1) The document discusses zygomaticomaxillary fractures, providing classifications, examination techniques, signs and symptoms, and treatment approaches. 2) Common classification systems include the Knight and North system that categorizes fractures based on displacement patterns. Treatment depends on factors like displacement and stability. 3) Approaches to treatment include no treatment for non-displaced fractures, indirect reduction using techniques like the temporal or buccal sulcus approaches, and direct open reduction using approaches like the coronal or maxillary vestibular approaches with fixation if needed.

1. ZYGOMATICO MAXILLARY
FRACTURE
PRESENTED BY :
PROF.DR.SHIVARAJ.S.WAGDARGI
DEPT OF ORAL AND MAXILLOFACIAL SURGERY
NAVODAYA DENTAL COLLEGE RAICHUR

2. CONTENTS
• INTRODUCTION
• CLASSIFICATION.
• EXAMINATION.
• SIGNS AND SYMPTOMS.
• MANAGEMENT.
• SURGICAL APPROACHES.
• COMPLICATIONS.
• REFERENCES

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
• 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

4. CLASSIFIACTION
Knight and North (1961)
Rowe and Killey (1968)
Yanagisawa ( 1973)
Larsen and Thomson (1978)
Rowe and Williams (1985)
Spiessl & Schroll (1972)
Poswillo’s classification
Markus zing classification
Manson and colleages
Henderssons classification
Zingg classification
Ozyagzan classification

5. According to Knight and North (1961)
Group I – No significant displacement.
Group II – Arch fracture.
Group III – Unrotated body fracture
(downward and backward).
Group IV – Medially rotated body fracture
(inward and backward).
Group V – Lateral rotated body fracture.
Group VI – Complex body fractures.

6. According to Larsen and Thomsen (1968)
 Stable fractures that shows - minimal or no displacement ( no
intervention)
Stable fracture – with displacement ( no fixation)
 Unstable fracture with great displacement and disruption at
frontozygomatic suture and comminuted fractures.
Fractures of zygomatic arch are classified again into:
Minimum or no displacement.
V type in fracture.
Comminuted fracture.

7. ROWE’S AND KILLEY (1968)
 Type I : No significant displacement
 Type II : Fracture of the zygomatic arch
 Type III : Rotation around horizontal 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
enbloc - Medial
-Inferior
- lateral (Rare)
 Type VI : Displacement of orbitoantral
partition - Inferiorly
-Superiorly
 Type VII : Displacement of orbital rim
segments
 Type VIII : Complex comminuted fractures

8. ROWE & WILLIAMS CLASSIFICATION
Fractures unstable after
elevation
a)Arch only (inferiorly displaced)
b)Rotation around horizontal axis
i)medially
ii)Laterally
c)Dislocations en bloc
i) inferiorly
ii)medially
iii)Postero-laterally
Fractures stable after elevation
a)Arch only (medially displaced)
b)Rotation around the vertical axis
i)medially
ii)Laterally

9. SPIESSLAND SCHROLL (1972)
• TYPE 1- zygomatic arch fracture.
• TYPE 2- zygomatic - complex fracture with no significant displacement.
• TYPE 3- zygomatic complex fracture - partial medial displacement. (Kinking
at F-Z suture)
• TYPE 4 - Z.C with total medial displacement(complex fracture of F-Z suture).
• TYPE 5- Z.C dorsal displacement (2 fracture sites in zygomatic arch).
• TYPE 6- Z.C, inferior displacement.
• TYPE 7- Z.C, comminuted fracture.

10. YANAGISAWA(1973)
• GROUP 1- non displaced fracture- no treatment.
• GROUP 2- arch fracture(pure)
• GROUP 3- medial/lateral rotation around vertical axis.
• GROUP 4- medial/ lateral rotation around longitudinal axis.
• GROUP 5-medial/ lateral displacement without rotation.
• GROUP 6- isolated rim fracture.
• GROUP 7- all complex fracture.

11. EBERHARD KRUGER(1986)
FRACTURE OF ZYGOMA
• No displacement.
• Partial medial
• Total medial
• Dorsal displacement.
• Inferior displacement.
• Comminuted fracture.

12. MANSON& COLLEAGUES(1990)
Based on
- Amount of energy dissipated by the facial bones.
- Secondary to the traumatic force.
- Findings in CT scans
High energy fractures Lower energy fractures
• Extreme displacement. Displacement
• Comminution of articulations. NIL
• Segmentation of bones.
Treatment- Treatment-
• Require extensive exposure Less agressive
and Aggressive fixation.

13. ANATOMY
PRINCIPAL STRUCTURE OF MIDFACE
MAJOR ROLE IN FACIAL CONTOUR
4 PROCESSES -ORBITAL
-FRONTAL
-TEMPORAL
-MAXILLARY
4 ARTICULATIONS -FRONTAL
-TEMPORAL
-MAXILLARY
-SPHENOID
MUSCLE ATTACHMENTS - MASSETER
-TEMPORAL FASCIA

14. ANATOMY - ZYGOMA
ARTICULATIONS

15. MUSCLE FORCES ON ZYGOMA

16. FRACTURE PATTERNS
• Depends on- DIRECTION & MAGNITUDE OF FORCE
• Fracture lines pass through lines of greatest weakness
• Malar bone represent strong bone on fragile suppport
• Force appiled on zygoma - distributed through four processes
to adjacent articulating bone –weaker than zygoma
• Three lines of fracture extend from IOF
Anteromedial – orbital floor
Superolateral -
Inferior direction

17. Clinical examination
1.NEUROLOGICAL STATUS.
• First step is to assess neurological
status…….
• Associated neurologic injury was
encountered in 57% of patients.
2.VISUAL STATUS
3.EXAMINATION OF ZYGOMA

18. INSPECTION
Symmetry of arches.
Pupillary level.
Presence of orbital oedema.
Sub-conjunctival ecchymosis.
Ant & lat projection of zygoma.
Intra-oral.
• PALPATION
-Systematic & thorough.
-Compare one side with another.

19. SIGNS AND SYMPTOMS
• Periorbital ecchymosis and edema.
• Flattening of the malar prominence.
• Flattening of the zygomatic arch.
• Pain.
• Ecchymosis of the maxillary buccal sulcus.
• Deformity of the zygomatic buttress of the maxilla.
• Deformity of the infra-orbital margin.
• Trismus.
• Abnormal nerve sensibility.
• Epistasis.
• Subconjunctival ecchymosis.
• Crepitation from air emphysema.
• Displacement of palpebral fissure.
• Diplopia.
• Enopthalmos.

20. Orbital signs and symptoms
Periorbital
Oedema
Circumorbital
ecchymosis
Subconjunctival
haemorrhage
Orbital
Emphysema Diplopia
Unequal
pupillary
levels

21. Flattening of malar prominence
• Characteristic sign
• Presence of edema flattening may be difficult to discern
Flattening of zygomatic arch
• Loss of normal convex curvature

22. Displacement of
palpebral fissure Deformity of orbital margin

23. ORBITAL EXAMINATION
FORCED DUCTION TEST
• To determine presence of
mechanical obstruction to
globe movement.
• Test done to assess the cause
of reduced movement of
extraocular muscles
following trauma to mid-face
region.
• It helps to determine if the
cause is mechanical/
neurological.
DIPLOPIA

25. 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

26. CT SCANS

27. TREATMENT

28. STEPS IN TREATING ZMC FRACTURE
1. Prophylactic antibiotics.
2. Anesthesia.
3. Clinical examination and forced duction test.
4. Protection of the globe.
5. Antiseptic preparation.
6. Reduction of the fracture.
7. Assessment of reduction.
8. Determination of necessity for fixation.

29. 9. Application of fixation device.
10. Assessment of ocular motility.
11. Bone graft for extra orbital osseous defects.
12. Post surgical ocular examinations.
13. Post surgical images.

30. 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.
• Ellis et al reviewed series of isolated ZMC fractures treated by different
approaches and fixation schemes and found no evidence of post reduction
instability

31. TREATMENT MODALITIES
NO TREATMENT
INDIRECT REDUCTION-
• Gillies approach.
• Keens approach.
• Lateral coronoid approach.
• Eyebrow approach.
• Percutaneous approach.
• Transnasal approach.
DIRECT REDUCTION
FIXATION.
Coronal approach/bicoronal.
Upper eyelid/ blepharoplasty.
Supraorbital eyebrow approach.
Transconjunctival .
Subcilliary.
Infraorbital.
Maxillary vestibular approach

32. TEMPORARY SUPPORT
INDIRECT FIXATION-
• Internal pin fixation.
• Transfixation with kirshner wire.
DIRECT FIXATION-
• Transosseous wiring.
• Bony platting.

33. NO TREATMENT
NON-DISPLACED FRACTURES-9-50 % OF ZMC #
MEDICAL CONTRAINDICATIONS
MINIMAL DEGREE OF DISPLACEMENT.
UNLIKELY TO RESULT IN
COSMETIC DEFORMITY
DISTURBANCE OF VISION
PARESTHESIA
IMPAIRED MANDIBULAR MOVEMENTS.

34. DECISION TO INTERVENE
DEPENDS ON
SIGNS & SYMPTOMS.
FUNCTIONAL IMPAIRMENT.
PRESENCE OF OPHTHALMIC INJURIES.
PROGRESSIVE PROPTOSIS.
VISUAL ACUITY DETERIORATION.
VISUAL INTEGRITY ON UNAFFECTED SITE.
OTHER RELATED FACIAL INJURIES.
MEDICAL CONDITION OF PATIENT.

35. DELAYED TREATMENT
1. MANIPULATION OF ORBITAL BONES
2. RISK OF EYEBALL INJURY.
3. EXISTING HAEMORRGHAGE.
4. PROGRESSIVE PROPTOSIS.
5. PRE-EXISTING BLINDNESS IN OTHER EYE.
6. GENERAL MEDICAL CONDITION.
7. NEUROLOGICAL STATUS QUESTIONABLE.
8. GROSS OEDEMA.
9. CRITICAL PERIOD - 5-10th DAY

36. DELAYED TREATMENT
ADVANTAGES
OEDEMA RESOLVES- DETAILED EXAMINATION OF
EYE.
ANTRUM CLEARS - BETTER RADIOGRAPH.
HAEMATOMA STILL NOT ORGANISED –DISSECTION
EASIER.
>5-10 DAYS
DIFFICULTY IN DISIMPACTING & REDUCING.
PHYSIOLOGICAL RESORPTION OF # MARGINS.
INTERDIGITATION LESS ACCURATE.
INELASTICITY OF FIBROUS TISSUE AT SITE OF
MALUNION.

37. IMMEDIATE TREATMENT
• IN THE ABSENCE OF COMPLICATIONS.
• NO OEDEMA.
ADVANTAGES
EXCELLENT REDUCTION -NOT COMPROMISED
NO SOFT TISSUE SCARRING
NO CHANGE IN MORPHOLOGY
SUPERIOR FACIAL SOFT TISSUE CONTOUR.

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

39. TEMPORAL APPROACH
Popular approach
First described by Gillies & coworkers in 1927 – arch fractures
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

40. Incision – 2.5cm, through skin & subcutaneous tissue
White glistening surface Temporalis muscle bulge

41. PLACEMENT OF ROWES
ZYGOMATIC ELEV
ATOR
AND ELEVATION.

42. BUCCALSULCUS APPROACH
Keen’s Technique (1909)
ADVANTAGES:
Avoidance of any external scar.
Used for both arch and ZMC fracture
DISADVANTAGES:
Unstable fractures – external incision for fixation
TECHNIQUE:
•A small incision (approximately 1 cm) is made in the mucobuccal fold, beneath the
zygomatic buttress of the maxilla.
•Sharp end of periosteal elevator – inserted & swept in a sweeping motion to
contact infratemporal surface of maxilla & zygoma.
•A heavier instrument inserted behind the infratemporal surface of the zygoma,
using superior, lateral & anterior force to reduce the bone.

43. LATERAL CORONOID APPROACH
Quinnin1977–described
Usedonlyforarchfractures
TECHNIQUE :
•3 to 4 cm incision -anterior border of the ramus.
•Insision made - to the depth of the temporal muscle
insertion (not to the bone)
•Instrument between the temporal muscle and the
zygomatic arch - readily palpable.
•A flat-bladed instrument- inserted into the pocket&
arch is elevated while palpating the arch extraorally.

44. ELEVATION FROM EYEBROWAPPROACH
•Used for both ZMC & arch fracture
ADVANTAGE:
•Fracture at the orbital rim is visualized
directly
•Fixation can be done with same incision.
DISADVANTAGE:
•Difficult to generate a large amount of force,
especially in the superior direction.
DINGMAN ZYGOMATIC
ELEVATOR

45. PERCUTANEOUS APPROACH
•Most simple of all techniques as no soft tissue dissection is necessary
•Direct route to elevate 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
DISADVANTAGE:
Scar on the face in a very noticeable location.

46. ELEVATION OF THE ZYGOMA WITH A
BONE HOOK
•Strohmeyer in 1844
•Poswillo`s
intersecting lines.
•Stab incision made
and hook inserted.
•Apply strong traction.
Stacey bone hook

47. Carrol-Girard bone screw
Elongated corkscrew with a T- bar handle.
Contains threads on its working end.
Screw is threaded into body of zygoma
following a hole placement & is used as a
handle to reduce fracture
Can control ZMC position in all 3 planes of
space.
LARGE BONE SCREW

48. SURGICALAPPROACHES TO ZMC
 Maxillary vestibular approach
 Supraorbital eyebrow approach
 Upper eyelid approach
 Lower eyelid approach
 Transconjunctival approach
 Coronal approach
DIRECT REDUCTION

49. MAXILLARY VESTIBULAR APPROACH
• Most useful when performing any of
wide variety of procedures in the
midface.
• 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:
• Hidden intraoral scar.
• Rapid and simple approach
• Complications are few.

50. TECHNIQUE
Subperiosteal Dissection
V –Y Closure
Incision through the mucosa, submucosa, facial
musculature,and periosteum (3-5mm superior to
mucogingival junction)
Infraorbital rim, anterior
maxilla & ZMC Buttress -
treated

51. LATERAL BROW APPROACH
Popular approach - Access to the lateral
orbital rim and the frontozygomatic suture
ADVANTAGE:
Simple, safe and rapid approach
Scar is usually hidden within the confines of
the eyebrow
No important neurovascular structures are
involved in this approach.

52. DISADVANTAGE :
 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.
 Extremely limited access.

53. TECHNIQUE
•Incision – parallel to the eyebrow hair.
•The incision is made through skin and subcutaneous tissue
to the level of the periosteum in one stroke. (2cm)
•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.

54. UPPER EYELID APPROACH
 The upper eyelid approach to the superolateral orbital rim is also called UPPER
BLEPHAROPLASTY, UPPER EYELID CREASE, & SUPRATARSAL FOLD
APPROACH.
 In this approach, a natural skin crease in the upper eyelid is used to make the
incision.
Advantage: ADVANTAGE:
Inconspicuous scar it creates - best
approaches to the region.

55. 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.
Periosteum is divided 2-3mm posterior to the orbital rim with a scalpel.
Sagittal section through orbit and globe showing dissection
between orbicularis oculi muscle and the orbital septum
Incision – begins 10mm superior to upper lid margin
& lies 6mm above lateral canthus as it extends laterally.
The initial incision is made through skin and muscle.

56. LOWER EYELID APPROACH
SUBTARSAL approach:
• Frequently employed – access to infraorbital rim & orbital floor
• Along natural skin crease at/below the level of tarsus, approx half
distance between lash margin and orbital rim
ADVANTAGE:
• Relatively easy
• Scar is imperceptible
• Minimal complication

57. SUBCILIARY approach:
• Also called INFRACILIARY APPROACH/ BLEPHAROPLASTY
• Incision is - approx 2 mm below the eyelashes and can be extended laterally as necessary
(top dashed line) along the natural crease inferior to lateral canthal ligament.
ADVANTAGE:
• Imperceptible scar
• Simultaneously exposes infraorbital
& F-Z areas.
DISADVANTAGE:
• Technically difficult
• Risk of postoperative ectropion

58. TECHNIQUE
•Skin incision
•Dissect b/w skin & muscle
until orbital rim is reached
•2nd incision – through muscle
& periosteum to bone
•Incision – skin & muscle at
same level
•Dissect down anterior to
orbital septum to orbital rim
•Combination of these – STEPPED
incision
•Subcutaneous dissection toward
rim – few mm
•Followed by muscle incision at
lower level & then following orbital
septum to rim.
•Fine scissors are used during dissection –spreading motion.
•Incision through periosteum – 3-4mm below rim

59. TRANSCONJUNCTIVALAPPROACH
 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.

60. RETROSEPTAL PRESEPTAL

61. TECHNIQUE
Sagital section through orbit showing preseptal and
retroseptal placement of incision.
Initial incision for lateral canthotomy
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

62. 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.
 Rapid and no skin or muscle dissection is necessary.
DISADVANTAGE :
• medial extent of the incision is limited by the lacrimal
drainage system.

63. CORONALAPPROACH
 The coronal or bi-frontal 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.
•Excellent acess to orbits, zygoma & arch.

64. TECHNIQUE
Incision placement:
•Hairline of patient
•Amount of inferior access
•Incision – skin, subcutaneous tissue & galea
•Lateral aspect of skull- superficial layer of temporal fascia incised 2cm supr
to zygomatic arch
•Dissect inferiorly - zygomatic arch
•Periosteal incision – along the superior aspect of arch
•Pericranium is incised along lateral orbital rim – FZ suture
•Wound is closed in layers – fascia , galea, skin.

65. HEMICORONAL APPROACH

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

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

68. 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

69. 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

70. FIXATION TECHNIQUES

71. INDIRECT FIXATION
• Zygomatic bone - rigidly secured to facial skeleton.
INDICATION
• Gross loss of bone in FZ region and infra orbital rim.
 ZYGOMATICO-ZYGOMATIC
 NASO-ZYGOMATIC
 ZYGOMATICO-PALATAL
 MAXILLO-ZYGOMATIC
 FRONTO-ZYGOMATIC
 CRANIO-ZYGOMATIC

72. INDIRECT
FIXATION
TRANSFACIAL WIRE
TRANSNASALWIRE
ZYGOMATICOMAXILLARY ZYGOMATICOPALATAL

73. 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.

74. DIRECT FIXATION
• TRANS-OSSEOUS WIRING/ OSTEOSYNTHESIS
FZ SUTURE
INFRA ORBITAL MARGIN
• BONE PLATES

75. 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.

76. 5. Use a thin 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.

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

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

79. TWO POINT FIXATION-
 SIMPLE NON-COMMINUTED ZMC
FRACTURES
 SITES OF FIXATION-
F-Z SUTURE
 INFRAORBITAL RIM
OR
MAXILLARY BUTTRESS

80. PLACEMENT OF FIRST PLATE FIXATION OF FIRST PLATE

81. PLACEMENT OF SECOND PLATE PLACEMENT OF THIRD PLATE

82. COMPLICATIONS

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

84. 5.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 / light touch .
 ZMC fracture which are treated with rigid fixation
– early recovery of neurosensory deficit .

85. 6.Persistent Diplopia
 Binocular diplopia initially present with ZMC fracture should
resolve 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.

86. 7.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, hydroxyapatite, metallic mesh or plate)

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

88. 10.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

89. 11. 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

90. CONCLUSION
 Surgical intervention is an effective treatment modality
of depressed ZMC fracture, whereas a nonsurgical
approach is often used for nondisplaced fractures.
 Most of them can be treated solely by an intraoral
approach & rigid fixation at ZM buttress.
 Further exposure of FZ junction or infra orbital rim is
necessary for severely displaced fractures, requiring
additional fixation.

91. REFERENCES
• ORAL AND MAXILLOFACIAL TRAUMA-FONSECA
• PETERSON’S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY
• ROWE AND WILLIAMS MAXILLOFACIAL TRAUMATOLOGY
• TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY