Malar bone fractures and their sequelae

64

J. Cranio-Max.-Fac. Surg. 17 (1989)

j. Cranio-Max.-Fac. Surg. 17 (1989) 64-68 © Georg Thieme Verlag Stuttgart • New York

Summary The authors analyse the results of 1.393 cases of malar fractures treated in the maxillo-facial Departments of Montpellier and Perpignan. A clinical and therapeutic classification is given. Study of the sequelae demonstrated that the most frequent were infra-orbital nerve lesions, residual displacement of the malar bone, diplopia, and enophthalmos. A point is made about the use of Franchebois's inflatable balloon as a means of retention. Its indications as well as its contra-indications are clearly defined. The reduction in the number of bone sequelae, when compared to cases treated without the balloon, demonstrates the efficacy and simplicity of this method.

Malar Bone Fractures and Their Sequelae A Statistical Study of 1.393 Cases Covering a Period of 20 Years Franqois Souyris 1, Franqois Klersy, Patrick Jammet, Claude Payrot 2 1Dept. of Maxillo-Facial Surgery (Head: Prof. F. Souyris, MD.), University Hospital, Montpellier, France 2 Dept. of Maxillo-Facial Surgery (Head: CI. Pellequer, M.D.) General Hospital, Perpignan, France

Key words Malar bone fracture - Sequelae - Franchebois's antral balloon

Submitted 21.1. 1988; accepted 7.6. 1988

Introduction Our study is based on a retrospective analysis of 1,393 malar fracture cases treated in the maxillo-facial surgery units of Montpellier's University Hospital and Perpignan's General Hospital between 1964 and 1985, from which 3 medical doctoral theses have been published (Hirbec, 1985; Klersy, 1985; Lambert, 1987). The evolution of ideas about the management of malar fractures can be summarized as follows: 1751 first report by Duverney. 1895 Dennis described the first silver wire osteosynthesis. 1906 Lothrop advocated antral packing. 1942 Adams used stainless steel wiring. 1952 First inflatable antral balloon described by An-

thony. 1959 Refinement of Anthony's principles by Franchebois in Montpellier and introduction of his new balloon (Franchebois, 1960, 1963; Franchebois and Lapeyre, 1962). Treatment of these fractures is difficult because of the range and importance of their functional and aesthetic sequelae, which are characteristic of the difficulties often encountered during secondary treatment. Aetiopathogenic factors will be discussed first, then the different therapeutic modalities and the sequelae are analysed in order to explain our choice of treatment methods. Material and Methods As in the other series of traumatic lesions of the face (Crepy et al., 1976), we found 74% of malar bone fractures in men and 26 % in women. The incidence is greater in younger people. -

45 % in the age group under 25 yrs. 37.5 % in the age group 2 5 - 3 0 y r s . 10.5 % in the age group 5 0 - 7 5 yrs. 2% in the age group 12-16yrs.

The main causes of fractures are M. V. A. (Motor Vehicle

Accidents [67.6 %]), aggravated battery (9.1%), sport accidents (11.9 %) and industrial injuries (3.8 %). The anatomical types of fracture are: -

78 % displacement fractures of the malar bone. 11% malar bony fractures. 6.5 % comminuted fractures. 4.5 % blow-out fractures.

In 62 % of the cases in our series, the malar fracture was isolated. In 11% of our cases, there was an associated craniofacial fracture: Le Fort II or Le Fort III type. In 23% of the cases, the malar fracture was associated with another craniofacial fracture or an ophthalmic lesion. In 15 % of the cases, there was an associated lesion elsewhere (abdominal or orthopaedic). 27% of our cases presented with an associated facial wound. Cases Analyses Displacements are seen in the 3 planes of space, following associated translational and rotational movements (Fig. 1). This accounts for a total number of movements greater that the total number of cases. These are described in Table 1. The surgical treatment was carried out within the first post-trauma week in 71% of our cases. Delayed treatment, after the end of the first week, results in a more difficult procedure. The different methods of treatment are summarized in Table 2. The discrepancy between the number of non-displaced fractures (7.7 %) and the number of non-operated cases: only 2 %, will be noted. We had 382 cases with residual sequelae (27.4 %) after the 3rd month, with an increase in the number of such complications in the patients treated after the end of the first week.

The different sequelae are listed, according to their frequency (Table3). Indications for a secondary surgical procedure, and its type, are given.

Malar Bone Fractures and Their Sequelae

Fig.1

J. Cranio-Max.-Fac. Surg. 17 (1989)

Fig.2 Post-operative view of the same fracture after internal fixation associated with antral balloon.

Pre-operative view of right malar bone fracture.

The most frequent complications are lesions of the infraorbital nerve, displacement of the malar bone, diplopia, and enophthalmos. Secondary surgical procedures have been carried out in 72 of these 382 cases.

Operative Procedures In 15 % of the cases, we performed a simple reduction using the percutaneous Ginestet's hook, with good and stable results (Fig. 3). Surgical reduction by Gillies temporal approach was used in 10.9% (Gillies et al., 1927). Among the great variety of retention methods we mainly use Franchebois's antral inflatable balloon (74.4 %). Antral

Table1

Table2

7,7% 45.3 % 42.9 % 40.6 % 32.8% 8.8% 11.7% 11.1% 0.5% 0.2%

Primary reduction and the different methods.

No treatment Closed hook reduction Reduction + antral balloon Reduction + antral balloon + 1 osteosynthesis Reduction + antral balloon + 2 osteosyntheses Reduction + 1 or 2 osteosyntheses Bone graft to the orbital floor

packing was used mostly for comminuted fractures (8.7%). The introduction of the balloon is performed after incising the upper buccal sulcus. The anterior wall of the antrum is often found to be open after the fracture. An osteo-periosteal flap is elevated. The balloon is introduced into the antral cavity, and its tube is withdrawn through the ipsilateral nostril. A small perforation of the inner antral wall is necessary (Fig. 4). A syringe is connected to the tube and the balloon is progressively inflated with air. The surgeon palpates the orbital rim to verify the correction. Two days after the operation depending upon the results of the X-ray examination, the balloon volume can be variably inflated or deflated to achieve the best anatomical reduction (Fig. 2). The balloon is withdrawn after ten days.

Simultaneous Osteosynthesis and Balloon Placement

Frequency of displacements.

No displacement Medial displacement Inward displacement Downward displacement Medial rotation along a horizontal axis Lateral rotation along a horizontal axis Medial rotation along a vertical axis Lateral rotation along a vertical axis Upward displacement Forward displacement

65

2% 15 % 31% 26 % 17% 9% 9%

We prefer a simple fronto-zygomatic screw-plate instead of a two wire osteosynthesis (one in the fronto-zygomatic region and one in the infra-orbital rim), as did Fain et al. (1981). After more than 15 years, we are still satisfied with the vitallium screw plate (Souyris and Caravel, 1974). Primary bone grafting of the orbital floor is performed only for very large defects (9 % of the cases). In 80 % of these patients, the fractures were treated by simultaneous bone grafting and antral balloon placement.

Definitive Complications and Sequelae The most frequent complications, which occurred in 7.2 % of the patients, are infra-orbital nerve disorders (Fig. 5). 42 % of these cases had been treated with the antral balloon, and 58 % without the antral balloon. In 4.8 % of the patients, we observed a maIunited displacement consolidation. About one half of these unfavonrable results occurred after the use of the balloon, but one must consider that 75 % of the patients of our series were operated on with this device. With the balloon, we observed a hypercorrection in one third of these patients (1.5 % of the

66

F. Souyris et al.

J. Cranio-Max.-Fac. Surg. 17 '1989)

Fig.3 Surgical instrument and appliances: Ginestet's hook, antral balloon, Mohr tubing clamp. Table3

Fig.4 Immediate post-operative view (external part of the antral balloon).

Description of the sequelae after the 3rd month.

Sequelae Infraorbital nerve lesion analgesia paraesthesia

107cases 77cases 30 cases

Aesthetic and/or functional disturbance

Late operative treatment

Aetiology displacement of malar bone nerve section hypertrophic callus osteosynthesis

9osteotomies 3 neurolyses 6osteotomies + neurolyses 3 removals of material

Anomaly of the malar position insufficient reduction over-reduction

68cases 57 cases 11 cases

Symptoms diplopia anaesthesia enophthalmos limited mouth opening

Diplopia

62cases

Aetiology mechanical neurological

Altered position of the globe enophthalmos lowering upward displacement

72cases 44cases 21 cases 7 cases

Functional disturbance 26diplopia

Restricted opening

28 cases

Aetiology masseteric contraction

Maxillary sinusitis

16 cases

Aetiology 10 cases when using antral balloon in the primary treatment 6 cases without antral balloon

Lesion of the ocular globe

16cases

Aetiology 3enucleations 6blindness 7partial loss of sight

Surgical scar

Other sequelae

5 cases

11 cases

ectropion and lagophthalmos most frequent in the secondary complications, but few are found after 3 months persistent oedema sepsis

9osteotomies (with bone graft in 5 cases) 5 bone grafts 3 profiloplasties

18freeing of the muscle with associated antral balloon in 15cases

7bone grafts 3dermo grafts 1 osteotomy

the 5 cases were treated surgically

Malar Bone Fractures and Their Sequelae

J. Cranio-Max.-Fac. Surg. 17 (1989)

67

% cases 1

91,0

62

72

/

25,0107 72 68 62 25 16 16 5 11

infra-orbital nerve lesion displacement of the globe anomaly of the malar position diplopia limitation of mouth opening maxillary sinusitis lesion of the globe surgical scar other sequelae

9,0 4,5-

"",,,25 %

--_ - . . . . . . . . . . without balloon

initial

Fig.S

Incidence of the different sequelae (382cases). 107 infraorbital nerve lesion; 72 displacement of the globe; 68 anomaly of the malar position; 62 diplopia; 25 limitation of mouth opening; 16 maxillary sinusitis; 16 lesion of the globe; 5 surgical scar;

Hg.6

I

3rd month

Evolution of diplopia in the first 3 months. Improvement after

3 months in about 72% of the cases with a balloon and 50% of the cases without a balloon,

11 other sequelae. % I00,

El .£ 50

1

o

iWiiii!i~ !iiiiiiiiiiiiiiii~i

.E ~=

;;~ili:i~ili~i:i!

Fig.7

Sequelae after 3 months. For each type of sequel, the incF dence of the cases treated with a balloon (black), versus those without a balloon is given.

total). Without the balloon 2.4% of the patients had an union with undercorrection and none had a hypercorrection. Diplopia was often observed immediately, but improved in 66% of the cases when the balloon was used, and less without the balloon (Fig. 6). After three months, diplopia was noticed in 4.4% of the cases, and in 2% after one year. Enophthalmos, like diplopia, was observed less in patients treated with the balloon than in others. Considered as a definitive complication, it was observed in 3 % of the patients (Fig. 7).

A correction osteotomy after a mal-united fracture was performed in 1.8% of the total cases. Freihofer and Van Damrne (1987) reported about the same percentage of osteotomies.

Discussion The antral balloon reduced the fractures and supports the orbital floor without the necessity for a surgical approach or primary bone or material implantation. We agree with Roncevic and Malinger (1981) that the percutaneous surgical approach to the orbit may lead to fibrosis and scar retraction of the lid. On the other hand, these authors observed an increased rate of infection when bone autotransplants were used. Fischer-Brandies and Dielert (1984) reported 3 cases of infection out of 15 when biologically inert implants were used. The major criticism of the inflatable balloon is the pressure exerted in all directions (Fischer-Brandies and Dielert, 1984). For that reason we utilize fronto-zygomatic osteosynthesis together with the balloon. As long as the outer part of the malar bone is stabilized, the action of the balloon can be directed to the orbital floor and to the anterior wall of the maxillary sinus. In a few patients, the balloon resulted in an overcorrection. This was confirmed by Fain and Peri (1981), but nevertheless after a few months, spontaneous correction was observed due to the action of the muscles. Vargervik et al. (1987) also confirmed this with an experimental study. Franchebois's antral balloon is a simple and efficient means of correction. Its use is easy and it permits an active and adaptable stabilization, thus giving good results with less complications.

68

]. Cranio-Max.-Fac. Surg. 17 (1989)

Its anatomical adaptation to the antral shape prevents any collection of interposed fluids. Its gentle and progressive expansion can be used as an efficient compliment to any other reduction manoeuvre especially an external approach. O u r indications are: displaced fractures, associated with fractures of the anterior wall of the maxilla, and fractures of the orbital floor with or without diplopia; - b l o w out fractures. -

In such cases, we found no need for bone graft reconstruction. We do not advocate its use as a p r i m a r y treatment in: f r o n t o - m a l a r or zygomatico-malar displacements; - comminuted fractures, where antral packing is preferred. -simple,

Conclusions O u r experience with 1393 malar fractures treated between 1964 and 1985 has led us to a d o p t a precise diagnostic and therapeutic attitude. Franchebois's antral balloon is our preferred treatment modality. We have used it in our department for nearly 30 years, with a high percentage of g o o d results, and a low complication rate at 3 months post-operatively. Simplicity of use and efficacy f r o m the aesthetic and functional points o f view, are the main advantages o f this method. References

Adams, W.M.: Internal wiring fixation of facial fractures. Surg. 12 (1942) 523-540 Anthony, D.H.: Symposium: Facial injuries: diagnosis and surgical treatment of fractures of the orbit. Tr. Am. Acad. Opht. 56 (1952) 580-587 Bartkowski, S.B., K.M. Krzystkowa: Blow-out fracture of the orbit. Diagnostic and therapeutic considerations and results in 90 patients treated. J. Max.-Fac. Surg. 10 (1982) 155-164 Crepy, C., J.M. Soubiran, A. Goddo, B. Lefevbre: Etude sur 290 cas de traumatismes crfinio-faciaux - consid&ations &iologiques et th~rapeutiques. Rev. de Stomatol. Paris 77 (1976) 1 256-259 Dennis, F.S.: System of surgery. Philadelphia, Lea Brothers, 11 (1895) 765 Duverney, J.G.: La fracture de l'apophyse zygomatique. Trait6 des maladies des os. Paris 1 (1751) 182-187

F. Souyris et al.: Malar Bone Fractures and Their Sequelae Ellis, E., A. EI-Attar, K.F. Moos: An analysis of 2.067 cases of zygomatico-orbital fracture. J. Oral Max.-Fac. Surg. 43 (1985) 417-428 Fain, J. G. Peri, P. Verge, D. Thevonen: The use of a single fronto-zygomatic osteosynthesis plate and a sinus balloon in the repair of fractures of the lateral middle third of the face. J. Max.-Fac. Surg. 9 (1981) 188-193 Fischer-Brandies, E., E. Dielert: Treatment of isolated lateral midface fractures. J. Max.-Fac. Surg. 12 (1984) 103-106 Franchebois, P.: Discussion au XVIe Congr~s Fran~ais de Stomatologie. Rev. de Stomatol. 9 (1960-61) 520-521 Franchebois, P.: Traitement des fractures enfoncements du malaire par ballonnet endosinusien. 6e Congr~s Soc. Ital. Store. Chir. Max.-Fac., Milan, Juin 1963 Franchebois, P., P. Lapeyre: Traitement des fractures du malaire par ballonnet gonflable endosinusien. Rev. de Stomatol. 63 (1962) 7-8 Freihofer, H. P. M., Ph. A. van Damme: Secondary post-traumatic periorbital surgery - Incidence and results. J. Cranio-Max.-Fac. Surg. 15 (1987) 183-187 Gillies, H.D., T.P. Kilner, D. Stone: Fracture of the malar zygomatic complex with a description of new X-ray position. Brit. J. Surg. 14 (1927) 651 Hirbec, P.: Les fractures du malaire et leurs sSquelles. Etude statistique. Th~se M~decine, Tours, 1985 Klersy, F.: Le traitement des fractures du malaire par le ballonnett endosinusien de Franchebois. Historique et experience aus Centre Hospitalier GSn~ral de Perpignan. Th~se M~decine, Montpellier 1985 Lambert, M.A.: Int&& du ballonnet endosinusien de Franchebois dans les fractures du malaire. A propos de 802 observations. Th~se M~decine, Montpellier, 1987 Lothrop, H.A.: Fractures of the superior maxillary bone caused by direct blows over the malar bone. A method for treatment of such fractures. Boston M.S.J. 154 (1906) 8-11 Roncevic, R., B. Malinger: Experience with various procedures in the treatment of orbital floor fractures. J. Max.-Fac. Surg. 9 (1981) 81-84 Souyris, F., J.B. Caravel: Ost~osynth~se par plaques viss~es en chirurgie maxillo-faciale et craniofaciale. Ann. Chir. Plast. 19 (1974) 2 131-137 Vargervik, K., M. Farias, D. Ousterhout: Changes in zygomatic arch position following experimental lateral displacement. J. CranioMax.-Fac. Surg. 15 (1987) 208-212

Prof. F. Souyris Service ChirurgieMaxillo-Faciale HSpital Lapeyronie 555, Route de Ganges F-34059 MontpellierCedex France