Fracture of the zygomatic bone - diagnosis, treatment and consequences

The zygomatic bone is a paired bone of the facial part of the skull and consists of dense spongy plates. Against the background of sports, domestic and industrial injuries, a fracture of the zygomatic bone often occurs, which is divided into injuries with displacement of fragments and without displacement. A fracture of the zygomatic arch, which does not affect the zygomatic bone itself and its processes, is also common.

This type of injury occurs every day in departments of maxillofacial surgery and, in terms of frequency of occurrence, occupies an honorable second position after trauma to the nasal bones.

Features of a zygomatic bone fracture

A cheekbone fracture is considered to be various injuries that contribute to the disruption of the integrity of one or a group of its articulations with adjacent structures of the facial and cerebral skull. It can be either isolated or combined with other injuries of the facial skeleton.

Often the entire zygomatic bone is fractured. The isolated type of zygomatic arch fractures is quite rare and contributes to minimal collapse of the tissues of the lateral part of the cheek.

The displacement of bone fragments of the zygomatic bone is determined by the magnitude and direction of the traumatic factor. As a rule, it occurs in parallel with the impact of damaging forces and the masticatory muscle. A fracture causes the zygomatic bone to rotate in a vertical or horizontal plane and promote backward, downward, lateral or medial displacement. In this case, a bone fragment displaced inwardly often interferes with the movement of the coronoid process of the mandible and requires urgent surgical intervention.

Conservative treatment

Conservative treatment is carried out for linear fractures and loss of bone integrity without displacement. Therapy consists of the following activities and procedures:

Taking anti-inflammatory drugs (NSAIDs) and painkillers. The choice of drug is made individually and depends on the general health of the patient and the intensity of pain. Typically used are injections of ibuprofen, combinations of Analgin with Diphenhydramine, Ketoprofen, Ketanov and Dicloberl;
Taking vitamins by injection;
Ensuring proper rest;
Participation in physiotherapeutic procedures. This can be laser therapy, quartz therapy, electrophonophoresis, shock wave and magnetic therapy.

Until the bone tissue is completely united, nutrition should be only liquid. Food intake occurs through a tube.

Symptoms of damage

Specific symptoms of a zygomatic arch fracture are determined by trauma to structures that are located in close proximity. There are also signs characteristic of fractures of all types: changes in bone integrity, hematoma and swelling, pain.

The following symptoms are considered traditional for a fracture of the zygomatic bone:

Swelling at the site of impact, bleeding and damage to the skin, masking the collapsed tissue in the cheekbone area;
The occurrence of nosebleeds from the nostril corresponding to the side of the injury;
Severe swelling of the eyelids, preventing the eyes from closing;
Inability to open the mouth and make any movements with the lower jaw;
The retraction of the zygomatic arch is accompanied by sharp pain, aggravated by palpation;
Diplopia may develop due to displacement of the eyeball;
With combined injuries of the zygomatic bone and arch, the angle of displacement of the bone fragments is directed towards the sides of the temporal fossa.

If an injury to the zygomatic bone results in damage to the salivary gland, the victim may not experience any discomfort at all. But, with the transition of the inflammatory process to the facial nerve, severe pain and disruption of the motor activity of the facial and chewing muscles occur. The consequence of such an injury may be continuous lacrimation.

Diagnostics

After being examined by a doctor, the patient is sent for an X-ray of the facial bones. The image is informative for ordinary fractures, but if there is displacement or a comminuted fracture, a more accurate study is prescribed - computed tomography (CT). For complex injuries, magnetic resonance imaging (MRI) is indicated, which reveals damage to the bone and soft tissues - muscles, blood vessels, nerves.

There may also be a need for diagnostics if a brain injury is suspected - tomography, electroencephalography, echoencephalography.

Diagnostic methods

To identify a cheekbone fracture, it is enough for an experienced traumatologist to conduct a visual examination of the victim and palpation.

The diagnostic features are determined by the specific manifestations of this type of damage, so radiography can be used as an additional method to confirm the diagnosis.

If the rectus muscle is pinched in the area of the fracture, the patient’s ability to look up is most often impaired. The lateral ligament, which is fixed to the frontal process of the zygomatic arch, can move downward. When palpating the lower boundaries of the orbit from the side of the injury, some deformation of the facial part of the skull is determined.

First aid

In a situation with a serious injury, the people around him must provide first aid to the victim. Medical recommendations exclude independent adjustment of individual parts of the skull or contact with open wounds. The main tasks are to create conditions of complete rest, eliminate re-injury, try to stop the bleeding and call an ambulance team.

In case of acute pain, an injection of an anesthetic is allowed. To stop continuous bleeding, it is necessary to press down the artery. In cases where the wound is small, you can treat the area with hydrogen peroxide, as well as ensure careful application of cold.

Types of treatment

The choice of the necessary method of therapy is determined by the traumatologist based on an analysis of the injuries, their characteristics, and also takes into account the time interval between the moment of injury and the visit to a medical facility.

Fresh injuries of the zygomatic bone, as a rule, are easily amenable to manual reduction and require an exclusively conservative approach to treatment

Conservative therapy

Fractures of the zygomatic arch with minimal displacement or its complete absence usually do not provoke functional disorders, nor are they a source of aesthetic defects. Such injuries do not require surgical intervention.

If an uncomplicated fracture of the zygomatic bone occurs, the patient must be re-examined after 8-12 days to determine bone displacement, identify cosmetic defects and latent fractures of the orbital floor. If one of the listed complications is detected, the attending doctor decides on further tactics.

The key features of conservative therapy for a cheekbone fracture are absolute rest of the jaw and the administration of NSAIDs (non-steroidal anti-inflammatory drugs) together with analgesic drugs.

To relieve excessive pain, it is advisable to administer drugs intramuscularly or intravenously.

Surgery

The absolute indications for surgical treatment of a zygomatic arch fracture are:

Obvious deformation of the orbit and facial contours;
Significant displacement of bone fragments;
Decreased or absent motor activity of the lower jaw;
Instability and complexity of the fracture, such as a comminuted fracture or a rupture of the frontozygomatic suture;
Enophthalmos (retraction of the eyeball);
Diplopia (double vision);
Dystopia of the eyeball (drooping).

The operation involves the use of one of the following methods:

Keen method. Used in cases of separation of the zygomatic bone from the upper jaw or adjacent joints. The operation involves dissection of the mucous surface located behind the zygomaticalveolar ridge. In this case, a special surgical instrument is inserted under the displaced bone, with the help of which the doctor places the displaced fragment in an anatomically correct position.
Malarchuk-Khadarovich method. It is used for both fresh and old fractures. The operation involves placing a special hook into the space under the bone and performing reposition. The hook plays the role of a kind of lever, the support of which falls on the bones of the skull. As a result of the intervention, the zygomatic arch and its fragments are moved into the correct position.
Kazanyan method. It is used by traumatologists for particularly complex injuries, when bone fragments vary significantly in size, are difficult to assemble and there is no possibility of self-fixation. Excision of tissue is carried out under the upper eyelid, partially exposing the infraorbital bone area. Special channels are made in the cheekbone, through which a stainless steel wire passes. Thanks to this device, the bone can be securely fixed.
Liberg method. Its use implies mild damage to the cheekbone or jaw sinuses. The operation requires turning the victim's head to the side opposite the fracture. A single-prong hook is inserted strictly horizontally under the displaced area of the zygomatic arch through the puncture. Then the surgeon turns the hook at a right angle, moving the pointed end to the inner border of the cheekbone. As a result, the broken section of the bone is set in place until a characteristic click is heard.
Dubov's method. Allowed for use in cases of combined fracture of the upper jaw and sinuses. At the beginning of the operation, tissue is excised in the projection of the upper first and second incisors, exposing the sinuses of the upper jaw. Bone fragments are fixed using an artificial joint. Then tamponade of the nasal sinuses is performed with a gauze pad soaked in iodophor. The wound surface is sutured and the tampon is subsequently removed after 12-14 days.
Duchant's method. Its use is advisable in the treatment of minor injuries. Thanks to this technique, the bone is fixed in an anatomically correct position using surgical forceps - through a puncture, they grasp the displaced fragment of the cheekbone and set it in place.

In recent years, as a result of an increase in the number of man-made disasters, criminal disputes and road traffic accidents (RTA), the number of victims with injuries to the maxillofacial area remains high (about 40%) and continues to grow, on average by 2% per year [1]. According to statistics, zygomatic bone fractures account for 20 to 37.5% of all injuries to facial bones [3, 4]. In case of fractures of the zygomatic bone, in 39% of cases there is damage to the lower wall of the orbit, in 6.6% of cases the fractures are combined with damage to the eyeball, in 25.5% - to the eyelids, and in 72.2% - to the soft tissues of the face [1].

Traumatic injuries of the zygomaticoorbital complex and the walls of the orbit are characterized by displacement of bone fragments, the formation of small-fragmented fractures of the lower wall of the orbit, leading to deformation of the shape of the orbit, prolapse of its entire contents, including the eyeball, into the maxillary sinus, which leads to pinching of the inferior oblique muscle of the eye and the development of limited mobility eyeballs, diplopia, hypo- and enophthalmos [3, 5]. The result of severe injuries to the midface area is not only anatomical and functional disorders, but also significant disfigurement of the patient, which contributes to the development of severe mental disorders, social maladaptation and disability.

There is no uniform approach to the treatment of traumatic fractures of the zygomaticoorbital complex and the lower wall of the orbit, or to the use of one or another method of plastic surgery of the orbital floor. There are many different auto- and allogeneic grafts and implants for orbital reconstruction. Each of them has advantages and disadvantages described in the literature [3–6, 8]. A promising method for restoring the zygomatic-orbital area is the production of an individualized precision implant after computer modeling and stereolithography. This method is ideal, but quite expensive; manufacturing such an implant requires time, which is not available when treating patients with acute trauma.

Existing treatment methods are often technically complex or require the use of expensive consumables [3, 4, 6, 8]. The lack of a unified approach to the treatment of traumatic fractures of the zygomaticoorbital complex and the floor of the orbit, to the use of one or another method of plastic surgery of the lower wall of the orbit, which would meet the optimal conditions for the functioning of the eyeball, led us to the development of a new method and new polymer implants for the treatment of fractures of the zygomaticoorbital complex, combined with damage to the lower wall of the orbit.

The purpose of the work is to optimize methods of surgical rehabilitation of patients with fractures of the zygomaticoorbital complex and the lower wall of the orbit.

Material and methods

We carried out examinations and surgical interventions in 65 victims with fractures of the zygomatic orbital complex, who were treated at the clinical bases of the Department of Surgical Dentistry and Maxillofacial Surgery of the Nizhny Novgorod State Medical Academy - in the departments of maxillofacial surgery of the Nizhny Novgorod Regional Clinical Hospital named after. ON THE. Semashko and Clinical Hospital No. 3 of the Volga District Medical Center of the Federal Medical and Biological Agency of Russia - in 2009-2013. The average age of patients was 34.6 years (from 20 to 60 years); gender distribution: 52 (80%) men and 13 (20%) women. The causes of injury to the midface in 37 (56.9%) cases were road accidents, and in 28 (43.1%) - domestic trauma. Fractures of the orbital walls, which required reconstructive treatment, were diagnosed in 48 (73.8%) patients. In 5 (10.35%) cases there were injuries to the upper wall of the orbit, trauma to the brain and naso-ethmoid complex; treatment of these patients was carried out jointly with a neurosurgeon. In 8 (16.7%) patients, damage to the lateral, medial and inferior walls of the orbit was observed, accompanied by severe deformation of the orbit, dislocation of fatty tissue and extraocular muscles in the fracture gap, and the development of strabismus; an ophthalmologist was involved in their treatment. Isolated injuries to the lower wall of the orbit (blow-out) were diagnosed in 3 (6.25%) cases. The most common (32 (66.7%) cases) were fractures of the zygomaticoorbital complex and the lower wall of the orbit. In the preoperative period, all patients had orbital deformation and varying degrees of enophthalmos and hypophthalmos, as well as diplopia of varying types. Limitation of eyeball mobility in the preoperative period was observed in 43 (89.6%) people.

Upon admission, all patients underwent a classic comprehensive examination, including diagnosis by related specialists (neurosurgeon, ophthalmologist, otorhinolaryngologist, etc.), spiral computed tomography with 3D reconstruction in 3 projections (frontal, sagittal and axial), magnetic resonance imaging of the orbits ( Fig. . 12).

Figure 1. Axial tomogram of the orbits of patient L. with a fracture of the lower wall of the orbit, enophthalmos and displacement of the optic nerve trunk are visible.

Figure 2. Patient with a fracture of the right zygomaticoorbital complex and inferior orbital wall before treatment.
The examination made it possible to: clarify the location and nature of the damage; assess the condition of the extraocular muscles, optic nerve, position of the eyeball; detect prolapse of orbital tissue and clarify the size of the defect in the orbital walls, which is especially important for choosing an orbital endoprosthesis and planning surgical intervention. Photo documentation was mandatory before and after surgical treatment to assess the nature of the deformation and movement of the eyeball, the degree of hypophthalmos and enophthalmos (Fig. 4, 5).

Figure 4. Endoprosthetics of the lower orbital wall with a Reperen implant.

Figure 5. Patient with a fracture of the left zygomaticoorbital complex and the lower wall of the orbit, cicatricial deformity of the left upper eyelid before treatment. Severe hypo- and enophthalmos.

All patients underwent surgical intervention under general anesthesia, which included the stage of osteosynthesis of the zygomatic bone and plastic surgery of the lower orbital wall. The timing of surgical treatment was as follows: on the 1st day after the injury, 6 (9.2%) patients were operated on, from the 5th to the 14th days - 51 (78.5%) and after 1-2 months - 8 (12 .3%). Surgical treatment of injuries to the zygomaticoorbital complex and the lower wall of the orbit was performed according to the technique we developed [2]. Classical osteosynthesis was performed along the fracture lines of the zygomatic bone in the area of the frontozygomatic fracture along the lower edge of the orbit and zygomatic arch. To reduce and fix the fracture along the lower edge of the orbit, we used our method: a transconjunctival incision with lateral canthotomy was made, exposing the fracture line along the lower orbital edge and the lower wall of the orbit. The next, most important, stage of the operation was the careful lifting of the eyeball and revision of the lower wall of the orbit towards the apex of the orbit; the inferior rectus muscle was released, then osteosynthesis was performed along the inferior orbital edge. Orbital fat prolapse was eliminated by closing the bone defect with an implant. The Reperen synthetic implant was placed on small bone fragments of the orbital floor (Fig. 3).

Figure 3. Patient with a fracture of the right zygomaticoorbital complex and the inferior wall of the orbit on the 7th day after surgery.
Before use, the implant was heated to the required temperature (60-80 °C) for its modeling. Thanks to its structure, the endoprosthesis optimally changed the volume of the orbit, covered the bone defect, isolated the maxillary sinus, reliably held the eye in the correct position and was easily fixed to the bone with microscrews. Layer-by-layer suturing of the wound completed the operation. In the postoperative period, all patients were prescribed standard anti-inflammatory therapy, and also underwent rehabilitation together with an ophthalmologist to restore eye function. 14 days after surgery, diplopia persisted in 6 (12.5%) patients. The restoration of binocular vision in them lasted up to 2-3 months, which was associated with the nature of the injury to the eyeball and the late timing of surgical treatment ( see Fig. 4, 5, and also Fig. 6).

Figure 6. Patient with a fracture of the left zygomaticoorbital complex and the lower wall of the orbit, scar deformity of the left upper eyelid after treatment. Hypo- and enophthalmos were eliminated.

Results and discussion

Previously conducted clinical and experimental studies allowed us to develop a method for treating fractures of the zygomaticoorbital complex and the lower wall of the orbit. The 1st stage of the study was the development of different types and types of implants for plastic surgery of the lower orbital wall. The Reperen implant is made from a spatially cross-linked polymer obtained by photopolymerization of methacrylic oligomers. Then experimental work was carried out on animals. The surgical technique was developed, and the effect of the polymer implant on surrounding tissue was assessed. Experimental studies made it possible to once again prove the biostability and biocompatibility of Reperen endoprostheses, their good germination with connective tissue without creating a capsule, and the absence of inflammatory reactions to the implant. The advantage of the implant is the single-stage synthesis of a polymer product with optical precision, which allows the implant to be regarded as the closest in structure to biological tissues [7].

Despite the variety of surgical treatment methods and types of implants for plastic surgery of the lower orbital wall, the development of new methods and endoprostheses is very relevant. The method of plastic surgery of the lower orbital wall using Reperen implants is a competitive direction in reconstructive maxillofacial surgery. The advantages of the proposed method are cosmetic access, one-stage and high-tech, which allows you to obtain an optimal functional and aesthetic result in a shorter time and gives a large socio-economic effect (reducing the time and stages of treatment in the hospital, eliminating repeated operations for complications, rapid psychological rehabilitation of the patient ). The use of a simulated implant allows you to quickly produce an individual endoprosthesis with low thermal conductivity, non-toxic, zero electrical conductivity, and well fixed in the orbit. Thanks to the mesh structure, the endoprosthesis does not interfere with tissue regeneration, grows well with connective tissue and helps prevent secondary enophthalmos. The cost of such an endoprosthesis is significantly lower than the cost of other orbital implants, which makes reconstruction of the lower orbital wall accessible in regular surgical hospitals.

The treatment method we developed resulted in 99.9% of cases without postoperative complications associated with infection and suppuration of the implant, changes in its position both in the immediate and long-term period. The patients were observed by us for a period of 1-3, 6 months (short-term follow-up) and for a period from 6 months to 2 years (long-term follow-up). 1 (0.1%) patient required repeat surgery 6 months after surgery due to the development of progressive diplopia and enophthalmos. This complication was due to the presence of an extensive small-comminuted fracture of the lower wall of the orbit, cicatricial changes in the orbital tissue and inferior rectus muscle, and displacement of the implant due to scarring in the maxillary sinus. Repeated surgery performed to restore the lower orbital wall and its volume using the Reperen implant allowed us to obtain a good aesthetic and functional result.

Thus, the proposed method of surgical rehabilitation of patients with fractures of the zygomaticoorbital complex and the lower wall of the orbit using Reperen polymer implants gives good aesthetic and functional results, helps reduce the incidence of post-traumatic and postoperative complications and improves the quality of life of patients.

Nutritional Features

Treatment of a fracture of the zygomatic bone requires the introduction of restrictions on opening the mouth for a period of up to 12–14 days. Until restrictions are lifted, artificial nutrition must be administered intravenously. These may be preparations based on glucose or other nutritional components.

After the period when the patient is able to eat on his own, doctors transfer him to traditional nutrition. This approach is a kind of stimulator for the zygomatic-orbital complex.

During this period, the patient should eat exclusively crushed, liquid dishes and food products. The eating process involves the use of disposable straws. The diet usually consists of traditional dishes: broths, yoghurts, eggs, lactic acid drinks, drinking yoghurts.

Fruit smoothies or baby food can help diversify your diet somewhat.

Rehabilitation

How long it will take for a fracture to heal - this period depends on its nature and severity. With conservative treatment, consolidation occurs within 3 weeks; after surgery, it may take more than a month.

Throughout this period, rehabilitation is carried out, which is aimed at accelerating consolidation, restoring function and eliminating cosmetic disorders. It includes electrical procedures, phototherapy, and magnetic therapy.

After the fixation is removed, the diet is expanded; chewing gum is recommended to develop muscles. A massage is prescribed with ointments that improve microcirculation to restore blood circulation and nerve sensitivity, and eliminate facial numbness.

Consequences

Identification of this type of injury rarely occurs without the onset of undesirable consequences, which can only be eliminated through surgical treatment. The situation becomes much worse if the patient, overestimating his condition, neglects to seek medical help. In this case, eliminating complications may require a number of operations.

If a patient with a fracture of the zygomatic bone delays his visit to the trauma center, then he will inevitably face the following negative consequences:

Pathological mobility of the lower jaw and curvature of the zygomatic arch;
Chronic inflammatory processes of the sinuses up to the development of sinusitis;
Inflammation of the cheekbone.

When diagnosing an uncomplicated fracture of the bones of the zygomatic arch, one can hope for a favorable outcome of fusion of the bone boundaries - the chances of self-healing of the fracture are high.

A fracture of the zygomatic bone is rightfully considered one of the most severe injuries in traumatology. Untimely medical intervention or its complete absence entails a whole list of problems. Receiving damage to the jaws is an absolute indication for visiting a specialist in the field of maxillofacial surgery. The doctor will determine the severity of the fracture, conduct the necessary diagnostics and draw up an appropriate treatment plan.