Management of Persistent Diplopia and Epiphora in Mismanaged Orbital Blowout Fracture - A Case Report.

ABSTRACT: A 31-year-old male with a history of right zygomaticomaxillary complex (ZMC) fracture presented with aesthetic concerns, continuous tearing, and double vision. The patient had undergone multiple surgeries post accident, resulting in an asymmetrical cheek bulge, persistent diplopia, and epiphora. Investigations revealed abnormal placement of an orbital mesh and damage to the lacrimal sac. A surgical plan was devised to remove the plates, reposition the muscles, secure the floor, correct the epiphora, and provide the desired aesthetics. The surgery involved removal of the mesh and a long plate, refracturing of the zygoma, approximation and securing of the fractured zygoma with plates, and creation of an osteum on the lateral wall of the nose. Post-operatively, the patient's healing was uneventful and he was satisfied with the outcome. This case underscores the importance of a proper surgical technique and patient-centered care in managing complex facial fractures.

'Y' Modification of the cutaneous incision of the preseptal transconjunctival approach for the management of zygomatico-maxillary complex fractures: A prospective clinical study.

AIM: The purpose of this clinical study was to evaluate the efficacy of the preseptal transconjunctival approach with Y modification of the cutaneous extension for the management of zygomaticomaxillary complex (ZMC) fractures. METHODS: This prospective interventional study was conducted at our institute from 2012 to 2020. The study included patients aged 15-65 years with displaced ZMC fractures. Patients with uncontrolled systemic conditions, infected and/or comminuted fractures were excluded. The variables evaluated were age, gender, mechanism of injury, fracture side, clinical features, surgical exposure time, adequacy of exposure, complications, scar evaluation scores and cosmetic outcomes. The parameters for comparison were operated versus non operated side Eye Fissure Index (EFI) and surgical exposure time was compared with respect to the types of scars. RESULTS: A total of 49 patients were included in this study. The average exposure time was 18.87 ± 1.92 min. The exposure of fracture site was excellent in 73.5 % and satisfactory in 26.5 %. The mean EFI of operated side was 34.2 ± 5.04 mm while that of non-operated side was 34.22 ± 5 mm. On comparison of the same there was no significant difference. Invisible scars were noted in 71.4 % and barely visible scars in 22.4 %. The comparison of exposure time with type of scars showed a significant association (p = 0.02). The complications noted were chemosis, lower eyelid edema, conjunctival granuloma and entropion. Cosmetic outcomes were fairly satisfactory. CONCLUSION: The Y modification of the transconjunctival approach can provide excellent surgical exposure without the need for a second incision. Although this approach is technique sensitive and requires experience, the advantages outweigh the learning curve. Since this approach has been widely studied, a systematized review is recommended to further substantiate its reliability and advantages.

Clinical Significance of Diplopia and the Orthoptic Examination in Zygomatic Maxillary Complex Fractures.

Literature describes variable rates of diplopia of associated with zygomatic maxillary complex (ZMC) fractures (6% to 40%). The aim of this study was to retrospectively assess the prevalence of diplopia in ZMC fracture patients, the usefulness of the orthoptic evaluation compared with the clinical finger-tracking examination, and to seek possible relations of this symptom with clinical parameters. Data of patients attending the Maxillofacial Surgery Units of the University of Messina and University of Naples "Federico II", between January 2012 and December 2022 were retrieved. Statistical analysis of positive versus negative diplopia at both the clinical examination and the orthoptic evaluation and subgroup analysis were performed. 320 patients were included in the analysis. 50 (15.6%) patients reported diplopia at the clinical examination, whereas 70 (21.9%) resulted positive at the orthoptic evaluation. Statistical analysis for every determinant and subgroup did not show statistical significance ( P >0.05). Performing routine preoperative orthoptic evaluation allowed an increase of 6.3% in positive reports. Although it seems that no basic clinical parameter can predict diplopia, results suggest that the orthoptic evaluation is superior in the assessment of this symptom. Clinical analysis was shown to be a moderate/low efficient test and should not be used as a decisional standard.

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.

Effect of tranexamic acid on postoperative blood loss.

The aim of this article was to evaluate the efficacy of tranexamic acid (TXA) to reduce blood loss after maxillofacial fracture surgery. Clinical data were collected retrospectively on patients with unilateral fractures of the zygomaticomaxillary complex (ZMC) or mandibular condyle. Patients were then further divided into TXA and control groups according to whether or not TXA was used after surgery. The amount of postoperative blood loss was evaluated by negative pressure drainage volume. Data were statistically analysed. In patients with unilateral ZMC fractures, total postoperative blood loss in the TXA group was about 30 ml less than that in the control group (p = 0.006). It was significantly less on the first and second postoperative days. However, in patients with unilateral mandibular condylar fractures, there was no significant difference between the TXA and control groups (p = 0.917). TXA can reduce postoperative bleeding in patients with ZMC fractures, and the optimal usage time is on the first and second postoperative days. For patients with mandibular condylar fractures, TXA may not be used.

The 'Manchester' method of minimal access fixation of the zygomatic arch in zygomatic complex fractures: a case series.

We have introduced a minimally invasive approach for the fixation of the zygomatic arch during the surgical management of zygomatic complex fractures. Access for this technique is provided by a preauricular approach and eyelid incisions with the addition of transcutaneous stab incisions overlying the arch. These stab incisions allow transcutaneous drilling and screw placement through a size CH 20 (5.0 mm) paediatric nasopharyngeal airway (NPA). We present a case series of seven patients. In all patients the arch component was successfully reduced and fixed, and no intraoperative or postoperative complications were observed. The use of an NPA is novel. It functions as a flexible self-irrigating sleeve and protects the skin from mechanical and thermal damage. The technique uses readily available equipment, is easy to learn, and simplifies surgery to the zygomatic arch.

Enhancing Surgical Approach: Breakthrough Markerless Surface Registration With Augmented Reality for Zygomatic Complex Fracture Surgeries.

BACKGROUND: Innovative technologies with surgical navigation have been used for enhancing surgical accuracies for zygomaticomaxillary complex (ZMC) fractures and offers advantages in precision, accuracy, effectiveness, predictability, and symmetry improvement. Moreover, augmented reality (AR) navigation technology combines virtual reality, 3-dimensional (3D) reconstruction, and real-time interaction, making it ideal for bone tissue operations. Our study explored the usefulness and clinical efficacy of AR technology in intraoperative guidance for reducing ZMC fractures. METHODS: We retrospectively studied 35 patients with zygomatic complex fractures, comparing outcomes of AR-guided and conventional methods. Furthermore, the AR system provided real-time visualization and guidance. The evaluation included reduction accuracy using root mean square (RMS) value and symmetry analysis using a mirror image of 3D models. Results demonstrated the feasibility and effectiveness of the AR-guided method in improving outcomes and patient satisfaction. RESULTS: In 35 patients (25 males, 10 females), AR-guided (n = 19) and conventional (n = 16) approaches were compared. Age, sex, and fracture type exhibited no significant differences between groups. No complications occurred, and postoperative RMS error significantly decreased ( P < 0.001). The AR group had a lower postoperative RMS error ( P = 0.034). CONCLUSIONS: Augmented reality-guided surgery improved accuracy and outcomes in zygomatic complex fractures. Real-time visualization enhanced precision during reduction and fixation. This innovative approach promises enhanced surgical accuracy and patient outcomes in craniofacial surgery.

Patient reported outcome measures (PROMs) in zygomatic fracture surgery.

Attitudes towards healthcare in the NHS and in other Western healthcare systems have been changing dramatically in recent years. There is a significant movement calling for a shift from the traditional paternalistic model, with patients as passive recipients of treatments that are supported by objective and observable evidence, towards a more holistic approach, in which patients have agency, and treatments are tailored to the individual needs of a particular patient. Whilst patient safety and clinical effectiveness remain intrinsic to the traditional measurement of successful healthcare, Patient Reported Outcome Measures (PROMs) are increasingly being advocated as an important tool to uphold patient-centric care in the NHS.The aim of this study is to complete the first evaluation of PROMs that we know of in patients receiving surgical management of zygomatic fractures, by comparing two interventions commonly used in this condition: the zygomaticomaxillary complex open reduction and internal fixation (ZMC ORIF), and the Gillies approach to zygomatic elevation. We demonstrate high levels of patient satisfaction across all domains, irrespective of surgical approach, but that mood and anxiety remain an issue after surgery.

Effects of melatonin on postoperative pain and sensory recovery following zygomaticomaxillary complex fractures - A randomized controlled trial.

Posttraumatic and postsurgical sensory disturbance is a known complication of almost all zygomaticomaxillary (ZMC) complex fractures involving the infraorbital nerve, for which few treatments are effective. Our study used neurosensory assessments to evaluate the efficacy of melatonin on pain and nerve healing following ZMC surgery. Sixty-four randomly allocated ZMC fracture patients were prophylactically administered either oral melatonin or an identical placebo for 15 consecutive days. Pre- and postsurgical clinical parameters included subjective pain, numbness, and objective neurosensory function. Melatonin significantly reduced subjective pain perception in the early postoperative days, with a significant difference in VAS scores between the groups from postoperative day 3 (p = 0.048) until day 7 (p = 0.002). The VAS assessment of subjective numbness perception showed significantly lower self-perceived neurosensory disturbance for patients in the interventional group from the first month (p = 0.039) until the third month (p = 0.005). Objective neurosensory assessment using the pinprick test and two-point discrimination showed statistically significant improvement to almost normal sensation by the first month (p = 0.014) to fully normal sensation by the third month (p = 0.001). The study findings suggest that the prophylactic administration of melatonin confers significant clinical benefits in terms of reduced postoperative pain and improved sensory recovery.

Maxillofacial fractures among non-indigenous ethnic groups in the Irish national maxillofacial unit: a review.

BACKGROUND: This study investigates maxillofacial fractures in non-indigenous ethnic groups who were reviewed in the national maxillofacial unit in Ireland. The aim of this study was to highlight any potential trends in presentation of facial fractures in non-indigenous groups in comparison to previous reports which have included all ethnicities. This unique study is based on the fact that Ireland has only recently transformed into a diverse, multi-cultural country. This is unlike countries such as the UK and USA which have a long history of multicultural integration. MATERIALS AND METHODS: This retrospective study evaluated the trauma database of 4761 patients with 5038 fractures who attended the national maxillofacial unit over a 5-year period from 2015 to 2019. Parameters included age, gender, mechanism of injury, fracture sustained, time of the day, day of the week, month of injury, and the referral source were obtained from patient records. RESULTS: The study identified 456 patients who did not identify as being born in Ireland, with 384 males and 72 females. The most common fracture seen was of the zygomatic bone, and the most common mechanism of injury was alleged assault for this cohort. Most injuries occurred in late afternoon with Friday being the most common day of the week. CONCLUSION: This study shows how maxillofacial units need to adapt to the changing trends in Irish demographics with increased demand for resources such as translation services. A further study could evaluate the rapidly changing demographic with mass migration of people currently seeking refuge in Western Europe.

Feasibility of 2-Point Fixation by Absorbable Plates Using the Transoral Approach in Management of the Zygomatic Complex Fractures.

PURPOSE: The purpose of this study was to retrospectively evaluate the feasibility of 2-point fixation using absorbable plates by the transoral approach in the management of the zygomatic complex (ZMC) fractures. METHODS: Twenty-five patients (15 male and 10 female, age range 16 y to 55 y) with Knight and North Group Ⅲ zygomatic fractures were included in this case series. Open reduction by intraoral approach was performed on these patients, and the fractures were fixed using absorbable plates placed at the zygomaticomaxillary buttress and infraorbital rim. Postoperatively, follow-up was undertaken to evaluate the fracture healing, mouth opening, facial asymmetry, diplopia, and paresthesia. RESULTS: Postoperatively, all patients achieved uneventful healing; facial symmetry and wound healing were achieved, along with sensory recovery involving the infraorbital nerve. Complications such as sensory disturbances, infection, diplopia, malunion, and nonunion were not encountered in these patients. CONCLUSIONS: Two-point fixation using absorbable plates by transoral approach can provide sufficient stabilization for Knight and North Group III zygomatic fractures.

Symmetry recovery in zygomaticomaxillary complex fractures compared to normal unfractured population: A new reliable 3D evaluation.

OBJECTIVE: This study aims to quantify the facial symmetry of surgically treated zygomaticomaxillary complex (ZMC) fractures through a new reliable three-dimensional evaluation method, which is crucial for improving post-operative aesthetic and functional outcomes. MATERIAL AND METHODS: Healthy patients and patients with surgically treated ZMC fractures were retrospectively reviewed. Using Brainlab Elements® the zygomatic bone and the orbit of each patient was segmented and mirrored. Subsequently, the mirrored side was matched with the other side via volume-based registration, using the segmented orbit as reference. Volumetric asymmetry was measured using 3-matic software, and a surface-based matching technique was used to calculate the mean absolute differences (MAD) between the surfaces of the two sides of the ZMC. The reliability of this novel method using volume-based registration was tested, and the intra-class correlation coefficient was assessed. RESULTS: The MAD between the surfaces of the left and right sides in the control group was 0.51 mm (±0.09). As for the ZMC fracture group, MAD was 0.78 mm (±0.20) and 0.72 mm (±0.15) pre- and post-operatively, respectively. The MAD showed statistically significant differences between pre- and post-operative groups (p = 0.005) and between control and post-operative groups (p < 0.001). The intra-class correlation coefficient was high (≥0.99). CONCLUSIONS: This evaluation method using mirroring and volume-based registration to determine the symmetrical position of the ZMC is reliable. The surface-based measurements revealed an improved symmetry after surgery. However, the symmetry of the treated patients remained lower than the control group.

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.

Modeling stability post zygomatic fracture reconstruction.

Zygomaticomaxillary complex (ZMC) fracture repair is one of the most common surgical procedures performed in craniomaxillofacial trauma management. Miniplates and screws are used to stabilize the fractured bone using small local incisions, however, these procedures are not infrequently associated with hardware-related post-operative complications. The amount of fixation hardware utilized varies depending on the fracture pattern and surgical judgment, with three-point fixation being the conventionally accepted treatment. However, limited experimental testing and clinical studies have suggested that ZMC stabilization may be achieved with less than three-point fixation. In this study, we utilized a previously developed finite element modeling approach that allows for detailed bone and muscle representation to study the mechanical behavior of the fractured craniomaxillofacial skeleton (CMFS) under one, two, or three-point fixation of the ZMC. Results suggest that using a miniplate along the infraorbital rim in three-point fixation increases the amount of strain and load transfer to this region, rather than offloading the bone. Two-point (zygomaticomaxillary and zygomaticofrontal) fixation yielded strain patterns most similar to the intact CMFS. One-point (zygomaticofrontal) fixation resulted in higher tensile and compressive strains in the zygomaticofrontal region and the zygomatic arch, along with a higher tensile strain on the zygomatic body. These modeling results provide biomechanical evidence for the concept of over-engineering in the stabilization of facial fractures. Furthermore, they support previous suggestions that less than three-point fixation of ZMC fractures may be adequate to achieve uneventful healing.

BoneTape: A novel osteosynthetic device for the stabilization of zygomatic fractures.

BACKGROUND: The study aims to assess the safety and effectiveness of BoneTape™, a new resorbable bone fixation device, using a zygomatic fracture model in rabbits. METHODS: The study followed BoneTape™ samples and control (sham) groups over 2-, 6-, and 12-week periods post-zygomaticomaxillary (ZM) osteotomy and zygomaticofrontal (ZF) disarticulation. The osteotomized segments were analyzed for bone healing, inflammatory response, and tissue healing. µCT imaging and histological analysis were used to examine the axial alignment, offset, and quality of new bone formation. RESULTS: BoneTape™ samples demonstrated enhanced maintenance of the initial intraoperative positioning, reduced axial offset, and better alignment when compared with the control group, enabling stable bone healing under physiological loading conditions. Complete union was observed at 12-weeks in both groups. The BoneTape™ group experienced minimal immune and tissue reactions, classically associated with wound healing, and showed an increased number of giant cells at 6 and 12-weeks. CONCLUSION: BoneTape™ represents a promising advancement in osteosynthesis, demonstrating efficacy in maintaining stable zygomatic reconstruction and eliciting minimal immune response in a rabbit model. This study introduces BoneTape™ as a disruptive solution specifically designed for clinical application in cranio-maxillofacial fracture fixation, with the potential to eliminate the use of over-engineered solutions while offering benefits such as ease of application and fewer biologically disruptive steps.

Evaluating Mixed Reality as a Tool for Patient Education of Facial Fractures.

Background: Patients may be educated about facial fractures using two-dimensional computed tomography (2DCT); however, three-dimensional mixed reality (3DMR) goggles may improve patient education by delivering content in an immersive environment. Objective: To compare the effectiveness of 2DCT and 3DMR formats used for patient education on facial fractures, as measured by surveys. Methods: In this prospective, randomized, crossover study, video tutorials intended for facial fracture informed consent were created in 2DCT and 3DMR formats from a single CT data set of a zygomaticomaxillary complex (ZMC) fracture. Subjects were randomly assigned into two groups. Group 1 (n = 25) viewed the 2DCT tutorial, answered self-assessment and information recall surveys, viewed the 3DMR tutorial, repeated the prior surveys as well as a comparison survey. Group 2 (n = 25) followed the same sequence but viewed the 3DMR tutorial and then the 2DCT tutorial. Results: Participants (n = 50) had no differences in age (group 1-51.9 years/standard deviation [SD] 20.9; group 2-44.7 years/SD 17.6 years; p = 0.223), gender (group 1-10 male/15 female; group 2-11 male/14 female; p = 0.999), college education level (group 1-25 yes; group 2-25 yes; p = 0.844), or prior 2DCT or 3DMR experience (group 1-9 yes/16 no; group 2-13 yes/12 no; p = 0.393). The 3DMR format was preferred over 2DCT (p < 0.05), and it was reported to enhance understanding as compared to 2DCT (p < 0.05). No differences for information recall were noted (p = 0.753). Conclusion: In this study, participants preferred 3DMR goggles over 2DCT for a simulated ZMC fracture-informed consent.

Is Gillies Temporal Incision Necessary to Successfully Reduce Zygomaticomaxillary Fracture Combined With Orbital Wall Fracture?

Gillies temporal approach has been widely used to reduce zygoma fractures. Traditionally, it is the preferred method to reduce the isolated zygomatic arch fracture. It can be combined with other approaches, such as subciliary and intraoral incisions for more complex zygomatic fractures, so-called tripod fractures. In this study, the author hypothesized that complex zygomaticomaxillary bone fracture reduction can successfully be achieved without Gillies temporal incision. The author retrospectively analyzed the medical records and 3D facial Computed Tomography (CT) scans of 80 patients who had orbitozygomaticomaxillary fractures that affected >3 sites among the frontozygomatic suture, zygomaticomaxillary buttress, zygomatic arch, and orbital walls from May 2021 to August 2023. A single surgeon performed all surgical operations. All fractures were reduced with 2 incisions, lower eyelid incisions (subciliary or subconjunctival) and intraoral incisions (gingivobuccal approach), within a week of the initial traumatic event. After sufficient exposure to fractured sites using 2 incisions, the author reduced the fracture with a bony hook at the inferior orbital rim, lateral wall, or Boise elevator at the intraoral incision. All cases were successfully corrected without any complications. In conclusion, the author can successfully reduce complex zygomaticomaxillary fracture combined with orbital wall fractures without temporal Gillies approach.

Role of finite element analysis for selection of single point fixation in zygomaticomaxillary complex fracture.

BACKGROUND: One-point fixation was superior to the two and three-points fixation in minimally displaced zygomaticomaxillary complex (ZMC) fracture regarding the cost, invasiveness, scaring, number of wounds, and operation time. Accordingly, this study aimed to predict which one-point fixation is the most stable in managing minimally displaced ZMC fracture. MATERIAL & METHODS: This study simulated the different one-point fixation approaches on three ZMC models after fracture reduction and application of all forces exerted on the fractured area. The findings were represented as stress impact on the ZMC fracture and plating system as well as the inter-fragments micro-motion. RESULTS: The von misses stresses of plates for the zygomaticofrontal, infra-orbital rim, and zygomaticomaxillary buttress model were (66.508, 1.285, and1.16 MPa) respectively. While the screws' von misses for the infraorbital rim, zygomaticofrontal, and zygomaticomaxillary buttress models were (13.8, 4.05, and 1.60 MPa) respectively. Whereas, the maximum principles stress at zygomaticofrontal, zygomaticomaxillary buttress, and infraorbital rim models were (37.03, 37.01, and 34.46 MPa) respectively. In addition, the inter-fragment micro-motion for zygomaticomaxillary buttress, infraorbital rim, and zygomaticofrontal models were (0.26, 0.25, and 0.15 mm) respectively. CONCLUSION: One-point fixation at zygomaticomaxillary buttress is the preferred point because it is exposed to low stresses, and the inter-fragment micro-motion is within the approved limit with the elements in the same direction of fixation which indicates the rigid fixation. In addition, it is less palpable and scarless. TRIAL REGISTRATION: clinical trial.gov (NCT05819372) at 19/04/2023.

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.

Combining Patient-specific Implant With Malar Reduction to Repair Mid-facial Asymmetry Caused by Craniofacial Fractures in Asians.

Mid-facial asymmetry caused by bone defect or deformation resulted from craniofacial fracture was a common secondary complication needed to repair. Patient-specific implant (PSI) designed with the unaffected side as a template is a good choice to repair this kind of facial asymmetry. However, in Asians, the broad and prominent zygomatic bone in unaffected side is not an optimal template, because the oval facial shape was considered as a more attractive appearance in Asian esthetic concept. To repair the mid-facial asymmetry and to improve the facial contour, the authors combined PSI implantation with malar reduction in one-stage surgery. The authors referred the facial proportion index (the optimal ratio of mid and lower face was 1.27) as a basis for preoperative precise design to determine the ideal facial shape of unaffected side, and used mirror image overlay technique with the ideal shape of unaffected side as a template to design the PSI. With this surgical strategy, patients not only can repair facial asymmetry but also can get a more attractive appearance.