One thousand maxillo-facial and related fractures at the ENT-clinic in Gothenburg. A two-year prospective study

Neurosensory Assessment of Infraorbital Nerve Injury Following Unilateral Zygomaticomaxillary Complex Fracture – A Prospective Study

Background:

This study aimed to assess the difference in the recovery pattern of branches of infraorbital nerve paraesthesia after zygomaticomaxillary complex (ZMC) fracture in both surgically and non-surgically managed patients.

Materials & Methods:

A prospective, observational study involving 31 patients with unilateral ZMC fracture - 15 in the surgical group (Group A) and 16 in the non-surgical group (Group B) was evaluated. These patients were assessed at the time of injury, 3-months follow-up, and 6-months follow-up for the sensory function of the infraorbital nerve. The assessment of paraesthesia by cotton wisp test, light touch monofilament test, and the cold thermal test was subjected to intra-group and inter-group correlation by McNemar test and Fischer's exact test. Repeated Measures ANOVA with post-hoc Bonferroni test for intra-group correlation and independent sample t-test for inter-group correlation were used for two-point discrimination.

Results:

A statistically significant improvement was noted on both 3 and 6 months follow-up in the malar region in group A. Other statistically significant improvements were noted only on 6 months follow-up in the infraorbital region in group A. On the 2-point discrimination test, all the facial regions showed significant improvement in both the groups over 3 months and 6 months of follow-up.

Conclusion:

There was a significant improvement in the infraorbital nerve sensory function following ZMC fracture over 6 months; however, the surgical intervention showed no statistical significance. Further, it can also be concluded that the inferior palpebral branch of the infraorbital nerve shows maximum functional disruption resulting in a higher incidence of paraesthesia in the infraorbital and malar region.

Effect of Alcohol Intake on the Radiographic Quality in Patients with Midfacial Trauma

The initial reports on radiologic examinations in 618 consecutive patients with midfacial injuries were compared with the final clinical diagnoses. Alcohol had to some degree been imbibed by 31 per cent of the patients. Influence of alcohol was 3 times more common outside than within office hours. Radiographic analysis included estimation of blurring, errors in straightness, angulation, beam centering and limitation. Image quality was scored as visibility of ‘the imaginary lines of bony continuity’. There was no statistically significant correlation between the degree of inebriety and image quality or diagnostic performance with the radiographic technique used, with the patient supine. There is no need to postpone midfacial radiography in inebriate patients.

Trancutaneous Versus Intraoral Approach to Isolated Zygomatic Arch Fractures: A Comparison of Two Techniques

Zygomatic arch fractures are caused by a vector force orthogonal to the bone segment that causes the collapse of the arch through depression of the bone fragments. Reduction of isolated zygomatic arch fractures are usually only of esthetic interest, with the exception of those cases where the fracture causes an impingement with the underlying mandibular coronoid process, causing limitation of mandibular movements. Reduction is usually performed with an extraoral approach, more rarely through a transoral approach. In this article, authors compare the traditional transcutaneous technique with the intraoral approach in 2 groups for a total number of 42 patients.For what concerns the correct alignment of the fragments, the 2 techniques have shown being equivalent. Although the intraoral approach has shown being a faster surgical procedure leaving no visible incision, allowing faster recovering and reduced postoperative pain.

Clinical Evaluation of Neurosensory Changes in the Infraorbital Nerve Following Surgical Management of Zygomatico-Maxillary Complex Fractures

INTRODUCTION

Zygomatico-orbital fractures are the second most common facial injuries. Trauma to mid-facial region can lead to an alteration or loss of sensation in the facial region which sometimes requires early surgical intervention to aid in an early recovery.

AIM

To evaluate the different neurosensory changes in the infraorbital nerve function following common treatment modalities used in the management of zygomatico-maxillary complex fractures.

MATERIALS AND METHODS

Thirteen patients selected for the study had unilateral zygomatic complex fracture with altered sensation in the region of distribution of the infraorbital nerve. The fractures were managed either by reduction followed by internal fixation with mini-plates (Group A), reduction alone (Group B) or conservatively (Group C). Infraorbital nerve function tests were done by mechanical, heat and pain threshold detection. Evaluation was done on 1(st), 3(rd), 7(th) day, one month, three months and six months interval in a manner similar to that done at the beginning of the study (Day0).

RESULTS

A male predominance with male:female ratio of 5.5:1 and an age range of 21 to 50 years was found with the right side mostly affected. Road traffic accident was the most common aetiology. Most common clinical presentations were sub-conjunctival haemorrhage (84.61%), flattening of the malar prominence (69.23%) with deficit in neurosensory function of infra orbital nerve. Recovery in the infraorbital nerve function was relatively complete in 76.92% cases with partial recovery in 23.07% of the patients.

CONCLUSION

Marked improvement in the neurosensory function of the infraorbital nerve was found when some form of treatment either in the form of Open Reduction and Internal Fixation (ORIF) or approach through Gillie's temporal or Keen's intraoral approach were applied as compared to when conservative treatment was provided. In zygomatic complex fractures, any form of treatment employed brought about decompression of the infraorbital nerve which aided in the recovery of the nerve within a span of 1-6 months, except when no treatment was applied.

Painful posttraumatic trigeminal neuropathy: a case report of relief with topiramate

A case of chronic neuropathic pain in the infraorbital region following an untreated displaced zygomatic fracture is presented. The case responded favorably to topiramate and sensory testing revealed signs of nerve damage that remained unchanged over the follow-up period (six months) parallel to an analgesic effect. The clinical pharmacology of topiramate, which is reviewed, includes enhanced neuronal stability and neuroprotection, making it a possible candidate in the treatment of painful orofacial neuropathies.

Facial fractures: a 1-year retrospective study in a hospital in Belo Horizonte

A retrospective study was performed to assess facial fractures in patients treated at a public hospital in Belo Horizonte, in 2000. The data collected included age, gender, etiology, distribution of maxillofacial trauma considering day of the week and month, anatomic site of the fracture, and treatment. The analyses involved descriptive statistics and chi-squared test, Bonferroni test and analysis of variance. A total of 1,326 facial fractures were found in 911 patients. Most fractures occurred in adults with age ranging from 21 to 30 years. Men were more affected than women, with a male-female ratio of 4.69:1. Accidents causing facial fractures occurred predominantly on weekends. Bicycle and motorcycle accidents were the major cause of trauma, followed by interpersonal violence, automobile accidents, and falls. When the relation between the gender and the etiology of facial fractures was analyzed, a significant relation was noted between these variables (p < 0.001). There was also a relation between the patients' age and the site of the fractures (p = 0.0014). The mandible was found to be the most commonly fractured bone in the facial skeleton, followed by the zygomatic complex and the nose. A non-surgical approach was chosen in most cases. There were significant differences between the kind of treatment applied and the site of the fracture (p < 0.001).

Neurosensory changes in the infraorbital nerve following zygomatic fractures

OBJECTIVE

To document the neurosensory changes in the infraorbital nerve following zygomatic fractures managed in various ways.

STUDY DESIGN

Twenty-five patients were included in the study. Neurosensory function was assessed with calibrated nylon monofilaments, electrical stimulation, heat detection thresholds and response to pin prick in the infraorbital, supraorbital, and mental nerve regions. Patients were seen immediately post-trauma, then 1 and 6 months following surgery.

RESULTS

Nine fractures were caused by traffic accidents (TAs), 8 by falls, and 8 by a local blow in a physical dispute. The fractures consisted of 15 displaced and 10 minimally or nondisplaced zygomatic complex fractures, and were left surgically untreated in 7 cases (None group), reduced but not fixed in 8 cases (Reduction group), and fixed with plates in 10 cases (Plates group). Plates were employed significantly more often in displaced fractures (chi-squared P = .0006). At 6 months significantly improved infraorbital nerve function was found in the Plate and None groups relative to the Reduction group (ANOVA P = .006). Only 1 case of chronic neuropathic pain was found.

CONCLUSIONS

This study concurs with previous studies in finding that plate fixation allows for significantly better restoration of infraorbital nerve function. Chronic neuropathic pain following zygomatic fractures is rare.

When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus

PURPOSE

To determine current professional advice to patients about refraining from nose blowing and air travel following treatment of zygomatic fractures.

METHODS

A postal questionnaire was sent to 261 consultant oral and maxillofacial surgeons (OMFS) in the UK. They were asked about advice given to patients regarding length of time to refrain from nose blowing and air travel following treatment of zygomatic fractures.

RESULTS

A total of 184 (71%) replies were received. Advice regarding the length of time to refrain from nose blowing and air travel ranged from no advice to 8 weeks. About 90% of respondents based their advice on common sense and traditional practice.

CONCLUSIONS

Advice given to the patients following the treatment of zygomatic fractures varies widely. Most consultants based their advice on traditional practice and common sense. In the absence of widely accepted guidelines, there is a need for an agreement among clinicians on advice given to the patients.

Pattern of soft tissue injuries to the oro-facial region in Nigerian children attending a teaching hospital

OBJECTIVE

This study was designed to determine the aetiological factors and pattern of oro-facial soft tissue injuries among children in a suburban Nigerian population. The problems encountered in the management of the patients are also highlighted.

SETTING

Obafemi Awolowo University Teaching Hospitals' Complex, Ile-Ife, Osun State Nigeria.

SAMPLE AND METHODS

This prospective study was carried out in children aged < or = 15 years who presented with oro-facial soft tissue injuries between July 1996 and December 1997. Data was collected from a clinical examination of the child and a questionnaire completed by the parent or carer.

RESULTS

During the study period, 174 children were managed for oro-facial soft tissue injuries, an incidence of 1.1%, out of a total of 15 582 child admissions. A male preponderance was found (1 : 0.74). The mean age +/- SD was 7.3 +/- 4.2 years and the range was 9 months-15 years. Falls were the most common aetiology followed by road traffic accident. The forehead was the most frequently injured site. A mortality of 3.4% was found. Although animal bites and burns accounted for only 13.8% of all injuries, all the deaths were a result of these aetiologies. Road traffic accidents and burn victims had the longest hospital stay.

CONCLUSION

Although falls and road traffic accidents are frequent causes of oro-facial soft tissue injuries, less common causes, like burns and dog bites are more likely to result in death.

The use of computed tomography to define zygomatic complex position

PURPOSE

The purpose of this study was to analyze the use of midline references and landmarks to assess the position of the zygomatic complex relative to the cranial base, and to test the reliability of these measurements in assessing facial symmetry.

METHODS

Direct skull measurements were compared with measurements made on computed tomography (CT) images. The effect of CT scanner error, technologist error, gantry angle error, error of skull inclination, and error due to the presence of titanium rigid fixation hardware were assessed. To test observer variation and the effect of each level of error, 4 blinded bilateral measurements were repeated 3 times by 5 observers on both dry skull and CT scans. A mixed effect analysis of variance model then assessed for effect of method of measurement (dry skull vs CT), observer, CT scanner, technologist, gantry angle, skull inclination, and rigid fixation.

RESULTS

A total of 2,040 measurements were made. Measurements for zygomatic complex posterior and anterior width and height were reliable and had an interobserver variations of 0.02 +/- 0.03 mm, 0.5 +/- 0.4 mm, and 0.37 +/- 0.3 mm, respectively. The difference between dry skull and CT assessment for the 3 reliable measurements was 1.2 +/- 0.3 mm, 0.44 +/- 0.4 mm, and 1.1 +/- 0.5 mm, respectively. The errors produced by the CT scanner, technologist, and rigid internal fixation hardware were not clinically significant. The measurements were not sensitive to gantry angle and skull inclination changes of 10 degrees or less. A fourth measurement assessing zygomatic complex projection was found not to be accurate or reliable.

CONCLUSIONS

These findings suggest that the 3 CT scan measurements describing the position of the zygomatic complex relative to the cranial base are clinically useful.

Maxillofacial injuries in a group of South Africans under 18 years of age

OBJECTIVE

To find out the incidence of maxillofacial injuries in South African children aged 18 years or less.

DESIGN

Retrospective study of casenotes.

SETTING

Six teaching hospitals affiliated to the University of Witwatersrand, Johannesburg, serving a population of about 5 million people.

SUBJECTS

All 326 children treated for facial injuries in the maxillofacial and oral departments of the six hospitals between 1 January 1989 and 30 June 1992.

MAIN OUTCOME MEASURES

Classification of the types of injury, associated injuries, cause of the injury, and methods of diagnosis.

RESULTS

Of the total of 4192 patients of all ages treated for facial injuries, 326 (8%) were within the age range of the study. The female:male ratio was 1:2.3. Most of the injuries (227, 70%) occurred in the 13-18 age group, and assaults, fights and gunshot wounds accounted for 155 injuries (48%). Of the 326 children, 173 (53%) had single injuries and 153 (47%) had multiple injuries. Mandibular fractures were the most common (64%) followed by maxillomandibular fractures (25%). Violence was the most common cause of injury, as in the USA and Zimbabwe, but unlike the rest of the world in which it is motor vehicle accidents. Soft tissue injuries were the most common associated injuries, and conventional plain radiography was the usual investigation.

CONCLUSION

The incidence of 8% compares favourably with those in other countries, but far too many injuries are the result of violence.

The closed reduction of nasal fractures: an evaluation of two techniques

Two techniques of closed reduction and fixation of nasal fractures are reported and the results compared. Both patients' and surgeon's postoperative evaluations of these techniques were favorable.

The characteristics of midfacial fractures and the association with ocular injury: a prospective study

Ocular injuries commonly occur in patients with facial fractures. This prospective study was set up to determine the incidence of ocular injuries, as assessed by an ophthalmologist, in patients who had sustained midfacial fractures. Over a 2-year period, a study of 363 patients who had sustained midfacial trauma sufficient to lead to a facial bone fracture (438 fractures) was undertaken and patients received a comprehensive examination by an ophthalmologist and an orthoptist within 1 week of injury. The characteristics of the eye injuries sustained were related to the aetiology of the fracture, the type of fracture, and the sex and age of each patient. Ninety percent of patients sustained ocular injuries of various severities. Sixty three percent of patients sustained only minor or transient ocular injuries, 16% suffered moderately severe ocular injury and 12% experienced severe eye injuries. Road traffic accident was associated with the highest incidence of severe ocular disorder (9/45 = 20%) whilst assaults had the second highest incidence at 11% (20/181). One third of all patients with comminuted malar fracture suffered a severe ocular disorder (9/27) whilst blow-out fracture came second at 16.7% (6/36). Fifty six patients (15.4%) had a decrease in their visual acuity and 9 patients (2.5%) had significant traumatic optic neuropathy. Decrease in visual acuity was the main clinical finding accompanying the majority of significant eye injuries. When ocular injuries were related to aetiology, it was apparent that road traffic accidents and assaults associated with alcohol abuse showed the highest incidence of major ocular dysfunction. It is suggested that all patients sustaining midfacial fracture associated with a significant decrease in visual acuity either pre- or postoperatively should have an early ophthalmological review.

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

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

Orbital injury complicated by entrapment of the superior oblique tendon: a case report

Fractures of the orbital roof are rare. Entrapment of the extraocular muscles in such fractures has not, to our knowledge, been reported previously. A case of acquired Brown's syndrome due to entrapment of the superior oblique muscle tendon in an orbital roof fracture is reported.

Delayed healing of fractures of the mandibular body

401 mandibular body fractures occurring during a 5-year period were analysed retrospectively. Out of these, 38 fractures (9.5%) were not consolidated by 50 days and made up the delayed healing group (DHG). A control group (CG) of another 38 fractures was constituted using the first mandibular body fracture consecutively following one in the DHG. The mean time until consolidation of the fractures was 116 days in the DHG and 35 days in the CG. The 2 groups were statistically analysed and mutually compared using a great number of variables including patient-, fracture site-, treatment- and end-result characteristics. It was concluded that a few days delay between trauma and treatment did not necessarily lead to a delayed healing. Uncooperative alcoholics with psycho-social handicaps, and general as well as local periodontitis, were found to be especially liable to consolidate their fractures at a slower rate than the average patient. The DHG more often required changes of unstable dental fixation, prolonged maxillo-mandibular fixation time and treatment for late infections at the fracture site. The patients in this group lost more teeth than those in the CG but above all required considerably extended therapeutic efforts. It is suggested that patients with the above-mentioned characteristics should be given special attention and care.

Incidence and aetiological pattern of jaw fractures in Greenland

All of the cases involving fractures of the mandible and/or maxilla in Greenland were recorded in a 1 1/2 year period beginning 1 July 1981. Further information of aetiological patterns was added from 2 studies of mandibular fractures in Godthåb/Greenland. The incidence of jaw fractures in Greenland (17 to 10,000 per year) was the highest ever reported. In 90% of these cases, the cause of fractures were interpersonal violence. Jaw fractures were encountered in nearly all districts of Greenland, most often in urban areas and the patients were chiefly of Greenlandic descent. The % of patients in the age group of 20-29 years was extremely high (57%) as was the women (36%). 75% of the women were ill-treated by their spouses. In half of the cases, the victims and the assailants were related. Victims unknown to the assailants made up only 20% of the cases. These were trends typical of a small society. Compared to other reports, violence in Greenland was aggravated and involvement of alcohol was seen in 4 out of 5 cases. Regulation and deregulation of alcohol in Greenland had only temporary effects on the occurrence of jaw fractures. Aetiological patterns of jaw fractures changes from one subculture to another depending on social conditions. The figures from Greenland demonstrated this.

An analysis of 2,067 cases of zygomatico-orbital fracture

A ten-year review of 2,067 cases of zygomatico-orbital fractures is presented. The age and sex distribution, anatomical types of fractures, associated maxillofacial and nonmaxillofacial trauma, and causes of the injuries are described. The majority of fractures were sustained by males and resulted from trauma inflicted in altercations. The most common associated facial fractures were mandibular; the most common associated nonmaxillofacial trauma was extremity fractures. Motorcycle accidents caused the most significant amount of associated trauma, followed by motor vehicle accidents in which no seat restraint was used by the victim. Treatment, when indicated, consisted of elevation via a temporal approach followed by fixation where necessary. The fixation methods used are presented and discussed.

Jaw fractures in the county of Stockholm (1978-1980) (I). General survey

The material comprised patients from the Stockholm region with jaws fractured during the years 1978-1980. It is the first time a total material is reported from this area. The following data were registered from case sheets and radiographs: age, sex and nationality, time of injury, admittance clinic, time spent in hospital, delay before treatment, aetiology of injury, associated consumption of alcohol or narcotics, localisation and number of fractures, additional injuries, treatment complications and cooperation.

Role of fixation in the treatment of nasal fractures

Following the reduction of nasal fractures, fixation was performed in 3 ways: 1 Packing for 72 h and plaster cast for 1 week. 2 Packing for 72 h and adhesive tape for 1 week. 3 Adhesive tape for 1 week. At follow-up 3 months after the reduction, these groups were compared with a group of patients with nasal fractures which had not needed treatment and with a group of normals. It was concluded that among the group fixed with packing and plaster cast, significantly fewer patients were dissatisfied than in the other groups, and fewer complained of deformity. The physical examination showed an appreciable number of minor deformities in all groups including the normal group. A significantly higher frequency of nasal obstruction was found in the group of patients operated upon compared to the non-operated group and the normal group by physical examination, but not by the questionnaire. The present study does not support the point of view that a high percentage of cases of nasal fracture have to be operated upon by open reduction. Radiology has no medical or legal value in patients with nasal fractures and should not be used.

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

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

Spatial analysis of midfacial fractures with multidirectional and computed tomography: clinicopathologic correlates in 44 cases

The use of conventional tomography and recent application of computed tomography to the assessment of facial injuries permit a more precise preoperative spatial analysis of complex midfacial fractures. Forty-four patients sustaining Le Fort I, II, or III maxillary fractures underwent multidirectional or computed tomography (CT) or both. The patterns of fractures of the maxilla and associated fractures of the mandible, zygomas, nasoethmoidal complex, frontal sinus, skull base, and cranial vault were correlated with surgical or clinical findings or both. In 91% of cases, CT or multidirectional tomography or both correctly identified the spatial pattern of fracture of the maxilla and its supporting pillars. Pure Le Fort II fractures were seen in only nine patients, while an isolated pure Le Fort I or III fracture was not encountered. Le Fort II and III fractures were commonly associated with additional tripod, frontal sinus, or nasoethmoidal complex dislocations.

Mandibular fractures. I. An analysis of their etiology and location in 286 patients

Case histories were studied of 286 patients treated for mandibular fractures by the Department of Plastic Surgery in conjunction with the Dental Department at Odense University Hospital between 1964 and 1973. 46.5% of the patients were aged 18-30 years; and 73.4% were male. Mandibular fractures associated with mid-face fractures were most frequently caused by traffic accidents (81%). When the mandible alone was fractured traffic accidents accounted for 50%, while assaults were responsible for 20%. Accidents at work only occurred among the men. Of the 487 mandibular fractures the most frequent site was the condylar process (36%) where half of the fractures in women were localized. Assaults most frequently caused fracture of the angle of the mandible; while falls were most frequently responsible for fracture of the condylar process. The fracture distribution in dentulous and edentulous mandibles differed despite the aetiology being the same.