Orbitozygomatic Fracture

Repairs : Are
Antibiotics Necessary?
1.Department of Oral and Maxillofacial Surgery,
Westmead Hospital, Sydney, New South Wales,
Australia, 2.Maxillofacial Unit, Royal Brisbane and
Womens Hospital, Brisbane, Queensland, Australia,
3.Trauma Service, Royal Brisbane and Womens
Hospital,
Brisbane,
Queensland,
Australia
September 13, 2014

Introduction
The orbitozygomatic fracture
is one of the most commonly
encountered maxillofacial
injuries.
This study aims to review
orbitozygomatic fractures
and present :
Outcomes, complications,
infection rate, and to suggest
whether antibiotic use is
appropriate

Material and Methods

A retrospective case
selection study using the
RBWH Database of
Queensland Health which
prospectively registers all
maxillofacial cases at the
RBWH from January 1, 2011,
to December 31, 2011.

Material and Methods

Patients were excluded :
Younger than 14 years and 6 months
Isolated orbital fractures
Fractures involving more than the
orbitozygomatic complex.
Datawere reviewed and follow-up
examinations at 1-, 2-, and 6-week
postoperative period.
Clinical assessments and plain film
radiographs were performed to
document the progress and
complications of these fractures such
as implant failure, reoperations, and

Material and Methods

The current standard protocol at the
RBWH for surgical management of
orbitozygomatic fractures involves the
use of prophylactic intravenous
ampicillin with metronidazole in all
cases
These are started preoperatively and
continued for 24 hours postoperatively.

Results
The most common age group
to have had an
orbitozygomatic fracture was
in the third decade of life

Results
Mechanism of injury of
patients with orbitozygomatic
fractures at the RBWH.

Results
Number of fixation points in
the treatment of
orbitozygomatic fractures at
the RBWH.

Results
The average waiting time to
surgery was 3.7 days.
In total, 75 cases (46.9%)
were managed
conservatively.

Results
Three of the surgical cases
(1.9%) had complications
that required further surgery.
Two cases were due to
inadequate cosmesis
One was due to exposure of the
mini-plate requiring its removal
along with the screws

Complications-1
A 32-year-old man,
due to an alleged
assault.
Severe left
orbitozygomatic
fracture. The
patient had
paraesthesia to the
distribution of the
left infraorbital
nerve

Complications-1
He complained of an
inadequate aesthetic
result
The patient underwent
reoperation with
removal of the
fixation, correct
anatomical reduction,
and refixation with
mini-plates

Complications-2
A 28-year-old man
injured, due to an
assault.
There was an
anatomical defect
in the left
zygomatic arch

Complications-2
The arch was reduced
via the Gillies
approach. This
resulted in inadequate
reduction, poor
cosmesis, and
subsequently the
patient returned for
appropriate correction.
The second procedure
was repeat reduction
without fixation via
the same approach

Complications-3
A 21-year-old man
who sustained a
right
orbitozygomatic
injury due to an
assault.
The six-hole miniplate became
exposed intraorally
after 3 months. It
was removed
uneventfully under

Discussion
This study examined the
incidence and complications
of orbitozygomatic fractures
at a tertiary referral center of
the RBWH with good
outcomes and a very low
complication rate.

Discussion
There were 160
orbitozygomatic fractures
treated at the RBWH in 2011.
There were no cases of early
postoperative infection.

Discussion
Knepil and Loukota report awide
variation in use of antibiotic regimes
with surgical repair of orbitozygomatic
fractures and that the infection rate is
low at 1.5%.
Andreasen suggests a one-shot or 1day administration of a range of
prophylactic antibiotics in any fracture
of the facial skeleton.
There was a similar very low infection rate with
antibiotics used over 7 days and there were no
infections related to zygomatic fractures.

Antibiotic Use
Australian therapeutic guidelinesantibiotic prophylaxis should be
considered for procedures that
involve :
an incision through oral, nasal,
pharyngeal, or esophageal mucosa,
or the insertion of prosthetic
material

Intravenous cephazolin 1 g (adult

80 kg or more: 2 g) (child 25
mg/kg up to 1 g) be given at the
time of induction

Antibiotic Use
Intravenous
ampicillin and metronidazole

Used at the RBWH as

prophylaxis for common oral
flora such as
streptococci, lactobacilli,
staphylococci, and Bacteroides
anaerobes particularly with oral
mucosal incisions.

Imaging
Imaging for orbitozygomatic
fractures at the RBWH
usually involves a computed
tomographic (CT) scan at 2mm intervals
Plain films for postoperative
assessment.

Management and
Surgical Repair
Displaced orbitozygomatic
fractures at the RBWH are
repaired with open reduction and
internal fixation.
Common surgical approaches, the
intraoral approach as described
by Keens and the Gillies et als
temporal approach

Complications
Posttraumatic
orbitozygomatic
complications include
Ocular injury
Residual telecanthus
Enophthalmos, Diplopia
Nerve paraesthesia
Cosmetic deformities
Problems with rigid fixation and
scarring.

Complications
Infection most often occurred
when the intraoral approach
was used and mainly in
patients with poor oral
hygiene.
The complication rate of this
particular injury subtype
managed at the RBWH
Maxillofacial unit was
exceptionally low.

Conclusion
The complication rate is very low at
1.9% with the infection rate is nil.
Surgical repair of orbitozygomatic
fractures may in fact be one surgical
procedure that does not require
antibiotics
The authors have considered to
modifying the antibiotic protocol by
limiting its use to surgical prophylaxis
only and not extending it beyond the
24 hours postoperative period

Thank You