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This study aimed to assess the sensory function of the infraorbital nerve in patients with fractures of the zygomatic complex who underwent open reduction and internal fixation at different time points using quantitative sensory testing, which was established by the German Neuropathic Pain Research Network, comprising a 7-item mechanical and thermal sensory test. A total of 21 patients (age range 17-46 y, 14 males) with unilateral zygomatic complex fractures were included. Quantitative sensory testing was conducted before the operation and at 1 week, 3 months, and 6 months operatively, with cold detection threshold, warmth detection threshold, cold pain threshold, heat pain threshold, mechanical detection threshold, mechanical pain threshold, pressure pain threshold, and vibration detection threshold being measured in bilateral infraorbital regions. Notable changes in sensitivity were observed in all values except for the mechanical pain threshold. In the majority of patients with zygomaticomaxillary complex fractures, infraorbital hypoesthesia was significantly improved within 3 months postoperatively, and almost complete recovery could be achieved by 6 months postoperatively., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Regarding the three distinct types of zygomaticomaxillary complex (ZMC) fractures, this study developed finite element models (FEMs) of absorbable material and titanium material for repair and fixation, respectively. By applying a force of 120 N to the model to simulate the masseter muscle strength, the maximum stress and displacement of the repair materials and the fracture ends were measured. In discussing various models, the maximum stress values of absorbable and titanium materials are less than their yield strength, and the maximum displacement values of the titanium material and fracture end were less than 0.1 mm and 0.2 mm. The maximum displacement values of absorbable material and fracture end in incomplete zygomatic fracture and dislocation were less than 0.1 mm and 0.2 mm. While in the zygomatic complex complete fractures and dislocation, the maximum displacement values of the absorbable material and the fracture end exceeded 0.1 mm and 0.2 mm. Consequently, the distinction between the maximum displacement values of the two materials was 0.08 mm, and the distinction between the maximum displacement values of the fracture ends was 0.22 mm, despite the fact that the absorbable material can withstand the fracture end's strength, it is not as stable as the titanium material., Competing Interests: Declaration of Competing Interest All authors were fully involved in the study and preparation of the manuscript and declare that there is no conflict of interest., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Aim: The purpose of this clinical study was to evaluate the efficacy of the preseptal transconjunctival approach with Y modification of the cutaneous extension for the management of zygomaticomaxillary complex (ZMC) fractures., Methods: This prospective interventional study was conducted at our institute from 2012 to 2020. The study included patients aged 15-65 years with displaced ZMC fractures. Patients with uncontrolled systemic conditions, infected and/or comminuted fractures were excluded. The variables evaluated were age, gender, mechanism of injury, fracture side, clinical features, surgical exposure time, adequacy of exposure, complications, scar evaluation scores and cosmetic outcomes. The parameters for comparison were operated versus non operated side Eye Fissure Index (EFI) and surgical exposure time was compared with respect to the types of scars., Results: A total of 49 patients were included in this study. The average exposure time was 18.87 ± 1.92 min. The exposure of fracture site was excellent in 73.5 % and satisfactory in 26.5 %. The mean EFI of operated side was 34.2 ± 5.04 mm while that of non-operated side was 34.22 ± 5 mm. On comparison of the same there was no significant difference. Invisible scars were noted in 71.4 % and barely visible scars in 22.4 %. The comparison of exposure time with type of scars showed a significant association (p = 0.02). The complications noted were chemosis, lower eyelid edema, conjunctival granuloma and entropion. Cosmetic outcomes were fairly satisfactory., Conclusion: The Y modification of the transconjunctival approach can provide excellent surgical exposure without the need for a second incision. Although this approach is technique sensitive and requires experience, the advantages outweigh the learning curve. Since this approach has been widely studied, a systematized review is recommended to further substantiate its reliability and advantages., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Purpose: The purpose of this study was to analyse Gillies Temporal approach Vs Towel Clip method for reduction of zygoma fractures., Method: A randomised comparative study was conducted on 30 patients having zygoma fractures confirmed with pre-operative NCCT face with 3 D reconstruction. Patients were divided into 2 groups, Group-1- Gillies temporal approach and Group-2- Towel clip method. Clinical observations were recorded in a predesigned proforma for all the patients and analysed statistically., Results: Gillies Temporal Approach significantly p < 0.001 took longer time for reduction than Towel Clip Method. Post-operative pain was experienced more in Group 1 than Group 2. Intraocular pressure was compared at different time intervals and significant difference was noted. Also, Occulocardiac reflex was observed in Group 1. Mean trismus index was 16.87 ± 5.12 mm in Group 1 and 13.33 ± 4.11 mm in Group 2 preoperatively which significantly increased to 51.93 mm in Group 1 and 51.73 mm in Group 2 one month post-op. Reduction was maintained post-operatively with good quality of outcome in both the groups., Conclusion: Non-comminuted zygomatic complex fractures can be effectively treated using Towel Clip Method as this method is cost-effective, minimally invasive, safe, causing minimum or no damage to soft tissue and easy to perform based on surgeon's skill and requires less operating time, proving it equally efficient method with excellent aesthetic outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The purpose of this study was to retrospectively evaluate the feasibility of 2-point fixation using absorbable plates by the transoral approach in the management of the zygomatic complex (ZMC) fractures., Methods: Twenty-five patients (15 male and 10 female, age range 16 y to 55 y) with Knight and North Group Ⅲ zygomatic fractures were included in this case series. Open reduction by intraoral approach was performed on these patients, and the fractures were fixed using absorbable plates placed at the zygomaticomaxillary buttress and infraorbital rim. Postoperatively, follow-up was undertaken to evaluate the fracture healing, mouth opening, facial asymmetry, diplopia, and paresthesia., Results: Postoperatively, all patients achieved uneventful healing; facial symmetry and wound healing were achieved, along with sensory recovery involving the infraorbital nerve. Complications such as sensory disturbances, infection, diplopia, malunion, and nonunion were not encountered in these patients., Conclusions: Two-point fixation using absorbable plates by transoral approach can provide sufficient stabilization for Knight and North Group III zygomatic fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Background: Innovative technologies with surgical navigation have been used for enhancing surgical accuracies for zygomaticomaxillary complex (ZMC) fractures and offers advantages in precision, accuracy, effectiveness, predictability, and symmetry improvement. Moreover, augmented reality (AR) navigation technology combines virtual reality, 3-dimensional (3D) reconstruction, and real-time interaction, making it ideal for bone tissue operations. Our study explored the usefulness and clinical efficacy of AR technology in intraoperative guidance for reducing ZMC fractures., Methods: We retrospectively studied 35 patients with zygomatic complex fractures, comparing outcomes of AR-guided and conventional methods. Furthermore, the AR system provided real-time visualization and guidance. The evaluation included reduction accuracy using root mean square (RMS) value and symmetry analysis using a mirror image of 3D models. Results demonstrated the feasibility and effectiveness of the AR-guided method in improving outcomes and patient satisfaction., Results: In 35 patients (25 males, 10 females), AR-guided (n = 19) and conventional (n = 16) approaches were compared. Age, sex, and fracture type exhibited no significant differences between groups. No complications occurred, and postoperative RMS error significantly decreased ( P < 0.001). The AR group had a lower postoperative RMS error ( P = 0.034)., Conclusions: Augmented reality-guided surgery improved accuracy and outcomes in zygomatic complex fractures. Real-time visualization enhanced precision during reduction and fixation. This innovative approach promises enhanced surgical accuracy and patient outcomes in craniofacial surgery., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Plate fixation to zygomatic arch fractures carries the risk of facial nerve palsy and scarring of the cheek; however, without plate fixation, bone deviation or displacement may reoccur after surgery. Furthermore, zygomatic arch fractures combined with zygomatic body fractures are more postoperatively unstable than single zygomatic arch fractures. Few reports have focused on this combined fracture type, and no consensus has been reached regarding treatment. Because plate fixation for slight deviation of the zygomatic body has little advantage for stabilization, the authors, usually opt for transmalar pinning alone instead of plate fixation at the hospital. This study is a retrospective case series of 7 patients, among 100 zygomatic fractures excluding isolated zygomatic arch fractures, treated using transmalar pinning under ultrasound scanning. The reduction was performed through the oral and temporal incision as a surgical procedure. Under ultrasound observation, a Kirshner wire was inserted into the zygomatic body from the unaffected side while maintaining the reduced position. The wire was removed at an outpatient visit 2 to 3 months following surgery. In all cases, the zygomatic body was of the laterally rotated type, and postoperative morphologic evaluation showed improvement without postoperative complications. Scores were higher in middle-aged and older than in young people. Correction of zygomatic rotation also scored higher than zygomatic arch morphology. Transmalar Kirshner wire fixation under ultrasound observation is a simple and minimally invasive method for zygomatic arch fractures, which avoids the possible complications related to plate fixation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Gillies temporal approach has been widely used to reduce zygoma fractures. Traditionally, it is the preferred method to reduce the isolated zygomatic arch fracture. It can be combined with other approaches, such as subciliary and intraoral incisions for more complex zygomatic fractures, so-called tripod fractures. In this study, the author hypothesized that complex zygomaticomaxillary bone fracture reduction can successfully be achieved without Gillies temporal incision. The author retrospectively analyzed the medical records and 3D facial Computed Tomography (CT) scans of 80 patients who had orbitozygomaticomaxillary fractures that affected >3 sites among the frontozygomatic suture, zygomaticomaxillary buttress, zygomatic arch, and orbital walls from May 2021 to August 2023. A single surgeon performed all surgical operations. All fractures were reduced with 2 incisions, lower eyelid incisions (subciliary or subconjunctival) and intraoral incisions (gingivobuccal approach), within a week of the initial traumatic event. After sufficient exposure to fractured sites using 2 incisions, the author reduced the fracture with a bony hook at the inferior orbital rim, lateral wall, or Boise elevator at the intraoral incision. All cases were successfully corrected without any complications. In conclusion, the author can successfully reduce complex zygomaticomaxillary fracture combined with orbital wall fractures without temporal Gillies approach., Competing Interests: The author reports no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

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.)

Purpose: This study aimed to assess the maxillary sinus volume (MSV), Chronic Sinusitis incidence, and asymmetry of the zygomaticomaxillary complex (ZMC) following ZMC fracture surgery with various numbers of fixation points., Materials and Methods: In a prospective non-randomized cohort, 50 adults with unilateral ZMC fractures who treated by open reduction and internal fixation (ORIF) between November 2019 and October 2021 were assigned to accomplish this study. They distributed into three groups as per fixation points (2, 3, or 4 Points). Preoperative (T1), Immediate postoperative (T2), and follow-up (T3) cone beam computed topography were analyzed using the Mimics software. The main measures were MSV and asymmetry indexes (ASI) of six paired bilateral anatomical landmarks (Orbital, Suprajugal, Jugale, Zygon, Maxillozygion 1, and Maxillozygion 2)., Results: MSV decreased significantly on the affected sides postoperatively in 2P and 3P groups, both in T2 and T3. Further, the T2-T3 comparisons showed a significant MSV change (p = 0.001). ASI reduced considerably to clinically tolerated levels (<3 mm) on landmarks near the fixation sites postoperatively. The ASI on the Zygon and Maxillozygion 1 landmarks showed significant changes among the three groups in both T2 and T3. Interestingly, only five cases had reported postoperative sinusitis symptoms., Conclusions: Although the MSV was changed among the different fixation point groups, the incidence of chronic sinusitis was uncommon. Bilateral asymmetry affected by number and position of the fixation points, fixation with 4 points provide more symmetry., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023. Published by Elsevier Masson SAS.)

Objective: This study aims to quantify the facial symmetry of surgically treated zygomaticomaxillary complex (ZMC) fractures through a new reliable three-dimensional evaluation method, which is crucial for improving post-operative aesthetic and functional outcomes., Material and Methods: Healthy patients and patients with surgically treated ZMC fractures were retrospectively reviewed. Using Brainlab Elements® the zygomatic bone and the orbit of each patient was segmented and mirrored. Subsequently, the mirrored side was matched with the other side via volume-based registration, using the segmented orbit as reference. Volumetric asymmetry was measured using 3-matic software, and a surface-based matching technique was used to calculate the mean absolute differences (MAD) between the surfaces of the two sides of the ZMC. The reliability of this novel method using volume-based registration was tested, and the intra-class correlation coefficient was assessed., Results: The MAD between the surfaces of the left and right sides in the control group was 0.51 mm (±0.09). As for the ZMC fracture group, MAD was 0.78 mm (±0.20) and 0.72 mm (±0.15) pre- and post-operatively, respectively. The MAD showed statistically significant differences between pre- and post-operative groups (p = 0.005) and between control and post-operative groups (p < 0.001). The intra-class correlation coefficient was high (≥0.99)., Conclusions: This evaluation method using mirroring and volume-based registration to determine the symmetrical position of the ZMC is reliable. The surface-based measurements revealed an improved symmetry after surgery. However, the symmetry of the treated patients remained lower than the control group., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

We have introduced a minimally invasive approach for the fixation of the zygomatic arch during the surgical management of zygomatic complex fractures. Access for this technique is provided by a preauricular approach and eyelid incisions with the addition of transcutaneous stab incisions overlying the arch. These stab incisions allow transcutaneous drilling and screw placement through a size CH 20 (5.0 mm) paediatric nasopharyngeal airway (NPA). We present a case series of seven patients. In all patients the arch component was successfully reduced and fixed, and no intraoperative or postoperative complications were observed. The use of an NPA is novel. It functions as a flexible self-irrigating sleeve and protects the skin from mechanical and thermal damage. The technique uses readily available equipment, is easy to learn, and simplifies surgery to the zygomatic arch., (Copyright © 2024 The British Association of Oral and Maxillofacial Surgeons. 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.)

Attitudes towards healthcare in the NHS and in other Western healthcare systems have been changing dramatically in recent years. There is a significant movement calling for a shift from the traditional paternalistic model, with patients as passive recipients of treatments that are supported by objective and observable evidence, towards a more holistic approach, in which patients have agency, and treatments are tailored to the individual needs of a particular patient. Whilst patient safety and clinical effectiveness remain intrinsic to the traditional measurement of successful healthcare, Patient Reported Outcome Measures (PROMs) are increasingly being advocated as an important tool to uphold patient-centric care in the NHS.The aim of this study is to complete the first evaluation of PROMs that we know of in patients receiving surgical management of zygomatic fractures, by comparing two interventions commonly used in this condition: the zygomaticomaxillary complex open reduction and internal fixation (ZMC ORIF), and the Gillies approach to zygomatic elevation. We demonstrate high levels of patient satisfaction across all domains, irrespective of surgical approach, but that mood and anxiety remain an issue after surgery., (Copyright © 2024 The British Association of Oral and Maxillofacial Surgeons. 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.)

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

The zygomaticomaxillary complex and the orbital floor are commonly affected by mid-face fractures; their fractures pose challenges in reconstruction and can result in complications, such as enophthalmos. This study explores an intraoral approach with the help of a customized balloon technique and a contrast agent as an alternative to the conventional methods. A case report of a 67-year-old man with complex midfacial trauma is presented. The surgical process involved open reduction through an intraoral approach along with a transantral approach with the customized balloon technique. The procedure aimed to achieve reduction, fixation, and reconstruction of a complex mid-face fracture., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

This study introduces a method to overcome technical challenges in using intraoperative ultrasound for the closed reduction of nasal bone and zygomatic arch fractures. The curvature of the face makes it difficult to apply an ultrasound probe to the facial area. We used a solid gel pad as a coupling medium during surgery to improve the scanning of facial bone fractures. The results show that the fracture sites observed on preoperative computed tomography scans can be easily visualized using intraoperative ultrasound, and real-time manipulation confirms successful reduction. The solid gel pad is light, malleable, easy to use, and provides accurate images. Overall, the use of ultrasound with a solid gel pad enhances the accuracy of closed reduction in facial bone fracture surgeries, confirming fracture patterns and ensuring precise reduction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

The authors present the case of a 15-year-old male who sustained a unilateral zygomaticomaxillary complex fracture and underwent open reduction and rigid internal fixation, for which a U-shaped elevator was utilized. The authors discuss techniques in reduction and fixation of zygomaticomaxillary complex fractures, focusing on the use of various elevators during reduction, including straight-type and curved elevators. The U-shaped elevator is a handheld tool with bilateral symmetrically curved ends that is seldom used, despite its specific benefits including nonslip serrated tips, symmetrical nature that allows for direct loading needed for accurate reduction, visualization of the fracture site, and avoidance of tissue compression during elevation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: One-point fixation was superior to the two and three-points fixation in minimally displaced zygomaticomaxillary complex (ZMC) fracture regarding the cost, invasiveness, scaring, number of wounds, and operation time. Accordingly, this study aimed to predict which one-point fixation is the most stable in managing minimally displaced ZMC fracture., Material & Methods: This study simulated the different one-point fixation approaches on three ZMC models after fracture reduction and application of all forces exerted on the fractured area. The findings were represented as stress impact on the ZMC fracture and plating system as well as the inter-fragments micro-motion., Results: The von misses stresses of plates for the zygomaticofrontal, infra-orbital rim, and zygomaticomaxillary buttress model were (66.508, 1.285, and1.16 MPa) respectively. While the screws' von misses for the infraorbital rim, zygomaticofrontal, and zygomaticomaxillary buttress models were (13.8, 4.05, and 1.60 MPa) respectively. Whereas, the maximum principles stress at zygomaticofrontal, zygomaticomaxillary buttress, and infraorbital rim models were (37.03, 37.01, and 34.46 MPa) respectively. In addition, the inter-fragment micro-motion for zygomaticomaxillary buttress, infraorbital rim, and zygomaticofrontal models were (0.26, 0.25, and 0.15 mm) respectively., Conclusion: One-point fixation at zygomaticomaxillary buttress is the preferred point because it is exposed to low stresses, and the inter-fragment micro-motion is within the approved limit with the elements in the same direction of fixation which indicates the rigid fixation. In addition, it is less palpable and scarless., Trial Registration: clinical trial.gov (NCT05819372) at 19/04/2023., (© 2023. The Author(s).)

Mid-facial asymmetry caused by bone defect or deformation resulted from craniofacial fracture was a common secondary complication needed to repair. Patient-specific implant (PSI) designed with the unaffected side as a template is a good choice to repair this kind of facial asymmetry. However, in Asians, the broad and prominent zygomatic bone in unaffected side is not an optimal template, because the oval facial shape was considered as a more attractive appearance in Asian esthetic concept. To repair the mid-facial asymmetry and to improve the facial contour, the authors combined PSI implantation with malar reduction in one-stage surgery. The authors referred the facial proportion index (the optimal ratio of mid and lower face was 1.27) as a basis for preoperative precise design to determine the ideal facial shape of unaffected side, and used mirror image overlay technique with the ideal shape of unaffected side as a template to design the PSI. With this surgical strategy, patients not only can repair facial asymmetry but also can get a more attractive appearance., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Malar reduction surgery can increase its susceptibility to fractures in case of trauma. Patients who had malar reduction surgery and sustained a zygoma fracture pose unique challenges for treatment and management. This is a case of a 28-year-old female patient who presented with a unilateral zygoma fracture following bilateral malar reduction and augmentation rhinoplasty 6 years ago. Physical examination revealed a clicking sound when opening the mouth at the right zygomatic buttress and a depressed preauricular area, suggesting arch fracture. Computed tomography imaging demonstrated a loosened screw at the right zygomatic buttress and a depressed arch fracture. She wanted to remove all plates and treat her right fractured zygoma with absorbable materials. Through the bilateral intraoral incisions, the authors removed the plates and screws and reduced the depression with the Langenbeck elevator through the same right intraoral incision without fixation. The reduction was well-maintained without complications based on postoperative plain x-rays 1 month after surgery. She reported that the pain was mostly gone and that she did not hear any abnormal sounds when opening her mouth after the surgery. In this case, if the zygomaticomaxillary buttress is minimally displaced, but the zygomatic arch fracture is significantly depressed, the authors believe that fracture reduction with only an intraoral incision would be enough to achieve an optimal outcome. If the plates and screws used in the previous malar reduction are not well maintained, it may be necessary to remove them., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: The use of intraoperative imaging (IOI) to improve the reduction adequacy of zygomatic arch (ZMA) fractures has been reported, but few systematic reviews have examined this topic. The aim of this review was to investigate and compare the value of IOI with conventional methods without IOI (N-IOI) for the closed reduction of ZMA fractures., Methods: Electronic retrieval of MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, and citation search until December 2, 2022, was used to identify controlled clinical trials that employed IOI for improving adequacy in closed reduction of ZMA fractures. The predictor variable was the use of IOI-yes/no (IOI vs N-IOI). The covariates included imaging technique (ultrasound, C-arm, and cone beam computed tomography) and ZMA fracture type (M-shape fracture, mechanistic force in 1 direction; variable fracture, mechanistic force in 2 directions). The primary outcome variables were the reduction adequacy of ZMA fractures (the remaining cortical step and dislocation angle) compared with the ideal mirrored position. Weighted or mean differences, risk ratios, and corresponding 95% confidence intervals were calculated, where P >.05 and I 2 ＜50% fixed effect model was adopted, and a vice versa random effect model was adopted., Results: A total of 1250 studies were identified, of which 6 studies with 259 participants were included. The meta-analysis results indicated that compared with N-IOI, IOI yielded fewer cortical steps (-1.76 [-2.42, 1.10], P ＜.00001, fixed model) and dislocation angles (-5.60 [-8.08, 3.12], P＜.00001, fixed model) in patients with variable ZMA fractures, while no significant difference was detected in the M-shape ZMA fracture (-0.72, [-2.93, 1.48], P = .52; -1.48, [-3.51, 0.55], P = .15). Although there was no significant difference in postoperative correction (0.35, [0.06, 2.01] P = .24, fixed model), all secondary revision cases occurred in the N-IOI group. Descriptive analysis showed that IOI yielded better symmetry and appearance satisfaction., Conclusion: IOI improved the adequacy of the procedure and led to a better postoperative appearance, especially for patients with variable ZMA fractures. Furthermore, the use of IOI avoided the risk of secondary surgery. In future studies, researchers should standardize the scale and outcomes to facilitate the intuitive evaluation of reduction adequacy., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Zygoma is considered the main support of the midface. Zygoma is frequently fractured owing to its prominent site on the face. Treatment of zygomaticomaxillary complex fractures can be performed through either conservative or surgical measures (closed or open reduction). The study was a cross-sectional retrospective observational investigation done at 4 hospitals in Ramadi and Baghdad cities, Iraq. This investigation covered a duration of 6 years (2016-2021). We reviewed the medical records of patients with ZCFs. The participants were divided into 2 groups according to the approach used for their management (direct versus indirect approach). Data regarding the demographic and clinical characteristics were recorded for each subject. Of 265 patients with ZCFs, 209 (78.9%) were males. The highest age group affected was 18 to 40 years (51.7%). The majority of the ZCFs were caused by road traffic accidents (31.7%). Most of the cases belong to single fractures (72.1%). Cheek flattening (73.6%) was the commonest sign of the ZCFs. The majority of the fractures were treated by direct approach, 65.4% of the isolated fractures and 62.2% for multiple fractures. Excellent patient satisfaction was seen in the majority of the cases. There were no statistically significant differences between the 2 approaches regarding the abovementioned variables ( P -value > 0.05). The majority of the cases were with excellent patient satisfaction (n = 149) while only 7 patients with poor satisfaction. The age groups below 18 years and 18 to 40 years were associated with excellent patient satisfaction than good and poor satisfaction. All (n = 7) of the cases with poor satisfaction belong to the age group above 40 years. The majority of male (n = 113) and female (n = 36) patients were with excellent satisfaction, while all patients with poor results were males (n = 7). There were statistically significant differences between the results of the patient satisfaction and age group and complications ( P -value < 0.05). The ophthalmic complications were the most complications seen after ZCF surgical treatment (2.56%). Direct and indirect approaches can be used safely in the treatment of ZCFs owing to excellent patient satisfaction in the majority of the cases and a low complication rate. This study aims to evaluate the demographic and clinical characteristics and to compare different surgical procedures to treat patients with zygomaticomaxillary complex fractures in a country overwhelmed by violence., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

A sagittal fracture at the temporal root of the zygomatic arch (ZAR) often occurs as a component of zygomaticomaxillary complex (ZMC) fractures. However, this area is difficult to access, and anchorage is limited due to the unstable structure around it. Therefore, a preauricular approach using single-screw fixation is proposed, and this study reports its results and usefulness. Forty-four patients with sagittal fractures of ZAR occurring with ZMC fractures were evaluated from 2012 to 2021. Open reduction and internal fixation were performed on all patients with ZMC fractures. Closed reduction using Dingman incision and external finger pressure in group A (indirect approach; 30 patients) and single-screw fixation using a preauricular approach in group B (direct approach; 14 patients) were performed to address sagittal fractures in ZAR. For single-screw fixation, the additional mean operation time was 11.34±3.25 minutes. On postoperative 3-dimensional computed tomography and plain radiographs, group B showed more accurate reduction and less deformity and trismus ( P <0.05). Moreover, a normal diet was initiated more quickly in group B than in group A ( P <0.05). Some cases in group A showed nonunion or malunion. This study revealed that a direct approach (group B) toward sagittal fractures of ZAR is recommended due to more accurate results and fewer complications than those observed with the indirect approach (group A). Moreover, the total operation time and complications may be lesser than those with the bicoronal approach., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Due to the complex anatomical morphology and lack of anatomic markers on the surface of zygomatic complex (ZMC), the treatment results of ZMC fractures are often suboptimal., Purpose: The study aimed to evaluate the effectiveness of intraoperative computed tomography (ICT) in the treatment of unilateral ZMC fractures, and further study the feasibility of ICT to replace early postoperative Computed Tomography (CT)., Study Design, Setting, and Sample: The investigators designed a retrospective cohort study. Adult patients who underwent surgery with unilateral ZMC fractures were enrolled., Predictor Variable: According to whether intraoperative CT was used, the subjects were divided into the ICT group and the control group (without ICT)., Main Outcome Variables: Five distances and 3 angles representing bilateral ZMC symmetry were main outcome variables. The differences of outcome variables were compared between the 2 groups and the indices of ICT group were further compared with their postoperative indices., Covariates: Demographics (eg age), etiology (eg traffic injury), dysfunction (eg diplopia), and surgical approach (eg vestibular incision) were collected as covariates while we conducted clinical investigation, examination, and implementation., Analyses: The data were analyzed using independent-samples t test, paired-samples t test, Mann-Whitney U test, and χ 2 test. P value < .05 was considered statistically significant., Results: A total of 60 patients (18 to 59 years) were enrolled in this study. All median values of the measurements in the ICT group were smaller than those in the control group, and the differences of horizontal displacement distance (0.56 vs 1.02 mm), anteroposterior displacement distance (1.69 vs 2.34 mm, 0.90 vs 2.35 mm), horizontal angle of bilateral zygomatic arch (2.31 vs 4.19°), and horizontal angle of bilateral zygomatic process (1.77 vs 2.94°) were significantly different between the 2 groups with P value < .05. Moreover, there was no statistically significant difference in all indices between the intraoperatively and postoperatively injured sides in the ICT group., Conclusions: ICT can improve the treatment outcomes of ZMC fractures by evaluating the fracture reduction adequacy during surgery. Moreover, ICT can replace early postoperative CT., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Orbital floor (OF) fractures accompany all zygomaticomaxillary complex (ZMC) fractures, but guidelines for repair of OF fractures in this setting are unclear. Objectives: To compare ophthalmologic outcomes of ZMC repair with and without concurrent OF repair. Methods: We retrospectively reviewed patients undergoing ZMC fracture repair with and without OF repair between 2016 and 2018. Patients were reviewed for demographics, preinjury characteristics, and ophthalmologic outcomes. Results: Of 61 total patients, 32 underwent concomitant OF repair while the remaining 29 underwent ZMC repair alone. The OF repair group had increased OF fracture size, displacement in the coronal plane, and malar eminence displacement ( p  < 0.05). Eight patients in the OF repair group had postoperative diplopia compared with no patients in the group without OF repair ( p  < 0.05). Conclusion: Retrospective analysis of ZMC fracture repair without and with OF repair did not reveal a significant difference in short-term ophthalmologic outcomes while controlling for fracture size.

Fractures of the pediatric midface are infrequent, particularly in children in the primary dentition, due to the prominence of the upper face relative to the midface and mandible. With downward and forward growth of the face, there is an increasing frequency of midface injuries seen in children in the mixed and adult dentitions. Midface fracture patterns seen in young children are quite variable; those in children at or near skeletal maturity mimic patterns seen in adults. Non-displaced injuries can typically be managed with observation. Displaced fractures require treatment with appropriate reduction and fixation and longitudinal follow-up to evaluate growth., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Facial fractures, particularly mid-facial fractures, can result in various complications, such as functional and esthetic problems. Prompt reconstruction of the fractured bones is crucial for restoring normal anatomy and function and preventing complications. However, such procedures can be complex and carry the risk of potential complications. The authors report the case of a 27-year-old man who underwent open reduction and internal fixation of the left zygomatic complex fracture and reconstruction of the left inferior orbital wall. During the surgery, heavy bleeding from the posterior superior alveolar artery due to a broken bone near the pterygomaxillary region caused a prolonged surgery time and the development of a pseudoaneurysm. The pseudoaneurysm was eventually treated with superselective transcatheter embolization using 25% N-Butyl cyanoacrylate glue. This case highlights the challenges in the management of mid-facial fractures and the potential complications that can arise during surgery, particularly when dealing with the pterygomaxillary region., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

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.)

Objective: For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation., Methods: This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos., Result: All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm., Conclusion: This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Many approaches have been suggested for management of zygomaticomaxillary fractures. Each approach has its own advantages and limitations., Aim of This Study: The study is intended to compare between the subtarsal approach, conventional transconjuctival approach and the Y- modification of the transconjuctival approach in the management of zygomatico-maxillay complex fractures., Materials and Methods: Twenty-four patients with age range of 20-50 years requiring open reduction and fixation of a fractured zygomatic complex were randomly divided into three equal groups. Group A: subtarsal approach group, group B: a conventional transconjunctival approach group and group C: Y- modification of the transconjunctival approach group. Intraoperative and postoperative parameters were evaluated., Results: As for the exposure time, group C had the longest duration. Easy access to the site of fracture was reached in all groups with no statistically significant difference. During the first 24 h, the pain was only statistically significant between groups A and B with higher pain level in group A. After the first week, pain was significantly higher in groups A and C, with respect to group B. The least edema was observed in group B after 24 h, one week and four weeks postoperatively. Regarding ocular complications, wound healing and sensory nerve function, there was no statistically significant difference between the groups. Scarring was only noticeable in group A patients., Conclusion: The transconjunctival approach provides adequate exposure with excellent esthetics and minor complications. The Y-modification also delivers an esthetic access with inconspicuous scar to the frontozygomatic region., Trial Registration: The trial has been registered on clinicaltrials.gov (ID: NCT05695872)., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: The application of a computer-aided navigation system (CANS) in zygomatic complex (ZMC) fractures has been extensively reported, but individual results are heterogeneous. The purpose of this systematic review was to evaluate the role of CANS in the surgical treatment of unilateral ZMC fractures., Methods: Electronic retrieval of MEDLINE, Embase, and Cochrane Library (CENTRAL) and manual searching until November 1, 2022 were used to identify cohort studies and randomized controlled trials employing CANS in the surgical treatment of ZMC fractures. The identified reports contained at least 1 of the following outcome variables: accuracy of reduction, total treatment time, amount of bleeding, postoperative complications, satisfaction, and cost. Weighted or mean differences (MD), risk ratios, and corresponding 95% confidence intervals (CI) were calculated, where P＜.05 and I 2 ＞50% random-effect model was adopted, and a vice versa fixed-effect model was adopted. Descriptive analysis was applied to qualitative statistics. The protocol was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered with PROSPERO (CRD42022373135)., Results: A total of 562 studies were identified, of which 2 cohort studies and 3 randomized controlled trials with 189 participants were included. Meta-analysis indicated that employing CANS significantly decreased the reduction error (MD = -0.86, 95% CI -1.58 to -0.14; P = .02, random-effect model) compared with conventional surgery without using CANS. The differences in total treatment time (preoperative planning time: MD = 1.44, 95% CI -3.55 to 6.43; P = .57 and operative time: MD = 3.02, 95% CI -9.21 to 15.26; P = .63, fixed-effect model) and amount of bleeding (MD = 14.86, 95% CI -8.86 to 38.58; P = .22, fixed-effect model) were not statistically significant between the two groups. Descriptive analysis suggested that postoperative complications, postoperative satisfaction, and cost were also similar with or without CANS., Conclusion: Within the limitations of the present review, the reduction accuracy of unilateral ZMC fractures using CANS is superior to that of conventional surgery. CANS presents limited influence on operation time, amount of bleeding, postoperative complications, postoperative satisfaction, and cost., (Copyright © 2023. Published by Elsevier Inc.)

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p -value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p  < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p  = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p  = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Traditionally, in zygomaticomaxillary complex and orbital fractures, miniplates and titanium orbital mesh are used and adapted intraoperatively, which may cause fatigue of the metal and increase the surgical time. Recently, computer-assisted surgery and 3-dimensional printing enable the surgeon to employ 3-dimensional segmentation and mirroring tools, which mimic the pretraumatized anatomy on which the miniplates and titanium orbital mesh are preoperatively molded to precisely duplicate the orbital volume, enophthalmos, and zygomatic bone position., Aim: To evaluate the results of computer technology using 3-dimensional printing model to prebend miniplates and titanium orbital mesh in the restoration of orbital volume, enophthalmos, and zygomatic bone position in the initial management of patients with zygomaticomaxillary complex and/or orbital fractures., Patients and Methods: This prospective clinical study included 10 Iraqi male patients who met the eligibility criteria and subjected to open reduction and internal fixation utilizing virtual surgical planning and a 3-dimensional model to prebend miniplates and titanium orbital mesh as a treatment modality for facial fractures. The data were analyzed according to the orbital volume, enophthalmos, zygomatic bone position, age, gender, etiology of the fracture, and complications. The patients were radiographically followed up with a computed tomography scan at 4 months postoperatively. The statistical analysis was performed using percentages, the mean±SD, Shapiro-Wilk test, Paired t test, One Way Anova, and Independent t test., Results: The age of the patients ranged from 18 to 66 years, with an average of 28.6 years and a SD of±14.5 years. Regarding gender, all patients were males. By utilizing virtual surgical planning and 3-dimentional model to prebend miniplates and titanium orbital mesh and concerning the fracture types, which include the zygomaticomaxillary complex, orbital, and combined fractures, there was no significant difference between the measurement of intact side and 4 months postoperatively in orbital volume, enophthalmos, and zygomatic bone position ( P >0.05)., Conclusion: This study demonstrated that computer-aided techniques, virtual planning, and the use of prebend miniplates and titanium orbital mesh enable anatomically precise reduction and fixation of the orbital, zygomaticomaxillary complex, and combined fractures regarding orbital volume, enophthalmos, and zygomatic bone position., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Isolated depressed zygomatic arch fractures are often treated with closed reduction. Reduction is usually performed through the Gillies approach or Keen approach. comminuted zygomatic arch fractures generally require open reduction and fixation to achieve good results. This article describes how to use a pair of surgical templates to assist in the fixation of comminuted zygomatic arch fractures with absorbable plates., Methods: A pair of computer-designed surgical templates were applied to restore the main part of zygomatic arch. Placing a surgical template on the medial side of the zygomatic arch can provide a supporting force and improves the stability of the reduced bone fragments. The lateral template of zygomatic arch limits the excessive uplift of bone fragments., Results and Discussion: The operation was performed according to the predetermined procedure. Postoperative computed tomography showed satisfactory reduction effect. In conclusion, with the aid of surgical templates, the reduction and fixation of comminuted zygomatic arch fractures can be more easily performed using absorbable plates., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objective: This systematic review aims to investigate the effect of virtual planning on the treatment of zygomaticomaxillary complex (ZMC) traumatology followed by intraoperative navigation. Furthermore, clinical outcomes following intraoperative navigation surgery or conventional surgery will be compared., Materials and Methods: A systematic literature search was conducted in PubMed, Embase, Web-of-Science, and Cochrane on January 1st, 2022. Inclusion criteria were articles using preoperative three-dimensional (3D) virtual planning combined with intraoperative navigation or comparing these 3D methods with conventional methods. Furthermore, at least one of the following outcomes needed to be included in the article: technical accuracy of the procedure, preoperative planning time, operative time, number of fixation points, patient satisfaction, complications, or total costs of the intervention., Results: Following the screening of 4478 articles, 17 were included. Five articles appeared to indicate a significantly better technical linear accuracy, one article reported better accuracy for rotation and two articles showed better accuracy in restoring orbital volume when using navigation. Nine articles investigated operative time with varying results. Seven articles calculated the additional costs, of which three concluded no extra cost while the others indicated high additional costs or questionable cost-effectiveness., Conclusion: Virtual planning and intraoperative navigation technologies have the potential to assist maxillofacial trauma surgeons in reducing ZMC fractures significantly more accurately and restoring the facial contour in a less invasive manner at an acceptable cost., Registration: The protocol for this systematic review (CRD42020216717) was registered in the International Prospective Register of Systematic Reviews (PROSPERO)., Competing Interests: Declaration of Competing Interest The authors declare that there are no conflicts of interest regarding this analysis., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Lateral midface fractures occasionally require open reduction and internal fixation to restore function and facial symmetry. However, some patients retain facial asymmetry despite undergoing surgery due to hard tissue displacement or soft tissue sagging. This study aimed to determine the influence of soft tissue sagging on the postoperative facial symmetry., Methods: We examined the medical records of 590 patients who underwent planned plate removal after lateral midface or zygomatic bone fractures. After applying the inclusion and exclusion criteria, we analyzed 106 cases of lateral midface fractures for hard tissue displacement and soft tissue sagging using pre- and postoperative radiological imaging and postoperative face scanning., Results: We observed significantly larger soft tissue sagging (p &lt; 0.001) and hard tissue displacement (p = 0.006) on the fractured side than on the non-fractured side. There was no correlation between differences in the soft tissue sagging and those in the hard tissue displacement (|rho|=0). Linear regression analysis showed no statistical influence of sex or age group on the soft tissue sagging and hard tissue displacement., Conclusion: Therefore, we recommend treating soft tissue sagging as a discrete aspect of midfacial fracture treatment to achieve optimal postoperative facial symmetry. From a clinical perspective, we recommend better soft tissue management during open fracture treatment than focusing mainly on the reduction of bony hard tissues., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

We aimed to explore the predictors of hospital length of stay for patients admitted and with maxillofacial injuries. Patients presenting with maxillofacial trauma were included. Poly-trauma involving neurosurgery and/ or needing orthopaedics intervention were excluded. Logistic regression was applied to explore the predictors associated with the hospital stay of > 4 days. There were 241 patients with mean age 29.35 ± 12.5 years (age range 12-80 years). Mandibular fracture was the commonest observation 121(50.2%), followed by maxillary 48(19.9%), and zygomatic bone fracture 9 (3.7%). Road traffic accident 196 (81.3%) appears to be the most common etiology of maxillofacial injuries in the studied sample. The mean length of hospital stay among bone plating patients was 5.96 ±6.8 days compared to 4.15±6.2 days for ones treated without bone plating; p-value 0.05. It was concluded that longer length of stay is required in patients with more complex management including bone plates.

The aim of this study was to examine whether ultrasonography and three-dimensional radiological procedures produce significantly different measurement results with respect to fracture dislocation. This was a retrospective study of patients who were admitted to the department for oral and maxillofacial surgery of the Medical Highschool Hannover with facial skull fracture and underwent high-resolution computed tomography and ultrasonography imaging during a period from 1 January 2019 to 31 August 2019. A 10 mHz transducer was used for fracture imaging, and the largest dislocation of each fracture was measured. A paired t-test for dependent samples was used for statistical evaluation of the measured differences, and the p-value was set at 0.05. A total of 16 patients with 29 fractures were included. The fractures were characterized as follows: zygomatic arch (n = 7), lateroorbital region (n = 4), maxilla/zygomatic bone (n = 15), mandible (n = 2), and frontal sinus (n = 1). Regardless of the fracture location, we found no statistical difference in fracture measurements between the ultrasonography and the computed tomography (p = 0.17 (fractures of the zygomatic arch) to p = 0.85 (all fractures)). The study findings suggest that ultrasonography not only allows basic detection but also a quantification of the dislocation in facial skull fractures. The ultrasonography results are not significantly different from those of the computed tomography. In everyday clinical practice, ultrasonography of facial fractures can be considered an adequate imaging procedure. If used correctly, additional radiation exposure to the patient can be avoided, thus representing a diagnostic alternative to computed tomography., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest regarding this original article., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: Orbital floor fracture (OFF) are frequently associated with zygomatic fractures (ZF). The reduction of the ZF may modify the features of the associated OFF. Intraoperative cone beam CT (CBCT) has shown diagnostic performance of OFF. The aim of our study was to evaluate how intraoperative CBCT control made after the reduction of ZF may help to take a decision on the associated OFF., Material and Method: Patients with a unilateral displaced ZF associated with an OFF were consecutively included during a 3-year period. Intraoperative CBCT, systematically performed after reduction of the ZF, allowed to decide if the OFF needed reconstruction. The preoperative estimation made on MDCT and the intraoperative decision regarding the OFF were compared., Results: Fifty-nine consecutive patients could be included in the study. Nineteen OFF were presumed to be surgical indications on the preoperative MDCT but only 16 indications were confirmed on the intraoperative CBCT, meaning that 3 OFF behaved favorably during the ZF reduction. Forty orbital floor fractures were presumed to be non-surgical on the preoperative MDCT but 6 of them worsened during ZF reduction and became surgical indications. Overall, the intraoperative CBCT control had an impact on 9 (15.3%) of the OFF., Conclusion: Our study showed that OFF after ZF reduction may evolve favorably or, on the contrary, get worse in 15% of the cases. Surgical indication on an OFF can therefore be confirmed intraoperatively. This allows to avoid under-treatment in the patients where the OFF worsens after ZF reduction and over-treatment in the patient where the OFF reduces after ZF., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Accurate reduction is of vital importance in the treatment of zygomaticomaxillary complex (ZMC) fractures. Computer-assisted navigation systems (CANS) have been employed in ZMC fractures to improve the accuracy of surgical reduction. However, randomized controlled trials on this subject are rare and the benefits of CANS remain controversial. The aim of this study was to compare reduction errors between navigation-aided and conventional surgical treatment for ZMC fractures. Thirty-eight patients with unilateral type B ZMC fractures were enrolled. Preoperative computed tomography data were imported into ProPlan software for virtual surgical planning. Open reduction and internal fixation was performed with CANS (experimental group) or without CANS (control group). Postoperative computed tomography scans were obtained to examine the difference between surgical planning and the actual postoperative outcome, namely reduction errors. The median translational reduction errors in the X, Y, and Z axes were 0.80 mm, 0.40 mm, and 0.80 mm, respectively, in the experimental group and 0.53 mm, 0.86 mm, and 0.83 mm, respectively, in the control group (P > 0.05). The median rotational reduction errors in pitch, roll, and yaw were 0.92°, 2.47°, and 1.54°, respectively, in the experimental group and 1.45°, 3.68°, and 0.76°, respectively, in the control group (P > 0.05). In conclusion, compared with conventional reduction surgery, navigation-aided surgery showed no significant improvement in reduction accuracy in the treatment of type B ZMC fractures (Chinese Clinical Trial Registry, registration number ChiCTR1800015559)., (Copyright © 2021 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Identify associations between preoperative radiographic measurements and clinical findings of zygomatic arch fractures and postoperative radiographic measurements. Based on those findings, propose a comprehensive treatment algorithm for the solitary zygomatic arch fracture and combined zygomatic arch-zygomatic complex fracture., Methods: Retrospective cohort study with patients referred to our department for zygomatic arch fractures between 2013 and 2018. Data analyzed included patient demographics, clinical evaluation, and radiographic information. Predictor variables were preoperative morphometric measurements: the initial latero-lateral (LL) defect was determined by the difference between the preoperative LL distances of the fractured and the healthy arches, LL distance was measured from the midsagittal plane in the cranium to the inner cortex of the most displaced arch segment, initial arch coronoid distances were measured from the medial part of the most dislocated arch fragment to the lateral aspect of the coronoid, and the anterior-posterior telescoping was measured as the distance between the 2 points in the arch that lost continuity and overlapped as a result of the fracture. The outcome was defined as the residual defect. It was calculated as the ratio between the postoperative remaining LL distance and the initial LL defect., Results: A total of 179 cases were enrolled, all involving head residual defects. Statistical analysis was performed only on 149 medially displaced fractures. Results show that an initial LL defect larger than 3.5 mm has an 86.3% chance of remaining with a better residual defect (<84.1%), P = .001. Cases with antero-posterior (AP) telescoping > 1.45 mm showed a 72.4% chance of remaining with a poor residual defect >84% (P = .003). Arch-coronoid initial distance showed little effect on the chance of remaining with a large remining defect (P = .417, CI = 95%) CONCLUSION: Based on our results, we found that morphometric measurements can be used to predict the reduction results and can assist the clinician in choosing the optimal reduction method and thus increasing the success rate., (Copyright © 2022 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a reliable and accurate method to quantify the symmetry of the zygomaticomaxillary complex (ZMC)., Methods: Virtual three-dimensional models were created from 53 computed-tomography scans: 15 healthy cases without maxillofacial disorders and 38 patients with ZMC fractures requiring surgical treatment.Asymmetry of the ZMC was measured using a mirroring and surface-based matching technique that uses the anterior cranial fossa as reference to determine the symmetrical position of the ZMC. The measure for ZMC asymmetry was defined as mean surface distance (MSD) between the ZMC-surface and the symmetrical position.Reliability of the method was tested in the 15 healthy cases. Inter-and intra-observer correlation coefficients (Ce) and variabilities were assessed. Accuracy was assessed by comparing ZMC asymmetry between healthy and ZMC fracture cases, and by assessing correlation of ZMC fracture severity with ZMC asymmetry., Results: The average MSD of the 15 healthy cases was 1.40 ± 0.54 mm and the average MSD of the 38 ZMC fracture cases was 2.69 ± 0.95 mm ( P < 0.01). Zygomaticomaxillary complex asymmetry correlated with fracture severity ( P = 0.01). Intra-rater CC was 0.97 with an intra-rater variability of 0.09 ± 0.11 mm. Inter-rater Ce was 0.95 with an inter-rater variability of 0.12 ± 0.13 mm., Conclusions: Our method is reliable and accurate for quantitative three-dimensional analysis of ZMC-symmetry. It takes into account asymmetry caused by the shape of the ZMC as well as asymmetry caused by the position of the ZMC., Clinical Relevance: This method is useful for the evaluation of ZMC asymmetry associated with congenital and acquired disorders of craniofacial skeleton, for surgical planning and for evaluation of postoperative results., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Abstract: This study aimed to assess the zygomaticosphenoidal (ZS) angle in patients with reducted unilateral zygomatico-maxillary complex (ZMC) fracture and compare it with the normal control group. This study was performed on CT images of 60 cases and 60 controls with a mean age of 35.1 ± 14.6. The ZS angle was measured on axial images containing the equator of the eyeball. Moreover, the mean absolute difference value and asymmetry index were calculated. Chi-square test, independent-sample t test, 1-way ANOVA, paired-sample t test, and ROC curve analysis were applied. The mean ZS angle in the control group was 46.6° ± 3.5°. Considering laterality, the mean of ZS was not significant in the control group. However, after reduction of unilateral ZMC fracture, there was a significant difference between the mean ZS angle in right and left sides. The mean absolute difference between right and left ZS angles was significantly higher in the case group. A threshold number of 0.9° is established in the mean absolute difference value which is the difference between the right and left ZS angles in an individual for detecting asymmetry. The ZS angle can be a useful anatomical aid to guide surgeons in achieving facial symmetry in ZMC fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: Zygomatic arch fractures can occur either as isolated fractures or as a part of multiple facial fractures. There are several techniques available for reduction of zygomatic arch fractures, which include closed reduction and open reduction with fixation using metallic splints, closed reduction via Gillies or a gingivobuccal approach is preferred for minimal invasiveness, short operative time, and low complication rate. The aim of the present study is to present a simple, easy, and reliable method for closed reduction of isolated zygomatic arch fractures., Patients and Methods: This study included twenty patients presented with isolated zygomatic arch fractures between January of 2017 and December of 2018. All patients were evaluated based on the clinical and radiographic findings. Closed reduction of the zygomatic arches was carried on by a stainless steel wire. Surgical outcomes were subjected for objective assessment based on the postoperative alignment of the zygomatic arch in the computed tomography (CT scan) immediately after surgery and after 3 months. Subjective evaluation was carried out comparing preoperative, 1 and 3 months photographs assessing facial symmetry, as well as the patients' satisfaction., Results: After a period of 3 to 6 months follow-up between January 2017 and December 2019, all patients were satisfied by the overall results, no major complications were recorded and no additional surgery needed for them., Conclusions: The suture wire method is quick, simple, easy, and effective for the reduction of isolated, depressed fractures of the zygomatic arch., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Purpose: Reduction of the bilateral zygomaticomaxillary complex (ZMC) fracture with individualized templates based on computer- aided surgical simulation system. To evaluate the practicality and accuracy of this approach in the treatment of bilateral ZMC fracture., Methods: Sixteen patients with bilateral ZMC fractures were collected to create a study model. The authors reconstruct the ZMC on one side via the three-dimensional (3D) model, and then mirrored to the opposite side. Multiple individualized templates were made based on the 3D model, and used as intraoperative guidance to reduce fractures. After surgery, the facial symmetry and the position of zygoma were observed. The mouth opening, pupil level, and sensation of infraorbital nerve were evaluated. Some mark points on zygoma were measured and the postoperative horizontal asymmetry rate (H) was calculated. Besides, orbital height and width were measured., Results: For all patients, the position of bilateral ZMC was basically restored. The patients with restriction of mouth opening all recovered to normal. The H values were less than 3.0% at all mark points. There was almost no difference in bilateral orbital width and height. Meanwhile, there was no significant difference between the preoperative measurements of the ideal virtual 3D model and the postoperative measurements of patients., Conclusions: The study proves that application of computer-aided design and individualized templates can accurately guide the reduction operation of ZMC fracture, restore the ideal shape of ZMC, and obtain good facial symmetry., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Management of zygomaticomaxillary complex (ZMC) fractures can be challenging. Consequently, there is a difference in treatment amongst clinicians. In the literature it remains unclear if the number of fixation points affects the quality of the anatomical reduction, stability through time, and potential complications. Therefore, the objective of this study was to assess the outcome of no fixation, one-point fixation and multiple-point fixation of ZMC fractures. MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials were searched to identify eligible studies. After screening 925 articles, 17 studies fulfilled the inclusion criteria. Based on this systematic review no clear conclusions can be drawn on how stability, repositioning, and postoperative complications are affected by the number of fixation points. Nevertheless, it can be concluded that the advantage of multiple approaches is direct visualisation, and the downside is potentially approach-related complications. This review suggests that intraoperatively assisted cone-beam computed tomography (CBCT) can help improve the quality of the repositioning and by minimising the number of fixation points, the number of postoperative complications could be further reduced., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)