Outcome of treatment of Zygomatic bone fracture by two point fixation versus three point fixation in Mayo Hospital Lahore.

OBJECTIVE: To compare the outcome of two-point internal fixation versus three-point internal fixation for the treatment of zygoma fractures. METHODS: The quassi-experimental study was conducted at the King Edward Medical University, Mayo Hospital, Lahore, Pakistan, from April to September 2016, and comprised patients with zygomatic bone fracture who were randomly divided into two groups. In Group A, patients were treated with two-point fixation and in Group B, patients were treated with three-point fixation. All patients were treated by the same consultant. Patients were followed up on first, third and sixth week postoperatively and malar height and mouth opening were recorded at the sixth week follow-up. Data was analysed using SPSS 17. RESULTS: Of the 60 patients, there were 30(50%) in each of the two groups. There were 39(65%) males and 21(35%) females. The mean age in Group A was 29.56±9.89 years (range: 17-50 years), while in Group-B it was 29.45±8.68 years (range: 17-49 years). Mean malar height at 6th week post-operative follow up showed a significant reduction in Group B compared to Group A (p= 0.001). Significant improvement in mouth opening was seen in Group B compared to Group A (p= 0.034). CONCLUSIONS: Three-point fixation was found to give more stable reduction compared to 2-point fixation for treating zygomatic bone fractures in terms of malar height and mouth opening.

"Radiological morphometric analysis of the zygomatic arch: Application of osteosynthesis on the upper arch border for rigid fixation".

BACKGROUND: This study was designed to introduce a novel method of applying osteosynthetic materials to the upper zygomatic arch border for fracture fixation through a temporal incision, and analyze the radiologic morphometric dimensions of the arch to verify its validity. METHODS: Radiological morphometry was analyzed in 51 adult patients with unilateral isolated zygomatic arch fractures. Frequent fracture sites, sites of minimal thickness and height, and their correlation were evaluated, as were the locations and dimensions of fixation vantage points. The novel surgical method based on the results was implemented in 17 clinical cases. RESULTS: Frequent fracture sites, occurring 4.40, 16.47 and 30.48 mm posterior to the arch origin, did not correlate to sites of minimal height and thickness. Arch minimal thickness and height locations were 12.23 and 27.09 mm behind its origin, respectively. Fixation vantage point dimensions varied from point to point, with upper thickness ranging from 1.67 to 4.86 mm and mid-portion thickness ranging from 2.06 to 7.36 mm, and height ranging from 8.99 to 22.53 mm. Arch vertical axis inclination ranged from 6.51° to 16.47°, which increased as the arch stretches posteriorly. These results suggested the use of 1.5 mm-wide plates and 1 mm-diameter screws with 6-8 mm length. Patients received surgery based on these morphometry results for satisfactory stabilization. CONCLUSIONS: This study introduces a new method for open reduction and internal fixation of arch fractures, with morphometric analysis of the arch verifying the validity of tangential plate application to the upper border.

Analysis of Facial Symmetry After Zygomatic Bone Fracture Management.

PURPOSE: The location of the zygomatic bone plays an important role in facial symmetry and esthetics. The aim of this study was to determine and compare the frequency of facial asymmetry in a sample of patients who had undergone treatment of unilateral zygomaticomaxillary complex (ZMC) fractures (study group) and a sample of patients without ZMC fracture (control group). MATERIALS AND METHODS: This was a retrospective controlled cross-sectional study. The primary predictor variable was the type of ZMC fracture (linear or comminuted). The primary outcome variable was facial asymmetry characterized by the bilateral difference in the position of the malar eminence (ME) in 3 dimensions based on computed tomographic images. The other variables for this study were classified as demographic (age and gender) and anatomic (side of ZMC fracture). Descriptive and bivariate statistics were computed. Statistical significance was set at a P value less than .05 with 95% reliability. RESULTS: The entire sample consisted of 134 patients (n = 67 per group). The mean bilateral difference of the ME position in the study group was markedly greater than in the control group. More than half the study patients had facial symmetry and almost 10% of them had marked asymmetry, whereas none of the control patients had marked asymmetry. All patients with marked asymmetry and approximately 70% of them with greater than maximum normal asymmetry had a comminuted fracture. CONCLUSIONS: The results of this study show that although the frequency of facial asymmetry in patients with ZMC fracture was higher than in the control patients, it was found in all patients to a certain extent. Patients' awareness of this fact can decrease their dissatisfaction.

Retrospective analysis of 471 surgically treated zygomaticomaxillary complex fractures.

PURPOSE: Zygomaticomaxillary complex (ZMC) fractures are frequent in facial trauma; only fractures of the mandible are more common. Although the frequency of these fractures is geographically consistent, the aetiology differs widely among countries and even regions. Differences in socio-economic status and the ageing population seem to be two causes. This retrospective epidemiological study evaluates patients who were surgically treated for ZMC fractures at a Swiss university clinic. MATERIALS AND METHODS: This study included 471 patients who were surgically treated for ZMC fractures in an oral and maxillofacial surgery clinic at a Swiss university hospital between January 2004 and December 2012. Complicated fractures such as LeFort II/III and bilateral ZMC fractures were excluded. Data on gender, age, and type of trauma were recorded. Fractures were classified by aetiology: motorised road traffic (car or motorcycle), bicycle, interpersonal violence, sports, falls (both less than and greater than 3 m in height) and other causes. RESULTS: A total of 350 patients were male (74%), and 121 were female (26%). The ZMC fractures were most likely to occur in the third decade (117 cases, 25%). A predominance of male patients was found in the young age groups, but an equal ratio was found in the elderly groups. Etiologically, falls of less than 3 m were the most common cause of ZMC fractures (125 cases, 27%). Interpersonal violence was second (88 patients, 19%); male patients dominated this group, which had a male-to-female ratio of 21:1. A predominance of male patients was found in every subdivision when analysing by aetiology and gender. The lowest proportion of males (57%) was found for falls of less than 3 m. CONCLUSION: In our study, interpersonal violence and falls outnumbered road traffic accidents among causes of maxillofacial fractures. This is probably a consequence of strict road and work laws. Additionally, the older and more active populations accounted for the highest proportion of falls, and young male patients were the predominant victims of ZMC fractures.

Preoperative evaluation and surgical technique of functional and cosmetic aspects in zygomatic complex fracture patients.

The zygomatico-maxillary complex functions as the principle buttress of the face and is the cornerstone to an individual’s aesthetic appearance. Its fracture not only creates cosmetic deformities owing to its position and facial contour, but can also cause disruption of ocular and mandibular functions. The aim of this study was to evaluate the quality, efficacy and impact of internal fixation of zygomatic complex fractures on functional and cosmetic outcomes. A prospective study was carried out on 100 patients who were divided according to the classification and the severity of injury. Subjective evaluation was submitted based on the patient’s perception of signs and symptoms in the preoperative and postoperative periods. Intraoperative and postoperative assessment of bone reduction quality was made according to the type of the fracture and related difficulties; also, the difference between these groups was observed as functional and esthetic outcome. To optimize the treatment of zygomatic bone fractures, a pre-designed questionnaire was used for subjective evaluation of symptoms and treatment outcome. In 70% of cases, ophthalmologic consultation was taken and was most common in type VII fractures (100% cases). Neurosensory disturbance was the most common finding (60%), followed by diplopia (56R%), pain upon mouth opening (54%) and malar depression (50%). Out of all possible 400 fracture sites in 100 patients of zygomatic complex fractures, 266 (66.5%) fractures were detected by clinical examination, in contrast to 330 (82.5%) on radiological examination, which were highest at zygomatic-maxillary buttress (93%) followed by infraorbital rim (91%) and almost equal among fronto-zygomatic site (72%) and zygomatic arch (74%). The scores from the questionnaire for annoyance were significantly higher for paraesthesia (23%) than for trismus (10%), pain (8.5%), or deformity (8.25%). Residual deformity and pain significantly influenced the total satisfaction. Conclusively, there are many treatment modalities available for zygomatic complex fractures, and the preferred methods should be selected on the basis of fracture type, fracture severity, pre-operative signs and symptoms. Regarding the requirements of fracture site exposure and actual fixation, one priority should be to minimize postoperative complications, morbidity and residual deformities.

Surgical treatment of unilateral zygomaticomaxillary complex fractures: A 7-year observational study assessing treatment outcome in 153 cases.

This study investigates treatment outcome in zygomaticomaxillary complex (ZMC) fracture repair. METHODS: The medical records and CT-images of patients that received treatment for a unilateral ZMC fracture in 2005-2011 were studied. ZMC fractures were categorised as incomplete (type A), tetrapod (type B) or comminuted (type C). The incidence of sequelae, wound infection and secondary surgical interventions was analysed per fracture category. RESULTS: A total of 153 patients were treated in the selected period. Persisting sensory disturbances in the area innervated by the infraorbital nerve were observed in 50 cases (37%), facial asymmetry in 19 cases (14%), enophthalmos in 10 cases (7%) and persisting diplopia in 9 cases (7%). Wound infection occurred in 6 cases (4%). Secondary surgical procedures of the ZMC, orbital floor, and/or extraocular muscles were performed in 14 cases (9%). C-type fractures were associated with more secondary corrections for ZMC malreduction (12%, p = 0.03), more secondary reconstructions of the orbital floor (10%, p < 0.01), and more functional corrections of diplopia by extraocular muscle correction (5%, p = 0.02). CONCLUSION: Treatment outcome in C-type ZMC fractures is less favourable than treatment outcome in A-type and B-type fractures. Intraoperative imaging, surgical navigation devices and 3D-planning software may improve treatment outcome in C-type ZMC fractures.

Measuring zygomaticomaxillary complex symmetry three-dimensionally with the use of mirroring and surface based matching techniques.

OBJECTIVE: The study aim was to validate a new method for measuring zygomaticomaxillary complex (ZMC) symmetry, which can be helpful in analyzing ZMC fractures. METHODS: Three-dimensional virtual hard-tissue models were reconstructed from computed tomography (CT) datasets of 26 healthy individuals. Models were mirrored and superimposed. Absolute average distance (AD) and 90th percentile distance (NPD) were used to measure overall and maximal symmetry. The Intraclass Correlation Coefficient (ICC) was calculated to measure interobserver consistency. In order to determine whether this technique is applicable in ZMC fracture cases, 10 CT datasets of individuals with a unilateral ZMC fracture were analyzed. RESULTS: For the unaffected group the mean AD was 0.84 ± 0.29 mm (95% CI 0.72-0.96) and the mean NPD was 1.58 ± 0.43 mm (95% CI 1.41-1.76). The ICC was 0.97 (0.94-0.98 as 95% CI), indicating almost perfect interobserver agreement. In the affected group the mean AD was 2.97 ± 1.76 mm (95% CI 1.71-4.23) and the mean NPD was 6.12 ± 3.42 mm (95% CI 3.67-8.57). The affected group showed near-perfect interobserver agreement with an ICC of 0.996 (0.983-0.999 as 95% CI). CONCLUSIONS: The method presented is an accurate instrument for evaluation of ZMC symmetry, which can be helpful for advanced diagnostics and treatment evaluation.

Does Training Background Influence Decision-Making in the Management of Zygomaticomaxillary Complex Fractures?

PURPOSE: Management of zygomaticomaxillary complex (ZMC) fractures should be based on injury patterns and not on training background. This study assessed management decisions for ZMC injuries among surgeons with different training backgrounds. MATERIALS AND METHODS: This was a cross-sectional study of surgeons who evaluated 5 ZMC injury cases. The primary predictor variable was training background: plastic and reconstructive surgeons (PRSs), craniofacial PRSs (c-PRSs), and oral and maxillofacial surgeons (OMSs). Other variables were years in practice, fellowship training, practice scope, and comfort with managing facial injuries. The primary outcome variable was management of the ZMC and orbital floor (operative vs nonoperative). Secondary outcome measurements were related to surgical approaches and fixation. Descriptive, bivariate, and regression statistics were computed. RESULTS: Twenty-one surgeons (7 PRSs, 7 c-PRSs, and 7 OMSs) with an average of 14.4 ± 12.6 years of experience provided a total of 105 treatment plans. There was significant agreement between c-PRSs and OMSs for management of ZMC and orbital floor injuries (rs = 0.70 and 0.76, respectively; P ≤ .001). PRSs did not have substantial agreement with c-PRSs or OMSs with regard to ZMC fractures (rs = 0.39 and 0.49, respectively; P ≤ .06), but significant agreement with regard to orbital floor injuries (rs = 0.70 and 0.76, respectively; P < .001). In a regression model, injury pattern was the only factor associated with operative management (P ≤ .001). CONCLUSIONS: There is substantial agreement between OMSs and c-PRSs regarding the management of ZMC fractures and associated orbital floor injuries.

Are Biodegradable Osteosyntheses Still an Option for Midface Trauma? Longitudinal Evaluation of Three Different PLA-Based Materials.

The aim was to evaluate three different biodegradable polylactic acid- (PLA-) based osteosynthesis materials (OM). These OM (BioSorb, LactoSorb, and Delta) were used in 64 patients of whom 55 (85.9%) had fractures of the zygoma, five (7.8%) in the LeFort II level, two of the frontal bone (3.1%), and two of the maxillary sinus wall (3.1%). In addition to routine follow-up (FU) at 3, 6, and 12 months (m) (T1, T2, and T3) all patients were finally evaluated at a mean FU after 14.1 m for minor (e.g., nerve disturbances, swelling, and pain) and major (e.g., infections and occlusal disturbances) complications. Out of all 64 patients 38 presented with complications; of these 28 were minor (43.8%) and 10 major (15.6%) resulting in an overall rate of 59.4%. Differences in minor complications regarding sensibility disturbance at T1 and T3 were statistically significant (P = 0.04). Differences between the OM were not statistically significant. Apart from sufficient mechanical stability for clinical use of all tested OM complications mostly involved pain and swelling probably mainly related to the initial bulk reaction attributable to the drop of pH value during the degradation process. This paper includes a review of the current aspects of biodegradable OM.

Tactics of surgical treatment at traumatic injuries of maxillo-zygomatic-orbital complex and the lower edge of the orbit.

The maxilla-facial traumatic injuries, zygomatic - orbital complex and orbit lower edge injuries are characterized by dislocation of bone fragments, causing not only the anatomo-functional disorders but well-expressed deformity/ abnormality of the patient. 28 patients with traumatic fractures of zygomatic - alveolar complex and orbit lower edge have been studied and got surgical treatment by the authors. At admission to the hospitals, all the patients were the subjects to a classic comprehensive / complex examination including a Spiral Computed Tomography, with 3D reconstruction (three-dimensional) (in 3 projections). All the patients underwent surgical treatment under endotracheal anesthesia that included osteosynthesis of zygomatic bone body and arch and plasty of orbit lower edge. Osteosynthesis of zygomatic bone body and arch was conducted with titanium plates and screws (hanging zygomatic arch by steel wires), restoration of bony wall was carried out by prosthesis of titanium (net) plate made individually (auto-graft, taken from calvaria bone was used for restoration of orbit lower edge defect in 2 cases). According to the study materials no complications of transplanted grafts like purulency, removal reaction, or dislocation were observed. The obtained data have proved over again, that endoprothesis made of medical titasnium are effective for treatment of the patients with middle third facial traumatic injuries.

The zygomaticomaxillary complex fracture - an anthropometric appraisal of surgical outcomes.

Before undergoing repair of zygomaticomaxillary complex fractures, most patients are worried about their postoperative appearance. Furthermore, there is an ongoing discussion about the selection of the surgical approach to the inferior orbita and resulting eyelid deformities. We present a photo-assisted postoperative evaluation of zygomaticomaxillary complex fracture repair based on reference anthropometric data. Two hundred and twenty-one patients underwent zygomaticomaxillary complex fracture repair. An analysis of standardized postoperative photographs included measurements of eye fissure width and height, lid sulcus height, upper lid height, upper and lower coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, and whether a transconjunctival or a subciliary approach was performed. Surgery per se significantly influenced eyelid deformities as measured by its impact on eye fissure index, lower iris coverage and rate of scleral show and ectropion. The surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating distortion of the lower eyelid. Investigations regarding orbital fractures should clearly differentiate the type of fracture. The subciliary approach included the highest risk of postoperative lower eyelid deformity in zygomaticomaxillary complex fracture repair. The standardized measurements described here are accurate and objective to evaluate postoperative results.

Assessment for treatment of tripod fractures of the zygoma with microcompressive screws.

PURPOSE: The present prospective study sought to evaluate a new rigid internal fixation device called a "neck screw," which was applied to patients presenting with a tripod fracture of the zygomaticomaxillary complex. PATIENTS AND METHODS: Seventeen patients with tripod fractures received surgical treatment from 2007 to 2010, and had their zygomaticomaxillary complex monofragments fixed using the neck screw protocol. The adequacy of fracture reduction, stability of the zygomatic monofragment after fixation, cosmetic outcomes, and postoperative complications were used to determine the efficacy of this protocol. The stability provided by the neck screw was evaluated by computed tomography (CT) scans by comparing the immediate postoperative distances between the fractured bone segments (control group) with those distances measured on CT scans obtained 5 weeks later (late group). RESULTS: The average distance observed between the fractured ends on the immediate postoperative CT scan was less than 0.58 mm, demonstrating adequate fracture reduction. No significant changes were seen in these postoperative values after 5 weeks (Wilcoxon test, P = 1.0000), demonstrating no displacement of the zygomaticomaxillary complex monofragment after fixation using the neck screw. CONCLUSIONS: The proposed surgical treatment proved efficient in 17 patients. The fixation stability provided by the neck screw was confirmed by subsequent CT scan measurements, statistical analysis, and clinical follow-up during the postoperative period, in which patients showed no significant associated complications, facial asymmetry, enophthalmos, or diplopia.

Treatment of zygomatic arch fracture with lag screws.

Zygomatic arch fractures often occur as part of a zygoma fracture or Le Fort type III fractures of the maxillary. Isolated fractures of the zygomatic arch comprise around 10% of all zygoma fractures. The main etiologic factors are traffic accidents, falls, assaults, and sport accidents. Treatment may involve minimally invasive surgical procedures for slightly dislocated fractures or surgery with more extensive access for large dislocations of bone segments. This article reports the case of a 41-year-old male victim of physical aggression to the face with a steel sickle with an exposed, unstable fracture of the zygomatic arch. The patient underwent general anesthesia, and after the reduction of the fractures, the bone segments were fixed with 2.0-mm screws.

[Forensic medical criteria for the assessment of severity of harm to the health in subjects with zygomatic bone fractures].

Expert reports concerning subjects with zygomatic bone fractures were analysed and comprehensively evaluated using investigatory, clinical and anamnestic data. A total of 704 forensic medical reports were available for the purpose including 225 (32%) isolated and 479 (68%) combined fractures. It was shown that most complications of zygomatic fractures develop late in the post-traumatic period which requires repeated examination of the patients within at least one month after the injury. It is emphasized that such examination must involve neuropathologist, ophthalmologist, and maxillofacial surgeon to adequately evaluate harm to the health in patients with isolated zygomatic fractures. The main causes of discrepancy between results of estimation of harm to the health during primary and subsequent forensic medical examination of subjects with zygomatic fractures are considered.

Individual design and rapid prototyping in reconstruction of orbital wall defects.

PURPOSE: We examined the application of individual digital design and rapid prototyping in the reconstruction of orbital wall defects for different stages of orbital volume (OV) changes. PATIENTS AND METHODS: Patients with unilateral post-traumatic orbital defects underwent individual digital design and rapid prototyping to manufacture specific titanium mesh implants to create ideal OV recovery. Features of orbital wall fracture deformities and OV changes were analyzed and measured with 3-Dimensional Medical Surface Rendering image software system. RESULTS: Most cases involving enophthalmos and diplopia were rectified, except for 5 cases of enophthalmos and 2 cases of diplopia with fresh fractures and 11 cases of enophthalmos and 7 cases of diplopia cases with old fractures. Ocular movements and facial malformations were improved. The OV values between the uninjured and injured sides had a significant deviation (P < .05). The degree of enophthalmos had no significant deviation with OV changes pre- and postoperatively in the early fracture stages. The degree of enophthalmos in the old fracture stages had a significant deviation with OV changes pre- and postoperatively. CONCLUSIONS: This study showed that orbital wall fractures can be diagnosed in early fracture stages and that the degree of long-term enophthalmos can be predicted with 3-Dimensional Medical Surface Rendering software. Our results suggest that early-stage orbital wall fractures should recover OV as early as possible, and that advanced stage orbital wall fractures should overcorrect OV. The degree of accuracy and rational of OV reconstruction can be improved by appropriate individual digitalization design and rapid prototyping technology.

The pattern of combined maxillofacial and cervical spine fractures.

PURPOSE: Prompt recognition of cervical fractures in patients with facial fractures is of prime importance, as failure to diagnose such injuries carries a significant risk of causing neurologic abnormalities, long-term disabilities, and even death. The aim of this retrospective case study is to describe the different patterns of combinations of maxillofacial and cervical spine (C-spine) injuries to provide guidance in diagnosis and care of patients with combined injuries. PATIENTS AND METHODS: The trauma directory of 1 academic institution was searched for records of 701 patients admitted with cervical spine fractures between January 2000 and June 2006. Patients who did not sustain a facial fracture in addition to their C-spine fracture were excluded. The search was narrowed to 44 patients (6.26%) who presented with combined C-spine and facial fractures. Descriptive statistics were performed in which the frequencies of the variables were presented and then exploration of the interaction between the different variables was carried out. RESULTS: A 6.28% incidence rate of combined C-spine and maxillofacial fractures is noted in this study. The most common cause of trauma was motor vehicle accidents (45.5%), followed by falls (36.4%). In regards to the types of maxillofacial fractures, 27.3% of the cases presented with isolated orbital fractures and 13.6% with isolated mandibular fractures. A total of 68.2% of the combined C-spine and facial fracture cases involved orbital fractures of some form. The most frequent level of C-spine fracture was isolated C2 fractures (31.8%) followed by isolated C4 and C6 fractures (6.8% each). When the mechanism of trauma were compared to the types of C-spine and maxillofacial fractures, falls were found to be the most frequent mechanism causing both isolated orbital and C2 fractures. CONCLUSION: The rule of presuming that all patients with maxillofacial fractures have an unstable C-spine injury should stand. This should be emphasized in patients with orbital fractures and we plead for a higher index of suspicion for C-spine injuries in such patients.

Maxillofacial injuries sustained during soccer: incidence, severity and risk factors.

A very popular sport worldwide, soccer generates a great number of maxillofacial injuries, mainly fractures, resulting in esthetic or functional problems. The aim of this retrospective study was to contribute to the knowledge of soccer-related maxillofacial injuries, and call attention to the risk factors that favor these injuries. A total of 108 patients, who attended hospital because of maxillofacial injuries during soccer within a period of 8 years, were included in this study. The relationship of the patients with soccer, the type, the site, the severity, the mechanism of the injuries and the applied treatment were analyzed. The injured were all males, and were principally amateurs. Around 89.8% of the patients suffered maxillofacial fractures while 10.2% presented only soft tissue injuries; 13.9% had multiple fractures; 50% of the maxillofacial fractures concerned the zygomatic complex and 38.2% the mandible where the majority occurred at the angle. The prevailing mechanism was the direct impact of players. Head to head impact outnumbered. Elbow to head impact caused contusions of the temporomandibular joint. Kick to head impact was the main cause of multiple fractures. The treatment of fractures was mainly surgical (68.2%). These findings support the fact that maxillofacial injuries sustained during soccer tend to be severe, demanding surgical treatment. The mandibular angle is in danger due to the usual existence of impacted and semi-impacted third molars. There should be a preventive intervention on the above contributors, and mainly coaches and sports physicians should be properly informed about the specificity of the maxillofacial injuries.

Orbitozygomatic fracture management.

Orbitozygomatic fractures are frequently encountered in plastic surgery. Management depends on a thorough preoperative physical examination, with attention to the ophthalmologic assessment. Coronal and axial computed tomography is essential for identifying fracture extent and orbital involvement. Adequate exposure and mobilization of fracture segments is essential for successful anatomical reduction. Failure to perform effective fixation may lead to subsequent complications, such as enophthalmos and diplopia. The authors illustrate the appropriate management of orbitozygomatic fractures in an effort to reduce complications and attain aesthetically satisfying results.

Evaluation and treatment of zygomatic fractures.

Orbitozygomatic fractures are some of the most common facial fractures evaluated and treated by plastic surgeons. A considerable debate remains surrounding the manner of evaluation and appropriate treatment modalities. On the one hand, some would suggest that few fractures need formal open reduction and internal fixation, whereas others would argue that the pull of the strong masseter muscle ultimately leads to inferior and lateral rotation of the zygoma, which justifies open reduction and internal fixation of most fractures excepting those fractures that are nondisplaced at all points of articulation. The authors hope to shed some light on these issues by conveying their perspective on these fractures that has developed over several decades while servicing a single, major Level I trauma center. In general, the authors feel that through a detailed evaluation including an accurate physical examination of the face and orbit combined with detailed computed tomographic scanning of the craniofacial skeleton and soft tissues, an appropriate treatment plan can be generated. The common goal among all treatment plans should be the exact three-dimensional restoration of the disturbed anatomy, that is, anatomical reduction and the need for accurate restoration of orbital anatomy and volume when necessary.