ORIF 4-point fixation (with orbital reconstruction)

Each fracture case should be individualized for treatment planning and execution because fixation requirements differ from one fracture to another. There are some general principles for fixation of zygomatic complex fractures when plate and screw fixation is used:

• Self-threading screws are utilized.
• Plate selection: titanium plates and screws have reduced scatter in postoperative CT scans. Selecting an L-, T-, or Y- shaped plate for zygomaticomaxillary buttress region fixation allows greater flexibility in positioning screws to avoid tooth roots in the alveolar process.
• Use a thin plate at, or preferably below, the infraorbital rim to minimize visibility and palpability. The skin and muscles overlying the infraorbital rim are thin and may atrophy with open reduction procedures.
• In cases that have concomitant fractures of other midfacial bones, it may be necessary to use additional points of fixation. Maxillomandibular fixation (MMF), should be completed before reduction and fixation are begun.
• Areas of bone loss: span the gap after initial reduction with a bone plate stabilized at either end of the defect. Alternatively, the comminuted fragments can be provisionally reassembled, stabilized with inter-fragment wires, their position improved, and the entire structure then stabilized with rigid fixation. In the case of extensive comminution with or without bone loss, judgment is required to fix the bone in the proper position without spanning the gap, or the pieces can be reassembled provisionally to confirm proper zygoma positioning. Generally, gaps over 5 mm can be bone grafted if native bone is unavailable. Grafts or comminuted fragments should be stabilized to the bone plate with individual fixation screws, the number of which is left to the operator’s judgment. This technique allows optimal osseous healing throughout the defect.

Correct anatomical reduction is required to reproduce the original structure of the zygomaticomaxillary complex and the proper alignment of the orbital walls. The greater wing of the sphenoid and the zygoma must be aligned appropriately to reduce the lateral orbital wall. It is difficult to use the lateral orbital wall as a landmark if the fractures of the lateral orbital wall are comminuted. Further, reduction at the zygomaticomaxillary buttresses plays a vital role in the proper alignment of the zygomatic complex to achieve a good surgical outcome.

The zygomatic arch can help achieve 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.

The goal is to restore the proper orbital volume and projections in all three dimensions. Accurate positioning of the zygomatic arch addresses the AP dimension and width of the midface.

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 reducing the zygoma to ensure that the patient does not have entrapment of the soft tissues of the periorbita. Pre- and postoperative ophthalmologic exams should be considered in all patients who have sustained periorbital trauma.

Completion of all the fractures should be performed prior to attempts at reduction in order to reposition the zygoma accurately without tension. This should be accomplished before any attempts at reduction and fixation. Complex zygoma fractures require exposure through three or four incisions. It is not possible to confirm alignment in more than one incision (one location) at a time. Therefore, some surgeons will place positioning inter-fragment wires or single loose screw-plates in one or two locations to provide temporary relative stabilization in a single location while the surgeon works in another location. Commonly, attempts to achieve alignment in one location will inadvertently reciprocally displace another location.

As a general principle, at least two screws should be placed on either side 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 fracture.

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

In a fracture of this nature, the reduction should be performed first by mobilization or osteotomy. This must include the zygomatic arch, orbital rim, and zygomaticomaxillary buttress, and the zygomaticofrontal process. The difference from the 3-point technique is that with this technique the surgeon visualizes the zygomatic arch with a coronal incision.

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 zygomaticofrontal 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 zygomaticofrontal plate.

The order of placement of the second, third and fourth plates is debated in the 4-point technique. It generally begins with the zygomaticomaxillary buttress. A complex zygoma fracture requires serial comparison of what is happening at each buttress articulation as one buttress is reduced. While some emphasize the lateral wall as a reference point, there is no single buttress which, in itself, confirms alignment in the other buttresses. Therefore, observation of all buttresses should be compared and analyzed as each buttress is stabilized. If a single reference point is comminuted, analysis of the proper position of the comminuted buttress will be improved by assessing the alignment at the least damaged buttress articulation. The order of fixation of the remainder of the buttresses is determined individually, often utilizing the least damaged landmarks first.

The zygomatic arch may be an excellent reference for the proper restoration of the AP projection of the midface. In cases where the arch has been fractured and displaced at several different levels, the use of the arch to reposition the zygoma is more challenging.

It is important to serially analyze all of the reference points sequentially after each single buttress is stabilized.

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, achievable if the lateral wall has a simple fracture. The most common mistake, even if there is only a single fracture, is that the zygoma is incompletely reduced despite approximation of this fracture. The lateral wall is normally a straight line between the orbital process of the zygoma and the greater wing of the sphenoid. Angulation of this junction increases the volume of the orbit. When the lateral wall is comminuted, there should be a straight line between the greater wing of the sphenoid and the orbital process of the zygoma. The internal fragments of the fracture have to be adjusted to fit the straight-line concept. In this situation, the surgeon must place a higher emphasis on the reduction of other sites.

The size and strength of the plate along the zygomatic arch depends on the comminution, instability, and strength required to stabilize the contour of the fracture. Extreme care should be taken during the dissection around the zygomatic arch not to injure the temporal branch of the facial nerve. This nerve lies very close to the periosteum over the zygomatic arch and is best avoided by careful subperiosteal dissection.
A smaller (thinner) plate is recommended for the inferior orbital rim and may be placed lower on the rim to minimize fibrosis in the lid and visible and palpable plate silhouette through the thin overlying soft tissue.

A larger (thicker) plate (commonly an L-shaped plate) is recommended for the zygomaticomaxillary buttress.

Many surgeons argue that the potential cosmetic sequela caused by a coronal approach to the zygomatic arch are worse than the defect of a minimally displaced arch. The coronal approach is indicated in cases of lateral displacement of both the zygomatic body and the zygomatic arch. In other situations, it is usually unnecessary. Cosmetic sequelae include alopecia along the coronal scar, injury to the temporal branch of the facial nerve, and temporal hollowing. These sequelae may be minimized by the use of blocking sutures rather than Raney clips, which create hair loss from prolonged ischemia. Blocking sutures also minimize the blood loss during opening and closing which accompanies the use of Raney clips. Alopecia is best managed by hair grafting. Temporal hollowing is prevented by dissecting absolutely in the described planes as one approaches the arch, minimizing damage to fat. Closing internal layers of incisions also helps reposition the soft tissue appropriately.

Isolated lateral orbital wall fractures are rare and only occur after isolated trauma to the lateral orbital rim. A lateral orbital wall fracture is a portion of every complete 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). The increase in orbital volume may be camouflaged by posttraumatic swelling so that the sequelae mentioned above often become apparent only after swelling has decreased, which usually takes about two weeks.

For a detailed description of clinical and radiographic examination click here.

Clinical evaluation of fractures in the lateral orbital wall area may be more difficult due to the swollen overlying soft tissues. However, a CT scan can demonstrate fracture displacement at the lateral orbital wall area.

Severely inward displaced lateral orbital wall fractures might require emergency treatment if the intraorbital pressure is increased (due to displacement or intraorbital hematoma) or there are signs of compromised optic nerve function (see axial CT scan).

Some surgeons recommend placing 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 ensure a proper reduction of this fracture. If there is comminution of the lateral wall of the orbit, the internal segments of the fracture should be reduced after alignment of the greater wing of the sphenoid beyond the comminuted fracture segments is confirmed with the orbital process of the zygoma to be a straight line. Placement of this plate is challenging because of need for significant globe retraction.

This plate is best placed through a generous exposure provided by a coronal incision. It is difficult or impossible to do this through a short upper eyelid incision alone.

AO Teaching video on fixation of a zygomaticomaxillary fracture and an orbital floor fracture

Computer assisted surgery and intra-operative imaging have greatly improved the management of craniomaxillofacial trauma. Whenever an intraoperative CT scanner is available, an intraoperative scan should be obtained for intraoperative evaluation of the reduction.

When using computer assisted surgery, reduction and fixation, if necessary, is performed according to standard procedures as described in the AO Surgery Reference. CAS should be considered an adjunct to surgical treatment.

Further details about virtual planning, intraoperative imaging, and intraoperative navigation are available here.

Various approaches may be used for this procedure. They commonly include an intraoral maxillary vestibular approach, a lower-eyelid incision (transcutaneous or transconjunctival), an upper eyelid incision (upper blepharoplasty or brow incision), or a coronal incision with direct exposure of the zygomatic arch and lateral orbital region. Where possible, existing lacerations may also be used. Extension of existing lacerations is generally not preferred.

The intraoral maxillary vestibular approach facilitates the exposure of the medial and lateral inferior buttresses of the midface. It can also be used to expose the anterior and inferior portion of the inferior orbital rim. The maxillary vestibular approach is routinely used to reposition the depressed or comminuted zygoma.

Lower-eyelid incisions are ideal for exposing the orbital floor, the orbital rim, and the lateral orbital wall.

• Transcutaneous lower-eyelid approaches
• Transconjunctival lower-eyelid approaches

A coronal incision is ideal for exposure of the zygomatic arch, lateral orbital rim (zygomaticofrontal suture), and lateral wall of the orbit (sphenozygomatic suture). It can also be used to harvest split calvarial bone graft.

The lateral orbital wall can be approached via the lower eyelid incision (transconjunctival or transcutaneous) or the upper eyelid incision (blepharoplasty incision). It can also be approached via a coronal incision (if a coronal incision is otherwise required).

Many zygoma fractures are incomplete, partial, and impacted. The first step in these injuries is to complete the zygoma fracture in order to freely position the zygoma with a minimum of forceable manipulation. First, determine which fracture sites are incomplete, and complete them with an osteotomy. The most common location for the incomplete fracture is at the zygomaticofrontal suture. This may be approached with an appropriate incision such as the lateral portion of an upper lid blepharoplasty, and an osteotome utilized to complete this fracture. Levering the osteotome after completing its passage through the zygomaticofrontal suture effectively displaces the zygoma. This sequence may be applied to any fracture site until the zygoma is freely movable. This sequence minimizes the use of forceable disimpaction maneuvers described below. Some feel that forceable disimpaction maneuvers have a chance of extending fractures within the orbit, producing visual impairment.

The first step is to obtain the proper 3D reduction of the zygoma using an elevator, eg, Bristow, Rowe’s zygoma 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.

The illustration shows reduction being performed via a transoral (Keen) approach using an elevator.

The illustration shows the reduction performed via the coronal incision.

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.

A threaded reduction tool (Carroll-Girard screw) is inserted into the zygoma through the lower eyelid or coronal incisions and used for reduction.

One of the initial plates is usually placed loosely across the zygomaticofrontal fracture area.

We recommend a minimum of a 5-hole plate with one hole spanning the fracture line. The plate should be properly adapted.

We recommend that lower profile plates are used at the zygomaticofrontal area since the skin is very thin in this region and will get thinner over time.

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 reduce the fracture further.

Placing a single incompletely tightened screw on each side of the fracture allows further subtle adjustments to be completed while aligning the other buttresses. It is challenging to determine the 3D rotation of the zygoma by looking through the upper eyelid incision.

While drilling holes in the periorbital area, it may be desirable to use a drill bit with a stop (commonly a 6 mm stop).

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

The order of placement of the second, third, and fourth plates is debated in the 4-point technique. It generally begins with the zygomaticomaxillary buttress. A complex zygoma fracture requires serial comparison of what is happening at each buttress articulation as one buttress is reduced. While some emphasize the lateral wall as a reference point, there is no single buttress which, in itself, confirms alignment in the other buttresses. Therefore, observation of all buttresses should be compared and analyzed as a single buttress is stabilized. If a single reference point is comminuted, analysis of the proper position of the comminuted buttress will be improved by assessing the alignment at the least damaged buttress articulation. The order of fixation of the remainder of the buttresses is determined individually, often utilizing the least damaged landmarks initially.

The zygomatic arch may be an excellent reference for the proper restoration of the AP projection of the midface. In cases where the arch has been fractured and displaced at several different levels, the use of the arch to reposition the zygoma is more challenging.

It is important to serially analyze all of the reference points sequentially after each single buttress is stabilized.

The zygomatic plate should be adequately adapted while looking through the coronal incision. Use a minimum of a 5-hole plate with one hole spanning the fracture line. Reconfirm that the zygomatic arch has been adequately reduced before placing this plate. A minimum of two screws should be placed on each side of the fracture. Before securing this plate, make sure that the reference point of the lateral orbital wall, the inferior orbital rim, and the lateral maxillary buttress are correctly reduced.

When looking through the lower eyelid incision, the orbital rim plate should be appropriately adapted. Use a minimum of a 5-hole plate with one hole spanning the fracture line. Reconfirm that the lateral orbital wall and other reference points have been adequately reduced before placing this plate. A minimum of two screws should be placed on each side of the fracture.

The fracture of the zygomaticomaxillary buttress is aligned, looking through the maxillary vestibular approach. A larger L-shaped plate is ideal for the fixation of this fracture. The L-plate is the most difficult to be adapted to a zygoma fracture.

The leg of the L-plate must be placed on the most lateral portion of the lateral maxillary buttress, where the bone is fairly thick.
The foot of the L-plate must be placed along the alveolar bone, avoiding the dental roots with the screws.

A common problem with this plate is the 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.

A stronger plate is recommended for the zygomaticomaxillary buttress.

The illustration shows a comminuted segment of the lateral column, a common presentation in this kind of fracture.

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 and stronger plate is needed.

In this case, a lag technique was used to secure the posterior segment of the arch to the temporal bone. Care needs to be used to ensure that the drill does not penetrate the calvaria or violate the temporomandibular joint. A drill bit with a stop may be utilized. Click here for a detailed description of the lag screw technique.

There is variability in the shape of the zygomatic arch, but almost always it is flat in the center and curved internally at each end. In this case, the center of the arch is flat.

A common mistake is to reconstruct the arch in a completely curved fashion, as seen in this illustration.

Projection of the zygomatic body is decreased because some of the length necessary for proper projection has been absorbed by projection of the curvature of the arch.

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.

More information about isolated orbital floor fractures is provided in the orbital reconstruction technique in the orbital floor fracture section of this module.

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).

The mesh is cut.

Then 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).

The mesh is then contoured to achieve the shape required to accommodate key anatomical structures (lacrimal fossa, infraorbital nerve, and optic nerve).

The posterior extent of the implant should reach the posterior ledge of the fracture but remain at least 8 mm anterior to the optic canal entrance.

A sterile artificial skull facilitates proper anatomical contouring of the implant. This is not required when using a prebent mesh.

Note the following:

• When using a 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.
• The necessity for screw fixation varies with the type of material used and the nature of the fracture.

Some surgeons have used the screw holes on a fan-shaped titanium plate to fix the orbital rim. We recommend a complete reduction of the fracture at the orbital rim with fixation using a separate plate. (See the description of placement of the inferior orbital rim plate).

The surgeon may choose to use one or more of the holes on the fan-shaped plate to fix it to the orbital rim or orbital floor (as illustrated). Generally, a single screw will suffice.

The fan-shaped plate must span the entire orbital defect to the most posterior portion of the orbital floor defect. Care should be taken to ensure no entrapment of the orbit’s soft tissues during placement of the plate. Following placement of the plate, a forced duction test should be performed.

Alternatives to using a fan-shaped plate include bone graft, porous polyethylene, titanium with porous polyethylene, and orbital floor plates.

Another alternative to a fan-shaped plate is a patient-specific implant.

Preformed orbital plates provide another alternative to fan-shaped plates.

The advantage of bone graft is that the material is inexpensive. The disadvantages are that it takes additional time to harvest the bone graft, and there is an additional donor site and associated morbidity. Screw fixation is preferred.

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 imaging.

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

Screw fixation is preferred.

Titanium with porous polyethylene has the combined advantages of being more rigid than porous polyethylene alone and less likely to have sharp barbs on the edges. It is visible on postoperative radiographic imaging.

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

Screw fixation is recommended.

This postoperative cone beam image shows the position of a fan plate reconstructing the orbital floor and medial orbital wall in a coronal view.

An oblique parasagittal view of the implant reconstructing the orbital floor is seen in a patient with an associated zygomatic-complex fracture.

Patient vision is evaluated after awakening from anesthesia and then at appropriate intervals.

A swinging flashlight test may serve the same function in the unconscious or noncooperative patient. In some centers, an electrophysiological examination can be utilized if the appropriate equipment is available (VEP).

Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly reduce edema and pain.

Nose blowing should not involve pressing on the sides of the nose to increase intranasal pressure. Finger pressure on the nose should not accompany nose blowing for at least two weeks following orbital fracture repair to minimize the chance of orbital emphysema.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for seven days
• Analgesia as necessary
• Antibiotics (Many surgeons use perioperative antibiotics. There is no clear advantage beyond perioperative antibiotics, unless fracture repair has been delayed and there is maxillary sinus obstruction. Here the duration of treatment is dependent upon the circumstances.)
• Regular perioral and oral wound care must include disinfectant mouth rinse, lip care, etc.

Postoperative examination by an ophthalmologist may be requested if indicated. The following signs and symptoms are usually evaluated:

• Vision
• Extraocular motion (motility)
• Diplopia
• Globe position
• Perimetric examination
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked

Postoperative imaging should be performed within the first days after surgery. 3D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.

Remove sutures from the skin after approximately five days.

Ice packs are effective in the short term to minimize edema.

Avoid sun exposure and tanning to skin incisions for several months.

An antibiotic-based ointment can be applied at the suture incision site until the removal of sutures.

Diet depends on the fracture pattern.

A soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.

Usually, a liquid and semi-solid diet is advised for 2–3 weeks.

Nasogastric tube feeds may be considered in cases with oral bone exposure and soft-tissue defects.

Patients in MMF will remain on a liquid diet until such time as the MMF is released.

Clinical follow-up depends on the complexity of the surgery and whether the patient has any postoperative problems.

With patients having fracture patterns including periorbital trauma, issues to consider are the following:

• Globe position
• Double vision
• Other vision problems

Other issues to consider are:

• Facial deformity (including asymmetry)
• Sensory nerve compromise
• Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:

• Problems of dentition and dental sensation
• Problems of occlusion
• Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)

Following orbital fractures, eye movement exercises should be considered.

Generally, orbital implant removal is not necessary except in the event of infection or exposure. Readmission may be indicated if the long-term stability of the orbital volume has not been maintained.

The duration and use of MMF are controversial and highly dependent on the patient and complexity of the trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases, the surgeon may decide to place the patient in MMF after resolving these considerations.

The need for and duration of MMF are very much dependent on the following:

• Fracture morphology
• Type and stability of fixation (including palatal splints)
• Dentition
• Coexistence of mandibular fractures
• Premorbid occlusion

Tooth brushing and mouth washes should be prescribed and used at least twice a day to help sanitize the mouth. Gently brushing the teeth occurs with a soft toothbrush (dipped in warm water to make the bristles softer).

Travel in commercial airlines is permitted following orbital fractures. Commercial airlines pressurize their cabins. Mild pain on descent may be noticed. However, flying in military aircraft should be avoided for a minimum of six weeks.

No scuba diving should be permitted for at least six weeks.