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

Midfacial trauma patients:

An epidemiological survey

Erik Salentijn

The studies presented in this thesis were performed at the department of Oral and

Maxillofacial Surgery, VU University Medical Center / Academic Center for Dentistry

Amsterdam (ACTA), Amsterdam, the Netherlands.

This research was conducted as part of the research

program Restoration and Development of research

institute Amsterdam Movement Sciences, founded by VU

Amsterdam, VU University Medical Center Amsterdam,

and Academic Medical Center, University of Amsterdam.

Publication and distribution of this thesis has been financially supported by:

‐ Nederlandse Vereniging voor Mondziekten, Kaak‐ en Aangezichtschirurgie

(NVMKA)

‐ Academisch Centrum Tandheelkunde Amsterdam (ACTA)

‐ VU medisch centrum

‐ Maatschap MKA Alrijne ziekenhuis Leiderdorp

‐ KLS Martin Group

‐ Henry Schein Dental

‐ ORFEO‐kliniek Zoetermeer

‐ Straumann B.V.

‐ Dam Medical B.V.

‐ Dentalair Products Nederland B.V.

Printed by Gildeprint, Enschede

Layout by Tiny Wouters

Cover design by Jeroen Schuiten

ISBN 978‐94‐6233‐776‐3

Copyright 2017, E.G. Salentijn, Amsterdam, the Netherlands.

All rights reserved. No part of this publication may be reproduced or transmitted in any

form or by any means, electronic or mechanical, including photocopy, recording, or any

information storage and retrieval system, without prior permission from the author.

VRIJE UNIVERSITEIT

Midfacial trauma patients:

An epidemiological survey

ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad Doctor aan

de Vrije Universiteit Amsterdam,

op gezag van de rector magnificus

prof.dr. V. Subramaniam,

in het openbaar te verdedigen

ten overstaan van de promotiecommissie

van de Faculteit der Tandheelkunde

op woensdag 13 december 2017 om 15.45 uur

in de aula van de universiteit,

De Boelelaan 1105

door

Erik Gerrit Salentijn

geboren te Dordrecht

promotoren: prof.dr. T. Forouzanfar

prof.dr. E.A.J.M. Schulten

leescommissie: prof.dr. R.R.M. Bos

dr. E.M. van Cann

prof.dr. J.P.R. van Merkesteyn

prof.dr. F.R. Rozema

prof.dr. D.B. Tuinzing

dr. J.G.A.M. de Visscher

paranimfen: drs. R. Koop

drs. J.A. Posthumus

“De kracht van een boom wordt bepaald door zijn wortels”

Voor mijn ouders

Contents

Chapter 1 General introduction 11

Chapter 2 A ten‐year analysis of the “Amsterdam” protocol in the treatment 21

of zygomatic complex fractures

Chapter 3 The epidemiological characteristics of zygomatic complex fractures: 39

A comparison between the surgically and non‐surgically treated

patients

Chapter 4 The clinical and radiographic characteristics of zygomatic 51

complex fractures: A comparison between the surgically and

non‐surgically treated patients

Chapter 5 A ten‐year analysis of midfacial fractures 67

Chapter 6 A ten‐year analysis of the traumatic maxillofacial and brain injury 87

patient in Amsterdam: Incidence and aetiology

Chapter 7 A ten‐year analysis of the traumatic maxillofacial and brain injury 103

patient in Amsterdam: Complications and treatment

Chapter 8 Summary and conclusions 117

Chapter 9 Future perspectives 129

Chapter 10 Samenvatting 135

Dankwoord 143

List of publications 149

1

General introduction

Chapter 1

12


13

1General introduction

Anatomy of the midfacial skeleton

The midfacial bones include the maxilla (and palatine bone), zygomatic complex, nasal

bone, naso‐orbital‐ethmoid complex, orbit and the supraorbital structures, all of

which may be affected by traumatic injury to the midface.1‐3 These bones are

regarded to form several paired vertical and horizontal buttresses that protect vital

organs, such as the brain, optic nerves and brainstem, making them closely related to

the senses of vision and smell and to other attributes such as speech, mastication and

facial appearance.3,4 Damage to the midfacial buttress system can therefore cause

both functional and cosmetic deformity, as the facial profile may be affected.3‐5

In general, fractures of the midfacial bones are divided into zygomatic complex

fractures, orbital fractures, naso‐orbital‐ethmoid complex fractures, Le Fort I, Le Fort

II, Le Fort III fractures and frontal sinus fractures.2,3,6,

Incidence and aetiology of midfacial trauma patients

Midfacial fractures account for a substantial proportion of maxillofacial injuries,

predominantly presenting in young (20 to 40‐year‐old) male patients.7,9,10 Trauma to

the midface regularly leads to lesions of the soft tissues, teeth and fractures of the

aforementioned bone structures, consecutively the maxilla, zygomatic complex, nasal

bone, naso‐orbital‐ethmoid complex, orbit and the supraorbital structures.2,3,6,8

In general the incidence of maxillofacial fractures may vary, depending on

conditions such as geographic area, cultural differences, environmental factors and

socioeconomic trends.7,9,11‐15 In developed countries maxillofacial injuries are mainly

caused by road traffic collisions (motorcycle, car, bicycle, pedestrian), falls, and

sport‐related accidents, whereas in less developed countries maxillofacial injuries are

most often caused by interpersonal violence.7,11,16 An understanding of the causes of

these fractures may guide clinical research towards the development of more

effective prevention and treatment of maxillofacial injuries.7

Some authors note that the most common fracture site associated with

maxillofacial injuries is within the midface, whereas others have found mandibular

fractures to be the most commonly encountered.9,11,17,18 The incidence of midfacial

fractures is reported to range from 42.6–48.0% of all maxillofacial fractures.16,19,20

Treatment of midfacial trauma patients

Surgeons may encounter a wide variety of diagnostic challenges and treatment

dilemmas in the treatment of midfacial fractures.

Chapter 1

14

Over the past 20 years, both the evaluation and treatment of midfacial fractures

have evolved considerably. With better‐quality computed tomography scans, the

preoperative diagnostic process has been significantly enhanced. In addition, the

development of improved surgical approaches and the introduction of rigid internal

fixation with osteosynthesis have facilitated repair.21

In general, the fractured bones should be repositioned in their anatomically

correct position and secured safely, with the objective of reconstructing the shape

and restoring the function of all midfacial structures. The fundamental idea is to

restore the supporting buttresses of the midface, the bony prominences, the bone

cavities and to correct dental occlusion.4,8,22

The best treatment results of midfacial fractures are achieved with a

multidisciplinary team approach to the overall management of the injury.23,24 In many

cases of traumatic maxillofacial and brain injury patients, expertise of several

disciplines is required, such as general surgeons, ophthalmologists, otolaryngologists,

anaesthesiologists and intensive care specialists.8,25,26 Furthermore, awareness and

close cooperation between oral and maxillofacial surgeons and neurosurgeons is

required to facilitate rapid diagnosis and appropriate treatment.23

Treatment decision‐making in zygomatic complex fractures

One of the most common fracture sites in the midface is the zygomatic complex.

Adequate reduction of a zygomatic complex fracture remains a challenge for

surgeons, due to its anatomical position and the inability to have direct view of all

fracture sites. Whether or not to treat a zygomatic complex fracture surgically is still a

matter of debate, as there are no clear evidence‐based guidelines for decision‐

making. The decision is usually based on clinical signs and symptoms, and radiographic

features. Displacement of a zygomatic complex fracture associated with functional

and/or aesthetic problems is regarded to be a clear indication for surgery, unless

there are profound contraindications, such as comorbidities of the patient, the

patient’s refusal or lack of informed consent.27,28

Although occipitomental and submentovertex radiographs are used to be the 2D‐

radiographic examination of choice, nowadays 3D‐computed tomography is routinely

used to evaluate zygomatic complex fractures with regard to displacement.1,27,29

Suspected and/or minor displaced zygomatic complex fractures may easily be missed

clinically at initial assessment, particularly when soft tissue swelling may be present.

Therefore, both clinical examination and radiologic evaluation are essential for

appropriate diagnosis and management.1,29 A treatment algorithm for zygomatic

complex fractures would be beneficial, but the wide variety of clinical signs and

symptoms of these fractures hampers the development of such a treatment

algorithm. A comparative analysis of the clinical and radiographic features of surgically


15

1and non‐surgically treated patients with zygomatic complex fractures may potentially

lead to a valuable management protocol.

Midfacial trauma patients and concomitant injury

High‐energy trauma to the midface can cause complex fracture patterns of the

midfacial bones as mentioned before.3 As the high‐energy nature of these injuries

often leads to multisystem involvement, a thorough systematic evaluation of the

whole patient should precede the management of the facial injury.3,4,30 Common

concomitant injuries in patients with panfacial fractures include intracranial

haemorrhage, abdominal organ injury, pneumothorax, pulmonary contusion, and

fractures of spine, rib, extremity or pelvis. When midfacial trauma surgery is being

considered, it would be appropriate to investigate the possible presence of associated

traumatic brain injury, as the frequency of neurologic injury associated with facial

fractures is reported to be 76%.31‐34 This will help to recognize and treat unsuspected

and undiagnosed neurologic injuries, resulting in decreased morbidity and mortality in

midfacial trauma patients.33

Maxillofacial fractures and traumatic brain injury

Traumatic brain injury (TBI) is defined as evidence of loss of consciousness and/or

post‐traumatic amnesia in a patient with a non‐penetrating head injury.35 The

Glasgow Coma Scale (GCS) is used to describe the level of consciousness in patients

with TBI.36,37 There have been many attempts to assess the association between facial

trauma and neurological injury, with the goal to address the role of facial bones in

protecting the brain against neurological injury. From an evolutionary and mechanical

standpoint, the description of the facial bones as an impact‐ or stress‐bearing region

to absorb forces that would otherwise be transmitted to the brain seems logical.38,39

Following this logic, it is shown that the presence of facial fractures is associated with

decreased TBI, theorizing that the midfacial bones are suspected to act as an

absorption barrier against high‐impact energy, and thus protecting the brain from

damage.40,41 On the other hand, however, midfacial fractures are thought to be

frequently associated with the presence of simultaneous brain injury, as in midfacial

trauma patients, energy may be directly transmitted to the cranium, causing damage

to the brain.35,36,41‐45 Hence, the barrier‐function of the midface remains to be

investigated.

Complications in maxillofacial and traumatic brain injury patients

Treating patients with maxillofacial, especially midfacial, fractures and associated TBI

is challenging, and can involve a variety of complications that may occur in the early

and late postoperative periods.46 Early postoperative complications include

Chapter 1

16

haemorrhage, infection, neurological disorder, nerve injury, inadequate fracture

reduction, airway obstruction and morbidity or mortality from concurrent injuries.

Late postoperative complications include cosmetic deformity, neurological deficits,

such as spasticity, epilepsy and neuropathic pain, enophthalmus, meningitis and

mucocele formation. As an alternative to classification by time, complications could

be categorized by severity. Major complications include loss of vision, major

neurological injury, severe infection requiring prolonged hospitalization or death.

Minor complications include seroma, haematoma, wound dehiscence and infection

managed with medical treatment.47 As traumatic maxillofacial and TBI patients are

more prone to develop complications and therefore require a multidisciplinary

approach, these patients are mainly hospitalized in specialised trauma centres. More

knowledge concerning these complications, as well as a standardized classification

may be regarded as beneficial to the outcome of patients.

Aims of this thesis

Considering the disparity of views concerning the incidence, aetiology, treatment and

complications of fractures to the midface, especially zygomatic complex fractures, and

the association with TBI, the aims of this research project are:

1) To investigate the outcomes and complications of surgically treated zygomatic

complex fractures, according to a standardized treatment protocol.

2) To contribute towards the formation of a consensus view on the treatment of

zygomatic complex fractures.

3) To investigate the epidemiological, clinical and radiographic features of surgically

and non‐surgically treated patients with zygomatic complex fractures, providing

physicians with a more complete view for making a decision on whether or not to

treat a zygomatic complex fracture surgically.

4) To investigate the incidence and aetiology of midfacial fractures.

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

fractures, with traumatic brain injury requiring neurosurgical and maxillofacial

intervention.

6) To investigate the complications, treatment modalities and follow‐up of traumatic

maxillofacial and brain injury patients requiring neurosurgical and maxillofacial

intervention.


17

1References

1. Kuhnel TS, Reichert TE.: Trauma of the midface. GMS Curr Top Otorhinolaryngol Head Neck Surg (14) Doc06‐2015

2. Kochhar A, Byrne PJ.: Surgical management of complex midfacial fractures. Otolaryngol Clin North Am

(46) 759‐778, 2013 3. Alvi A, Doherty T, Lewen G.: Facial fractures and concomitant injuries in trauma patients.

Laryngoscope (113) 102‐106, 2003

4. Gentile MA, Tellington AJ, Burke WJ, Jaskolka MS.: Management of midface maxillofacial trauma. Atlas Oral Maxillofac Surg Clin North Am (21) 69‐95, 2013

5. Buchanan EP, Hopper RA, Suver DW, Hayes AG, Gruss JS, Birgfeld CB.: Zygomaticomaxillary complex

fractures and their association with naso‐orbito‐ethmoid fractures: a 5‐year review. Plast Reconstr Surg (130) 1296‐1304, 2012

6. Calderoni DR, Guidi M de C, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the

surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011 7. Ozkaya O, Turgut G, Kayali MU, Ugurlu K, Kuran I, Bas L.: A retrospective study on the epidemiology

and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg (15) 262‐266, 2009

8. Bogusiak K, Arkuszewski P.: Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg (21) 1018‐1023, 2010

9. Mast G, Ehrenfeld M, Cornelius CP.: [Maxillofacial fractures: midface and internal orbit. Part 2:

therapeutic options]. Unfallchirurg (115) 145‐163, 2012 10. Bos RR, Jansma J, Vissink A.: [Fractures of the midface]. Ned Tijdschr Tandheelkd (104) 440‐443, 1997

11. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence of

maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg (40) e165‐e169, 2012

12. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of zygomatico‐orbital

complex and/or zygomatic arch fractures over a 71‐month period. Dent Traumatol (27) 135‐142, 2011 13. Olate S, Lima SM Jr, Sawazaki R, Moreira RW, de Moraes M.: Surgical approaches and fixation

patterns in zygomatic complex fractures. J Craniofac Surg (21) 1213‐1217, 2010

14. Bormann KH, Wild S, Gellrich NC, Kokemuller Horst, Stuhmer C Schmelzeisen R, Schon R.: Five‐year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and

complications. J Oral Maxillofac Surg (67) 1251‐1255, 2009

15. Erdmann D, Price K, Reed S, Follmar KE, Levin LS, Marcus JR.: A financial analysis of operative facial fracture management. Plast Reconstr Surg (121) 1323‐1327, 2008

16. Naveen S, Ashwini NS, Vemanna H, Nidarsh S, Prasad R.: The pattern of the maxillofacial fractures ‐ A

multicentre retrospective study. J Craniomaxillofac Surg (40) 675‐679, 2012 17. Uzelac A, Gean AD.: Orbital and facial fractures. Neuroimaging Clin N Am (24) 407‐24, vii, 2014

18. Iida S, Kogo M, Sugiura T, Mima T, Matsuya T.: Retrospective analysis of 1502 patients with facial

fractures. Int J Oral Maxillofac Surg (30) 286‐290, 2001 19. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB.: Changing pattern in the characteristics of maxillofacial

fractures. J Craniofac Surg (24) 929‐933, 2013

20. Kyrgidis A, Koloutsos G, Kommata A, Lazarides N, Antoniades K.: Incidence, aetiology, treatment outcome and complications of maxillofacial fractures. A retrospective study from Northern Greece. J

Craniomaxillofac Surg (41) 637‐643, 2013

21. McRae M. Frodel J.: Midface fractures. Facial Plast Surg (16) 107‐113, 2000 22. Hollier LH, Sharabi SE, Koshy JC, Stal S.: Facial trauma: general principles of management. J Craniofac

Surg (21) 1051‐1053, 2010

23. Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK.: Craniofacial and skull base trauma. J Trauma (54) 1026‐1034, 2003

24. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H.: Cranio‐maxillofacial trauma: a 10 year review of 9,543

cases with 21,067 injuries. J Craniomaxillofac Surg (31) 51‐61, 2003

Chapter 1

18

25. Hosemann W, Schroeder HW, Kaduk W, Augst D, Friedrich J.: [Interdisciplinary management of severe

midfacial trauma]. HNO (53) 479‐498, 2005 26. Raveh J, Vuillemin T.: The surgical one‐stage management of combined cranio‐maxillo‐facial and

frontobasal fractures. Advantages of the subcranial approach in 374 cases. J Craniomaxillofac Surg

(16) 160‐172, 1988 27. Evans BG, Evans GR.: MOC‐PSSM CME article: Zygomatic fractures. Plast Reconstr Surg (121) 1‐11,

2008

28. Kelley P, Hopper R, Gruss J.: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg (120) 5S‐15S, 2007

29. Marinho RO, Freire‐Maia B.: Management of fractures of the zygomaticomaxillary complex. Oral

Maxillofac Surg Clin North Am (25) 617‐636, 2013 30. Sandner A, Kern CB, Bloching MB.: [Experiences with the subfrontal approach to manage extensive

fractures of the frontal skull base]. Laryngorhinootologie (85) 265‐271, 2006

31. McCabe JB, Angelos MG.: Injury to the head and face in patients with cervical spine injury. Am J Emerg Med (2) 333‐335, 1984

32. Morgan BD, Madan DK, Bergerot JP.: Fractures of the middle third of the face‐‐a review of 300 cases.

Br J Plast Surg (25) 147‐151, 1972 33. Pappachan B, Alexander M.: Correlating facial fractures and cranial injuries. J Oral Maxillofac Surg (64)

1023‐1029, 2006

34. Turvey TA.: Midfacial fractures: a retrospective analysis of 593 cases. J Oral Surg (35) 887‐891, 1977 35. Davidoff G, Jakubowski M, Thomas D, Alpert M.: The spectrum of closed‐head injuries in facial trauma

victims: incidence and impact. Ann Emerg Med (17) 6‐9, 1988

36. Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC.: Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction:

comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma (71) 1185‐

1192, 2011 37. Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC.: Effect of the

modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction:

comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma (71) 1185‐1192, 2011

38. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR.: The impact‐absorbing effects of facial fractures in closed‐

head injuries. An analysis of 210 patients. J Neurosurg (66) 542‐547, 1987 39. MacLennan WD.: Fractures of the mandibular condylar process. Br J Oral Surg (7) 31‐39, 1969

40. Chang CJ, Chen YR, Noordhoff MS, Chang CN.: Maxillary involvement in central craniofacial fractures

with associated head injuries. J Trauma (37) 807‐811, 1994 41. Lee KH, Antoun J.: Zygomatic fractures presenting to a tertiary trauma centre, 1996‐2006. N Z Dent J

(105) 4‐7, 2009

42. Brandt KE, Burruss GL, Hickerson WL, White CE, DeLozier JB.: The management of mid‐face fractures with intracranial injury. J Trauma (31) 15‐19, 1991

43. Haug RH, Savage JD, Likavec MJ, Conforti PJ.: A review of 100 closed head injuries associated with

facial fractures. J Oral Maxillofac Surg (50) 218‐222, 1992 44. Haug RH, Adams JM, Conforti PJ, Likavec MJ.: Cranial fractures associated with facial fractures: a

review of mechanism, type, and severity of injury. J Oral Maxillofac Surg (52) 729‐733, 1994

45. Keenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP.: Does the face protect the brain? A case‐control study of traumatic brain injury and facial fractures. Arch Surg (134) 14‐17, 1999

46. Cannon DE, Wells TS, Poetker DM.: Two late complications of craniofacial trauma: case report and

review of the literature. Am J Otolaryngol (33) 615‐618, 2012 47. Shibuya TY, Karam AM, Doerr T, Stachler RJ, Zormeier M, Mathog RH, McLaren CL, Li KT.: Facial

fracture repair in the traumatic brain injury patient. J Oral Maxillofac Surg (65) 1693‐1699, 2007


19

1

Chapter 1

20

2

A ten‐year analysis of the “Amsterdam” protocol in

the treatment of zygomatic complex fractures

This chapter is an edited version of the manuscript:

Forouzanfar T, Salentijn EG, Peng G, van den Bergh B.

A ten‐year analysis of the “Amsterdam” protocol in the treatment of zygomatic

complex fractures. J Craniomaxillofac Surg. 2013 Oct;41(7):616‐22.

Chapter 2

22

Abstract

Introduction

Despite many publications on the epidemiology, incidence and aetiology of zygomatic

complex (ZC) fractures there is still a lack of information about a consensus on its

treatment. The aim of the present study is to retrospectively investigate the

“Amsterdam” protocol for surgical treatment of ZC fractures.

Results

The ten‐year results and complications are presented. The study population consisted

of 236 patients (170 males, 66 females; 210 ZC fractures, 26 solitary zygomatic arch

fractures) with a mean age of 39.3 years (SD: ±15.6) (range: 4‐87 years). The main

cause of injury was due to traffic related accidents, followed by violence and fall. A

total of 225 plates and 943 screws were used. Twenty‐nine patients presented with

complications, including suboptimal reduction (15 patients), wound infection (9

patients) and transient paralysis of the facial nerve (1 patient). Seven patients (3%)

needed surgical retreatment of whom 4 needed a secondary orbital floor

reconstruction, as these patients developed enophthalmus and diplopia.

Conclusion

This report provides important data for reaching a consensus in the treatment of


A ten‐year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures

23

2

Introduction

Maxillofacial fractures account for a substantial proportion of traumatic injuries.1,2

The incidence of maxillofacial fractures varies with geographical area, socioeconomic

trends, incidence of road traffic accidents, alcohol abuse, drug abuse and by season.

The pattern of maxillofacial facture presentation varies, depending on the aetiology of

the injury. Common causes of maxillofacial fractures include road traffic accidents

(including motorcycle, automobile, bicycle and pedestrian), assault, falls, sports,

industrial/work related accidents and other miscellaneous causes (e.g. gunshot

injuries, pathological fractures).1,3,4 An understanding of these factors may guide

clinical research into the development of more effective prevention and treatment of

these injuries.1

Several authors have noted that the zygomatic complex and maxilla are the most

common maxillofacial fracture sites.2,4 As with other maxillofacial fractures, the

prevalence of zygomatic complex fractures is related to different conditions.1,4‐6

Adequate fracture reduction is a constant challenge for surgeons due to the

anatomical position of the zygomatic complex. The zygomatic complex consists of

4 pillars attached by 4 suture lines. It includes the part of the orbital floor lateral to

the infraorbital fissure. As a result, a fracture of this complex is always accompanied

with an orbital floor fracture. The aim of the treatment is reduction of the zygomatic

complex, orbital floor and zygomatic arch.7‐9

In the past, wire fixation was a treatment modality for zygomatic complex

fractures.10,11 The introduction of rigid internal fixation, using miniplates, has led to

greater stability and less complications. The use of miniplates is now a state of the art

treatment modality.5

There is no consensus on the best surgical access to the orbitozygomatic complex.

The majority of authors prefer to initially use the lower lid and lateral orbital rim

approach. On the other hand, some authors use the transoral approach as first choice,

because it results in a more stable reduction with a lower complication rate.1

Despite various publications on the epidemiology, incidence and aetiology of

zygomatic complex fractures, there remains no consensus agreement regarding its

treatment.

The aim of this study was to retrospectively investigate the outcomes and

complications arising in patients, surgically treated for zygomatic complex fractures

according to our treatment protocol over a ten‐year period. We hope that this study

will contribute towards the formation of a consensus view on the treatment of


Chapter 2

24

Materials and methods

Data collection

Hospital and outpatient records of patients surgically treated for zygomatic complex

fractures from January 2000 to January 2010 were reviewed and analysed

retrospectively. The patients were identified using the hospital database. All types of

zygomatic complex fractures, surgically treated by open or closed reduction, were

included. Patients with panfacial trauma and solitary orbital blowout fractures were

excluded. Data collected included gender, age, cause of the injury, pre‐ and

postoperative radiographic analysis, type of zygomatic complex fracture, treatment

modality and complications.

Treatment protocol

Zygomatic complex fractures were diagnosed at presentation to the outpatient

department or emergency ward, using both clinical and radiographic examination.

Radiographic analysis included submentovertex and occipitomental views or a

(conebeam) CT‐scan. If necessary, an ophthalmology opinion was obtained pre‐ and

postoperatively to record enophthamus and/or eye‐movement disturbances.

Patients were treated according to the department’s protocol, as demonstrated in

Figure 2.1. The fracture reduction was performed using a bone hook and, if necessary,

the fractured bones were fixed with plate osteosynthesis. The preferred site of

fixation was on the lateral orbital rim. If the reduction was unstable, a second

miniplate was fixed on the zygomaticomaxillary buttress. If necessary, a third

miniplate was fixed on the infraorbital rim. KLS Martin 2.0 mm and/or 1.5 mm plates

were used.

As a training unit, the departmental policy was to adhere to the treatment

protocol. However, the surgeon had the ability to deviate from the protocol if needed.

During the surgical procedure, a forced duction test was performed twice, before

and after reduction of the zygomatic complex. If ocular movements were restricted

and entrapment of the rectus inferior muscle was suspected, the orbital floor would

be explored. Another reason for exploration was the detection of a comminuted

orbital floor fracture on the CT‐images. If necessary the orbital floor would be

reconstructed using Medpor‐titanium implants, titanium implants, polydioxanone

(PDS) sheets or autogenous bone grafts. The reconstruction material was chosen by

the operating surgeon.


25

2

Figure 2.1 Treatment protocol. (s.r: stable reposition; i.r: instable reposition; s.f: stable fixation).

Clinical signs

Radiographic analysis

Zygomatic arch fracture

Zygomatic complex fracture

with muscle entrapment

RepositionGillies approach


Reposition bone hook Reposition bone hook

Fixationlateral orbital rim


Finished

Fixationzygomaticomaxillary buttress

Fixationinfraorbital rim

Orbital floor explorationand reconstruction

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


Zygomatic arch fracture


with muscle entrapment

RepositionGillies approach


Reposition bone hook Reposition bone hook



Finished

Fixationzygomaticomaxillary buttress


Orbital floor explorationand reconstruction

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

Chapter 2

26

All patients received standard analgetics postoperatively (diclofenac 50 mg three

times daily or paracetamol/codeine 1000/20 mg four times daily). Patients received

prophylactic antibiotics for one week if either the zygomaticomaxillary buttress or the

infraorbital rim had been used for fixation (either amoxicillin/clavulanic acid 500/125

mg three times daily or clindamycin 600 mg three times daily). Patients also received

prophylactic antibiotics after orbital floor reconstruction.

Conventional radiographs (submentovertex and occipitomental views) were

performed postoperatively to analyse the reduction and for teaching and medicolegal

reasons. If the reduction was performed suboptimally and there were clinical signs of

a malpositioned zygomatic complex, the patient would be retreated.

All of the patients were closely followed up for the first 6 weeks postoperatively.

After this period, patients were followed up at 3 and 6 months postoperatively, as

demonstrated in the department’s protocol.

Osteosynthesis material was removed in cases of persistent infection that did not

respond to oral antibiotics (after 2‐3 months postoperatively) and also for age‐related

reasons. To prevent any possible growth restriction of the zygomatic complex in

patients under 18 years of age, all of the osteosynthesis material would be removed in

the period between 6 and 12 months after the primary surgery.

Statistics

Data was analysed using the Statistical Package for Social Sciences (SPSS) version 15.0.

For parametric data, Student’s t‐tests, and for non‐parametric data, Chi‐Square tests

were performed, if data were sufficient enough.

Results

The study population consisted of 170 males and 66 females with a mean age of

39.3 years (SD: ±15.6) and a range of 4‐87 years. In 210 patients (89%), the zygomatic

complex was fractured, whereas 26 patients (11%) presented with a solitary

zygomatic arch fracture. Figure 2.2 demonstrates the cause of the zygomatic complex

fractures, which was mainly the result of vehicle accidents, followed by violence.

The left side was more affected (145 patients) than the right side (91 patients).

There were no significant differences between male and female patients. The clinical

signs and symptoms are shown in Table 2.1. Most patients presented with

paraesthesia in the infraorbital nerve (47.0%), followed by malar depression (37.3%)

and hematomas/ecchymosis (36.0%).


27

2

Figure 2.2 Mechanism of the injury.

Table 2.1 Clinical signs and symptoms.

N (%) Missing files (%)

Edema 64 (27.1) 38 (16.1)

Pain 62 (26.3) 173 (73.3) Hematomas/ecchymosis 85 (36.0) 23 (9.7)

Malar depression 88 (37.3) 108 (45.8)

Palpable bone deformity – intraoral 37 (15.7) 136 (57.6) Palpable bone deformity – extraoral 72 (30.5) 115 (48.7)

Paraesthesia infraorbital nerve 111 (47.0) 69 (29.2)

Limited mouth opening 32 (13.6) 88 (37.3) Diplopia 20 (8.5) 68 (28.8)

Enophthalmus 10 (4.2) 78 (33.1)


The type of pre‐ and postoperative radiographic analysis was divided into

conventional radiographs, consisting of submentovertex and occipitomental views,

and a (conebeam) CT‐scan. In total 413 preoperative radiographic analyses were

performed. Postoperatively, 361 radiographs were made.

Treatment modalities and operation duration

All of the 26 patients (11%) with solitary zygomatic arch fractures were treated with

closed reduction, using the Gillies approach, which was consistent with the

department’s protocol. The mean operating time was 31.0 (SD: ±8.9) minutes.

Postoperative radiographs consisted of submentovertex and occipitomental views. No

CT‐scans were performed.

Out of the 210 patients with zygomatic complex fractures, 33 patients (14%) were

treated with closed reduction. The remaining 177 patients (75%) underwent open

reduction and internal fixation, using 225 osteosynthesis plates (22 x 1.5 mm KLS

0

20

40

60

80

100

120

Fall Violence Vehicle

accident

Sport

accident

Other Missing

Patients

Chapter 2

28

Martin plates and 203 x 2.0 mm KLS Martin plates) and 943 screws. The distribution

and localisation of the osteosynthesis plates are demonstrated in Figures 2.3 and 2.4.

Figure 2.3 Used osteosynthesis plates.

Figure 2.4 Location of the osteosynthesis plates.

The mean operating time for all zygomatic complex fractures was 65.9 (SD: ±3.7)

minutes.

In 141 patients, only one plate was required for fracture reduction. In

137 patients, a plate was fixed on the lateral orbital rim. Fixation only at the

zygomaticomaxillary buttress was performed in 2 patients using the transoral

approach, as in these patients most of the fracture displacement was found in this

area. The infraorbital rim was used for fixation in 2 other patients. In both patients, it

had preoperatively already been clear that an orbital floor reconstruction would be

necessary.

In 29 patients two plates were necessary for fracture reduction. In 26 patients, the

first plate was fixed on the lateral orbital rim and in 3 patients on the zygomatico‐

0

20

40

60

80

100

120

140

160

0 1 2 3 4 5

Patients

0

20

40

60

80

100

120

140

160

180

Lateral

orbital rim

ZM

buttress

Inraorbital

rim

Paranasal Zygomatic

arch

Patients


29

2

maxillary buttress. The second plate was fixed on the zygomaticomaxillary buttress in

15 patients and on the infraorbital rim in 14 patients.

Three patients needed fixation on all of the three buttresses. A 1.5 mm plate was

fixed paranasally in 3 patients in addition to the 3 buttresses. One patient was treated

with 5 osteosynthesis plates: 3 on the buttresses, 1 paranasally and 1 on the

zygomatic arch.

Orbital floor reconstruction was performed in 13 patients, using PDS sheets

(8 patients) and Medpor‐titanium implants (5 patients).

Complications and retreatment

As demonstrated in Table 2.2, the main complication consisted of a suboptimal

fracture reduction (15 patients). In 12 patients, retreatment was not necessary. The

second most common complication was wound infection (9 patients). In all of the

patients the infection developed within 2 to 3 weeks after surgery. In 8 patients, the

infection was localised intraorally at the zygomaticomaxillary buttress, whereas in

1 patient the infection was localised in the region of the lateral orbital rim. In the

latter patient, the osteosynthesis material had been removed 5 weeks

postoperatively. All other patients had been treated successfully with

amoxicillin/clavulanic acid 500/125 mg, three times daily for one week.

Table 2.2 Postoperative complications.

N (%)

Wound infection 9 (3.8)

Suboptimal fracture reduction – no retreatment 12 (5.1) Suboptimal fracture reduction – retreatment 3 (1.3)

Secondary orbital floor reconstruction – retreatment 4 (1.7)

Facial nerve damage – transient 1 (0.4)

A total of 7 patients needed surgical retreatment. Two patients were retreated during

their hospital stay. The first patient was treated for a zygomatic complex fracture.

After open reduction and internal fixation clinical analysis demonstrated a displaced

zygomatic complex, which required further treatment. The second patient presented

with a displaced zygomatic arch fracture. Radiographic analysis demonstrated a

suboptimal reduction after surgical treatment. This patient underwent successful

surgical retreatment. Four patients underwent surgical retreatment after discharge.

One of these patients had been treated for a zygomatic complex fracture by closed

reduction. This patient presented with clinical signs of displacement one week after

discharge, which required further treatment. However, retrospective review of the

postoperative radiographs made prior to discharge demonstrated no malposition,

neither an indication for further treatment.

Chapter 2

30

The remaining 3 patients were retreated surgically between 2 and 4 weeks after

discharge. These patients needed a secondary correction of the orbital floor, following

fracture reduction of the zygomatic complex. The orbital floor had not initially been

treated during the reduction of the zygomatic complex, as these patients initially did

not show any clinical signs that could justify a primary orbital floor reconstruction

(according to the department’s protocol, Figure 2.1). The pre‐ and postoperative

radiographs were simple plain views (submentovertex and occipitomental

radiographs), which demonstrated no displacement.

The seventh patient underwent correction of an orbital floor reconstruction, one

month after the initial treatment. The inserted PDS sheet had dislodged anteriorly.

The fracture was part of a zygomatic complex fracture. Despite the primary

reconstruction and retreatment this patient developed late enophthalmus and

diplopia. A further successful reconstruction using a Medpor‐titanium implant had

been necessary.

Discussion

There is considerable information available concerning the epidemiology and

mechanism of the injury of zygomatic complex fractures. However, there is a lack of

information regarding its treatment protocols and there is still no consensus on the

treatment of these fractures. This retrospective analysis was performed to investigate

the department’s protocol. Doing so, we hope to contribute to the development of a

consensus on the treatment of zygomatic complex fractures.

In the last 10 years, 236 patients with zygomatic complex fractures were admitted

to our department for surgical treatment. The main cause of the injury was vehicle

accidents, followed by violence and falls. These results are consistent with the

literature, as traffic accidents are frequently mentioned as the most frequent cause of

maxillofacial trauma in many countries.1,3,4 In recent years interpersonal violence has

increased and surpassed traffic accidents as the main causative event.4 Others point

out an aetiological transition tendency towards a rise in aggression over traffic

accidents.12‐16

Twenty‐six patients were diagnosed with a solitary zygomatic arch fracture. All of

these patients were treated using the Gillies approach.

In seven patients, the reduction was not satisfactory on clinical analysis or

following review of the postoperative radiographs. Thirty‐three of 210 patients with

zygomatic complex fractures were treated with closed reduction. The remaining

patients were treated with open reduction and internal fixation. As plate

osteosynthesis has become state of the art in the treatment of facial bone fractures,

all remaining fractures (n=177) were secured with plates.17‐19 A total of 225 plates

were used.


31

2

Recent studies have stated that standard postoperative radiographic analysis of

maxillofacial fractures is not necessary. Radiographs are made routinely after

treatment of maxillofacial trauma for several reasons, including surgical treatment

evaluation, detection of defects after surgery before patient discharge, identification

of the osteosynthesis material for future removal, and for teaching and medicolegal

reasons.20,21,22 In total 413 preoperative and 361 postoperative radiographs were

analysed in the treatment of 236 patients with zygomatic complex fractures. This issue

should be investigated further and will not be thoroughly discussed here, as it is out of

the scope of this study. The author’s opinion performing routine postoperative

radiographs is of questionable value, considering that 361 postoperative radiographs

were performed, whereas only 1 patient had been retreated on the basis of this

evidence.

Several authors propose a CT‐scan as the gold standard for diagnosing and

planning zygomatic complex fractures.23,24 Our department’s protocol applies

conventional radiographs as a standard to diagnose zygomatic complex fractures,

whereas a CT‐scan would be performed when required for further analysis and

treatment planning. Conventional radiographs have the advantage of being more cost

effective and expose the patient to less irradiation. Figures 2.5 and 2.6 demonstrate a

zygomatic complex fracture with minimal displacement on conventional radiographs

(occipitomental and submentovertex views).

Figure 2.5 Preoperative occipitomental radiograph of a zygomatic complex fracture on the right side.

Chapter 2

32

Figure 2.6 Preoperative submentovertex radiograph of a zygomatic arch fracture on the right side.

In this case, a CT‐scan would be beneficial. Figures 2.7 and 2.8 demonstrate

conventional postoperative images after reduction of a zygomatic complex fracture

using a bone hook.

Figure 2.7 Postoperative occipitomental radiograph of a zygomatic complex fracture on the right side. Fixation was not necessary.


33

2

Figure 2.8 Postoperative submentovertex radiograph of a zygomatic arch fracture on the right side.

A CT‐scan may be advantageous for treatment planning in cases of comminuted

orbital floor fractures, as demonstrated in Figure 2.9.

Figure 2.9 Preoperative CT‐image of a comminuted orbital floor fracture on the left side.

Figure 2.10 demonstrates a postoperative coronal CT‐image of a comminuted

orbital floor fracture, which was reconstructed with a Medpor‐titanium implant.

Chapter 2

34

Irrespective of the increased costs and irradiation we have to admit that the decision

to perform a scan is much easier nowadays, following the introduction of the

conebeam CT‐scan.

Figure 2.10 Postoperative CT‐image of a reconstructed orbital floor on the left side. A Medpor‐titanium

implant was used for the reconstruction.

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

reference point for fracture reduction and that a second or perhaps even a third area

of evaluation would be beneficial.25 Habal demonstrated good fracture reduction by

their sequential surgical approach, using the zygomaticomaxillary buttress as first

choice approach, followed by the infraorbital rim and lateral orbital rim in the third

place.26,27 Ellis advised the zygomaticomaxillary buttress approach as the first choice,

followed by the infraorbital rim and lateral orbital rim.26,28 In contrast, our department

applies the lateral orbital rim approach as the first choice, followed by the

zygomaticomaxillary buttress and the infraorbital rim, as the latter approach seems to

be associated with higher complication rates.22,29 During surgery the reduction is

assessed by palpating the infraorbital rim and the zygomaticomaxillary buttress. When

the fracture is adequately reduced, fixation is performed using plate osteosynthesis at

the frontozygomatic suture. The development of the department’s approach was

clarified by interviewing the senior surgeons. In the past, fixation had been performed

by wiring, and the best accessible area for fixation with wires proved to be the lateral

orbital rim. Following the introduction of plate osteosynthesis, it had been decided to


35

2

use this approach as first choice. Therefore, the same approach is still used in the

present protocol.

This study did not demonstrate any differences in the incidence of infection

between different fixation areas, which is in line with the literature. Recently Knepil

and Loukota described the type of contamination during surgery.30 Most fractures of

the zygomatic complex may be classified as clean or clean‐contaminated, depending

on whether the surgical approach is transcutaneous or transoral. Clean operations in

healthy patients have a low risk of infection, ensuring no indication for antibiotic

prophylaxis. Avoiding a transoral approach converts a clean‐contaminated operation

into a clean operation, which makes the use of prophylactic antibiotics unnecessary.

Published data regarding the effectiveness of prophylactic antibiotics in the surgical

treatment of maxillofacial fractures, and especially zygomatic bone fractures, is scarce

and the level of evidence is low.31 The authors of the present study only prescribed

prophylactic antibiotics according to the department’s protocol. This protocol states

that patients only receive prophylactic antibiotics if either the zygomaticomaxillary

buttress or the infraorbital rim is used for fixation.

As the patients’ opinion was not obtained, regarding the formation of scar tissue

at the lateral orbital rim, strong recommendations regarding the best surgical access

could not be provided. Although our results are in line with the literature concerning

the extraoral approach, it is questionable if the same results could be achieved using a

transoral approach.

Conclusion

This study gives an overview of 236 patients who underwent surgical treatment for

zygomatic complex fractures, according to the “Amsterdam” protocol. Twenty‐nine

patients presented with complications, including suboptimal fracture reduction (15

patients), wound infection (9 patients) and transient paralysis of the facial nerve (1

patient). Seven patients (3%) needed surgical retreatment, of whom four patients

needed a secondary orbital floor reconstruction due to enophthalmus and diplopia.

This report demonstrates important data that may improve the treatment of

zygomatic complex fractures and contribute towards reaching a consensus opinion on

the management of this fracture type.

Chapter 2

36

References

1. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011

2. Bogusiak K, Arkuszewski P.: Characteristics and epidemiology of zygomaticomaxillary complex

fractures. J Craniofac Surg (21) 1018‐1023, 2010 3. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R.: The pattern of the maxillofacial

fractures ‐ A multicentre retrospective study. J Craniomaxillofac Surg (40) 675‐679, 2012

4. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg

(40) e165‐e169, 2012

5. Olate S, Lima SM Jr, Sawazaki R, Moreira RWillian, de Moraes M.: Surgical approaches and fixation patterns in zygomatic complex fractures. J Craniofac Surg (21) 1213‐1217, 2010

6. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of zygomatico‐orbital

complex and/or zygomatic arch fractures over a 71‐month period. Dent Traumatol (27) 135‐142, 2011 7. He D, Blomquist PH, Ellis E.: Association between ocular injuries and internal orbital fractures. J Oral

Maxillofac Surg (65) 713‐720, 2007

8. Hwang K.: One‐point fixation of tripod fractures of zygoma through a lateral brow incision. J Craniofac Surg (21) 1042‐1044, 2010

9. Wang S, Xiao J, Liu L, Lin Y, Li X, Tang W, Wang H, Long J, Zheng X, Tian W.: Orbital floor

reconstruction: a retrospective study of 21 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (106) 324‐330, 2008

10. Lund K.: Fractures of the zygoma: a follow‐up study on 62 patients. J Oral Surg (29) 557‐560, 1971

11. Pozatek ZW, Kaban LB, Guralnick WC.: Fractures of the zygomatic complex: an evaluation of surgical management with special emphasis on the eyebrow approach. J Oral Surg (31) 141‐148, 1973

12. Gomes PP, Passeri LA, Barbosa JR.: A 5‐year retrospective study of zygomatico‐orbital complex and

zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg (64) 63‐67, 2006 13. Hwang K, You SH, Sohn IA.: Analysis of orbital bone fractures: a 12‐year study of 391 patients. J

Craniofac Surg (20) 1218‐1223, 2009

14. Lee KH.: Interpersonal violence and facial fractures. J Oral Maxillofac Surg (67) 1878‐1883, 2009 15. Lee KH. and Antoun, Joseph: Zygomatic fractures presenting to a tertiary trauma centre, 1996‐2006.

N Z Dent J (105) 4‐7, 2009

16. van Beek GJ, Merkx CA.: Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral Maxillofac Surg (28) 424‐428, 1999

17. Alkan A, Celebi N, Ozden B, Bas B, Inal S.: Biomechanical comparison of different plating techniques in

repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (104) 752‐756, 2007

18. de Matos FP, Arnez,MF, Sverzut CE, Trivellato AE.: A retrospective study of mandibular fracture in a

40‐month period. Int J Oral Maxillofac Surg (39) 10‐15, 2010 19. Ellis E, el‐Attar A, Moos KF.: An analysis of 2,067 cases of zygomatico‐orbital fracture. J Oral Maxillofac

Surg (43) 417‐428, 1985

20. Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, Edwards K.: Postoperative radiographs after open reduction and internal fixation of the mandible: are they useful? Br J Oral


21. Jain MK, Alexander M.: The need of postoperative radiographs in maxillofacial fractures‐‐a prospective multicentric study. Br J Oral Maxillofac Surg (47) 525‐529, 2009

22. van den Bergh B, Goey Y, Forouzanfar T.: Postoperative radiographs after maxillofacial trauma: Sense

or nonsense? Int J Oral Maxillofac Surg (40) 1373‐1376, 2011 23. Jarrahy R, Vo V, Goenjian HA, Tabit CJ, Katchikian HV, Kumar A, Meals C, Bradley JP.: Diagnostic

accuracy of maxillofacial trauma two‐dimensional and three‐dimensional computed tomographic

scans: comparison of oral surgeons, head and neck surgeons, plastic surgeons, and neuroradiologists. Plast Reconstr Surg (127) 2432‐2440, 2011


37

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24. Kaufman Y, Stal D, Cole P, Hollier L Jr.: Orbitozygomatic fracture management. Plast Reconstr Surg

(121) 1370‐1374, 2008 25. Markowitz BL, Manson PN.: Panfacial fractures: organization of treatment. Clin Plast Surg (16) 105‐

114, 1989

26. Habal MB.: The orbits: it is less important what you put in than how you secure it. J Craniofac Surg (21) 965‐966, 2010

27. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT.: The incidence of lower eyelid malposition after

facial fracture repair: a retrospective study and meta‐analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg (124) 1578‐1586, 2009

28. Ellis E, Kittidumkerng W.: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J

Oral Maxillofac Surg (54) 386‐400, 1996 29. Bahr W, Bagambisa FB, Schlegel G, Schilli W.: Comparison of transcutaneous incisions used for

exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg (90) 585‐

591, 1992 30. Knepil GJ, Loukota RA.: Outcomes of prophylactic antibiotics following surgery for zygomatic bone

fractures. J Craniomaxillofac Surg (38) 131‐133, 2010

31. Zhang Y, He Y, Zhang ZY, An JG.: Evaluation of the application of computer‐aided shape‐adapted fabricated titanium mesh for mirroring‐reconstructing orbital walls in cases of late post‐traumatic

enophthalmos. J Oral Maxillofac Surg (68) 2070‐2075, 2010

Chapter 2

38

3

The epidemiological characteristics of zygomatic

complex fractures: A comparison between the

surgically and non‐surgically treated patients


Salentijn EG, Boffano P, Boverhoff J, van den Bergh B, Forouzanfar T.

The epidemiological characteristics of zygomatic complex fractures: A comparison

between the surgically and non‐surgically treated patients.

Natl J Maxillofac Surg. 2013 Jul;4(2):214‐218.

Chapter 3

40

Abstract

Introduction

This retrospective study is aimed at the documentation of a more complete view of

epidemiological data with particular focus on the characteristics of surgically and non‐

surgically treated patients with zygomatic complex fractures.

Material and Methods

A total of 133 surgically and 150 non‐surgically treated patients with zygomatic

complex fractures at VU University Medical Center in Amsterdam from January 2007

to January 2012 was analyzed. These patient groups were further subdivided into

displaced or non‐displaced fractures and compared with each other according to age,

gender and trauma aetiology.

Results

The mean age of all 283 patients was 42.8 years (SD: ±19.8). Surgically and non‐

surgically treated patients differed in presentation with a significantly overall higher

age of female patients, especially within the non‐surgically treated patients group

with fracture displacement (mean age of 59.5 years, SD: ±27.4). The mean age of

males from the different subgroups was more consistent with the overall mean age.

The main cause of the trauma was traffic accidents, whereas the contribution of falls

and assault depended on age group, gender, treatment management and even

fracture displacement.

Conclusions

This report provides us important epidemiological data regarding patients with

zygomatic complex fractures. The non‐surgically treated patients group contained

patients of higher age, more females and a fall‐related cause, compared to the

surgically treated patients group. The surgically treated patients group showed the

same epidemiological characteristics as were demonstrated in previous studies.

The epidemiological characteristics of zygomatic complex fractures

41

3

Introduction

Fractures of the zygomatic complex are common after facial trauma and are

frequently associated with additional traumatic injury.1‐4 Early diagnosis of zygomatic

complex fractures is essential for optimal treatment and is directly dependent on

appropriate initial evaluation, correct injury assessment, and timely initiation of the

chosen therapy. Surgical intervention is the treatment of choice for displaced

zygomatic complex fractures, unless patients are medically unfit to undergo surgery, if

patients refuse surgery, or if patients present with none or minimal functional and/or

aesthetic problems.5,6 In the literature many studies can be found concerning

evaluation of the surgical treatment management of zygomatic complex fractures.7,8

Literature concerning the preoperative assessment of zygomatic complex fractures, in

particular the epidemiological differences between the surgically and non‐surgically

indicated treatment groups, is lacking. To the best of our knowledge, only one study

by Back et al. specifically investigated the non‐surgically treated patients.9 However,

the study by Back et al. included all facial fractures and did not focus on patients with

zygomatic complex fractures in particular.9 The purpose of this retrospective study

was to provide physicians a more complete view of the epidemiological characteristics

of surgically and non‐surgically treated patients with zygomatic complex fractures.


Subjects

A retrospective review was performed from all hospital and outpatient records of

283 patients diagnosed with a fractured zygomatic complex, from January 2007 to

January 2012. The eligible patients were identified using the hospital database. Data

collection consisted of age, gender, fracture site, fracture displacement, cause of the

trauma (assault, traffic accident, sport accident, fall or other), date of the trauma,

date of the first consultation, and treatment management (surgical or non‐surgical

treatment). Diagnosis (and the presence of fracture displacement) of all patients was

established at the same day of initial assessment by plain radiographic analysis

(submentovertex and occipitomental radiographs) and/or a computed tomography‐

scan (CT‐scan). Exclusion criteria were the presence of a Le Fort fracture, other facial

fractures that were associated with the (four‐sided) zygomatic complex (e.g., isolated

lateral orbital rim and/or wall, orbital floor or zygomatic arch), and bilateral zygomatic

complex fractures. Furthermore, patients were excluded if the initial clinical

assessment was more than 1 week after the trauma and if radiographic analyses (e.g.

plain radiographs or CT‐scans) were not available. After data retrieval, patients were

divided into surgically treated or non‐surgically treated patient groups. Furthermore,

Chapter 3

42

patients in the non‐surgically treated group were subdivided into groups based on

displacement of the fractured zygomatic complex (displacement versus non‐

displacement).

Statistics

Nominal data were presented as absolute and relative frequencies, metric data as

mean and standard deviation (SD). Comparisons between the groups were done by

the Chi‐Square test for nominal data and the Mann‐Whitney U test for age. P<0.05

was considered to be significant. All calculations were made using Statistical Package

for the Social Sciences (IBM) V 19.0.

Results

Patient demographics

As demonstrated in Table 3.1, the patient demographics are listed.

Table 3.1 Patient demographics.

Surgical n=133

Non‐surgical n=150

Displacement

n=55

Non‐displacement

n=95

Gender

male 102 36 63

female 31 19 32 Age (Mean (yrs) ±SD) 38.8 ±15.7 51.2 ±23.6 43.4 ±20.6

The study population consisted of 283 patients, of which 133 were surgically treated

and 150 were non‐surgically treated. The mean age of the population was 42.8 years

(SD: ±19.8). Subdivided by gender, 201 male patients (71%) and 82 female patients

(29%) were included. There was a significant (P<0.05) difference in age between male

patients (mean age: 40.6 years, SD: ±17) and female patients (mean age: 48.2 years,

SD: ±23.6).

Compared with the surgically treated patients group, the patients in the non‐

surgically treated group were significantly older (P<0.05). Concerning the non‐

surgically treated patients group, the 55 patients with a displaced zygomatic complex

fracture differed from the 95 patients with a non‐displaced zygomatic complex

fracture. The mean age of those with displaced zygomatic complex fractures was

higher (51.2 years, SD: ±23.6), compared to those with the non‐displaced fractures


43

3

(43.4 years, SD: ±20.6), especially with regard to the female patients (mean age of

59.5 years, SD: ±27.4). The differences were not significant (P=0.055).

As demonstrated in Table 3.2, the main cause of zygomatic complex fractures was

traffic related accidents (43.1%), followed by falls (27.2%) and assault (20.5%). Sport

related accidents and other causes were considered as less common causes.

Table 3.2 Cause of injury according to age groups in all patients with a fractured zygomatic complex.

Age Fall Assault Traffic accident Sports Other Total (%)

0‐9 2 0 0 0 0 2 (0.7)

10‐19 5 8 13 3 4 33 (11.7)

20‐29 10 18 34 4 1 67 (23.7) 30‐39 5 12 16 1 3 37 (13.1)

40‐49 11 9 22 4 2 48 (17.0)

50‐59 7 8 20 0 2 37 (13.1) 60‐69 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)

The main causes differed substantially between male and female patients, as shown in

Table 3.2a and 3.2b. Concerning male patients, traffic accidents accounted for 43.3%

of the cases, followed by assault (26.4%) and falls (20.9%). With regard to female

patients, both traffic accidents (42.7%) and falls (42.7%) were found as the most

common causes, whereas zygomatic complex fractures due to assault were not found

frequently (6.1%). Trauma due to fall accounted significantly more for the older ages,

whereas trauma due to traffic accidents and assault accounted for the younger ages

(P<0.05). The male patients were mainly in their 20th year of age (26.4%), whereas the

female patients were mainly over 70 years of age (20.7%).

Table 3.2a Cause of injury according to age for male patients.


0‐9 ‐ ‐ ‐ ‐ ‐ ‐ ‐

10‐19 4 8 9 2 ‐ 23 (11.4) 20‐29 7 17 24 4 1 53 (26.4)

30‐39 3 12 13 1 3 32 (15.9)

40‐49 9 7 14 3 1 34 (16.9) 50‐59 4 6 15 ‐ 2 27 (13.4)

60‐69 8 2 10 1 1 21 (10.4)

70 + 7 1 2 ‐ 1 11 (5.5) Total 42 53 87 11 8 201

(%) (20.9) (26.4) (43.3) (5.5) (4.0)

Chapter 3

44

Table 3.2b Cause of injury according to age for female patients.


0‐9 2 ‐ ‐ ‐ ‐ 2 (2.4)

10‐19 1 ‐ 4 1 4 10 (12.2)

20‐29 3 1 10 ‐ ‐ 14 (17.1)

30‐39 2 ‐ 3 ‐ ‐ 5 (6.1) 40‐49 2 2 8 1 1 14 (17.1)

50‐59 3 2 5 ‐ ‐ 10 (12.2)

60‐69 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)

For both patient groups traffic accidents mainly consisted of bicycle and motorcycle

accidents with relative more bicycle accidents for the female patients (Figure 3.1).

Figure 3.1 Traffic accidents divided by mode of transport for male and female patients.

The main cause of injury regarding the surgically treated patients accounted for

almost 50% of traffic accidents, followed by assault (24.1%) and falls (13.5%) (Table

3.3a). In the non‐surgically treated patients group, falls were found as the main cause

(39.3%), closely followed by traffic accidents (37.3%). Assault accounted for 17.3% of

the patients (Table 3.3b).

0

10

20

30

40

50

60

Per

cen

t

Pedestrian

hit

Bicycle

accident

Motorcycle

accident

Automobile

accident

Cause of injury

Male

Female


45

3

Table 3.3a Cause of injury for surgically treated patients.


0‐9 ‐ ‐ ‐ ‐ ‐ ‐ ‐

10‐19 ‐ 5 7 3 1 16 (12.0)

20‐29 4 9 21 3 ‐ 37 (27.8)

30‐39 1 7 7 1 2 18 (13.5) 40‐49 5 8 12 3 2 30 (22.6)

50‐59 3 3 11 1 1 18 (13.5)

60‐69 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)

Table 3.3b Cause of injury for non‐surgically treated patients.


0‐9 2 ‐ ‐ ‐ ‐ 2 (1.3)

10‐19 5 3 6 ‐ 3 17 (11.3)

20‐29 6 9 13 1 1 30 (20.0)

30‐39 4 5 9 ‐ 1 19 (12.7) 40‐49 6 1 10 1 ‐ 18 (12.0)

50‐59 4 5 9 ‐ 1 19 (12.7)

60‐69 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)

Non‐surgically treated patients divided into displaced and non‐displaced fractures

The relative share of male patients was almost equally divided between the displaced

(65.5%) and the non‐displaced fractures (66.3%). The most common causes differed

between both groups within the non‐surgically treated patients group. Displaced

zygomatic complex fractures were mainly caused by falls (47.3%) (Table 3.4a),

whereas non‐displaced fractures were more often caused by traffic accidents (41.1%).

(Table 3.4b). Assault as a cause of the trauma was almost equally divided between

both groups.

Chapter 3

46

Table 3.4a Cause of injury for displaced zygomatic complex fractures in the non‐surgically treated

patients group.


0‐9 ‐ ‐ ‐ ‐ ‐ ‐ ‐

10‐19 2 1 4 ‐ 1 8 (14.5)

20‐29 2 1 4 ‐ 1 8 (11.0) 30‐39 1 3 1 ‐ ‐ 5 (9.1)

40‐49 2 ‐ 2 ‐ ‐ 4 (7.3)

50‐59 1 2 3 ‐ ‐ 6 (10.9) 60‐69 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)

Table 3.4b Cause of injury for non‐displaced zygomatic complex fractures in the non‐surgically treated

patients group.


0‐9 2 ‐ ‐ ‐ ‐ 2 (2.1)

10‐19 3 2 2 ‐ 2 9 (9.5) 20‐29 4 7 10 1 ‐ 22 (23.2)

30‐39 3 2 8 ‐ 1 14 (14.7)

40‐49 4 1 8 1 ‐ 14 (14.7) 50‐59 3 3 6 ‐ 1 13 (13.7)

60‐69 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 of

epidemiological data, as well as to analyze differences between surgically and non‐

surgically treated patients with zygomatic complex fractures.

The mean age of all 283 patients was 42.8 years (SD: ±19.8). Surgically treated and

non‐surgically treated patients differed substantially in presentation and, in particular,

the females of the non‐surgically treated patients group. As expected, non‐surgically

treated patients had a higher mean age (46.2 years, SD: ±22.0), especially when there

was fracture displacement. This latter group almost consisted of symptomatic patients

and will mainly consist of patients with treatment refusal or patients that are

medically unfit. Strikingly, only female patients of the non‐surgically treated patients

group and none of the surgically treated patients group were much older (mean age

of 52.3 years, SD: ±26.3), and especially those within the group of displaced fractures

(mean age of 59.5 years, SD: ±27.4). The mean age of our surgically treated patients


47

3

group demonstrated similar results with other publications in which predominance of

younger patients, aged between 21 and 30 years, and, moreover, no large differences

in age between male and female patients were reported.2‐4 We found an overall

higher mean age and this was due to our non‐surgically treated patients, consisting of

an old‐aged female population.

As in line with other previous studies the sex distribution of patients was markedly

higher for males compared to females, with a male‐female ratio of 2.4:1 over all

patients.1‐4

In our study, the most common causes in all patients were mainly attributed to

traffic accidents, assault and falls. In many other studies, traffic accidents and assault

were the most common causes, which was in accordance with our surgically treated

population but not with the non‐surgically treated population.1‐4,10 Fall (39.3%) was

the main cause, regarding the non‐surgically treated patients group and in particular

those with displaced zygomatic complex fractures (47.3%), followed by traffic

accidents. This is not in accordance with Back et al., who reported a high incidence of

assault (46%), followed by falls (20%) regarding their non‐surgically treated patients.9

However, the study of Back et al. included all facial fractures and was conducted in

Australia with a lower mean age of 38 years. Our higher incidence of falls is partially

due to old aged (above 50 years) female patients who have a higher risk on and are

more prone to falls and have other living and/or social habits.11 Assault occurs more

often in young male adults, as in accordance with our surgically treated population.

Additional explanation for our higher incidence of falls might be due to our

governmental safety measurements that could have decreased traffic accidents and

citizen safety (less alcohol abuse and assault) in our country.10

This study was a retrospective analysis, which means that it was automatically

subject to measurements and registration styles by physicians and might therefore

have a subjective bias. Another shortcoming of our study is, whether our

epidemiological data is representative for the whole population of Amsterdam, as

there are four hospitals treating patients with trauma injury. However, to our

knowledge this is the first report of a Dutch trauma population, also including the

non‐surgically treated patients.

There are several differences between the non‐surgically and the surgically treated

patients, and even within the non‐surgically treated patients group there are

differences based on the presence of fracture displacement. From an epidemiological

point of view, neglecting this non‐surgically treated patients group in studies and

solely describing the surgically treated patients could be considered a data gap and

may also be an explanation for the large variability of incidence and aetiology

between different countries.1,2,4,8,10 Standardized and comparable studies, including

non‐surgically treated patients and, more specifically, comparing non‐surgically with

surgically treated patients are therefore highly required.

Chapter 3

48

Conclusion

This retrospective analysis provides us important data for a detailed view of patients

with zygomatic complex fractures. It shows several epidemiological differences

between the surgically and non‐surgically treated patient groups and even differences

within the latter group. The surgically treated patients mainly consisted of young male

adults and the traffic‐ and assault‐related cause highly contributed to this group,

which is in accordance with previous studies. On the contrary, the non‐surgically

treated patients consisted of a high number of elderly female patients, especially in

the patients group with displaced zygomatic complex fractures. Furthermore, there

was a high number of fall‐related causes. Epidemiological studies should be based on

surgically, as well as non‐surgically treated patients. This will help to realize the

importance of differences between these groups and perhaps provide us future plans

for injury prevention.


49

3

References

1. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH.: Changing patterns in the epidemiology and treatment of zygoma fractures: 10‐year review. J Trauma (37) 243‐248, 1994


cases with 21,067 injuries. J Craniomaxillofac Surg (31) 51‐61, 2003 3. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of zygomatico‐orbital

complex and/or zygomatic arch fractures over a 71‐month period. Dent Traumatol (27) 135‐142, 2011


(40) e165‐e169, 2012

5. Evans BG, Evans GR.: MOC‐PSSM CME article: Zygomatic fractures. Plast Reconstr Surg (121) 1‐11, 2008

6. Kelley P, Hopper R, Gruss J.: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg

(120) 5S‐15S, 2007 7. Carr RM, Mathog RH.: Early and delayed repair of orbitozygomatic complex fractures. J Oral


8. Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, Raveh J.: Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg (50) 778‐790, 1992

9. Back CP, McLean NR, Anderson PJ, David DJ.: The conservative management of facial fractures:

indications and outcomes. J Plast Reconstr Aesthet Surg (60) 146‐151, 2007 10. van Beek GJ, Merkx CA.: Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral


11. Iida S, Hassfeld S, Reuther T, Schweigert HG, Haag C, Klein J, Muhling J.: Maxillofacial fractures resulting from falls. J Craniomaxillofac Surg (31) 278‐283, 2003

Chapter 3

50

4

The clinical and radiographic characteristics of

zygomatic complex fractures: A comparison

between the surgically and non‐surgically treated

patients


Salentijn EG, Boverhoff J, Heijmans MW, van den Bergh B, Forouzanfar T. The clinical and radiographic characteristics of zygomatic complex fractures: A

comparison between the surgically and non‐surgically treated patients.

J Craniomaxillofac Surg. 2014 Jul;42(5):492‐7.

Chapter 4

52

Abstract

Introduction

In this retrospective study, we evaluated the clinical and radiographic differences

between surgically and non‐surgically treated patients with zygomatic complex

fractures at their initial assessment in our clinic, over a period of 5 years. More

knowledge of the clinical similarities and/or differences between the non‐surgically

and surgically treated patient groups will provide us a more complete view and may

help physicians to develop any future methods in clinical decision making, or even

methods in distinguishing patients benefiting from a surgical treatment.

Methods

Surgically and non‐surgically treated patients were included in the study if clinical and

radiographic confirmation of zygomatic complex fractures were present at initial

assessment. The patient groups were divided into surgically and non‐surgically treated

fractures, with and without fracture displacement. The groups were compared

according to age, gender, degree of fracture displacement and clinical signs.

Results

In total 283 patients were diagnosed with zygomatic complex fractures, with a mean

age of 42.8 years (SD: ±19.8) and a domination of male patients. The mean age was

higher in the non‐surgically treated patients group and contained more female

patients. Overall type C fractures and the majority of the type B fractures were

treated surgically. Only 2.1% of the type A fractures were treated surgically. Facial

swelling and paraesthesia of the infraorbital nerve were found as most common

clinical features. Additionally, malar depression and extraoral steps were frequently

found in the surgically treated patients group, as in the non‐surgically treated patients

group only facial swelling was found frequently, whether there was fracture

displacement or not. Extraoral steps, intraoral steps, and malar depression were

found as clinical characteristics to be significantly associated with surgical treatment.

Conclusion

Extraoral steps, intraoral steps, and malar depression were significantly associated

with surgical treatment. The group of non‐surgically treated patients with zygomatic

complex fractures is a valuable group to investigate, as this group also consists of

patients with displaced zygomatic complex fractures (meaning surgical indication),

and thus could provide us more insight in future clinical decision methods. Therefore,

we highly recommend more research of the non‐surgically treated patients group.

The clinical and radiographic characteristics of zygomatic complex fractures

53

4

Introduction

Fractures of the zygomatic complex are commonly seen after facial trauma and are

frequently associated with additional traumatic injury.1‐4 Early diagnosis of these

fractures is essential for optimal treatment and is directly dependent on appropriate

initial evaluation, correct injury assessment and timely initiation of the chosen

therapy. Generally, displacement of zygomatic complex fractures is a surgical

indication, unless there are clinical contraindications, such as being medically unfit for

surgery, patient’s refusal or the absence of functional and/or aesthetic problems.5,6

However, a suspected and/or displaced zygomatic complex fracture could be easily

missed clinically at the initial assessment, due to the additional associated symptoms

of the trauma injury, such as facial swelling. Subsequently, computed tomography is

routinely used to determine zygomatic complex fractures and their potential

displacement, but this radiographic examination is supersensitive: showing minor

zygomatic complex fractures that are clinically not relevant. Evaluation of clinical signs

is therefore not replaceable by radiographic imaging and still remains essential for an

adequate treatment management. In their study, Forouzanfar et al. demonstrated

their treatment protocol for zygomatic complex fractures.7 An important aspect of a

treatment protocol concerns the decision‐making, whether or not to treat a patient

surgically or non‐surgically in case of a zygomatic complex fracture. This decision is

based on clinical signs and radiographic analysis. The absence of knowledge of the

similarities and differences of the clinical characteristics of zygomatic complex

fractures could hamper the development of any future clinical decision‐making in

treatment methods or even bother to distinguish patients benefiting from a surgical

treatment.

Literature of the preoperative assessment, and in particular the clinical differences

between the surgically and non‐surgically indicated treatment groups, is lacking.

Numerous studies only evaluated the surgical treatment management.8,9 To our

knowledge only one study investigated non‐surgically treated patients with facial

fractures.10

Neglecting this group of non‐surgically treated patients in studies, and solely

describing the surgically treated patients, could be considered as a data gap in the

literature. Standardized and comparable studies, including non‐surgically treated

patients, and, more specifically, comparing the non‐surgically treated with the

surgically treated patients group are therefore highly required.

The aim of the present study was to investigate the clinical characteristics of the

surgically and non‐surgically treated patients with zygomatic complex fractures in our

department. Thereby, we attempted to provide physicians a more complete view of

the clinical and radiographic presentation of patients with fractures of the zygomatic

complex.

Chapter 4

54


Subjects

The hospital and outpatient records of 283 patients diagnosed with a zygomatic

complex fracture, from January 2007 to January 2012, were reviewed and analyzed

retrospectively. These patients were identified using the hospital database. Data

collected were age, gender, degree of fracture displacement, clinical signs,

radiographic analysis and treatment management (surgical or non‐surgical treatment).

Diagnosis and the degree of fracture displacement of all patients were established at

the same day of initial assessment by plain radiographic analysis (submentovertex and

occipitomental radiographs) and/or a CT‐scan. Exclusion criteria were the presence of

a Le Fort fracture, other facial fractures that were associated with the (four‐sided)

zygomatic complex (e.g. isolated orbital rim and/or wall, orbital floor or zygomatic

arch), and bilateral zygomatic complex fractures. Furthermore, patients were

excluded if the initial clinical assessment was more than one week after the trauma

and if radiographic analyses (plain radiographs or CT‐scan) were not available.

In all of the patients, the department’s protocol was used for the decision‐making

process in the treatment of zygomatic complex fractures, as demonstrated below:

1) zygomatic complex fracture without/with mild displacement and without

paraesthesia of the infraorbital nerve: no surgical treatment

2) zygomatic complex fracture without/with mild displacement and with

paraesthesia of the infraorbital nerve: no surgical treatment and a follow‐up

period for 10 days;

a. if there is an improvement of sensibility after ten days: no surgical treatment

b. if there is no improvement of sensibility after 10 days: surgical treatment

3) zygomatic complex fracture with moderate/severe displacement and

with/without paraesthesia of the infraorbital nerve: surgical treatment

4) zygomatic complex fracture with moderate/severe displacement, with/without

paraesthesia of the infraorbital nerve and entrapment of the inferior rectus

muscle: surgical treatment (ORIF and reconstruction of the orbital floor).

In our department, absolute criteria for surgical treatment of zygomatic complex

fractures are displacement, diplopia due to rectus muscle entrapment, enophthalmus

and impingement of the coronoid process with the zygomatic arch. Relative criteria

for surgical treatment are cosmetic reasons, paraesthesia of the infraorbital nerve and

patient related reasons, such as age‐ and health‐related causes.

After data retrieval patients were divided into groups according to the treatment

management (surgical or non‐surgical treatment), as shown in Figure 4.1. These

groups were further subdivided into groups based on the presence of fracture

displacement (displacement versus no displacement).


55

4

All

(283)

Surgically

treated

(133)

Displacement

(133)

No displacement

(0)

Symptoms

(116)

No sym

ptoms

(6)

Missing

(11)

Symptoms

(49)

No sym

ptoms

(5)

Missing

(1)

Displacement

(55)

No displacememt

(95)

Non‐surgically

treated

(150)

Symptoms

(48)

(39)

Missing

(8)

No sym

ptoms

Figure 4.1

Overview of the different patient groups.

( ) = number of patients in each patient group.

All

(283)

Surgically

treated

(133)

Displacement

(133)

No displacement

(0)

Symptoms

(116)

No sym

ptoms

(6)

Missing

(11)

Symptoms

(49)

No sym

ptoms

(5)

Missing

(1)

Displacement

(55)

No displacememt

(95)

Non‐surgically

treated

(150)

Symptoms

(48)

(39)

Missing

(8)

No sym

ptoms

Figure 4.1

Overview of the different patient groups.

( ) = number of patients in each patient group.

Chapter 4

56

Furthermore, the patient groups (surgically and non‐surgically treated) were classified

according to the degree of zygomatic complex fracture displacement, using the

classification according to Zingg et al.9 In this classification zygomatic complex

fractures are classified into 3 types: incomplete (isolated zygomatic arch, lateral

orbital rim or infraorbital rim) fractures (type A), complete (classic) fractures (type B)

and multi‐fragmented fractures (type C) (Figure 4.2).

Figure 4.2 Classification system for zygomatic complex fractures: Isolated fractures including types A1,

A2, and A3. Type A1 (A) are isolated zygomatic arch fractures; type A2 (B) are isolated lateral

orbital wall fractures, A3 (C) are isolated infraorbital rim fractures. Type B (D) fractures are

tetrapod fractures and type C (E) fractures are multi‐fragmented zygomatic complex fractures.

Type A fractures were considered as mild fracture displacement, whereas type B

fractures were considered as moderate fracture displacement and type C fractures

were considered as severe fracture displacement. It should be mentioned that the

non‐displaced zygomatic complex fractures were all classified as type A fractures.


57

4

Statistical analyses

Nominal data were presented as frequencies, metric data as mean and standard

deviation (SD). Comparisons between the treatment groups were performed by the

Chi‐Square test for nominal data and the Mann‐Whitney U test for age, because age

was not normally distributed. A logistic regression model was used in which treatment

was the dependent variable and the different clinical symptoms were the

independent variables, to further explore which clinical symptoms were most

indicative for a specific treatment group. The p‐values <0.05 were considered to be

significant. All calculations were made using IBM SPSS Statistics 19.

Results

Demographic factors of all patient groups

In Table 4.1 the patient demographics are shown. The mean age of all patients was

42.8 years (SD: ±19.8) and was dominated by male patients (71% male, 29% female).

The mean age and relative share of males/females was less in the surgically treated

patients group compared to the overall results, as described above. However, the

mean age was higher in the non‐surgically treated patients group and this group also

had a higher share of females, compared to the surgically treated patients group and

the overall results.

Table 4.1 Overview of the demographic characteristics of the patient groups.

Treatment group Surgical

(n=133)

Non‐surgical,

displacement (n=55)

Non‐surgical,

no displacement (n=95)

Age (mean (yrs) ±SD) 38.8 (±15.7) 51.2 (±23.6) 43.4 (±20.6)

Gender (%)

Male 76.7% 65.5% 66.3%

Female 23.3% 34.5% 33.7%

N: total number of patients.

Radiographic findings

As the zygomatic complex fractures were radiographically diagnosed with

conventional radiographs (submentovertex and occipitomental radiographs) and/or a

CT‐scan, this classification is demonstrated in Table 4.2.

Chapter 4

58

Table 4.2 Classification of patients according to the type of radiographic analysis.

Radiographic analysis No. of patients

CT‐scan 196

Conventional radiographs 48

CT‐scan and conventional radiographs 39

Total 283

Table 4.2 shows that 196 (69.3%) of the patients were diagnosed radiographically

with a CT‐scan and that only 48 (17.0%) of the patients were diagnosed using

conventional radiographs. In 39 patients (13.7%) both conventional radiographs and a

CT‐scan were performed for radiographic examination, due to the fact that in certain

cases conventional radiographs were not accurate enough for exact radiographic

examination of the fractured zygomatic complex.

In Table 4.3 the zygomatic complex fractures are demonstrated according to the

degree of fracture displacement in the surgically and non‐surgically treated patient

groups. It shows that all of the type C fractures and the majority (68.6%) of the type B

fractures were treated surgically. Only 2.1% of the type A fractures were treated

surgically.

Table 4.3 Zygomatic complex fractures classified according to the degree of fracture displacement.

Degree of fracture displacement No. of patients Surgical Non‐surgical

Type A (mild) 97 2 (2.1%) 95 (97.9%)

Type B (moderate) 175 120 (68.6%) 55 (31.4%)

Type C (severe) 11 11 (100%) 0 (0%)

Total 283 133 150

Clinical findings

Table 4.4 demonstrates an overview of the clinical characteristics of zygomatic

complex fractures according to the degree of fracture displacement.


59

4

Table 4.4 Overview of the clinical characteristics of all zygomatic complex fractures according to the

degree of fracture displacement.

Degree of fracture displacement Mild displacement

(type A)

(97)

Moderate

displacement (type B)

(175)

Severe displacement

(type C)

(11)

Extraoral steps 6 (6.2%) 96 (54.9%) 2 (18.2%)

available data 89 151 4

missing data 8 24 7

Intraoral steps 4 (4.1%) 56 (32.0%) 2 (18.2%) available data 89 143 8

missing data 8 32 3

Malar depression 7 (7.2%) 87 (49.7%) 6 (54.5%) available data 88 149 10

missing data 9 26 1

Facial swelling 79 (81.4%) 126 (72.0%) 3 (27.3%) available data 90 143 7

missing data 7 32 4

Subconjunctival ecchymosis 22 (22.7%) 36 (20.6%) 1 (9.1%) available data 88 120 4

missing data 9 55 7

Paraesthesia infraorbital nerve 31 (32.0%) 107 (61.1%) 7 (63.6%) available data 90 159 8

missing data 7 16 3

Restricted mouth opening 6 (6.2%) 13 (7.4%) 0 (0%) available data 86 117 5

missing data 11 58 6

Restricted extraocular movements 9 (9.3%) 15 (8.6%) 3 (27.3%) available data 92 146 7

missing data 5 29 4

Diplopia 12 (12.4%) 15 (8.6%) 3 (27.3%) available data 91 150 7

missing data 6 25 4

Enophthalmus 0 (0%) 4 (2.3%) 2 (18.2%) available data 89 115 4

missing data 8 60 7

Data are presented as absolute and % presence.

Although not significant, as described in Table 4.4, enophthalmus, diplopia,

restricted extraocular movements and paraesthesia of the infraorbital nerve are more

frequently found in the severely displaced zygomatic complex fractures, whereas

intraoral and extraoral steps are more frequently found in the moderately displaced

fractures. Probably this is due to the loss of bony landmarks in the severely displaced

(multi‐fragmented) zygomatic complex fractures. Furthermore, it should be noted

that 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 in

total) was missing, which could explain the relatively low percentages in the severely

displaced fracture group.

Chapter 4

60

Table 4.5 demonstrates an overview of the clinical characteristics of zygomatic

complex fractures in all of the patient groups according to the treatment type

(surgical versus non‐surgical treatment).

Table 4.5 Overview of the clinical characteristics of the patient groups.

Treatment group All Surgical Non‐surgical

Extraoral steps 104 (41.8%) 70 (65,5%) 34 (23.9%)


missing data 34 26 8 Intraoral steps 62 (25.9%) 46 (47.4%) 16 (11.3%)


missing data 44 36 8 Malar depression 98 (39.4%) 74 (69.8%) 24 (16.7%)


missing data 34 27 7 Facial swelling 208 (87.4%) 78 (80.4%) 130 (92.2%)


missing data 45 36 9 Subconjunctival ecchymosis 60 (28.4%) 22 (31.4%) 38 (27.0%)


missing data 72 63 9 Paraesthesia infraorbital nerve 145 (56.4%) 97 (84.3%) 48 (33.8%)


missing data 26 18 8 Restricted mouth opening 19 (9.1%) 12 (17.4%) 7 (5.0%)


missing data 75 64 11 Restricted extraocular movements 27 (11.0%) 10 (9.9%) 17 (11.7%)


missing data 37 32 5 Diplopia 30 (12.1%) 12 (11.5%) 18 (12.5%)


missing data 35 29 6 Enophthalmus 6 (2.9%) 5 (7.6%) 1 (0.7%)


missing data 75 67 8

Data are presented as absolute and % of presence.

As shown in Table 4.5 the two clinical characteristics that have a very high

frequency in the all‐patients group were facial swelling (87.4%) and paraesthesia of

the infraorbital nerve (56.4%). These two symptoms were also frequently found in the

surgically treated patients group, respectively 80.4% and 84.3%. Additionally, malar

depression (69.8%) and extraoral steps (65.5%) were also frequently found in this

group. In the non‐surgically treated patients group only facial swelling (92.2%) was

frequently found. The clinical characteristics frequently found in the surgically treated

patients group were found less common in the non‐surgically treated patients group.


61

4

For example, malar depression accounted for 16.7% and extraoral steps accounted for

23.9% in the non‐surgically treated patients group. Two clinical characteristics were

almost equally distributed over both patient groups: restricted extraocular

movements and diplopia. Enophthalmus was the only symptom solely present in the

patient groups (surgically and non‐surgically treated) with fracture displacement.

The Chi‐Square test confirmed a significant correlation between clinical symptoms

and surgical treatment (p<0.001). The logistic regression model demonstrated that

extraoral steps, intraoral steps and malar depression were significantly associated

with surgical treatment (p<0.05). Disturbances of the infraorbital nerve seemed not to

be associated with surgical treatment.

After a period of 6 weeks postoperatively, all of the patients, surgically treated or

not, were reassessed. As far as could be analyzed, none of the patients had disagreed

with the chosen therapy (surgical or non‐surgical treatment), as all of the trauma

patients had been informed well about the advantages and disadvantages of surgical

or non‐surgical treatment of the zygomatic complex fracture. Overall, patients were

treated non‐surgically if they did not feel like treatment for aesthetic purposes

(mostly older patients and patients that were medically unfit) or if treatment could

not predict an increase in functional behavior, such as a decrease of paraesthesia after

fracture reduction. Further follow‐up of this important subject would be useful.

Discussion

This retrospective study is aimed as an analysis of the clinical differences between the

surgically and non‐surgically treated patients with a zygomatic complex fracture at

their first consultation. In our population, surgical treatment was significantly

associated with the presence of intraoral steps, extraoral steps and a malar

depression, which might suggest that surgical treatment was particularly performed

for aesthetic reasons.

Non‐surgically treated patients with fracture displacement were generally aged

higher. Hypothetically, in older patients a non‐surgical treatment would be advised

more often, as in this group aesthetics seemed to be less important and more patients

were supposed to be medically unfit, causing surgical treatment to be hazardous.

In the “Material and Methods” section the absolute and relative criteria for

surgical treatment of zygomatic complex fractures in our department are described.

To our knowledge no publications exist, in which the absolute indications for surgical

treatment of zygomatic complex fractures are described or studied. However, the

publications of Kaufman et al. and Hollier et al. mention that the most common

criterion for the treatment of zygomatic complex fractures is fracture

Chapter 4

62

displacement.11,12 Furthermore, Ceallaigh et al. suggest surgical treatment to be

indicated when there is a limited mouth opening, and/or when there are aesthetic

problems.13 They suppose that paraesthesia is not specifically an indication for

surgical treatment of zygomatic complex fractures, which corresponds to our results.

As in line with other previous studies the sex distribution was markedly higher for

males compared to females, and a relative higher share of males in the surgically

treated patients group.4,14‐16

As expected, clinical assessment showed that there was a significant association

between the clinical findings, referred to as palpatory and visual assessment of

deformity (palpable extraoral and intraoral steps, visual malar depression), and

surgical treatment of the fractured zygomatic complex. As facial swelling was almost

present in all patients, it could mask the clinical findings, particularly if the fracture

displacement was minimal. Swelling of the soft‐tissues, due to the injury, could

conceal any depression of the malar eminence or any disturbance within the orbital

anatomy, such as enophthalmus. Furthermore, posttraumatic swelling could cause a

transitory nerve paraesthesia of the infraorbital nerve.

In the literature, the incidence of posttraumatic sensory disturbances following

fractures of the zygomatic complex is reported to be between 33% and 82%.17‐20 We

found a higher incidence of paraesthesia regarding the surgically treated patients

(84.3%), compared with the non‐surgically treated patients (33.8%), with an overall

incidence of 56.4% regarding the all‐patients group. However, paraesthesia was not

significantly associated with the treatment method (surgical or non‐surgical

treatment). Follow‐up records of the patients are necessary to determine the duration

and frequency of paraesthesia and, furthermore, relating this to radiographic scans.

At last, posttraumatic swelling could cause intraorbital pressure on the globe

and/or extraocular muscles, leading to diplopia or disturbed extraocular movements.

As these symptoms were almost equally distributed in our study, it could be expected

that swelling contributes most likely to a large amount of the disturbed eye

movements and/or diplopia. However, it is highly important to identify those patients

with entrapment of the rectus inferior muscle in orbital floor fractures, as the orbital

floor is always part of the zygomatic complex, which requires immediate surgical

treatment in these cases.

One could argue that a shortcoming of this study is the retrospective nature of

recording the clinical findings, and therefore the results being more subject to

subjective measurements and registration between physicians. Like other

retrospective studies, this retrospective analysis may lead to information bias.

Nevertheless, due to the large number of patients the results still demonstrate

valuable information concerning the characteristics of surgically and non‐surgically

treated zygomatic complex fractures. Prospective studies would be necessary to

standardize clinical examination and reporting style of these symptoms.


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Conclusion

Management of zygomatic complex fractures remains a challenging problem and lacks

an accepted consensus internationally. In the present study, the surgically treated

zygomatic complex fractures are compared with the non‐surgically treated fractures,

and furthermore both groups are divided into fractures with mild, moderate and

severe fracture displacement. We found that the mean age of non‐surgically treated

patients, even with fracture displacement, compared to the surgically treated patients

group was higher and had a higher share of female patients. Concerning the clinical

characteristics, malar depression, intraoral and extraoral steps were found to be

significantly correlated with surgical treatment. Paraesthesia of the infraorbital nerve

was not correlated with the surgical treatment policy of zygomatic complex fractures.

In summary, we state that the non‐surgically treated patients group is a valuable

group to investigate, as this group also consists of patients with displaced fractures

and thus could provide us more insight in future clinical decision methods. Therefore,

we highly recommend more research of the non‐surgically treated patients group.

Chapter 4

64

References

1. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH.: Changing patterns in the epidemiology and treatment of zygoma fractures: 10‐year review. J Trauma (37) 243‐248, 1994


cases with 21,067 injuries. J Craniomaxillofac Surg (31) 51‐61, 2003 3. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of zygomatico‐orbital

complex and/or zygomatic arch fractures over a 71‐month period. Dent Traumatol (27) 135‐142, 2011


(40) e165‐e169, 2012

5. Evans BG, Evans GR.: MOC‐PSSM CME article: Zygomatic fractures. Plast Reconstr Surg (121) 1‐11, 2008

6. Kelley P, Hopper R, Gruss J.: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg

(120) 5S‐15S, 2007 7. Forouzanfar T, Salentijn E, Peng G, van den Bergh B.: A 10‐year analysis of the "Amsterdam" protocol

in the treatment of zygomatic complex fractures. J Craniomaxillofac Surg (41) 616‐622, 2013

8. Carr, R. M. and Mathog, R. H.: Early and delayed repair of orbitozygomatic complex fractures. J Oral Maxillofac Surg (55) 253‐258, 1997

9. Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, Raveh J.: Classification and

treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg (50) 778‐790, 1992 10. Back CP, McLean NR, Anderson PJ, David DJ.: The conservative management of facial fractures:

indications and outcomes. J Plast Reconstr Aesthet Surg (60) 146‐151, 2007

11. Kaufman Y, Stal D, Cole P, Hollier L Jr.: Orbitozygomatic fracture management. Plast Reconstr Surg (121) 1370‐1374, 2008

12. Hollier LH, Thornton J, Pazmino P, Stal S.: The management of orbitozygomatic fractures. Plast

Reconstr Surg (111) 2386‐92, quiz, 2003 13. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW.: Diagnosis and management of common

maxillofacial injuries in the emergency department. Part 3: Orbitozygomatic complex and zygomatic

arch fractures. Emerg Med J (24) 120‐122, 2007 14. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the

surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011

15. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R.: The pattern of the maxillofacial fractures ‐ A multicentre retrospective study. J Craniomaxillofac Surg (40) 675‐679, 2012

16. Salentijn EG, van den Bergh B, Forouzanfar T.: A ten‐year analysis of midfacial fractures. J

Craniomaxillofac Surg (41) 630‐636, 2013 17. Jungell P, Lindqvist C.: Paraesthesia of the infraorbital nerve following fracture of the zygomatic

complex. Int J Oral Maxillofac Surg (16) 363‐367, 1987

18. Sakavicius D, Juodzbalys G, Kubilius R, Sabalys GP.: Investigation of infraorbital nerve injury following zygomaticomaxillary complex fractures. J Oral Rehabil (35) 903‐916, 2008

19. Vriens JP, Moos KF.: Morbidity of the infraorbital nerve following orbitozygomatic complex fractures.

J Craniomaxillofac Surg (23) 363‐368, 1995 20. Westermark A, Jensen J, Sindet‐Pedersen S.: Zygomatic fractures and infraorbital nerve disturbances.

Miniplate osteosynthesis vs. other treatment modalities. Oral Surg Oral Diagn (3) 27‐30, 1992


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A ten‐year analysis of midfacial fractures


Salentijn EG, van den Bergh B, Forouzanfar T. A ten‐year analysis of midfacial

fractures. J Craniomaxillofac Surg 2013 Oct;41(7):630‐636.

Chapter 5

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Abstract

Introduction

With respect to maxillofacial trauma a substantial part consists of midfacial fractures.

The distribution of fracture sites seems to be influenced by the cause of the injury,

geographic location, local behaviour and socioeconomic trends. This retrospective

study presents an investigation of the incidence and aetiology of midfacial fractures in

Amsterdam over a period of 10 years.

Results

The study population consisted of 278 patients, 200 males and 78 females, with a

mean age of 38.2 years (SD: ±16.0) and a male‐female ratio of 2.6:1. Most of the

fractures were found in the age group of 20‐29 years for male patients and the age

group of 50 years and older for female patients. The most common cause of the

fractures was traffic related accidents. The main fracture site was the zygomatic

complex, followed by the zygomatic arch and the orbital floor. In patients with alcohol

consumption, violence demonstrated to be the main cause of the injury.

Complications consisted mainly of suboptimal fracture reduction, followed by

temporary paraesthesia of the infraorbital nerve and wound infection. Complications

were treated by retreatment, removal of the osteosynthesis material and antibiotic

therapy.

Conclusion

This study presents the incidence and aetiology of midfacial fractures in a Dutch

population over a period of 10 years. Furthermore, our treatment protocols for these

fractures are discussed.


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Introduction

A substantial proportion of traumatology consists of maxillofacial fractures.1 Several

authors note that the most common fracture site of maxillofacial fractures affects the

midfacial bones.2 Midfacial fractures are classified into Le Fort I, II and III fractures,

zygomatic complex fractures, naso‐orbital‐ethmoid complex fractures and orbital

bone fractures.3,4

Epidemiological studies tend to classify maxillofacial trauma according to the

anatomical site. Although this seems to be applicable for the development of

treatment strategies, it is more informative to consider aetiology and the applied

forces that produce the maxillofacial fractures.5

The distribution of fracture sites seems to be influenced by the cause of the injury,

which in turn is influenced by geographic location, local behaviour and socioeconomic

trends.6,7 These injuries are mostly related to trauma, including traffic accidents,

interpersonal violence, falls and sport related injuries.7‐11

Fractures of the midface are a challenge to all surgeons treating maxillofacial

trauma. They present a wide variety of patterns, diagnostic challenges, and treatment

dilemmas. When considering repair of such fractures, the most important

consideration to remember is that restoration of the vertical buttresses is necessary

to re‐establish the structure of the midface, whereas restoration of horizontal

buttresses is necessary to re‐establish aesthetics of the midface. Understanding the

features of facial injury may inform clinical research in developing more effective

treatment for, and prevention of, these injuries. Several authors suggest that

comparing data from different countries could increase the understanding of facial

trauma in different regions, resulting in optimized treatment and improved quality of

life. In the literature, there are many studies concerning the incidence and aetiology

of maxillofacial trauma. However, to our knowledge not much information is available

investigating these features in midfacial fractures. Therefore, this study was designed.


The hospital and outpatient records of 278 patients surgically treated for midfacial

fractures from January 2000 to January 2010 were reviewed and analyzed

retrospectively. The patients were identified using the hospital database. Patients

with all types of midfacial fractures, which were treated surgically by open or closed

reduction, were included. Patients with dentoalveolar fractures were excluded, as

these patients were mostly treated by dentists. Although they are certainly

considered as midfacial fractures, nasal bone fractures were also excluded, as in our

hospital these types of fractures are treated by the ENT surgeons. Data collected

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70

included gender, age, cause of the injury, type of the trauma, alcohol consumption,

treatment modality and complications.

Classification

The midfacial fractures were classified into zygomatic complex fractures, zygomatic

arch fractures, orbital blowout fractures, Le Fort I, Le Fort II, Le Fort III fractures and a

combination of these fractures.

Treatment protocols

Zygomatic complex / orbital floor fractures

At presentation to our department or the emergency ward, zygomatic complex

fractures were diagnosed using either submentovertex and occipitomental

radiographs or a (conebeam) CT‐scan.

Treatment consisted of reduction of the zygomatic complex fracture using a bone

hook. If necessary, fixation would be performed at the lateral orbital rim. If reduction

was not stable a second miniplate would be fixed on the zygomaticomaxillary

buttress. If necessary, a third microplate would be fixed on the infraorbital rim. For

fixation, osteosynthesis material (2.0 mm or/and 1.5 mm KLS Martin plates) was used.

Figures 5.1, 5.2, 5.3, and 5.4 demonstrate conventional (submentovertex and

occipitomental) pre‐ and postoperative radiographs of a zygomatic complex fracture,

for which open reduction and internal fixation at the lateral orbital rim and the

zygomaticomaxillary buttress was performed.

During the surgical procedure, a forced duction test was performed twice, before

and after the reduction of the fractured zygomatic complex. If ocular movements

were restricted and entrapment of the inferior rectus muscle was expected, the

orbital floor would have to be explored. Another reason for exploration was a

comminuted orbital floor fracture, as demonstrated on the CT‐images. If

reconstruction of the orbital floor was required, Medpor‐titanium implants, titanium

implants, polydioxanone (PDS) sheets, or autogenous bone grafts, harvested from the

iliac crest, would be used. Depending on the surgeon’s preference, the most suitable

material was chosen. Figures 5.5 and 5.6 demonstrate pre‐ and postoperative coronal

CT‐images of a comminuted orbital floor fracture. In this case, reconstruction of the

orbital floor had been performed using a Medpor‐titanium implant.


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Figure 5.1 Preoperative occipitomental radiograph of a zygomatic complex fracture on the right side.

Figure 5.2 Preoperative submentovertex radiograph of a zygomatic complex fracture on the right side.

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72

Figure 5.3 Postoperative occipitomental radiograph of a zygomatic complex fracture on the right side.

Fixation was performed at the lateral orbital rim and the zygomaticomaxillary buttress.

Figure 5.4 Postoperative submentovertex radiograph of a zygomatic complex fracture on the right side.

Fixation was performed at the lateral orbital rim and the zygomaticomaxillary buttress.


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Figure 5.5 Preoperative CT‐image of a comminuted orbital floor fracture on the left side.

Figure 5.6 Postoperative CT‐image of a reconstructed orbital floor fracture on the left side with a

Medpor‐titanium implant.

If there was an orbital blowout fracture with functional disorders, diagnosed by

the ophthalmologist, an exploration and reconstruction of the orbital floor would

have to be performed. In these cases, transconjunctival or subciliary approaches were

used. Fixation was performed with osteosynthesis material (1.0 mm and/or 1.5 mm

KLS Martin plates).

Zygomatic arch fractures

Zygomatic arch factures were visualized using a submentovertex radiograph or a

(conebeam) CT‐scan. If there were clinical signs, such as an aesthetically unfavourable

Chapter 5

74

appearance or a reduced mouth opening due to coronoid impingement, zygomatic

arch fractures were treated mainly by closed reduction, using the Gillies approach. A

transoral approach was rarely performed. Figures 5.7 and 5.8 demonstrate pre‐ and

postoperative submentovertex radiographs of a solitary zygomatic arch fracture for

which closed reduction, using the Gillies approach, had been performed.

Figure 5.7 Preoperative submentovertex radiograph of a zygomatic arch fracture on the right side.

Figure 5.8 Postoperative submentovertex radiograph of a zygomatic arch fracture on the right side.

Reduction was performed using the Gillies approach.


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Le Fort fractures

Radiographic analysis consisted of a (conebeam) CT‐scan. If there were clinical

signs, such as a dislocated maxilla with a malocclusion, the treatment would start with

intermaxillary fixation using arch bars or bone screws. Fixation was performed with

osteosynthesis material (2.0 mm and/or 1.5 mm KLS Martin plates). Figures 5.9 and

5.10 demonstrate a preoperative coronal CT‐image and a postoperative radiograph of

a Le Fort I fracture and a zygomatic complex fracture on the right side. In this case

bone screws had been used for intermaxillary fixation and fixation of the maxilla had

been performed bilaterally at the zygomaticomaxillary buttress and the paranasal

region.

In case of an edentulous situation, surgical treatment would only be performed if

clinical signs of dislocated fracture sites were visible.

Figure 5.9 Preoperative CT‐image of a Le Fort I fracture and a zygomatic complex fracture on the right

side.

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Figure 5.10 Postoperative radiograph of a Le Fort I fracture and a zygomatic complex fracture on the right

side. Fixation of the maxilla was bilaterally performed at the zygomaticomaxillary buttress and the paranasal region.

Statistics

Data were processed using the Statistical Package for Social Sciences (SPSS) version

15.0. For parametric data, Student’s t‐test and for non‐parametrics, Chi‐Square tests

were performed, if data were sufficient enough.

Results

Patient demographics

The study population consisted of 200 male patients and 78 female patients (male‐

female ratio of 2.6:1) with a mean age of 38.2 years (SD: ±16.0). The youngest patient

was 3 years of age and the oldest patient was 88 years of age. There were no

significant differences in age between the male and female patients. As shown in

Table 5.1a and 5.1b, most fractures were found in the age group of 20‐29 years for

the male patients, and in the age group of 50 years and older for the female patients.


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Table 5.1a Cause of injury according to age for male patients.

Age Group (yrs) Fall Violence Traffic accident Sport accident Other Missing file Total

0‐9 1 1 1 1 4

10‐19 2 4 6 1 13

20‐29 3 13 17 11 2 6 52

30‐39 7 11 15 9 2 2 46 40‐49 5 14 12 4 6 7 48

50‐ 11 4 16 2 1 3 37

Total 28 47 67 26 12 20 200

Table 5.1b Cause of injury according to age for female patients.

Age Group (yrs) Fall Violence Traffic accident Sport accident Other Missing file Total

0‐9 1 1

10‐19 3 4 7

20‐29 3 11 14

30‐39 2 8 1 1 2 14 40‐49 3 2 9 1 2 17

50‐ 8 2 12 3 25

Total 12 9 43 6 3 5 78

The patients most often presented with sensibility disturbances of the infraorbital

nerve region, followed by hematomas of the orbital region and malar depression

(Table 5.2).

Table 5.2 Preoperative clinical signs.

Number of patients

Swelling 78

Hematoma orbital region 92 Laceration 40

Step infraorbital margin 77

Step zygomaticomaxillary buttress 39

Malar depression 89 Sensibility disturbance infraorbital nerve 122

Malocclusion 23

Disturbed ocular movements 23 Subconjunctival ecchymosis 15

Diplopia 32

Enophthalmus 13

Injury cause according to gender

In 67 male patients (24.1%), as well as in 43 female patients (15.5%), traffic accidents

demonstrated to be the main cause of the midfacial injuries (Table 5.1a and 5.1b),

followed by violence for the males (16.9%) and falls for the females (4.3%). When

Chapter 5

78

comparing male patients with female patients, violence related midfacial injuries

proved to be significantly (P<0.01) more common in the male patients.

Fracture site according to cause

Zygomatic complex fractures demonstrated to be the most common midfacial

fracture site, followed by zygomatic arch fractures and orbital blowout fractures

(Table 5.3). In all of the midfacial fracture sites, except for zygomatic arch fractures,

the trauma was most often caused by traffic related accidents and violence.

Zygomatic arch fractures were most often caused by violence, followed by sport

related accidents.

Table 5.3 Midfacial fractures according to cause.

Cause Zygomatic complex

Zygomaticarch

Blow‐out

Le FortI

Le FortII

Le Fort III

Le Fort I

and II

Le Fort II

and III

Le Fort I and

zygoma

Total

Traffic accident 94 3 2 1 3 3 1 1 2 110

Violence 38 7 3 2 3 3 56

Fall 36 2 1 1 40 Sport accident 23 6 29

Missing file 16 4 3 3 1 1 28

Other 9 2 3 1 15 Total 216 22 13 6 8 5 1 2 5 278

Influence of alcohol consumption

The data of 57 patients (20.5%) regarding alcohol abuse were missing. Regarding the

remaining patients, in 80.1% of the patients no alcohol consumption was involved in

the event causing the midfacial fracture, whereas alcohol was consumed before the

injury in 19.9 % of the patients. There was no correlation between alcohol

consumption and specific midfacial fracture sites, neither was there a correlation

between alcohol consumption and age of the patients. Compared to non‐alcoholic

patients, violence was the main cause of the injury in patients whose alcohol

consumption was involved (P<0.05).

Treatment modalities and operating time

The different types of pre‐ and postoperative radiographic analyses were divided into

dental panoramic tomography, submentovertex radiograph, occipitomental

radiograph, Towne’s view, cephalometric radiograph, postero‐anterior radiograph and

(cone‐beam) CT‐scan. In total 628 preoperative and 503 postoperative radiographic

analyses were made. A total of 292 plates and 1209 screws were used.


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An orbital floor reconstruction was performed in 22 patients, using PDS sheets

(11 patients), Medpor‐titanium implants (9 patients), titanium mesh (1 patient) and

autogenous bone grafts (1 patient). Unfortunately, we were not able to find out how

often transconjunctival and subciliary approaches were performed.

In all of the patients with a Le Fort fracture, surgical treatment started with

intermaxillary fixation using arch bars or bone screws, as described in our

department’s protocol. After achieving maximal occlusion, fixation was performed

with osteosynthesis plates. In 7 patients with a Le Fort III fracture, a coronal approach

was performed. The mean operating time was 72.13 minutes (SD: ±24.9) with a range

of 30‐190 minutes.

Complications

As shown in Table 5.4, the most common complication was a suboptimal fracture

reduction (21 patients). The second most common complication was temporary

paraesthesia of the infraorbital nerve region. Most patients were treated with open

reduction and internal fixation of a zygomatic complex fracture. Wound infection was

found in 9 patients. In all of these patients, the infection developed 2 to 3 weeks after

the surgery. In 8 patients, the infection was situated intraorally at the

zygomaticomaxillary buttress, whereas in 1 patient the infection was situated around

the region of the lateral orbital rim. Regarding the latter patient, the osteosynthesis

material had been removed 5 weeks after the surgery. All of the remaining patients

had been treated successfully with antibiotic therapy (amoxicillin/clavulanic acid

500/125 mg, three times daily for one week).

Table 5.4 Postoperative complications.

N

Suboptimal fracture reduction – no retreatment 12

Suboptimal fracture reduction – retreatment 9

Paraesthesia infraorbital nerve 10

Wound infection 9 Facial nerve paralysis – transient 1

In 9 patients, a secondary procedure was necessary. Three patients had been

retreated during their hospital stay. In one of them, the zygomatic complex was still

clinically displaced after initial surgical treatment of a complex panfacial trauma. The

second of these patients was treated for a solitary zygomatic complex fracture. After

open reduction and internal fixation, clinical analysis demonstrated still displacement

of the zygomatic complex fracture. Consequently, a retreatment had been necessary.

The third of these three patients presented with a displaced zygomatic arch fracture.

After closed reduction, the radiographic analysis demonstrated a suboptimally

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80

reduced zygomatic arch fracture. The patient underwent surgical retreatment.

Regarding the three patients, the clinically observed malpositions had been confirmed

by postoperative radiographs. One patient presented one week after discharge with

clinical signs of a displaced zygomatic complex fracture, after he had been treated for

a fracture of the zygomatic bone by closed reduction. A second operation had been

necessary. Retrospectively, the postoperative radiographs made prior to discharge

showed no malposition, so initially there seemed to be no indication for retreatment.

Another 3 patients had been retreated surgically between 2 to 4 weeks after

discharge. These three patients required a secondary reconstruction of the orbital

floor after having had a fracture of the zygomatic complex. The orbital floor had

initially not been treated during repositioning of the zygomatic complex, as these

patients initially did not show clinical signs justifying a primary orbital bone

reconstruction. One patient underwent a secondary reconstruction of the orbital

floor, one month after the initial treatment. The fracture was part of the zygomatic

complex fracture. Initially, this patient demonstrated no clinical signs, but the patient

developed enophthalmus and diplopia later on. A suboptimal reconstruction of the

orbital floor had been detected on the postoperative CT‐scan of one patient. One

patient with a surgically treated Le Fort II fracture developed occlusal disturbances. In

this situation retreatment, consisting of a Le Fort II osteotomy, had been necessary.

One patient presented with a transient paralysis of the facial nerve.

Discussion

Several authors have stated that the epidemiology of fractures is consistently

influenced by geographic area, population density, socioeconomic status and cultural

differences.9,12‐16 To optimize treatment modalities and improve patients’ quality of

life, comparison of data from different countries is indispensable.8,14,17‐19

This study demonstrates the epidemiology of 278 patients with midfacial fractures

in a Dutch population. The male‐female ratio was 2.6:1, which is in accordance with

the studies of Calderoni et al. and Naveen Shankar et al., as their populations also

consisted mostly of male patients.5,20

The injuries were most often caused by traffic related accidents in both sexes,

followed by violence for the male patients and falls for the female patients. The

zygomatic complex was the main fracture site, followed by the zygomatic arch and the

orbital floor. This is in line with the studies of Naveen Shankar et al. and Ozkaya et al.,

but in contrast with the reports of previous studies, which showed that the most

common midfacial fractures were Le Fort I fractures.5,21‐24

In patients whose alcohol consumption was involved, most often the injury was

associated with violence. For the treatment of 278 patients, 628 preoperative and 503


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postoperative radiographs were made. The mean operating time was approximately

72 minutes and in total 292 plates and 1209 screws were used.

Complications consisted mainly of suboptimal fracture reduction and paraesthesia

of the infraorbital nerve. Wound infection was noted 9 times and treated most often

with antibiotics.

The Vetter study demonstrated that the main fracture site in midfacial fractures

consists of the zygomatic complex, followed by the orbital wall.25 In contrast with this

study, our population demonstrates fractures of the zygomatic complex, followed by

isolated zygomatic arch fractures as the most common midfacial fracture sites.

In line with other recent studies, the majority of patients were in their

twenties.2,5,20,26 Comparison of the male and the female patients demonstrated that

most of the male patients were in their twenties and most of the female patients

were over 50 years of age.

Traffic related accidents were the major cause of the injuries. Comparing these

results with the literature showed that in most studies traffic accidents are commonly

involved in facial fractures.2,5,6,10,20 Several other studies demonstrate violence as the

major cause of the injuries.1,7

According to the literature, maxillofacial injuries can be reduced by the use of

restraints, which could decrease the frequency of health care services. To reduce the

number of traffic related accidents as a cause of maxillofacial fractures, preventive

measures have been used, such as obligatory wearing of crash helmets, seat belts,

better enforcement of law regarding “drinking and driving”, and providing proper

safety guidelines for vehicles.2,5,27,28

The management of maxillofacial fractures has changed over the recent past,

starting with closed reduction and ending up with open reduction and internal fixation

being used more commonly. Gabrielli et al. demonstrated coronal flaps to provide

wide surgical access for the treatment of upper and middle third facial fractures.29 In

our study, access using a coronal flap was performed in patients with a Le Fort III

fracture.

Instrumentation, biocompatibility of osteosynthesis materials and surgical

techniques have improved over the past few years. As a result, most of our patients

were treated using plate osteosynthesis. This is in line with data of Calderoni et al.,

whose most common treatment of orbitozygomatic fractures was open reduction and

internal fixation with miniplates and screws (83.7% of the cases).20

Treatment with plate osteosynthesis will probably lead to better results, less

complications, shorter operating time and faster hospital discharge. In this study, we

lacked information to confirm these assumptions. Furthermore, in our department

postoperative radiographic analyses were performed routinely, leading to a delay in

hospital discharge. According to Van den Bergh et al., postoperative radiographs

should only be made in patients with multiple facial injuries and for educational

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82

purposes.30 They should not be made routinely, as this will lead to increased radiation

dose, costs and probably more inefficient discharge.

In Amsterdam, there are 4 hospitals treating patients for maxillofacial injuries. As

the number of midfacial trauma patients is not equally distributed among the

different hospitals, it is questionable whether the results of our study could be

extrapolated to the whole population of Amsterdam.

Like other retrospective studies, this retrospective analysis may lead to

information bias. Nevertheless, the results provide valuable information concerning

the incidence and aetiology of midfacial fractures. Our treatment protocol, as well as

the complication rates, are also described.

Conclusion

An overview of 278 patients surgically treated for midfacial fractures over a period of

10 years is presented, and our departmental treatment protocol is described. Traffic

related accidents were the main cause of the injuries, followed by violence for the

male patients and falls for the female patients. The male‐female ratio was 2.6:1, with

male patients were mainly in their twenties and female patients were over 50 years of

age. Zygomatic complex fractures were the most common midfacial fractures,

followed by zygomatic arch fractures and orbital blowout fractures. In patients whose

alcohol consumption was involved, violence was the main cause of the injury.

Complications consisted most often of suboptimal fracture reduction, paraesthesia of

the infraorbital nerve region and wound infections. These data provide valuable

information concerning the incidence, aetiology and treatment of midfacial fractures.


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References


2. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence of

maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg (40) e165‐e169, 2012

3. Mast G, Ehrenfeld M, Cornelius CP.: [Maxillofacial fractures: midface and internal orbit : Part 1:

classification and diagnosis]. Unfallchirurg (114) 1007‐1017, 2011 4. Bos RR, Jansma J, Vissink A.: [Fractures of the midface]. Ned Tijdschr Tandheelkd (104) 440‐443, 1997

5. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R.: The pattern of the maxillofacial

fractures ‐ A multicentre retrospective study. J Craniomaxillofac Surg (40) 675‐679, 2012 6. Bormann KH, Wild S, Gellrich NC, Kokemuller H, Stuhmer C, Schmelzeisen R, Schon R.: Five‐year

retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and

complications. J Oral Maxillofac Surg (67) 1251‐1255, 2009 7. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, Mukundan S, Marcus JR.: A

retrospective analysis of facial fracture etiologies. Ann Plast Surg (60) 398‐403, 2008

8. Jain MK, Alexander M.: The need of postoperative radiographs in maxillofacial fractures‐‐a prospective multicentric study. Br J Oral Maxillofac Surg (47) 525‐529, 2009

9. Zachariades N, Mezitis M, Mourouzis C, Papadakis D, Spanou A.: Fractures of the mandibular condyle:

a review of 466 cases. Literature review, reflections on treatment and proposals. J Craniomaxillofac Surg (34) 421‐432, 2006

10. Brasileiro BF, Passeri LA.: Epidemiological analysis of maxillofacial fractures in Brazil: a 5‐year

prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (102) 28‐34, 2006 11. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H.: Cranio‐maxillofacial trauma: a 10 year review of 9,543

cases with 21,067 injuries. J Craniomaxillofac Surg (31) 51‐61, 2003

12. Lee HB, Oh JS, Kim SG, Kim HK, Moon SY, Kim YK, Yun PY, Son JS.: Comparison of titanium and biodegradable miniplates for fixation of mandibular fractures. J Oral Maxillofac Surg (68) 2065‐2069,

2010

13. Elgehani RA, Orafi MI.: Incidence of mandibular fractures in Eastern part of Libya. Med Oral Patol Oral Cir Bucal (14) e529‐e532, 2009

14. Chuong R, Donoff RB, Guralnick WC.: A retrospective analysis of 327 mandibular fractures. J Oral

Maxillofac Surg (41) 305‐309, 1983 15. Olson RA, Fonseca RJ, Zeitler DL, Osbon DB.: Fractures of the mandible: a review of 580 cases. J Oral


16. Lee JH, Cho BK, Park WJ.: A 4‐year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg (38) 192‐196, 2010

17. Alkan A, Celebi N, Ozden B, Bas B, Inal S.: Biomechanical comparison of different plating techniques in

repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (104) 752‐756, 2007

18. Alkan A, Metin M, Muglali M, Ozden B, Celebi N.: Biomechanical comparison of plating techniques for

fractures of the mandibular condyle. Br J Oral Maxillofac Surg (45) 145‐149, 2007 19. Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, Edwards K.: Postoperative

radiographs after open reduction and internal fixation of the mandible: are they useful? Br J Oral

Maxillofac Surg (44) 279‐282, 2006 20. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the

surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011

21. Ozkaya O, Turgut Gursel Ki, Mahmut U, Ugurlu K, Kuran I, Bas L.: A retrospective study on the epidemiology and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg (15) 262‐266,

2009

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22. Al Ahmed HE, Jaber MA, Abu F, Salem H, Karas M.: The pattern of maxillofacial fractures in Sharjah,

United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (98) 166‐170, 2004

23. Guven O.: Self‐curing acrylic in the treatment of unstable zygomatic arch fracture. J Nihon Univ Sch

Dent (30) 141‐144, 1988 24. Abiose BO.: Maxillofacial skeleton injuries in the western states of Nigeria. Br J Oral Maxillofac Surg

(24) 31‐39, 1986

25. Vetter JD, Topazian RG, Goldberg MH, Smith DG.: Facial fractures occurring in a medium‐sized metropolitan area: recent trends. Int J Oral Maxillofac Surg (20) 214‐216, 1991

26. Motamedi MH.: An assessment of maxillofacial fractures: a 5‐year study of 237 patients. J Oral

Maxillofac Surg (61) 61‐64, 2003 27. Holmes PJ, Koehler J, McGwin G Jr, Rue LW.: Frequency of maxillofacial injuries in all‐terrain vehicle

collisions. J Oral Maxillofac Surg (62) 697‐701, 2004


29. Gabrielli MA, Monnazzi MS, Gabrielli MF, Hochuli‐Vieira E, Pereira‐Filho VA, Mendes Dantas MV.:

Clinical evaluation of the bicoronal flap in the treatment of facial fractures. Retrospective study of 132 patients. J Craniomaxillofac Surg (40) 51‐54, 2012

30. van den Bergh B, Goey Y, Forouzanfar T.: Postoperative radiographs after maxillofacial trauma: Sense

or nonsense? Int J Oral Maxillofac Surg (40) 1373‐1376, 2011


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A ten‐year analysis of the traumatic maxillofacial

and brain injury patient in Amsterdam:

Incidence and aetiology


Salentijn EG, Peerdeman S, Boffano P, van den Bergh B, Forouzanfar T. A ten‐year

analysis of the traumatic maxillofacial and brain injury patient in Amsterdam:

Incidence and aetiology. J Craniomaxillofac Surg 2014 Sept;42(6):705‐710.

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Abstract

Introduction

In the literature, it is questioned if the presence of maxillofacial trauma is associated

with the presence of brain injury. The aim of this study is to present a ten‐year

retrospective study of the incidence and aetiology of maxillofacial trauma associated

with brain injury that required both oral and maxillofacial and neurosurgical

intervention during the same hospital stay.

Results

Forty‐seven patients from a population of 579 trauma patients undergoing

maxillofacial surgery were identified. The main cause of the injury was road traffic

collisions, followed by falls. Interpersonal violence correlated less well with traumatic

brain injury. Most of the patients were males, aged 20‐39 years. Frontal sinus

fractures were the most common maxillofacial fractures (21.9%) associated with

neurosurgical input, followed by zygomatic complex fractures and mandibular

fractures. In the general maxillofacial trauma population, frontal sinus fractures were

only found in 4.5% of the cases. At presentation to the emergency department, the

majority of patients were diagnosed with severe traumatic brain injury and a Marshall

CT class II. Intracranial pressure monitoring was the most common neurosurgical

intervention, followed by reconstruction of a bone defect and hematoma evacuation.

Conclusion

Although it is a small population, our data suggest that maxillofacial trauma does have

an association with the presence of traumatic brain injury requiring neurosurgical

intervention (8.1%). In comparison with the overall maxillofacial trauma population,

our results demonstrate frontal sinus fractures being more commonly diagnosed in

association with traumatic brain injury, most likely owing to the region of impact of

the trauma. In these cases, the frontal sinus seems not specifically to act as a barrier

to protect the brain. This report provides useful data concerning the joint

management of oral and maxillofacial surgeons and neurosurgeons for the treatment

of maxillofacial trauma and brain injury patients in Amsterdam.

A ten‐year analysis of the maxillofacial and TBI patient in Amsterdam: Incidence and aetiology

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Introduction

Maxillofacial injury comprises a substantial proportion of all trauma cases. The major

aetiological factors in these cases are interpersonal violence and road traffic collisions,

with a male preponderance and a peak incidence between 20‐30 years of age.1‐10

According to several authors, maxillofacial fractures are often associated with multiple

injuries to the cranium, especially following high‐energy trauma.

Traumatic brain injury (TBI) is defined as evidence of loss of consciousness and/or

post‐traumatic amnesia in a patient with a non‐penetrating head injury.11 The

Glasgow Coma Scale (GCS) is used to describe the level of consciousness in patients

with traumatic brain injury (TBI). GCS measures a TBI patient’s best eye, motor, and

verbal responses, and classifies TBI in clinical practice as mild (14‐15), moderate

(9‐13), or severe (3‐8).12

Comminution of the craniofacial skeleton in high‐energy trauma can cause damage

to the frontal lobes and neurovascular structures located between the face and the

anterior and middle cranial fossae, with significant potential for morbidity or

mortality.1,13

Davidoff et al. found facial fractures to be strongly associated with traumatic brain

injury, corresponding with Haug et al. who found a 76% incidence of neurologic injury

associated with facial fractures.11,14 Haug et al. stressed that in case of a trauma to the

midface, energy will be directly transmitted to the cranium, causing damage to the

brain.15 Furthermore, Keenan et al. found that the risk of intracranial hemorrhage was

increased in patients with maxillofacial fractures, compared with patients without

maxillofacial fractures due to trauma.16 Regarding aetiology, road traffic collisions are

thought to have a significantly higher incidence of concomitant closed head injury,

compared with interpersonal violence, due to the high energy often associated. In

contrast to this theory, many authors have the opinion that no association exists

between maxillofacial trauma and brain injury. Lee et al. reported that facial fractures

are not associated with an increased risk of traumatic brain injury, theorizing that the

facial bones act as a protective cushion for the brain.17 This view was shared by Chang

et al., who stated that the maxilla and the surrounding midfacial bones act as an

absorption barrier against high impact energy caused by trauma, thus protecting the

brain from damage.18 Due to these mechanisms fewer brain injuries are expected to

occur. The association between maxillofacial trauma and brain injury is still a matter

of current debate.

Treatment of patients with maxillofacial fractures, accompanied with traumatic

brain injury, remains a challenging problem, due to conflicting priorities for treatment:

early repair favours good outcomes in OMFS, but TBI requires optimization of

intracranial pressure (ICP) and ventilation. Management of these injuries requires a

multidisciplinary team approach to improve outcomes.19,20 Good awareness and close

Chapter 6

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cooperation between oral and maxillofacial surgeons and neurosurgeons is required

to facilitate rapid diagnosis and appropriate treatment.19

According to Pappachan and Alexander there is a paucity of evidence regarding

the correlation between maxillofacial trauma and head injury.21

The aim of this study was to investigate the association of maxillofacial trauma and

traumatic brain injury requiring neurosurgical intervention.


Hospital and outpatient records from January 2000 to January 2010 were reviewed

and analyzed to identify trauma patients undergoing maxillofacial surgery who also

presented with traumatic brain injury (TBI) that required neurosurgical intervention.

The diagnosis of TBI was based on evaluation and consultation by the Department

of Neurosurgery/Neurology in our hospital. Indications for neurosurgical intervention

were aesthetic appearance, open skull fractures with dural lesions, intracranial

haemorrhage (e.g. subdural, epidural and intracerebral hematoma), and combinations

thereof. Patients were included if they had been treated surgically for their

maxillofacial skull and brain injuries by the oral and maxillofacial surgeons and the

neurosurgeons during the same hospital stay. Exclusion criteria were neurosurgical

interventions of non‐skull related injuries (e.g. spine injuries / vertebral injuries).

The patients were identified using the hospital database. Data collected included

gender, age, cause of the trauma, radiographic examination, type of maxillofacial

fractures, neurological injury (GCS), neurological deficits and treatment modalities.

Clinical judgement of the neurological injury was dependent on the level of

consciousness and based on the GCS score at admission of the emergency department

of our hospital. TBI was defined as mild (GCS 14‐15), moderate (GCS 9‐13) and severe

(3‐8).

Furthermore, if available, for each included patient the initial CT‐scan was

analyzed and scored according to the Marshall CT classification.22 The Marshall CT

classification describes the pathological changes on the initial CT‐scan after TBI and

could help in the prognostication of neurological outcome (Table 6.1a). In our study,

we used a modified classification for the initial CT‐scan, leaving out the surgically

evacuated mass lesion (Table 6.1b)


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Table 6.1a Marshall CT Classification.

Class Definition

I: Diffuse injury (no visible pathology) No visible intracranial pathology seen on CT‐scan

II: Diffuse injury

Cisterns are present with midline shift of 0–5 mm and/or: lesion

densities present; no high‐ or mixed‐density lesion >25 cc; may

include bone fragments and foreign bodies III: Diffuse injury (swelling)

Cisterns compressed or absent with midline shift 0–5 mm, no high‐

or mixed‐density lesion >25 cc

IV: Diffuse injury (shift) Midline shift >5 mm, no high‐ or mixed‐density lesion >25 cc V: Evacuated mass lesion Any lesion surgically evacuated

VI: Non‐evacuated mass lesion High‐ or mixed‐density lesion >25 cc, not surgically evacuated

CT: computed tomography.

Table 6.1b Modified Marshall CT Classification.

Class Definition

I: Diffuse injury (no visible pathology) No visible intracranial pathology seen on CT‐scan

II: Diffuse injury

Cisterns are present with midline shift of 0–5 mm and/or: lesion

densities present; no high‐ or mixed‐density lesion >25 cc; may include bone fragments and foreign bodies

III: Diffuse injury (swelling)

Cisterns compressed or absent with midline shift 0–5 mm, no high‐

or mixed‐density lesion >25 cc IV: Diffuse injury (shift) Midline shift >5 mm, no high‐ or mixed‐density lesion >25 cc

V: Non‐evacuated mass lesion High‐ or mixed‐density lesion >25 cc, not surgically evacuated

CT: computed tomography.

The maxillofacial fractures were classified as zygomatic complex fractures,

mandibular fractures, orbital wall fractures, naso‐orbital‐ethmoid fractures, Le Fort

fractures and anterior skull (panfacial) fractures.

Neurosurgical intervention consisted of a combination of different treatment

modalities that were subdivided into early stage surgery (treatment within 48 hours

after presentation of the emergency department) or late stage surgery (treatment

after 48 hours after presentation of the emergency department).

Statistics


17.0.

Chapter 6

92

Results

Trauma cause according to gender

The general maxillofacial trauma population over 10 years consisted of 579 patients.

Table 6.2 demonstrates the frequency of all treated maxillofacial trauma patients, as

well as those with a neurosurgical treatment indication, according to the cause of the

injury for the male and female population. Sport related accidents, suicide attempts

and other causes were classified into one subgroup (other/miscellaneous).

Table 6.2 General population description.

Treated OMFS patients (total)

n (%)

Treated OMFS patients with a

neurosurgical treatment indication n (%)

Total 579 47

Male 408 (70.5%) 42 (89.4%)

Female 171 (29.5%) 5 (10.6%)

Cause Traffic accident 217 (37.5%) 26 (55.3%)

Violence 129 (21.3%) 2 (4.3%)

Fall 99 (17.1%) 12 (25.5%) Other/miscellaneous 75 (13.0%) 7 (14.9%)

Missing 59 (10.2%) ‐

OMFS: Oral and Maxillofacial Surgery

Within the overall maxillofacial trauma population, the main cause of maxillofacial

fractures was road traffic collision related (37.5%), followed by interpersonal violence

(21.9%). Forty‐seven patients (8.1%) fulfilled the inclusion criteria for the present

study. The male‐female ratio was 8.4:1. In patients with associated traumatic brain

injury, the most common cause of the trauma was also traffic related (55.3%), but this

was followed by falls (25.5%). Maxillofacial fractures due to interpersonal violence

were least likely to be associated with traumatic brain injury (4.3%).

Injury according to age classification

The mean age was 31.4 years (SD: ±12.1) with a range of 15‐69 years of age. The age

group of 20‐29 years accounted for the largest subgroup (36.2%) in both sexes,

followed by the subgroup of 30‐39 years (29.8%) (Figure 6.1). In both subgroups, road

traffic collisions were the main cause of the trauma. For male patients (42) the age

group of 20‐29 years accounted for the largest subgroup (38.1%). For female patients

(5) the age group of 30‐39 years accounted for the largest subgroup (60%).


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Figure 6.1 Age groups of treated maxillofacial trauma patients with a neurosurgical treatment indication.

Overview of maxillofacial fractures and location

Table 6.3 presents an overview of maxillofacial fractures according to the fracture site,

with and without an associated neurosurgical treatment indication. In 47 maxillofacial

trauma patients with a neurosurgical treatment indication, 105 maxillofacial fractures

were found, meaning that multiple patients were diagnosed with more than one

maxillofacial fracture. Patients with a neurosurgical treatment indication presented

most commonly with frontal sinus fractures (21.9%), followed by zygomatic complex

fractures (16.2%) and mandibular fractures (16.2%). This is in contrast to the overall

maxillofacial trauma population, in which mandibular fractures (42.5%) and zygomatic

complex fractures (40.8%) were found most commonly and frontal sinus fractures

(4.5%) were rarely found.

Table 6.3 Description of fractures.

Maxillofacial fractures (total)

n (%)

Maxillofacial fractures in patients

with a neurosurgical treatment

indication n (%)

Total 579 105

Frontal sinus 26 (4.5%) 23 (21.9%) Zygomatic complex 236 (40.8%) 17 (16.2%)

Mandible 246 (42.5%) 17 (16.2%)

Le Fort 15 (2.6%) 15 (14.3%) Naso‐orbital‐ethmoid 18 (3.1%) 12 (11.4%)

Anterior skull (panfacial) 26 (4.5%) 12 (11.4%)

Orbital wall 12 (2.1%) 9 (8.6%)

0

5

10

15

20

25

30

35

40

Patients (%)

10‐19 20‐29 30‐39 40‐49 50‐59 60‐69

Age group (yrs)

Chapter 6

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Neurological diagnosis according to cause

In total 47 patients were included who required neurosurgical intervention. Twenty‐

seven patients (57.4%) were diagnosed with severe TBI, 10 patients (21.3%) with

moderate TBI and 10 patients (21.3%) with mild TBI (Table 6.4). All of the female and a

majority of the male patients were diagnosed with severe TBI at presentation to the

emergency department. Most of the patients were involved with traffic related

accidents. In this group 73.1% of the patients were diagnosed with severe TBI, and

only 3.7% were diagnosed with mild TBI. Regarding the other/miscellaneous causes,

none of them were related to severe TBI in this study.

Regarding the mode of transport, it is demonstrated that if motorcycle accidents

were involved, 100% of the patients presented with severe TBI, whereas in case of

scooter/moped accidents, 63.3% of the patients presented with severe TBI. If the

trauma was caused by car accidents, only 50% of the patients presented with severe

TBI cases and, furthermore, only 16.7% of the patients presented with mild TBI.

Table 6.4 Demographic characteristics and causation.

All

n

Severe

n (%)

Moderate

n (%)

Mild

n (%)

Total 47 27 (57.4%) 10 (21.3%) 10 (21.3%)

Male 42 22 (52.4%) 10 (23.8%) 10 (23.8%)

Female 5 5 (100%) ‐ ‐ Cause

Traffic accident 26 19 (73.1%) 6 (22.2%) 1 (3.7%)

Violence 2 1 (50%) ‐ 1 (50%) Fall 12 7 (58.3%) 1 (8.3%) 4 (33.3%)

Other/miscellaneous 7 ‐ 3 (42.9%) 4 (57.1%)

Traffic accident: mode of transport Car 6 3 (50%) 2 (33.3%) 1 (16.7%)

Motorcycle 4 4 (100%) ‐ ‐

Scooter/moped 11 7 (63.6%) 4 (36.4%) ‐ Bicycle 5 3 (60%) 2 (40%) ‐

In 45 patients, initial CT‐scans were performed and analysed according to the

modified Marshall CT classification (Figure 6.2). In 1 patient, only conventional

radiographs were made and in 1 other patient only an MRI was available. Most of the

patients (56%) were assessed as diffuse injuries (Class II). Three patients (7%)

demonstrated no visible pathologic changes (Class I), whereas 7 patients (15%)

presented with a non‐evacuated mass lesion (Class V). In these 7 patients, however, a

CT‐scan at admission was not available. Three patients (7%) presented with diffuse

brain injury, including a midline shift (Class IV) and 7 patients (15%) were assessed as

Class III, correlating with diffuse brain injury, including intracranial swelling.


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Figure 6.2 CT‐scan according to modified Marshall CT classification.

Neurological deficits and nerve injuries due to trauma

In 26 patients 65 neurological deficits were noted. These were classified into 2 groups:

1) nerve injuries, and 2) focal neurological deficits (Table 6.5). The neurological deficits

were not subdivided into central and peripheral neurological deficits, as these

specifics had not been described in the outpatient records. The nerve injuries

consisted of focal nerve injury (facial nerve, supraorbital nerve, infraorbital nerve,

hypoglossal nerve, alveolar inferior nerve, oculomotor nerve injuries), disturbed

olfaction, audition, vision, and gustation. Focal neurological deficits consisted of

disturbed speech, disturbed cognition, paresis/paralysis, and spasticity/epilepsy.

Multiple patients presented with more than 1 neurological deficit. In 21 patients

existing neurological deficits were not retrievable, as these symptoms were not

described in the hospital database. In this study, focal nerve injuries were found most

commonly (34%), followed by a disturbed cognition (31.9%) and a disturbed speech

(17%). The infraorbital nerve injuries were most commonly described (41.2%),

followed by facial nerve injuries (23.5%) and supraorbital nerve injuries (11.8%).

Table 6.5 Frequency of neurological deficits.

Neurological deficit (n) % of population

Nerve injury

focal nerve injury 16 34.0

disturbed olfaction 6 12.8

disturbed vision 3 6.4 disturbed audition 2 4.3

disturbed sensibility 2 4.3

disturbed gustation 1 2.1 Focal neurological deficit

disturbed cognition 15 31.9

disturbed speech 8 17.0 spasticity/epilepsy 7 14.9

paresis/paralysis 5 10.6

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Treatment

Maxillofacial intervention involved a total of 76 plates (2‐ to 16‐holes), with

thicknesses of 1.0, 1.5, 2.0 and 2.7 mm, and 725 screws. Different brands of

osteosynthesis materials were employed, including KLS Martin, Champy, Wurzburg

and Leibinger. The mean operating time for the oral and maxillofacial surgeons was

151 minutes with a range of 10‐580 minutes. In 13 patients, the operating time was

not described.

In 47 patients, 79 surgical interventions were performed by the neurosurgeons,

ensuring that 1 to 5 neurosurgical interventions per patient were performed during

the same hospital stay. Every neurosurgical intervention consisted of a combination of

different treatment modalities, which were classified into 11 different groups (Table

6.6). In total 137 neurosurgical treatment modalities were described. Most of the

interventions consisted of intracranial pressure monitoring (24.1%), summarizing

insertion of an intracranial and/or extracranial pressure gauge, as well as drain

insertion or removal. Secondly, reconstruction of facial bone defects, frequently

performed in cooperation with the oral and maxillofacial surgeons, was described

(16.1%). Most of the neurosurgical treatment was early staged (89.8%), whereas

10.2% of the treatment was late staged. The mean operating time for the

neurosurgeons was 104 minutes with a range of 20‐290 minutes. In 14 patients, the

operating time was not described. Many of these interventions were performed

during the same surgical procedure: i.e. craniotomy with replacement of bone flap,

combined with cranialization of the frontal sinus, duraplasty and insertion of an ICP

monitor.

Table 6.6 Description of neurosurgical treatment modalities.

Treatment modality Stage of surgery n (%)

Total early (8) / late (3) 137

ICP monitoring early 33 (24.1%)

Reconstruction bone defect early 22 (16.1%)

Evacuation hematoma early 17 (12.4%) Duraplasty early 12 (8.8%)

Craniotomy with replacement bone flap early 12 (8.8%)

Craniotomy without replacement bone flap early 11 (8.0%) Cranialization/obliteration frontal sinus early 10 (7.3%)

Evacuation hygroma late 6 (4.4%)

Replacement bone flap secondarily early 6 (4.4%) Preparation periosteal flap late 6 (4.4%)

Removal infected bone flap late 2 (1.5%)


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Discussion

Craniomaxillofacial trauma includes trauma to the facial bones, as well as the

associated injuries to the head and neck region, including the brain. This ensures

trauma as a common cause of death, especially in older people.23

Principal aetiological factors of maxillofacial injuries are traffic related accidents,

assaults, falls and sport related injuries. The main cause in the western world is traffic

related, with male patients most of the time involved.1‐3,6,9,10,24

On the one hand, maxillofacial fractures are thought to have an association with

the presence of simultaneous brain injury.15,21,25 Alternatively, it has been supposed

that the maxillofacial bones protect the brain from traumatic injury, as described by

several authors.17,18,21 In this study, an incidence of 47 (8.1%) maxillofacial and TBI

patients with a neurosurgical treatment indication selected from a population of 579

surgically treated maxillofacial trauma patients, over a period of 10 years in

Amsterdam is described. In 57% of the patients severe TBI was diagnosed. According

to Andriessen et al., 40% of the severe TBI cases are potentially fatal, making them an

important patients group to take into account.26

According to several authors, zygomatic bone fractures and mandibular fractures

are the most common maxillofacial fractures, which is in accordance with our overall

maxillofacial trauma population.9,10,27 Frontal sinus fractures were found in 4.5% of

the overall trauma population, whereas in the group of maxillofacial and TBI patients

with a neurosurgical treatment indication, frontal sinus fractures were found as the

most common maxillofacial fractures. This suggests that frontal sinus fractures are

more commonly seen in association with brain injury than other maxillofacial

fractures, indicating that maxillofacial trauma could be regarded as a risk factor for

traumatic brain injury, in which the frontal sinus does not specifically act as a barrier

to protect the brain. This supports the studies of Pappachan and Alexander and Haugh

et al., who postulated that the force of impact in facial trauma is directly transmitted

to the cranium.15,21

Road traffic collisions were identified as the most common cause of maxillofacial

and severe traumatic brain injury (55.3%), which agrees with the studies of Davidoff et

al. and Pappachan and Alexander, where road traffic accidents are described to be the

most common cause of maxillofacial and associated brain injury.11,21 In our study,

traffic accidents were followed by falls (25.5%), which is in contrast with the overall

population of surgically treated maxillofacial trauma patients, in which traffic

accidents were followed by violence as the second most common cause of the

trauma. Different authors state that only high‐energy trauma (e.g. falls from height) to

the craniofacial skeleton could cause injury to the brain tissue, with consequence of

neurological morbidity and mortality.1,13 The greater force transferred to the cranium,

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98

compared with interpersonal violence, may be more likely to cause significant damage

to the frontal bones and cranium.

Regarding falls as a cause of the trauma, most of the patients (58.3%) were

diagnosed with severe TBI and 33.3% of the patients were diagnosed with mild TBI.

This dichotomy may be due to all falls being collected in one group. Yet, falls from

height (>3 metres) will cause more severe injury to the brain than mechanical falls due

to stumbling. In the study of Andriessen et al., this is illustrated, as in their study falls

<3 metres seem to cause less severe TBI compared with falls >3 metres.26

Motorcycle accidents caused severe TBI in 100% of the patients, as well as

scooter/moped accidents causing severe TBI in 63.3% of the cases. This is maybe due

to the high velocity achieved by these vehicles in conjunction with the inconvenience

of wearing helmets, which makes them more vulnerable in traffic. Car accidents

accounted for only 50% of severe TBI cases and 16.7% of mild TBI cases, probably due

to compulsory wearing of seat belts and aggressive enforcement of ‘drinking and

driving’ laws.8,9

Most of the patients were diagnosed with a Marshall Class II, indicating that a

majority of the patients suffered from diffuse cerebral injuries with a midline shift of

0–5 mm and/or lesion densities, sometimes including bone fragments and foreign

bodies. To afford insights into the prognosis of these patients, at least a 6‐month

follow‐up with Glasgow Outcome Scores would be necessary. In this study the

modified Marshall CT classification was used, instead of the conventional Marshall CT

classification22, as none of the initially performed CT‐scans would demonstrate an

‘already’ evacuated mass lesion (Class V according to the conventional Marshall

Classification). Neurosurgical intervention would only occur if CT‐scans were

performed immediately after presentation at the emergency department, revealing a

necessity to surgical intervention.

Of all the neurosurgical interventions, intracranial pressure monitoring was most

commonly undertaken (24.1%), followed by reconstruction of bone defects (16.1%)

and hematoma evacuation (12.4%). Intracranial brain pressure monitoring is

performed in patients with severe TBI (GCS ≤8), or in patients with mild or moderate

brain injury under sedation. According to the international TBI guidelines, prepared by

the Brain Trauma Foundation, significant reductions in mortality and morbidity could

be achieved in patients with severe TBI by using intensive management protocols,

including early intubation, early CT scanning and immediate evacuation of intracranial

mass lesions, followed by ICP monitoring. The aim of ICP monitoring is maintaining

adequate cerebral perfusion and oxygenation and avoiding secondary injury while the

brain recovers. Furthermore, ICP monitoring could be the first indicator of worsening

intracranial pathology and surgical mass lesions.28 In our study, early stage treatment

is most commonly undertaken (72.7%). Early surgical intervention is associated with

improved outcomes, although some neurosurgeons prefer to delay surgery in TBI,


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while monitoring neurological status and stabilising intracranial and blood

pressures.13,29

There are clear indications for primary single–stage treatment of neurological

lesions and craniofacial fractures by a multidisciplinary team, as anaesthetic time and

blood loss are reduced and new skin incisions are avoided.13,30

The present study has several shortcomings. The retrospective design introduces

information bias and the population was small. However, it provides insight into the

joint OMFS and neurosurgical management of patients with maxillofacial trauma and

brain injury in Amsterdam. Long‐term neurological follow‐up of this population may

provide further insight into this patients group.

Conclusion

This study gives an overview of the incidence and aetiology of traumatic maxillofacial

and brain injury patients requiring neurosurgical and maxillofacial intervention. 8.1%

of the surgically treated maxillofacial trauma patients needed neurosurgical

intervention during the same hospital stay. At presentation to the emergency

department a majority of the patients were diagnosed with severe TBI and, regarding

the initial CT‐scans, a Marshall Class II was most frequently found. Traumas were

mainly caused by road traffic collisions, followed by falls. Violence was correlated less

well with severe traumatic brain injury, due to the low energy level of the trauma.

Frontal sinus fractures were the most common (21.9%) maxillofacial fractures

requiring neurosurgical input, whereas these fractures were found in only 4.5% of the

overall maxillofacial trauma population. In comparison with the overall maxillofacial

trauma population, our results demonstrate that frontal sinus fractures are more

frequently diagnosed in association with brain injury. This seems to be caused due to

the region of impact in these kinds of traumas. In this study, one could consider that

maxillofacial fractures are associated with TBI, and that the frontal sinus does not

specifically act as a barrier protecting the brain. Focal facial nerve injuries were most

commonly described, followed by disturbed cognition, and speech. Intracranial

pressure monitoring was the most common neurosurgical intervention. Despite our

small population we conclude that, if male patients in the age group of 20‐39 years

present with a maxillofacial fracture due to trauma, following a road traffic collision

(especially motorcycle and scooter accidents), one should be aware of the possibility

of additional TBI requiring neurosurgical intervention. In these cases, the

multidisciplinary approach of oral and maxillofacial surgeons and neurosurgeons in

the treatment of traumatic maxillofacial and brain injury patients seems to be

beneficial.

Chapter 6

100

References


2. Fasola AO, Lawoyin JO, Obiechina AE, Arotiba JT.: Inner city maxillofacial fractures due to road traffic

accidents. Dent Traumatol (19) 2‐5, 2003 3. Forouzanfar T, Salentijn E, Peng G, van den Bergh B.: A 10‐year analysis of the "Amsterdam" protocol

in the treatment of zygomatic complex fractures. J Craniomaxillofac Surg (41) 616‐622, 2013

4. Lee KH, Antoun J.: Zygomatic fractures presenting to a tertiary trauma centre, 1996‐2006. N Z Dent J (105) 4‐7, 2009

5. Lee KH.: Interpersonal violence and facial fractures. J Oral Maxillofac Surg (67) 1878‐1883, 2009

6. Salentijn EG, van den Bergh B, Forouzanfar T.: A ten‐year analysis of midfacial fractures. J Craniomaxillofac Surg (41) 630‐636, 2013

7. Salentijn EG, Boverhoff J, Heymans MW, van den Bergh B, Forouzanfar T.: The clinical and

radiographical characteristics of zygomatic complex fractures: a comparison between the surgically and non‐surgically treated patients. J Craniomaxillofac Surg (42) 492‐497, 2014

8. van Beek GJ, Merkx CA.: Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral

Maxillofac Surg (28) 424‐428, 1999 9. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T.: Aetiology and incidence of

maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg

(40) e165‐e169, 2012 10. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R.: The pattern of the maxillofacial


11. Davidoff G, Jakubowski M, Thomas D, Alpert M.: The spectrum of closed‐head injuries in facial trauma victims: incidence and impact. Ann Emerg Med (17) 6‐9, 1988

12. Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC.: Effect of the

modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma (71) 1185‐

1192, 2011

13. Giuliani G, Anile C, Massarelli M, Maira G.: Management of complex craniofacial traumas. Rev Stomatol Chir Maxillofac (98 Suppl 1) 100‐102, 1997

14. Haug RH, Savage JD, Likavec MJ, Conforti PJ.: A review of 100 closed head injuries associated with

facial fractures. J Oral Maxillofac Surg (50) 218‐222, 1992 15. Haug RH, Adams JM, Conforti PJ, Likavec MJ.: Cranial fractures associated with facial fractures: a

review of mechanism, type, and severity of injury. J Oral Maxillofac Surg (52) 729‐733, 1994

16. Keenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP.: Does the face protect the brain? A case‐control study of traumatic brain injury and facial fractures. Arch Surg (134) 14‐17, 1999

17. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR.: The impact‐absorbing effects of facial fractures in closed‐

head injuries. An analysis of 210 patients. J Neurosurg (66) 542‐547, 1987 18. Chang CJ, Chen YR, Noordhoff MS, Chang CN.: Maxillary involvement in central craniofacial fractures

with associated head injuries. J Trauma (37) 807‐811, 1994


20. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H.: Cranio‐maxillofacial trauma: a 10‐year review of 9,543

cases with 21,067 injuries. J Craniomaxillofac Surg (31) 51‐61, 2003 21. Pappachan B, Alexander M.: Correlating facial fractures and cranial injuries. J Oral Maxillofac Surg (64)

1023‐1029, 2006

22. Marshall LF, Marshall SB, Klauber MR, Van Berkum CM, Eisenberg H, Jane JA, Luerssen TG, Marmarou A, Foulkes MA.: The diagnosis of head injury requires a classification based on computed axial

tomography. J Neurotrauma (9 Suppl 1) S287‐S292, 1992

23. Chrcanovic BR, Souza LN, Freire‐Maia B, Abreu MH.: Facial fractures in the elderly: a retrospective study in a hospital in Belo Horizonte, Brazil. J Trauma (69) E73‐E78, 2010


101

6

24. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the

surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011 25. Brandt KE, Burruss GL, Hickerson WL, White CE, DeLozier JB.: The management of mid‐face fractures

with intracranial injury. J Trauma (31) 15‐19, 1991

26. Andriessen TM, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, Steyerberg EW, Vos PE.: Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a

prospective multicenter study. J Neurotrauma (28) 2019‐2031, 2011

27. Singh V, Malkunje L, Mohammad S, Singh N, Dhasmana S, Das SK.: The maxillofacial injuries: A study. Natl J Maxillofac Surg (3) 166‐171, 2012

28. Servadei F, Antonelli V, Giuliani G, Fainardi E, Chieregato A, Targa L.: Evolving lesions in traumatic

subarachnoid hemorrhage: prospective study of 110 patients with emphasis on the role of ICP monitoring. Acta Neurochir Suppl (81) 81‐82, 2002

29. Weider L, Hughes K, Ciarochi J, Dunn E.: Early versus delayed repair of facial fractures in the multiply

injured patient. Am Surg (65) 790‐793, 1999 30. Lee TT, Ratzker PA, Galarza M, Villanueva PA.: Early combined management of frontal sinus and

orbital and facial fractures. J Trauma (44) 665‐669, 1998

Chapter 6

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7

A ten‐year analysis of the traumatic maxillofacial

and brain injury patient in Amsterdam:

Complications and treatment


Salentijn EG, Collin JD, Boffano P, Forouzanfar T. A ten‐year analysis of the traumatic

maxillofacial and brain injury patient in Amsterdam: Complications and treatment.

J Craniomaxillofac Surg. 2014 Dec;42(8):1717‐1722.

Chapter 7

104

Abstract

Introduction

Maxillofacial trauma is often associated with injuries to the cranium, especially in

high‐energy trauma. The management of such cases can be challenging and requires

close cooperation between oral and maxillofacial surgery and neurosurgical teams.

There are few reports in the current literature describing the complications that

develop in patients with maxillofacial trauma and traumatic brain injury (TBI).

Complications can be categorized as ‘early’ or ‘late’ and/or ‘minor’ and ‘major’. The

exact definition of complications and their categorization remains a matter of current

debate. We present a ten‐year retrospective study of complications and their

subsequent management in patients receiving maxillofacial and neurosurgical

treatment for maxillofacial trauma associated with TBI.

Results

The study population of maxillofacial and TBI patients consisted of 47 people. A total

of 36 patients (76.6%) developed complications. Patients involved in road traffic

collision were most likely to develop complications (92.3%). This was followed by falls

(66.7%) as mechanism of the injury. One patient aged 60‐69 years experienced the

highest complication rate (5), followed by patients aged 20‐29 years (4.1) and

30‐39 years (3.5). The majority of complications were infection/inflammation (36.4%),

followed by neurological deficit (24.0%), physiological dysregulation (11.6%) and facial

bone deformity (8.3%). The most common treatment modality employed to manage

complications was pharmacological, followed by antibiotic treatment, conservative

treatment and decompression therapy. The mean hospital stay after the trauma for

the patients with complications was 28 days. Thirteen patients (36.1%) were

transferred to a rehabilitation centre, a nursing home, or a home for the elderly. Nine

patients (25%) completely recovered from their complications and 4 patients (11.1%)

eventually died after the trauma.

Conclusion

This report provides useful data concerning the rate and type of complications that

occur, and the multidisciplinary treatment that is required in traumatic maxillofacial

and brain injury patients.

A ten‐year analysis of the maxillofacial and TBI patient in Amsterdam: Complications and treatment

105

7

Introduction

Maxillofacial trauma with associated traumatic brain injury (TBI) carries significant

potential for mortality and neurological morbidity.1‐3 Traumatic brain injury (TBI) is

defined as loss of consciousness and/or post‐traumatic amnesia in a patient with a

non‐penetrating head injury.4 Maxillofacial fractures are often associated with injuries

to the cranium, especially in high‐energy trauma. Approximately one third of the

patients presenting with maxillofacial fractures have some form of intracranial

injury.5,6 Within this cohort, frontal sinus fractures, panfacial fractures and orbito‐

ethmoid fractures are most prevalent, as these fracture sites involve a wall of the

anterior cranial fossa and a proportion of the force applied will be transmitted directly

to the frontal lobes.5,7 In their population Salentijn et al. found that 8.1% of all the

surgically treated maxillofacial and TBI patients, also required neurosurgical

intervention during the same hospital stay.8 A number of studies report road traffic

collisions as the main mechanism of injury in these patients.5,6,8‐10

Management of maxillofacial injury associated with TBI can be challenging and

frequently necessitates a multidisciplinary team approach of oral and maxillofacial

surgeons and neurosurgeons.8,11 Keen awareness and efficient cooperation between

specialities facilitates rapid diagnosis and appropriate, timely treatment.12

A variety of complications may occur, in the immediate and late postoperative

period.13 Early postoperative complications include airway compromise, infection,

inadequate fracture reduction, and morbidity or mortality from concurrent injuries.

Late postoperative complications include cosmetic deformity, malunion or non‐union

of fractures, enophthalmus, temporomandibular joint ankylosis, meningitis and

mucocele formation. Alternatively, complications could be categorized as ‘major’ or

‘minor’.14 Minor complications are defined as seroma, hematoma, wound dehiscence,

and infection managed with medical treatment. Major complications are defined as

loss of vision, major neurological injury, death or severe infection requiring prolonged

hospitalization.14

To our knowledge there are few reports of the complications arising in patients

with maxillofacial trauma and TBI in the current literature. Furthermore, the exact

definition of complications and their categorization remains a matter of current

debate.

The aim of this retrospective study is to investigate the complications, treatment

modalities, and follow‐up of traumatic maxillofacial and brain injury patients, treated

by oral and maxillofacial surgeons and neurosurgeons during the same hospital stay.

Chapter 7

106


Hospital and outpatient records from January 2000 to January 2010 were reviewed

and analysed to identify trauma patients undergoing maxillofacial surgery and

neurosurgical intervention during the same hospital stay. The diagnosis of TBI was

based on evaluation and consultation by the Department of Neurosurgery and

Neurology in our hospital. Clinical judgement of the neurological injury was

dependent on the level of consciousness and based on the GCS score at admission of

the Emergency Department of our hospital. TBI was defined as mild (GCS 14‐15),

moderate (GCS 9‐13) and severe (3‐8).15

Indications for neurosurgical intervention were aesthetic appearance, open skull

fractures with dural lesions, intracranial haemorrhage (e.g. subdural, epidural and

intracerebral hematoma), and combinations thereof. Patients were included if they

had been treated surgically for their maxillofacial skull and brain injuries by the oral

and maxillofacial surgeons and the neurosurgeons during the same hospital stay.

Patients were excluded if they had been treated by the neurosurgeons for non‐skull

related injuries (e.g. spine injuries / vertebral injuries).

Medical notes for the study population were reviewed to collect data including:

gender, age, mechanism of injury, maxillofacial fracture type, complications and

treatment modality.

Statistics


17.0.

Results

Patient demographics concerning complications

In total 579 patients with maxillofacial fractures were treated surgically over a period

of 10 years. Of these patients, 47 were diagnosed with associated traumatic brain

injury (TBI) that required neurosurgical intervention and were therefore included in

the study population. This means that the study population of maxillofacial and

traumatic brain injury patients consisted of 47 people. A total of 36 patients (76.6%)

developed complications, meaning that in 11 patients (23.4%) no complications were

encountered (Table 7.1). All 5 (100%) female patients and 31 (73.8%) of the 42 male

patients developed complications. Patients involved in road traffic collision were most

likely to develop complications (92.3% of the cases), followed by falls (66.7% of the

cases).


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7

Table 7.1 General population description.

Patients treated for OMFS trauma

and TBI (2000‐2010) n (%)

Number of patients developing

complications n (%)

Total 47 36 (76.6%)

Male 42 (89.4%) 31 (73.8%)

Female 5 (10.6%) 5 (100%)

Cause Traffic accident 26 (55.3%) 24 (92.3%)

Violence 2 (4.3%) 1 (50%)

Fall 12 (25.5%) 8 (66.7%) Other 7 (14.9%) 3 (42.9%)

OMFS: Oral and Maxillofacial Surgery; TBI: Traumatic Brain Injury

Complications according to age classification

The mean age of the patients with complications was 32.2 years (SD: ±12.9). The

youngest patient was 15 years of age and the oldest patient was 69 years of age.

Overall, patients aged 20‐29 years accounted for the largest group in which

complications occurred (37.2%), followed by the group of 30‐39 years of age (32.2%)

(Figure 7.1). Patients aged 60‐69 years experienced the highest complication rate (5),

followed by patients aged 20‐29 years (4.1) and those aged 30‐39 years (3.5). The

majority of male patients were aged 20‐29 years (38.1%) and the majority of female

patients were 30‐39 years of age (60%).

Figure 7.1 Patients and complications according to age.

0

5

10

15

20

25

30

35

40

45

10‐19 20‐29 30‐39 40‐49 50‐59 60‐69

Age (yrs)

Complications

Patients

Chapter 7

108

Overview of complications and classification into groups

A total of 121 complications were described (Figure 7.2), which were classified into

10 different groups (Table 7.2). As described in Figure 7.2, the overall main

complication was infection and inflammation (36.4%), followed by neurological deficit

(24%), physiological dysregulation (11.6%) and facial bone deformity (8.3%).

Figure 7.2 Incidence of complications by category.

Complications per person

Most of the patients with complications developed more than 1 complication. Eleven

patients (30.6%) developed 2 complications, 7 patients (19.4%) developed 3

complications, 5 patients (13.9%) developed 4 complications and 5 patients (13.9%)

developed 5 complications.

Complications according to severity of the trauma

Of the 47 patients that were included, 27 patients (57.4%) were diagnosed with

severe TBI, 10 patients (21.3%) with moderate TBI and 10 patients (21.3%) with mild

TBI at presentation to the emergency department. It is demonstrated that

physiological dysregulation (85.7%), infection/inflammation (79.5%), psychiatric/

psychological disorders (71.4%) and neurological deficits (55.2%) were most often

found as complications in the patients presenting with severe TBI, whereas nerve

injuries (75%), facial bone defects (50%) and soft tissue damages (50%) were relatively

often found as complications in patients presenting with moderate TBI. Patients who

developed no complications most often presented with mild TBI at the emergency

department.

0

5

10

15

20

25

30

35

40

45

Ne rve injury Infe c tion/infla mma tion

Oc c lusa ldisturba nce

Visua lde fic ie ncy

Soft tissueda ma ge

Fac ia l bonede fec t

P sychia tric /psyc hologic a l

Neurologic a lde fic it

Ha e morrha geblood loss

P hysiologica ldysre gula tion


109

7

Table 7.2

Composition of complications by category.

1) Infection / inflam

mation

2) Neurological deficit

3) Nerve injury

4) Visual deficiency

respiratory infection

neurological deterioration

inferior alveolar nerve injury

restricted

eye m

ovement

meningitis

spasticity

infraorbital nerve injury

visual field defect

urinary tract infection

epileptic seizure

supraorbital nerve injury

corneal erosion

herpetiform

infection

dysphagia

facial nerve injury

hem

ianopsia

thrombophlebitis

speech problems

sensibility disorder upper leg

sinusitis

raised

intracranial pressure

hem

iparesis

middle ear inflam

mation

hydrocephalus

infected

osteosynthesis m

aterial

pneu

mocephalus

wound infection

neuropathic pain

CSF leak

nasal fistula

keratitis sicca

loss of autogenous bone

5) Facial bone defect

6) Soft tissue dam

age

7) Occlusal disturbance

8) Psychiatric / psychological disorders

temporal hollowing

scar form

ation

open

bite

delirium

facial deform

ity / asym

metry

ectropion

disturbed

occlusion

post‐traumatic stress disorder

suboptimal skull contour

displaced zygomatic arch

9) Haemorrhage / blood loss

10) Physiological dysregulation

hem

atothorax

cardiac (rhythm) disorder

epistaxis

autonomic dysregulation

intracranial bleed

liver problems

anaemia

respiratory insufficiency

diabetes insipidus

adrenal insufficiency

Chapter 7

110

Table 7.3 Complications according to severity of the trauma (GCS score).

All Severe Moderate Mild

n n (%) n (%) n (%)

Total (patients) 47 27 (57.4%) 10 (21.3%) 10 (21.3%)

No complication 11 1 (9.1%) 2 (18.2%) 8 (72.7%)

Complication Infection / inflammation 44 35 (79.5%) 8 (18.2%) 1 (2.3%)

Neurological deficit 29 16 (55.2%) 11 (37.9%) 2 (6.9%)

Nerve injury 4 ‐ 3 (75%) 1 (25%) Visual deficiency 4 2 (50%) 1 (25%) 1 (25%)

Facial bone defect 10 5 (50%) 5 (50%) ‐

Soft tissue damage 2 1 (50%) 1 (50%) ‐ Occlusal disturbance 4 3 (75%) 1 (25%) ‐

Psychiatric / psychological disorders 7 5 (71.4%) 2 (28.6%) ‐

Haemorrhage / blood loss 3 2 (66.7%) 1 (33.3%) ‐ Physiological dysregulation 14 12 (85.7%) 2 (14.3%) ‐

GCS: Glasgow Coma Scale.

Treatment modalities after complications classified into groups

The majority of the 36 patients with complications were treated for their

complications. A total of 114 various interventions were performed to treat the

complications and these were divided into 13 treatment groups (Table 7.4). Each

treatment group was composed of a number of different treatment modalities. As

described in Figure 7.3, the most common treatment modality was pharmacological

(non‐antibiotic) treatment (24.4%), followed by antibiotic treatment (16.7%),

conservative treatment (10.5%), and decompression therapy (9.6%).

Figure 7.3 Treatment modalities after complications.


111

7

Table 7.4

Composition of treatment modalities by category.

1) Conservative treatm

ent

2) Decompression

3) Antibiotic treatm

ent

4) (Surgical) intervention

‐ bone flap rem

oval

antibiotics

elastic IM

F

hem

atoma evacuation

bactrim

el

scar revision

drain placement

co‐trimoxazol

drain rep

lacemen

t

5) Secondary facial correction

6) Rem

oval foreign body / drain /

osteosynthesis material

7) Consultation with m

edical specialist

8) Pharmacological treatmen

t

(non‐antibiotic)

improval of facial deform

ities

drain removal

anesthesist

xylomethazoline

bone flap

rep

lacemen

t removal of foreign body

psychiatrist

mannitol

orthognathic surgery / distraction

osteogenesis

removal osteo

synthesis plate

ophthalmolgist

eye ointm

ent/eye drops

ENT

DDAVP

antipsychotics

ben

zodiazepines

anxiolytics

anti‐epileptics

antihypertensives

valaciclovir

antihistaminics

morphine

hydrocortisone

dexam

ethasone

Baclofen

9) Cooling / sedation

10) Compression

11) Bood transfusion

12) Ven

tilatory support

cooling

compression bandage

‐ ‐

sedation

bellocq compression

13) Resuscitation

‐

Chapter 7

112

Follow‐up for patients with complications

The mean hospital stay after the trauma for the 36 patients with complications was

28 days with a range of 3‐57 days. Six of the 36 patients needed to be retreated as a

new admission to the hospital, after they had been discharged. Three of these six

patients needed 2 further treatments, which occurred in 2 extra admissions to the

hospital.

The follow‐up period for patients at the department of Oral and Maxillofacial

surgery was an average of 4.5 months, with a range of 1 to 31 months. In 10 patients,

no follow‐up was necessary with the department of Oral and Maxillofacial surgery. In

4 patients, the follow‐up is still on‐going. In 2 patients, follow‐up data were not

described in the hospital records.

The follow‐up period for patients at the department of Neurosurgery/Neurology

was an average 7.5 months, with a range of 2 to 27 months. In 11 patients, no follow‐

up period was required with the department of Neurosurgery/Neurology. In

2 patients, the follow‐up period is ongoing. In 8 patients, the follow‐up period was not

described in the hospital records.

During their review appointments in the follow‐up period, several symptoms were

described in the hospital database by the departments of Oral and Maxillofacial

Surgery and Neurosurgery/Neurology. The symptoms described are presented in

Table 7.5.

Table 7.5 Symptoms during follow‐up period in patients with complications.

Symptom Number of patients

Neurological state improvement 9

Neurological state decrease 3

Nerve injury improvement 8

Facial contour improvement 3 Eye function improvement 3

Scar formation 2

Headache 4

Overall, after treatment of their complications, 13 patients (36.1%) were transferred

to a rehabilitation centre or a nursing home. Three patients (8.3%) were transferred

for observation elsewhere and 9 patients (25%) showed no evidence of disease during

their follow‐up appointments. Four patients (11.1%) eventually died after the trauma.


113

7

Discussion

The aim of this study was to retrospectively investigate the complications and

treatment modalities of traumatic maxillofacial and brain injury patients, which were

treated by oral and maxillofacial surgeons and neurosurgeons during the same

hospital stay. We found that 36 (76.6%) out of 47 patients developed one or more

complications after surgical intervention, which is much higher compared with the

studies of Kaufman et al. and Shibuya et al., in which complication rates were 30% and

11% respectively.14,16 This could be explained by the differences in definition of

complications. In our study all neurological deficits were recorded, comprising a

significant proportion (24%) of complications, whereas in the study of Kaufman et al.

only infection and incorrect fracture reduction were noted as most common

complications.16 It is questionable whether neurological disorders should be

mentioned as complications, as it is not clear if they occurred due to surgical

intervention or as a direct consequence of the trauma. In the studies of Brandt et al.

and Shibuya et al., neurological injury was also categorized as a (major)

complication.5,14

One of the contributory factors to complications in this patients group might be

that traumatic maxillofacial and brain injury patients are often combative and poorly

cooperative, compared with other patient groups, which may compromise optimal

treatment.16

Craniomaxillofacial trauma is often complicated by cerebrospinal fluid leakage,

intracranial haematoma and other neurological disorders. Fractures occurring without

significant displacement but with cerebrospinal fluid leak are treated conservatively

(bed rest, lumbar punctures and drainage), whereas in cases with bone displacement,

facial disfigurement, suspected dural tear, and persistent leak, surgery may be

indicated.17‐19 Compared to this classification of interventions, the treatment

modalities described in our population could be roughly categorized into conservative,

pharmacological and surgical.

Early interventions could lower the risk of complications, such as infection and scar

tissue formation between displaced bone fragments.12 In patients with closed head

injuries, timing of the surgery is of primary concern. Although early treatment could

reduce complications arising from untreated fractures, a 7‐10‐day window exists for

fractures of the mandible, whereas an extended window exists for middle and upper

third facial fractures (14 days). These time periods (shorter in children, longer in

geriatric patients) should generally allow for adequate resolution of cerebral

haematoma and neurological stabilisation.20

Cannon et al. classified complications into ‘early’ and ‘late’ complications.13

Whether the most common complication (infection/inflammation) found in our study

should be categorized as early or late is not completely clear according to the

Chapter 7

114

literature. On the one hand this complication was classified as early, whereas on the

other hand, Brandt et al. found that all of the infectious complications occurred in the

delayed surgery group, theorising that bacterial colonization on haematomas and

damaged tissue would have been avoided with early debridement.5,13 Alternatively,

Shibuya et al. categorized complications as ‘minor’ or ‘major’.14 Infection was defined

as a minor, but also as a major complication, as severe infection could require

prolonged hospitalization. A more unanimous classification for categorizing

complications would help in future studies. A simple classification of complications, as

'early' or 'late', with further subdivision into infection, bleeding, functional and

cosmetic categories, is therefore recommended.

As with previous studies, infection was the most common complication in our

population.5,14,21 Pharmacological and antibiotic therapy were therefore the most

common interventions.

Patients aged 60‐69 years were found to have the highest number of

complications, which might be due to impaired capacity to heal and less physiological

reserve, compared with younger patients. On the other hand, only one patient was

described in this age group, so grounded conclusions could not be drawn.

Road traffic collisions were found as the most common cause of the trauma from

which complications arose. This is in accordance with the studies of Brandt et al. and

Calderoni et al., but in contrast to the study of Shibuya et al., in which assault was

found as the most common cause of the trauma resulting in complications.5,14,21

Osteosynthesis plates can be associated with a number of complications, such as

migration, failure, infection, extrusion and malunion.13 In our study infection was the

most common complication, but only caused by the osteosynthesis plates in some

cases.

Conclusion

The management of patients presenting with both maxillofacial and traumatic brain

injury is challenging. Optimal treatment of maxillofacial injuries may be compromised

in such cases, when deference to neurosurgical concerns is necessary. Our study

shows that a variety of complications frequently arises, which often necessitate

further treatment and a prolonged hospitalisation. Even large trauma centres may

only see a handful of such patients every year and, therefore, this retrospective study

should help clinicians to anticipate on the frequency and type of complications that

occur. Standardized classification of the diverse complications that arise is currently

lacking. We therefore recommend simple classification of complications as 'early' or

'late' with further subdivision into infection, bleeding, functional and cosmetic

categories.


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References


2. Giuliani G, Anile C, Massarelli M, Maira G.: Management of complex craniofacial traumas. Rev

Stomatol Chir Maxillofac (98 Suppl 1) 100‐102, 1997 3. Stiver SI.: Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus

(26) E7‐2009


5. Brandt KE, Burruss GL, Hickerson WL, White CE, DeLozier JB.: The management of mid‐face fractures

with intracranial injury. J Trauma (31) 15‐19, 1991 6. Haug RH, Prather J, Indresano AT.: An epidemiologic survey of facial fractures and concomitant

injuries. J Oral Maxillofac Surg (48) 926‐932, 1990

7. Haug RH, Adams JM, Conforti PJ, Likavec MJ.: Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury. J Oral Maxillofac Surg (52) 729‐733, 1994

8. Salentijn EG, Peerdeman SM, Boffano P, van den Bergh B, Forouzanfar T.: A ten‐year analysis of the

traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg (42) 705‐710, 2014

9. Pappachan B, Alexander M.: Correlating facial fractures and cranial injuries. J Oral Maxillofac Surg (64)

1023‐1029, 2006 10. Salentijn EG, van den Bergh B, Forouzanfar T.: A ten‐year analysis of midfacial fractures. J

Craniomaxillofac Surg (41) 630‐636, 2013


(40) e165‐e169, 2012


13. Cannon DE, Wells TS, Poetker DM.: Two late complications of craniofacial trauma: case report and

review of the literature. Am J Otolaryngol (33) 615‐618, 2012 14. Shibuya TY, Karam AM, Doerr T, Stachler RJ, Zormeier M, Mathog RH, McLaren CL, Li KT.: Facial


15. Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC.: Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction:

comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma (71) 1185‐

1192, 2011 16. Kaufman MS, Marciani RD, Thomson SF, Hines WP.: Treatment of facial fractures in neurologically

injured patients. J Oral Maxillofac Surg (42) 250‐252, 1984

17. Clauser L, Dallera V, Sarti E, Tieghi R.: Frontobasilar fractures in children. Childs Nerv Syst (20) 168‐175, 2004

18. Fishman G, Fliss DM, Benjamin S, Margalit N, Gil Z, Derowe A, Constantini S, Beni‐Adani L.:

Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma. Childs Nerv Syst (25) 915‐923, 2009

19. Kanowitz SJ, Bernstein JM.: Pediatric meningoencephaloceles and nasal obstruction: a case for

endoscopic repair. Int J Pediatr Otorhinolaryngol (70) 2087‐2092, 2006 20. Lee TT, Ratzker PA, Galarza M, Villanueva PA.: Early combined management of frontal sinus and

orbital and facial fractures. J Trauma (44) 665‐669, 1998

21. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011

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Summary and conclusions

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This thesis aims to give an overview of the incidence, aetiology and treatment

modalities of patients with traumatic injuries of the midface, especially zygomatic

complex fractures, and their consequences.

The incidence of midfacial fractures is influenced by contributing factors, such as

geographical area, cultural differences and socioeconomic status. The pattern of

midfacial facture presentation varies, depending on the trauma aetiology. Common

causes of maxillofacial fractures include road traffic collisions (e.g. motorcycle,

automobile, scooter, bicycle), violence, falls, sport related accidents, industrial/work

related accidents and other miscellaneous causes (e.g. gunshot injuries, pathological

fractures).

As there is still no consensus on the treatment of zygomatic complex fractures,

Chapter 2 investigates the incidence and aetiology of surgically treated patients with

zygomatic complex fractures (period 2000‐2010), as well as the department’s protocol

for the treatment of zygomatic complex fractures at VU University Medical Center in

Amsterdam. The study population consisted of 236 patients, mostly males (72%) with

a mean age of 39.3 years (SD: ±15.6). A total of 210 zygomatic complex fractures

(89%), and 26 solitary zygomatic arch fractures (11%) were identified. In accordance

with the literature, the main cause of the injury was road traffic collisions, followed by

interpersonal violence.1‐5 An aetiological transition tendency towards a rise in

aggression over traffic accidents might explain why the left side (145 patients) was

more affected than the right side (91 patients). The majority of people are right‐hand

dominant, and therefore more likely to deliver a blow on the left zygomatic complex

in the violence‐related cases. Clinical features most often demonstrated, were

paraesthesia of the infraorbital nerve (47.0%), malar depression (37.3%) and

periorbital hematoma/ecchymosis (36.0%). All of the patients with a solitary

zygomatic arch fracture (11%) were treated with closed reduction, using the Gillies

approach. Thirty‐three patients (14%) with zygomatic complex fractures were treated

with closed reduction, using a bone hook. As plate osteosynthesis has become state of

the art in the treatment of maxillofacial fractures (greater stability and fewer

complications), the remaining 177 zygomatic complex fractures (75%) were treated

with open reduction and internal fixation (ORIF).6‐8 Most of the fractures were fixed

with 1 plate on the lateral orbital rim. With regard to surgical access of the zygomatic

complex, there seems to be no consensus. In contrast to what is often shown in the

literature, the department’s protocol demonstrates the lateral orbital rim approach

(frontozygomatic suture) as the first‐choice approach.9,10 Besides the low infection

risk, which makes the use of prophylactic antibiotics unnecessary, the lateral orbital

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rim approach is easy accessible for plate osteosynthesis. However, the

frontozygomatic area is thought to be a less clear reference point for fracture

reduction.11 On the other hand, the intraoral approach would result in a more stable

reduction with a lower complication rate, whereas the infraorbital rim approach

seems to be associated with higher complication rates.3,9,10,12‐14 As the patients’

opinion was not obtained, regarding the formation of scar tissue at the lateral orbital

rim, strong recommendations regarding the best surgical approach could not be

provided. Twenty‐nine patients (12.3%) presented with complications after surgical

treatment, of which suboptimal fracture reduction (15 patients) was most commonly

described, followed by wound infection (9 patients). In 7 patients (3%) surgical

retreatment was necessary, of whom 4 patients (1.7%) required a secondary orbital

floor reconstruction due to enophthalmos and diplopia. Although no absolute

indications for surgical treatment of zygomatic complex fractures have been

demonstrated in the literature so far, it is supposed that in many studies, fracture

displacement is considered as an indicator for surgical treatment, unless there are

profound contraindications, such as comorbidities, the patient’s refusal or the

absence of functional and/or aesthetic problems.15‐18

In Chapters 3 and 4 the epidemiological, clinical and radiographic features of

surgically and non‐surgically treated patients with zygomatic complex fractures over

the period of 2007‐2012 are retrospectively evaluated. Both patient groups were

compared according to age, gender, cause of the trauma, clinical features, fracture

site and the degree of fracture displacement (mild, moderate or severe displacement).

In this way, an attempt was made to establish guidelines whether or not to treat a

zygomatic complex fracture surgically. The population included 283 patients (71%

males, 29% females), of whom 133 patients were treated surgically and 150 patients

were treated non‐surgically. The mean age was 42.8 years (SD: ±19.8), which was

slightly higher compared to what is demonstrated in the literature (20‐30 years), as

also the non‐surgically treated patients were included.3‐5 However, a predominance of

zygomatic complex fractures (23.7%) in the age group of 20‐29 years was found.

The mean age of the non‐surgically treated patients was significantly higher,

compared to the surgically treated patients. Furthermore, the non‐surgically treated

patients with fracture displacement were aged higher (51.2 years, SD: ±23.6),

especially the female patients (59.5 years, SD: ±27.4), compared to the non‐surgically

treated patients without fracture displacement (43.4 years, SD: ±20.6). Hypothetically,

the non‐surgically treated patients were older, as in this group aesthetics are arguably

less important and more of the patients are regarded to be medically unfit for surgical

treatment. Traffic accidents were the main cause of the trauma (43.1%), followed by

fall (27.2%) and assault (20.5%). With regard to the male patients, traffic accidents

accounted for 43.3% of the cases, followed by assault (26.4%) and falls (20.9%).

Concerning the female patients, both traffic accidents (42.7%) and falls (42.7%) were


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found as the most common cause, whereas zygomatic complex fractures due to

assault were not found frequently (6.1%). In many other studies, traffic related

accidents and assault are the most common causes, which is in accordance with our

surgically treated population, but not with the non‐surgically treated population. Fall

was the main cause of injury in the non‐surgically treated patients group and, in

particular in those with displaced zygomatic complex fractures. This higher incidence

of fall‐related injuries, compared to what is demonstrated in the literature, could

partially be attributed to the older aged female patients, who are greater at risk of

falling and have different living and/or social habits.19,20 Overall, the surgically treated

patients mainly consisted of young male adults and the traffic‐ and assault‐related

cause highly contributed to this group, whereas the non‐surgically treated patients

consisted of a high number of elderly female patients, especially where there was

displacement of the zygomatic complex. Furthermore, there was a high number of

fall‐related causes, which accounted significantly more for the older ages (> 60 years).

In both the surgically and non‐surgically treated patients, traffic related accidents

mainly consisted of bicycle and motorcycle accidents with relatively more bicycle

accidents accounting for the female patients. Amsterdam is a city with a lot of cyclists,

which could explain this high prevalence of bicycle accidents.

All of the severely displaced and a majority (68.6%) of the moderately displaced

zygomatic complex fractures were treated surgically, whereas only 2.1% of the mildly

displaced zygomatic complex fractures were treated surgically. Surgical treatment of

zygomatic complex fractures was significantly associated with the presence of

palpable intraoral and extraoral step defects and malar depression. As paraesthesia of

the infraorbital nerve was not significantly associated with surgical management, this

feature should not be mentioned as an indicator for surgical treatment, which is also

reported in the literature.14,15 21

In contrast to maxillofacial fractures in general, less information is available

concerning the incidence and aetiology of midfacial fractures. Chapter 5 comprises a

retrospective descriptive study, investigating the incidence, aetiology, surgical

treatment and complications arising from the treatment of midfacial fractures at VU

University Medical Center in Amsterdam during the period of 2000–2010. The

purpose of this study was to have a close look on midfacial fractures in a Dutch

trauma population. A total of 278 patients were treated surgically for their midfacial

fractures by open or closed reduction. The midfacial fractures were classified into

zygomatic complex fractures, zygomatic arch fractures, orbital blowout fractures, Le

Fort I, Le Fort II, Le Fort III fractures and a combination of these fractures. The mean

age was 38.2 years (SD: ±16.0). In accordance with what is reported in the literature,

most of the patients were male (male‐female ratio of 2.6:1) and were found in the age

group of 20–29 years.3‐5 Most of the female patients were aged 50 years and older.

Road traffic collisions were identified as the most common cause of midfacial

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fractures (39.5%), followed by violence for males (16.9%) and falls for females (4.3%).

When comparing male with female patients, violence‐related midfacial injuries proved

to be significantly more common in male patients. Compared with non‐alcoholic

patients, in patients whose alcohol consumption was involved, violence was found as

the main cause of the injury. Accordingly, several other studies demonstrate that

interpersonal violence has surpassed traffic accidents as the main causative event,

most likely due to an aetiological transition tendency towards a rise in, alcohol

induced, aggression over traffic accidents.13,22‐27 As in line with the literature,

zygomatic complex fractures were found to be the most common midfacial fracture

site4,28, followed by zygomatic arch fractures and orbital floor fractures. Complications

arising after surgical treatment of midfacial fractures consisted mainly of suboptimal

fracture reduction (7.6%), followed by temporary paraesthesia of the infraorbital

nerve (3.6%) and wound infection (3.2%). Complications were dealt with by either

surgical retreatment, removal of the osteosynthesis material, antibiotic therapy or an

expectant approach. As instrumentation, biocompatibility of osteosynthesis materials

and surgical techniques have improved over the last few years, the management of

maxillofacial fractures has changed, ending up with open reduction and internal

fixation being used more commonly.3 Treatment with plate osteosynthesis will

probably lead to better results, fewer complications, shorter operating time and faster

hospital discharge.

Maxillofacial trauma is often associated with injuries to the cranium, especially

following high energy trauma.22,29 Chapter 6 focuses on the incidence and aetiology of

maxillofacial, especially midfacial, trauma patients with associated traumatic brain

injury (TBI), requiring maxillofacial and neurosurgical intervention. TBI is defined as

evidence of loss of consciousness and/or post‐traumatic amnesia in a patient with a

non‐penetrating head injury.30 The Glasgow Coma Scale (GCS) is used to describe the

level of consciousness in patients with TBI, and classifies TBI as mild (GCS 14‐15),

moderate (GCS 9‐13) or severe (GCS 3‐8).31 According to the literature, 40% of the

severe TBI cases are potentially fatal, making them an important patients group to

take into account.32 The extent to which midfacial fractures have an association with

traumatic brain injury remains unclear. Several authors demonstrate midfacial

fractures to be strongly associated with traumatic brain injury, assuming that in case

of trauma to the midface, energy will be directly transmitted to the cranium, causing

damage to the brain.33 Others deny an association of facial fractures with an increased

risk of traumatic brain injury, theorizing that the midfacial bones act as a protective

barrier against high energy trauma, thus protecting the brain from damage.34

A total of 47 patients (8.1%) were identified from a general maxillofacial trauma

population of 579 patients over a period of 10 years (2000‐2010) for this part of the

study. Data collected included age, gender, cause of the trauma, radiographic

examination, maxillofacial fracture type, neurological injury, neurological deficits and


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treatment modalities. The main cause of injury was road traffic collisions (55.3%),

followed by falls (25.5%). Violence (4.3%) correlated less with TBI, as only high‐energy

trauma to the craniofacial skeleton seems to cause injury to the brain tissue with the

consequence of neurological morbidity and mortality.22,29,30,35 Most of the patients

were males (89.4%) aged 20‐29 years, followed by those aged 30‐39 years. The mean

age was 31.4 years (SD: ±12.1). The frontal sinus was the most common maxillofacial

fracture site (21.9%) associated with neurosurgical input, followed by the zygomatic

complex (16.2%). However, in the general maxillofacial trauma population, frontal

sinus fractures were only found in 4.5% of the cases. This finding, as well as the fact

that 8.1% of the surgically treated maxillofacial trauma patients also suffered from TBI

indicating neurosurgical intervention, might suggest an association of midfacial

trauma with TBI, which could question the barrier function of the frontal sinus.

Twenty‐seven patients (57.4%) presented with severe TBI (GCS 3‐8), 10 patients

(21.3%) with moderate TBI (GCS 9‐13) and 10 patients (21.3%) with mild TBI (GCS

14‐15). For prognostication of neurological outcome, the initial CT‐sans were analysed

using the modified Marshall CT classification. Most of the patients (56%) were

diagnosed with a Marshall CT class II, indicating diffuse cerebral injuries with a midline

shift of 0–5 mm and/or lesion densities, sometimes including bone fragments and

foreign bodies. Neurological deficits were classified into nerve injuries and focal

neurological deficits. Focal nerve injuries (e.g. infraorbital, facial and supraorbital

nerve injuries) were found most commonly (34.0%), followed by disturbed cognition

(31.9%), and disturbed speech (17.0%).

Intracranial pressure (ICP) monitoring was demonstrated as the most common

neurosurgical intervention (24.1%) in traumatic maxillofacial and brain injury patients.

This was followed by reconstruction of craniofacial bone defects (16.1%) and

hematoma evacuation (12.4%). The aim of ICP monitoring is maintenance of adequate

cerebral perfusion and oxygenation and avoiding of secondary injury while the brain

recovers.36 In our study, early stage treatment was most commonly undertaken

(72.7%), as early surgical intervention seems to be associated with improved

outcomes. However, sometimes a delay of surgery is preferred in TBI patients, while

monitoring neurological status and stabilising intracranial and blood pressures is

undertaken first.29,36

Despite the small population in this study, it could be concluded that if male patients,

in the age group of 20‐39 years, present with a traumatic maxillofacial injury following

a road traffic collision (especially motorcycle and scooter accidents), one should be

aware of the possibility of additional TBI, requiring neurosurgical intervention. In

these cases, the multidisciplinary approach of oral and maxillofacial surgeons and

neurosurgeons in the treatment of traumatic maxillofacial and brain injury patients

seems to be beneficial.

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In chapter 7 the focus is on the rate and type of complications, as well as the

treatment modalities and follow‐up, occurring in the study population as described in

chapter 6. The exact definition of complications and their classification remains a

matter of current debate. The study population consisted of 47 traumatic maxillofacial

and brain injury patients, 36 (76.6%) of whom developed complications. The high

complication rate, compared to what is demonstrated in the literature (11%‐30%),

might be explained by definition differences.37,38 Neurological deficits were all

recorded. However, it seems to be unclear whether neurological injury occurred due

to surgical intervention or as a direct consequence of the trauma.38,39 In total 121

complications were found, which were classified into 10 different groups. In

accordance with the literature, infection and inflammation (36.4%) were

demonstrated as the most common complication, followed by neurological deficit

(24%).3,34,35 Patients involved in road traffic collisions (26 patients) were most likely to

develop complications (92.3% of the cases), followed by falls (12 patients) as the

mechanism of injury (66.7% of the cases). Patients aged 20‐29 years accounted for the

largest group in which complications occurred (37.2%), followed by the group of 30‐39

years of age (32.2%). Patients aged 60–69 years experienced the highest complication

rate (5 complications), which might be due to an impaired capacity to heal and less

physiological reserve, compared with younger patients. Twenty‐seven patients

(57.4%) were diagnosed with severe TBI, 10 patients (21.3%) with moderate TBI and

10 patients (21.3%) with mild TBI. Patients with severe TBI developed most of the

complications (90 in total), whereas patients presenting with mild TBI developed few

complications (5 in total) with most of them (80%) demonstrating no complications.

Complications in traumatic maxillofacial and brain injury patients could be categorized

as ‘early’ (e.g. airway compromise) or ‘late’ (e.g. malunion/non‐union) and as ‘minor’

(e.g. wound dehiscence) or ‘major’ (e.g. vision loss).38 However, the most commonly

encountered complication, infection, could be categorized in some cases as early and

in some cases as a late complication. Furthermore, infection could be categorized as

both a minor and major complication, depending on the consequences. As

complications easily seem to occur (76.6%) in these extensively traumatized patients,

a more unanimously accepted classification for categorizing complications could

facilitate treatment and would help in future studies. A simple classification of

complications, as 'early' or 'late', with further subdivision into infection, bleeding,

functional and cosmetic categories, is therefore recommended.

A total of 114 interventions were performed to treat the complications, which were

subdivided into 13 different treatment groups and treatment modalities. The most

common treatment modality was pharmacological (non‐antibiotic) treatment (24.4%),

followed by antibiotic treatment (16.7%), conservative treatment (10.5%) and

decompression therapy (9.6%). According to the classification of interventions, the

treatment modalities described in this population could be roughly categorized into

conservative, pharmacological and surgical. Consensus on this plain classification of


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complications and treatment modalities could lead to faster decision‐making and

hence even better quality of life after trauma care in this patients group.

The mean hospital stay was 28 days (range: 3 – 57 days). The follow‐up of patients for

the department of Oral and Maxillofacial surgery was an average 4.5 months and for

the department of Neurosurgery an average 7.5 months. Patients demonstrated

improved neurological status in 25% of the cases and improvement of nerve injuries in

22.2% of the cases. A total of 13 patients (36.1%) were transferred to a rehabilitation

centre or a nursing home. However, 4 patients (11%) eventually died after the trauma.

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References

1. Bormann KH, Wild S, Gellrich NC, Kokemuller H, Stuhmer C, Schmelzeisen R, Schon R.: Five‐year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and

complications. J Oral Maxillofac Surg (67) 1251‐1255, 2009 2. Brasileiro BF, Passeri LA.: Epidemiological analysis of maxillofacial fractures in Brazil: a 5‐year

prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (102) 28‐34, 2006

3. Calderoni DR, Guidi MdC, Kharmandayan P, Nunes PH.: Seven‐year institutional experience in the

surgical treatment of orbito‐zygomatic fractures. J Craniomaxillofac Surg (39) 593‐599, 2011 4. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R.: The pattern of the maxillofacial



(40) e165‐e169, 2012

6. Alkan A, Celebi N, Ozden B, Bas B, Inal S.: Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (104) 752‐756,

2007

7. de Matos FP, Arnez MF, Sverzut CE, Trivellato AE.: A retrospective study of mandibular fracture in a 40‐month period. Int J Oral Maxillofac Surg (39) 10‐15, 2010

8. Ellis E, el‐Attar A, Moos KF.: An analysis of 2,067 cases of zygomatico‐orbital fracture. J Oral Maxillofac

Surg (43) 417‐428, 1985 9. Bahr W, Bagambisa FB, Schlegel G, Schilli W.: Comparison of transcutaneous incisions used for

exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg (90) 585‐

591, 1992 10. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT.: The incidence of lower eyelid malposition after

facial fracture repair: a retrospective study and meta‐analysis comparing subtarsal, subciliary, and

transconjunctival incisions. Plast Reconstr Surg (124) 1578‐1586, 2009 11. Markowitz BL, Manson PN.: Panfacial fractures: organization of treatment. Clin Plast Surg (16) 105‐

114, 1989

12. Ellis E, Kittidumkerng W.: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg (54) 386‐400, 1996

13. Gomes PP, Passeri LA, Barbosa JR.: A 5‐year retrospective study of zygomatico‐orbital complex and

zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg (64) 63‐67, 2006 14. Habal MB.: The orbits: it is less important what you put in than how you secure it. J Craniofac Surg

(21) 965‐966, 2010

15. Hollier LH, Sharabi SE, Koshy JC, Stal S.: Facial trauma: general principles of management. J Craniofac Surg (21) 1051‐1053, 2010

16. Kaufman Y, Stal D, Cole P, Hollier L Jr.: Orbitozygomatic fracture management. Plast Reconstr Surg

(121) 1370‐1374, 2008 17. Kelley P, Hopper R, Gruss J.: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg

(120) 5S‐15S, 2007

18. Marinho RO, Freire‐Maia B.: Management of fractures of the zygomaticomaxillary complex. Oral Maxillofac Surg Clin North Am (25) 617‐636, 2013

19. Back CP, McLean NR, Anderson PJ, David DJ.: The conservative management of facial fractures:

indications and outcomes. J Plast Reconstr Aesthet Surg (60) 146‐151, 2007 20. Iida S, Hassfeld S, Reuther T, Schweigert HG, Haag C, Klein J, Muhling J.: Maxillofacial fractures

resulting from falls. J Craniomaxillofac Surg (31) 278‐283, 2003

21. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW.: Diagnosis and management of common maxillofacial injuries in the emergency department. Part 3: Orbitozygomatic complex and zygomatic

arch fractures. Emerg Med J (24) 120‐122, 2007



127

8

23. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, Mukundan S, Marcus JR.: A

retrospective analysis of facial fracture etiologies. Ann Plast Surg (60) 398‐403, 2008 24. Hwang K, You SH, Sohn IA.: Analysis of orbital bone fractures: a 12‐year study of 391 patients. J

Craniofac Surg (20) 1218‐1223, 2009

25. Lee KH, Antoun J.: Zygomatic fractures presenting to a tertiary trauma centre, 1996‐2006. N Z Dent J (105) 4‐7, 2009

26. Lee KH.: Interpersonal violence and facial fractures. J Oral Maxillofac Surg (67) 1878‐1883, 2009


28. Ozkaya O, Turgut Gl, Kayali MU, Ugurlu K, Kuran I, Bas L.: A retrospective study on the epidemiology

and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg (15) 262‐266, 2009 29. Giuliani G, Anile C, Massarelli M, Maira G.: Management of complex craniofacial traumas. Rev

Stomatol Chir Maxillofac (98 Suppl 1) 100‐102, 1997


31. Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC.: Effect of the

modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma (71) 1185‐

1192, 2011

32. Andriessen TM, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, Steyerberg EW, Vos PE.: Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a

prospective multicenter study. J Neurotrauma (28) 2019‐2031, 201139

33. Haug RH, Adams JM, Conforti PJ, Likavec MJ.: Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury. J Oral Maxillofac Surg (52) 729‐733, 1994

34. Chang CJ, Chen YR, Noordhoff MS, Chang CN.: Maxillary involvement in central craniofacial fractures

with associated head injuries. J Trauma (37) 807‐811, 1994 35. Pappachan B, Alexander M.: Correlating facial fractures and cranial injuries. J Oral Maxillofac Surg (64)

1023‐1029, 2006

36. Weider L, Hughes K, Ciarochi J, Dunn E.: Early versus delayed repair of facial fractures in the multiply injured patient. Am Surg (65) 790‐793, 1999

37. Kaufman MS, Marciani RD, Thomson SF, Hines WP.: Treatment of facial fractures in neurologically

injured patients. J Oral Maxillofac Surg (42) 250‐252, 1984 38. Shibuya TY, Karam AM, Doerr T, Stachler RJ, Zormeier M, Mathog RH, McLaren CL, Li KT.: Facial


39. Brandt KE, Burruss GL, Hickerson WL, White CE, DeLozier JB.: The management of mid‐face fractures with intracranial injury. J Trauma (31) 15‐19, 1991

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9

Future perspectives

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Future perspectives

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9

Future perspectives

Road traffic collisions are the main cause of midfacial fractures in western countries.

Preventive measures such as obligatory wearing of seat belts and helmets, providing

proper safety guidelines for vehicles and strict legislation of drinking and driving,

could lead to a reduction of victims in this part of the world. Furthermore, raising the

minimum age for alcohol consumption, more severe punishments, as well as an

increase of social security service, could reduce violence as a cause of midfacial

fractures in less developed countries. It is thought that further research into

preventive measures would be necessary to decrease the worldwide maxillofacial

trauma population.

Despite various publications on the incidence, aetiology and epidemiology of

zygomatic complex fractures, there seems to be no evidence‐based consensus

agreement regarding its treatment. Fracture displacement alone does not always

seem to be a reason for surgical treatment. An evidence‐based protocol, based on

patient demographics, as well as clinical and radiographic features, medical history,

etc. would be beneficial in this respect and could inform whether or not to treat a

patient surgically, as well as which approach to choose, and if internal fixation would

be required. Comparing different features of non‐surgically and surgically treated

patients with zygomatic complex fractures provides information that may help to

develop such clinical decision‐making algorithms. Further research of the non‐

surgically treated patients, as well as the investigation of evidence‐based guidelines

for decision‐making in the treatment of zygomatic complex fractures should therefore

be conducted.

For the composition of an evidence‐based protocol concerning the treatment of

zygomatic complex fractures there should be consensus of its best surgical access

(lateral orbital rim, zygomaticomaxillary buttress or infraorbital rim). Since patient’s

opinion on the quality of life after surgical treatment, following all of the three

approaches, has not been studied yet, firm conclusions about this subject could not be

drawn. Research for quality of life in patients having been treated surgically for

zygomatic complex fractures, using the different surgical approaches, would be

beneficial for choosing the best surgical access and could be helpful in the decision‐

making process.

In this thesis, an association between maxillofacial trauma and the occurrence of TBI

requiring neurosurgical intervention has been determined 8.1% of the patients. Young

(20‐39 years) male patients involved in road traffic collisions (motorcycle or scooter

accidents) were most commonly affected. It may be that this subgroup of patients

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should be transported to a specialized trauma center immediately after the trauma, as

neurosurgical intervention might be necessary and outcomes could be improved. As

our data have not demonstrated significance, firm conclusions could not be drawn.

Prospective research with larger trauma populations, perhaps multi‐centered, seems

to be required. On the other hand, it is doubtful if these young male patients are

always thoroughly investigated by a neurologist or neurosurgeon. Doing so might

provide better personalized patient care, with the goal to minimize neurological

complications and afford the best neurological prognosis. On the other hand, it might

increase general health care costs unnecessarily and put healthcare systems under

undue pressure.

In this thesis, the initial CT‐scans of most of the patients were radiographically

diagnosed with a Marshall Class II. To afford insights into the prognosis of these

patients, a 6‐month follow‐up with Glasgow Outcome Scores would be advisable and

could help demonstrating importance of treatment of this group.

As treatment of traumatic maxillofacial and brain injury patients is challenging and

complications occur in a large proportion (76.6%) of these extensively traumatized

patients, a more widely accepted classification for categorizing complications could

facilitate treatment and would help in future studies. A simple classification of

complications into ‘early’ and ‘late’, with further subdivision into infection, bleeding,

functional and cosmetic categories is recommended. Being aware of the different

complications that occur could help to develop strategies in prevention and improve

the patients’ outcome and quality of life after the trauma.

Future perspectives

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9

Chapter 9

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10

Samenvatting

Samenvatting

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10

Samenvatting

Hoofdstuk 1 begint met een algemene inleiding over de anatomie van de

verschillende botstukken in het middelste gedeelte van het aangezicht, het

middengezicht, en de fracturen die hierin kunnen ontstaan. Vervolgd wordt met het

beschrijven van de incidentie en etiologie van patiënten met fracturen in het

middengezicht, alsmede een beschrijving van het principe van operatieve behandeling

van dergelijke fracturen. Er wordt dieper ingegaan op patiënten met zygomafracturen.

Hiervan worden de epidemiologische, klinische en röntgenologische kenmerken

gepresenteerd en er wordt een stroomdiagram voor de behandeling van

zygomafracturen getoond. Verder wordt de mogelijke associatie tussen het ontstaan

van fracturen in het aangezicht, met name middengezichtsfracturen, en het

voorkomen van traumatische hersenschade nader onderzocht en wordt de

multidisciplinaire behandeling van MKA‐chirurgen en neurochirurgen van patiënten

met aangezichtsfracturen en traumatische hersenschade, alsmede de complicaties en

follow‐up die hieruit voorvloeien, beschreven.

In hoofdstuk 2 worden de 10‐jaars resultaten (periode 2000‐2010) van operatief

behandelde patiënten met zygomafracturen, en complicaties die hierbij ontstaan,

retrospectief geanalyseerd. Verder wordt een protocol voor de operatieve

behandeling van zygomafracturen in het VU medisch centrum, in de vorm van een

stroomdiagram weergegeven, met als doel het bereiken van consensus. De

studiepopulatie bestond uit 236 patiënten, 170 mannen en 36 vrouwen, met een

gemiddelde leeftijd van 39.3 jaar (SD: ±15.6).

Er waren 210 klassieke zygomafracturen (89%) en 26 solitaire arcus zygomaticus

fracturen (11%). Verkeersongevallen waren de meest voorkomende oorzaak, gevolgd

door geweld. Een toename van geweld als oorzaak voor het ontstaan van

zygomafracturen zou kunnen verklaren, waarom deze fracturen vaker aan linkerzijde

(145 patiënten) dan aan rechterzijde (91 patiënten) voorkomen. De meest

voorkomende klinische kenmerken waren sensibiliteitsstoornis van de nervus

infraorbitalis (47.0%), afvlakking van de wangkoon (37.3%) en de aanwezigheid van

een monocle hematoom/subconjunctivale ecchymose (36.0%). Alle patiënten met een

solitaire arcus zygomaticus fractuur werden behandeld middels de Gillies approach.

Drieëndertig patiënten (14%) werden behandeld middels stabiele reductie, zonder

fixatie. De overige 177 zygomafracturen (75%) werden behandeld middels open

reductie en interne fixatie, waarvan de meeste fracturen ter plaatse van de laterale

orbitarand werden gefixeerd. Hoewel de verschillende benaderingen (laterale

wenkbrauw, transoraal en transconjunctivaal) voor‐ en nadelen hebben, lijkt er geen

consensus te bestaan omtrent de beste benadering van zygomafracturen.

Negenentwintig patiënten (12.3%) presenteerden zich met complicaties na operatieve

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behandeling van zygomafracturen. De meest voorkomende complicatie was

suboptimale fractuurreductie (15 patiënten), gevolgd door wondinfectie (9 patiënten).

Zeven patiënten (3%) werden operatief herbehandeld, waarvan 4 patiënten (1.7%)

een secundaire orbitabodemreconstructie moesten ondergaan in verband met

enophthalmus en diplopie. Hoewel in de literatuur de meningen verschillen over de

behandeling van zygomafracturen, wordt dislocatie in meerdere studies als operatie‐

indicatie beschouwd, tenzij er contra‐indicaties bestaan, zoals medische

comorbiditeit, het nadrukkelijk weigeren van een operatieve behandeling of het

ontbreken van functionele en/of esthetische problemen.

In hoofdstuk 3 worden de epidemiologische gegevens omtrent de behandeling van

patiënten met operatief en niet‐operatief behandelde zygomafracturen retrospectief

onderzocht gedurende de periode 2007‐2012. De patiëntenpopulatie bestond uit 283

patiënten met zygomafracturen. De operatief behandelde en niet‐operatief

behandelde patiënten werden met elkaar vergeleken op grond van leeftijd, geslacht

en oorzaak van het trauma. Er waren 133 operatief behandelde en 150 niet‐operatief

behandelde zygomafracturen, waarvan 201 mannen (71%) en 82 vrouwen (29%). De

gemiddelde leeftijd was 42.8 jaar (SD: ±19.8) en de meeste patiënten (23.7%)

bevonden zich in de leeftijdsgroep van 20‐29 jaar. Vrouwen hadden een significant

hogere leeftijd (48.2 jaar, SD: ±23.6) dan mannen (40.6 jaar, SD: ±17.0). De

gemiddelde leeftijd van de niet‐operatief behandelde patiënten was significant hoger

dan van de operatief behandelde patiënten. Binnen de groep niet‐geopereerde

patiënten waren er 55 zygomafracturen met dislocatie en 95 zygomafracturen zonder

dislocatie. De gemiddelde leeftijd van de niet‐geopereerde zygomafracturen met

dislocatie was hoger (51.2 jaar, SD: ±23.6), vergeleken met de niet‐geopereerde

zygomafracturen zonder dislocatie (43.4 jaar, SD: ±20.6). Vrouwen in de niet‐

geopereerde patiëntengroep hadden zelfs een gemiddelde leeftijd van 59.5 jaar (SD:

±27.4). Verondersteld wordt dat vrouwen ouder dan 50 jaar een hoger risico hebben

om te vallen en geneigd zijn zich minder snel om esthetische redenen te laten

opereren. Daarbij is er vaker sprake van medische comorbiditeit, hetgeen

operatierisico’s met zich meebrengt. Verkeersongevallen (43.1%) waren de meest

voorkomende oorzaak voor het ontstaan van zygomafracturen, gevolgd door

valtrauma (27.2%) en geweld (20.5%). Onder de verkeersongevallen werden fiets‐ en

motorongevallen het meest gezien en waren er relatief meer vrouwen dan mannen

betrokken bij fietsongevallen. Bij mannen werden verkeersongevallen (43.3%) gevolgd

door geweld (26.4%) en valtrauma (20.9%), terwijl bij vrouwen verkeersongevallen

(42.7%) en valtrauma (42.7%) even hoog scoorden en geweld slechts in 6.1% van de

gevallen voorkwam. Globaal gezien, en in overeenstemming met de literatuur, kan

worden gesteld dat binnen de operatief behandelde patiënten met zygomafracturen

vaak jonge mannen worden aangetroffen met geweld als oorzaak van het trauma,

terwijl de niet‐operatief behandelde groep patiënten zich kenmerkt door een groter

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10

aantal oudere, vrouwelijke patiënten, met name onder de zygomafracturen met

dislocatie.

In hoofdstuk 4 worden de klinische en röntgenologische eigenschappen van patiënten

met operatief en niet‐operatief behandelde zygomafracturen gedurende een periode

van 5 jaar (2007‐2012) onderzocht. Hiermee wordt een poging gedaan om richtlijnen

te ontwikkelen voor het al dan niet operatief behandelen van zygomafracturen. In

totaal werden 283 patiënten met zygomafracturen geïncludeerd en ingedeeld in

groepen van operatief en niet‐operatief behandelde patiënten. Beide

patiëntengroepen werden onder andere met elkaar vergeleken op grond van klinische

en röntgenologische eigenschappen en de mate van dislocatie (matig, gemiddeld,

ernstig gedisloceerd). Alle zygomafracturen met ernstige dislocatie en een

meerderheid (68.8%) van de zygomafracturen met gemiddelde dislocatie werden

operatief behandeld, in tegenstelling tot de zygomafracturen met matige dislocatie,

waarvan slecht 2.1% operatief werd behandeld. Extra‐orale steps, intra‐orale steps en

afvlakking van de wangkoon waren klinische kenmerken die een significante relatie

hadden met een operatieve behandeling. Sensibiliteitsstoornis van de nervus

infraorbitalis en zwelling van het aangezicht waren de meest voorkomende klinische

kenmerken, echter beide waren niet significant gerelateerd aan een operatieve

behandeling. Een sensibiliteitsstoornis van de nervus infraorbitalis zou dan ook niet

gekozen moeten worden als indicator voor een operatieve behandeling. Aangezien

onder de niet‐operatief behandelde patiënten ook zygomafracturen met dislocatie

voorkwamen, wordt verondersteld dat dislocatie niet altijd als een indicatie voor

operatieve behandeling moet worden gezien. Voor het bereiken van consensus

omtrent de behandeling van zygomafracturen wordt nader onderzoek van de niet‐

operatief behandelde patiëntengroep geadviseerd.

In hoofdstuk 5 worden de incidentie en etiologie van fracturen van het

middengezicht, alsmede de behandeling en de complicaties die hieruit voorvloeien,

over de periode 2000‐2010 retrospectief onderzocht. De verschillende

middengezichtsfracturen werden onderverdeeld in zygomafracturen, arcus

zygomaticus fracturen, blowout fracturen, Le Fort I, Le Fort II, Le Fort III fracturen en

een combinatie van deze fracturen. De traumapopulatie bestond uit 278 operatief

behandelde patiënten met middengezichtsfracturen. Er waren 200 mannen en 78

vrouwen met een gemiddelde leeftijd van 38.2 jaar (SD: ±16.0). In overeenstemming

met de literatuur was er een meerderheid van mannen (man‐vrouw verhouding van

2.6:1) uit de leeftijdscategorie van 20‐29 jaar. De meeste vrouwen waren ouder dan

50 jaar. Verkeersongevallen (39.5%) waren de meest voorkomende oorzaak, gevolgd

door fracturen als gevolg van geweld bij de mannen (16.9%) en valtrauma bij de

vrouwen (4.3%). Fracturen veroorzaakt door geweld kwamen significant vaker voor bij

mannen. Bij patiënten die onder invloed waren van alcohol werd geweld als meest

140

voorkomende oorzaak van het trauma gevonden. In de literatuur wordt gesproken

over een inhaalslag van geweld, vergeleken met verkeersongevallen, als oorzaak voor

het ontstaan van aangezichtsletsel, waarschijnlijk als gevolg van aan alcohol

gerelateerde agressie. Omdat verkeersongevallen in de literatuur als meest

voorkomende oorzaak van aangezichtsfracturen worden gevonden, is preventie van

verkeersongevallen van groot belang. Preventieve maatregelen, zoals het verplicht

dragen van helmen en gordels en strenge wetgeving omtrent alcohol in het verkeer

zijn hierbij van groot belang. In overeenstemming met de literatuur waren

zygomafracturen de meest voorkomende fracturen in het middengezicht. De meest

voorkomende complicatie was suboptimale fractuurreductie (7.6% van de patiënten),

gevolgd door een sensibiliteitsstoornis van de nervus infraorbitalis (3.6% van de

patiënten) en wondinfectie (3.2% van de patiënten). Behandeling van complicaties

bestond grotendeels uit herbehandeling van de fractuur, verwijdering van het

aangebrachte osteosynthesemateriaal, het toedienen van antibiotica, of een

expectatief beleid dat werd afgesproken. Open reductie en interne fixatie met behulp

van osteosynthesemateriaal leidt naar verwachting tot minder complicaties, kortere

operatietijd en spoediger ontslag uit het ziekenhuis.

Aangezien er bij patiënten met aangezichtsfracturen ook vaak sprake is van

hersenschade, met name in geval van een hoogenergetisch trauma, worden in

hoofdstuk 6 de incidentie en etiologie van patiënten met aangezichtsfracturen en

bijkomende hersenschade nader onderzocht. Traumatische hersenschade wordt

gedefinieerd als bewustzijnsverlies en/of posttraumatische amnesie bij patiënten met

een niet‐penetrerend hoofdletsel. De Glasgow Coma Scale (GCS) wordt gebruikt om

het bewustzijnsniveau bij patiënten met traumatische hersenschade te bepalen.

Aangezien 40% van de patiënten met ernstige hersenschade komt te overlijden, lijkt

dit een belangrijke patiëntengroep om rekening mee te houden. In de literatuur

bestaan er 2 verschillende theorieën over het al dan niet ontstaan van traumatische

hersenschade. Door sommige auteurs wordt beschreven dat de botstukken van het

middengezicht een barrièrefunctie van de hersenen hebben, waardoor het ontstaan

van traumatische hersenschade wordt voorkomen. Door andere auteurs wordt juist

gesteld dat, in geval van een trauma, de energie die hierbij vrijkomt direct via de

botstukken van het middengezicht wordt overgebracht naar de hersenen, wat

traumatische hersenschade veroorzaakt. De incidentie en etiologie van een patiënten

met aangezichtsfracturen en traumatische hersenschade, die zowel kaakchirurgische

als neurochirurgische interventie behoefden, werden retrospectief onderzocht

gedurende een periode van 10 jaar (2000‐2010). De totale maxillofaciale

traumapopulatie bestond uit 579 patiënten, waaruit 47 patiënten (8.1%) werden

geïdentificeerd. De meest voorkomende oorzaak was verkeersongevallen (55.3%),

gevolgd door valtrauma (25.5%). Trauma als gevolg van geweld had slechts in 4.3%

van de gevallen een relatie met traumatische hersenschade, waarschijnlijk doordat de

Samenvatting

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10

hierbij ontstane energie niet hoog genoeg was om schade aan het brein te kunnen

veroorzaken. De meeste patiënten waren mannelijk (89.4%) en kwamen uit de

leeftijdsgroep van 20‐29 jaar, gevolgd door de leeftijdsgroep van 30‐39 jaar. Sinus

frontalis fracturen waren de meest voorkomende fracturen (21.9%), gevolgd door

zygomafracturen (16.2%). Dit was in tegenstelling tot de algehele maxillofaciale

traumapopulatie, waarin sinus frontalis fracturen slechts in 4.5% van de gevallen

voorkwamen. Het feit dat sinus frontalis fracturen vaker voorkomen in aanwezigheid

van hersenschade, suggereert dat er mogelijk een associatie tussen

aangezichtsfracturen en traumatische hersenschade bestaat, waarbij de sinus frontalis

niet specifiek als barrière van de hersenen fungeert. Zevenentwintig patiënten

(57.4%) presenteerden zich met ernstige hersenschade, 10 patiënten (21.3%) met

gemiddelde hersenschade (GCS 9‐13) en 10 patiënten (21.3%) met matige

hersenschade (GCS 14‐15). Van de verkeersongevallen, bleken motorongevallen in

100% van de gevallen ernstige hersenschade te veroorzaken, terwijl dit bij auto‐

ongevallen 50% was. Het dragen van gordels zou dit lagere percentage bij auto‐

ongevallen kunnen verklaren. Gelet op de klinische kenmerken werd zenuwletsel (o.a.

sensibiliteitsstoornis van de nervus infraorbitalis en facialisletsel) het meest gezien

(34%), gevolgd door cognitieve veranderingen (31.9%) en spraakstoornissen (17%).

Het monitoren van intracraniële druk was de meest voorkomende neurochirurgische

interventie (24.1%), gevolgd door de reconstructie van schedeldefecten (16.1%) en

evacuatie van hematomen (12.4%). Het monitoren van intracraniële druk heeft als

doel om adequate perfusie en oxygenatie van de hersenen te bevorderen en om

secundair letsel aan het herstellende brein te voorkomen. Ondanks de kleine

populatie kan worden geconcludeerd, dat als een jonge, mannelijke patiënt zich

presenteert met een aangezichtsfractuur, veroorzaakt door een verkeersongeval (met

name motor‐ en scooterongevallen), men bedacht moet zijn op de aanwezigheid van

hersenschade. In dergelijke gevallen zou de multidisciplinaire benadering van MKA‐

chirurgen en neurochirurgen van groot belang kunnen zijn.

In hoofdstuk 7 worden de complicaties, alsmede de behandelmodaliteiten en follow‐

up, van patiënten met aangezichtsfracturen en traumatische hersenschade

beschreven. Deze complicaties vereisen vaak verdere behandeling met een verlengde

ziekenhuisopname tot gevolg. Uit de maxillofaciale traumapopulatie van 579

patiënten gedurende de periode 2000‐2010 werden 47 patiënten geïdentificeerd,

waarvan 36 patiënten (76.6%) complicaties ontwikkelden. Dit betrekkelijk hoge

percentage complicaties, in tegensteling tot het percentage van 11‐30% uit de

literatuur, zou verklaard kunnen worden door verschillen in definitie van complicaties.

De exacte definitie van dergelijke complicaties en een duidelijke classificatie

hieromtrent blijven onderdeel van discussie. Zo zou neurologische schade als direct

gevolg van het trauma, of als consequentie van de operatieve interventie kunnen

worden beschouwd. In totaal werden 121 complicaties beschreven die werden

142

onderverdeeld in 10 verschillende groepen. In overeenstemming met de literatuur

was infectie/ontsteking (36.4%) de meest voorkomende complicatie, gevolgd door

neurologische uitval (24%). Van patiënten die betrokken waren bij verkeersongevallen

(26 in totaal) ontwikkelden de meeste (92.3%) complicaties, gevolgd door patiënten

met een valtrauma (12 in totaal), waarvan 66.7% complicaties ontwikkelden. In de

leeftijdsgroep van 20‐29 en 30‐39 jaar werden de meeste complicaties gevonden. Eén

patiënt in de leeftijdsgroep van 60‐69 jaar ontwikkelde de meeste complicaties (5 in

totaal), hetgeen zou kunnen worden verklaard door een verminderde

genezingscapaciteit en een verminderde fysiologische reserve. Patiënten die zich

presenteerden met ernstige traumatische hersenschade (27) ontwikkelden de meeste

complicaties (90 in totaal), terwijl patiënten die geen complicaties ontwikkelden, zich

meestal met milde traumatische hersenschade (10 in totaal) presenteerden.

Gestandaardiseerde classificatie van complicaties ontbreekt momenteel. Aanbevolen

wordt een simpele classificatie in ‘vroege’ of ‘late’ complicaties, met verdere

onderverdeling in infectie, bloeding, functioneel en cosmetisch. Voor de behandeling

van complicaties werden in totaal 114 interventies verricht, die werden

onderverdeeld in 13 groepen van verschillende behandelmodaliteiten. De meest

voorkomende behandelmodaliteit was farmacologische (niet‐antibiotische)

behandeling (24.4%), gevolgd door behandeling met antibiotica (16.7%),

conservatieve behandeling (10.5%) en decompressie therapie (9.6%). Conform deze

bevindingen zou de behandeling van complicaties ruwweg kunnen worden

geclassificeerd als conservatief, farmacologisch en chirurgisch. Consensus over deze

simpele classificatie van behandelmodaliteiten zou kunnen leiden tot het sneller

nemen van beslissingen en daarmee tot een betere kwaliteit van leven voor

patiënten, nadat zij behandeld zijn voor hun trauma en complicaties. De gemiddelde

ziekenhuisopname was 28 dagen. De follow‐up periode was gemiddeld 4.5 maand op

de afdeling Mondziekten, Kaak‐ en Aangezichtschirurgie en 7.5 maand op de afdeling

Neurochirurgie/Neurologie. In totaal werden 16 patiënten (44.4%) overgeplaatst.

Negen patiënten (25%) toonden neurologische verbetering, terwijl 3 patiënten (8.3%)

neurologisch verslechterden. Vier patiënten (11.1%) kwamen uiteindelijk te overlijden

na het trauma.

Dankwoord

Dankwoord

145

D

Dankwoord

Het werk in de algemene kaakchirurgische praktijk geeft een hoop voldoening,

evenals het verrichten van wetenschappelijk onderzoek. Ik ben blij dat ik aan beide

een bijdrage kan, en heb kunnen, leveren. De totstandkoming van dit proefschrift heb

ik met name te danken aan een groot aantal dierbare personen uit mijn naaste

omgeving. Middels onderstaand schrijven zou ik hen graag persoonlijk willen

bedanken.

Prof. dr. Forouzanfar, hooggeleerde promotor, beste Tim. Zonder jouw positieve kijk

was het een stuk minder stimulerend geweest om met wetenschappelijk onderzoek te

beginnen, laat staan om een proefschrift te schrijven. Jouw vertrouwen in mij en jouw

doelgerichtheid gedurende het promotietraject, hebben ervoor gezorgd dat door mij

gecreëerde olifanten snel tot muggen werden gemaakt. Humor en

relativeringsvermogen hebben me gestimuleerd om door te gaan met schrijven en

publiceren. Mijn oprechte dank hiervoor.

Prof. dr. Schulten, hooggeleerde mede‐promotor, beste Bert. Jij bent vooral bij de

afronding van mijn proefschrift betrokken geweest. Bedankt voor de nuttige

toevoegingen en correcties. Verder is mijn dank groot voor de opgedane kennis

gedurende de opleiding tot MKA‐chirurg. Ik pluk hier nog dagelijks de vruchten van.

Dr. Kommers en Dr. Martin, beste Sofie en Pim. Wat ben ik blij dat jullie er zijn. Mede

dankzij jullie geduld en inspanning om mij wijzer te maken met SPSS en Endnote (die

verrekte referenties) en jullie hulp en adviezen omtrent het finetunen van de

verschillende hoofdstukken, heb ik dit proefschrift tot een goed einde kunnen

brengen. Computers zijn niet altijd mijn beste vriend, maar gelukkig konden jullie hier

de humor wel van inzien. Heel erg bedankt.

Dr. van den Bergh, beste Bart. Tijdens onze opleidingstijd hebben we geregeld

samengewerkt, een hoop lol gemaakt en kon ik zo nu en dan op je terugvallen. Ik kan

me de verschillende onderbouwende en goed bedoelde kritieken herinneren, die

hebben bijgedragen aan de afronding van enkele van mijn publicaties. Verder ben ik je

dankbaar voor je geniale ingevingen bij het schrijven van de laatste hoofdstukken van

dit proefschrift. Heel veel dank hiervoor.

Dr. van Steenbergen, beste Martijn. Bij deze wil ik je bedanken voor je inspanningen

rondom de verschillende procedures die doorlopen moeten worden om tot een

promotie te komen. Door jouw uitgebreide kennis van de academische wereld wordt

alles een heel stuk duidelijker. Mijn oprechte dank hiervoor.

146

Collega‐MKA‐chirurgen van het VU medisch centrum, leden van ‘take‐it‐or‐leave‐it’,

beste Pim, Bart, Farrah, Erni, Sofie, Marjolijn, Jitske, Maarten en Luc. We hebben er

een mooie opleidingstijd op zitten en gaan een nog zeker zo mooie periode als

collega’s tegemoet. Steengoed dat onze vriendschap pasgeleden nog eens

onderstreept is tijdens een lang weekend in de Oostenrijkse sneeuw. Ik hoop jullie

nog veel te blijven zien en spreken.

Beste Sjoerd en Jeroen. Bedankt voor het werk dat jullie hebben verzet bij het creëren

van de verschillende illustraties en het ontwerpen van de omslag van dit proefschrift.

Het is heel erg mooi geworden.

Maatschap MKA Alrijne ziekenhuis, lieve Margo, Frank en Maartje. Ik mag van geluk

spreken dat ik zo’n mooie maatschap heb getroffen. Naast dat ik me op mijn plek voel,

weet ik jullie regelmatig te vinden voor een advies of goed gesprek. Heel fijn dat we

elkaar continu bijstaan op de momenten dat dit nodig is, in goede en in minder goede

tijden. Ik hoop op een nog lange, vruchtbare samenwerking met veel mooie operaties

en een hoop vertier. Mede dankzij jullie interesse en vertrouwen heb ik dit

proefschrift kunnen afronden en ga ik met plezier naar mijn werk.

Lief personeel van de afdeling MKA van het Alrijne ziekenhuis Leiderdorp, wat een

kanjers zijn jullie! Door de goede sfeer op de werkvloer en de grote hoeveelheden

werk die jullie me afhandig maken, voel ik mij gesteund in alles wat ik doe. Ik vind het

fijn om met jullie te werken en hoop op nog vele mooie jaren van samenwerking.

Jasper, beste paranimf. Niet alleen was je mijn eerste echte maat in Amsterdam, je

was ook mijn huisgenoot en later dispuutgenoot. Daarnaast was je getuige op mijn

huwelijk, hebben we samen heel veel meegemaakt en hebben we na al die jaren nog

steeds een heel goed contact. Ik ben enorm blij dat jij mij opnieuw wilt bijstaan bij

deze belangrijke beproeving en hoop dat onze vriendschap nog een leven lang mag

voortduren.

Richard, beste paranimf. Ook jou ken ik vanaf het begin dat ik naar Amsterdam kwam.

Vele vakanties, wintersport, etentjes en goede gesprekken volgden en 2 jaar geleden

stond jij mij bij als getuige van mijn huwelijk in Italië, wat een waanzinnig weekend

was. Ik ben blij dat je me wilt bijstaan bij deze beproeving en hoop op nog veel goede

gesprekken in de toekomst.

Bas D., Dolf, Chris en Bas E. en Jorrit, heren van het goede leven. Ik mag van geluk

spreken dat ik mij, ondanks de momenten van drukt en stress, onder jullie mag

bevinden en dat er nog regelmatig tijd is voor bier, vlees en een goed gesprek. Dit

Dankwoord

147

D

houdt mijn soms hectische leven goed in balans. Ik hoop op nog veel mooie feestjes,

fietstochten, weekenden weg en skivakanties.

Dr. Collin, dear John. Thank you for giving me a great time as a fellow OMFS in Bristol.

It has been a wonderful experience and I have learned a lot. Your sense of humor, as

well as your relaxed way to explain things, are noteworthy. Furthermore, thank you

for all of the corrections and editing you performed for this PhD. I hope to see you

again soon.

Beste mede‐auteurs die ik nog niet heb genoemd, beste Gina Peng, Jolanda Boverhoff,

Martijn Hermans en Paolo Boffano. Jullie zijn van groot belang geweest bij de

publicatie van de verschillende artikelen die ten grondslag liggen aan dit proefschrift.

Heel erg bedankt hiervoor.

Leden van de leescommissie, prof. dr. R.R.M. Bos, dr. E.M. van Cann, prof. dr. J.P.R.

van Merkesteyn, prof. dr. F.R. Rozema, prof. dr. D.B. Tuinzing, dr. J.G.A.M. de Visscher.

Bedankt voor het nemen van uw tijd voor het kritische beoordelen van dit proefschrift

en het zitting nemen in de oppositie.

Charlotte en Pieter, lieve zus en broer. Wat fijn dat ik jullie altijd in mijn naaste

omgeving heb gehad. De een tegenwoordig iets verder weg, de ander inmiddels een

stuk dichterbij. Jullie oprechte interesse en eerlijkheid houden me met 2 benen op de

grond als de situatie dit vraagt. Gelukkig wordt er ook een hoop gelachen. Stijn, jouw

Brabantse gastvrijheid wordt heel erg gewaardeerd. Jij weet wat het goede leven

inhoudt. Ik zie het als een eer om oom te zijn van jullie kids, mijn lieve nichtjes. En

Pieter, wanneer kom je weer oppassen..?

Mijn schoonfamilie, lieve Patrick, Piera, Vivian, Ralph en Herman. Bedankt voor alle

fijne vakanties en de gezellige bijeenkomsten van samenzijn. Zonder jullie is het nooit

saai en ongezellig. Ik ben blij met de oprechte interesse die jullie in mij en mijn

promotie hebben getoond. Verder vind ik het geweldig dat jullie altijd zo goed voor de

kleine frummel zorgen. Ik weet dat het voor jullie niet als oppassen voelt en dat dit

eigenlijk nooit een probleem is, maar de vanzelfsprekendheid is bijzonder. Ik ben heel

erg dankbaar dat hij altijd in zo’n warm nest terecht komt en dat hij ook Italiaans

leert.

Mijn ouders, lieve pap en mam. Jullie hebben mij onvoorwaardelijk gesteund, mij de

juiste keuzes laten maken en mij een warm nest geboden. Ik weet dat ik altijd op jullie

kan terugvallen en dat jullie advies meestal het juiste is. Zonder jullie inzicht,

doortastendheid, vertrouwen en liefde had ik hier nu niet gestaan. Jullie hebben me

148

gestimuleerd om mijzelf te kunnen ontplooien en het uiterste uit me te halen. Ik kan

jullie niet genoeg bedanken.

Lieve vrienden en familie die ik niet heb genoemd. Door jullie heb ik een heel mooi en

dynamisch leven en is geen enkele dag hetzelfde. Jullie betekenen heel veel voor me,

ik ben blij dat jullie er zijn.

Lieve Patty. Het werk zit erop, het boek is klaar. Wat heb je moeten afzien en wat ben

ik me ervan bewust dat dit zonder jou niet zomaar was gelukt. Ik ben blij dat je me vrij

hebt gelaten, maar dat je me op bepaalde momenten ook hebt laat weten als de

aandacht ergens anders moest worden gelegd. Je bent mijn rots in de branding. We

kunnen ons nu helemaal gaan focussen op ons nieuwe huis en op de vele momenten

samen en met die kleine oliebol. Ik heb er zin in!

Lieve Victor. Wat gaat de tijd snel. Alweer een jaar oud en wat vindt papa jou een

ontzettend lief kereltje. Altijd vrolijk, behoorlijk actief en een goede slaper. Zelfs

oesters en haring benijd je niet, hou dat vol! Ik mag me een bevoorrecht vader

noemen. Dit proefschrift draag ik op aan jou.

List of publications


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P


1. Salentijn EG, Ras F, Mensink G, van Merkesteyn JP.

The unerupted maxillary second molar, due to an overlying and malformed upper

third molar: treatment and follow‐up.

J Orthod. 2008 Mar;35(1):20‐4. 2. Salentijn EG, Boffano P, Boverhoff J, van den Bergh B, Forouzanfar T.

The epidemiological characteristics of zygomatic complex fractures: A comparison

between the surgically and non‐surgically treated patients.

Natl J Maxillofacial Surg. 2013 Jul;4(2):214‐8. 3. Moghimi M, Salentijn EG, Debets‐Ossenkop Y, Karagozoglu KH, Forouzanfar T.

Treatment of cervicofacial actinomycosis: a report of 19 cases and review of

literature.

Med Oral Patol Oral Cir Bucal. 2013 Jul; 18(4): e627‐32. 4. Forouzanfar T, Salentijn EG, Peng G, van den Bergh B.

A 10‐year analysis of the “Amsterdam” protocol in the treatment of zygomatic

complex fractures.

J Craniomaxillofac Surg. 2013 Oct;41(7):616‐22. 5. Salentijn EG, van den Bergh B, Forouzanfar T.

A ten‐year analysis of midfacial fractures.

J Craniomaxillofac Surg. 2013 Oct;41(7):630‐6. 6. Boffano P, Salentijn EG, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T.

Closed management by Ginestet hook elevator of V‐shaped fractures of the

zygomatic arch.

J Craniofac Surg. 2014 May;25(3):1130‐2. 7. Salentijn EG, Boverhoff J, Heymans MW, van den Bergh B, Forouzanfar T.

The clinical and radiographical characteristics of zygomatic complex fractures: A

comparison between surgically and non‐surgically treated patients.

J Craniomaxillofac Surg. 2014 Jul;42(5):492‐7. 8. Salentijn EG, Peerdeman S, Boffano P, van den Bergh B, Forouzanfar T.

A ten‐year analysis of the traumatic maxillofacial and brain injury patient in

Amsterdam: Incidence and aetiology.

J Craniomaxillofac Surg. 2014 Sep;42(6):705‐10. 9. Salentijn EG, Collin JD, Forouzanfar T.

A ten‐year analysis of the traumatic maxillofacial and brain injury patient in

Amsterdam: Complications and treatment.

J Craniomaxillofac Surg. 2014 Dec;42(8):1717‐22.

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