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.

A Method for Precise Reduction of Facial Bone Fractures Using Intraoperative Ultrasound With a Solid Gel Pad as a Coupling Medium.

This study introduces a method to overcome technical challenges in using intraoperative ultrasound for the closed reduction of nasal bone and zygomatic arch fractures. The curvature of the face makes it difficult to apply an ultrasound probe to the facial area. We used a solid gel pad as a coupling medium during surgery to improve the scanning of facial bone fractures. The results show that the fracture sites observed on preoperative computed tomography scans can be easily visualized using intraoperative ultrasound, and real-time manipulation confirms successful reduction. The solid gel pad is light, malleable, easy to use, and provides accurate images. Overall, the use of ultrasound with a solid gel pad enhances the accuracy of closed reduction in facial bone fracture surgeries, confirming fracture patterns and ensuring precise reduction.

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.

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.

Successful Reduction of Unilateral Zygoma Fracture Following Bilateral Malar Reduction Surgery.

Malar reduction surgery can increase its susceptibility to fractures in case of trauma. Patients who had malar reduction surgery and sustained a zygoma fracture pose unique challenges for treatment and management. This is a case of a 28-year-old female patient who presented with a unilateral zygoma fracture following bilateral malar reduction and augmentation rhinoplasty 6 years ago. Physical examination revealed a clicking sound when opening the mouth at the right zygomatic buttress and a depressed preauricular area, suggesting arch fracture. Computed tomography imaging demonstrated a loosened screw at the right zygomatic buttress and a depressed arch fracture. She wanted to remove all plates and treat her right fractured zygoma with absorbable materials. Through the bilateral intraoral incisions, the authors removed the plates and screws and reduced the depression with the Langenbeck elevator through the same right intraoral incision without fixation. The reduction was well-maintained without complications based on postoperative plain x-rays 1 month after surgery. She reported that the pain was mostly gone and that she did not hear any abnormal sounds when opening her mouth after the surgery. In this case, if the zygomaticomaxillary buttress is minimally displaced, but the zygomatic arch fracture is significantly depressed, the authors believe that fracture reduction with only an intraoral incision would be enough to achieve an optimal outcome. If the plates and screws used in the previous malar reduction are not well maintained, it may be necessary to remove them.

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.

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.

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.

The Role of Intraoperative Navigation in Surgical Treatment of Unilateral Zygomatic Complex Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: The application of a computer-aided navigation system (CANS) in zygomatic complex (ZMC) fractures has been extensively reported, but individual results are heterogeneous. The purpose of this systematic review was to evaluate the role of CANS in the surgical treatment of unilateral ZMC fractures. METHODS: Electronic retrieval of MEDLINE, Embase, and Cochrane Library (CENTRAL) and manual searching until November 1, 2022 were used to identify cohort studies and randomized controlled trials employing CANS in the surgical treatment of ZMC fractures. The identified reports contained at least 1 of the following outcome variables: accuracy of reduction, total treatment time, amount of bleeding, postoperative complications, satisfaction, and cost. Weighted or mean differences (MD), risk ratios, and corresponding 95% confidence intervals (CI) were calculated, where P＜.05 and I2＞50% random-effect model was adopted, and a vice versa fixed-effect model was adopted. Descriptive analysis was applied to qualitative statistics. The protocol was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered with PROSPERO (CRD42022373135). RESULTS: A total of 562 studies were identified, of which 2 cohort studies and 3 randomized controlled trials with 189 participants were included. Meta-analysis indicated that employing CANS significantly decreased the reduction error (MD = -0.86, 95% CI -1.58 to -0.14; P = .02, random-effect model) compared with conventional surgery without using CANS. The differences in total treatment time (preoperative planning time: MD = 1.44, 95% CI -3.55 to 6.43; P = .57 and operative time: MD = 3.02, 95% CI -9.21 to 15.26; P = .63, fixed-effect model) and amount of bleeding (MD = 14.86, 95% CI -8.86 to 38.58; P = .22, fixed-effect model) were not statistically significant between the two groups. Descriptive analysis suggested that postoperative complications, postoperative satisfaction, and cost were also similar with or without CANS. CONCLUSION: Within the limitations of the present review, the reduction accuracy of unilateral ZMC fractures using CANS is superior to that of conventional surgery. CANS presents limited influence on operation time, amount of bleeding, postoperative complications, postoperative satisfaction, and cost.

Role of Intraoperative Imaging in Improving Closed Reduction of Zygomatic Arch Fractures: A Systematic Review and Meta-analysis.

PURPOSE: The use of intraoperative imaging (IOI) to improve the reduction adequacy of zygomatic arch (ZMA) fractures has been reported, but few systematic reviews have examined this topic. The aim of this review was to investigate and compare the value of IOI with conventional methods without IOI (N-IOI) for the closed reduction of ZMA fractures. METHODS: Electronic retrieval of MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, and citation search until December 2, 2022, was used to identify controlled clinical trials that employed IOI for improving adequacy in closed reduction of ZMA fractures. The predictor variable was the use of IOI-yes/no (IOI vs N-IOI). The covariates included imaging technique (ultrasound, C-arm, and cone beam computed tomography) and ZMA fracture type (M-shape fracture, mechanistic force in 1 direction; variable fracture, mechanistic force in 2 directions). The primary outcome variables were the reduction adequacy of ZMA fractures (the remaining cortical step and dislocation angle) compared with the ideal mirrored position. Weighted or mean differences, risk ratios, and corresponding 95% confidence intervals were calculated, where P >.05 and I2＜50% fixed effect model was adopted, and a vice versa random effect model was adopted. RESULTS: A total of 1250 studies were identified, of which 6 studies with 259 participants were included. The meta-analysis results indicated that compared with N-IOI, IOI yielded fewer cortical steps (-1.76 [-2.42, 1.10], P ＜.00001, fixed model) and dislocation angles (-5.60 [-8.08, 3.12], P＜.00001, fixed model) in patients with variable ZMA fractures, while no significant difference was detected in the M-shape ZMA fracture (-0.72, [-2.93, 1.48], P = .52; -1.48, [-3.51, 0.55], P = .15). Although there was no significant difference in postoperative correction (0.35, [0.06, 2.01] P = .24, fixed model), all secondary revision cases occurred in the N-IOI group. Descriptive analysis showed that IOI yielded better symmetry and appearance satisfaction. CONCLUSION: IOI improved the adequacy of the procedure and led to a better postoperative appearance, especially for patients with variable ZMA fractures. Furthermore, the use of IOI avoided the risk of secondary surgery. In future studies, researchers should standardize the scale and outcomes to facilitate the intuitive evaluation of reduction adequacy.

The Value of Intraoperative Computed Tomography in the Treatment of Zygomatic Complex Fractures.

BACKGROUND: Due to the complex anatomical morphology and lack of anatomic markers on the surface of zygomatic complex (ZMC), the treatment results of ZMC fractures are often suboptimal. PURPOSE: The study aimed to evaluate the effectiveness of intraoperative computed tomography (ICT) in the treatment of unilateral ZMC fractures, and further study the feasibility of ICT to replace early postoperative Computed Tomography (CT). STUDY DESIGN, SETTING, AND SAMPLE: The investigators designed a retrospective cohort study. Adult patients who underwent surgery with unilateral ZMC fractures were enrolled. PREDICTOR VARIABLE: According to whether intraoperative CT was used, the subjects were divided into the ICT group and the control group (without ICT). MAIN OUTCOME VARIABLES: Five distances and 3 angles representing bilateral ZMC symmetry were main outcome variables. The differences of outcome variables were compared between the 2 groups and the indices of ICT group were further compared with their postoperative indices. COVARIATES: Demographics (eg age), etiology (eg traffic injury), dysfunction (eg diplopia), and surgical approach (eg vestibular incision) were collected as covariates while we conducted clinical investigation, examination, and implementation. ANALYSES: The data were analyzed using independent-samples t test, paired-samples t test, Mann-Whitney U test, and χ2 test. P value < .05 was considered statistically significant. RESULTS: A total of 60 patients (18 to 59 years) were enrolled in this study. All median values of the measurements in the ICT group were smaller than those in the control group, and the differences of horizontal displacement distance (0.56 vs 1.02 mm), anteroposterior displacement distance (1.69 vs 2.34 mm, 0.90 vs 2.35 mm), horizontal angle of bilateral zygomatic arch (2.31 vs 4.19°), and horizontal angle of bilateral zygomatic process (1.77 vs 2.94°) were significantly different between the 2 groups with P value < .05. Moreover, there was no statistically significant difference in all indices between the intraoperatively and postoperatively injured sides in the ICT group. CONCLUSIONS: ICT can improve the treatment outcomes of ZMC fractures by evaluating the fracture reduction adequacy during surgery. Moreover, ICT can replace early postoperative CT.

Direct or Indirect Surgical Approach of Zygomatic Complex Fracture: A Comparative Study.

Zygoma is considered the main support of the midface. Zygoma is frequently fractured owing to its prominent site on the face. Treatment of zygomaticomaxillary complex fractures can be performed through either conservative or surgical measures (closed or open reduction). The study was a cross-sectional retrospective observational investigation done at 4 hospitals in Ramadi and Baghdad cities, Iraq. This investigation covered a duration of 6 years (2016-2021). We reviewed the medical records of patients with ZCFs. The participants were divided into 2 groups according to the approach used for their management (direct versus indirect approach). Data regarding the demographic and clinical characteristics were recorded for each subject. Of 265 patients with ZCFs, 209 (78.9%) were males. The highest age group affected was 18 to 40 years (51.7%). The majority of the ZCFs were caused by road traffic accidents (31.7%). Most of the cases belong to single fractures (72.1%). Cheek flattening (73.6%) was the commonest sign of the ZCFs. The majority of the fractures were treated by direct approach, 65.4% of the isolated fractures and 62.2% for multiple fractures. Excellent patient satisfaction was seen in the majority of the cases. There were no statistically significant differences between the 2 approaches regarding the abovementioned variables ( P -value > 0.05). The majority of the cases were with excellent patient satisfaction (n = 149) while only 7 patients with poor satisfaction. The age groups below 18 years and 18 to 40 years were associated with excellent patient satisfaction than good and poor satisfaction. All (n = 7) of the cases with poor satisfaction belong to the age group above 40 years. The majority of male (n = 113) and female (n = 36) patients were with excellent satisfaction, while all patients with poor results were males (n = 7). There were statistically significant differences between the results of the patient satisfaction and age group and complications ( P -value < 0.05). The ophthalmic complications were the most complications seen after ZCF surgical treatment (2.56%). Direct and indirect approaches can be used safely in the treatment of ZCFs owing to excellent patient satisfaction in the majority of the cases and a low complication rate. This study aims to evaluate the demographic and clinical characteristics and to compare different surgical procedures to treat patients with zygomaticomaxillary complex fractures in a country overwhelmed by violence.

Management of Mid-Facial Fracture Complicated by Pseudoaneurysm of Posterior Superior Alveolar Artery.

Facial fractures, particularly mid-facial fractures, can result in various complications, such as functional and esthetic problems. Prompt reconstruction of the fractured bones is crucial for restoring normal anatomy and function and preventing complications. However, such procedures can be complex and carry the risk of potential complications. The authors report the case of a 27-year-old man who underwent open reduction and internal fixation of the left zygomatic complex fracture and reconstruction of the left inferior orbital wall. During the surgery, heavy bleeding from the posterior superior alveolar artery due to a broken bone near the pterygomaxillary region caused a prolonged surgery time and the development of a pseudoaneurysm. The pseudoaneurysm was eventually treated with superselective transcatheter embolization using 25% N-Butyl cyanoacrylate glue. This case highlights the challenges in the management of mid-facial fractures and the potential complications that can arise during surgery, particularly when dealing with the pterygomaxillary region.

Treatment of Sagittal Fracture of the Zygomatic Arch Root.

A sagittal fracture at the temporal root of the zygomatic arch (ZAR) often occurs as a component of zygomaticomaxillary complex (ZMC) fractures. However, this area is difficult to access, and anchorage is limited due to the unstable structure around it. Therefore, a preauricular approach using single-screw fixation is proposed, and this study reports its results and usefulness. Forty-four patients with sagittal fractures of ZAR occurring with ZMC fractures were evaluated from 2012 to 2021. Open reduction and internal fixation were performed on all patients with ZMC fractures. Closed reduction using Dingman incision and external finger pressure in group A (indirect approach; 30 patients) and single-screw fixation using a preauricular approach in group B (direct approach; 14 patients) were performed to address sagittal fractures in ZAR. For single-screw fixation, the additional mean operation time was 11.34±3.25 minutes. On postoperative 3-dimensional computed tomography and plain radiographs, group B showed more accurate reduction and less deformity and trismus ( P <0.05). Moreover, a normal diet was initiated more quickly in group B than in group A ( P <0.05). Some cases in group A showed nonunion or malunion. This study revealed that a direct approach (group B) toward sagittal fractures of ZAR is recommended due to more accurate results and fewer complications than those observed with the indirect approach (group A). Moreover, the total operation time and complications may be lesser than those with the bicoronal approach.

Changes in Facial Symmetry Following Computer-Assisted Secondary Correction of Craniofacial Fractures.

OBJECTIVE: For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation. METHODS: This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos. RESULT: All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm. CONCLUSION: This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction.

Virtual Surgical Planning and 3-Dimensional Printing for the Treatment of Zygomaticomaxillary Complex and/or Orbital Fracture.

BACKGROUND: Traditionally, in zygomaticomaxillary complex and orbital fractures, miniplates and titanium orbital mesh are used and adapted intraoperatively, which may cause fatigue of the metal and increase the surgical time. Recently, computer-assisted surgery and 3-dimensional printing enable the surgeon to employ 3-dimensional segmentation and mirroring tools, which mimic the pretraumatized anatomy on which the miniplates and titanium orbital mesh are preoperatively molded to precisely duplicate the orbital volume, enophthalmos, and zygomatic bone position. AIM: To evaluate the results of computer technology using 3-dimensional printing model to prebend miniplates and titanium orbital mesh in the restoration of orbital volume, enophthalmos, and zygomatic bone position in the initial management of patients with zygomaticomaxillary complex and/or orbital fractures. PATIENTS AND METHODS: This prospective clinical study included 10 Iraqi male patients who met the eligibility criteria and subjected to open reduction and internal fixation utilizing virtual surgical planning and a 3-dimensional model to prebend miniplates and titanium orbital mesh as a treatment modality for facial fractures. The data were analyzed according to the orbital volume, enophthalmos, zygomatic bone position, age, gender, etiology of the fracture, and complications. The patients were radiographically followed up with a computed tomography scan at 4 months postoperatively. The statistical analysis was performed using percentages, the mean±SD, Shapiro-Wilk test, Paired t test, One Way Anova, and Independent t test. RESULTS: The age of the patients ranged from 18 to 66 years, with an average of 28.6 years and a SD of±14.5 years. Regarding gender, all patients were males. By utilizing virtual surgical planning and 3-dimentional model to prebend miniplates and titanium orbital mesh and concerning the fracture types, which include the zygomaticomaxillary complex, orbital, and combined fractures, there was no significant difference between the measurement of intact side and 4 months postoperatively in orbital volume, enophthalmos, and zygomatic bone position ( P >0.05). CONCLUSION: This study demonstrated that computer-aided techniques, virtual planning, and the use of prebend miniplates and titanium orbital mesh enable anatomically precise reduction and fixation of the orbital, zygomaticomaxillary complex, and combined fractures regarding orbital volume, enophthalmos, and zygomatic bone position.

Critical Degree of Orbital Floor Displacement Drives Operative Repair of Zygomaticomaxillary Complex Fractures: Findings from a 10-Year Retrospective Study.

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.

Zygomaticomaxillary complex fractures: finding the least complicated surgical approach (A Randomized Clinical Trial).

BACKGROUND: Many approaches have been suggested for management of zygomaticomaxillary fractures. Each approach has its own advantages and limitations. AIM OF THIS STUDY: The study is intended to compare between the subtarsal approach, conventional transconjuctival approach and the Y- modification of the transconjuctival approach in the management of zygomatico-maxillay complex fractures. MATERIALS AND METHODS: Twenty-four patients with age range of 20-50 years requiring open reduction and fixation of a fractured zygomatic complex were randomly divided into three equal groups. Group A: subtarsal approach group, group B: a conventional transconjunctival approach group and group C: Y- modification of the transconjunctival approach group. Intraoperative and postoperative parameters were evaluated. RESULTS: As for the exposure time, group C had the longest duration. Easy access to the site of fracture was reached in all groups with no statistically significant difference. During the first 24 h, the pain was only statistically significant between groups A and B with higher pain level in group A. After the first week, pain was significantly higher in groups A and C, with respect to group B. The least edema was observed in group B after 24 h, one week and four weeks postoperatively. Regarding ocular complications, wound healing and sensory nerve function, there was no statistically significant difference between the groups. Scarring was only noticeable in group A patients. CONCLUSION: The transconjunctival approach provides adequate exposure with excellent esthetics and minor complications. The Y-modification also delivers an esthetic access with inconspicuous scar to the frontozygomatic region. TRIAL REGISTRATION: The trial has been registered on clinicaltrials.gov (ID: NCT05695872).

The Relationship Between Morphometric Measurements, Severity, and Success of Zygomatic Arch Fracture Reduction.

PURPOSE: Identify associations between preoperative radiographic measurements and clinical findings of zygomatic arch fractures and postoperative radiographic measurements. Based on those findings, propose a comprehensive treatment algorithm for the solitary zygomatic arch fracture and combined zygomatic arch-zygomatic complex fracture. METHODS: Retrospective cohort study with patients referred to our department for zygomatic arch fractures between 2013 and 2018. Data analyzed included patient demographics, clinical evaluation, and radiographic information. Predictor variables were preoperative morphometric measurements: the initial latero-lateral (LL) defect was determined by the difference between the preoperative LL distances of the fractured and the healthy arches, LL distance was measured from the midsagittal plane in the cranium to the inner cortex of the most displaced arch segment, initial arch coronoid distances were measured from the medial part of the most dislocated arch fragment to the lateral aspect of the coronoid, and the anterior-posterior telescoping was measured as the distance between the 2 points in the arch that lost continuity and overlapped as a result of the fracture. The outcome was defined as the residual defect. It was calculated as the ratio between the postoperative remaining LL distance and the initial LL defect. RESULTS: A total of 179 cases were enrolled, all involving head residual defects. Statistical analysis was performed only on 149 medially displaced fractures. Results show that an initial LL defect larger than 3.5 mm has an 86.3% chance of remaining with a better residual defect (<84.1%), P = .001. Cases with antero-posterior (AP) telescoping > 1.45 mm showed a 72.4% chance of remaining with a poor residual defect >84% (P = .003). Arch-coronoid initial distance showed little effect on the chance of remaining with a large remining defect (P = .417, CI = 95%) CONCLUSION: Based on our results, we found that morphometric measurements can be used to predict the reduction results and can assist the clinician in choosing the optimal reduction method and thus increasing the success rate.

The Volume Difference Along the External Surface of the Zygomatic Bone: A Novel Method of Measuring Zygomatic Bone Asymmetry.

ABSTRACT: This study introduced the volume difference along the external surface (VDAES) of the zygomatic bone as a novel approach to assess zygomatic bone asymmetry and was the first to describe a distinctive, 4-step method of measuring it. VDAES has a potential to be used as an objective tool to evaluate dislocation and can assist surgeons in predicting risks of long-term cosmetic complications in patients with zygomaticomaxillary complex fractures. After having measured 100 healthy study participants, the observed median VDAES was 1.48 cm3 for all study participants, 2.02 cm3 for males, and 1.09 cm3 for females, with the gender difference being significant (P = 0.003). Additional studies are needed to test the hypothesis of whether VDAES is more relevant than conventional methods of clinically evaluating zygomatic bone asymmetry.