Comparative evaluation of 2-point vs 3-point fixation in the treatment of zygomaticomaxillary complex fractures - A systematic review.

Background: The zygomaticomaxillary complex (ZMC) functions as the main buttress for the lateral portion of the middle third of the facial skeleton and because of its prominent position & convex shape, it is frequently fractured, alone or along with other bones of the midface. The management of the ZMC fractures is debatable as the literature is saturated with various theories. A number of techniques, from closed reduction to open reduction and internal fixation can be effectively used to manage these fractures. Controversies lie right from the amount of fixation (1-, 2-, 3- or 4- point fixation) required to the ideal approach, and there is no conclusive view on its ideal line of management.

Objective: To compare Malar asymmetry after 2-point vs 3-point fixation in the treatment of zygomaticomaxillary complex fractures.

Data Source: Electronic search of Pub Med, Google Scholar, Institutional Library, Email to authors and manual search of various journals.

Study Eligibility Criteria: The following criteria were used to select the studies on 2- point and 3-point fixation methods in Zygomaticomaxillary complex fractures. Inclusion criteria had articles that included clinical studies published in the English language or those having sufficient data in English on 2-point or 3-point fixation in the treatment of zygomaticomaxillary complex fractures between the period of 1st January 2008 to 30th September 2018. While exclusion criteria were articles not published in the English language before 1st January 2008 and after 30th September 2018, any reviews, abstracts, letters to editors, editorials and in vitro studies were excluded. Studies that included patients with craniofacial and secondary deformities were also excluded.

Intervention: Open reduction and internal fixation using 2-point and 3-point fixation methods in the treatment of Zygomaticomaxillary complex fractures.

Results: Preliminary screening consisted of 757 studies and additional records identified through other sources of 272 studies. Amongst these 1029 studies, 837 studies were excluded after reviewing the titles. A review of abstract further excluded 71 studies, so 34 studies that remained were evaluated to fit the eligibility criteria. On the basis of information on fixation methods and parameters of evaluation of fixation method, 26 studies were further excluded. Thus 8 studies with a total of 823 estimates were included in qualitative synthesis.

Limitations: Parameters assessed by all the authors varied and hence a standardisation for comparison could not be done.

Conclusion: Five out of eight studies showed that the use of 3-point fixation in the treatment of zygomaticomaxillary complex fractures was superior than 2-point fixation for the same. Hence it can be concluded that 3-point fixation is superior than 2-point fixation in reducing malar asymmetry in zygomaticomaxillary complex fractures.

Future Implications: Future studies with uniform parameters being assessed can be done. 3-point fixation can be used as a standard treatment modality in the effective management of Zygomaticomaxillary complex fractures.