LETTER TO THE EDlTOR

MINIPLATE FIXATION OF ZVGOMATIC FRACTURES

TO THE EDITOR:

We read with interest the paper by Berman and Jacobs’ and would like to address several matters. The authors admit that the principle of rigid internal fixation of unstable zygomatic fractures by miniplates applied to the region of the fronto-zygomatic suture is not new. The technique has been common practice, in maxillofacial units, at least for many years, in fact since the seminal work of Champy and Lodde in 1976.’ In view of the well-established principles and wide usage of this technique, it seems a trifie presumptuous of the authors to suggest “guidelines” for the use of miniplates based on a review of only 20 cases collected over a 2 year period. In the units we work in we expect to see as many, if not more, of these fractures in a 2 month period. We suspect that the authors’ routine use of the brow incision as an approach for zygomatic elevation is a result of their intention, or a t least desire, to plate all such fractures. We take issue with the authors’ statement that the Gillies temporal approach offers “greater mechanical advantage for greatly impacted fractures.” We respectfully introduce them to the intraoral technique discussed by Balasubramaniam in 19673 and used since the beginning of the ~ e n t u r yExamination .~ of a dried skull will confirm the mechanical advantage that this technique has over others. The routine use of CT scanning in addition to plain radiography in all zygomatic fractures, as suggested by this paper, certainly seems to us overinvestigation, needlessly exposing the patient to ionizing radiation. The majority of these fractures can be assessed quite adequately with plain radiography alone. The statement that the CT scan helps “define depression” suggests an inability to interpret plain radiographs or indeed clinical signs. Indications for CT scanning include those particularly complex cases of mid-face trauma that may involve the malar complex. Cases where clinically there is significant orbital floor involvement will benefit from coronal CT scanning or reformatting.

Letter to the Editor

The authors surely do not intend us to believe that all patients requiring surgical treatment of their zygomatic fractures require internal rigid fixation, with 60% requiring fixation at the infraorbital margin in addition to the fronto-zygomatic region. if this is their intention, they overtreat their fractures. If this is not their intention, their paper is misleading. What do they mean by the term “uncomplicated when applied to zygomatic fractures? Our understanding is that uncomplicated but displaced fractures are those that may be elevated by one of several techniques and then remain stable following elevation, requiring no direct fixation of any sort. Complicated fractures are unstable following elevation and require fixation. Miniplate osteosynthesis a t one or more points is one method of achieving this. In a 10-year review of 2,067 cases of zygomatico-orbital fractures, Ellis et a15 showed that 23% of these fractures required no surgical treatment; of the remainder, 70% were adequately treated by elevation alone, and only 30% required any form of fixation. Although these figures are very different from those presented in this paper, they are similar to the results of other large series. Berman and Jacobs discuss functional indications for repair but fail to mention infraorbital nerve neuropraxia. De Man and Bax‘ have shown that recovery of nerve function is significantly improved by rigid fixation following reduction of unstable fractures. The same authors state, however, that infraorbital nerve involvement alone with minimal or no zygomatic displacement is not an indication for surgical intervention because full regression of neurologic symptoms occurs in 70% of these cases. We are concerned that this paper recommends overinvestigation and overtreatment of this type of injury. Nicholas M. Whear, MBBS, FDSRCS, FRCS Graeme A. Zaki, MBBS, FDSRCS, FRCS South West & South East Thames Regional Health Authorities Training Rotation, Oral & Maxillofacia

Surgery St. Thomas’ Hospital London, England

HEAD & NECK

September/October 1992

419

1. Berman PD, Jacobs JB. Miniplate fixation of zygomatic fractures. Head Neck 1991;13:424-426. 2. Champy M and Lodde JP. Osteosynthesis of the external orbital cavity using screwed plates: therapeutic indications and results. Rev Otoneuroophthalmol 1976;48:243. 3. Balasubramaniam S. Intraoral approach for the reduction of malar fractures. Br J Oral Surg 1967;4:189. 4. Lothop HA. Fractures of the superior maxillary bone caused by direct blows over the malar bone: a method for the treatment of such fractures. Boston Medical and Surgical Journal. CLIV 1906;1:8. 5. Ellis E, El-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 1985;43:417. 6. De Man D, Bax WA. The influence of the mode of treatment of zygomatic bone fractures on the healing process of the infraorbital nerve. Br J Oral Maxillofac Surg 1988;26:419.

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Letter to the Editor

REPLY:

This group of 20 patients sustained severe facial trauma and presented for evaluation and treatment at Bellevue Hospital. We strongly believe that significantly displaced fractures in this patient population should be plated. Follow-up evaluations postoperatively are rare, and repeat early facial trauma is common. The brow incision is cosmetic, and the miniplates have all been well tolerated. Therefore, if reduction under anesthesia is necessary, we prefer to plate at least one fracture line and achieve a more stable fixation. Joseph B. Jacobs, MD NYU Medical Center New York, New York

HEAD & NECK

Septernber/October1992

Miniplate fixation of zygomatic fractures.

LETTER TO THE EDlTOR MINIPLATE FIXATION OF ZVGOMATIC FRACTURES TO THE EDITOR: We read with interest the paper by Berman and Jacobs’ and would like...
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