近中骨折端稳定的颧骨、颧弓骨折的简略复位固定技术

目的 颧骨、颧弓骨折通常需要冠状切口、下睑切口和口内切口进路,逐一进行裂开骨折段的复位固定。本文旨在探索一种简便而可靠的修复方法。方法 针对颧骨、颧弓骨折其内侧相邻的上颌骨结构稳定、颧骨的近中骨折端移位不明显的6例患者,采取半冠状切口,按顺序复位固定的方法,由后向前做颧弓骨折段的复位固定,核查眶外壁颧额缝和颧蝶缝的衔接无误,最后完成颧额缝处骨折的固定。不需做下眼睑、口内切口以及眶下缘颧上颌缝的固定和口内颧牙槽嵴的骨折固定。结果 本组6例病例均顺利完成骨折复位与固定。术后CT扫描显示各个骨折断端,包括上颌窦后外壁、眶外壁等,都获得精确的解剖复位和牢固固定。两侧面部宽度和颧骨突度基本对称,面形恢复满意。开、闭口功能正常。未发生颞下颌关节损伤、视力损害及面神经额支损伤。结论 应用近中骨折端稳定的颧骨骨折的简略复位固定技术,可恢复颧骨、颧弓的解剖位置。     

Treatment of zygomatic fractures without inferior orbital rim fixation

Zygomatic fractures can be associated with functional and esthetic problems. Recent improvements in surgical techniques and materials have enabled stable fixation of zygmomatic fractures. Multiple-point fixation is most commonly used for internal fixation. Generally, reduction and fixation are performed through lateral brow, subciliary, temporal, or intraoral incisions (three-point fixation). Our experience indicates that postoperative scarring and sensory disturbances are caused by a subciliary incision with inferior orbital rim fixation. It is thus recommended that inferior orbital rim fixation with mini- or microplates be avoided. In patients in whom the fracture does not involve the orbital floor, reduction of the zygoma and zygomatic arch through a temporal incision is performed at this institution. Fixation of the lateral zygomaticomaxillary buttress and anterior wall of the maxilla with miniplates through an intraoral incision is also performed. If necessary, zygomaticofrontal suture fixation with a miniplate or wire is performed through a lateral brow incision. The status of inferior orbital rim reduction is confirmed by palpitation. Inferior orbital rim fixation with mini- or microplates is recommended for reduction of comminuted fractures and orbital floor fractures with herniation of internal orbit components. Patients who did not undergo inferior orbital rim fixation were free of inferior orbital rim deformity, diplopia, and postreduction rotation.     

Analysis of zygomatic fractures

The purpose of this study was to evaluate the natural history of zygomatic fractures in 469 cases over 14 years. The medical records of patients seeking treatment for zygomatic fractures were reviewed. The zygomatic fractures were classified as monopod, dipod, or tripod fractures for most patients. The monopod fractures included (1) zygomaticofrontal, (2) zygomaticomaxillary, and (3) zygomatic arch fractures. The dipod fractures were subclassified into 3 types according to combination of the previously mentioned 3 sites, which were 1 and 2, 1 and 3, and 2 and 3. Tripod fracture included all 1, 2, and 3. Among 469 cases of zygomatic fractures, tripod fractures (n = 238, 50.7%), zygomaticomaxillary fracture (n = 121, 25.8%), and isolated fracture of the zygomatic arch (n = 98 20.9%) formed most of the cases (n = 457, 97.4%). About one-half cases were tripod fractures (n = 238, 50.7%), and another half cases were monopod fractures (n = 220, 46.9%). Only 11 cases (2.4%) were dipod fractures. Most of the monopod fractures were zygomaticomaxillary (n = 121, 25.8%) and zygomatic arch fractures (n = 98, 20.9%). Among the dipod fractures, no cases of zygomaticofrontal and zygomatic arch fractures were reported. An open reduction was performed in 73.8% (346 cases), closed reduction in 24.5% (115 cases), and conservative treatment in only 1.7%. In tripod fracture (n = 238), an open reduction and internal fixation was performed for most of the cases (n = 225, 94.5%), and closed reduction was performed in only 11 cases (4.6%). In monopod zygomaticomaxillary fracture (n = 121), internal fixation was performed for most of the cases (n = 108, 89.3%), and closed reduction was performed in only 9 cases (7.7%). However, in monopod fracture of the zygomatic arch (n = 98), most of the cases (n = 95, 96.9%) were treated with closed reduction; open reduction was performed in only 1 case (1.0%). At zygomaticofrontal area (n = 241), internal fixation was performed in most of the cases (n = 198, 82.2%). At the infraorbital rim (n = 364), internal fixation was carried out in most cases (n = 257, 70.6%). At the zygomaticomaxillary buttress (n = 279), internal fixation was performed in about one third of the cases (n = 91, 32.6%). At the zygomatic arch (n = 339), only 1 case (0.3%) was fixed internally. The postoperative complication rate occurred in 88 cases (19.1%) among 461 cases operated. The most common complication was hypesthesia (50 cases, 56.8%), followed by diplopia (15 cases, 17.0%), limitation of mouth opening or closure (11 cases, 12.5%), infection (6.8%), and hematoma (4.5%). Most patients with hypesthesia improved at 2 months. About 90% of the patients with diplopia improved within 2 months. Limitation of mouth opening was improved immediately after operation in most of the cases. Our findings demonstrate significant differences in the demographics and clinical presentation that will enable a more accurate diagnosis and prediction of concomitant injuries and sequelae.     

Upper buccal sulcus approach to management of fractures of the zygomatic complex: a retrospective study of 50 cases

A retrospective study was conducted of 50 consecutive cases of fractures of the zygomatic complex reduced by the upper buccal sulcus approach. All were treated successfully with simple elevation (n=38), elevation with intraoral plating at the zygomatic buttress (n=8), or extraoral placement of bone plates (n=4). In no case was the approach deemed unsuitable, or abandoned in favour of another technique. There was minimal morbidity (one case each of mild diplopia, trismus, and swelling, all of which settled spontaneously). The upper buccal sulcus approach is a safe, rapid and effective technique for the reduction of zygomatic body and arch fractures.     

Biomechanical analysis of the rigid fixation of zygoma fractures: an experimental study

In this experimental study, the goal was to test the sufficiency of actual fixation plates in zygomatic complex fractures and the efficiency of a modified plate at the zygomaticofrontal suture in a suitable model, which was designed for biomechanical study. To address this issue, a zygomatic fracture model produced by using a cadaveric cranium was simulated and the fractures were fixed by the actual and modified fixation materials. The force simulating masseter muscle pull was applied with the Lloyd material testing apparatus, and the rotation of the zygoma was determined using displacement transducers. In this study, there were three different experimental groups. Although miniplates at the zygomaticomaxillary buttress and microplates at the infraorbital rim were used in all three groups, three different plates (miniplate, microplate, and modified plate) were used at the frontozygomatic suture in these groups. Rotational displacement of the zygoma with the effects of simulated masseter muscle force was determined. According to the results obtained, microplates are not effective in stabilizing the frontozygomatic suture when the masseter muscle forces are within physiological range. Although miniplates stabilize zygomatic complex fractures, it was shown that modified microplates, which have no ondulation along the plate border, have a higher resistance to rotation than that of the conventional plates. The rotation angle at the instant of fracture with microplates was 4.59 degrees, and that with miniplates was 1.26 degrees. The maximum rotation angle with modified microplates was 0.32 degrees. Modified microplates designed for the fixation of fractures in the zygomatico-orbital region have been shown to be suitable in a well-designed experimental model and might be appropriate for clinical use.     

The validity of ultrasonography in the diagnosis of zygomaticomaxillary complex fractures

The aims of this study were to determine the sensitivity, specificity, positive and negative predictive values of ultrasonography in detecting zygomaticomaxillary complex fractures, and to highlight factors that may affect the validity of ultrasonography in the diagnosis of zygomaticomaxillary complex fracture. Twenty-one patients with suspected fractures of the zygomaticomaxillary complex presenting at the authors' hospital were included in this prospective study. All the patients had plain radiographic and computed tomography (CT) investigations. All underwent ultrasonographic examination of the affected region using an ultrasound machine with a 7.5 MHz probe. The different radiologists were not aware of the results of the other two investigations. Statistical significance was inferred at P<0.05. The validity of ultrasonography varied with fracture sites with a sensitivity of 100% for zygomatic arch fractures, 90% for infraorbital margin fractures and 25% for frontozygomatic suture separation. Specificity was 100% for the three types of fracture. There was no statistically significant difference in the ability of CT scan and ultrasonography to diagnose fractures from various zygomaticomaxillary complex fracture sites (P=0.47). Ultrasonography has proved to be a valid tool for the diagnosis of zygomatic arch and displaced infraorbital margin fractures.     

Percutaneous osteosynthesis of the zygomatic buttress.

We describe a technique of percutaneous miniplate osteosynthesis of the zygoma, using the transbuccal approach. It can be used in conjunction with an extraoral approach, or in isolation. Excellent access was achieved to the posterior zygomatic buttress and arch of zygoma, and the infraorbital rim. No complications developed in the two cases presented. This technique is a useful addition to the armamentarium of maxillofacial surgeons.     

Blending of the eyelid–cheek junction and removal of protruding fat: an intraoral approach to blepharoplasty of the lower eyelid

Blepharoplasty is one of the most common aesthetic procedures done today. The protruding fat and lid–cheek junction are the most conspicuous signs of aging that need attention. During zygomatic reduction by an intraoral approach we found occasionally that the orbital fat can be exposed through the perforated periosteum at the inferior obital rim. We therefore developed a new blepharoplasty procedure using an oral approach.Seventeen patients aged from 26 to 38 years, of whom six had had a previous unsuccessful blepharoplasty and one had a history of injury to the lower lid, were studied. The operation was done under an infraorbital nerve block and local anaesthesia through an intraoral incision at the upper vestibular groove. The periosteum was raised on the surface of the maxilla to the infraorbital rim, and the infraorbital nerve preserved. The periosteum and the orbital septum were incised along the whole length of the infraorbital rim. The fat that was exposed through the incision was either removed or preserved and fixed to the outer soft tissue with sutures.Cosmetic results were good and the oral incision healed without infection. Six patients developed numbness in the infraorbital region, five of whom recovered within 3 months; the other recovered by 6 months postoperatively.     

Classification and treatment of zygomatic fractures: a review of 1,025 cases.

The treatment of zygomatic fractures varies among surgeons, and the cosmetic and functional results are frequently less than optimal. A treatment guideline based on a simple classification of zygomatic fractures is presented. The emphasis is placed on the indications for closed and open reduction, consistent methods of three-dimensional alignment and fixation, and the management of concomitant infraorbital rim and orbital floor fractures. Postoperative results with regard to infraorbital nerve and maxillary sinus dysfunction, malar asymmetry, and orbital complications in the treatment of 1,025 consecutive zygomatic fractures are presented.     

颧眶骨折手术治疗的临床研究

目的:回顾性研究颧眶区骨折的手术治疗方法。方法:统计我科2002-03~2006-02病房收治的118例口腔颌面部骨折患者病历资料,对其中手术治疗的38例颧眶区骨折患者的手术治疗方法、疗效进行分析。结果:手术治疗的颧眶区骨折患者均获得良好疗效,患者面型、咬合恢复满意,无严重手术并发症发生。结论:手术治疗应为颧眶区骨折确定性治疗的首选方法,复位后颧颞缝(或颧弓)、颧额缝和颧上颌支柱3点固定可以保持颧骨体的稳定,伴有眶底缺损者应同期手术修复。     

小切口配合提骨钩用于颧骨复合体骨折治疗的临床总结

目的:探讨提骨钩、小切口在颧骨复合体骨折三维复位中的临床效果。方法:32例颧骨复合体骨折患者,经术前X线片或三维CT成像等影像学检查确诊后,手术取眉弓外、下睑结膜内及同侧上颌磨牙区前庭沟切口,配合提骨钩行三维复位后,分别用小型钛板进行颧额缝、眶下缘、颧上颌缝3点的坚强内固定。结果:所有患者切口均一期愈合,颧面部外形满意,张口度正常,无复视、眼睑外翻、面部麻木等并发症。结论:小切口配合提骨钩可减少手术损伤,并能达到骨折三维复位的目的,具有一定的临床推广价值。     

Lateral coronoid approach for intraoral reduction of fractures of the zygomatic arch.

A technique for reduction of fractures of the zygomatic arch with use of a more direct anatomical approach is presented. This method obviates the potential difficulty of coronoid interposition and elevation of an isolated fragment encountered with use of the old Keen approach.     

Maxillary antral bone grafts for repair of orbital fractures.

Use of bone from the maxillary antrum to repair defects in the orbital floor was described more than 20 years ago but has not been reported for correction of orbital rim fractures. The method is appealing because the source is contiguous with the recipient site; enhanced exposure might allow better fracture reduction and evacuation of debris and hematoma from the maxillary sinus. The intraoral approach also avoids an external incision and scar, prevents such complications as pneumothorax or dural perforation, and reduces postoperative pain. In 60 cases of orbital and zygomatic complex fractures seen between 1985 and 1990, less than 8% required more extensive graft material than the maxillary antra could provide. To assess the potential advantages of local over extraanatomical bone grafts, we evaluated maxillary antral bone grafts obtained through buccal sulcus incisions in 14 patients for restoration following fractures of the orbit. Several of these patients are described. Bone union was complete in all patients and there was no morbidity related to infection, oroantral fistula formation, dehiscence, or disfigurement. Sufficient bone was available from the uninvolved contralateral side to repair even severely comminuted fractures. In zygomatic complex fractures, maxillary antral grafts appeared to provide additional strength in the region of the fractured maxillary buttress. The success of the procedure in our experience, coupled with the safety of bone harvesting from this source, and the avoidance of an external scar make maxillary antral bone well suited to reconstruction of all areas of the orbit.     

Treatment of noncomminuted zygomatic fractures with percutaneous screw reduction and fixation

The standard treatment modality of zygomatic fractures is open reduction and rigid fixation of the fractured segments. Although most of the zygomatic fractures deserve this attentive surgical manipulation to prevent late residual asymmetry, minimally depressed noncomminuted zygomatic fractures can be reduced and fixed percutaneously. Percutaneous intervention causes minimal scarring and morbidity than open techniques and it is possible to align fragments precisely by using high-quality three-dimensional computed tomography (3-D CT) imaging. Six patients with noncomminuted fractures of the zygomaticomaxillary skeleton were evaluated with plain radiographs of facial bones, axial, coronal and 3-D CT. Reduction of the displaced bone segments were achieved by traction of percutaneously applied screw. Either reduced segments were not fixated at all or one of the two new fixation techniques, described in detail in the article, were used for stabilization of reduced segments. In all patients, accurate reduction was obtained. None of the patients showed any recurrent displacement or infection during the follow-up period of six months. The screws were removed in the clinical settings without difficulty. Although percutaneous reduction and external fixation of noncomminuted zygomatic fractures has limited indications, it has its own advantages over open techniques. This method is a less invasive technique and can be performed without any problem in selected cases. Our technique is not suitable for complex zygomatic and periorbital fractures.     

Comparison of various approaches for exposure of infraorbital rim fractures of zygoma

Objective  The aim of this study was to randomly compare four incisionssubciliary, subtarsal, infraorbital and transconjunctival with lateral canthotomy for treatment of orbital rim or floor fractures. Methods  40 patients with zygomatic complex fractures either isolated or in association with pan facial fractures, were selected for the study. They were divided into four groups of 10 patients each, Group I-Transconjunctival with lateral canthotomy, Group II-Subciliary [single eyelid incision], Group III-Subtarsal incision, and Group IV-Infraorbital incision. The following parameters were compared a) The average time from incision to fracture exposure b) The amount of exposure of the site provided c) The aesthetic appearance of the ‘scar’ d) Complications e) Factor of ‘time’ — its effect on scar and complications. Results  The study revealed that all four incisions provided adequate exposure of fracture site and transconjunctival (22 minutes) required the maximum time for exposure. The complications included ectropion in group I and prolonged edema in group IV. Group II and III patients had relatively lesser number of complications. Group IV patients had visible scar as compared to no scar in group I patients. Conclusion  We conclude by saying that transconjunctival approach provides an excellent aesthetic result when done meticulously. However the subciliary and the subtarsal incisions provide a more rapid, direct approach to the orbital floor and infraorbital rim with minimal morbidity and an aesthetically acceptable scar. The infraorbital incision is the least acceptable aesthetically.     

口内入路微创治疗颧骨骨折

目的:探讨口内入路微创治疗颧骨骨折的临床可行性。方法:对15例颧骨复合体骨折经口内径路切开复位及微型钛板坚固内固定手术。结果:术后1、3、6月复查,全部患者的开口度正常,咬合关系良好,面部皮肤无瘢痕,无面瘫症状和术后感染。结论:口内入路治疗颧骨骨折是一种较理想的治疗方法。     

Modified Gillies approach for zygomatic arch fracture reduction in the setting of bicoronal exposure

Zygomatic arch fractures are common injuries, occurring in isolation in 5% of all patients with facial fractures and in 10% of patients with any fracture to the zygomaticomaxillary complex. Isolated noncomminuted depressed zygomatic arch fractures are easily treated with the minimally invasive Gillies approach, which most often provides long-term stability. However, zygomatic arch fractures often occur in conjunction with zygomaticomaxillary complex, Le Fort, calvarial, and naso-orbitoethmoid fractures. In situations requiring a bicoronal incision to address concomitant injuries, zygomatic arch fractures are frequently treated with wide dissection and rigid fixation. Using principles obtained from isolated arch fractures, we present for the first time to our knowledge the use of a modified Gillies approach to noncomminuted zygomatic arch fractures in a case requiring a bicoronal incision. With the deep temporal fascia exposed from the reflected bicoronal flap, a 1-cm horizontal incision is made within the deep temporal fascia allowing a Gillies elevator to easily reduce the arch fracture in a plane between the deep layer of the deep temporal fascia and the temporalis muscle. This technique exploits the advantages of the traditional Gillies approach, preserving fascial attachments, avoiding neurovascular injury, and obviating the need for rigid fixation. Moreover, this method saves time and money and decreases morbidity. Our modified Gillies approach to zygomatic arch fractures in the setting of a bicoronal incision can be applied to a wide range of cases because of the frequency with which arch fractures occur with concomitant craniomaxillofacial injuries requiring wide exposure.     

Tomographic analysis of nasomaxillary and zygomaticomaxillary buttress bone thickness for the fixation of miniplates

The purpose of this study was to evaluate the bone thickness of the nasomaxillary and zygomaticomaxillary buttresses to identify the most favourable region for the installation of miniplates. Bilateral tomographic images of 103 individuals were evaluated, for a total of 206 nasomaxillary and zygomaticomaxillary buttresses. Measurements of bone thickness were performed in the parasagittal reconstructions along three vertical lines on the nasomaxillary buttress (21 measurement points) and four vertical lines on the zygomaticomaxillary buttress (28 measurement points). The vertical line measurements for each buttress were compared using the Kruskal–Wallis test. Spearman’s correlation coefficient was used to determine the correlation between the thicknesses obtained and patient sex and side (right/left). The level of significance adopted was 5%. The nasomaxillary and zygomaticomaxillary buttresses presented statistical differences in thickness at their respective points (P = 0.001). The analysis of the nasomaxillary buttress showed that the thicker bone for the installation of miniplates follows the long axis of the upper canine at a distance of 3 mm from the root apex. For the zygomaticomaxillary buttress, thicker bone to install miniplates was found distal to the distobuccal root of the first molar, at a distance of 3.5 mm from the limit of the infraorbital foramen.     

Immediate reconstruction of an orbital complex fracture with autogenous mandibular bone.

A case of fracture of the zygomaticomaxillary complex with an associated defect of the infraorbital rim and orbital floor is discussed. Use of the lateral plate of the mandibular ramus to reconstruct the defect and advantages of this technique are discussed.     

Retroseptal transconjunctival approach for fractures of the zygomaticomaxillary complex: a retrospective study

We designed a retrospective study to evaluate the efficacy of retroseptal transconjunctival approaches in the management of fractures of the zygomaticomaxillary complex (ZMC). The patients were from a single institution, and had had three-point fixation of fractures of the ZMC between 2008 and 2016. A total of 77 patients (56 men and 21 women with a mean (range) age of 28 (18–54) years), were divided into two groups. Group I (n = 51) had had reduction and fixation of the infraorbital rim using a retroseptal transconjunctival approach. In group II (n = 26) the same approach had been used with lateral canthotomy and inferior canthlolysis for both the infraorbital rim and the zygomaticofrontal region. We analysed the association of both approaches with the outcomes of reduction, fixation, and complications. Suboptimal results were found in 13 patients in group I and one in group II (p = 0.017). There were also three patients with trichiasis and two with entropion in group I, and one each of both complications in group II. There was only one patient with a malopposed lateral canthus in group II. All 26 patients in group II had no perceptible scar along the extended line of incision. The risk of a suboptimal outcome was reduced by 20% (relative risk = 0.8) in group II. The retroseptal transconjunctival approach with lateral canthotomy and inferior cantholysis is safe, aesthetic, and effective in the management of fractures of the ZMC.