|Year : 2018 | Volume
| Issue : 1 | Page : 22-25
Treatment of zygomatic complex fractures in an urban Saudi Arabian population: A 10-year retrospective survey
Ali-Alsuliman Dawood1, Braimah Ramat Oyebunmi1, Ibrahim El-Hakim2
1 Department of Oral and Maxillofacial Surgery, Najran Regional Specialty Dental Centre, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
|Date of Web Publication||14-May-2018|
Dr. Braimah Ramat Oyebunmi
Department of Oral and Maxillofacial Surgery, Najran Regional Specialty Dental Centre, Medical City Complex, Najran
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Background: Zygomatic complex fractures (ZMCF) are treated by various closed and open reduction procedures. The common goal, however, is to achieve three-dimensional stability of the fractured zygoma. Patients and Methods: All cases diagnosed with ZMCF were included in this study over a 10-year-period starting from December 2002 to December 2012 at Riyadh Dental Centre, King Saud Medical City-Riyadh, Saudi Arabia. Patient's gender, age, etiology, and type of treatment modality of the zygomatic bone fracture were retrieved and recorded. Data were stored and statistically analyzed using SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA). Results were presented as simple frequencies and percentages. Results: A total of 306 patients were diagnosed with ZMCF during the study period. There were 271 (88.6%) males and 35 (11.4%) females with a male-to-female ratio of 7.7:1. Age range of 21–30 years had the highest number of maxillofacial fracture. A total of 62 (20.3%) cases were treated by closed reduction while 235 (76.8%) cases were treated by open reduction and internal fixation using titanium miniplate (2.0 mm) and screws. Combination of treatment modalities was utilized in only 9 (2.9%) cases. Complications observed during the review period were palpable plate and screws in 26 (8.4%) patients. These palpable plates and screws, however, did not necessitate plate and screw removal from any of these patients. Conclusion: Most of the ZMCF were treated by open reduction and rigid internal fixation. Advances in imaging, surgical technique, and materials for fixation have allowed for improved functional and esthetic outcomes.
Keywords: Fractures, open reduction and internal fixation, reduction, titanium, zygomatic complex
|How to cite this article:|
Dawood AA, Oyebunmi BR, El-Hakim I. Treatment of zygomatic complex fractures in an urban Saudi Arabian population: A 10-year retrospective survey. J Dent Res Rev 2018;5:22-5
|How to cite this URL:|
Dawood AA, Oyebunmi BR, El-Hakim I. Treatment of zygomatic complex fractures in an urban Saudi Arabian population: A 10-year retrospective survey. J Dent Res Rev [serial online] 2018 [cited 2021 Jan 21];5:22-5. Available from: https://www.jdrr.org/text.asp?2018/5/1/22/232365
| Introduction|| |
The zygomatic bone also known as the cheekbone articulates with the maxilla, the temporal, the sphenoid bone, and the frontal bones. It forms the prominence of the cheek and therefore susceptible to varying degrees of trauma. It has been reported that the incidence of maxillofacial fractures varies widely between different countries.,, The large variability in reported prevalence is due to a variety of contributing factors, such as environment, sex, age, and socioeconomic status of the patient, as well as the mechanism of injury. The most zygomatico–orbito–maxillary complex fractures are caused by violent assaults and motor vehicle accidents; the majority of patients are young males in their third decade of life., About 30%–50% of patients have associated concomitant facial fractures. The frequency of zygomaticomaxillary complex fracture (ZMCF) has been reported to be second only to nasal fractures, which are the most common type of facial fracture.
Attempts to treat facial fractures were recorded in the 25–30 centuries BC. The Smith Papyrus as described by Lothrop was the first document, in which treatment of several types of ZMCF was described. He invented an antrostomy technique to treat fractured zygoma through Highmore antrum below the inferior turbinate. This transantral approach is today known as the Caldwell-Luc approach. The technique allowed the rotation of the fractured zygoma upward and outward for a proper reduction. This method avoided external incisions, with access to the maxillary sinus for drainage and the debridement of any mucosal debris. Nondisplaced or minimally displaced fractures may be treated conservatively. Gillies temporal approach is used for depressed ZMCF. Dingman and Natvig  concluded from their study that open reduction and internal fixation (ORIF) should be reserved for cases that are severely angulated or comminuted when the zygomatic bone became displaced again after reduction because of extrinsic forces. Fractures with displacement require surgery consisting of fracture reduction with miniplates, microplates, and screws. Untreated ZMCF may cause a cosmetic deformity (flattening of the cheek) or limited mandibular movement caused by the depressed zygoma impinging on the coronoid process of the mandible. Therefore, the current study hopes to highlight the different treatment methods for ZMCF in an urban Saudi Arabian population, which has not been reported to the best of our knowledge in this population.
| Patients and Methods|| |
All patients with maxillofacial fractures presenting at Riyadh Dental Centre at King Saud Medical City (KSMC)-Riyadh, Saudi Arabia, were reviewed retrospectively. All cases diagnosed with ZMCF were included in this study over a 10-year-period starting from December 2002 to December 2012. Patient's gender, age, etiology, and type of treatment modality of the zygomatic bone fracture were retrieved and recorded. The study was approved by the Ethical Committee of KSMC with protocol number GRP/43236002/38.
Inclusion criteria comprised all patients diagnosed clinically and radiographically with ZMCF. Exclusion criteria included; patients with other maxillofacial injuries or body injuries not associated with zygomatic bone fracture, and patients under the care of other specialty such as neurosurgery and orthopedic surgery.
Data were stored and statistically analyzed using SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA). Results were presented as simple frequencies and percentages.
| Results|| |
A total of 306 patients were diagnosed with ZMCF during the study period [Figure 1]. There were 271 (88.6%) males and 35 (11.4%) females with a male-to-female ratio of 7.7:1. Age range of 21–30 years had the highest number of maxillofacial fracture [Table 1]. Most of the ZMCF were due to road traffic accident (221 [72.2%]), followed by assault 54 (17.6%) cases, while only 4 (1.3%) cases were due to camel attack [Table 1].
|Figure 1: Gender distribution of patients with zygomatic complex fracture|
Click here to view
|Table 1: Distribution of etiology of zygomatic bone fracture according to patient's age group|
Click here to view
This study showed that both right and left sides of zygoma fracture are equally affected by fracture (141 [46.1%] and 140 [45.8%]), respectively. Bilateral fracture was observed in 25 (8.2%) cases [Table 2]. The most common fracture site was zygomatic-maxillary suture which was observed in 284 cases (92.8%) followed by zygomatic arch fracture which was diagnosed in 22 cases (7.2%) [Table 2].
A total of 62 (20.3%) cases were treated by open indirect reduction using Gillies temporal approach, while 235 (76.8%) cases were treated by ORIF using titanium miniplate (2.0 mm) and screws. Combination of treatment modalities was utilized in only 9 (2.9%) cases [Figure 2].
|Figure 2: Distribution of treatment modalities of the zygomatic complex fracture|
Click here to view
Complications observed during the review period were palpable plate and screws in 26 (8.4%) patients. These palpable plates and screws, however, did not necessitate plate and screw removal from any of these patients.
| Discussion|| |
Road traffic accident was the main cause of midface fracture in many studies. A retrospective study in Al Madinah, Saudi Arabia, reported that road traffic accident was the predominant causative factor (63%). It was also the main cause of midface fracture in the United Arab Emirates, Iran, with a predominance occurrence in males., Our study has supported these findings as most of our cases were secondary to road traffic accidents with male preponderance. However, other studies have reported assault as the main etiological factor., This is because etiology of maxillofacial injuries varies from one country to another and even within the same country depending on socioeconomic, cultural, and environmental factors., The male predominance was attributed to the fact that female is less susceptible to accidents, assaults, work, and sport injuries. In addition, women are not allowed to drive in Saudi Arabia, and are therefore, less susceptible to accidents.
Untreated ZMCF may cause a cosmetic deformity (flattening of the cheek) or limited mandibular movement caused by the depressed zygoma impinging on the coronoid process of the mandible.
The optimal method for achieving postreduction stability of the fractured zygoma remains controversial. Various closed and open reduction procedures are available as treatment option for ZMCF. However, the choice of technique depends on the clinician's evaluation of the fracture, experience, and preference as well as the available facilities. In 1927, Gillies was the first to create an incision made behind the hairline and over the temporal muscle to reach the malar bone. Gillies further described the use of a periosteal elevator that is slid under the depressed bone below the temporalis fascia enabling the surgeon to use the leverage of the elevator to reduce the fracture. All our cases with open indirect reduction 62 (20.3%) were performed using the Gillies temporal approach. This technique in the reduction of ZMCF has been reported by other studies.,,, Understanding the advantage of the mechanical forces of the masseter and temporalis muscles on the zygoma in this approach helped the use of the open indirect reduction techniques.
When the ZMCF is comminuted then, there is need for more stabilization. This was recognized by Adams  and was the first to write about internal wire fixation. This technique for many years remained the mainstay treatment by surgeons. Furthermore, Dingman and Natvig  established that many ZMCF managed with a closed reduction (CR) or open indirect reduction method later became displaced again due to extrinsic forces of temporalis and masseter muscles. Therefore, they concluded that most displaced fractures of the zygoma should be treated by open reduction and direct wire fixation. None of our patients had displaced zygomatic bone fractures after open indirect reduction. We opined that early treatment with strict instructions not to lie on the elevated zygoma side may have contributed to this success. Other materials used as internal fixation for middle-third facial fractures include Kirschner wires either alone or in combination with direct wiring.
In year 1970s, the Swiss Association for Osteosynthesis group and Association for the Study of Internal Fixation developed miniplate fixation, and thereafter, osteosynthesis became a reality for facial fractures. The success of miniplates was further advanced by introducing different techniques for reduction and fixation of facial fractures using miniplates. In the current study, 76.8% of the treatment modality was ORIF. Such method of treatment had been reported in countries where armamentarium and ORIF hardware are available and free for patients.,, However, in resource-limited countries were such is unavailable and payment has to be made by patients, treatment options remained CR.,, Biomechanical properties are of primary importance in the treatment of zygoma fractures using ORIF. Two-point fixation of zygomatic fractures are used commonly, however, it frequently leaves an axis of rotation for the zygoma by masseter muscle., Therefore, choosing the correct approach to establish three-point fixation and ultimate stability is essential for obtaining a successful outcome. All our cases of ORIF had three-point fixation at the zygomatico-maxillary, zygomatico-frontal, and infraorbital rim using titanium 2.0 mm miniplates. Other plating systems available include the use of biodegradable plates and screws and cyanoacrylate glue fixation. Gosain et al. compared directly titanium miniplates with biodegradable plate and screws and discovered that titanium miniplates were the strongest in compression across the central fracture gap.
Complications do arise from the ORIF system for ZMCF. Such complications have been reported to include palpable plates and screws (35%), followed closely by pain, infection, or loosening/fracture of the fixation device (approximately 25%)., From the current study, only palpable plates and screws at the frontozygomatic suture and infraorbital rim were observed as complications. These, however, did not warrant removal of the plates and screws.
| Conclusion|| |
ZMCFs remain the most common facial fracture behind nasal fractures. Advances in imaging, surgical technique, and materials for fixation have allowed for improved functional and esthetic outcomes.
The authors are grateful to the entire clinical and administrative staffs of the Riyadh Dental Centre of KSMC, Kingdom of Saudi Arabia, for their support during the period of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chowdhury SR, Menon PS. Etiology and management of zygomaticomaxillary complex fractures in the armed forces. Med J Armed Forces India 2005;61:238-40.
Fasola AO, Obiechina AE, Arotiba JT. Zygomatic complex fractures at the University College Hospital, Ibadan, Nigeria. East Afr Med J 2002;79:137-9.
Fasola AO, Nyako EA, Obiechina AE, Arotiba JT. Trends in the characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg 2003;61:1140-3.
Abdullah WA, Al-Mutairi K, Al-Ali Y, Al-Soghier A, Al-Shnwani A. Patterns and etiology of maxillofacial fractures in Riyadh city, Saudi Arabia. Saudi Dent J 2013;25:33-8.
Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States army soldiers, 1980-2000. Otolaryngol Head Neck Surg 2004;130:164-70.
Al-Khateeb T, Abdullah FM. Craniomaxillofacial injuries in the United Arab Emirates: A retrospective study. J Oral Maxillofac Surg 2007;65:1094-101.
Abbas I, Fayyaz M, Shah I, Khan MA, Qazi SH, Munir N, et al.
Demographic distribution of maxillofacial fractures in Ayub Teaching Hospital: 7-year review. J Ayub Med Coll Abbottabad 2009;21:110-2.
Lothrop HA. Fractures of the superior maxillary bone caused by direct blows over the malar bone. Boston Med Surg 1906;154:8.
Swanson E, Vercler C, Yaremchuk MJ, Gordon CR. Modified gillies approach for zygomatic arch fracture reduction in the setting of bicoronal exposure. J Craniofac Surg 2012;23:859-62.
Dingman RO, Natvig P. Surgery of Facial Fractures. Philadelphia: WB Saunders Co.; 1964.
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 2007;24:120-2.
Rabi AG, Khateery SM. Maxillofacial trauma in al Madina region of Saudi Arabia: A 5-year retrospective study. Asian J Oral Maxillofac Surg 2002;14:10-4.
Mesgarzadeh AH, Shahamfar M, Azar SF, Shahamfar J. Analysis of the pattern of maxillofacial fractures in North Western of Iran: A retrospective study. J Emerg Trauma Shock 2011;4:48-52.
] [Full text]
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 2011;27:135-42.
Rowe NL, Williams JL. Maxillofacial Injuries. New York: Churchill Livingstone; 1985.
Adeyemo WL, Ladeinde AL, Ogunlewe MO, James O. Trends and characteristics of oral and maxillofacial injuries in Nigeria: A review of the literature. Head Face Med 2005;1:7.
Menon S, Sinha R, Thapliyal G, Bandyopadhyay T. Management of zygomatic complex fractures in a tertiary hospital: A retrospective study. J Maxillofac Oral Surg 2011;10:138-41.
Davidson J, Nickerson D, Nickerson B. Zygomatic fractures: Comparison of methods of internal fixation. Plast Reconstr Surg 1990;86:25-32.
Gillies H, Kilner TP, Stone D. Fractures of the malar-zygomatic compound: With a description of a new X-ray position. Br J Surg 1927;14:651-6.
Ugboko V, Udoye C, Ndukwe K, Amole A, Aregbesola S. Zygomatic complex fractures in a suburban Nigerian population. Dent Traumatol 2005;21:70-5.
Adams WM. Internal wiring fixation of facial fractures. Surgery 1942;12:523-40.
Brown JB, Fryer MP, McDowell F. Internal wire-pin stabilization for middle third facial fractures. Surg Gynecol Obstet 1951;93:676-81.
Muller ME. Manual of Internal Fixation: Technique Recommended by the AO-Group, Swiss Association for the Study of Internal Fixation: ASIF. Davos: AO-Swiss; 1970.
Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg 1973;1:79-84.
Zhuang QW, Zhang XP, Wang X, Zhang J, Li ZP, Si YM, et al.
Coronal approach to zygomaticomaxillary complex fractures. Eur Rev Med Pharmacol Sci 2015;19:703-11.
Rinehart GC, Marsh JL, Hemmer KM, Bresina S. Internal fixation of malar fractures: An experimental biophysical study. Plast Reconstr Surg 1989;84:21-5.
McGalliard RJ, Kimpton J, McLeod NM. Ophthalmic outcomes of fractured zygomas. Br J Oral Maxillofac Surg 2017;55:363-6.
Gosain AK, Song L, Corrao MA, Pintar FA. Biomechanical evaluation of titanium, biodegradable plate and screw, and cyanoacrylate glue fixation systems in craniofacial surgery. Plast Reconstr Surg 1998;101:582-91.
Orringer JS, Barcelona V, Buchman SR. Reasons for removal of rigid internal fixation devices in craniofacial surgery. J Craniofac Surg 1998;9:40-4.
Zachariades N, Mezitis M, Anagnostopoulos D. Changing trends in the treatment of zygomaticomaxillary complex fractures: A 12-year evaluation of methods used. J Oral Maxillofac Surg 1998;56:1152-6.
[Figure 1], [Figure 2]
[Table 1], [Table 2]