eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Trauma

Zygomaticomaxillary Complex Fractures: Workup

Author: Travis T Tollefson, MD, FACS, Assistant Professor, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center
Coauthor(s): E Bradley Strong, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of California at Davis
Contributor Information and Disclosures

Updated: Sep 24, 2009

Workup

Imaging Studies


  • Traditional facial radiographs have limited usefulness in the diagnosis of zygomaticomaxillary complex (ZMC) fractures. The submental-vertex view offers excellent resolution of the zygomatic arches; however, the Townes, anteroposterior, and Waters views offer much less information. Gross bony disruption of the orbital rim or opacification of the maxillary sinus can be diagnosed; however, the dense temporal bone makes subtle findings difficult. Even if a facial fracture is diagnosed using plain radiographs, a CT scan usually is needed to determine the extent of the injury.10
  • CT scans are considered the criterion standard for radiologic diagnosis of ZMC fractures (see Image 1).

 

Axial CT scan demonstrating zygomaticomaxillary c...

Axial CT scan demonstrating zygomaticomaxillary complex fracture on right with severe displacement.

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Axial CT scan demonstrating zygomaticomaxillary c...

Axial CT scan demonstrating zygomaticomaxillary complex fracture on right with severe displacement.

  • The CT scan helps the physician make a more accurate preoperative diagnosis and guides decisions about the operative treatment. Patients with traumatic injuries frequently require CT scans of the brain to evaluate intracranial injuries. If significant clinical suspicion of a facial fracture exists, the images can be continued through the facial bones. Modern helical scanners can reformat thin cut (1- to 1.5-mm) axial images into coronal and sagittal cuts with acceptable resolution to avoid neck flexion and extension.

Other Tests

  • Visual acuity: Any injury resulting in significant disruption of the bony orbit requires an ophthalmologic evaluation.
  • Forced-duction tests: Forced-duction testing can be used to determine the presence of mechanical restriction of globe motion. This test must be performed bilaterally to compare the uninjured and injured sides. It is generally performed with the patient under general anesthesia because most patients cannot relax enough to allow accurate testing.

Diagnostic Procedures

  • Unfortunately, the diagnostic studies available to differentiate muscle contusion from muscle entrapment (eg, thin-cut CT scans, forced-duction testing) are not 100% accurate. These tests are quite specific when muscle entrapment is observed; however, they often are not sensitive enough to rule out entrapment in subtle cases. Therefore, diagnostic surgical exploration must be considered for patients with significant orbital disruption and extraocular muscle dysfunction, even if gross muscle entrapment cannot be identified clearly. Transmaxillary endoscopic evaluation of the orbital floor is a relatively new technique that can also be used to assess the integrity or the orbital floor.
    • Axial preoperative CT scans do not clearly define the extent of orbital blowout fractures. Patients with facial traumatic injuries with suspected cervical spinal cord injuries cannot hyperextend their head for coronal CT scan, and thin cut reconstructions are not always available. Consequently, the degree of orbital floor disruption is not known until the time of surgery. Before the surgical endoscope, evaluation of the orbital floor necessitated a lid or rim incision to evaluate the extent of disruption. In such cases, the risk of orbital exploration must be weighed against the risk of missing an occult injury to the orbital floor and orbital contents. The exacerbation of an orbital floor injury after reduction of the zygomaticomaxillary complex should also be considered. A large lateral movement of the ZMC may actually widen a small orbital floor disruption requiring an orbital exploration for diagnosis and treatment.
    • The endoscope can be used to evaluate the orbital floor (ie, the roof to the maxillary sinus) by passing it through preexisting fractures in the face of the maxilla. When gross disruption of the anterior maxillary face is not present, a 4-mm osteotome is used to open a small maxillary sinusotomy, taking care not to injure the infraorbital. A Kerrison can then be inserted into the sinusotomy and an antrostomy 1.5 cm by 2.0 cm can be performed (ie, Caldwell-Luc sinusotomy). When the endoscope is then inserted into the maxillary sinus, the integrity of the orbital floor can be evaluated from below.
    • Gentle pressure on the globe (ie, pulse test) exaggerates any significant prolapse of the orbital contents into the maxillary sinus. After the evaluation is complete, the sublabial incision is closed in the traditional fashion. Repair of the Caldwell Luc sinusotomy is not necessary.
    • This technique involves a significant learning curve, and surgeons are encouraged to continue using a standard approach to these injuries to confirm what is noted on endoscopy. Once experience is ample, the surgeon can confidently identify smaller, inconsequential orbital floor defects and avoid a formal orbital exploration.

More on Zygomaticomaxillary Complex Fractures

Overview: Zygomaticomaxillary Complex Fractures
Workup: Zygomaticomaxillary Complex Fractures
Treatment: Zygomaticomaxillary Complex Fractures
Follow-up: Zygomaticomaxillary Complex Fractures
Multimedia: Zygomaticomaxillary Complex Fractures
References
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Further Reading

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Keywords

maxillary zygomatic fractures, zygomaticomaxillary complex, zygomaticomaxillary fractures, zygomaticomaxillary complex fracture, facial fractures, facial fracture, jaw fracture, cheek fracture, ZMC, ZMC fracture, upper jaw bone, upper jaw, jaw, broken jaw, os zygomaticum, zygomatic bone, cheek bone, cheekbone, broken cheek bone, broken cheekbone

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Contributor Information and Disclosures

Author

Travis T Tollefson, MD, FACS, Assistant Professor, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center
Travis T Tollefson, MD, FACS is a member of the following medical societies: American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

Coauthor(s)

E Bradley Strong, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of California at Davis
E Bradley Strong, MD is a member of the following medical societies: Alpha Omega Alpha and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Erik Kass, MD, Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia
Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American Medical Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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