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\begin{document}

\title{META-ANALYSIS OF THE MAJOR CLINICAL FRACTURE RESULTS OF THE
ZYGOMATIC-MAXILLARY COMPLEX WITH 1-POINT FIXATION: SUCCESS RATE AND
COMPLICATIONS}



\author[1]{Dr. Idiberto Jose Zotarelli Filho, MSc, Ph.D}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 21, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Introduction:} Fractures of the zygomatic-maxillary complex
(ZMC) are common facial fractures. Annually 5.8 million people die from
trauma worldwide. According to WHO data, head and face injuries can
account for half of traumatic deaths. \textbf{Objective:} To analyze the
success rates of fracture stability of the ZMC, incidences of
complications and aesthetic satisfaction after 1-point fixation.
\textbf{Methods:} This study followed the rules of PRISMA, with
publications from 2010 to 2020. The Chi-Square Test and the Poisson's
Probability Test were performed in relation to the occurrence of
complications Low = 1, Moderate = 2 and NO = 0, adopting the \selectlanguage{greek}α-\selectlanguage{english}level
less than 0.05 with a statistical difference for 95\% CI. The R-sq
(R\textsuperscript{2}) value was also analyzed among the complications
variables. \textbf{Results:} The results of these studies showed in a
general way that the use of 1-point fixation presented good results in
the short, medium and long term, showing fracture stability, with or
without open reduction. Complication rates were low and patients'
satisfaction with aesthetics was considerable. \textbf{Conclusion:} The
success rate of the 1-point fixation procedure for the
zygomatic-maxillary complex is high, with minimal complications.

\textbf{~}

\textbf{Keywords:} Zygomatic-maxillary complex. 1-point fixation.
Fracture stability. Complications. Aesthetics.%
\end{abstract}%



\sloppy


\par\null

\textbf{Ramiro Murad Saad Neto}\textsuperscript{\textbf{1}}\selectlanguage{ngerman}\textbf{,
Idiberto José Zotarelli Filho}\textsuperscript{\textbf{2,3}}\textbf{,
Carlos Eduardo Xavier S. Ribeiro da Silva}\textsuperscript{\textbf{1}}

~1.~~~~~ Prevent Senior, Health plan, São Paulo/SP, Brazil

2.~~~~~ Faceres - Medical School of São José do Rio Preto/SP, Brazil.

3.~~~~~ Zotarelli-Filho Scientific Work, São José do Rio Preto/SP,
Brazil.



\textbf{Introduction}

In the scenario of facial trauma, fractures of the Zygomatic-maxillary
complex (ZMC) are common facial fractures. Annually 5.8 million people
die from trauma worldwide {[}1{]}. Trauma mortality accounts for 10\% of
all causes of death. Thus, trauma is a worldwide public health problem.
Still, trauma is the main cause of death among patients aged 1 to 44
years and the fourth major cause considering all age groups. According
to WHO data, head and face injuries can represent half of traumatic
deaths {[}1{]}.

In this context, the ZMC is an important structure, serving as an
important buttress of the middle third of the face. The ZMC also
aesthetically projects anterolaterally to form the malar eminence and
establish the width and medial-facial contour of the orbital border
{[}2{]}. Attempts to treat ZMC fractures are to achieve stability and
restore aesthetic appearance through three-dimensional reduction and
rigid fixation. After adequate fracture reduction, it is important to
maintain stability and rigid fixation to avoid functional impairment and
aesthetic sequelae. Thus, open reduction and internal fixation have been
used as a standard method for the treatment of these fractures {[}3{]}.

Therefore, several surgical and technical procedures, including fixation
of one, two and three points are used according to the severity and
extent of ZMC fractures {[}4{]}. Among these techniques, some authors
argue that fixation of just one point provides sufficient stability of
the ZMC fracture when the ZMC fracture is not crushed {[}5,6{]}. At the
moment, it is not yet clear which treatment, fixation of one point,
fixation of two points or fixation of three points, is better {[}7{]}.
In addition, there is a growing interest in minimally invasive
procedures and concerns about scarring, further highlighting the use of
fixing a point. Thus, fixing a point of the zygomatic- maxillary (ZM)
buttress through a gingivobuccal incision has the advantage of not
leaving an external scar {[}8,9{]}.

In this sense, the main indications for the use of fixation at 1 point
of the tripod fracture are minimal or moderate displacement of the
infra-orbital border in the zygoma tripod fracture, no ocular sign of
diplopia or enophthalmia and comminuted infraorbital edge fractures in
which internal fixation is difficult {[}10{]}. Successful repair
requires not only an accurate diagnosis, but also a careful
consideration of the complex three-dimensional anatomy, because even
minimally displaced fractures in the ZMC can result in functional and
aesthetic deformities {[}10{]}.

Therefore, the present study aimed to analyze, through a meta-analysis,
the success rates of fracture stability of the Zygomatic-maxillary
complex, incidences of complications and aesthetic satisfaction after
1-point fixation.

\textbf{Methods}

\textbf{Study design}

This study followed the international model of Systematic Review and
Meta-analysis, following the rules of PRISMA (preferred reporting items
for systematic reviews and meta-analysis) {[}11{]}. \textbf{Table
1}shows the main variables of the present study that will be addressed
according to the classification of the acronym PICOS (P = Patients; I =
Intervention; C = Control; O = Outcomes; S=Study design).

\textbf{Data sources and research strategy}

The search strategies for this systematic review was based on the
descriptors (MeSH Terms) \emph{``Zygomatic-maxillary complex. 1-point
fixation. Fracture stability. Complications. Aesthetics''} , with
publications from 2010 to 2020, in order to analyze the most recent
scientific publications. The research was carried out in June 2020 and
developed at SCOPUS (Elsevier and non-Elsevier database), PUBMED
(MEDLINE biomedical literature, life science magazines, and online
books) and SCIENCE DIRECT (Elsevier database), including the National
Institutes of Health RePORTER Grant database and clinical trial records.
In addition, a combination of the keywords with the Booleans ``OR'', AND
and the operator ``NOT'' was used to target scientific articles of
interest. The title and abstracts was examined under all conditions. The
research structure used in the databases is shown in \textbf{Table 2.}

\textbf{Selection of studies- Eligibility}

The inclusion criteria were clinical studies published from 2010 to 2020
on fractures of the ZMC and treatment with 1-point fixation, with or
without open reduction, and with the use of bioabsorbable plates or not.
Exclusion criteria were case report studies, review studies and
meta-analysis or clinical studies that presented discreet results. 32
scientific articles were found at the clinical level. After applying the
article selection filter, 15 articles were found, of which only 7
articles are strictly related to the analysis criteria of the present
study to compose the meta-analysis (Figure 1).

\textbf{Risk of bias}

The quality of the evidence was classified as high, moderate, low or
very low, according to the risk of bias in the body of evidence,
openness of comparisons, accuracy and consistency in the effects of
treatment. High quality of evidence has been attributed to well-designed
randomized controlled trials (RCTs) with consistent results. The quality
of the evidence was downgraded to moderate if 1 of the 4 criteria for
the quality of the evidence had not been met and lower if 2 or more were
not met. A low quality of evidence was attributed to non-randomized
studies. The Cochrane instrument was be adopted to assess the quality of
the included studies {[}12{]}.

\textbf{Summary of Literary Findings}

The present study had some limitations as few clinical studies in the
last ten years on 1-point fixation in the ZMC (n = 7), with three
studies being retrospective and three were prospective, and only one
study was randomized.

\textbf{Statistical Analysis}

The statistical analysis of the data was performed by Dr. Idiberto José
Zotarelli Filho and interpreted by the principal investigator. For data
analysis, a database was built on the Microsoft Excel spreadsheet which
was exported to the Minitab 18\textsuperscript{®} statistical program
(version 18, Minitab, LLC, State College, Pennsylvania, USA) (Minitab®)
and also to the OriginPro® 9 (DPR Group, Inc., Northampton,
Massachusetts, USA). A common descriptive statistical analysis was
performed, obtaining the values of total n, mean and standard deviation,
confidence interval (CI), and percentage for all the variables. The
Chi-Square and the Poisson Probability Test were performed in relation
to the occurrence of complications Low = 1, Moderate = 2 and NO = 0,
adopting the \selectlanguage{greek}α-\selectlanguage{english}level less than 0.05 with a statistical difference for
95\% CI. The R-sq (R\textsuperscript{2}) value was also analyzed among
the complications variables, with the codes being adopted, low
association = \textless{}25\%, medium association 25\% \textless{}X
\textless{}50\% and high association =\textgreater{} 50\%.

\textbf{Results of Meta-analysis}

After the application of the descriptors (MeSH Terms) in the databases
presented in the item Data sources and research strategy, 32 scientific
articles were found at the clinical level. After applying the article
selection filter for the last 10 years, 16 articles were found, of which
only 7 articles are strictly related to the objective of the present
study and entered the meta-analysis.

Table 3 presents the general data of each study analyzed, such as Type
of study, number of patients in each study, the types of fixation points
used, highlighting the priority for the analysis of 1-point fixation,
the main results of each study and the Follow up or Period of analysis
of each study. It also presents, in a manner described below, in Table
3, which were the main complications presented in some of the studies.
Two of the studies used biodegradable plates to compare fracture
stability with other plates.

Table 4 shows in quantitative terms the main complications in each
study, using the numeric codes Low = 1, Moderate = 2 and NO = 0, as well
as showing the success rates related to each study technique,
highlighting that in one study the technique was used by
three-dimensional photogrammetric analysis and in another study the
ultrasound-guided technique was used and titanium and biodegradable
plates were used.

After the statistical analysis to find out what the associations were
between the complications of the studies by the Chi-Square Test, the
results showed that there was no statistical difference between them,
with p = 0.305\textgreater{} 0.05 and R\textsuperscript{2} = 55.2\%
(high association). In addition, using the Poisson Probability Test, it
was found that the probability of complications Low = 1, Moderate = 2
and NO = 0 was 0.65, 0.28 and 0.07, respectively (Table 5). This same
Table shows that the frequency of occurrence of NO-Complication was 5
(71.43\%), Low-Complication was 1 (14.29\%) and Moderate-Complication
was 1 (14.29\%).

Figure 2 shows the graph with data on frequency, probability and
percentage of occurrence of complications.

\textbf{Discussion}

The present study presented the state-of-the-art with presentation of a
meta-analysis of the last ten years of publications of clinical studies
on the use of 1-point fixation for fractures of the ZMC, both with the
use of non-absorbable plates and bioabsorbable. The results of these
studies showed in a general way that the use of 1-point fixation
presented good results in the short, medium and long term, showing
fracture stability, with or without open reduction. Complication rates
were low and patients' satisfaction with aesthetics was considerable.

The studies of the present work also showed that the use of
three-dimensional photogrammetric analysis and the ultrasound-guided
technique can greatly favor the procedure and, in addition, they also
showed that the use of biodegradable plates can offer good advantages,
given that they showed equal stability of the fracture when compared
with conventional plates. In this sense, achieving satisfactory results
in the treatment of complex fractures of the middle and zygomatic
maxillary face involves a series of decisions that include the approach
of the zygomatic arch as the main point of treatment. In addition, a
distinct pattern of fractures can generate more challenges to achieve
satisfactory results.

The ZMC plays a fundamental role in the structure, function and
aesthetic appearance of the facial skeleton. They can be responsible for
approximately 40\% of midface fractures. They are the second most common
facial bone fracture after injuries to the nasal bones {[}3{]}. The
fracture complex results from a direct impact on malar eminence and
results in three distinct fracture components that interrupt the
anchorage of the zygoma. In addition, the fracture components can result
in temporal muscle shock, trismus (difficulty in chewing) and compromise
the foramen / infraorbital nerve, resulting in hypesthesia in its
sensory distribution {[}4{]}.

In this context, a study performed a four-year retrospective review of
all patients treated for ZMC fractures in the department of oral and
maxillofacial surgery. A total of 245 patients were identified for
fractures of the ZMC. Closed or open reduction methods were performed in
order to treat the preservation of normal facial structure, sensory
function, globe position and chewing functionality. Significant facial
asymmetry that requires surgical revision occurs in 3-4\% of patients.
Postoperative infection rates have proved to be extremely low, and these
infections almost always resolve with oral antibiotics. Thus, the
long-term prognosis after repair of ZMC fractures is usually very good
{[}5{]}.

In this scenario, no clinical consensus was reached regarding the number
of fixation points required when performing open reduction and internal
fixation. A retrospective study of 211 patients over a 20-year period
looked at the usefulness of single-point fixation in the treatment of
ZMC fractures. The average follow-up time was 3.4 months. Of the 211
patients, 162 with ZMC fractures were treated with single-point
fixation. During the follow-up period, 1 patient suffered tooth loss
because of a root present in the fracture line, 7 experienced intraoral
exposure of the plaque, with 2 subsequently in exchange for the plaque
and 8 developed wound infection. No patient required orthognathic
surgery or cheek implant for malar asymmetry. No patient developed
hypoglobus or enophthalmia, and none required a review of the internal
fracture fixation {[}6{]}. Despite this, there is still controversy as
to the ideal degree of exposure, reduction and anatomical fixation
required during open reduction and internal fixation of fractures of the
ZMC {[}7{]}.

In addition, a prospective controlled study functionally assessed the
behavior of the masticatory muscles (masseter and temporal) after
fractures of the ZMC, evaluating the strength of the bite, the
electromyography (EMG) and the mandibular movements. Group I consisted
of 20 patients with unilateral fractures of the ZMC who were treated
surgically with fixations of one, two or three points in the
frontozygomatic, infraorbital or zygomatic maxillary buttress region.
The control group in group II included 20 normal patients. Muscle
activity was functionally assessed before and after surgery for a period
of 6 months. The evaluation consisted of measuring the bite force, EMG
analysis of the masseter and temporal muscles and measures of the
mandibular movements. There was an increase in bite strength and
electromyographic activity over the evaluated postoperative period, but
at the end of 6 months, the values were still below the control levels
for most patients. The maximum mouth opening increased considerably
after surgery. According to the bite force and the EMG, the masticatory
muscles returned to almost normal levels in the third month after
surgery, mainly with 1-point fixation. Thus, this study supports the
current clinical concept of minimized fixation in the treatment of ZMC
fractures {[}8{]}.

In addition, fracture of the zygomatic tripod is relatively common and
usually requires open fixation with internal reduction through several
incisions. However, the lateral incisions of the eyebrow sometimes leave
unpleasant scars and, therefore, one point fixation can be used through
a bucco-gingival incision to not leave scars in selected cases. Thus, a
5-year retrospective study with 30 patients compared the fixation of 1
point in the ZMC with the fixation of 2 points in the ZM and
frontozygomatic (FZ) areas in tripod fractures. We investigated 14
patients with fixation of 1 point in the ZMC (group 1), 1 of whom had
bilateral tripod fractures and 16 patients with fixation of 2 points in
the ZM and FZ area (group 2). Of the 16 patients in group 2, 10 (63\%)
complained of ugly scars at the site of the lateral incision of the
eyebrow, while none of the patients in group 1 complained of external
scars. None of the patients complained of bone movement and pain in the
FZ area in both groups. In group 2, 4 of 16 patients (25\%) complained
of palpability in the FZ area, while none in group 1 complained of
palpability. The satisfaction score for the surgery was 9.4 \selectlanguage{ngerman}± 1.6 in
group 1 and 7.7 ± 2.6 in group 2 (p \textless{}0.05). In addition, two
patients underwent surgery to remove plaque in group 2. None of the
patients in group 1 complained of aesthetic problems, without fixation
in the FZ area {[}9{]}.

Zygoma is an important buttress of the medial-facial skeleton, which is
often injured due to its prominent location. Zygoma fractures are
classified according to Knight and North based on the direction of
anatomical displacement and the pattern created by the fracture. In
fractures of the ZMC, many incisions, such as the lateral eyebrow, upper
lateral blepharoplasty, transconjunctival, subciliary, subciliary,
subversal, intraoral and direct percutaneous approaches are useful
{[}13{]}.

Therefore, a study analyzed the cases of lateral incision of the
forehead and fixation of 1 point and introduced the criteria for
applying this selective approach. Among 70 patients with tripod
fractures, 14 patients (20\%) underwent the 1-point fixation technique
through lateral incisions of the forehead. The preoperative and
postoperative displacements of the infra-orbital border were measured
radiologically. Of these patients, 7 cases (50\%) were type III, 6 cases
(43\%) type IV and 1 (7\%) type V, according to Knight. and North
Classification. Simple fracture of the infra-orbital border was observed
in 10 patients (71\%) and crushed fracture was observed in 4 patients
(29\%). In 11 patients, the front zygomatic sutures were fixed with
square microplates with 4 holes and 0.5 mm thick, and straight mini
plates with 4 holes and 1.0 mm thick were used in 3 patients. Of the 14
tripod fractures, 6 (43\%) were associated with floor fractures. Seven
had displacement of the infraorbital border (range 2.0-7.6 mm; mean, 4.6
+/- 0.8 mm), and the other 7 had no displacement of the infraorbital
border. After surgery, the deformities of the steps at the infraorbital
edges were improved. All 14 patients were satisfied with the
postoperative appearance {[}10{]}.

Another 2019 retrospective study evaluated the results of stability and
aesthetic appearance of fixing a point using a three-dimensional
photogrammetric analysis. In nine months of medical record analysis, 34
patients with ZMC fractures were treated by fixing a point on the ZM
buttress using non-sintered hydroxyapatite (u-HA) / poly-L-lactide
(PLLA) plates. The differences in the inter-malar height of the soft
tissues between the fractured side and the non-fractured side were
assessed by photogrammetric analysis with a three-dimensional camera
(Morphius®) preoperatively and 1 week, 1 and 3 months after surgery. All
patients achieved satisfactory bone stability and a symmetrical malar
appearance. There was no statistically significant difference between 1
and 3 months after surgery. The comparison of differences in inter-malar
bone height revealed a statistically significant difference between
before and 6 months after surgery (p \textless{}0.01). Therefore, the
use of three-dimensional photogrammetric analysis for fixation to a
point of the ZM buttress using a u-HA / PLLA plate produced reliable,
satisfactory and safe clinical results in patients with ZMC fractures
{[}14{]}.

In addition, a prospective study with 24 patients analyzed the precision
and postoperative stability of the 1-point ultrasound-guided fixation in
the ZM buttress for the treatment of ZMC fractures, without fracture
separation in the frontal process of the zygomatic bone. The authors
used titanium plates in the first 6 cases and biodegradable plates in
the remaining 18 cases. The results suggested that the fixation of 1
point guided by ultrasound in the ZM buttress can provide an accurate
reduction of the fractures of the ZMC without the separation of the
frontal process of the fracture of the zygomatic bone. In addition,
fracture stability has been established, even with the use of
biodegradable plates {[}15{]}.

Also, a randomized study with 20 patients performed to compare the
fracture stability of the ZMC using biodegradable plates and titanium
miniplates with fixation at one point. Patients with fractures of the
ZMC were randomly selected and divided into two groups, which were
divided into two subgroups. Group I patients were treated with a
titanium miniplate in the zygomatic buttress and group II was treated
with bio-resorbable plates. The fixation of a point was carried out in
the zygomatic buttress or in the frontozygomatic suture and it was
observed that the site has been the most preferred site for rigid
internal fixation in terms of stability, aesthetics and prevention of
rotation of the fracture segment, vertical or horizontal axis. There was
no significant difference in postoperative results between two groups,
but the system still bioresorbable has some advantage over the titanium
system, as these plates reabsorb for a period of time and do not
interfere with growth and postoperative radiotherapy {[}16{]}.

Still, the reduction and fixation of the zygomatic arch is a key point
in the treatment of complex fractures of the middle face and zygomatic
maxillary. High-impact frontal trauma can cause posterior displacement
of the zygomatic bone, with a sagittal fracture of the root of the
zygomatic arch extending posteriorly to the glenoid fossa. The fixation
of the mini-plate and screw of this fracture requires a great detachment
of soft tissues, being technically more difficult for an adequate
fixation and increasing the risk of damage to the soft tissues.
Therefore, a study described an operative approach for fixing this type
of fracture using an adaptation of the delay screw technique. After the
initial reduction of the zygomatic bone, the proximal segment of the
zygomatic arch containing the sagittal fracture is anatomically reduced
and a 2.0 mm titanium screw is placed with a lower inclination of 10 °
to 15 ° in the mastoid cells of the temporal bone, thus avoiding the
placement of intracranial screws. Thus, excellent results in reduction
and long-term stability were presented, it facilitates the surgical
procedure, reduces the risk of damage to soft tissues and can reduce
costs in comparison with the conventional mini-plate and fixation by
screws {[}17{]}.

\textbf{Conclusion}

The present study showed that the success rate of the 1-point fixation
procedures for the Zygomatic-maxillary complex is high, with minimal
complications.

\textbf{Limitations}

Despite the satisfactory results presented on the 1-point fixation
technique of the Zygomatic-maxillary complex, the present study had some
limitations as few studies on the 1-point fixation, limited number of
studied patients and presented three retrospective studies, three
prospective and only one randomized study.

\textbf{Declaration of conflicts of interest}

The authors declare nothing and all authors are aware of the article.

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\item
  Sato A,~Imai Y,~Muraki K,~Tachi M. Reliability of Ultrasound-Guided
  One-Point~Fixation~for Zygomaticomaxillary~Complex~Fractures. J
  Craniofac Surg.~2019 Jan;30(1):218-222. doi:
  10.1097/SCS.0000000000005133.
\item
  Tripathi N,~Goyal M,~Mishra B,~Dhasmana S. Zygomatic~complex~fracture:
  A comparative evaluation of stability using titanium and
  bio-resorbable plates as one point~fixation. Natl J Maxillofac
  Surg.~2013 Jul;4(2):181-7. doi: 10.4103/0975-5950.127648.
\item
  Ribeiro Ribeiro AL,~Rodrigues TM,~Alves-Junior Sde M,~Pinheiro Jde J.
  Interfragmentary screw~fixation~of the~zygomatic~arch
  in~complex~midface and zygomaticomaxillary~fractures. J Oral
  Maxillofac Surg.~2015 Mar;73(3):494-8. doi:
  10.1016/j.joms.2014.09.028. Epub 2014 Oct 17.
\end{enumerate}

\textbf{Table 1.} PICOS (PATIENT, PROBLEM, POPULATION; INTERVENTION;
COMPARISON, CONTROL; OUTCOMES; STUDY DESIGN) FRAMEWORK.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Population & Adults with zygomaticomaxillary complex fractures
(quadripod fracture, quadramalar fracture, tripod fracture, or trimalar
fracture); unilateral or bilateral factures.\tabularnewline
Intervention & 1-point fixation with or without miniplates and
reduction.\tabularnewline
CONTROL & Different types of plates; Use of three-dimensional
photogrammetric analysis; Use of ultrasound-guided
technique.\tabularnewline
outcomes & Patient satisfaction with function and aesthetics results;
Stable fracture fixation; Pain; Quality of life; Surgical complications;
Masticatory force.\tabularnewline
STUDY DESIGN &\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Example of the research structure in PubMed, the same
search strategy was used

in the other databases.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
PubMed\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Zygomatic-maxillary complex OR Fracture OR 1-point fixation\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{AND}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
PubMed\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Fracture stability \textbf{OR} Complications \textbf{OR} Aesthetic
\textbf{OR} Masticatory force \emph{Aest}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{NOT}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
PubMed\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Case report \textbf{OR} 2 to 4 point fixings\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure 1.} Flow chart.

\textbf{Table 3.} General data of the selected studies to compose the
meta-analysis.

* 7 experienced intraoral plaque exposure, with 2 subsequently in
exchange for plaque complications, 8 infections.\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Authors (n=7) /Major points and results}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Type of Study}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{N patients}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Procedures} \textbf{(} \textbf{Fixings-Points )}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Major Results}\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\textbf{Follow up or} \textbf{Analysis period}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Shokri et al., 2020}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prospective\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
162\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
The ZMC fracture responded well with the 1-point fixation.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3.4 months\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Panchanathan et al., 2016}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Controlled prospective\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
40 (n=20 control)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1 (n=4) 2 (n=12) 3 (n=4)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Increased bite strength and muscle activity.\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6 months\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Kim et al., 2011}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Retrospective\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1 (n=14) 2 (n=16)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
There was no statistical difference between the three types of
fixation.\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Evaluation of 5-year medical records\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Hwang, 2010}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Retrospective\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Fixing a point on the ZMC can prevent unpleasant scarring and provide
high satisfaction in patients with tripod fractures.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Evaluation of 1.5-year medical records\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Kim et al., 2019}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Retrospective\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1*\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
The deformities of the steps of the infraorbital edges were
improved.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Evaluation of medical records of 9 months\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Sato et al., 2019}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prospective\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1**\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
All patients were satisfied with the postoperative appearance.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 months\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Tripathi et al., 2013}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Randomized\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1***\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
All patients achieved satisfactory bone stability and a symmetrical
malar appearance.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 months\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

** Group I: Titanium. Swelling was observed in all patients on the first
postoperative day. Diplopia was observed in 5\% of patients for 3 months
in subgroup A. Palpability was also observed in 5\% of cases in subgroup
B for 6 months. On the contrary, enophthalmia, paraesthesia, screw
breakage, plaque exposure, infection at the site, malocclusion and
thermal sensitivity were not observed in the postoperative period and
the bite efficiency of all patients was normal in the postoperative
period.

** Group II: Biomaterial. As the postoperative complication found in
group II - Swelling was observed in all patients on the first
postoperative day. Diplopia was observed in 10\% of patients, screw
rupture was observed in 10\% of the patient at the time of surgery,
plaque exposure and infection at the site was observed in 10\% of cases
in the 6-month review. On the contrary, enophthalmia, paresthesia,
palpability, thermal sensitivity and malocclusion were not observed in
any patient in the postoperative period. Bite efficiency was considered
normal in all patients.

*** n = 10 with titanium plates and n = 10 with biodegradable plates.

\textbf{Table 4.} Data on the findings of complications and success rate
of the studies addressed.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Authors} & \textbf{Complications (Low=1, Moderate=2 and NO=0)} &
\textbf{Technique Success Rate (\%)}\tabularnewline
\midrule
\endhead
\textbf{Shokri et al., 2020} & \textbf{2} & \textbf{90.0}\tabularnewline
\textbf{Panchanathan et al., 2016} & \textbf{0} &
\textbf{74.2}\tabularnewline
\textbf{Kim et al., 2011} & \textbf{0} & \textbf{100}\tabularnewline
\textbf{Hwang, 2010} & \textbf{0} & \textbf{100}\tabularnewline
\textbf{Kim et al., 2019*} & \textbf{0} & \textbf{100}\tabularnewline
\textbf{Sato et al., 2019} & \textbf{0} & \textbf{100}\tabularnewline
\textbf{Tripathi et al., 2013**} & \textbf{1} &
\textbf{70}\tabularnewline
\bottomrule
\end{longtable}

* Used non-sintered hydroxyapatite (u-HA) / poly-L-lactide (PLLA) plates
and three-dimensional photogrammetric analysis

** Guided by ultrasound and used titanium and biodegradable plates.

\textbf{Table 5.} Statistical results of the Chi-Square analysis,
Poisson's Probability, frequency and percentage of occurrence of the
levels of complications, with p \textless{}0.05 with statistical
difference, CI95\%.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\textbf{Complications} \textbf{(Low=1, Moderate=2 and NO=0)}\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\textbf{Poisson} \textbf{Probability}\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\textbf{Frequency}\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\textbf{Percent(\%)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.65\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
71.43\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.28\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14.29\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2 \textbf{CHI-SQUARE TEST} \textbf{p-value=0.305\textgreater{}0.05}
\textbf{R\textsuperscript{2} = 55.2\%}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.07\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
14.29\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 2.} Graph showing the comparisons between the levels of
complications, being Low = 1, Moderate = 2 and NO = 0.

\selectlanguage{english}
\FloatBarrier
\end{document}

