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General considerations

Correct anatomical reduction is required to reproduce the original structure of thezygomaticomaxillary complex and the proper alignment of the orbital walls. In order toachieve proper reduction of the lateral orbital wall the greater wing of the sphenoid and thezygoma must be properly aligned. It is difficult to use the lateral orbital wall as a landmarkif the fractures of the lateral orbital wall are comminuted.

The zygomatic arch can be useful in achieving the proper width of the midface and AP projection of the zygoma. It should be noted that the zygomatic arch is not a true arch andis often relatively straight in its central portion.

A goal is to restore the proper orbital volume and to restore the proper projections in allthree dimensions. Accurate positioning of the zygomatic arch addresses the AP dimensionand width of the midface.

It is possible that the periorbital contents may have been affected by the reduction of thezygomatic-complex fracture. A forced duction test should be performed before and after thereduction of the zygoma to make sure that the patient does not have entrapment of the softtissues. Pre- and postoperative ophthalmologic exams should be considered in all patientswho have sustained periorbital trauma.

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Plate fixation

As a general principle with all plate fixation, at least two screws should be placed on bothsides of the fracture. This often requires a plate with at least one extra screw hole to span

the fracture. Ideally, the first screw should be placed on the side of the mobile fragment,and the plate used as a handle to close the gap and reduce the bone.

The first two screws should be placed in the plate holes closest to the fracture, one on eachside of the fracture. Make sure that the fracture is adequately spanned so that each screw is

placed in solid bone.
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Order of reduction and fixation

In a fracture of this nature, the reduction and fixation of the zygoma, including thezygomatic arch, orbital rim, and zygomaticomaxillary buttress should be performed first.Reconstruction of the orbital floor should be performed after the zygoma has been reducedand fixated.

The first step should be the placement of a plate or wire at the frontozygomatic suture. If a plate is used, we recommend placing only one screw on each side of the fracture, allowingthe zygoma to swing into its proper position for reduction. After the other plates and screwshave been placed at the zygomatic arch, infraorbital rim, and zygomaticomaxillary buttress,the final screws can be placed in the frontozygomatic plate.

Using the 4-point technique it is controversial as to the proper order of placement of thesecond, third and fourth plate. The 4-point technique is unique from the 3-point techniquein that the surgeon has visualization of the zygomatic arch. If the lateral wall of the orbit isnot comminuted, this reference point is still singularly the most important landmark todetermine whether a proper reduction has been performed. If this reference point iscomminuted, the order of placement of the other three plates will be dependent on whichlandmarks are the least damaged. The zygomatic arch may be an excellent reference as towhether the proper AP projection of the midface has been restored. In cases where the archhas been fractured and displaced at several different levels, use of the arch to reposition thezygoma may be less reliable. A general principle is to begin with the reference points thatare least comminuted. At the same time it is important to have wide exposure of all thereference points, and to recheck the reduction of each reference point as each new plate is

placed.

Whenever possible the surgeon should try to achieve a perfect reduction of the lateral wallof the orbit. This requires the alignment of the greater wing of the sphenoid and thezygoma. This should be achievable if the lateral wall is a simple fracture. When the lateralwall is comminuted, the lateral wall is not so reliable as a landmark in determining the

proper reduction of the zygoma. In this situation the surgeon has to place higher emphasisin the reduction of other sites. It would be unusual to have to place a mesh to reconstructthe lateral wall of the zygoma, because the comminuted segments of bone are supported bythe temporalis muscle.The size and strength of the plate along the zygomatic arch depends on the comminutionand instability of the fracture. Extreme care should be taken during the dissection aroundthe zygomatic arch so as not to injure the temporal branch of the facial nerve. This nerve
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lies very close to the periosteum of the zygomatic arch.A smaller plate is recommended for the infraorbital rim. A larger plate (commonly an L-shaped plate) is recommended for the zygomaticomaxillary buttress.Many surgeons argue that the potential cosmetic defects caused by a coronal approach tothe zygomatic arch are worse than the defect of a minimally displaced arch. These cosmetic

defects include alopecia from the coronal scar, risk of injury to the temporal branch of thefacial nerve, and temporal hollowing.

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Involvement of lateral orbital wall

Isolated lateral orbital wall fractures are rare and only occur after isolated trauma to thisanatomical structure. Much more common is a lateral orbital wall fracture together with azygoma fracture (as shown).

Displacement of the lateral orbital wall (with or without combined zygomatic complexfracture) directly affects the intraorbital volume (ie, inwards displacement results inexophthalmos whereas outward displacement results in enophthalmos). However, suchglobe displacements are camouflaged by posttraumatic swelling so that the abovementioned sequelae often become apparent only after swelling has decreased, whichnormally takes about 2 weeks.

Click here for detailed description of clinical and radiographic examination.

Clinical examination of the lateral orbital wall area is camouflaged by the overlying softtissues. However, this CT scan nicely shows contour differences at the lateral orbital wallarea.

Severely inward displaced lateral orbital wall fractures might require emergency treatment,

if intraorbital pressure (due to displacement and/or intraorbital hematoma) is compromisingoptic nerve function (see axial CT scan).
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Lateral orbital wall plateSome surgeons recommend placement of a plate to reduce and fixate the lateral wall of theorbit between the greater wing of the sphenoid and the zygoma. This helps to guarantee a

proper reduction of this fracture. It can only be used if there is no comminution of thelateral wall of the orbit. Placement of this plate is difficult because of necessary globeretraction. If a surgeon decides to position a plate in this location there is limited room, andoften only one screw can be placed on each side of the fracture. If this plate is to be used,

the authors recommend placing this as the second plate after the plate on thezygomaticofrontal suture.

This plate can be placed through the upper eyelid incision or if the fracture is not as posterior as in this illustration through the inferior eyelid incision.

2 Zygoma reduction methods top

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The first step is to obtain the proper 3-D reduction of the zygoma using an elevator, hook,screw, or Carroll-Girard type device, or digital pressure can be used to mobilize the zygomainto its proper position.

The repositioning can be done through a transoral (Keen) incision, or directly through acoronal approach.

Illustration showing reduction being performed via a transoral (Keen) approach using anelevator.
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Illustration shows the reduction performed via the coronal incision.

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lternative: screw and traction A screw is inserted into the zygomatic bone through the skin or coronal incisions. Thisallows fracture reduction using the screw and a holding instrument.

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Threaded reduction tool

A threaded reduction tool (Carroll-Girard screw) is inserted into the zygoma through thelower eyelid or coronal incisions and used for reduction.
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3 Placement and fixation of first plate top

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Placement of first plate

The first plate is placed across the frontozygomatic fracture area.We recommend a minimum of a 5-hole plate with one hole spanning the fracture line. The

plate should be properly adapted.

In this illustration, the first screw is placed in the unstable zygomatic fracture. Aninstrument is then used to pull the plate and zygomatic fragment in the cephalad directionto further reduce the fracture.

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Fixation of first plate

Only one screw should be placed on each side of the fracture in the holes nearest to thefracture, until the surgeon has verified the proper 3-D reduction of the zygoma at the othertwo points. Looking through the upper eyelid incision, it is very difficult to determine the3-D rotation of the zygoma.
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While drilling holes in the periorbital area, it may be desirable to use a drill bit with a stop(commonly 6 mm stop).

The final two screws in the zygomaticofrontal plate should be placed at the end of theintervention.

4 Placement of additional plates top

enlarge

Placement of second plate

Using the 4-point technique it is controversial as to the proper order of placement of thesecond, third, and fourth plate. The 4-point technique is different from the 3-pointtechnique in that the surgeon has visualization of the zygomatic arch. If the lateral wall ofthe orbit is not comminuted, this reference point is still singularly the most importantlandmark 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 onwhich landmarks are the least destroyed. The zygomatic arch may be an excellent referenceas to whether the proper AP projection of the midface has been restored. In cases where thearch 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 thereference points that are least comminuted. At the same time it is important to have wideexposure of all the reference points, and to recheck the reduction of each reference point aseach new plate is placed.

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

Placement of third plate

When looking through the lower eyelid incision, the orbital rim plate should be properlyadapted. Use a minimum of a 5-hole plate with the extra hole spanning the fracture line.Reconfirm that the lateral orbital wall, and other reference points have been properlyreduced prior to placing this plate. A minimum of two screws should be placed on each sideof the fracture.

enlarge

Placement of fourth plate

Looking through the maxillary vestibular approach, the fracture of the zygomaticomaxillary buttress is aligned. A larger L-shaped plate is ideal for the fixation of this fracture. This isthe most difficult plate to properly adapt in a zygoma fracture. It is important that the leg ofthe L-plate be placed on the most lateral portion of the lateral maxillary buttress, where the

bone is fairly thick.It is similarly important that the foot of the L-plate is placed along the alveolar bone in amanner that the screws will not be placed into the dental roots. A common problem withthis third plate is failure to properly adapt the L-plate, resulting in screw placement into thethin wall of the anterior maxillary sinus. It is not uncommon for the lateral maxillary

buttress to be comminuted. In this instance using a longer L-plate with multiple screw holesmay be ideal.

We recommend that lower profile plates are used at the zygomaticofrontal suture and theinfraorbital rim. A stronger plate is recommended for the zygomaticomaxillary buttress.

In the illustration we can see that there is a comminuted segment of the lateral column. This
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Helpful devices

Many different devices have been used to facilitate retraction of the orbital contents,including malleable retractors, spoons, and special orbital retractors designed for the globe(as illustrated).

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Cutting and bending

The mesh is cut,

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all sharp edges of the plate are trimmed off to protect the soft tissues (note the shape ofthe fan has only a minimum number of screw holes),
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and contoured to achieve the required shape, and accommodate key anatomicalstructures (nasolacrimal duct, infraorbital nerve, and optic nerve)

It is advisable not to extend the implant further posterior than 1 cm anterior to the opticcanal entrance (if the posterior support to the orbit can be reached).

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A sterile artificial skull allows a proper anatomical contour of the implant. This is not

required when using a prebent mesh.

Note:

1. When using the fan-shaped plate, the outer circumference of the mesh is widest in thearea of the infraorbital rim. The mesh should be trimmed so that the outer circumferenceis as small as possible but still provides enough width to cover the defect.

2. The necessity for screw fixation varies with the type of material used and nature of thefracture.

3.

It is important to use a plate large enough to span the entire defect.
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Implants used

Some surgeons have used the screw holes on a fan-shaped titanium plate as their fixation ofthe orbital rim. We recommend a complete reduction of the fracture at the orbital rim withfixation by a separate plate. (See description of second plate application).

The surgeon may chose to use one or more of the holes on the fan plate for fixation of thefan-shaped plate to the orbital rim or orbital floor (as illustrated). Generally, a single screwwill suffice.

It is imperative that the fan-shaped plate spans the entire orbital defect to the most posterior portion of the orbital floor defect. Care should be taken to make sure that there is not anyentrapment of soft tissues of the orbit during placement of the mesh plate. Following

placement of the mesh plate, a forced duction test should be performed. Click here for adescription of the forced duction test.

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Alternatives to using the fan plate include:Bone graft, porous polyethylene, titanium with porous polyethylene, pre-bent implant fororbital floor fractures,
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or preformed orbital plates.

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Bone graft The advantage of bone graft is that the material is inexpensive. A disadvantage is that ittakes additional time to harvest the bone graft and that there is an additional donor site.

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Porous polyethylene

Porous polyethylene has the advantage of being easy to work with and not having sharp barbs on the edges after being trimmed. It has the disadvantage of being invisible on postoperative radiological imaging.

A possible disadvantage is that drainage of orbital exudate may be compromised.

Screw fixation is controversial.
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