Zygoma Fractures

Armamentarium

  • #9 Periosteal elevator

  • #15 Blade, #11 blade, #10 blade

  • Adson forceps

  • Appropriate sutures

  • Balanced salt solution

  • Bite block

  • Carol-Girard screw

  • Corneal shield

  • Desmarres retractors

  • Freer elevator

  • Joker elevator

  • Local anesthetic with vasoconstrictor

  • Malleable retractors

  • Manhattan forceps

  • Mayo scissors (curved)

  • Midface fixation kit (with drill and drill bits)

  • Needle tip electrocautery

  • Obwegeser soft tissue retractors

  • Ophthalmic antibiotic ointment

  • Raney clips

  • Senn retractors

  • Stapler

  • Tenotomy scissors (curved)

History of the Procedure

The diagnosis and management of zygomatic fractures have undergone considerable development since they were originally described. Classification schemes that attempt to customize treatment according to the complexity of the fracture have been proposed by Keen, Knight and North, Manson et al, Gruss et al, Zingg et al, and Ellis and Kittidumkerng. Fixation schemes have evolved from internal wire-pin stabilization to internal fixation using miniplates. Innovations in fixation technologies continue to emerge today.

Surgical approaches to zygomatic fractures have undergone significant development as well. Keen described an intraoral approach to the zygomatic arch for the first time in 1909. The approach still carries his name. In 1927, Gillies described a temporal incision that allows the surgeon to reduce zygomatic fractures. The incision is still widely used, especially in cases of isolated zygomatic arch fractures.

More recent developments in the area of zygomatic fractures include intraoperative imaging, navigation, and the use of the surgical endoscope. These technologies hold potential for reducing the number of soft tissue incisions, improving accuracy, reducing patient morbidity, and enhancing outcomes.

History of the Procedure

The diagnosis and management of zygomatic fractures have undergone considerable development since they were originally described. Classification schemes that attempt to customize treatment according to the complexity of the fracture have been proposed by Keen, Knight and North, Manson et al, Gruss et al, Zingg et al, and Ellis and Kittidumkerng. Fixation schemes have evolved from internal wire-pin stabilization to internal fixation using miniplates. Innovations in fixation technologies continue to emerge today.

Surgical approaches to zygomatic fractures have undergone significant development as well. Keen described an intraoral approach to the zygomatic arch for the first time in 1909. The approach still carries his name. In 1927, Gillies described a temporal incision that allows the surgeon to reduce zygomatic fractures. The incision is still widely used, especially in cases of isolated zygomatic arch fractures.

More recent developments in the area of zygomatic fractures include intraoperative imaging, navigation, and the use of the surgical endoscope. These technologies hold potential for reducing the number of soft tissue incisions, improving accuracy, reducing patient morbidity, and enhancing outcomes.

Indications for the Use of the Procedure

Many zygomatic fractures do not require surgical intervention. The decision to proceed with surgical intervention should be made on a case-by-case basis, taking into consideration the patient’s treatment expectations, comorbidities, and the severity of the injury. In their classic review of zygomatic fracture severity, Manson and colleagues divided the fractures into high-, medium-, and low-energy injuries. Low-energy injuries may not require any surgical intervention, whereas medium- and high-energy injuries often require open reduction and internal fixation. Indications for surgical intervention are listed as follows.

Functional Indications

Impingement on the coronoid process of the mandible can occur following fractures of the zygoma. Impingement leads to pain upon mandibular function as well as restriction in the mouth opening (trismus). In these cases, reduction of the zygomatic fracture is necessary to restore the full range of motion of the mandible.

The unique three-dimensional position of the zygomatic bone supports the globe in its spatial orientation. Zygomatic fractures that cause a change in the volume of the orbit or in the position of the globe often produce visual disturbances. If binocular diplopia persists after the initial swelling has subsided, surgical treatment is required.

Although rare, entrapment of ocular muscles identified on clinical examination is an indication for immediate surgical intervention. Entrapment can occur in association with zygomatic fractures or in isolated orbital floor fractures. More of this topic can be found elsewhere in this text.

Impingement on the second distribution of the trigeminal nerve (V2) is likely after zygomatic fractures. Anesthesia in the V2 distribution most often resolves following fracture reduction. However, patients should be advised of the possibility of an incomplete recovery of the sensory innervation.

Aesthetic Indications

Asymmetry of the malar projection, enophthalmos, orbital dystopia, and zygomatic arch depression are indications for repair. The surgeon’s perception of an aesthetic problem should be in line with the patient’s perception of the problem and the need for repair.

Limitations and Contraindications

Surgical treatment of fractures of the facial skeleton is rarely an emergency. Life-threatening injuries should be identified and treated prior to treatment of zygomatic fractures. Likewise, injuries to the globe (e.g., globe laceration, rupture, or hyphema) pose a significant problem. It may be necessary to delay treatment of a zygomatic fracture until the injury to the globe is treated or adequately controlled. This becomes critically important when the vision in the contra lateral eye is affected. Even though the risk to the vision is minimal when repairing zygomatic fractures, the risk is still present. The decision to surgically repair the fracture in the presence of globe injury should be made with utmost care and in consultation with an ophthalmologist.

Delaying the treatment for 10 to 14 days to allow edema to resolve makes the surgical procedure easier and leads to better aesthetic outcomes. However, delaying the treatment longer than 2 weeks can complicate the surgical procedure. Fracture edge resorption can make reduction more difficult, and longer waiting times may lead to malunion. Bony osteotomies may be necessary. Soft tissue response to the delay is detrimental to the aesthetic result and soft tissue resuspension techniques become necessary to achieve the best outcome.

Technique: Maxillary Vestibular, Transconjunctival, and Lateral Canthotomy Approach

Step 1:

Intubation

An angled oral endotracheal tube is preferred. It can either be taped or sutured to the midline of the chin away from the surgical field. A regular oral endotracheal tube can be utilized but may interfere with the access to the oral cavity. Alternatively, a nasal tube may be utilized, but is not necessary and may interfere with evaluation of the facial symmetry.

Step 2:

Forced Duction Test

Small Adson or Manhattan forceps are used to perform the forced duction test preoperatively. The conjunctiva in the inferior fornix is gently grasped with the forceps and the globe is then gently moved in all directions. If present, points of resistance are identified. Ease of globe movement preoperatively is also compared to that measured on a repeat test postoperatively; ease of globe movement should be identical ( Figure 73-1, A and B ).

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Zygoma Fractures
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