CLINICAL STUDY. Surgical Approaches and Fixation Patterns in Zygomatic Complex Fractures

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1 CLINICAL STUDY Surgical Approaches and Fixation Patterns in Zygomatic Complex Fractures Sergio Olate, MS, Sergio Monteiro Lima Jr, DDS, Renato Sawazaki, PhD, Roger Willian Fernandes Moreira, PhD, and Márcio de Moraes, PhD Abstract: The aim of this research was to analyze the surgical approaches and methods of rigid fixation used to treat zygomatic complex (ZC) fractures over a 10-year period. One hundred fiftythree patients who underwent surgery to treat ZC fractures between 1999 and 2008 were retrospectively evaluated. Demographic information, signs, and symptoms of the fractures, classification, surgical approaches, and methods of internal fixation were obtained from the medical records. The data were analyzed using statistical descriptive analysis and W 2 test (P G 0.05). The mean age of the sample was 31 years, and males were predominant (82.3%). In 60.1% of the patients, one surgical approach was used to treat the ZC fractures, whereas 2 surgical approaches were used in 24.8% of the patients. The zygomaticomaxillary buttress was fixed in 86.9% of the patients, followed by infraorbital rim fixation and zygomaticofrontal. There was a statistical significance between fracture displacement and surgical approach for the infraorbital rim (P G ) and zygomaticofrontal suture (P G ). Considering that adequate reduction and fixation should be performed and that we try to minimize the amount of scarring, the intraoral zygomaticomaxillary buttress approach is the first choice to treat ZC fractures. In cases of displacement bigger than 5 mm, approaches to 3 of 4 points of the ZC are mandatory to reduce the fractures. The infraorbital rim and zygomaticofrontal suture approaches are indicated to treat displaced fractures. Key Words: Zygomatic bone fracture, surgical approach, open reduction and rigid fixation (J Craniofac Surg 2010;21: 1213Y1217) Zygomatic complex (ZC) fractures are common maxillofacial injuries. Their prevalence is related to different conditions, and the surgical treatment with adequate reduction is a permanent challenge for surgeons. 1 Anatomically, the zygoma constitutes most of the lateral orbital wall and part of the orbital floor lateral to the infraorbital From the Division of Oral and Maxillofacial Surgery, Piracicaba Dental School, State University of Campinas, Brazil, and Division of Biomedical Research, Universidad Autónoma de Chile, Chile. Received February 20, 2010 Accepted for publication March 16, Address correspondence and reprint requests to Márcio de Moraes, PhD, Departamento de Diagnóstico Oral, Faculdade de Odontologia de Piracicaba, Avenida Limeira 901, Bairro Areião, Piracicaba, São Paulo, Brazil; mmoraes@fop.unicamp.br or solate@fop.unicamp.br The authors declared that no funding was received for this research. The authors report no conflicts of interest. Copyright * 2010 by Mutaz B. Habal, MD ISSN: DOI: /SCS.0b013e3181e1b2b7 groove. Therefore, a ZC fracture by definition is also an orbital floor fracture. 2 Because there are 4 suture lines, the fractures become separated from adjacent bones or near these suture lines. The complex facial anatomy suggests that reduction of the zygoma, orbital floor, and zygomatic arch are necessary to reestablish facial symmetry and position of the eye globe and ensure adequate movement of the mandible. 2,3 Historically, wire fixation of ZC fracture was used with unsatisfactory results because displacement of the fracture ends were expected and the reduction and fixation of small fragments could not always be achieved. 4,5 In the last decades, rigid internal fixation (RIF) altered these methods of treatment and miniplates became the standard in maxillofacial fractures treatment because of better stability of reduction and low complication rates. Miniplates are also easy to adapt and support tension and flexion movements of the bone structure. 6,7 Beccelli et al 6 showed immediate and firm stabilization of the osseous segments in the 3 planes in delaying treatment of the ZC fracture. On the other hand, the application of biodegradable material has gained acceptance in the management of maxillofacial trauma and has been indicated for fixation of ZC fractures because this region is a low load-bearing area. 8 In fact, the load related to ZC fracture is not associated to masseteric muscle, and only minor zygomatic muscles can submit some force in this bone. This muscle is related to facial expression with low force activity for fracture dislocation. For this reason, the anatomic position of the ZC fracture is principally related to a surgical procedure with proper reduction and stabilization of fracture. 9 Lacking that, an important volume of literature exists on the treatment of this injuries, but without consensus. Different kinds of treatments were used for ZC fracture 10 ; some researches show variations in auxiliary examinations for ZC fracture diagnoses and variations in treatment; these methods should be effective in the management of ZC fracture, considering each one of the individual case, age, sex, energy of trauma, functional and aesthetic considerations, complications, and others. Some of these variations are related to fracture exposition in 3-point and liberal fixation 11 or related exposition and fixation of 2 points for reduction and stabilization of fracture 12 and others with sequential surgical approach and fixation. 7 Almost all the articles are retrospective researches or experienced work; this type of research presents some deficiencies but can obtain some important data. The aim of this retrospective research was to present our surgical cases treated over a 10-year period and relate some surgical variables like RIF sequence and surgical approach. MATERIALS AND METHODS Data were collected from patients who attended at the Division of Oral and Maxillofacial Surgery of the State University of Campinas in Brazil from April 1, 1999, to December 31, Information was obtained retrospectively from clinical notes and surgical records from each patient using a standardized data collection form that was specifically developed to investigate the variables and features of ZC trauma. The data recorded included The Journal of Craniofacial Surgery & Volume 21, Number 4, July

2 Olate et al The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 TABLE 1. Distribution of the Etiology and Sex of 153 Patients With Surgical Treatment of ZC and/or ZA Fracture Etiology Sex Car Motorcycle Bike Pedestrian Motor Crash Work Sport Violence Fall Other Total Female V Male Total % patient sex, age, etiology, diagnosis, pattern of zygoma fracture, dislocation of fractures, associated facial and general trauma, methods of treatment, complications, status of dentition, and occupation;the patient had to submit to at least 3 months of postoperative follow-up. The exclusion criteria were charts that did not have complete information about the trauma, unacceptable postoperative reduction of fracture (evaluated with computed tomography), and postsurgical follow-up less than 3 months. The patients were divided in groups of 10 years according to their ages. The etiology of the zygoma fractures included car, motorcycle, bicycle, pedestrian motor vehicle crashes, work-related and sports-related problems, falls, individual violence, and others that did not fit any of the categories previously mentioned. Other facial fractures were classified as mandible fractures, condilar fractures, maxillary fractures, isolated nasal bone fractures, frontal fractures, nasal-orbital-ethmoid (NOE) complex fractures, and dentoalveolar fractures. General trauma was classified according to the anatomic location of the injury (cranium, neck, thorax, abdomen, upper limb, and lower limb). Occupation activities were divided into working active patients, students, and retirees. The sign and the symptoms of the patients were evaluated for pain, neurologic disturbance of the infraorbital nerve, facial asymmetry with evaluation of osseous dislocation, occlusion alteration, and diplopia. The ZC fractures were diagnosed as unilateral or bilateral. The zygomatic arch (ZA) fractures were diagnosed as isolated, associated to ZC fracture, or other maxillofacial fractures. Diagnosis and classifications of fractures were based on clinical characteristic (sign and symptoms) conventional radiographic study and computed tomographic examinations; infraorbital rim dislocation and lateral wall dislocation of ZC was evaluated with clinical analysis and computed tomography; there were classified in nondislocated and dislocated fractures. They were also classified in noncomminuted and comminuted fractures. A new computed tomography postoperatively was executed to assess the control of reduction. For the surgical treatment of ZC fractures, the type and the quantity of the surgical approach and the sequence of RIF were analyzed. Diagnosis and indications of surgical reduction and osteosynthesis was executed by the senior authors (M.M. and R.W.F.M.) and were related basically to dislocated fracture with facial asymmetry, functional alteration of vision and ocular movements, functional alteration of mandible movement and presence of other fractures of maxillofacial region. Data analysis involved a descriptive analysis for each variable. W 2 test was used to compare the counts of categorical response between 2 independent variables. The association between the variables had been considered significantly when the P G RESULTS One hundred fifty-three patients, 126 men (82.4%) and 27 (17.6%) women, with a mean age of 31 years (range, 11Y69 y), were diagnosed with ZC and/or ZA fracture. All the patients examined had undergone open reduction and internal rigid fixation with general anesthesia. Table 1 shows the distribution of patient sex and etiology of trauma. The ZC fracture was associated principally to the middle- and low-energy trauma (Table 1); 90.2% of the patients were working, 8.5% were students, and 1.3% were retired. Preoperative symptoms and signs of the patients can be observed in Table 2. Neurosensory disturbance of the infraorbital nerve was observed in 52%. Diplopia was present in 16 patients with TABLE 2. Distribution of Associated Sign and Symptoms of 153 Patients With Surgical Treatment of ZC/ZA Fractures Age Infraorbital Rim and Lateral Wall Dislocated Pain Other Symptoms Occlusion Modification Associated Body Trauma Diplopia Neurosensory Disturbance Y N T Y N T Y N T Y N T Y N T Y N T Y N T 11Y Y Y Y Y Y T % N indicates not; T, total; Y, yes * 2010 Mutaz B. Habal, MD

3 The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 Zygomatic Complex Fractures 10.4%. Alteration of occlusion was present in 25%; this symptom did not correlate with isolated ZC fracture and was obtained together with maxillary or mandible fracture. Dislocation of the infraorbital rim and the lateral wall of the ZC was observed in 33.3% of the samples. In the initial evaluation, almost 50% had experienced spontaneous pain. Other symptoms were edema and emphysema, and ecchymosis was observed in 71.2%. Other body traumas were present in 39.7% and 33.3% of the patients with ZC and/or ZA fracture who presented more than 1 facial fracture. Six patients (3.9%) presented only ZA fracture, and 17 cases (11.1%) were associated with ZA and ZC fractures. Nine patients (5.9%) presented with bilateral ZC fracture. For RIF status, 99 patients (64.7%) received 1 area of fixation, 39 (25.5%) received 2 areas of fixation, 13 (7.9%) received 3 points of fixation, and 2 were treated with 4 points of fixation (Table 3). When 1 point of fixation was used, 83 patients received zygomaticomaxillary buttress fixation (54.2% of the samples), 9 received exclusively infraorbital rim fixation (5.9%), 3 were with exclusive zygomaticofrontal suture fixation, and 3 were with AZ fixation. When 2-point fixations were used, 36 patients (23.5%) received zygomaticomaxillary buttress fixation and only 3 did not receive fixation on this pillar. When 3-point fixation was used, only 1 patient did not receive zygomaticomaxillary buttress fixation. Finally, for total RIF, zygomaticomaxillary buttress was fixed in 133 patients (86.9%), infraorbital rim in 42 (27.5%), and zygomaticofrontal suture in 39 (25.5%). For orbital analysis, 29.6% of the patients required orbital floor reconstruction and were treated with osseous graft stabilized with screw and plates, moldable titanium mesh, or other alloplastic materials. When statistical association was analyzed for area of fixation needed, dislocated fracture was associated with more than 1 area of fixation, and the zygomaticofrontal and infraorbital rim approaches have a significant relation with more than 1 area of fixation (P G 0.05; Table 4). One surgical approach was necessary in 85 patients (55.5%), 2 surgical approaches for 24.8%, and 3 surgical approaches for 19.7%; the zygomaticomaxillary surgical approach was used in 140 patients (91.5%); the infraorbital rim approach, in 55 (35.9%); the zygomaticofrontal approach, in 45 (25.4%); the coronal approach, in 7 for ZA fracture, NOE fracture, and zygomaticofrontal fracture. Considering this approach, the zygomaticofrontal area was submitted to open reduction in 33.9% of the patients, similar to the infraorbital rim area. Finally, ZA approach with coronal (7 cases) or Gillies approach (two cases) were used in 9 patients. Postoperatively, a new computed tomography was executed to control reduction and showed acceptable reduction in all of the patients. A minimum of 3 months follow-up was used in this research. Five patients presented postsurgical infection related to the surgical procedure, the fixation system, the dehiscence of suture, unsuccessful fixation related to lack of stability, and nonunion fracture. TABLE 3. Distribution of Surgical Approach and RIF Used in 153 Patients Submitted to Surgical Treatment of ZC Fracture Surgical Approach No. RIFs T % 1 85 V V V V V T % TABLE 4. Distribution of Surgical and Nonsurgical Variables Associated to More Than 1 Site of RIF in 153 Patients With ZC and ZA Fracture Treatment Variable More Than 1 Site of RIF Isolated ZC fracture Comminuted ZC fracture Clinical and radiographic fracture displacement Frontozygomatic area approach G Infraorbital approach G Zygomaticomaxillary buttress approach P G 0.05 is statistically significant. Italics indicate statistically significant values or close to the value statistically significant. In 4 patients, the treatment was a second surgery with fixation removal and new osteosynthesis. Neurosensory after surgical complication was observed in 15 patients with partial anesthesia of the infraorbital nerve. Ectropion of the lower eyelid was observed in 6 patients being treated within the first week after the initial surgical treatment. One patient presented with eyelid ptosis associated to comminute ZC fracture, being later treated in the division of ophthalmologic plastic surgery. Three patients presented postsurgical enophthalmos associated to extensive orbital reconstruction, and 1 patient presented postsurgical epiphora related to comminute NOE and maxillary fractures. DISCUSSION Like other retrospective research, this paper has several recognizable problems: no standardized treatment plan, no homogenization of trauma or patient, and no standard follow-up. However, valorous information can be obtained and could be used for surgical practice. The patient with acceptable postoperative reduction of ZC fracture were analyzed because the objective of this research was to relate the pattern of fixation and approach in patients with acceptable postoperative result; unacceptable reduction was a variable not included in this research. Postoperative evaluation of reduction was assessed by computed tomography and analyzed by the senior authors (MM and RWFM). The condition between the sex and the age of our sample is in agreement with other maxillofacial trauma reports. 1,6,13 In our study group, a nonpediatric patient was submitted to surgical treatment and most of the patients presented between 20 and 40 years old. The most important principle in treating fractures is proper reduction; if their position is not correct, stabilization is weak. Treatment of these patients did not involve the use of the 3-point visualization and liberal fixation proposed by Karlan and Cassini 14 or Makowski and Van Sickles. 11 For another one, Ellis and Kittidumkerng 7 presented a well-developed algorithm where the kind of trauma and sequential surgical approach and fixation could be evaluated, initiating on zygomaticomaxillary buttress, lateral orbit, and infraorbital rim. Our results show a sequential surgical approach related to stability of reduction; the approach used more often was the use of the zygomaticomaxillary buttress. This is a simple and rapid approach and provides valuable information related to reduction of fracture. 11 The infraorbital rim approach was present in a second place; and the zygomaticofrontal area, in the third place, but with a little difference (2%). Lee et al 12 evaluated 53 patients without comminuted ZC fractures treated with transconjunctival and lateral canthal incisions; * 2010 Mutaz B. Habal, MD 1215

4 Olate et al The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 in this sequence, if reduction of the zygoma was incomplete or unsatisfactory, an additional small incision in the gingivobuccal area was made. The authors of this research does not prefer this surgical approach because Markowitz and Manson 15 showed that the zygomaticofrontal area is not a good reference reduction and that this area can be helped with a second or maybe third area of evaluation. For another one, an infraorbital rimlike first approach of choice is a good reference reduction like the zygomaticomaxillary buttress. In this situation, the intraoral approach could present the same quality of reduction with less anatomic and surgical complications. Kovács and Gharemani 16 treated 52 patients with ZC fracture initially by the zygomaticofrontal area. When stability was not achieved, the intraoral approach was executed. In this research, displacement of the zygoma was not evaluated and subjective assessment of the patients asymmetry was self-performed. For these authors, the minimal surgical approach is associated to diminished multiple surgical approaches, consequent potential infections, additional scars, and nerve palsy. In our sample, multiple surgical approaches have been used when stability of reduction is not obtained. Infection was observed in 3.1% of the samples and was favorably resolved with a new surgery and antibiotic medication. In our opinion, if the objective is to reduce the chance of scarring, the more efficient approach is the intraoral technique and not a lateral eyebrow incision. Manson et al 17,18 showed that the paradox of the zygomaticofrontal suture is having the best bone for fixation but the worst single-alignment guide. They show that the zygomaticomaxillary buttress is a good place for zygoma alignment. After them, the infraorbital rim and the lateral wall of the orbit can be used for the same objective. It is clear that in the fixation procedure, the best place is obtained in the zygomaticofrontal suture, the zygomaticomaxillary buttress, the zygomatic arch, and the infraorbital rim. 17,18 In the surgical treatment of the ZC fracture, some imprecision in reduction may be tolerable and clinically insignificant, depending on the magnitude, the location, and the soft tissue and skin on the fracture. 7 In our sample, aesthetic demand was observed after surgery in 2 panfacial fracture cases. In these cases, the extensive fracture of the middle third and lower third of the face was difficult to treat with adequate reduction and fixation of fractures. Osseous displacement with clinical facial asymmetry was observed in 52 cases (33%); however, none of the patients presented with aesthetic subjective complications for the first clinical evaluation. Before the introduction of the RIF, the surgical technique chosen for the ZC fractures was reduction and repositioning of the zygomatic bone with wire, both for functional and aesthetic problems. For these cases, aesthetic recovery was almost always uncompleted; synthesis with wire did not stabilize the gap between the bone ends. Enophthalmos, asymmetry, and lack of anterioposterior projection were frequent complications. 15 In this situation, Zingg et al 1 related that a single miniplate may be adequate to preserve the reduction in the correct form. Champy et al 19 who used a single plate at a zygomaticofrontal suture showed that only 1.8% had an unsatisfactory result in isolated ZC fracture. In the same direction, Choung and Kaban 20 showed that rotational tendency after reduction necessitates at least 1 point of fixation, usually at the zygomaticofrontal suture, and in the study of Zachariades et al, 21 only in certain cases was the RIF used in the zygomaticomaxillary buttress, with a fixation protocol in the lateral and infraorbital rim. A basic question for these results is whether it is possible to find the same result for one miniplate fixation in the zygomaticomaxillary area, considering that this point is a good reduction area. Although we know that generally, the zygomaticomaxillary pillar is a more comminuted fracture, the authors believe that this 1216 pillar is a basic point for surgical treatment of ZC fracture. 17 Our opinion is in agreement with that of Ellis and Kittidumkerng, 7 and our results show the same tendency. In 64% of the cases, 1-point fixation was used, and 85 cases (55.5%) required only 1 surgical approach. In 7 cases, 2 surgical approaches were used; and in another 7, 3 surgical approaches were used. This approach without fixation was used only for confirmation of anatomic reduction, and it might not be necessary for that purpose. Zingg et al 1 described that fixation of the zygomaticomaxillary buttress may be indicated to give the proper anterior projection of the ZC in cases of unstable or complex ZC fracture. Lacking that, an extensive number of plate in the facial skeleton should be limited to areas of load bearing, such as the zygomaticomaxillary pillar. The results of Zingg et al 1 and Markowitz and Manson 15 showed that the greater wing of the sphenoid is a key area in determining the final result. Undetected axial rotation of the zygoma at the greater wing of the sphenoid is often the culprit in an unsatisfactory outcome. For our sample, only 2 patients presented RIF in this suture area. They presented a panfacial fracture with multiple approaches for NOE, ZC, maxilla, and mandible fractures. Eighty-three patients presented isolated ZC fractures. In 14 patients, ZC and ipsilateral ZA fractures were observed. Three patients presented with ZC, ZA, and other facial fractures, and the final 53 patients presented with ZC fracture with other facial fractures without ZA fracture. When analyzed with the W 2 test, the relation of some variables to more than 1 RIF and the dislocated fracture was observed to be statistically significant. The overall results are in agreement with other descriptive researches that show that the existence of a rotation or a change of the normal position of ZC indicates reduction and stabilization with more than 1 miniplate. 7 For surgical procedure, in our sample, zygomaticofrontal suture and infraorbital rim approach have a strong association with the presence of more than 1 fixation area. This situation shows that the zygomaticomaxillary buttress is an important local appropriation for initial stabilization. The fixation of this pillar was used more often than that in other areas. REFERENCES 1. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg 1992;50:778Y Wang S, Xiao J, Liu L, et al. Orbital floor reconstruction: a retrospective study of 21 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:324Y He D, Blomquist PH, Ellis E 3rd. Association between ocular injuries and internal orbital fractures. J Oral Maxillofac Surg 2007;65:713Y Lund K. Fractures of the zygoma: a follow-up study on 62 patients. J Oral Surg 1971;29:557Y Pozatek ZW, Kaban LB, Guralnick WC. Fractures of the zygomatic complex: an evaluation of surgical management with special emphasis on the eyebrow approach. J Oral Surg 1973;31:141Y Beccelli R, Carboni A, Cerulli G, et al. 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