Midfacial trauma patients: An epidemiological survey dissertation.pdf · effective prevention and...

Midfacialtraumapatients:Anepidemiologicalsurvey

ErikSalentijn

The studiespresented in this thesiswere performed at thedepartmentofOral andMaxillofacial Surgery,VUUniversityMedical Center /Academic Center forDentistryAmsterdam(ACTA),Amsterdam,theNetherlands.

This research was conducted as part of the researchprogram Restoration and Development of researchinstituteAmsterdamMovementSciences, foundedbyVUAmsterdam, VU University Medical Center Amsterdam,andAcademicMedicalCenter,UniversityofAmsterdam.

Publicationanddistributionofthisthesishasbeenfinanciallysupportedby:

NederlandseVerenigingvoorMondziekten,KaakenAangezichtschirurgie(NVMKA)

AcademischCentrumTandheelkundeAmsterdam(ACTA) VUmedischcentrum MaatschapMKAAlrijneziekenhuisLeiderdorp KLSMartinGroup HenryScheinDental ORFEOkliniekZoetermeer StraumannB.V. DamMedicalB.V. DentalairProductsNederlandB.V.

Printedby Gildeprint,EnschedeLayoutby TinyWoutersCoverdesignby JeroenSchuitenISBN 9789462337763Copyright2017,E.G.Salentijn,Amsterdam,theNetherlands.Allrightsreserved.Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronicormechanical,includingphotocopy,recording,oranyinformationstorageandretrievalsystem,withoutpriorpermissionfromtheauthor.

VRIJEUNIVERSITEIT

Midfacialtraumapatients:Anepidemiologicalsurvey

ACADEMISCHPROEFSCHRIFT

terverkrijgingvandegraadDoctoraandeVrijeUniversiteitAmsterdam,opgezagvanderectormagnificus

prof.dr.V.Subramaniam,inhetopenbaarteverdedigen

tenoverstaanvandepromotiecommissievandeFaculteitderTandheelkunde

opwoensdag13december2017om15.45uurindeaulavandeuniversiteit,

DeBoelelaan1105

door

ErikGerritSalentijngeborenteDordrecht

promotoren: prof.dr.T.Forouzanfar prof.dr.E.A.J.M.Schulten

leescommissie: prof.dr.R.R.M.Bos dr.E.M.vanCann prof.dr.J.P.R.vanMerkesteyn prof.dr.F.R.Rozema prof.dr.D.B.Tuinzing dr.J.G.A.M.deVisscher paranimfen: drs.R.Koop drs.J.A.Posthumus

Dekrachtvaneenboomwordtbepaalddoorzijnwortels

Voormijnouders

Contents

Chapter1 Generalintroduction 11Chapter2 AtenyearanalysisoftheAmsterdamprotocolinthetreatment 21 ofzygomaticcomplexfracturesChapter3 Theepidemiologicalcharacteristicsofzygomaticcomplexfractures: 39 Acomparisonbetweenthesurgicallyandnonsurgicallytreated patientsChapter4 Theclinicalandradiographiccharacteristicsofzygomatic 51 complexfractures:Acomparisonbetweenthesurgicallyand nonsurgicallytreatedpatientsChapter5 Atenyearanalysisofmidfacialfractures 67Chapter6 Atenyearanalysisofthetraumaticmaxillofacialandbraininjury 87 patientinAmsterdam:IncidenceandaetiologyChapter7 Atenyearanalysisofthetraumaticmaxillofacialandbraininjury 103 patientinAmsterdam:ComplicationsandtreatmentChapter8 Summaryandconclusions 117Chapter9 Futureperspectives 129Chapter10 Samenvatting 135 Dankwoord 143 Listofpublications 149

1

Generalintroduction

Chapter1

12

Generalintroduction

13

1GeneralintroductionAnatomyofthemidfacialskeletonThemidfacialbonesincludethemaxilla(andpalatinebone),zygomaticcomplex,nasalbone, nasoorbitalethmoid complex, orbit and the supraorbital structures, all ofwhich may be affected by traumatic injury to the midface.13 These bones areregarded to form severalpairedverticalandhorizontalbuttresses thatprotectvitalorgans,suchasthebrain,opticnervesandbrainstem,makingthemcloselyrelatedtothesensesofvisionandsmellandtootherattributessuchasspeech,masticationandfacial appearance.3,4Damage to themidfacial buttress system can therefore causebothfunctionalandcosmeticdeformity,asthefacialprofilemaybeaffected.35

In general, fracturesof themidfacialbones aredivided into zygomatic complexfractures,orbitalfractures,nasoorbitalethmoidcomplexfractures,LeFortI,LeFortII,LeFortIIIfracturesandfrontalsinusfractures.2,3,6,

IncidenceandaetiologyofmidfacialtraumapatientsMidfacial fractures account for a substantial proportion of maxillofacial injuries,predominantlypresenting inyoung (20to40yearold)malepatients.7,9,10Traumatothemidface regularly leads to lesionsof the soft tissues, teethand fracturesof theaforementionedbonestructures,consecutivelythemaxilla,zygomaticcomplex,nasalbone,nasoorbitalethmoidcomplex,orbitandthesupraorbitalstructures.2,3,6,8

In general the incidence of maxillofacial fractures may vary, depending onconditions such as geographic area, culturaldifferences, environmental factors andsocioeconomic trends.7,9,1115 Indevelopedcountriesmaxillofacial injuriesaremainlycaused by road traffic collisions (motorcycle, car, bicycle, pedestrian), falls, andsportrelatedaccidents,whereasinlessdevelopedcountriesmaxillofacialinjuriesaremostoftencausedby interpersonalviolence.7,11,16Anunderstandingofthecausesofthese fractures may guide clinical research towards the development of moreeffectivepreventionandtreatmentofmaxillofacialinjuries.7

Some authors note that the most common fracture site associated withmaxillofacial injuries iswithin themidface,whereas others have foundmandibularfractures tobe themost commonlyencountered.9,11,17,18The incidenceofmidfacialfracturesisreportedtorangefrom42.648.0%ofallmaxillofacialfractures.16,19,20

TreatmentofmidfacialtraumapatientsSurgeons may encounter a wide variety of diagnostic challenges and treatmentdilemmasinthetreatmentofmidfacialfractures.

Chapter1

14

Overthepast20years,boththeevaluationandtreatmentofmidfacialfractureshave evolved considerably. With betterquality computed tomography scans, thepreoperative diagnostic process has been significantly enhanced. In addition, thedevelopmentof improvedsurgicalapproachesand the introductionof rigid internalfixationwithosteosynthesishavefacilitatedrepair.21

In general, the fractured bones should be repositioned in their anatomicallycorrectposition and secured safely,with theobjectiveof reconstructing the shapeand restoring the function of allmidfacial structures. The fundamental idea is torestore the supportingbuttressesof themidface, thebonyprominences, thebonecavitiesandtocorrectdentalocclusion.4,8,22

The best treatment results of midfacial fractures are achieved with amultidisciplinaryteamapproachtotheoverallmanagementoftheinjury.23,24Inmanycases of traumatic maxillofacial and brain injury patients, expertise of severaldisciplinesisrequired,suchasgeneralsurgeons,ophthalmologists,otolaryngologists,anaesthesiologists and intensive care specialists.8,25,26 Furthermore, awareness andclose cooperation between oral and maxillofacial surgeons and neurosurgeons isrequiredtofacilitaterapiddiagnosisandappropriatetreatment.23

TreatmentdecisionmakinginzygomaticcomplexfracturesOne of themost common fracture sites in themidface is the zygomatic complex.Adequate reduction of a zygomatic complex fracture remains a challenge forsurgeons,due to itsanatomicalpositionand the inability tohavedirect viewofallfracturesites.Whetherornottotreatazygomaticcomplexfracturesurgicallyisstillamatter of debate, as there are no clear evidencebased guidelines for decisionmaking.Thedecisionisusuallybasedonclinicalsignsandsymptoms,andradiographicfeatures.Displacement of a zygomatic complex fracture associatedwith functionaland/or aesthetic problems is regarded to be a clear indication for surgery, unlessthere are profound contraindications, such as comorbidities of the patient, thepatientsrefusalorlackofinformedconsent.27,28

Althoughoccipitomentalandsubmentovertexradiographsareusedtobethe2Dradiographicexaminationofchoice,nowadays3Dcomputedtomographyisroutinelyused to evaluate zygomatic complex fractures with regard to displacement.1,27,29Suspectedand/orminordisplacedzygomaticcomplexfracturesmayeasilybemissedclinicallyat initialassessment,particularlywhensofttissueswellingmaybepresent.Therefore, both clinical examination and radiologic evaluation are essential forappropriate diagnosis and management.1,29 Atreatment algorithm for zygomaticcomplex fractures would be beneficial, but the wide variety of clinical signs andsymptoms of these fractures hampers the development of such a treatmentalgorithm.Acomparativeanalysisoftheclinicalandradiographicfeaturesofsurgically

Generalintroduction

15

1andnonsurgicallytreatedpatientswithzygomaticcomplexfracturesmaypotentiallyleadtoavaluablemanagementprotocol.

MidfacialtraumapatientsandconcomitantinjuryHighenergy trauma to the midface can cause complex fracture patterns of themidfacial bones asmentioned before.3As the highenergy nature of these injuriesoften leads tomultisystem involvement, a thorough systematic evaluation of thewhole patient should precede the management of the facial injury.3,4,30 Commonconcomitant injuries in patients with panfacial fractures include intracranialhaemorrhage, abdominal organ injury, pneumothorax, pulmonary contusion, andfracturesof spine, rib, extremityorpelvis.Whenmidfacial trauma surgery isbeingconsidered,itwouldbeappropriatetoinvestigatethepossiblepresenceofassociatedtraumatic brain injury, as the frequency of neurologic injury associatedwith facialfracturesisreportedtobe76%.3134Thiswillhelptorecognizeandtreatunsuspectedandundiagnosedneurologicinjuries,resultingindecreasedmorbidityandmortalityinmidfacialtraumapatients.33

MaxillofacialfracturesandtraumaticbraininjuryTraumatic brain injury (TBI) is defined as evidence of loss of consciousness and/orposttraumatic amnesia in a patient with a nonpenetrating head injury.35 TheGlasgowComaScale (GCS) isused todescribe the levelofconsciousness inpatientswithTBI.36,37Therehavebeenmanyattemptstoassesstheassociationbetweenfacialtraumaandneurological injury,with thegoal toaddress the roleof facialbones inprotectingthebrainagainstneurologicalinjury.Fromanevolutionaryandmechanicalstandpoint,thedescriptionofthefacialbonesasan impactorstressbearingregiontoabsorbforcesthatwouldotherwisebetransmittedtothebrainseems logical.38,39Followingthislogic,itisshownthatthepresenceoffacialfracturesisassociatedwithdecreased TBI, theorizing that the midfacial bones are suspected to act as anabsorption barrier against highimpact energy, and thus protecting the brain fromdamage.40,41 On the other hand, however, midfacial fractures are thought to befrequentlyassociatedwiththepresenceofsimultaneousbrain injury,as inmidfacialtraumapatients,energymaybedirectlytransmittedtothecranium,causingdamageto the brain.35,36,4145 Hence, the barrierfunction of the midface remains to beinvestigated.

ComplicationsinmaxillofacialandtraumaticbraininjurypatientsTreatingpatientswithmaxillofacial,especiallymidfacial,fracturesandassociatedTBIischallenging,andcan involveavarietyofcomplicationsthatmayoccur intheearlyand late postoperative periods.46 Early postoperative complications include

Chapter1

16

haemorrhage, infection, neurological disorder, nerve injury, inadequate fracturereduction, airway obstruction andmorbidity ormortality from concurrent injuries.Late postoperative complications include cosmetic deformity, neurological deficits,such as spasticity, epilepsy and neuropathic pain, enophthalmus, meningitis andmucocele formation.Asanalternative toclassificationby time,complicationscouldbe categorized by severity. Major complications include loss of vision, majorneurological injury, severe infection requiring prolonged hospitalization or death.Minor complications include seroma, haematoma,wound dehiscence and infectionmanagedwithmedical treatment.47As traumaticmaxillofacial and TBIpatients aremore prone to develop complications and therefore require a multidisciplinaryapproach,thesepatientsaremainlyhospitalizedinspecialisedtraumacentres.Moreknowledge concerning these complications, aswell as a standardized classificationmayberegardedasbeneficialtotheoutcomeofpatients.

Aimsofthisthesis

Consideringthedisparityofviewsconcerningtheincidence,aetiology,treatmentandcomplicationsoffracturestothemidface,especiallyzygomaticcomplexfractures,andtheassociationwithTBI,theaimsofthisresearchprojectare:1) To investigate the outcomes and complications of surgically treated zygomatic

complexfractures,accordingtoastandardizedtreatmentprotocol.2) To contribute towards the formationof a consensus viewon the treatmentof

zygomaticcomplexfractures.3) Toinvestigatetheepidemiological,clinicalandradiographicfeaturesofsurgically

andnonsurgically treatedpatientswithzygomaticcomplex fractures,providingphysicianswithamorecompleteviewformakingadecisiononwhetherornottotreatazygomaticcomplexfracturesurgically.

4) Toinvestigatetheincidenceandaetiologyofmidfacialfractures.5) To investigate the association of maxillofacial fractures, especially midfacial

fractures,with traumatic brain injury requiring neurosurgical andmaxillofacialintervention.

6) Toinvestigatethecomplications,treatmentmodalitiesandfollowupoftraumaticmaxillofacial and brain injury patients requiring neurosurgical andmaxillofacialintervention.

Generalintroduction

17

1References1. KuhnelTS,ReichertTE.:Traumaofthemidface.GMSCurrTopOtorhinolaryngolHeadNeckSurg(14)

Doc062015 2. KochharA,ByrnePJ.:Surgicalmanagementofcomplexmidfacialfractures.OtolaryngolClinNorthAm

(46)759778,20133. Alvi A, Doherty T, Lewen G.: Facial fractures and concomitant injuries in trauma patients.

Laryngoscope(113)102106,20034. GentileMA, TellingtonAJ, BurkeWJ, JaskolkaMS.:Management ofmidfacemaxillofacial trauma.

AtlasOralMaxillofacSurgClinNorthAm(21)6995,20135. BuchananEP,HopperRA,SuverDW,HayesAG,GrussJS,BirgfeldCB.:Zygomaticomaxillarycomplex

fracturesand theirassociationwithnasoorbitoethmoid fractures:a5year review.PlastReconstrSurg(130)12961304,2012

6. CalderoniDR,GuidiMdeC,KharmandayanP,NunesPH.:Sevenyear institutionalexperience inthesurgicaltreatmentoforbitozygomaticfractures.JCraniomaxillofacSurg(39)593599,2011

7. OzkayaO,TurgutG,KayaliMU,UgurluK,KuranI,BasL.:Aretrospectivestudyontheepidemiologyandtreatmentofmaxillofacialfractures.UlusTravmaAcilCerrahiDerg(15)262266,2009

8. Bogusiak K, Arkuszewski P.: Characteristics and epidemiology of zygomaticomaxillary complexfractures.JCraniofacSurg(21)10181023,2010

9. Mast G, EhrenfeldM, Cornelius CP.: [Maxillofacial fractures: midface and internal orbit. Part 2:therapeuticoptions].Unfallchirurg(115)145163,2012

10. BosRR,JansmaJ,VissinkA.:[Fracturesofthemidface].NedTijdschrTandheelkd(104)440443,199711. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence of

maxillofacialtrauma inAmsterdam:aretrospectiveanalysisof579patients.JCraniomaxillofacSurg(40)e165e169,2012

12. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of zygomaticoorbitalcomplexand/orzygomaticarchfracturesovera71monthperiod.DentTraumatol(27)135142,2011

13. Olate S, Lima SM Jr, Sawazaki R,Moreira RW, deMoraesM.: Surgical approaches and fixationpatternsinzygomaticcomplexfractures.JCraniofacSurg(21)12131217,2010

14. BormannKH,WildS,GellrichNC,KokemullerHorst,StuhmerCSchmelzeisenR,SchonR.:FiveyearretrospectivestudyofmandibularfracturesinFreiburg,Germany:incidence,etiology,treatment,andcomplications.JOralMaxillofacSurg(67)12511255,2009

15. ErdmannD,PriceK,ReedS,FollmarKE,LevinLS,MarcusJR.:Afinancialanalysisofoperativefacialfracturemanagement.PlastReconstrSurg(121)13231327,2008

16. NaveenS,AshwiniNS,VemannaH,NidarshS,PrasadR.:ThepatternofthemaxillofacialfracturesAmulticentreretrospectivestudy.JCraniomaxillofacSurg(40)675679,2012

17. UzelacA,GeanAD.:Orbitalandfacialfractures.NeuroimagingClinNAm(24)40724,vii,201418. IidaS,KogoM, SugiuraT,MimaT,MatsuyaT.:Retrospectiveanalysisof1502patientswith facial

fractures.IntJOralMaxillofacSurg(30)286290,200119. ZhouHH,OngodiaD,LiuQ,YangRT,LiZB.:Changingpattern in thecharacteristicsofmaxillofacial

fractures.JCraniofacSurg(24)929933,201320. Kyrgidis A, Koloutsos G, Kommata A, Lazarides N, Antoniades K.: Incidence, aetiology, treatment

outcomeandcomplicationsofmaxillofacialfractures.AretrospectivestudyfromNorthernGreece.JCraniomaxillofacSurg(41)637643,2013

21. McRaeM.FrodelJ.:Midfacefractures.FacialPlastSurg(16)107113,200022. HollierLH,SharabiSE,KoshyJC,StalS.:Facialtrauma:generalprinciplesofmanagement.JCraniofac

Surg(21)10511053,201023. KatzenJT,JarrahyR,EbyJB,MathiasenRA,MarguliesDR,ShahinianHK.:Craniofacialandskullbase

trauma.JTrauma(54)10261034,200324. GassnerR,TuliT,HachlO,RudischA,UlmerH.:Craniomaxillofacialtrauma:a10yearreviewof9,543

caseswith21,067injuries.JCraniomaxillofacSurg(31)5161,2003

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25. HosemannW,SchroederHW,KadukW,AugstD,FriedrichJ.:[Interdisciplinarymanagementofseveremidfacialtrauma].HNO(53)479498,2005

26. Raveh J, Vuillemin T.: The surgical onestagemanagement of combined craniomaxillofacial andfrontobasal fractures.Advantagesof the subcranialapproach in374 cases. JCraniomaxillofacSurg(16)160172,1988

27. EvansBG,EvansGR.:MOCPSSMCMEarticle:Zygomatic fractures.PlastReconstrSurg (121)111,2008

28. KelleyP,HopperR,Gruss J.:Evaluationand treatmentof zygomatic fractures.PlastReconstr Surg(120)5S15S,2007

29. Marinho RO, FreireMaia B.:Management of fractures of the zygomaticomaxillary complex. OralMaxillofacSurgClinNorthAm(25)617636,2013

30. SandnerA,KernCB,BlochingMB.: [Experienceswith thesubfrontalapproach tomanageextensivefracturesofthefrontalskullbase].Laryngorhinootologie(85)265271,2006

31. McCabe JB,AngelosMG.: Injury to the head and face in patientswith cervical spine injury.Am JEmergMed(2)333335,1984

32. MorganBD,MadanDK,BergerotJP.:Fracturesofthemiddlethirdofthefaceareviewof300cases.BrJPlastSurg(25)147151,1972

33. PappachanB,AlexanderM.:Correlatingfacialfracturesandcranialinjuries.JOralMaxillofacSurg(64)10231029,2006

34. TurveyTA.:Midfacialfractures:aretrospectiveanalysisof593cases.JOralSurg(35)887891,197735. DavidoffG,JakubowskiM,ThomasD,AlpertM.:Thespectrumofclosedheadinjuriesinfacialtrauma

victims:incidenceandimpact.AnnEmergMed(17)69,198836. Mena JH,SanchezAI,RubianoAM,PeitzmanAB,Sperry JL,GutierrezMI,Puyana JC.:Effectof the

modifiedGlasgowComaScalescorecriteria formild traumaticbrain injuryonmortalityprediction:comparingclassicandmodifiedGlasgowComaScalescoremodelscoresof13.JTrauma(71)11851192,2011

37. Mena JH,SanchezAI,RubianoAM,PeitzmanAB,Sperry JL,GutierrezMI,Puyana JC.:Effectof themodifiedGlasgowComaScalescorecriteria formild traumaticbrain injuryonmortalityprediction:comparingclassicandmodifiedGlasgowComaScalescoremodelscoresof13.JTrauma(71)11851192,2011

38. LeeKF,WagnerLK,LeeYE,SuhJH,LeeSR.:Theimpactabsorbingeffectsoffacialfracturesinclosedheadinjuries.Ananalysisof210patients.JNeurosurg(66)542547,1987

39. MacLennanWD.:Fracturesofthemandibularcondylarprocess.BrJOralSurg(7)3139,196940. ChangCJ,ChenYR,NoordhoffMS,ChangCN.:Maxillaryinvolvementincentralcraniofacialfractures

withassociatedheadinjuries.JTrauma(37)807811,199441. LeeKH,AntounJ.:Zygomaticfracturespresentingtoatertiarytraumacentre,19962006.NZDentJ

(105)47,200942. BrandtKE,BurrussGL,HickersonWL,WhiteCE,DeLozierJB.:Themanagementofmidfacefractures

withintracranialinjury.JTrauma(31)1519,199143. HaugRH,Savage JD,LikavecMJ,ConfortiPJ.:A reviewof100closedhead injuriesassociatedwith

facialfractures.JOralMaxillofacSurg(50)218222,199244. Haug RH,Adams JM, Conforti PJ, LikavecMJ.: Cranial fractures associatedwith facial fractures: a

reviewofmechanism,type,andseverityofinjury.JOralMaxillofacSurg(52)729733,199445. KeenanHT,BrundageSI,ThompsonDC,MaierRV,RivaraFP.:Doesthefaceprotectthebrain?Acase

controlstudyoftraumaticbraininjuryandfacialfractures.ArchSurg(134)1417,199946. CannonDE,WellsTS,PoetkerDM.:Two latecomplicationsofcraniofacial trauma:case reportand

reviewoftheliterature.AmJOtolaryngol(33)615618,201247. Shibuya TY, Karam AM, Doerr T, Stachler RJ, ZormeierM,Mathog RH,McLaren CL, Li KT.: Facial

fracturerepairinthetraumaticbraininjurypatient.JOralMaxillofacSurg(65)16931699,2007

Generalintroduction

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1

Chapter1

20

2

AtenyearanalysisoftheAmsterdamprotocolin

thetreatmentofzygomaticcomplexfractures

Thischapterisaneditedversionofthemanuscript:ForouzanfarT,SalentijnEG,PengG,vandenBerghB.

AtenyearanalysisoftheAmsterdamprotocolinthetreatmentofzygomaticcomplexfractures.JCraniomaxillofacSurg.2013Oct;41(7):61622.

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Abstract

IntroductionDespitemanypublicationsontheepidemiology,incidenceandaetiologyofzygomaticcomplex (ZC) fractures there is still a lack of information about a consensuson itstreatment. The aim of the present study is to retrospectively investigate theAmsterdamprotocolforsurgicaltreatmentofZCfractures.ResultsThetenyearresultsandcomplicationsarepresented.Thestudypopulationconsistedof236patients (170males,66 females;210ZC fractures,26solitaryzygomaticarchfractures)with ameanageof39.3 years (SD:15.6) (range:487 years).Themaincauseof injurywasdue to traffic relatedaccidents, followedbyviolenceand fall.Atotalof225platesand943screwswereused.Twentyninepatientspresentedwithcomplications, including suboptimal reduction (15 patients), wound infection (9patients)and transientparalysisof the facialnerve (1patient).Sevenpatients (3%)needed surgical retreatment of whom 4 needed a secondary orbital floorreconstruction,asthesepatientsdevelopedenophthalmusanddiplopia.ConclusionThis report provides important data for reaching a consensus in the treatment ofzygomaticcomplexfractures.

AtenyearanalysisoftheAmsterdamprotocolinthetreatmentofzygomaticcomplexfractures

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2

Introduction

Maxillofacial fractures account for a substantial proportion of traumatic injuries.1,2The incidenceofmaxillofacialfracturesvarieswithgeographicalarea,socioeconomictrends, incidenceofroadtrafficaccidents,alcoholabuse,drugabuseandbyseason.Thepatternofmaxillofacialfacturepresentationvaries,dependingontheaetiologyofthe injury. Common causes ofmaxillofacial fractures include road traffic accidents(including motorcycle, automobile, bicycle and pedestrian), assault, falls, sports,industrial/work related accidents and other miscellaneous causes (e.g. gunshotinjuries, pathological fractures).1,3,4 An understanding of these factors may guideclinicalresearchintothedevelopmentofmoreeffectivepreventionandtreatmentoftheseinjuries.1

Severalauthorshavenotedthatthezygomaticcomplexandmaxillaarethemostcommon maxillofacial fracture sites.2,4 As with other maxillofacial fractures, theprevalence of zygomatic complex fractures is related to different conditions.1,46Adequate fracture reduction is a constant challenge for surgeons due to theanatomical position of the zygomatic complex. The zygomatic complex consists of4pillarsattachedby4suture lines. It includes thepartof theorbital floor lateral tothe infraorbitalfissure.Asaresult,afractureofthiscomplex isalwaysaccompaniedwithanorbitalfloorfracture.Theaimofthetreatmentisreductionofthezygomaticcomplex,orbitalfloorandzygomaticarch.79

In the past, wire fixation was a treatment modality for zygomatic complexfractures.10,11The introductionof rigid internal fixation,usingminiplates,has led togreaterstabilityandlesscomplications.Theuseofminiplatesisnowastateofthearttreatmentmodality.5

Thereisnoconsensusonthebestsurgicalaccesstotheorbitozygomaticcomplex.Themajority of authors prefer to initially use the lower lid and lateral orbital rimapproach.Ontheotherhand,someauthorsusethetransoralapproachasfirstchoice,becauseitresultsinamorestablereductionwithalowercomplicationrate.1

Despite various publications on the epidemiology, incidence and aetiology ofzygomatic complex fractures, there remains no consensus agreement regarding itstreatment.

The aim of this study was to retrospectively investigate the outcomes andcomplicationsarising inpatients, surgically treated for zygomatic complex fracturesaccordingtoourtreatmentprotocoloveratenyearperiod.Wehopethatthisstudywill contribute towards the formation of a consensus view on the treatment ofzygomaticcomplexfractures.

Chapter2

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Materialsandmethods

DatacollectionHospitalandoutpatientrecordsofpatientssurgicallytreated forzygomaticcomplexfractures from January 2000 to January 2010 were reviewed and analysedretrospectively.Thepatientswereidentifiedusingthehospitaldatabase.Alltypesofzygomatic complex fractures, surgically treated by open or closed reduction,wereincluded.Patientswithpanfacial traumaandsolitaryorbitalblowout fractureswereexcluded. Data collected included gender, age, cause of the injury, pre andpostoperative radiographic analysis, typeof zygomatic complex fracture, treatmentmodalityandcomplications.

TreatmentprotocolZygomatic complex fractures were diagnosed at presentation to the outpatientdepartment or emergencyward, using both clinical and radiographic examination.Radiographic analysis included submentovertex and occipitomental views or a(conebeam)CTscan. Ifnecessary,anophthalmologyopinionwasobtainedpreandpostoperativelytorecordenophthamusand/oreyemovementdisturbances.

Patientsweretreatedaccordingtothedepartmentsprotocol,asdemonstratedinFigure2.1.Thefracturereductionwasperformedusingabonehookand,ifnecessary,the fractured bones were fixed with plate osteosynthesis. The preferred site offixation was on the lateral orbital rim. If the reduction was unstable, a secondminiplate was fixed on the zygomaticomaxillary buttress. If necessary, a thirdminiplatewasfixedontheinfraorbitalrim.KLSMartin2.0mmand/or1.5mmplateswereused.

As a training unit, the departmental policy was to adhere to the treatmentprotocol.However,thesurgeonhadtheabilitytodeviatefromtheprotocolifneeded.

Duringthesurgicalprocedure,aforcedductiontestwasperformedtwice,beforeandafter reductionof the zygomaticcomplex. Ifocularmovementswere restrictedandentrapmentoftherectus inferiormusclewassuspected,theorbitalfloorwouldbe explored. Another reason for exploration was the detection of a comminutedorbital floor fracture on the CTimages. If necessary the orbital floor would bereconstructed using Medportitanium implants, titanium implants, polydioxanone(PDS)sheetsorautogenousbonegrafts.Thereconstructionmaterialwaschosenbytheoperatingsurgeon.


25

2

Figure2.1 Treatmentprotocol. (s.r:stablereposition;i.r:instablereposition;s.f:stablefixation).

Clinical signs

Radiographic analysis

Zygomatic arch fracture

Zygomatic complexfracture

with muscle entrapment

RepositionGilliesapproach


Reposition bone hook Reposition bone hook

Fixationlateral orbital rim


Finished

Fixationzygomaticomaxillary buttress

Fixationinfraorbital rim

Orbital floor explorationandreconstruction

Fixationzygomaticomaxillary

buttress


s.ri.r i.r

s.f

s.r

i.r i.r

s.f

s.f

i.r

i.r

s.f

s.f

Clinical signs

Radiographic analysis

Zygomatic arch fracture


with muscle entrapment

RepositionGilliesapproach


Reposition bone hook Reposition bone hook



Finished

Fixationzygomaticomaxillary buttress


Orbital floor explorationandreconstruction

Fixationzygomaticomaxillary

buttress


s.ri.r i.r

s.f

s.r

i.r i.r

s.f

s.f

i.r

i.r

s.f

s.f

Chapter2

26

Allpatientsreceivedstandardanalgeticspostoperatively (diclofenac50mgthreetimesdailyorparacetamol/codeine1000/20mg four timesdaily).Patients receivedprophylacticantibioticsforoneweekifeitherthezygomaticomaxillarybuttressortheinfraorbitalrimhadbeenusedforfixation(eitheramoxicillin/clavulanicacid500/125mgthreetimesdailyorclindamycin600mgthreetimesdaily).Patientsalsoreceivedprophylacticantibioticsafterorbitalfloorreconstruction.

Conventional radiographs (submentovertex and occipitomental views) wereperformedpostoperativelytoanalysethereductionandforteachingandmedicolegalreasons.Ifthereductionwasperformedsuboptimallyandtherewereclinicalsignsofamalpositionedzygomaticcomplex,thepatientwouldberetreated.

Allofthepatientswerecloselyfollowedupforthefirst6weekspostoperatively.After thisperiod,patientswere followedupat3and6monthspostoperatively,asdemonstratedinthedepartmentsprotocol.

Osteosynthesismaterialwasremovedincasesofpersistentinfectionthatdidnotrespondtooralantibiotics(after23monthspostoperatively)andalsoforagerelatedreasons. To prevent any possible growth restriction of the zygomatic complex inpatientsunder18yearsofage,alloftheosteosynthesismaterialwouldberemovedintheperiodbetween6and12monthsaftertheprimarysurgery.

StatisticsDatawasanalysedusingtheStatisticalPackageforSocialSciences(SPSS)version15.0.Forparametricdata,Studentsttests,andfornonparametricdata,ChiSquaretestswereperformed,ifdataweresufficientenough.

Results

The study population consisted of 170males and 66 femaleswith amean age of39.3years(SD:15.6)andarangeof487years.In210patients(89%),thezygomaticcomplex was fractured, whereas 26 patients (11%) presented with a solitaryzygomaticarchfracture.Figure2.2demonstratesthecauseofthezygomaticcomplexfractures,whichwasmainlytheresultofvehicleaccidents,followedbyviolence.

The left sidewasmoreaffected (145patients) than the right side (91patients).Therewerenosignificantdifferencesbetweenmaleandfemalepatients.Theclinicalsigns and symptoms are shown in Table 2.1. Most patients presented withparaesthesia inthe infraorbitalnerve (47.0%), followedbymalardepression (37.3%)andhematomas/ecchymosis(36.0%).


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Figure2.2 Mechanismoftheinjury.Table2.1 Clinicalsignsandsymptoms.

N(%) Missingfiles(%)Edema 64(27.1) 38(16.1)Pain 62(26.3) 173(73.3)Hematomas/ecchymosis 85(36.0) 23(9.7)Malardepression 88(37.3) 108(45.8)Palpablebonedeformityintraoral 37(15.7) 136(57.6)Palpablebonedeformityextraoral 72(30.5) 115(48.7)Paraesthesiainfraorbitalnerve 111(47.0) 69(29.2)Limitedmouthopening 32(13.6) 88(37.3)Diplopia 20(8.5) 68(28.8)Enophthalmus 10(4.2) 78(33.1)

RadiographicanalysisThe type of pre and postoperative radiographic analysis was divided intoconventional radiographs, consisting of submentovertex and occipitomental views,and a (conebeam) CTscan. In total 413 preoperative radiographic analyses wereperformed.Postoperatively,361radiographsweremade.

TreatmentmodalitiesandoperationdurationAllofthe26patients(11%)withsolitaryzygomaticarchfracturesweretreatedwithclosed reduction, using the Gillies approach, which was consistent with thedepartments protocol. The mean operating time was 31.0 (SD: 8.9) minutes.Postoperativeradiographsconsistedofsubmentovertexandoccipitomentalviews.NoCTscanswereperformed.

Outofthe210patientswithzygomaticcomplexfractures,33patients(14%)weretreatedwith closed reduction. The remaining 177 patients (75%) underwent openreduction and internal fixation, using 225 osteosynthesis plates (22 x 1.5mm KLS

0

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Martinplatesand203x2.0mmKLSMartinplates)and943screws.ThedistributionandlocalisationoftheosteosynthesisplatesaredemonstratedinFigures2.3and2.4.Figure2.3 Usedosteosynthesisplates.

Figure2.4 Locationoftheosteosynthesisplates.

Themeanoperatingtimeforallzygomaticcomplexfractureswas65.9(SD:3.7)minutes.

In 141 patients, only one plate was required for fracture reduction. In137patients, a plate was fixed on the lateral orbital rim. Fixation only at thezygomaticomaxillary buttress was performed in 2 patients using the transoralapproach,as in thesepatientsmostof the fracturedisplacementwas found in thisarea.Theinfraorbitalrimwasusedforfixationin2otherpatients.Inbothpatients,ithadpreoperativelyalreadybeenclear thatanorbital floor reconstructionwouldbenecessary.

In29patientstwoplateswerenecessaryforfracturereduction.In26patients,thefirstplatewas fixedon the lateralorbital rimand in3patientson the zygomatico

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maxillarybuttress.Thesecondplatewasfixedonthezygomaticomaxillarybuttressin15patientsandontheinfraorbitalrimin14patients.

Threepatientsneededfixationonallofthethreebuttresses.A1.5mmplatewasfixedparanasallyin3patientsinadditiontothe3buttresses.Onepatientwastreatedwith 5 osteosynthesis plates: 3 on the buttresses, 1 paranasally and 1 on thezygomaticarch.

Orbital floor reconstruction was performed in 13 patients, using PDS sheets(8patients)andMedportitaniumimplants(5patients).

ComplicationsandretreatmentAs demonstrated in Table 2.2, the main complication consisted of a suboptimalfracture reduction (15patients). In12patients, retreatmentwasnotnecessary.Thesecondmost common complicationwaswound infection (9 patients). In all of thepatientstheinfectiondevelopedwithin2to3weeksaftersurgery.In8patients,theinfectionwas localised intraorally at the zygomaticomaxillary buttress,whereas in1patient the infectionwas localised in the region of the lateral orbital rim. In thelatter patient, the osteosynthesis material had been removed 5 weekspostoperatively. All other patients had been treated successfully withamoxicillin/clavulanicacid500/125mg,threetimesdailyforoneweek.

Table2.2 Postoperativecomplications.

N(%)Woundinfection 9(3.8)Suboptimalfracturereductionnoretreatment 12(5.1)Suboptimalfracturereductionretreatment 3(1.3)Secondaryorbitalfloorreconstructionretreatment 4(1.7)Facialnervedamagetransient 1(0.4)Atotalof7patientsneededsurgicalretreatment.Twopatientswereretreatedduringtheir hospital stay. The first patientwas treated for a zygomatic complex fracture.Afteropenreductionand internal fixationclinicalanalysisdemonstratedadisplacedzygomaticcomplex,whichrequiredfurthertreatment.Thesecondpatientpresentedwith a displaced zygomatic arch fracture. Radiographic analysis demonstrated asuboptimal reduction after surgical treatment. This patient underwent successfulsurgical retreatment. Fourpatientsunderwent surgical retreatmentafterdischarge.Oneof thesepatientshadbeen treated forazygomaticcomplex fracturebyclosedreduction.Thispatientpresentedwithclinicalsignsofdisplacementoneweekafterdischarge,which required further treatment.However, retrospective review of thepostoperative radiographsmade prior to discharge demonstrated nomalposition,neitheranindicationforfurthertreatment.

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Theremaining3patientswereretreatedsurgicallybetween2and4weeksafterdischarge.Thesepatientsneededasecondarycorrectionoftheorbitalfloor,followingfracturereductionof thezygomaticcomplex.Theorbital floorhadnot initiallybeentreatedduringthereductionofthezygomaticcomplex,asthesepatients initiallydidnot show any clinical signs that could justify a primary orbital floor reconstruction(according to the departments protocol, Figure 2.1). The pre and postoperativeradiographs were simple plain views (submentovertex and occipitomentalradiographs),whichdemonstratednodisplacement.

Theseventhpatientunderwentcorrectionofanorbitalfloorreconstruction,onemonth after the initial treatment.The insertedPDS sheethaddislodged anteriorly.The fracture was part of a zygomatic complex fracture. Despite the primaryreconstruction and retreatment this patient developed late enophthalmus anddiplopia. A further successful reconstruction using aMedportitanium implant hadbeennecessary.

Discussion

There is considerable information available concerning the epidemiology andmechanismofthe injuryofzygomaticcomplexfractures.However,there isa lackofinformation regarding its treatmentprotocolsand there isstillnoconsensuson thetreatmentofthesefractures.Thisretrospectiveanalysiswasperformedtoinvestigatethedepartmentsprotocol.Doingso,wehopetocontributetothedevelopmentofaconsensusonthetreatmentofzygomaticcomplexfractures.

Inthelast10years,236patientswithzygomaticcomplexfractureswereadmittedtoourdepartment for surgical treatment.Themaincauseof the injurywasvehicleaccidents, followed by violence and falls. These results are consistent with theliterature,astrafficaccidentsarefrequentlymentionedasthemostfrequentcauseofmaxillofacialtraumainmanycountries.1,3,4Inrecentyearsinterpersonalviolencehasincreasedandsurpassedtrafficaccidentsasthemaincausativeevent.4Otherspointout an aetiological transition tendency towards a rise in aggression over trafficaccidents.1216

Twentysixpatientswerediagnosedwithasolitaryzygomaticarchfracture.AllofthesepatientsweretreatedusingtheGilliesapproach.

In seven patients, the reduction was not satisfactory on clinical analysis orfollowingreviewof thepostoperativeradiographs.Thirtythreeof210patientswithzygomatic complex fractures were treated with closed reduction. The remainingpatients were treated with open reduction and internal fixation. As plateosteosynthesishasbecomestateoftheart inthetreatmentoffacialbonefractures,all remaining fractures (n=177)were securedwith plates.1719A total of 225 plateswereused.


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Recent studieshave stated that standardpostoperative radiographic analysisofmaxillofacial fractures is not necessary. Radiographs are made routinely aftertreatment ofmaxillofacial trauma for several reasons, including surgical treatmentevaluation,detectionofdefectsaftersurgerybeforepatientdischarge, identificationof theosteosynthesismaterial for futureremoval,and for teachingandmedicolegalreasons.20,21,22 In total 413 preoperative and 361 postoperative radiographs wereanalysedinthetreatmentof236patientswithzygomaticcomplexfractures.Thisissueshouldbeinvestigatedfurtherandwillnotbethoroughlydiscussedhere,asitisoutofthe scope of this study. The authors opinion performing routine postoperativeradiographs isofquestionablevalue,consideringthat361postoperativeradiographswere performed,whereas only 1 patient had been retreated on the basis of thisevidence.

Several authors propose a CTscan as the gold standard for diagnosing andplanning zygomatic complex fractures.23,24 Our departments protocol appliesconventional radiographs as a standard to diagnose zygomatic complex fractures,whereas a CTscan would be performed when required for further analysis andtreatmentplanning.Conventionalradiographshavetheadvantageofbeingmorecosteffectiveandexposethepatienttolessirradiation.Figures2.5and2.6demonstrateazygomaticcomplex fracturewithminimaldisplacementonconventionalradiographs(occipitomentalandsubmentovertexviews).

Figure2.5 Preoperativeoccipitomentalradiographofazygomaticcomplexfractureontherightside.

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Figure2.6 Preoperativesubmentovertexradiographofazygomaticarchfractureontherightside.In this case, a CTscan would be beneficial. Figures 2.7 and 2.8 demonstrate

conventionalpostoperative imagesafter reductionofa zygomatic complex fractureusingabonehook.

Figure2.7 Postoperativeoccipitomental radiographofa zygomaticcomplex fractureon the right side.

Fixationwasnotnecessary.


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Figure2.8 Postoperativesubmentovertexradiographofazygomaticarchfractureontherightside.

ACTscanmaybeadvantageous for treatmentplanning incasesofcomminuted

orbitalfloorfractures,asdemonstratedinFigure2.9.

Figure2.9 PreoperativeCTimageofacomminutedorbitalfloorfractureontheleftside.

Figure 2.10 demonstrates a postoperative coronal CTimage of a comminuted

orbital floor fracture, which was reconstructed with a Medportitanium implant.

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Irrespectiveoftheincreasedcostsandirradiationwehavetoadmitthatthedecisionto perform a scan is much easier nowadays, following the introduction of theconebeamCTscan.

Figure2.10 PostoperativeCTimageofa reconstructedorbital flooron the leftside.AMedportitanium

implantwasusedforthereconstruction.Markowitz and Manson showed that the frontozygomatic area is not a good

referencepointforfracturereductionandthatasecondorperhapsevenathirdareaofevaluationwouldbebeneficial.25Habaldemonstratedgood fracturereductionbytheir sequential surgical approach, using the zygomaticomaxillary buttress as firstchoiceapproach, followedby the infraorbital rimand lateralorbital rim in the thirdplace.26,27Ellisadvisedthezygomaticomaxillarybuttressapproachasthefirstchoice,followedbytheinfraorbitalrimandlateralorbitalrim.26,28Incontrast,ourdepartmentapplies the lateral orbital rim approach as the first choice, followed by thezygomaticomaxillarybuttressandtheinfraorbitalrim,asthelatterapproachseemstobe associated with higher complication rates.22,29 During surgery the reduction isassessedbypalpatingtheinfraorbitalrimandthezygomaticomaxillarybuttress.Whenthefractureisadequatelyreduced,fixationisperformedusingplateosteosynthesisatthe frontozygomatic suture. The development of the departments approach wasclarifiedbyinterviewingtheseniorsurgeons.Inthepast,fixationhadbeenperformedbywiring,andthebestaccessibleareaforfixationwithwiresprovedtobethelateralorbitalrim.Followingtheintroductionofplateosteosynthesis,ithadbeendecidedto


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use this approach as first choice. Therefore, the same approach is stillused in thepresentprotocol.

This study did not demonstrate any differences in the incidence of infectionbetweendifferent fixationareas,which is in linewith the literature.RecentlyKnepilandLoukotadescribedthetypeofcontaminationduringsurgery.30Mostfracturesofthezygomaticcomplexmaybeclassifiedascleanorcleancontaminated,dependingonwhetherthesurgicalapproachistranscutaneousortransoral.Cleanoperationsinhealthy patients have a low risk of infection, ensuring no indication for antibioticprophylaxis.Avoidingatransoralapproachconvertsacleancontaminatedoperationintoacleanoperation,whichmakestheuseofprophylacticantibioticsunnecessary.Publisheddata regarding theeffectivenessofprophylacticantibiotics in the surgicaltreatmentofmaxillofacialfractures,andespeciallyzygomaticbonefractures,isscarceand the levelofevidence is low.31Theauthorsof thepresentstudyonlyprescribedprophylacticantibioticsaccording to thedepartmentsprotocol.Thisprotocolstatesthat patients only receive prophylactic antibiotics if either the zygomaticomaxillarybuttressortheinfraorbitalrimisusedforfixation.

Asthepatientsopinionwasnotobtained,regardingtheformationofscartissueatthe lateralorbitalrim,strongrecommendationsregardingthebestsurgicalaccesscouldnotbeprovided.Althoughourresultsareinlinewiththeliteratureconcerningtheextraoralapproach,itisquestionableifthesameresultscouldbeachievedusingatransoralapproach.

Conclusion

This studygivesanoverviewof236patientswhounderwent surgical treatment forzygomatic complex fractures, according to the Amsterdam protocol. Twentyninepatients presentedwith complications, including suboptimal fracture reduction (15patients),wound infection (9patients)and transientparalysisof the facialnerve (1patient). Seven patients (3%) needed surgical retreatment, ofwhom four patientsneededa secondaryorbital floor reconstructiondue toenophthalmusanddiplopia.This report demonstrates important data that may improve the treatment ofzygomaticcomplexfracturesandcontributetowardsreachingaconsensusopiniononthemanagementofthisfracturetype.

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References

1. CalderoniDR,GuidiMdC, Kharmandayan P,Nunes PH.: Sevenyear institutional experience in thesurgicaltreatmentoforbitozygomaticfractures.JCraniomaxillofacSurg(39)593599,2011

2. Bogusiak K, Arkuszewski P.: Characteristics and epidemiology of zygomaticomaxillary complexfractures.JCraniofacSurg(21)10181023,2010

3. NaveenShankarA,NaveenShankarV,HegdeN,Sharma,PrasadR.:ThepatternofthemaxillofacialfracturesAmulticentreretrospectivestudy.JCraniomaxillofacSurg(40)675679,2012

4. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence ofmaxillofacialtrauma inAmsterdam:aretrospectiveanalysisof579patients.JCraniomaxillofacSurg(40)e165e169,2012

5. OlateS,LimaSM Jr,SawazakiR,MoreiraRWillian,deMoraesM.:Surgicalapproachesand fixationpatternsinzygomaticcomplexfractures.JCraniofacSurg(21)12131217,2010


7. HeD,BlomquistPH,EllisE.:Associationbetweenocularinjuriesandinternalorbitalfractures.JOralMaxillofacSurg(65)713720,2007

8. HwangK.:Onepointfixationoftripodfracturesofzygomathroughalateralbrowincision.JCraniofacSurg(21)10421044,2010

9. Wang S, Xiao J, Liu L, Lin Y, Li X, Tang W, Wang H, Long J, Zheng X, Tian W.: Orbital floorreconstruction:aretrospectivestudyof21cases.OralSurgOralMedOralPatholOralRadiolEndod(106)324330,2008

10. LundK.:Fracturesofthezygoma:afollowupstudyon62patients.JOralSurg(29)557560,197111. PozatekZW,KabanLB,GuralnickWC.:Fracturesofthezygomaticcomplex:anevaluationofsurgical

managementwithspecialemphasisontheeyebrowapproach.JOralSurg(31)141148,197312. GomesPP,PasseriLA,Barbosa JR.:A5year retrospectivestudyofzygomaticoorbitalcomplexand

zygomaticarchfracturesinSaoPauloState,Brazil.JOralMaxillofacSurg(64)6367,200613. Hwang K, You SH, Sohn IA.:Analysis of orbital bone fractures: a 12year study of 391 patients. J

CraniofacSurg(20)12181223,200914. LeeKH.:Interpersonalviolenceandfacialfractures.JOralMaxillofacSurg(67)18781883,200915. LeeKH.andAntoun,Joseph:Zygomaticfracturespresentingtoatertiarytraumacentre,19962006.

NZDentJ(105)47,200916. vanBeekGJ,MerkxCA.:Changes inthepatternoffracturesofthemaxillofacialskeleton. IntJOral

MaxillofacSurg(28)424428,199917. AlkanA,CelebiN,OzdenB,BasB,InalS.:Biomechanicalcomparisonofdifferentplatingtechniquesin

repairofmandibularanglefractures.OralSurgOralMedOralPatholOralRadiolEndod(104)752756,2007

18. deMatosFP,Arnez,MF,SverzutCE,TrivellatoAE.:Aretrospectivestudyofmandibularfracture ina40monthperiod.IntJOralMaxillofacSurg(39)1015,2010

19. EllisE,elAttarA,MoosKF.:Ananalysisof2,067casesofzygomaticoorbitalfracture.JOralMaxillofacSurg(43)417428,1985

20. Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, Edwards K.: Postoperativeradiographs afteropen reduction and internal fixationof themandible: are theyuseful?Br JOralMaxillofacSurg(44)279282,2006

21. Jain MK, Alexander M.: The need of postoperative radiographs in maxillofacial fracturesaprospectivemulticentricstudy.BrJOralMaxillofacSurg(47)525529,2009

22. vandenBerghB,GoeyY,ForouzanfarT.:Postoperativeradiographsaftermaxillofacialtrauma:Senseornonsense?IntJOralMaxillofacSurg(40)13731376,2011

23. Jarrahy R, Vo V,GoenjianHA, Tabit CJ, KatchikianHV, Kumar A,Meals C, Bradley JP.:Diagnosticaccuracy of maxillofacial trauma twodimensional and threedimensional computed tomographicscans:comparisonoforalsurgeons,headandnecksurgeons,plasticsurgeons,andneuroradiologists.PlastReconstrSurg(127)24322440,2011


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24. KaufmanY,StalD,ColeP,HollierL Jr.:Orbitozygomatic fracturemanagement.PlastReconstrSurg(121)13701374,2008

25. MarkowitzBL,MansonPN.:Panfacial fractures:organizationof treatment.ClinPlastSurg (16)105114,1989

26. HabalMB.:Theorbits: it is less importantwhatyouput inthanhowyousecure it.JCraniofacSurg(21)965966,2010

27. RidgwayEB,ChenC,ColakogluS,GautamS,LeeBT.:Theincidenceoflowereyelidmalpositionafterfacial fracture repair: a retrospective study andmetaanalysis comparing subtarsal, subciliary, andtransconjunctivalincisions.PlastReconstrSurg(124)15781586,2009

28. EllisE,KittidumkerngW.:Analysisoftreatmentforisolatedzygomaticomaxillarycomplexfractures.JOralMaxillofacSurg(54)386400,1996

29. Bahr W, Bagambisa FB, Schlegel G, Schilli W.: Comparison of transcutaneous incisions used forexposureoftheinfraorbitalrimandorbitalfloor:aretrospectivestudy.PlastReconstrSurg(90)585591,1992

30. KnepilGJ, LoukotaRA.:Outcomesofprophylacticantibiotics following surgery for zygomaticbonefractures.JCraniomaxillofacSurg(38)131133,2010

31. Zhang Y,He Y, Zhang ZY, An JG.: Evaluation of the application of computeraided shapeadaptedfabricated titaniummesh formirroringreconstructing orbitalwalls in cases of late posttraumaticenophthalmos.JOralMaxillofacSurg(68)20702075,2010

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3

Theepidemiologicalcharacteristicsofzygomatic

complexfractures:Acomparisonbetweenthe

surgicallyandnonsurgicallytreatedpatients

Thischapterisaneditedversionofthemanuscript:SalentijnEG,BoffanoP,BoverhoffJ,vandenBerghB,ForouzanfarT.

Theepidemiologicalcharacteristicsofzygomaticcomplexfractures:Acomparisonbetweenthesurgicallyandnonsurgicallytreatedpatients.

NatlJMaxillofacSurg.2013Jul;4(2):214218.

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Abstract

IntroductionThisretrospectivestudy isaimedatthedocumentationofamorecompleteviewofepidemiologicaldatawithparticularfocusonthecharacteristicsofsurgicallyandnonsurgicallytreatedpatientswithzygomaticcomplexfractures.MaterialandMethodsA total of 133 surgically and 150 nonsurgically treated patients with zygomaticcomplexfracturesatVUUniversityMedicalCenter inAmsterdamfromJanuary2007to January 2012was analyzed. These patient groupswere further subdivided intodisplacedornondisplacedfracturesandcomparedwitheachotheraccordingtoage,genderandtraumaaetiology.ResultsThemean age of all 283 patientswas 42.8 years (SD: 19.8). Surgically and nonsurgically treatedpatientsdiffered inpresentationwithasignificantlyoverallhigherage of female patients, especiallywithin the nonsurgically treated patients groupwith fracture displacement (mean age of 59.5 years, SD: 27.4). Themean age ofmalesfromthedifferentsubgroupswasmoreconsistentwiththeoverallmeanage.Themaincauseofthetraumawastrafficaccidents,whereasthecontributionoffallsand assault depended on age group, gender, treatment management and evenfracturedisplacement.ConclusionsThis report provides us important epidemiological data regarding patients withzygomatic complex fractures. The nonsurgically treated patients group containedpatients of higher age, more females and a fallrelated cause, compared to thesurgically treatedpatients group. The surgically treatedpatients group showed thesameepidemiologicalcharacteristicsasweredemonstratedinpreviousstudies.

Theepidemiologicalcharacteristicsofzygomaticcomplexfractures

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Introduction

Fractures of the zygomatic complex are common after facial trauma and arefrequentlyassociatedwithadditionaltraumaticinjury.14Earlydiagnosisofzygomaticcomplex fractures is essential for optimal treatment and is directly dependent onappropriate initialevaluation,correct injuryassessment,and timely initiationof thechosen therapy. Surgical intervention is the treatment of choice for displacedzygomaticcomplexfractures,unlesspatientsaremedicallyunfittoundergosurgery,ifpatientsrefusesurgery,orifpatientspresentwithnoneorminimalfunctionaland/oraesthetic problems.5,6 In the literature many studies can be found concerningevaluationofthesurgicaltreatmentmanagementofzygomaticcomplex fractures.7,8Literatureconcerningthepreoperativeassessmentofzygomaticcomplexfractures,inparticular theepidemiologicaldifferencesbetween the surgically andnonsurgicallyindicatedtreatmentgroups, is lacking.Tothebestofourknowledge,onlyonestudybyBacketal.specifically investigatedthenonsurgicallytreatedpatients.9However,thestudybyBacketal.includedallfacialfracturesanddidnotfocusonpatientswithzygomatic complex fractures in particular.9 The purpose of this retrospective studywastoprovidephysiciansamorecompleteviewoftheepidemiologicalcharacteristicsofsurgicallyandnonsurgicallytreatedpatientswithzygomaticcomplexfractures.

Materialsandmethods

SubjectsA retrospective reviewwas performed from all hospital and outpatient records of283patients diagnosedwith a fractured zygomatic complex, from January 2007 toJanuary2012.Theeligiblepatientswere identifiedusingthehospitaldatabase.Datacollectionconsistedofage,gender,fracturesite,fracturedisplacement,causeofthetrauma (assault, traffic accident, sport accident, fall or other), date of the trauma,date of the first consultation, and treatmentmanagement (surgical ornonsurgicaltreatment).Diagnosis(andthepresenceoffracturedisplacement)ofallpatientswasestablished at the same day of initial assessment by plain radiographic analysis(submentovertex andoccipitomental radiographs) and/or a computed tomographyscan(CTscan).ExclusioncriteriawerethepresenceofaLeFortfracture,otherfacialfracturesthatwereassociatedwiththe(foursided)zygomaticcomplex(e.g.,isolatedlateralorbitalrimand/orwall,orbitalfloororzygomaticarch),andbilateralzygomaticcomplex fractures. Furthermore, patients were excluded if the initial clinicalassessmentwasmorethan1weekafterthetraumaandifradiographicanalyses(e.g.plainradiographsorCTscans)werenotavailable.Afterdataretrieval,patientsweredivided intosurgicallytreatedornonsurgicallytreatedpatientgroups.Furthermore,

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patients in the nonsurgically treated groupwere subdivided into groups basedondisplacement of the fractured zygomatic complex (displacement versus nondisplacement).

StatisticsNominal datawere presented as absolute and relative frequencies,metric data asmeanand standarddeviation (SD).Comparisonsbetween thegroupsweredonebytheChiSquare test fornominaldataand theMannWhitneyU test forage.P


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(43.4 years, SD:20.6),especiallywith regard to the femalepatients (mean ageof59.5years,SD:27.4).Thedifferenceswerenotsignificant(P=0.055).

Asdemonstrated in Table 3.2, themain causeof zygomatic complex fractureswastrafficrelatedaccidents(43.1%),followedbyfalls (27.2%)andassault (20.5%).Sportrelatedaccidentsandothercauseswereconsideredaslesscommoncauses.

Table3.2 Causeofinjuryaccordingtoagegroupsinallpatientswithafracturedzygomaticcomplex.

Age Fall Assault Trafficaccident Sports Other Total (%)09 2 0 0 0 0 2 (0.7)1019 5 8 13 3 4 33 (11.7)2029 10 18 34 4 1 67 (23.7)3039 5 12 16 1 3 37 (13.1)4049 11 9 22 4 2 48 (17.0)5059 7 8 20 0 2 37 (13.1)6069 15 2 13 1 0 31 (11.0)70+ 22 1 4 0 1 28 (9.9)Total 77 58 122 13 13 283 (%) (27.2) (20.5) (43.1) (4.6) (4.6)

Themaincausesdifferedsubstantiallybetweenmaleandfemalepatients,asshowninTable3.2aand3.2b.Concerningmalepatients,trafficaccidentsaccountedfor43.3%of the cases, followed by assault (26.4%) and falls (20.9%).With regard to femalepatients, both traffic accidents (42.7%) and falls (42.7%) were found as themostcommoncauses,whereaszygomaticcomplexfracturesduetoassaultwerenotfoundfrequently(6.1%).Traumaduetofallaccountedsignificantlymorefortheolderages,whereastraumaduetotrafficaccidentsandassaultaccountedfortheyoungerages(P

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Table3.2b Causeofinjuryaccordingtoageforfemalepatients.

Age Fall Assault Trafficaccident Sports Other Total (%)09 2 2 (2.4)1019 1 4 1 4 10 (12.2)2029 3 1 10 14 (17.1)3039 2 3 5 (6.1)4049 2 2 8 1 1 14 (17.1)5059 3 2 5 10 (12.2)6069 7 3 10 (12.2)70+ 15 2 17 (20.7)Total 35 5 35 2 5 82 (%) (42.7) (6.1) (42.7) (2.4) (6.1)

Forbothpatientgroups trafficaccidentsmainlyconsistedofbicycleandmotorcycleaccidentswithrelativemorebicycleaccidentsforthefemalepatients(Figure3.1).

Figure3.1 Trafficaccidentsdividedbymodeoftransportformaleandfemalepatients.

The main cause of injury regarding the surgically treated patients accounted foralmost50%of trafficaccidents, followedbyassault (24.1%)and falls (13.5%) (Table3.3a).Inthenonsurgicallytreatedpatientsgroup,fallswerefoundasthemaincause(39.3%),closelyfollowedbytrafficaccidents(37.3%).Assaultaccountedfor17.3%ofthepatients(Table3.3b).

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Table3.3a Causeofinjuryforsurgicallytreatedpatients.

Age Fall Assault Trafficaccident Sports Other Total (%)09 1019 5 7 3 1 16 (12.0)2029 4 9 21 3 37 (27.8)3039 1 7 7 1 2 18 (13.5)4049 5 8 12 3 2 30 (22.6)5059 3 3 11 1 1 18 (13.5)6069 2 6 1 9 (6.8)70+ 3 2 5 (3.8)Total 18 32 66 11 6 133 (%) (13.5) (24.1) (49.6) (8.3) (4.5)

Table3.3b Causeofinjuryfornonsurgicallytreatedpatients.

Age Fall Assault Trafficaccident Sports Other Total (%)09 2 2 (1.3)1019 5 3 6 3 17 (11.3)2029 6 9 13 1 1 30 (20.0)3039 4 5 9 1 19 (12.7)4049 6 1 10 1 18 (12.0)5059 4 5 9 1 19 (12.7)6069 13 2 7 22 (14.7)70+ 19 1 2 1 23 (15.3)Total 59 26 56 2 7 150 (%) (39.3) (17.3) (37.3) (1.3) (4.7)

NonsurgicallytreatedpatientsdividedintodisplacedandnondisplacedfracturesTherelativeshareofmalepatientswasalmostequallydividedbetweenthedisplaced(65.5%)and thenondisplaced fractures (66.3%).Themostcommoncausesdifferedbetween both groups within the nonsurgically treated patients group. Displacedzygomatic complex fractures were mainly caused by falls (47.3%) (Table 3.4a),whereasnondisplacedfracturesweremoreoftencausedbytrafficaccidents(41.1%).(Table3.4b).Assaultasa causeof the traumawasalmostequallydividedbetweenbothgroups.

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Table3.4a Cause of injury for displaced zygomatic complex fractures in the nonsurgically treatedpatientsgroup.

Age Fall Assault Trafficaccident Sports Other Total (%)09 1019 2 1 4 1 8 (14.5)2029 2 1 4 1 8 (11.0)3039 1 3 1 5 (9.1)4049 2 2 4 (7.3)5059 1 2 3 6 (10.9)6069 9 1 3 1 12 (21.8)70+ 9 1 1 12 (21.8)Total 26 9 17 3 55 (%) (47.3) (16.4) (30.9) (5.5)

Table3.4b Causeof injury fornondisplaced zygomatic complex fractures in thenonsurgically treatedpatientsgroup.

Age Fall Assault Trafficaccident Sports Other Total (%)09 2 2 (2.1)1019 3 2 2 2 9 (9.5)2029 4 7 10 1 22 (23.2)3039 3 2 8 1 14 (14.7)4049 4 1 8 1 14 (14.7)5059 3 3 6 1 13 (13.7)6069 4 2 4 10 (10.5)70+ 10 1 11 (11.6)Total 33 17 39 2 4 95 (%) (34.7) (17.9) (41.1) (2.1) (4.2)

Discussion

This retrospective study was aimed to demonstrate a more complete view ofepidemiologicaldata,aswellas toanalyzedifferencesbetween surgicallyandnonsurgicallytreatedpatientswithzygomaticcomplexfractures.

Themeanageofall283patientswas42.8years(SD:19.8).Surgicallytreatedandnonsurgicallytreatedpatientsdifferedsubstantiallyinpresentationand,inparticular,thefemalesofthenonsurgicallytreatedpatientsgroup.Asexpected,nonsurgicallytreatedpatientshadahighermeanage(46.2years,SD:22.0),especiallywhentherewasfracturedisplacement.Thislattergroupalmostconsistedofsymptomaticpatientsand will mainly consist of patients with treatment refusal or patients that aremedicallyunfit.Strikingly,onlyfemalepatientsofthenonsurgicallytreatedpatientsgroupandnoneofthesurgicallytreatedpatientsgroupweremucholder(meanageof52.3years,SD:26.3),andespeciallythosewithinthegroupofdisplacedfractures(meanageof59.5years,SD:27.4).Themeanageofoursurgicallytreatedpatients


47

3

groupdemonstratedsimilarresultswithotherpublicationsinwhichpredominanceofyoungerpatients,agedbetween21and30years,and,moreover,nolargedifferencesin age betweenmale and female patients were reported.24We found an overallhighermeanageandthiswasduetoournonsurgicallytreatedpatients,consistingofanoldagedfemalepopulation.

Asinlinewithotherpreviousstudiesthesexdistributionofpatientswasmarkedlyhigher formales compared to females,with amalefemale ratio of 2.4:1 over allpatients.14

Inour study, themostcommon causes inallpatientsweremainlyattributed totrafficaccidents,assaultandfalls.Inmanyotherstudies,trafficaccidentsandassaultwerethemostcommoncauses,whichwas inaccordancewithoursurgicallytreatedpopulationbutnotwith thenonsurgically treatedpopulation.14,10 Fall (39.3%)wasthemaincause,regardingthenonsurgicallytreatedpatientsgroupand inparticularthose with displaced zygomatic complex fractures (47.3%), followed by trafficaccidents.ThisisnotinaccordancewithBacketal.,whoreportedahighincidenceofassault(46%),followedbyfalls(20%)regardingtheirnonsurgicallytreatedpatients.9However, thestudyofBacketal. includedall facial fracturesandwasconducted inAustraliawitha lowermeanageof38years.Ourhigher incidenceoffalls ispartiallyduetooldaged(above50years)femalepatientswhohaveahigherriskonandaremorepronetofallsandhaveother livingand/orsocialhabits.11Assaultoccursmoreoften inyoungmaleadults,as inaccordancewithoursurgically treatedpopulation.Additional explanation for our higher incidence of falls might be due to ourgovernmentalsafetymeasurements thatcouldhavedecreased trafficaccidentsandcitizensafety(lessalcoholabuseandassault)inourcountry.10

This studywas a retrospective analysis,whichmeans that itwas automaticallysubject tomeasurements and registration stylesbyphysicians andmight thereforehave a subjective bias. Another shortcoming of our study is, whether ourepidemiological data is representative for thewhole population of Amsterdam, asthere are four hospitals treating patients with trauma injury. However, to ourknowledge this is the first reportof aDutch traumapopulation, also including thenonsurgicallytreatedpatients.

Thereareseveraldifferencesbetweenthenonsurgicallyandthesurgicallytreatedpatients, and even within the nonsurgically treated patients group there aredifferencesbasedonthepresenceoffracturedisplacement.Fromanepidemiologicalpoint of view, neglecting this nonsurgically treated patients group in studies andsolelydescribing the surgically treatedpatientscouldbeconsideredadatagapandmay also be an explanation for the large variability of incidence and aetiologybetween different countries.1,2,4,8,10 Standardized and comparable studies, includingnonsurgically treatedpatientsand,morespecifically,comparingnonsurgicallywithsurgicallytreatedpatientsarethereforehighlyrequired.

Chapter3

48

Conclusion

Thisretrospectiveanalysisprovidesus importantdataforadetailedviewofpatientswith zygomatic complex fractures. It shows several epidemiological differencesbetweenthesurgicallyandnonsurgicallytreatedpatientgroupsandevendifferenceswithinthelattergroup.Thesurgicallytreatedpatientsmainlyconsistedofyoungmaleadults and the traffic and assaultrelated cause highly contributed to this group,which is in accordance with previous studies. On the contrary, the nonsurgicallytreatedpatientsconsistedofahighnumberofelderly femalepatients,especially inthepatientsgroupwithdisplaced zygomatic complex fractures. Furthermore, therewasahighnumberoffallrelatedcauses.Epidemiologicalstudiesshouldbebasedonsurgically, as well as nonsurgically treated patients. This will help to realize theimportanceofdifferencesbetweenthesegroupsandperhapsprovideusfutureplansforinjuryprevention.


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3

References

1. CovingtonDS,WainwrightDJ,TeichgraeberJF,ParksDH.:Changingpatternsintheepidemiologyandtreatmentofzygomafractures:10yearreview.JTrauma(37)243248,1994

2. GassnerR,TuliT,HachlO,RudischA,UlmerH.:Craniomaxillofacialtrauma:a10yearreviewof9,543caseswith21,067injuries.JCraniomaxillofacSurg(31)5161,2003





7. Carr RM, Mathog RH.: Early and delayed repair of orbitozygomatic complex fractures. J OralMaxillofacSurg(55)253258,1997

8. Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, Raveh J.: Classification andtreatmentofzygomaticfractures:areviewof1,025cases.JOralMaxillofacSurg(50)778790,1992

9. Back CP,McLean NR, Anderson PJ, David DJ.: The conservativemanagement of facial fractures:indicationsandoutcomes.JPlastReconstrAesthetSurg(60)146151,2007

10. vanBeekGJ,MerkxCA.:Changes inthepatternoffracturesofthemaxillofacialskeleton. IntJOralMaxillofacSurg(28)424428,1999

11. Iida S, Hassfeld S, Reuther T, Schweigert HG, Haag C, Klein J,Muhling J.:Maxillofacial fracturesresultingfromfalls.JCraniomaxillofacSurg(31)278283,2003

Chapter3

50

4

Theclinicalandradiographiccharacteristicsof

zygomaticcomplexfractures:Acomparison

betweenthesurgicallyandnonsurgicallytreated

patients

Thischapterisaneditedversionofthemanuscript:SalentijnEG,BoverhoffJ,HeijmansMW,vandenBerghB,ForouzanfarT.

Theclinicalandradiographiccharacteristicsofzygomaticcomplexfractures:Acomparisonbetweenthesurgicallyandnonsurgicallytreatedpatients.

JCraniomaxillofacSurg.2014Jul;42(5):4927.

Chapter4

52

Abstract

IntroductionIn this retrospective study, we evaluated the clinical and radiographic differencesbetween surgically and nonsurgically treated patients with zygomatic complexfractures at their initial assessment in our clinic, over a period of 5 years.Moreknowledgeof the clinical similarities and/ordifferencesbetween thenonsurgicallyandsurgicallytreatedpatientgroupswillprovideusamorecompleteviewandmayhelpphysicians todevelop any futuremethods in clinicaldecisionmaking,or evenmethodsindistinguishingpatientsbenefitingfromasurgicaltreatment.MethodsSurgicallyandnonsurgicallytreatedpatientswereincludedinthestudyifclinicalandradiographic confirmation of zygomatic complex fractures were present at initialassessment.Thepatientgroupsweredividedintosurgicallyandnonsurgicallytreatedfractures, with and without fracture displacement. The groups were comparedaccordingtoage,gender,degreeoffracturedisplacementandclinicalsigns.ResultsIntotal283patientswerediagnosedwithzygomaticcomplexfractures,withameanageof42.8years (SD:19.8)andadominationofmalepatients.Themeanagewashigher in the nonsurgically treated patients group and contained more femalepatients. Overall type C fractures and the majority of the type B fractures weretreated surgically.Only2.1%of the typeA fractureswere treated surgically. Facialswelling and paraesthesia of the infraorbital nerve were found asmost commonclinical features.Additionally,malardepressionandextraoral stepswere frequentlyfoundinthesurgicallytreatedpatientsgroup,asinthenonsurgicallytreatedpatientsgroup only facial swelling was found frequently, whether there was fracturedisplacement or not. Extraoral steps, intraoral steps, and malar depression werefoundasclinicalcharacteristicstobesignificantlyassociatedwithsurgicaltreatment.ConclusionExtraoral steps, intraoral steps, andmalar depressionwere significantly associatedwithsurgicaltreatment.Thegroupofnonsurgicallytreatedpatientswithzygomaticcomplex fractures is a valuable group to investigate, as this group also consists ofpatientswith displaced zygomatic complex fractures (meaning surgical indication),andthuscouldprovideusmoreinsightinfutureclinicaldecisionmethods.Therefore,wehighlyrecommendmoreresearchofthenonsurgicallytreatedpatientsgroup.

Theclinicalandradiographiccharacteristicsofzygomaticcomplexfractures

53

4

Introduction

Fracturesof the zygomaticcomplexarecommonly seenafter facial traumaandarefrequently associated with additional traumatic injury.14 Early diagnosis of thesefractures isessentialforoptimaltreatmentand isdirectlydependentonappropriateinitial evaluation, correct injury assessment and timely initiation of the chosentherapy. Generally, displacement of zygomatic complex fractures is a surgicalindication,unlessthereareclinicalcontraindications,suchasbeingmedicallyunfitforsurgery,patients refusalor theabsenceof functionaland/oraestheticproblems.5,6However, a suspected and/ordisplaced zygomatic complex fracture couldbeeasilymissedclinicallyattheinitialassessment,duetotheadditionalassociatedsymptomsofthetrauma injury,suchasfacialswelling.Subsequently,computedtomography isroutinely used to determine zygomatic complex fractures and their potentialdisplacement, but this radiographic examination is supersensitive: showing minorzygomaticcomplexfracturesthatareclinicallynotrelevant.Evaluationofclinicalsignsisthereforenotreplaceablebyradiographicimagingandstillremainsessentialforanadequate treatmentmanagement. In their study, Forouzanfar et al. demonstratedtheirtreatmentprotocolforzygomaticcomplexfractures.7An importantaspectofatreatmentprotocolconcerns thedecisionmaking,whetherornot to treatapatientsurgicallyornonsurgically in caseofa zygomatic complex fracture.Thisdecision isbasedon clinical signs and radiographic analysis. The absenceof knowledgeof thesimilarities and differences of the clinical characteristics of zygomatic complexfractures could hamper the development of any future clinical decisionmaking intreatmentmethodsorevenbothertodistinguishpatientsbenefitingfromasurgicaltreatment.

Literatureofthepreoperativeassessment,andinparticulartheclinicaldifferencesbetween the surgically and nonsurgically indicated treatment groups, is lacking.Numerous studies only evaluated the surgical treatment management.8,9 To ourknowledge only one study investigated nonsurgically treated patients with facialfractures.10

Neglecting this group of nonsurgically treated patients in studies, and solelydescribing the surgically treatedpatients, couldbe consideredasadatagap in theliterature. Standardized and comparable studies, including nonsurgically treatedpatients, and, more specifically, comparing the nonsurgically treated with thesurgicallytreatedpatientsgrouparethereforehighlyrequired.

Theaimofthepresentstudywasto investigatetheclinicalcharacteristicsofthesurgicallyandnonsurgicallytreatedpatientswithzygomaticcomplexfracturesinourdepartment.Thereby,weattemptedtoprovidephysiciansamorecompleteviewoftheclinicalandradiographicpresentationofpatientswithfracturesofthezygomaticcomplex.

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54

Materialsandmethods

SubjectsThe hospital and outpatient records of 283 patients diagnosed with a zygomaticcomplex fracture, from January2007 to January2012,were reviewedandanalyzedretrospectively. These patients were identified using the hospital database. Datacollected were age, gender, degree of fracture displacement, clinical signs,radiographicanalysisandtreatmentmanagement(surgicalornonsurgicaltreatment).Diagnosisandthedegreeoffracturedisplacementofallpatientswereestablishedatthesamedayofinitialassessmentbyplainradiographicanalysis(submentovertexandoccipitomentalradiographs)and/oraCTscan.Exclusioncriteriawerethepresenceofa Le Fort fracture,other facial fractures thatwere associatedwith the (foursided)zygomatic complex (e.g. isolated orbital rim and/orwall, orbital floor or zygomaticarch), and bilateral zygomatic complex fractures. Furthermore, patients wereexcluded if the initialclinicalassessmentwasmore thanoneweekafter the traumaandifradiographicanalyses(plainradiographsorCTscan)werenotavailable.In all of the patients, thedepartments protocolwas used for the decisionmakingprocessinthetreatmentofzygomaticcomplexfractures,asdemonstratedbelow:1) zygomatic complex fracture without/with mild displacement and without

paraesthesiaoftheinfraorbitalnerve:nosurgicaltreatment2) zygomatic complex fracture without/with mild displacement and with

paraesthesia of the infraorbital nerve: no surgical treatment and a followupperiodfor10days;a. ifthereisanimprovementofsensibilityaftertendays:nosurgicaltreatmentb. ifthereisnoimprovementofsensibilityafter10days:surgicaltreatment

3) zygomatic complex fracture with moderate/severe displacement andwith/withoutparaesthesiaoftheinfraorbitalnerve:surgicaltreatment

4) zygomatic complex fracturewithmoderate/severe displacement,with/withoutparaesthesia of the infraorbital nerve and entrapment of the inferior rectusmuscle:surgicaltreatment(ORIFandreconstructionoftheorbitalfloor).

In our department, absolute criteria for surgical treatment of zygomatic complexfracturesaredisplacement,diplopiaduetorectusmuscleentrapment,enophthalmusand impingementof thecoronoidprocesswith the zygomaticarch.Relativecriteriaforsurgicaltreatmentarecosmeticreasons,paraesthesiaoftheinfraorbitalnerveandpatientrelatedreasons,suchasageandhealthrelatedcauses.

Afterdataretrievalpatientsweredivided intogroupsaccordingtothetreatmentmanagement (surgical or nonsurgical treatment), as shown in Figure 4.1. Thesegroups were further subdivided into groups based on the presence of fracturedisplacement(displacementversusnodisplacement).


55

4

All

(283)

Surgically

treated

(133)

Displacemen

t(133)

Nodisplacemen

t(0)

Symptom

s(116)

Nosy

mptom

s(6)

Miss

ing

(11)

Symptom

s(49)

Nosymptom

s(5)

Missing

(1)

Displacemen

t(55)

Nodisplacemem

t(95)

Non

surgically

treated

(150)

Symptom

s(48)

(39)

Miss

ing

(8)

Nosymptom

s

Figure4.1

Overviewofthe

differen

tpatientgroup

s.()=num

bero

fpatientsineachpatientgroup

.

All

(283)

Surgically

treated

(133)

Displacemen

t(133)

Nodisplacemen

t(0)

Symptom

s(116)

Nosy

mptom

s(6)

Miss

ing

(11)

Symptom

s(49)

Nosymptom

s(5)

Missing

(1)

Displacemen

t(55)

Nodisplacemem

t(95)

Non

surgically

treated

(150)

Symptom

s(48)

(39)

Miss

ing

(8)

Nosymptom

s

Figure4.1

Overviewofthe

differen

tpatientgroup

s.()=num

bero

fpatientsineachpatientgroup

.

Chapter4

56

Furthermore,thepatientgroups(surgicallyandnonsurgicallytreated)wereclassifiedaccording to the degree of zygomatic complex fracture displacement, using theclassification according to Zingg et al.9 In this classification zygomatic complexfractures are classified into 3 types: incomplete (isolated zygomatic arch, lateralorbitalrimorinfraorbitalrim)fractures(typeA),complete(classic)fractures(typeB)andmultifragmentedfractures(typeC)(Figure4.2).Figure4.2 Classificationsystem forzygomaticcomplex fractures: Isolated fractures including typesA1,

A2,andA3.TypeA1(A)areisolatedzygomaticarchfractures;typeA2(B)areisolatedlateralorbitalwall fractures,A3 (C)are isolated infraorbital rim fractures.TypeB (D) fracturesaretetrapodfracturesandtypeC(E)fracturesaremultifragmentedzygomaticcomplexfractures.

TypeA fractureswereconsideredasmildfracturedisplacement,whereastypeBfractureswere considered asmoderate fracturedisplacement and typeC fractureswere considered as severe fracturedisplacement. It shouldbementioned that thenondisplacedzygomaticcomplexfractureswereallclassifiedastypeAfractures.


57

4

StatisticalanalysesNominal data were presented as frequencies,metric data asmean and standarddeviation (SD).Comparisonsbetween the treatmentgroupswereperformedby theChiSquaretestfornominaldataandtheMannWhitneyUtestforage,becauseagewasnotnormallydistributed.Alogisticregressionmodelwasusedinwhichtreatmentwas the dependent variable and the different clinical symptoms were theindependent variables, to further explore which clinical symptoms were mostindicative foraspecific treatmentgroup.Thepvalues

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58

Table4.2 Classificationofpatientsaccordingtothetypeofradiographicanalysis.

Radiographicanalysis No.ofpatientsCTscan 196Conventionalradiographs 48CTscanandconventionalradiographs 39Total 283

Table4.2showsthat196(69.3%)ofthepatientswerediagnosedradiographically

with a CTscan and that only 48 (17.0%) of the patients were diagnosed usingconventionalradiographs.In39patients(13.7%)bothconventionalradiographsandaCTscanwereperformedforradiographicexamination,duetothefactthatincertaincases conventional radiographs were not accurate enough for exact radiographicexaminationofthefracturedzygomaticcomplex.

InTable4.3 thezygomaticcomplex fracturesaredemonstratedaccording to the

degreeof fracturedisplacement in the surgically andnonsurgically treatedpatientgroups.ItshowsthatallofthetypeCfracturesandthemajority(68.6%)ofthetypeBfractureswere treated surgically. Only 2.1% of the type A fractureswere treatedsurgically.

Table4.3 Zygomaticcomplexfracturesclassifiedaccordingtothedegreeoffracturedisplacement.

Degreeoffracturedisplacement No.ofpatients Surgical NonsurgicalTypeA(mild) 97 2(2.1%) 95(97.9%)TypeB(moderate) 175 120(68.6%) 55(31.4%)TypeC(severe) 11 11(100%) 0(0%)Total 283 133 150

ClinicalfindingsTable 4.4 demonstrates an overview of the clinical characteristics of zygomaticcomplexfracturesaccordingtothedegreeoffracturedisplacement.


59

4

Table4.4 Overviewof the clinical characteristicsof all zygomatic complex fractures according to thedegreeoffracturedisplacement.

Degreeoffracturedisplacement Milddisplacement(typeA)(97)

Moderatedisplacement(typeB)

(175)

Severedisplacement(typeC)(11)

Extraoralsteps 6(6.2%) 96(54.9%) 2(18.2%)availabledata 89 151 4missingdata 8 24 7Intraoralsteps 4(4.1%) 56(32.0%) 2(18.2%)availabledata 89 143 8missingdata 8 32 3Malardepression 7(7.2%) 87(49.7%) 6(54.5%)availabledata 88 149 10missingdata 9 26 1Facialswelling 79(81.4%) 126(72.0%) 3(27.3%)availabledata 90 143 7missingdata 7 32 4Subconjunctivalecchymosis 22(22.7%) 36(20.6%) 1(9.1%)availabledata 88 120 4missingdata 9 55 7Paraesthesiainfraorbitalnerve 31(32.0%) 107(61.1%) 7(63.6%)availabledata 90 159 8missingdata 7 16 3Restrictedmouthopening 6(6.2%) 13(7.4%) 0(0%)availabledata 86 117 5missingdata 11 58 6Restrictedextraocularmovements 9(9.3%) 15(8.6%) 3(27.3%)availabledata 92 146 7missingdata 5 29 4Diplopia 12(12.4%) 15(8.6%) 3(27.3%)availabledata 91 150 7missingdata 6 25 4Enophthalmus 0(0%) 4(2.3%) 2(18.2%)availabledata 89 115 4missingdata 8 60 7

Dataarepresentedasabsoluteand%presence.

Although not significant, as described in Table 4.4, enophthalmus, diplopia,restrictedextraocularmovementsandparaesthesiaoftheinfraorbitalnervearemorefrequently found in the severely displaced zygomatic complex fractures, whereasintraoralandextraoralstepsaremorefrequentlyfound inthemoderatelydisplacedfractures.Probablythisisduetothelossofbonylandmarksintheseverelydisplaced(multifragmented) zygomatic complex fractures. Furthermore, it should be notedthat regarding to the important clinical signs, such as restricted mouth opening,enophthalmus and extraoral steps, data of 6 and 7 patients (out of 11 patients intotal)wasmissing,whichcouldexplaintherelativelylowpercentagesintheseverelydisplacedfracturegroup.

Chapter4

60

Table 4.5 demonstrates an overview of the clinical characteristics of zygomaticcomplex fractures in all of the patient groups according to the treatment type(surgicalversusnonsurgicaltreatment).

Table4.5 Overviewoftheclinicalcharacteristicsofthepatientgroups.

Treatmentgroup All Surgical NonsurgicalExtraoralsteps 104(41.8%) 70(65,5%) 34(23.9%)availabledata 249 107 142missingdata 34 26 8Intraoralsteps 62(25.9%) 46(47.4%) 16(11.3%)availabledata 239 97 142missingdata 44 36 8Malardepression 98(39.4%) 74(69.8%) 24(16.7%)availabledata 249 106 143missingdata 34 27 7Facialswelling 208(87.4%) 78(80.4%) 130(92.2%)availabledata 238 97 141missingdata 45 36 9Subconjunctivalecchymosis 60(28.4%) 22(31.4%) 38(27.0%)availabledata 211 70 141missingdata 72 63 9Paraesthesiainfraorbitalnerve 145(56.4%) 97(84.3%) 48(33.8%)availabledata 257 115 142missingdata 26 18 8Restrictedmouthopening 19(9.1%) 12(17.4%) 7(5.0%)availabledata 208 69 139missingdata 75 64 11Restrictedextraocularmovements 27(11.0%) 10(9.9%) 17(11.7%)availabledata 246 101 145missingdata 37 32 5Diplopia 30(12.1%) 12(11.5%) 18(12.5%)availabledata 248 104 144missingdata 35 29 6Enophthalmus 6(2.9%) 5(7.6%) 1(0.7%)availabledata 208 66 142missingdata 75 67 8

Dataarepresentedasabsoluteand%ofpresence.As shown in Table 4.5 the two clinical characteristics that have a very high

frequency in theallpatientsgroupwere facial swelling (87.4%)andparaesthesiaoftheinfraorbitalnerve(56.4%).Thesetwosymptomswerealsofrequentlyfoundinthesurgically treatedpatientsgroup, respectively80.4%and84.3%.Additionally,malardepression (69.8%) and extraoral steps (65.5%)were also frequently found in thisgroup. In thenonsurgically treatedpatients grouponly facial swelling (92.2%)wasfrequentlyfound.Theclinicalcharacteristicsfrequentlyfoundinthesurgicallytreatedpatientsgroupwerefoundlesscommoninthenonsurgicallytreatedpatientsgroup.


61

4

Forexample,malardepressionaccountedfor16.7%andextraoralstepsaccountedfor23.9% in thenonsurgically treatedpatientsgroup.Twoclinicalcharacteristicswerealmost equally distributed over both patient groups: restricted extraocularmovementsanddiplopia.Enophthalmuswastheonlysymptomsolelypresent inthepatientgroups(surgicallyandnonsurgicallytreated)withfracturedisplacement.

TheChiSquaretestconfirmedasignificantcorrelationbetweenclinicalsymptomsand surgical treatment (p

Chapter4

62

displacement.11,12 Furthermore, Ceallaigh et al. suggest surgical treatment to beindicatedwhen there isa limitedmouthopening,and/orwhen thereareaestheticproblems.13 They suppose that paraesthesia is not specifically an indication forsurgicaltreatmentofzygomaticcomplexfractures,whichcorrespondstoourresults.

Asinlinewithotherpreviousstudiesthesexdistributionwasmarkedlyhigherformales compared to females, and a relative higher share ofmales in the surgicallytreatedpatientsgroup.4,1416

Asexpected,clinicalassessment showed that therewasa significantassociationbetween the clinical findings, referred to as palpatory and visual assessment ofdeformity (palpable extraoral and intraoral steps, visual malar depression), andsurgicaltreatmentofthefracturedzygomaticcomplex.Asfacialswellingwasalmostpresent inallpatients, itcouldmask theclinical findings,particularly if the fracturedisplacement was minimal. Swelling of the softtissues, due to the injury, couldconcealanydepressionofthemalareminenceoranydisturbancewithintheorbitalanatomy,suchasenophthalmus.Furthermore,posttraumaticswellingcouldcauseatransitorynerveparaesthesiaoftheinfraorbitalnerve.

In the literature, the incidence of posttraumatic sensory disturbances followingfracturesofthezygomaticcomplex isreportedtobebetween33%and82%.1720Wefound a higher incidence of paraesthesia regarding the surgically treated patients(84.3%), comparedwith thenonsurgically treatedpatients (33.8%),withanoverallincidenceof56.4% regarding theallpatientsgroup.However,paraesthesiawasnotsignificantly associated with the treatment method (surgical or nonsurgicaltreatment).Followuprecordsofthepatientsarenecessarytodeterminethedurationandfrequencyofparaesthesiaand,furthermore,relatingthistoradiographicscans.

At last, posttraumatic swelling could cause intraorbital pressure on the globeand/orextraocularmuscles,leadingtodiplopiaordisturbedextraocularmovements.Asthesesymptomswerealmostequallydistributedinourstudy,itcouldbeexpectedthat swelling contributes most likely to a large amount of the disturbed eyemovementsand/ordiplopia.However,itishighlyimportanttoidentifythosepatientswithentrapmentoftherectusinferiormuscleinorbitalfloorfractures,astheorbitalfloor is always part of the zygomatic complex, which requires immediate surgicaltreatmentinthesecases.

One couldargue thata shortcomingof this study is the retrospectivenatureofrecording the clinical findings, and therefore the results being more subject tosubjective measurements and registration between physicians. Like otherretrospective studies, this retrospective analysis may lead to information bias.Nevertheless, due to the large number of patients the results still demonstratevaluable information concerning the characteristics of surgically and nonsurgicallytreated zygomatic complex fractures. Prospective studies would be necessary tostandardizeclinicalexaminationandreportingstyleofthesesymptoms.


63

4

Conclusion

Managementofzygomaticcomplexfracturesremainsachallengingproblemandlacksan accepted consensus internationally. In the present study, the surgically treatedzygomaticcomplexfracturesarecomparedwiththenonsurgicallytreatedfractures,and furthermore both groups are divided into fractures withmild,moderate andseverefracturedisplacement.Wefoundthatthemeanageofnonsurgicallytreatedpatients,evenwithfracturedisplacement,comparedtothesurgicallytreatedpatientsgroupwashigherandhadahighershareof femalepatients.Concerningtheclinicalcharacteristics, malar depression, intraoral and extraoral steps were found to besignificantlycorrelatedwithsurgicaltreatment.Paraesthesiaoftheinfraorbitalnervewasnotcorrelatedwiththesurgicaltreatmentpolicyofzygomaticcomplexfractures.In summary,we state that the nonsurgically treated patients group is a valuablegroup to investigate,as thisgroupalsoconsistsofpatientswithdisplaced fracturesandthuscouldprovideusmoreinsightinfutureclinicaldecisionmethods.Therefore,wehighlyrecommendmoreresearchofthenonsurgicallytreatedpatientsgroup.

Chapter4

64

References

1. CovingtonDS,WainwrightDJ,TeichgraeberJF,ParksDH.:Changingpatternsintheepidemiologyandtreatmentofzygomafractures:10yearreview.JTrauma(37)243248,1994

2. GassnerR,TuliT,HachlO,RudischA,UlmerH.:Craniomaxillofacialtrauma:a10yearreviewof9,543caseswith21,067injuries.JCraniomaxillofacSurg(31)5161,2003





7. ForouzanfarT,SalentijnE,PengG,vandenBerghB.:A10yearanalysisofthe"Amsterdam"protocolinthetreatmentofzygomaticcomplexfractures.JCraniomaxillofacSurg(41)616622,2013

8. Carr,R.M.andMathog,R.H.:Earlyanddelayedrepairoforbitozygomaticcomplexfractures.JOralMaxillofacSurg(55)253258,1997

9. Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, Raveh J.: Classification andtreatmentofzygomaticfractures:areviewof1,025cases.JOralMaxillofacSurg(50)778790,1992

10. Back CP,McLean NR, Anderson PJ, David DJ.: The conservativemanagement of facial fractures:indicationsandoutcomes.JPlastReconstrAesthetSurg(60)146151,2007

11. KaufmanY,StalD,ColeP,HollierL Jr.:Orbitozygomatic fracturemanagement.PlastReconstrSurg(121)13701374,2008

12. Hollier LH, Thornton J, Pazmino P, Stal S.: The management of orbitozygomatic fractures. PlastReconstrSurg(111)238692,quiz,2003

13. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW.: Diagnosis and management of commonmaxillofacial injuries intheemergencydepartment.Part3:Orbitozygomaticcompl

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