case report An Atypical Zygomaticomaxillary Frontotemporal Complex Fracture: A Case Report Dilshan Gunawardena1, Michael Proothi2, Salvatore Ruggiero3 Abstract This is a case report of a unique zygomaticomaxillary frontotemporal complex (ZFT) fracture that is rarely reported in the literature. Key words: Zygomaticomaxillary, Frontotemporal complex, ZFT, ZMC. Introduction: T he zygoma is an integral component of the facial skeleton that provides structure, strength, and stability to the midface. This forward projection also causes the zygoma to be injured frequently separating it from its articulating sutures: zygomaticomaxillary, zygomaticofrontal, zygomaticosphenoid, and zygomaticotemporal. These are the common sites associated with fractures of the zygoma and it is rare to see fractures at other locations. The common patterns of fracture often lead to a quadrangular disarticulation of the zygoma from the midface. On clinical examination of a displaced zygomaticomaxillary complex (ZMC) fracture, it is often possible to palpate one or 1 Chief Resident, Department of Oral and Maxillofacial Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA 2 The New York Center for Orthognathicand Maxillofacial Surgery Assistant Professor, Department of Oral and Maxillofacial Surgery, Stony Brook University Attending Surgeon, Long Island Jewish Medical Center 3 The New York Center for Orthognathic and Maxillofacial Surgery Clinical Professor, Department of Oral and Maxillofacial Surgery, Stony Brook University Clinical Professor, Hofstra North Shore-LIJ School of Medicine Corresponding Author Dr. Dilshan Gunawardena Email id: [email protected] 1000 more of the displaced sutural attachments at the temporal, frontal, maxillary or infraorbital rim. Furthermore, ZMC fractures involve the orbital skeleton and floor and it is important to evaluate these structures for possible entrapment of the extraocular muscles on examination. The purpose of this case report is to highlight a unique presentation of a zygomaticomaxillary frontotemporal (ZFT) fracture with separation at the zygomaticomaxillary and zygomaticotemporal bones that required the combined efforts of both the neurosurgery and OMFS teams for treatment. Case Report: A 28 year old male pedestrian struck at an unknown speed was brought in to the emergency department by helicopter for immediate evaluation and treatment. On presentation he was intubated and sedated with a GCS score of 3T and was hemodynamically stable. He had an unknown medical history. The OMFS examination revealed a 12 cm right scalp laceration that extended to the calvarium. The wound was grossly approximated to provide hemostasis (Figure 1). Right periorbital edema and chemosis were present, as well as a right infraorbital step deformity and right malar depression. Voluntary extraocular muscle movements could not be evaluated as the patient was sedated. However a forced duction test was negative for inferior or superior rectus Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 3, May - July 2014 CASE REPORT entrapment. The opthalmologic evaluation revealed no evidence of globe or retinal injury. The CT scan of the head showed a right frontal subdural hematoma with pneumocephalus and an intracerebral hemorrhage involving the right frontal, occipital, and right tentorial regions. An intracranial pressure (ICP) monitor was placed into the left frontal bone by the neurosurgical team.The intracranial pressures ranged from 8-15 mm Hg in the perioperative time period. The CT Maxillofacial scan illustrated a right ZMC fracture. The fracture extended through the zygomatic arch and the zygomaticomaxillary suture as normally seen in these types of fractures. " However, the superior site of the fracture did not involve the frontozygomatic suture but rather it extended from the maxilla through the orbit and into the cranium, with involvement of the right frontal and temporal bones (Figures 2 and 3). Trauma and neurosurgery clearances were obtained three days later for open reduction and internal fixation of the right facial and skull fractures.The plan was for an open reduction of the fractures with concomitant neurosurgery evaluation of the right frontal and temporal bones as well as an assessment of the dural membrane with constant monitoring of the ICP. The intraoperative course involved utilizing the scalp wound with extension of the existing laceration. A right maxillary vestibular incision was also created in order to assess the fractures from the zygomaticomaxillary buttress. The right frontal bone fracture was visualized (Figure 4), debrided, and a right epidural hematoma was evacuated. A small dural tear was noted and gelfoam was placed to cover the defect. The right zygoma was exposed via a transoral approach. Additional control of the ZMC was obtained by placing a Carroll-Girard screw with a percutaneous stab incision. Once the fracture was properly reduced the ICP remained less than 15 mmHg. Low profile plates were placed over the right supraorbital rim and the frontal bone (Figure 5) as well as at the zygomaticomaxillary buttress (Figure 6). A forced duction test was again performed for evaluation of the inferior and superior recti muscles which were negative for entrapment. Layered soft tissue closure was completed with good primary approximation of the tissues. Postoperative CT scan showed good reduction (Figure 7, 8, 9) and no interval changes in his intracranial hemorrhage. The patient was then transferred to the ICU for further monitoring. He was discharged home on hospital day twenty and followed up as an outpatient. Figure 1: Initial presentation in the Emergency Department. Anterior forehead laceration sutured for hemostasis Figure 2: Frontal 3D reconstruction of CT images Figure 3: Sagittal 3D reconstruction showing the involvement of the right frontal and temporal bones in the zygomaticomaxillary frontotemporal (ZFT) fracture Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 3, May - July 2014 1001 CASE REPORT Figure 4: Photograph illustrating the displaced frontal bone fracture Figure 8: Sagittal view showing a well approximated temporal bone and satisfactory position of the zygoma Figure 5: Low profile plates were placed over the right supraorbital rim and the frontal bone to maintain the reduction Figure 9: Coronal view showing the X plate reducing the frontal bone Discussion: Figure 6: Zygomatic buttress fixated with a 5 hole L plate Figure 7: Postoperative scan illustrating adequate reduction 1002 The association between midface fractures and cranial fractures has been well studied and documented. However, the presence of a combined zygomaticomaxillary complex fracture with disarticulation at the frontal and temporal bones is rarely reported in the literature. Many Classification systems for zygoma fractures have been described but do not encompass ZFT pattern of fractures.1,2 Zingg, et al. developed a classification system based on 1025 ZMC cases and described the patterns as Type A, B, and C.1 Type A fractures were incomplete zygomatic fractures, Type B were complete tetrapod fractures, and Type C were multifragmented zygomas that included the body of the zygoma. However, extension of the zygomatic fractures into the cranial vault was not delineated. Also, algorithms for treatment of zygoma fractures fail to encompass ZFT pattern fractures.3 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 3, May - July 2014 CASE REPORT Haug and associates looked at the incidence of cranial fractures in patients with pan-facial facial fractures.4 In their review of 882 facial fracture patients, 39 (4.4%) had concomitant cranial fractures. Of those patients, the cranial bones most frequently injured were the frontal bone (38%), followed by the sphenoid bone (24%), and temporal bones (22%). In cases with a combination of facial and cranial bone fractures, the zygoma is often involved. Pappachan and Alexander also studied the relationship of cranial and facial fractures at the Kasturba hospital in India.5 In their study, 108 (14%) of 772 patients with facial fractures had cranial injuries. The most common fracture in their review was the zygoma (30%) followed by Lefort II level fractures (8.46%). The cranial bones most frequently fractures were the frontal bone (37%), followed by temporal (18%), sphenoid (18%), occipital (3%), and parietal (1%). Although these studies reflect the relationship of cranial and facial fractures, not many studies report on the aberrant combination of zygomatic, frontal, and temporal bones. In these unusual ZFT fractures that extend into the cranial vault, it is important to work closely with the trauma and neurosurgery teams. OMFS intervention can commence once the trauma team has addressed the acute injuries that are an immediate threat to the patient’s life. The operative plan must be coordinated with the neurosurgery team so that they can address any potential dural or intracranial injuries. In this case, we were able to utilize the existing laceration to provide access to the cranial fractures. However, if this laceration was not present, a coronal incision would have provided access to the cranial fractures. The intracranial pressure should be monitored during treatment of these ZFT fractures. Unlike ZMC fractures, ZFT complex fracture manipulation can cause an elevation of the ICP which can further compromise CNS function. In our case, an epidural hematoma initially prevented the proper reduction of the fracture and we noticed an increase in ICP during the initial attempt at reducing the fracture. However, once the hematoma was evacuated the reduction became more passive and the ICP remained under 15mmHg. Miniplates were utilized to reduce, stabilize and provide for a good esthetic result. References: 1. Zingg, Markus, Kurt Laedrach, Joseph Chen, et al. "Classification and Treatment of Zygomatic Fractures: A Review of 1,025 Cases." Journal of Oral and Maxillofacial Surgery. 50. (1992): 778-790. 2. Knight, JS, and JF North. "The classification of malar fractures: An analysis of displacement as a guide to treatment." Journal of Plastic Surgery. 13:525. (1961). 3. Ellis III, Edward, and Winai Kittidumkerng. "Analysis of Treatment of Isolated Zygomaticomaxillary Complex Fractures ." Journal of Oral and Maxillofacial Surgery. 54. (1996): 386-400. 4. Haug, Richard, James Adams, et al. "Cranial fractures associated with facial fractures: A review of mechanism, type, and severity of injury." Journal of Oral and Maxillofacial Surgery. 52.7 (1994): 729733. 5. Pappachan, Biju, and Mohan Alexander. "Correlating Facial Fractures and Cranial Injuries." Journal of Oral and Maxillofacial Surgery. 64.7 (2006): 1023-1029. Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 3, May - July 2014 1003