ORAL AND MAXILLOFACIAL SURGERY - 52.172.27.147:8080

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

“ EVALUATION OF VARIOUS SURGICAL APPROACHES TO

THE

FRACTURED ZYGOMATICO-MAXILLARY COMPLEX ”

By

Dr. SHEERAZ BADAL

Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF DENTAL SURGERY

In the speciality of

ORAL AND MAXILLOFACIAL SURGERY

Under the Guidance of

Dr. UMASHANKAR K.V Associate Professor

Department of Cranio Maxillofacial Plastic and Reconstructive Surgery

COLLEGE OF DENTAL SCIENCES DAVANGERE-577 004, KARNATAKA, INDIA.

2006 - 2009

DDeeddiiccaatteedd ttoo

MMyy PPaarreennttss wwhhoossee BBlleessssiinnggss,,

LLoovvee aanndd SSaaccrriiffiicceess hhaavvee mmaaddee

TThhiiss wwoorrkk aa rreeaalliittyy……

ACKNOWLEDGEMENT

To begin with, I would like to bow my head and thank the most merciful and

compassionate, The Almighty God for his blessings on me, without which no

endeavour would ever be success.

I consider it my utmost privilege and honour to express my deep sense of

gratitude, appreciation and indebtedness to my respected teacher and Guide Dr. Uma

Shankar K.V, Associate Professor, Department of Cranio Maxillofacial Plastic and

Reconstructive Surgery, Davangere, for his efficacious guidance, altruistic co-

operation and support during the preparation of this Dissertation and throughout my

post graduation course. I am indeed deeply indebted for his kindness, courtesy,

untiring patience and meticulous care in correcting my mistakes during the course of

this study. This dissertation could not have been written without him, who not only

served as my supervisor but also encouraged and challenged me throughout my

academic program.

With gratitude and humbleness, I sincerely thank Dr. David P Tauro,

Professor and Head, Department of Cranio Maxillofacial Plastic and Reconstructive

Surgery, College Of Dental Sciences, Davangere for his supportive encouragement,

co-operation and support during my post graduation course. As his student, I have

not only inculcated knowledge in the art and science of Oral and Maxillofacial

Surgery, but also in other humane qualities of life. His abstruse knowledge,

proficiency in the subject, sincerity and dedication will always be a source of

inspiration to strive for excellence.

I take this opportunity to express my heartfelt gratitude to Dr. Rajendra

Desai, Professor, Department of Cranio Maxillofacial Plastic and Reconstructive

Surgery, College of Dental Sciences, Davangere, He is excellence personified with the

VI

highest of ideals and the deepest of convictions, which have been truly inspirational

for me and will continue to be in future

I wish to express my sincere appreciation and heart felt gratitude to

Dr. Shiv Bharani, Professor, Department of Cranio Maxillofacial Plastic and

Reconstructive Surgery, College of Dental Sciences, Davangere, for ushering me

towards academic & clinical excellence. His constant support and valuable advice

kept me motivated always.

I sincerely thank Dr. Manjunath, Professor, Department of Cranio

Maxillofacial Plastic and Reconstructive Surgery, College of Dental Sciences,

Davangere, for his constant support and indispensable suggestions.

It is with a humble sense of gratitude and heartfelt appreciation that I express

my sincere thanks to Dr. Shubha Lakshmi, Associate Professor, Department of

Cranio Maxillofacial Plastic and Reconstructive Surgery, College of Dental Sciences,

Davangere, for her professional guidance and whole hearted support throughout my

post-graduate course.

My sincere and warm gratitude to Dr. Kiran Neswi, Anaesthetist, Department

of Cranio Maxillofacial Plastic and Reconstructive Surgery, College of Dental

Sciences, Davangere,Reader, for her overwhelming encouragement, unflinching

support.

This is a great opportunity to express my respect to the other faculty members,

Dr. Yeshvanth, Assistant professor, Dr. Raya A.D. Kamath, Assistant professor and

Dr. Kiran H.Y, Assistant professor, I thank them all , for there overwhelming

encouragement and support during my study.

VII

My deepest gratitude goes to Dr. V.V. Subba Reddy, Principal, and Sri.

Shamanur Shivashankarappa, Hon. Secretary, for providing the kind of atmosphere,

fully equipped with near latest technologies.

I acknowledge Dr.Sudhanashu Saxena, for helping me in carrying out the

statistical analysis of this study.

Heartfelt thanks to my senior Dr.Rohit for his constant support, love and

encouragement throughout my course. I am thankful to My Batchmates, My Juniors

and the non-teaching Staff Members for their support and co-operation during my

study.

I am thankful to all My Patients who participated in the study and without

whom the study would have been incomplete.

This acknowledgement would be incomplete without the mention of My

Parents, My Sisters and My Friends for their innumerable sacrifices, support and

encouragement throughout my life. Indeed, without them this effort would not have

been possible.

Date : Signature of Candidate

Place : DAVANGERE Dr. SHEERAZ BADAL

VIII

LIST OF ABBREVATIONS

HRS HOURS

MINS MINUTES

PREOP POST OPERATIVE

POSTOP POST OPERATIVE

RTA ROAD TRAFFIC ACCIDENT

SD STANDARD DEVIATION

ZMC ZYGOMATIC COMPLEX

PNS PARANASAL SINUS RADIOGRAPH

SMV SUBMENTOVERTEX RADIOGRAPH

df DEGREE OF FREEDOM

IX

ABSTRACT

Background and Objectives: The “zygomaticomaxillary complex” forms a key

component of structural facial aesthetics. The surgical treatment of zygoma fracture

varies from surgeon to surgeon and also depending on the type of fracture and

circumstances. Objectives of this study are to assess the efficacy of various surgical

approaches to the treatment of fractured zygomaticomaxillary complex fractures with

the main emphasis on the adequate exposure, post operative stability achieved and

improvement in the functional and esthetic restoration.

Methods: Twenty five patients with displaced zygomaticomaxillary complex

fractures who reported to the Department of Cranio Maxillofacial Plastic and

Reconstructive Surgery, College of Dental Sciences, Davanagere were included in the

study to evaluate the efficacy of various surgical approaches to the treatment of

fractured zygomaticomaxillary complex fractures under General Anesthesia. Follow

up period for the study was six months. Stability was assessed by adequate reduction,

approximation of the fractured fragments and by return of normal contour of

prominence of cheek and infraorbital rim, which was determined by the inspection

and palpation.

Results: A variety of surgical approaches were used to gain access to the fractured

zygomaticomaxillary complex. Gradual resolution of infraorbital paresthesia was

seen, and by sixth month follow up it was completely resolved in all the patients.

One patient (4%) where combination of lateral eyebrow and infraorbital

approach was used complained of burning sensation, One patient (4%) where

combination of Coronal and Infraorbital approach was used complained of epiphora,

another patient (4%) had developed pre-auricular and temporal infection with pus

X

discharge which lead to sutural abscess. Two patients (8%) where intra-oral maxillary

vestibular approach was used developed post-op infection. Diplopia was not recorded

at the last follow up visit.

Interpretation and conclusion: Combination of Lateral eyebrow and Infra orbital

approaches are the simple, easy and effective approaches to be used in means of

treating fractures of zygomaticomaxillary complex with adequate access to the

fractured segments and minimal complications. The esthetic result were not superior

with the infraorbital approach as compared to the studies which claims that the

Transconjunctival, Subciliary and Blepharoplasty approaches have superior esthetics

results with inconspicuous scar. The intra-oral maxillary vestibular approach is a

simple, easy and effective means of treating fractures of zygomaticomaxillary

complex fractures but is associated with increase risk of postoperative infection. For

late reconstruction, maximum exposure and treatment of comminuted fractures of the

zygomaticomaxillary complex a coronal approach or an extended pre auricular

approach is preferable.

Key Words: Zygomaticomaxillary complex fractures, Lateral eyebrow approach,

Infraorbital approach, Coronal approach, Extended Preauricular approach, Maxillary

vestibular approach, Gillies temporal approach.

XI

TABLE OF CONTENTS

Page No.

1. Introduction 01

2. Objectives 04

3. Surgical Anatomy 05

4. Review of Literature 09

5. Methodology 21

6. Results 30

7. Discussion 43

8. Conclusion 61

9. Summary 63

10. Bibliography 66

11. Annexures

Proforma 74

Master Chart 77

Key to master chart 79

XII

LIST OF TABLES

SL. NO. TITLE PAGE

NO.

TABLE 1 AGE DISTRIBUTION OF THE STUDY POPULATION 33

TABLE 2 GENDER DISTRIBUTION OF THE STUDY POPULATION 33

TABLE 3 OCCUPATION WISE DISTRIBUTION OF THE STUDY POPULATION 33

TABLE 4 ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION 34

TABLE 5 DISTRIBUTION OF TYPE OF FRACTURE IN THE STUDY POPULATION 34

TABLE 6 DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE STUDY POPULATION 34

TABLE 7 DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE AMONG THE STUDY POPULATION

35

TABLE 8

DISTRIBUTION OF PRESENCE OF INFRAORBITAL NERVE PARESTHESIA AND SUBCONJUNCTIVAL HEMORRHAGE DURING SIX MONTH STUDY PERIOD AMONG THE STUDY POPULATION

35

TABLE 9 DISTRIBUTION OF STABILITY OF INFRAORBITAL RIM CONTOUR DURING SIX WEEK STUDY PERIOD AMONG THE STUDY POPULATION

35

TABLE 10 DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY POPULATION

36

TABLE 11 DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH USED AMONG THE STUDY POPULATION

36

TABLE 12 DISTRIBUTION OF TIME TAKEN FOR THE SURGERY IN HOURS AMONG THE STUDY POPULATION

37

TABLE 13 ADDITION PROCEDURES REQUIRED AFTER INITIAL TREATMENT AMONG THE STUDY POPULATION AND IN CASES REQUIRING ADDITIONAL PROCEDURES FOR STABILITY

37

XIII

LIST OF GRAPHS

SL. NO. TITLE PAGE

NO.

GRAPH 1

AGE DISTRIBUTION OF THE STUDY POPULATION 38

GRAPH 2

GENDER DISTRIBUTION OF THE STUDY POPULATION 38

GRAPH 3

OCCUPATION WISE DISTRIBUTION OF THE STUDY POPULATION 39

GRAPH 4

ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION 39

GRAPH 5

DISTRIBUTION OF TYPE OF FRACTURE IN THE STUDY POPULATION

40

GRAPH 6

DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE STUDY POPULATION 40

GRAPH 7

DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE AMONG THE STUDY POPULATION

41

GRAPH 8

DISTRIBUTION OF RESTRICTED MANDIBULAR MOVEMENTS AMONG THE STUDY POPULATION

41

GRAPH 9

DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY POPULATION 42

GRAPH 10

DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH USED AMONG THE STUDY POPULATION

42

XIV

LIST OF FIGURES

SL. NO. TITLE PAGE

NO.

FIGURE 1 FRONTAL VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 2 LATERAL VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 3 OBLIQUE VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 4 BASALVIEW OF FRACTURE PATTERNS OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 5

TEMPORO-POSTERIOR VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 6 INFERIOR VIEW OF FRACTURE PATTERN OF ZYGOMATICO-MAXILLARY COMPLEX

8

FIGURE 7 VARIOUS SURGICAL APPROACHES 50

FIGURE 8 GILLIES TEMPORAL APPROACH

50

FIGURE 9 CORONAL APPROACH 50

FIGURE 10 LATERAL EYEBROW APPROACH 50

XV

LIST OF PHOTOGRAPHS

SL. NO. TITLE PAGE NO.

PHOTOGRAPH 1 ARMAMENTARIUM 25

PHOTOGRAPH 2 PRE-OP FRONTAL VIEW OF PATIENT 25

PHOTOGRAPH 3 PRE-OP OBLIQUE VIEW OF PATIENT 25

PHOTOGRAPH 4 PRE-OP RADIOGRAPH- PNS VIEW 26

PHOTOGRAPH 5 PRE-OP RADIOGRAPH- SMV VIEW 26

PHOTOGRAPH 6 POST-OP RADIOGRAPH- PNS VIEW 27

PHOTOGRAPH 7 GILLIES TEMPORAL APPROACH 27

PHOTOGRAPH 8 CORONAL APPROACH 28

PHOTOGRAPH 9 INFRAORBITAL APPROACH 28

PHOTOGRAPH 10 LATREAL EYEBROW APPROACH 29

PHOTOGRAPH 11 MAXILLARY VESTIBULAR APPROACH 29

XVI

Introduction

Introduction

1

INTRODUCTION

The zygoma, a major buttress of the facial skeleton, is the principle structure

of the lateral midface. A thick, strong bone, the zygoma is roughly quadrilateral in

shape, with an outer convex (cheek) surface and an inner concave (temporal) surface.

The convexity on the outer surface of the zygomatic body forms the point of greatest

prominence of the cheek. Therefore zygomas place a major role in facial contour. It

has temporal, orbital, maxillary and frontal processes, and articulates with four bones-

the frontal, sphenoid, maxillary and temporal bones1.

It has an important role in protecting the eye, and participates in the formation

of orbital cavity, the maxillary sinus, the temporal fossa, and the zygomatic arch. The

convex shape and protrusion of the zygoma, in addition to giving contour to the

cheek, also makes this area of the midface more vulnerable to injury or fracture2.

Zygomaticomaxillary complex fractures are the common facial injuries after

maxillofacial trauma3. The main causes of fractures are trauma due to road traffic

accidents, assaults, falls, sports related injuries, and the civilian warfares3. The

prominent location of the zygoma exposes it to frequent trauma4.

The zygomatic arch, a laterally positioned element of the craniofacial skeleton

comprised of the zygoma and temporal bone, is susceptible to local trauma. Isolated

zygomatic arch fractures comprise about 10% of all zygomatic fractures and results in

noticeable depression at the arch fracture site. There may be impingement of the

fractured arch on the coronoid process, resulting in limited mouth opening5.

When not treated properly, the arch fractures may lead not only to various

cosmetic deformities related to skeletal structure of the face, but also to function

Introduction

2

disorders resulting from the pressure on the coronoid process or ankylose with the

mandible6.

The zygomatic complex injury, by definition, includes orbital involvement and

the possibility of associated ocular damage. Anatomic reduction of the lateral and

inferior orbital rims and orbital floor are necessary to reestablish facial symmetry and

the position of the globe, and to restore the normal sensations to the structures

innervated by the infraorbital nerve7.

Precise repair of fractures of the orbital zygomatic complex requires four

essential features: a through understanding of the regional anatomy; an accurate and

precise diagnosis; an unimpeded exposure; and a rigid fixation of fracture to restore

premorbid form. Although the zygomatic arch may be fractured in isolation, more

commonly it is associated with complex orbital maxillary zygomatic (OMZ) and

midface fractures. If the horizontal and vertical buttress of the orbital

zygomaticomaxillary complex and orbital floor are not properly aligned, a variety of

sequelae can occur, including enophthalmus, diplopia, rotational zygomatic

displacement, orbital dystopia and midface widening. All of these conditions are

difficult to address with revision8.

Fractures of the face and mandible have been recognized for a long time, and

attempts to treat such fractures have been recorded as far back as 25-30 centuries BC.

Zygomatic fractures were not brought to the spotlight in the literature again until

1751, when du Verney described the anatomy, type of fractures of the zygoma

observed, and his approach to reduction in two case reports. Recognizing the

importance of reduction for proper healing, Du Verney took advantage of the

Introduction

3

mechanical forces of the masseter and temporalis muscles on the zygoma in a unique

approach to closed reduction techniques.

In 1906, Lothrop was the first to describe an antrostomy approach in which he

reached the fractured zygoma through the Highmore antrum below the inferior

turbinate. He then was able to rotate the fractured zygoma upward and outward for a

proper reduction. In 1909, Keen categorized zygomatic fractures as those of the arch,

the body, or the sutural disjunction. He was the first to describe an intraoral approach

to the zygomatic arch in which an incision is made in the gingivobuccal sulcus.

In 1927, Gillies described an original approach to reduce a depressed malar

bone. He was the first to reach the malar bone through an incision made behind the

hairline and over the temporal muscle. Gillies further described the use of a small,

thin elevator that is slid under the depressed bone, thus enabling the surgeon to use the

leverage of the elevator to reduce the fracture9.

The ideal surgical approach to treat the maxillofacial injuries should provide

maximum exposure of the fractured fragments, ensure less potential for injury to the

facial structures, and allow for good cosmetic results. Limited access to the fracture

site, lack of adequate exposure, and subsequent facial scars are among the list of

objections to most of these techniques.10

Various methods for the repair of zygomatic complex fractures have been

advocated, and in this study with emphasis to the different surgical approaches. After

reviewing the advantages and limitations of various surgical approaches, a sincere

effort has been made in the form of a prospective clinical study to manage

zygomaticomaxillary complex fractures with these techniques and there efficacy is

evaluated in the larger interest of the patients.

Objectives

Objectives

4

OBJECTIVES

To assess the efficacy of various surgical approaches used for reduction of

zygomaticomaxillary complex fractures with the main emphasis on the post operative

stability achieved and improvement in the functional and esthetic restoration with

minimal complications.

Need for the study:

Zygomaticomaxillary complex fractures are the most common facial injuries

after maxillofacial trauma. Anatomic reduction of the Zygomaticomaxillary complex

is necessary to reestablish facial symmetry, position of the globe and to restore normal

sensations to the structures innerveted by the infraorbital nerve1. Displaced fractures

are treated by open reduction and internal fixation. Adequate surgical exposure is

necessary for proper reduction and fixation of the fractured fragments, requiring

various surgical approaches.

An ideal surgical approach should provide maximum necessary exposure of

the fractured segments and minimize potential for further injury to facial structures

and enable good cosmetic results. Properly placed incisions offers excellent access

with minimal morbidity and scarring. This determines the need for the study.

Surgical Anatomy

SURGICAL ANATOMY

The zygoma is a thick strong bone roughly quadrilateral in shape. The

convexity on the outer surface of the zygomatic body forms the point of greatest

prominence of the cheek. The term "trimalar" fracture actually is a misnomer as the

zygoma, having four projections, is more nearly quadrangular in shape. The frontal

process forms the superior projection; the temporal process forms the posterior

projection; the lateral portion of the infraorbital rim and part of the articulation with

the maxilla forms the inferior projection and the buttress, palpable in the buccal

sulcus, forms the medial projection.

The zygoma articulates with four bones: the frontal, temporal, maxilla and the

greater wing of the sphenoid. The zygomas inheritent architectural strength all to

withstand blows of great force without fracturing. Fractures of the zygomatic

complex, therefore, usually occur near the suture lines.

Two neurovascular bundles course through this bone first the infraorbital

nerve, and second the zygomaticofacial nerve (zygomaticotemporal nerve may course

through the zygomaticofrontal suture area). The muscles attached to it are the

zygomaticus, quadratus labii superioris, orbicularis oculi and the masseter. The

temporalis muscle and the fascia are closely associated with it.

FRACTURE PATTERNS:

When a vector forcibly comes in contact with the prominent and sturdy forces

tend to be transmitted to its four weaker articulating surfaces, the frontozygomatic,

zygomaticomaxillary, zygomatico-sphenoid and zygomaticotemporal sutures as well

as to the weaker bones that articulate with the zygoma. The zygoma is much stronger

5

Surgical Anatomy

6

than the bones with which it articulates, that it is rare to find a fracture of the body of

zygoma itself.

Edward Ellis mentioned the inferior orbital fissure is the key to remembering

the usual lines of zygomaticomaxillary complex fractures. Three lines of fracture

extending from the infraorbital fissure in an anteriomedial, a superiolateral and an

inferior direction (Fig.1- Fig6). One fracture extends anteromedially along the orbital

floor mostly through the orbital process of the maxilla, toward the infraorbital rim, the

orbital floor and the medial are often comminuted, creating multiple lines of fracture

within the internal orbit. The infraorbital canal is usually crossed by the fracture line

or lines because the fracture frequently extends through the infraorbital rim to the

facial surface of maxilla above or even slightly medial to the infraorbital foramen.

The fracture extends from the infraorbital rim in the maxilla laterally and inferiorly

under the zygomatic buttress of the maxilla.

A second fracture line extends from the inferior orbital fissure inferiorly

through the infratemporal aspect of the maxilla and joins the previously mentioned

fracture under the zygomaticomaxillary buttress.

The third fracture line extends superiorly from the inferior orbital fissure along

the lateral orbital wall posterior to the rim, usually separating the zygomaticosphenoid

suture. Extending superiorly, laterally and anteriorly towards the lateral orbital rim,

the fracture frequently separates the frontozygomatic suture, at the lateral orbital rim.

A zygomaticomaxillary complex fracture that follows this pattern usually has

one additional fracture line through the zygomatic arch. Since the point of least

resistance to fracture is not at the zygomatico temporal suture, but approximately

1.5cm more posteriorly, the point of fracture when a single fracture exists is usually in

Surgical Anatomy

7

the approximate middle of the zygomatic arch, in the zygomatic process of the

temporal bone. Frequently however, three fractures exist through the arch, producing

two free segments when the fractures are complete. These segments can be displaced

by associated muscle pull or may be pushed medially into the infratemporal fossa.

Often the fractures are incomplete or greenstick fractures, producing a medial or

lateral warping of the zygomatic arch without notable upward or downward

displacement. The variability of these fractures is great, owing to the differences in

the magnitude and direction of the force, the amount of soft tissues covering the

zygoma and the density of the adjacent bones.

It should be understood that all fractures of the zygomatic complex involve the

floor of the orbit. However, linear fractures of the floor of orbit without herniation or

entrapment of orbital contents, or both, need to be treated only if there is interference

with binocular vision or extraocular muscle function. On the other hand, isolated

fractures of the floor of the orbit can occur secondary to direct trauma to the globe.

The floor of the orbit, which along with the ethmoid bone is one of the weakest

portions of the bony orbit, may be "blown out" as force is applied to the

incompressible soft tissue contents of the rigid orbit.

Surgical Anatomy Surgical Anatomy

8

8

Review of Literature

Review of literature

9

REVIEW OF LITERATURE

In this study 85 patients with depressed fractures of zygomaticomaxillary

complex during the period from July 1, 1969, through June 30, 1972, were treated by

the oral surgical service at the Massachutsetts General Hospital, Boston. 77 fractures

required surgical intervention. The predominant approach was via the lateral eyebrow

and 16 of 17 zygomatic arch fractures were treated by the Gillies approach and left

one was treated by Tracheal hook reduction. In this study, various surgical approaches

to the fractured zygomatic complex were discussed. Data illustrated that a great many

of these fractures are unstable after reduction. For this reason, lateral eyebrow

approach, with internal wire fixation if necessary was used as the initial surgical

approach in the management of zygomatic complex fractures 24.

A technique for reduction of fractures of the zygomatic arch with the use of a

more direct anatomical approach was presented. This lateral coronoid approach

obviates the potential difficulty of coronoid interposition and elevation of an isolated

fragment encountered with the use of old keen approach. This technique provided a

more direct approach to the fractured zygomatic arch. This technique has the

advantage of elevating both the fractured segments of the arch simultaneously rather

than individually which is seen with keens approach, as with this only the anterior

fragment may be elevated alone26.

This paper reviews the morbidity of the procedure in 24 patients in whom

Bicoronal flaps were raised for access to mid and upper facial skeleton. Study was

carried out in Cannes Bur Hospital, Glassgow. 6 patients had post-operative sensory

disturbances. Ptosis was seen in patients operated for craniostenotic syndromes.

Epiphora was seen unilaterally in the patient undergoing enopthalmus correction and


10

probably followed trauma to the nasolacrimal duct. In no case did infection of the flap

occurred. It was found that low incidence of infection of the flap was due to its

profuse blood supply aided by the absence of hematoma formation which is achieved

by the suturing of the galea, suction drainage and pressure dressing. It was concluded

that Bicoronal flap was found to be useful in management of trauma and deformity of

the mid and upper facial skeleton. It provides good access for surgery of

Temperomandibular joint and zygomatic arch60.

In this study 77 patients who were treated in Brigham and Womens

Hospital, during the four and half period from july 1979 to December 1984 for the

fractures of zygomaticomaxillary complex and arch were studied. Various surgical

approaches were used to treat the fractured zygomaticomaxillary complex. Buccal

sulcus and Gillies temporal incisions were used to treat isolated zygomatic arch

fractures. The Gillies incision was used in conjunction with eyelid incisions in four

cases to provide greater leverage. The coronal flap was used in one case of severe

craniomaxillofacial trauma. Lower eyelid incisions were necessary for stabilization at

the infraorbital rims in this case. 28 cases were approached through lateral eyebrow

and lower eyelid incisions. Upper eyelid incision was the method of choice for initial

access to the zygomatic complex fractures and for late reconstruction coronal incision

was preferred. 3 patients had minor wound infections, 2 with in the lower eyelid

incision and 1 with an eyebrow incision7.

A study was conducted on 50 patients, whom the procedure Lower

blepharoplasty was performed and were followed up for 66 weeks at Walton Hospital,

Liverpool.. Ectropion was seen in 10 cases. It was transient in 8 cases and permanent

in 2 cases. It was found that the extension of the Lower blepharoplasty incision did

not increase the incidence of the ectropion. It was concluded that the Lower


11

blepharoplasty, post orbicularis approach offers an excellent exposure to the lower

half of the orbit and is therefore recommended for complicated wiring or plating

procedures and it was observed to be esthetically pleasing and associated with

minimal complications72.

A study was carried out on 68 patients, from January 1984 to June 1985, with

fractures of zygomaticomaxillary complex, who were diagnosed and treated at the

Department of Maxillofacial Surgery University of Central Hospital, Helsinki,

Finland. Follow up time was ranged from 2 weeks to 4 years. Surgical approaches like

Gillies temporal, Lateral eyebrow, Percutaneous, Buccal sulcus approach were used.

A total of 81% of the patients had paraesthesia of the infraorbital nerve, and the

figure was higher in the group of the patients with fractures requiring operative

treatment (94%). Although a regeneration was evident in a majority of cases, some

degree of hypoesthesia was found in 21(42%) out of 52 patients. However in 10 out

of 12 patients in which direct fixation with transosseous wiring of the infraorbital

margin was performed, persisting hypoesthesia was encountered. In 3 out of patients

where the nerve was also explored primarily, the sensation returned totally. A

secondary nerve deliberation was also found to be beneficial in 4 out of 5 patients

with persisting total loss of sensation. No significant differences were found between

the different methods of indirect reduction used. In majority of cases, regeneration

took place during the 1st postoperative week. It was observed that full recovery of the

nerve was achieved by 5 months45.

A study was conducted in which 16 cases of the facial bone fractures

including the malar arch treated in Hamamatsu University School of Medicine,

Hamamatsu, Japan. And the usefulness of the “Preauricular Tragus skin incision

elongated to the haired temporal region” was presented. It was concluded that


12

extension of Preauricular Tragus skin incision was carried out to improve the

visibility and safety to the malar arch during surgery. Facial nerve palsy, that is to say

inability of wrinkling unilateral forehead was observed in four patients, however this

complication disappeared over a 3 to 4 months period.

A retrospective study on the use of Bicoronal approach in treatment of

craniomaxillofacial trauma was carried out in 28 patients treated at Presbyterian

University Hospital, Pittsburg. Bilateral Lefort III with zygomaticomaxillary complex

fractures and combination of Lefort II and Lefort I. A Bicoronal flap with subciliary

and maxillary vestibular incisions were used. This study showed that this technique

provides optimum exposure of fractured site allowing for accurate anatomic reduction

and fixation of the fractured segments and good cosmetic results. Follow up period

was ranged from 3 months to 3 years. Both Bicoronal and Hemicoronal approach

allowed accurate anatomic results. Sensory nerve deficit was reported in 5 patients

which returned normal in 6 weeks. 2 patients developed hematoma in temporal

regionon 9th and 10th post-operative day. It was concluded that with an adequate

knowledge of the surgical anatomy, a coronal approach will provide an exposure that

facilitates accurate reduction and fixation of the fractures and will allow superior

cosmetic results with minimal or no complications48.

A study was conducted in 48 patients who had undergone open reduction and

internal fixation of malar fractures during 1988 at the University Of Southern

California School Of Medicine, Los Angeles. 8 of these accompanied Lefort fractures,

they were considered to be malar fractures because the zygomatic complex was truly

displaced as an intact unit.43 of the malar fractures were treated using a variable

combination of Lateral eyebrow, Subciliary and Gingivobuccal incisions to obtain a

three point reduction. In the remaining 5 patients either a coronal or hemicoronal


13

incision was used to expose the Zygomatic arch for use a fourth point of reduction. 3

of these patients had accompanied Lefort fractures, and concluded that complications

appeared to be more related to the severity of the injury than to the technique itself.

The observations justify the use of this extended access approach in selected patients

severe injuries of the Zygomatic complex15.

This prospective study analyzed 105 cases treated with Gillies temporal

approach for fractures of zygoma in Dundee Hospital and School, Scotland from 1987

to 1989. Eight of these cases required open reduction. This study suggested that

Gillies method offers the best advantage of being quick, decreasing the possibility of

facial nerve damage or direct trauma to the Globe by the instruments inserted to

protect the eye, associated with minimal complications and not being represented with

a visible scar28.

1025 consecutive zygomatic fractures managed by the Department of

Craniomaxillofacial surgery at the University Hospital in Bern, Switzerland during

1978 – 1989, were reviewed retrospectively. Zygomatic arch were reduced with ‘J’

shaped, curved hook elevator. Lateral orbital rim fractures were reduced and fixed

through Lateral Eyebrow incision. Infra-orbital rim fractures are mostly associated

with orbital floor fractures. Transconjunctival route without lateral canthotomy was

used exclusively & it was observed that this approach gives optimal exposure of the

fractured area without any cutaneous scars and causes fewer complications than the

standard approaches.

Tetrapod fractures were reduced by closed reduction, performed with a ‘J’

shaped curved hook elevator inserted through an intra oral incision and open

reduction was indicated if there was instability following reduction. For


14

multifragment zygomatic fractures combination of Lateral Eyebrow and a Buccal

Sulcus incision combined with the Transconjunctival approach avoiding a Lateral

Canthotomy were used. A Coronal flap was used only if there were concomitant skull

base fractures and or craniofacial fractures. Follow up period was 2-5 years with

average of 18 months.

Infraorbital nerve dysfunction was noted in 23.9% cases treated with open

reduction. Maxillary nerve dysfunction in the form of clinical or subclinical sinusitis

and oro-antral fistula was very low about 8.4%.

Enopthalmos with Diplopia was found in 40 patients in 3.9%. Complications

related to the Transconjunctival approach were mainly Entropion in 0.4%, Extropion

in 0.7% and Corneal abrasion in 0.1% cases38.

A study was conducted in a group consisting of 183 patients with isolated

simple Zygomatic Complex fractures treated at the Department of Oral and

Maxillofacial Surgery, Chaim, Sheba Medical Center, Israel, between 1985 and 1990.

Follow up period was ranging 6 to 12 months. The purpose of the study was to

compare the incidence of persistant sensory disturbances after recovery from isolated

simple fracture of zygomatic complex with four treatment methods. Closed reduction

via subcutaneous approach, open reduction via oroantral approach, closed reduction

via Gillies and lastly open reduction and fixation of the frontozygomatic fracture by

lateral eyebrow approach. Analysis revealved that patients treated with miniplate

osteosynthesis exhibiting a trend for higher recovery rate of infraoabital nerve than

with others. It can be explained by the fact that fixation with a miniplate provides the

best rigidity to the complex because of the three dimensional stability that can be

achieved by it. In addition it also provides the complete decompression of the


15

infraorbital nerve which is incompletely achieved by the wire osteosynthesis which

provides two dimensional stability to the bone39.

Seventeen patients with zygomatic complex fractures were treated from

December 1989 to December 1991 at Louisana University Medical Center and Shreve

Port or University of Kansas Medical Center, Kanas City. Patients had three to six

months follow up. All patients underwent a Transconjunctival approach with Lateral

canthotomy, seven subjects also had associated Sublabial flaps. Five patients required

Hemicoronal or Coronal approach. Seven minor complications were noted. Two

patients had prolonged conjunctival edema. This was believed to be secondary to

interruption of the orbital lymphatic system. Two patients had frontal nerve weakness,

both of theses were patients with Hemicoronal flap. Management of the trimalar

complex fractures was greatly facilitated by application of these approaches. 93% of

patients surveyed were either very satisfied or satisfied with their functional and

cosmetic results8.

A variety of surgical approaches were used in 48 patients with isolated

unilateral Zygomatic Complex fractures in patients who were treated at Parkland

Memorial Hospital, University of Texas, by the same staff surgeon from January 1st ,

1989 until December 31st . Most of the patients had satisfactory result with no facial

deformity. In this study maxillary vestibular incision was commonly used either alone

or in combination with other approaches. Approximately 20% of those having lower

eyelid incisions, had some amount of sclera show at the longest follow up. It was

concluded that the first area of surgical exposure, if necessary for reduction and

fixation is an intraoral approach. An incision in the lower eyelid is avoided, if

possible, to minimize the chance of postoperative scleral show. A coronal approach

was used in cases with displacement of the Zygomatic Complex posteriorly and


16

laterally and comminution of the arch and also associated medial orbital wall

fractures2.

An experience of an author with transconjunctival approach to access the

orbital floor, infraorbital rim and zygomatic frontal and zygomatic temporal sutures in

40 patients with fractures in the orbital and zygomatic region in Santa Casa Medical

Hospital, Sao Paulo, Brazil was presented. The preseptal and the retroseptal approach

were used. Ectropion was present in one patient and intropion in others. One patient

had a corneal ulcer caused by laceration during operative procedure. It was concluded

that despite the complication rate of 12.5% the esthetic results and simultaneously

visualization of infraorbital rim and lateralorbital rim supports the use of the

Transconjunctival approach because of the esthetic results and the direct and

simultaneous access to the orbital rim and the zygomatico frontal region70.

78 patients who had undergone 81 surgical procedures for fractures of

Orbitozygomatic complex over a period of 10 years were analysed during 1997, at

Department of Otolaryngology – Head and Neck Surgery, Wayne State University,

Detroit. The series consisted of 49 primary repairs (1 to 22 days postinjury), 10

delayed repairs using osteotomies at 21 days to 5 months post injury, and 22 delayed

repairs requiring onlay bone grafting from 4 months to 16 years post injury. 43

patients were available for follow up. Early surgical intervention dramatically

improved esthetic and functional outcomes, whereas late repair was less satisfactory.

Hypoesthesia was not improved by surgery. Osteotomy and onlay grafting techniques

were necessary for delayed treatment. And it was concluded that Orbitozygomatic

fractures can be repaired upto 21 days post injury using primary reduction and

fixation techniques. Osteotomies are required after 21 days and can be used


17

successfully up to 4 months post injury. After 4 months, successful repair requires

onlay bone grafting4.

1277 patients with fracture of zygomaticomaxillary complex fractures and 196

patients with arch fractures treated between 1984 & 1995 were evaluated at Oral and

Maxillofacial Clinic of K.A.T Hospital, Greece. In 514 cases Gillies temporal

approach was used to reduce fractures of zygomaticomaxillary complex. And

concluded that theGillies temporal approach method was not always successful,

because postoperative reduction was occasionally insufficient and the zygomatic

complex was not always elevated. Post operative radiographic examination showed

inadequate elevation, and in two cases arch fracture reoperation was necessary. Others

were treated with open reduction and internal fixation using various approaches. Intra

oral Buccal sulcus approach with antral packing was used in comminuted fractured

cases, but this was also found to be of less satisfaction because of risk of collapse

after removal of the pack and more chances of intra oral infection. Elevation of the

lateral orbital rim through the Lateral eyebrow approach and reduction of the

fractured fragments through the same approach was the method of choice, as its

associated with limited morbidity and improved functions68.

A retrospectively study was conducted in 50 patients with Zygomatic

Complex reduced by upper buccal sulcus approach. In 13 cases the arch alone was

fractured, in 31 cases the left zygomatic complex was fractured and one case

presented with isolated bilateral fractures of zygomatic complex. Mean follow up

period was 6 weeks. 38 patients were treated by simple elevation, 8 pateints were

treated with plating at zygomatic buttress and 4 patients with extra-oral placement of

bone plates. There was minimal morbidity, one case had mild diplopia, trismus and

swelling all of which setteled spontaneously. It was concluded that the upper buccal


18

sulcus approach is a safe, rapid and effective technique for the reduction of zygomatic

body and arch fractures22.

68 patients who were treated with Bicoronal flap were retrospectively

analysed between January 1991 and December 1996 in Queen Victoria Hospital, East

Grinsted, United Kingdom. 5 year follow up showed that the incidence of permanent

morbidity was low. 24 patients experienced some form of sensory abnormality

immediately after the operation. This persisted for longer than two years in one.

Complete motor recovery occurred by one year in 15 patients who developed frontal

nerve weakness. 3 patients developed male pattern baldness post-operatively, which

resulted in exposure of scar and poor cosmosis. They found that the pivotal point of

the bi-coronal flap was found to lie at its most inferior aspect, by extending the

incision into the skin crease in front of the lobe of the ear, it was possible to adjust the

anteroposterior position of the bicoronal incision without limiting access to facial

skeleton. They advocated the use of this type of flap in patients who are prone to male

pattern baldness53.

A series of 11 patients with comminuted zygomatic complex fractures and one

patient with comminuted malar arch fracture were treated with endoscopically

assisted fracture repair. Subciliary incision was used to access the orbital floor and

infraorbital rim. A Lateral Eyebrow incision gave access to the zygomatic frontal

buttress via the upper buccal sulcus incision the zygomatico-maxillary buttress was

reduced. The zygomatic arch was primarily approached endoscopically in all patients

via the upper buccal sulcus. In four patients an additional pre-auricular incision

extending 1.5cms above the auricle, it was necessary in order to visualize the

proximal stump of the arch. Post-operative the frontal branch of facial nerve was

intact in all patients. Scarring was minimal in 3patients plating of arch resulted in arch


19

necrosis and resorption in long term follow up. Operating time was remarkably longer

than in conventional procedures due to difficult technique33.

911 patients who were treated between 1989 and 2000 for fractures of the

zygoma were investigated in Eppendorf University Hospital, Hamburg, Germany. A

standardized interview was completed with 410 of these 911 patients in order to

collect self reports on treatment results and residual damages. The bone was exposed

via an infraorbital approach, following external reduction and osteosynthesis with

miniplates. Follow up revealed sensory disturbances in 25.6% (severe in 7.2%). The

patients reported impaired eye mobility in 1%, reduction of visual acuity in 3.9%, an

ectropion in 1%, hypersensitivity of the affected eye in 6.8%, and tear dropping in

5.8%. The patient assessed their face as asymmetry following trauma in 2.2% and

reported that the maxillary sinus caused complaints in 3.7%. And concluded that the

rate of complaints following the zygomatic complex fractures (attributable to trauma)

is in the range of other reports. The infraorbital approach is a safe technique and is

particularly preferred approach for training of young surgeons16.

A study was conducted in between January 1998 and January 2003 in Wuhan

University, Wuhan city, Peoples Republic of china, in which coronal incision was

carried out on 69 of 83 patients with zygomaticomaxillary complex fractures, the rest

14 patients were treated by various approaches. In early postoperative period, 5

patients suffered from by haemorrhage, 2 had infections, 24 patients reported with

immediate postoperative anaesthesia and paresthesia affecting the supraorbital region.

6 patients had signs and symptoms of facial nerve injury and it was explained that this

coronal approach offers advantages such as extensive site exposure and had

disadvantage of obvious scar, long operating time, infections, haemorrhage,


20

paresthesia and facial nerve palsy and therefore indicated that coronal incisions

should be strictly applied and should not be overused5.

40 Patients with isolated zygomatic arch fractures were analysed clinically in

Department of Oral and Maxillofacial Surgery, Nara Medical University, Japan in a

12 year period between January 1993 and December 2004. Gillies method was the

method of choice, because the procedure can be performed consistently and the

results are satisfactory. It was concluded that good functional and radiological

outcomes were obtained in isolated zygomatic arch fractures and the reduction status

was not influenced by either the fracture type or the interval between reduction and

injury. And the recovery achieved was excellent6.

A retrospective study was conducted in patients treated in the Department of

Oral and Maxillofacial Surgery at Jordan University Hospital between 2000 and 2006,

only cases where Subtarsal approach was used to explore the orbital floor were

included with a follow up of maximum 72 months. The study group compressed of 12

patients. All examined patients expressed their satisfaction regarding the incision both

esthetically and functionally. One patient suffered from Scleral show, one patient had

mild lid edema and one patient had keratoconjunctivitis. And concluded that subtarsal

approach when used to expose the inferior orbit in patients with isolated and

combined fractures of orbital floor produced nominal postoperative complications and

led to good surgical results, especially in terms of esthetics and ophthalmologic

outcomes71.

Methodology

Methodology

21

MATERIALS AND METHOD

SOURCE OF DATA:

This study is a prospective clinical study involving twenty five patients having

displaced zygomaticomaxillary complex fractures with insignificant medical history

to evaluate the versatility of various surgical approaches, its management, with the

main emphasis on the wound healing, post operative stability, functional restoration in

the form of mouth opening, esthetic restoration of the prominence of cheek and the

complications encountered. This study was conducted in the Department of Cranio

Maxillofacial Plastic and Reconstructive Surgery, at the College of Dental Sciences

Davanagere. The study was done under the topic “Evaluation of Various Surgical

Approaches To The fractured Zygomatico-Maxillary Complex”.

INCLUSION CRITERIA:

1. Patients reporting with zygomaticomaxillary complex fractures.

2. Patients reporting with isolated zygomatic arch fractures.

EXCLUSION CRITERIA:

1. Patients suffering with uncontrolled systemic diseases.

2. Patients not willing for the treatment.

METHOD OF STUDY:

The criteria used to determine the need for the surgical correction consisted of

a both clinical and radiologic assessment. Radiographic evidence of displacement and

combination of one or more of the following clinical signs and symptoms, restricted

Methodology

22

mandibular movements, infraorbital dysesthesia, palpable step deformity of the orbital

rim, tenderness at the fractured points, subconjunctival or periorbital ecchymosis,

diplopia and visible depression of the prominence of the cheek. A proforma was

completed for each patient requiring surgical treatment, detailing the name, age, sex,

date of injury, etiology, medical history, site of injury, involved side of the face, type

of fracture, clinical signs and symptoms, surgical approach used, duration of the

surgery, and postoperative evaluation in the form of assessment of wound healing,

functional stability, esthetic appearance and associated complications were recorded

in a exclusively designed proforma. The water’s view and submento-vertex view

radiographs were taken for the patients preoperatively and postoperatively. The latter

reviewed and post-operative assessment carried out during the immediate

postoperative period, after one week, one month, three months and six months.

SURGICAL PROCEDURE:

All the patients were treated on an inpatient basis under general anesthesia. A

variety of surgical approaches were used. The approaches used for the

zygomaticomaxillary complex were the Lateral eyebrow approach, Infraorbital

approach, Coronal approach, the Maxillary vestibular approach and the Gillies

temporal approach.

Access was gained to the particular fracture site with its corresponding

surgical approach. Stability was determined by reduction of the fractured segment and

return to normal contour of the orbital rim as assessed by palpation and proper

approximation & fixation of the fractured fragments. The incision wound was closed

with sutures using 3.0 vicryl for muscle and mucosa and 3.0 black silk for skin.

Subcuticular suturing was done using 5.0 prolene for Infraorbital approaches.

Methodology

23

All patients were administered antibiotics and analgesic. Patients were

instructed not to sleep on the side of injury and take soft diet orally. And eye cap was

placed over the zygoma for one week. This was to ensure that no pressure is exerts

upon the fractured site and to avoid unintentional trauma to the fractured site, to

contribute towards proper clinical union. Post-operative evaluation was done during

the immediate postoperative period, after one week, one month, three months and six

months, during which the assessment of wound healing, functional stability, esthetic

appearance and associated complications were recorded.

EVALUATION CRITERIA:

Wound Healing: Approximation of the incision was assessed visually and the

process of healing was noted for any tendency towards potential complications.

1. Functional Disturbances:

A) Stability of reduction:

Intraoperatively

- Reduction of the fractured fragments

- Proper approximation of the fractured fragments

Postoperatively

- Visible improvement in prominence of cheek when viewed.

- Return of normal contour of cheek and orbital rim as assessed by palpation.

- Postoperative radiographs.

Methodology

24

B) Improvement in Mouth Opening:

The improvement in mandibular movement is assessed by measuring the

interincisal distance between the maxillary and mandibular central incisors.

2. Esthethic Appearance :

It was judged according with the perception of the operator and the patient as

Acceptable or Unacceptable.

3. Complications:

Complications like Persisting pain, Infection, Wound dehiscence, Plate

exposure, Infraorbital Nerve Paresthesia, Step deformity and Depression over

the cheek, Malformed fractures, Non Union, Epiphora, Ectropion and Diplopia

were recorded.

Method of statistical analysis:

For discrete data, frequency and percentages; and for continuous data mean

and standard deviation were calculated. Further data analysis was done using Chi

square test wherever applicable. Data analysis was carried out using Statistical

Package for Social Science (SPSS, V 16) package. P value< 0.05 was considered

statistically significant.

Results are presented in Tables and Graphs.

Photographs

Photographs

25

Photographs

26

Photographs

27

Photographs

28

Photographs

29

Results

Results

30

RESULTS

A total of twenty five patients underwent the treatment of zygomatic complex

fractures. All the cases included were treated during the period from September 2006

to May 2008 in the Department of Oral and Maxillofacial surgery, College of Dental

Sciences, Davangere. The extremes of ages in this study ranged from 17-55 years

with the mean of 33.52±10.43 years. (Table-1, Graph-1) The peak incidence was seen

in the second and third decade of life. Out of the total twenty five patients selected for

the study 20(80%) were males and 5(20%) were females (Table-2, Graph-2).

Occupation wise 10 patients 12 (48%) were agriculturist making the largest group

among the study population (Table-3, Graph-3).

According to the distribution of the cause of injury of the twenty five patients,

selected in the study group road traffic accident (RTA) being the most common cause

of the injury 23 (92%) patients while only 2 (8%) patients of the study population

reported the history of Assault(Table-4 ,Graph-4). Isolated arch fracture has the least

incidence in the study with only 1 (4%) of the total 25 patients reporting arch fracture.

zygomatic complex fracture has the maximum with 24 (96%) patients (Table-5,

Graph-5).

Average reporting day after the injury to the centre was 6.6 days with

maximum of 5 patients (25%) reported the next day of injury itself. Maximum delay

between the injury day and the day of reporting was 14 days which includes 3 (12%)

patients (Table-6, Graph-6). Majority of the patients were treated two days after their

reporting. This constitutes 5 patients (20%) and 1 patient (4%) was treated on the next

day itself, 1 patient (4%) on the third day, 2 patients (8%) on the fifth day, 2 patients

(8%) on the sixth day, 4 patients (16%) were treated on the eight day, 2 patients (8%)

Results

31

on the ninth day, 4 patients (16%) on the tenth day, 1 patient (4%) on the eleventh

day, 3 patients (12%) on the 15th day.

Among the preoperative clinical findings, isolated arch fractures are

associated with the lowest signs and symptoms. Subconjunctival hemorrhage was a

significant finding with 15(60%) of the total 25 patients. Infra-orbital paresthesia was

present in 3(12%) patients. Restricted mandibular movements and reduced mouth

opening has been reported by 10(40%) patients. Depression over the prominence of

cheek can be appreciated in all of the patients of the study (100%). Step deformity

was reported by all 25(100%) of the patients. Incidence of diplopia was nil reported

among the inclusion criteria taken for this study. (Table-7-10, Graph-7&8).

Resolution of subconjunctival hemorrhage after one week was evident in

100% of the cases (Table-7,Graph-7) There was gradual improvement in the status of

infra orbital paresthesia with eventual restoration of normal sensation in 5 patients

(20%) out of which 3 (12%) patients had pre-operative infra orbital paresthesia and 2

(4%) patients had developed it post-operatively. At the end of first week infraorbital

paresthesia completely resolves in one patient, who had developed it post-operatively.

In one more patient it resolved by 3rd month and at sixth month follow u it was

completely resolved in all then patients (Table-7). Depression of cheek was corrected

in 100% of the cases with relapse recorded in only one patient (4 %) at follow up of

third month. At the end of 6th month all the 25 patients were stable with maintenance

of cheek contour. There was a drastic improvement in the mouth opening at the

immediate postoperative period. Significant limitation of mandibular movement was

seen in 10(40%) patients (Table -8, Graph-8). There was complete restoration of step

deformity in all the patients (100%) which was consistent at the end of 6th month

follow up period (Table-8).

Results

32

Observed difference for subconjunctival hemorrhage between different time

duration was statistically found significant ( χ2 =75.000, df= 5, p= < 0.001), and for

infraorbital paraesthsia between different time duration was statistically found not

significant. ( χ2 =5.364, df= 5, p= 0.373).

According to the side of the face involved, 16(64%) patients reported injury to

the right side of face, 6 (24%) had injury to the left side, and remaining 3(12%)

patients had bilateral involvement (Table-10, Graph-9). In twenty four patients (96%)

of the series the reduction and fixation obtained were stable according to the criteria

used for this study. Out of 25 patients, only 1 patient (4%) required additional

procedure for stability after 3 months.

Uneventful recovery was achieved in all the individuals (100%). One patient

(4%) where combination of Coronal and Infraorbital approach was used complained

of epiphora on 18th follow up day. One patient (4%) where combination of lateral

eyebrow and infraorbital approach was used complained of burning sensation in eye

on 20th day follow up. One patient (4%) where combination of Coronal and

infraorbital approach was used had developed pre-auricular and temporal infection

with pus discharge, which lead to sutural abscess by 40th post-op day. Two patients

(8%) where intra-oral maxillary vestibular approach was used developed infection,

one on 1st month follow up another on 3rd month follow up and they required plate

removal. One patient (4%) where combination of lateral eyebrow and infraorbital

approach was used complained of burning sensation in eye on 20th day follow up. In

this case on 3rd month follow up patient reported back to our unit with a complaint of

pain over the operated site and inability to open mouth (Table-11, Graph-10).

Graphs and Table

Results

30

TABLE 1: AGE DISTRIBUTION OF THE STUDY POPULATION

MEAN 33.52

MEDIAN 30.00

MODE 25

STD. DEVIATION 10.43

RANGE 38

MINIMUM 17

MAXIMUM 55

TABLE 2: GENDER DISTRIBUTION OF THE STUDY POPULATION

GENDER FREQUENCY PERCENTAGE

MALE 20 80.0

FEMALE 5 20.0

TOTAL 25 100.0

TABLE 3: DISTRIBUTION OF THE STUDY SUBJECTS BASED ON

OCCUPATION

Results

34

OCCUPATION FREQUENCY PERCENTAGE

AGRICULTURIST 12 48.0

LABOURER 4 16.0

BUSINESSMAN 3 12.0

HOUSEWIFE 3 12.0

SERVICE 2 8.0

STUDENT 1 4.0

TOTAL 25 100.0

TABLE 4: ETIOLOGY FOR FRACTURE AMONG THE STUDY

POPULATION

ETIOLOGY FREQUENCY PERCENTAGE

ROAD TRAFFIC ACCIDENT 23 92.0

SELF FALL 2 8.0

TOTAL 25 100.0 TABLE 5: DISTRIBUTION OF TYPE OF FRACTURE AMONG STUDY

POPULATION

TYPE OF FRACTURE FREQUENCY PERCENTAGE

ZYGOMATIC BODY FRACTURE 21 84

ZYGOMATIC ARCH FRACTURE 1 4

BOTH 3 12

TOTAL 25 100.0

Results

35

TABLE 6: DISTRIBUTION OF REPORTING DAY AFTER INJURY AMONG

THE STUDY POPULATION

N MEAN MEDIAN MODE SD MIN MAX

Reporting Day After Injury

25 6.60 7 2 4.02 1 14

TABLE 7: DISTRIBUTION OF STATUS OF PRESENCE INFRAORBITAL

NERVE PARESTHESIA AND SUBCONJUNCTIVAL HEMORRHAGE

DURING SIX MONTH STUDY PERIOD AMONG THE STUDY

POPULATION

Time of

Admission Immediate

Postop 7th day

1st month

3rd month

6th month

p-value

IOP 3 5 4 4 3 0 0.373 SCH 15 15 0 0 0 0 0.001

TABLE 8: DISTRIBUTION OF RESTRICTED MANDIBULAR

MOVEMENTS AMONG THE STUDY POPULATION

RESTRICTED MANDIBULAR MOVEMENT FREQUENCY PERCENTAGE

Yes 10 40.0

No 15 60.0

Total 25 100.0

Results

36

TABLE 9: DISTRIBUTION OF STABILITY OF INFRAORBITAL RIM

CONTOUR DURING SIX WEEK STUDY PERIOD AMONG THE STUDY

POPULATION

Time of Admission

Immediate Postop

7th day

1st month

3rd month

6th month

YES 0 25 25 25 25 25 No 25 0 0 0 0 0

TABLE 10: DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY

POPULATION

FREQUENCY PERCENTAGE

RIGHT 16 64 LEFT 6 24

BILATERAL 3 12

TOTAL 25 100

TABLE 11: DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH

USED AMONG THE STUDY POPULATION

SURGICAL APPROACH FREQUENCY PERCENTAGE

COMBINATION OF LATERAL EYEBROW AND INFRAORBITAL APPROACH

15 60.0

LATERAL EYEBROW APPROACH 2 8.0

GILLIES TEMPORAL APPROACH 2 8.0

Results

37

COMBINATION OF CORONAL AND INFRAORBITAL APPROACH 2 8.0

COMBINATION OF LATERAL EYEBROW, INFRAORBITAL AND MAXILLARY VESTIBULAR APPROACH

2 8.0

COMBINATION OF LATERAL EYEBROW AND MAXILLARY VESTIBULAR APPROACH

1 4.0

INFRAORBITAL APPROACH 1 4.0

TOTAL 25 100.00

TABLE 12: DISTRIBUTION OF TIME TAKEN FOR THE SURGERY IN

HOURS AMONG THE STUDY POPULATION.

SURGICAL APPROACH

Time Taken In Hrs Frequency

2 11 COMBINATION OF LATERAL EYEBROW AND INFRAORBITAL APPROACH 2.5 5

1 1 LATERAL EYEBROW APPROACH

2 1

GILLIES TEMPORAL APPROACH 1 2

3 1 COMBINATION OF CORONAL AND INFRAORBITAL APPROACH

3.5 1

COMBINATION OF LATERAL EYEBROW, INFRAORBITAL AND MAXILLARY VESTIBULAR APPROACH

2 2

COMBINATION OF LATERAL EYEBROW AND MAXILLARY VESTIBULAR APPROACH

2.5 1

INFRAORBITAL APPROACH 1 1

Results

38

TABLE 13: ADDITION PROCEDURES REQUIRED AFTER INITIAL

TREATMENT AMONG THE STUDY POPULATION.

Additional Procedure Frequency Percent

REQUIRED 1 4.0

NOT REQUIRED 24 96.0

TOTAL 25 100.0

GRAPH 1: AGE DISTRIBUTION OF THE STUDY POPULATION

Results

39

GRAPH 2: GENDER DISTRIBUTION OF THE STUDY POPULATION

GRAPH 3: DISTRIBUTION OF THE STUDY SUBJECTS BASED ON

OCCUPATION

Results

40

GRAPH 4: ETIOLOGY FOR FRACTURE IN THE STUDY POPULATION

GRAPH5: DISTRIBUTION OF TYPE OF FRACTURE AMONG STUDY

POPULATION

Results

41

GRAPH 6: DISTRIBUTION OF REPORTING DAY AFTER INJURY IN THE

STUDY POPULATION

GRAPH 7: DISTRIBUTION OF SUBCONJUNCTIVAL HEMORRHAGE

AMONG THE STUDY POPULATION

Results

42

GRAPH 8: DISTRIBUTION OF RESTRICTED MANDIBULAR

MOVEMENTS AMONG THE STUDY POPULATION

GRAPH 9: DISTRIBUTION OF SITE OF FRACTURE AMONG THE STUDY

POPULATION

Results

43

GRAPH 10: DISTRIBUTION OF THE TYPE OF SURGICAL APPROACH

USED AMONG THE STUDY POPULATION

Discussion

DISCUSSION

Various Surgical Approaches for the treatment of fractured Zygomatico-

Maxillary Complex are mainly categorized as:

- REDUCTION APPROACHES

- FIXATION APPROACHES

REDUCTION APPROACHES

1. Extra Oral Approaches

a) Gillies Temporal Approach

b) Percutaneous Approach

c) Lateral Eyebrow Approach

Discussion

44

2. Intra Oral Approaches

a) Buccal Sulcus Approach

b) Lateral Coronoid Approach

c) Intranasal Transoral Approach

FIXATION APPROACHES:

EXTRA ORAL APPROACHES

a) Lateral Eyebrow Approach

b) Infra Orbital Approach

c) Lateral Coronal Approach

d) Transconjunctival Approach

e) Subciliary Approach (Lower Blepharoplasty Approach)

f) Lateral Upper Lid Blepharoplasty Approach

g) Crows foot Approach

h) Through Existing Laceration

INTRA ORAL APPROACHES:

Discussion

45

a) Maxillary Vestibular Approach

REDUCTION APPROACHES:

1. BUCCAL SULCUS APPROACH

This technique has been in use since the beginning of the century and it was

discussed in detail by Balasubramaniam in 1967. Incision about 1cm in length

placed at the reflection of the upper buccal sulcus immediately behind the zygomatic

buttress, so that a pointed curved elevator can be passed upwards supraperiosteally to

contact the deep or infra temporal surface of the zygomatic bone and thus an

upward, forward and outward pressure can be exerted to elevate the depressed

zygoma.

2. GILLIES TEMPORAL APPROACH

Described by Gillies, in 1927. A 2-cm incision placed behind the temporal

hairline approximately 6 cm above the zygoma. The incision is carried through the

skin, temporoparietal fascia (superficial temporal fascia) and temporalis muscle fascia

(deep temporal fascia). A tunnel is dissected superficial to the temporalis muscle and

deep to the zygomatic arch. Dissection is limited around the fracture site to minimize

the risk of fracture destabilization. Once the dissection is beneath the zygomatic arch,

Elevator is inserted and lateral pressure is applied to reduce the bone fragments. Care

must be taken to avoid using the parietal scalp as a fulcrum for these instruments. This

can result in a parietal skull fracture.

Discussion

46

OPEN REDUCTION AND FIXATION APPROACHES

1. MAXILLARY VESTIBULAR APPROACH

The maxillary vestibular approach provides access to the entire midface

skeleton from the zygomatic arch, to the infraorbital rim, to the frontal process of the

maxilla, which can be achieved in a safe manner. The greatest advantage is the hidden

intraoral scar that results. The incision is placed approximately 3-5mm superior to

mucogingival junction and extended as far as possible posteriorly as necessary to

provide exposure usually to the first molar tooth and traverses mucosa, submucosa,

facial muscles and periosteum. Subperiosteal dissection is carried out to expose the

fractured site and care is taken to preserve neurovascular bundle above and posterior

superior alveolar vessels along the posterior maxilla, which infrequently causes

bleeding.

2. LATERAL BROW APPROACH

The incision is placed within or just below the lateral brow and carried it onto

the frontozygomatic buttress. The advantage of this approach is that the fracture of the

frontozygomatic region can be visualized directly and fixed and simultaneously

allows the reduction of the zygoma as well. Once exposure has been accomplished, a

heavy instrument is inserted posterior to the zygoma along its temporal surface, the

instrument is then used to lift the zygoma anteriorly, laterally, and superiorly while

one hand palpates along the infraorbital rim and body of the zygoma and

simultaneously allows fixation of the frontozygomatic fracture.

3. INFRA ORBITAL APPROACH

Discussion

47

A 3-4cm incision is positioned directly over the bony orbital rim

approximately 1.5-2.0 cm below the lower lid margin. The incision is carried directly

through the skin, orbicularis oculi muscle, subcutaneous tissue and periosteum. While

this approach is faster than eyelid incisions and is associated with minimal risk of

postoperative eyelid malposition.

4. CORONAL APPROACH

High-energy injuries often result in extensive posterior and lateral dislocation

of the malar eminence and posterior and inferior depression of the zygomatic body.

Incision is placed at least 5 cm behind the hairline. A zigzag or "w" pattern can be

used to help camouflage the incision. This is most effective in patients with straight

hair that falls over the suture line. The dissection can be performed in a hemicoronal

or bicoronal plane. After injection with local anesthetic, incision is placed, starting at

the vertex and moving toward the helical root. Incision is carried through the galea

aponeurosis, leaving the pericranium and temporalis muscle fascia (deep temporal

fascia) intact. Raney clips or suturing to the incision edges to be done to control blood

loss. Special care must be taken to avoid injury to the temporal branch of the facial

nerve that lies in the temporoparietal fascia (superficial temporal fascia). The galea

aponeurosis elevates easily from the pericranium. Careful blunt dissection to be made

to elevate the temporoparietal fascia free from the temporalis muscle fascia. The two

dissection planes are should sharply join at the temporal line. The incision can be

carried across the midline to the contralateral ear for more exposure or for access to

the frontal sinus and orbital rims. To expose any fracture of the frontozygomatic

buttress or orbital rim, the periosteum can be incised and elevated. Allows entire

visualization of the zygomaticomaxillary complex.

Discussion

48

The various surgical approaches, for the treatment of the fractures of

zygomaticomaxillary complex may form the treatment of choice for different types of

zygomaticomaxillary complex fractures.

The total twenty five patients selected for the study 20(80%) were males and

5(20%) were females. This observation was confirmed with the study carried out by

Ellis et al.2, they reported 80.2% incidence of male predominance, and the study by

Schnetler21 also reported that, the majority affected were males with a peak at 30

years of age. Age group of our study also confirms with the study of Adekeye O.E 63,

who found that out of 337 Nigerian patients with zygomatic complex fractures, 80%

were between the age group of twenty one and forty years. Age group of our study are

also similar with the work of Haider Z42, Gomes Pereira et al. 3, Courtney D.J22,

Esben Kaastad27 and Atte Freng, Ogden. R.G28.

In this study, road traffic accidents were the most common cause of

zygomaticomaxillary complex fractures accounting for 92% of cases, while 8%

resulted from falls. This was contradicting with the study of Ellis et al, where alleged

assault was the major cause of zygomatico-orbital fractures amounting to 46.6% of

the entire sample, while motor vehicle accidents constituted only 13.3%. This low

figure of incidence of motor vehicle accidents in the study of Ellis et al.2 may be

attributed to the compulsory wearing of seat belts and head devices. The high

incidence of zygoma fractures in the present study could be attributed to the increase

in number of automobiles and lack of safety measures. Out of total twenty five

patients, 16 have suffered fractures on the right side of the face (64%), 6 suffered on

left side of the face (24%) and 3 suffered bilaterally (12%). Isolated zygomatic arch

fracture has the least number of occurrences in the present study with only two

patients (8%).

Discussion

49

The clinical signs and symptoms that were most helpful in the preoperative

diagnosis were consistent with that of the other studies. Isolated arch fractures were

associated with the lowest percentage of sign and symptoms. This was also observed

by Ellis et al and Ogden. However restricted mandibular movement was a persistent

finding in all the patients included in this study. According to Row and Killey12,

limitation of mouth opening or lateral excursion resulted from mechanical obstruction

by the zygomatic bone or arch impinging on coronoid process of the mandible.

The current study showed infraorbital nerve paresthesia in 12% of the cases.

Isolated zygomatic arch fractures were not associated with paraesthesia or anaesthesia

of the infraorbital nerve. But Ogden28 noted that paraesthesia or anaesthesia of the

infraorbital nerve was the most frequently reported symptom. Subconjunctival

hemorrhage was observed in 60% of the total patients in the present study, nearing

approximately to a study done by Weisenbaug28, who noted occurrence in 70.5% of

the patients. In the analysis of 2067 cases by Ellis et al. 2 subconjunctival hemorrhage

occurred variably ranging from a surprising 20% in zygomatic arch fractures to 65%

in those zygomatic fractures which had multiple lines of fracture. The incidence of

diplopia was nil. According to Nordgaard54 diplopia occurred in 8-22% of malar

fractures.

Palpable step deformity of the orbital rim was found and depression over the

cheek was noted in every patient. Ogden28 found some form of palpable bony

asymmetry of the zygomatic bone in 95 of the 105 cases studied.

The surgical treatment of zygoma fracture varies from surgeon to surgeon and

also depending on the type of fracture and circumstance. The intra-oral maxillary

vestibular approach, and extraoral approaches like Lateral eyebrow, Infraorbital,

Discussion

50

Coronal, Extended preauricular approach and reduction approach ie. Gillies temporal

approach were used in this particular study.

Discussion Discussion

50

50

Discussion

51

REDUCTION APPROACHES:

Lateral eyebrow approach

In a study conducted by Zigmunt W Pozatek24, the predominant approach

was via the lateral eyebrow approach. In this study, various surgical approaches to the

fractured zygomatic complex were discussed. There data illustrated that a great many

of the fractures were unstable after reduction. They concluded that the lateral eyebrow

approach, with internal wire fixation if necessary was used as the initial surgical

approach in the management of zygomatic complex fractures.

This was in similar with this present study, where the lateral eyebrow

approach was the predominant approach used in 20 cases (80%), none of the patients

had esthetic concern. In addition, this approach offered a number of other advantages.

Incarcerated tissue in the fracture, which may hinder proper reduction, can readily be

released and retracted. The elevator is in direct contact with a large mass of bone and,

thus the force of reduction is exerted over a large area. Force may be exerted in more

directions than with the Gillies or the antral approaches. Because the fracture is

directly exposed with the eyebrow approach, an assessment of anatomical reduction

can be made intraoperatively, and an opportunity for fixation at the time of reduction

is offered, and was not associated with any other complications. For all these reasons,

the lateral eyebrow approach is the more versatile approach.

Buccal sulcus approach, Gillies temporal approach

This transbuccal elevation, originally described by Keen69, was recommended

by Yanag1sawa55 as the standard initial method for all types of zygomatic fractures

Discussion

52

except arch and rim fractures. It was noted to be particularly effective for posterior

displacement and lateral rotation around the vertical axis.

The upper buccal sulcus approach has been reviewed by Apfelberg et al.20

and was reported as a fast, simple technique, virtually eliminating the need for open

reduction. Manstein et al described in detail, the reduction of fracture zygomatic arch

in the elderly unfit patient, via a Gillies lift under local anesthesia. However no

mention of the fracture of whole zygomatic complex was made and the technique was

not intended for routine use.

Balasubramaniam also mentioned that less force was required for elevation

than for the external approach and the technique could be performed within minutes,

with minimum chance of hemorrhage. The buccal pad of fat was too small for a

dehiscence to occur during the surgery.

Courtney D.J22 has done a retrospective study on 50 patients treated with

Upper buccal sulcus approach. He cited various advantages like no skin scar, closer

and more precise application of force by the operator, minimal bleeding, simplified

antral bone harvest if needed, and simple mucosal closure. An additional advantage of

this technique includes the elevation of comminuted zygomatic body fracture which is

not indicated when a Percutaneous hook is used to reduce the fracture. He concluded

that results of intra-oral approach are comparable to extraoral Gillie’s temporal

approach. According to him the upper buccal sulcus approach is a safe, rapid and

effective technique for the reduction of zygomatic body and arch fractures.

Kazuhiko Yamamoto et al.5 analyzed the characteristics of isolated

zygomatic arch fractures reduced through Gillies temporal approach, to evaluate the

functional and radiological outcomes of the treatment. Good functional and

Discussion

53

radiological outcomes were obtained in isolated zygomatic arch fractures. Reduction

status was not influenced by either the fracture type or the interval between reduction

and injury, and recovery infraorbital nerve achieved was excellent with fair reduction.

This was similar with our study where we used Gillies temporal approach in 2 cases

(8%), the reduction and stability achieved was excellent. It was not associated with

any other complications.

Ogden G.R28, treated 105 cases of fractures of zygoma using Gillies temporal

approach. They concluded that Gillies method offers the advantage of being quick

(thereby shortening the duration of anesthesia), decreasing the possibility of facial

nerve damage or direct trauma to the globe by instruments inserted to protect the eye,

and not being associated with a visible scar ( the scar from the Gillies method being

within the hairline). However so many zygomatic fractures can be treated by only

Gillies method, it was suggested as a logical starting point in most cases.

This was in contradiction with a study carried out by Zigmunt W Pozatek24,

who studied 16 cases of arch fractures which were treated with Gillies temporal

approach. In their study they found great number of fractures were unstable after

reduction.

In this current study we preferred Gillies temporal approach for the reduction

of isolated arch fractures and we found the lateral eyebrow approach was the best

approach to reduce the fractured zygoma, as it has the advantage of reduction with

fixation of the fractured segment at the same time.

Discussion

54

OPEN REDUCTION AND FIXATION APPROACHES

Rigid fixation techniques have gained popularity during the past decade,

because they offer greater versatility in the treatment of the zygomaticomaxillary

complex fractures. Fractures that tend to rotate after stabilization at the zygomatico-

frontal and the zygomaticomaxillary areas may be successfully managed with bone

plates, thereby avoiding antral or infratemporal space packs.

A study performed by Dingman and Natvig demonstrated that many zygoma

fractures treated with a closed reduction technique and then later re-examined were

more severe than they had appeared clinically or by roentgenographic evaluation. It

appeared that although the fracture was reduced at one point, the bone became

displaced again due to extrinsic forces. Therefore, they concluded that most displaced

fractures of the zygoma should be treated by open reduction and direct wire fixation.

Perhaps the four most important considerations in treating

zygomaticomaxillary complex fractures are proper reduction, adequate stabilization,

adequate orbital reconstruction (when necessary), and adequate handling, positioning

of periorbital soft tissues. Because this study suffers from some problems as limited

sample size, it does not answer all questions concerning treatment of

zygomaticomaxillary complex fractures. However, it does provide some valuable

information on a few specifics of treatment.

In this current study open reduction was indicated in 92% of cases, this was

nearing the values reported by Robert Chuong and Kaban7 (85.5%), and higher than

the values reported by Pozatek et al.24 (58%) and Wiesenbaugh49 (64%).

Discussion

55

Robert Chuong and Kaban7 in their study recommended the lateral eyebrow

approach for the initial access to the zygomatic complex fractures as it has the

advantages of producing an inconspicuous scar and providing direct access to the

zygomatico-frontal region for fracture reduction and fixation, and they restricted the

use of Gillies temporal approach to the management of isolated arch fractures and

occasionally to assist in the reduction of the zygomaticomaxillary complex fractures.

They used lateral eyebrow approach predominantly to gain access to the

zygomatico-frontal suture and for direct visualization and fixation of the fractured

fragment. No specific complications were reported and it provided a better long term

esthetic result. This was similar to our study where lateral eyebrow was the

predominant approach used in 80% of cases.

Maxillary vestibular appoach

According to a study done by Edward Ellis III and Winai Kittidumkerng 2,

who studied a variety of surgical approaches, the maxillary vestibular approach was

used more frequently, either alone or in combination with other approaches. The next

frequently used approach was through lower eyelid. Complications associated with

maxillary vestibular approach were not significant and approximately 20% of those

having lower eyelid approach had some amount of sclera.

In this present study three fractures were approached through Intra-oral

maxillary vestibular approach, Infection and plate exposure was seen in two patients

(66.6%). One on 1st month follow up another on 3rd month follow up and they

required plate removal. This approach has a high chance of infection.

Discussion

56

Infra orbital approach

A study conducted by Friedrich R.E and Henning16. They studied the

infraorbital approach, Follow up revealed sensory disturbances in 25.6% (severe in

7.2%). The patients reported impaired eye mobility in 1%, reduction of visual acuity

in 3.9%, an ectropion in 1%, hypersensitivity of the affected eye in 6.8%, and tear

dropping in 5.8%. The patient assessed their face as asymmetry following trauma in

2.2% and reported that the maxillary sinus caused complaints in 3.7%. And they

concluded that the rate of complaints following the zygomatic complex fractures

(attributable to trauma) is in the range of other reports. The infraorbital approach is a

safe technique and is particularly preferred approach for training of young surgeons.

In our experience infraorbital approach was used in alone in 1 case (4%), in

combination with lateral eyebrow approach in 17 cases (68%) and in combination

with coronal approach in 2 cases (8%). Infra orbital paresthesia was observed

postoperatively in 2 cases (4%), epiphora in 1 case (4%). This technique should be

considered as a simple and useful alternative along with the more complicated

procedures like Transconjunctival, Subciliary and Blepharoplasty approaches, which

requires valuable operating skill and experienced surgeons, and these approaches may

be considered as initial procedures required for the most of the zygomatic complex

fractures. The esthetic result were not superior with the infra orbital approach, where

11 patients (55%) were not satisfied with the resultant scar.

Coronal Approach

A retrospective study on the use of Bicoronal approach in treatment of

craniomaxillofacial trauma was carried out in 28 patients by Omar Abubaker et al.48

showed that this technique provides optimum exposure of fractured site allowing for

accurate anatomic reduction and fixation of the fractured segments and good cosmetic

Discussion

57

results. Both Bicoronal and Hemicoronal approach allowed accurate anatomic results.

Sensory nerve deficit was reported in 5 patients, which returned normal in 6 weeks. 2

patients developed hematoma in temporal region on 9th and 10th post-op day. It was

concluded that with an adequate knowledge of the surgical anatomy, a coronal

approach will provide an exposure that facilitates accurate reduction and fixation of

the fractures and will allow superior cosmetic results with minimal or no

complications. And a study was conducted in 48 patients who had undergone open

reduction and internal fixation of malar by Robert Stanley15, he treated the malar

fractures using a variable combination of Lateral eyebrow, Subciliary and

Gingivobuccal incisions to obtain a three point reduction. In the remaining 5 patients

either a coronal or hemicoronal incision was used to expose the Zygomatic arch for

use a fourth point of reduction.

This was in contradiction to our study where in majority of cases we used a

two point fixation in 23 of 25 cases (92%), and in a few cases with concomitant

zygomaticomaxillary buttress fractures we used three point fixation in 2cases (8%).

We used coronal approach in 2 cases (8%), with a comminuted fracture of

zygomaticomaxillary complex, where a wide access was required. In one case (50%)

we encountered a complication as temporal abscess on 40th follow up day.

High-energy injuries often result in extensive posterior and lateral dislocation

of the malar eminence and posterior and inferior depression of the zygomatic body. A

coronal exposure is often required to align the malar eminence and correct facial

width. Alignment of the sphenoid wing allows for good confirmation of anatomic

reduction of the arch and malar eminence.

Discussion

58

Coronal incisions with careful dissection allow for the prevention of

postoperative morbidities related to damage to the frontal branch of the facial nerve,

atrophy of the temporalis muscle, and displacement of the lateral canthal ligament

resulting in downward inclination of the lateral canthus. The use of a coronal incision

allows for temporary interosseous wiring of the frontozygomatic fracture site. The

anteroposterior displacement of the zygomatic body then can be rotated into place,

checking alignment of the lateral orbital wall, inferior orbital rim, and

zygomaticomaxillary buttress, and fixed with miniplates and screws. Furthermore, the

malar arch at this time can be reconstructed and repaired with a plate and screw

system.

Indications for this approach include superior orbital rim fractures and

comminuted fractures of the ZMC, including the zygomatic arch. When possible, this

approach should be avoided in patients with male pattern baldness.

Delayed and Malformed Zygomaticomaxillary Complex Fractures

The various surgical approaches, for the treatment of the fractures of

zygomaticomaxillary complex may form the treatment of choice for different types of

zygomaticomaxillary complex fractures. According to study conducted by Perino et

al.36 used the temporal approach for all the delayed and malformed

zygomaticomaxillary complex fractures, and they reported no major complications in

ten patients who received temporal approach for osteotomy (9 cases) and zygomatic

implant (1 case), of these 3 patients needed an additional implant after osteotomy.

There was no transient mydriasis as reported with zygomatic osteotomies. Although

temporal flap procedures may seem radical in terms of the extent of the soft tissues

Discussion

59

dissection, they confer an advantage by providing the necessary exposure to perform

meticulous and accurate surgery. Beyond this, benefits to the patient may include

enhanced cosmesis, less danger to important anatomical structures, and the ability to

perform secondary or ancillary procedures which enhance the post operative result

and eliminate or minimize the need of secondary intervention. This was in

accordance with our study where we encountered a patient who reported with a

complaint of pain and asymmetry, after 3months post treatment. The

zygomaticomaxillary complex was found to be laterally rotated, and was approached

via an extended preauricular, temporal approach. Recontouring of arch and

zygomaticomaxillary buttress was performed. This approach has the advantage of

providing a wide exposure to the zygomaticomaxillary complex. Though not used in

our case but the temporal approach has also an added advantage of reconstruction of

the depression over the zygoma region with temporalis flap and eliminate the need of

a second procedure.

This was in contradiction to study carried out by Richard M et al4, who

analysed 10 cases of delayed repair zygomaticomaxillary complex fractures with 21

days to 5 month post injury. They concluded that the lateral eyebrow and the

infraciliary approach are the best approach for the osteotomy of the malformed

zygoma and a coronal approach can be used in cases of pan facial trauma and

preferred coronal approach for cases which require onlay bone grafting, where a

cranial bone can be harvested with decrease donor site morbidity and use of same

approach for access of both the donor and the recipient site.

The most important principle in treating fractures, especially those of the face,

is proper reduction if the bone is not placed into the correct position, stabilization

becomes superfluous. Recommendations in the literature for reduction of zygomatic

Discussion

60

complex fractures range from “closed reduction” technique to three or four point

surgical exposure and fixation with miniplates or transosseous wires. Rigid fixation

techniques have gained popularity because they offer greater, versatility in the

treatment of complex zygomaticomaxillary fractures. Rohrich and Wattumull65

retrospectively evaluated 85 patients treated with miniplates or wires. They arrived at

the conclusion that miniplate fixation produced better malar projection as well as

fewer ocular and infraorbital nerve complications. In this present study, a sincere

attempt has been made to evaluate the efficacy of various surgical approaches in the

treatment of zygomaticmaxillary complex fractures and the results of this study are in

accordance with the studies conducted by different authors.

The temporal approach can be used for all the delayed and malformed

zygomaticomaxillary complex fractures, associated with minimal complications.

Although temporal flap procedures may seem radical in terms of the extent of the soft

tissues dissection, they confer an advantage by providing the necessary exposure to

perform meticulous and accurate surgery. Beyond this, benefits to the patient may

include enhanced cosmesis, less danger to important anatomical structures, and the

ability to perform secondary or ancillary procedures which enhance the post operative

result and eliminate or minimize the need of secondary intervention.

Conclusion

Conclusion

61

CONCLUSION

For a fracture to be considered as zygomaticomaxillary complex fractures it

has to fracture at minimum of three points, and two point stabilization would be

effective in restoring the proper contour, form and function of the facial skeleton.

As fractures of zygomaticomaxillary complex usually require a minimum of 2

point stabilization, therefore it is unduly necessary to mainly plate two important

buttresses in this region, that is the infra orbital buttress and the zygomatico frontal

buttress and for reduction and fixation of these buttresses the periorbital approaches

are required, combination of Lateral eyebrow and Infra orbital approaches are the

simple, easy and effective approaches to be used in means of treating fractures of

zygomaticomaxillary complex. This technique should be considered as a simple and

useful alternative along with the more complicated procedures like Transconjunctival,

Subciliary and Blepharoplasty approaches, which requires valuable operating skill and

experienced surgeons, and these approaches may be considered as initial procedures

required for the most of the zygomatic complex fractures. The esthetic result were not

superior with the infra orbital approach as compared to the studies which claims that

the Transconjunctival, Subciliary and Blepharoplasty approaches have its superior

esthetics results with inconspicuous scar. The advantage of Lateral eyebrow approach

is that the fracture of the frontozygomatic region can be visualized directly and fixed

and simultaneously allows the reduction of the zygoma as well.

The intraoral maxillary vestibular approach is a simple, easy and effective

means of treating uncomplicated simple fractures of zygomatic complex. It is a

technique which saves operating time but has a high risk op postoperative infection as

compared with the other extra oral approaches and is usually required unless the

Conclusion

fractured buttress is completely displaced and results in malocclusion. It also has an

advantage of elevating and reducing the displaced zygoma before fixation.

Gillies temporal approach is the best approach to reduced the fractured

zygomatic arch. It offers the best advantage of being quick, decreasing the possibility

of facial nerve damage or direct trauma to the globe by the instruments inserted to

protect the eye, associated with minimal complications and not being represented with

a visible scar. Depressed fractures of the zygomatic body can also be reduced via

Gillies temporal approach, except the inability to achieve functional stability through

only reduction approaches they not commonly practiced.

With an adequate knowledge of the surgical anatomy, a Coronal approach

will provide complete exposure of the zygomaticomaxillary complex with the

zygomatic arch. It facilitates accurate reduction and fixation of the fractures and will

allow superior cosmetic results with minimal complications. Preferred in cases of

bilateral zygomaticomaxillary complex fractures and those which involve additional

fractures of frontal bone. For late reconstruction of the zygomaticomaxillary complex,

we prefer wide access through a coronal approach or an extended pre auricular

approach (temporal approach).

62

Summary

Summary

63

SUMMARY

Twenty five patients with minimally displaced zygomatic complex

fractures reported to the Department of Cranio Maxillofacial Plastic and

Reconstructive Surgery, College Of Dental Sciences, Davangere were included in the

study to evaluate the efficacy of various surgical approaches used for the reduction of

zygomaticomaxillary complex fractures with the main emphasis on the post operative

stability achieved and the improvement in the functional and esthetic restoration with

minimal complications.

Follow up period for the study was six months. Recordings were made at the

immediate post operative period, in the first week, 1st month, 3rd month and at the end

of 6th month. Stability was assessed by reduction of the fractured fragments, fixation

and by return of normal contour of prominence of cheek and infraorbital rim, which

was determined by inspection and palpation. Waters view radiographs were taken

preoperatively and at the first week post operative visit.

Wound healing was uneventful in 100% of cases from immediate

postoperative day till 7th postoperative day when the sutures were removed. The

functional stability was satisfactory (96%) according to the stability criteria used for

the study. Out of 25 patients only 1 patient (4%) required additional procedure for

stability after 3 months, which was believed to be malunited.

The esthetic results were not superior with the Infraorbital approach, where 11

patients (55%) were not satisfied with the resultant scar. Where as the esthetic result

were superior with the lateral eyebrow approach, where the resultant scar was hidden

behind the eyebrow, and in cases of Coronal, Gillies temporal approach where the

scar was well within the hairline and hidden in cases of intraoral approaches. The

Summary

64

esthetic result was superior in cases of the other approaches with exception in cases of

the Infraorbital approach.

Resolution of Subconjunctival hemorrhage after one week was evident in

100% of the cases. There was gradual improvement in the status of infraorbital

paresthesia with eventual restoration of normal sensation in 5 patients (20%) out of

which 3 patients (12%) had pre-operative infra orbital paresthesia and 2 patients (4%)

had developed it post-operatively. At the end of first week infra orbital paresthesia

completely resolves in one patient, who had developed it post-operatively. In one

more patient it resolved by 3rd month and at 6th month follow up it was completely

resolved in all the patients. Depression of cheek was corrected in 100% of the cases

with relapse recorded in only one patient (4 %) at follow up of 3rd month. At the end

of 6th month all the 25 patients were stable with maintenance of cheek contour.

Significant limitation of mandibular movement preoperatively was seen in 10 patients

(40%), which drastically improved postoperatively. There was complete restoration

of step deformity in all the patients (100%) which was consistent at the end of 6th

month follow up period.

Nineteen fractures were approached through Infraorbital approach, Epiphora

was seen in 1 patient (5.26%), and burning sensation in eye was seen in another

patient (5.26%). Two fractures were approached through Coronal approach, Temporal

abscess was seen in 1 patient (33.3%).

Three fractures were approached through Intra-oral maxillary vestibular

approach, Infection and plate exposure was seen in two patients (66.6%). Twenty

fractures were approached through Lateral eyebrow approach and two fractures were

Summary

65

approached through Gillies temporal approach, none of the patients reported with any

complications.

Malunited zygoma was noticed in one patient at 3rd month follow up visit. It

was believed to be over elevation of the zygoma or unintensional trauma to the bone,

examination revealed prominence at the arch and the zygomatic buttress, which was

oteotomised under next procedure using a combination of extended pre-auricular

approach (Temporal approach) and the Infraorbital approach.

Diplopia was not recorded at the last follow up visit. There was no relapse in

infraorbital rim contour. There was no anesthetic complication nor post operative

blindness.

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Annexure

Annexures

74

ANNEXURE–I

PROFORMA

SL.No: DATE:

NAME: IP.No:

AGE:

SEX:

ADDRESS:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PAST DENTAL HISTORY:

DRUG HISTORY:

FAMILY HISTORY:

PERSONAL HISTORY:

GENERAL PHYSICAL EXAMINATION:

EXTRA-ORAL EXAMINATION:

INTRA-ORAL EXAMINATION:

PROVISIONAL DIAGNOSIS:

Annexures

75

INVESTIGATIONS:

FINAL DIAGNOSIS:

TREATMENT PLAN:

VARIOUS PARAMETERS

DATE OF R.T.A / ASSAULT / OTHERS:

DATE OF ADDMISSION:

DATE OF OPERATION:

BEFORE TREATMENT RECORD

1) SITE OF THE FRACTURE:

2) TIME ELAPSED:

3) OTHER FACIAL BONES INVOLVED:

4) SOFT TISSUES INVOLVED:

INTRA-OPERATIVE RECORDS

TYPE OF SURGICAL APPROACH (ES) USED:

IMMEDIATE POST-OPERATIVE RECORDS

1) SOFT TISSUE EVALUATION:

2) FUNCTIONAL DISTURBANCES:

3) ESTHETIC EVALUATION:

4) COMPLICATIONS ENCOUNTERED:

Annexures

76

5) DATE OF DISCHARGE:

6) POST OPERATIVE FOLLOW UP:

7TH

DAY

1ST

MONTH

3RD

MONTH

6TH

MONTH

WOUND

HEALING

FUNCTIONAL

DISTURBANCES

ESTHETIC

CONSIDERATION

COMPLICATIOS

Annexures ANNEXURE – II MASTER CHART

IMMEDIATE POSTOP

SI NAME IP N AG SX OC ET TY DF SH IP RM SD SF SA DS AP WH FS EA C0

1 Md.Kasim 20 M LB R C 2 P N A P R LI 2 N WA NS A NL 2 Gowramma 555 45 F H R A 9 A N P P R L 2 N WA NS A NL 3 Mohan Kumar 557 26 M AG A A 14 A N P P R LB 2.5 N WA NS A NL 4 Sudhakar 558 45 M AG R A 7 P N P P R LI 2 N WA NS A NL 5 Sanappa 560 55 M AG R A 2 A N A P R LI 2.5 N WA NS A NL 6 Obalesh 575 34 M SR R A 4 P N A P L LI 2 N WA NS A NL 7 Rathnamma 585 50 F H A A 2 P N P P R I 1 N WA NS A NL 8 Manjappa 586 28 M BS R A 7 P N A P R HI 3 N WA NS A NL 9 Venkat Rao 594 50 M LB R A 7 P N A P R LI 3 N WA NS A NL

10 Basvaraj 595 22 M BS R C 2 P N P P R LI 2 N WA NS A NL 11 Shiva Kumar 601 36 M BS R A 7 P N P P R LI 2 N WA NS A NL 12 Jyothamma 606 30 F AG R C 5 A N A P L G 1 N WA NS A NL 13 Rathnamma 614 30 F H R A 5 A Y P P R LI 2 N WA NS A I 14 Shashidhar 646 17 M ST R A 2 P N P P R LI 2 Y WA NS A I 15 Parshuram 666 26 M AG R A 14 P N P P R HI 3.5 N WA NS A NL 16 Thippashetty 673 46 M AG R A 9 P N P P L LI 1.5 N WA NS A NL 17 Rathnabai 682 25 F LB A B 1 A N P P R G 1 N WA NS A NL 18 Neelesh 686 25 M SR R A 4 P Y A P R LI 2 N WA NS A I 19 Kalappa 705 38 M AG R A 3 P N P P L LI 2 N WA NS A NL 20 Janardhan 711 38 M AG R A 9 A N P P B LIB 2 N WA NS A NL 21 Kariyappa 738 24 M AG R A 8 P N A P L LIB 2 N WA NS A NL 22 Raju G.K 765 25 M AG R A 9 A N P P R LI 2.5 N WA NS A I 23 Jamaal Sab 766 35 M AG R A 8 P Y P P B LI 2 N WA NS A I 24 Eranna 778 40 M AG R A 14 A N A P R L 1 N WA NS A NL 25 Ranganath 787 28 M LB R A 10 A N A P B LI 2 N WA NS A NL

77

Annexures ANNEXURE – II MASTER CHART

78

7TH DAY 1ST MONTH 3RD MONTH 6TH MONTH

SI NAME WH FS EA CO FS EA C0 FS EA CO FS EA C0

1 Md.Kasim WA NS A NL NS A NL NS A NL NS A NL 2 Gowramma WA NS A NL NS A NL NS A NL NS A NL 3 Mohan Kumar WA 1R A NL NS A NL NS A NL NS A NL 4 Sudhakar WA NS B NL NS B NL NS B NL NS B NL 5 Sanappa WA NS B NL NS B B NS B NL NS B NL 6 Obalesh WA NS B NL NS B NL NS B NL NS B NL 7 Rathnamma WA NS A NL NS A NL NS A NL NS A NL 8 Manjappa WA NS B NL NS B E NS B NL NS B NL 9 Venkat Rao WA NS B NL NS B NL NS B NL NS B NL

10 Basvaraj WA NS A NL NS A NL NS A NL NS A NL 11 Shiva Kumar WA NS B NL NS B NL NS B NL NS B NL 12 Jyothamma WA NS A NL NS A NL NS A NL NS A NL 13 Rathnamma WA NS A I NS A IC NS A L NS A NL 14 Shashidhar WA NS B I NS B I P B l NS B 1L 15 Parshuram WA 1R B NL NS B IF NS B I NS B NL 16 Thippashetty WA NS A NL NS A NL NS A NL NS A NL 17 Rathnabai WA NS A NL NS A NL NS A NL NS A NL 18 Neelesh WA NS A I NS A l NS A NL NS A NL 19 Kalappa WA NS B NL NS B F NS B NL NS B NL 20 Janardhan WA NS A NL NS A NL NS A FG NS A NL 21 Kariyappa WA NS A NL NS A NL NS A FG NS A NL 22 Raju G.K WA NS B NL 1P B NL NS B NL NS B NL 23 Jamaal Sab WA NS A I NS A I NS A I NS A NL 24 Eranna WA NS A NL NS A NL NS A NL NS A NL 25 Ranganath WA NS B NL NS B NL NS B NL NS B NL

Annexures

79

KEY TO MASTER CHART

1. IP.N – IN PATIENT ADMISSION NUMBER

2. AGE IN YEARS

3. SX- SEX

4. OC- OCCUPATION

SR- SERVICE AG- AGRICULTURIST

HW- HOUSEWIFE LB- LABOURER

ST- STUDENT BS- BUSINESSMAN

5. ETIOLOGY- ET

R- RTA

A- ASSUALT

6. TY- TYPE OF FRACTURE

A- ZYGOMATIC BODY FRACTURE

B- ZYGOMATIC ARCH FRACTURE

C- BOTH

7. DF- DURATION OF FRACTURE IN DAYS

8. SH- SUBCONJUNCTIVAL HEMORRHAGE

P- PRESENT

A- ABSENT

9. IP- INFRAORBITAL PARAESTHESIA

P- PRESENT

A- ABSENT

10. RM- RESTRICTED MANDIBULAR MOVEMENT

Annexures

80

P- PRESENT

A- ABSENT

11. SD- STEP DEFORMITY OVER THE FRACTURED FRAMENT

P- PRESENT

A- ABSENT

12. SF- SIDE OF THE FACE OF FRACTURE

R- RIGHT

L- LEFT

B- BILATERAL

12 SA- TYPE OF SURGICAL APPROACH USED

LI- COMBINATION OF LATERAL EYEBROW AND

INFRAORBITAL APPROACH

L- LATERAL EYEBROW APPROACH

I - INFRAORBITAL APPROACH

HI- COMBINATION OF HEMICORONAL AND INFRAORBITAL

APPROACH

LIB- COMBINATION OF LATERAL EYEBROW, INFRAORBITAL

AND MAXILLARY VESTIBULAR APPROACH

LB- COMBINATION OF LATERAL EYEBROW AND BUCCAL

SULCUS APPROACH

G- GILLIES TEMPORAL APPROACH

13. DS- DURATION OF SURGERY IN HOURS

Annexures

81

14. AP- ADDITIONAL PROCEDURES REQUIRED

Y- YES

N- NO

15. WH- WOUND HEALING

WA- WELL APPROXIMATION OF THE INCISION

IM- IMPROPER APPROXIMATION OF THE INCISION

16. FS- FUNCTIONAL STABILITY

NS- NOTHING SIGNIFICANT

RM- RESTRICTED MANDIBULAR MOVEMENTS

17. EA- ESTHETIC APPEARANCE

A- ACCEPTABLE

B- UNACCEPTABLE

18. CO- COMPLICATIONS

A- NO COMPLICATIONS

B- BURNING SENSATION IN EYES

C- PAIN IN EAR

D- DIPLOPIA

E- EPIPHORA

F- INFECTION

G- PLATE EXPOSURE

H- R- RESTRICTED MANDIBULAR MOVEMENTS

I- INFRAORBITAL PARESTHESIA

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