Fractures of the zygomatic complex are common facial injuries that often involve displacement of the zygomatic bone from its normal position. Clinical examination involves inspection for deformities and palpation of the zygomatic bone and arch. Radiographic evaluation with CT scanning is important to fully assess the fracture pattern and displacement. Successful management requires accurate reduction and fixation of the zygomatic bone to restore facial contour and function.

1. ZYGOMATIC COMPLEX FRACTURE
DR HIMANSHU SONI
OMFS

2. CONTENTS
 Introduction
 Surgical anatomy
 Mechanism of injury
 Classification
 Signs & symptoms
 Examination- clinical & radiological
 Historical review of management
 Steps in management
 Surgical approaches for ZMC fractures.
 Complication

3. INTRODUCTION
 The zygoma or malar
complex forms the central
support of the cheek and is a
strong buttress of the lateral
and middle third of the facial
skeleton
 It is for this reason that it is
frequently fractured, either
alone or in combination with
other bony structures of the
midface

4. Zygomatic or malar fracture are the terms commonly
used to described fractures that involve the lateral one
third of the middle face. Other names for this fracture
are:
 Zygomaticomaxillary complex
 Zygomaticomaxillary compound
 zygomatico orbital
 Zygomatic complex
 Malar
 Trimalar
 Tripod

5. History
 Treatment of facial fractures recorded 25-30 century
BC
 Smith Papyrus -first document in which treatment of
several types of zygomatic fractures are described.
 du Verney 1751 – describe the anatomy & took
advantage of the mechanical forces of the masseter
and temporalis muscles on the zygoma in his
approach to closed reduction techniques

6. Cont…
 1906, Lothrop – antrostomy to reach fractured zygoma
through highmore Antrum (inferior turbinate)
 1909, Keen – intra oral approach through
gingivobuccal sulcus.
 1927, Gillies – temporal approach
 1942 ,Adams – internal wire fixation
 1951, Brown, Fryer, and McDowell – K wire.
 1970 AO/ ASIF – told the role of osteosyntheis &
developed miniplate for reduction of Zygoma
fractures.

7. Biomechanics of maxillofacial skeleton

8. Vertical buttresses
Naso-
frontal Zygomati
c
Pterygomaxillar
y
Nasoethmoidal
buttress

9. Horizontal buttress
Superio
r
Middl
e Inferior

10. Sicher and DeBrul were the first to
depict facial anatomy in terms of
structural pillars or buttresses. This
concept allows consideration of an
approach for reduction of midface
fractures and ultimately production of
a stable reconstruction.
 nasomaxillary buttress
 pterygomaxillary or posterior buttress
 lateral or zygomaticomaxillary
buttress
These buttresses help give the zygoma an intrinsic strength such
that blows to the cheek usually result in fractures of the
zygomatic complex at the suture lines, rarely of the zygomatic
bone.

11. Zygomatic Bone Complex
Anatomy
Star-shape like with four processes
 Frontal process
 Temporal process
 Maxillary process
 orbital process
11
The integrity of the zygoma is critical in
maintaining normal facial width and
prominence of the cheek.
The zygomatic bone is a major contributor
to the orbit.

12.  From a frontal view, the zygoma
can be seen to articulate with 3
bones: medially by the maxilla,
superiorly by the frontal bone,
and posteriorly by the greater
wing of the sphenoid bone
within the orbit.
From a lateral view, the
temporal process of the
zygoma join the zygomatic
process of the temporal bone
to form the zygomatic arch.

13. Articulations with facial bones

14. Muscle attachments
14
Muscle attachments to the
zygoma :
Masseter
Zygomaticus major
Zygomaticus minor
Levator labi superioris
Temporal muscle & fascia
Foramen :
zygomatico facial foramen
zygomatico temporal foramen

15. FUNCTIONS OF THE ZYGOMATIC BONE :
 Protect the globe of the eye
 Gives origin to the masseter muscle
 Transmit part of the masticatory forces to the
cranium.
 Absorb forces of an impact before it reaches brain.

16. Some applied points
 Zygomatic bone
represents a strong bone
on fragile supports
 The traumatic force
distributed through the
adjacent, comparatively
weaker articulating bone

17. Some applied points
2. The coronoid process of mandible moves between the
arch and the infratemporal fossa .
3. The temporal fascia attached to zygomatic bone (
temporal process ) , where as the temporalis muscle
via its tendon inserted in to the tip and anteriomedial
surface of coronoid process of mandible .
The space b/w fascia and muscle provides a route to
approach the posterior surface of the zygomatic bone
and the medial aspect of the arch .
Utilized for elevation of bone during reduction
procedure

18. Etiology
 RTAs; 74.7%
 IPV; 15.8%)
 Forty-two cases were isolated ZMC fractures. The
total number of facial fractures documented was
316, of which 222 were purely related to the ZMC .
 Ophthalmic injuries occurred in 30.52% of cases.

19. Other developed countries
 Assaults (64.5%)
 Traffic accidents (13.9%)
 Falls (13.0%).
 More than one-third of all the patients experienced
injury after alcohol consumption.

20. Other facts…
 Left Zygoma, affected most
 Bilateral Zygoma #, rare-4%.
 Male predilection with a ratio of
approximately 4:1 over females.
 Second and third decades of life.
 50 gram/cm2 is required.

21. Child Adult
The Journal of Craniofacial Surgery & Volume 22, Number 4, July
2011

22. Fracture Patterns
• Fracture lines pass through the areas of greatest
weakness of bone / between bones.
• Owing to the strong buttressing nature of the zygoma
and the thin bone surrounding it, most injuries
involving the zygoma are frequently accompanied by
disruption of adjacent articulating bones.

24. Zygomatic arch fracture

25. Vertical axis
 Shows displacement of # in
horizontal plane
 Blow in front of vertical
axis --- outward movement
of center of zygomatic arch
 Blow behind the vertical
axis --- outward
displacement of
infraorbital rim and floor .

26. Horizontal axis :
 Shows displacement in
vertical plane
 Impact above --- medial
rotation of frontal process
and slight outward
rotation of buttress .
 Impact below horizontal
axis --- lateral movement
of frontal process and
medial displacement of
buttress in to antral cavity

27. MECHANISM OF INJURY
 Zygomatic fractures occur as a result of
direct impact of the bone which causes
fractures at one or more of its processes.
 Direct blows usually impact on a prominent
portion like the malar eminence.
 Leads to a relative in bending at the point
of impact and a relative out bending at
weaker points.

28.  Bilateral fractures are seen following higher
energies
 Zygoma fractures are generally dislocated
posteriorly and inferiorly and are frequently
dislocated posteriorly, inferiorly and medially.
 The direction of the dislocation of the zygoma may
involve rotation around several planes.

29. INCIDENCE
In 90% of cases,
 At least one fracture line crosses the orbital floor
 75% are fractures of the zygomatic complex including the
orbital floor
 9% are isolated fractures of the zygomatic arch
Pfeifer Et Tal 1975, Blumel & Pfeifer 1977
(Rowe & Williams)

30. CLASSIFICATION
Knight and North (1961)
Rowe and Killey (1968)
Yanagisawa ( 1973)
Larsen and Thomson (1978)
Rowe and Williams (1985)
Poswillo’s classification
Markus zing classification
Manson and colleages
Henderssons classification
Zingg classification
Ozyagzan classification

31. Knight and North Classification(1961)
Group I : Undisplaced fractures
Group II : Arch fractures.
Group III : Unrotated body fractures
Group IV : Medially rotated body
fractures.

32.  Group V : Laterally rotated body
fractures.
 Group VI : Complex fractures.

33. ROWE AND KILLEY 1968
 Type I : No significant displacement
 Type II : Fracture of the zygomatic arch
 Type III : Rotation around vertical axis
- Inward displacement of orbital rim
- Outward displacement of orbital rim
 Type IV : Rotation around longitudinal axis
- Medial displacement of frontal process
- Lateral displacement of frontal process
 Type V : Displacement of the complex en
bloc - Medial
- Inferior
- lateral (Rare)
 Type VI : Displacement of orbitoantral
partition - Inferiorly
- Superiorly
 Type VII : Displacement of orbital rim
segments
 Type VIII : Complex comminuted
fractures.

34. Zygomatic Complex Fractures (Rowe & Williams)
Fractures stable after elevation
a)Arch only (medially displaced)
b)Rotation around the vertical axis
i) medially (medial vertical axial rotation)
ii) laterally (lateral vertical axial rotation)
Fractures unstable after elevation
a)Arch only (inferiorly displaced)
b)Rotation around horizontal axis
i) medially (medial displacement following longitudinal axial
rotation)
ii) laterally (lateral displacement following longitudinal axial
rotation)
c)Dislocations en bloc
i) inferiorly
ii) medially
iii) postero – laterally
Communited fractures

35. ROWE’S CLASSIFICATION(1985)
1) Fractures stable after elevation
Arch only (medially displaced)

36. 1) Fractures stable after elevation
Rotation around the vertical axis.
Medially Laterally

37. 2) Fractures unstable after elevation.
Arch only (inferiorly displaced).

38. 2) Fractures unstable after elevation.
Rotation around the horizontal axis.

39. Fractures unstable after elevation
Dislocations enbloc
Inferiorly Medially Postero-
laterally

40. LARSEN AND THOMSEN
CLASSIFICATION
Journal of Oral and Maxillofacial Surgery Volume 50, Issue 8,
August 1992, Pages 778–790
Group A : Stable fracture
 Group B : Unstable fracture
 Group C : Predicted Stable fracture
Fractures of the zygomatic arch alone
Minimum or no displacement.
V type in fracture.
Comminuted fracture

41. Yanagisawa ( 1973)
 GROUPS I & II – unchanged
 GROUP III - medial or lateral rotation around a vertical
axis
 GROUP IV - medial or lateral rotation around a
longitudinal axis
 GROUP V - medial or lateral displacement without
rotation
 GROUP VI - isolated rim fracture
 GROUP VII -all complex fractures

42. POSWILLO’S CLASIFICATION
 Inward and downward
displacement
 Inward and posterior
displacement
 Outward displacement
of the zygomatic complex
 Communition
 Fracture of the arch alone

43. MARKUS ZING
Type A : Incomplete zygomatic fracture
Type B : Complete monofragment
zygomatic fracture
Type C : Multifragment zygomatic fracture.

44. Based on pattern of segmentation , displacement and amount
of energy dissipated by facial bones secondary to traumatic
force:
• High energy
• Moderate energy
• Low energy fractures
Manson and Colleagues (1990) based on the
findings in the C.T. SCAN

45. Henderson's classification
 I Undisplaced fracture, any site
 II Zygomatic arch fracture only
 III Tripod fracture with undistracted frontozygomatic
suture
 IV Tripod fracture with distracted frontozygomatic
suture
 V Pure blow out fracture of the orbit
 VI Fracture of the orbital rim only
 VII Comminuted fracture or other than above

46. BASED ON ANATOMIC POINTS DIVIDES
FRACTURES INTO 3 CATEGORIES:
CATEGORY A
Isolated # of 1 of the 3 processes of zygomatic bone.
CATEGORY B:
# Of all 4 processes, detaching zygomatic bone from
facial skeleton.
CATEGORY C:
same as type b, but with fragmentation, including the
body of zygoma.
ZINGG CLASSIFICATION SYSTEM

48. OZYAZGAN et al
Classification for arch fractures
Isolated zygomatic arch fractures (type I)
A) Dual fracture (type I – A)
B) More than 2 fractures (type I – B)
1) V-shaped fractures (type I – B – V)
2) displaced fractures (type I – B – D)
Combined zygomatic arch fractures (type
II)
A) Single fracture (type II –A )
B) Plural fracture ( type II – B)
1) reduced ( type II – B – R)
2) displaced ( type II – B – D)
(JOMS, vol 65, 2007)

49. Classification of zygomatic arch fractures
Type I:
No displacement
Type II:
Displacement with
bone contact at all
fracture lines

50. Type III: Displacement without
bone contact at 1 fracture line
Type IV: Displacement without bone
contact at 2 fracture lines
Type V: Comminution or
displacement without bone contact
at 3 or more fracture lines.
J Oral Maxillofac Surg 2007.

51. A New Proposal of Classification of
Zygomatic Arch Fractures

52. Signs & Symptoms
 Flattening of cheek
 Swelling of cheek
 Periorbital haematoma
 Subconjunctival haemorrhage
 Ecchymosis and tenderness intra-orally over zygomatic
buttess
 Limitation of ocular movement
 Diplopia
 Enophthalmos
 Lowering of pupil level

53.  Epistaxis
 Tenderness over orbital rim and frontozygomatic suture
 Step deformity of infra-orbital margin
 Seperation at frontozygomatic suture
 Limitation of mandibular movement
 Anesthesia of cheek, temple, upper teeth and gingiva
 Possible gagging of back teeth on injured side.

54. DIAGNOSIS OF
ZYGOMATICOMAXILLARY COMPLEX
FRACTURES

55. Clinical examination
 First step is to assess neurological status…….
 Associated neurologic injury was encountered in 57%
of patients.
Classification and Surgical Management of Orbital
Fractures: Experience With 111 Orbital
Reconstructions
Manolidis, S.*; Weeks, B. H.*; Kirby, M.*; Scarlett,
M.†; Hollier, L.‡
Journal of Craniofacial Surgery:
November 2002 - Volume 13 - Issue 6 - pp 726-737

56. Clinical examination
Inspection :
 performed from frontal, lateral,
superior and inferior views
Should be systemic and thorough
Orbital rims – with index finger
Lateral orbital rim – with index finger and thumb
Fractures are mostly associated with step deformity
and tenderness
Zygoma and zygomatic arch are best palpated with
two or three fingers in circular motion.
Intraoral palpation
Palpation

57. Peri-orbital examination
Oedema Circumorbital
ecchymosis
Subconjunctival
haemorrhage
Orbital
Emphysema

58. Laceration Ptosis
Canalicular
injury
Canthal tendon
displacement

59. Visual acuity
Visual fields
pupils
diplopia
ALSO SEE !!

60. Extraocular movements

61. Flattening of malar prominence

62. Unequal pupillary level

64. Trismus
Abnormal Nerve
sensibility
present in approx. 50% to 90%

65. Radiographical evaluation
65
Nothing is more valuable to the surgeon in
determining the extent of injury and the
position of the fragments-both before and
after operation- than a good skiagram
(radiograph)
HD Gillies, TP Kilner and D Stone, 1927

66. RADIOGRAPHIC EXAMINATION
 Postero-anterior oblique view (OM/PNS
view): excellent assessment of sinuses and
their walls, zygoma and its processes and
rims of orbit
 Submentovertex view is specific for
zygomatic arch fractures

67. Normal P-A oblique (waters view)
Emergency Medicine Journal 2007

69. SUBMENTOVERTEX RADIOGRAPH.

70. CT Scans

72. Treatment
Timing:
 As early as possible unless there are ophthalmic,
cranial or medical complications
 Preiorbital edema and ecchymosis obscure the fine
details of the fracture, intervention can be
postponed but not more than a week
Indications:
•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye

73.  Management of the ZMC and arch fractures depends on the
degree of displacement and the resultant aesthetic and
functional deficits.
 Treatment ranges between simple observation of resolving
swelling, extraocular muscle dysfunction and paraesthesia
to open reduction and internal fixation of multiple fractures

74. Goals in management of zygomatic fractures :
 Diplopia to be corrected- pupillary levels to be leveled
 Eye muscles function to be restored
 Mandibular movements rendered free
 Facial contour repositioned
 Proper restoration of bony anatomy.
 Prophylactic antibiotics
 Anesthesia
 Clinical examination and forced duction test
 Protection of the globe
 Antiseptic preparation
 Reduction of the fracture
 Assessment of the reduction
 Determination of necessity for fixation

75. STEPS IN SURGICALLY TREATING A ZMC
FRACTURE
 Application of fixation device
 Internal orbit reconstruction
 Assessment of ocular mobility
 Bone graft extraorbital osseous defects
 Soft tissue resuspension
 Postsurgical ocular examination
 Postsurgical images

76. HISTORICAL REVIEW
Attempts to treat facial fractures were recorded in the 25-30
centuries BC. The Smith Papyrus is likely the first document
in which treatment of several types of zygomatic fractures
are described.
In 1751, du Verney described the anatomy, type of fractures
observed, and approach to reduction in two cases. He
described the intra oral and external manipulation of
fragments.

77.  In 1906, Lothrop was the first to describe an
antrostomy reaching the fractured zygoma through a
Highmore antrum below the inferior turbinate. This
allowed for rotation of the fractured zygoma upward
and outward for a proper reduction. This transantral
approach is known today as the Caldwell-Luc
approach.
 In 1909, Keen categorized zygomatic fractures as those
of the arch, the body, or the sutural disjunction. He was
the first to describe an intraoral approach to the
zygomatic arch via a gingivobuccal sulcus incision.

78.  In 1927, Gillies was the first to create an incision made
behind the hairline and over the temporal muscle to
reach the malar bone. Gillies further described the use
of a small, thin elevator that is slid under the
depressed bone enabling the surgeon to use the
leverage of the elevator to reduce the fracture. The
Gillies method remains in use today to elevate the
arch.
 Adams recognized the need for greater stabilization in
more comminuted fractures and was one of the first to
write of internal wire fixation.

79. SURGICAL APPROACHES TO ZMC FRACTURES
 A standard series of approaches has been
used extensively for approaching the
fractured zmc and orbit.
 Existing laceration are often used for this
purpose.in the absence of lacerations,
properly placed incisions offer excellent
access with minimal morbity and scarring.

80. GENERAL PRINCIPLES
Avoid important neurovascular structures
Use as long incision as necessary
Place incision perpendicular to surface of non hair
bearing skin
Place incision in the line of minimal tension
Seek other favorable sites for incision placement

81. APPROACHES
 Temporal approach – Gillies (1927)
 Buccal sulcus approach – Keen (1909),
Balasubramanium (1967)
 Lateral coronoid approach – Quinn (1977)
 Eyebrow approach- Dingman & Natvig (1964)
 Percutaneous approach - Stroymeyer (1844)
INDIRECT REDUCTION

82. Temporal approach
First described by Gillies & coworkers in
1927
Advantages :
 Allows application of greater amount of
controlled force to disimpact even the most
difficult zygomatic fracture .
 For treatment of fractures which are
consolidated already
 Quick and simple method
Disadvantage:
encountered temporal vessels---- hemorrhage

84. PLACEMENT OF ROWES
ZYGOMATIC ELEVATOR AND
ELEVATION.

86. Buccal sulcus approach
Keen’s Technique (1909)
Avoidance of any external scar.
•A small incision (approximately 1 cm)
is made in the mucobuccal fold, just
beneath the zygomatic buttress of the
maxilla.
•A heavier instrument inserted behind
the infratemporal surface of the
zygoma, and using superior, lateral,
and anterior force, the surgeon
reduces the bone.

88. Technique of lateral
coronoid approach
•Simple method for isolated arch
fractures.
•3 to 4 cm incision -anterior border of the
ramus.
•To the depth of the temporal muscle
insertion
•Instrument between the temporal
muscle and the zygomatic arch - readily
palpable.
•A flat-bladed instrument, inserted into
the pocket
•Arch is elevated

89. Elevation From upper eyelid
Approach
Advantage
•Fracture at the orbital rim is
visualized directly, and fixation of
the fracture at this point can be
undertaken through the same
incision.
Disadvantage
•Difficult to generate a large
amount of force, especially in the
superior direction.
DINGMANS ZYGOMATIC ELEVATOR

90. Percutaneous Approach
Most simple of all techniques as no soft tissue dissection
is necessary
Direct route to elevation of the depressed zygoma is
through the skin surface of the face overlying the
zygoma.
Advantage Produces forces anteriorly, laterally, and
superiorly in a very direct manner, without having to
negotiate adjacent structures with the instruments.
Disadvantage -Scar on the face in a very noticeable
location.

91. Elevation Of The Zygoma With A Bone Hook.
•Poswillo`s intersecting
lines.
•Stab incision made and
hook inserted.
•Apply strong traction.
Carrol-Girard bone screw

95. Surgical approaches to
zygomaticomaxillary complex
fracture
 Maxillary vestibular approach
 Supraorbital eyebrow approach
 Upper eyelid approach
 Lower eyelid approach
 Transconjunctival approach
 Coronal approach
DIRECT REDUCTION

96. Maxillary Vestibular Approach
 The Maxillary vestibular approach
is one of the most useful when
performing any of a wide variety of
procedures in the midface. It allows
relatively safe access to the entire
facial surface of the midfacial
skeleton, from the zygomatic arch
to the infraorbital rim to the frontal
process of the maxilla
Advantage
the greatest advantage is the hidden intraoral scar.
The approach is also relatively rapid and simple, and complications are few.

97. Surgical anatomy
 Infraorbital nerve
 Nasolabial musculature
 Buccal fat pad
Note that the fat
pad extends
anteriorly to
approximately the
first molar. Also,
posterior to the
origin of the
buccinator muscle
on the maxilla, the
buccal fat pad is
just lateral to the
periosteum.
Important facial muscualature when performing the
maxillary vestibular approach

98. Technique
Subperiosteal Dissection
Closure
Incision through the mucosa, submucosa, facial
musculature,
and periosteum

99. LATERAL BROW APPROACH
 Access to the lateral
orbital rim and the
frontozygomatic suture
 Simple, safe and rapid
approach
 Scar is usually hidden
within the confines of the
eyebrow

100. SUPRAORBITAL APPROACH
 A previously popular incision used to gain access
to the superolateral orbital rim is the eyebrow
incision.

101. ADVANTAGE:
 No important neurovascular structures are
involved in this approach.
 It gives simple and rapid access to the
frontozygomatic area.
 If the incision is made almost entirely within
the confines of the eyebrow, the scar is usually
imperceptible. Occasionally, however, some
hair loss occurs, making the scar perceptible

102. DISADVANTAGE
 Unfortunately, in individual who has no eyebrows
extending laterally and inferiorly along the orbital
margin, this approach is undesirable.
 Incisions made along the lateral orbital rim
outside of the eyebrow are very conspicuous in
such individuals, and another type of incision may
be indicated.
 The main disadvantage of the approach is
extremely limited access.

103. TECHNIQUE
Incision within confines of eyebrow hair. The incision
is made through skin and subcutaneous tissue to the
level of the periosteum in one stroke.
Incision through periosteum along lateral orbital rim
and subperiosteal dissection into lacrimal fossa.
Because of the concavity just behind the orbital rim in
this area, the periosteal elevator is oriented laterally as
dissection proceeds posteriorly.
Closure:
The incision is closed in two layers, the periosteum and the skin.

104. UPPER EYELID APPROACH
 The upper eyelid approach to the superolateral orbital rim
is also called upper blepharoplasty, upper eyelid crease,
and supratarsal fold approach. In this approach, a natural
skin crease in the upper eyelid is used to make the incision.
Advantage:
Inconspicuous scar it creates, which
makes it one of the best approaches
to the region.

105. TECHNIQUE
Closure:The wound is closed in two layers, periosteum and skin/muscle.
To facilitate retraction of the skin/muscle flap, it can be
widely undermined laterally and retracted with small
retractors. Because of the concavity just behind the
orbital rim in this area, the periosteal elevator is
oriented laterally as dissection proceeds posteriorly.
Sagittal section through orbit and globe showing dissection
between orbicularis oculi muscle and the levator aponeurosis
below and orbital septum above
The incision may be extended farther laterally if
necessary. The initial incision is made through skin and
muscle.

106. Lower eyelid approaches

107. Subciliary incision is made approx 2 mm below the eyelashes and can be
extended laterally as necessary (top dashed line). It is made throug skin
only. the incision must follow the crease as it tails off inferiorly

108. TRANSCONJUNCTIVAL APPROACH
 Originally described by Bourguet in 1928.
 Also called inferior fornix approach.
 2 types: preseptal (Tessier) & retroseptal (Tenzel&Miller)
approaches.
 Converse & colleagues added a lateral canthotomy to
transconjunctival retroseptal incision for improved lateral
exposure.

109. Advantage :
 produce excellent cosmetic results because the scar is
hidden in the conjunctiva.
 If a canthotomy is performed in conjunction with the
approach, the only visible scar is the lateral extension,
which heals with an inconspicuous scar.
 Another advantage is that these techniques are rapid, and
no skin or muscle dissection is necessary.
Disadvantage :
• medial extent of the incision is limited by the lacrimal
drainage system.

110. TECHNIQUE
Sagital section through orbit showing preseptal and
retroseptal placement of incision.
Initial incision for lateral canthotomy
the initial canthopexy incision to dissect in the
subconjunctival plane. The dissection should be just
below the tarsal plate and extend no farther medially
than the lacrimal punctum.
Closure of transconjunctival incision and inferior
canthopexy

111. CORONAL APPROACH
 The coronal or bi-temporal incision is a
versatile surgical approach to the
upper and middle regions
of the facial skeleton, including the
zygomatic arch
Advantage:
the surgical scar is hidden within the hairline.
When the incision is extended into the preauricular area, the surgica
scar is inconspicuous.

112. TECHNIQUE
Incision placement
Incision of periosteum across the forehead from one superior
temporal line to the other. The tension through periosteum
should be 3 to 4 cm superior to the orbital rims
Amount of exposure obtained with complete dissection of the
upper and middle facial bones using the coronal approach.

113. HEMICORONAL APPROACH

114. MODIFICATION OF HEMICORONAL
APPROACH
The anterior arm of the
incision is curved downward
toward the superior wall of
the orbit befor it reaches the
vertex of the skull within the
hairline.
The ‘backcut’ provides
excellent exposure of the
entire zygomatic complex
and the arch, is aesthetic and
is less invasive thereby
being quite acceptable by
patients.
Journal of Maxillofacial and Oral Surgery 2010
Volume 9, Number 3, 270-272

115.  Common methods include wire osteosynthesis and
rigid fixation by plates
 Less common methods include external pin fixation
and maxillary antral support
IMMOBILIZATION

116. PIN FIXATION
 External pin fixation
Can be used for fractures that
demonstrate an intact body of
the zygoma but severe
communition at the junction
with the surrounding bones
 Internal pin fixation
Was introduced by Fryer and
results in stable
entity and relatively free of
complications
Techniques make use of K-wire placement

117. SINUS PACKING SUPPORT
 Gauze or balloon can be used to
provide inferior support to the zygoma
 Lateral wall is approached through a
Caldwell-Luc
 ½ inch gauze dipped in antibiotic of
choice is placed along the floor
anteroposteriorly
 Antral balloon can be used by it is
relatively imprecise and cannot adapt
to the topography

118. Applied aspect
Access to zygomatic buttress region :
 Modified intraoral buccal sulcus approach
Access to frontozygomatic buttress :
 Upper eyelid approach
 Supra-orbital eyebrow approach
 Hemicoronal approach

119. Access to infraorbital buttress :
 Transconjunctival approach
 Subciliary approach
 Endoscopic approach ( intrasinus approach )
Access to zygomatic arch :
 Direct percutaneous approach
 Gillies temporal approach
 Keen’s buccal sulcus approach
 Lateral coronoid approach
 Hemicoronal approach

120. Need for fixation
Indications for fixation
1. Comminuted fracture fragments.
2. Doubt regarding the stability
Role of masseter in displacement.
• Albright and McFarland recommended IMF following fracture
reduction helps to reduce the pull of the masseter muscle on
the repositioned ZMC.
• Dal Santo and colleagues compared masseter muscle force
post trauma and found that the muscle developed significantly
less force amongst pts who sustained zmc fractures and even
after 4 weeks the force was below control levels.
• Ellis et al reviewed series of isolated ZMC fractures treated by
different approaches and fixation schemes and found no
evidence of post reduction instability

121. PURPOSE OF FIXATION
Infraorbital
rim and
buttress
Lateral orbital
rim
Buttress of
zygoma
Vertical Height Facial width &
orbital volume
Malar Projection

122. WIRING
 Generally, a wire in the zygomatico - frontal suture
and at the infraorbital rim is prevents inferior
displacement
 In case of displaced fracture. Three-wire fixation of
the zygoma usually provides stable fixation
 Inferior rim wiring
 Frontozygomatic suture wiring
 Buttress region wiring

123. WIRE FIXATION
Advantages.
1. Material availability.
2. Minimal incision
necessary.
3. Ease of use.
Disadvantages.
1. Wires stretch.
2. Provides one
dimensional stability.
3. Requires direct
apposition of bone at
fracture site.
4. Zygoma malpositioning
and malunion.

124. Holes at FZ suture area drilled
into orbit.
Wires inserted at FZ region
infraorbital rim and
zygomaticobuttress regions.
TECHNIQUE

125. Holes at FZ suture area drilled
into temporal fossa.
Wires twisted in the
temporal fossa.

126. KEY POINTS.
Three point wire fixation and two point wire
fixation, including the FZ region and infraorbital
region or maxillary buttress are probably stable in
simple fractures of the zygoma.
If there are areas of comminution or a
continuity defect at any of the planned fixation
points then rigid fixation with bone plates is
necessary.

127. INDIRECT FIXATION
TRANSFACIAL WIRE TRANSNASAL WIRE
ZYGOMATICOMAXILLARY WIRE ZYGOMATICOPALATAL WIRE

128. EXTERNAL FIXATION
Accomplished with wires suspended from plaster
head caps, head frames and by pins connected to one
another with universal joints and cold cure acrylic.
ADVANTAGES-
1. Three dimensional stability.
2. Minimal scarring.
3. Adjustability of the reduction.
DISADVANTAGES-
1. Patient comfort is compromised.
2. Need for specific hardware.
3. Lack of usefulness in comminuted fractures.

129. FIXATION TECHNIQUES - PRINCIPLES
1. Use self-threading bone screws.
2. Use hardware that will not scatter postoperative CT
scans.
3. Place at least two screws through the plate on each side
of the fracture.
4. Avoid important anatomic structures.
Use Y,L,T shaped plates
where fracture line in the
zmc buttress region is low.
Prevents damage to the
roots and nerve bundle.

130. 5. Use as thin a plate as possible in the periorbital areas.
6. Place as many bone plates in as many locations as
necessary for ensuring stability.
7. If concomitant fractures of other midfacial bones exist, it
will be necessary to apply fixation devices more liberally.
8. In areas of comminution or bone loss, span the gap with
the bone plate.

131. BONE PLATES
 FOUR POINT FIXATION-
 COMMINUTED ZMC FRACTURES
SITES OF FIXATION-
1. F-Z SUTURE.
2. INFRAORBITAL RIM.
3. ZYGOMATIC ARCH.
4. MAXILLARY BUTTRESS.

132. THREE POINT FIXATION-
NON-COMMINUTED ZMC FRACTURES
SITES OF FIXATION-
F-Z SUTURE.
INFRAORBITAL RIM.
ZYGOMATIC ARCH.
(OR)
MAXILLARY BUTTRESS.

133. TWO POINT FIXATION-
SIMPLE NON-COMMINUTED ZMC FRACTURES
SITES OF FIXATION-
F-Z SUTURE.
INFRAORBITAL RIM.
MAXILLARY BUTTRESS.

134. Order of reduction and fixation in ZMC
fracture with orbital floor recontruction.

136. Placement of first plate

137. Fixation of first plate

138. Placement of second plate

139. Placement of third plate

140. Complications

141. Complications of periorbital incision –
Minor - dehiscence
hematoma /seroma
lymphedema
Vertical shortening of lower lid
prevention - superior support of lower lid for several
days( best achieved with frost sutures).
Ectropion – associated with subciliary incision and trans
conjunctival incision(mild /moderate/severe)
Entropion - occurs less commonly
but more distressing

142. Infraorbital nerve injury –
 Either direct injury to nerve due to trauma or
iatrogenic
 Mostly these injuries are temporary(neuropraxia)
due to stretching or compression of infraorbital
nerve.
 Markedly displaced fractures - neurotmesis can
occur
 Patient may complain of numbness , different
sensation and pain on heat /cold or light touch .
 ZMC fracture which are treated with rigid fixation
– early recovery of neurosensory deficit .

143. Persistent Diplopia-
 Diplopia, commonly known as double vision, is the simultaneous
perception of two images of a single object
 Binocular diplopia initially present with ZMC fracture should resolute
within 5-7 days after fracture treatment
 Result of
 edema or hematoma of one or more
extraocular muscles or their nerves
 Introrbital edema
 Ocassionally muscle entrapment
 If persists , it may be due to scar contracture and adhesions either within
the ocular muscles or between them and other structures.

144. Enopthalmos
 Most commonly caused by increased volume of
orbit
 Difficult to correct secondarily, however
improvement is possible.
 Surgery can be done to reduce orbital volume by
– reconstructing the internal orbit
- by placing a space occupying material
behind the globe
( glass beads , silicon sheets , sponges , teflon
beads , cartilage graft, hydroxyl apatite, metallic
mesh or plate)

145. Blindness
 Occasionally reported after ZMC fracture
Causes- direct damage to optic nerve
- hemorrhage into optic sheath
- intraocular edema
- retrobulbar hemorrhage
Maxillary sinusitis-
 Caused by inflammation of sinus membrane and
occlusion of ostium.
 Usually respond to antibiotic and decongestant
therapy.

146. Ankylosis of zygoma to coronoid process :
 - very rare
- when noted usually fibrous.
Causes-
- improper reduction of zygoma leaving arch
in close proximity to coronoid process.
- untreated zygomatic fracture
- post-operative infection

147. Malunion of the zygoma
Signs and symptoms –
Flattening of malar prominence
Enopthalmos
Altered pupillary level
Limitation of mandibular movements
Treatment
- camouflaging the defect with implant or
transplant
- repositioning of malpositioned bone

148. CONCLUSION
 The treatment of zygomatic fractures has
dramatically progressed over the past several
decades from an entirely closed approach to the
more aggressive open reduction and rigid
miniplate fixation of today.