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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 119-122

Recovery of neurosensory deficit in zygomatic complex fracture: A prospective study


1 CMDC (EC), Kolkata, West Bengal, India
2 Department of Dental Surgery and OHS, AFMC, Pune, India
3 INDC Danteshwari, Mumbai, Maharashtra, India

Date of Submission04-Mar-2021
Date of Decision08-Dec-2021
Date of Acceptance14-Jul-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Serat Rahman
CMDC (EC), Alipore, Kolkata - 700 027, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_9_21

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  Abstract 


Aim: This study is aimed to prospectively evaluate neurological alteration subsequent to zygomatic complex fracture.
Objective: To evaluate recovery of neurosensory deficit in unilateral zygomatic complex fracture cases.
Materials and Methods: 30 Cases with unilateral zygomatic complex fracture having neurosensory deficit were divided into three Groups based on their Management. Gp-I Cases were managed with indirect reduction without fixation. Gp-II cases were managed with open reduction and internal fixation and no surgical intervention in Gp-III cases. Neurosensory function was assessed with light touch, two point discrimination, brush directional stroke and response to thermal stimuli in the infraorbital nerve region.
Results: Neurosensory changes were evaluated preoperatively, postmanagement after 1 week, 1 month, 3 months and 6 months. Recovery in Group II was better than in Group I, however, it was statistically insignificant. Recovery in Group I was better than in Group III, however, the comparative recovery was statistically insignificant. Recovery in Group II was statistically significant than in Group III.
Conclusion: It was observed that in most of the cases, neurosensory deficit recovered within 6 months. Recovery was better in the cases where patients were managed with open reduction and internal fixation. On the basis of the current study, it is recommended that in such cases where there is significant displacement or rotation of fractured fragments, direct reduction and internal fixation should be performed to achieve early return to normal form, function, and decompression of the nerve.

Keywords: Hypoesthesia, neurosensory deficit, recovery, paresthesia, zygomatic complex fracture


How to cite this article:
Rahman S, Roy ID, Kumari P. Recovery of neurosensory deficit in zygomatic complex fracture: A prospective study. J Dent Def Sect. 2022;16:119-22

How to cite this URL:
Rahman S, Roy ID, Kumari P. Recovery of neurosensory deficit in zygomatic complex fracture: A prospective study. J Dent Def Sect. [serial online] 2022 [cited 2023 Jan 31];16:119-22. Available from: http://www.journaldds.org/text.asp?2022/16/2/119/364527




  Introduction Top


Zygomatic bone contributes significantly to the strength and stability of the midface. It forms the cheek prominence, part of the lateral, inferior orbital rim, and the orbital floor. The zygomatic complex is important in the function of the globe and facial symmetry and gives passage to the infraorbital nerve that innervates the midfacial region.[1],[2] The architectural pattern of zygomatic bone allows it to withstand blows of great forces without fracturing. Due to its forward projection, the zygoma is frequently injured. In response to such heavy forces, zygomatic bone gets separated from the adjacent bone at or near suture lines.

Fractures of the zygomatic complex frequently result in sensory disturbances in the infraorbital nerve distribution. These symptoms include the altered sensation of the skin of the nose, cheek, lower eyelid, upper lip, gingiva, and teeth of the affected side. These arise because fractures generally occur in the vicinity of the infraorbital foramen and canal. This incidence can range from 50% to 94% with long-term dysfunction of 20%–50%, depending on the technique of sensory measurement.[3],[4] Several authors have noted significant improvement in sensory function after open reduction and internal fixation with plates versus a closed reduction technique.

Objectives of the study

  1. To focus on the neurological alteration subsequent to zygomatic complex fracture
  2. To define the incidence of neuropathy that results from this kind of fracture
  3. To assess the time of recovery of neurosensory function following management.



  Materials and Methods Top


Subject selection

  1. Cases with unilateral zygomatic complex fracture have a neurosensory deficit
  2. 30 patients were selected for the above study.


Inclusion criteria

  1. Age group 5 years and above
  2. Both sexes were included in the study
  3. Patients having unilateral Class III/IV/V/VI fractures of Knight and North (1961) system of classification.


Exclusion criteria

  1. Patients suffering from peripheral neuropathies tend to affect the outcome of the study
  2. Expression of nonconsent toward the requirement/protocol of the study.



  Methods Top


All the cases underwent a thorough clinical assessment including a detailed history and physical examination.

  1. Following clinical assessment, patients underwent radiographic evaluation. Routine radiographs included Waters' view and submentovertex view
  2. Neurosensory function was assessed with a light touch [Figure 1], two-point discrimination [Figure 2], brush directional stroke [Figure 3], and response to thermal stimuli [Figure 4] in the infraorbital nerve region
  3. All the tests were carried out by a single investigator only
  4. All data were recorded by the same investigator
  5. Patients managed by indirect reduction without fixation were placed in Group I
  6. Group II included patients managed by direct reduction with fixation
  7. Patients managed conservatively without any surgical intervention were placed in Group III
  8. Neurosensory changes were evaluated preoperatively, postmanagement after 1 week, 1 month, 3 months, and 6 months.
Figure 1: Light Touch Test

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Figure 2: Two Point Discrimination Test

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Figure 3: Brush Directional Stroke Test

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Figure 4: Thermal Stimuli Test

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  Results Top


Thirty-six out of 87 patients (41.37%) had an objective neurosensory deficit. The age distribution of the patients was between 14 and 76 years with the mean age being 34.63 years. Selected cases were predominantly male comprising 73.33% of the total of 30 cases. Recovery in Group II was better than in Group I, however, the comparative recovery was statistically insignificant between the two groups (P ≥ 0.05). Recovery in Group I was better than in Group III, however, the comparative recovery was statistically insignificant between the two groups (P ≥ 0.05). Recovery in Group II was better than in Group III. Comparative recovery in Group II was significantly better statistically than in Group III (P ≤ 0.05). At the time of the first presentation of injury, 66.6% of cases (n = 30) had hypesthesia compared to 23.3% of cases who had paresthesia. Anesthesia was present in 6.6% of cases while 3.3% of cases had dysesthesia. Significant improvement was noted starting at 3 months' time where recovery was 50%, 60%, and 20% in Group I, II, and III, respectively. However, the recovery was not significantly different among the groups. At 6 months, 60% of cases of Group I, 100% of cases of Group II, and 30% of cases of Group III recovered. Recovery of all the groups combined was statistically significant with a P = 0.038. However, in the comparative recovery, the difference was statistically significant between Group II and Group III (P = 0.009). At the time of presentation of injury and after 1 week postoperatively or after 1 week of presentation of injury all the cases had a neurosensory deficit. Recovery was noted starting at 1 month where 2 cases each (20%) of Group I and II while 1 case of Group I (10%) recovered from the neurisensory deficit (NSD). At 3 months, 6 cases each of Group I and II, while 4 cases of Group III recovered. At 6 months' period, 8 cases of Group I, all cases of Group II, and 4 cases of Group III recovered from NSD. There was a definite improvement in sensory function amongst all the groups at 3 months and 6 months' postinjury. However, the improvement was statistically significant between Group II and Group III at 6 months (P ≤ 0.05).


  Discussion Top


In our study, 56.32% (n = 87) of cases had subjective neurosensory deficit as compared to 41.37% who had objective neurosensory deficit which is less as compared to studies of Ahmed et al.[9] (91.73%, n = 122) and Westermark et al.[5] (80%). However, the finding showed a higher incidence as compared to studies of Zingg et al. (7.4%)[6] and Larsen and Thomsen (7%).[7]

It was observed that in most of the cases neurosensory deficit recovered within 6 months of management of injury which is in conjunction with previous studies of Kumar et al.,[12] Ahmed et al.[9] and Benoliel et al.[10]

There was a significant difference based on the modality of treatment adopted. All cases managed with direct reduction and internal fixation recovered within 6 months compared to 80% of cases in which only indirect reduction was employed. Recovery in cases where no surgical intervention was employed was the poorest at 40%. Statistically, there was a significant improvement in Group II compared with Group III at 6 months (P ≤ 0.05).

The correlation between open reduction and internal fixation and indirect reduction was comparable to previous studies of Vriens et al. (93% and 47%, respectively).[11] The recovery in our study group in cases where no surgical intervention was employed (40%) was significantly poor than most of the previous studies of Vriens et al. (90%),[11] Ahmed et al.,[9] and Kumar et al.[12] In most of these studies, the no treatment group consisted of cases with minimal or no displacement in which healing is excellent without any surgical intervention. However, in our study, the no surgical intervention group consisted of patients with significant displacement or rotation in which surgery was not carried out because of the patient's unwillingness.


  Conclusion Top


Within the limitations of this study, the following conclusions were drawn:

  1. The incidence of neurosensory deficit in cases of zygomatic complex fracture is common and a potential source of irritation to patients
  2. It was observed that in most of the cases, neurosensory deficit recovered within 6 months
  3. Recovery was better in the cases where patients were managed with open reduction and internal fixation
  4. Most of the subjective NSD response was hypoesthesia, however, during the recovery period paresthesia was the most common complaint
  5. Recovery was faster in younger age groups as compared to older age groups
  6. Due to the small sample size comparative evaluation of nerve healing between both the sexes could not be performed
  7. Most of the injuries to ION were probably neuropraxic in this study.


The occurrence of the high percentage of persistent neurological sequelae in zygomatic complex fractures can probably be demonstrated because of the lack of stability of the bony fragments around the infraorbital canal and foramen. As a result, impingement of the infraorbital nerve continues. On the basis of the current study, it is recommended that in such cases where there is significant displacement or rotation of fractured fragments, direct reduction, and internal fixation should be performed to achieve the early return to normal form, function, and decompression of the nerve.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lundin K, Ridell A, Sandberg N, Ohman A. One thousand maxillo-facial and related fractures at the ENT-clinic in Gothenburg. A two-year prospective study. Acta Otolaryngol 1973;75:359-61.  Back to cited text no. 1
    
2.
Ellis E 3rd, el-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 1985;43:417-28.  Back to cited text no. 2
    
3.
Lund K. Fractures of the zygoma: A follow-up study on 62 patients. J Oral Surg 1971;29:557-60.  Back to cited text no. 3
    
4.
Tajima S. Malar bone fractures: Experimental fractures on the dried skull and clinical sensory disturbances. J Maxillofac Surg 1977;5:150-6.  Back to cited text no. 4
    
5.
Westermark A, Jensen J, Sindet-Pedersen S. Zygomatic fractures and infraorbital nerve disturbances. Miniplate osteosynthesis vs. other treatment modalities. Oral Surg Oral Diagn 1992;3:27-30.  Back to cited text no. 5
    
6.
Zingg M, Chowdhury K, Lädrach K, Vuillemin T, Sutter F, Raveh J. Treatment of 813 zygoma-lateral orbital complex fractures. New aspects. Arch Otolaryngol Head Neck Surg 1991;117:611-20.  Back to cited text no. 6
    
7.
Larsen OD, Thomsen M. Zygomatic fracture. I. A simplified classification for practical use. Scand J Plast Reconstr Surg 1978;12:55-8.  Back to cited text no. 7
    
8.
Lothrop HA. Fractures of the superior maxillary bone caused by direct blows over the malar bone. Boston Med Surg 1906;154:8.  Back to cited text no. 8
    
9.
Ahmed SS, Afshan B, Hashmi GS, Hashmi SH. Neurosensory deficit in cases of zygomatic complex fractures. Curr Neurobiol 2010;1:01-6.  Back to cited text no. 9
    
10.
Benoliel R, Birenboim R, Regev E, Eliav E. Neurosensory changes in the infraorbital nerve following zygomatic fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:657-65.  Back to cited text no. 10
    
11.
Vriens JP, van der Glas HW, Moos KF, Koole R. Infraorbital nerve function following treatment of orbitozygomatic complex fractures. A multitest approach. Int J Oral Maxillofac Surg 1998;27:27-32.  Back to cited text no. 11
    
12.
Kumar P, Godhi S, Lall AB, Ram CS. Evaluation of neurosensory changes in the infraorbital nerve following zygomatic fractures. J Maxillofac Oral Surg 2012;11:394-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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