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Zygomatic Orbital Fracture Treatment & Management

  • Author: Stuart Seiff, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 19, 2014
 

Medical Care

The aims of treatment of zygomatic complex fractures include the restoration of normal facial form, normal sensory nerve function, normal globe position, and normal masticatory function. Indications for repair of zygomatic complex fractures include displacement or instability of the fracture, mechanical restriction of mandibular movement (chewing), alteration in facial contour, globe dystopia, enophthalmos, diplopia, or sensory nerve deficit.[9]

  • The literature indicates that 10-50% of all zygomaticomaxillary complex fractures require no surgical intervention. This is suitable for fractures that are nondisplaced or minimally displaced or where systemic status precludes operative intervention.
  • Stable, nondisplaced fractures may be observed weekly for healing.
  • Avoidance of nose blowing is mandatory in the medical care of these patients. The disrupted orbital walls can allow air to be forced into the retrobulbar space and cause pain and visual loss.
  • The routine use of systemic antibiotics for isolated zygomatic arch fractures generally is not recommended.
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Surgical Care

Generally, it is suggested to avoid surgery during times of maximum edema but prior to the adhesion of displaced bony fragments and scarring of soft tissues into bony defects. Most surgeons advise surgical intervention prior to the formation of dense scar tissue. As a general guideline, surgery should be undertaken prior to 3 weeks postinjury.[4, 10, 11]

Traditionally, closed-reduction techniques were the method of choice for nearly all zygomatic fractures. In the past, simple techniques, such as exerting pressure under the zygomatic arch and resetting the bones in their anatomic position (eg, Gilles approach), were hindered by unsatisfactory cosmetic results and persistent diplopia. Although open techniques currently are favored, closed-reduction techniques may be suitable for isolated arch fractures and minimally displaced noncomminuted fractures.[12]

A more aggressive approach using open-reduction techniques and rigid stabilization with plating systems (eg, Synthes or Leibinger) is the standard of care today, particularly for unstable or potentially unstable fractures.[13]

  • This approach provides direct access to the frontozygomatic suture, orbital floor, and infraorbital rims.
  • The inferior orbital rim and floor can be exposed via an infraciliary approach or a transconjunctival approach. The transconjunctival incision gives excellent exposure and saves the patient a visible scar on the face.
  • The floor of the orbit is routinely explored and reconstructed, if needed, to restore orbital volume. At this point, the zygomatic arch and orbital rims should be aligned. [14]
  • Typically, the inferior rim defects are visible through the orbital incision. The lateral rim fracture frequently occurs at the frontozygomatic suture line. This sometimes can be reached via the lateral lid crease or canthal incision. Rarely, a second incision may be needed under the lateral brow. This can be used to approach the lateral fracture and to provide access to elevate that bony fragment.
  • Once proper access to the lateral rim has been achieved, an elevator is passed along the lateral rim and under the zygomatic arch at its anterior origin. Firm anterior pressure, not prying, is applied to the elevator to align the lateral and inferior fragments.
  • Once these are positioned, they are fixated with miniplates.
  • Precise reconstruction with rigid internal fixation of the zygoma at 2 or 3 points (across the frontozygomatic suture, the inferior orbital rim, and the lateral midfacial buttress) is needed to counter the force of the masseter muscle. The orbital contents can be supported as for simple orbital floor fractures.
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Consultations

Consultations with other services, such as otolaryngology, the oral maxillofacial service, facial plastic surgery, and neurosurgery, may be needed if significant concomitant nasal, oral, and/or cranial fractures are present.

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Diet

Patients commonly are placed on a soft diet for several days to weeks. A dietary consultation may be warranted.

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Activity

Advise patients to avoid nose blowing for several weeks after the surgery. All contact sports and most strenuous activity also should be avoided for several weeks.

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Contributor Information and Disclosures
Author

Stuart Seiff, MD, FACS Emeritus Professor of Ophthalmology, University of California, San Francisco, School of Medicine; Chief, Department of Ophthalmology, San Francisco General Hospital; Consultant, Oculofacial and Aesthetic Plastic Surgery, California Pacific Medical Center and Mills Peninsula Medical Center

Stuart Seiff, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Dan D DeAngelis, MD, FRCSC Assistant Professor of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Ophthalmologist, Department of Ophthalmology and Vision Sciences, Hospital for Sick Children

Dan D DeAngelis, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, California Medical Association, Canadian Medical Association, Canadian Ophthalmological Society, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Susan Carter, MD Clinical Associate Professor of Ophthalmology, Institute of Ophthalmology and Visual Science, New Jersey Medical School

Susan Carter, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Jesus Torres, MD Fellow, Section of Oculoplastic Surgery, Hospital de Viladecans, Spain

Jesus Torres, MD is a member of the following medical societies: American Academy of Ophthalmology, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.

References
  1. Gruss JS, Van Wyck L, Phillips JH, et al. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. 1990 Jun. 85(6):878-90. [Medline].

  2. Song WC, Choi HG, Kim SH, et al. Topographic anatomy of the zygomatic arch and temporal fossa: A cadaveric study. J Plast Reconstr Aesthet Surg. 2008 Oct 21. [Medline].

  3. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg. 1992 Aug. 50(8):778-90. [Medline].

  4. Covington DS, Wainwright DJ, Teichgraeber JF, et al. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. 1994 Aug. 37(2):243-8. [Medline].

  5. Barry C, Coyle M, Idrees Z, et al. Ocular findings in patients with orbitozygomatic complex fractures: a retrospective study. J Oral Maxillofac Surg. 2008 May. 66(5):888-92. [Medline].

  6. He D, Li Z, Shi W, Sun Y, Zhu H, Lin M, et al. Orbitozygomatic Fractures With Enophthalmos: Analysis of 64 Cases Treated Late. J Oral Maxillofac Surg. 2011 Jul 11. [Medline].

  7. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. 1993 Jul-Aug. 22(4):145-88. [Medline].

  8. Friedrich RE, Heiland M, Bartel-Friedrich S. Potential of ultrasound in the diagnosis of midface fractures. Clinical Oral Investigations. 2003. 7:226-229. [Full Text].

  9. Parashar A, Sharma RK, Makkar SS. Treatment of simple zygoma fractures. Plast Reconstr Surg. 2008 Oct. 122(4):1285; author reply 1285-6. [Medline].

  10. McLoughlin P, Gilhooly M, Wood G. The management of zygomatic complex fractures--results of a survey. Br J Oral Maxillofac Surg. 1994 Oct. 32(5):284-8. [Medline].

  11. Randall DA, Bernstein PE. Epistaxis balloon catheter stabilization of zygomatic arch fractures. Ann Otol Rhinol Laryngol. 1996 Jan. 105(1):68-9. [Medline].

  12. af Geijerstam B, Hultman G, Bergstrom J, et al. Zygomatic fractures managed by closed reduction: an analysis with postoperative computed tomography follow-up evaluating the degree of reduction and remaining dislocation. J Oral Maxillofac Surg. 2008 Nov. 66(11):2302-7. [Medline].

  13. Smyth AG. A modified miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg. 1995 Jun. 33(3):169-70. [Medline].

  14. Czerwinski M, Izadpanah A, Ma S, et al. Quantitative analysis of the orbital floor defect after zygoma fracture repair. J Oral Maxillofac Surg. 2008 Sep. 66(9):1869-74. [Medline].

  15. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE. A retrospective study of zygomatico-orbital complex and/or zygomatic arch fractures over a 71-month period. Dent Traumatol. 2011 Apr. 27(2):135-42. [Medline].

 
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The zygoma forms a firm buttress for the orbit and typically fractures at its sutures.
Waters view demonstrating a zygomatic complex fracture involving the zygomaticofrontal suture, inferior orbital rim, and opacification of the maxillary sinus.
CT scan of the orbit demonstrating disruption of the zygomatic arch.
CT scan demonstrating disruption of the lateral wall of the orbit and medial inferior orbital rim.
 
 
 
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