Executive Editor: Edward Ellis III, Kazuo Shimozato General Editor: Daniel Buchbinder

Authors: Carl-Peter Cornelius, Nils Gellrich, Søren Hillerup, Kenji Kusumoto, Warren Schubert

Midface - Zygomatic complex fracture

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Glossary

General considerations

It can be very difficult to decide whether to use a 1-point, 2-point, 3-point, or 4-point exposure and fixation for a fracture of the zygomatic-complex. This varies according to the experience of the surgeon and the technology available in the operating room (ie, intraoperative CT, navigation, etc.).

Closed treatment
Main indication Skill Equipment
Displaced fracture amenable for minimally invasive reduction techniques such as bone hook or a Carroll-Girard type screw. Some specialized surgical experience Basic equipment only

Contraindications

  • Displaced comminuted injury of the zygomatic complex
  • Stable reduction is not achievable using a closed technique
  • The need for internal orbital reconstruction

Advantage

  • Less invasive technique

Disadvantages

  • Difficult assessment of proper reduction
  • Risk of displacement due to the absence of fixation hardware
  • Possible injury to soft tissues, due to poor placement of bone
ORIF, 1-point fixation (without orbital reconstruction)
Main indication Skill Equipment
Displaced simple noncomminuted fracture with minimal separation of zygomaticofrontal suture. Some specialized surgical experience Simple surgical and imaging resources

Further indication

  • Stable reduction is not achievable using a closed technique

Contraindications:

  • Displaced comminuted injury of the zygomatic complex
  • Stable reduction is not achievable using one point fixation
  • The need for internal orbital reconstruction

Advantage

  • Less invasive technique if fragment "snaps" into place with reduction

Disadvantage

  • Difficult assessment of proper reduction at nonvisualized sites (frontozygomatic, internal orbit, zygomatic arch)
ORIF, 2-point fixation (without orbital reconstruction)
Main indication Skill Equipment
Displaced fracture requiring 2-point exposure to verify reduction. Some specialized surgical experience Simple surgical and imaging resources

Further indication

  • Anatomic reduction cannot be confirmed using one point fixation

Contraindications:

  • Displaced comminuted injury of the zygomatic complex
  • Anatomic reduction cannot be confirmed using two point fixation
  • The need for extended internal orbital reconstruction

Advantage

  • Allows for visualization of the sphenozygomatic and frontozygomatic sutures in addition to the zygomaticomaxillary buttress

Disadvantage

  • Difficult assessment of proper reduction at nonvisualized sites ( orbital floor, medial orbital wall, and zygomatic arch)

Alternatively, a second point of exposure can be the infraorbital rim.

ORIF, 3-point fixation (without orbital reconstruction)
Main indication Skill Equipment
Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction. Some specialized surgical experience Simple surgical and imaging resources

Further indication

  • Anatomic reduction cannot be confirmed using two point exposure

Contraindications:

  • The need for extended internal orbital reconstruction
  • Anatomic reduction cannot be confirmed using three point exposure

Advantage

  • Allows for visualization of the infraorbital rim, in addition to the sphenozygomatic and frontozygomatic sutures, and the zygomaticomaxillary buttress

Disadvantage

  • Difficult assessment of proper reduction at nonvisualized sites (orbital floor, medial orbital wall, and zygomatic arch)
ORIF, 3-point fixation (with orbital reconstruction)
Main indication Skill Equipment
Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction and need for orbital reconstruction. Some specialized surgical experience Full specialized surgical and imaging resources

Contraindication

  • Need for arch reduction and fixation

Advantage

  • Allows for visualization of the relevant regions of the internal orbit, , in addition to the infraorbital rim, sphenozygomatic and frontozygomatic sutures, and the zygomaticomaxillary buttress

Disadvantage

  • Difficult assessment of the zygomatic arch fracture
ORIF, 4-point fixation (with orbital reconstruction)
Main indication Skill Equipment
Complex zygomatic fractures where exposure of the zygomatic arch (4th point) is necessary to ensure proper reduction of the zygomatic complex. Some specialized surgical experience Full specialized surgical and imaging resources

Further indication

  • Associated multiple fractures that require a coronal approach (frontal sinus fractures, NOE fractures, or a necessity to harvest split calvarial bone graft)

Advantage

  • Allows for the visualization of the zygomatic arch (to ensure restoration of facial projection and facial width) in addition to all other zygomatic complex fracture lines

Disadvantages

  • Visible scar
  • Time consuming
  • Risk of temporal hollowing
  • Risk of injury to temporal branch of the facial nerve
CAS: Intraoperative imaging (ORIF without orbital reconstruction)
Main indication Skill Equipment
Any zygomatic fracture benefits from intraoperative CT scanning to confirm fracture reduction. Some specialized surgical experience Full specialized surgical and imaging resources

Whenever an intraoperative CT scanner is available, an intraoperative scan should be obtained for intraoperative evaluation of the reduction.

Any zygomatic fracture benefits from intraoperative CT scanning to confirm fracture reduction and to determine the need for orbital wall reconstruction after zygoma reduction.

CAS: Virtual planning and intraoperative imaging (ORIF without orbital reconstruction)
Main indication Skill Equipment
Zygomatic fractures that have a significant amount of displacement, with or without internal orbital disruption, benefit from virtual planning. Some specialized surgical experience Full specialized surgical and imaging resources

Whenever an intraoperative CT scanner is available, an intraoperative scan should be obtained for intraoperative evaluation of the reduction.

Zygomatic fractures that have a significant amount of displacement and internal orbital disruption benefit from virtual planning. After zygomatic reduction, an intraoperative CT-scan can be fused to the virtual plan to determine the adequacy of zygoma reduction and the status of the internal orbit.

CAS: Virtual planning and intraoperative imaging (ORIF with orbital reconstruction)
Main indication Skill Equipment
Zygomatic fractures that have a significant amount of displacement, with internal orbital disruption benefit from virtual planning. Some specialized surgical experience Full specialized surgical and imaging resources

Zygomatic fractures that have a significant amount of displacement and internal orbital disruption benefit from virtual planning.

Whenever an intraoperative CT scanner is available, an intraoperative scan should be obtained for intraoperative evaluation of the reduction.

After zygomatic reduction, an intraoperative CT-scan can be fused to the virtual plan to determine the adequacy of zygoma reduction and the status of the internal orbit.

CAS: Virtual planning and intraoperative navigation (ORIF with orbital reconstruction)
Main indication Skill Equipment
Zygomatic fractures that have a significant amount of displacement, with internal orbital disruption, benefit from virtual planning and intraoperative navigation. Some specialized surgical experience Full specialized surgical and imaging resources

Zygomatic fractures that are severely displaced, have significant internal orbital disruption, and/or whose articulations are comminuted benefit from virtual planning and intraoperative navigation.

Whenever an intraoperative CT scanner is available, an intraoperative scan should be obtained for intraoperative evaluation of the reduction.

Additionally, after zygomatic reduction, an intraoperative CT-scan can be fused to the virtual plan to determine the adequacy of zygoma reduction and the status of the internal orbit.

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2009-12-03