List of Abbreviations
BP – blood pressure
TMJ – Temporomandibular joint
MFR – maxillofacial region
TBI – traumatic brain injury
RTA – road traffic accident
ZB – zygomatic bone
MSCT – multislice computed tomography
CBCT – cone-beam computed tomography
PAP – perioperative antibiotic prophylaxis
SSI – surgical site infection
Terms and Definitions
Subcutaneous emphysema – accumulation of air or gas bubbles in the subcutaneous adipose tissue.
Bone crepitus – a crunching sensation upon palpation during movements at the fracture site.
Subcutaneous crepitus – a characteristic crunching sound caused by the movement of gas bubbles in the tissues.
«Step-off» sign – palpation finding of a displaced bone fragment edge.
Indirect load sign – sharp pain at the fracture site due to the displacement of fragments and irritation of the damaged periosteum when pressure is applied to a clearly intact area of the jaw.
Hypoesthesia — decreased sensitivity.
Malevich's sign ("Cracked pot" sign) — a sign of a fracture of the zygomatic bone or maxilla; percussion of the teeth produces a dull, rattling sound resembling that of a cracked clay pot when lightly struck.
Diplopia — seeing double of a single object.
Open fracture of the zygomatic bone is a type of fracture in which the fracture gap communicates with the external environment through a skin wound, a wound (tear) of the oral mucosa, or a wound of the maxillary sinus mucosa with the development of hemosinus.
Fragment reduction – a procedure aimed at repositioning and aligning bone fragments.
Osteosynthesis – surgical fixation of bone fragments.
Anisocoria – a condition characterized by unequal pupil sizes, and possible slight pupillary deformity.
Closed fracture of the zygomatic bone — a type of fracture in which the fracture gap does not communicate with the external environment through a skin wound, a wound (tear) of the oral mucosa, or the mucosa of the maxillary sinus with the development of hemosinus. This type of fracture most commonly occurs in isolated fractures of the zygomatic arch.
External approach — a type of surgical approach performed by sequential dissection of the skin/conjunctival mucosa and deeper layers of soft tissue to visualize the fragments of the zygomatic bone.
Intraoral approach — a type of surgical approach performed in the oral cavity by sequential dissection of the oral mucosa, periosteum, and sometimes deeper soft tissue layers to visualize the zygomatic bone fragments.
Isolated maxillofacial trauma — trauma involving a single injury within the maxillofacial region.
Multiple maxillofacial trauma — trauma characterized by multiple injuries within the maxillofacial region.
Multiple head trauma — injury to multiple parts of the head (maxillofacial region, ENT organs, visual system, or brain) resulting from one or more wounding projectiles.
Polytrauma of the maxillofacial region — simultaneous injury to the maxillofacial region and other anatomical regions of the body (head, neck, abdomen, pelvis, spine, extremities).
1. Brief information on the disease or condition
The zygomatic bone is the strongest of the facial bones. The zygomatic bone (Latin: *os zygomaticum*) is a paired bone of the facial skeleton. It articulates with the frontal and temporal bones (via the frontal and temporal processes), the greater wing of the sphenoid bone, and the maxilla. It participates in the formation of the lateral and inferior walls of the orbit and the infratemporal fossa. Together with the zygomatic process of the temporal bone, it forms the zygomatic arch, which serves as the lateral boundary of the temporal fossa. In addition to its processes, the zygomatic bone has lateral, temporal, and orbital surfaces. The orbital surface features the zygomaticoorbital foramen, which leads to a canal opening into the zygomaticofacial foramen (on the lateral surface of the bone) and the zygomaticotemporal foramen (on the temporal surface).
Typical sites for a zygomatic bone fracture: from the infraorbital suture to the zygomaticoalveolar crest, in the region of the frontozygomatic, frontomaxillary, and temporozygomatic sutures. When injured, the body of the zygomatic bone typically displaces inferiorly and medially, which leads to disruption of the integrity of the lateral orbital wall, rupture of the maxillary sinus mucosa resulting in epistaxis, and compression of the infraorbital nerve.
1.1 Definition of the disease or condition
Zygomatic bone fracture — injury to the zygomatic bone with disruption of its integrity or the synostoses between the zygomatic bone and surrounding bones.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Mechanical (traumatic) fracture of the zygomatic bone — injury to the zygomatic bone resulting in loss of its integrity when subjected to a load exceeding the strength of the injured bone area [1].
Fractures of the zygomatic bone and arch can occur either as a result of a direct blow or due to compression of the facial skeleton.
Displacement of fragments depends on the direction of the traumatic force. Usually, the fragment is displaced medially and inferiorly.
Pathological fracture of the zygomatic bone — complete or partial disruption of bone integrity in an area of pathological remodeling (affected by a disease such as osteoporosis, tumor, osteomyelitis, etc.) [2,29].
1.3 Epidemiology of the Disease or Condition
Zygomatic bone fractures account for 16% to 25% of all facial skeleton fractures [1,3,35].
Non-occupational trauma holds the leading place among midface bone fractures, averaging 95%. Domestic injuries account for 75–80%. Traffic accidents account for approximately 11%.
Sports injuries occupy an intermediate position among all types of trauma in quantitative terms: 5–6%.
Occupational injuries rank near the bottom of the causes of traumatology at 2–3%. Agricultural injuries occur casuistically and sporadically [1,3,35].
Regarding gender differences, the ratio of zygomatic bone fractures in males and females is characterized by a significant male predominance, with reported ratios of 8:1 and 9:1.
According to most authors, the highest number of zygomatic bone fractures occurs in patients aged 20 to 30 years. Zygomatic bone fractures occur in 3.5% of cases in children and in 2–3% of cases in elderly individuals.
1.4 Features of Coding the Disease or Condition
S02.4 – Fracture of zygomatic bone and maxilla
1.5 Classification of the disease or condition
1.5.1. Classification of zygomatic bone fractures according to localization and presence/absence of fragment displacement (Nizova R.F., 1967)
Zygomatic bone fractures without displacement / with displacement;
Zygomatic arch fractures without displacement / with displacement;
Simultaneous fractures of the zygomatic bone and arch without displacement / with displacement [4,21,25].
Zygomatic bone fractures frequently compromise the integrity of adjacent facial bones. Fracture lines may not run strictly along bony sutures but cross into neighboring bones. Zygomatic bone injuries are frequently combined with maxillary fractures. Since the zygomatic bone participates in forming the orbital walls, a fracture of the frontozygomatic/zygomaticoorbital complex is invariably observed.
In the absence of pronounced displacement of the orbital floor bone fragments, it is advisable to use these clinical guidelines (ICD code: S02.4); otherwise, clinical guidelines for the management of patients with orbital floor fractures should be followed (ICD code: S02.3).
1.5.2. Classification of zygomatic bone fractures according to the time elapsed since the injury
Recent (up to 14 days post-injury), (acute fracture — up to 4 weeks)
Delayed/stale (14 to 28 days post-injury) (developing post-traumatic deformity — 4 weeks to 2 months)
Malunited (over 28 days post-injury). (Post-traumatic deformity — from 2 months)
Classification according to A.S. Karayan
If more than 28 days have passed since the moment of the fracture (the last movement of the fragments), such a fracture no longer belongs to this group of conditions and is coded according to ICD-10 as T90.2 – Sequelae of skull and facial bone fracture.
1.5.3. Classification of zygomatic bone fractures according to the pattern of the fracture line
Linear;
Comminuted
1.6 Clinical presentation of the disease or condition
Patients present with pain, edema, and restricted mouth opening. When the orbital surface and frontal process of the zygomatic bone are injured, patients experience pain, restricted eyeball movement, and diplopia. In the early stages after injury, diplopia may not manifest due to periorbital soft tissue edema; therefore, monitoring for the appearance of this symptom over time is recommended.
Isolated zygomatic bone fractures with fragment displacement present with the following symptoms: facial deformity due to depression (flattening) of the soft tissues in the zygomatic region.
Tissue depression is often masked by rapidly developing soft tissue edema, which frequently extends to the lower eyelid (up to complete closure of the palpebral fissure).
Palpation of edematous tissues may reveal subcutaneous crepitus, which auscultatorily resembles the sound of crunching dry snow.
"Step-off" sign in the middle portion of the inferior orbital rim and in the region of the zygomaticoalveolar crest.
Hemorrhage into the mucosa of the transitional fold in the region of the upper premolars and the first or second molar may occur; numbness of the skin in the infraorbital region, lower eyelid, upper lip, upper teeth, and the nasal bridge on the affected side; hemorrhage into the orbital fat and sclera; chemosis may develop (due to damage to the inferior orbital wall); epistaxis (resulting from maxillary sinus injury).
Bleeding specifically from one half of the nose on the side of the injury is characteristic.
In an isolated fracture of the zygomatic arch, soft tissue depression is present due to the medial and inferior displacement of bone fragments. The soft tissue depression is masked by rapidly developing edema. There is limitation and pain upon opening the mouth, as well as difficulty with lateral movements of the mandible on the affected side. These symptoms are associated not only with the entrapment of the coronoid process of the mandible by the displaced fragment of the zygomatic arch, but also with trauma to the masseter and temporal muscles themselves.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
anamnestic data (history of trauma, epistaxis, etc.);
collection of complaints (edema, bruising, pain, decreased facial skin sensitivity, altered facial shape, limited mouth opening, etc.);
physical examination (altered facial shape, edema, bruising, pathological mobility and crepitus of bone fragments, subcutaneous emphysema, epistaxis, nasal breathing difficulty, hypesthesia of the facial skin and maxillary teeth, percussion sound, etc.);
instrumental examination (presence of a fracture line in typical locations according to X-ray data). Computed tomography or radiography of the facial skeleton bones (axial or semi-axial projection) reveals disruption of the integrity of the inferior and lateral orbital margins, continuity in the area of the zygomaticoalveolar crest and the temporal process of the zygomatic bone, and decreased pneumatization of the maxillary sinus due to hemosinus.
2.1 Complaints and Anamnesis
When taking a history in patients with suspected zygomatic bone fracture, it is recommended to pay special attention to the circumstances of the injury.
Comments: The circumstances of the injury, its date, and time provided by the patient must be recorded in the medical documentation. If the injury resulted from battery or a traffic accident, the exact address or approximate location should also be noted if the patient has difficulty remembering. If the injury occurred as a result of a domestic conflict, it should be noted whether the patient was beaten by a known or unknown person. This information must be immediately reported to the law enforcement agencies at the location of the injury in the established manner (Order of the Ministry of Health and Social Development No. 565n dated May 17, 2012, "On approval of the procedure for medical organizations to inform internal affairs bodies about the admission of patients for whom there are sufficient grounds to believe that harm to their health was caused as a result of illegal actions"
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
When taking a history in patients with suspected zygomatic bone fracture, it is recommended to clarify whether there was dizziness, nausea, vomiting, headache, loss of consciousness, and memory loss to verify TBI (traumatic brain injury) and ensure timely referral for a neurology (neurosurgery) consultation [5,29,36].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
2.2 Physical Examination
All patients with suspected zygomatic bone fracture are recommended to undergo a physical examination to clarify the diagnosis and determine the treatment tactics [6,21]:
- assessment of the patient's general condition;
- examination of the maxillofacial region and oral cavity;
- palpation and percussion of the maxillofacial region;
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
2.3 Laboratory Diagnostics
Laboratory diagnostic tests are recommended for patients with maxillary fracture during the preparation and planning of surgical intervention to rule out contraindications to its performance [7,28].
Comments: Performance of a general (clinical) blood test, general (clinical) urine test, general therapeutic biochemical blood test (mandatory determination of: total protein, aspartate aminotransferase activity, alanine aminotransferase activity, total and free bilirubin, urea and/or creatinine, blood glucose), coagulogram (exploratory hemostasis study), determination of hepatitis B virus surface antigen (HBsAg), antibodies to hepatitis C virus (Hepatitis C virus), antibodies of classes M, G (IgM, IgG) to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) and human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2), antibodies to Treponema pallidum in the blood, determination of main blood groups by the ABO system, and determination of the D antigen of the Rh system (Rh factor)
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Laboratory diagnostic tests for ethanol (determining blood ethanol concentration by gas chromatography or quantitative determination of urine ethanol by gas chromatography) are recommended for all patients with a zygomatic bone fracture if acute alcohol intoxication is suspected, as well as in cases where circumstances of illegal actions are being investigated, or if the injury resulted from traffic accidents or occupational incidents [8].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Laboratory diagnostic tests of biological material (blood, urine, hair, nails) for the presence of narcotic and potent psychopharmacological substances (B01.045.012) are recommended for all patients if drug intoxication is suspected.
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
All patients with suspected zygomatic bone fracture at the diagnosis stage are recommended to undergo X-ray examination in the volume of: radiography of the zygomatic bones in at least 2 projections (A06.03.001.002) [37].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
It is recommended to perform computed tomography of the maxillofacial region (A06.07.013) to clarify the extent of damage, determine indications for surgical treatment, and plan it in patients with a zygomatic bone fracture [9,29,37,38].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Patients after zygomatic bone osteosynthesis surgery are recommended to undergo computed tomography of the maxillofacial region to monitor the restoration of the anatomical position of bone fragments and rule out secondary displacement of fragments. According to indications, computed tomography of the maxillofacial region (A06.07.013) is performed [9,29,37,38].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Comments: A patient with suspected zygomatic bone fracture is recommended to undergo X-ray examination in the volume of: direct and lateral (from the affected side) skull projections, axial and semi-axial projections of the zygomatic bones. If necessary, CBCT or MSCT of the middle third of the face is performed [9,29,37,38].
2.5 Other Procedures
All patients with a zygomatic bone fracture (with a history of headache, dizziness, nausea, vomiting, loss of consciousness, memory loss) at the diagnosis stage are recommended to undergo a consultation with a neurologist (neurosurgeon) to rule out TBI [10,37,39,40,41].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
If a patient with a zygomatic bone fracture has signs of damage and/or pathological changes in ENT organs (hemosinus, etc.), it is recommended to conduct an otorhinolaryngologist consultation to clarify the diagnosis and examination tactics [10].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
If a patient with a zygomatic bone fracture has extraocular motility disorders, enophthalmos, hypophthalmos, hyphema, anisocoria, diplopia, visual acuity changes, and other manifestations of visual organ damage at the diagnosis stage, it is recommended to perform an ophthalmologist consultation to clarify the diagnosis and examination tactics [11,34].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
All patients with a maxillary fracture, according to the modern "Pain management" concept in surgery, are recommended to be prescribed painkillers in accordance with the principle of prioritizing the assessment of pain syndrome intensity, taking into account possible contraindications to the prescription of the most frequently used groups — analgesics and non-steroidal anti-inflammatory and antirheumatic drugs (M01A) [3,47,48].
GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)
Comments: various painkillers are used to reduce pain [42,43,44,45,47,48]
differential approach to the choice of analgesic drug:
- mild pain — paracetamol** [47,48],
- moderate pain — combinations of paracetamol** + ibuprofen** or paracetamol** + diclofenac**, or paracetamol** + ketorolac**, or paracetamol** + ketoprofen**, or opioids (N02AJ) in combination with non-opioid analgesics [46,47],
- severe pain — opioids (N02A) (morphine**, trimeperidine**, fentanyl**, tramadol**). In certain cases, patients may be prescribed "adjuvant" drugs from the group: other general anesthetics (N01AX); gabapentinoids (N02BF) — gabapentin and pregabalin — as part of multimodal analgesia to reduce postoperative pain intensity, decrease opioid tolerance, and reduce the risk of developing chronic pain syndrome and for its treatment**[46,47,48]
In patients with traumatic brain injury, the prescription of opioids (N02AJ) is contraindicated.
All patients scheduled for surgical treatment of a zygomatic bone fracture are recommended to undergo prophylaxis of surgical site infections (SSI) [6,45,49,50,51,52].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
All patients with a zygomatic bone fracture undergoing perioperative antibiotic prophylaxis are recommended to be prescribed a systemic antibacterial drug (J01) (see Table 1) at a dose corresponding to the single therapeutic dose of this drug [5,6,45,49,50,51,52].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
All patients with zygomatic bone fracture undergoing perioperative antibiotic prophylaxis are recommended to receive an additional intraoperative single dose of a systemic antibacterial drug if the duration of the surgery exceeds 2 half-lives of the drug, as well as in case of massive intraoperative blood loss [5,6,45,49,50,51,52].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Patients with zygomatic bone fracture undergoing perioperative antibiotic prophylaxis are recommended a single administration of a systemic antibacterial drug; if prolonged prophylaxis is necessary, the drug is discontinued no later than 24 hours after surgery, even in the presence of a drain [5,6,45,49,50,51,52].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Table 1. Algorithm for selecting a systemic antibacterial drug for perioperative prophylaxis of infectious complications in patients with zygomatic bone fractures.
Type of surgical intervention for zygomatic bone fractures | First-line drugs | Alternative drugs | Timing administration | Route of administration | Notes |
|---|---|---|---|---|---|
Performance of operations with type I wounds ("clean wound"), where the development of postoperative complications is accompanied by a high risk of harm to the patient's health and life | |||||
Surgical treatment of patients with a closed zygomatic bone fracture via an external approach without the risk of communication between the surgical wound and the oral cavity/nasal cavity | Cefazolin**2 2.0–3.0 g, or #Cefuroxime** 1.5 g [50,52,53,54] | Vancomycin**1,3 15 mg/kg [50,53,54] #Clindamycin** 0.9 g [52,56–59] | 30–60 min before incision | Intravenous infusion | AMP is administered once |
Performance of operations with type II wounds ("clean-contaminated wound") communicating with the upper respiratory tract and type III wounds ("contaminated wound") communicating with the digestive tract | |||||
- Surgical treatment with an intraoral approach - Planned (risk of) communication of the surgical wound with the oral cavity or maxillary sinus) - Surgical treatment of patients with an open zygomatic bone fracture | Cefazolin**2 2.0–3.0 g + #Metronidazole** 0.5–1.0 g; or #Cefuroxime** 1.5 g + #Metronidazole** 0.5–1.0 g; or Amoxicillin + clavulanic acid** 1000 mg + 200 mg [50,52,53,54] | Vancomycin**1,3 15 mg/kg [50,53,54,56] | 30–60 min before the incision. | Intravenous infusion | PAP is administered as a single dose, except in contaminated surgeries where PAP antibiotics are administered for no more than 24 hours postoperatively |
#Clindamycin**4 0.6–0.9 g [50,51,52,53,55–58] |
1 allergy to beta-lactam antibiotics, high risk of MRSA [49]
2 for body weight over 120 kg, the dose should be 3 g [49,52,53].
3 120 minutes before the incision [50,53,54].
In patients with a zygomatic bone fracture with wound type IV "infected wound" – in case of old trauma, prior infection, presence of purulent discharge, non-viable tissues, all patients are recommended to receive antibiotic therapy with systemic drugs (J01) [5,6,45,49,50,51,52,55]
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
In patients with a zygomatic bone fracture with compromised integrity of the maxillary sinus walls, it is recommended to prescribe drugs from the group of decongestants and other nasal topical preparations to reduce edema of the maxillary sinus mucosa and the ostium into the nasal cavity, in order to improve its drainage function and prevent inflammatory processes [8,10,29].
GOR CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
3.2 Surgical Treatment
Indications and contraindications for surgical treatment:
Indications: displacement of bone fragments, presence of functional and/or aesthetic disorders resulting from the zygomatic bone fracture [1,12].
Contraindications: severe diseases of various organs and systems in the stage of decompensation. If improvement in the patient's condition can be achieved after treatment, surgery becomes feasible.
Patients with linear zygomatic bone fractures with fragment displacement are recommended to undergo minimally invasive zygomatic bone reposition via a puncture below the zygomatic bone to restore the anatomical shape of the midface bones (A16.03.034.001) [4,5].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Comments: In case of posterior displacement of the zygomatic bone body with damage to the orbital floor, reposition and osteosynthesis are indicated with simultaneous elimination of the resulting orbital floor defect using a plastic implant (A16.03.056).
Performing closed repositioning using a Limberg hook is indicated only for an isolated zygomatic arch fracture provided that a stable position of the bone fragments is achieved
Minimally invasive zygomatic bone repositioning using a Limberg hook is possible only in case of a linear fracture. If correct positioning of fragments cannot be achieved during repositioning, or if repositioning is unstable and fragments displace again, it is advisable for the patient to undergo zygomatic bone osteosynthesis. If the orbital floor is involved in the traumatic process, open osteosynthesis must be performed with elimination of the resulting defect using a plastic implant.
Patients with comminuted zygomatic bone fractures with fragment displacement, as well as when stable fixation of fragments during repositioning with a Limberg hook is not possible, are recommended to undergo osteosynthesis surgery to restore the anatomical shape of the midface bones (A16.03.053) [12,14,15,23,26,27,32].
GIB CLOE 4Grade of Recommendation – C (Level of Evidence – 4)
Comments: Zygomatic bone osteosynthesis can be performed using various fixation devices, which include: resorbable craniofacial fixation plate*** (code 190570), resorbable bone fracture fixation plate with screws*** (code 246280), non-resorbable craniofacial fixation plate*** (code 190580), non-resorbable craniofacial fixation plate set*** (code 190600), non-resorbable sterile bone fracture fixation plate with screws*** (code 246140); resorbable craniofacial bone screw*** (code 190640), non-resorbable sterile craniofacial bone screw*** (code 190650). Typically, the fixation device is placed in the region of the main buttresses of the zygomatic bone: frontozygomatic suture and/or infraorbital margin, and/or zygomaticoalveolar crest, and, if necessary, the zygomatic arch and nasal buttress
The type and number of approaches for this surgical intervention are determined by the surgeon individually for each patient depending on the nature of the fracture and the surgeon's qualifications. The following approaches are usually used:
- in the region of the frontozygomatic suture
- in the upper eyelid region
- lower palpebral
- middle palpebral
- subciliary
- transconjunctival
- intraoral
In cases of zygomatic bone fracture combined with multiple fractures of the upper and middle facial zones, a bicoronal approach is used.
For an isolated linear fracture within the zygomatic arch after minimally invasive repositioning, to confirm the reduction of bone fragments into the anatomically correct position, it is recommended to perform radiography of the zygomatic bones in 2 projections (A06.03.001.002) [9,29,37,38].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
For widespread zygomatic bone fractures involving the body and orbital surface, comminuted damage patterns accompanied by fragment displacement, after surgical intervention, it is recommended to perform follow-up computed tomography of the maxillofacial region (A06.07.013) to confirm the reduction of bone fragments into the anatomically correct position [9,29,37]
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
3.3 Pain management
Patients with displaced zygomatic bone fractures are recommended to undergo reposition and osteosynthesis procedures under general anesthesia [2].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
3.4 Dietary Therapy
In patients with zygomatic bone fracture in the pre- and postoperative periods, it is recommended to exclude food requiring intense chewing effort (meat, nuts, rusks, etc.) from the diet to prevent fragment displacement due to muscular traction and reduce pain afferentation [3,5].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
All patients who have undergone surgical treatment for a zygomatic bone fracture are recommended to undergo rehabilitation measures aimed at the complete social and physical recovery of the patient [16].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Comment: The need for patient rehabilitation is due to maxillofacial trauma. The presence of postoperative wounds (loss of integrity) in this aesthetically significant anatomical region, their healing, pain syndrome of varying severity, and potential disorders of facial muscle function, mastication, as well as neurological disorders can lead to significant social maladjustment and reduce the quality of life of this category of patients.
General principles of rehabilitation after surgical treatment of zygomatic bone fractures:
1) Comprehensive assessment of the patient's initial condition and formulation of a rehabilitation program;
2) Drawing up a plan for diagnostic and therapeutic measures necessary for rehabilitation;
3) Multidisciplinary principle of organizing rehabilitation care;
4) Monitoring the efficacy of therapy during restorative treatment and upon completion of the rehabilitation course.
Stages of patient rehabilitation after surgical treatment:
Stage 1 – early rehabilitation, from 7 to 10 days after surgery. During this period, the patient undergoes inpatient rehabilitation treatment for 3–5 days, after which further rehabilitation takes place on an outpatient basis for 10–15 days.
The most important tasks of stage 1 rehabilitation are the control of hemostasis, the wound healing process, and relief of postoperative pain syndrome.
Stage 2, from 15 to 45 days after surgery, aims to accelerate reparative processes and prevent the development of postoperative complications, traumatic maxillary sinusitis, extraarticular mandibular contracture, and visual organ pathology.
The main tasks at this stage are:
Myotherapy of the masticatory muscles is one of the important components of early postoperative rehabilitation aimed at normalizing masticatory function. The patient is given recommendations regarding dietary restrictions, and the dynamics of normalization of the lower jaw range of motion are monitored.
Oculomotor muscle myogymnastics is performed to restore the synchrony of eyeball movements and eliminate diplopia.
Pain management: the severity of pain depends on the extent of intraoperative trauma and individual pain threshold. Systemic analgesics for pain relief are selected individually by the attending physician based on the intensity of pain and the severity of psychoemotional disorders.
Programmed wound process: one of the most important aspects of postoperative patient recovery, allowing to avoid the development of late postoperative complications (scar deformity, prevention of inflammatory complications in the area of the postoperative wound and maxillary sinus, etc.).
Proper management of the wound process, starting from the 2nd postoperative day until complete healing of soft tissue wounds, includes: daily treatment of the wound area with antiseptic solutions, dressings with ointment applications (the composition of the ointment is determined by the stage of the wound process); dynamic monitoring by a maxillofacial surgeon; microbiological control (if purulent-septic complications and wound infection are suspected).
To accelerate reparative processes and reduce the inflammatory response, it is advisable to perform physiotherapeutic procedures as recommended by a physical therapy physician [16].
When titanium miniplates and screws are used during surgical treatment, the question of whether to remove them after consolidation of the zygomatic bone fragments is decided on an individual basis and strictly according to indications.
5. Prevention and Dispensary Observation
All patients are recommended to undergo a follow-up X-ray examination of the zygomatic bones (A06.03.001.002) or computed tomography of the maxillofacial region (A06.07.013) 4 weeks after surgery to confirm fragment consolidation in the correct position and rule out a post-traumatic inflammatory process in the maxillary sinus [18,19,20,24,33,37,38].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
All patients are indicated for follow-up observation by a maxillofacial surgeon and an ophthalmologist for 5–8 months postoperatively to assess the position of the eyeball (ruling out hypo- and enophthalmos). If necessary, a follow-up MSCT (A06.07.013) is performed to assess the position of the eyeball (ruling out hypo- and enophthalmos) [10].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
6. Organization of Medical Care
Indications for emergency hospitalization to a medical organization:
Presence of a zygomatic bone fracture with fragment displacement, presence of functional and aesthetic disorders accompanied by damage to surrounding soft tissues, in case of polytrauma
Indications for planned hospitalization in a medical organization:
no indications.
Since a bone fracture is an emergency condition, all patients with this disease (condition) are recommended to be hospitalized on an emergency basis.
If more than 28 days have passed since the moment of injury (the fact of the last movement of fragments), this condition does not belong to this group of diseases and is coded according to ICD-10 as T90.2 – Sequel of skull and facial bone fracture.
Indications for patient discharge:
1) in the absence of indications for further inpatient treatment (uneventful postoperative period, satisfactory fragment alignment, no progressive purulent-inflammatory diseases of the maxillofacial region of traumatic origin);
2) if the patient needs to be transferred to another medical institution;
3) at the request of the patient or their legal representative;
4) in cases of patient non-compliance with prescriptions or internal hospital regulations, provided this does not threaten the patient's life and the health of others [2,5].
7. Additional Information
Factors negatively affecting treatment outcomes:
1) Development of infectious complications.
2) Non-compliance with the regimen of local contact hypothermia.
3) Pressure on the zygomatic bone.
4) Poor oral hygiene.
5) Non-compliance with the prescribed diet and masticatory activity restrictions.
6) Non-compliance with postoperative physical therapy recommendations.
7) Participation in contact sports for 3 months.
8) Failure to attend follow-up examinations.
9) Non-compliance with other recommendations of the attending physician.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1 | X-ray examination of the patient upon admission, including: anteroposterior and lateral (affected side) projections of the skull, axial and semi-axial projections of the zygomatic bones (A06.03.001.002). To clarify the extent of damage, determine indications for surgical treatment, and plan it – computed tomography of the maxillofacial region (A06.07.013). | Yes/no |
2 | Follow-up X-ray examination of the postoperative patient prior to discharge, including: anteroposterior and lateral (affected side) projections of the skull, axial and semi-axial projections of the zygomatic bones (A06.03.001.002) in cases where the fracture is limited to the zygomatic arch, or computed tomography of the maxillofacial region for extensive fractures involving the body and orbital surface (A06.07.013). | Yes/no |
3 | Consultation with a neurologist (neurosurgeon) if clinical signs of TBI are detected | Yes/no |
4 | Consultation with an otolaryngologist if clinical signs of ENT organ damage are detected | Yes/no |
5 | Consultation with an ophthalmologist if clinical signs of visual system pathology are detected | Yes/no |
6 | Stable fragment fixation | Yes/no |
7 | Anatomic reduction of fragments (according to follow-up X-ray data) | Yes/no |
References
Show references
Soloviev, M.M. Classification of non-firearm mechanical injuries of the facial part of the head / Soloviev, M.M., Chebotarev S.Y., Meskhia S.M. // Institut Stomatologii. - 2008. - No. 3 (39). - P. 58 - 61.
Petrenko, V.A. Treatment of zygomatic bone fractures according to the Department of Maxillofacial Surgery / Petrenko, V.A., Dubrov A.S., Ivanova Y.E. / Municipal Enterprise "Central City Clinical Hospital No. 23", Yekaterinburg // Problemy Stomatologii. - 2007. - No. 6. - P. 48 - 49.
Ceallaigh P.O., Ekanaykaee K. Diagnosis and management of common maxillofacial injures in the emergency department. Part 3: Orbitozygomatic complex and zygomatic arch fractures. // Emerg. Med. J., 2007. - 24: 120-122 p.
Chowdhury R., Menon S. Etiology and management of zygomaticomaxillary complex fractures in the armed forces. // MJAFI., 2005. - 61: 238-240 p.
Kenbayev, V.O. Maxillofacial Traumatology. – Shymkent, 2006. – 118 p.
Karayan, A.S. Simultaneous elimination of post-traumatic defects and deformations of the zygomaticomaxillary complex: Abstract of DSc Thesis in Medical Sciences: 14:00:21 / A.S. Karayan; Moscow, 2008. - 45 p.
Chowdhury R., Menon S. Etiology and management of zygomaticomaxillary complex fractures in the armed forces. // MJAFI 2005; 61: 238-240.
Sadovsky, I. M. Features of surgical treatment tactics for post-traumatic midface deformities. // Thesis for the degree of Candidate of Medical Sciences: 14.00.27 / I. M. Sadovsky; Moscow, 2005. – 34 p.
Reuben A. D., Watt-Smith S.R. A comparative study of evaluation of radiographs, CT and 3D reformatted CT in facial trauma: what is the role of 3D // Br. J. of radiology., 2005. - 198-201: 32-36 p.
Meskhia, S.M. Long-term results of treatment of patients with midface bone fractures in polytrauma: PhD Thesis in Medical Sciences; 14:00:21 / S.M. Meskhia; St. Petersburg, 2009. - 12 p.
Tzung Chen Ch., Faye Yuang. Management of posttraumatic enophthalmos. // Chang Gung Med J., 2006. - 29: 61 p.
Dubrov, A.S. Device and method of osteosynthesis for zygomatic bone injuries / A.S. Dubrov et al. // Uralsky Meditsinsky Zhurnal. - 2008. - No. 5 (45). - P. 119 - 110.
Petrenko, V.A. Device and method of closed reduction for zygomatic bone and arch injuries / V.A. Petrenko, Y.E. Ivanova, A.S. Dubrov // Uralsky Meditsinsky Zhurnal. - 2008. - No. 5 (45). - P. 111-112.
Alaverdov, V.P. Application of biodegradable material structures for bone fragment fixation in maxillofacial surgery // Abstract of PhD Thesis in Medical Sciences: 14.00.21 / V.P. Alaverdov; Moscow, 2005. – P. 12-16.
Bell R.B., Kindsfater C.S. The use of biodegradable plates and screws to stabilize facial fractures // J. Oral Maxillofac. Surg. - 2006. - Vol. 64. - P. 31-39.
Bogolyubov, V.M. Medical Rehabilitation / V.M. Bogolyubov – M.: BINOM, 2010. – 416 p.
Meskhia, S.M. Characteristics and treatment outcomes in patients with non-firearm injuries of the middle section of the facial head in associated neurotrauma / Meskhia S.M., Sokirko E.L., Absaeva K.A. // Institut Stomatologii. - 2008. - No. 3 (40). - P. 24 - 27.
Vasiliev A.Y. Comprehensive diagnostic imaging of combined injuries of the facial skeleton and orbital structures / A.Y. Vasiliev, N.S. Serova, D.A. Lezhnev // Rossiysky Stomatologichesky Zhurnal. - 2006. - No. 1. - P. 23-26.
Beloshenkov V.V. Anatomical and physiological features of the maxillofacial region and methods of its examination / V.V. Beloshenkov et al., M.: Meditsinskaya Kniga, 2005. - 180 p.
Vasiliev A.Y. Diagnostic Imaging in Dentistry: Textbook / A.Y. Vasiliev et al. // M.: GEOTAR-Media, 2008. – 176 p.
Carter T. G., Bagheri S., Dierks E. J. Towel clip reduction of the depressed zygomatic arch fracture // J. Oral Maxillofac. Surg. 2005. - Vol. 63. - P. 1244- 1246.
Cavalcanti B., Lago C. A., Nogueira R. V. Usso da cirugia video-assistida no tratamento de fratura do zigomatico. // Rev. cienc. Med. Campinas 16 (2): 127133.2007 Brasil. P. 12-17.
Eppley B. L. Use of resorbable plates and screws in pediatric facial fractures // J. Oral Maxillofac. Surg. 2005. - Vol. 63. - P. 385 - 91.
Folkestad L., Aberg- Bengtsson L. Recovery from orbital floor fractures: a prospective study of patients' and doctors' experiences. // J oral maxillofac. Surg. 2006. Vol. 35. - P. 499-505.
Garcia-Roco O.N. Zygomatic fractures: value of the Knight and North classification in therapeutics. // Rev. Cubana Estomatol. - 2006. - Vol. 43. - P. 14-17.
Garcia-Roco O.N. Reparación de fracturas de suelo orbitario. Nuestra experiencia con diversos materiales.// Portales Medicos .com Cuba. 2008. - P. 5-9.
Iizuka T., Hallermann W., Seto I., Smolka W., et al. A titanium arch bar for maxillomandibular fixation in oral and maxillofacial surgery // J. Oral Maxillofac. Surg. - 2006. - Vol. 64. - P. 989 - 992.
King C., Schicho K, Ploder O., Yerit K, et ah Point-to-point computer-assisted navigation for precise transfer of planned zygoma osteotomies from the stereolithographic model into reality // J. Oral Maxillofac. Surg. 2006. -Vol. 64. - P. 550-559.
Manson P.N. Facial fractures. // Plastic surgery. 2006. - P. 77-381.
Maubleu S., Marecaux Ch. Chirurgie assistée par ordinateur et chirurgie maxillofaciale. // Revue de stomat. Et chir. M.fac. 2005. - P. 405-411.
Nitsch A., Bruns A. Evaluation des resultants cliniques postoperatoires du repositionnement de fractures isolees de 1'os zygomatique. // Rev. mens. Suisse odontostomatol. 2006. -Vol. 116. - P. 49-53.
Olennikova M. M., Litvinov S. D., Olennikov M. K. The application of the material «LitAr» in maxillofacial surgery // Balkan Journal of Stomatology. - 2005. - Vol. 9. - № 1. - P. 59.
Ortiz G., Arango J.C., giraldo c. analisis retrospective de pacientes intervenidos por cirugia maxillofacial en el hospital general de Medellin. Revista CES odont. 2007. - Vol. 20 - P. 17-21.
Paton G. J., Aquilina P. J., Lynham A., Lee G. A., et al. Intraocular pressure changes secondary to reduction of orbito-zygomatic complex fractures // J. Oral Maxillofac. Surg. - 2006. - Vol. 64. - P. 100 - 103.
Pereira Gomes P., Passeri L. A., de Albergaria Barbosa J. R. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in San Paulo state, Brazil // J. Oral Maxillofac. Surg. - 2006. - Vol. 64.- P. 63-67.
Pereira P., Passeri L. A five year retrospective study of zygomatico-orbital complex in Sao Paulo State Brazil. //J Oral maxillofc surg. 2006. - P. 63-67.
Pankratov, A.S., Ushakov, R.V., Korkin, V.V. First aid for patients with maxillofacial injuries: Textbook. Moscow: FGBOU DPO RMANPO, 2017. – 89 p.
Sun Yu-hua, Tang you-sheng: Establishment of a new method for quantitative diagnosis of zygomatic complex fractures with three dimensional CT. // Journal of Chinese clinical medicine. 2006. - Vol. 15. - P. 3.
Golovko, S.A. Diagnostic errors in traumatic intracranial hematomas (TIH) and ways to overcome them / S.A. Golovko, V.V. Krylov // Proceedings of the 1st Congress of Neurosurgeons of the Russian Federation. — M., 2006. — P. 325.
Ivchenko, I.G. Combination of secondary brain injury factors and organization of intensive care regarding the course and outcome of severe traumatic brain injury / I.G. Ivchenko, I.S. Ruslyakova // Proceedings of the 1st Congress of Neurosurgeons of the Russian Federation. — M., 2006. — P. 331.
Lebedev, V.V. On diagnostic errors during hospitalization of patients with traumatic brain injury / V.V. Lebedev // Neyrokhirurgiya. — 2005. — No. 2. — P. 30–34.
Melnichenko, G.A. Federal clinical guidelines for the diagnosis, treatment, and prevention of osteoporosis / G.A. Melnichenko // Problemy Endokrinologii. – 2017. – Vol. 63, No. 6. – P. 392–426.
Kyvernitakis I, Kostev K, Kurth A, Albert US, Hadji P. Differences in persistency with teriparatide in patients with osteoporosis according to -gender and health care provider. Osteoporos Int. 2014, Dec; 25.
Bischoff-Ferrari H.A., Dawson-Hughes B., Baron J.A., et al. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am. J Clin. Nutr. 2007.
Sherstyannikov, A.S. Antibiotic prophylaxis in traumatology and orthopedics: guidelines / Guidelines. – Kirov: Kirov State Medical Academy, Department of Healthcare of Kirov Region, 2007. – 25 p.
Belousov Y.B. Clinical Pharmacology: National Guidelines / ed. by Y.B. Belousov, V.G. Kukes, V.K. Lepakhin, V.I. Petrov - M. : GEOTAR-Media, 2014. - 976 p.
Ovechkin, A.M. et al. Postoperative pain management. Clinical guidelines // Annals of Critical Care named after A.I. Saltanov. – 2019. – No. 4. – P. 9-33. DOI: 10.21320/1818-474X-2019-4-9-33
Volchkov, V.A., Kovalev, S.V., Kubynin, A.N. Modern aspects of postoperative analgesia (literature review) // Bulletin of Saint Petersburg University. Series 11. Medicine. – 2018. – Vol. 13. – No. 3.
Leaper, D.J., Edmiston, C.E. World Health Organization: global guidelines for the prevention of surgical site infection // Journal of Hospital Infection. – 2017. – Vol. 95, No. 2. – P. 135-136.
Yakovlev, S.V., Briko, N.I., Sidorenko, S.V., Protsenko, D.N. SCAT program (Antimicrobial Therapy Control Strategy) in inpatient medical care: Russian clinical guidelines / Moscow: Pero Publishing House, 2018. – 156 p.
Aslanov B.I. et al. Principles of organizing perioperative antibiotic prophylaxis in healthcare facilities. – 2014.
Bratzler, D. W. et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery // Surgical infections. – 2013. – Vol. 14. – No. 1. – P. 73-156.
Milic T., Raidoo, P., Gebauer, D. Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review. British Journal of Oral and Maxillofacial Surgery.-2020.-doi:10.1016/j.bjoms.2020.09.020
Hussain Z., Curtain C., Mirkazemi C., Gadd K., Peterson G.M., Zaidi S.T.R. Prophylactic Cefazolin Dosing and Surgical Site Infections: Does the Dose Matter in Obese Patients? Obes Surg. 2019 Jan;29(1):159-165. doi: 10.1007/s11695-018-3497-0.
Mottini M., Wolf R., Soong P.L., Lieger O., Nakahara K., Schaller B. The role of postoperative antibiotics in facial fractures: Comparing the efficacy of a 1-day versus a prolonged regimen. J. Trauma Acute Care Surg. 2014;76:720–724. doi: 10.1097/TA.0000000000000123.
Langerman A, Thisted R, Hohmann S, Howell M. Antibiotic and Duration of Perioperative Prophylaxis Predicts Surgical Site Infection in Head and Neck Surgery. Otolaryngol Head Neck Surg. 2016 Jun;154(6):1054-63. doi: 10.1177/0194599816634303. Epub 2016 Mar 1. PMID: 26932957.
Vila PM, Zenga J, Jackson RS. Antibiotic Prophylaxis in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017 Oct;157(4):580-588. doi: 10.1177/0194599817712215. Epub 2017 Jul 11. Erratum in: Otolaryngol Head Neck Surg. 2018 Aug;159(2):402. doi: 10.1177/0194599818765191. PMID: 28695786.
Lazzarini L, Brunello M, Padula E, de Lalla F. Prophylaxis with cefazolin plus clindamycin in clean-contaminated maxillofacial surgery. J Oral Maxillofac Surg. 2004 May;62(5):567-70. doi: 10.1016/j.joms.2003.12.004. PMID: 15122561.
Goormans F. et al. Systemic Antibiotic Prophylaxis in Maxillofacial Trauma: A Scoping Review and Critical Appraisal // Antibiotics. 2022. Vol. 11. No. 4. p. 483.
Appendix A1. Working Group Composition
Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.
Brailovskaya T. V. – Doctor of Medical Sciences, Professor, Executive Secretary of the Association of Specialists in Maxillofacial Surgery.
Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
Ivanov S.Yu. – Corresponding Member of the RAS, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.
Drobyshev A.Y. – MD, Professor, Vice-President of the LLC "Association of Maxillofacial Surgery Specialists".
Yaremenko A.I. – MD, Professor, Vice-President of the LLC "Association of Maxillofacial Surgery Specialists".
Roginsky V.V. – MD, Professor, Member of the LLC "Association of Maxillofacial Surgery Specialists".
Belchenko, V.A. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Topolnitsky, O.Z. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Sysolyatin P.G. – MD, Professor, Board Member of the LLC "Association of Maxillofacial Surgery Specialists".
Durnovo E.A. – MD, Professor, Board Member of the LLC "Association of Maxillofacial Surgery Specialists".
Lepilin A.V. – MD, Professor, Board Member of the LLC "Association of Maxillofacial Surgery Specialists".
Tarasenko, S.V. – MD, Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Epifanov, S. A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
Pankratov A.S. – MD, Professor, Member of the LLC "Association of Maxillofacial Surgery Specialists".
Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".
Baranov, I.V. – PhD in Medical Sciences, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Sviridenko, A.D. – Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Stolyarenko, P.Yu. – PhD in Medical Sciences, Associate Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
All members of the working group are members of the All-Russian Public Organization "Association of Specialists in Maxillofacial Surgery". There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Maxillofacial surgeons
Trauma and orthopedic surgeons
Neurosurgeons
Otolaryngologists
Ophthalmologists
Physiotherapists
Mid-level medical personnel
Healthcare organizers
Medical insurance experts (including conducting medical and economic expertise)
Medical students, residents, postgraduate students.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory legal documents:
Article 76 of Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", regarding the development and approval of clinical guidelines (treatment protocols) by medical professional non-profit organizations on the provision of medical care;
Order of the Russian Ministry of Health No. 422n dated June 14, 2019, "On Approval of the Procedure for Providing Medical Care in the Field of 'Maxillofacial Surgery'";
Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010 (as amended on July 3, 2016) "On Compulsory Medical Insurance in the Russian Federation".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
The zygomatic bone is one of the many bones that make up the facial skeleton. A fracture usually occurs in the area of connection with adjacent bones.
Zygomatic complex fractures occur when a traumatic force is directed at the area of the zygomatic eminence (the most prominent point beneath the eye).
Such injuries most commonly involve damage not only to the zygomatic bone but also to adjacent bones.
A fracture of the zygomatic bone with fragment displacement can lead to facial deformity, impaired chewing and vision, and altered facial sensation.
Complications arising after a zygomatic bone fracture:
Enophthalmos and downward displacement of the eyeball, double vision.
Inflammation of the maxillary paranasal sinus, so-called sinusitis.
"Numbness" of the upper teeth and the skin in the region of the nose, lip, and lower eyelid on the affected side.
Limited mouth opening and restricted lateral jaw movements, which cause difficulty and pain during eating.
Undisplaced zygomatic bone fractures without functional impairment are managed conservatively and do not require hospitalization.
Zygomatic bone fractures with fragment displacement require surgical treatment.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.