a case report

case report
An Atypical Zygomaticomaxillary Frontotemporal
Complex Fracture: A Case Report
Dilshan Gunawardena1, Michael Proothi2, Salvatore Ruggiero3
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.
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
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
Chief Resident, Department of Oral and Maxillofacial Surgery,
Long Island Jewish Medical Center,
New Hyde Park, New York, USA
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
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]
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
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
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
Figure 6: Zygomatic buttress fixated
with a 5 hole L plate
Figure 7: Postoperative scan illustrating
adequate reduction
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
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.
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.
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