From the Guidelines
The algorithm for treating zygomaticomaxillary complex (ZMC) fractures involves a standardized approach with or without intraoperative CT, prioritizing accurate reduction and fixation to minimize morbidity and improve quality of life. When treating ZMC fractures, the primary goal is to restore facial symmetry, proper occlusion, and orbital volume while preventing complications like enophthalmos, diplopia, and facial asymmetry.
Key Steps Without Intraoperative CT
- Expose the fracture sites through standard approaches (typically lateral eyebrow, lower eyelid, and intraoral incisions)
- Reduce the fracture by manipulating the zygoma into proper position using instruments like a Carroll-Girard screw or bone hook
- Visually and manually assess alignment at key areas: zygomaticofrontal suture, infraorbital rim, and zygomaticomaxillary buttress
- Fixation is then performed with titanium miniplates and screws at these three points to ensure stability, as supported by the use of CT scans in evaluating the complexity of such fractures 1
Key Steps With Intraoperative CT
- Obtain a scan after reduction but before fixation to confirm proper anatomical alignment
- If the CT shows inadequate reduction, the surgeon can immediately revise the position before applying fixation
- After fixation, a second CT scan can be obtained to verify final position, leveraging the benefits of CT in detecting subtle nondisplaced fractures and evaluating naso-orbital-ethmoid fractures 1 Intraoperative CT is particularly valuable in complex or comminuted fractures where visual assessment alone may be insufficient, as it offers superb delineation of osseous and soft-tissue structures, and allows for multiplanar and 3-D image reconstructions. The use of intraoperative CT in ZMC fracture treatment is supported by its ability to provide high image resolution with thin-section acquisitions, and its role in evaluating the zygomaticosphenoid suture status, which is an indicator of asymmetry and orbital volume changes 1.
From the Research
Treatment Algorithm for ZMC Fractures
The treatment algorithm for zygomaticomaxillary complex (ZMC) fractures involves several steps, including diagnosis, reduction, and fixation.
- Diagnosis: ZMC fractures are commonly encountered in the trauma setting and require accurate diagnosis to determine the best course of treatment 2.
- Reduction: The goal of reduction is to restore the premorbid form and function of the zygoma 2.
- Fixation: Fixation can be achieved using various methods, including titanium plates and bioresorbable mini screws and plates 2.
Treatment with Intraop CT
Intraoperative computed tomography (CT) can be used to improve the quality of reduction and minimize postoperative complications 3.
- Intraoperative CT can provide direct visualization of the fracture segments and help achieve stable reduction.
- The use of intraoperative CT can also help reduce the number of fixation points, which can minimize approach-related complications.
Treatment without Intraop CT
Without intraoperative CT, the treatment of ZMC fractures relies on clinical experience and available evidence.
- The use of 3D navigation, contralateral mirroring, and advances in fixation technology can help achieve better outcomes, particularly in severely comminuted or displaced fractures 2.
- Soft tissue management is also important in the treatment of ZMC fractures, and approaches to internal orbital reconstruction should be discussed 4.
Fixation Points
The number of fixation points used in the treatment of ZMC fractures can vary, and there is no clear consensus on the optimal number of fixation points 3.
- Multiple-point fixation can provide stable reduction, but it may also increase the risk of approach-related complications.
- Single-point fixation may be sufficient in some cases, but it may not provide adequate stability for more complex fractures.