This document provides an overview of zygomaticomaxillary complex (ZMC) fractures. It begins with an introduction that describes the anatomy and common causes of ZMC fractures. It then covers the classification systems used to categorize ZMC fractures, clinical examination findings, radiographic evaluation, historical management approaches, current management techniques, potential complications, and differences in pediatric cases. The document provides a comprehensive review of ZMC fractures from surgical anatomy to treatment options.

1. Zygomatico Maxillary
Complex Fractures
Presented by:
Dr Neha Umakant Chodankar
PG OMFS

2. Contents
• Introduction
• Surgical anatomy
• Mechanism of zygomatic injury
• Fracture Lines
• Classification
• Clinical examination
• Signs and symptoms
• Radiographic examination
• History of Management
• Management
• Complications
• Pediatric ZMC Fractures
• Conclusions
• References

3. Introduction
• Zygomatic fractures are common facial fractures and the second in
frequency after nasal fractures.
• The highest incidence of these fractures probably relates to the zygomas
prominent position within the facial skeleton, which frequently exposes it
to traumatic forces.
• Most studies indicate male predilection with a ratio of approximately 4:1
over females. The peak incidence of such injuries occurs around the second
and third decades of life.

4. • The commonest cause of zygomatic fractures is motor vehicle accidents
according to most studies followed by interpersonal violence.
• In zygomatic fractures caused by altercations, the left zygoma is most
commonly affected, probably because of greater incidence of right-handed
individuals.
• Unilateral fractures caused by MVAs show no such predilection.
• Bilateral fractures of the zygoma are rare and are commonly the result of
MVAs than altercations, indicating that the trauma inflicted in MVAs is
more severe than that inflicted in altercations.

5. Terminology
• Zygomaticomaxillary complex
• Zygomaticomaxillary compound
• Zygomatico-orbital
• Zygomatic complex
• Malar
• Trimalar
• Tripod

6. • Central support of the cheek.
• Quadrilateral in shape
• Principal structure of lateral mid face.
• Strong buttress.
• Facial contouring
Surgical Anatomy

7. • Four processes: Temporal
Orbital
Maxillary
Frontal
• Articulations of zygoma:
Angular process of the frontal bone, orbital
floor, greater wing of the sphenoid, maxilla,
zygomatic process of the temporal bone.

8. Muscular attachments:
• Malar surface – zygomatic major, levator labii superioris.
• Temporal surface – masseter muscle
• Temporal process – Temporal fascia
• Temporalis muscle passes beneath the arch.
Nerves:
• Zygomatico temporal nerve
• Zygomatico facial nerve.
Blood Supply:
• Transverse Facial Artery
• Maxillary Artery

9. Functions
• Protect globe of eye
• Origin to masseter
• Transmit part of masticatory force to cranium
• Absorbs impacts before it reaches the brain .
• Cheek prominence

10. • Direct blow to malar eminence----causes a relative in-bending at the area of
impact and a reciprocal out bending at week areas, located distant to the point
of impact.
• Violent blows to contra lateral midface---- causes a fracture dislocation of the
zygoma by reciprocal transfer of forces from the opposite side of the facial
skeleton
• Dislocation
posterior
inferior
medial
lateral
Mechanisms of Injury

11. Fracture Lines
The inferior orbital fissure is the key to
remembering the usual lines of ZMC
fractures. Three lines of fracture
extend from the inferior orbital fissure
in an
• anteromedial,
• superolateral, and
• inferior direction

12. Fracture Lines
Antero-medial

13. Fracture Lines
Supero-lateral

14. Fracture Lines
Inferior

15. Knight and Norths: 1961, based on the PNS view
in 120 cases:
Group I - Undisplaced
Group II - Arch Fractures
Group III - Unrotated Body Fractures
Group IV - Medially Rotated Body Fractures
Group V - Laterally Rotated Body Fractures
Group VI - Complex Fractures - Additional Fractures Across Zygoma
Classification

16. Rowe and Killeys classification 1968:
• Type I: minimal or no displacement.
• Type II: isolated arch #
• Type III: displacement along vertical axis
• A: inward rotation
• B:outward rotation
• Type IV: displacement along longitudinal
axis
• A: medial rotation
• B: lateral rotation
III A III B

17. • Type V: enbloc displacement
• A: medial
• B: inferior
• C: lateral
• Type VI: orbital floor fractures
• A: superior displacement of floor
• B: inferior displacement of floor.
• Type VII: displacement of orbital rim
• Type VIII: communited fractures
Modifications: Yanagisawa,
• Added type V D: enbloc displacement posteriorly.
• Omitted type VI as he considered orbital floor #
as associated condition.

18. Fracture line along the Imaginary Axis
• Along the vertical axis in Horizontal
plane
stable
• Along the Longitudinal Axis in coronal
plane
Unstable

19. Larsen and Thomsen (1968):
Group A - Stable fractures that shows - minimal or no displacement.
Group B - Unstable fracture with great displacement and disruption at fronto-
zygomatic suture and comminuted fractures.
Group C - Stable fracture

20. Rowe 1985 changed the earlier classification into more clinical one:
• Group A – stable fracture- minimal/ no displacement
• Group B – unstable fracture with great displacement of the FZ region
requiring both reduction and fixation
• Group C – stable fracture – other fractures of ZMC that require reduction
but no fixation.

21. Rowe & Williams :
Fractures stable with elevation:
• Arch only- medial displacement
• Rotation along vertical axis – medial and lateral
Fractures unstable after reduction:
• Arch only- inferior displacement
• Rotation around horizontal axis
• Dislocation enbloc Inferior, medial, postero lateral .
• Communited fracture .

22. Fugii-Yamashiro,1983
• Type I : no displacement
• Type II: Isolated arch #
• Type III: ZMC body # without rotation in A-P A: body dissociated
B:depressed in sinus
• Type IV: body of malar complex rotated along Z-axis
A: site of rotation axis is at base of arch.
B: site of rotation is at Z-M suture
C: fracture involving zygoma /main body.

23. Spiessel & Schroll 1972
• Type 1-Isolated ZMC fracture
• Type 2- no significant displacement
• Type3- partial medial displacement
• Type4- complete medial displacement
• Type5-dorsal displacement
• Type 6-inferior displacement
• Type 7- communited fracture

24. Manson (1990)
Based on CT
•Low Energy
Fractures -- little or no displacement were classified as low-energy injuries.
Incomplete fractures which do not require operative reduction
•Middle Energy
Middle-energy fractures - complete fracture of all articulations with mild to
moderate displacement. Comminution may be present
•High Energy
High-energy injuries - comminution in the lateral orbit and lateral displacement
with segmentation of the zygomatic arch. They are often part of panfacial fractures

25. Markuss Zingg et al : (1992)
• Type A: Incomplete zygomatic fractures: A1 isolated zygomatic arch
A2 isolated orbital lateral wall
A3 isolated infraorbital rim
• Type B: Complete mono fragment zygomatic fractures.(classic tripod
fracture)
• Type C: Multi fragment zygomatic fracture.

26. Fractures of zygomatic arch :
• Minimum or no displacement.
• V type in fracture.
• Comminuted fracture.

27. Zygomatic Arch Fractures by Ozyazgan:
1. Type I : Isolated zygomatic arch fractures
A. Dual fracture (Type I-A)
B. More than 2 fractures ( Type I-B)
1) V –Shaped fracture (Type I-B-V)
2) Displaced (Type I-B-D)
2. Type II : Combined arch fracture
A. Single fracture (Type II-A)
B. Plural fracture (Type II-B)
1) Reduced (Type II-B-R)
2) Displaced (Type II-B-D)
Irfan Ozyazgan et al. Classification of Zygomatic Arch Fractures.
Jr. Oral and Maxillofac. Surgery, March 2007

28. Clinical Examination
• History
• Time and mechanism of injury
• Change in appearance of eye
• State of vision immediately after injury
• Immediate loss of vision – severe damage to retina
• Loss of light perception - vascular occlusion or optic nerve
compression
• Initial good vision – compression optic neuropathy

29. Inspection and Palpation
• It should be performed from the frontal, lateral,
superior and inferior vantages
• The most useful method of evaluating the position of
the body of the zygoma is from the superior view
• Intraoral examination to evaluate buccal ecchymosis
in the superior buccal sulcus
• Palpation of the infraorbital rim, FZ suture, body of
the zygoma and arch.

30. Signs and Symptoms
Periorbital tissues:
• Circumorbital ecchymosis and edema
• Subconjuctival Hemorrhage and chemosis
• Crepitation from air emphysema
Eyelids:
• Abnormality of palpebral fissure
(height/width/inclination)
• Mobility affected (ptosis/psuedoptosis)
• Integrity of margins and tarsal plates
Ligaments:
• Alteration in canthal level
• Alteration in ocular level
Epistaxis

31. Unequal Pupillary Level:
Tenon’s Capsule
Suspensory Ligaments
Diplopia :
Monocular diplopia
Detached lens, hyphema
Binocular diplopia
Soft tissue injury
muscle entrapment,
neuromuscular injury

32. Eye:
• Unequal pupillary level
• Diplopia
• Enophthalmos/exopthalmus
• Pupillary reflex
• Opthalmic injuries
• Preservation of vision
• Limitation of ocular movements
• Increased inter-pupillary distance
Flattening of the Malar Prominence
Flattening of Zygomatic arch
Pain and tenderness
Loss of normal curvature
Ecchymosis of Maxillary Buccal Sulcus
Ant. / Post. Displacement of maxilla

33. Neurological deficits:
• Paresthesia
• Paresis of EOM
Pain on palpation or step deformity at
superior margin
FZ suture
infraorbital margin
Zygomatic bone / arch
ZM buttress
Lateral antral wall
The mandible:
• Limited opening with deviation to opposite side
• Restricted lateral excursion to affected side

34. Ophthalmologic Evaluation
• Visual acuity
• Pupillary function
• Ocular motilty
• Anterior chamber for hyphema
• Fundoscopic exam
• If in question ophthalmologic consultation is indicated

35. Forced duction test:

36. Radiographic examination
• Plain films:
Waters view (P-A Skull)
Reverse waters view (A-P Skull)
Submentovertex view.
• CT Scans:
Axial sections
Coronal sections
• 3-D CT Scans:

37. Plain films: Waters view (P-A Skull), Submentovertex view.

38. McGregor Campbell & Trapnell’s lines

39. Dolan & Jacob’s lines:

40. Four ‘S’ by Delbalso
• Symmetry
• Sharpness
• Sinus and
• Soft tissues

41. ‘Hot sites’ and fracture patterns

42. CT Scans

43. 3 Dimensional Reconstruction

44. • Duverney - 1751, Described intra oral and external manipulation of fracture
fragments.
• Ferrier - 1825, Reduced fracture zygoma by an incision above the zygoma but
his assistant M. Rolland found that the temporal muscle and aponeurosis
caused some hindrances - removing them led to easy manipulation of the
fracture fragments.
• Duputryen - 1847- Used attachments of the arch to lift the arch – compound
fractures
History of Treatment

45. • Treves - 1896 - Fracture of antral wall --perforate the canine fossa, introduce
instrument and push the wall out.
• Chyne & Burghard 1901:- Discussed the intra oral digital manipulation
technique, but in some complicated injuries they needed to add an additional
incision on the arch for reduction.
• Gillies- 1927 modified some principles, the hair line.
• Shea- 1931 described the blind approach for treatment of depressed
zygomatic bone -- intra nasal antrostomy and introduction of nasal pack.
• Anthony- 1952, devised an antral balloon - one to five minutes constant
pressure.

46. 1. Conservative management
2. Indirect reduction
a) No fixation
b) Temporary support (antral pack / percutaneous wire)
c) Direct fixation (TO wire / bone plates)
d) Indirect fixation (External pins)
3. Direct reduction and fixation
4. Immediate reconstruction by grafting
5. Delayed reconstruction by osteotomy and/or grafting
6. Late restoration of contour by onlay grafts.
Management

47. Controversies.
• Should one surgically intervene ?
• What is the optimal time ?
• What is the most effective method ?
- closed reduction without fixation ?
- open reduction and fixation ?
• Demann & Dortzbach recommended early intervention for muscle
entrapment injuries

48. • Fixation is required/ not-
• post reduction dislocation is most commonly assoctd with the masseter- to
prevent this albright et al went up to immobilization
• Dal santo et al work on masseter in unilateral ZMC # shows that the muscle has
considerably less pull- and regains strength after 4 week post reduction but still
less than control.
• Larsen et al & Fischer et al – only reduction good results.
• Champy used only one plate at FZ and found good results only 1.6 %
displacement.

49. • Ideally fixation done between 5-7 days for resolution of edema
• Pre- or intra-operative steroids can help with edema
• After 10 days masseter begins to shorten

50. Initial Management
• Ice on affected area for 48 hours
• Use of nasal decongestants
• Antibiotics
• Oral steroids to prevent fibrosis
• No nose blowing

51. TIMING OF SURGERY
• Early : surgery performed prior to significant swelling
• Late : after resolution of significant edema
• If possible surgery should be performed within 7-14 days before significant
healing has begun
• Stable nondisplaced fractures may be observed weekly for proper healing
• After 10 days masseter begins to shorten
• Usually seven to ten days after trauma : CRITICAL PERIOD

52. 1. Prophylactic antibodies
2. Anesthesia
3. Clinical Examination and FDT
4. Protection of the Globe
5. Antiseptic Preparation
6. Reduction of the Facture
7. Assessment of the Reduction
8. Determination of necessity for Fixation
Steps in Treatment
9. Application of the Fixation Device
10. Assessment of Ocular Mobility
11. Soft tissue repositioning
12. Postsurgical ocular examination
13. Postsurgical Radiography

53. Indirect reduction – no fixation
• Category I – stable after elevation
A) Temporal fossa – Gillies 1927
B) Upper buccal sulcus –Keen Technique /
Taylor Monks Elevator
or extraction forceps
- Quinn modification(Lateral
Coronoid Approach)
C) Percutaneous Approach – Poswillo’s hook
D) Transcutaneous Approach -Carroll-Girard screw
E) Intranasal transantral – intranasal antrostomy
F) Dingman Eyebrow Approach – Dingman elevator / Kelly hemostat

54. Indirect Fixation
• Fixation away from the fracture site
• Steinmann pins / transfacial pin Intramedullary (internal) pins or wires or external
pins and rods
• Attachment of external framework
• Indication: gross loss of bone in FZ region or inf orbital rim
• Methods:
-Zygomatico-zygomatic
-Naso-zygomatic
-Zygomatico-palatal
-Maxillo-zygomatic
-Fronto-zygomatic
-Cranio-zygomatic

55. Indirect Fixation
TRANSFACIAL PIN TRANSNASAL WIRE

56. ZYGOMATICOMAXILLARY WIRE ZYGOMATICOPALATAL WIRE

57. Temporal Approach:
- Gillies and co-workers in 1927
-Quick and simple
Technique:
- Area 2.5cms above and 2.5cms anterior to helix of ear.
- 2.5 cms long incision from anterosuperior to
posteroinferior direction

58. - Taken down till temporalis fascia is seen
- Incision on the fascia, muscle bulges out
- A flat instrument is inserted here until medial aspect of zygoma is felt.

59. - Rowe zygomatic elevator is inserted and elevated.
- An audible crack accompanies elevation.

60. Buccal Sulcus Approach:
- Keen in 1909
- Small incision below muco- buccal fold at buttress.
- Through mucosa, submucosa,
and buccinator
- Freer elevator is inserted
- Infratemporal surface of maxilla, zygoma, and arch
- Heavier instrument and lifted, reduced.
- Dental extraction forceps

61. Technique of lateral coronoid approach -1977
•Simple method for isolated arch fractures.
•3 to 4 cm incision -anterior border of the
ramus.
•To the depth of the temporal muscle insertion
•The lateral aspect of the temporal muscle with
blunt dissection.
•Instrument placed between the temporal
muscle and the zygomatic arch - readily
palpable.

62. Elevation from Eyebrow Approach:
- Popular in US
- Direct visualization
- Difficult to generate large amount of force
Technique:
- Exposure at Frontozygomatic area
- Heavy instrument to lift anteriorly, laterally and superiorly
- Palpating infraorbital rim
- Dingman zygomatic elevator
- Large Kelly hemostat

63. Percutaneous Approach:
- Very direct route by Strohmeyer in1844
- Force in all direction, anteriorly, laterally and superiorly.
- Scar on surface
Technique:
- Bone hook
- Point just inferior and posterior to zygoma prominence.
- Engages infratemporal aspect
- Vertical line from lateral cantus, horizontal line from ala of nose
- Stab incision here
- Large bone screw
- T-bar handle

64. • By Antral pack, Percutaneous wire, penrose
drains, gauze, gelfoam, silastic, antral balloon
placement
INDICATIONS:
• When unstable following reduction
• Gross comminution of zygomatic bone
• Comminution w/o bone loss of orbital floor

65. STABILIZATION
.

66. Surgical Approaches to ZMC
1. Existing lacerations
2. Maxillary vestibular (Sublabial)
3. Lateral Eyebrow (Supraorbital)
4. "Crows Foot" incision
5. Upper eyelid (upper blepharoplasty/ supratarsal fold/ upper lid crease)
6. Lower eyelid
7. Infraorbital
8. Transconjunctival (Inferior fornix approach)
9. Coronal
-Subciliary(Blepharoplasty/infraciliary)
Subtarsal
-Preseptal
Retroseptal

67. Maxillary Vestibular Approach:
- Entire midface can be approached
- Hidden intraoral scar
- Rapid, simple and few complications
Technique:
- Area of interest- half/ unilateral
- Injection of vasoconstrictor
- 3-5 mm superior to mucogingival junction
- Mucosa, submucosa, facial muscles, periosteum.
- # of infraorbital rim, ant. Maxilla, Zygomatiomaxillary
buttress.

68. Supraorbital Eyebrow approach:
- Lateral Orbital Rim
- Frontozygomatic area
- Scar is imperceptible
- No great amount of surgical access
Technique:
- Support the skin over the rim
- 2 cm incision
- Parallel to the hair of eyebrow
- To the periosteum in one stroke
- Minimal undermining, then periosteal incision
- Tissues retracted inferiorly, better access.

69. Crow’s Foot Incision
• For older patients with well developed skin creases
• Incision 1cm above the outer canthus
• Almost invisible postoperative scar

70. Upper Eyelid Approach:
- Upper blepharoplasty, upper eyelid crease, supratarsal fold
approach
- Inconspicuous scar
Technique:
- Curvilinear incision along supratarsal line
- 10 mm superior to upper eye lid margin
- 6 mm above the lateral cantus
- Skin and orbicularis oculi M
- Expose periosteum

71. Lower Eyelid Approaches:
- Subciliary incision, Subtarsal incision
- Relatively easy
- Scar is minimal
- Technique is difficult and high risk of post operative
ectropion

72. Subtarsal Approach:
• Access: Infraorbital rim & floor
Exposure of lateral orbital rim not recommended
• Incision at/below level of tarsus ; half the distance between rim & eyelash margin.
• Advantages:
-relatively easy
-imperceptible scar
-minimal complications
Subcilliary Approach:
• Incision 2mm inferior to gray line
• Advantages:
-imperceptible scar
-can be extended laterally 1-1.5cm to expose lateral orbital rim – FZ + Infra rim

73. Technique:
- 2 mm below gray line of lower lid
Dissection is done in 3 methods:
- Subcutaneous dissection, raising a thin skin flap
- Dissection between muscle and orbital septum
- Combination of both.

74. a) Extremely thin skin flap- button holing
darkening of skin
increased incidence of ectropion
entropion / lash problems/ skin necrosis also
b) Less difficult
fat herniation if septum breached
better blood supply / no pigmentation problem
c) Simplest of the 3
prevents disadvantages of others
leaves 4-5mm of muscle strip attached to tarsus – maintain lower eyelid
position on globe

75. Transconjuctival Approach:
- Inferior Fornix approach
- Retroseptal by Tenzel and Miller
- Presepral by Tessier.
- No scar
- Easy to perform, no skin/muscle dissection
- Lateral canthotomy for lateral exposure.

76. Technique:
- Two traction sutures are placed through tarsal plate.
- Initial lateral canthotomy is done
- The scissors are directed downwards to transect
inferior portion of lateral canthal ligament

77. - Undermining of the palpebral fissure
- Blunt dissection towards the orbital rim is performed
- Incision is made periorbita just posterior to orbital rim
- Subperiosteal dissection can then proceed

78. Closure:
- Periosteum may be difficult to close
- Transconjuctival incision by running 6-0 gut
- Inferior limb of the lateral canthal tendon is sutured to the inner aspect of the
lateral orbital rim with use of 4-0 slowly resorbing or non resorbing suture

79. Coronal Approach:
- Radial approach
Technique:
- 2 cms strip of hair removed.
- Incision from one preauricular area to the other.
- Skin, subcutaneous tissue and galea
- Later loose areolar tissue over the periosteum.
- Flap is raised in this plane
- Hemostatic clips are applied
- In lateral aspect temporal facial becomes visible

80. - At 2 cm above of the body of zygoma, superficial temporal fascia is incised.
- After this, a layer of fat and areolar tissue is encountered
- Further inferior dissection provides access to zygoma
- A periosteal incision is made on the arch of zygoma and subperiosteal
dissection is carried out.

82. - Pericranium is incised across forehead
- Subperiosteal elevation is carried out till lateral orbital rim.
- After reduction and fixation of the fractures, flap is closed
in layers

83. The following criteria mandate extended exposure (anterior and posterior
approaches) and multipoint realignment supported by the zygomatic arch:
• Multifragmentation of the arch with lateral displacement of the middle section
• Fracture of the temporal arch root and glenoid fossa with tendency to shear
and telescope posteriorly
• Fragmentation of the zygomatic body
• Fragmentation of the lateral orbital margin and orbital process with need for
fixation
• Fractures through the upper base of the zygomatic process of the frontal bone
• Extensive fractures of the medial orbital wall or associated
nasoorbitoethmoidal (NOE) fractures
• Skull-base fractures involving the orbital apex, the greater wing of the
sphenoid, and its transition into the middle cranial fossa

84. Direct Fixation
• For Category II - unstable after reduction
• By TO wiring (osteosynthesis) / bone plating
• FZ suture-
- separation >2-3mm direct fixation necessary
- tenderness is another indication
• Infra orbital margin-
- when exposed always examination of floor to
be carried out

85. 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.

86. 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.

87. 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.

88. BONE PLATES
• Four Point Fixation-
Comminuted Zmc Fractures
Sites Of Fixation-
1. F-Z Suture.
2. Infraorbital Rim.
3. Zygomatic Arch.
4. Maxillary Buttress.

89. Three Point Fixation-
Non-comminuted Zmc Fractures
Sites Of Fixation-
F-z Suture.
Infraorbital Rim.
Zygomatic Arch.
(Or)
Maxillary Buttress.

90. Two Point Fixation-
Simple Non-comminuted ZMC Fractures
• Sites Of Fixation-
F-z Suture.
Infraorbital Rim.

91. Orbital Floor
Indications For Exploration
• Persistent Diplopia (>7 days), within 30 of primary visual axis
• Positive Forced Duction Test
• Evidence of Extraocular Muscle Entrapment
• Early Enophthalmos (>3mm)
• Large Orbital Floor Defect >1cm (0.5-1cm if forced duction positive)
• Abnormally Low Vertical Globe Level
• Comminuted orbital rim by CT
• Combined floor/medial wall defects by CT
• Fracture of zygoma body by CT
• “Blow-in” fractures with exophthalmos
• Associated Orbital Rim or Other Craniofacial Fractures

92. • Open reduction with internal fixation is the mainstay of ZMC fracture repair
• controversy exists regarding the need for 1-, 2-, or 3-point fixation.
• Davidson (1990) -Minimal increases in stability were added using3-point
miniplate fixation when compared to 2-point miniplate fixation, regardless of the
application site. frontozygomatic suture second buttress acceptable
• comminution rotatory forces of the masseter muscle – not accounted for.

93. • Davis and others in their study evaluated a complex question of how many
and what type of fixation is really best in achieving proper reduction and
fixation.
• three-point fixation with miniplates or wires offered the greatest stability.
Two-point fixation with miniplates also offered acceptable fixation.
• Plates offer greater stability than the wires with less points of fixation, mainly
with two-point and one-point fixations. They also found that clinically stable
fixation can also be achieved with either one miniplate at the frontal
zygomatic suture line and the wire on the second buttress.
• In addition, they concluded that acceptable stability can be achieved with a
single point fixation with a miniplate at the frontal zygomatic suture line or
the infraorbital rim.

94. Indications for exploration of the orbital floor
Shumrick et al reviewed ZMC fracture
• Persistent diplopia
• Cosmetically significant and clinically apparent Enopthalmos
• Radiological evidence
• Radiological evidence of significant comminution
• Herniation of soft tissue into the maxillary sinus
• Combined orbital floor and medial wall defects
• Physical or radiological evidence of exopthalmous or orbital content
impingement caused by displaced fracture fragment

95. J Oral Maxillofac Surg 54:386-400, 1996 Analysis of Treatment for Isolated Zygomaticomaxillary Complex Fractures

96. Zygoma
Algorithm

99. Complications of periorbital incisions:
Ectropion
Entropion
Orbital complications:
Infraorbital nerve disorders
Persistent diplopia
Enophthalmos
Blindness
Retrobulbar and intraorbital hemorrhage
Maxillary sinusitis
Ankylosis of zygoma to coronoid process
Malunion of the zygoma
Complications

100. • Ophthalmologic :
• Blindness
• Surgeon to keep watch on pupillary size - Local anesthesia containing
epinephrine can result in transient pupillary dilation, which will resolve
• Mild postoperative visual acuity changes can occur transiently in up to
30% of patients (Crumley, 1977) – more adverse when orbital implants
are used.
• Persistent diplopia is probably the most common ophthalmologic
complication -upward and far lateral gaze- at least 6 months- before
surgical re exploration.

101. Ocular complications :
• Traumatic diplopia
• Enopthalmos
• Retrobulbar hemorrhage & blindness
• Superior orbital fissure syndrome- oedema of peri orbita, proptosis,
subconjunctival hemorrhage, Dilatation of pupil ,direct light reflex
absent. Radiologic evidence of reduction in dimension- obstruction
to lymphatic, extra conal intra conal hemorrhage,involvement of
nerves occulomotor, nasociliary etc.
• Neurologic complications :
Damage to the infra-orbital nerve

102. Eyelid malposition
• Eyelid ectropion occurs from excessive scarring in the outer lamella ,
injury to the inner lamella
• The subciliary approach -28% incidence
• 3% incidence with the transconjunctival approach
• Entropion - effectively treated - release of the contracture and
placement of a palatal mucosal spreader graft in the posterior lamella.
• Transconjunctival approach –0-1.2%
• The spreader graft facilitates eversion of the lower lid and prevents
repeat contracture (Patel, 1997).

103. Facial asymmetry
• 20-40% of patients , failure to obtain adequate exposure and precise
reduction
• major asymmetry – 3-4% - osteotomy
Paresthesia
• infraorbital nerve injury -from 22-65% for open reductions and 9-40% for
closed reductions
• Attempts at surgical decompression or ablation are highly unpredictable
• supraorbital and supratrochlear -Coronal incisions

104. • Miscellaneous
-Plate exposure: In the absence of infection, Intraoral exposure of plates or wires
can be monitored conservatively. These wounds often granulate with appropriate
oral hygiene. Persistent exposure for longer than 3 months, evidence of loose
hardware, or gross infection are indications for hardware removal.
-Cold sensitivity: Patients will rarely complain of pain over titanium implants with
cold exposure. When present, cold sensitively is an indication for hardware
removal.

105. Sinusitis: Zingg (1991) reported a 7% incidence of maxillary sinus
opacification after ZMC fracture repair; however, only 1.6% of
patients were symptomatic. Postoperative sinusitis was related
directly to the severity of injury. Reserve sinus surgery for patients
who do not respond to conservative medical management.

106. Retrobulbar hemorrhage :
• Severe and alarming complication
• Permanent blindness
• Signs:
- Proptosis
- Subconjunctival hemorrhage
- Globe very hard on palpation
- Dilating pupil
- Loss of direct light reflex
- Preservation of consensual light reflex
- Constriction of retinal arterioles
- slight pallor of the optic disc
- opthalmoplegia

107. Inj mannitol (200 ml of 20% solution)- increase renal out put
Inj acetazolamide 500mg
Inj hydrocortisone 100 mg
Inj dexamethasone 3-4 mg/kg 6 hourly –reduce circulatory spasm,
cell necrosis, oedema.
• Surgical decompression:
Transethmoidal / Sphenoidal Approach
Lateral Canthotomy between IR & LR muscle
Antrostomy
Paracentesis of anterior chamber

108. Chronic ZMC Fractures
• Secondary reconstruction more challenging
• Clinically evaluate for enopthalmos, hypopthalmus, lateral canthus
malposition, loss of malar projection.
• GOAL: reduce anatomically ZM buttress & ZS suture.

109. C-Osteotomy
• Prefered over fracture line osteotomy cause less
dissection, maintains anatomical refrences, avoids
muscle pull, less relapse.
• Segments to be rotated sup & ant 8-10mm across ant
max wall & at ZM buttress
• Arch not involved in C-Osteotomy
• Interpositional bone grafts or porous hydroxyapetite
to fill gaps.

110. Reasons for low incidence
• Prominence of calavarium
• Relative retrusions of the midface.
• Lack of development of the maxillary sinus.
• Elasticity of facial bones
• Thicker layer of adipose tissue
• Suture lines are flexible.
• Stability is increased by the presence of tooth buds within the jaws
• Lack of ossification of sutures
Pediatric Zygomatic Complex Fractures

111. Conclusion
• Since the gross shape of the face is influenced largely by the underlying
osseous structure, the zygoma plays an important role in facial contour.
• Disruption of zygomatic position also has great functional significance
because it creates impairment of ocular and mandibular function.
• Therefore, for both cosmetic and functional reasons, it is imperative that
zygomatic injuries be properly and fully diagnosed and adequately treated.

112. References:
• Rowe and Williams – vol 1
• Fonseca Trauma- 4th edition
• Fonseca 3rd edition
• Peterson’s Principles of Oral and Maxillofacial Surgery; II- Edition, Vol-I.
• Peter Ward Booth – vol 1
• Edward Ellis Approaches to Facial Skeleton
• Slideshare
• Pubmed articles
• Ellis , Kittidumkerng W. Analysis of treatment of isolated
zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 1996;54:386.