Comparison of the modified lateral orbitotomy approach and

modified hemicoronal approach in the treatment of

unstable malunions of zygomatic complex fractures
Viraj R. Kharkar, MDS,a B. M. Rudagi, MDS,b Rajshekhar Halli, MDS,c and
Yogesh Kini, MDS, DNB,b Maharashtra, India
RURAL DENTAL COLLEGE

Objective. The objective of this study was to evaluate immediate and late postoperative complications in treating
zygomatic complex fractures by 2 modified approaches; namely, the modified lateral orbitotomy approach and the
modified hemicoronal approach.
Study design. Twenty zygomatic complex fractures were treated, with 10 being treated with the modified lateral
orbitotomy approach and the other 10 by the modified hemicoronal approach. Both groups were evaluated for
postoperative complications, ie, hematoma, infection, swelling, and nerve injury. The incisions were also evaluated in
all patients using clinical evaluation and visual analogue scales.
Results. Patients in both groups had temporary facial nerve injury that was primarily related to retraction of the
nerve. There were no hematomas observed in any of the groups. As compared to the modified lateral orbitotomy
approach, swelling was observed on more occasions with the modified hemicoronal approach. Infection was not
observed in any of the groups. As far as the esthetics in relation to the incision was concerned, the patients
accepted the modified hemicoronal approach more strongly as compared with the modified lateral orbitotomy
approach.
Conclusion. The modified hemicoronal approach seems to be preferred to the modified lateral orbitotomy
approach with respect to treating zygomatic complex fractures. (Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2010;109:504-509)

Forty-five percent of trauma to the midface constitutes
fractures to the zygomatic complex (ZMC).1 Various
approaches and surgical incisions have been described
to treat fractures of the zygomatic complex. Traditional
closed techniques and total exposure of all fracture
lines by conventional multiple incisions2 have been
routinely used. All these approaches or a single routine
hemicoronal incision are always in a constant state of
contention.3 The ideal and the best surgical approach to
treat ZMC fractures should provide maximum neces-
sary exposure of the fracture segments, minimize po-
tential for injury to facial structures, and enable good
cosmetic results.
There have always been controversies as to the use of
the most simple and efficient approach to treat ZMC
fractures. Malunited ZMC fractures cause inadequate
mouth opening because of the encumbrance of the
zygomatic arch to the coronoid process of the mandible
which brings about functional impairment, thereby jus-
tifying surgical management. Facial esthetics also fea-
tures as one of the absolute indications for surgical
management of these fractures. When they are involved
with the concomitant existence of the zygomatic arch
(Figs. 1 and 2), the situation becomes more challenging
and adequate planning needs to be exercised to achieve
superior results.
The aim of this article is to compare 2 modified
approaches, i.e., the modified lateral orbitotomy ap-
proach (MLA) and the modified hemicoronal approach
(MHA), and evaluate the best-suited approach to treat
ZMC fractures.

a
Senior Lecturer, Department of Oral & Maxillofacial Surgery, Rural
MATERIALS AND METHODS
Dental College, Loni–Bk, Maharashtra, India.
b
Reader, Department of Oral & Maxillofacial Surgery, Rural Dental Twenty patients, 16 males and 4 females with a
College, Loni–Bk, Maharashtra, India. mean age of 32 years, with zygomatic complex frac-
c
Professor, Department of Oral & Maxillofacial Surgery, Rural Den- tures involving the displaced arch were randomly
tal College, Loni–Bk, Maharashtra, India. selected to undergo treatment with 2 different ap-
Received for publication Aug 26, 2009; returned for revision Sep 10,
proaches (MLA or MHA) incorporating 2 different
2009; accepted for publication Oct 7, 2009.
1079-2104/$ - see front matter surgeons operating these approaches evenly. Ten pa-
© 2010 Mosby, Inc. All rights reserved. tients underwent the MLA, and the other 10 under-
doi:10.1016/j.tripleo.2009.10.012 went the MHA.

504
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Volume 109, Number 4 Kharkar et al. 505

Fig. 1. CT scan showing ZMC fracture with involvement of the zygomatic arch.

Table I. Visual analog scale

Scale Results
0-3 Convincingly content
4-7 Moderately content
8-10 Mildly content

All patients were evaluated for any complications

observed postoperatively. Incidence of hematoma and
swelling was evaluated by keeping the patient under
observation for 5 days. Swelling was assessed clinically
by the surgeon as well as with the help of a visual
analog scale (Table I). All patients were observed for
any signs of infection or nerve injury after 2 days, 5
days, 15 days, 1 month, and 6 months. Morbidity and
scarring of the incisions were also assessed at 5 days, 1
Fig. 2. Skin incision for modified hemicoronal approach month, and 6 months by the visual analog scale, as well
(MHA). as clinically.

506 Kharkar et al.
Fig. 3. Exposure achieved using the MHA technique with postoperative PNS view.
Technique for modified lateral orbitotomy
approach
Under general anesthesia, a lazy S-shaped skin inci-
sion (Fig. 3) was used and curved up to the brow and
then posteriorly along the upper region of the zygo-
matic arch for approximately 35 to 40 mm from the
lateral canthus to avoid damage to the zygomatic
branch of the facial nerve.4 After skin incision, the
fascia of the temporal muscle was incised and subpe-
riosteal tunneling was done posteriorly to expose the
zygomatic arch. The frontozygomatic suture area and
the zygomatic arch were then identified, reduced, and
fixed (Fig. 4) using titanium miniplates and screws. The
fascia and subcutaneous tissue were sutured with 3-0
Vicryl and finally the skin suturing was done using 5-0
prolene.5
Technique for modified hemicoronal approach
Under general anesthesia, a hemicoronal incision
was made as routinely practiced with the only modifi-
cation (Figs. 5 and 6) being the anterior arm of the
incision, which is curved downward toward the supe-
rior wall of the orbit well before it reaches the vertex of
the skull within the hairline, thereby forming a “back-
cut” providing excellent exposure of the entire zygo-
matic complex and the arch.
In both groups, the zygomaticomaxillary buttress
was exposed by the sublabial incision intraorally with
the combination of the modified approaches. Forced
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April 2010
duction tests were carried out for all patients and orbital
floors were only explored as needed.
RESULTS
All patients were evaluated in the hospital for the
first 5 days, after which they were discharged. Of the 20
patients, 14 reported with road traffic accidents, whereas 6
reported with assaults. Twelve of these patients had fresh
fractures whereas 8 of them were old malunited fractures.
They were equally distributed between groups, i.e., 6 fresh
and 4 old in each group.
No incidence of hematoma or infection was reported
in either group. With the MHA technique, 7 patients
reported with temporary facial nerve involvement (only
the temporal branch), whereas 3 patients reported with
involvement of both temporal and zygomatic branches.
There was no involvement of the temporal branch of
the facial nerve with the MLA technique. Six patients
showed involvement of the zygomatic branch of the
facial nerve, whereas 4 showed no involvement with
MLA technique. By 1 month of follow-up, patients of
both groups showed absolutely no involvement of the
facial nerve (Table II).
With the MHA technique, 6 patients had postopera-
tive swelling that gradually settled by 5 days. There
was no postoperative swelling in any of the patients
who underwent the MLA technique.
Incisions were again assessed clinically by the
surgeon and the visual analog scale. Of the 10 pa-
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Volume 109, Number 4 Kharkar et al. 507

Fig. 4. Three-dimensional scan showing ZMC fracture with involvement of the zygomatic arch.

Fig. 5. Skin incision and exposure using MLA technique.

tients operated by the MHA technique, all were con- were moderately content, whereas the other 5 were
tent with the postoperative result at the 6-month mildly content with the postoperative result at the
follow-up visit. With the MLA technique, 5 patients 6-month follow-up.
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508 Kharkar et al. April 2010

Fig. 6. Postoperative mouth opening and PNS view using the MLA technique.

Table II. Results

Criteria
Hematoma and infection
Facial nerve involvement
Postoperative swelling
Incision assessment
Modified hemicoronal approach Modified lateral orbitotometry approach
None None
7/10 (only temporal) 6/10 (only zygomatic)
3/10 (temporal and zygomatic)
6/10 had swelling None
All (convincingly content) 5/10 (moderately content)
5/10 (mildly content)

DISCUSSION gaining access to skull base tumors. Also this approach

Concepts and ideas of various authors differ to a large
extent with respect to the use of different approaches to
treating zygomatic complex fractures. Formerly, coronal
incisions were used commonly in craniofacial surgery,6
orthopedic surgery,7 and head and neck cancer surgery8
and are still used in orthognathic and trauma surgery.
Zhang et al.9 still prefer the coronal approach to treat
zygomatic complex fractures. Local incisions were pre-
ferred by 71% of surgeons as per a survey conducted by
McLoughlin et al.10 among British maxillofacial sur-
geons. Kovacs and Ghahremani1 also reported a pref-
erence for local incisions in their study.
The lateral orbitotomy approach to the orbit was first
proposed by Krönlein in 1889,11 later modified by
Berke in 1953,12 and thereafter by Maroon and Ken-
nerdell in 1976.4 We have incorporated only the mod-
ified lateral orbitotomy incision to approach zygomatic
complex fractures. The lateral orbitotomy approach is
more frequently used for intraorbital tumors and for
is used for tumors located in the lateral, superior, and
inferior compartments of the orbit.4,13,14
A comfortable access for the ease in reduction and
fixation of the fractured segments emphasizes as one of
the customary essentials to treat zygomatic complex frac-
tures. As a rule, the stability of zygomatic complex frac-
tures figures as a strong focal point in treating these
fractures. The concomitant existence of an unstable arch
(inferiorly displaced) necessitates the use of a rather
modified approach. A single modified approach that is
esthetic and provides excellent access and imparts sta-
bility after fixation with minimal functional impairment
is necessary. The MHA and MLA techniques seem to
convincingly satisfy these norms and are hence evalu-
ated.
The reasons for using these modified incisions were
2-fold. First, of the 20 patients, 12 had zygomatic
complex fractures caused by accidents leading to mul-
tiple and sometimes comminuted fractures for which
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Volume 109, Number 4
local incisions do not provide full exposure with ease in
reduction and fixation. Second, the other 8 patients had
old malunited fractures, wherein again local incisions
were inefficient in providing adequate exposure to re-
fracture the malunited segments and proficiently reduce
and immobilize them.
All the necessary steps, i.e., injecting local anesthetic
with adrenalin under the galea aponeurotica as well as
electric coagulation were used thereby preventing any
hematoma formation in both of the techniques. There
was absolutely negligible swelling in all 10 patients
who underwent the MLA technique. With the MHA
technique, because of the detailed dissection of the
layers of the scalp, a moderate amount of swelling was
noticed in most of the patients that was evident even at
the fifth postoperative day, but gradually subsided by
the next follow-up visit.
All the patients in both groups were postopera-
tively put on broad-spectrum antibiotics with the
incision lines scrupulously taken care of, rendering
them impervious to infection. Temporary facial
nerve injury (neuropraxia) was observed in both the
groups. This was a result of the retraction of the
nerves in both the groups, which resolved within 1
month. The temporal and zygomatic branches were
involved with the MHA technique. Here the dissec-
tion was carried out with identification of the tem-
poralis fascia and incising it 2 cm above the root of
the zygoma. This dissection path along the deep
fascia prevented any permanent injury to the tempo-
ral and zygomatic branches, which are well secure in
the skin flap. In the MLA technique, only the zygo-
matic branch of the facial nerve seemed to be involved.
Here the incision was made well above the zygomatic
arch, thus preventing any transection of the zygomatic
branch of the facial nerve.
Both the MHA and the MLA incisions had minimal
scarring, but as the MHA technique had its incision well
inside the hairline it was hardly conspicuous and well
accepted by the patients. As far as the MLA technique is
concerned, the incision was evidently exposed and satis-
factorily accepted by the patients.
Both the techniques provide excellent accessibility
to the ZMC with minimal morbidity with respect to
postoperative swelling and temporary involvement of
the branches of the facial nerve. To convince a patient
to undergo treatment for the surgical manipulation of
the ZMC fracture, the MHA approach was much easier
to accept with regard to the MLA approach. With
regard to patient satisfaction and appreciation, the
MHA technique received more recognition and repute
as compared with the MLA technique.
Kharkar et al. 509
Hence, in due regard for the negligible complications
and patient appreciation that were discerned from the
evaluation of both the modified techniques to treat the
zygomatic complex fractures, the MHA technique seems
to have a finer edge over the MLA technique.
CONCLUSION
The modified hemicoronal approach seems to have
an edge over the modified lateral orbitotomy approach
as far as treating zygomatic complex fractures is con-
cerned.
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Reprint requests:
Viraj R. Kharkar, MDS
Department of Oral & Maxillofacial Surgery
Rural Dental College
Loni–Bk, Maharashtra, India
virajkharkar@gmail.com