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Posttraumatic and postsurgical sensory disturbance is a known complication of almost all zygomaticomaxillary (ZMC) complex fractures involving the infraorbital nerve, for which few treatments are effective. Our study used neurosensory assessments to evaluate the efficacy of melatonin on pain and nerve healing following ZMC surgery. Sixty-four randomly allocated ZMC fracture patients were prophylactically administered either oral melatonin or an identical placebo for 15 consecutive days. Pre- and postsurgical clinical parameters included subjective pain, numbness, and objective neurosensory function. Melatonin significantly reduced subjective pain perception in the early postoperative days, with a significant difference in VAS scores between the groups from postoperative day 3 (p = 0.048) until day 7 (p = 0.002). The VAS assessment of subjective numbness perception showed significantly lower self-perceived neurosensory disturbance for patients in the interventional group from the first month (p = 0.039) until the third month (p = 0.005). Objective neurosensory assessment using the pinprick test and two-point discrimination showed statistically significant improvement to almost normal sensation by the first month (p = 0.014) to fully normal sensation by the third month (p = 0.001). The study findings suggest that the prophylactic administration of melatonin confers significant clinical benefits in terms of reduced postoperative pain and improved sensory recovery., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Our study aimed to evaluate modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex (ZMC) fractures. The retrospective non-randomized study was conducted in a single hospital in China. All patients diagnosed with unilateral comminuted ZMC fractures between January 1, 2018 and December 31, 2022 were retrospectively reviewed. All patients underwent preoperative spiral computed tomography (CT). CT data were processed using software to DICOM format and transferred to Proplan CMF3.0 for preoperative virtual surgical planning and postoperative evaluation. All data were extracted from standardized electronic medical records. All statistical analyses were performed using SPSS version 20.0. The chi-square test and t-test were used for statistical analyses. The 54 included patients were divided into two comparable, equal cohorts of 27 patients, and followed up for at least 6 months. Fracture reduction was assisted using the modified patient-specific surgical guides in the guide group (23 males, four females; mean age 37.74 ± 12.07 years) and without the modified patient-specific surgical guides in the control group (20 males, seven females; mean age 37.44 ± 13.58 years). In the guide group, the mean eminence deviation between the affected and unaffected sides was 1.01 ± 0.92 mm, and the mean width deviation between the affected and unaffected sides was 1.29 ± 1.32 mm. In the control group, the mean eminence deviation between the affected and unaffected sides was 1.99 ± 1.69 mm, and the mean width deviation between the affected and unaffected sides was 2.68 ± 2.01 mm. The differences in facial protrusion (p = 0.001) and width (p = 0.003) symmetry between the affected and healthy sides of the two groups were statistically significant (p < 0.05). In conclusion, applying the modified patient-specific surgical guides to unilateral comminuted zygomaticomaxillary complex fracture reduction has the advantages of greater predictability and effectiveness, and improved bilateral ZMC symmetry. It should be noted that this approach would be especially beneficial for less-experienced surgeons., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Zygomaticomaxillary complex (ZMC) fracture repair is one of the most common surgical procedures performed in craniomaxillofacial trauma management. Miniplates and screws are used to stabilize the fractured bone using small local incisions, however, these procedures are not infrequently associated with hardware-related post-operative complications. The amount of fixation hardware utilized varies depending on the fracture pattern and surgical judgment, with three-point fixation being the conventionally accepted treatment. However, limited experimental testing and clinical studies have suggested that ZMC stabilization may be achieved with less than three-point fixation. In this study, we utilized a previously developed finite element modeling approach that allows for detailed bone and muscle representation to study the mechanical behavior of the fractured craniomaxillofacial skeleton (CMFS) under one, two, or three-point fixation of the ZMC. Results suggest that using a miniplate along the infraorbital rim in three-point fixation increases the amount of strain and load transfer to this region, rather than offloading the bone. Two-point (zygomaticomaxillary and zygomaticofrontal) fixation yielded strain patterns most similar to the intact CMFS. One-point (zygomaticofrontal) fixation resulted in higher tensile and compressive strains in the zygomaticofrontal region and the zygomatic arch, along with a higher tensile strain on the zygomatic body. These modeling results provide biomechanical evidence for the concept of over-engineering in the stabilization of facial fractures. Furthermore, they support previous suggestions that less than three-point fixation of ZMC fractures may be adequate to achieve uneventful healing., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest related to the research presented in this article., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The study aims to assess the safety and effectiveness of BoneTape™, a new resorbable bone fixation device, using a zygomatic fracture model in rabbits., Methods: The study followed BoneTape™ samples and control (sham) groups over 2-, 6-, and 12-week periods post-zygomaticomaxillary (ZM) osteotomy and zygomaticofrontal (ZF) disarticulation. The osteotomized segments were analyzed for bone healing, inflammatory response, and tissue healing. µCT imaging and histological analysis were used to examine the axial alignment, offset, and quality of new bone formation., Results: BoneTape™ samples demonstrated enhanced maintenance of the initial intraoperative positioning, reduced axial offset, and better alignment when compared with the control group, enabling stable bone healing under physiological loading conditions. Complete union was observed at 12-weeks in both groups. The BoneTape™ group experienced minimal immune and tissue reactions, classically associated with wound healing, and showed an increased number of giant cells at 6 and 12-weeks., Conclusion: BoneTape™ represents a promising advancement in osteosynthesis, demonstrating efficacy in maintaining stable zygomatic reconstruction and eliciting minimal immune response in a rabbit model. This study introduces BoneTape™ as a disruptive solution specifically designed for clinical application in cranio-maxillofacial fracture fixation, with the potential to eliminate the use of over-engineered solutions while offering benefits such as ease of application and fewer biologically disruptive steps., Competing Interests: Declaration of Competing Interest Michael C Floros, Alex J Lausch, Janaina F Bortolatto, and Alexandra Johnson Valiente are salaried employees of Cohesys and also own shares or option. Eli D. Sone, J. Paul Santerre, Cari Whyne, and Jeffrey A. Fialkov hold Cohesys shares or options., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Zygomatic bone contributes to the orbital walls, and therefore associated injuries carry a high risk of severe dysfunction of the visual apparatus. The aim of our study was to retrospectively assess the spectrum and frequency of ophthalmic involvement in patients presenting with malar fracture, and the need for referral to an ophthalmologist for evaluation. In total, 102 patients presenting with malar fracture between January 2008 and August 2017 at Bapuji Dental College and Hospital, Davangere, Karnataka were enrolled in this study. Patients with confirmed malar fracture were categorized according to Henderson's classification, and associated ocular injuries were recorded. Assessment of the spectrum and frequency of ophthalmic involvement in patients presenting with different types of malar fracture was then carried out, followed by categorization of the need for referral to the ophthalmologist with regard to the associated ocular injury, as per the Al-Qurainy et al. (1991) scoring system, allocating the patients to early, routine, and non-referral categories. Statistically significant differences in proportions of various types of ophthalmic involvement were found between categories of malar fracture, and in degrees of ophthalmic involvement within each category of malar fracture, except in the Type II group of patients. The most severe ocular injuries were noted in Type VII followed by Type V, with the least severe injuries noted in Type II patients. According to the Al-Qurainy et al. (1991) scoring system, eight patients required early referral, 10 patients needed routine referral, and 84 patients were in the non-referral category. Categorization of referral of patients to an ophthalmologist in hospitals lacking ophthalmology departments can be based on the Al-Qurainy et al. classification of referral for Henderson's Type III, IV, and VI. Henderson's Type I and II patients need to be referred only in medicolegal cases. Henderson's Type VII and V patients require mandatory referral., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Fixation is critical in zygomaticomaxillary complex (ZMC) fractures to avoid malunion; however, controversy exists as to how much hardware is required to achieve adequate stability. Current fixation regimens may not represent the minimum stabilization needed for uneventful healing. Craniomaxillofacial (CMF) computational models have shown limited load transmission through the infraorbital rim (IOR), and a previous experimental study of ZMC fractures has suggested that IOR plating does not alter CMF bone strain patterns. This study aimed to measure the impact of stabilization on fracture site displacement under muscle loading, testing the hypothesis that three-point fixation is not critical for ZMC fracture stability. Four ZMC complex fractures were simulated on two cadaveric samples and stabilized with three-point plating. Displacements simulating mouth openings of 20 mm and 30 mm were applied to the mandible using a custom apparatus. Fracture gap displacement under load was measured at multiple points along each fracture line, and bone strain was captured using a combination of uniaxial and rosette gauges. Data capture was repeated with the IOR plate removed (two-point fixation) and with the zygomaticomaxillary plate removed (one-point fixation). Fracture displacement under muscle loading was consistent, with gaps of less than 1 mm in 95% of cases (range 0.05-1.44 mm), reflecting clinical stability. Large variabilities were observed in the strain measurements, which may reflect the complexity of CMFS load patterns and the sensitivity of strain values to gauge placement. This study supports the concept of hardware reduction, suggesting that two-point (or even one-point) fixation may provide sufficient stability for a ZMC fracture under applied muscle loading., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest related to the research presented in this article., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The present study aimed to quantitatively evaluate the outcomes of the application of customized integration titanium mesh (CITM) in treating unilateral complicated zygomatic complex fractures. A prospective, randomized, controlled clinical study was conducted. Patients were randomly divided into the experimental group who underwent treatment with CITM, and the control group who underwent treatment just with traditional titanium plates. The X 2 test and student t-test were used for statistical analyses. Twenty patients who required surgery for unilateral complicated zygomatic complex fracture were included in this study. The results showed that the mean of average distance (AD) between pre- and postoperative CT measurements was 0.487 mm in the experimental group and 1.173 mm in the control group (P < 0.001). Compared with the control group, the experimental group had superior zygomatico-facial symmetry (P＜0.05), a shorter average operation time (150 min versus 229 min; P < 0.001), and a higher rate of anatomic reduction (80.0% versus 30.0%; P＜0.05). In conclusion, CITM deserves to be promoted for the treatment of complicated zygomatic complex fractures. TRIAL REGISTRATION: www.chictr.org.cn (ChiCTR1800016818)., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2022 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Inappropriate treatment of zygomatic fractures can reduce esthetic and functional outcomes. The aim of this study was to answer the research question: "Among patients with a unilateral zygomatic fracture, is the use of computer-assisted real-time navigation system during fracture reduction precise and accurate to create postoperative facial symmetry?", Methods: Using a retrospective cohort study design, we enrolled a cohort of unilateral zygomatic fractures undergoing open reduction and internal fixation (ORIF) with the aid of the computer-based navigation system at Chang Gung Memorial Hospital, Taiwan, during January 2015 and March 2018. The predictor variable was the comparison before and after surgery. The main outcome variables included (1) two-dimensional (2D) reduction of the displacement at five anatomical landmarks: zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, zygomaticomaxillary, and zygomaticotemporal lines/buttresses and (2) three-dimensional (3D) differences on distances between zygomatic surface to the porion plane and the midpoint of zygomatic arch (ZA) to the mid-porion (MP) plane. The Wilcoxon signed-rank test was computed to compare between pre- and postoperative data, and a p-value less than 0.05 was considered statistically significant., Results: The cohort comprised 24 subjects (50% females, 75% left-sided) with a mean age of 30.5 +/- 13.8 years. On 2D analysis, the significant fracture reduction was found: 4.78 vs. 1.22 mm, 1.78 vs. 0.40 mm, 3.50 vs. 0.07 mm, 3.06 vs. 0.55 mm, and 2.55 vs. 0.50 mm at zygomaticomaxillary, zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, and zygomaticotemporal landmarks. The 3D evaluations revealed the significant reduction of the differences between the left and right zygomatic surface to the porion plane (4.09 ± 2.12 vs. 0.46 ± 0.35 mm) and between the left and right ZA midpoints to the MP plane (4.89 ± 2.59 vs. 0.71 ± 0.44 mm) (p<0.001 for both 2D and 3D analyses)., Conclusions: The results of this study suggest that the real-time surgical navigation system can effectively guide the ORIF of zygomatic fractures. Future research studies should focus on the learning curve and cost-effectiveness analysis of this technique., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The aim of this study was to evaluate the value of intraoperative conebeam computed tomography (CBCT) imaging in the treatment of zygomaticomaxillary complex (ZMC) fractures. A prospective single center cohort study was performed. Included were consecutive patients who underwent surgery for a unilateral ZMC fracture. An intraoperative CBCT scan was performed after reduction of the ZMC fracture. Revision reduction was performed of the ZMC and/or orbital floor (OF) on indication. The preoperative and postoperative asymmetry of the outer surface of the ZMC was measured on digital 3D-models of CBCT scans, using a mirroring and surface-based matching technique. The postoperative asymmetry of the ZMC in the study group was compared to the asymmetry of the ZMC in the control group with healthy individuals. A total of 38 patients with a unilateral ZMC fracture were included. The mean postoperative asymmetry in the study group (1.67 mm, SD 0.89) was less than the mean preoperative asymmetry (2.69 mm, SD 0.95) (paired samples T-test p < 0.01) but showed no statistically significant difference with the mean asymmetry in the healthy control group (1.40 mm, SD 0.54) (independent samples T-test p = 0.31). Revision reduction of the ZMC and/or OF fracture had been performed in 11 cases after malalignment was noted on the intraoperative CBCT. The indication for intraoperative revision reduction was associated with comminuted ZMC fractures and/or fractures with indication for OF reduction (Pearson Chi Square p < 0.01). Within the limitations of the study, intraoperative CBCT imaging seemed to have a positive influence on ZMC fracture treatment, especially in the case of comminuted ZMC fractures and/or fractures with indication for OF treatment., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The deep temporal fascia (DTF) is known to separate into two layers that descend to attach to the zygomatic arch. When surgeons reduce an isolated fracture of the zygomatic arch through a temporal approach, the temporal incision site needs to be superior to the split line of the DTF., Materials and Methods: Sixty-seven hemifacial cadavers were investigated after removing the skin, subcutaneous tissue, and superficial temporal fascia. The superficial layer of the DTF was exposed. We cut the superficial layer along the line along, which it adhered to the deep layer inseparably. The heights of the split line of the DTF from the superior border of the zygomatic arch and from the top of the helix were measured at three points: at the jugale, zygion, and 3 cm from the tragus., Results: In all cases there were thick identifiable deep layers of the DTF. The mean heights of the split line of the DTF from the superior border of the zygomatic arch were 49.8, 46.7, and 42.6 mm at the jugale, zygion, and 3 cm from the tragus, respectively; the corresponding mean heights of the split line from the top of the helix were 19.1, 15.6, and 11.4 mm., Conclusions: Knowledge of the mean height of the split line of the DTF will be helpful for surgeons to determine the temporal incision site for ensuring the safe reduction of a zygomatic arch fracture., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest concerning the materials or methods used in this study and no source of funding., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Several resorbable fixation systems are used for osteosynthesis in craniofacial surgery. Recently, ultrasonic-assisted pinned resorbable systems have been introduced; however, few studies have described the associated complications during the long-term follow-up until complete resorption. In this study, we investigated the complications of craniofacial surgery using the ultrasonic-assisted pinned resorbable system with a follow-up of at least 30 months. Among patients who underwent craniofacial surgery using a commercially available ultrasonic-assisted pinned resorbable system between 2014 and 2016, those with follow-up visits for at least 30 months were included in this study. We investigated the development of complications such as local infection, exposure of the device, and reoperation related to the implant. Twenty-four patients aged 6 months to 69.4 years (median: 3.5 years) were followed up for more than 30 months. None of the patients required reoperation regardless of implants. Further, no infection or device exposure was seen among all patients. However, two patients aged 6 and 22 months who underwent cranioplasty for craniosynostosis and another patient aged 148 months who underwent cranioplasty for cranial defect exhibited plate-related bulging in the scalp during the course of resorption between 7 and 12 months of follow-up. The bulges were characterized by swelling without pain or redness and resolved spontaneously within 18 months of follow-up, which was considered to occur after complete absorption of the plate. In conclusion, subcutaneous swelling is related to resorbable plates and has a benign clinical course. We recommend that patients be informed of this phenomenon preoperatively to relieve their anxiety., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The zygomaticomaxillary complex (ZMC) functions as the main buttress for the lateral portion of the middle third of the facial skeleton and because of its prominent position & convex shape, it is frequently fractured, alone or along with other bones of the midface. The management of the ZMC fractures is debatable as the literature is saturated with various theories. A number of techniques, from closed reduction to open reduction and internal fixation can be effectively used to manage these fractures. Controversies lie right from the amount of fixation (1-, 2-, 3- or 4- point fixation) required to the ideal approach, and there is no conclusive view on its ideal line of management., Objective: To compare Malar asymmetry after 2-point vs 3-point fixation in the treatment of zygomaticomaxillary complex fractures., Data Source: Electronic search of Pub Med, Google Scholar, Institutional Library, Email to authors and manual search of various journals., Study Eligibility Criteria: The following criteria were used to select the studies on 2- point and 3-point fixation methods in Zygomaticomaxillary complex fractures. Inclusion criteria had articles that included clinical studies published in the English language or those having sufficient data in English on 2-point or 3-point fixation in the treatment of zygomaticomaxillary complex fractures between the period of 1st January 2008 to 30th September 2018. While exclusion criteria were articles not published in the English language before 1st January 2008 and after 30th September 2018, any reviews, abstracts, letters to editors, editorials and in vitro studies were excluded. Studies that included patients with craniofacial and secondary deformities were also excluded., Intervention: Open reduction and internal fixation using 2-point and 3-point fixation methods in the treatment of Zygomaticomaxillary complex fractures., Results: Preliminary screening consisted of 757 studies and additional records identified through other sources of 272 studies. Amongst these 1029 studies, 837 studies were excluded after reviewing the titles. A review of abstract further excluded 71 studies, so 34 studies that remained were evaluated to fit the eligibility criteria. On the basis of information on fixation methods and parameters of evaluation of fixation method, 26 studies were further excluded. Thus 8 studies with a total of 823 estimates were included in qualitative synthesis., Limitations: Parameters assessed by all the authors varied and hence a standardisation for comparison could not be done., Conclusion: Five out of eight studies showed that the use of 3-point fixation in the treatment of zygomaticomaxillary complex fractures was superior than 2-point fixation for the same. Hence it can be concluded that 3-point fixation is superior than 2-point fixation in reducing malar asymmetry in zygomaticomaxillary complex fractures., Future Implications: Future studies with uniform parameters being assessed can be done. 3-point fixation can be used as a standard treatment modality in the effective management of Zygomaticomaxillary complex fractures., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: This study was designed to introduce a novel method of applying osteosynthetic materials to the upper zygomatic arch border for fracture fixation through a temporal incision, and analyze the radiologic morphometric dimensions of the arch to verify its validity., Methods: Radiological morphometry was analyzed in 51 adult patients with unilateral isolated zygomatic arch fractures. Frequent fracture sites, sites of minimal thickness and height, and their correlation were evaluated, as were the locations and dimensions of fixation vantage points. The novel surgical method based on the results was implemented in 17 clinical cases., Results: Frequent fracture sites, occurring 4.40, 16.47 and 30.48 mm posterior to the arch origin, did not correlate to sites of minimal height and thickness. Arch minimal thickness and height locations were 12.23 and 27.09 mm behind its origin, respectively. Fixation vantage point dimensions varied from point to point, with upper thickness ranging from 1.67 to 4.86 mm and mid-portion thickness ranging from 2.06 to 7.36 mm, and height ranging from 8.99 to 22.53 mm. Arch vertical axis inclination ranged from 6.51° to 16.47°, which increased as the arch stretches posteriorly. These results suggested the use of 1.5 mm-wide plates and 1 mm-diameter screws with 6-8 mm length. Patients received surgery based on these morphometry results for satisfactory stabilization., Conclusions: This study introduces a new method for open reduction and internal fixation of arch fractures, with morphometric analysis of the arch verifying the validity of tangential plate application to the upper border., (Copyright © 2018. Published by Elsevier Ltd.)

Importance: Conventional plating systems include titanium plates for the fixation of facial bone fractures. However, titanium plates result in artifacts on computed tomography images and appear unstable on magnetic resonance images. Therefore, absorbable plates have been widely used for the fixation of facial bone fractures of late in Asia., Objective: To compare stability and symmetry among four different absorbable plates used for internal fixation of zygomaticomaxillary complex fractures., Participants: The subjects were patients with zygomaticomaxillary complex fractures that were diagnosed and treated by internal fixation with absorbable plates between January 2012 and April 2018. Patients aged ≤14 years and ≥76 years were excluded. Patients with other fracture types were also excluded. All patients underwent surgery within 2 weeks of the injury., Intervention: Internal fixation was performed with one of four types of absorbable plates, namely Inion ® , Polymax ® , Osteotrans ® , and Biosorb ® ., Main Outcome Measures: The stability of the four plates was investigated by evaluation of the orbital height ratio (A'/A), zygoma angle (a'/a), distance (b'/b) from the midline, and gap (c) of the temporal process on three-dimensional facial computed tomography images obtained before, 3 weeks after, and 3-6 months after surgery. Any plate-associated complications were recorded., Results: In total, 400 patients were enrolled, and there were 100 patients in each of the four groups. There were no significant differences with regard to postoperative stability and relapse among the four plates. Moreover, facial symmetry showed no changes over time in any group. Complications such as infection and sensory disturbance were not frequent. All plates except Biosorb ® were palpable for more than 6 months after surgery, with Osteotrans ® remaining palpable for several years., Conclusions and Relevance: Our findings suggest that all four types of absorbable plates are useful for treating isolated zygomaticomaxillary complex fractures. While Biosorb ® is unsuitable for severe comminuted fractures. Polymax ® and Inion ® are not bendable at room temperature. It is important to select an appropriate absorbable plate according to each patient's condition and the fracture severity., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the effects of surgical navigation in zygomaticomaxillary complex (ZMC) fracture reduction. ZMC symmetry was assessed quantitatively., Materials and Methods: The sample comprised 25 patients who underwent surgical reduction of comminuted ZMC fractures. They were divided into two groups according to the use of surgical navigation. Reduction outcomes were evaluated using three-dimensional computed tomography models. Five pairs of landmarks were identified on all craniofacial models, and asymmetry scores were calculated based on their coordinates. In quantitative analyses, symmetry and orbital volume were compared between groups., Results: All patients recovered uneventfully. Greater symmetry was observed in the navigation group than in the control group for three of the five pairs of landmarks (p < 0.05). Although postoperative volumes of the injured orbits were similar between the two groups (p > 0.05), reduced orbital volumes were larger in the navigation group, indicating better restoration of the fractured orbits (p < 0.05)., Conclusions: The use of surgical navigation can increase postoperative symmetry of the bilateral ZMC. The quantitative evaluation of clinical outcomes is precise and highly reliable., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Although different proposals have been made to categorize isolated zygomatic arch fractures (ZAF), an investigation about fracture type and clinical outcome has not been published. In this study, we analyzed the geometric fracture morphology in isolated ZAF and provide a survey of reduction outcomes in accordance with 4 independent classifications., Materials and Methods: Geometric measurements were performed in radiologic images of 94 patients with isolated ZAF, which were consecutively treated by closed reduction over transbuccal approach. Fracture types were allocated to the classifications of Rowe and Williams, Honig and Merten, Yamamoto et al., and Ozyazgan et al. The odds of achieving a satisfactory outcome were calculated for all categories., Results: Wide preoperative dislocation angles of more than 22° presented in M-type fractures (77.1%) more frequently compared to 2 fragments without the M-shape (33.3%) and one fragment (14.8%, p < 0.001). Favorable reduction outcome was significantly higher for M-shaped fractures than for differently configured fractures (83.3% vs. 30.4%, odds ratio 11.43, confidence interval 4.27-30.61). The rate of reduction in 100%-75% was most frequent for the Honig and Merten type I as well as Ozyazgan type IBV (both 85.4%, p < 0.001) and Yamamoto type II (84.2%, p < 0.001)., Conclusion: The classifications of Honig and Merten, Yamamoto et al., and Ozyazgan were quite applicable, and subgroups showed significant increments in reduction outcome. Our analysis emphasizes that the differentiation of two clinical relevant groups, M-shaped and variable arch fractures, is feasible to manage and efficient to determine the odds of reduction outcome., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Fractures of the zygoma and orbit are common facial skeleton injuries. Inadequate reduction and internal fixation may result in functional and aesthetic impairment. The aim of this study was to assess the use of intraoperative 3-dimensional (3-D) cone beam computed tomography (CBCT) for determining the intraoperative revision rate and the need for additional reconstruction of the orbit., Study Design: We conducted a retrospective analysis of 48 consecutive patients (15 females, 33 males) suffering from simple or complex zygomatic fractures, seen between June 2015 and October 2016. Intraoperative 3-D CBCT (Xoran Technologies, Ann Arbor, MI) was performed, and the intraoperative image was overlaid on the preoperative image by using iPlan software (Brainlab, Feldkirchen, Germany) for quality control. Categorical variables were cross-tabulated and compared using Fisher's exact test. P values and 95% confidence intervals were assessed., Results: In 6 of 48 patients, intraoperative revision was deemed necessary on the basis of the superimposition on the preoperative images. Five of these 6 patients had comminuted fractures (P = .001). In 7 patients, the indication for orbital reconstruction was revised after intraoperative 3-D CBCT., Conclusions: Intraoperative 3-D CBCT allows for immediate revision and prevents unnecessary orbital reconstruction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Zygoma fracture is of clinical importance because malar prominence plays an essential role in facial appearance. Traditionally, most maxillofacial surgeons perform osteosynthesis with titanium plates and screws for rigid fixation. However, this procedure has certain disadvantages that include the possibility of implant exposure, palpability or loosening of the screws, painful irritation, temperature sensitization, and radiographic artifacts. In this study, we compared the function and satisfaction outcome between Bonamates ® bioabsorbable implant and Leibinger titanium implant., Method: Consecutively 53 patients with isolated unilateral zygomatic fracture that were treated with the Bonamates ® bioabsorbable plate system, n = 53 were compared to patients with the titanium plate system, n = 55 in the period between 2009 and 2013. All patients were followed-up at least 6 months. Preoperative and postoperative facial computed tomography (CT) scans were performed and scored from 0 to 2 in the 5 areas of zygoma. A score of 2 indicated the most severely displaced fracture in one of the areas. A visual analogue scale ranging from 0 to 10 was used to assess the postoperative aesthetic and functional satisfactions., Result: The mean ages of the patients in the bioabsorbable and titanium plate groups were 33 years and 30 years, respectively. The male to female ratios were 1.2:1 (bioabsorbable plate group) and 1.1:1 (titanium plate group). The average preoperative CT scan scores of the bioabsorbable and titanium plate groups were 5.7 and 5.1, respectively. The postoperative CT scan scores of the bioabsorbable and titanium plate groups were 1.3 and 1.1, respectively. The implant cost of the bioabsorbable group was approximately 6-fold higher than that of the titanium plate group. The complication rate was similar in both groups and included complications such as palpable implant, skin irritation, and hypersensitive cheek. The patients in both groups attained similar mouth-opening function and a satisfactory score at 6 months after operation., Conclusion: This study revealed that the bioabsorbable plate outcome was similar to the titanium plate outcome for patients with isolated unilateral zygomatic fracture. The bioabsorbable implant system provides another option for internal fixation devices in the treatment of zygomatic fractures and avoids implant removal surgery; however, the implant cost of bioabsorbable plates is higher than that of titanium plates in Taiwan., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

For this study we developed an anatomical thin titanium mesh (ATTM) plate for Asian zygomaticomaxillary complex (ZMC) fracture repair with reduction guidance and fixation function. The ATTM plate profile was designed as an L-shape to fix at the anterior maxilla and lateral buttress of the ZMC. Computer-aided stamping analysis was performed on four screw-hole patterns in the ATTM plate - a control without screw-holes, square screw-holes, double screw-holes, and large-diameter, double screw-holes - using upper/lower dies of averaged ZMC reconstruction models. A regular ATTM plate of 0.6 mm thickness was manufactured and pre-bent using a patient-matched stamping process to verify its feasibility on three ZMC fracture models with one, two, and three fracture segments. The stamping analysis found that the double screw-holes design resulted in the most favorable performance among all the designs because of maximum von Mises stress (408 MPa) under the ultimate tensile strength. Positioning practice showed that the stamped, pre-bent ATTM plate can be used as a reduction guide to provide precise ZMC segment fixation in a completely passive fashion while limiting redundant rotation/micromovement between the separate bones in all directions. This study concluded that the ATTM plate with double screw-hole pattern design, using a patient-matched, pre-bent technique, can fit the ATTM plate/ZMC interface well, decrease mobility of unstable fracture segments, and provide good original facial contour recovery, while improving reduction efficiency., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Zygomaticomaxillary complex (ZMC) fractures are frequent in facial trauma; only fractures of the mandible are more common. Although the frequency of these fractures is geographically consistent, the aetiology differs widely among countries and even regions. Differences in socio-economic status and the ageing population seem to be two causes. This retrospective epidemiological study evaluates patients who were surgically treated for ZMC fractures at a Swiss university clinic., Materials and Methods: This study included 471 patients who were surgically treated for ZMC fractures in an oral and maxillofacial surgery clinic at a Swiss university hospital between January 2004 and December 2012. Complicated fractures such as LeFort II/III and bilateral ZMC fractures were excluded. Data on gender, age, and type of trauma were recorded. Fractures were classified by aetiology: motorised road traffic (car or motorcycle), bicycle, interpersonal violence, sports, falls (both less than and greater than 3 m in height) and other causes., Results: A total of 350 patients were male (74%), and 121 were female (26%). The ZMC fractures were most likely to occur in the third decade (117 cases, 25%). A predominance of male patients was found in the young age groups, but an equal ratio was found in the elderly groups. Etiologically, falls of less than 3 m were the most common cause of ZMC fractures (125 cases, 27%). Interpersonal violence was second (88 patients, 19%); male patients dominated this group, which had a male-to-female ratio of 21:1. A predominance of male patients was found in every subdivision when analysing by aetiology and gender. The lowest proportion of males (57%) was found for falls of less than 3 m., Conclusion: In our study, interpersonal violence and falls outnumbered road traffic accidents among causes of maxillofacial fractures. This is probably a consequence of strict road and work laws. Additionally, the older and more active populations accounted for the highest proportion of falls, and young male patients were the predominant victims of ZMC fractures., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Transconjunctival approach is a standard procedure to address fractures of orbit and the infraorbital rim. Modifications such as transcaruncular or lateral canthal widening allow for extended orbital wall exposure. Especially concerning aesthetics, the transconjunctival approach shows benefits compared to the transcutaneous incisions, such as the transciliary and infraorbital access. Moreover, transconjunctival approach is favored in the literature concerning lid retraction. Monopolar devices have become popular in surgery in the past decades because of good depth control and simultaneous hemostasis with consequently improved overview. Also numerous surgeons use monopolar device in orbital surgery, their safety have never been proved. In this study monopolar microneedle device is compared with conventional access by scalpel concerning lid retraction, foreign body sensation and formation of symblepharon. In our collective complication rates were comparable between the scalpel and the microneedle group. The monopolar microneedle device shows favorable results compared with the scalpel and is easy to handle. Weather the conventional access by scalpel or the access by monopolar device is selected, is rather driven by the surgeon's preferences than by statistical relevance. Nevertheless, monopolar microneedle device shows better depth control and simplifies readaptation of the conjunctival wound's margin., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Orbitozygomatic fractures often lead to infraorbital nerve (ION) injury, and affected sensibility is a common long-term complaint within this patient group. We present a long-term follow-up study where the validated von Frey filament system was used for testing ION sensibility. Furthermore, we examined the incidence of persistent nerve injury and whether more complex fractures led to more pronounced ION sensibility disturbances., Methods: Patients treated for facial fractures involving the orbitozygomatic complex were included and the follow-up time was 3 years or more. Depending on the location and severity of the fractures, the patients were divided into 4 groups. The patients answered a questionnaire before ION sensibility testing with von Frey filaments., Results: Eighty-one patients were examined: 65 males (80%) and 16 females (20%). Examinations were conducted between 3.0 and 7.6 years (mean 4.9 years) after injury. Sixteen patients (20%) had affected and 6 patients (7.4%) had severely affected ION sensibility according to von Frey testing. No statistically significant differences were found in terms of questionnaire score between the groups. There was also no statistically significant correlation between questionnaire results and log von Frey values. Although the effect of groups could not be statistically verified using the log von Frey values, a larger proportion of patients with complex fractures had higher log von Frey values than the other groups., Conclusions: Patients with complex fractures report more permanent sensory disturbance of the ION after surgery than those with isolated orbitozygomatic fractures, although this could not be verified statistically with von Frey filament testing at several locations. Hence, a validated method for testing facial sensibility such as von Frey filaments, although sensitive, is inadequate to determine all aspects of sensory malfunction after orbitozygomatic fractures. This suggests that the patient's experience of long-term sensation after trauma may not be correlated with objective measures., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Lateral displacement of fracture zygomaticomaxillary complex (ZMC) can cause significant increase in orbital volume leading to enophthalmos. The aim of this study was to radiologically evaluate the efficacy of sphenozygomatic (SZ) suture fixation for restoration of orbital volume after elevation of the temporalis in cases of fracture ZMC where the fixation of zygomatic arch (ZA) was deemed necessary through latero-posterior approach., Materials & Methods: 43 operated cases of fracture ZMC using 4-point fixation were divided into two groups. Group I (n = 24) cases had undergone reduction and fixation of SZ suture as fourth point of fixation by elevating temporalis muscle using hemicoronal approach. Group II (n = 19) cases had undergone reduction and fixation of Infraorbital (IO) rim as fourth point of fixation using preseptal transconjunctival approach. Both the groups were analyzed separately and compared for restoring the increased orbital volume on CT., Results: Difference in the pre-surgical orbital volume of both the groups was found to be statistically insignificant [p = .678]. In group I, the average bony orbital volume significantly reduced by 3.6 cc from 25.5 cc to 21.9 cc [p = .000] post-surgically. In group II, the average bony orbital volume reduced by 1.5 cc from 25.6 cc to 24.1 cc post-surgically There was a significant difference in the reduction of the increased orbital volume among the 2 groups (Group I: 3.6 cc, group II: 1.5 cc). The amount of reduction was more and statistically significant [p = .000] in the group I than group II., Conclusion: SZ suture fixation is reliable in reducing fractures ZMC and restoring the increased orbital volume where the fixation of zygomatic arch (ZA) was deemed necessary through latero-posterior approach., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

This study investigates treatment outcome in zygomaticomaxillary complex (ZMC) fracture repair., Methods: The medical records and CT-images of patients that received treatment for a unilateral ZMC fracture in 2005-2011 were studied. ZMC fractures were categorised as incomplete (type A), tetrapod (type B) or comminuted (type C). The incidence of sequelae, wound infection and secondary surgical interventions was analysed per fracture category., Results: A total of 153 patients were treated in the selected period. Persisting sensory disturbances in the area innervated by the infraorbital nerve were observed in 50 cases (37%), facial asymmetry in 19 cases (14%), enophthalmos in 10 cases (7%) and persisting diplopia in 9 cases (7%). Wound infection occurred in 6 cases (4%). Secondary surgical procedures of the ZMC, orbital floor, and/or extraocular muscles were performed in 14 cases (9%). C-type fractures were associated with more secondary corrections for ZMC malreduction (12%, p = 0.03), more secondary reconstructions of the orbital floor (10%, p < 0.01), and more functional corrections of diplopia by extraocular muscle correction (5%, p = 0.02)., Conclusion: Treatment outcome in C-type ZMC fractures is less favourable than treatment outcome in A-type and B-type fractures. Intraoperative imaging, surgical navigation devices and 3D-planning software may improve treatment outcome in C-type ZMC fractures., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: In the last 20 years, surgical approach to the orbitozygomatic fracture has evolved to limit skin incisions and minimize external scars., Methods: The treatment approach to the orbitozygomatic fracture was evaluated by a retrospective chart review from 1992 to 2012, and advantages, disadvantages, and complications were studied., Results: Surgical approach to the orbitozygomatic fracture has evolved from a subciliary to a transconjunctival approach and to a novel extended transconjunctival approach without skin incisions in the last 20 years. The greatest advantage of using an extended transconjunctival approach is the wide exposure of the inferior orbital rim, orbital floor, lateral orbital wall, and the frontozygomatic suture in an unobstructed operative field without any skin incisions. Precise assessment of the reduction at the sphenozygomatic suture is possible with a wide exposure of the lateral orbital wall. As the dissection plane in a transconjunctival approach is entirely posterior to the lacrimal apparatus, the medial incision can be placed medially beyond the lacrimal punctum and by combining this approach with the transcaruncular approach, a wide operative field for the medial orbital wall can be obtained, which is the most advantageous point for choosing a transconjunctival approach over a subciliary approach. The complication rate was comparable to a subciliary approach., Conclusions: The author advocates an extended transconjunctival approach for orbitozygomatic fractures to avoid skin incisions and to precisely assess the reduction status., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Computer-assisted surgery is used for decision making, treatment, and quality control throughout the reconstruction process of unilateral midface defects. The current approaches exploit the symmetry of the face by mirroring the intact side on the defect side using various segmentation methods. All commercially available implementations, however, are somewhat time consuming and dependent on the level of expertise of the user. We present a method for automatic reconstruction of unilateral midface defects using registration., Material and Methods: To reconstruct a skull by registration, the defect volume has to be virtually deleted from the skull. This modified data set is then mirrored and registered onto the original, defect-free skull. The fusion of these two skulls is the virtual reconstructed skull bridging the defect. Reconstruction by registration was performed for 24 different skulls without motion or dental restoration artifacts. Subsequently, simulation was performed with four accurately defined, various-sized, defects of the orbito-zygomatic complex. The results of the automated virtual reconstructions were compared with those obtained for the same defects as determined using conventional atlas-based planning software (iPlan). To simulate various clinical situations, four groups each containing six skulls were evaluated: the complete skull, midface and neurocranium, midface and lower jaw, and midface alone. The differences were compared using the similarity coefficients of Sørensen-Dice and Jaccard. Statistical analyses were performed using the t-test and Mann-Whitney U test., Results: The reconstruction results were similar for all the groups. The Sørensen-Dice coefficients of similarity for all reconstructed skulls were 0.869 and 0.874 for the registration and atlas-based reconstructions, respectively. The corresponding Jaccard coefficients were 0.774 and 0.781, respectively. Atlas-based reconstruction showed significantly better results in group 3 (midface and lower jaw) alone., Conclusion: Virtual automated reconstruction by registration had equivalent accuracy to conventional atlas-based reconstruction across a spectrum of defects, from simple orbital to complex orbito-zygomatic defects. However, for those involving the midface and lower jaw, atlas-based reconstruction showed significantly better results. Although the new approach is somewhat hardware demanding, it is user independent, dispensing with the need for time-consuming adjustments to the results of planning. The first clinical application of registration reconstruction revealed performance equivalent to that of the conventional approach., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of the present study was to assess the indications, results and complications of patients treated with porous polyethylene (Medpor(®)) implants in the Department of Oral and Maxillofacial Surgery of VU Medical Centre, Amsterdam over 17 years. A total of 69 high-density porous polyethylene implants (Medpor(®) Biomaterial; Porex Surgical, Newman, GA) were used in forty patients (22 males, 18 females). All patients were analysed for gender, age, diagnosis, indications for surgery, follow-up period and postoperative complications. A mean age of 34.1 years was observed. The main reason for implant surgery was post-traumatic functional impairment (27.5%). Most implants were placed at the mandibular angel and the orbital floor. Unsatisfactory appearance scored the highest in postoperative complications (10.1%) followed by infection rate (7.2%). Comparing the number of implants placed over the years and the incidence of complications, makes the overall complications rate of porous polyethylene very low. A consensus about antibiotic prophylaxis is needed. The objective measurements in patient satisfaction and proper implant design would be of great use., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

An isolated fracture of the orbital floor needs reconstruction if there is a clear herniation of adipose tissue or of the rectus inferior muscle into the maxillary sinus. A prospective study was carried out treating 20 patients with an isolated blow-out fracture of the orbital floor or with a combined zygomatico-orbito-maxillary complex fracture, using a newly designed anatomically drop-shaped implants made of bioactive glass (BAG) S53P4. Computed tomography (CT) was performed immediately postoperatively to confirm the correct position of the plate. The patients were followed up for an average of 32 months clinically and radiologically with magnetic resonance imaging (MRI) for an average of 31 months. None of the patients had any signs of complications related to the implant and the clinical outcome was very good. None of the patients had persisting diplopia. The level of the pupillas was normal in 15 of 20 patients. Minor hypo-ophthalmos ranging from 0.5 to 1.0 mm was observed in three patients, and moderate hypo-ophthalmos of 2.0 mm was seen in one patient. Hyperophthalmos of 1.0 mm was seen in one patient. Minor enophthalmos on the operated side ranging from 0.5 to 1.0 mm was seen in eight patients. Mild to moderate paraesthesia of the infraorbital nerve was observed in six patients. The immediate postoperative CT and the long term follow-up MRI revealed that the drop-shaped BAG implants retained their correct position in the orbital floor and did not show any evidence of losing their original shape or material resorption. No adverse tissue reaction was associated with the material. Due to the anatomical drop shape, the implants could successfully maintain the orbital volume and compensate for the retrobulbar adipose tissue atrophy., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this study was to assess numbers of patients that required removal of miniplates after open reduction and internal fixation of the orbitozygomatic complex over a six-year period, and review the reasons for removal., Patients and Methods: This was a retrospective study from February 2007 to December 2013. All patients who had open reduction and internal fixation for traumatic orbitozygomatic complex fractures were included and those who returned to theatre for plate removal were identified., Results: 307 plates were placed in 216 patients. Eight plates were removed from six patients giving a 2.6% incidence of plate removal (2.78% of patients). Infection or exposure occurred within the first year in five out of six patients, accounting for the seven buttress plates, which were in situ for an average of 180 days. The infraorbital plate was in situ for 972 days. The majority of plates used were buttress plates as single point fixation., Conclusions: In our experience placement of buttress plates for one-point fixation of traumatic orbitozygomatic complex fractures seems to be a safe and effective method with a low rate of complication. Complications seem to occur within a year, which is similar to previous studies., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Correction of post traumatic orbital and zygomatic deformity is a challenge for maxillofacial surgeons. Integration of different technologies, such as software planning, surgical navigation and stereolithographic models, opens new horizons in terms of the surgeons' ability to tailor reconstruction to individual patients. The purpose of this study was to analyze surgical results, in order to verify the suitability, effectiveness and reproducibility of this new protocol., Methods: Eleven patients were included in the study. Inclusion criteria were: unilateral orbital pathology; associated diplopia and enophthalmos or exophthalmos, and zygomatic deformities. Syndromic patients were excluded. Pre-surgical planning was performed with iPlan 3.0 CMF software and we used Vector Vision II (BrainLab, Feldkirchen, Germany) for surgical navigation. We used 1:1 skull stereolithographic models for all the patients. Orbital reconstructions were performed with a titanium orbital mesh. The results refer to: correction of the deformities, exophthalmos, enophthalmos and diplopia; correspondence between reconstruction mesh positioning and preoperative planning mirroring; and the difference between the reconstructed orbital volume and the healthy orbital volume., Results: Correspondence between the post-operative reconstruction mesh position and the presurgical virtual planning has an average margin of error of less than 1.3 mm. In terms of en- and exophthalmos corrections, we have always had an adequate clinical outcome with a significant change in the projection of the eyeball. In all cases treated, there was a complete resolution of diplopia. The calculation of orbital volume highlighted that the volume of the reconstructed orbit, in most cases, was equal to the healthy orbital volume, with a positive or negative variation of less than 1 cm(3)., Conclusion: The proposed protocol incorporates all the latest technologies to plan the virtual reconstruction surgery in detail. The results obtained from our experience are very encouraging and lead us to pursue this path., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Intraoperative imaging seems to be the next step to improve surgical outcome in the treatment of zygomaticomaxillary complex (ZMC) fractures. Many publications have appeared on intraoperative imaging for trauma surgery, but in most hospitals intraoperative imaging is not routinely performed for ZMC fracture repair. The goal of this review was to assess the value of intraoperative imaging in ZMC fracture repair., Material and Methods: The literature was reviewed with focus on the effects of intraoperative imaging on facial symmetry, fracture reduction and the frequency of additional reduction after intraoperative imaging in ZMC fractures., Results: Six publications were found on the frequency of additional reduction after intraoperative imaging in ZMC fracture repair. Revision of the reduction of the zygoma was performed in 18% (95% CI 10.5%-29.0%), revision of the orbital floor was performed in 9% (95% CI 3.6%-17.2%). No publications were found on the effects of intraoperative imaging on facial symmetry or on the accuracy of fracture reduction., Conclusions: Information obtained from intraoperative imaging often has consequences on the surgical management of ZMC fractures. However, the effect on restoration of facial symmetry and fracture reduction is yet to be established., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Between 3 and 18% of craniofacial osteosynthesis plates are removed due to chronic infection. Removal of the plate is necessary to manage the chronic infective state i.e. miniplate removal results in resolution of the infection. These observations are suggestive of a biofilm-related infection. The aim of this retrospective study was to characterise the presence of biofilm on the removed miniplates from oral and maxillofacial surgery., Materials and Methods: A total of 12 plates and associated screws were recovered from eleven patients suffering from persistent, trauma site infection. The recovered plates plus 1 control plate were imaged using scanning electron microscopy (SEM). One recovered plate was also imaged using confocal microscopy (CM) for comparative purposes., Results: Of the 12 plates, 3 (25%) demonstrated highly localised polymicrobial biofilms, five (42%) demonstrated coccal biofilms, one possessed a filamentous biofilm and one showed attached yeast. Overall, 75% of the plates and 82% of the patients exhibited evidence of biofilm to varying degrees. All of the infections resolved following removal of the plates and antibiotic treatment., Conclusion: Microbial biofilms can explain the clinical course of chronic infections associated with miniplates., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

In a recent RCT comparing biodegradable (Inion CPS) with titanium (KLS Martin) plates and screws for fixation of osteotomies or fractures, we found that in 21% of the cases the surgeon decided intra-operatively to switch from biodegradable to titanium. The aim of the current retrospective cohort study was to analyse the reasons for these switches in order to find predictor variables that may be helpful in the decision to use biodegradable devices or not. The surgeons' opinion about the biodegradable system, and if there was a learning curve in the application of the biodegradable system were also investigated. All variables were assessed during the original RCT by using a questionnaire that was completed by the OMF surgeon directly post-operatively. For the outcome variable "surgeons' opinion" a separate questionnaire was used. Regarding the predictor variables a mandibular fracture had a higher risk of switching compared to a BSSO. However, looking at the reasons for these switches no firm conclusions can be drawn. There was a subjective learning curve to acquire the application-skills for the biodegradable system. There were no changes in isolated Le-Fort-I osteotomies despite the fact that the biodegradable system seems more difficult to apply in the midface. Inadequate stability was the main reason for switching. This can be material-related, or related to inexperience with or lack of confidence in the system, or impatience of the surgeon. A learning curve and personal preferences probably play an important role in the decision to switch. We think that with more patience and more experience it should be possible to increase both user comfort and confidence in the biodegradable system of Inion CPS, which likely will decrease the number of intra-operative switches., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: In this retrospective study we evaluated the epidemiological data and the clinical and radiographical 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-surgical and the surgical group 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 radiographical confirmation of zygomatic complex fractures were present at initial assessment. The patient groups were divided into surgically treated zygomatic complex fractures, and non-surgically treated fractures, with and without 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 43 years (±20 years) and a domination of male patients. The mean age was higher in the non-surgically treated 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. Overall facial swelling and paraesthesia of the infraorbital nerve were found as most common clinical findings. Additionally, malar depression and extraoral steps were frequently found in the surgically treated group, as in the non-surgically treated group only facial swelling was found frequently, whether there was fracture displacement or not. The clinical characteristics 'extraoral steps', 'intraoral steps', and 'malar depression' were found to be significantly related to surgical treatment., Conclusion: Extraoral steps, intraoral steps, and malar depression were significantly related to surgical treatment. The group of non-surgically treated zygomatic complex fractures is a valuable group to investigate as this group also consists of patients with displaced fractures (i.e. 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 group., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Surgical treatment of zygomatico-orbital (ZO) fractures is a common procedure in maxillofacial surgery. Often accompanied by pain, trismus and swelling, postoperative morbidity is a major disadvantage, affecting patients' quality of life. The appliance of kinesiologic tape (KT) improves the blood and lymph flow, removing congestions of lymphatic fluid and haemorrhages. The aim of this study was to find out if the application of kinesiologic tape prevents or improves swelling, pain and trismus after zygomatico-orbital fracture surgery, improving patients' postoperative quality of life. A total of 30 patients were assigned for treatment of zygomatico-orbital fractures and were randomly divided into treatment either with or without kinesiologic tape. Tape was applied directly after surgery and maintained for at least 5 days postoperatively. Facial swelling was quantified using a five-line measurement at six specific time points. Pain and degree of mouth opening was measured. Patient's subjective feeling and satisfaction was queried. The results of this study show that application of kinesiologic tape after zygomatico-orbital surgery significantly reduced the incidence of swelling with an earlier swelling maximum, and decreased the maximum turgidity for more than 60% during the first 2 days after surgery. Although, kinesiologic tape has no significant influence on pain control and trismus, mouth opening increased earlier after operation in the kinesiologic tape group compared to the no-kinesiologic tape group. Furthermore, patients with kinesiologic tape felt significantly lower morbidity than those without kinesiologic tape. Therefore kinesiologic tape is a promising, simple, less traumatic, economical approach, which is free from adverse reaction and improves patients' quality of life., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The aims of the study were to clarify the occurrence of disturbance in surgical wound healing (DSWH) after surgery of zygomatic complex (ZC) fractures and to determine whether perioperatively applied dexamethasone increases the risk for DSWH., Study Design: Of 64 patients who were included in a single-blind prospective trial, 33 perioperatively received a total dose of 10 mg or 30 mg of dexamethasone. The remaining 31 patients served as controls., Results: DSWH occurred in 9 patients (14.1%). Occurrence of DSWH was 24.4% in patients who received dexamethasone and 3.2% in controls. The association between DSWH and dexamethasone was significant (P = .016). Intraoral approach also was associated with DSWH significantly (P = .042). No association emerged between DSWH and age, gender, time span from accident to surgery, or duration of surgery., Conclusions: DSWH occurred significantly more frequently in patients who received perioperative dexamethasone. Because of increased risk of DSWH, perioperative dexamethasone cannot be recommended in open reduction and fixation of ZC fractures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: In Japan we currently use absorption properties for facial fractures. OSTEOTRANS MX(®) (Takiron co., ltd, Japan) is an absorption device, which is called Super FIXSORB MX(®) in Japan. This absorbable osteosynthetic device constitutes unsintered hydroxyapatite particles/poly l-lactide (u-HA/PLLA) composites. This study focuses on reporting clinical cases of using OSTEOTRANS MX(®)., Materials and Methods: Seventeen patients (16 men and 1 woman) aged 10-80 years (mean: 39.9 years, SD: ±20.7) with 86 fracture sites were treated. In all cases we used 1.0 mm plates and 5 mm or 7 mm screws. The postoperative observation period was 6-60 months (mean: 21.8 months, SD: ±14.5)., Results: The fracture site recovered in all cases. Complications included one bone excess on the forehead and one foreign-body reaction on the frontozygomatic suture, but the fracture sites were recovered and had no problems. In the case with the longest observation time 60 months, the plate was almost fully absorbed. However, in other cases the plate was not fully absorbed because of a shorter observation time., Conclusion: OSTEOTRANS MX(®) is a useful device because of its suitable intensity, thinness, radiopaque, and few complications. A longer observation time is required for a plate to be absorbed completely., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To explore the indication and application of computer-assisted navigation in oral and maxillofacial surgery., Patients and Methods: One hundred and four patients including 34 zygomatic-orbital-maxillary fractures, 27 unilateral TMJ ankylosis, 29 craniofacial fibrous dysplasia, 9 mandibular angle hypertrophia, 3 cartilage/bone tumours of jaw and 2 cases with facial foreign bodies were enrolled in this study. CT scans were performed and data was saved in DICOM (digital imaging and communications in medicine) format. The osteotomy lines, amount and range of resection, the reduction position of bony segments and the reconstruction morphology was determined and displayed by preoperative simulation with mirroring and superimposing procedures. All operations were performed under the guidance of navigation system. The accuracy of navigation was evaluated by comparing the postoperative CT 3-D model with preoperative surgical planning., Results: Through registration, an accurate match between the intraoperative anatomy and the CT images was achieved. The systematic error checked by computer was within 1 mm. All operations were performed successfully with the guidance of real-time navigation. The mean error between virtual simulation and surgical results was 1.46 ± 0.24 mm. All patients healed uneventfully and function and profile was improved significantly., Conclusions: With the opportunity to perform preoperative planning, surgical simulation and postoperative prediction, computer-assisted navigation shows great value in improving the accuracy of maxillofacial surgery, reducing operation risk and postsurgical morbidity, and restoring facial symmetry. It is regarded as a valuable technique in these potentially complicated procedures., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Despite many publications on the epidemiology, incidence and aetiology of zygomatic complex (ZC) fractures there is still a lack of information about a consensus in its treatment. The aim of the present study is to investigate retrospectively the Amsterdam protocol for surgical treatment of ZC fractures. The 10 years 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 (SD: ±15.6) years (range 4-87 years). The mean cause of injury was traffic accident followed by violence and fall. A total of 225 plates and 943 screws were used. Twenty-eight patients presented with complications, including wound infection (9 patients) and transient paralysis of the facial nerve (one patient). Seven patients (2.8%) needed surgical retreatment of whom four patients needed secondary orbital floor reconstruction as these patients developed enophthalmos and diplopia. In conclusion this report provides important data for reaching a consensus for the treatment of these types of fractures., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Before undergoing repair of zygomaticomaxillary complex fractures, most patients are worried about their postoperative appearance. Furthermore, there is an ongoing discussion about the selection of the surgical approach to the inferior orbita and resulting eyelid deformities. We present a photo-assisted postoperative evaluation of zygomaticomaxillary complex fracture repair based on reference anthropometric data. Two hundred and twenty-one patients underwent zygomaticomaxillary complex fracture repair. An analysis of standardized postoperative photographs included measurements of eye fissure width and height, lid sulcus height, upper lid height, upper and lower coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, and whether a transconjunctival or a subciliary approach was performed. Surgery per se significantly influenced eyelid deformities as measured by its impact on eye fissure index, lower iris coverage and rate of scleral show and ectropion. The surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating distortion of the lower eyelid. Investigations regarding orbital fractures should clearly differentiate the type of fracture. The subciliary approach included the highest risk of postoperative lower eyelid deformity in zygomaticomaxillary complex fracture repair. The standardized measurements described here are accurate and objective to evaluate postoperative results., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The purpose of this study was to examine the influence of zygomaticomaxillo-orbitalis (ZMO) fracture and its symptoms on mucociliary transport (MCT)., Study Design: The study encompassed 144 patients who sustained ZMO fracture. A saccharine test was conducted in every patient both on the side of fracture and on the unaffected side. The results were analyzed in connection with the patients' age, sex, degree of injury, method of treatment, time since fracture, and duration of surgery., Results: It was shown that MCT was considerably impaired on the affected side compared with the control side. However, the degree of impairment did not vary significantly in the patients regardless of the analyzed parameters., Conclusions: ZMO fracture induces the disorder of MCT. Balloon Foley catheter in the open reduction of ZMO fracture impairs MCT. The analyzed parameters do not affect the disorders of MCT., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Facial trauma is a common injury in the urban setting. Many studies have been published on the epidemiology of facial fractures, but few of them conducted in Brazil. The purpose of this study was to analyze the epidemiological characteristics of patients treated for orbito-zygomatic fractures at our institution., Methods: Retrospective analysis of 141 patients with orbito-zygomatic complex fractures who underwent surgical treatment between May 2001 and May 2008., Results: The population studied consisted mostly of males (86.5% of patients), with a male:female ratio of 6.4:1. A marked predominance of patients aged 21-30 years was observed (34.3%). Traffic-related causes were the most common, with motorcycle accidents as the most frequent aetiology (24.8% of patients), followed by car accidents (19.2%) and interpersonal violence (15.2%). Associated injuries accounted for 88 lesions in 65 patients, and their occurrence was statistically associated with traffic-related causes. All patients enrolled in the study were managed with operative treatment. The most utilized method for treatment was internal fixation with miniplates and screws (83.7% of the cases). The complication rate was 24.8%., Conclusion: Orbito-zygomatic fractures can cause significant morbidity and impairment in patients' quality of life. Despite recent improvements in legislation and educational campaigns, traffic remains the main cause of these injuries. More intensive efforts should be made in order to reduce its impact in the aetiology of facial trauma., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of this study is to discuss the application of mirror imaging and preshaped titanium plates in the treatment of unilateral malar and zygomatic arch fractures., Study Design: Four patients with unilateral malar and zygomatic arch fractures were included in this study. All patients underwent preoperative CT scan. CT data were processed with Surgicase. Two 3D skull models were reconstructed using a rapid prototyping device. The first model was the original model obtained from CT scanning; the other model was obtained by mirroring the unaffected side onto the fractured side. Simulation surgery was performed on the first model. For the second model, titanium plates were shaped in advance and a resinous guide plate was created to guide surgical reduction. When using the resinous guide plates, 4 patients' fractures were reduced and fixed with preshaped titanium plates. The pre- and postoperative displacement of zygomatic markers were analyzed in Surgicase., Results: According to the measurement of fracture displacements, the facial asymmetry of all 4 patients was greatly improved at the 1-month follow-up., Conclusions: Mirror imaging and preshaped titanium plates are viable choices for the treatment of unilateral malar and zygomatic arch fractures. Combined use of these techniques can improve facial symmetry., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Introduction: The management of post-traumatic deformity in the midface region poses challenges for the maxillofacial surgeon. Ensuring symmetry after zygomatic osteotomy can be difficult and precise positioning of the osteotomised bony fragments requires careful treatment planning. It may be necessary to use a coronal flap to allow the surgeon to compare the contralateral zygomatic bone to allow symmetrical reduction. The authors present a new technique for the positioning of osteotomised zygomatic bones using a combination of computer assisted surgical simulation and rapid prototyping., Method: A patient presented to our unit with a post-traumatic zygomatic deformity. Using surgical simulation software the displaced zygomatic bone was osteotomised and placed in the idéal position on a three-dimensional computed tomography scan (3D CT). The position was determined by reference to the contralateral zygoma. In addition the repositioning of the soft tissues was simulated. A surgical guide which allowed intraoperative positioning of the osteotomised zygoma was manufactured by a rapid prototyping process. Use of the guide allowed a minimally invasive approach to the affected zygoma. The post-operative results were compared to the predicted outcome., Results: The post-operative appearance was satisfactory and corresponded well with the predicted result. There was a significant reduction in operative time compared to the previous management of similar cases., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of this study was to identify the behavior of masticatory muscles after fractures of the zygomatico-orbital complex (ZOC) and subsequent surgical treatment, by using analyses of bite force, electromyography (EMG), and mandible mobility during a 6-month period after surgery., Study Design: Five patients with fractured ZOCs treated surgically by using an intraoral approach and fixation exclusively in the region of the zygomaticomaxillary buttress were evaluated. The control group included 12 other patients. During postoperative follow-up, bite force, mandible mobility, and EMG analysis of the masticatory muscles were evaluated., Results: There was an increase in bite force with time, but a decline in EMG activity during the same period. In the mandible mobility analysis, only maximum mouth-opening values increased significantly after the surgical treatment., Conclusions: The masticatory musculature, according to bite force and EMG, returned to its normal condition by the second month after surgery, and maximum mouth opening was observed after the first month., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Unlabelled: Trauma and facial fractures in a population of children have been analysed in several studies mainly regarding their incidence and much less their treatment modalities., Aim: The aim of this study was to retrospectively analyse the treatment methods and outcome of facial fractures in children and young adolescents during the last decade and to discuss findings and propose treatment protocols., Patients and Methods: Patients of the Paediatric Maxillofacial department, treated for fractures of the facial skeleton were included in the study. Open reduction and osteosynthesis plate fixation (titanium and resorbable material) was the main treatment method with conservative treatment saved for selected cases. Titanium plates were removed after bone healing. Intermaxillary fixation (IMF) was not used regularly in mandibular fractures, with the exception of condylar fractures., Results: 156 children and young adolescents with 208 fracture sites in total were treated. 139 fracture sites (66.8%) were treated with open reduction and 69 conservatively. The mandible was affected in 49.0% of the cases, the maxilla in 21.2% (both with the alveolar process fractures included), the zygomatic complex in 10.1%, the orbital walls in 9.6%. There were 38 alveolar process fractures., Conclusion: The results of the fracture treatment verified the usefulness of open reduction and plate fixation in children. There was no need for wire suspension and only occasional need for IMF. Closed reduction was selectively applied in condylar fractures and dento-alveolar trauma., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to evaluate immediate and late postoperative complications in treating zygomatic complex fractures by 2 modified approaches; namely, the modified lateral orbitotomy approach and the modified hemicoronal approach., Study Design: Twenty zygomatic complex fractures were treated, with 10 being treated with the modified lateral orbitotomy approach and the other 10 by the modified hemicoronal approach. Both groups were evaluated for postoperative complications, ie, hematoma, infection, swelling, and nerve injury. The incisions were also evaluated in all patients using clinical evaluation and visual analogue scales., Results: Patients in both groups had temporary facial nerve injury that was primarily related to retraction of the nerve. There were no hematomas observed in any of the groups. As compared to the modified lateral orbitotomy approach, swelling was observed on more occasions with the modified hemicoronal approach. Infection was not observed in any of the groups. As far as the esthetics in relation to the incision was concerned, the patients accepted the modified hemicoronal approach more strongly as compared with the modified lateral orbitotomy approach., Conclusion: The modified hemicoronal approach seems to be preferred to the modified lateral orbitotomy approach with respect to treating zygomatic complex fractures., (Copyright 2010 Mosby, Inc. All rights reserved.)

Data regarding the use of prophylactic antibiotics and infection rate following surgery for fractures of the zygomatic bone is scarce. Therefore an audit of the use and outcomes of antibiotic prophylaxis for surgery of fractures of the zygoma was undertaken. Following audit approval, four maxillofacial surgery units in the Yorkshire Region gathered prospective data for 134 patients undergoing surgery for fractures of the zygoma. Data was collected on four groups of patients undergoing surgery for fractures of the zygomatic bone: uncomplicated reductions of the zygomatic arch, reductions of the zygomatic complex without mini-plate fixation, reductions of the zygomatic complex using mini-plate fixation but excluding zygomatico-maxillary buttress, and fixation of the zygomatic complex with miniplates including the zygomatico-maxillary buttress. The choice and timing of any antibiotics given peri-operatively was recorded, and 30 days after the operation, the patients' notes were reviewed to identify any episodes of surgical site infection (SSI) requiring the prescription of antibiotics, or any instances of plate removal in the post-operative period. This data has demonstrated that the prescription of antibiotic prophylaxis for surgery for fractures of the zygomatic bone is extremely variable, and that the infection rate is low.