The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Brief Clinical Studies
Isolated Bilateral Zygomatic Arch Fracture: An Unusual Pattern Mermod Maxime, MD, Zweifel Daniel, MD, DMD, Hoarau Remy, MD, Broome Martin, MD, DMD Abstract: Isolated fractures of the zygomatic arch represent 5% to 14% of all zygomatic complex fractures. Bilateral isolated zygomatic arch fractures, which are defined as fractures of both zygomatic arches without any other facial fracture, are extremely rare. In this case report, we present a rare case of this facial fracture pattern.
FIGURE 1. Preoperative CT scanner.
Key Words: Zygomatic arch fracture, bilateral, altercation
T
he zygomatic complex plays a critical role in maintaining facial contour and prominence of the cheek. The zygomatic complex is connected via 3 buttresses to major bones of the faceVthe temporal bone (zygomaticotemporal buttress), the frontal bone (frontozygomatic buttress), and the maxilla (zygomaticomaxillary buttress)Vproviding a functional structure that can transmit, if necessary, the force of impact in different directions to protect the eye and the brain. Given its prominent position in the facial skeleton, it is not surprising that zygomatic fractures are the second most common facial fracture. Less commonly are isolated unilateral zygomatic arch fractures with an incidence ranging between 5% and 14% of all patients with facial trauma.1Y3 Isolated bilateral zygomatic arch fracture is defined as bilateral fractures without any other facial bone fractures. In the last few years, there has been a lot of controversy regarding the existence of this fracture pattern. To date, only 7 cases without other fractures have been reported in the English literature.1,4,5 We present a rare case of isolated bilateral zygomatic fracture without any other associated facial bone fracture.
CLINICAL REPORT A 32-year-old male patient was referred to the department of maxillofacial surgery with the chief complaint of bilateral tenderness of his cheeks. He was involved in an altercation the previous night and reported multiple blows to his face, without loss of consciousness. On examination, a depression was found in both preauricular regions, with a clear step deformity and tenderness to palpation. He had slight restriction of mouth opening with an interincisal distance of 32 mm. Computed tomography (CT) was performed, which demonstrated isolated bilateral zygomatic arch fracture (Fig. 1) The patient underwent operation under general anesthesia, and reduction was performed percutaneously with a bone hook. The From the Oral and Maxillo-Facial Surgery Department, Lausanne University Hospital, Lausanne, Switzerland. Received June 24, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Martin Broome, MD, DMD, Division de chirurgie Maxillo-Faciale, CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
FIGURE 2. Postoperative x-ray.
postoperative submentovertex radiograph (Fig. 2) confirmed the adequate position of the reduced bony fragments on the right side, with however an incomplete reduction of the left zygomatic arch. This was not clinically evident, and on follow-up, the patient was happy with the result.
DISCUSSION To our knowledge, this is the only published case of bilateral isolated zygomatic fractures due to a fight. In the study of Kelamis et al,1 all 5 cases were due to road traffic accidents, and in all cases there was an associated skull base or skull fracture suggesting an indirect traumatism. It is hypothesized that the mechanism of that fracture’s pattern involves a direct force transmission of vectors through the skull base to both the petrous triangles and then to the zygomatic arch, which present a point of least resistance. In our case, the absence of any other fracture and the event’s circumstances suggest a direct trauma to both zygomatic arches individually. Various alternative surgical treatments can be used for zygomatic arch fractures. To allow direct exposure, for reduction and fixation of comminuted fractures, a coronal incision must be performed. However, this approach is in most cases not considered to be necessary due to the risks of complications such as alopecia, temporal hollowing, and injury to the facial nerve. Many surgeons therefore prefer indirect open approaches or closed reductions for simple fractures. The temporal approach, described by Gillies, is still commonly used.6 A small incision behind the hairline is performed, followed by a dissection beneath the deep layer of the deep temporal fascia on the temporalis muscle. An upward elevation force is then applied on the bone fragments until they go back into position. This technique allows access to the arch with a minimal incision, but without a direct view of the alignment of the bone. Another indirect open reduction can be performed through an intraoral approach such as described initially by Keen.7,8 In this technique, the zygomatic arch is reached through an intraoral incision, in the lateral maxillary vestibular area. As with the Gillies approach, there is no direct view of the reduction. Another alternative is a closed reduction using a transcutaneous bone hook. The main problem with this treatment modality is the blind nature of the technique, wherein the operator has to rely on digital palpation, reduction click, and step deformity. As with our case, this however is not always a guarantee. The facial
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1111
The Journal of Craniofacial Surgery
Brief Clinical Studies
contour and mouth opening were back to normal, but the postoperative x-ray did not show an adequate reduction. As bone fragments are not stabilized with indirect and closed reduction, there is also a risk of a relapse, especially in comminuted fractures. Submentovertex radiographs, the most common way to assess the adequacy of reduction, are done once the patient is awake, and if secondary corrective surgery is warranted it adds to the overall cost, time, and discomfort to the patient. Various methods of intraoperative radiographic methods exists, the most widely accepted being the ‘‘C’’-arm image intensifier,9,10 which is widely available and can be easily performed. Alternative to that intraoperative imaging techniques could be plain x-ray, ultrasonography, and hybrid CT, but they present more disadvantages than the ‘‘C’’-arm image intensifier.
REFERENCES 1. Kelamis JA, Mundinger GS, Feiner JM, et al. Isolated bilateral zygomatic arch fractures of the facial skeleton are associated with skull base fractures. Plast Reconstr Surg2011;128:962Y970 2. Adam AA, Zhi L, Bing LZ, et al. Evaluation of treatment of zygomatic bone and zygomatic arch fractures: a retrospective study of 10 years. J Maxillofac Oral Surg2012;11: 171Y176 3. Gomes PP, Passeri LA, Barbosa JR. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg2006;64:63Y67 3. Ho V. Isolated bilateral fractures of zygomatic arches: report of a case. Br J Oral Maxillofac Surg1994;32:394Y395 5. Ramanathan M, Cherian MP. Isolated bilateral zygomatic complex and arch fracture: a rare case report. Craniomaxillofac Trauma Reconstr2010;3:185Y188 6. Gillies HD, Kilner TPStone D. Fractures of the malar-zygomatic compound: with a description of a new x-ray position. Br J Surg1927;14:651Y656 7. Keen WW. Surgery, Its Principles and Practice. Philadelphia: WB Saunders; 1909:1906Y1921 8. Robiony M, Tenani G, Bellini P, et al. Intraoral approach for aesthetic restoration of posttraumatic zygomatic arch deformities. J Craniofac Surg2012;23:1418Y1420 9. Ramanoojam S, Gadre P, Shah S, et al. Assessment of the adequacy of closed reduction in fractures of the zygomatic arch using ‘‘C’’-arm image intensifier. J Craniofac Surg2011;22: 1383Y1386 10. Woolley EJ, Jones DC. The use of the image intensifier in fractures of the zygomatic archVa technical note. Int J Oral Maxillofac Surg2005;34:440Y442
Osseous Reconstruction Using an Occlusive Titanium Membrane Following Marginal Mandibulectomy: Proof of Principle Luc Vrielinck, MD, DDS,* Yi Sun, MSC, PhD,*Þ Serge Schepers, MD, DDS,*þ Constantinus Politis, MD, DDS,Þ§ Sarah Van Slycke, MD, DDS,* Jimoh Olubanwo Agbaje, BDS, DMD*§ Abstract: Guided bone regeneration using barrier membranes is useful in bone augmentation. In contrast to flexible membranes, stiff membranes such as titanium membranes are capable of maintaining
1112
& Volume 25, Number 3, May 2014
sufficient space underneath them. We report a case of bone regeneration under an occlusive titanium membrane following marginal mandibulectomy in a 50-year-old patient with odontogenic keratocyst. Preoperative analysis of the anatomical conditions was evaluated with panoramic radiographs and spiral computer tomography (CT) scan. The digital data from the CT scan were transferred to a personal computer. Using Simplant software, a mirror image of the right mandible was constructed from which a custom-made titanium membrane was made. The cyst with the remaining inferior alveolar nerve was removed and curettage of the lesion was performed under general anesthesia. The definitive titanium plate was inserted and fixated with osteosynthesis screws, and then removed 5 years later. Postoperative CT scanning showed good healing, bone growth under the titanium plate, and no evidence of residual cyst The titanium plate reinforced the mandibular skeleton and restored the shape of the mandible and facial symmetry; it also promoted new bone formation to fill in the mandibular defects. Key Words: Titanium occlusive membrane, guided bone regeneration, mandibular reconstruction
T
he idea of increasing the available bone volume and restoring bone defects by means of auto-, allo-, and xenografts has been tested since the beginning of the 20th century. The highest success rate occurs when endosseous implants are placed in conjunction with bone autografts.1Y3 An alternative approach for increasing bone volume is to place a subperiosteal barrier membrane over the defect, which allows the underlying blood clot to mineralize.4,5 In early guided bone regeneration studies, flexible membranes were used. However, creating and maintaining sufficient space underneath the barrier is an important factor for a successful outcome. Therefore, titanium-reinforced polytetrafluoroethylene membranes (Gore-Tex; WL Gore, Flagstaff, AZ) and titanium membranes were introduced to increase the stability of barrier membranes.6 By using the osseoconductive properties of a full titanium membrane, a gain in jaw bone height of more than 10 mm could be achieved in humans.3 One of the best ways to promote bone formation under a barrier is to use an occlusive titanium membrane where the titanium oxide surface favors this upgrowth through osteoconductivity.7,8 Invasive and malignant lesions of the mandible are often treated with partial resection of the osseous structure adjacent to the lesion (marginal mandibulectomy). Autogenous bone grafts and composite bone grafts are used to fill the osseous defects with various degrees of success.9 Utilization of membrane barriers and the principle of guided bone regeneration to fill these defects may be an alternative approach. In an experimental study on dogs, Peled et al10 compared the amount of bone formation following marginal mandibulectomy From the *Oral and Maxillofacial Surgery, St. John_s Hospital, Genk; †Faculty of Medicine, Hasselt University, Diepenbeek; ‡Oral and Maxillofacial Surgery, Faculty of Medicine, Gent University, Gent; and §Department of Imagine & Pathology/OMFS-IMPATH Research Group, KU Leaven, Group Biomedical Sciences, Oral and Maxillofacial Surgery, UZ Leaven, Leuven, Belgium. Received July 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Luc Vrielinck, MD, DDS, Department of Oral and Maxillofacial Surgery, St. John_s Hospital, Genk, Belgium; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 25, Number 3, May 2014
Brief Clinical Studies
Isolated Bilateral Zygomatic Arch Fracture: An Unusual Pattern Mermod Maxime, MD, Zweifel Daniel, MD, DMD, Hoarau Remy, MD, Broome Martin, MD, DMD Abstract: Isolated fractures of the zygomatic arch represent 5% to 14% of all zygomatic complex fractures. Bilateral isolated zygomatic arch fractures, which are defined as fractures of both zygomatic arches without any other facial fracture, are extremely rare. In this case report, we present a rare case of this facial fracture pattern.
FIGURE 1. Preoperative CT scanner.
Key Words: Zygomatic arch fracture, bilateral, altercation
T
he zygomatic complex plays a critical role in maintaining facial contour and prominence of the cheek. The zygomatic complex is connected via 3 buttresses to major bones of the faceVthe temporal bone (zygomaticotemporal buttress), the frontal bone (frontozygomatic buttress), and the maxilla (zygomaticomaxillary buttress)Vproviding a functional structure that can transmit, if necessary, the force of impact in different directions to protect the eye and the brain. Given its prominent position in the facial skeleton, it is not surprising that zygomatic fractures are the second most common facial fracture. Less commonly are isolated unilateral zygomatic arch fractures with an incidence ranging between 5% and 14% of all patients with facial trauma.1Y3 Isolated bilateral zygomatic arch fracture is defined as bilateral fractures without any other facial bone fractures. In the last few years, there has been a lot of controversy regarding the existence of this fracture pattern. To date, only 7 cases without other fractures have been reported in the English literature.1,4,5 We present a rare case of isolated bilateral zygomatic fracture without any other associated facial bone fracture.
CLINICAL REPORT A 32-year-old male patient was referred to the department of maxillofacial surgery with the chief complaint of bilateral tenderness of his cheeks. He was involved in an altercation the previous night and reported multiple blows to his face, without loss of consciousness. On examination, a depression was found in both preauricular regions, with a clear step deformity and tenderness to palpation. He had slight restriction of mouth opening with an interincisal distance of 32 mm. Computed tomography (CT) was performed, which demonstrated isolated bilateral zygomatic arch fracture (Fig. 1) The patient underwent operation under general anesthesia, and reduction was performed percutaneously with a bone hook. The From the Oral and Maxillo-Facial Surgery Department, Lausanne University Hospital, Lausanne, Switzerland. Received June 24, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Martin Broome, MD, DMD, Division de chirurgie Maxillo-Faciale, CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
FIGURE 2. Postoperative x-ray.
postoperative submentovertex radiograph (Fig. 2) confirmed the adequate position of the reduced bony fragments on the right side, with however an incomplete reduction of the left zygomatic arch. This was not clinically evident, and on follow-up, the patient was happy with the result.
DISCUSSION To our knowledge, this is the only published case of bilateral isolated zygomatic fractures due to a fight. In the study of Kelamis et al,1 all 5 cases were due to road traffic accidents, and in all cases there was an associated skull base or skull fracture suggesting an indirect traumatism. It is hypothesized that the mechanism of that fracture’s pattern involves a direct force transmission of vectors through the skull base to both the petrous triangles and then to the zygomatic arch, which present a point of least resistance. In our case, the absence of any other fracture and the event’s circumstances suggest a direct trauma to both zygomatic arches individually. Various alternative surgical treatments can be used for zygomatic arch fractures. To allow direct exposure, for reduction and fixation of comminuted fractures, a coronal incision must be performed. However, this approach is in most cases not considered to be necessary due to the risks of complications such as alopecia, temporal hollowing, and injury to the facial nerve. Many surgeons therefore prefer indirect open approaches or closed reductions for simple fractures. The temporal approach, described by Gillies, is still commonly used.6 A small incision behind the hairline is performed, followed by a dissection beneath the deep layer of the deep temporal fascia on the temporalis muscle. An upward elevation force is then applied on the bone fragments until they go back into position. This technique allows access to the arch with a minimal incision, but without a direct view of the alignment of the bone. Another indirect open reduction can be performed through an intraoral approach such as described initially by Keen.7,8 In this technique, the zygomatic arch is reached through an intraoral incision, in the lateral maxillary vestibular area. As with the Gillies approach, there is no direct view of the reduction. Another alternative is a closed reduction using a transcutaneous bone hook. The main problem with this treatment modality is the blind nature of the technique, wherein the operator has to rely on digital palpation, reduction click, and step deformity. As with our case, this however is not always a guarantee. The facial
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1111
The Journal of Craniofacial Surgery
Brief Clinical Studies
contour and mouth opening were back to normal, but the postoperative x-ray did not show an adequate reduction. As bone fragments are not stabilized with indirect and closed reduction, there is also a risk of a relapse, especially in comminuted fractures. Submentovertex radiographs, the most common way to assess the adequacy of reduction, are done once the patient is awake, and if secondary corrective surgery is warranted it adds to the overall cost, time, and discomfort to the patient. Various methods of intraoperative radiographic methods exists, the most widely accepted being the ‘‘C’’-arm image intensifier,9,10 which is widely available and can be easily performed. Alternative to that intraoperative imaging techniques could be plain x-ray, ultrasonography, and hybrid CT, but they present more disadvantages than the ‘‘C’’-arm image intensifier.
REFERENCES 1. Kelamis JA, Mundinger GS, Feiner JM, et al. Isolated bilateral zygomatic arch fractures of the facial skeleton are associated with skull base fractures. Plast Reconstr Surg2011;128:962Y970 2. Adam AA, Zhi L, Bing LZ, et al. Evaluation of treatment of zygomatic bone and zygomatic arch fractures: a retrospective study of 10 years. J Maxillofac Oral Surg2012;11: 171Y176 3. Gomes PP, Passeri LA, Barbosa JR. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg2006;64:63Y67 3. Ho V. Isolated bilateral fractures of zygomatic arches: report of a case. Br J Oral Maxillofac Surg1994;32:394Y395 5. Ramanathan M, Cherian MP. Isolated bilateral zygomatic complex and arch fracture: a rare case report. Craniomaxillofac Trauma Reconstr2010;3:185Y188 6. Gillies HD, Kilner TPStone D. Fractures of the malar-zygomatic compound: with a description of a new x-ray position. Br J Surg1927;14:651Y656 7. Keen WW. Surgery, Its Principles and Practice. Philadelphia: WB Saunders; 1909:1906Y1921 8. Robiony M, Tenani G, Bellini P, et al. Intraoral approach for aesthetic restoration of posttraumatic zygomatic arch deformities. J Craniofac Surg2012;23:1418Y1420 9. Ramanoojam S, Gadre P, Shah S, et al. Assessment of the adequacy of closed reduction in fractures of the zygomatic arch using ‘‘C’’-arm image intensifier. J Craniofac Surg2011;22: 1383Y1386 10. Woolley EJ, Jones DC. The use of the image intensifier in fractures of the zygomatic archVa technical note. Int J Oral Maxillofac Surg2005;34:440Y442
Osseous Reconstruction Using an Occlusive Titanium Membrane Following Marginal Mandibulectomy: Proof of Principle Luc Vrielinck, MD, DDS,* Yi Sun, MSC, PhD,*Þ Serge Schepers, MD, DDS,*þ Constantinus Politis, MD, DDS,Þ§ Sarah Van Slycke, MD, DDS,* Jimoh Olubanwo Agbaje, BDS, DMD*§ Abstract: Guided bone regeneration using barrier membranes is useful in bone augmentation. In contrast to flexible membranes, stiff membranes such as titanium membranes are capable of maintaining
1112
& Volume 25, Number 3, May 2014
sufficient space underneath them. We report a case of bone regeneration under an occlusive titanium membrane following marginal mandibulectomy in a 50-year-old patient with odontogenic keratocyst. Preoperative analysis of the anatomical conditions was evaluated with panoramic radiographs and spiral computer tomography (CT) scan. The digital data from the CT scan were transferred to a personal computer. Using Simplant software, a mirror image of the right mandible was constructed from which a custom-made titanium membrane was made. The cyst with the remaining inferior alveolar nerve was removed and curettage of the lesion was performed under general anesthesia. The definitive titanium plate was inserted and fixated with osteosynthesis screws, and then removed 5 years later. Postoperative CT scanning showed good healing, bone growth under the titanium plate, and no evidence of residual cyst The titanium plate reinforced the mandibular skeleton and restored the shape of the mandible and facial symmetry; it also promoted new bone formation to fill in the mandibular defects. Key Words: Titanium occlusive membrane, guided bone regeneration, mandibular reconstruction
T
he idea of increasing the available bone volume and restoring bone defects by means of auto-, allo-, and xenografts has been tested since the beginning of the 20th century. The highest success rate occurs when endosseous implants are placed in conjunction with bone autografts.1Y3 An alternative approach for increasing bone volume is to place a subperiosteal barrier membrane over the defect, which allows the underlying blood clot to mineralize.4,5 In early guided bone regeneration studies, flexible membranes were used. However, creating and maintaining sufficient space underneath the barrier is an important factor for a successful outcome. Therefore, titanium-reinforced polytetrafluoroethylene membranes (Gore-Tex; WL Gore, Flagstaff, AZ) and titanium membranes were introduced to increase the stability of barrier membranes.6 By using the osseoconductive properties of a full titanium membrane, a gain in jaw bone height of more than 10 mm could be achieved in humans.3 One of the best ways to promote bone formation under a barrier is to use an occlusive titanium membrane where the titanium oxide surface favors this upgrowth through osteoconductivity.7,8 Invasive and malignant lesions of the mandible are often treated with partial resection of the osseous structure adjacent to the lesion (marginal mandibulectomy). Autogenous bone grafts and composite bone grafts are used to fill the osseous defects with various degrees of success.9 Utilization of membrane barriers and the principle of guided bone regeneration to fill these defects may be an alternative approach. In an experimental study on dogs, Peled et al10 compared the amount of bone formation following marginal mandibulectomy From the *Oral and Maxillofacial Surgery, St. John_s Hospital, Genk; †Faculty of Medicine, Hasselt University, Diepenbeek; ‡Oral and Maxillofacial Surgery, Faculty of Medicine, Gent University, Gent; and §Department of Imagine & Pathology/OMFS-IMPATH Research Group, KU Leaven, Group Biomedical Sciences, Oral and Maxillofacial Surgery, UZ Leaven, Leuven, Belgium. Received July 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Luc Vrielinck, MD, DDS, Department of Oral and Maxillofacial Surgery, St. John_s Hospital, Genk, Belgium; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
