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Asian Journal of Surgery (2017) xx, 1e7

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Original Article

Surgical treatment of isolated zygomatic

fracture: Outcome comparison between
titanium plate and bioabsorbable plate
Chao-Ming Wu a, Ying-An Chen b, Han-Tsung Liao c,
Chih-hao Chen c, ChuneHao Pan d, Chien-Tzung Chen d,*

a
Department of Plastic Surgery, Chang Gung Memorial Hospital at Chiayi, Taiwan
b
Craniofacial Center, Department of Plastic Surgery, Chang Gung Memorial Hospital at Linkou, Taiwan
c
Division of Trauma Plastic Surgery, Department of Plastic Surgery, Chang Gung Memorial Hospital at
Linkou, Taiwan
d
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, College
of Medicine, Chang Gung University, Craniofacial Research Center, Taoyuan, Taiwan

Received 22 November 2016; received in revised form 12 March 2017; accepted 15 March 2017

KEYWORDS Summary Background: Zygoma fracture is of clinical importance because malar prominence
Bioabsorbable plate; plays an essential role in facial appearance. Traditionally, most maxillofacial surgeons perform
Titanium plate; osteosynthesis with titanium plates and screws for rigid fixation. However, this procedure has
Comparison; certain disadvantages that include the possibility of implant exposure, palpability or loosening
Zygoma fracture of the screws, painful irritation, temperature sensitization, and radiographic artifacts. In this
study, we compared the function and satisfaction outcome between Bonamates
bio-
absorbable implant and Leibinger titanium implant.
Method: Consecutively 53 patients with isolated unilateral zygomatic fracture that were
treated with the Bonamates
bioabsorbable plate system, n Z 53 were compared to patients
with the titanium plate system, n Z 55 in the period between 2009 and 2013. All patients were
followed-up at least 6 months. Preoperative and postoperative facial computed tomography
(CT) scans were performed and scored from 0 to 2 in the 5 areas of zygoma. A score of 2 indi-
cated the most severely displaced fracture in one of the areas. A visual analogue scale ranging
from 0 to 10 was used to assess the postoperative aesthetic and functional satisfactions.
Result: The mean ages of the patients in the bioabsorbable and titanium plate groups were 33
years and 30 years, respectively. The male to female ratios were 1.2:1 (bioabsorbable plate
group) and 1.1:1 (titanium plate group). The average preoperative CT scan scores of the bio-
absorbable and titanium plate groups were 5.7 and 5.1, respectively. The postoperative CT
scan scores of the bioabsorbable and titanium plate groups were 1.3 and 1.1, respectively.

* Corresponding author. Department of Plastic and Reconstruction Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung
University, College of Medicine, Craniofacial Research Center, 222, Maijin Road, Keelung, Taoyuan, Taiwan. Fax: þ886 2 24313161.
E-mail address: ctchenap@cgmh.org.tw (C.-T. Chen).

http://dx.doi.org/10.1016/j.asjsur.2017.03.003
1015-9584/ª 2017 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
 + MODEL
2 C.-M. Wu et al.

The implant cost of the bioabsorbable group was approximately 6-fold higher than that of the
titanium plate group. The complication rate was similar in both groups and included complica-
tions such as palpable implant, skin irritation, and hypersensitive cheek. The patients in both
groups attained similar mouth-opening function and a satisfactory score at 6 months after
operation.
Conclusion: This study revealed that the bioabsorbable plate outcome was similar to the tita-
nium plate outcome for patients with isolated unilateral zygomatic fracture. The bio-
absorbable implant system provides another option for internal fixation devices in the
treatment of zygomatic fractures and avoids implant removal surgery; however, the implant
cost of bioabsorbable plates is higher than that of titanium plates in Taiwan.
ª 2017 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services
by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction efficiency of the new bioabsorbable plate, we conducted a

Zygoma fracture is of clinical importance regarding facial
appearance and function. Displaced malar prominence
plays an essential role in the overall facial appearance and
results in deformity of the facial contour. Open reduction
and internal fixation are required to avoid ophthalmic
complications and masticatory dysfunctions in displaced
fractures.1 The most essential criteria for the successful
treatment of zygomatic fractures are accurate reduction
and the 3-dimensional stability of the displaced fracture to
achieve favorable aesthetic and functional results.2,3
Titanium plates and screws are used regularly for the
rigid fixation of zygomatic fractures. However, certain
disadvantages including the possibility of implant exposure,
palpable implant, screws loosening, pain sensation, cold
intolerance, and radiographic artifacts still exit.4,5 Some
patients require secondary operation to remove plates, and
the removal rate is 10e22.7%.6e8
To overcome the complications inherent in the titanium
implant system, bioabsorbable osteosynthesis has been
developed. The use of bioabsorbable plates and screws is
an attractive alternative compared with that of the tradi-
tional metal plate system.9 Because bioabsorbable implants
are completely resorbed, secondary surgery for removing
implants and long-term interference with nerves and the
growing skeleton can be prevented. In addition, the risk of
implant-associated stress shielding, peri-implant osteopo-
rosis, and infections is reduced. Furthermore, bio-
absorbable implants do not interfere with clinical imaging
and do not cause sensitivity to cold weather.10
The strength of the bioabsorbable plate system is a
major concern in its implementation. Hanemann et al re-
ported that combination of titanium plating and resorbable
plating systems exhibits adequate strength with negligible
complications for the treatment of isolated zygomatic
fractures in adults.11 Furthermore, using only the bio-
absorbable plate system showed stable fixation in displaced
zygomaticomaxillary complex fractures.12
There are 2 types of bioabsorbable plate: homopolymer
(Poly-L-lactic acid (PLLA), and polyglycolic acid (PGA)) and
copolymer (Lactosorb, BioSorb, and DeltaSystem). A
commercially available bioabsorbable system composed of
1.2-mm-thick plates and 2.5-mm-diameter screws (Bona-
Plates, PD series, Bonamates
, BioTech One, Taipei,
Taiwan) has recently been developed in Taiwan. To test the
study to compare the outcomes of the Bonamates
bio-
absorbable implants and titanium implants on a group of
patients with isolated zygomatic complex fractures.
2. Materials and methods
This is a retrospective caseecontrol study. Consecutively 53
patients with isolated unilateral zygomatic complex frac-
ture were treated with the bioabsorbable plate system
(Bonamates
) between 2009 and 2013. Patients with simple
zygomatic arch fracture, comminuted fracture at each
junction of zygoma and other facial bone, and multiple
midfacial fractures were excluded in this study. To compare
the outcome between the bioabsorbable and titanium plate
systems, control group are patients of similar isolated
zygomatic complex fractures (n Z 55) was treated with the
titanium plate system between the 2009 and 2013.
The fracture site is explored through the gingivobuccal
incision (Fig. 1). After achieved adequate reduction, fixa-
tion is performed with a bioabsorbable or titanium plate at
the lateral buttress, and this is the first fixation point. If
fixation was not rigid or reduction was not adequate during
operation, it is necessary to explore other fracture sites for
the second or third fixation points. We created an infra-
cilliary incision to approach the infraorbital rim and zygo-
maticofrontal (Z-F) junction. The infraorbital rim is the
typical second fixation point and followed by the Z-F
junction if necessary. All the surgical procedures were
performed by a single surgeon to avoid surgical bias.
For evaluation the fracture displacement and adequacy
of fracture reduction, we developed a CT scan scoring
system. Five anatomic points with the total score range
from 0 to 10 (0e2 for each point). A score of 2 represented
the most comminuted preoperative displacement and
inadequate reduction of more than 2 mm after operation.
A score of 1 indicated fracture displacement of less than
2 mm or nonunion (absence of calcified bone crossing the
fracture site). A score of 0 represented a minimal to non-
displaced fracture line preoperatively and accurate align-
ment with bone union postoperatively. Five evaluation
points, including the ZeF junction, sphenoidezygomatic
(SeZ) junction, inferior orbital rim, zygomatic arch,
and lateral buttress, were assessed in a series of
CT scans preoperatively and 6 months postoperatively
(Table 1).

Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
 + MODEL
Surgical treatment of isolated zygomatic fracture 3

Figure 1 Intraoperative view showing the bioabsorbable plate used to stabilize the fracture sites of the zygomaticomaxillary
buttress.

Table 1 Scoring system for assessment of the degree of fracture displacement and adequacy of reduction.
Score 0 1 2
Preoperative Minimal displacement Moderate displacement Segmental or comminuted displacement
Postoperative Adequate reduction and union Mild displacement and nonunion Inadequate reduction

The postoperative clinical assessments were performed
regularly at 4, 12, and 24 weeks to evaluate patient satis-
faction, using the visual analogue scale and functional
outcome. A 10-cm line with both ends labeled as extremes
and a score of 10 indicates high satisfaction. The patients
marked an X at the point that represents their satisfaction
most appropriately.
The outcome of preoperative and postoperative score
and satisfactory score between two plate groups are
compared using the two-sample t-test for unpaired com-
parisons. For each test, a p value < 0.05 is considered
statistically significant.
3. Results
Both the bioabsorbable and titanium plate groups included
patients (n Z 53, 55) with a follow-up at least 6 months.
The mean of patient age in the bioabsorbable and titanium
plate groups were 33 years and 30 years, respectively. The
male-to-female ratios were 1.2:1 and 1.1:1 in the bio-
absorbable and titanium plate groups, respectively. Co-
morbidity, associated injury, and trauma mechanisms
were comparable between the groups. In both groups, the
initial symptoms included malar depression with numbness
in the territory of the infraorbital nerve in all patients. In
addition, 6% diplopia and 4% enophthalmos (1 mm
difference than normal eye) were observed in the
bioabsorbable plate group. By contrast, 22% diplopia and
18% enophthalmos were observed in the titanium plate
group.
The average preoperative CT scan scores of the bio-
absorbable plate group were 5.5 (36% of patients), 5.9
(60%), and 5.1 (4%) for the one, two, and three points fix-
ations, respectively. By contrast, the average preoperative
CT scan scores of the titanium plate group were 4.5 (35%),
5.4 (62%) and 4.2 (2%) for the one, two and three points
fixations respectively. The average preoperative CT scan
score in the bioabsorbable plate group was 5.7 and
improved to 1.3 postoperative with an improvement degree
of 4.3 (Figs. 2 and 3). In the titanium plate group, the
average preoperative CT scan score was 5.1 and improved
to 1.1 postoperative with an improvement degree of 4. The
average operation time for the bioabsorbable plate group
was 40 min longer than that for the titanium plate group. In
addition, the average implant cost of the bioabsorbable
plate group was 5.52-fold higher than that of the titanium
plate group (Table 2).
The complications included palpable implant, hyper-
sensitive cheek, skin irritation, and ectropion. The
complication rate was similar in both groups. The maximal
mouth-opening function was higher in the bioabsorbable
plate group in the first 3 postoperative months, but a
similar function was observed in both groups in the first 6
postoperative months (Fig. 4). The appearance satisfaction

Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
 + MODEL
4 C.-M. Wu et al.

Figure 2 A Preoperative 3-dimensional computed tomographic scan showing the left zygomatic complex fracture with severe
displacement over the inferior orbital rim and lateral buttress fracture. Figure 2B Postoperative CT scan at 6 months revealing the
bioabsorbable plate located at the inferior orbital rim and lateral buttress.

Figure 3 A Preoperative 3-dimensional CT scan showing the moderate displacement of the left zygoma complex. Figure 3B
Postoperative 3-dimensional CT scan at 23 months postoperation showing the adequate reduction of left zygoma with the bio-
absorbable plate fixed at the lateral buttress.

was assessed in both groups at 1, 3, and 6 months post-
operation (Fig. 5). No case in either group required a sec-
ondary procedure for removing the implant during the
follow-up period of 6 months.
4. Discussion
In general, 2 types of bioabsorbable plate are available on
the market; one is homopolymer, including PLLA and PGA.
PLLA was the first bioabsorbable material applied in
treating facial trauma, which was used in the treatment of
patients with zygomatic fracture by Rudolf in 1987. PGA has
more rapid hydrolysis and triggers higher inflammatory re-
action.13 The disadvantages of homopolymer include unfa-
vorable degradation, foreign body reaction, prominent
swelling irrespective of the implant location, and the
requirement of surgical removal.14 Therefore, pure PLLA
and PGA are no longer used.
The other type of bioabsorbable plate is copolymer,
which includes the following: (1) Lactosorb, comprising
PLLA/PGA (82/18) with crystallinity of <10%, which retains
70% of initial strength for 6e8 weeks and dissolves
completely after 12e15 months, (2) BioSorb, comprising
PLLA/P (L/DL) LA (70/30), and (3) DeltaSystem, comprising
PLLA/PGA/PDLA (85/10/5). Previous studies have reported
satisfactory results of fixing zygomatic fractures with bio-
absorbable plates and screws.14e17
A randomized study was conducted by Wittwer et al18 to
compare the treatment outcomes and complication rates in
patients with displaced zygomatic fractures. The patients
were divided, on the basis of the fixation material, into 4
groups (A: LactoSorb, total number of patients (n) Z 15; B:
BioSorb, n Z 17; C: DeltaSystem, n Z 17; and D: Titanium,
n Z 15), whereas patients with comminuted zygomatic
fractures were excluded. No difference was observed in the
handling characteristics of the 3 materials (LactoSorb

Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
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Surgical treatment of isolated zygomatic fracture 5

Table 2 Outcomes between bioabsorbable plate and Titanium plate groups.

Bioabsorbable plate Titanium plate
Preoperative CT score (SD) 5.6 (1.1) 5.0 (0.4) P Z 0.277
Postoperative CT score (SD) 1.4 (1.6) 1.2 (1.1) P Z 0.297
Operation time (minutes) (SD) 136.1 (37.7) 94.2 (16.0) P Z 0.142
Postoperative hospital stay (d) (SD) 4.0 (1.3) 3.8 (0.7) P Z 0.595
Cost of plate and screw (NTD) (SD) 23,087 (2110) 4182 (480)
Follow-up period (month) (SD) 10.6 (4.3) 8.6 (3.2) P Z 0.156
NTD: New Taiwan Dollar.

Figure 4 Comparison of maximal mouth opening postoperation in both groups.

Figure 5 Comparison of the satisfactory score of appearance postoperation in both groups.

1.5 mm, BioSorb FX 1.5 mm, and DeltaSystem 1.7 mm). No
significant differences among all the bioabsorbable osteo-
synthesis materials or between bioabsorbable and titanium
fixation materials were observed with respect to fracture
healing and postoperative complications.18
In a study conducted by Enislidis et al, 65 patients with
isolated unilateral zygomatic fracture fixed with Lactosorb
plates and screws were included. Thirty patients received
the first fixation point at the zygomaticomaxillary buttress.
All patients showed a high postoperative symmetry (65/65).

Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
 + MODEL
6 C.-M. Wu et al.
The short-term complication rate was 22.8% and included
complications such as intraoral dehiscence with or without
implant exposure, temporary swelling, and ectropion. Five
patients had a long-term complication of ectropion,
whereas no implant-related complications were observed in
the long-term follow-up period. Thus, the authors reported
that bioabsorbable osteosynthesis materials can be
considered additional tools, but not for the replacement of
conventional metal osteosynthesis materials.19
The complications in using the bioabsorbable plate re-
ported in previous studies have included infection, fracture
instability, relapse, and implant-related tissue reaction,16
which was the most common complication causing recur-
rent pain and erythema of the overlying skin.18 In our study,
we used Bonamates (BonaPlates, PD series, Bonamates
,
BioTech One, Taipei, Taiwan) in the bioabsorbable plate
system. The molecular ratio of Bonamates was PLLA:
PDLA Z 95:5. The L-Lactide can provide strength to implants
and degrades slowly because of hydrophobicity. The D-Lac-
tide can disrupt crystallinity and has more flexibility. In our
study, we observed 2 cases of skin irritation on cheeks and
one case of palpable plate at the ZeF junction. The overall
complication rate observed in our study was 15%, which was
lower than that observed in a previous study (22.8%).19
However, a long-term follow-up period is required to
investigate the probability of the local tissue inflammation
or implant exposure caused by a new biodegradable plate.
The other disadvantage of bioabsorbable implants is
incomplete screw insertion because of inadequate screw
tapping and screw breakage; thus, an experienced surgeon
is required for handling bioabsorbable screws. No screw
breakage was observed during the operations in our study.
In addition, the mean operation time was 136 min longer in
the bioabsorbable plate group than in the titanium plate
group. Furthermore, this explained that the intraoperative
handling procedure involved a learning curve for both the
surgeons and scrubbing nurses.10 We supposed that the
operation time could be reduced as the staff gains
experience.
A previous study20 used craniofacial anthropometry
techniques to describe the position of the orbitozygomatic
complex in 3-dimensions and to allow the comparison or
measurement of post-trauma complex displacement.
However, the amount of facial swelling should be consid-
ered using this measurement tool. Ellis et al used a CT scan
to quantify the amount of malalignment of the zygomati-
comaxillary complex at only 3 different points to assess its
outcome.21 We developed a scoring system based on the CT
scan scores to evaluate the severity of fracture displace-
ment and adequacy of fracture reduction in 5 junctional
points. This system provided more objective assessment
and presented the quantitative difference between the
preoperative and postoperative CT scan images.
Bioabsorbable devices have limitations such as the bulk
and large diameter of bioabsorbable materials and they
cannot be used under certain conditions, such as poor
stability of fixation and small bone fragments. Because of
this limitation Wittwer et al combined the bioabsorbable
and titanium plates to treat isolated zygomatic complex
fractures.18
Although the cost of bioabsorbable plates is much higher
than that of traditional titanium plates, the implant cost of
Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003
both types are covered by Taiwan’s National Health Insur-
ance program. Furthermore, the bioabsorbable plate group
had a similar functional outcome and patient satisfaction
rate as the titanium plate group. The advantage of the
bioabsorbable plate is that it can avoid a secondary surgical
procedure for plate removal if necessary in comparison
with 12% of hardware removal in Francel’s study.4
5. Conclusion
Both the bioabsorbable and titanium plate groups had
similar outcomes without major complications. The
Bonamates
plate provides reliable results for isolated,
non-comminuted zygomatic fractures in selective cases and
presents another optional fixation device for zygomatic
fracture. However, a longer follow-up period is required to
observe possible long-term complications.
Conflict of interest
There are no commercial associations or conflicts of inter-
est for disclosure by the authors.
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Please cite this article in press as: Wu C-M, et al., Surgical treatment of isolated zygomatic fracture: Outcome comparison between
titanium plate and bioabsorbable plate, Asian Journal of Surgery (2017), http://dx.doi.org/10.1016/j.asjsur.2017.03.003