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| IMC Wiki | Zygomatic bone fractures

Zygomatic bone fractures

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Definition

Lateral midface fractures affect the zygomatic bone and/or the zygomatic arch
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Therapeutic goals

Restoration of the facial shape and mandibular function, with an additional focus on the restoration of sensory nerves (infraorbital nerve) and, not least, eye function. If enophthalmia is present, it should also be corrected without delay

Diagnostics

Inspection

#pic# , #pic#

Symptoms
  • Unilateral periocular haematoma
  • Subconjunctival haemorrhage
  • Swelling
  • Flattened face (sometimes)
Palpation
  • Infraorbital fracture steps
  • Lateral orbital border
  • Zygomatic buttress
Function tests
  • V2 sensitivity
  • Facialis function
  • Ocular motility
  • Diplopia
  • Mouth opening
  • Protrusion and laterotrusion

Further examinations

Ophthalmological examinatio

Radiographic examinations in two planes

#pic# , #pic#

Standard
  • Paranasal sinuses
  • Bucket handle
  • OPG
Extended
  • CT

Indications for therapy

  • Clinical and/or radiographic demonstration of fracture
  • Sensory or motor dysfunction
  • Mandibular dysfunction
  • Ocular motility dysfunction (diplopia)
  • Facial deformity

Conservative therapy

  • Wait-and-see strategy in cases of discrete fracture dislocation
  • Decongestant measures
  • Soft diet, if necessary

Surgical treatment

Surgical fracture management is the treatment of choice in all dislocated fractures and in the presence of impaired ocular function and/or sensitivity.
Surgical therapy may include the following measures:

Repositioning using a single-prong hook
  • Insertion of the single-prong hook below the zygomatic bone #pic#
  • Repositioning, infraorbital step control #pic#
  • Step control #pic#
Insertion of the single-prong hook
  • The single-prong hook is safely inserted under the zygomatic bone/arch for repositioning
  • CAUTION: soft-tissue trauma
  • Stable results within 2–3 days; if later, use additional plate fixation
#pic# , #pic# , #pic# , #pic# , #pic#


Need for osteosynthesis after repositioning by a single-prong hook
  • If the zygomatic bone is unstable
  • If the fracture is grossly dislocated, involving functional deficits
  1. Stabilization of the lateral orbital margin (zygomatico-frontal suture)
    Incision in the eyebrow. (Caution: Do not shave eyebrow!)
    #pic#
    Incision must not extend beyond the extended palpebral fissure. (Caution: facial nerve!)
    #pic#

  2. Stabilization through an intraoral access
    Intraoral incision from center to tuber single-prong hook repositioning, adaptation of a 2.0 plate, fixation, verification of fragment repositioning, rinsing of maxillary sinus (if indicated), suturing. Inspection of infraorbital foramen and, if indicated, decomminution.
    #pic#

  3. Infraorbital stabilization with orbital floor reconstruction
    In cases of extremely mobile zygomatic bone fractures or comminuted fractures, the infraorbital border may have to be additionally stabilized.
    #pic# , #pic#

  4. Comminuted fracture
    If the zygomatic bone and arch are comminuted: coronal incision with complete exposure and reconstruction, but intraoral access is also an option.
    #pic#

Complications

  • Ocular motility dysfunction
  • Amaurosis
  • Bulb dislocation
  • Airway obstruction
  • Impaired pneumatisation of the paranasal sinuses
  • Malfunction (limited incisal edge distance or mandibular excursion)
  • Chronic pain
  • Chronic neurological dysfunction (motor and/or sensory)

Additional measures

  • It is recommended that ocular findings are verified by ophthalmologists before and after surgery
  • Antibiotic prophylaxis if required

Risk factors

  • Loss of bone structures (e.g. alveolar process)
  • Degree of fracture dislocation
  • Fragment or comminuted fracture
  • Infection
  • Additional maxillofacial trauma
  • Delay until fracture management

Recommendation

  • Conservative fracture management can be performed on an outpatient basis.
  • Surgical fracture management usually requires an inpatient setting.