PMC7433986_01
Maxillofacial injuries sustained in a fall from a 2-wheeler. (a-e) Swelling of the right cheek region, periorbital edema, and ecchymosis with subconjunctival hemorrhage and marked enophthalmos with epiphora, restriction in ocular movements and diplopia. (f) Severely restricted interincisal mouth opening (g) No derangement on occlusion noted. (h) Non-contrast computed tomographic of craniomaxillofacial region demonstrating grossly displaced and comminuted fracture of the right zygomatico-orbito-maxillary complex region
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F1
There was extensive periorbital edema, and subconjunctival ecchymosis of the right eye, as well evidence of enophthalmos [Figure 1a-e]. Although there was no derangement of occlusion, there was severe restriction in mouth opening [Figure 1f]. Oral hygiene was poor, with calculus deposits and generalized gingivitis [Figure 1f and g]. Non-contrast computed tomographic scans (NCCT) of the craniomaxillofacial region (axial, coronal and sagittal sections with three-dimensional reformatting) [Figures 1h and 3] revealed an unusual pattern and orientation of fracture lines involving multiple areas of the entire right zygomatico-orbito-maxillary complex, associated with severe comminution and extensive displacement of the numerous fracture fragments.
Comparison of pre- and post-operative radiographs. (a, c and e) Preoperative Water's View skull, Lateral view skull and orthopantomogram showing a grossly displaced fracture of the right zygomatic complex, involving a horizontally oriented fracture through the right body of zygoma, comminuted fracture of the zygomatic arch and wide separation at the frontozygomatic suture, lateral orbital wall and zygomatic buttress regions. (b, d and f) Postoperative PNS (Paranasal Sinuses View) view skull, lateral view skull and orthopantomography showing reduced, reapproximated, and well-aligned fracture fragments with fixation implants in situ
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F2
Radiographs (Orthopantomogram, Lateral View Skull and Water's View Skull) [Figure 2a, c and e] revealed a right zygomatico-orbito-maxillary complex fracture with extensive comminution of the right zygomatic arch and an unusual fracture pattern which ran horizontally across of the body of the zygomatic bone with severe downward displacement of its lower half, together with significant disruption of the right maxillary antrum and zygomatic buttress region.
Preoperative non-contrast computed tomographic scans. (a) Three dimensional images showing an unusual fracture pattern of the right zygomatico-orbito-maxillary complex. A horizontally oriented displaced fracture running across the body of zygoma. (b) Sagittal sections showing disjunction at all the articulations of the zygoma. (c) Coronal sections showing the grossly increased right orbital volume, (d) Axial sections showing gross comminution of the right zygomatic arch, disruption of the anterolateral and posterolateral walls of the right maxillary antrum, with hemosinus
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F3
Non-contrast computed tomographic scans (NCCT) of the craniomaxillofacial region (axial, coronal and sagittal sections with three-dimensional reformatting) [Figures 1h and 3] revealed an unusual pattern and orientation of fracture lines involving multiple areas of the entire right zygomatico-orbito-maxillary complex, associated with severe comminution and extensive displacement of the numerous fracture fragments. The body of the right zygoma had a horizontal fracture line running across its entire breadth with severe downward displacement of its lower half and wide separation between the upper and lower fragments [Figure 3]. In addition to hemosinus, the interior of the antrum was filled with multiple fragments and spicules of bone collapsed and detached from the antral walls [Figure 3].
(A-C) Hemicoronal incision line. (D and E) Flap raised in the subgaleal plane. (F and G) Incision placed through the superficial layer of the temporal fascia, exposing the temporal fat pad. (H) Frontozygomatic suture region fixed with a 4-hole miniplate. (I-M) Exposure of comminuted fractured fragments of the zygomatic arch. (N-R) Fixation using a long titanium microplate (S and T) fractured zygoma reduced and fixed. (U-X) fracture at zygomatic buttress and anterolateral wall of the maxillary antrum reduced and fixed using a three-dimensional miniplate. (Y-AD') Closure in layers
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F4
The hemicoronal incision line was marked [Figure 4A] and 2% lignocaine with 1:100,000 adrenaline was infiltrated subcutaneously along this line. Hemostatic sutures were placed on both sides of the proposed incision line to reduce bleeding from the edges of the scalp flap [Figure 4B and C]. Once the correct, relatively avascular subgaleal plane was established, the separation of the scalp flap proceeded effortlessly up to the helix of the ear [Figure 4D and E]. A long incision was placed beginning from the root of the zygomatic arch and carried forward at an angle of 45  through the superficial layer of the temporal fascia, exposing the temporal fat pad in the pocket just beneath this layer [Figure 4F and G]. The displaced fracture of the lateral orbital wall, at the frontozygomatic suture region, was carefully reduced, reapproximated, and fixed using 4-hole titanium minibone plates and screws [Figure 4H], thereby restoring the orbital volume. Next, the multiple, delicate fragments of the shattered arch were exposed [Figure 4I-L], carefully grasped, meticulously reduced, realigned, held in place using mosquito artery forceps [Figure 4M] and fixed using a long, low profile (1.7 mm thick) titanium microplate, and screws [Figure 4N-R]. The descended half of the body of the zygoma was pushed upward by finger pressure applied intraorally against the zygomatic buttress and simultaneous fixation of the body of the zygoma was carried out through the hemicoronal incision site [Figure 4S-U], retaining the upward finger pressure intraorally. The comminuted fracture of the anterolateral wall of the right maxillary antrum was then reduced and fixed intraorally using a three-dimensional 4-hole titanium plate and screws [Figure 4V-X]. After ensuring adequate hemostasis, the hemicoronal incision was meticulously closed in layers after placement of a Minivac closed suction drain and an extraoral pressure dressing was applied [Figure 4Y-AD'].
(a-d) Postoperative non-contrast computed tomographic scans. (a) Three-dimensional images showing precisely reduced and well-aligned fracture fragments. (b) Sagittal sections showing precise reapproximation and fixation at the frontozygomatic suture region, lateral orbital wall, infraorbital rim, and zygomatic arch. (c) Coronal sections depicting restoration of the orbital volume (d) Axial sections showing reapproximation of the multiple comminuted fracture fragments of the right zygomatic arch, precise realignment of the lateral wall of the right orbit and Frontozygomatic region, fixed in place with micro- and minibone plates and screws
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F5
(a) Restoration of facial symmetry, balance and esthetics. Successful correction of enophthalmos of the right eye, with achievement of bilaterally symmetrical ocular levels, full, free, and unrestricted ocular movements and absence of diplopia in all gazes. (b and c) Hemicoronal incision scar healing well and well camouflaged within the hairline. (d-f) Absence of any neurological deficit involving the frontal and temporal divisions of the facial nerve, evidenced by unaffected eye closure and normal raising of eyebrows and forehead wrinkling on looking upwards
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F6
Postoperative esthetic and functional results were gratifying [Figure 6] with frontozygomatic suture restoration of ideal facial balance, projection and symmetry, unrestricted interincisal mouth opening, satisfactory masticatory efficiency, and successful correction of the enophthalmos and diplopia.