Fixation Points in the Treatment of Traumatic Zygomaticomaxillary Complex Fractures: A Systematic Review and Meta-Analysis

Evaluation of Different Patterns of Zygomaticoorbital Complex Fractures

Study Design

Very few studies exist regarding the fracture pattern variability of the zygomaticoorbital (ZMO) complex. The retrospective evaluation of a large series of surgically treated unilateral ZMO fractures would in certain circumstances help intraoperative predictability and define sensitive indicators for open reduction and internal fixation.

Objective

The aim of this study was to investigate the different fracture patterns after ZMO complex injury regarding the 5 anatomic sutures of the zygoma as well as the concomitance of the paranasal buttress and maxillary sinus wall fracture.

Methods

The medical records of all patients with unilateral ZMO fractures who underwent surgical intervention in a single trauma center department between April 2015 and June 2020 were retrospectively reviewed. Demographic and anamnesis data, radiologic findings, and surgical reports were evaluated. According to the preoperative radiologic evaluation, ZMO fractures were classified as unisutural, bisutural, trisutural, tetrasutural, and complete based on the number of zygomatic sutures. The prevalence of various fracture patterns was analyzed. The impact of patient's age and trauma etiology on the fracture pattern was evaluated using descriptive statistical analysis.

Results

The study included 492 patients with unilateral ZMO fractures, with a mean age of 49.93 years (SD = 20.66) and a male:female ratio of 2.23:1. The most affected age group was 19-44 years (41.67%) and tripping falls were the most common etiology (27.24%). Trisutural (57.32%) and unisutural fractures (23.17%) were the most common, followed by tetrasutural (8.94%), bisutural (8.54%), and complete fractures (2.03%). A trisutural fracture involving the zygomaticomaxillary suture, the infraorbital rim, and the zygomaticosphenoidal suture was the most common fracture pattern (52.03%). Most fractures were observed in the zygomaticosphenoidal suture (86.99%), followed by the infraorbital rim (74.59%) and the zygomaticomaxillary suture (68.29%). Fractures of the maxillary sinus wall and the paranasal buttress co-existed in 9.55% and 31.30% of all cases, respectively. No correlation was detected between age and fracture pattern (P = .4111). Tripping falls and bicycle accidents significantly influenced the fracture pattern (P < .0001).

Conclusions

According to the results, knowledge of the fracture pattern variability of the ZMO complex could in certain circumstances designate CT or CBCT as mandatory before operating on ZMO fractures. Consequently, unnecessary incisions could be avoided. The high concomitance of paranasal buttress fracture also suggests its intraoperative surgical exploration. Further studies should correlate the clinical findings with indication for surgery and postoperative outcome for the different fracture patterns described.

Transmalar Kirshner Wire Fixation Under Ultrasound Scanning is Useful for Unstable Zygomatic Arch Fracture Combined With Zygomatic Body Fracture

Plate fixation to zygomatic arch fractures carries the risk of facial nerve palsy and scarring of the cheek; however, without plate fixation, bone deviation or displacement may reoccur after surgery. Furthermore, zygomatic arch fractures combined with zygomatic body fractures are more postoperatively unstable than single zygomatic arch fractures. Few reports have focused on this combined fracture type, and no consensus has been reached regarding treatment. Because plate fixation for slight deviation of the zygomatic body has little advantage for stabilization, the authors, usually opt for transmalar pinning alone instead of plate fixation at the hospital. This study is a retrospective case series of 7 patients, among 100 zygomatic fractures excluding isolated zygomatic arch fractures, treated using transmalar pinning under ultrasound scanning. The reduction was performed through the oral and temporal incision as a surgical procedure. Under ultrasound observation, a Kirshner wire was inserted into the zygomatic body from the unaffected side while maintaining the reduced position. The wire was removed at an outpatient visit 2 to 3 months following surgery. In all cases, the zygomatic body was of the laterally rotated type, and postoperative morphologic evaluation showed improvement without postoperative complications. Scores were higher in middle-aged and older than in young people. Correction of zygomatic rotation also scored higher than zygomatic arch morphology. Transmalar Kirshner wire fixation under ultrasound observation is a simple and minimally invasive method for zygomatic arch fractures, which avoids the possible complications related to plate fixation.

Modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex fractures: A 5-year retrospective study

Our study aimed to evaluate modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex (ZMC) fractures. The retrospective non-randomized study was conducted in a single hospital in China. All patients diagnosed with unilateral comminuted ZMC fractures between January 1, 2018 and December 31, 2022 were retrospectively reviewed. All patients underwent preoperative spiral computed tomography (CT). CT data were processed using software to DICOM format and transferred to Proplan CMF3.0 for preoperative virtual surgical planning and postoperative evaluation. All data were extracted from standardized electronic medical records. All statistical analyses were performed using SPSS version 20.0. The chi-square test and t-test were used for statistical analyses. The 54 included patients were divided into two comparable, equal cohorts of 27 patients, and followed up for at least 6 months. Fracture reduction was assisted using the modified patient-specific surgical guides in the guide group (23 males, four females; mean age 37.74 ± 12.07 years) and without the modified patient-specific surgical guides in the control group (20 males, seven females; mean age 37.44 ± 13.58 years). In the guide group, the mean eminence deviation between the affected and unaffected sides was 1.01 ± 0.92 mm, and the mean width deviation between the affected and unaffected sides was 1.29 ± 1.32 mm. In the control group, the mean eminence deviation between the affected and unaffected sides was 1.99 ± 1.69 mm, and the mean width deviation between the affected and unaffected sides was 2.68 ± 2.01 mm. The differences in facial protrusion (p = 0.001) and width (p = 0.003) symmetry between the affected and healthy sides of the two groups were statistically significant (p < 0.05). In conclusion, applying the modified patient-specific surgical guides to unilateral comminuted zygomaticomaxillary complex fracture reduction has the advantages of greater predictability and effectiveness, and improved bilateral ZMC symmetry. It should be noted that this approach would be especially beneficial for less-experienced surgeons.

The performance tests of three-dimensional printing titanium alloy craniomaxillofacial bone plate: A preliminary preclinical study

Background/purpose

Because of the complex anatomical structure of the maxillofacial skeleton, bending plates is necessary during surgery. The fast developing three-dimensional printing (3DP) technology has provided a new method for making personalized craniomaxillofacial bone plates. However, the properties of these bone plates remain unknown. This study evaluates the mechanical, fatigue, and morphological properties of these bone plates, which may provide data supporting future clinical applications.

Materials and methods

The 3DP bone plate was fabricated by selective laser melting (SLM) and electron beam melting (EBM) technologies. Mechanical, surface, and defect analyses were performed to compare their properties with a standard machined sample. One-way analysis of variance was applied, with p < 0.05 considered significant.

Results

The 3DP craniomaxillofacial bone plate had better bending strength than that of the standard machined plate (p < 0.01). Whereas the fatigue resistance of the 3DP bone plate needs to be improved in the future. Surface analysis indicated greater roughness of the 3DP bone plate (p < 0.01). However, the surface roughness could be significantly reduced by polishing the surface, which would meet the needs of clinical application after polishing. Further defect analysis revealed the internal defect inside the plate, which should be avoided to improve the mechanical strength of the printed sample in the future.

Conclusion

The 3DP titanium craniomaxillofacial bone plate has good mechanical performance and surface morphology, meeting the requirements of clinical application. However, poorer fatigue resistance and a high number of internal defects should be modified in the future.

Meta-analysis of the Major Clinical Results of the Treatment with 1-Point Fixation in Fractures in the Zygomatic-Maxillary Complex: Success Rate and Complications

Introduction

Fractures of the zygomatic-maxillary complex (ZMC) are common facial fractures. After adequate fracture reduction, it is important to maintain stability and rigid fixation to avoid functional impairment and aesthetic sequelae. In this sense, the fixation of just one point can provide sufficient stability of the ZMC fracture when the ZMC fracture is not crushed.

Objective

To analyze the success rates of fracture stability of the ZMC, incidences of complications, and aesthetic satisfaction after 1-point fixation.

Methods

This study followed the rules of PRISMA, with publications from 2010 to 2020. The chi-square test and the Poisson probability test were performed to the occurrence of complications Low = 1, Moderate = 2, and NO = 0, adopting the α-level less than 0.05 with a statistical difference for 95% CI. The R-sq (R 2) value was also analyzed among the complications variables.

Results

The results of these studies showed in a general way that the use of 1-point fixation with open reduction presented good results in the short, medium, and long term, showing fracture stability. Complication rates were low and patients' satisfaction with aesthetics was considerable.

Conclusion

The success rate of the 1-point fixation procedure for the zygomatic-maxillary complex is high, with minimal complications.

Evaluation of the Properties of 3D-Printed Ti Alloy Plates: In Vivo and In Vitro Comparative Experimental Study

Titanium (Ti)-based implants play a significant role in rigid internal fixation in maxillofacial surgery. No study has reported that three-dimensional-printed Ti alloy plates (3D-Ti plates) have comprehensively excellent properties similar to standard plates (Matrix-MANDIBLE, SYNTHES, Switzerland) (Synthes-Ti plates). In this work, we manufactured 3D-Ti plates by selective laser melting with Ti6Al4V powder. The surface morphology, mechanical properties, and bone-plate contact rate of the 3D-Ti plates and the Synthes-Ti plates were characterized and compared via electron microscopy, atomic force microscopy, Vickers hardness test, three-point bending test, and software calculation. Human bone marrow stromal cells (HBMSCs) were cultured on the plates to test their biocompatibility. Importantly, the 3D-Ti plates were placed into a mandibular fracture model to assess the effect of medical application for 4 and 24 weeks. The 3D-Ti plates were demonstrated to have similar biocompatibility and stability for rigid internal fixation with the Synthes-Ti plates, lower roughness (106.44 ± 78.35 nm), better mechanical strength (370.78 ± 1.25 HV10), and a higher bone-plate contact rate (96.9%). These promising results indicate the feasibility of using 3D-Ti plates for irregular shapes and complex anatomical structures in a clinical context.

Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study

BACKGROUND

Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes.

METHODS

An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant.

RESULTS

Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05).

CONCLUSIONS

Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Evaluation of Zygomaticosphenoidal Angle in Patients With Unilateral Zygomaticomaxillary Complex Fracture

ABSTRACT

This study aimed to assess the zygomaticosphenoidal (ZS) angle in patients with reducted unilateral zygomatico-maxillary complex (ZMC) fracture and compare it with the normal control group. This study was performed on CT images of 60 cases and 60 controls with a mean age of 35.1 ± 14.6. The ZS angle was measured on axial images containing the equator of the eyeball. Moreover, the mean absolute difference value and asymmetry index were calculated. Chi-square test, independent-sample t test, 1-way ANOVA, paired-sample t test, and ROC curve analysis were applied. The mean ZS angle in the control group was 46.6° ± 3.5°. Considering laterality, the mean of ZS was not significant in the control group. However, after reduction of unilateral ZMC fracture, there was a significant difference between the mean ZS angle in right and left sides. The mean absolute difference between right and left ZS angles was significantly higher in the case group. A threshold number of 0.9° is established in the mean absolute difference value which is the difference between the right and left ZS angles in an individual for detecting asymmetry. The ZS angle can be a useful anatomical aid to guide surgeons in achieving facial symmetry in ZMC fractures.

Zygomaticomaxillary Fractures

Fractures of the zygomaticomaxillary complex and zygomatic arch are common athletic injuries. Fracture displacement can lead to midfacial retrusion and widening, causing noticeable deformity. Associated signs and symptoms include hypoesthesia of the infraorbital nerve distribution, trismus, and subjective malocclusion. Operative treatment is indicated in cases of significant displacement or functional disturbance. The approach and details of osteosynthesis are catered to the specific characteristics of the fracture. Technology, such as virtual surgical planning, intraoperative navigation, and intraoperative imaging, has the potential to improve accuracy of treating challenging fractures.

Biomechanical Impact of a Zygoma Complex Fracture Using Human Cadaver

ABSTRACT

Zygomaticomaxillary complex fractures are common in midface trauma, with treatment often involving repair using titanium mini plates. However, the need for plate fixation along the zygomaticomaxillary suture on the infraorbital rim remains controversial. This study utilized a previously reported bite force simulator to investigate craniofacial strain patterns following zygomaticomaxillary complex fracture repairs with and without plating of the infraorbital rim. Osteotomies were made to 6 fresh-frozen cadaveric heads to simulate 2 types of zygomatic complex fractures: a dipod fracture with osteotomies at the zygomaticofrontal and zygomaticomaxillary sutures, and a tripod fracture with an additional osteotomies at the zygomaticotemporal suture. Repairs with and without the use of a titanium mini plate across the infraorbital rim were compared in both dipod and tripod fractures. Physiologically proportional masticatory loads were applied using the bite force simulator by actuating intrinsic muscle lines of action. The outcome metric was facial bone strains measured using uniaxial strain gauges. Mixed-effects linear models did not find a significant main effect on the overall strain pattern with the use of an infraorbital rim plate in both dipod (P = 0.198) and tripod (P = 0.117) fracture repairs. However, statistically significant differences were found locally at the zygomatic buttress (P = 0.019) and the zygomatic arch (P = 0.027) on the fractured side in dipod fractures. This is the first known study that successfully utilized a mechanical simulator to reproduce physiological intrinsic masticatory loads in a fracture fixation study. This new technology opens avenues for future biomechanical investigations on maxillofacial fracture repairs and other surgical treatments.

Evaluation of 3 and 2-point internal fixation in the management of zygomaticomaxillary complex fractures: Case report

Introduction

The ZMC has a prominent shape compared to other parts in the midfacial region, thus small injuries will generate fractures in the ZMC. The management of ZMC fracture depends on the fracture deformity and the surgeon's considerations. Various studies have revealed the success of ZMC reconstruction with one fixation point to 4 fixation points fitting to the tetrapod shape.

Case report

We report two cases of ZMC fractures which comparing the efficacy of 3- and 2-point internal fixations for improving clinical outcomes The first patient underwent ORIF which placed at 2 fixation points, the first point in the left ZF suture and the second point in the left ZMB. The second patient underwent ORIF reconstruction at 3 fixation points, the first point in the right inferior orbital rim, the second point in the right ZF suture, and the third point in the right ZMB.

Discussion

The most common surgical approach for ZMC fractures is through a gingivobuccal groin incision. This approach is for body exposure of the ZMB, which is the main buttress. The 3-point internal fixation improved the postoperative clinical outcome of fracture fragment stability compared to two-point fixation, but the mean malar height projection, vertical dystopia, and enophthalmos were not different between the two fixation methods.

Conclusion

Three-point internal fixation can improve the clinical outcome of fracture fragment stability compared to 2-point fixation; however, it has a mean operative duration 22.2 minutes longer than 2-point fixation, so its application must be considered during the COVID-19 pandemic.

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The incidence of ZMC fracture is reported to be 13%–40% of all facial fractures.

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Improper reduction of ZMC fracture can cause facial asymmetry and malposition.

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3-point internal fixation improved the postoperative fracture fragment stability.

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3-point internal fixation has a mean operative duration 22.2 minutes longer than the 2-point.

Comparison of the Biomechanical Stiffness of Titanium and Sonic Weld RX Osteofixation Systems for Monoblock Zygomaticomaxillary Complex Fractures

ABSTRACT

Resorbable osteosynthesis systems are widely used for the fixation of zygomaticomaxillary complex (ZMC) fractures instead of titanium systems, because they do not have postoperative hardware-related complications. However, the strength of conventional resorbable systems is inferior to that of titanium systems. Recently, ultrasound-aided resorbable osteosynthesis systems, which have higher fixation than conventional resorbable osteosynthesis systems, have become available.The purpose of this study was to compare the mechanical stiffness of the ultrasound-aided resorbable and titanium osteosynthesis systems in a cadaveric monoblock ZMC fracture model. Three human cadaveric monoblock ZMC fracture models (6 zygomas) were created. The fixation materials included the titanium (Level One Fixation; KLS Martin, Germany) and ultrasound-aided resorbable osteofixation systems (SonicWeld RX; KLS Martin). The fixation methods included the 3-point (zygomaticofrontal [ZF], zygomaticomaxillary buttress, and inferior orbital rim [Group I]) and the 2-point (ZF + inferior orbital rim [Group IIa] and ZF + zygomaticomaxillary buttress [Group IIb]) fixations. Each fixation model was mechanically tested with a load of up to 100 N, based on the previously reported postoperative masseter muscle strength, and the stiffness was calculated. Titanium was found to be stiffer than SonicWeld RX, though not significantly different. The fixation points in decreasing order of stiffness were Group I, Group IIa, and Group IIb, though the differences were not significant. In conclusion, the 2-point fixation, including the ZF fixation with SonicWeld RX, can be used as an alternative to the 3-point titanium fixation, which is considered to be stronger and stiffer.

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations

BACKGROUND

Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients.

METHODS

This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures.

RESULTS

Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients.

CONCLUSIONS

High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Unilateral Zygomatic Complex Fracture - A Comparison Between non Surgical Treatment and Surgical Treatment

BACKGROUND

Medical advances have enabled zygomatic complex (ZMC) fractures to be treated by various approaches. This study aim to analyse the demographics and treatment outcomes of unilateral ZMC fractures, treated non-surgically or surgically.

METHODS

This 5 year non-randomized prospective study had included 65 cases of unilateral ZMC fractures from October 2014 until December 2019. Patients were treated and divided into non-surgical and surgically treated group. Treatment outcomes in terms of step deformities, malar depression, diplopia, infraorbital hypoaesthesia and mouth opening were evaluated up to 6 months post trauma/intervention.

RESULTS

Road traffic accident (96.9%) was the main cause, with predominant male involvement (80%) and median age of 28 years. Significant improvements (p<0.05) were observed for step deformities and malar depression among the surgically treated group at postoperative day 1 and week 1. Throughout the 6 months review, infraorbital hypoesthesia and diplopia showed no significant differences between both groups, (p>0.05). Besides, all patients showed significant mouth opening improvement (p < 0.05) over 6 months period.

CONCLUSION

We found that infraorbital hypoaesthesia and limited of mouth opening should not be the absolute indications for surgical treatment of ZMC fractures. Non-surgical treatment that included early jaw exercise and symptomatic treatment had potential value for satisfactory functional gain.

Two-point versus three-point fixation in the management of zygomaticomaxillary complex fractures: A comparative study

Introduction:

The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore, zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements that require a protocol for management and long-term follow-up. The objectives of this study were to compare the efficacy of zygomatic bone after treatment with open reduction internal fixation (ORIF) using two-point fixation and ORIF using three-point fixation and compare the outcome of two procedures.

Materials and Methods:

Twenty patients were randomly divided equally into two groups. In Group A, ten patients were treated by ORIF using two-point fixation by miniplates and in Group B, ten patients were treated by ORIF using three-point fixation by miniplates. They were evaluated with their advantages and disadvantages and the difference between the two groups was observed.

Results:

We found that postoperative facial and neurological complications are minimum in two-point fixation group. Based on this study, open reduction and internal fixation using two-point fixation by miniplates is sufficient and the best available treatment of choice for the management of zygomaticomaxillary complex fractures.

Discussion:

Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Two-point interosseous fixation at the “buttress” fracture and the frontozygomatic (FZ) fracture is suitable for routine surgery. The results of these studies confirm with the present study that two-point fixation provided better stability in patients with clinical and radiological evidence of fracture in FZ and zygomaticomaxillary buttress area.