Fractures of the pediatric zygoma: a review of the clinical trends, management strategies, and outcomes associated with zygomatic fractures in children.

ORIGINAL ARTICLE

Fractures of the Pediatric Zygoma: A Review of the Clinical Trends, Management Strategies, and Outcomes Associated With Zygomatic Fractures in Children Michael V. DeFazio, MD,* Kenneth L. Fan, MD,* Yash J. Avashia, MD,Þ Gary H. Danton, MD, PhD,* and Seth R. Thaller, MD, DMD* Abstract: Fractures of the pediatric zygoma are uncommon and are often associated with high-impact trauma, as evidenced by the relatively increased prevalence of concomitant injuries observed in these patients. Despite advances in the prevention, diagnosis, and management of pediatric craniofacial injuries, data regarding zygomatic fractures in children remain poorly established. The diagnosis of zygomatic disruption is more difficult in children and requires the maintenance of a high index of suspicion on behalf of the surgeon. Early recognition and implementation of appropriate therapy are critical and depend on the acquisition of a thorough history and physical examination as well as the accurate interpretation of computed tomographic imaging. Options for management depend on fracture severity and can range from observation or closed reduction in nondisplaced or only minimally displaced fractures, to open reduction and internal fixation in fractures that are comminuted or severely displaced. Currently, there is a lack of level I evidence evaluating the long-term consequences associated with pediatric zygomatic fractures and their management. A review of the epidemiology, clinical characteristics, diagnosis, and management of pediatric zygomatic fractures is essential for optimizing function and aesthetic outcomes in children who sustain these injuries. Key Words: Facial fractures, maxillofacial trauma, pediatric zygomatic fractures, zygoma Abbreviations: CT, computed tomographic, MVA, motor vehicle accident, ZMC, zygomaticomaxillary complex (J Craniofac Surg 2013;24: 1891Y1897) What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.

From the *Division of Plastic, Aesthetic, and Reconstructive Surgery, The DeWitt Daughtry Family Department of Surgery, and †Department of Radiology, Miller School of Medicine, University of Miami Health System, Miami, Florida. Received March 6, 2013. Accepted for publication June 22, 2013. Address correspondence and reprint requests to Seth R. Thaller MD, DMD, FACS, Division of Plastic, Aesthetic, and Reconstructive Surgery, The DeWitt Daughtry Family Department of Surgery University of Miami Health System, 1120 NW 14th St, 4th Floor, Miami, FL 33136; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a24659

The Journal of Craniofacial Surgery

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ediatric zygomatic fractures represent a rare challenge along the spectrum of craniofacial injuries faced by the plastic and reconstructive surgeon. Both the location and pattern of facial fractures in children are dependent on the interplay between etiology, force of injury, and stage of craniofacial development.1 Altered geometric proportions and unique anatomical properties of the pediatric facial skeleton make the occurrence of zygomatic disruption much less common in young children.2 Regardless of age, however, distortion of the functional or aesthetic integrity of the face may substantially alter one’s sense of identity. The zygoma, in particular, serves as the cornerstone of facial contour, making significant contributions to the shape and projection of the midface. In addition, it provides a site of attachment for multiple muscles of mastication and facial expression as well as an anchor for supporting connective tissues that influence the shape and position of the eye. Therefore, disruption or displacement of this structure may have devastating effects on facial symmetry and function, with direct implications on a child’s perception of self as well as his/her interactions with the external environment. Despite advances in the prevention, diagnosis, and management of craniomaxillofacial injuries, over the past 3 decades, data regarding zygomatic fractures in pediatric patients are less robust and are often overshadowed by the considerably greater focus on mandibular traumas in this age group.3Y6 Therefore, a comprehensive review of the anatomic, physiologic, social, and environmental factors that influence the development of zygomatic fractures is necessary to optimize the management of patients who sustain these injuries. The purpose of this article was to provide such a review as well as examine the clinical implications, management strategies, and outcomes of zygomatic fractures in the pediatric population.

UNIQUE FEATURES OF CRANIOFACIAL DEVELOPMENT Age-dependent variation in both the frequency and distribution of pediatric facial fractures stems from a constellation of physical and environmental changes that evolve during development. At birth, the ratio of cranial to facial volume is approximately 8:1. However, as craniofacial growth accelerates, these proportions shift dramatically, approaching nearly 2.5:1 by adulthood.7 The increased prominence of the skull during early development accounts for the relatively higher proportion of cranial injuries observed in children younger than 5 years.1,7Y11 With vertical and forward projection of the face as the child matures, however, frontal prominence diminishes, and the midface and mandible come to occupy more dominant positions, making them more susceptible to traumatic injury.8,9,12 The architectural changes that accompany facial enlargement stem from bone growth and mineralization, as well as pneumatization of the paranasal sinuses.7Y9 The lack of aeration and thickened walls of the immature pediatric sinuses reinforce the zygomaticomaxillary buttress and promote an increased resistance to facial fractures

& Volume 24, Number 6, November 2013

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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TABLE 1. Summary of Series Reporting on the Incidence, Etiologies, Management, and Outcomes Associated With Fractures of the Pediatric Zygoma

Author

Year

Study Period

Total No. (%) Patients With Facial Fractures

No. of Patients (%) With Zygomatic Fractures

Average Age, y

Age Range, y

Rottgers et al38

2011

2003Y2007

177

10 (6); ZMC: 100%

9.8

0Y18

2:1

Chapman et al14 Eggensperger et al15

2009 2008

2001Y2005 2001Y2003

188 291

41 (22); ZMC: 91%; isolated arch: 9% 11 (3)

9.17 6.1

0Y18 0Y16

1.7:1 1.5:1

Ogunlewe et al43

2006

1997Y2004

37

6 (13); ZMC: 100%

9.1

1Y15

1.5:1

Ferreira et al20

2005

1993Y2002

912

13.2

0Y18

3.1:1

Gassner et al11

2004

1991Y2000

389

92 (15); ZMC: 85%; isolated arch: 15%

9.7

0Y15

1.7:1

Iida and Matsuya22

2002

1982Y1996

178

14 (8); ZMC: 64%; isolated arch 36%

N/A

0Y15

2:1

Bamjee et al18

1996

1989Y1992

326

13 (4); ZMC: 38%; isolated arch: 31%; combined: 31%

4.0

0Y18

2.3:1

Iizuka et al12

1995

1980Y1990

54


10.3

1Y15

1.16:1

Posnick et al9

1993

1986Y1990

137


10.2

0Y18

1.7:1

Thaller and Huang26

1992

1990Y1991

53

7 (14)

N/A

0Y16

3:1

Stylogianni et al3

1991

1980Y1987

116

3 (3)

N/A

0Y13

1.14:1

Fortunato et al21

1982

V

67

7 (10)

8.1

2Y15

2.4:1

Adekeye25

1980

V

85

6 (7); ZMC: 100%

N/A

0Y13

2.1:1

Kaban et al23

1977

1965Y1974

109

6 (6); ZMC: 100%

N/A

0Y16

1.5:1

295 (24)

early in life.13,14 Development of the maxillary sinuses and eruption of the permanent teeth cause the midface and mandible to expand, leaving the midface relatively less protected.1,7,8,15,16 As a result, there is a shift of fracture distribution from the upper to lower regions of the face that accompanies facial maturation.8,9,12 Additional protection is provided by an increased cancellousto-cortical bone ratio and suture line flexibility.13,17 These properties impart elasticity on the craniofacial skeleton, which accounts for the relatively higher incidence of minimally displaced fractures seen in this age group.1,16 Furthermore, a higher buccal fat content cushions the impact and lessens the force transmitted to the bony architecture, thereby serving to protect the midface as well.1,7,9 When compared with adults, the low prevalence of zygomatic fractures observed in children likely results from a combination of these unique anatomic and physiologic characteristics.

DEVELOPMENT-SPECIFIC TRENDS IN PEDIATRIC FACIAL FRACTURES Incidence Large retrospective reviews, involving both children and adults, reveal that less than 15% of all facial fractures occur in patients younger than 16 years.1,11Y13,15,18,19 Although the incidence before age 5 years lies between 0.6% and 1.4%, the risk of

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Sex Ratio (Male:Female)

sustaining facial bone fractures increases by approximately 4.4% with each advancing year.1,10,11,19,20 Midfacial fractures, in particular, are even rarer, with frequencies in the range of 0.2% to 13% in studies analyzing pediatric facial trauma only (Table 1).3,8,10,21 The highest incidence of midfacial fractures occurs in those 13 to 15 years of age, at which point the frequency and distribution of these fractures approach those seen in adults (Figs. 1A, B).8,11,12,14,20,22

Sex The sex distribution of maxillofacial trauma worldwide demonstrates a significant male predominance in nearly all age groups. Previous series have reported a male-to-female ratio varying from 1.16:1 to 8.5:1, which has been attributed to increased violence and more aggressive tendencies among growing males.1,3,4,7,11,12,15,18,20,22 Not surprisingly, however, sex-specific differences become less significant in younger age groups, where the etiologies of facial fractures are similar between both sexes.1,16

Etiology Direct comparison of the causative factors for pediatric zygomatic fractures is difficult, because few studies investigating the mechanisms of such injuries in children exist. In the United States, motor vehicle accidents (MVAs), sports-related injuries, and falls constitute the main causes of midfacial fractures in children.1,8,12,20,22 * 2013 Mutaz B. Habal, MD




Pediatric Zygomatic Fractures

TABLE 1. Summary of Series Reporting on the Incidence, Etiologies, Management, and Outcomes Associated With Fractures of the Pediatric Zygoma

Method of Treatment

Etiologies of Facial Fractures

Associated Complications/Adverse Outcomes

Observation: 20%; operative intervention: 80%

N/A

Adverse outcomes (60%); enophthalmos (30%); V2 numbness (30%); malar flattening (20%); scleral show (10%); multiple (30%) N/A Associated injuries (33%); dental (18%); cerebral (48%); thorax (6%); abdominal (8%); extremities (20%) Associated injuries (49%); facial lacerations (55%); long bone fractures (22%); craniocerebral (11%); blindness (6%); facial nerve palsy (6%) adverse outcomes (22%); infection (50%); malocclusion (24%); hypertrophic scar (13%); oroantral fistula (13%) Associated injuries (65%); cerebral (52%); extracerebral (21%); multiple (26%) adverse outcomes (8%); facial scarring (46%); unsatisfactory repair (28%); ectropion (13%); epiphora (8%); enophthalmos (4%); facial asymmetry (1%) Associated injuries (50%); craniocerebral (80%); extremities (12%); trunk (7%); spine (1%) N/A

N/A Observation: 82%; closed reduction: 4%; open reduction: 13% Observation: 19%; closed reduction: 81%

N/A For all fractures: falls 188 (64%); traffic 63 (22%); sports 26 (9%); violence 14 (5%) For all fractures: traffic 24 (65%); falls 9 (24%); violence 3 (8%); other 1 (3%)

Observation: 30%; Gilles elevation: 32%; open reduction: 38%

For all fractures: MVA 486 (53%); fall 151 (17%); bicycle 104 (11%); violence 46 (5%); other 125 (14%)

N/A N/A

N/A

Observation: 38%; elevation only: 10%; open reduction wire fixation: 10%; open reduction plate fixation: 38%; external pin fixation: 4% Observation: 38%; open reduction internal fixation: 62%

Observation: 43%; open reduction rigid internal fixation with plates and screws: 57% Elevation only: 67%; open reduction and wiring: 33% Observation: 57%; closed reduction: 14%; open reduction internal fixation: 29% N/A Observation: 33%; Caldwell-Luc reduction: 33%; open reduction with wire fixation: 33%

For all fractures: sports 184 (47%); play 119 (33%); traffic 49 (13%); violence 19 (5%); other 8 (2%) For isolated midface fractures: traffic 7 (37%); bicycle 4 (21%); sports 4 (21%); violence 2 (11%); falls 1 (5%); other 1 (5%) For all fractures: violence 155 (48%); traffic 94 (29%); accidents 48 (14%); sports 25 (7%); child abuse 1 (G1%); other 3 (1%) For zygomatic fractures: MVA 14 (37%); sports 5 (19%); hit by object 2 (9%); falls 1 (5%)

For all fractures: traffic 68 (50%); falls 32 (23%); sports 21 (15%); violence 7 (5%); other 9 (7%)

For midfacial fractures: MVA 29 (55%); violence 6 (11%); bicycle 5 (9%); falls 4 (8%); other 9 (17%) For all fractures: traffic 93 (80%); falls 9 (8%); violence 6 (5%); sports 5 (4%); other 3 (3%) For all fractures: traffic 33 (50%); falls 22 (33%); violence 3 (4%); hit by object 3 (4%); sports 3 (4%); child abuse 2 (3%); other 1 (2%) For all fractures: traffic: 54%; falls: 31%; violence: 6%; sports: 1%; other: 8% For all fractures: falls: 32 (29%); hit by object: 30 (28%); traffic: 19 (17%); violence: 6 (6%); sports: 4 (4%); traumatic birth: 1 (1%); other: 17 (15%)

The relative percentage of the various etiologies reported, however, varies according to the age group being evaluated. Before age 6 years, low-impact falls predominate, and the safety afforded by a protective home environment is thought to be the main reason for the extremely low rate of midfacial fractures in this age group.12,15,18,20,22,23 As the child emerges out from under the protective home environment, the etiologies of facial fractures become more predictable. Involvement in traffic accidents, as a pedestrian or bicyclist, is a common cause of maxillofacial trauma in children 6 years or older.1,3,9,23 Sports-related injuries peak in children 10 to 14 years of age, and interpersonal violence becomes a significant source of facial fractures in adolescents and adults.1,12,13 In addition, these injuries are seen in approximately 2.3% of victims of child abuse.24 Maintenance of a high index of suspicion in children who present with repeated or multiple injuries, an inadequate history, or delayed presentation is therefore imperative. Because of the increased resilience of the pediatric facial skeleton, fractures of the midface in children most often require highimpact and/or high-velocity forces, such as those associated with MVAs.8,10,23 Several studies report MVAs as the leading cause of maxillofacial trauma, death, and concomitant injuries in young children who sustain midfacial fractures.1,3,4,8,9,12,13,19,25Y27 Zygomatic complex fractures are among the more frequently associated with high-impact

Associated injuries (41%); soft tissue (67%); cranial (8%); orthopedic (8%); neck (5%); ophthalmic (4%); otolaryngeal (4%); thoracic (2%); abdominal (2%) Associated injuries (48%); craniocerebral (92%); extracerebral (42%); multiple 50% adverse outcomes (6%); insufficient reduction requiring revision (100%) Associated injuries (89%); soft tissue (63%); craniocerebral (16%); extremities (9%); eye (8%); thorax (4%); abdomen (1%) adverse outcomes (4%); infection (40%); exposed hardware (20%); other (40%) Associated injuries (49%); neurosurgical (49%); orthopedic (26%); ophthalmologic (15%); thoracic (11%); dental (9%); abdominal (7%); multiple (15%) Associated injuries (31%); soft tissue injury (56%); craniocerebral (45%) Associated injuries (74%)

N/A Associated injuries (29%); craniocerebral (38%); facial (34%); extremity (16%); ocular (6%); abdominal (3%); cervical (3%)

traumas, following maxillary alveolar and nasal bone injuries.1,12 The incidence of MVA-related maxillofacial trauma increases with age and is inversely related to the stringency of motor vehicle legislation mandating the use of seatbelts and child safety restraints.19,20,28Y30

Concomitant Injuries Severe concomitant injuries are seen in up to 25% to 88% of children with facial fractures.8,9,12,18,19,27 In particular, children who sustain comminuted zygomatic fractures, resulting from highimpact trauma (eg, MVAs), have a higher incidence of associated injuries, including closed head trauma, neurocranial injuries, and extremity fractures, as well as abdominal, thoracic, and cervical spine injuries.8,9,12,18,19,27 This observation likely reflects the high energy requirement necessary to produce comminuted fractures of the pediatric midface (Figs. 2A, B).1,4 In addition, several studies have demonstrated a significantly higher percentage of concomitant injuries in children than adults.1,4 McGraw and Cole8 attributed the higher frequency of associated head trauma found in their study to the unique anatomical properties of the pediatric craniofacial skeleton, mentioned previously. However, Iizuka et al12 found no significant difference in the frequency of concomitant head injuries among the various age groups analyzed. Rather, a distinct relationship between the development of comminuted zygomatic fractures

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FIGURE 1. Maxillofacial CT scan of a 13-year-old boy on admission following MVA. A, Axial view demonstrates a minimally displaced comminuted fracture of the right zygomatic arch (arrow). B, Three-dimensional reconstruction of a CT angiogram illustrating mild displacement of an isolated zygomatic arch fracture in the same patient. Patterns of zygomatic fractures in this age group resemble those seen in adult patients.

and associated injuries was noted, suggesting that the severity of the insult appears to be a more decisive factor in determining the pattern of fracture development as well as the likelihood of associated injuries.

CLINICAL SIGNS AND SYMPTOMS OF ZYGOMATIC FRACTURES Signs and symptoms of pediatric zygomatic fractures resemble those seen in adults and often include a combination of periorbital or subconjunctival hematoma, as well as sensory disturbances in the distribution of the infraorbital nerve.1,13,31,32 The absence of these 2 findings in particular makes the diagnosis questionable (Fig. 3). Ipsilateral epistaxis is common, as is inferior displacement of the zygoma, which alters the position of the lateral canthus, producing facial asymmetry and lateral displacement of the eye.31 If a significant component of the orbit is fractured, entrapment of the extraocular muscles or alteration in the position of the globe

may be noted. Enophthalmos may result from expansion of the orbital volume leading to diplopia or visual disturbance. The presence of bilateral diplopia correlates with fracture severity and is found in approximately 30% of those with comminuted fractures, 22% with noncomminuted, displaced fractures and only 8% with minimally or nondisplaced zygomaticomaxillary complex (ZMC) fractures.2,33 Furthermore, motion of the mandible may be inhibited secondary to impingement of the zygomatic arch on the coronoid process producing painful limitation of mouth opening.1,31,32 Zygomatic fractures rarely present as isolated facial fractures due to the buttressing nature of the zygoma and the thin bones surrounding it. The force required to fracture the zygoma in children is distributed to adjacent, weaker bones, leading to contiguous fractures, especially within the skull, orbital roof, and naso-orbital-ethmoid complex.1,14 In adults, the pneumatized sinuses serve as an absorptive barrier to fracture extension, preventing the transmission of external forces to the central nervous system.7,14 The lack of this property

FIGURE 2. Computed tomographic scan of the maxillofacial skeleton of a 10-year-old girl who sustained multiple concomitant injuries following a high-impact fall from a 6-story balcony. A, Axial view demonstrating a comminuted fracture of the left zygomatic arch along with a depression fracture of the left anterior wall of the maxillary sinus (arrows). In addition, fractures of the right and left posterior lateral walls of the maxillary sinuses, the medial and lateral walls of the pterygoid plates, and the nasal bone are also appreciated. B, Coronal view in the same patient demonstrating fractures through the bilateral inferior orbital walls, the left lateral orbital wall, left zygoma (arrow), and the midline maxilla and hard palate. Multiple missing teeth are noted.

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Radiographic Evaluation of the Midface Radiographic evaluation provides evidence to confirm the findings of the physical examination and may be the only means of evaluating patients in whom thorough clinical examination is not possible. Plain film radiography is of limited diagnostic value in children, particularly with fractures involving the midface, where the presence of underdeveloped sinuses and tooth buds obscures anatomic landmarks and fracture lines.1,37 Use of this modality may offer false reassurance, leading to a delay in the diagnosis of zygomatic fractures in children.27 Computed tomographic (CT) imaging, on the other hand, greatly increases diagnostic accuracy and has emerged as the standard of care in the diagnosis and evaluation of pediatric midfacial fractures.9,27 In their retrospective review of 59 pediatric facial fractures, Holland et al27 reported a diagnostic accuracy of 100% associated with the use of facial CT imaging. Thus, for children in whom zygomatic fractures are suspected based on history and physical examination, early CT evaluation is justified to clearly define the injury and avoid further delays in diagnosis.13,27 FIGURE 3. Axial CT scan of a 14-year-old male victim of physical assault demonstrating displacement of a left zygomatic arch fracture in conjunction with a fracture of the left inferior orbital rim and surrounding left periorbital soft tissue edema.

in children accounts for the lower Glasgow Coma Scale scores observed in children who sustain facial fractures.7

DIAGNOSIS OF ZYGOMATIC FRACTURES IN CHILDREN Pediatric facial fractures are often overlooked in the emergency room setting. The relative infrequency of these injuries leads to a low index of suspicion on behalf of the health care provider. Accurate diagnosis in children is dependent on the acquisition of a thorough history and physical examination as well as the interpretation of appropriate diagnostic imaging.

Clinical Examination The clinical examination begins with an evaluation of facial symmetry, which can be formally assessed with the surgeon at the head of the bed overlooking the patient in the supine position. From this approach, globe position can be evaluated by comparing eye projection, and the anterior and lateral position of the zygomatic bodies can be visualized. Placing an index finger on each side of the infraorbital margin helps to reduce any distortion caused by facial swelling, allowing accurate evaluation of the malar prominence and any step deformities along the orbital rims or upper buccal sulcus to be appreciated.17,20,32,34,35 The presence of chemosis, decreased or painful ocular mobility, and blurred vision all indicate zygomatic disruption.1 Hemorrhage into the subconjunctiva is the most common feature, occurring in up to 64% of zygomatic fractures.36 Inspection for the presence of septal hematomas, mobile facial bone segments, maxillary instability, and improperly aligned teeth or malocclusion must be undertaken. A complete neurologic examination is essential and should assess for disturbances in facial sensation, motor deficits, alterations in visual acuity, diplopia, and entrapment of the globe. Any abnormality of extraocular muscle movement should be confirmed by a forced duction test and mandates further evaluation by an ophthalmologist. The presence of clear fluid draining from the nose or open wounds should alert the clinician to the possibility of a central nervous system injury. A low threshold for neurosurgical consultation should be maintained secondary to the relatively high incidence of associated cranial injuries reported in children.8,31

MANAGEMENT OF PEDIATRIC ZYGOMATIC FRACTURES As with any trauma, the initial management of zygomatic fractures in children identifies conditions that require immediate treatment for the prevention of life-threatening complications. These include maintenance of an adequate airway, control or prevention of hemorrhage, protection against aspiration, and identification of concomitant injuries.31,35 As with adults, the primary goal in the management of pediatric facial fractures includes restoration of preinjury form and function. Clinical judgment must be exercised, however, to determine whether operative intervention is required. Traditionally, a conservative, nonsurgical approach has been preferred to prevent disturbances in dentition and growth associated with more invasive modalities.20,23,38 In general, the criteria for nonoperative observation include nondisplaced or only minimally displaced fractures that are not large enough to produce functional or severe aesthetic deformities.1,9,19,20,31 However, with the high incidence of comminuted or displaced fractures in this patient population resulting form high-impact injuries, open reduction and internal fixation is frequently required to prevent future growth disturbances.1,8,9,20,27,31 Open reduction and internal fixation with miniplates and screws has become the standard of care for management of displaced or comminuted fractures, as it provides stable three-dimensional reconstruction, promotes primary bone healing, shortens treatment time, and reduces dependence on maxillomandibular fixation.1,9 Because of the high osteogenic potential and rapid healing rates in children, anatomic reduction must be accomplished earlier, and immobilization times should be shorter to prevent malformed fibrous union.1,3,11,19 Zygomatic surgery should be performed within 3 to 5 days after the initial edema has resolved, as delays in reduction and stabilization may result in complications that require reoperation and revision.1,3,16,17,27 The use of established craniofacial techniques to achieve wide exposure and mobilization of the entire zygoma is of paramount importance to accurate anatomical reduction of the severely displaced and comminuted zygoma. In children, open reduction can be accomplished through a number of approaches, depending on the location of the fracture. Lateral upper eyelid, lower lid subciliary/ transconjunctival, and upper buccal sulcus incisions can be used to gain access to the frontozygomatic suture, infraorbital rim/orbital floor, and zygomatic buttress, respectively (Fig. 4).1,32 Reduction of the sphenozygomatic suture first, before other fracture lines, allows for more precise reconstruction with better aesthetic results.31,32 In children, fracture stabilization using 1-point (frontozygomatic suture), 2-point (frontozygomatic suture, infraorbital rim),



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FIGURE 4. Open reduction and internal fixation of multiple ZMC fractures in a 15-year-old male unrestrained passenger of an MVA. A, Three-dimensional reconstruction of the preoperative maxillofacial CT scan demonstrating fractures of the frontozygomatic suture, infraorbital rim, zygomaticomaxillary buttress, and zygomatic arch. B, Rigid fixation of the frontozygomatic suture following exposure via an upper lateral eyelid incision. C, Reduction and fixation of the zygomaticomaxillary buttress with 2 plates using an upper gingivobuccal sulcus approach. D, Postoperative three-dimensional reconstruction of the maxillofacial CT scan demonstrating 3-point fixation of the frontozygomatic suture, infraorbital rim, and zygomaticomaxillary buttress.

or 3-point (frontozygomatic suture, infraorbital rim, zygomaticomaxillary buttress) fixation is generally accepted as adequate, depending on the type and location of the fracture.1,39 An incision made along the upper gingivobuccal sulcus permits adequate exposure for reduction of the fractured segment before rigid fixation. For children younger than 6 years, exposure of the frontozygomatic suture and/or infraorbital rim during plate and screw fixation reduces the risk of trauma to the maxillary tooth buds associated with plating at the zygomatic buttress.1,13 While long-term studies regarding the effects of rigid fixation on pediatric craniofacial growth are currently lacking, the use of microplates for this role has been cited to produce acceptable results in children.13,16 Isolated zygomatic arch fractures may be managed through the use of a temporal (Gilles) or transoral (Keen) approach to elevate and reduce the fracture.40 These fractures are usually stable without requirement of additional fixation.1 Orbital floor reconstruction following zygomatic disruption is indicated in the presence of entrapment, enophthalmos, and defects greater than 1 cm2 or those involving more than 50% of the orbital floor.31,41 Autologous bone grafts should be used for repair when possible in children, as bone growth around synthetic materials can result in significant contour deformities.1,13 Furthermore, restoration of soft tissue defects is critical. Resuspension and fixation of the midface and lateral canthus and prevention of ectropion allow restoration of appropriate facial symmetry, which is vitally important for an acceptable aesthetic outcome.31

OUTCOMES FOLLOWING ZYGOMATIC FRACTURES IN CHILDREN Despite advances in the diagnosis, management, and prevention of pediatric facial fractures, little has been published on adverse outcomes related to the management of these injuries. Variability with respect to both the definition and reporting of adverse events

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within the literature makes direct comparison of existing data difficult. In the pediatric population, reported complication rates range from 2.6% to 21.6%, depending on fracture pattern, management, and protocol for reporting.42,43 Complications following pediatric zygomatic fractures are rare and include persistent sensory deficits in the infraorbital nerve (V2) distribution, enophthalmos, facial widening, and flattening of the malar eminence.42 Soft tissue injuries have been reported in as many as 55.6% of children who sustain facial fractures.44 Ferreira et al20 found facial scarring to be the most common complication resulting from midfacial fractures in children, accounting for 45.8% of all complications in their review. Disturbances of midfacial growth are rare in this population because of the greater osteogenic potential of the pediatric craniofacial skeleton.12 A lower incidence of malunion and more rapid healing rates are associated with enhanced bony remodeling in children.1,12,16 The reported incidence of complications following surgical reduction and fixation of facial fractures is less than 5%.42 Adverse outcomes following repair of the zygoma are rare if proper surgical technique and appropriate indications are followed. In a retrospective review of 371 patients, Gomes et al44 reported a complication rate of 6.5% associated with the treatment of ZMC fractures, the most frequent being infection, hypertrophic scar formation, ectropion, and scleral show. Rottgers et al38 reported adverse outcomes in 60% of children who sustained isolated ZMC fractures, with a considerably greater proportion of adverse events occurring in those who underwent operative management. Controversy regarding the use of rigid internal fixation in the pediatric patient has been attributed to the increased risk of infection, translocation, growth restriction, and dental injury associated with the use of standard titanium fixation systems.42 However, use of absorbable plates and screws in recent reports has enabled accurate realignment and stabilization of rapidly healing fracture fragments.45 * 2013 Mutaz B. Habal, MD




With proven tolerability in cranial vault surgery, favorable biomechanical properties, and eventual resorption, bioabsorbable polymers offer a potential solution to the growing pediatric facial skeleton while obviating the adverse effects related to long-term foreign body retention. Prospective, longitudinal studies are still needed to evaluate the true efficacy and safety of resorbable fixation devices, before their routine use in the management of pediatric zygomatic fractures can be justified.

CONCLUSIONS Fractures of the pediatric zygoma are rare as the result of unique anatomic, physiologic, social, and environmental factors that accompany craniofacial development. Currently, level I evidence investigating the optimal management of these injuries is lacking, as the majority of previously published data have focused on elucidating the epidemiology, management strategies, and outcomes associated with more common pediatric facial fracture subtypes. Stable three-dimensional reconstruction through accurate anatomical reduction of the fractured zygoma is the most important objective in preventing future growth disturbances, which may have significant psychosocial implications as the child ages. Large-scale, prospective, longitudinal studies are needed to identify effective management strategies as well as potential risks and complications that may preclude optimal function and aesthetic outcomes in children who sustain zygomatic fractures.

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