To

Honorary director RTM

Bangladesh College of Physicians and Surgeons

Mohakhali, Dhaka-1212

Subject: Prayer for the approval of the title of dissertation for FCPS Part-II Examination.

Title: Comparative study between miniplate osteosynthesis and wire osteosynthesis for the treatment
of Zygomatico-maxillary complex fracture.

Guide: Col. Golam Mohiuddin chowdhury

Classified specialist in Oral and
Maxillofacial Surgery
Combined Millitary Hospital, Dhaka.

Sir,

Respectfully to state that I am Dr. Farjana Karim wish to do study titled ‘’Comparative study between
miniplate osteosynthesis and wire osteosynthesis for the treatment of zygomatico-maxillary complex
fracture.’’ Under the supervision of Col.Md Golam Mohiuddin chowdhury and Co-supervision of Lt
Col Abdur Rab for appearing FCPS part-II examination.

Would you please be kind enough to accept my protocol for dissertation and oblige thereby.

Sincerely Yours

Dr. Farjana Karim

Trainee
Department of Oral and Maxillo-facial Surgery
Combined Millitary Hospital, Dhaka.
 Protocol for Dissertation

Title: Comparative study between miniplate osteosynthesis and wire osteosynthesis for the
treatment of Zygomatico-maxillary complex fracture.

Investigator: Dr. Farjana Karim

FCPS(part-II) Trainee
Department of Oral and Maxillofacial Surgery
Combined Millitary Hospital, Dhaka.

Supervisor: Col. Dr.Golam Mohiuddin chowdhury

Classified specialist in Oral and Maxillofacial Surgery
Combined Millitary Hospital,Dhaka.

CO-Supervisor: Lt Col Dr. Abdur Rab

Classified specialist in Oral and Maxillofacial Surgery
Combined Millitary Hospital,Dhaka.
FCPS Dissertation Research Protocol
Protocol No:

1. Date of
submission of
protocol
2. Relevant
faculty of
BCPS
3. Name of the D R F A R Z A N A K A R I M
examinee

4. Address of Trainee officer in oral and maxillo-facial surgery,

correspondences Department of Oral and Maxillofacial Surgery,
of the examinee Combined Millitary Hospital, Dhaka.
and contact phone Phone: 01745788333.
number
5. Title of the Comparative study between miniplate osteosynthesis and wire
dissertation osteosynthesis for the treatment of Zygomatico-maxillary complex
research fracture
6. Summary of The Zygoma or malar complex forms the central support of check and is a
protocol strong buttress of lateral portion of middle third of facial skeleton. Because
of it’s prominent position it is frequently subjected to fracture and
dislocation either alone or in combination with other structures of midface
such as maxillae, nasoethmoidal and orbital area. Patterns of zygomatic
bone fractures ranges from simple fracture to comminuted and from
minimally displaced to severely displace. Treatment option for reduction of
isolated zygomatic bone fractures range from close reduction without
fixation to open reduction and fixation with wire osteosynthesis or
miniplate osteosynthesis (Ralf-Bodo Trons, 2009). The treatment should be
based on degree of displacement of fracture as evident by radiographic
evaluation. Oral surgeons need to decide whether patients with
Zygomatico-maxillary complex fractures should be treated by close
reduction or open reduction technique. In cases where open reduction is
required intra-osseous fixation can be done either by miniplate or wire
osteosynthesis ( L.J.Peterson).

7. Place of Study Department of Oral and Maxillofacial

Surgery, Combined Millitary Hospital
Dhaka and Dhaka Dental College and Hospital.
8. Period of study July 2010 to July 2012.
9. Overview of the This will be a prospective study.
study design
10. Introduction The maxillofacial region may frequently hold trauma due to various
factors such as road traffic accidents, violence, assault, fall from height,
industrial injury and sports injury (Hafiz Aamer Iqbal , 2009). Zygomatic
fractures are common facial injuries, representing either the most common
fracture or the second in frequency after nasal fracture. The prominent
convex shape of the zygoma makes it vulnerable to traumatic injury. The
fracture pattern of any bone depends on several factors, including the
direction and magnitude of the force. Fracture lines thus created pass
through the areas of greatest weakness of a bone or between bones. Owing
to the strong buttressing nature of the zygoma and the thin bones
surrounding it. Most injuries involving the zygoma are accompanied by
disruption of adjacent articulating bones. These types of fractures are
referred to as Zygomatico-maxillary complex or Zygomatic complex or
malar or trimalar and tripod fracture ( Rymond .J.Fonseca, 1991).

Zygomatico-maxillary complex fracture causes a liability to facial

deformity and dysfunction, mainly consisting of zygomatico-facial
collapse, zygomatic arch depression or outward arch rise, limited mouth
opening, diplopia and numbness of upper lip from injured infra-orbital
nerve ( NL Rowe and JLI Williams , 2010).

The principles of treatment of zygomatico-maxillary complex fracture

consist of reduction and fixation of the fractured bones to one
another and to the skull. Since Duverney first described the fractured
zygoma, numerous methods have been suggested for treating it
(Rymond .J.Fonseca, 1991). These treatment ranges from non
intervention and observation to open reduction and internal fixation.
Ellis and Kittidumkerang reviewed a series of isolated zygomatico-
maxillary complex fractures treated by a number of different approaches
and fixation schemes both immediately and several weeks after repair
and found no evidence of post-reduction instability in any patient. These
methods ranges from reduction without fixation to reduction with
three or four point fixation using bone plates. The decision to intervene
should be based on signs, symptoms and functional impairment. After
reduction, if constant reduction force is necessary for maintaining
zygomatico-maxillary complex in position, the ZMC should be stabilized
with some form of fixation device ( Rymond .J.Fonseca, 1991). One of
the most controversial topics in maxillo-facial trauma is what type of
fixation is best to prevent post reduction displacement of fractured
zygomatic bone. Fixation devices can be placed internally or externally.
Internal skeletal fixation are the devices which are totally enclosed
within the tissue and uniting the bone ends by direct approximation.
Direct internal skeletal fixation is carried out with trans-osseous or
intra-osseous wiring or bone plating systems(Omar F Shehabuldin,
1998).

Treatment of zygomatico maxillary complex fractures must achieve

adequate, proper reduction and rigid fixation at the fracture site. However
the precise stability of the zygomatico-maxillary complex with reference
to the number of fixation points as well as the sites of fixation still remain
a topic of debate ( Hafiz Aamer Iqbal, 2009). There are both advantages
and disadvantages of wire osteosynthesis and bone plate osteosynthesis.
Whatever method is used our goal is to achieved better stabilization of
fracture fragments and prevention of displacement of fracture
fragments.
 DATA SHEET

SL.NO: Date:

TITLE : Comparative study between miniplate osteosynthesis and wire osteosynthesis

for the treatment of Zygomatico- maxillary complex fracture.

Investigator:

Dr. Farzana Karim

FCPS ( Oral and Maxillo –facial Surgery. Part-II) Trainee
Department Of OMS, Combined Millitary Hospital .Dhaka.
Phone : 01745788333

Supervisor : Col Golam Mohiuddin chowdhury Co-Supervisor :Lt Col Abdur Rab
Particular of the patients:

Name : Age: Sex: 1)Male 2) Female Reg.No:

Place of Resident : 1) Rural 2) Urban 3) Semirural, Contact Number:

Institution : Dhaka Dental College and Hospital –OPD/ Indoor (Bed no…….)
Combined Millitary Hospital .Dhaka. –OPD

Co-morbidity:1) Hepatic disorder 2) Metabolic. 3) CVS dis. 4) Respiratory dis. 5) None

Incidence of aetiology:
1) Sports
2) Fall
3) Road traffic accidents
4) Others
A Neurological assessment and careful evaluatuin of all cranial nerve was done.

1) Paresthesia
2) Anesthesia
3) Paralysis

PREOPERATIVE ASSESSMENT
Examination of Nasal Complex with a speculum.

Intranasal laceration : Present / Absent

Septum deviation: Present / Absent
Epistaxis : Present / Absent
CSF rhinorrhea: Present / Absent

Determination of the visual status of both eye by through ocular and fundoscopic
Examination.

Proptosis of eye : Present / Absent

Diplopia: Present / Absent
Circum orbital ecchymosis : Present / Absent
Subconjunctival haemorrhage: Present / Absent
Periorbital oedema: Present / Absent
Displacement of palpebral fissure: Present / Absent
Unequal papillary level: Present / Absent
Enopthalmos: Present / Absent
Blurring of vision: Present / Absent
 Blindness: Present / Absent

Mouth opening:
Maximum interincisal opening: mm
Lateral excursion; left : mm
Lateral excursion; right: mm
Protrusion: mm
Deviation on opening: mm

Examination of infra-orbital margin:

Step deformily of infra-orbital margin: Present / Absent
Traumatic emphysema ( Crepiiation)
in the infraorbital region: Present / Absent

Examination of cheek:
Flattening of cheek : Absent./ Present
Oedema of ckeek: Absent./ Present
Anaeslthesia of cheek: Absent./ Present

RADIOLOGICAL EVALUATION:

Occipito -mental view 15 and 30 degree of maxilla.

PA View –Water’s position of maxilla.
Submentovertex projection.
Tomography / CT scan of the orbit

CLINICAL FUNCTIONAL ASSESSMENT:

Vertical dystopia: Present / Absent

Enopthalmas : Present / Absent
( measured with Hertel exophthalmetry)

Operation Group:
1. Trans-osseous wiring
2. Miniplate ( bone plate)

Baseline Dtata

Site of facture :

(a)

(b)

(c)
Treatment option :

Operation:

a) Open reduction with miniplate osteosynthesis.

b) Open reduction with trans-osseous wiring.

Post operative assessment ( outcome assessment at 3rd weeks)

Pain at the Fracture site : Yes / no

Trismus : Present / Absent

Jaw movement : centric/ deviated

Position of the malar prominence : Normal / flattened.

Position of the Zygomatic arch : Normal / flattened.

Diplopia : Present / Absent

Blurring of vision : Present / Absent

Maximum interincisal opening: mm

Range of ocular movement : Normal / Altered

Blindness : Present / Absent

Post operative assessment ( outcome assessment at 10thweeks)

Pain at the fracture site : Yes / no

Trismus : Present / Absent

Jaw movement : centric/ deviated

Position of the malar prominence : Normal / flattened.

Position of the Zygomatic arch : Normal / flattened.

Diplopia : Present / Absent

Blurring of vision : Present / Absent

Maximum interincisal opening: mm

Range of ocular movement : Normal / Altered

Blindness : Present / Absent

Radiological evaluation outcome :

Union status.

Union.

Non union.

Mal union.

Biomeric evaluation:

Duration of hospital stay……………. day

Result of the management . Excellent/Good/Average/Poor.