1. Dr.Hanan Shanab

2.  The zygomaticomaxillary
complex (ZMC) plays a key
role in the structure, function,
and aesthetic appearance of
the facial skeleton.
 It provides normal cheek
contour and separates the
orbital contents from the
temporal fossa and the
maxillary sinus.
 It also has a role in vision and
mastication.

3. ANATOMY
•The zygomaticomaxillary complex is a
quadrupled structure,
•It relates to 4 different bones:
•Temporal bone,,by
zygomaticotemporal
suture.
•maxilla,,by
zygomaticomaxillary
suture.
•frontal bone,,by
frontozygomatic suture.
•skull base,,by
zygomaticosphenoidal
suture.

4. A zygomatic complex fracture is a fracture that involves the
zygoma and its surrounding bones. The typical lines of a
zygomatic complex fracture are:

5. At least 3 points of fixation in order to achieve a good
anatomical reduction of ZMC Fx

6. Facial Buttress system
•The buttresses represent areas
of relative increased bone
thickness that support the
functional units of the face
(muscles, eyes, dental occlusion)
in an optimal relation.
From :Stanley RB. Maxillary and Periorbital Fractures. In :Bailey BJ ed., Head and Neck Surgery-Otolaryngology, third edition, Philadelphia, Lippincott Williams
& Wilkins 2001, pg 777.

7. •define the form of the face by
projecting the overlying soft-
tissue envelope.
• Owing to the reliance of facial
form and function on these
buttresses, as well as the
mechanical force exerted on
them

8. Facial buttress
 Buttresses have sufficient bone thickness to
accommodate metal screw fixation.
 Buttresses are all linked either directly or through
another buttress to the cranium or cranial base as a
stable reference point.

9. Some authors describe the zygomaticomaxillary and
zygomaticosphenoidal suture lines as a single unit. Using this
definition, ZMC fractures are called tripod fractures. However,
the term tetrapod fracture is a more accurate description
because 4 suture lines are disrupted.

10. The frontozygomatic and zygomaticosphenoidal
buttresses are very strong. Isolated injuries in these
areas are uncommon. When displaced fractures are
noted, a high velocity injury with other associated
fractures is likely.

11. •The inferior orbital rim is a
common location for
displaced and comminuted
fractures. These injuries
can be isolated, but they
are often associated with
orbital floor fractures.

12. •Isolated injuries often
occur in the zygomatic
arch because of its length
and unprotected location.

13. ZMC Fracture involves:
Lateral orbital wall (zygomaticofrontal region). Infraorbital rim.
Zygomatic buttress. Isolated zygomatic arch

14. Frequency of ZMC Fracture
 A much higher percentage of zygomaticomaxillary
complex (ZMC) fractures occur in males (80%) than in
females (20%).
 Incidence of ZMC fractures peaks in persons aged 20-
30 years.
 Women who have been domestically abused are
more likely to suffer ZMC fractures and orbital blow-
out fractures.

15. Etiology
 Assault (age 18-25y/o)
 RTA, MVA
 Gunshot wounds
 Sports..
 Falls..
 Industrial accidents
 War and civil disorder.

16. Associated Injuries
Haug et al 1990
(402 patients with midfacial trauma)
 with Zygoma fractures:
 Lacerations 43%
 Orthopedic injuries 32%
 Additional facial fractures 22%
 Neurologic injury 27%
 Pulmonary, abdominal, cardiac 7%, 4.1%, 1%

17.  Maxillary fractures:
 Lacerations and abrasions 75%
 Orthopedic injury 51%
 Other facial fractures 42%
 Neurologic injury 51%
 Pulmonary 13%, abdominal 5.7%,
cardiac 3.8%

18. Ocular injury
Al-Qurainy et al 1991
 363 patients with midface fractures
63 - 90.6% of patients had ocular injury

19. Classification
 Zingg (1992) separates these injuries into types A, B, and
C.
 Type A injuries are isolated to one component of the
tetrapod structure,
 zygomatic arch (type A1),
 the lateral orbital wall (type A2), and
 the inferior orbital rim (type A3).
 Type B fractures involve all 4 buttresses (ie, classic
tetrapod fracture).
 Type C injuries are complex fractures with comminution
of the zygomatic bone itself.

20. LeFort fractures
 Rene LeFort 1901 in cadaver skulls
 Frequently different levels on either side
 LeFort I
 LeFort II
 LeFort III

21. LeFort fractures
Le Fort I Le Fort II Le Fort III

22. Assessment
 The initial evaluation of facial trauma patients is focused on
areas that can result in the greatest morbidity.
 Airway control and hemodynamic stability are the primary
concerns.
 Next, spinal cord injury must be ruled out by a thorough
clinical and/or radiological examination.
 Finally, any overt globe injury should be evaluated.

23.  Often midface fracture patients are admitted to the hospital
unconscious and intubated. Special regard has to be given
to foreign bodies obstructing the airways such as dislocated
partial or full dentures or teeth fragments

24.  As well as hard-tissue considerations, severe bleeding
and/or cerebrospinal fluid (CSF) leakage may accompany
and aggravate the treatment outcome.

25. General considerations
 To clinically evaluate possible midfacial injuries a standard
examination protocol is strongly recommended and has to
include full examination of the head, eyes, ears, nose,
throat, and neck.

26. Eye examination

27. Ophthalmic evaluation..
•Globe integrity.
•Occular motility.
•Visual acuity and light
perception.

28. Retrobulbar hemorhage:
Signs and Symptoms:
•non-pulsating exophthalmous
with resistance to retropulsion.
•elevated IOP.
•EOM restriction.

29. • Central retinal artery pulsation (indicating a possible
impending central retinal artery occlusion),
• choroidal folds, and possibly signs of optic
neuropathy.

30. Management
 medically lower the patients IOP.
 Immediate surgical consult for a lateral canthotomy
and cantholysis to reduce orbital pressure.
 An emergent orbital decompression.

31. Signs and symptoms of
ZMC fractures:
•Bilateral periorbital
ecchymosis is termed Owl’s
sign and typically is
representative of a Le Fort II
or III fracture.
•pain, edema, and
ecchymosis of the cheek
and eyelids.

32. Clinical Findings
Physical findings such as
severe conjunctival
hemorrhage or hyphema
are suggestive of direct
globe injury, rupture, and
visual loss.

33. Clinical Findings
• Fractures of the zygomatic
bone evoke pain on
palpation in 70% of
patients.
• Significant malar
depression
• Step deformity

34. •Orbital floor disruption can result in
subcutaneous emphysema and
ecchymosis.
• (enophthalmos) globe
displacement.

35. Epistaxis on the side of the fracture
due to blood draining from involved
maxillary sinus.

36. Evaluation
 initial documentation
 Hess screen field of binocular
vision.
 forced duction test under
sedation, local, or general
anesthesia.
 Electromyography
 orbital CT scan

37. Diplopia
Mechanisms
There are three principal
mechanisms causing diplopia
in trauma cases
1- Edema and hematoma
2- Restrictive motility disorder
(mechanical)
3- Cranial nerve injury
(neurogenic)

38. Management of diplopia
 Conservative treatment
 Motility exercises.
 patching.
 prisms.

39.  SURGICAL:
 Bone repair 6-12 months
 Muscles surgery .
 Botulinum toxin.

40. Trismus
 The traumatic force and pull of the masseter muscle may result in
medial, inferior, and posterior rotation of the zygoma result in:
• Compression of the zygomatic arch on the temporalis muscle and
coronoid process result in trismus

41. Pseudoptosis
Inferior displacement of the lateral
canthal angle may indicate inferior
migration of the fractured zygomatic
bone.

42. Guerin’s Sign:
Guerin's sign is characterised by
ecchymosis in the region of greater
palatine vessels

43. Nerve injury
Facial trauma is associated
with an increased risk of
optic nerve injury and
visual loss.
According to Al-Qurainy et al.

44. The mechanisms of trauma
Ocular globe.
1- Rupture
2- Intraocular hemarrhage
Optic never
1- Edema
2- Bleeding
3-Vasospasm

45. Visual function impairment
Orbit
1- Retrobulbar hematoma
2- Blow in fracture
Optic canal
1- Shearing of nerve
2- Contusion
3- Bone fragment injury

46. Infraorbital nerve injury
may result in anesthesia
or paresthesias of the
cheek, nose, upper lip,
and lower eyelid.

47. Radiographic
Studies
 1- Plane Films:
 Water’s view : (occipitomental view
)

48. Submental vertex view:
 Fractured zygomatic
arch (M).
 Rotation of zygoma
around vertical axis.

49. Lines of Dolan and the
elephants of Rogers 1-orbital line.
2-zygomatic line.
3-maxillary line.

50. McGrigor and Campbells’ lines
McGrigor’s line 1
McGrigor’s line 2
McGrigor’s line 3
Campbell’s line 4
Campbell’s line 5

51.  2- CT scan:
Axial and coronal view & 3D
Areas of fracture are camouflaged by the
overlying soft tissues. However, this CT scan
nicely shows contour differences between
different parts of the face.

52. MRI
MRI might be indicated to better detect soft-
tissue problems such as:
* Optic nerve edema or hematoma
* Ocular muscle disorders (incarceration,
hematoma, disruption)
* Intraocular disorders (hematoma)
* Foreign bodies in the orbit

53. Treatment modalities
Most maxillofacial injuries involve
extensive soft tissue violation.
Adequate tetanus vaccination
and coverage with oral or
intravenous broad spectrum
antibiotics is the rule.

54.  Any associated life
threatening injuries must
be addressed first.
 TIMING:
 As early as possible
unless there are
ophthalmic, cranial or
medical complications
 Until the edema to
decrease.

55. Treatment modalities
 Restore pre-injury facial
configuration
 Prevent cosmetic deformity and
visual disturbances.
 Closed Vs. ORIF with plating
and screws.
 Soft diet and malar protection.
 Possible need for bone grafting.
 Soft tissue injury.

56. Surgical approaches
2-For Orbital Rim Fracture.
Infraorbital approach.
Subciliary incision.
Transcongunctival Approach.
3-For the fractured Maxillary Buttress
Gingival buccal sulcus approach. (transoral
approach).
1-For ZF Frcature.
Lateral eyebrow approach.
Upper blepharoplasty incision.

57. 4-For Isolated Zygomatic Arch Fractrue.
 Extraoral Approach:
 Gillie’s Approach.
 Dingman Approach.
 Intraoral Approach:
 Keen Approach( lateral vestibular approach).
5-For comminuted Fracture.
Coronal approach.

58.  Correct anatomical reduction is required to reproduce
the original structure of the zygomaticomaxillary
complex and the proper alignment of the orbital walls.
In order to achieve proper reduction of the lateral
orbital wall the greater wing of the sphenoid and the
zygoma must be properly aligned.
 The aim is to restore the proper orbital volume and to
restore proper width, AP projection, and height of the
midface.
GENERAL CONSEDERATION

59. One must consider 2 needs in analyzing a ZMC Fx:
 Need to expose a particular Fx site for confirmation of
alignment.
 Need to expose a particular Fx site for application of
fixation.

60. Plate Fixation
The first two screws should be placed
in the plate holes closest to the
fracture, one on each side of the
fracture. Make sure that the fracture is
adequately spanned so that each
screw is placed in solid bone.

61. Approaches to
Infraorbital
Rim •Transcongunctival approach.
• Subciliary incision.
•Infraorbital approach.

62. Approaches to Infraorbital
Rim
*Transconjunctival Approach. *Subciliary approach.
*Lower lid Approach. *Infraorbital approach.

64. Transcongunctival Approach
 Retroseptal
method:
In this method an
incision is sited
2mm below the
tarsal plate to
reach the orbital
rim.

65.  Preseptal method: In this
method incision is made
at the edge of the tarsal
plate to create a space
infront of the orbital
septum to reach the
orbital rim.

66. Tranconjunctival approaches
 is that they produce excellent cosmetic results
 no skin or muscle dissection is necessary.
Advantage:

67.  limited medial extension by the lacrimal drainage
system.
Disadvantage:

68. TECHNIQUE
•Protection of the globe.
•Tarsorrhaphy.
•Lateral Canthotomy
and Inferior
Cantholysis.

70.  Transconjunctival
Incision

71. Subperiosteal Orbital Dissection
Periosteal elevators are used to strip
the periosteum over the orbital rim and
anterior surface of the maxilla and
zygoma, and orbital floor.
A broad malleable retractor should be
placed as soon as feasible to protect the
orbit and to confine any herniating
periorbital fat.

72. Suturing
1- A running 6-0 gut suture is
initially placed through the
conjunctiva (and lower lid
retractors).
2-A 4-0 polyglactin or other long lasting suture
for the canthopexy.
The bulk of the lateral canthal tendon
attaches to the orbital tubercle, 3 to 4 mm
posterior and superior to the orbital margin.
3-Finally, subcutaneous
sutures and 6-0 skin suture
are placed along the
horizontal lateral
canthotomy.

73. Subciliary Approach
1
2
1
•2nd Incision:
•periorbital fat to
herniate into the wound.
•The skin and muscle
flap, maintains a better
blood supply to the skin,
and pigmentation of the
lower lid has not been
seen.
3
1•1ST Incision:
•"buttonhole" dehiscence.
•slight darkening of the skin in this
area after healing.
• An increase in the incidence of
ectropion has also been noted by
some investigators with this
approach.
3rd Incision:
•the pretarsal fibers of the
orbicularis oculi can be kept
attached to the tarsal plate,
presumably assisting in
maintaninig the position of
the eyelid and its contact
with the globe
postoperatively.

74. Technique

75. Technique

77. Materials used for Reconstruction

78.  Avoid risk of infected implant.
✘ Additional operative time.
✘ donor site morbidity .
✘ Graft resorption.
 Examples:
Calvarial bone, iliac crest, rib, septal or auricular cartilage
AutogenousTissues

79. Alloplastic implants
 Decreased operative time,
 easily available,
 no donor site morbidity,
 can provide stable support
✘Risk of infection 0.4-7%.
✘invisible on postoperative radiological
imaging.
Examples:
Gelfilm, polygalactin film, silastic, marlex mesh, teflon,
prolene, polyethylene, titanium

80.  Ellis andTan 2003
 58 patients, compared titanium
mesh with cranial bone graft
 Used postoperative CT to assess
adequacy of reconstruction
 Titanium mesh group subjectively
had more accurate reconstruction

81. Approaches to
ZF Suture

82. Approaches to ZF suture
 Upper eye lid
Approach.
 Lateral Brow
Approach.
 Hemicoronal
Approach.

83. Extended Subciliary Approach
Technique used to obtain increased exposure of the lateral orbital rim.The
initial incision is extended laterally 1 to 1,5 cm, and supraperiosteal dissection
along the lateral orbital rim proceeds

84.  Upper eye lid composed of:
1-Skin.
2-Orbicularis Oculi muscle.
3-Orbital Septum/Levator
Aponeurosis Complex.
4-Müller's Muscle/Tarsus
Complex.
5-Congunctiva.

85.  also called upper
blepharoplasty, upper
eyelid crease, and
supratarsal fold
approach.
Upper eye lid Approach

86. Upper eye lid Approach
 Technique:
1-globe protection.
2-Identification of and marking
Incision Line.
3-incision.
4-Disection
5-closure.

87.  Technique:
1-Vasoconstriction.
2-Skin Incision.
3-Periosteal Incision.
4-Subperiosteal Dissection
of Lateral Orbital Rim
and Lateral Orbit.
5. Closure.
Lateral eye brow Approach

88. Lateral eye brow Approach
 Technique:
1-Vasoconstriction.
2-Skin Incision.
3-Periosteal Incision.
4-Subperiosteal Dissection
of Lateral Orbital Rim
and Lateral Orbit.
5. Closure.

89. Lateral eye brow
Approach
•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.
Advantage:

90. •extremely limited access.
•Occasionally, some hair loss occurs, making the scar perceptible.
•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.
Disadvantage:
Lateral eye brow
Approach

91. Zygomatic
Buttress Fracture

92. Zygomatic Buttress Fracture
Gingival Buccal Sulcus
Incision
 The transoral approach was
popularized by Keen in 1909
with later modifications by
Goldthwaite and Quinn.

93. Advantages :
 avoiding any skin incision
 avoiding any visible scaring.
 Allow for minimal dissection and
an excellent vector for reduction.

94. Disadvantage:
✘ they may result in
increased rates of infection
by introducing oral flora
into the infratemporal
fossa.

95. Approach
 Reduction by inserting a bone
screw (Carroll-Girard screw) after
drilling a small hole .
By using a hook.
By making 3 mm incision in the cheek
directly over the inferior tubercle of
malar eminence with a blade.
Subperiosteum dissection over the
zygoma body.

96. Isolated Zygomatic
Arach Frcature

97. Isolated Zygomatic Arach
Frcature
Closed Reduction:
1-Extraoral Approach:
 Gillie’s Approach.
 Dingman Approach.
2-Intraoral Approach:
 Keen Approach( lateral
vestibular approach).
3- percutaneous method.

98. Isolated Zygomatic Arach
Frcature
 Open Reduction and
Internal Fixation:
Periauricular Approach.

99. Extraoral Approach
1-Gillies Approach.
 Gillies et al described
the temporal fossa
approach in 1927.
 By using a Rowe
zygoma elevator

100. Technique
•A temporal incision is
made. Care is taken to
avoid the superficial
temporal artery.
•The Gillies technique
describes a temporal
incision (2 cm in length),
made 2.5 cm superior
and anterior to the helix,
within the hairline.

101. •An instrument is inserted
deep over the temporalis
muscle. Using a back-and-
forth motion the instrument is
advanced until it is medial to
the depressed zygomatic
arch.
A Rowe zygomatic
elevator is inserted just
deep to the depressed
zygomatic arch and an
outward force is applied.

102.  Advantage:
 Minimal dissection.
 Save time.
 Disadvantage:
✘ significant scar alopecia.
✘ temporal hollowing.
✘ remote chance of injury to the temporal branch of facial
nerve.

103. Extraoral Approach
2- Dingman Approach
 Dingman and Native described the supraorbital
approach as an extraoral alternative in 1964.
 It involves an incision near the ZF suture with
dissection beneath the temporal fascia and place
an elevator along the fronatl process of the
zygoma and underneath the zygomatic arch .

104. Intraoral Approach
•Insert an elevator shortly
under the malar eminence .
•Care should be taken not to
inter the the orbit or
Keen Approach.1909
through
zygomaticomaxillary
incision.

105. Percutaneous Methods
Hwang and Lee in 1999
 less invasive.
 These include the using of a towel clip
to directly grasp the bone fragments
and allow for lateral force to be applied.

106. Towel Clip Method
Advantages:
 Quick, simple, and effective
technique.
 It is minimally invasive,
 Carries little risk of infection
or neurovascular injury.

107.  No visible scarring.
 This technique may be
performed under local
anesthesia or sedation in an
emergency department or
clinic setting, making it a
highly cost effective.
addition to the oral and
maxillo- facial surgeon’s
armamentarium.

108.  Disadvantages :
✘ include a lack of direct
visualization of the bony
insult.
✘ imprecise reduction.
✘ lack of fracture
stabilization.

109. Open Reduction &Internal
Fixation

110. Open Reduction &Internal
Fixation

112. Bicoronal Approach
 surgical approach to the upper
and middle regions of the facial
skeleton, including the zygomatic
arch.
 It provides excellent access to
these areas with minimal
complications and scar.

113. Skin Layer
•S = skin
•C = subcutaneous tissue
•A = aponeurosis and muscle
•L = loose areolar tissue
•P = pericranium (periosteum)

114. Anatomical Relation

115. A thick layer arises from the
superior temporal line, where it
fuses with the pericranium .
 At the level of the superior
orbital rim, the temporalis fascia
splitts into the superficial & deep
layer.
Temporalis Fascia
Superficial Temporal Fat Pad
Buccal Fat Pad

116. Temporal Branch of
Facial Nerve

117. TECHNIQUE

118. TECHNIQUE

122. Conclusions
 High index of suspicion for associated injuries- especially ocular
 Assessment of buttress system.
 Wide exposure via cosmetically acceptable incisions
 Open reduction and Rigid fixation with plates and screws.
 Soft tissue resuspension.
 With early, accurate repair of these injuries more patients will be
returned to their pretraumatic state.

123. THANKYOU
THANK YOU