Simplified practice for ophthalmologist consultation in malar fractures: A retrospective study

Zygomatic bone contributes to the orbital walls, and therefore associated injuries carry a high risk of severe dysfunction of the visual apparatus. The aim of our study was to retrospectively assess the spectrum and frequency of ophthalmic involvement in patients presenting with malar fracture, and the need for referral to an ophthalmologist for evaluation. In total, 102 patients presenting with malar fracture between January 2008 and August 2017 at Bapuji Dental College and Hospital, Davangere, Karnataka were enrolled in this study. Patients with confirmed malar fracture were categorized according to Henderson's classification, and associated ocular injuries were recorded. Assessment of the spectrum and frequency of ophthalmic involvement in patients presenting with different types of malar fracture was then carried out, followed by categorization of the need for referral to the ophthalmologist with regard to the associated ocular injury, as per the Al-Qurainy et al. (1991) scoring system, allocating the patients to early, routine, and non-referral categories. Statistically significant differences in proportions of various types of ophthalmic involvement were found between categories of malar fracture, and in degrees of ophthalmic involvement within each category of malar fracture, except in the Type II group of patients. The most severe ocular injuries were noted in Type VII followed by Type V, with the least severe injuries noted in Type II patients. According to the Al-Qurainy et al. (1991) scoring system, eight patients required early referral, 10 patients needed routine referral, and 84 patients were in the non-referral category. Categorization of referral of patients to an ophthalmologist in hospitals lacking ophthalmology departments can be based on the Al-Qurainy et al. classification of referral for Henderson's Type III, IV, and VI. Henderson's Type I and II patients need to be referred only in medicolegal cases. Henderson's Type VII and V patients require mandatory referral.

Unreported variant foramen of the frontal bone: the latero-orbital foramen

Variant foramina of the skull can lead to misdiagnosis on medical imaging and potentially, intraoperative complications if not appreciated. Here, we report an unusual foramen found superior to the frontozygomatic suture. The foramen was located on the left side at the superolateral rim of the orbit, 2.36 cm inferolateral to the supraorbital foramen. It was positioned 2.5 mm superior to the frontozygomatic suture. The foramen had a length of 3.1 mm and a width of 1.3 mm. The internal opening of the foramen was located 1.45 cm superolateral to the zygomaticotemporal foramen. We suggest that this foramen is a pathway for either a branch of the zygomatic nerve or lacrimal nerve and/or their vascular bundles. Although the prevalence of such a finding cannot be confirmed, such a case is of archival value as a comparison for future similar cases.

Anatomical variations of the zygomaticofacial foramen and its related canal through the zygomatico-orbital and zygomaticotemporal foramina in dry human skulls

PURPOSE

The aim of this study is to reveal the location of the zygomaticofacial foramina, the variations of their numbers, and their connections between the zygomatico-orbital and zygomaticotemporal foramina.

METHODS

Ethics committee approval of our study was received by the Istanbul Medical Faculty Clinical Research Ethics Committee (date:30.07.2021, number:358356). 171 zygomatic bones of unknown gender from the Department of Anatomy, Istanbul University, were included in this study. The number of zygomaticofacial foramina and their connections with the zygomatico-orbital foramen and the zygomaticotemporal foramina were examined. Also, the morphometric distances between the zygomaticofacial foramen were calculated. Evaluation of the data was done with SPPS v.21.

RESULTS

The number of zygomaticofacial foramina was found as 299. It was found single, double, three, four, five and six foramina, in 52 (30.4%), 52 (30.4%), 24 (14.03%), 10 (5.85%), 5 (2.93%), 1 (0.58%) zygomatic bone, respectively. Zygomaticofacial foramen was absent in 27 (15.8%) bones. Of these 299 foramina, 129 were found to be connected with zygomatico-orbital foramen and 23 with zygomaticotemporal foramen. It was noted that 147 zygomaticofacial foramina had no connection with any foramina. The distances between the zygomaticofacial foramen and the frontozygomatic suture, temporal process, maxillary process, the lowest point of the zygomatic bone, and orbital rim were found as 25.30 ± 2.81mm, 18.74 ± 3.56mm, 21.56 ± 4.16mm, 18.72 ± 2.57mm, 6.67 ± 3.27mm, respectively.

CONCLUSION

Consequently, the location and variations of ZFF are of great importance for maxillofacial surgery and regional block anesthesia. Knowing its location and variations will help prevent complications during any surgical intervention in this region.

Case report of a zygomatic bone hemangioma surgery with reconstruction by a custom-made implant

Intraosseous hemangiomas are rare tumors. A 43-year-old woman was referred with a mass in the right zygomatic bone, showing a slow volume increase and pain symptomatology. A surgical management with bone reconstruction using a custom-made implant was decided. Historically, various autografts and alloplastic materials have been used for this type of bone loss. The use of custom-made biomaterials opens new possibilities in maxillofacial reconstructive surgery. The patient showed no symptoms postoperatively and her zygomatic bones were symmetrized. For the authors, this approach seems to be a reliable and reproducible method for zygomatic bone reconstructions.

Three-dimensional zygomatic changes after rapid maxillary expansion in growing patients

PURPOSE

To assess the effects of rapid maxillary expansion (RME) treatment on the zygomatic bone complex (ZBC).

METHODS

In this single-center retrospective study, pre- and posttreatment cone-beam computed tomography (CBCT) images of 38 patients treated with RME were analyzed to investigate changes in the coordinates of the ZBC landmarks. At the start of treatment (T0), the patients' mean age was 11.1 ± 3.8 years (range 8.3-14.9 years). Cohen's d test was used to evaluate statistical differences.

RESULTS

There were statistically significant differences between T0 and T1 (P < 0.01) in the measurement values for the maxillary transverse width (ΔT: 3.18 ± 2.58, d: 1.23), frontozygomatic sutures (ΔT: 1.09 ± 0.56, d: 0.43), lowest point of the zygomaticomaxillary sutures (ΔT: 3.16 ± 1.78, d: 0.78), frontomaxillary angular parameter (right side ΔT: 2.81 ± 1.63, d: 1.73; left side ΔT: 2.52 ± 1.20, d: 2.10), frontozygomatic angular parameter (right side ΔT: 2.81 ± 1.63 d: 1.07; left side ΔT: 2.21 ± 2.79, d: 0.61), anterior intermaxillary distance (ΔT: 2.11 ± 1.42, d: 0.99), interzygomaticotemporal distance (ΔT: 2.00 ± 2.42, d: 0.99), and zygomatic angular parameter (right side ΔT: 2.06 ± 1.29, d: 1.6; left side ΔT: 2.02 ± 1.86, d: 1.09).

CONCLUSIONS

After RME in growing patients, the zygomatic bone showed pyramidal expansion in the coronal plane and parallel palatal expansion in the axial plane. In addition, significant lateral relocation of the zygomatic bone occurred. The zygomatic bone tended to rotate outward in conjunction with the maxilla, with a typical center of rotation close to the superior side of the frontozygomatic suture. These results shed light on the patterns of skeletal expansion in the zygomatic bone associated with RME in growing patients.

Hyperbaric Oxygen Therapy in the Management of Zygomatic Bone Osteomyelitis

Introduction

Zygomatic bone osteomyelitis is a rare condition having an incidence of 1.42%. Zygomatic osteomyelitis can be due to haematogenous infection with tubercle bacillus, facial bone fractures or very rarely due to an unknown aetiology like in our case. If surgically managed alone, it would lead to complete loss of zygomatic bone, causing high morbidity to the patient in terms of function and aesthetics like loss of globe support causing dystopia, loss of facial projection causing facial asymmetry. Restoration of facial symmetry and globe support would require extensive procedures such as non-vascular bone grafting or patient-specific implant placement or microvascular bone flap transfer.

Materials and Methods

Hyperbaric oxygen therapy (HBOT) was used to try and preserve the zygoma by promoting revascularisation. The patient received 100% oxygen at 2.5 absolute atmospheric pressure for 90 min, one session per day for 5 days in a week using a mask system in a multiplace chamber. The patient was reviewed clinically and radiologically after each 5 dives of HBOT sessions. After a total of 30 dives of HBOT, CT examination was repeated. There was partial reconstitution of cortical bone without any additional residual bone lesion. Minimal residual sequestra were noted. At this stage, the patient underwent conservative sequestrectomy in contrast to extensive surgery if HBOT was not contemplated.

Conclusion

HBOT has the potential to be a very useful adjunct in the treatment of osteomyelitis in head and neck surgery; however, there is a need for carefully designed trials, avoiding methodological bias due to the great variability of patients, infectious agents, antibiotic resistance, host factors, to broaden the evidence of this therapeutic modality.

Intramuscular hemangioma in the zygomaticus muscle: A rare case report presentation and diagnosis

INTRODUCTION

intramuscular hemangioma (IMH) is a relatively rare benign vascular tumor of the skeletal muscles. It shows less than 1% of all soft tissue hemangiomas. In the head and neck area, it occurs usually in the masseter muscle followed by temporalis and sternocleidomastoid muscles.

PRESENTATION OF CASE

we present a case of 25-year-old male patient with a chief complaint of slowly growing facial swelling in the left zygomatic area. Clinical, imaging and histopathological evaluation lead to the diagnosis of intramuscular hemangioma in the zygomaticus major muscle.

DISCUSSION

IMH in the zygomaticus muscle is very rare; hence, the clinical diagnosis of IMH is challenging. Different diagnostic procedures can be used such as CT and MRI. In addition, the ideal therapy for esthetic disfiguring IMH in the head are is the complete surgical excision of the lesion. Through the review of literature and to our knowledge this case is the first report of intramuscular hemangioma in the zygomaticus muscle.

CONCLUSION

IMHs are rare in the head and neck area and must be considered in differential diagnosis of isolated muscle mass in this region.

Cryptococcal osteomyelitis of the Zygomatic bone: a case report

Background

Disseminated cryptococcosis is a well-characterized complication in immunocompromised patients with cryptococcal pneumonia or meningitis; however, isolated cryptococcal osteomyelitis is a rare entity that occurs in approximately 5% of patients with cryptococcosis. Cryptococcal osteomyelitis in the head and neck region is extremely rare. To the best of our knowledge, no cases of cryptococcal osteomyelitis affecting only the zygomatic bone have been reported to date.

Case presentation

A 78-year-old man without other comorbidities presented with progressive swelling of the right cheek along with pain and trismus. Clinical examination revealed a tender swelling in the right zygomatic region; the maximal mandibular opening was about 2 cm. Laboratory data showed mildly elevated inflammatory indices (C-reactive protein: 0.45 mg/dL; erythrocyte sedimentation rate: 35 mm/h). Computed tomography showed a 30-mm-diameter lesion at the right zygomatic arch. A part of the lesion has extended to the subcutaneous area of the cheeks with signs of bone destruction and surrounding contrast effects. Histopathological examination of fine-needle aspirate and needle biopsy showed cryptococcus. Furthermore, culture of the aspirate showed growth of Cryptococcus neoformans. No evidence of any other site involvement was observed. Therefore, the patient was diagnosed with isolated cryptococcal osteomyelitis and was initiated on fluconazole therapy. The treatment was effective, and all symptoms were resolved in 4 weeks. Fluconazole therapy was stopped after 6 months. There are no signs of recurrence as of 15-month follow-up. The patient has no cosmetic abnormalities or sequelae.

Conclusions

Fine-needle aspiration cytology, needle biopsy, and fungal culture were useful for definitive diagnosis. Immunocompetent patients with isolated osteomyelitis may be cured with oral fluconazole alone.

Extraoral anatomy in CBCT – a literature review. Part 2: Zygomatico-orbital region

This second article about extraoral anatomy as seen in cone beam computed tomography (CBCT) images presents a literature review of the zygomatico-orbital region. The latter bounds the maxillary sinus superiorly and laterally. Since pathologic changes of the maxillary sinus are a frequent indication for three-dimensional radiography, the contiguous orbital cavity and the zygomatic bone may become visible on CBCT scans. The zygomatic bone forms the cheek prominence and has large contact areas with the maxilla through the zygomaticomaxillary suture in the infraorbital region as well as with the sphenoid bone along the lateral orbital wall. Each of the three surfaces of the zygomatic bone displays foramina that transmit neurovascular structures. The orbital cavity is located immediately above the maxillary sinus from which it is separated only by a thin bony plate simultaneously serving as the orbital floor and the roof of the maxillary sinus. Several openings, such as the superior and inferior orbital fissures, the ethmoidal and cranio-orbital foramina, and the optic and infraorbital canals, connect the orbit to the anterior and middle cranial fossae as well as to the infratemporal and pterygopalatine fossae.

Computer guided resection and reconstruction of intra-osseous zygomatic hemangioma: Case report and systematic review of literature

OBJECTIVES

to systemically integrate the available data on various published treatment strategies for intraosseous hemangioma of the zygoma in an updated comprehensive systematic review, and to present a new case of treated resection and immediate reconstruction using computer guided patient specific composite graft.

CASE PRESENTATION

A 29 years old female patient with intraosseos zygomatic hemangioma treated using computer guided resection and immediate reconstruction. The resection was performed using a resection template constructed based on preoperative 3D planning. The reconstruction was performed using ramus bone graft and titanium mesh. The patient was followed up for 3 years with no complications.

METHODS

An electronic search was performed on 3 data bases; additional hand search of bibliographies of selected articles was performed. Eligibility criteria include human studies presenting intraosseous zygomatico-orbital hemangioma with clearly reported therapeutic strategies.

RESULTS

53 articles with 73 cases were included. The lesion was highly prevalent in females compared to males (2.28:1). Fifth decade represents the highest prevalence with mean age of 44.1 ± 1.8 years. The main patient concern was swelling and facial deformity. Total tumor resection can assure no recurrence, while partial resection and curettage are associated with high recurrence rate.

Primary tuberculosis of zygomatic bone: A rare case report

Tubercular osteomyelitis of zygomatic bone is extremely rare. Here we have reported a rarest case of primary tuberculosis (TB) of zygomatic bone in a 20 year male who presented with discharging sinus over right zygomatic region. Anti-tubercular chemotherapy given and patient improved well.

Zygomaticomaxillary buttress and its dilemma

Zygomatic fractures are the second most common fractures of the facial skeleton, after nasal bone fractures. Due to its uniqueness, the malar bone plays a very important role in maintaining appropriate facial contours. Zygomatic fractures can cause ocular and mandibular functional impairment, along with cosmetic defects. With the help of advanced imaging techniques and various treatment options, the management of zygomatic fractures has become more sophisticated and less invasive. This article discusses zygomatic fractures in detail: their clinical and radiographic features, and the various treatment options available.

Unusual occurrence of orbital hemangiopericytoma in the zygomatic bone of an adolescent: a case report

Background

Hemangiopericytoma and solitary fibrous tumor are considered related variants on the same spectrum and both may essentially be the same tumor. They are infrequently encountered in the orbital region while the zygomatic bone is an extremely rare location for these neoplasms to occur.

Case presentation

A 14-year-old boy presented with complaint of deformity of left infraorbital area and a firm, regular mass in the region. Orbital CT scan revealed a well-defined round isodense intraosseous lesion in the lowermost portion of the lateral orbital wall (zygomatic bone), expanding the bone and protruding anteriorly and medially. MRI showed the mass to be heterogenous and strongly enhancing with contrast medium. Inferior transconjunctival orbitotomy was performed and the mass was removed. The histopathologic examination and immunohistochemistry staining results (positive for CD34, CD31 and smooth muscle actin, but negative for CD99, S100, B-cell lymphoma 2 (bcl-2) and desmin) confirmed the diagnosis of hemangiopericytoma. The postoperative course was uneventful, with no evidence of recurrence after 5 years follow up.

Conclusions

This case represents the second hemangiopericytoma reported in the zygomatic bone. Although extremely rare, hemangiopericytoma/solitary fibrous tumor might be considered in the differential diagnosis of intraosseous lesions of the orbital and zygomatic region.

Assessing symmetry of zygomatic bone through three-dimensional segmentation on computed tomography scan and "mirroring" procedure: A contribution for reconstructive maxillofacial surgery

PURPOSE

Surgical reconstruction of zygomatic bones in cases of traumatic injuries is a frequent event: assessment of symmetry is mandatory for a correct restoration of zygomatic shape, but the literature is discordant about its quantification. The purpose of this study is to show a novel method for assessing symmetry of zygomatic bone through mirroring of 3D models segmented on CT-scan.

MATERIALS AND METHODS

A total of 100 patients (50 male and 50 female), divided into two age groups (18-49 years and 50-92 years) were selected from the computed tomography (CT) scan database of a hospital in northern Italy. Zygomatic bones from each patient were segmented, and the left bone was automatically mirrored and registered on the right one according to the least point-to-point distance between the two surfaces. The mean and root mean square (RMS) distance between the two models was then calculated. Statistically significant differences according to sex and age groups were assessed through two-way analysis of variance (p < 0.05). In addition, the effect size of differences was calculated.

RESULTS

The method proved to be repeatable, with inter- and intraoperator errors lower than 5%. Overall, mean and RMS point-to-point distances were respectively 0.01 mm and 0.84 mm, without statistically significant differences according to sex or age (p > 0.05), and with negligible effect size.

CONCLUSION

This study provides an innovative method for assessing the symmetry of the zygomatic bone based on surface analysis. Results may provide useful indications for the reconstruction of zygomatic bones in maxillofacial surgery.

Endoscopically-Assisted Zygomatic Implant Placement: A Novel Approach

BACKGROUND

Zygomatic implants (ZIs) have been proposed as a valid alternative to advance bone-grafting procedures in the rehabilitation of the severe atrophied upper maxilla, with a reported overall success rate of more than 95 %. Otherwise, the use of the endoscope has been described for the treatment of maxillofacial trauma, orthognatic surgical procedures, sinonasal pathology, salivary gland disease, and TMJ internal derangement. A careful identification of anatomical landmarks is of utmost importance while trying to avoid potential complications during the insertion of ZIs. Several approaches for ZI insertion have been reported, such as the classical approach; the sinus slot technique; and the exteriorized approach.

MATERIALS AND METHODS

The authors first introduce in the literature the endoscopically-assisted approach for the insertion of ZIs in the extremely severe atrophic maxilla.

RESULTS

Optimal results in terms of ZIs positioning with no damage to surrounding structures were obtained.

CONCLUSIONS

By means of this new technique the surgeon may minimize the risk of complications related to the damage of neighbouring anatomic structures, such as orbital disruption or infraorbitary nerve damage, while ensuring an adequate drill positioning and angulation for the placement of one or two implants into the zygomatic bone.

A clinical study of the outcomes and complications associated with zygomatic buttress block bone graft for limited preimplant augmentation procedures

PURPOSE

The aim of this study was to evaluate the possibility of using the zygomatic buttress as an intraoral bone harvesting donor site and determine the safety of this harvesting procedure for later optimal positioning of dental implants in accordance with prosthodontic and functional principles.

MATERIAL AND METHODS

A consecutive retrospective study was conducted on patients who had been treated at the Department of Oral and Maxillofacial Surgery of Ulm military and academic hospital, over a 3-year period (January 2008 to December 2010). Medical history, smoking status, area of surgery, and complications were recorded. The need for bone grafting was defined by the impossibility of installing implants of adequate length or diameter to fulfill prosthetic requirements, or for esthetic reasons. The patients were treated using a 2-stage technique. During the first operation, bone blocks harvested from the zygomatic buttress region were placed as lateral onlay grafts and fixed with titanium osteosynthesis screws after exposure of the deficient alveolar ridge. After 3-6 months of healing, the flap was reopened, the screws removed and the implants placed.

RESULTS

A total of 113 zygomatic buttress bone block grafts in 112 patients were performed. Graft loss and graft removal were defined as failure; swelling, wound dehiscence, infection with pus, temporary paresthesia, and perforations of the maxillary sinus membrane were defined as complications. According to our criteria, 4 (3.5%) of the patients presented postoperative complications of the donor site and 20 (17.8%) of the recipient site. Throughout, 93 (82.3%) of the bone grafts were successful and 20 (17.6%) had complications, regardless of the final success of the implant procedure. Smoking was associated with a high rate of complications and graft failure. Early graft exposure appeared to compromise the results, whereas pain and swelling were comparable to usual dentoalveolar procedures. However, in 1.7% of all cases, concerning 2 patients, the final rehabilitation with dental implants was not possible.

CONCLUSIONS

The zygomatic buttress block bone graft is a safe intraoral donor site for the reconstruction of small- to medium-sized alveolar defects, providing the greatest surgical access with minimal postoperative complications.

Intraosseous venous malformation of the zygoma: A case report and literature review

INTRODUCTION

Venous malformations of the zygoma are rare. Historically, venous malformations have been misrepresented as "hemangiomas". The International Society for the Study of Vascular Anomaly (ISSVA) classification is a reasonable classification that leads to appropriate clinical diagnosis and treatment strategies. Collaboration between surgeons, radiologists, and pathologists is necessary for accurate diagnosis and management.

PRESENTATION OF CASE

We present here a case of an IOVM in a 59-year-old woman who was treated with a multidisciplinary approach. Superselective arteriography and embolization were effective for diagnosis as well as for prevention of large hemorrhage during surgery. En-bloc resection of the zygoma was performed within hours after embolization and autologous calvarial bone graft was used for primary reconstruction.

DISCUSSION

We performed a literature review consisting of reviewing 52 cases of IOVM of the zygoma discussing optimal material for reconstruction of the defect for intraosseous venous malformation of the zygoma nationally and internationally.

CONCLUSION

The combination of surgery and preoperative angiography makes it possible to prevent high risk of hemorrhage. For primary reconstruction of the zygoma, use of autologous calvarial bone can maintain the volume and reconstruct the natural malar contour.

Morphomic analysis as an aid for preoperative risk stratification in patients undergoing major head and neck cancer surgery

BACKGROUND

Patients undergoing major head and neck cancer surgery (MHNCS) may develop significant postoperative complications. To minimize the risk of complications, clinicians often assess multiple measures of preoperative health in terms of medical comorbidities. One emerging method to decrease surgical complications is preoperative assessment of patient frailty measured by specific tissue characteristics. We hypothesize that morphomic characteristics of the temporalis region serve as predictive markers for the development of complications after MHNCS.

METHODS

We performed a retrospective review of 69 patients with available computed tomography (CT) imaging who underwent MHNCS from 2006-2012. To measure temporalis region characteristics, we used morphomic analysis of available preoperative CT scans to map out the region. All available CT scans had been performed as part of the patient's routine work-up and were not ordered for morphomic analysis. We describe the correlation among temporalis fat pad volume (TFPV), mean zygomatic arch thickness, and incidence of postoperative complications.

RESULTS

We noted significant difference in the zygomatic bone thickness and TFPV between patients who had medical complications, surgical complications, or total major complications and those who did not. Furthermore, by use of binary logistic regression, our data suggest decreased TFPV and zygomatic arch thickness are stronger predictors of developing postoperative complications than previously studies preoperative characteristics.

CONCLUSIONS

We describe morphomic analysis of the temporalis region in patients undergoing MHNCS to identify patients at risk for complications. Regional anatomic morphology may serve as a marker to objectively determine a patient's overall health. Use of the temporalis region is appropriate in patients undergoing MHNCS because of the availability of preoperative scans as part of routine work up for head and/or neck cancer.

Multilobular tumor of the zygomatic bone in a dog

Multilobular tumor of bone (MTB) (also known as Multilobular Osteochondrosarcoma) is an uncommon bone tumor frequently located on the skull of dogs, rarely on the ribs or pelvis. These neoplasms are slow growing, locally invasive, and have the potential to compress and invade the brain. A 10-year-old mixed breed dog was presented with a history of approximately 4 months of progressive growth of a left zygomatic mass. Radiographic investigation revealed a finely granular or stippled non homogeneous radiopaque mass involving the zygomatic arch. After surgery, grossly the neoplasm consisted of multiple, variably sized, grayish-white to yellow nodules separated by collagenous septa of different thickness. Histologically, the tumor was characterized by the presence of multiple lobules containing osteoid and cartilage, separated by a net of fibrous septae. This neoplastic pattern was consistent with a typical multilobular tumor of bone and based on clinical, radiographical, gross and light microscopic findings the definitive diagnosis was made. While reviewing veterinary literature only few cases of MTB were found in dogs.

Congenital facial teratoma

Teratomas are neoplasm composed of three germinal layers of the embryo that form tissues not normally found in the organ in which they arise. These are most common in the sacrococcygeal region and are rare in the head and neck, which account for less than 6%. An unusual case of facial teratoma in a new born, managed successfully is described here with postoperative follow up of 2 years without any recurrence.