Journal Logo

Pediatric/Craniofacial: Original Articles

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations

Yesantharao, Pooja S. M.S.; Lopez, Joseph M.D., M.B.A.; Chang, Amy M.P.H.; Hicks, Jacqueline M.S., Ph.D.; Reategui, Maria L. B.A.; Thomas, Gianni B.A.; Manson, Paul N. M.D.; Dorafshar, Amir M.B.Ch.B.; Redett, Richard J. M.D.

Author Information
Plastic and Reconstructive Surgery: May 2021 - Volume 147 - Issue 5 - p 777e-786e
doi: 10.1097/PRS.0000000000007836

Abstract

Although midface fractures are more common in adults, the zygoma is still a relatively common site of injury in children given its position and prominence on the face.1 In fact, zygomaticomaxillary complex fractures constitute approximately 15 to 20 percent of all pediatric facial fractures.1–3 However, although there is extensive literature on zygomaticomaxillary complex and associated facial fractures in adults, there is a relative paucity of information on these fractures in pediatric patients, even though they can cause significant morbidity.4,5 Furthermore, there are many long-term implications of such fractures unique to children, such as their impact on immature dentition and on the growth of facial structures.6,7 Such injuries can have profound impact on structural and psychological development.8 Thus, it is critical to study zygomaticomaxillary complex and associated facial fractures in children.

In adults, zygomaticomaxillary complex fractures associated with ipsilateral naso-orbitoethmoid fractures result in significantly greater morbidity than zygomaticomaxillary complex fractures alone.9 The zygomatic bone constitutes the anterior and lateral facial projections, and the zygomaticomaxillary complex can typically handle a certain amount of traumatic force before fracturing.1 Fractures can occur at any of the five points of attachment of the zygomatic bone to the facial skeleton, including the frontozygomatic suture, infraorbital rim, zygomaticosphenoidal suture, zygomatic arch, and zygomaticomaxillary buttress.9,10 In children, zygomaticomaxillary complex fractures often present as dislocations and are caused in part by incomplete union at the frontozygomatic suture.11 With a great enough force, trauma is also seen in adjacent structures, causing an ipsilateral naso-orbitoethmoid fracture (Fig. 1).12 Hallmarks of zygomaticomaxillary complex fractures include malar flattening, bony stepoffs, lateral subconjunctival blood, numbness in the distribution of V2, and facial widening.13 Concomitant naso-orbitoethmoid fractures can present with shortened palpebral fissures, saddle nose deformity, airway obstruction, and telecanthus.9,14 Neglecting to appropriately treat a naso-orbitoethmoid fracture associated with a zygomaticomaxillary complex fracture can lead to substantial facial deformity and orbital complications that are difficult to secondarily correct.1,9 Even with adequate recognition and treatment of zygomaticomaxillary complex–associated naso-orbitoethmoid fractures, however, there is still a significantly greater incidence of complications and deformity compared to zygomaticomaxillary complex fractures alone.9

Fig. 1.
Fig. 1.:
Illustration of concomitant, ipsilateral zygomaticomaxillary complex fractures (red lines) and naso-orbitoethmoid fractures (black lines) in a pediatric patient.

No study to date has examined naso-orbitoethmoid fractures associated with zygomaticomaxillary complex fractures in pediatric patients. Because of differences in the craniofacial skeleton between children and adults, it is important to characterize these combined fractures in children specifically, especially given that this injury pattern in adults leads to poorer long-term outcomes.9,15 Adult studies of zygomaticomaxillary complex–naso-orbitoethmoid fractures cannot adequately shed light on the impact of this injury on skeletal and dental development, which is paramount to the appropriate treatment of these injuries in children.16,17 Thus, this study characterizes the incidence, treatment, and complications/outcomes of combined zygomaticomaxillary complex–naso-orbitoethmoid fractures in pediatric patients, in comparison to isolated zygomaticomaxillary complex fractures. In doing so, this study hopes to help optimize recognition and treatment of combined zygomaticomaxillary complex–naso-orbitoethmoid fractures in children.

PATIENTS AND METHODS

Study Design

This is a Johns Hopkins School of Medicine Institutional Review Board–approved retrospective cohort study of pediatric patients with zygomaticomaxillary complex fractures who presented to our institution’s pediatric emergency department from January of 1990 to January of 2015. Selection criteria included: (1) age 15 years (cutoff age for the pediatrics emergency department) or younger; (2) diagnosis of zygomaticomaxillary complex fracture confirmed by computed tomographic imaging/radiologic report; and (3) no previous history of facial trauma/congenital facial reconstruction. Patients with inadequate clinical documentation/follow-up were excluded. The study size consisted of all eligible patients identified during the study period.

Predictor/Outcome Variables

Computed tomographic imaging/radiology reports were used to compile fracture data by two independent reviewers (P.S.Y. and J.L.). Clinic and operative reports were reviewed for patients’ clinical and demographic data, and for fracture cause and treatment. For operatively managed patients, operative approach, fixation-site sequences, and hardware were also recorded. Patients were assigned to dentition groups by age: deciduous dentition if younger than 7 years; permanent dentition if older than 12 years; and mixed dentition for all others.18,19 A threshold age of 9 years (the age at which anterior dentition erupts) was also used to analyze the impact of age on outcome measures.

Primary outcome measures included the incidence of midface/orbital deformities and complications after the index fracture. All patients had preoperative ophthalmologic examinations to characterize postinjury complications. Complications were classified as major if they required operative repair and minor if they could be managed medically or with a bedside procedure. Postoperative complications were defined as issues related to the operation, including surgical technique and/or implant/device use. Postoperative complications/deformities and dental/endodontic outcomes were determined using clinic notes, computed tomographic imaging, and caregiver reports of care received outside of our institution. Length of follow-up was recorded for all patients.

Statistical Analysis

All statistical analyses were conducted on deidentified databases using SAS version 9.4 (SAS Institute, Inc., Cary, N.C.). Two investigations were conducted in each cohort (isolated zygomaticomaxillary complex fractures versus zygomaticomaxillary complex–naso-orbitoethmoid fractures): characterization analyses to study demographics/injury patterns, and outcomes analyses to study morbidity/complications. Two-tailed Mann-Whitney U and Fisher’s exact analyses were used to compare demographics and baseline patient injury data between various groups. Multiple regression was used to generate crude and adjusted odds ratios for outcomes data. The threshold for statistical significance was set at a value of p < 0.05. Patients with missing data or who were lost to follow-up were excluded.

RESULTS

Patient Characteristics

In the 25-year period reviewed, 49 patients met inclusion criteria. Three patients were excluded because of inadequate documentation/follow-up. Of the 46 remaining patients, 29 (63 percent) had isolated zygomaticomaxillary complex fractures, and 17 (37 percent) had zygomaticomaxillary complex fractures with associated ipsilateral naso-orbitoethmoid fractures (Table 1). In zygomaticomaxillary complex fracture patients, 24.1 percent of fractures were bilateral, whereas 47.1 percent of fractures were bilateral in the combined zygomaticomaxillary complex–naso-orbitoethmoid fracture cohort (p < 0.01).

Table 1. - Baseline Characteristics of Patients Younger Than 15 Years Admitted to Johns Hopkins Hospital for Zygomaticomaxillary Complex or Zygomaticomaxillary Complex–Naso-Orbitoethmoid Fractures from 1990 to 2015, by Diagnostic Status
Characteristic ZMC (%) ZMC-NOE (%)
No. of patients 29 17
Mean age ± SD, yr 8.23 ± 4.12 7.57 ± 4.26
Dentition group
 Deciduous 14 (48.3) 9 (52.9)
 Mixed 7 (24.1) 5 (29.4)
 Permanent 8 (27.6) 3 (17.6)
No. of girls 13 (44.8) 4 (23.5)
Race
 White 16 (55.2) 13 (76.5)
 Nonwhite 13 (44.8) 4 (23.5)
Has comorbidities 5 (17.2) 0 (0.0)
Mechanism of injury*
 Pedestrian 10 (34.5) 4 (23.5)
 Fall 2 (6.9) 0 (0.0)
 MVC 13 (44.8) 12 (70.6)
 Assault 1 (3.4) 0 (0.0)
 Sport 1 (3.4) 0 (0.0)
 Other 2 (6.9) 1 (5.9)
Laterality of fracture
 Unilateral 22 (75.9) 9 (52.9)
 Bilateral 7 (24.1) 8 (47.1)
Concomitant fractures
 Orbital floor 22 (75.9) 14 (82.4)
 Medial orbital wall 3 (10.3) 3 (17.6)
 Panfacial 0 (0.0) 6 (35.3)
Concomitant neurologic injury
 Cervical spine 0 (0.0) 2 (11.8)
 Skull 13 (44.8) 12 (70.6)
Surgical intervention 17 (58.6) 14 (82.4)
Follow-up, days
 Median 245 347
 IQR 41–623 118–2224
Hospital stay, days
 Median 5.5 9
 IQR 3.2–9.75 8–10
ZMC, zygomaticomaxillary complex; NOE, naso-orbitoethmoid; MVC, motor vehicle collision; IQR, interquartile range.
*Patients had only one mechanism of injury.

Both patient cohorts were predominantly male (55.2 percent and 76.5 percent, respectively). The most common mechanisms of injury in both cohorts were motor vehicle collisions (44.8 percent and 70.6 percent, respectively), followed by pedestrian accidents (pedestrian versus motor vehicle/bicycle; 34.5 percent and 23.5 percent, respectively). The median hospital length of stay for patients with isolated zygomaticomaxillary complex fractures was 5.5 days (interquartile range, 3.2 to 9.75 days), versus 9 days (interquartile range, 8 to 10 days) for patients with combined fractures. Median length of follow-up for patients with combined fractures was 347 days (interquartile range, 118 to 2224 days) versus 245 days (interquartile range, 41 to 623 days) for patients with isolated zygomaticomaxillary complex fractures.

Management Characteristics

Seventeen of the 29 patients with isolated zygomaticomaxillary complex fractures (58.6 percent) were managed surgically, compared to 14 of the 17 patients with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures (82.4 percent) (Fig. 2). Of the patients with isolated zygomaticomaxillary complex fractures who underwent surgery, 15 (88.2 percent) underwent a limited surgical approach, with largely gingivobuccal (58.8 percent), subciliary (41.2 percent), transconjunctival (35.3 percent), or laceration incisions (35.3 percent) (Table 2). In comparison, 42.9 percent of surgically treated patients in the combined fracture cohort underwent limited surgical approaches, whereas the remaining 57.1 percent required coronal incisions—a significantly greater proportion than those with isolated zygomaticomaxillary complex fractures (p = 0.007). In both cohorts, most surgically managed fractures were repaired with titanium miniplates (94.1 percent and 78.6 percent, respectively).

Table 2. - Surgical Characteristics for Patients by Zygomaticomaxillary Complex or Zygomaticomaxillary Complex–Naso-Orbitoethmoid Fracture Status
Characteristic ZMC (%) ZMC-NOE (%)
No. of patients 17 14
Operative approach
 Gingivobuccal 10 (58.8) 8 (57.1)
 Upper blepharoplasty 2 (11.8) 2 (14.2)
 Lateral brow 1 (5.9) 1 (7.1)
 Subciliary 7 (41.2) 2 (14.3)
 Transconjunctival 6 (35.3) 4 (23.5)
 Coronal 2 (11.8) 8 (57.1)
 Laceration 6 (35.3) 3 (21.4)
 Temporal 1 (5.9) 2 (14.3)
Hardware
 Metal plate 16 (94.1) 11 (78.6)
 Resorbable plate 1 (5.9) 3 (21.4)
 Implant 4 (23.5) 4 (28.6)
 Bone graft 0 (0.0) 4 (28.6)
ZMC fixation
 Zygomaticofrontal suture 10 (58.8) 9 (64.3)
 Zygomaticomaxillary buttress 13 (76.5) 11 (78.6)
 Infraorbital rim 8 (47.1) 7 (50.0)
 Zygomatic arch 3 (17.6) 3 (21.4)
NOE fixation
 Piriform aperture n/a 11 (78.6)
 Nasofrontal junction n/a 9 (64.3)
 Orbital rim n/a 13 (92.9)
 Transnasal wire n/a 3 (21.4)
Total no. of fixation points ± SD 1.94 ± 0.80 4.51 ± 1.03
ZMC, zygomaticomaxillary complex; NOE, naso-orbitoethmoid; n/a, not applicable.

Fig. 2.
Fig. 2.:
(Above) Preoperative and (below) postoperative computed tomographic images of a 10-year-old patient who presented with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures.

In isolated zygomaticomaxillary complex fracture patients, the average number of fixation points during surgical repair was 1.94 ± 0.80 versus 4.51 ± 1.03 in combined zygomaticomaxillary complex–naso-orbitoethmoid fracture patients. In both cohorts, the most common zygomaticomaxillary complex fixation sites were the zygomaticomaxillary buttress (n = 13 and n = 11, respectively), zygomaticofrontal suture (n = 10 and n = 9, respectively), and infraorbital rim (n = 8 and n = 7, respectively). The most common naso-orbitoethmoid fixation sites in the combined fracture cohort included the orbital rim (n = 13), nasomaxillary buttress (n = 11), and nasofrontal junction (n = 9). Coronal (55.6 percent), vertical midline (33.3 percent), and/or laceration approaches (22.2 percent) were used to fixate the nasofrontal junction.

Overall, most patients had orbital floor fractures (75.9 percent in the isolated zygomaticomaxillary complex fracture cohort and 82.4 percent in the combined fracture cohort). Orbital floor fractures were surgically corrected in 50 percent of patients with isolated zygomaticomaxillary complex fractures and 71.4 percent of patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures. The majority (66.7 percent) of surgically managed orbital floor fractures in both cohorts were corrected using porous 0.85-mm polyethylene implants (Medpor; Porex, Inc., Stryker CMF, Newnan, Ga.), whereas the remaining patients’ orbital floor fractures were repaired with resorbable plates (DePuy Synthes, Johnson & Johnson, Raynham, Mass.). No isolated zygomaticomaxillary complex fracture patients had panfacial fractures (i.e., concomitant frontal, midface, and mandible fractures), whereas 35.3 percent of patients with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures had panfacial fractures (p < 0.001). Among those with panfacial fractures, 100 percent had concomitant Le Fort and mandible fractures, and 33.3 percent had a concomitant frontal sinus fracture.

Outcomes

All reported odds ratios were adjusted for age and sex. Patients with isolated zygomaticomaxillary complex fractures had an overall midface/orbital postoperative complication rate of 35.3 percent versus 87.5 percent in zygomaticomaxillary complex–naso-orbitoethmoid fracture patients (OR, 42.5 compared to isolated zygomaticomaxillary complex fracture patients; p < 0.01) (Table 3) and 100 percent in panfacial fracture patients (OR, 55.1 compared to isolated zygomaticomaxillary complex fracture patients; p < 0.01). Complications were reported anywhere from the immediate postoperative period to over a decade after surgery. Approximately 17.2 percent of patients with isolated zygomaticomaxillary complex fractures had major complications versus 75.0 percent of patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures (OR, 65.4 compared to isolated zygomaticomaxillary complex fracture patients; p = 0.001) and 100 percent of patients with panfacial fractures (OR, 72.4 compared to isolated zygomaticomaxillary complex fracture patients; p < 0.001). Similarly, 20.7 percent of patients with isolated zygomaticomaxillary complex fractures had minor complications versus 62.5 percent of patients with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures (OR, 43.4 compared to isolated zygomaticomaxillary complex fracture patients; p < 0.001) and 100 percent of patients with panfacial fractures (OR, 59.9 compared to isolated zygomaticomaxillary complex fracture patients; p < 0.001). Midface complication rates did not differ significantly between patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures only versus those with zygomaticomaxillary complex–naso-orbitoethmoid fractures and panfacial fractures.

Table 3. - Postoperative Complications and Deformities by Fracture Type
Characteristic ZMC (%) ZMC-NOE (%) ZMC-NOE, with Panfacial (%)
No. of patients 17 8 6
Complications
 Major 6 (35.3) 7 (87.5) 6 (100.0)
 Strabismus/diplopia 3 (10.3) 3 (37.5) 3 (50.0)
 Cellulitis 1 (3.4) 2 (25.0) 2 (33.3)
 Osteomyelitis 0 (0.0) 0 (0.0) 1 (16.7)
 Hardware infection 1 (5.9) 0 (0.0) 1 (16.7)
 Hardware extrusion 1 (5.9) 1 (12.5) 3 (50.0)
Minor
 Nasolacrimal duct obstruction 2 (6.9) 1 (12.5) 4 (66.7)
 Sinusitis 1 (3.4) 2 (25.0) 2 (33.3)
 CSF rhinorrhea 0 (0.0) 0 (0.0) 2 (33.3)
 Dacryocystitis 0 (0.0) 0 (0.0) 2 (33.3)
 Keloid formation 0 (0.0) 0 (0.0) 1 (16.7)
 Hypertrophic scar formation 3 (10.3) 5 (62.5) 3 (50.0)
 Scar contracture 2 (6.9) 6 (75.0) 5 (83.3)
 Hematoma 3 (10.3) 0 (0.0) 1 (16.7)
 Anosmia 0 (0.0) 0 (0.0) 1 (16.7)
 Septal deviation 0 (0.0) 1 (12.5) 5 (83.3)
 Ectropion 3 (10.3) 3 (37.5) 2 (33.3)
Deformity
 Enophthalmos 3 (10.3) 3 (37.5) 4 (66.7)
 Orbital dystopia 2 (6.9) 2 (25.0) 3 (50.0)
 Midface retrusion 0 (0.0) 2 (25.0) 4 (66.7)
 Midface asymmetry 3 (10.3) 1 (12.5) 1 (16.7)
 Telecanthus 2 (6.9) 2 (25.0) 1 (16.7)
 Fracture nonunion 0 (0.0) 0 (0.0) 1 (16.7)
 Dental malocclusion 1 (3.4) 2 (25.0) 2 (33.3)
ZMC, zygomaticomaxillary complex; NOE, naso-orbitoethmoid; CSF, cerebrospinal fluid.

Among zygomaticomaxillary complex–naso-orbitoethmoid and panfacial fracture patients, those treated with a limited surgical approach had a lower overall midface/orbital postoperative complication rate compared to those treated with coronal incisions (83.3 percent versus 100 percent, respectively), and slightly lower rates of major (83.3 percent versus 87.5 percent, respectively) and minor (66.7 percent versus 87.5 percent, respectively) postoperative complications and postoperative deformity (83.3 percent versus 87.5 percent, respectively) (Table 4). These differences did not reach statistical significance. The most common ophthalmologic complications in all patients were postoperative strabismus and diplopia (10.3 percent in patients with zygomaticomaxillary complex fractures alone and 35.3 percent in patients with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures). All patients who developed strabismus and/or diplopia had concomitant orbital floor fractures. None of the patients who were managed operatively had strabismus or diplopia reported on preoperative ophthalmologic examination.

Table 4. - Complications and Deformities for Operatively Managed Zygomaticomaxillary Complex–Naso-Orbitoethmoid Patients by Incision Type
Characteristic Coronal (%) Noncoronal (%)
No. of patients 8 6
Complications
 Major 8 (100.0) 5 (83.3)
 Strabismus/diplopia 4 (50.0) 2 (33.3)
 Cellulitis 2 (25.0) 2 (33.3)
 Osteomyelitis 1 (12.5) 0 (0.0)
 Hardware infection 1 (12.5) 0 (0.0)
 Hardware extrusion 3 (37.5) 1 (16.7)
Minor
 Nasolacrimal duct obstruction 3 (37.5) 2 (33.3)
 Sinusitis 3 (37.5) 1 (16.7)
 CSF rhinorrhea 2 (25.0) 0 (0.0)
 Dacryocystitis 1 (12.5) 1 (16.7)
 Keloid formation 1 (12.5) 0 (0.0)
 Hypertrophic scar formation 4 (50.0) 4 (66.7)
 Scar contracture 6 (75.0) 5 (83.3)
 Hematoma 1 (12.5) 0 (0.0)
 Anosmia 1 (12.5) 0 (0.0)
 Septal deviation 4 (50.0) 2 (33.3)
 Ectropion 2 (25.0) 3 (50.0)
 Deformity
 Enophthalmos 5 (62.5) 2 (33.3)
 Orbital dystopia 4 (50.0) 1 (16.7)
 Midface retrusion 3 (37.5) 3 (50.0)
 Midface asymmetry 2 (25.0) 0 (0.0)
 Telecanthus 2 (25.0) 1 (16.7)
 Fracture nonunion 1 (12.5) 0 (0.0)
 Dental malocclusion 2 (25.0) 2 (33.3)
CSF, cerebrospinal fluid.

The incidence of postoperative midface/orbital deformities in patients with isolated zygomaticomaxillary complex fractures was 13.7 percent, versus 87.5 percent in patients with combined zygomaticomaxillary complex–naso-orbitoethmoid fractures (OR, 44.7; p < 0.001) and 83.3 percent in panfacial fracture patients (OR, 38.3; p < 0.001) (Table 3). The most common postoperative deformity in all patients was enophthalmos (10.3 percent in zygomaticomaxillary complex fracture patients, 37.5 percent in combined fracture patients, and 66.7 percent in panfacial injury patients). All zygomaticomaxillary complex fracture patients who developed enophthalmos had concomitant orbital floor fractures. Notably, postoperative midface retrusion was seen exclusively in patients with deciduous dentition who had zygomaticomaxillary complex–naso-orbitoethmoid fractures or zygomaticomaxillary complex–naso-orbitoethmoid fractures as part of their panfacial injuries (n = 6) (Fig. 3). (See Figure, Supplemental Digital Content 1, which shows short-term clinical follow-up images of a patient who presented with a zygomaticomaxillary complex–naso-orbitoethmoid fracture and panfacial injury at age 2.8 years, who later developed midface retrusion, http://links.lww.com/PRS/E426.) On long-term follow-up, no patient with deciduous or mixed dentition experienced issues with noneruption/delayed eruption of teeth as a result of rigid fixation.

Fig. 3.
Fig. 3.:
Clinical images of a patient who presented with a zygomaticomaxillary complex–naso-orbitoethmoid fracture and panfacial injury at age 2.8 years, who later developed midface retrusion as depicted here on long-term follow-up. This patient was treated with titanium plates (see Figure, Supplemental Digital Content 1, http://links.lww.com/PRS/E426).

Patients with isolated zygomaticomaxillary complex fractures who were younger than 9 years did not differ significantly in terms of postoperative complications or deformities when compared to patients aged 9 years or older. However, although postoperative complications did not vary by age in combined zygomaticomaxillary complex–naso-orbitoethmoid fracture patients (when excluding those with panfacial fractures), patients younger than 9 years with combined fractures had a significantly greater rate of postoperative deformity than patients aged 9 years or older (100 percent versus 50 percent, respectively; p = 0.01). In addition, after adjusting for fracture type among surgically treated patients, older age conferred significantly greater odds of infection (OR, 1.44; p = 0.013).

Among patients with concomitant zygomaticomaxillary complex–naso-orbitoethmoid fractures, fixation of the zygomaticomaxillary buttress was associated with a lower incidence of overall postoperative complications than other zygomaticomaxillary complex fixation sites, as was rigid fixation of the naso-orbitoethmoid fracture at the nasomaxillary buttress. Of the zygomaticomaxillary complex–naso-orbitoethmoid fracture patients who underwent surgery, one patient required hardware removal because of infection.

DISCUSSION

Zygomaticomaxillary complex fractures constitute up to one-fifth of all pediatric facial fractures and can cause significant morbidity, especially in conjunction with other facial fractures.2,20 In particular, it has been documented in adults that ipsilateral naso-orbitoethmoid fractures occurring in association with zygomaticomaxillary complex fractures can significantly increase complication rates and cause long-lasting morbidity when compared to isolated zygomaticomaxillary complex fractures.9 Combined zygomaticomaxillary complex–naso-orbitoethmoid fractures have not yet been investigated in pediatric patients—a critical topic of study, given that developing skeletal structures and dentition in these patients puts them at greater risk for substantial morbidity.21

This is a 25-year retrospective investigation of cozygomaticomaxillary complex–naso-orbitoethmoid fractures in pediatric patients. Ipsilateral naso-orbitoethmoid fractures occurred in 38 percent of all pediatric patients found to have zygomaticomaxillary complex fractures, demonstrating that this is a relatively common co-occurring injury. Those with isolated zygomaticomaxillary complex fractures had a wider distribution of injury types (e.g., assault, sports injuries, falls), whereas those with zygomaticomaxillary complex–naso-orbitoethmoid fractures predominantly suffered higher impact injuries (e.g., vehicular collisions). The greater forces from such injuries were likely required to extend a zygomaticomaxillary complex fracture into the naso-orbitoethmoid space.9,22 Given that zygomaticomaxillary complex–naso-orbitoethmoid fracture patients sustained higher energy injuries, it follows that a greater proportion of these patients had panfacial fractures and required surgery.

Patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures had significantly greater incidences of postoperative complications and deformities than patients with zygomaticomaxillary complex fractures alone, even after excluding patients with panfacial injuries. Strabismus, diplopia, orbital dystopia, and enophthalmos were common postoperative complications/deformities reported in zygomaticomaxillary complex–naso-orbitoethmoid fracture patients, especially those who had concomitant orbital fractures, with some patients requiring secondary surgical correction for enophthalmos and orbital dystopia. Only one patient in the combined zygomaticomaxillary complex–naso-orbitoethmoid fracture group who was nonoperatively managed developed diplopia on follow-up, and none of the nonsurgical patients in this cohort developed enophthalmos or orbital dystopia. Thus, although reduction of zygomaticomaxillary complex–naso-orbitoethmoid fracture was deemed adequate at the time of surgery for patients managed operatively, we cannot rule out inadequate bony reduction as a potential cause of these complications. Because patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures typically have malpositioning of the inferomedial orbital rim (which is often used as a landmark for alignment) as a consequence of the concomitant naso-orbitoethmoid fracture, reduction can be quite difficult.23,24 It should also be noted that most zygomaticomaxillary complex–naso-orbitoethmoid fracture patients who were managed nonoperatively had nondisplaced fractures. Therefore, the presence of more complex fractures in operatively managed zygomaticomaxillary complex–naso-orbitoethmoid fracture patients may also have caused in part the increased complication rate in this cohort. Lastly, orbital growth deviations, orbital tissue atrophy, and/or complex soft-tissue injuries could also have contributed to the high rate of adverse events in this patient cohort. Thus, further work is needed to optimize the management of pediatric patients presenting with this complex combination fracture pattern.25–28

Midface retrusion was exclusively seen in patients with deciduous dentition who had zygomaticomaxillary complex–naso-orbitoethmoid fractures or zygomaticomaxillary complex–naso-orbitoethmoid fractures as part of their panfacial injuries. In our study, all patients who developed midface retrusion (n = 6) were managed operatively. Thus, it is possible that rigid fixation may have contributed in part to midface growth restriction in these patients.29,30 It should be noted that resorbable fixation was more frequently used in the zygomaticomaxillary complex–naso-orbitoethmoid fracture cohort, the implications of which require further study. Furthermore, as discussed previously, malreduction could also have contributed to this deformity, especially given the complexity of zygomaticomaxillary complex–naso-orbitoethmoid fractures, even though adequate reduction was demonstrated in patients (n = 2) who had accessible postoperative computed tomographic scans. Midface retrusion may also have been caused by the underlying trauma/fracture: disruption of midface support structures in children, such as the nasomaxillary buttress, may lead to posttraumatic maxillary hypoplasia.2 This is especially the case in children with deciduous dentition, given that one of the most rapid periods of facial growth and development occurs from the neonatal period to age 5.11 In fact, a case of midface retrusion after zygomaticomaxillary complex–naso-orbitoethmoid fracture in a 5-year-old boy has been previously reported in the literature, as have other cases of facial hypoplasia in children who experienced trauma before age 5.8 This was further supported in our data by the fact that younger children with zygomaticomaxillary complex–naso-orbitoethmoid fractures had significantly greater odds of postoperative deformity. Other potential factors contributing to this deformity include the wider area of soft-tissue and periosteal dissection required to correct more extensive zygomaticomaxillary complex–naso-orbitoethmoid fractures.31,32 Three patients with midface retrusion required orthognathic surgery later in life.

This study has several limitations. The sample size was limited by the relatively low incidence of pediatric facial fractures, even over a 25-year study period, and thus this study was not adequately powered to detect statistical significance for many subgroup analyses. However, to our knowledge, this is the largest study investigating pediatric zygomaticomaxillary complex–naso-orbitoethmoid fractures. In addition, follow-up was not uniform in both cohorts; longer follow-up in patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures could have contributed to the higher rate of complications recorded in this group. Also, reported outcomes and complication rates are in part dependent on variable practices of surgeons. However, the majority of the surgeons in this study (n = 9) trained under the mentorship of the seniormost author (P.N.M.), reducing surgical variability at our institution. Lastly, this is a single-institution, retrospective study, limiting external validity. Prospective, multicenter studies of pediatric patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures could help to more comprehensively study this complex facial fracture pattern.

Our findings hold several implications for the management of zygomaticomaxillary complex–naso-orbitoethmoid fractures in children. At the time of operative repair, achieving adequate bony reduction is critical, given that abnormal orbital volume or imprecise skeletal fixation places pediatric patients at high risk for orbital complications.26 Therefore, use of low-dose intraoperative computed tomographic imaging, three-dimensionally–printed splints, or custom plates may be helpful to the novice or experienced surgeon to confirm adequate reduction.33,34 Also, pediatric patients with zygomaticomaxillary complex–naso-orbitoethmoid fractures should be monitored closely to evaluate for postoperative deformities and complications. These deformities may develop anywhere from a few weeks after surgery to a decade later and may confer substantial physical/psychological morbidity. Regular clinical follow-up is necessary as these patients reach skeletal maturity, because approximately one-third may develop midface retrusion and class III malocclusion, subsequently requiring distraction osteogenesis or orthognathic surgery as adults to correct facial disharmony.

CONCLUSIONS

Our results demonstrated that naso-orbitoethmoid fractures occur relatively commonly in association with zygomaticomaxillary complex fractures in pediatric patients. Compared to isolated zygomaticomaxillary complex fractures, zygomaticomaxillary complex–naso-orbitoethmoid fractures in children resulted in significantly greater postoperative complications and deformity, such as midface retrusion. Furthermore, orbital complications such as enophthalmos and dystopia were disproportionally seen during postoperative follow-up of combined zygomaticomaxillary complex–naso-orbitoethmoid fracture patients compared to patients with zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern may require extra care to achieve adequate fixation and should be more closely followed given a greater risk for long-term morbidity.

REFERENCES

1. Lee EI, Mohan K, Koshy JC, Hollier LH Jr. Optimizing the surgical management of zygomaticomaxillary complex fractures. Semin Plast Surg. 2010;24:389–397.
2. Luck JD, Lopez J, Faateh M, et al. Pediatric zygomaticomaxillary complex fracture repair: Location and number of fixation sites in growing children. Plast Reconstr Surg. 2018;142:51e–60e.
3. Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: A survey of the National Trauma Data Bank. J Am Coll Surg. 2008;207:710–716.
4. Alcalá-Galiano A, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric facial fractures: Children are not just small adults. Radiographics 2008;28:441–461; quiz 618.
5. Moffitt JK, Wainwright DJ, Bartz-Kurycki M, et al. Factors associated with surgical management for pediatric facial fractures at a level one trauma center. J Craniofac Surg. 2019;30:854–859.
6. Cole P, Kaufman Y, Hollier LH Jr. Managing the pediatric facial fracture. Craniomaxillofac Trauma Reconstr. 2009;2:77–83.
7. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: Recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg. 2006;35:2–13.
8. Converse JM, McCarthy JG, Littler JW, eds. Reconstructive Plastic Surgery. 1977.2nd ed. Philadelphia: Saunders;
9. Buchanan EP, Hopper RA, Suver DW, Hayes AG, Gruss JS, Birgfeld CB. Zygomaticomaxillary complex fractures and their association with naso-orbito-ethmoid fractures: A 5-year review. Plast Reconstr Surg. 2012;130:1296–1304.
10. Jazayeri HE, Khavanin N, Yu JW, et al. Fixation points in the treatment of traumatic zygomaticomaxillary complex fractures: A systematic review and meta-analysis. J Oral Maxillofac Surg. 2019;77:2064–2073.
11. McCarthy JG, May JW Jr, Littler JW, eds. Plastic Surgery: Volume 2, The Face. 1990.Philadelphia: Saunders;
12. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: What the surgeon needs to know. Radiographics 2006;26:783–793.
13. Peretti N, MacLeod S. Zygomaticomaxillary complex fractures: Diagnosis and treatment. Curr Opin Otolaryngol Head Neck Surg. 2017;25:314–319.
14. Rodriguez-Feliz J, Mehta K, Patel A. The management of pediatric type 1 nasoorbitoethmoidal fractures with resorbable fixation. J Craniofac Surg. 2014;25:e495–e501.
15. Andrew TW, Morbia R, Lorenz HP. Pediatric facial trauma. Clin Plast Surg. 2019;46:239–247.
16. Boyette JR. Facial fractures in children. Otolaryngol Clin North Am. 2014;47:747–761.
17. Braun TL, Xue AS, Maricevich RS. Differences in the management of pediatric facial trauma. Semin Plast Surg. 2017;31:118–122.
18. AlQahtani SJ, Hector MP, Liversidge HM. Brief communication: Atlas of human tooth development and eruption. Am J Phys Anthropol. 2010;143:481–490.
19. Nelson SJ. Wheeler’s Dental Anatomy, Physiology and Occlusion-E-Book. 2014.Amsterdam: Elsevier Health Sciences;
20. DeFazio MV, Fan KL, Avashia YJ, Danton GH, Thaller SR. Fractures of the pediatric zygoma: A review of the clinical trends, management strategies, and outcomes associated with zygomatic fractures in children. J Craniofac Surg. 2013;24:1891–1897.
21. Maqusi S, Morris DE, Patel PK, Dolezal RF, Cohen MN. Complications of pediatric facial fractures. J Craniofac Surg. 2012;23:1023–1027.
22. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg. 2005;115:1500–1508.
23. Hammer B, Prein J. Correction of post-traumatic orbital deformities: Operative techniques and review of 26 patients. J Craniomaxillofac Surg. 1995;23:81–90.
24. Parashar A, Sharma RK. Unfavourable outcomes in maxillofacial injuries: How to avoid and manage. Indian J Plast Surg. 2013;46:221–234.
25. Iliff NT. The ophthalmic implications of the correction of late enophthalmos following severe midfacial trauma. Trans Am Ophthalmol Soc. 1991;89:477–548.
26. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg. 2012;39:11–17.
27. Athanasiov PA, Prabhakaran VC, Selva D. Non-traumatic enophthalmos: A review. Acta Ophthalmol. 2008;86:356–364.
28. Broyles JM, Jones D, Bellamy J, et al. Pediatric orbital floor fractures: Outcome analysis of 72 children with orbital floor fractures. Plast Reconstr Surg. 2015;136:822–828.
29. Lin KY, Bartlett SP, Yaremchuk MJ, Grossman RF, Udupa JK, Whitaker LA. An experimental study on the effect of rigid fixation on the developing craniofacial skeleton. Plast Reconstr Surg. 1991;87:229–235.
30. Imola MJ, Hamlar DD, Shao W, Chowdhury K, Tatum S. Resorbable plate fixation in pediatric craniofacial surgery: Long-term outcome. Arch Facial Plast Surg. 2001;3:79–90.
31. Lopez J, Luck JD, Faateh M, et al. Pediatric nasoorbitoethmoid fractures: Cause, classification, and management. Plast Reconstr Surg. 2019;143:211–222.
32. Leipziger LS, Schnapp DS, Haworth RD, Hoffman LA, La Trenta GS. Facial skeletal growth after timed soft-tissue undermining. Plast Reconstr Surg. 1992;89:809–814.
33. Rabie A, Ibrahim AM, Lee BT, Lin SJ. Use of intraoperative computed tomography in complex facial fracture reduction and fixation. J Craniofac Surg. 2011;22:1466–1467.
34. Shaheen E, Sun Y, Jacobs R, Politis C. Three-dimensional printed final occlusal splint for orthognathic surgery: Design and validation. Int J Oral Maxillofac Surg. 2017;46:67–71.

Supplemental Digital Content

Copyright © 2021 by the American Society of Plastic Surgeons