Intraoperative cone beam assessment after reduction of zygomatic fractures helps in taking a decision on associated orbital floor fractures.

INTRODUCTION: Orbital floor fracture (OFF) are frequently associated with zygomatic fractures (ZF). The reduction of the ZF may modify the features of the associated OFF. Intraoperative cone beam CT (CBCT) has shown diagnostic performance of OFF. The aim of our study was to evaluate how intraoperative CBCT control made after the reduction of ZF may help to take a decision on the associated OFF. MATERIAL AND METHOD: Patients with a unilateral displaced ZF associated with an OFF were consecutively included during a 3-year period. Intraoperative CBCT, systematically performed after reduction of the ZF, allowed to decide if the OFF needed reconstruction. The preoperative estimation made on MDCT and the intraoperative decision regarding the OFF were compared. RESULTS: Fifty-nine consecutive patients could be included in the study. Nineteen OFF were presumed to be surgical indications on the preoperative MDCT but only 16 indications were confirmed on the intraoperative CBCT, meaning that 3 OFF behaved favorably during the ZF reduction. Forty orbital floor fractures were presumed to be non-surgical on the preoperative MDCT but 6 of them worsened during ZF reduction and became surgical indications. Overall, the intraoperative CBCT control had an impact on 9 (15.3%) of the OFF. CONCLUSION: Our study showed that OFF after ZF reduction may evolve favorably or, on the contrary, get worse in 15% of the cases. Surgical indication on an OFF can therefore be confirmed intraoperatively. This allows to avoid under-treatment in the patients where the OFF worsens after ZF reduction and over-treatment in the patient where the OFF reduces after ZF.

Medicolegal assessment in cases of zygomatico-maxillo-orbital fractures and isolated orbital floor fractures in criminal cases

AIM OF THE STUDY: The aim of the study was to evaluate the prevalence of effects equivalent to moderate and severe impairment to health within the meaning of the Penal Code in patients with zygomatico-maxillo-orbital fractures and isolated orbital floor fractures. In addition, the study addressed the possibilities of applying the presented results in the preparation of medicolegal opinions in cases provided for in Articles 158 and 160 of the PC with respect to evaluating the plausibility of inflicting such bodily injuries and causing moderate and severe health impairment. MATERIAL AND METHODS: The study covered a total of 124 patients operated on in the then Clinic of Cranio-Maxillofacial Surgery, Medical Academy of Lodz, in 1996-2001, because of fractures involving the inferior orbital wall including zygomatico-maxillo-orbital fractures (95 cases) and isolated orbital floor fractures (29 cases). The group was analyzed in a statistical and descriptive manner. RESULTS: All the study patients (100%) with both types of fractures involving the inferior orbital wall exhibit symptoms and disorders which, pursuant to the PC, would constitute at least moderate, or possibly even severe, impairment to health. CONCLUSIONS: Punches or kicks to the orbital region create a real danger of causing both types of orbital fracture under study, and resulting in at least moderate health impairment.

Quantitative assessment of symmetry recovery in navigation-assisted surgical reduction of zygomaticomaxillary complex fractures.

PURPOSE: To evaluate the effects of surgical navigation in zygomaticomaxillary complex (ZMC) fracture reduction. ZMC symmetry was assessed quantitatively. MATERIALS AND METHODS: The sample comprised 25 patients who underwent surgical reduction of comminuted ZMC fractures. They were divided into two groups according to the use of surgical navigation. Reduction outcomes were evaluated using three-dimensional computed tomography models. Five pairs of landmarks were identified on all craniofacial models, and asymmetry scores were calculated based on their coordinates. In quantitative analyses, symmetry and orbital volume were compared between groups. RESULTS: All patients recovered uneventfully. Greater symmetry was observed in the navigation group than in the control group for three of the five pairs of landmarks (p < 0.05). Although postoperative volumes of the injured orbits were similar between the two groups (p > 0.05), reduced orbital volumes were larger in the navigation group, indicating better restoration of the fractured orbits (p < 0.05). CONCLUSIONS: The use of surgical navigation can increase postoperative symmetry of the bilateral ZMC. The quantitative evaluation of clinical outcomes is precise and highly reliable.

How to produce pre-shaped rigid arch bars using low-cost 3D printing technology - A technical note.

Numerous oral and maxillofacial procedures in dentate patients begin with the fixation of occlusions. While several techniques exist to perform mandibulo-maxillary fixation, many surgeons use arch bars in common practice. In cases of severe craniofacial traumas or jaw malformations, such as temporomandibular joint ankylosis, it may be impossible to use rigid arch bars. This technical note reports on the development of a technique to produce pre-shaped rigid arch bars using 3D printing technology. We take the case of a patient who presents Le Fort 1, Le Fort 2 and Le Fort 3 fractures as well as a central palatine disjunction, an angular mandibular fracture and bilateral zygomatic fractures. We specify the indications and limitations of this technique.

Electromyography assessment in zygomaticomaxillary complex fractures.

OBJECTIVE: The aim of this study was to assess the activity of the masseter and temporalis muscles using surface electromyography (EMG) in patients with zygomaticomaxillary complex (ZMC) fractures. PATIENTS AND METHODS: This prospective study was carried out on 25 patients who had ZMC fractures. Fifteen patients were managed by open reduction and rigid fixation (ORIF) using titanium miniplates. This study, using surface electromyography, analyzed the activity of the masseter and temporalis muscles of 25 patients with ZMC fractures; 15 of them were surgically treated under general anesthesia (GA). Evaluations were made before surgery and 6 weeks after surgery by recording the mean of muscle contraction of 20 motor unit action potential (MUAP) against resistance, and statistical analyses were performed. RESULTS: A significant EMG difference between the normal and ZMC fracture sides was found (P < 0.0001) for both masseter and temporalis muscles and was significantly improved after ORIF. However, postoperative EMV values of the repaired side was significantly less than measured postoperatively in the normal side (P < 0.0001) for both muscles. CONCLUSION: ZMC fractures significantly diminish muscular activity of the masseter and temporalis and even though significant recovery of muscle activity was revealed after 6 weeks, it is still less than normal activity, highlighting the importance of postoperative rehabilitation.

Digital surgical templates for managing high-energy zygomaticomaxillary complex injuries associated with orbital volume change: a quantitative assessment.

PURPOSE: This study sought to introduce 3-dimensional (3D) virtual surgical planning and digital rapid-prototyping templates for zygomaticomaxillary complex (ZMC) injuries associated with orbital volume change and to evaluate the surgical outcomes quantitatively. PATIENTS AND METHODS: Eight patients who underwent open reduction and fixation for a ZMC injury with orbital volume change were studied. Computed tomographic (CT) scan of the zygomaticomaxillary area was performed before the operation in each case. Scanned data were converted into 3D models using Mimics software (Materialise, Brussels, Belgium) for surgical designs. Virtual surgical reductions and correlated guiding templates were designed using Mimics and Magics software (Materialise). The operations were performed with the help of prefabricated templates to reduce the fractures. A postoperative CT scan of each patient was obtained within 2 weeks after surgery, and quantitative measurements were made to assess the surgical outcomes. Preoperative volumes of the bilateral orbits were compared, and concordance with postoperative volumes of the bilateral orbits was assessed. Twenty-one pairs of distances from 7 marker points to 3 reference planes were measured to assess postoperative facial symmetry. RESULTS: Volumes of the injured orbits were significantly different from volumes of the uninjured orbits preoperatively (P < .05), whereas bilateral orbital volumes showed no statistically significant difference postoperatively (P > .05). In addition, 19 of the 21 pairs of bilateral distances showed no significant difference postoperatively (P > .05). CONCLUSIONS: Quantitative assessment showed that digitally designed, rapid-prototyping templates for ZMC fractures have a positive impact on restoring facial symmetry and concordance of bilateral orbital volumes.

Assessment for treatment of tripod fractures of the zygoma with microcompressive screws.

PURPOSE: The present prospective study sought to evaluate a new rigid internal fixation device called a "neck screw," which was applied to patients presenting with a tripod fracture of the zygomaticomaxillary complex. PATIENTS AND METHODS: Seventeen patients with tripod fractures received surgical treatment from 2007 to 2010, and had their zygomaticomaxillary complex monofragments fixed using the neck screw protocol. The adequacy of fracture reduction, stability of the zygomatic monofragment after fixation, cosmetic outcomes, and postoperative complications were used to determine the efficacy of this protocol. The stability provided by the neck screw was evaluated by computed tomography (CT) scans by comparing the immediate postoperative distances between the fractured bone segments (control group) with those distances measured on CT scans obtained 5 weeks later (late group). RESULTS: The average distance observed between the fractured ends on the immediate postoperative CT scan was less than 0.58 mm, demonstrating adequate fracture reduction. No significant changes were seen in these postoperative values after 5 weeks (Wilcoxon test, P = 1.0000), demonstrating no displacement of the zygomaticomaxillary complex monofragment after fixation using the neck screw. CONCLUSIONS: The proposed surgical treatment proved efficient in 17 patients. The fixation stability provided by the neck screw was confirmed by subsequent CT scan measurements, statistical analysis, and clinical follow-up during the postoperative period, in which patients showed no significant associated complications, facial asymmetry, enophthalmos, or diplopia.

Incidence and management of zygomatic fractures at a level I trauma center.

PURPOSE: The purpose of this study is to evaluate current treatment of zygomatic fractures presenting at a level I trauma center. METHODS: Radiology records over a 1-year period were retrospectively reviewed to determine all patients diagnosed with fractures through the zygoma. A total of 1049 computed tomography maxillofacial scans were reviewed which identified 243 patients with fractures through the zygoma. Of these, 200 patients were identified as clinically relevant zygomatic fractures defined as having 3 or more major buttress fractures. RESULTS: Among the 200 patients identified with zygomatic fractures, 132 patients were treated nonoperatively and 68 patients required operative management. In the operative group 31% were treated with a limited (one-buttress) approach. CONCLUSIONS: Review of our management of zygomatic fractures at a level I trauma center found a high incidence of zygomatic fractures (66%) that can be managed nonoperatively without significant complications. There is a select group of zygomatic fractures that can be successfully managed by the experienced surgeon with a limited one-buttress approach.

Assessment of the adequacy of closed reduction in fractures of the zygomatic arch using "C"-arm image intensifier.

Major problems in closed reduction of isolated, minimally displaced, and depressed zygomatic arch fractures are blind nature of the technique, reliability on digital palpation, reduction click, and step deformity between fragments. The purpose of this study was to objectively confirm the adequacy of closed reduction intraoperatively and the usefulness of the "C"-arm image intensifier. A total of 12 patients with 1- to 8-day-old unilateral isolated and depressed zygomatic arch fracture underwent closed reduction under "C"-arm image intensifier. Of these patients, 9 were men and 3 were women, with age ranging from 18 to 32 years. Intraoperative prereduction and postreduction images were obtained using the "C"-arm image intensifier. Criteria for adequate reduction were the following: intrafragmentary gap less than 0.5 mm, no overriding of fragments, no depression of fragments, and no step deformity. After being clinically satisfied about the reduction, images on "C"-arm showed no intrafragmentary gap. In 3 patients, there were residual overriding and minimal rotation around the anteroposterior axis of the posterior fragment. In 1 patient, rotation and step deformity remained. In this patient, additional stabilization was provided. The "C"-arm image intensifier shows some poorly reduced or unstable isolated depressed zygomatic arch fractures that remain unidentified even after careful palpation. Thus, it plays a recognizable role to avoid the trouble of second intervention.

National hardware removal rate associated with internal fixation of facial fractures.

PURPOSE: There has not been a broad national examination of complications and demographics of facial trauma reduction procedures. The literature has reported acceptable and unacceptable hardware removal rates in localized populations. MATERIALS AND METHODS: The 2007 Nationwide Inpatient Sample was used to determine all plate removal procedures associated with common complications from facial reductions. Statistical analysis was used to compare the differences in demographics of the reduction procedure and removal procedure groups. RESULTS: Some form of open fixation was reported in 4,879 patients. Plate removals associated with complications were reported in 246 patients. The "failure" removal rate as a percentage of the total number of open procedures for the year was 5.0%. Gender, race, age, primary payer, and median income of the patient were determined to significantly affect the likelihood for hardware removal due to complications. CONCLUSION: These results suggest that decreased lower bone quality and ability to pay affect the chances that a particular patient will undergo a hardware removal procedure. There is a strong possibility that the reported removal rate underestimates the actual failure rate of the procedures and devices used to treat facial trauma.

Is transfacial Kirschner wire fixation still indicated in isolated zygomaticomaxillary complex fractures? Retrospective study of 216 cases in CHRU of Lille: epidemiology, therapeutic management, and results.

INTRODUCTION: No consensus on both contention and reduction a type in zygomaticomaxillary complex (ZMC) fractures' treatment exists. We tried to evaluate the percutaneous hook reduction method and the transfacial Kirschner wire (K-wire) fixation method in these fractures' treatment. This study also analyses epidemiological data of 4 million inhabitants (Nord-Pas-de-Calais region) in this trauma type. MATERIALS AND METHODS: All the ZMC fractures treated in our department from September 2000 to November 2006 were reviewed retrospectively. The patients were evaluated by clinical and radiologic assessment. Therapeutic data and results were analyzed. RESULTS: We reviewed 216 consecutively isolated ZMC fractures managed in our unit: 39 women and 177 men were included (sex ratio, 1:4.5). Mean age is 33.1 years. Assault is the main etiology before motor vehicle crashes. The average treatment delay is 3.5 days, and the mean delay before surgery is 10.3 days. All of the patients who had surgery underwent percutaneous hook reduction, and 77.3% of reduced fractures needed a contention realized at least by interosseous K-wire fixation in 94.6% of the cases. Reduction results were not satisfying in 5.6% of the patients who had surgery. DISCUSSION: This study aimed to evaluate a method of ZMC fractures treatment and to eventually modify some aspects. We proposed a guideline allowing a main importance to clinical examination and to interosseous transfacial K-wire fixation associated with an open reduction with frontozygomatic and/or infraorbital rim osteosynthesis if mandatory.

Intraoperative repositioning assessment using navigation system in zygomatic fracture.

BACKGROUND: Intraoperative repositioning assessment in the zygomatic fracture operation is very important in achieving adequate facial symmetry. A navigation system that has been developed in neurosurgery has recently been applied in the otolaryngol, orthopedic, and maxillofacial surgeries. We used a navigation system (Stealth Station TREON; Medtronic) in zygomatic fracture operation, and found it useful in performing accurate reduction and confirming the symmetry. METHODS: We applied a navigation system in 6 patients with zygomatic bone fracture. Navigation aided reduction of the bone fracture was performed by evaluating intraoperative procedures: (1) an evaluation by measuring the distances from the midline of the face and (2) an evaluation by comparing the affected side to the mirror image of the nonaffected side. A method using the distance from the midline of the face was performed in 3 cases, and a method using the mirror image of the nonaffected side was used in 6 cases. RESULTS: Accurate reduction and symmetry were confirmed during the operation in all patients. Good symmetry was confirmed in postoperative computed tomographic scan. It was useful in performing accurate reduction of the fractures and confirming the symmetry of the face. CONCLUSIONS: We suggest that the system can also be applied for the treatment of untreated facial fractures requiring osteotomy and of comminuted facial fractures with third-bone fragments and for the evaluation of bone graft.

Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography.

INTRODUCTION: We conducted semi-closed reduction of isolated tripod fractures of the zygoma through only a brow incision under intraoperative assessment with ultrasonography. METHODS: Twenty-three patients with unilateral, non-comminuted tripod fractures of zygoma were selected for application of this method at Tokyo Women's Medical University and Tokyo Metropolitan Hiroo General Hospital between April 2002 and April 2006. Patients with orbital floor blowout fractures were excluded. A skin incision was made only at the lateral brow region and the reduction was performed by inserting an elevator beneath the zygomatic arch. The bone alignment was intraoperatively assessed by ultrasonography. When the reduction was accurate, the frontozygomatic suture was immobilised with a mini-plate under direct visualisation and transmaler Kirshner wire fixation was performed. The accuracy of the reduction and postoperative movement were evaluated by computed tomography (CT) scans taken at 1 and 6 months. In five cases, the DICOM (Digital Imaging and Communication in Medicine) data from the CT were analysed with 3D imaging software (V-works, CyberMed Co., Korea). RESULTS: In all cases, accurate reduction was obtained. The analysis of the 3D imaging data revealed that postoperative movement of bone fragment was minimal. CONCLUSIONS: When the accurate reduction was obtained under intraoperative assessment, the semi-closed reduction and one-plate fixation with transmaler Kirshner wire is enough to treat the simple tripod fractures of zygoma. This method is minimally invasive and takes less operative time.

Single lag screw fixation for malar fracture (type B) fixation: reduction of hardware treatment costs.

In an attempt to define the most simple and inexpensive method of achieving postreduction stability in zygomatic fractures, the authors compared two different methods of internal rigid fixation of the frontozygomatic suture line in one group with miniplates and in another group with Panfix lag screws. The randomized study protocol consisted of a control group of 20 patients and 40 patients with laterally displaced body fractures of the zygoma. Statistical differences were not seen between the control subjects and the patients who required open reduction and internal fixation either with one osteosynthesis plate at the frontozygomatic suture line or a lag screw osteosynthesis. Lag screw fixation in malar type B fractures could lower hardware treatment costs and is an alternative method that provides sufficient stability in indicated patients.

The use of computer-generated three-dimensional models in orbital reconstruction.

In this paper we describe the application of three-dimensional (3D) imaging and computer-generated models in the management of orbital deformity. The technique was found to be particularly useful in posttraumatic deformity and fibrous dysplasia involving the orbit. Further application was found in cases of radiation hypoplasia, high facial cleft, and facial atrophy. Funding restrictions necessitate appropriate selection of cases when using new and expensive 3D imaging rather than traditional and less expensive methods. To remain within a realistic budget only those patients who will clearly benefit from the third dimension compared with traditional methods of assessment and management should be selected. These include patients requiring precise reduction or secondary reconstruction in which there is a matched normal anatomical component for comparison. This application is also only beneficial where the planned reconstruction is dimensionally stable.

Portable fluoroscopy in the management of zygomatic arch fractures.

Operative methods that do not allow intraoperative visualization of the fracture fragments in patients with isolated zygomatic arch fractures often result in inadequate reduction. This article describes a technique using a portable, surgeon-operated fluoroscopic machine that can be used preoperatively, intraoperatively, and postoperatively in patients with isolated zygomatic arch fractures. Using the portable fluoroscopic unit, reduction of isolated zygomatic arch fractures was performed in 9 consecutive patients over a period of 1.5 years. Postoperative alignment was confirmed using computed tomography (CT). These CT images were compared with the fluoroscopic images in several of the patients. Eight of the nine fractures were reduced via an intraoral approach and one through a Gillies approach. All nine fractures were easily visualized and their reductions were confirmed with intraoperative dynamic visualization using a portable fluoroscopic unit. Postoperative CT revealed images of the reduction that were comparable with intraoperative and postoperative fluoroscopic images. The use of portable fluoroscopy intraoperatively allows for dynamic visualization of instrumentation and the immediate confirmation of the adequacy of fracture reduction. Moreover, this technique may eliminate the need for postoperative CT in isolated zygomatic arch fractures. Portable fluoroscopy may also have a place in the management of certain zygomatic complex fractures.

Costo estimado de la cirugía ambulatoria en la fractura cigomática estable / Estimated cost of the ambulatory surgery in the stable zygomatic fracture

Se realizó un estudio prospectivo relacionado con economía de la salud en 80 pacientes con fracturas cigomáticas estables. Los casos fueron distribuidos aleatoriamente en dos grupos similares: uno integrado por los tratados ambulatoriamente y el otro, por los hospitalizados en el servicio de Cirugía Maxilofacial del Hospital Provincial Docente "Saturnino Lora" de Santiago de Cuba durante los meses de abril a septiembre de 1994. El costo de un paciente con esta afección operado de forma ambulatoria resultó ser de $ 22,85, mientras que en el tratado bajo régimen de hospitalización fue de $ 222,23, lo que significó un ahorro por dicho concepto de $ 199,48. Como factores decisivos en este aspecto figuran los indicadores de hospitalización y unidad quirúrgica en el grupo ingresado. Este último fue estadísticamente significativo

Management of midface fractures: fifty years later.

Much has changed in the 50 years since Dr Parker described the development of rapid means of transportation as a portent of an increase in maxillofacial trauma. Contemporary surgeons must concern themselves with a host of nonsurgical care issues that are an integral part of oral and maxillofacial surgery practice. Expectations related to the patient, government, insurance carrier, and hospital staff have created a new practice environment. Standards of care are high and surgeon and patient needs are more complex. Dramatically improved diagnostic capabilities, use of open surgical techniques, improved rigid fixation devices, advances in techniques of resuscitation, and more focused surgical training have markedly improved the care of the facial trauma patient. The midface remains the central focus of our gaze when we engage in interpersonal relationships. Developmental and acquired aberrations of this region are likely to be more obvious than lower face abnormalities and, therefore, perceived as more disfiguring. Complex midface trauma repair requires precise surgical technique, with little margin for error. When ideal results are not achieved, the common contributing factors are intercurrent serious injury, anatomic and wound repair considerations, and failure to execute fracture repair principles. Hard and soft tissue volume changes may further compromise midface fracture repair, irrespective of the quality of the surgical outcome. Despite the advances made in the last 50 years, there is still room for future progress. An interdisciplinary committee of surgeons treating facial trauma should convene to establish a classification system for midface fractures that would satisfy medical record keeping and coding requirements, and facilitate fair and consistent reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)