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General considerations

Correct anatomical reduction is required to reproduce the original structure of the

zygomaticomaxillary complex and the proper alignment of the orbital walls. In order to
achieve proper reduction of the lateral orbital wall the greater wing of the sphenoid and the
zygoma must be properly aligned. It is difficult to use the lateral orbital wall as a landmark
if 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 and
is often relatively straight in its central portion.
A goal is to restore the proper orbital volume and to restore the proper projections in all
three dimensions. Accurate positioning of the zygomatic arch addresses the AP dimension
and width of the midface.
It is possible that the periorbital contents may have been affected by the reduction of the
zygomatic-complex fracture. A forced duction test should be performed before and after the
reduction of the zygoma to make sure that the patient does not have entrapment of the soft
tissues. Pre- and postoperative ophthalmologic exams should be considered in all patients
who 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 both
sides 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 each
side 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 the
zygomatic arch, orbital rim, and zygomaticomaxillary buttress should be performed first.
Reconstruction of the orbital floor should be performed after the zygoma has been reduced
and 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, allowing
the zygoma to swing into its proper position for reduction. After the other plates and screws
have 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 the
second, third and fourth plate. The 4-point technique is unique 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 damaged. 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.
Whenever possible the surgeon should try to achieve a perfect reduction of the lateral wall
of the orbit. This requires the alignment of the greater wing of the sphenoid and the
zygoma. This should be achievable if the lateral wall is a simple fracture. When the lateral
wall 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 emphasis
in the reduction of other sites. It would be unusual to have to place a mesh to reconstruct
the lateral wall of the zygoma, because the comminuted segments of bone are supported by
the temporalis muscle.
The size and strength of the plate along the zygomatic arch depends on the comminution
and instability of the fracture. Extreme care should be taken during the dissection around
the zygomatic arch so as not to injure the temporal branch of the facial nerve. This nerve

lies very close to the periosteum of the zygomatic arch.

A smaller plate is recommended for the infraorbital rim. A larger plate (commonly an Lshaped plate) is recommended for the zygomaticomaxillary buttress.
Many surgeons argue that the potential cosmetic defects caused by a coronal approach to
the 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 the
facial 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 this
anatomical structure. Much more common is a lateral orbital wall fracture together with a
zygoma fracture (as shown).
Displacement of the lateral orbital wall (with or without combined zygomatic complex
fracture) directly affects the intraorbital volume (ie, inwards displacement results in
exophthalmos whereas outward displacement results in enophthalmos). However, such
globe displacements are camouflaged by posttraumatic swelling so that the above
mentioned sequelae often become apparent only after swelling has decreased, which
normally 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 soft
tissues. However, this CT scan nicely shows contour differences at the lateral orbital wall
area.
Severely inward displaced lateral orbital wall fractures might require emergency treatment,
if intraorbital pressure (due to displacement and/or intraorbital hematoma) is compromising
optic nerve function (see axial CT scan).

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Lateral orbital wall plate

Some surgeons recommend placement of a plate to reduce and fixate the lateral wall of the
orbit 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 the
lateral wall of the orbit. Placement of this plate is difficult because of necessary globe
retraction. If a surgeon decides to position a plate in this location there is limited room, and
often 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 the
zygomaticofrontal 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 zygoma
into its proper position.
The repositioning can be done through a transoral (Keen) incision, or directly through a
coronal approach.
Illustration showing reduction being performed via a transoral (Keen) approach using an
elevator.

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Illustration shows the reduction performed via the coronal incision.

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Alternative: screw and traction

A screw is inserted into the zygomatic bone through the skin or coronal incisions. This
allows 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 the
lower 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. An
instrument is then used to pull the plate and zygomatic fragment in the cephalad direction
to 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 the
fracture, until the surgeon has verified the proper 3-D reduction of the zygoma at the other
two points. Looking through the upper eyelid incision, it is very difficult to determine the
3-D rotation of the zygoma.

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 the
intervention.
4 Placement of additional plates top

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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.

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Placement of third plate

When looking through the lower eyelid incision, the orbital rim plate should be properly
adapted. 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 properly
reduced prior to placing this plate. A minimum of two screws should be placed on each side
of the fracture.

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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 is
the most difficult plate to properly adapt in a zygoma fracture. It is important that the leg of
the 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 a
manner that the screws will not be placed into the dental roots. A common problem with
this third plate is failure to properly adapt the L-plate, resulting in screw placement into the
thin 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 holes
may be ideal.
We recommend that lower profile plates are used at the zygomaticofrontal suture and the
infraorbital 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

is a common presentation in this kind of fracture.

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Options to consider for arch reconstruction

The illustration on the left represents a zygomatic arch fracture, where the posterior fracture
extends to the temporal bone. In a situation like this, with fractures at multiple levels, a
longer plate is needed.
In this case a lag technique was used to secure the posterior segment of the arch to the
temporal bone. Extreme care needs to be used to make sure that the drill does not penetrate
the calvaria, and does not violate the temporomandibular joint. A drill bit with stop is
recommended. Click here for a detailed description of the lag technique.
There is a great deal of variability in the shape of the zygomatic arch. In this case, the arch
is a relatively straight segment.
5 Reconstruction of the orbital floor defect top

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General considerations

If it was determined pre- or intraoperatively that orbital floor reconstruction is required, it is

now performed.
The orbital floor defect is exposed by using orbital retractors and retractors on the lower
eyelid.
(For a discussion on isolated orbital floor fractures, please click here.)

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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 of
the fan has only a minimum number of screw holes),

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and contoured to achieve the required shape, and accommodate key anatomical
structures (nasolacrimal duct, infraorbital nerve, and optic nerve)
It is advisable not to extend the implant further posterior than 1 cm anterior to the optic
canal 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 the
area of the infraorbital rim. The mesh should be trimmed so that the outer circumference
is 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 the
fracture.
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 of
the orbital rim. We recommend a complete reduction of the fracture at the orbital rim with
fixation 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 the
fan-shaped plate to the orbital rim or orbital floor (as illustrated). Generally, a single screw
will 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 any
entrapment 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 a
description 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 for
orbital 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 it
takes 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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Titanium with porous polyethylene

Titanium with porous polyethylene has the combined advantages of being more rigid than
porous polyethylene alone, and being less likely to have sharp barbs on the edges. It is
visible on radiographic postoperative imaging.
A possible disadvantage is that drainage of orbital exudate may be compromised.
Screw fixation is controversial.
6 Postoperative examination top

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Postoperative cone beam images show the position of a fan plate reconstructing the orbital
floor and medial orbital wall in a coronal

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and oblique parasagittal view in a patient with associated zygomatic-complex fracture.

Note: recontouring of the plate shown was accomplished by help of an intraoperative

model. A standard fan plate can cover up to three wall of the orbit.

v1.0 2009-12-03
Note
Exposure of the zygomatic arch for the application of the fourth point of fixation requires a
separate extended surgical approach (coronal). The surgeon must consider the potential risk
associated with this approach.
Video

Fixation of a zygomaticomaxillary fracture