International Medical Journal Vol. 26, No. 3, pp. 256 - 257 , June 2019

CASE REPORT

Fractures of Zygomatic Complex and Their Treatment

Shaifulizan Ab Rahman1), Kow Hui Xuan1), Sanjida Haque2), Mohammad Khursheed Alam3)

ABSTRACTBackground: Fractures of Zygomatic Complex is a relatively common injury in Malaysia.Case Presentation: This case report is about a 53 year old patient who sustained right zygomatic complex fracture and close

fracture of right midshaft of tibia and fibula after involvement in a motor vehicle accident. This report will focus on the oral maxillofacial part, which is regarding the fracture of the zygomatic complex and the management.

Conclusion: Patient underwent open reduction and internal fixation (ORIF) with plates and screws at right zygomatic arch and right frontozygomatic suture via hemicoronal extended incision.

KEY WORDSzygomatic complex fracture, open reduction internal fixation, plates and screws

Received on April 17, 2018 and accepted on July 3, 20181) Oral surgery and Maxillofacial surgery Department, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia2) Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia3) Orthodontic Department, College of Dentistry, Jouf University Sakaka, KSACorrespondence to: Shaifulizan Ab Rahman(e-mail: shaifulrahman@lycos.com)

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INTRODUCTION

Facial injuries occur in a significant proportion of trauma patients requiring prompt diagnosis of fractures and soft tissue injuries, with possible emergency interventions. The facial area is one of the most fre-quently injured areas of the body, and the mandible is one of the most common maxillofacial bones fractured, due to its prominent position on the face1).

The incidence and aetiology of maxillofacial trauma and facial frac-tures vary widely in different regions of the world due to social, eco-nomic, cultural consequences, awareness of traffic regulations and alco-hol consumption. Countries like the United States, Finland and Sweden have high incidence of maxillofacial trauma resulting from assault while road traffic accidents is the main etiology in Nigeria, Singapore, United Arab Emirates, Jordan and Japan2).

In Malaysia, road traffic accidents were the main etiology for maxil-lofacial injury3). Among the bony fractures, mandible was the common bone involved followed by midface fractures. For mandibular fractures, condylar fractures are the most common (33.2%), while for midface fractures, zygomatic bone fractures are the most common due to its morphogenic prominence of zygomatic region (45.8%). Motorcyclists were affected most, followed by motorcar occupants3). The zygomatic complex is responsible for the mid-facial contour and for the protection of the orbital contents.

CASE REPORT

The patient was a 53-year-old Malay man underlying with hyperten-sion was referred to Oral surgery and Maxillofacial surgery Department, School of Dental Sciences, Universiti Sains Malaysia following a severe facial trauma as a result of motor vehicle accident.

Following the collision, there was a loss of consciousness of

unknown duration. However, there was no nausea or vomiting and no blurred vision. Patient complained of facial swelling and tenderness felt especially at the right malar area. There are a few abrasion wounds around the face. On examination, there was a facial asymmetry showing depressed right malar area from bird's view. There was soft tissue swell-ing at the right frontozygomatic suture area and right malar region. The area was associated with tenderness to palpation and step deformity was palpable. Mouth opening was limited to 2 finger breadths of his own fingers.

Computed tomography (CT scan) confirmed the diagnosis of right zygomatic complex fracture which involved fracture of right greater wing of sphenoid, right frontozygomatic suture, right zygoma, right zygomatic arch, right lamina papyracae, anterior and lateral wall of right maxillary sinus and right inferior orbital wall (Figure 1).

The patient underwent surgery for open reduction and internal fixa-tion (ORIF) with plates and screws at right zygomatic arch and right frontozygomatic suture via hemicoronal extended incision under general aneasthesia (Figure 2).

On the next day post operation, the patient claimed that he cannot raise his right eyebrow, otherwise was insignificant. Facial profile of patient was asymmetry with flattening of right temporal area (Figure 3). For the upper one-third of the face, there was a suture over coronal area which was intact with radivac drain. There was weakness over right temporal branch of facial nerve. Middle one-third, there was swelling over right malar region no paresthesia noted. Finding for middle one-third was insignificant. A soft diet was also recommended. Analgesics and antibiotics were prescribed. The patient was scheduled for a period-ic monitoring under oral maxillofacial surgery clinic.

DISCUSSION

Trauma to the facial region frequently results in injuries to soft tis-sue, teeth, and major skeletal components of the face. This includes the

C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation

Rahman S. A. et al. 257

mandible, maxilla, zygoma, naso-orbitalethmoid complex and supraor-bital structures. In this case, zygomatic complex were involved after a motor-vehicle accident.

The main aims of any fracture treatment are to provide reduction, fixation, and immobilization. This is to ensure rapid bone healing, to return patient's normal function including ocular, masticatory and nasal function and speech, and to obtain acceptable aesthetics. Generally, the best results in the treatment of facial fractures if the reduction is done within the first few days after the injury. However, this is not always possible due to factors such as presence of other more life-threatening concomitant injuries, distance from a suitable medical unit and failure of complete diagnosis. Sometimes, there will be a 3 to 4 days delay to eliminate tissue oedema before treatment is done4). The optimum time for primary reduction is a 2-week period following the injury and accu-rate reduction becomes difficult after the third week5).

The zygomatic complex is a key component of structural facial skeleton and aesthetics. Studies done in Kuala Lumpur suggested that zygoma fracture is the second most common fractured facial bone, after the mandible and also the most common type of mid facial fracture4). Displacement of zygomatic complex fractures is in principle a surgical indication, unless there is clinical contradictory, such as being medically unfit for surgery, patient refusal or the absence of functional and/or aes-

thetic problems6). A study in Malaysia, showed that more than half of the patients were treated by simple elevation via the Gillies temporal approach alone that did not require additional fixation7). However, for the patient in the study, as there was obvious displacement of zygomatic bone, accompanied by paresthesia of the right infraorbital nerve, surgi-cal treatment with internal fixation was required. Insufficient exposure and reduction of the zygomatic fragment result in facial asymmetry. Usually, these problems are noticed weeks after surgical treatment. For these reasons displaced fractures are best managed by open reduction and fixation. In the absence of comminuting or instability at the zygo-matic arch, reduction under direct visualization plus fixation at the zygomaticofrontal suture, zygomaticomaxillary buttress, and inferior orbital rim remains the best treatment option.

CONCLUSION

Maxillofacial injuries occur most commonly due to motor-vehicle accidents. These injuries should be properly managed and should not be delayed. Management of the patient does not stop after surgery. Patient has to be monitored after surgery, and after discharge, have to come for regular follow-up to ensure proper healing and to achieve the treatment goals of facial fracture management.

REFERENCES

1) Kumar SU, Ngeow WC. Prevalence and management of zygomatic fractures in a Malaysian population. Mal J Oral Maxillofax Surg 2004; 3: 14-17.

2) Rahman RA, Hussaini HM, Rahman NA, Rahman SR, Nor GM, Ai Idrus SM, Ramli R. Facial Fractures in Kajang Hospital, Malaysia: A 5-Year Review. Eur J Trauma Emerg Surg 2007; 33:90-95.

3) Muhammad H, Khairuddin NA, Zakaria AR, Yunus NNN, Wan Mustafa WM. Facial fractures presenting to a tertiary referral centre in Malaysia: A 9-year study. Malaysian Dent J 2012; 34: 10-15.

4) Ochs MW, Tucker MR. Current Concepts in Management of Facial Trauma. J Oral Maxillofac 1993; 51: 42-55.

5) Bernstein L. Delayed Management of facial fractures. The Laryngoscope 1970; 80: 1323-1341.

6) Salentijn EG, Boverhoff J, Heymans MW, van den Bergh B, Forouzanfar T. The clinical and radiographical characteristics of zygomatic complex fractures: A comparison between the surgically and non-surgically treated patients. Journal of Cranio-Maxillofacial Surgery. 2014; 42(5): 492-497.

7) Pohchi A, Razak NHA, Rajion ZA, Alam MK. Maxillofacial Fracture at Hospital Universiti Sains Malaysia (HUSM): A Five year Retrospective Study. Int Med J 2013; 20:487-489.

Figure 1. CT scan of patient. a) coronal view showed right fracture of zygomatic bone and right fontozygomatic suture area. There was also right inferior orbital wall fracture with no extraocular muscles or fat herniation through fracture site. b) axial view showed right lamina papyracea fracture with blood product noted in the ethmoid sinus and fracture of right greater wing of sphenoid. c) axial view showed anterior and lateral wall of right maxillary sinus fracture. Blood product noted in the right maxillary sinus. d) axial view showed right zygozatic arch fracture.

Figure 2. Incision done via hemicoronal extended incision folowed by plates and screws placement at right zygo-matic arch and right frontozygomatic suture area.

Figure 3. Post-op extraoral photographs of the patient.