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5Placement of additional plates

Placement of second plate

Using the 4-point technique it is controversial as to the proper order of placement of the second, third, and fourth plate. The 4-point technique is different from the 3-point technique in that the surgeon has visualization of the zygomatic arch. If the lateral wall of the orbit is not comminuted, this reference point is still singularly the most important landmark to determine whether a proper reduction has been performed. If this reference point is comminuted, the order of placement of the other three plates will be dependent on which landmarks are the least destroyed. The zygomatic arch may be an excellent reference as to whether the proper AP projection of the midface has been restored. In cases where the arch has been fractured and displaced at several different levels, use of the arch to reposition the zygoma may be less reliable. A general principle is to begin with the reference points that are least comminuted. At the same time it is important to have wide exposure of all the reference points, and to recheck the reduction of each reference point as each new plate is placed.

Looking through the coronal incision the zygomatic plate should be properly adapted. Use a minimum of a 5-hole plate with the extra hole spanning the fracture line. Reconfirm that the zygomatic arch has been properly reduced prior to placing this plate. A minimum of two screws should be placed on each side of the fracture. Prior to securing this plate, make sure that the reference point of the lateral orbital wall, the inferior orbital rim, and the lateral maxillary buttress are properly reduced.