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 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.

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

BACKGROUND: Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. METHODS: A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. RESULTS: Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. CONCLUSIONS: These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

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.

Pediatric Le Fort, Zygomatic, and Naso-Orbito-Ethmoid Fractures.

Fractures of the pediatric midface are infrequent, particularly in children in the primary dentition, due to the prominence of the upper face relative to the midface and mandible. With downward and forward growth of the face, there is an increasing frequency of midface injuries seen in children in the mixed and adult dentitions. Midface fracture patterns seen in young children are quite variable; those in children at or near skeletal maturity mimic patterns seen in adults. Non-displaced injuries can typically be managed with observation. Displaced fractures require treatment with appropriate reduction and fixation and longitudinal follow-up to evaluate growth.

Is three-point fixation needed to mechanically stabilize zygomaticomaxillary complex fractures?

Fixation is critical in zygomaticomaxillary complex (ZMC) fractures to avoid malunion; however, controversy exists as to how much hardware is required to achieve adequate stability. Current fixation regimens may not represent the minimum stabilization needed for uneventful healing. Craniomaxillofacial (CMF) computational models have shown limited load transmission through the infraorbital rim (IOR), and a previous experimental study of ZMC fractures has suggested that IOR plating does not alter CMF bone strain patterns. This study aimed to measure the impact of stabilization on fracture site displacement under muscle loading, testing the hypothesis that three-point fixation is not critical for ZMC fracture stability. Four ZMC complex fractures were simulated on two cadaveric samples and stabilized with three-point plating. Displacements simulating mouth openings of 20 mm and 30 mm were applied to the mandible using a custom apparatus. Fracture gap displacement under load was measured at multiple points along each fracture line, and bone strain was captured using a combination of uniaxial and rosette gauges. Data capture was repeated with the IOR plate removed (two-point fixation) and with the zygomaticomaxillary plate removed (one-point fixation). Fracture displacement under muscle loading was consistent, with gaps of less than 1 mm in 95% of cases (range 0.05-1.44 mm), reflecting clinical stability. Large variabilities were observed in the strain measurements, which may reflect the complexity of CMFS load patterns and the sensitivity of strain values to gauge placement. This study supports the concept of hardware reduction, suggesting that two-point (or even one-point) fixation may provide sufficient stability for a ZMC fracture under applied muscle loading.

E-scooters and maxillofacial fractures: a seven-year multi-centre retrospective review.

BACKGROUND: Standing electric scooters (e-scooters) are a cost-effective and environmentally-friendly transport alternative, but also elicit substantial concern regarding associated craniofacial injuries. This study aims to describe the patient factors, procedural factors and post-operative outcomes of maxillofacial fractures caused by e-scooter accidents. METHODS: Retrospective chart review of patients aged 18 years or older who were surgically treated for these injuries in 2014-2020 at two Australian tertiary hospitals. RESULTS: There were 18 cases included. Most cases were male (66%). The mean age was 35 years. Common risk factors were alcohol use (86%) and lack of helmet use (62%). The most common fracture pattern was zygomatico-maxillary complex (ZMC) fractures (50%). There were no associated systemic injuries. Mean operation timing was 12 days post-injury for ZMC fractures and 3 days post-injury for condyle fractures. For ZMC fractures, the most common method of fixation was 2-point fixation (66%). For condyle fractures, the most common surgical approach was arch bars only (83%). Post-operative complications were reported in six cases, with malocclusion being the most common (n = 3). Revision surgeries were performed in two cases. CONCLUSIONS: Maxillofacial fractures associated with e-scooter accidents appear to be increasing in incidence. Robust longitudinal evaluations with larger sample sizes are required to better understand associated presentations, surgical approaches and post-operative complications.

Ophthalmologic Outcomes in Zygomaticomaxillary Fracture Repair With and Without Orbital Floor Repair.

Introduction: Orbital floor (OF) fractures accompany all zygomaticomaxillary complex (ZMC) fractures, but guidelines for repair of OF fractures in this setting are unclear. Objectives: To compare ophthalmologic outcomes of ZMC repair with and without concurrent OF repair. Methods: We retrospectively reviewed patients undergoing ZMC fracture repair with and without OF repair between 2016 and 2018. Patients were reviewed for demographics, preinjury characteristics, and ophthalmologic outcomes. Results: Of 61 total patients, 32 underwent concomitant OF repair while the remaining 29 underwent ZMC repair alone. The OF repair group had increased OF fracture size, displacement in the coronal plane, and malar eminence displacement (p < 0.05). Eight patients in the OF repair group had postoperative diplopia compared with no patients in the group without OF repair (p < 0.05). Conclusion: Retrospective analysis of ZMC fracture repair without and with OF repair did not reveal a significant difference in short-term ophthalmologic outcomes while controlling for fracture size.

Age-Related Outcomes in Le Fort Fractures.

This study aims to provide patient characteristics and short-term clinical outcomes of Le Fort fractures. Using the National Surgical Quality Improvement Program database from 2016 to 2019, cases involving Le Fort fractures on initial encounters were reviewed. 130 cases from 3293 facial fractures were identified. 70 cases were diagnosed with type I, 41 with type II, and 19 with type III. The male-to-female ratio was 4.9:1. Compared to geriatric patients (>65 years old), Le Fort fractures were more common among patients between the ages of 18 and 65 (P < .003). 5.4% of patients had in-hospital complications, including sepsis, superficial-deep incisional surgical site infection, and wound disruption. Two patients (1.5%) were readmitted, while three (2.3%) underwent reoperation. Type I fractures in adult males are the most common presentation. Overall complication rates for surgical repairs are low.

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.

Open Mandible and Maxillary Fractures Associated with Higher Risk of Infection in Victims of Assault.

Background: Victims of assault (VOA) often present with fractures of the mandible and maxilla. They represent a complex challenge because of possible compromise of the airway, and infection-related complications because of potential involvement of the oral cavity. We hypothesized that open mandible and maxillary fractures in VOA are associated with a higher rate of infection compared with non-VOA patients with open facial fractures. Patients and Methods: Patients admitted to our level 1 trauma center from 2005 to 2020 with a diagnosis of open mandible and maxillary fractures were included. Demographics, mechanisms of injury, fracture location, cultures, infectious complications, antibiotic treatments, and clinical outcomes were abstracted. Patients were stratified by their mechanism of injury into VOA or non-VOA and were compared using χ2 and Student t-test using SPSS (IBM Corp, Armonk, NY). Results: We identified 316 patients with open mandible and maxillary fractures. There were 198 patients categorized as being VOA, and 118 as non-VOA. Nineteen of 316 patients were diagnosed with infection related to the fracture (3.8% abscesses, 1.9% cellulitis, and 1.9% osteomyelitis). Although the Injury Severity Score (ISS) was higher in non-VOA patients (5.8 ± 2.6 vs. 4.9 ± 1.8; p < 0.013), most of the infections were in the VOA cohort (17/19; 89.5%; p < 0.013). Conclusions: Open fractures of the mandible and maxilla in VOA are associated with a greater risk of infection compared with non-victims of assault. The relation between VOA and poor SDH has been studied recently; clinicians should be aware of this association and implement special considerations and appropriate follow-up visits to decrease the rate of infection in this currently expanding population.

Le Fort I Osteotomy Complicated by Presence of Maxillary Sinus Septa.

ABSTRACT: Presence of maxillary sinus septa, an anatomical variant, has never been documented as a possible complication of Le Fort I orthognathic surgery procedure. This case report describes the difficulty faced by an experienced surgeon during Le Fort I down-fracture procedure. The osteotomized maxilla remained firm despite confirmation that all osteotomy cuts have been performed adequately. The presence of a bilateral sagittally oriented maxillary sinus septa extending from the floor to the roof of the sinus in this case had prevented separation of the lower maxilla during down-fracture maneuver. Such normal anatomical variant must be identified during orthognathic surgery treatment planning session to avoid grave complications.

Orbital Reconstruction in Le Fort III Fractures.

BACKGROUND: Few quantitative results are reported about the surgical effect of orbital reconstruction in Le Fort III fractures. The authors' team proposed an ordered surgery method which was effective for Le Fort III fractures. The aim of this study was to evaluate the effectiveness of this method with quantitative outcomes. METHODS: A retrospective study was conducted of all patients who were diagnosed with Le Fort III fractures and underwent orbital and facial fractures repair from January 2015 to June 2019. Surgical reconstruction was performed with an ordered surgery method. Orbital volumes were used to evaluate the effectiveness of orbital reconstruction. RESULTS: Fifteen patients (21 eyes) with Le Fort III fractures were included in this study. Preoperative and postoperative orbital volume changes were statistically significant ( P <0.01). For unilateral fractures, orbital volumes were different in 2 eyes ( P <0.01). For bilateral fractures, orbital volumes were almost the same in 2 eyes ( P =0.34). For the affected eye in unilateral fractures group and eyes in bilateral fractures group, after surgery, orbital volume were almost the same ( P =0.35). CONCLUSIONS: This study showed effectiveness and safety of the ordered surgery in the treatment of Le Fort III fractures, which would result in significant decrease in orbital volumes.

Characteristics of Orbital Injuries Associated with Maxillofacial Trauma.

INTRODUCTION: The incidence of ocular injury associated with maxillofacial trauma remains poorly defined, with reported rates ranging from 0.8% to 92%. Our study aims to more accurately characterize ocular injuries associated with midface fractures. METHODS: We performed a retrospective review of 1677 patients from 2015 to 2020 with midface fractures at a Level I trauma center. Isolated nasal bone and frontal process of the maxilla fractures were excluded. Demographic information, mechanism of injury, need for surgery, and ophthalmologic findings were documented. Statistical analysis was conducted using SPSS. RESULTS: 773 patients between the ages of 15 and 92 were identified. Trauma most commonly resulted from assault (63.8%). The association between the mechanism of injury and ocular injury was statistically significant (p = 0.003), with 78.6% of gunshot wounds and 44.3% of assault patients having an ocular injury. The Ophthalmology service evaluated 62.6% of cases preoperatively. Minor ocular injury occurred in 36% of patients, including 46.1% of isolated orbital floor, and 28.2% of zygomaticomaxillary complex fractures. Major ocular injury occurred in 10.5% of patients. CONCLUSIONS: Over 10% of patients with midface fractures were found to have major ocular injuries. Ophthalmologic exams should be performed for all patients with midface fractures to guide clinical decision making and prevent further intraoperative ocular insults. LEVEL OF EVIDENCE: Level 4. This study represents a retrospective cohort study analyzing ocular injuries detected in patients presenting to a Level I trauma center with maxillofacial fractures between 2015 and 2020 Laryngoscope, 133:1624-1629, 2023.

Profile of Hospitalizations of Children and Adolescents Victims of Transport Accidents: A Retrospective Study

Abstract Objective: To present the profile of hospitalizations due to transport accidents in individuals aged 0-19 years in a reference hospital for urgent and emergency traumatology care. Material and Methods: This retrospective study is grounded on analyzing medical records of children and adolescents hospitalized due to transport accidents in 2016 and 2017. The bivariate analyses included Chi-square and Fischer's exact tests and binary logistic regression, with a 5% significance level. Results: Four hundred and seventy-five (43.7%) of the 1,088 medical records investigated corresponded to transport accidents, and accidents involving motorcycles were the most frequent (68.3%), affecting adolescents (81.3%), while children were more involved in accidents as pedestrians (57.1%). Advancing age increases the likelihood of the outcome, with a significant association in the multivariate analysis (p<0.001). The mandible was most frequently affected in maxillofacial fractures. Conclusion: Transport accidents predominantly affect male adolescents, involving motorcycles, and the lower limbs are the most affected. The mandible was the most affected bone in maxillofacial fractures.

What are the Risk Factors for Mortality Among Patients Who Suffer Le Fort III Fractures?

PURPOSE: Le Fort III fractures are the most severe subtype of the Le Fort fractures and are associated with adverse clinical outcomes. The purpose of this study was to identify risk factors for mortality among patients who suffer Le Fort III fractures. MATERIALS AND METHODS: A retrospective cohort study was completed using the 2016-2018 National Inpatient Sample. Patients with isolated Le Fort III fractures were selected. Patients who incurred bone fractures or organ injuries outside the head and neck were excluded. There were multiple, heterogenous predictor variables. The primary outcome variable was mortality. Relative risk was used to determine independent risk factors of mortality. Statistical significance was deemed for P values less than .05. RESULTS: The final sample consisted of 559 patients (mean age, 45.9 years) who suffered a Le Fort III fracture, of whom 15 patients (2.68%) died. Most patients were male (82.7%) middle-aged adults (42.9%) of White race (66.5%) within the lowest income quartile (31.7%) that lived in large metro areas (54.9%). Relative to males, females were nearly 62 times more likely to die (P < .01). Relative to privately insured subjects, uninsured subjects were 23 times (P < .05) more likely to die. Relative to weekday admissions, weekend admissions increased the risk of mortality by 8 times (P < .05). Cranial vault fractures (odds ratio, 7.24; P < .05) and upper cervical fractures (odds ratio, 63.27; P < .05) were risk factors for mortality. Relative to males, females were at an increased risk for mortality (relative risk [RR] 7.14, 95% confidence interval [CI] 2.60, 19.61). Skull base fracture (RR 2.99, 95 CI 1.04, 8.63), cranial vault fracture (RR 3.04, 95 CI 1.07, 8.65), subdural hemorrhage (RR 2.98, 95 CI 1.10, 8.05), subarachnoid hemorrhage (RR 6.73, 95 CI 2.34, 19.35), and injury of blood vessels at neck level (RR 13.24, 95 CI 2.46, 71.16) were each risk factors for mortality. CONCLUSIONS: Intracranial injury was not a risk factor for mortality. Instead, cranial vault fractures and skull base fractures increased the risk for mortality. In addition, uninsured patients and female patients were each at an increased risk for mortality.

Geriatric Craniomaxillofacial Fractures: Where do They Happen and Why?

PURPOSE: The geriatric population is a constantly growing population that is especially vulnerable to trauma. The primary purpose of this study was to determine what factors are associated with increased rates of hospital admission in geriatric patients who sustain craniomaxillofacial fractures secondary to falls. MATERIALS AND METHODS: This is a 5-year retrospective cross-sectional study that was conducted using the NEISS database. There were several, heterogenous predictor variables. The primary outcome variable was admission rate, which was used as a proxy to the severity of injury. Patient and injury characteristics were compared using chi-square and independent-sample t-tests. Binary logistic regression was conducted to determine the risk of hospital admission. RESULTS: The final sample included 2,879 cases in total. The mean age of the study sample was 78.8 years (SD, 8.6 years). Most patients were white (51.6%) females (64.2%) who were injured at their respective homes (58.7%). Relative to injuries that took place at a sports center, injuries that took place at the patient's home (OR, 2.52; P < .05) independently increased the risk for admission. Relative to maxilla fracture, orbital bone fracture (OR, 3.91; P < .05) was an independent risk factor for admission. Relative to lacerations, intracranial injuries (OR, 3.76; P < .01) increased the risk of admission. CONCLUSIONS: Craniomaxillofacial fractures that took place at the patients' home were at increased risk for admission. Orbital bone fractures and intracranial injuries were at increased risk for admission. From our, and other studies findings, screening and fall prevention interventions should be implemented amongst the geriatric population.

The Possibility of Internal Carotid-Cavernous Fistula After Maxillary Fracture.

The authors first reported a 42-year-old female patient with carotid-cavernous fistula (CCF) that occurred after maxillary fractures. She developed unilateral exophthalmos, bulbar conjunctival hyperemia, and complained of tinnitus after the operation, and was diagnosed as internal CCF through computerized tomography and Digital Substraction Angiography. After the diagnosis, the internal carotid artery was embolized with a coil under general anesthesia. The treatment effect was satisfactory but the vision of the affected side was eventually lost due to the long course of congestion. Although patients with maxillary fractures can safely undergo surgery, some unexpected complications may occur in trauma, such as internal CCF. Therefore, each patient must be subjected to accurate posttraumatic examinations and inquiries to discover possible clinical complications. Patients with exophthalmos, tinnitus, and conjunctival hyperemia may be accompanied by internal CCF. Once diagnosed, appropriate treatment such as embolization should be carried out in time to eliminate further serious sequelae.