Orbit

The International Journal on Orbital Disorders, Oculoplastic and

Lacrimal Surgery

ISSN: 0167-6830 (Print) 1744-5108 (Online) Journal homepage: http://www.tandfonline.com/loi/iorb20

Zygomatic dental implant induced orbital fracture

and inferior oblique trauma

Ann Q. Tran, Daniela P. Reyes-Capó, Nimesh A. Patel, Joshua Pasol, Hilda

Capó & Sara T. Wester

To cite this article: Ann Q. Tran, Daniela P. Reyes-Capó, Nimesh A. Patel, Joshua Pasol, Hilda
Capó & Sara T. Wester (2018): Zygomatic dental implant induced orbital fracture and inferior
oblique trauma, Orbit, DOI: 10.1080/01676830.2018.1444063

To link to this article: https://doi.org/10.1080/01676830.2018.1444063

Published online: 22 Mar 2018.

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ORBIT
https://doi.org/10.1080/01676830.2018.1444063

CASE REPORT

Zygomatic dental implant induced orbital fracture and inferior oblique trauma
Ann Q. Tran, Daniela P. Reyes-Capó, Nimesh A. Patel, Joshua Pasol, Hilda Capó, and Sara T. Wester
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA

ABSTRACT ARTICLE HISTORY

A 51-year-old female underwent four upper zygomatic dental implants (ZI) and one upper and Received 2 October 2017
four lower conventional implants. Immediately postoperatively, the patient had pain and diplopia Accepted 19 February 2018
upon manual elevation of the edematous eyelid. Panoramic x-ray showed a malpositioned right KEYWORDS
upper ZI, requiring removal of the right upper ZI the following day. The patient had delayed Zygomatic dental implant;
referral to ophthalmology one month later for persistent diplopia. Computed tomography scan orbital trauma; complex
and magnetic resonance imaging demonstrated a right inferolateral fracture with fibrosis sur- adult strabismus
rounding the inferior oblique muscle. Clinical exam showed right lower eyelid retraction, right
hypotropia, and inability to elevate in adduction, consistent with a right inferior oblique paresis.
Surgical exploration revealed incarceration of lid and orbital tissue into the fracture. After
repositioning of the prolapsed tissue, a high-density porous polyethylene implant was placed
for fracture repair. The inferior fornix was reconstructed with amniotic membrane and 5-fluorour-
acil was injected into the scar tissue. Six months later, the patient underwent strabismus surgery
with resolution of symptoms.

Introduction reconstruction and modeling can be completed and

important landmarks such as the inferior orbital
Modern techniques of combined conventional and
nerve can be identified. The inferior orbital nerve
zygomatic dental implants (ZI) are often used with
measurements from this landmark serve to aid in
high aesthetic and functional success rates for those
positioning of the drill to find the best anchorage
with complete or partial edentulism.1 ZIs are drilled
point in the zygoma.5 In situations where the body
directly into the alveolar crest and maxillary sinus
of the zygoma does not offer adequate bone support,
through the zygomatic bone and serve as an alter-
the implant may be directed more medially toward
native to traditional dental implants in patients with
the orbital socket and deviate from the preoperative
an atrophic maxilla. They offer secure support,
images.5
relieve the need for bone grafts, reduce the overall
We present herein a case of a previously unreported
morbidity of graft rejection without the need of
potential ocular complication of ZI: inferolateral orbital
donor bone graft, and decrease the overall treatment
floor fracture with inferior oblique paresis requiring
time and cost.2
orbital fracture repair and strabismus surgery.
While there are many advantages to ZIs, they
have potential significant complications as well,
and the complication rates are likely under- Case description
reported. A meta-analysis of ZI survival rate found
A 51-year-old female with a longstanding history of
that not all studies comment on complications of
tooth erosion, partial edentulism, and severe max-
dental implants.3 Placement of ZIs requires a
illary atrophy presented to an oral maxillofacial sur-
trained oral and maxillofacial surgeon as the proce-
geon for an evaluation of full upper and lower
dure demands precise anatomical knowledge and
dental implants prior to denture placement. Dental
cases of orbital perforation have been documented.4
CBCT demonstrated severe maxillary bone loss,
Many surgeons utilize cone beam computed guided
inadequate for traditional implants with only 14
tomography (CBCT) to direct placement of the
teeth present. She underwent four upper ZIs and
implant into the zygoma for the highest predicted
five conventional implants.
primary bone stability. From the images, 3D

CONTACT Sara T. Wester SWester2@med.miami.edu Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iorb.
© 2018 Taylor & Francis
2 A. Q. TRAN ET AL.

Immediately postoperatively, the patient noted

severe right periorbital swelling, inability to open her
right eye, and diplopia upon manual lid elevation.
Panoramic x-ray and dental CBCT showed concern of
failure and malposition of the ZI #6. Given the patient’s
persistent clinical symptoms and imaging findings, ZI
#6 was removed the following day (Figure 1). The
patient’s diplopia persisted despite resolution of the
periorbital swelling and she was referred for ophthal-
mic evaluation one month later.
The initial ophthalmologic examination showed pre-
served visual acuity with 20/20 vision in both eyes. The
persistent binocular vertical diplopia improved with a
chin-up position. Ocular motility demonstrated limited
elevation of the right eye in adduction (Figure 2).
Figure 3. Pre-operative computer tomography. Pre-opera-
Cover–uncover testing illustrated a right hypotropia of tive sagittal CT imaging two weeks following implant removal
10 prism diopters in primary gaze, worsened on with inferior floor fracture with fibrosis around inferior oblique
upgaze, left gaze, and left head tilt with 10° of incyclo- muscle.
torsion, and ocular torticollis. The right lower lid
retraction was more pronounced on upgaze, suggesting
fibrosis and bone fragments surrounding the inferior
tethering of eyelid tissue to the inferior orbital rim.
oblique muscle (Figure 3). Magnetic resonance imaging
Findings were consistent with right inferior oblique
of the orbit showed resolving hematoma and fibrosis
paralysis. A computerized tomography scan of the
surrounding the inferior oblique muscle.
orbit revealed an inferolateral orbital fracture with
The patient underwent an exploration and fracture
repair of the right eye. Forced ductions were performed
and demonstrated significant restriction. An incision
was made at the area of symblepharon where signifi-
cant scarring of the inferior conjunctiva with tethering
of the forniceal tissue was encountered. This scar tissue
was dissected and released where it was tethered to the
anterior aspect of the fracture. Exploration revealed a
round defect in the inferolateral floor just posterior to
the orbital rim with a floor fracture extending from this
area medially and posteriorly all the way to the inferior
orbital fissure (Figure 4A).
A hand-over-hand technique freed incarcerated
periorbital tissue from the orbital fracture. A high-den-
sity porous polyethylene implant was placed to repair
Figure 1. Panaromic radiograph of implants. Panoramic the defect along the area of the fracture, taking care that
radiograph post-operative day with failed upper zygomatic the orbital tissue was repositioned in the appropriate
dental implant.

Figure 2. Extraocular motility gaze. Right hypotropia with limitation in elevation in adduction of the right eye.

Table 1. Orbital complications after zygomatic dental implants.
Author Year Injury type
Tran, et al. 2017 Inferolateral orbital wall fracture and inferior oblique
paresis
Tzerbos, 2016 Cutaneous fistula in zygomatic-orbital area resulting
et al.9 in aseptic necrosis
Davó R, et 2013 Penetration of the orbital cavity resulting in a
4
al. conjunctival hematoma
Hinze, et 2013 Drilling zygomatic implant perforated orbital floor
8
al. into orbital fat compartment
Cikatricis, 2008 Iatrogenic lateral rectus transection
et al.10
Duarte, et 2007 Two cases of invasion orbital cavity with
al.5 subconjunctival hematoma
position (Figure 4B). Forced ductions were performed
with significant improvement in incyclotorsion, excy-
clotorsion, and supraduction. The symblepharon in the
inferior fornix was repaired using an amniotic mem-
brane graft and 5-fluorouracil injection was injected
into the scar tissue of both the eyelid and inferolateral
orbit.
Following orbital surgery, the patient had resolution
of her eyelid retraction, but continued to have binocu-
lar diplopia and a right hypotropia with no change in
the degree of incyclotorsion or ocular torticollis. Six
months after her initial injury, the patient underwent
strabismus surgery of the left yolk muscle, with a 2-mm
recession of the left superior rectus muscle with adjus-
table sutures to improve ocular alignment and head
posture. At postoperative month 2, the patient had
orthotropic alignment in primary gaze and no further
complaints of diplopia.
Discussion
Failure rates of ZI are low with a high predictability and
excellent clinical results even 12 years after implanta-
tion. Reported complications of ZI include acute and
recurrent sinusitis, intraoral soft tissue infections, per-
sistent pain, oroantral fistulas, facial or periorbital
hematomas, gingival hyperplasia, infraorbital nerve
paresthesia, epistaxis, and subcutaneous emphysema.3
Figure 4. Intraoperative orbitotomy photos. (A) Significant
symblepharon of lower fornix. (B) Incarcerated scar tissue of
inferior fornix.
ORBIT 3
Timing of injury Clinical sequala
Day 1 Implant removal, floor fracture and symblepharon repair, and
strabismus surgery
12 months Apical implant removed
Intraoperative The drilling direction was changed immediately
complication and the hematoma resorbed spontaneously
Intraoperative Implant removed during surgery
complication
Day 1 Removal of dental implant, botulinum-A toxin injection and
two subsequent strabismus surgeries
Intraoperative Resolved after 13 days with no symptoms
complication
In rare reports, intracerebral penetration has been
reported through ZI insertion through the pterygoid
region.6 As the implant is placed through the zygoma
and is in close proximity to the anterolateral orbital
rim, ocular complications may also occur (Table 1).
The infraorbital nerve serves as a landmark for cor-
rect positioning of the implant drill lateral to the nerve
toward the superior portion of the zygomatic bone that
composes the lateral orbital rim.5 Orbital penetration is
one of the most devastating of the reported
complications.7 Penetration of the orbital cavity by a
ZI drill can present with conjunctival hematoma and
periorbital edema as well as extraocular muscle injury.5
In cases of either migrated conventional implant or ZI,
rapid extraction of the implant can lead to resolution of
visual and orbital symptoms.8 While postoperative
complications can manifest early or late after the pro-
cedure, most traumatic orbital complications present
immediately. Chronic complications typically include
infection or fistula, such as in a case of a cutaneous
zygomatic-orbital fistula occurring one year after ZI
placement.9
To date, there have been limited reports in the medical
literature of severe ophthalmic complications of either tra-
ditional implants or ZI. Diplopia has been reported, with a
case of transection of the lateral rectus following a right ZI,
initially manifesting as lateral subconjunctival hemorrhage
and diplopia. 10 The ZI penetrated through the orbital floor
and the lateral rectus muscle belly was severely necrotic.
The patient required botulinum toxin-A injections and
then subsequent strabismus surgery, transposition of the
right vertical recti, and a Faden procedure of the left lateral
rectus and left superior rectus.
Additionally, there is a report of damage to the
inferior rectus from displacement of a conventional
maxillary implant, which initially presented as severe
intraoperative ocular pain and diplopia. Imaging dis-
closed penetration through the medial part of the right
orbital floor adjacent to the infraorbital nerve into the
inferior rectus muscle, which required immediate endo-
scopic removal (after which the symptoms resolved).11
4 A. Q. TRAN ET AL.
In the current case, the patient developed severe
unilateral periorbital edema and vertical diplopia fol-
lowing full upper ZIs. While penetrating through the
zygoma, the inferolateral orbital floor was fractured and
the inferior oblique was damaged from either direct
trauma, ischemia, or fibrosis. We advocate for urgent
ophthalmology referral in any ocular complaint after ZI
versus waiting until postoperative swelling has resolved.
Early orbitozygomatic complex fracture repairs within
22 days of injury has shown improved esthetic and
functional outcomes compared to delayed repairs.12
At postoperative month 1, the patient had extensive
fibrosis surrounding the inferior oblique muscle and
the inferior oblique paralysis did not improve with
fracture repair. The complications with ZI are likely
underreported in the literature and the risk of orbital
penetration may be higher than what is described.2
ZI placement can cause ophthalmologic complica-
tions, which should be recognized in the oral maxillo-
facial surgical field and promptly referred to an
ophthalmologist. Newer imaging software can measure
cortical bone thickness with CBCT imaging to better
assess bone quality and quantity.13 We also recommend
careful preoperative and intraoperative planning with
CBCT to help direct and monitor placement of ZI.14,15
Acknowledgment
The authors would like to acknowledge Jose Aponte for help-
ing obtain medical records.
Disclosure statement
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article.
Funding
NIH Center Core Grant P30EY014801.
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