Sabir Hussain* , Zia Abbas Rizvi**
- Assistant Professor Dept of Oral & Maxillofacial Surgery
- Institute of Dentistry, CMH Medical College Lahore.
Correspondence: “Dr. Sabir Hussain ”<email@example.com>
How to CITE:
J Pak Dent Assoc 2010;19(3): 164 – 168
The aim of this study was to determine the incidence, cause and characteristics of the zygomaticomaxillary complex fractures, modalities of treatment used and analysis of post operative complaints at tertiary care teaching hospital in Multan Pakistan and compare the findings with similar studies.
Study was conducted on 97 patients treated for zygomatic complex fractures during the period of January 2006 to June 2008 in the oral and maxillofacial surgery unit and trauma centre of a tertiary care, Nishter (teaching) hospital in Multan Pakistan.
Out of 277 maxillofacial injuries received at this teaching hospital, 97 individuals were treated for zygomatic fractures. Patients according to treatment modalities were classified into two basic groups; Group-I: open reduction and rigid fixation with mini or micro plates, Group-II: open reduction and fixation with soft stainless steel wire sutures. Data, regarding age, sex, location, etiology of zygomatic complex fracture, modality of treatment used and post operative complaints of patients, were collected, tabulated, analyzed and compared with similar other studies.
Total of 97 patients were treated for Zygomaticomaxillary fractures, male to female ratio was 13:1, majority (53.6%) of patients belonged to age group of 16-30 years, isolated zygomatic complex fractures were 35.1% followed by associated fractures with mandible (33%) and with maxilla (25.8%), majority of patients (74.2%) were treated in G-I and (25.8%) were treated in G-II. Uneventful recovery was there in 93 individuals (95.9%), four patients (4.2%) had post operative complications in the form of enophthalmos, limited opening of mouth, facial asymmetry and infection at surgery site. These complications were subsequently treated successfully as a secondary procedure for all the patients.
This study has shown that road traffic accidents are responsible for most zygomatic complex fractures in our environment. Zygomatic fractures are commonly associated with other facial fractures mainly mandible, open precise reduction and reliable internal miniplate fixation optimized the esthetic and functional results in treating such fractures
Zygomaticomaxillary fractures; maxillofacial injury; ORIF; miniplate osteosynthesis; Road Traffic Accidents (RTA) etiology; pattern.
A maxillofacial injury is frequent seen occurrence in Pakistan and is associated with high incidence of facial fractures in different combinations1-5. Fractures of the zygomatic complex are among the second most frequent in maxillofacial trauma2,4. The etiology of zygomatic complex fractures includes road traffic accidents, assaults, falls and sports injuries2,4,5-10. The relative contribution of these factors varies from region to region11-12. Fractures of the zygomatic complex appear commoner in young adult males1,4,,9-13. Clinical features of zygomatic complex fractures include enophthalmos, flattening of the cheek, trismus sensory disturbances and diplopia11,13,14-17. Diagnosis of zygomatic complex fractures is based on clinical findings, with radiographic confirmation18
Although isolated zygomatic complex fractures occur, several studies have shown that fractures of the zygomatic complex are often associated with other maxillofacial injuries. Different studies have shown that there is no consensus of opinion regarding the management of zygomatic complex fractures 1,2,18-21. The treatment of these fractures must achieve precise and stable reduction at the fracture sites. A number of clinical and experimental studies have found strong evidence of superiority and better long-term fracture stability with the use of rigid plating system when compared with wire fixation in the treatment of zygomatic fractures.22-23 However, the precise reduction and reliable stability of the zygoma with reference to the number of fixation points as well as the sites of rigid fixation still remain a topic of debate 24-25 .
This study aims to evaluate the clinical out come of two techniques of open reduction and internal fixations and to compare findings of this study with other similar studies in literature. This analysis will facilitate and encourage the use of advantageous open reduction and rigid fixation with titanium plates
Head, Dept of Oral & Maxillofacial Surgery, Institute of Dentistry, CMH Medical College Lahore
This study was conducted on 97 individuals who were surgically treated for zygomatic fractures during the period of January 2006 to June 2008 in the oral and maxillofacial unit and trauma centre of tertiary care teaching (Nishter) hospital in Multan, Pakistan. Data regarding age, sex, location and etiology of zygomatic complex fracture, side of fracture, modality of treatment used and post operative complaints of patients, were collected and analyzed. Conservatively treated patients were not included in this study.
Diagnosis was based on clinical examination, radiological investigation in the form of plain radiograph and CT scan of some patients. According to the treatment modality used patients were divided into two basic groups(G), G-I: open reduction and internal fixation using bone plates. G-II: open reduction and internal fixation using transosseous wiring, using the standard recommended surgical protocol.
Exposure of the zygomatic bone was achieved with lateral brow incision, subciliary incision and upper gingivo buccal sulcus incision. After ensuring precise reduction and satisfactory alignment at all three fracture sites, mini / micro plates in G-I and soft stainless steel wire in G-II, were applied at two points, Fronto-Zygomatic Suture(FZS) and Zygomatico-Maxillary Butterus(ZMB) in (G -I and G -II) patients and at third point at Inferior Orbital Rim(IOR) as per clinical requirement decided by surgeon. Wounds were closed in two layers after thorough irrigation. Post-operative evaluation protocol included functional assessment in the form of oral and facial functions, interincisal opening and the ability to masticate effectively. Regaining of satisfactory facial symmetry was an important part of evaluation protocol. The period of post operative review ranged from 3 to 6 months. Complications were based on clinical evaluation and patients’ feeling of dissatisfaction in restoring pretraumatic esthetics in the form of enophthalmos and depressed zygoma, restricted opening of mouth, altered sensation in the infra orbital region and persistent signs of infection at surgery site.
Above said post operative complications were recorded and compared between the two groups as well as with the findings of similar studies in literature.
Resultsp>Total of 97 patients treated for Zygomatic fractures were included in this study, male to female ratio was 13:1, majority patients belong to age group 16-30 yrs 52 (53.6%) table-2, common cause of fracture was RTA table-3
isolated fractures zygomatic complex were common (35.1%) followed by associated fracture of
according to the treatment modality used, majority of patients 72(74.2%) were treated in G-I and 25 (25.8%) were treated in G-II table-5
Uneventful recovery was there in 93 individuals (95.9%), four patients (4.2%) table-6 had post operative complications in the form of enophthalmos, limited opening of mouth, facial asymmetry and infection at surgery site. These complications were subsequently treated successfully as a secondary procedure for all the patients
The oral and maxillofacial surgery department of Nishter Medical College Multan is dedicated to undergraduate students, residents and the management of orofacial patients and post graduates.It is a major trauma referral centers for Southern of Punjab and a part of Baluchistan. This study recorded that remarkably higher number of male sustained zygomatic complex fractures than females (ratio 13:1) which is consistent with reports of other similar The age range of patients in this study was 5-70 years with mean age of 32.67 years St± 12.53,majority of patients (53.6%) were in 16-30-year age group and coincides with findings of other studies7,9,10,23. RTA was the leading etiologic factor in zygomatic complex fractures and same has been identified by some of the studies abroad and in Pakistan2,6-7,15,23,25. Due to poor enforcement of road traffic laws in our region, many drivers notoriously exceed the speed limits and do not use seat belts.Other reasons of RTA include economic recession in Pakistan; driver’s fit already used tires on their vehicles, increasing the chances of tyre burst. The findings of this study showed that mandibular fractures were most often associated with zygomatic complex fractures as reported in these studies4’22,26 also. Although several signs and symptoms ccompany zygomatic complex fractures.15-17,25-26,
during this study Circumorbital andsub-conjunctival ecchymosis were most frequently encountered, Flattening of the cheek 42(43.3%), Diplopia was observed in 5(5.2%), while in other study of isolated zygomatic fractures diplopia is reported in 9.6% and 19.8% in patients withmid-face factures15,16. Limitation of mandibular movement was seen in 47(48.5%) of patients and is usually a result of the fractured zygomatic complex impinging on the coronoid process of the mandible8.
Miniplate osteosynthesis (G-I) at ZF and ZM suture was the most frequently employed fixation technique in this study. The reason for opting miniplate fixation was early and excellent esthetic and functional recover by precise reduction and reliable stabilization of reduced fractured segments. The findings of this study was consistent to findings of earlier studies 15,16,17.
Different frequencies of post operative complications have been observed with various techniques ranging from 1.5 % to as high as 20.7% in studies15-17,27-28. In this study complication rate of 2.4% was recorded in G-Iand 8% in G-II. Complications in G-I was infection at FZS fixation site and was managed by plate removal. Complaints of facial asymmetry, enophthalmos, trismus, IO paresthesia, were recorded at early post operative stage in patients treated with wire osteosynthesis and were successfully treated with second surgery with plate osteosynthesis
This study has shown that road traffic accidents are responsible for most zygomatic complex fractures in our environment. Zygomatic fractures are commonly associated with other facial trauma,open reduction and internal miniplate osteosynthesis was found to be a reliable method for treating such fractures with minimal post operative complication.
1. Provision of latest diagnostic facilities and up dated instruments at all maxillofacial surgery centers.
2. Implementation of traffic laws especially seat belt, speed limits, use of recommended helmets for riders of two-wheelers
1. Hussain SS, Ahmad M, Khan MI, Anwar M, Amin M, Ajmal S et al. Maxillofacial trauma: current practice in management at Pakistan Institute of Medical Sciences. J Ayub Med Coll Abbottabad 2003; 15:8-11.
2. Cheema SA. Zygomatic bone fracture. J Coll. Physician Surg Pak. 2004; 14: 337-339
3. Zakai M.A, Islam T, Memon S, and Aleem A. The pattern of maxillofacial injuries received ann Abbasi Shaheed Hosp Kar Med Dent Coll 2002;7:291-293.
4. Zia UH, Lahri IA, Hussain F, Kumari M, An analysis of maxillofacial trauma patients treated during May 2002-April 2003 at dental section, BMC,Quetta. Pak Oral & Dental J. 2003; 23:87-90.
5. Ambreen A, Rauf S, causes of maxillofacial Injuries-a three year study,J Surg Pakistan 2001;6:25-7.
6. Afzelius LE, Rosen C. Facial fractures. A review of 368 cases. Int J Oral Surg. 1980;9:25-32.
7. Oji C. Jaw fractures in Enugu, Nigeria. 1985-1995. BrJ Oral Maxillofac Surg. 1999;37:106-109.
8. Banks P, Brown A. Fractures of the facial skeleton. 1 st ed. Oxford: Wright. 2001;40-155.
9. Klenk G, Kovacs A. Etiology and pattern of facial fractures in the United Arab Emirates. J Craniofac Surg. 2003;14:78-84.
10. Adebayo ET, Ajike OS, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigera. BrJ Oral Maxillofac Surg. 2003;41:396-400.
11. Motamedi MH. An assessment of maxillofacial fractures: a five-year study of 237 patients. J Oral Maxillofac Surg. 2003;61:61-64.
12. Tanaka N, Tomitsuka K, Shionoya K, et al. Aetiology of maxillofacial fractures. Br J Oral Maxillofac Surg. 1994;32:19-23.
13. Fasola AO, Nyako EA, Obiechina AE, et al.Trends in the haracterstics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg. 2003;61:1140-1143
14. Souyris K, Kersy F, Jammet P, et al. Malar bone fractures and their sequelae. A statistical study of 1,393 cases covering a period of 20 years. J Craniomaxillofac Surg. 1989;17:64-68.
15. Al-Qurainy IA, Stassen LF, Dutton GN, et al.Diplopia following mid-facial fractures. Br J OralMaxillofac Surg. 1991;29:302-307.
16. Hafiz I A, Saima C; Choice of operative method for management of isolated zygomatic bone fractures: evidence based study: J Pak Med Assoc. 59:615;2009
17. Al-Qurainy IA, Stassen LF, Dutton GN, et al.The characteristics of mid-facial fractures and the association with ocular injury: a prospective study. BrJ Oral Maxillofac Surg. 1991;29:291-301.
18. McLoughlin, Gilhooly M, Wood G. The management of zygomatic complex fractures-results of a survey. BrJ Oral Maxillofac Surg. 1994; 32: 284-288.
19. Mahood S, Keith DJ, Lello GE. Current practice of British oral and maxillofacial surgeons: advice regarding length of time to refrain from contact sports after treatment of zygomatic fractures. Br J Oral Maxillofac Surg. 2002; 40:488-490.
20. Mahmood S, Keith DJ, Lello GE. When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus. Injury. 2003; 34:908-91 1.
21. Rohrich RJ, Janis JE, Adams Jr WP. Subciliary versus subtarsal approaches to orbitozygomatic fractures. Plast Reconstr Surg. 2003;1 1 1:1 706-1 714.
22. Davidson J, Nickerson D, Nickerson B. Zygomatic fractures: Comparison of methods of internal fixation. Plast Reconstr Surg 1990;86:25-32.
23. Parashar A, Sharma RK,Makkar S, Rigid internal fixation of zygoma fractures; a comparison of two point and three point fixation. Indian Plast Surg 2007;40:18-24.
24. Schilli W, Ewers R, Niederdellmann H. Bone fixation with screws and plates in maxillofacial region. Int J Oral Surg 1981;10: 329-35.
25. Ellis E 3 rd , Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 1996;54:386-92
26. Zachariades N, Mezitis M, Anagnostopoulos D. Changing trends in treatment of zygomaticomaxillary complex fractures: A 12-year evaluation of methods used. J Oral Maxillofac Surg 1998;56:1152-
27. Tadj A, Kimble FW. Fractured zygoma. ANZ J Surg.2003;73:49-54
28. Convington DS, Wainwright DJ,Teichgraeber JF, etal. Changing pattern in epidemiology of zygoma fractures: 10-year review. J Trauma.1994;37:243-248