minimal risk of
postoperative eyelid malposition.
4. CORONAL APPROACH
High-energy injuries often result in extensive posterior and lateral dislocation
of the malar eminence and posterior and inferior depression of the zygomatic body.
Incision is placed at least 5 cm behind the hairline. A zigzag or "w" pattern can be
used to help camouflage the incision. This is most effective in patients with straight
hair that falls over the suture line. The dissection can be performed in a hemicoronal
or bicoronal plane. After injection with local anesthetic, incision is placed, starting at
the vertex and moving toward the helical root. Incision is carried through the galea
aponeurosis, leaving the pericranium and temporalis muscle fascia (deep temporal
fascia) intact. Raney clips or suturing to the incision edges to be done to control blood
loss. Special care must be taken to avoid injury to the temporal branch of the facial
nerve that lies in the temporoparietal fascia (superficial temporal fascia). The galea
aponeurosis elevates easily from the pericranium. Careful blunt dissection to be made
to elevate the temporoparietal fascia free from the temporalis muscle fascia. The two
dissection planes are should sharply join at the temporal line. The incision can be
carried across the midline to the contralateral ear for more exposure or for access to
the frontal sinus and orbital rims. To expose any fracture of the frontozygomatic
buttress or orbital rim, the periosteum can be incised and elevated. Allows entire
visualization of the zygomaticomaxillary complex.
Discussion
48
The various surgical approaches, for the treatment of the fractures of
zygomaticomaxillary complex may form the treatment of choice for different types of
zygomaticomaxillary complex fractures.
The total twenty five patients selected for the study 20(80%) were males and
5(20%) were females. This observation was confirmed with the study carried out by
Ellis et al.2, they reported 80.2% incidence of male predominance, and the study by
Schnetler21 also reported that, the majority affected were males with a peak at 30
years of age. Age group of our study also confirms with the study of Adekeye O.E 63,
who found that out of 337 Nigerian patients with zygomatic complex fractures, 80%
were between the age group of twenty one and forty years. Age group of our study are
also similar with the work of Haider Z42, Gomes Pereira et al. 3, Courtney D.J22,
Esben Kaastad27 and Atte Freng, Ogden. R.G28.
In this study, road traffic accidents were the most common cause of
zygomaticomaxillary complex fractures accounting for 92% of cases, while 8%
resulted from falls. This was contradicting with the study of Ellis et al, where alleged
assault was the major cause of zygomatico-orbital fractures amounting to 46.6% of
the entire sample, while motor vehicle accidents constituted only 13.3%. This low
figure of incidence of motor vehicle accidents in the study of Ellis et al.2 may be
attributed to the compulsory wearing of seat belts and head devices. The high
incidence of zygoma fractures in the present study could be attributed to the increase
in number of automobiles and lack of safety measures. Out of total twenty five
patients, 16 have suffered fractures on the right side of the face (64%), 6 suffered on
left side of the face (24%) and 3 suffered bilaterally (12%). Isolated zygomatic arch
fracture has the least number of occurrences in the present study with only two
patients (8%).
Discussion
49
The clinical signs and symptoms that were most helpful in the preoperative
diagnosis were consistent with that of the other studies. Isolated arch fractures were
associated with the lowest percentage of sign and symptoms. This was also observed
by Ellis et al and Ogden. However restricted mandibular movement was a persistent
finding in all the patients included in this study. According to Row and Killey12,
limitation of mouth opening or lateral excursion resulted from mechanical obstruction
by the zygomatic bone or arch impinging on coronoid process of the mandible.
The current study showed infraorbital nerve paresthesia in 12% of the cases.
Isolated zygomatic arch fractures were not associated with paraesthesia or anaesthesia
of the infraorbital nerve. But Ogden28 noted that paraesthesia or anaesthesia of the
infraorbital nerve was the most frequently reported symptom. Subconjunctival
hemorrhage was observed in 60% of the total patients in the present study, nearing
approximately to a study done by Weisenbaug28, who noted occurrence in 70.5% of
the patients. In the analysis of 2067 cases by Ellis et al. 2 subconjunctival hemorrhage
occurred variably ranging from a surprising 20% in zygomatic arch fractures to 65%
in those zygomatic fractures which had multiple lines of fracture. The incidence of
diplopia was nil. According to Nordgaard54 diplopia occurred in 8-22% of malar
fractures.
Palpable step deformity of the orbital rim was found and depression over the
cheek was noted in every patient. Ogden28 found some form of palpable bony
asymmetry of the zygomatic bone in 95 of the 105 cases studied.
The surgical treatment of zygoma fracture varies from surgeon to surgeon and
also depending on the type of fracture and circumstance. The intra-oral maxillary
vestibular approach, and extraoral approaches like Lateral eyebrow, Infraorbital,
Discussion
50
Coronal, Extended preauricular approach and reduction approach ie. Gillies temporal
approach were used in this particular study.
Discussion Discussion
50
50
Discussion
51
REDUCTION APPROACHES:
Lateral eyebrow approach
In a study conducted by Zigmunt W Pozatek24, the predominant approach
was via the lateral eyebrow approach. In this study, various surgical approaches to the
fractured zygomatic complex were discussed. There data illustrated that a great many
of the fractures were unstable after reduction. They concluded that the lateral eyebrow
approach, with internal wire fixation if necessary was used as the initial surgical
approach in the management of zygomatic complex fractures.
This was in similar with this present study, where the lateral eyebrow
approach was the predominant approach used in 20 cases (80%), none of the patients
had esthetic concern. In addition, this approach offered a number of other advantages.
Incarcerated tissue in the fracture, which may hinder proper reduction, can readily be
released and retracted. The elevator is in direct contact with a large mass of bone and,
thus the force of reduction is exerted over a large area. Force may be exerted in more
directions than with the Gillies or the antral approaches. Because the fracture is
directly exposed with the eyebrow approach, an assessment of anatomical reduction
can be made intraoperatively, and an opportunity for fixation at the time of reduction
is offered, and was not associated with any other complications. For all these reasons,
the lateral eyebrow approach is the more versatile approach.
Buccal sulcus approach, Gillies temporal approach
This transbuccal elevation, originally described by Keen69, was recommended
by Yanag1sawa55 as the standard initial method for all types of zygomatic fractures
Discussion
52
except arch and rim fractures. It was noted to be particularly effective for posterior
displacement and lateral rotation around the vertical axis.
The upper buccal sulcus approach has been reviewed by Apfelberg et al.20
and was reported as a fast, simple technique, virtually eliminating the need for open
reduction. Manstein et al described in detail, the reduction of fracture zygomatic arch
in the elderly unfit patient, via a Gillies lift under local anesthesia. However no
mention of the fracture of whole zygomatic complex was made and the technique was
not intended for routine use.
Balasubramaniam also mentioned that less force was required for elevation
than for the external approach and the technique could be performed within minutes,
with minimum chance of hemorrhage. The buccal pad of fat was too small for a
dehiscence to occur during the surgery.
Courtney D.J22 has done a retrospective study on 50 patients treated with
Upper buccal sulcus approach. He cited various advantages like no skin scar, closer
and more precise application of force by the operator, minimal bleeding, simplified
antral bone harvest if needed, and simple mucosal closure. An additional advantage of
this technique includes the elevation of comminuted zygomatic body fracture which is
not indicated when a Percutaneous hook is used to reduce the fracture. He concluded
that results of intra-oral approach are comparable to extraoral Gillie’s temporal
approach. According to him the upper buccal sulcus approach is a safe, rapid and
effective technique for the reduction of zygomatic body and arch fractures.
Kazuhiko Yamamoto et al.5 analyzed the characteristics of isolated
zygomatic arch fractures reduced through Gillies temporal approach, to evaluate the
functional and radiological outcomes of the treatment. Good functional and
Discussion
53
radiological outcomes were obtained in isolated zygomatic arch fractures. Reduction
status was not influenced by either the fracture type or the interval between reduction
and injury, and recovery infraorbital nerve achieved was excellent with fair reduction.
This was similar with our study where we used Gillies temporal approach in 2 cases
(8%), the reduction and stability achieved was excellent. It was not associated with
any other complications.
Ogden G.R28, treated 105 cases of fractures of zygoma using Gillies temporal
approach. They concluded that Gillies method offers the advantage of being quick
(thereby shortening the duration of anesthesia), decreasing the possibility of facial
nerve damage or direct trauma to the globe by instruments inserted to protect the eye,
and not being associated with a visible scar ( the scar from the Gillies method being
within the hairline). However so many zygomatic fractures can be treated by only
Gillies method, it was suggested as a logical starting point in most cases.
This was in contradiction with a study carried out by Zigmunt W Pozatek24,
who studied 16 cases of arch fractures which were treated with Gillies temporal
approach. In their study they found great number of fractures were unstable after
reduction.
In this current study we preferred Gillies temporal approach for the reduction
of isolated arch fractures and we found the lateral eyebrow approach was the best
approach to reduce the fractured zygoma, as it has the advantage of reduction with
fixation of the fractured segment at the same time.
Discussion
54
OPEN REDUCTION AND FIXATION APPROACHES
Rigid fixation techniques have gained popularity during the past decade,
because they offer greater versatility in the treatment of the zygomaticomaxillary
complex fractures. Fractures that tend to rotate after stabilization at the zygomatico-
frontal and the zygomaticomaxillary areas may be successfully managed with bone
plates, thereby avoiding antral or infratemporal space packs.
A study performed by Dingman and Natvig demonstrated that many zygoma
fractures treated with a closed reduction technique and then later re-examined were
more severe than they had appeared clinically or by roentgenographic evaluation. It
appeared that although the fracture was reduced at one point, the bone became
displaced again due to extrinsic forces. Therefore, they concluded that most displaced
fractures of the zygoma should be treated by open reduction and direct wire fixation.
Perhaps the four most important considerations in treating
zygomaticomaxillary complex fractures are proper reduction, adequate stabilization,
adequate orbital reconstruction (when necessary), and adequate handling, positioning
of periorbital soft tissues. Because this study suffers from some problems as limited
sample size, it does not answer all questions concerning treatment of
zygomaticomaxillary complex fractures. However, it does provide some valuable
information on a few specifics of treatment.
In this current study open reduction was indicated in 92% of cases, this was
nearing the values reported by Robert Chuong and Kaban7 (85.5%), and higher than
the values reported by Pozatek et al.24 (58%) and Wiesenbaugh49 (64%).
Discussion
55
Robert Chuong and Kaban7 in their study recommended the lateral eyebrow
approach for the initial access to the zygomatic complex fractures as it has the
advantages of producing an inconspicuous scar and providing direct access to the
zygomatico-frontal region for fracture reduction and fixation, and they restricted the
use of Gillies temporal approach to the management of isolated arch fractures and
occasionally to assist in the reduction of the zygomaticomaxillary complex fractures.
They used lateral eyebrow approach predominantly to gain access to the
zygomatico-frontal suture and for direct visualization and fixation of the fractured
fragment. No specific complications were reported and it provided a better long term
esthetic result. This was similar to our study where lateral eyebrow was the
predominant approach used in 80% of cases.
Maxillary vestibular appoach
According to a study done by Edward Ellis III and Winai Kittidumkerng 2,
who studied a variety of surgical approaches, the maxillary vestibular approach was
used more frequently, either alone or in combination with other approaches. The next
frequently used approach was through lower eyelid. Complications associated with
maxillary vestibular approach were not significant and approximately 20% of those
having lower eyelid approach had some amount of sclera.
In this present study three fractures were approached through Intra-oral
maxillary vestibular approach, Infection and plate exposure was seen in two patients
(66.6%). One on 1st month follow up another on 3rd month follow up and they
required plate removal. This approach has a high chance of infection.
Discussion
56
Infra orbital approach
A study conducted by Friedrich R.E and Henning16. They studied the
infraorbital approach, Follow up revealed sensory disturbances in 25.6% (severe in
7.2%). The patients reported impaired eye mobility in 1%, reduction of visual acuity
in 3.9%, an ectropion in 1%, hypersensitivity of the affected eye in 6.8%, and tear
dropping in 5.8%. The patient assessed their face as asymmetry following trauma in
2.2% and reported that the maxillary sinus caused complaints in 3.7%. And they
concluded that the rate of complaints following the zygomatic complex fractures
(attributable to trauma) is in the range of other reports. The infraorbital approach is a
safe technique and is particularly preferred approach for training of young surgeons.
In our experience infraorbital approach was used in alone in 1 case (4%), in
combination with lateral eyebrow approach in 17 cases (68%) and in combination
with coronal approach in 2 cases (8%). Infra orbital paresthesia was observed
postoperatively in 2 cases (4%), epiphora in 1 case (4%). This technique should be
considered as a simple and useful alternative along with the more complicated
procedures like Transconjunctival, Subciliary and Blepharoplasty approaches, which
requires valuable operating skill and experienced surgeons, and these approaches may
be considered as initial procedures required for the most of the zygomatic complex
fractures. The esthetic result were not superior with the infra orbital approach, where
11 patients (55%) were not satisfied with the resultant scar.
Coronal Approach
A retrospective study on the use of Bicoronal approach in treatment of
craniomaxillofacial trauma was carried out in 28 patients by Omar Abubaker et al.48
showed that this technique provides optimum exposure of fractured site allowing for
accurate anatomic reduction and fixation of the fractured segments and good cosmetic
Discussion
57
results. Both Bicoronal and Hemicoronal approach allowed accurate anatomic results.
Sensory nerve deficit was reported in 5 patients, which returned normal in 6 weeks. 2
patients developed hematoma in temporal region on 9th and 10th post-op day. It was
concluded that with an adequate knowledge of the surgical anatomy, a coronal
approach will provide an exposure that facilitates accurate reduction and fixation of
the fractures and will allow superior cosmetic results with minimal or no
complications. And a study was conducted in 48 patients who had undergone open
reduction and internal fixation of malar by Robert Stanley15, he treated the malar
fractures using a variable combination of Lateral eyebrow, Subciliary and
Gingivobuccal incisions to obtain a three point reduction. In the remaining 5 patients
either a coronal or hemicoronal incision was used to expose the Zygomatic arch for
use a fourth point of reduction.
This was in contradiction to our study where in majority of cases we used a
two point fixation in 23 of 25 cases (92%), and in a few cases with concomitant
zygomaticomaxillary buttress fractures we used three point fixation in 2cases (8%).
We used coronal approach in 2 cases (8%), with a comminuted fracture of
zygomaticomaxillary complex, where a wide access was required. In one case (50%)
we encountered a complication as temporal abscess on 40th follow up day.
High-energy injuries often result in extensive posterior and lateral dislocation
of the malar eminence and posterior and inferior depression of the zygomatic body. A
coronal exposure is often required to align the malar eminence and correct facial
width. Alignment of the sphenoid wing allows for good confirmation of anatomic
reduction of the arch and malar eminence.
Discussion
58
Coronal incisions with careful dissection allow for the prevention of
postoperative morbidities related to damage to the frontal branch of the facial nerve,
atrophy of the temporalis muscle, and displacement of the lateral canthal ligament
resulting in downward inclination of the lateral canthus. The use of a coronal incision
allows for temporary interosseous wiring of the frontozygomatic fracture site. The
anteroposterior displacement of the zygomatic body then can be rotated into place,
checking alignment of the lateral orbital wall, inferior orbital rim, and
zygomaticomaxillary buttress, and fixed with miniplates and screws. Furthermore, the
malar arch at this time can be reconstructed and repaired with a plate and screw
system.
Indications for this approach include superior orbital rim fractures and
comminuted fractures of the ZMC, including the zygomatic arch. When possible, this
approach should be avoided in patients with male pattern baldness.
Delayed and Malformed Zygomaticomaxillary Complex Fractures
The various surgical approaches, for the treatment of the fractures of
zygomaticomaxillary complex may form the treatment of choice for different types of
zygomaticomaxillary complex fractures. According to study conducted by Perino et
al.36 used the temporal approach for all the delayed and malformed
zygomaticomaxillary complex fractures, and they reported no major complications in
ten patients who received temporal approach for osteotomy (9 cases) and zygomatic
implant (1 case), of these 3 patients needed an additional implant after osteotomy.
There was no transient mydriasis as reported with zygomatic osteotomies. Although
temporal flap procedures may seem radical in terms of the extent of the soft tissues
Discussion
59
dissection, they confer an advantage by providing the necessary exposure to perform
meticulous and accurate surgery. Beyond this, benefits to the patient may include
enhanced cosmesis, less danger to important anatomical structures, and the ability to
perform secondary or ancillary procedures which enhance the post operative result
and eliminate or minimize the need of secondary intervention. This was in
accordance with our study where we encountered a patient who reported with a
complaint of pain and asymmetry, after 3months post treatment. The
zygomaticomaxillary complex was found to be laterally rotated, and was approached
via an extended preauricular, temporal approach. Recontouring of arch and
zygomaticomaxillary buttress was performed. This approach has the advantage of
providing a wide exposure to the zygomaticomaxillary complex. Though not used in
our case but the temporal approach has also an added advantage of reconstruction of
the depression over the zygoma region with temporalis flap and eliminate the need of
a second procedure.
This was in contradiction to study carried out by Richard M et al4, who
analysed 10 cases of delayed repair zygomaticomaxillary complex fractures with 21
days to 5 month post injury. They concluded that the lateral eyebrow and the
infraciliary approach are the best approach for the osteotomy of the malformed
zygoma and a coronal approach can be used in cases of pan facial trauma and
preferred coronal approach for cases which require onlay bone grafting, where a
cranial bone can be harvested with decrease donor site morbidity and use of same
approach for access of both the donor and the recipient site.
The most important principle in treating fractures, especially those of the face,
is proper reduction if the bone is not placed into the correct position, stabilization
becomes superfluous. Recommendations in the literature for reduction of zygomatic
Discussion
60
complex fractures range from “closed reduction” technique to three or four point
surgical exposure and fixation with miniplates or transosseous wires. Rigid fixation
techniques have gained popularity because they offer greater, versatility in the
treatment of complex zygomaticomaxillary fractures. Rohrich and Wattumull65
retrospectively evaluated 85 patients treated with miniplates or wires. They arrived at
the conclusion that miniplate fixation produced better malar projection as well as
fewer ocular and infraorbital nerve complications. In this present study, a sincere
attempt has been made to evaluate the efficacy of various surgical approaches in the
treatment of zygomaticmaxillary complex fractures and the results of this study are in
accordance with the studies conducted by different authors.
The temporal approach can be used for all the delayed and malformed
zygomaticomaxillary complex fractures, associated with minimal complications.
Although temporal flap procedures may seem radical in terms of the extent of the soft
tissues dissection, they confer an advantage by providing the necessary exposure to
perform meticulous and accurate surgery. Beyond this, benefits to the patient may
include enhanced cosmesis, less danger to important anatomical structures, and the
ability to perform secondary or ancillary procedures which enhance the post operative
result and eliminate or minimize the need of secondary intervention.
Conclusion
Conclusion
61
CONCLUSION
For a fracture to be considered as zygomaticomaxillary complex fractures it
has to fracture at minimum of three points, and two point stabilization would be
effective in restoring the proper contour, form and function of the facial skeleton.
As fractures of zygomaticomaxillary complex usually require a minimum of 2
point stabilization, therefore it is unduly necessary to mainly plate two important
buttresses in this region, that is the infra orbital buttress and the zygomatico frontal
buttress and for reduction and fixation of these buttresses the periorbital approaches
are required, combination of Lateral eyebrow and Infra orbital approaches are the
simple, easy and effective approaches to be used in means of treating fractures of
zygomaticomaxillary complex. This technique should be considered as a simple and
useful alternative along with the more complicated procedures like Transconjunctival,
Subciliary and Blepharoplasty approaches, which requires valuable operating skill and
experienced surgeons, and these approaches may be considered as initial procedures
required for the most of the zygomatic complex fractures. The esthetic result were not
superior with the infra orbital approach as compared to the studies which claims that
the Transconjunctival, Subciliary and Blepharoplasty approaches have its superior
esthetics results with inconspicuous scar. The advantage of Lateral eyebrow approach
is that the fracture of the frontozygomatic region can be visualized directly and fixed
and simultaneously allows the reduction of the zygoma as well.
The intraoral maxillary vestibular approach is a simple, easy and effective
means of treating uncomplicated simple fractures of zygomatic complex. It is a
technique which saves operating time but has a high risk op postoperative infection as
compared with the other extra oral approaches and is usually required unless the
Conclusion
fractured buttress is completely displaced and results in malocclusion. It also has an
advantage of elevating and reducing the displaced zygoma before fixation.
Gillies temporal approach is the best approach to reduced the fractured
zygomatic arch. It offers the best advantage of being quick, decreasing the possibility
of facial nerve damage or direct trauma to the globe by the instruments inserted to
protect the eye, associated with minimal complications and not being represented with
a visible scar. Depressed fractures of the zygomatic body can also be reduced via
Gillies temporal approach, except the inability to achieve functional stability through
only reduction approaches they not commonly practiced.
With an adequate knowledge of the surgical anatomy, a Coronal approach
will provide complete exposure of the zygomaticomaxillary complex with the
zygomatic arch. It facilitates accurate reduction and fixation of the fractures and will
allow superior cosmetic results with minimal complications. Preferred in cases of
bilateral zygomaticomaxillary complex fractures and those which involve additional
fractures of frontal bone. For late reconstruction of the zygomaticomaxillary complex,
we prefer wide access through a coronal approach or an extended pre auricular
approach (temporal approach).
62
Summary
Summary
63
SUMMARY
Twenty five patients with minimally displaced zygomatic complex
fractures reported to the Department of Cranio Maxillofacial Plastic and
Reconstructive Surgery, College Of Dental Sciences, Davangere were included in the
study to evaluate the efficacy of various surgical approaches used for the reduction of
zygomaticomaxillary complex fractures with the main emphasis on the post operative
stability achieved and the improvement in the functional and esthetic restoration with
minimal complications.
Follow up period for the study was six months. Recordings were made at the
immediate post operative period, in the first week, 1st month, 3rd month and at the end
of 6th month. Stability was assessed by reduction of the fractured fragments, fixation
and by return of normal contour of prominence of cheek and infraorbital rim, which
was determined by inspection and palpation. Waters view radiographs were taken
preoperatively and at the first week post operative visit.
Wound healing was uneventful in 100% of cases from immediate
postoperative day till 7th postoperative day when the sutures were removed. The
functional stability was satisfactory (96%) according to the stability criteria used for
the study. Out of 25 patients only 1 patient (4%) required additional procedure for
stability after 3 months, which was believed to be malunited.
The esthetic results were not superior with the Infraorbital approach, where 11
patients (55%) were not satisfied with the resultant scar. Where as the esthetic result
were superior with the lateral eyebrow approach, where the resultant scar was hidden
behind the eyebrow, and in cases of Coronal, Gillies temporal approach where the
scar was well within the hairline and hidden in cases of intraoral approaches. The
Summary
64
esthetic result was superior in cases of the other approaches with exception in cases of
the Infraorbital approach.
Resolution of Subconjunctival hemorrhage after one week was evident in
100% of the cases. There was gradual improvement in the status of infraorbital
paresthesia with eventual restoration of normal sensation in 5 patients (20%) out of
which 3 patients (12%) had pre-operative infra orbital paresthesia and 2 patients (4%)
had developed it post-operatively. At the end of first week infra orbital paresthesia
completely resolves in one patient, who had developed it post-operatively. In one
more patient it resolved by 3rd month and at 6th month follow up it was completely
resolved in all the patients. Depression of cheek was corrected in 100% of the cases
with relapse recorded in only one patient (4 %) at follow up of 3rd month. At the end
of 6th month all the 25 patients were stable with maintenance of cheek contour.
Significant limitation of mandibular movement preoperatively was seen in 10 patients
(40%), which drastically improved postoperatively. There was complete restoration
of step deformity in all the patients (100%) which was consistent at the end of 6th
month follow up period.
Nineteen fractures were approached through Infraorbital approach, Epiphora
was seen in 1 patient (5.26%), and burning sensation in eye was seen in another
patient (5.26%). Two fractures were approached through Coronal approach, Temporal
abscess was seen in 1 patient (33.3%).
Three fractures were approached through Intra-oral maxillary vestibular
approach, Infection and plate exposure was seen in two patients (66.6%). Twenty
fractures were approached through Lateral eyebrow approach and two fractures were
Summary
65
approached through Gillies temporal approach, none of the patients reported with any
complications.
Malunited zygoma was noticed in one patient at 3rd month follow up visit. It
was believed to be over elevation of the zygoma or unintensional trauma to the bone,
examination revealed prominence at the arch and the zygomatic buttress, which was
oteotomised under next procedure using a combination of extended pre-auricular
approach (Temporal approach) and the Infraorbital approach.
Diplopia was not recorded at the last follow up visit. There was no relapse in
infraorbital rim contour. There was no anesthetic complication nor post operative
blindness.
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Annexure
Annexures
74
ANNEXURE–I
PROFORMA
SL.No: DATE:
NAME: IP.No:
AGE:
SEX:
ADDRESS:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL HISTORY:
PAST DENTAL HISTORY:
DRUG HISTORY:
FAMILY HISTORY:
PERSONAL HISTORY:
GENERAL PHYSICAL EXAMINATION:
EXTRA-ORAL EXAMINATION:
INTRA-ORAL EXAMINATION:
PROVISIONAL DIAGNOSIS:
Annexures
75
INVESTIGATIONS:
FINAL DIAGNOSIS:
TREATMENT PLAN:
VARIOUS PARAMETERS
DATE OF R.T.A / ASSAULT / OTHERS:
DATE OF ADDMISSION:
DATE OF OPERATION:
BEFORE TREATMENT RECORD
1) SITE OF THE FRACTURE:
2) TIME ELAPSED:
3) OTHER FACIAL BONES INVOLVED:
4) SOFT TISSUES INVOLVED:
INTRA-OPERATIVE RECORDS
TYPE OF SURGICAL APPROACH (ES) USED:
IMMEDIATE POST-OPERATIVE RECORDS
1) SOFT TISSUE EVALUATION:
2) FUNCTIONAL DISTURBANCES:
3) ESTHETIC EVALUATION:
4) COMPLICATIONS ENCOUNTERED:
Annexures
76
5) DATE OF DISCHARGE:
6) POST OPERATIVE FOLLOW UP:
7TH
DAY
1ST
MONTH
3RD
MONTH
6TH
MONTH
WOUND
HEALING
FUNCTIONAL
DISTURBANCES
ESTHETIC
CONSIDERATION
COMPLICATIOS
Annexures ANNEXURE – II MASTER CHART
IMMEDIATE POSTOP
SI NAME IP N AG SX OC ET TY DF SH IP RM SD SF SA DS AP WH FS EA C0
1 Md.Kasim 20 M LB R C 2 P N A P R LI 2 N WA NS A NL 2 Gowramma 555 45 F H R A 9 A N P P R L 2 N WA NS A NL 3 Mohan Kumar 557 26 M AG A A 14 A N P P R LB 2.5 N WA NS A NL 4 Sudhakar 558 45 M AG R A 7 P N P P R LI 2 N WA NS A NL 5 Sanappa 560 55 M AG R A 2 A N A P R LI 2.5 N WA NS A NL 6 Obalesh 575 34 M SR R A 4 P N A P L LI 2 N WA NS A NL 7 Rathnamma 585 50 F H A A 2 P N P P R I 1 N WA NS A NL 8 Manjappa 586 28 M BS R A 7 P N A P R HI 3 N WA NS A NL 9 Venkat Rao 594 50 M LB R A 7 P N A P R LI 3 N WA NS A NL
10 Basvaraj 595 22 M BS R C 2 P N P P R LI 2 N WA NS A NL 11 Shiva Kumar 601 36 M BS R A 7 P N P P R LI 2 N WA NS A NL 12 Jyothamma 606 30 F AG R C 5 A N A P L G 1 N WA NS A NL 13 Rathnamma 614 30 F H R A 5 A Y P P R LI 2 N WA NS A I 14 Shashidhar 646 17 M ST R A 2 P N P P R LI 2 Y WA NS A I 15 Parshuram 666 26 M AG R A 14 P N P P R HI 3.5 N WA NS A NL 16 Thippashetty 673 46 M AG R A 9 P N P P L LI 1.5 N WA NS A NL 17 Rathnabai 682 25 F LB A B 1 A N P P R G 1 N WA NS A NL 18 Neelesh 686 25 M SR R A 4 P Y A P R LI 2 N WA NS A I 19 Kalappa 705 38 M AG R A 3 P N P P L LI 2 N WA NS A NL 20 Janardhan 711 38 M AG R A 9 A N P P B LIB 2 N WA NS A NL 21 Kariyappa 738 24 M AG R A 8 P N A P L LIB 2 N WA NS A NL 22 Raju G.K 765 25 M AG R A 9 A N P P R LI 2.5 N WA NS A I 23 Jamaal Sab 766 35 M AG R A 8 P Y P P B LI 2 N WA NS A I 24 Eranna 778 40 M AG R A 14 A N A P R L 1 N WA NS A NL 25 Ranganath 787 28 M LB R A 10 A N A P B LI 2 N WA NS A NL
77
Annexures ANNEXURE – II MASTER CHART
78
7TH DAY 1ST MONTH 3RD MONTH 6TH MONTH
SI NAME WH FS EA CO FS EA C0 FS EA CO FS EA C0
1 Md.Kasim WA NS A NL NS A NL NS A NL NS A NL 2 Gowramma WA NS A NL NS A NL NS A NL NS A NL 3 Mohan Kumar WA 1R A NL NS A NL NS A NL NS A NL 4 Sudhakar WA NS B NL NS B NL NS B NL NS B NL 5 Sanappa WA NS B NL NS B B NS B NL NS B NL 6 Obalesh WA NS B NL NS B NL NS B NL NS B NL 7 Rathnamma WA NS A NL NS A NL NS A NL NS A NL 8 Manjappa WA NS B NL NS B E NS B NL NS B NL 9 Venkat Rao WA NS B NL NS B NL NS B NL NS B NL
10 Basvaraj WA NS A NL NS A NL NS A NL NS A NL 11 Shiva Kumar WA NS B NL NS B NL NS B NL NS B NL 12 Jyothamma WA NS A NL NS A NL NS A NL NS A NL 13 Rathnamma WA NS A I NS A IC NS A L NS A NL 14 Shashidhar WA NS B I NS B I P B l NS B 1L 15 Parshuram WA 1R B NL NS B IF NS B I NS B NL 16 Thippashetty WA NS A NL NS A NL NS A NL NS A NL 17 Rathnabai WA NS A NL NS A NL NS A NL NS A NL 18 Neelesh WA NS A I NS A l NS A NL NS A NL 19 Kalappa WA NS B NL NS B F NS B NL NS B NL 20 Janardhan WA NS A NL NS A NL NS A FG NS A NL 21 Kariyappa WA NS A NL NS A NL NS A FG NS A NL 22 Raju G.K WA NS B NL 1P B NL NS B NL NS B NL 23 Jamaal Sab WA NS A I NS A I NS A I NS A NL 24 Eranna WA NS A NL NS A NL NS A NL NS A NL 25 Ranganath WA NS B NL NS B NL NS B NL NS B NL
Annexures
79
KEY TO MASTER CHART
1. IP.N – IN PATIENT ADMISSION NUMBER
2. AGE IN YEARS
3. SX- SEX
4. OC- OCCUPATION
SR- SERVICE AG- AGRICULTURIST
HW- HOUSEWIFE LB- LABOURER
ST- STUDENT BS- BUSINESSMAN
5. ETIOLOGY- ET
R- RTA
A- ASSUALT
6. TY- TYPE OF FRACTURE
A- ZYGOMATIC BODY FRACTURE
B- ZYGOMATIC ARCH FRACTURE
C- BOTH
7. DF- DURATION OF FRACTURE IN DAYS
8. SH- SUBCONJUNCTIVAL HEMORRHAGE
P- PRESENT
A- ABSENT
9. IP- INFRAORBITAL PARAESTHESIA
P- PRESENT
A- ABSENT
10. RM- RESTRICTED MANDIBULAR MOVEMENT
Annexures
80
P- PRESENT
A- ABSENT
11. SD- STEP DEFORMITY OVER THE FRACTURED FRAMENT
P- PRESENT
A- ABSENT
12. SF- SIDE OF THE FACE OF FRACTURE
R- RIGHT
L- LEFT
B- BILATERAL
12 SA- TYPE OF SURGICAL APPROACH USED
LI- COMBINATION OF LATERAL EYEBROW AND
INFRAORBITAL APPROACH
L- LATERAL EYEBROW APPROACH
I - INFRAORBITAL APPROACH
HI- COMBINATION OF HEMICORONAL AND INFRAORBITAL
APPROACH
LIB- COMBINATION OF LATERAL EYEBROW, INFRAORBITAL
AND MAXILLARY VESTIBULAR APPROACH
LB- COMBINATION OF LATERAL EYEBROW AND BUCCAL
SULCUS APPROACH
G- GILLIES TEMPORAL APPROACH
13. DS- DURATION OF SURGERY IN HOURS
Annexures
81
14. AP- ADDITIONAL PROCEDURES REQUIRED
Y- YES
N- NO
15. WH- WOUND HEALING
WA- WELL APPROXIMATION OF THE INCISION
IM- IMPROPER APPROXIMATION OF THE INCISION
16. FS- FUNCTIONAL STABILITY
NS- NOTHING SIGNIFICANT
RM- RESTRICTED MANDIBULAR MOVEMENTS
17. EA- ESTHETIC APPEARANCE
A- ACCEPTABLE
B- UNACCEPTABLE
18. CO- COMPLICATIONS
A- NO COMPLICATIONS
B- BURNING SENSATION IN EYES
C- PAIN IN EAR
D- DIPLOPIA
E- EPIPHORA
F- INFECTION
G- PLATE EXPOSURE
H- R- RESTRICTED MANDIBULAR MOVEMENTS
I- INFRAORBITAL PARESTHESIA
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