Treatment of zygomatic complex fractures in an urban Saudi Arabian population: A 10-year retrospective survey

Ali-Alsuliman Dawood; Braimah Ramat Oyebunmi; Ibrahim El-Hakim

doi:10.4103/jdrr.jdrr_8_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 5 | 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

Correspondence Address:
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

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DOI: 10.4103/jdrr.jdrr_8_18

Abstract

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.^[1] It has been reported that the incidence of maxillofacial fractures varies widely between different countries.^[2],[3],[4] 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.^[4] 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.^[5],[6] About 30%–50% of patients have associated concomitant facial fractures.^[5] 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.^[7]

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.^[8] 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.^[8] 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.^[9] Dingman and Natvig ^[10] 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.^[11] 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

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Table 1: Distribution of etiology of zygomatic bone fracture according to patient's age group

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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].

Table 2: Distribution of laterality and site of zygomatic bone fracture

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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

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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%).^[12] It was also the main cause of midface fracture in the United Arab Emirates, Iran, with a predominance occurrence in males.^[6],[13] 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.^[14],[15] 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.^[4],[16] The male predominance was attributed to the fact that female is less susceptible to accidents, assaults, work, and sport injuries.^[17] In addition, women are not allowed to drive in Saudi Arabia, and are therefore, less susceptible to accidents.^[4]

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.^[11]

The optimal method for achieving postreduction stability of the fractured zygoma remains controversial.^[18] 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.^[17] In 1927, Gillies was the first to create an incision made behind the hairline and over the temporal muscle to reach the malar bone.^[19] 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.^{[6],[12],[14],[20]} 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 ^[21] 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 ^[10] 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.^[22]

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.^[23] The success of miniplates was further advanced by introducing different techniques for reduction and fixation of facial fractures using miniplates.^[24] 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.^[4],[6],[25] However, in resource-limited countries were such is unavailable and payment has to be made by patients, treatment options remained CR.^{[2],[16],[20]} Biomechanical properties are of primary importance in the treatment of zygoma fractures using ORIF.^[26] Two-point fixation of zygomatic fractures are used commonly, however, it frequently leaves an axis of rotation for the zygoma by masseter muscle.^[26],[27] Therefore, choosing the correct approach to establish three-point fixation and ultimate stability is essential for obtaining a successful outcome.^[27] 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.^[28] 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%).^[29],[30] 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.

Acknowledgment

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

Nil.

Conflicts of interest

There are no conflicts of interest.

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