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• W4255782626 abstract "Archives of Facial Plastic SurgeryVol. 14, No. 1 Free AccessZygomaticomaxillary Complex FracturesDanny Meslemani and Robert M. KellmanDanny MeslemaniDepartment of Otolaryngology and Communicative Sciences, State University of New York Upstate Medical University, Syracuse.Search for more papers by this author and Robert M. KellmanCorrespondence: Robert M. Kellman, MD, Department of Otolaryngology and Communicative Sciences, State University of New York Upstate Medical University, 241 Campus W, 750 E Adams St, Syracuse, NY 13210 (E-mail Address: kellman@upstate.edu).Department of Otolaryngology and Communicative Sciences, State University of New York Upstate Medical University, Syracuse.Search for more papers by this authorPublished Online:2 Jan 2012AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The term zygomaticomaxillary (zygomaticomalar) complex (ZMC) fractures refers to the osseous disruption of the malar eminence at 4 buttresses: zygomaticomaxilllary, frontozygomatic (FZ), zygomaticosphenoid, and zygomaticotemporal1 (Figure 1).2 The ZMC fracture is the second most common facial fracture, after the nasal bones.1 The prominent nature of the malar eminence places this structure at great risk for fracture, and the intricate 3-dimensional (3D) nature of the ZMC can sometimes make the repair quite challenging (Figure 2). Several authors have noted the high rate of misalignment and displacement after repair.3,4 Despite seemingly adequate reduction and/or fixation, several authors have also noted high rates of asymmetry in up to 13% of cases.3,4 The asymmetry manifests because of an inadequate intraoperative reduction or a postreduction displacement encountered during the postoperative period. Surgeons may place the blame on inadequate fixation during the initial operation, postoperative displacement due to the pull of the masseter muscle, or poor initial reduction.Figure 1. The illustration shows the 4 suture lines that are associated with a zygomaticomaxillary complex fracture. The arrows show the distribution of energy after an impact on the malar eminence (reproduced with permission from Strong and Sykes2).Figure 2. The 3-dimensional Illustration of a representative craniofacial skeleton with the x-axis (X) through the inferior orbital rim and zygomatic arch. The y-axis (Y) extends from the frontozygomatic suture line, inferiorly along the lateral wall of the orbit. The z-axis (Z) is perpendicular to the malar eminence, parallel to the lateral wall of the orbit.A few classification systems have been cultivated to aid in the treatment planning of ZMC fractures and provide a quick description of each fracture. The first was the Knight and North5 classification, which was based on an anatomical scheme from I through VI: group I, no significant displacement; group II, direct blows that buckle the malar eminence inward; group III, unrotated body fractures; group IV, medially rotated body fractures; group V, laterally rotated body fractures; and group VI, complex fractures (presence of additional fracture lines across the main fragment). Knight and North stated that fractures in groups II and V needed only closed reduction without fixation and that those in groups III, IV, and VI needed fixation for adequate reduction. Consequently, Pozatek et al6 determined that up to 60% of group V cases were unstable for closed reduction. Other classification systems were later developed. Manson et al7 devised a system based on the patient's computed tomographic (CT) scan to classify ZMC fractures on 3 levels: low-, medium-, and high-energy fractures. Low-energy fractures involve minimal displacement and an incomplete fracture. Medium-energy fractures involve moderate displacement with complete fractures across all buttress. High-energy fractures are the most severe type and are associated with other midface fractures. Zingg et al4 developed a classification system to encompass all types of ZMC fractures. Type A involves only 1 site of the ZMC (A1, the arch; A2, the lateral orbital rim; or A3, the inferior orbital rim). Type B involves all 4 suture lines of the ZMC. Finally, type C involves comminuted fractures.Regardless of the fracture classification, the overall incidence of ZMC fractures has decreased over the past few decades as a result of the laws mandating seatbelt use in automobiles. Air bags have not been shown to be as protective against ZMC fractures as previously thought. The patterns for fractures of the nasal bones and ZMC fractures have not changed much since the federal law enforcing air bag installation in automobiles was passed.8 Unfortunately, to our knowledge, there is no current study that reports the incidence of ZMC fractures. However, in 1985, Ellis et al9 reported that most ZMC fractures are the result of assaults, falls, sporting activities, and motor vehicle crashes. Roughly 25% of all ZMC fractures are associated with other facial fractures.9Patients may have various presentations of ZMC fractures, depending on the severity of the fracture. Most patients present with swelling, edema, subcutaneous emphysema, and ecchymosis of the malar eminence. Frequently, the depression of the ZMC is not evident until the swelling and edema have resolved. Pain and tenderness may arise with palpation along the fracture lines or numbness. Also, the fracture sites may often disrupt the path of the infraorbital nerve and its branches. Some authors advocate open reduction and internal fixation to restore sensation when sensory dysfunction of the infraorbital nerve occurs, often as a result of compression.10,11 The recovery of the nerve seems to be expedited when open reduction rather than closed reduction is used.10,11Furthermore, patients may complain of trismus after a ZMC fracture. This complication is likely due to impingement of the depressed arch on the temporal muscle or coronoid process, depending on the site of the fracture. Posterior displacement of the fractured zygoma may result in impingement on the coronoid process and cause trismus. Zygomaticomaxillary complex fractures that compress the coronoid process need to be repaired because of the risk of osteogenesis and ankylosis of the mandible, which may require a coronoidectomy for correction (Figure 3).12 Also, the temporalis muscle may be a cause of and/or a contributor to trismus because the muscle may be compressed by a mid to posterior fracture of the zygomatic arch (Figure 4). Patients may complain of substantial pain when they attempt to open their mouths because the in-fractured bone is rubbing against the temporalis muscle.Figure 3. Compression of a fractured zygoma on the cornoid process (arrow).Figure 4. An axial computed tomogram showing a fractured zygoma compressing the temporalis muscle.Diplopia is a common feature of a complex ZMC fracture because 1 of the fracture sites involves the zygomaticosphenoid suture (Figure 5).13 The bone fragments can compress 1 or more of the extraocular muscles and cause entrapment with gaze limitation. Younger patients may develop a greenstick fracture of the orbital floor, which may cause a “white-eye fracture.” Entrapment of the inferior rectus can cause the affected orbit to remain stationary, while the other eye moves superiorly on upward gaze (Figure 6). Also, a hematoma may cause delayed diplopia; however, once the hematoma resolves, the diplopia improves. Ellis et al9 reviewed more than 2000 cases of ZMC fractures and noted that up to 12% of patients may have diplopia. Associated enophthalmos can accompany diplopia when a significant amount of orbital contents herniates into the maxillary sinus. As many as 3% to 4% of patients present with associated enophthalmos with a ZMC fracture.3 Repair of the orbital floor and proper reduction of the zygomaticosphenoid fracture resolves the enophthalmos and diplopia, respectively. Urgent or even emergent repair of a ZMC should be performed when there is muscle entrapment or an oculocardiac reflex. This situation is even more urgent in children.Figure 5. An axial computed tomogram showing a zygomaticosphenoid suture (arrow) in a zygomaticomaxillary complex fracture.Figure 6. “White-eye fracture” from inferior rectus muscle entrapment in a right orbital floor fracture.DIAGNOSISCurrently, ZMC fractures as well as other fractures of the maxillofacial area are diagnosed with high-resolution and 3D CT scans. Previously, plain films were used to diagnose fractures of the ZMC; however, with the accessibility of CT scans, CT has become the criterion standard for diagnosing ZMC fractures and guiding treatment options.14 Axial images allow the best view of the zygomatic arch, vertical orbital walls, and maxillary sinus, while coronal cuts are better for visualization of the FZ suture line and the lateral and infraorbital rims.12Also, 3D reconstructions of images enable surgeons to better visualize the malpositioned bone for repair (Figure 7).15 The 3D CT scans are useful for fractures of the ZMC and midface.16,17 Therefore, 3D CT does not replace 2D because it does not evaluate soft-tissue deformities, and it is limited only to bone. Furthermore, orbital fractures are not seen as well on 3D CT reconstructed images. Despite these limitations, 3D CT scans continue to be useful in operative planning and decision making. With increasing technology, they are becoming more available and better in quality.18Figure 7. A 3-dimensional computed tomographic reconstruction of a left zygomaticomaxillary complex fracture.TREATMENTDespite the high frequency of ZMC fractures, there is no consensus among reconstructive surgeons regarding the best operative management. There is substantial variability within ZMC fractures, which makes the proper surgical choice challenging. However, there are 4 basic principles that surgeons must consider when undertaking the repair of a facial fracture: adequate exposure, proper reduction, stable fixation, and minimal complications. Multiple research articles describe multiple methods for the approach to and fixation of a ZMC fracture. A review of the literature does show a common theme, which is to treat each fracture individually and to attempt to fixate the fracture with the least amount of plating and disruption of soft tissue.Fractures of the ZMC are approached by observation, closed reduction without fixation, or open reduction with fixation at 1 or more buttresses. Most (approximately 77%-94%) are surgically repaired.5,19 Those that involve any visual or orbital compromise or substantial functional or cosmetic deformity need surgical management and proper correction. Those that cause any extraocular muscle entrapment, exophthalmos (from an intraocular hematoma), or orbital apex syndrome (deficit of cranial nerves II, III, IV, V1, or VI) need emergent repair. A documented ophthalmologic evaluation is essential before surgical treatment in these cases.3 Minute ocular defects, eg, small retinal tears, may lead to blindness with orbital manipulation.Ellis and Kittidumkerng3 developed a schematic flow diagram for repairing ZMC fractures that did not require internal orbital reconstruction. They concluded that any approaches to the internal orbit involved risk of complications and should be avoided whenever possible. For example, a subciliary approach carries the risk of transient ectropion in 12% of patients and permanent scleral show in 28% of patients.20 Furthermore, a transconjunctival approach to the internal orbit has a 3% risk of permanent scleral show, a small risk of entropion, and no risk of ectropion.20 A subtarsal (inferior eyelid crease) approach should never be used unless a laceration exists at the site because of the poor cosmesis and prolonged edema that are associated with this incision.2 The severity of a ZMC fracture could be determined from a CT scan.7 If present, the infraorbital rim fracture is comminuted in 60% of cases and does not serve well for a site of stabilization. Also, a sublabial-vestibular incision is able to expose this fracture line, therefore lessening the need for a subciliary or transconjunctival approach unless an internal orbital wall or floor defect requires repair. A surgeon could determine the necessary treatment to adequately reduce and stabilize a ZMC fracture intraoperatively. With the help of a Carroll-Girard screw or a bone hook, the surgeon can manipulate a malar complex into the proper position and reduce the fracture. Finger palpation can test the fracture to determine stability. If any instability is noted, the zygomaticomaxillary buttress can be exposed with a vestibular sulcus incision and plated for additional stability; however, this approach does place the infraorbital nerve at risk. Therefore, if the reduction remains questionable, then the FZ suture line should be exposed either via a lateral brow incision or an upper blepharoplasty incision (the hemicoronal incision is usually reserved for severely comminuted fractures). The fracture at the FZ line should be reduced and plated. Some authors advocate plating the FZ suture in a ZMC fracture only if the following 3 stipulations are met: (1) minimal or moderate displacement of the infraorbital rim, (2) no ocular signs of diplopia or enophthalmos, and (3) comminuted infraorbital rim fractures where internal fixation is difficult.21,22 If instability continues to exist, the infraorbital rim and/or the zygomatic arch should be addressed, depending on which site is responsible for the continued instability. The zygomatic arch can be reduced via 3 main approaches: towel clip or bone hook reduction, Gilles, or hemicoronal.23 The latter approach is usually reserved for severely communited zygomatic arch fractures and posteriorly displaced ZMC fractures.24,25 It provides excellent exposure to the ZMC and allows adequate reduction and fixation; however, care must be taken to avoid damage to the temporal branch of the facial nerve that lies in the temporoparietal fascia.Another recent treatment option worth noting is the endoscopic approach. This approach allows the surgeon to use the sublabial approach to the zygomatic arch for reduction.26 Also, the orbital floor can be addressed via a transantral exposure. The endoscope can reveal the severity of orbital floor involvement in a ZMC fracture and assist in repair if needed27 or reveal any changes or disruptions to the orbital floor after ZMC reduction. The endoscopic approach avoids any incision near the eye and prevents the risk of scleral show and ectropion from subciliary or transconjunctival incisions.Moreover, the trend in the current literature is for surgeons to use less soft-tissue disruption and less exposure and plating unless necessary because of postoperative complications. Some authors argue the need for at least 2- or 3-point fixation of the ZMC to prevent inferior displacement and/or rotation due to the pull of the masseter muscle.28-31 The ZF suture seems to be most affected by the action of the masseter.32 Hanemann et al32 concluded that the ZF fracture site was not only the strongest suture in a ZMC but also one of the most important to repair to oppose the action of the masseter muscle.33 An injection of botulinum toxin has been advocated to paralyze the masseter muscle and to allow proper healing of a repaired ZMC.34 Kayikçioğlu et al34 promote this method of treatment to decrease the amount of plating that a ZMC needs since the masseter muscle no longer poses the risk of causing postoperative displacement, which can prevent facial asymmetry after an adequate reduction. Also, surgeons are now exploring the use of intraoperative CT scans after reduction. Rabie et al35 noted that intraoperative CT monitoring changed the management of a few facial fracture cases and confirmed their reduction.In conclusion, ZMC fractures can be quite challenging to manage. Their complex 3D nature and location make them difficult to reduce and fixate. There is no consensus regarding proper management.Author Contributions:Study concept and design: Kellman. Acquisition of data: Meslemani. Analysis and interpretation of data: Kellman. Drafting of the manuscript: Meslemani. Critical revision of the manuscript for important intellectual content: Kellman. Administrative, technical, and material support: Kellman and Meslemani. Study supervision: Kellman.Financial Disclosure: None reported.Online-Only Material: This article is featured in the Archives Journal Club. Go here to download teaching PowerPoint slides.REFERENCESEnglish GM, et al.. Otolaryngology: A Text Book.. Hagerstown, MD: Harper & Row; 1976 Google ScholarStrong B, Sykes J. Zygoma complex fracture.. 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New York, NY: Springer-Verlag NY Inc; 1998:133-138 Google ScholarKayikçioğlu A, Erk Y, Mavili E, Vargel I, Ozgür F. Botulinum toxin in the treatment of zygomatic fractures.. Plast Reconstr Surg. 2003;111(1):341–346 12496600 Google ScholarRabie A, Ibrahim AM, Lee BT, Lin SJ. Use of intraoperative computed tomography in complex facial fracture reduction and fixation.. J Craniofac Surg. 2011;22(4):1466–1467 21772153 Google ScholarFiguresReferencesRelatedDetails Volume 14Issue 1Jan 2012 InformationCopyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Danny Meslemani and Robert M. Kellman.Zygomaticomaxillary Complex Fractures.Archives of Facial Plastic Surgery.Jan 2012.62-66.http://doi.org/10.1001/archfaci.2011.1415Published in Volume: 14 Issue 1: January 2, 2012PDF download" @default.
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