Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Reasons for plate removal after treatment of orbitozygomatic complex fractures Hayley Llandro*, Richard Langford Department of Oral Surgery and Orthodontics, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 17 May 2014 Accepted 7 October 2014 Available online 15 October 2014
Purpose: The purpose of this study was to assess numbers of patients that required removal of miniplates after open reduction and internal fixation of the orbitozygomatic complex over a six-year period, and review the reasons for removal. Patients and methods: This was a retrospective study from February 2007 to December 2013. All patients who had open reduction and internal fixation for traumatic orbitozygomatic complex fractures were included and those who returned to theatre for plate removal were identified. Results: 307 plates were placed in 216 patients. Eight plates were removed from six patients giving a 2.6% incidence of plate removal (2.78% of patients). Infection or exposure occurred within the first year in five out of six patients, accounting for the seven buttress plates, which were in situ for an average of 180 days. The infraorbital plate was in situ for 972 days. The majority of plates used were buttress plates as single point fixation. Conclusions: In our experience placement of buttress plates for one-point fixation of traumatic orbitozygomatic complex fractures seems to be a safe and effective method with a low rate of complication. Complications seem to occur within a year, which is similar to previous studies. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Bone plates Device removal Zygomatic fractures Orbital fractures Internal rigid fixation
1. Introduction Maxillofacial surgeons routinely use titanium miniplates for internal fixation of facial bone fractures, orthognathic treatment and reconstruction. Not all plates are successful and many have to be removed for a variety of reasons such as infection, pain, patient preference and iatrogenic factors. Fractures of the orbitozygomatic complex (OZC) involve the zygomatic bone and one or all of its bony attachments, which include the zygomaticofrontal suture (ZF), the zygomaticomaxillary suture (ZM), the zygomaticotemporal suture (ZT), the zygomaticosphenoidal suture (ZS) and the infraorbital rim (IO). OZC fractures are among most common facial fracture after nasal bone fractures (Kelley et al., 2007) and can occur as a result of falls, sporting injuries, road traffic accidents and interpersonal violence. Surgical treatment is indicated when displacement occurs, which can lead to ocular and mandibular dysfunction and
* Corresponding author. 5 Grove Park Crescent, Gosforth, Newcastle Upon Tyne, NE3 1BP, UK. Tel.: þ44 07718077718. E-mail address: [email protected] (H. Llandro).
cosmetic deficit with facial flattening and asymmetry. Common areas of displacement are the infraorbital rim, the zygomatic arch and the ZF suture. These fractures may be treated via an open or closed approach. The closed approach first described by Gillies et al. (1927) and subsequent lift via a skin incision is very popular (Ogden, 1991) as is the hook elevation (Poswillo, 1976). The advantage is a cleansable surgical site and quick surgical time. However it can be difficult to assess the reduction and subsequent stability of the reduction. The intraoral approach via the buccal mucosa described by Keen (1909) and Ellis and Kittidumkerng (1996) provides direct access to fractures of the body of the zygoma, ability to visualise the reduction and availability of dense bone for fixation with miniplates. Courtney (1999) also adds the advantages of precise application of force to reduce fractures and simple mucosal closure with no skin scar or risk of scar alopecia. Fixation can be one, two or three point fixation, dependent on the severity of the displacement and required stability after reduction. Titanium miniplates are well tolerated when used to fix facial bone fractures but inevitably a proportion of these plates will require removal. Various studies for trauma plates tell us that the failure rate is between 10 and 17% (Brown et al., 1989; Bhatt and
http://dx.doi.org/10.1016/j.jcms.2014.10.003 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
18
H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20
Langford, 2003; Mosbah et al., 2003) and that most of the failures occur within the first year (Bhatt and Langford, 2003). In this study we present data over a study period of six years from the Oral and Maxillofacial unit at James Cook University Hospital. The purpose of the study was to assess the incidence of plate removal after open reduction and internal fixation of traumatic OZC fractures and review the reasons for removal. 2. Materials and methods The study population was identified using the inpatient theatre database. This database records patients' theatre attendance and the procedures performed using a series of OPCS codes devised by the NHS (Health and Social Care Information Centre). A study period from February 2007 to September 2012 was selected as reliable computerised data was available from 2007 and the time period of five years generated similar patient numbers to other comparable studies. All patients who had open reduction and internal fixation for traumatic OZC fractures were identified. This list was then cross-referenced to identify those who returned to theatre for plate removal within the study period. There was a follow up period of 16 months (September 2012 to December 2013) to capture any patients treated at the end of the study period. This allowed for at least 12 months follow up for all patients included as, from the literature search, most plate removals occur within a year of placement. Patients having repair for isolated orbital floor injuries were excluded and infraorbital meshes were not included in the analysis. Case notes and preoperative and postoperative radiographs were also reviewed. Age and gender were recorded, as well as the date of plate insertion and position of the plate used (indicating surgical approach). For those patients who had subsequent plate removal, the position of the plate, the number of days in situ, the surgical approach, and the reason for removal were further noted. The data were collected and analysed using Microsoft Excel. 3. Results Of the 216 patients included in the study population, 120 had left-sided OZC fractures, 93 had right-sided OZC fractures and 3 patients had bilateral fractures. 195 were male (91%) and 21 were female (9%) with a mean age of 27 years old (range, 17e69 years old). Stryker LeibingerMidface plates or SynthesMatrixMIDFACE plates were used in all cases. All patients in this study having ORIF of an OZC fracture or subsequent plate removal were treated under general anaesthetic, as is the protocol in this particular hospital. All patients had antibiotics and dexamethasone on induction. The majority of patients also received a course of post-operative antibiotics. A small number of patients did not receive post-operative antibiotics on specific instruction from the treating clinician. However, all patients who had plates removed in this study did receive a course of post-operative antibiotics. 155 patients underwent ORIF of an OZC fracture with one point fixation (71.8% of all patients). 120 (55.5%) patients had placement of a single maxillary buttress plate (67 on the left and 53 on the right). 34 patients (15.7%) had placement of a single ZF plate and 1 patient had placement of a single infraorbital plate (0.5%). Two-point fixation was used in 47 cases (21.8% of the total). 42 patients attended for placement of a buttress plate and an additional point of fixation (19.4%) and 5 patients had placement of a ZF plate with an additional infraorbital plate (2.3%). Three-point fixation was used in 11 cases (5.1% of the total). See Table 1.
Table 1 Points of fixation and plate positions. Number of points of fixation
Position
Number of patients
Percent of patients
One point fixation Total ¼ 155
LB RB LZF RZF RIO LB LZF RB RZF RB RIO LB LIO LZF LIO RZF RIO LB LZF LIO RB RZF RIO LZF LIO LARCH LB LZF RZF LB LZF RB LB LZF RB RIO
67 53 21 13 1 21 11 6 4 1 4 5 5 1 1 1 1
31.0% 24.5% 9.7% 6.0% 0.5% 9.7% 5.1% 2.8% 1.9% 0.5% 1.9% 2.3% 2.3% 0.5% 0.5% 0.5% 0.5%
Two point fixation Total ¼ 47
Three point fixation Total ¼ 11 Bilateral fixation Total ¼ 3
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, ZF ¼ zygomaticofrontal, IO ¼ infraorbital.
Bilateral fixation was required in 3 cases (1.4%). Two patients with bilateral fractures had a combination of one and two-point fixation and one patient had two-point fixation bilaterally. In terms of the number of plates used, 307 plates were placed in total. Of these 307 plates, 62.5% were buttress plates (110 on the left and 82 on the right). 28% of plates were ZF plates (52 on the left and 34 on the right) and 9.1% were infraorbital plates (11 on the left and 17 on the right). There was one plate placed on a left zygomatic arch (0.3%) See Table 2. Of the 216 patients in the study population, 6 had an additional operation for plate removal within in the study period, which represents 2.78% of all patients included. No patients required plate removal within the follow up period (September 2012eDecember 2013). Regarding these 6 patients, 4 had left OZC fractures and 2 had right OZC fractures. Four of these fractures occurred as a result of an alleged assault. One occurred due to a fall and one due to a road traffic accident. Five patients had 1 plate removed. One patient had 3 plates removed. Eight plates were removed in total giving a rate of plate removal of 2.6%. Seven plates were buttress plates placed via an intra-oral approach of which 4 were placed as one-point fixation and 3 plates (all 3 placed at the buttress in one patient) as part of twopoint fixation where an infraorbital plate was left in situ. One plate was an infraorbital plate placed via an extra-oral incision as part of a ZF/infraorbital plate combination where the ZF plate was left in situ. All six patients received antibiotics at induction and a post-operative course.
Table 2 Total plate types. Position
Number of plates
Percentage of total
Percentage removed
LB RB LZF RZF LIO RIO LARCH TOTAL
110 82 52 34 11 17 1 307
35.8% 26.7% 16.9% 11.1% 3.6% 5.5% 0.3%
1.6% 0.7% 0% 0% 0.3% 0% 0% 2.6%
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, ZF ¼ zygomaticofrontal, IO ¼ infraorbital, ARCH ¼ zygomatic arch.
H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20 Table 3 Plates removed. Patient & mode of injury
Age Fracture
Reason for removal
Plate removed
Days in situ
A: Alleged assault B: Alleged assault C: Alleged assault D: Road traffic accident E: Alleged assault F: Fall
20 31 52 56
LEFT LEFT LEFT LEFT
INFECTION INFECTION INFECTION EXPOSURE
LEFT BUTTRESS LEFT BUTTRESS LEFT INFRAORBITAL 3 LEFT BUTTRESS
187 175 972 268
18 39
RIGHT OZC EXPOSURE RIGHT BUTTRESS RIGHT OZC EXPOSURE RIGHT BUTTRESS
OZC OZC OZC OZC
159 111
Abbreviation OZC ¼ orbitozygomatic.
Infection affected 3 patients leading to removal of 2 buttress plates and the infraorbital plate. Exposure affected the other 3 patients leading to the removal of 5 buttress plates. See Table 3. The 7 buttress plates were in situ less than one year (range, 111 dayse268 days). The mean time in situ before removal of a buttress plate was 180 days (median, 175 days). The infraorbital plate was in situ for 972 days. See Table 4. The minimum amount of time it took for problems to present was 41 days (infection affecting patient A). The maximum time was 943 days (infection of the infraorbital plate in patient C). The mean time was 241.8 days but this figure is skewed by the infraorbital plate data. The mean time for problems to occur with the buttress plates alone was 101.6 days (range, 41e231 days). All plates and screws were removed successfully and there were no post-operative complications associated with the second surgery. In all cases the plate-related problems resolved following plate removal. One patient (patient C) experienced persistent infraorbital paraesthesia but this was present since the injury and not as a result of plate placement or removal. In all cases the OZC fracture had united and was stable at the time of plate removal. 4. Discussion In this study 6 of the 216 patients (2.78%) had a midface plate removed. Of the 307 plates placed, eight were removed, giving a removal rate over six years of 2.6%. This compares very favourably to equivalent studies in which the incidence of plate removal ranges between 7.5% and 17% (specific to midface plates; Olate et al., 2010; Thoren et al., 2010 and generally for trauma plates: Brown et al., 1989; Francel et al., 1992; Manor et al., 1999; Bhatt and Langford, 2003). The reasons for removal were infection and exposure. The most commonly removed plate was a buttress plate. Other studies found that in their experience, miniplates at the ZF suture had a high rate of complication due to visibility, palpability and thermo-hypersensitivity (Islamoglu et al., 2002; Thoren et al., 2010; Kubota et al., 2012). No patients in this study had plates removed for these reasons. Out of the total number of plates placed none of the intraoral plates that were in situ more than 12 months needed removal. Table 4 Timescale of plate removal. Patient
Plate position
Operation to presenting complaint (days)
Presenting complaint to removal (days)
Total days in situ (days)
A B C D E F
LB LB LIO 3 LB RB RB
41 55 943 231 94 87
146 120 29 37 65 24
187 175 972 268 159 111
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, IO ¼ infraorbital.
19
Regarding the removed intraoral plates, the average number of days the buttress plates were in situ was 180 days (range, 111e268 days). Out of the total 192 buttress plates placed, 3.6% were removed. These buttress plates were removed within a year of placement, which tallies with other trauma studies (Brown et al., 1989; Bhatt and Langford, 2003; O'Connell et al., 2009; Bakathir et al., 2008). The infraorbital plate, which was placed via a skin incision, was removed after 972 days (36 months). There was no obvious reason for infection to occur around this plate, having been in situ for such a long period of time. However such late presentation could be due to the fact that this patient received antibiotics from their general medical practitioner between the time they were discharged from the hospital and re-referral. The majority of the operations at this hospital for reduction of an OZC fracture are performed via a maxillary buttress approach and fixation is with a single buttress plate as opposed to an extra-oral approach with a plate placed at the ZF suture. A cadaveric study by Barry et al. showed that forces exerted by the masseter on the zygomatic complex cause distraction at the ZF suture postoperatively (Barry et al., 2007) and Choung and Kaban found that at least one point of fixation is needed to prevent rotation of OZC fractures (Choung and Kaban, 1986). Olate et al. postulated whether the buttress should be used as this one point of fixation due to the lack of rotational displacement after reduction and fixation, which could be a risk after single ZF plate placement due to the 3D nature of OZC fractures. In their study 86.9% of OZC fractures were stabilized using a buttress plate (Olate et al., 2010). This would seem to support the intra-oral method. A number of advantages of the maxillary buttress approach exist. The most important of these are the ability to visualise the fracture at the buttress, perform reduction under direct vision, assess the stability of the reduction and ability to apply fixation as required. Inadequate reduction or fixation can lead to rotation of the zygoma and perceptible cosmetic deficiencies (Ellis and Kittidumkerng, 1996). This would indicate that the best approach would be one that gives the best visual and surgical access. The availability of dense bone near to the fracture site also provides for stable rigid fixation (Courtney, 1999; Dingman and Natvig, 1964). Subsequent mucosal closure is simple and quick, leaving no visible scar and no risk of scar alopecia as with a Gillies approach. This intra-oral approach also has been found to be useful for significantly displaced fractures (Olate et al., 2010) and an anatomically safe area for reduction as less force is required during elevation (Balasubramaniam, 1967). Some surgeons favour the extra-oral approach due to the ability to cleanse the surgical site pre-operatively. Also there is some debate as to whether the presence of oral flora increases the post-operative risk of plate failure. However this study supports the use of the intraoral approach as although the main reason for removal was infection and the most common plate removed was a buttress plate, the overall rate of removal is very low at 2.6%. Only 7 out of the 192 buttress plates placed required removal (3.6% of buttress plates). A study by Knepil and Loukota showed that infection rate is low after surgery for zygomatic fractures even with very variable antibiotic prescribing (Knepil and Loukota, 2010). Some surgeons routinely remove trauma plates. One argument is that after osseous healing is complete, the plate acts as a foreign body (Alpert and Seligson, 1996) but Brown et al. found that plates that had been in situ more than 30 months did not require removal on these grounds (Brown et al., 1989). Titanium is also considered to be a well-tolerated material (Langford and Frame, 2002). The cost of a second operation and the potential risk of morbidity to the patient (e.g. inferior orbital nerve damage) should be evaluated when considering the removal of a miniplate.
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H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20
There is still no consensus regarding routine removal of maxillofacial miniplates, however most of the studies included in the literature search found that, as the rate of removal remains low, there is very little evidence to support routine removal (Brown et al., 1989; Langford and Frame, 2002; Mosbah et al., 2003; Rallis et al., 2006; O'Connell et al., 2009). 5. Conclusion The debate continues as to which method of fixation is used, the most appropriate surgical approach and whether to electively removed plates. In our experience the majority of plates remain in situ without the need for removal. Complications, mainly infection, seem to occur within the first year of placement. An intraoral approach with placement of a single buttress plate seems to be a safe and effective method for fixation of orbitozygomatic fractures with a low rate of complication. Funding None. Conflict of interest None. Acknowledgements Ms. J. Dobson for help with information retrieval and Mr. D Johnson for helpful suggestions. References Alpert B, Seligson D: Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures. J Oral Maxillofac Surg 54: 618e621, 1996 Bakathir AA, Margasahayam MV, AL-Ismayl MI: Removal of bone plates in patients with maxillofacial trauma: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105: 32e37, 2008 Balasubramaniam S: Intra-oral approach for reduction of malar fractures. Br J Oral Surg 4: 189e191, 1967 Barry CP, Ryan WJ, Stassen LF: Anatomical study of factors contributing to zygomatic complex fracture instability in human cadavers. Plast Reconstr Surg 119: 637e640, 2007 Bhatt V, Langford RJ: Removal of miniplates in maxillofacial surgery: University Hospital Birmingham experience. J Oral Maxillofac Surg 61: 553e556, 2003
Brown JS, Trotter M, Cliffe J, Ward-Booth RP, Williams ED: The fate of miniplates in facial trauma and orthognathic surgery: a retrospective study. Br J Oral Maxillofac Surg 27: 306e315, 1989 Choung R, Kaban L: Fractures of the zygomatic complex. J Oral Maxillofac Surg 44: 283e288, 1986 Courtney DJ: Upper buccal sulcus approach to management of fractures of the zygomatic complex: a retrospective study of 50 cases. Br J Oral Maxillofac Surg 37: 464e466, 1999 Dingman RO, Natvig P: The zygoma. In: Surgery of facial fractures. New York, NY: Saunders, 219, 1964 Ellis 3rd E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54: 386e400, 1996 Francel TJ, Birely BC, Ringelman PR, Mason PN: The fate of plates and screws after facial fracture reconstruction. Plast Reconstr Surg 90: 568e573, 1992 Gillies HD, Kilner TP, Stone D: Fractures of the malar-zygomatic compound: with a description of a new X-ray position. Br J Surg 14: 651e656, 1927 Islamoglu K, Coskunfirat OK, Tetik G, Ozgentas HE: Complications and removal rates of miniplates and screws used for maxillofacial fractures. Ann Plast Surg 48: 265e268, 2002 Keen WW: Surgery, its principles and practice. Philadelphia: WB Saunders, 1909 Kelley P, Hopper R, Gruss J: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg 120(Suppl. 2): 5Se15S, 2007 Knepil GJ, Loukota RA: Outcomes of prophylactic antibiotics following surgery for zygomatic bone fractures. J Craniomaxillofac Surg 38: 131e133, 2010 Kubota Y, Kuroki T, Akita S, Koizumi T, Hasegawa M, Rikihisa N, et al: Association between plate location and plate removal following facial fracture repair. J Plast Reconstr Aesthet Surg 65: 372e378, 2012 Langford RJ, Frame JW: Surface analysis of titanium maxillofacial plates and screws retrieved from patients. Int J Oral Maxillofac Surg 31: 511e518, 2002 Manor Y, Chaushu G, Taicher S: Risk factors contributing to symptomatic plate removal in orthognathic surgery. J Oral Maxillofac Surg 57: 679, 1999 Mosbah MR, Oloyede D, Koppel DA, Moos KF, Stenhouse D: Miniplate removal in trauma and orthognathic surgery-a retrospective study. Int J Oral Maxillofac Surg 32: 148e151, 2003 O'Connell J, Murphy C, Ikeagwuani O, Adley C, Kearns G: The fate of titanium miniplates and screws used in maxillofacial surgery: a 10 year retrospective study. Int J Oral Maxillofac Surg 38: 731e735, 2009 Ogden GR: The Gillies method for fractured zygomas: an analysis of 105 cases. J Oral Maxillofac Surg 49: 23, 1991 Olate S, Lima Jr SM, Sawazaki R, Moreira RW, de Moraes M: Surgical approaches and fixation patterns in zygomatic complex fractures. J Craniomaxillofac Surg 21: 1213e1217, 2010 Poswillo D: Reduction of the fractured malar by a traction hook. Br J Oral Surg 14: 76e79, 1976 Rallis G, Mourouzis C, Papakosta V, Papanastasiou G, Zachariades N: Reasons for miniplate removal following maxillofacial trauma: a 4 year study. J Craniomaxillofac Surg 34: 435e439, 2006 Thoren H, Snall J, Kormi E, Lindqvist C, Suominen-Taipale L, Tornwall J: Symptomatic plate removal after treatment of facial fractures. J Craniomaxillofac Surg 38: 505e510, 2010
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Reasons for plate removal after treatment of orbitozygomatic complex fractures Hayley Llandro*, Richard Langford Department of Oral Surgery and Orthodontics, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 17 May 2014 Accepted 7 October 2014 Available online 15 October 2014
Purpose: The purpose of this study was to assess numbers of patients that required removal of miniplates after open reduction and internal fixation of the orbitozygomatic complex over a six-year period, and review the reasons for removal. Patients and methods: This was a retrospective study from February 2007 to December 2013. All patients who had open reduction and internal fixation for traumatic orbitozygomatic complex fractures were included and those who returned to theatre for plate removal were identified. Results: 307 plates were placed in 216 patients. Eight plates were removed from six patients giving a 2.6% incidence of plate removal (2.78% of patients). Infection or exposure occurred within the first year in five out of six patients, accounting for the seven buttress plates, which were in situ for an average of 180 days. The infraorbital plate was in situ for 972 days. The majority of plates used were buttress plates as single point fixation. Conclusions: In our experience placement of buttress plates for one-point fixation of traumatic orbitozygomatic complex fractures seems to be a safe and effective method with a low rate of complication. Complications seem to occur within a year, which is similar to previous studies. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Bone plates Device removal Zygomatic fractures Orbital fractures Internal rigid fixation
1. Introduction Maxillofacial surgeons routinely use titanium miniplates for internal fixation of facial bone fractures, orthognathic treatment and reconstruction. Not all plates are successful and many have to be removed for a variety of reasons such as infection, pain, patient preference and iatrogenic factors. Fractures of the orbitozygomatic complex (OZC) involve the zygomatic bone and one or all of its bony attachments, which include the zygomaticofrontal suture (ZF), the zygomaticomaxillary suture (ZM), the zygomaticotemporal suture (ZT), the zygomaticosphenoidal suture (ZS) and the infraorbital rim (IO). OZC fractures are among most common facial fracture after nasal bone fractures (Kelley et al., 2007) and can occur as a result of falls, sporting injuries, road traffic accidents and interpersonal violence. Surgical treatment is indicated when displacement occurs, which can lead to ocular and mandibular dysfunction and
* Corresponding author. 5 Grove Park Crescent, Gosforth, Newcastle Upon Tyne, NE3 1BP, UK. Tel.: þ44 07718077718. E-mail address: [email protected] (H. Llandro).
cosmetic deficit with facial flattening and asymmetry. Common areas of displacement are the infraorbital rim, the zygomatic arch and the ZF suture. These fractures may be treated via an open or closed approach. The closed approach first described by Gillies et al. (1927) and subsequent lift via a skin incision is very popular (Ogden, 1991) as is the hook elevation (Poswillo, 1976). The advantage is a cleansable surgical site and quick surgical time. However it can be difficult to assess the reduction and subsequent stability of the reduction. The intraoral approach via the buccal mucosa described by Keen (1909) and Ellis and Kittidumkerng (1996) provides direct access to fractures of the body of the zygoma, ability to visualise the reduction and availability of dense bone for fixation with miniplates. Courtney (1999) also adds the advantages of precise application of force to reduce fractures and simple mucosal closure with no skin scar or risk of scar alopecia. Fixation can be one, two or three point fixation, dependent on the severity of the displacement and required stability after reduction. Titanium miniplates are well tolerated when used to fix facial bone fractures but inevitably a proportion of these plates will require removal. Various studies for trauma plates tell us that the failure rate is between 10 and 17% (Brown et al., 1989; Bhatt and
http://dx.doi.org/10.1016/j.jcms.2014.10.003 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
18
H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20
Langford, 2003; Mosbah et al., 2003) and that most of the failures occur within the first year (Bhatt and Langford, 2003). In this study we present data over a study period of six years from the Oral and Maxillofacial unit at James Cook University Hospital. The purpose of the study was to assess the incidence of plate removal after open reduction and internal fixation of traumatic OZC fractures and review the reasons for removal. 2. Materials and methods The study population was identified using the inpatient theatre database. This database records patients' theatre attendance and the procedures performed using a series of OPCS codes devised by the NHS (Health and Social Care Information Centre). A study period from February 2007 to September 2012 was selected as reliable computerised data was available from 2007 and the time period of five years generated similar patient numbers to other comparable studies. All patients who had open reduction and internal fixation for traumatic OZC fractures were identified. This list was then cross-referenced to identify those who returned to theatre for plate removal within the study period. There was a follow up period of 16 months (September 2012 to December 2013) to capture any patients treated at the end of the study period. This allowed for at least 12 months follow up for all patients included as, from the literature search, most plate removals occur within a year of placement. Patients having repair for isolated orbital floor injuries were excluded and infraorbital meshes were not included in the analysis. Case notes and preoperative and postoperative radiographs were also reviewed. Age and gender were recorded, as well as the date of plate insertion and position of the plate used (indicating surgical approach). For those patients who had subsequent plate removal, the position of the plate, the number of days in situ, the surgical approach, and the reason for removal were further noted. The data were collected and analysed using Microsoft Excel. 3. Results Of the 216 patients included in the study population, 120 had left-sided OZC fractures, 93 had right-sided OZC fractures and 3 patients had bilateral fractures. 195 were male (91%) and 21 were female (9%) with a mean age of 27 years old (range, 17e69 years old). Stryker LeibingerMidface plates or SynthesMatrixMIDFACE plates were used in all cases. All patients in this study having ORIF of an OZC fracture or subsequent plate removal were treated under general anaesthetic, as is the protocol in this particular hospital. All patients had antibiotics and dexamethasone on induction. The majority of patients also received a course of post-operative antibiotics. A small number of patients did not receive post-operative antibiotics on specific instruction from the treating clinician. However, all patients who had plates removed in this study did receive a course of post-operative antibiotics. 155 patients underwent ORIF of an OZC fracture with one point fixation (71.8% of all patients). 120 (55.5%) patients had placement of a single maxillary buttress plate (67 on the left and 53 on the right). 34 patients (15.7%) had placement of a single ZF plate and 1 patient had placement of a single infraorbital plate (0.5%). Two-point fixation was used in 47 cases (21.8% of the total). 42 patients attended for placement of a buttress plate and an additional point of fixation (19.4%) and 5 patients had placement of a ZF plate with an additional infraorbital plate (2.3%). Three-point fixation was used in 11 cases (5.1% of the total). See Table 1.
Table 1 Points of fixation and plate positions. Number of points of fixation
Position
Number of patients
Percent of patients
One point fixation Total ¼ 155
LB RB LZF RZF RIO LB LZF RB RZF RB RIO LB LIO LZF LIO RZF RIO LB LZF LIO RB RZF RIO LZF LIO LARCH LB LZF RZF LB LZF RB LB LZF RB RIO
67 53 21 13 1 21 11 6 4 1 4 5 5 1 1 1 1
31.0% 24.5% 9.7% 6.0% 0.5% 9.7% 5.1% 2.8% 1.9% 0.5% 1.9% 2.3% 2.3% 0.5% 0.5% 0.5% 0.5%
Two point fixation Total ¼ 47
Three point fixation Total ¼ 11 Bilateral fixation Total ¼ 3
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, ZF ¼ zygomaticofrontal, IO ¼ infraorbital.
Bilateral fixation was required in 3 cases (1.4%). Two patients with bilateral fractures had a combination of one and two-point fixation and one patient had two-point fixation bilaterally. In terms of the number of plates used, 307 plates were placed in total. Of these 307 plates, 62.5% were buttress plates (110 on the left and 82 on the right). 28% of plates were ZF plates (52 on the left and 34 on the right) and 9.1% were infraorbital plates (11 on the left and 17 on the right). There was one plate placed on a left zygomatic arch (0.3%) See Table 2. Of the 216 patients in the study population, 6 had an additional operation for plate removal within in the study period, which represents 2.78% of all patients included. No patients required plate removal within the follow up period (September 2012eDecember 2013). Regarding these 6 patients, 4 had left OZC fractures and 2 had right OZC fractures. Four of these fractures occurred as a result of an alleged assault. One occurred due to a fall and one due to a road traffic accident. Five patients had 1 plate removed. One patient had 3 plates removed. Eight plates were removed in total giving a rate of plate removal of 2.6%. Seven plates were buttress plates placed via an intra-oral approach of which 4 were placed as one-point fixation and 3 plates (all 3 placed at the buttress in one patient) as part of twopoint fixation where an infraorbital plate was left in situ. One plate was an infraorbital plate placed via an extra-oral incision as part of a ZF/infraorbital plate combination where the ZF plate was left in situ. All six patients received antibiotics at induction and a post-operative course.
Table 2 Total plate types. Position
Number of plates
Percentage of total
Percentage removed
LB RB LZF RZF LIO RIO LARCH TOTAL
110 82 52 34 11 17 1 307
35.8% 26.7% 16.9% 11.1% 3.6% 5.5% 0.3%
1.6% 0.7% 0% 0% 0.3% 0% 0% 2.6%
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, ZF ¼ zygomaticofrontal, IO ¼ infraorbital, ARCH ¼ zygomatic arch.
H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20 Table 3 Plates removed. Patient & mode of injury
Age Fracture
Reason for removal
Plate removed
Days in situ
A: Alleged assault B: Alleged assault C: Alleged assault D: Road traffic accident E: Alleged assault F: Fall
20 31 52 56
LEFT LEFT LEFT LEFT
INFECTION INFECTION INFECTION EXPOSURE
LEFT BUTTRESS LEFT BUTTRESS LEFT INFRAORBITAL 3 LEFT BUTTRESS
187 175 972 268
18 39
RIGHT OZC EXPOSURE RIGHT BUTTRESS RIGHT OZC EXPOSURE RIGHT BUTTRESS
OZC OZC OZC OZC
159 111
Abbreviation OZC ¼ orbitozygomatic.
Infection affected 3 patients leading to removal of 2 buttress plates and the infraorbital plate. Exposure affected the other 3 patients leading to the removal of 5 buttress plates. See Table 3. The 7 buttress plates were in situ less than one year (range, 111 dayse268 days). The mean time in situ before removal of a buttress plate was 180 days (median, 175 days). The infraorbital plate was in situ for 972 days. See Table 4. The minimum amount of time it took for problems to present was 41 days (infection affecting patient A). The maximum time was 943 days (infection of the infraorbital plate in patient C). The mean time was 241.8 days but this figure is skewed by the infraorbital plate data. The mean time for problems to occur with the buttress plates alone was 101.6 days (range, 41e231 days). All plates and screws were removed successfully and there were no post-operative complications associated with the second surgery. In all cases the plate-related problems resolved following plate removal. One patient (patient C) experienced persistent infraorbital paraesthesia but this was present since the injury and not as a result of plate placement or removal. In all cases the OZC fracture had united and was stable at the time of plate removal. 4. Discussion In this study 6 of the 216 patients (2.78%) had a midface plate removed. Of the 307 plates placed, eight were removed, giving a removal rate over six years of 2.6%. This compares very favourably to equivalent studies in which the incidence of plate removal ranges between 7.5% and 17% (specific to midface plates; Olate et al., 2010; Thoren et al., 2010 and generally for trauma plates: Brown et al., 1989; Francel et al., 1992; Manor et al., 1999; Bhatt and Langford, 2003). The reasons for removal were infection and exposure. The most commonly removed plate was a buttress plate. Other studies found that in their experience, miniplates at the ZF suture had a high rate of complication due to visibility, palpability and thermo-hypersensitivity (Islamoglu et al., 2002; Thoren et al., 2010; Kubota et al., 2012). No patients in this study had plates removed for these reasons. Out of the total number of plates placed none of the intraoral plates that were in situ more than 12 months needed removal. Table 4 Timescale of plate removal. Patient
Plate position
Operation to presenting complaint (days)
Presenting complaint to removal (days)
Total days in situ (days)
A B C D E F
LB LB LIO 3 LB RB RB
41 55 943 231 94 87
146 120 29 37 65 24
187 175 972 268 159 111
Abbreviations: L ¼ left, R ¼ right, B ¼ buttress, IO ¼ infraorbital.
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Regarding the removed intraoral plates, the average number of days the buttress plates were in situ was 180 days (range, 111e268 days). Out of the total 192 buttress plates placed, 3.6% were removed. These buttress plates were removed within a year of placement, which tallies with other trauma studies (Brown et al., 1989; Bhatt and Langford, 2003; O'Connell et al., 2009; Bakathir et al., 2008). The infraorbital plate, which was placed via a skin incision, was removed after 972 days (36 months). There was no obvious reason for infection to occur around this plate, having been in situ for such a long period of time. However such late presentation could be due to the fact that this patient received antibiotics from their general medical practitioner between the time they were discharged from the hospital and re-referral. The majority of the operations at this hospital for reduction of an OZC fracture are performed via a maxillary buttress approach and fixation is with a single buttress plate as opposed to an extra-oral approach with a plate placed at the ZF suture. A cadaveric study by Barry et al. showed that forces exerted by the masseter on the zygomatic complex cause distraction at the ZF suture postoperatively (Barry et al., 2007) and Choung and Kaban found that at least one point of fixation is needed to prevent rotation of OZC fractures (Choung and Kaban, 1986). Olate et al. postulated whether the buttress should be used as this one point of fixation due to the lack of rotational displacement after reduction and fixation, which could be a risk after single ZF plate placement due to the 3D nature of OZC fractures. In their study 86.9% of OZC fractures were stabilized using a buttress plate (Olate et al., 2010). This would seem to support the intra-oral method. A number of advantages of the maxillary buttress approach exist. The most important of these are the ability to visualise the fracture at the buttress, perform reduction under direct vision, assess the stability of the reduction and ability to apply fixation as required. Inadequate reduction or fixation can lead to rotation of the zygoma and perceptible cosmetic deficiencies (Ellis and Kittidumkerng, 1996). This would indicate that the best approach would be one that gives the best visual and surgical access. The availability of dense bone near to the fracture site also provides for stable rigid fixation (Courtney, 1999; Dingman and Natvig, 1964). Subsequent mucosal closure is simple and quick, leaving no visible scar and no risk of scar alopecia as with a Gillies approach. This intra-oral approach also has been found to be useful for significantly displaced fractures (Olate et al., 2010) and an anatomically safe area for reduction as less force is required during elevation (Balasubramaniam, 1967). Some surgeons favour the extra-oral approach due to the ability to cleanse the surgical site pre-operatively. Also there is some debate as to whether the presence of oral flora increases the post-operative risk of plate failure. However this study supports the use of the intraoral approach as although the main reason for removal was infection and the most common plate removed was a buttress plate, the overall rate of removal is very low at 2.6%. Only 7 out of the 192 buttress plates placed required removal (3.6% of buttress plates). A study by Knepil and Loukota showed that infection rate is low after surgery for zygomatic fractures even with very variable antibiotic prescribing (Knepil and Loukota, 2010). Some surgeons routinely remove trauma plates. One argument is that after osseous healing is complete, the plate acts as a foreign body (Alpert and Seligson, 1996) but Brown et al. found that plates that had been in situ more than 30 months did not require removal on these grounds (Brown et al., 1989). Titanium is also considered to be a well-tolerated material (Langford and Frame, 2002). The cost of a second operation and the potential risk of morbidity to the patient (e.g. inferior orbital nerve damage) should be evaluated when considering the removal of a miniplate.
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H. Llandro, R. Langford / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 17e20
There is still no consensus regarding routine removal of maxillofacial miniplates, however most of the studies included in the literature search found that, as the rate of removal remains low, there is very little evidence to support routine removal (Brown et al., 1989; Langford and Frame, 2002; Mosbah et al., 2003; Rallis et al., 2006; O'Connell et al., 2009). 5. Conclusion The debate continues as to which method of fixation is used, the most appropriate surgical approach and whether to electively removed plates. In our experience the majority of plates remain in situ without the need for removal. Complications, mainly infection, seem to occur within the first year of placement. An intraoral approach with placement of a single buttress plate seems to be a safe and effective method for fixation of orbitozygomatic fractures with a low rate of complication. Funding None. Conflict of interest None. Acknowledgements Ms. J. Dobson for help with information retrieval and Mr. D Johnson for helpful suggestions. References Alpert B, Seligson D: Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures. J Oral Maxillofac Surg 54: 618e621, 1996 Bakathir AA, Margasahayam MV, AL-Ismayl MI: Removal of bone plates in patients with maxillofacial trauma: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105: 32e37, 2008 Balasubramaniam S: Intra-oral approach for reduction of malar fractures. Br J Oral Surg 4: 189e191, 1967 Barry CP, Ryan WJ, Stassen LF: Anatomical study of factors contributing to zygomatic complex fracture instability in human cadavers. Plast Reconstr Surg 119: 637e640, 2007 Bhatt V, Langford RJ: Removal of miniplates in maxillofacial surgery: University Hospital Birmingham experience. J Oral Maxillofac Surg 61: 553e556, 2003
Brown JS, Trotter M, Cliffe J, Ward-Booth RP, Williams ED: The fate of miniplates in facial trauma and orthognathic surgery: a retrospective study. Br J Oral Maxillofac Surg 27: 306e315, 1989 Choung R, Kaban L: Fractures of the zygomatic complex. J Oral Maxillofac Surg 44: 283e288, 1986 Courtney DJ: Upper buccal sulcus approach to management of fractures of the zygomatic complex: a retrospective study of 50 cases. Br J Oral Maxillofac Surg 37: 464e466, 1999 Dingman RO, Natvig P: The zygoma. In: Surgery of facial fractures. New York, NY: Saunders, 219, 1964 Ellis 3rd E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54: 386e400, 1996 Francel TJ, Birely BC, Ringelman PR, Mason PN: The fate of plates and screws after facial fracture reconstruction. Plast Reconstr Surg 90: 568e573, 1992 Gillies HD, Kilner TP, Stone D: Fractures of the malar-zygomatic compound: with a description of a new X-ray position. Br J Surg 14: 651e656, 1927 Islamoglu K, Coskunfirat OK, Tetik G, Ozgentas HE: Complications and removal rates of miniplates and screws used for maxillofacial fractures. Ann Plast Surg 48: 265e268, 2002 Keen WW: Surgery, its principles and practice. Philadelphia: WB Saunders, 1909 Kelley P, Hopper R, Gruss J: Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg 120(Suppl. 2): 5Se15S, 2007 Knepil GJ, Loukota RA: Outcomes of prophylactic antibiotics following surgery for zygomatic bone fractures. J Craniomaxillofac Surg 38: 131e133, 2010 Kubota Y, Kuroki T, Akita S, Koizumi T, Hasegawa M, Rikihisa N, et al: Association between plate location and plate removal following facial fracture repair. J Plast Reconstr Aesthet Surg 65: 372e378, 2012 Langford RJ, Frame JW: Surface analysis of titanium maxillofacial plates and screws retrieved from patients. Int J Oral Maxillofac Surg 31: 511e518, 2002 Manor Y, Chaushu G, Taicher S: Risk factors contributing to symptomatic plate removal in orthognathic surgery. J Oral Maxillofac Surg 57: 679, 1999 Mosbah MR, Oloyede D, Koppel DA, Moos KF, Stenhouse D: Miniplate removal in trauma and orthognathic surgery-a retrospective study. Int J Oral Maxillofac Surg 32: 148e151, 2003 O'Connell J, Murphy C, Ikeagwuani O, Adley C, Kearns G: The fate of titanium miniplates and screws used in maxillofacial surgery: a 10 year retrospective study. Int J Oral Maxillofac Surg 38: 731e735, 2009 Ogden GR: The Gillies method for fractured zygomas: an analysis of 105 cases. J Oral Maxillofac Surg 49: 23, 1991 Olate S, Lima Jr SM, Sawazaki R, Moreira RW, de Moraes M: Surgical approaches and fixation patterns in zygomatic complex fractures. J Craniomaxillofac Surg 21: 1213e1217, 2010 Poswillo D: Reduction of the fractured malar by a traction hook. Br J Oral Surg 14: 76e79, 1976 Rallis G, Mourouzis C, Papakosta V, Papanastasiou G, Zachariades N: Reasons for miniplate removal following maxillofacial trauma: a 4 year study. J Craniomaxillofac Surg 34: 435e439, 2006 Thoren H, Snall J, Kormi E, Lindqvist C, Suominen-Taipale L, Tornwall J: Symptomatic plate removal after treatment of facial fractures. J Craniomaxillofac Surg 38: 505e510, 2010
