Etiology and Pattern of Zygomatic Complex Fractures: DISCUSSION
The UBTH and OAUTH have a combined capacity of over 1,000 bed spaces. Both have oral and maxillofacial surgery departments dedicated to the teaching of undergraduate students and residents, and the management of orofacial conditions. They are also major trauma referral centers. This study recorded that more males than females (ratio 3.2:1) sustained zygomatic complex fractures. This is consistent with other reports. Males (34.3%) in the 21-30-year age group were most often involved, and road traffic accidents were the leading etiologic factor (p<0.05). Many studies have shown that young adult males were commonly affected. The role of road traffic accidents as an etiologic factor in zygomatic complex fractures has been identified by some studies. A previous study had identified the contributory factors in road traffic accidents resulting in maxillofacial trauma in Nigeria. The young Nigerian male is more likely to engage in jobs that require intercity vehicular transport. Due to nonenforcement of road traffic laws, many Nigerian drivers notoriously exceed the speed limit, do not use seat belts, and drive under the influence of alcohol and other psycho-active substances. As a result of the economic recession in Nigeria, many drivers fit already used tires on their vehicles, while years of neglect have left the highways in disrepair. All these factors contribute to the rising role of road traffic accidents as a leading cause of maxillofacial trauma in Nigeria.
The present study recorded more fractures of the zygomatic bone (88.8%) than those of the arch (8.2%) or combined zygomatic bone and arch (3.0%). Isolated fractures of the arch are uncommon. This was probably because of the predominant role of road traffic accidents, in which most impacts to the face were most likely frontal. Arch fractures are more likely to involve some form of lateral impact and were more often encountered in cases of missile injuries, assaults and sport in this study.
As a result of the intimate association of the zygomatic complex with the rest of the facial skeleton, associated maxillofacial fractures are common. The findings from this study are similar to the associated facial bone fractures seen in patients with fractures of the zygomatic complex reported by Afzelius, Ellis et al. and Nam. These studies showed that mandibular fractures were most often associated with zygomatic complex fractures.
Although several signs and symptoms accompany zygomatic complex fractures, not all require active treatment. Circumorbital ecchymosis and subconjunctival ecchymosis were most frequently encountered in this study but were usually self-limiting. Banks and Brown have summarized the indications for treatment as follows: to restore the normal contour of the face both for cosmetic reasons and to establish skeletal protection for the globe of the eye, to correct diplopia and to remove any interference with the range of movement of the mandible. Flattening of the cheek was encountered among 47.8% of patients in the study. This is usually seen in tripod fractures that are most often displaced in wards to a greater or lesser extent. Diplopia was observed in 9.7% of patients in this study. Al-Qurainy et al. reported diplopia in 19.8% of patients with mid-face factures and found that zygomatic fractures were a principal risk factor in the development of diplopia. Limitation of mandibular movement occurred in 56% of patients and is usually a result of the fractured zygomatic complex impinging on the coronoid process of the mandible. Going without your pills? Buy valtrex online
Radiographic examination in fractures of the zygomatic complex appears somewhat unresolved. In the 1994 survey of British oral and maxillofacial surgeons, 93.3% of respondents use two or more radiographs for diagnostic purposes. Only 6.7% of surgeons would rely on a single radiograph for diagnosis. This is similar to the findings in this study where in 73.1% of the cases two or more radiographs were requested for diagnosis. In only 25.4% of the cases was one radiograph requested. Earlier, Ogden et al. had proposed that in some fractures of the zygomatic complex, clinical criteria alone were sufficient for postoperative assessment. Pogrel et al. evaluated the efficacy of a single radiograph to screen for mid-face fractures and concluded that a single 30° occipitomental radiograph (augmented with CT scans when indicated) can identify all mid-face fractures requiring treatment. In this study, only 12.7% of patients had postoperative radiographs taken. The most frequent radiologic findings were fractures at the ZM and ZF sutures (38.8%). The suture lines of the zygomatic complex are the weak points of the bone, as it is unusual for the zygomatic bone itself to be fractured.
The Gillies temporal approach (25.4%) was the commonest method of reduction. This is consistent with other reports. In grossly displaced fractures, rigid fixation was obtained with transosseous wires and fixation at the ZF suture was most common. This is consistent with an earlier report. There was no use of miniplates in this study, their use being limited by nonavailability. McLoughlin et al. found that the use of the bone plating was not significantly greater than the use of transosseous wiring among British oral and maxillofacial surgeons. However, Tadj and Kimble, in a study of 263 cases of fractured zygomatic complex, found that bone plating was the most frequently employed fixation.
Most (70%) patients in this study were lost to follow-up. As is common with patients in our study environment, once the acute phase of a medical condition is resolved, they tend to default on appointments. This may be a factor in our reported frequency of postoperative complications. This study found postoperative complications among 6.7% of the patients. Covington et al. reported a complication rate of 1.5%, while Tadj and Kimble reported a rate of 20.7%. Blindness is an extremely morbid event and was encountered in 3.0% of patients. In all cases, it was preceded by decreasing visual acuity. In this study, ophthalmic consultation was usually sought for patients with impaired ocular functions. The role of the ophthalmologist in the perioperative assessment of patients with zygomatic complex has been documented.
Zacchariades et al., in an analysis of5,936 patients with facial trauma, found that vision in 19 eyes were lost in 18 patients. Zygomatic complex fractures accounted for 0.45% of cases. Apart from direct injury to the globe of the eye, the mechanism for the devel¬opment of blindness in zygomatic complex fractures is thought to be due to hemorrhage within the muscle cone and ultimately spasm or occlusion of the short posterior ciliary arteries, causing ischemia of a critical zone of the optic nerve. Other complications were persistent flattening of the cheek (3.0%) and persistent enophthalmos (0.7%), and these were as a result of inadequate surgical management. generic omnicef
In conclusion, this study has shown that road traffic accidents are responsible for most zygomatic complex fractures in our environment. Urgent enforcement of road traffic legislation is therefore necessary to minimize zygomatic complex fractures due to road traffic accidents. It also showed a low utilization of technological advances in the imaging and treatment of these fractures. These may play a role in the frequency of postoperative complications.