Introduction:

All ZMC fractures involve orbital fractures, with orbital floor fracture severity varying depending on the mechanism and energy of injury. Disruption of the orbital floor changes the orbital volume, increasing the risk of ocular signs/symptoms (e.g. enophthalmos, diplopia). This must be assessed at primary presentation to decide if primary orbital surgery should be performed alongside ZMC repair.

There is currently no standardised set of criteria to guide the decision-making process for orbital exploration in ZMC fractures. This study will evaluate whether the absence of ocular signs/symptoms pre-operatively can safely exclude the need for orbital exploration.

Method:

Data was retrospectively collected from a consecutive series of 98 patients who had ZMC fractures requiring ORIF intervention at the QEUH between 2021-2024. The presence/absence of ocular signs/symptoms at initial assessment was recorded. The cohort was then assessed to determine which patients underwent primary orbital exploration. Post-operative outcomes were reviewed, including whether any patients subsequently required secondary orbital surgery.

Results:

27 patients (28%) presented with ocular signs/symptoms, 6 of them underwent primary orbital surgery. Among the 71 patients (72%) who had no ocular findings at initial presentation, none required orbital surgery. Only 1 patient in the cohort required secondary orbital surgery, and this patient had also undergone primary orbital surgery.

Conclusion:

The absence of pre-operative ocular signs/symptoms may be a reliable indicator for excluding the need for orbital exploration. No patients who did not receive primary orbital exploration needed secondary orbital exploration, proving there were no late ocular complications from this approach.

Odontogenic Keratocysts (OKC) are benign cystic lesions that are known to be locally aggressive and have a high recurrence rate. Here we describe a case of a particularly extensive OKC.

A 28 year-old female presented to the Oral and Maxillofacial department with a 2-month history of facial swelling and pain. On examination, there was a left mid-facial swelling which was extremely tender on palpation, with intra-oral buccal expansion. Medically, she had depression and was a non-smoker. An OPG and CT neck with contrast was carried out; this revealed a substantial lesion, filling the left maxillary sinus, in association with a superiorly impacted UL8 tooth located just below the orbital apex. The lesion had cystic characteristics, measuring 6.6cm vertically, and 5.8 x 3.8cm in a transverse dimension. The lesion was shown to project medially into the nasal cavity, resulting in septal deviation to the right. Superiorly, there was associated convex bulging of the orbital floor.

Subsequently, antibiotics were prescribed; enucleation of the cyst and extraction of UL8 was carried out. The pathology result was in favour of Odontogenic Keratocyst. Infection reoccurred 1 month later which led to a washout of the cystic cavity, placement of a drain, extraction of a resorbed UL6 and additional antibiotic therapy. Gabapentin was then commenced due to associated neuropathic pain. 3 months following initial surgery, further enucleation of a 1x1cm residual cyst was carried out. 6 months later, a repeat CT scan revealed mildly progressive bony infill in line with ongoing healing and no evidence of recurrence.

This case highlights the aggressive nature of the OKC despite their slow growth. The presence of such an expansile lesion in the maxillary sinus with an associated ectopic tooth just below the orbital apex is rare. Close follow-up to detect recurrence is important.