SEMINAR ON ZYGOMATICO MAXILLARY COMPLEX FRACTURE

1. Zygomatico-maxillary complex
fractures
BY: DR. NITISH CHANDRA GUPTA
DEPARTMENT OF OMFS
NAVODAYA DENTAL COLLAGE,RAICHUR

2. Contents :
Introduction
Anatomy: zygoma and orbit
Classification of Zygomaticomaxillary Complex Fractures
Diagnosis of Zygomaticomaxillary Complex Fractures
◦ Clinical Examination
◦ Radiologic Evaluation
Treatment of Zygomaticomaxillary Complex Fractures
◦ Need for Fixation
◦ Principles in the Treatment of Zygomaticomaxillary Complex Fractures
◦ Surgical Approaches to Zygomaticomaxillary Complex Fractures
◦ Reduction Techniques
◦ Fixation Techniques
◦ Internal Orbital Reconstruction
◦ Intrasinus Approach to the Orbital Floor

3. Complications
◦ Periorbital Incision Problems
◦ Infraorbital Nerve Disorders
◦ Implant Extrusion, Displacement, and Infection
◦ Persistent Diplopia
◦ Enophthalmos
◦ Blindness
◦ Retrobulbar and Intraorbital Hemorrhage
◦ Malunion of the Zygoma
CONCLUSION

4. Introduction
ZMC fractures are the 2nd most common facial fractures after nasal fractures .
High incidence is because of prominent position with in facial skeleton.
Male : female= 4:1
Peak incidence: 2-3 decade
Left ZMC # > Right # due to more frequency of right handed people
Bilateral fractures are rare= 4% ( Ellis et al sample=2067 in 10 year review)
It can affect facial contour ,ocular and mandibular functioning.

5. ANATOMY
ZYGOMA:
It is one of the principal buttress of facial skeleton
and prominent structure of the lateral mid face.
Shape: Quadrilateral
Surface:
•Outer surface(convex): Convexity forms the point of
greatest prominence of the cheek.
•Inner surface(concave)

6. It is roughly equivalent of a four sided pyramid sides are
represented by four processes
1. Temporal
2. Orbital
3. Maxillary
4. Frontal

7. Articulating surfaces
A zygomatic complex fracture causes disruption
of four articulating sutures:
• Zygomatico- frontal
• Zygomatico-temporal
• Zygomatico -maxillary
• Zygomatico- sphenoid
• In a series of 134 zygoma fractures at the
District of Columbia General Hospital, the
zygomaticotemporal suture line on the arch was
fractured most frequently, followed by fractures
of the suture line on the infraorbital rim and
then by the zygomaticofrontal and
zygomaticomaxillary suture lines

8. Muscle attachment
• Muscles of facial expression
zygomaticus major and labii superioris.
Nerve supply: VII.
• The masseter muscle inserts along the
temporal surface of the zygoma and
arch.
Nerve supply: Mandibular nerve
• The temporalis fascia: Attach to the
frontal process of the zygoma and
zygomatic arch

9. Orbit anatomy
•All zygomatic complex fractures involve
the orbital floor.
•The orbit is a quadrilateral pyramid that
is based anteriorly.
•It is composed of the orbital plate of the
maxilla, the orbital surface of the
zygomatic bone, and the orbital process
of the palatine bone
•The position of the globe horizontally is
maintained by Lockwood’s suspensory
ligament

10. Terminology
•Injury to zygoma causes disruption of adjacent articulating bones because of strong
zygomatic buttress and thin surrounding bones.
•Isolated fracture of the zygoma are rare because force get distributed to weaker
articulating bones.
•ZMC term distinguish between the zygoma and adjacent bones fractures from isolated
zygomatic arch fractures.
•Other names included Zygomatic maxillary complex, zygomatic maxillary compound,
zygomatico-orbital,zygomatic complex. malar, trimalar, and tripod fractures

11. Fracture patterns
Common fracture pattern in ZMC injury:
1. Fracture medial to a zygomatico-maxillary
suture and along a zygomatic-cosphenoid
suture within orbit.
2. Fractures through a fronto-zygomatic
suture and posterior to a
zygomaticotemporal suture.
3. Fractures extending from the inferior
orbital fissure superiorly through the
zygomatico-sphenoid suture and inferiorly
through the zygomatic buttress of the
maxilla.
4. Triple fracture through the zygomatic
arch.

12. CLASSIFICATION
•Knight and North (1961)
•Rowe and Killey (1968)
•Yanagisawa ( 1973)
•Larsen and Thomson (1978)
•Rowe and Williams (1985)
•Poswillo (1988)

13. Knight and North (1961)
Based on the direction of displacement on a
Water’s view radiograph,
• Group I – no significant displacement
• Group II – zygomatic arch fracture
• Group III – Unrotated fractures
• Group IV – Medially rotated fractures
• lateral zygomatic prominence
Medial at ZF suture
• Group V - Laterally rotated body fractures
Superior at infra orbital margin
Laterally at zygomatic frontal suture
• Group VI – Complex fractures

14. ROWE AND KILLEY (1968)
Type I – no significant displacement
Type II – fracture of the arch
Type III – rotation around a vertical axis
Type IV – rotation around a longitudinal axis
Type V – displacement of the complex en bloc
Type VI – displacement of orbito-antral partition
Type VII – displacement of the orbital rim segments
Type VIII – Complex comminuted fractures

15. 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 arch fracture
GROUP VII - All complex fractures

16. Larsen and Thomson (1978)
GROUP I – Non displaced fractures requiring no treatment
GROUP II – All fractures requiring treatment

17. ROWE AND WILLIAMS (1985)
Fractures stable after elevation
a) Arch only (medially displaced)
b) Rotation around the vertical axis
i) medially
ii) laterally

18. ROWE AND WILLIAMS (1985)
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
d) Communited fractures

19. POSWILLO’S CLASIFICATION
•Inward and downward displacement
•Inward and posterior displacement
•Outward displacement of the
zygomatic complex
•Comminution
•Fracture of the arch alone

20. Clinical examination
1. Neurological status
2. Visual status of involved status
3. Examination of zygoma

22. INSPECTION
Symmetry
 Pupillary level
 Presence of orbital oedema
 Sub-conjunctival ecchymosis
 Ant & lat projection of zygomatic bodies
 Intra-oral
PALPATION
systematic & thorough
Compare one side with another

23. Signs and symptoms

24. Periorbital Ecchymosis and Edema:
Edema and bleeding into the loose
connective tissue of the eyelids and
periorbital areas is the most common sign
following fracture of the orbital rim

25. Flattening of the Malar Prominence.
A characteristic sign and striking feature of zygomatic
injury is a flattening of the normal prominence in the malar
area.
Seen in especially those in which distraction of the
frontozygomatic suture and medial rotation and/or
comminution have occurred.
Reported in 70% to 86% of cases.
Observed in birds and worms view.

26. Flattening over the Zygomatic Arch. A
characteristic indentation or loss of the normal
convex curvature in the temporal area
accompanies fractures of the zygomatic arch.
Pain. Severe pain is normally not a feature of
zygomatic injuries unless the fractured
segment is mobile.
Ecchymosis of the Maxillary Buccal Sulcus:
Ecchymosis may occur even with a small
disruption of the anterior or lateral maxilla and
should be sought in patients with suspected
zygomatic fractures.

27. Deformity at the Zygomatic Buttress of the Maxilla. Intraoral
palpation frequently reveals irregularities of the normally smooth
contour, especially in the area of the zygomatic buttress of the
maxilla.
Deformity of the Orbital Margin: Fractures running through the
orbital rim often result in a gap, or step deformity, if displacement
has occurred.

28. Abnormal Nerve Sensibility:
Infraorbital nerve paresthesia is
more common in fractures that are
displaced than non displaced.
A related symptom is altered
sensitivity of the maxillary teeth
and gingiva.
Reported in 50% to 90% of ZMC
injuries.

29. Trismus:
• Limitation of mouth opening in
approximately one third of cases. 45% in arch
@ cases.
• This is because of impingement of the
coronoid process due to the displaced
zygomatic fragments.
• But impinging coronoid large displacement is
required.
• Therefore more accepted theory says trismus
if due to muscle spasm rather than direct
contact with coronoid.

30. Subconjunctival Ecchymosis :
Subconjunctival haemorrhage
reported in 50% to 70% of cases.
It will not have posterior limit
It will be bright red because of the
ability of oxygen to diffuse through
the conjunctiva to the collection of
blood.

31. Epistaxis:
Whenever the sinus mucosa is
disrupted, haemorrhage into the sinus
is possible.
Because the maxillary sinus drains into
the nose via the middle meatus,
unilateral hemorrhage from the nose is
possible.
It is reported in 30% to 50% of ZMC
injuries.

32. Crepitation from Air Emphysema:
Can be palpated by alternatively rolling two fingers gently over the tissue, which
produces a characteristic crackling sensation.
The soft tissue of the periorbital area, especially the eyelids, is prone to inflation
with air because of its loose areolar nature.
Disappears spontaneously in 2 to 4 days without treatment.

33. Displacement of the Palpebral Fissure.
The lateral palpebral ligament is attached to
the zygomatic portion of the orbital rim.
Displacement of the zygoma carries the
palpebral attachment with it and thus
produces a dramatic visual deformity.
Inferior displacement of zygoma produces
downward slope to the fissure
(antimongoloid slant).

34. Unequal Pupillary Levels.
With the disruption of the orbital floor and lateral aspect of the orbit causes
loss of osseous support for the orbital contents and displacement of Tenon’s
capsule and the suspensory ligaments of the globe permit depression of the
globe

35. Diplopia. Diplopia is the name given to the symptom of blurred vision.
Monocular diplopia, or blurring of vision through one eye with the other closed
usually indicates a detached lens, hyphema, or other traumatic injury to the
globe.
Binocular diplopia : Blurring of vision occurs only when the patient looks through
both eyes simultaneously. Reported in 10% to 40% of zygomatic injuries.
Causes:
Muscle entrapment: doesnt resolve by itself. Checked by forced duction test.
Edema or hemorage: Resolve in few days.

37. Enophthalmos.
Increase in orbital volume due to lateral and inferior displacement
of the zygoma and/or disruption of the orbital walls causes
herniation of orbital resulting into enophthalmos.
Reported in 5 % cases.

38. RADIOLOGIC EXAMINATION
Plain films and Computed Tomography have their place in determining the type, location,
magnitude, and direction of displacement of zygomatic fractures.
This includes,
Water’s view, Submentovertex view,
Computed Tomography.

39. RADIOLOGICAL EVALUATION
WATERS VIEW :Waters’ view is the most useful view to evaluate for zygomatic injuries
because it defines the injury involving the arch, lateral wall of the maxillary sinus,
inferior orbital rim, and floor of the orbit

40. Jug handle view
It is essential for demonstrating the
status of the zygomatic arch, posterior
displacement, and lateral or medial
rotation on the vertical axis.
SMV with 30% less exposure

41. Radiographic signs of zygomatic arch fracture seen on plain films include the
following:
•1. Displacement of the arch seen on Water’s and Caldwell’s views
•2. Superimposed radiopaAque band over the body of the zygoma on Water’s
and Caldwell’s views
•3. Diastasis of the zygomaticotemporal suture seen on Water’s and SMV views
•4. Depression of the temporal process of the zygoma and zygomatic process of
the temporal bone, resulting in a so-called W deformity better visualized on a
SMV view

42. CT SCAN

45. Controversies in Treatment of
Zygomatic Fractures
Should fixation devices be routinely applied
 Should surgical exposure of zygoma in 2 /3 locations be
routinely performed to confirm reduction ?

46. NEED FOR FIXATION
One of the most controversial topics in maxillofacial surgery is the
amount of fixation necessary to prevent postreduction displacement of
the fractured ZMC.
Some authors believe reduction alone is not sufficient enough because
the downward pull of the masseter muscle will cause a medial rotation
of the zygomatic body before healing.
However there is no evidence in the literature that postreduction
displacement of a ZMC fracture has occurred in patients.

47. When comminution of the fragments has occurred, instability usually
results and fixation devices become necessary.
Comminuted fractures behave differently from linear fractures .
If there is any question about the stability of a reduced zygomatic
fracture it is necessary to apply fixation.

48. Types of fixation:
One-point fixation can be done by ORIF at the ZMB or by ORIF at the FZS using brow or
lateral upper-eyelid incisions.
Two point fixation: In some more unstable type B fractures, fixation at both sites (FZS and
ZMB) is necessary to ensure sufficient stability and to warrant accurate vertical positioning
and anterior-posterior projection of the ZMC

49. If the fracture still proves unstable third
point of fixation can be placed at the
IOR using a lowerlid skin incision or
transconjunctival incision.
In some even more complex injuries the
arch can be approached via a coronal
incision, with a fourth point of fixation
created to ensure adequate stability of
the reduced fracture

50. According to fonseca

51. Atlas of Operative Maxillofacial Trauma Surgery: Primary Repair of
Facial ...
edited by Michael Perry, Simon Holmes

52. Treatment types:
1. No treatment
2. Delayed treatment
3. Immediate treatment

53. NO TREATMENT
Medical contraindications
Non-displaced fractures-9-50 % of zmc #
Minimal degree of displacement
Unlikely to result in -
◦ Cosmetic deformity
◦ Disturbance of vision
◦ Paresthesia
◦ Mandibular movements impaired

54. DELAY TREATMENT
Manipulation of orbital bones risk of eyeball injury with existing
haemorrghage
Progressive proptosis
Pre-existing blindness in other eye
General medical condition
Neurological status questionable
Gross oedema

55. CRITICAL PERIOD - 5-10 th day
Advantages:
Oedema resolves-detailed examination of eye
Antrum clears-better radiograph
Haematoma still not organised –dissection easier

56. Delay >5-10 DAYS
•Difficulty in disimpacting & reducing
•Physiological resorption of # margins
•Interdigitation less accurate
•Inelasticity of fibrous tissue at site of malunion

57. IMMEDIATE TREATMENT
Indicated:
◦ In absence of complications
◦ No oedema
Advantages
◦ Excellent reduction not compromised
◦ No soft tissue scarring
◦ No change in morphology
◦ Final soft tissue contour superior

58. Principals of treatment of zmc fractures:
1) Prophylactic antibiotics:
In ZMC # sinus wall breach and orbital floor disruption can occur hence fracture
are considered compound #. Hence it is appropriate to give prophylactic
antibiotics (ampicillin,amoxicillin,clindamycin or cephalosporins)
2) Anesthesia:
In isolated zmc # oral intubation is helpful.
3) Clinical examination:
After G.A induction surgeon should examine patient more carefully.
This can confirm earlier findings and add new information
Forced duction test should also be done .

59. 4) Protection of globe:

60. 5) Antiseptic preparation:
It depends largely on the type of approach(es) that are anticipated.
It is helpful to prepare the forehead, both periorbital areas and cheeks to the
level of the mouth, and both sides of the preauricular area.
Always prepare the mouth with throat pack and antiseptic rinse, because an oral
approach to the sinus and/or zygoma is frequently useful.

61. 6) SURGICAL APPROACHES
MAXILLARY VESTIBULAR APPROACH:
The maxillary vestibular is one of the most useful approaches for open
treatment of ZMC fractures.
Access area: provide access to entire facial surface of the midfacial
skeleton including
• zygomatic arch
• infraorbital rim
• frontal process of the maxilla

62. Technique :
The length of the incision and amount of
subperiosteal dissection depend on the
area of interest and extent of surgery
For unilateral ZMC fracture—the incision
can be made on one side only, leaving
the other side intact.
The incision is usually placed
approximately 3 to 5 mm superior to the
mucogingival junction.

63. Periosteal elevators are used to elevate the tissue in the subperiosteal plane
Restitution of the nasolabial muscles should be performed as three uniform steps
during closure of the maxillary vestibular incision.

64. To help control the width of the alar base, an alar cinch suture is placed
before

65. • A V-Y advancement closure of the maxillary vestibular incision is recommended where the incision
has been placed across the base of the nose and subperiosteal dissection of the tissue along the
piriform aperture.
Closer should begin in the posterior to anteriorly with running resorbable sutures (3-0 chromic
catgut) through the mucosa, submucosa, musculature, and periosteum.

66. Supraorbital Eyebrow Approach
A popular approach used to gain access to the lateral orbital
rim is the eyebrow incision.
No significant neurovascular bundle present.
Advantage: Scar is usually imperceptible.

67. Technique:
2cm incision over orbital rim holding
with two fingers.
It should be parallel to the hair of
the eyebrow
In one stroke of the depth till
periosteum
Another incision to the periosteum.

68. Two sharp periosteal elevators are used
to expose the lateral orbital rim on the
lateral, medial (intra-orbital), and
posterior (temporal) surfaces.
One stays in the subperiosteally space,
there is almost no chance of damaging
vital structures
The incision is closed in two layers, the
periosteum and skin.

69. Upper Eyelid Approach :
The upper eyelid approach to the
superolateral orbital rim is also called
the upper blepharoplasty, upper eyelid
crease, and supratarsal fold approach.
A natural skin crease in the upper eyelid
is used to make the incision.
Advantage: inconspicuous scar .

70. Technique:
The incision should begin at
least 10 mm superior to the
upper lid margin and be 6 mm
above the lateral canthus as it
extends laterally.
The incision is through both the
skin and orbicularis oculi
muscle.

71. • The dissection is carried over the
orbital rim, exposing periosteum
• The periosteum is divided 2 to 3
mm posterior to the orbital rim
with a scalpel.
•

72. • Periosteal elevators are used to
perform subperiosteal dissection of
the orbit and orbital rims .
• The wound is closed in two layers,
periosteum and then skin and muscle

73. Transconjunctival Approach:
The transconjunctival approach, also called the
inferior fornix approach, was originally described
by Bourguet in 1928.
Two basic transconjunctival incisions are:
1. preseptal :Tenzel and Miller133 have
developed the transconjunctival retroseptal
incision and Tessier134 elaborated on the
transconjunctival preseptal incision
2. retroseptal :. The retroseptal approach is
more direct than the preseptal approach and
is easier to perform.

74. Advantages: (1) these techniques are rapid (2) no skin or muscle
dissection is necessary.
Wray et al in 56% of cases transconjunctival approach along with
lateral canthotomy was used for improving access.

80. 7)Reduction of fracture:
Temporal Approach : First described by Gillies et al in 1971 for use in
zygomatic arch fractures
Advantage: large amount of controlled force can be applied.
Disadvantage :hemorrhage due to temporal vessels .

81. Technique:
A 3- × 3-cm area of hair is shaved approximately 2.5 cm
above and 2.5 cm anterior to the helix of the ear.
A cotton pellet is placed within the external auditory canal to
prevent blood from entering during surgery.
A 2.5-cm incision is made through the skin and subcutaneous
tissue at an angle running from anterosuperior to
posteroinferior in the area previously shaved.
This incision placed superior to the bifurcation of the
superficial temporal artery.
The incision passes through skin and subcutaneous tissue
until the white glistening surface of the temporalis fascia is
visualized.
Second, deeper incision is made through the fascia to expose
temporalis muscle bulge.

82. Rowe's or bristows elevator is introduced in
the space between muscle and fascia
medial to the arch.
Firm anterior superior and lateral elevation
force is applied. An audible click sound
could be heard following elevation.
Once reduction and resistance to
displacement is verified the elevator is
withdrawnand incision is closed in two
layers.

83. Buccal Sulcus Approach:
Described by keen in year 1909.
Approach is through the maxillary buccal sulcus.
Advantage: prevention of any external scar.
This can be used for both ZMC and zygomatic arch fractures.
Technique: small incision of 1 cm in mucobuccal fold.
Sharp end no. 9 periosteal elevator or curved freer is inserted.
Use side to side sweeping motion cant with infratemporal surface
of maxilla , zygoma and arch and dissect soft tissue in supra
periosteal plane.

84. Heavier instrument can be inserted and
superior lateral and anterior force is applied
to reduce the zygoma.
Take care not to use anterior surface of
maxilla as fulcrum.
Instrument like monks or cushing elevator
and also rowes elevator can be used.
It is stressed when temporal surface of
body is followed laterally to stay close to
the bone otherwise instrument will lie
medial to coronoid.

85. Elevation from Eyebrow Approach: it is
one of the popular technique for the
elevation of zygomatic fractures in
united states.
Advantage : fracture at the orbital rim is
visualized directly and fixation can be
done through same incision.
Disadvantage: difficult to generate a
large amount of force.
Dingmans elevator

86. • TECHNIQUE:
• After exposure of frontozygomatic area of the
lateral orbital done a heavy instrument is inserted
posteriorly to the zygoma along its temporal
surface.
• Force can be applied in anteriorly, laterally, and
superiorly direction while one hand palpates along
the infraorbital rim and body of the zygoma.
• Useful instruments are the Dingman zygomatic
elevator, urethral sound, or even large Kelly
hemostat.

87. Percutaneous Approach
A direct route to elevation of the depressed zygoma is through the
skin surface of the face overlying the zygoma.
Advantage: one can produce forces anteriorly, laterally, and
superiorly in a direct manner.
Disadvantage: scar on the face in a very noticeable location.
Simple technique because no soft tissue dissection necessary.
Bone hook instrument introduced by Strohmeyer in 1844.

88. TECHNIQUE:
Poswillo draws two intersecting lines
on the face to determine the proper
location for application of the bone
hook.
The first is a vertical line dropped from
the lateral canthus of the eye.
The second is a horizontal line drawn
laterally from the ala of the nose.

89. A small stab incision is made at the
point of intersection of these lines and
the hook is inserted.
The hook is then rotated to engage the
temporal surface of the zygoma.
Strong traction in any direction can then
be applied to reduce a displaced
zygoma.
A large bone screw, such as the Carroll-
Girard screw can be used. Its advantage
of this screw one can control force in
three planes.

90. 8)Assessment of Reduction:
The success or failure of reduction will be obvious in case of three site exposer.
If this is not done start palpating in following sequence:
Firsorbital rim : in case of satisfactory reduction margins will be smooth and continuous
Second zygomatic frontal suture area: it is a worst indicators of proper reduction even when
surgically exposed.
Third maxillary vestibule: If there is any flatness still visible, the zygoma has not been properly
elevated
If there is any doubt about proper reduction, exposure is mandatory.

91. 9)Determination of the Necessity for Fixation:
The second most important step in which we assess that the reduction will be stable by itself or
needs fixation.
If constant reduction force is necessary for maintaining ZMC position fixation will be required.
If constant reduction force is not required one should press with moderate pressure on the malar
eminence with the fingers and check for any displacement.
No displacement: no fixation device required
Displacement occurs: fixation required.
However in case of any doubt its better to put some form of fixation device.

92. Application of a Fixation Device:
Each case must be individualized, because the fixation requirements differ greatly from one
fracture to the next.
General principles of its application for ZMC fractures:
A. Use self-threading bone screws: It has been shown that self threading screws have more
holding power in thin bones than when the holes are tapped.
B.Use hardware that will not scatter postoperative CT scans: Titanium plates and screws have
the advantage of not causing scatter in CT scans.
Vitallium causes more scatter therefore smaller plates and screws should be used to minimize
CT artifacts.

93. C. Place at least two screws through the plate on each
side of the fracture:
The three-dimensional stability provided by plate and
screw fixation demands that the bone plate be
adequately secured to each fragment.
At least two screws are necessary for stabilizing a bone
plate to each fragment.
D: Avoid important anatomic structures:
Bone plates screws should not cause damage to any
vital structures such as the tooth roots and infraorbital
nerve.
For low zygomaticomaxillary buttress # L-, a T-, or Y-
shaped bone plate should be used.

94. E) Use as thin a plate as possible in the periorbital areas.
The skin overlying the orbital rims is very thin so a bone plate should be extremely
thin to prevent visibility and reduce palpability. This is especially true of the
infraorbital rim.
Avoid placing bone plates in this location unless absolutely necessary.
F) Place as many bone plates in as many locations as necessary to ensure stability:
Many fractures can be adequately stabilized with a single bone plate applied at
the frontozygomatic area* or at the zygomaticomaxillary buttress.
FOR comminuted FRACTURES, it will be necessary to apply additional bone plates
in additional areas.

95. 10) INTERNAL ORBITAL RECONSTRUCTION:
It is a supplementary procedure that is frequently but not always indicated.
Postsurgical enophthalmos can occur if orbital reconstruction is not done when
indicated.
CT scan allows prediction of whether the orbital floor and/or walls require
reconstruction

96. Intrasinus Approach to the Orbital Floor:
Packing the sinus with gauze or a balloon to provide support to the orbital floor for 2 weeks
provides healing to occur.
However, this technique is rarely possible and should not be used as the routine approach to the
orbital floor.
More recently endoscope is used for evaluating and reconstructing the orbital floor.
Endoscope is inserted through a bony window in the lateral maxilla to examine the status of the
floor.
Reconstruction can be done by insertion of a materials like bone, metallic mesh, or porous
polyethylene into the orbital defect

97. External Approach to the Internal Orbit
lower eyelid approach (subciliary, subtarsal, or
transconjunctival)is used.
Gently elevates the periorbita along the floor of the orbit
and follow the contour of the rim to prevent perforation
of the periorbital.
Periorbital dissection should follow from sound bone
toward the fractured areas
malleable retractor is used for protection of the periorbita
and globe.
The area of disrupted orbit may be a crack along the floor
or severely comminuted floor and walls

98. Continue dissection posteriorly along the orbital floor and medial
wall until sound bone is found.
In cases if defect is a narrow linear groove: no reconstruction
required
In case of large defect and disrupted periorbital: reconstruction of
the internal orbit is necessary

99. Bone has been used extensively for many years with excellent results
and is often chosen when the orbital defect is large.
Donor sites:
iliac crest(MOST COMMON)
split ribs
anterior surface of the opposite maxilla
buccal or lingual cortex of the mandible
calvarium(1980-2000)

100. Disadvantages:
bone resorption
donor site morbidity
increased operative time involved in graft harvesting and carving.
calvarial bone grafts are difficult to shape and are brittle.
These factors led to the development and acceptance of alloplastic
substitutes.

101. alloplastic materials:
Complications:
infection, extrusion, and implant displacement.
Morrison et al reported failure rate of 13% in implanted silicon.
when used in small defects and properly stabilized, silicone, Teflon
have proven useful.

102. Bioresorbable products: such as gelatin film and polydioxanone or
polyglactin plates,
Advantages:
provide the necessary support to orbital tissue
minimizing the chance of late reactions.
Disadvantage:
Not stiff enough to use in large defects

103. Metallic mesh has become popular for orbital reconstruction in
recent years.
Advantages:
conform to the desired contours
stiff enough to maintain adequate support of the periorbital tissue
it is extremely thin.
readily visible on postoperative CT scans.

104. Principals for implant placement:
The size of the implant or transplant:
Sufficient size to cover the whole defect and supported along most
margins by sound bone.
The most common error is leaving the posterior edge unsupported.
Ensure posterior limit by dissecting toward the apex if not able to
confirm make sure that material must be well supported laterally
and medially.

105. The thickness of the implant or transplant:
Determined by the flexibility of the material.
If flexible, a thicker piece is necessary for reconstructing a large defect without
allowing sagging of the periorbital soft tissue into the sinus
The volume of the implant or transplant.
In case of enopatholmos extra volume of implantfor reestablishing the former
position of the floor and walls.
The added bulk should be posterior to the axis of the globe to displace it
anteriorly.

106. Tension-free placement of the implant or transplant:
If the implant too large implant has tendency to bend when placed.
To prevent this implant must be passive when inserted into the wound.
Stabilization of the implant or transplant.
To prevent displacement implant can be secured with sutures, wires, or bone
screws.
it should be placed behind the rim, with the rim acting as a physical impediment
to anterior migration.
Stabilization with bone screws and/or bone plates will prevent migration

107. Vertical shortening of the lower lid following
healing.
•Occurs as a result of scarring between the
tarsal plate and periosteum, shortening the
orbital septum.
• Frost suture - in which a suture is placed
through the dermal surface of the lower lid
just inferior to the gray line and is taped to
the forehead .
complications

108. Ectropion, or an outward curl to the lower eyelid
Contracture of the lower eyelid and the resultant scleral
show
Mild - slight lifting of the lid from the globe.
Moderate - lifting of the lid from the globe and a
shortening of the vertical height of the lower eyelid.
Severe- combination of shortening of the eyelid and true
eversion of the eyelid, not just a lifting away
Mild and moderate ectropion usually resolve with the
passage of time and with gentle massage of the lid.
Severe ectropion may require surgical correction.

109. Implant Extrusion, Displacement, And Infection
When the implants become displaced or extruded,
they should be removed
It is usually not necessary to place another at the time
of surgery
If enophthalmos or ptosis occurs, reconstruction of
the internal orbit can be undertaken secondarily

110. PERSISTENT DIPLOPIA
Muscle entrapment is the cause of diplopia but such entrapment should
be apparent with the use of a forced duction test.
The cause of persistent diplopia is not known, but it has been thought to
◦ Result from scar contracture ,
◦ Adhesions in ocular muscles or between them and other structures
◦ Neural injuries from the trauma
Refer to an ophthalmologist for evaluation and possible treatment with
exercises and/or surgery.

111. ENOPHTHALMOS
Causes:
◦ Decrease in volume of the orbital contents,
◦ Increase in volume of the bony orbit,
◦ Loss of ligament support,
◦ Scar contracture,
◦ Combination of these.
The goal of surgery is to reduce orbital volume by reconstructing
the internal orbit and, if necessary, placing a space-occupying
material behind the globe, thus displacing the globe anteriorly.

112. BLINDNESS
Incidence of postoperative retrobulbar hemorrhage and
blindness following treatment of zygomatic fractures is
0.3%.
◦Direct damage to the optic nerve
◦Osseous compression,
◦Laceration of the nerve, or
◦Hemorrhage into the nerve itself.
◦Retrobulbar hemorrhage

113. Retrobulbar hematoma
Signs and symptoms of retrobulbar hematoma include
◦ Tense proptosis (exophthalmos),
◦ Periorbital swelling that may be in the process of
increasing in size
◦ Retroorbital pain,
◦ Dilation of the pupil
Most ophthalmologists treat them conservatively with
the
◦ Application of ice,
◦ Sedatives,
◦ Bed rest,
◦ Diuretics, such as intravenous mannitol

114. MALUNION OF THE ZYGOMA
The signs and symptoms are the same as those seen in a patient
with a fresh zygomatic fracture, including
◦ Flattening of the malar prominence,
◦ Enophthalmos,
◦ Altered pupillary level,
◦ Limitation of mandibular motion.
Treatment alternatives—
◦ Camouflaging the defect with an implant or transplant or
◦ Repositioning the malpositioned bone.

115. CONCLUSION
Face is the most prominent and expressive part of human body and adds to well
being of a personality.
Maxillofacial region is vulnerable various injuries due to variety of external
causative factors.
Zygomatic complex forms key to structure of anterolateral surface of face.
The importance of zygomatic complex in facial skeleton lies in protecting globe
of eye and absorbing and redistributing masticatory and external load.

116. THANK YOU