Zygomatic Reconstruction

Q: Dr. Eppley, I’m contacting you in order to get some information on my recent zygomatic reconstruction. I had zygomatic bone (whole complex) reposition after overlooked fracture. The bone healed in wrong position and it had to be cut then repositioned. CAS (computer assisted surgery) was performed. 

It’s 5 weeks since surgery and my masseter muscle looks strange when I open my mouth. I wonder why ? My surgeon only says me “wait, wait it will go away”. There is 0% of improvement. I’m not sure if the problem its gonna resolve itself.  I’m afraid of TMJ since this muscle works improperly now. I feel some restriction in my occlusion (mouth opening) but not big. I can eat normally with little discomfort. My occlusion amplitude is about 3cm. Before surgery I had about 4cm. I realized that after fracture I didn’t have such problem because the displaced bone adjusted to muscles. Hence they were working perfectly.

IMPORTANT: After surgery new position is forced. My logic thinking says me, there may be not proper angle and eventually “distance between 2 parts of zygomatic arch, what gives strange position for different parts of masseter muscle. I never had symmetry .. I wonder what if my surgeon was focused too much on symmetry and set the bone in the position very uncomfortable for my muscles. What if waiting will not help and it’s gonna stay like this and some irreversible complications will occur. 

Is it due to wrong position of the zygoma bone including zygomatic arch ? 

swelling.? I do not see swelling there. I have mostly little swelling on the cheek, but no on the side of the face near the muscle Too big change ? Muscle need more time to adjust ?

A: Thank you for your inquiry and sending your pictures. As I interpret your current situation, you have a right zygomatic osteotomy done about 5 weeks for an initial displaced ZMC fracture. Your current symptoms are that of some persistent limited oral opening and right facial masseter ‘asymmetry’. As a general statement at this point after this major facial surgery, what you are experiencing is very common and expected. It will take you a full six months to achieve a full recovery…and this includes to have all of the facial swelling to go away. (I believe the masseter muscle/facial asymmetry you are seeing is still some swelling) At the least five weeks after surgery is not a complete resolution time for all facial swelling to go away.

I would also expect you to not have complete normal oral range of opening just yet. You should certainly begin oral range of motion exercises at this point to workout the muscle stiffness and increase the amount of opening that will be comfortable=y achieved. It will take a full three months to get back the normal range of interincisal opening. You didn’t have these symptoms after the injury because all of the masseter muscle attachments to the zygoma were not disrupted, but to reposition the zygomatic bone some of them must be. The reconstruction effort causes greater internal trauma to the area than that of the original injury.

Such zygomatic reconstruction is always done based on ideal bone positioning. It is never done based on any consideration for the exposure and partial release of a few anterior attachments of the masseter muscle that are needed.

Dr. Barry Eppley

Indianapolis, Indiana