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SEMINAR

FRACTURES OF THE ZYGOMATICOMAXILLARY COMPLEX

PRESENTED BYDR PRATIK S

HANDE

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#

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INTRODUCTION

ANATOMY OF THE ZYGOMA BONE

CLASSIFICATION OF THE ZMC #

RADIOGRAPHIC TECHNIQUES

SURGICAL APPROACHES TO ZMC#

COMPLICATIONS

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SHAPE

ARTICULATIONS WITH FACIAL BONES

ANATOMY

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MUSCLE ATTACHMENTS

Z M

Z m L L

S L A

O

BUCCINATOR

MASSETER

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WHY ZYGOMATICOMAXILLA

RY COMPLEX FRACTURE???

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CLASSIFICATION

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ROWE AND WILLIAM’S

1) FRACTURES STABLE AFTER ELEVATION

A. ARCH ONLY(MEDIALLY DISPLACED)

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MEDIAL ROTATION LATERAL ROTATION

1) FRACTURES STABLE AFTER ELEVATION

B. ROTATION AROUND VERTICAL AXIS

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2) FRACTURES UN STABLE AFTER ELEVATION

A. ARCH ONLY(INFERIORLY DISPLACED)

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2. FRACTURE UNSTABLE AFTER ELEVATION

B. ROTATION AROUND HORIZONTAL AXIS.

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2. FRACTURES UNSTABLE AFTER ELEVATION

C. DISLOCATION EN BLOC

INFERIOR MEDIAL POSTEROLATERAL

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LARSEN AND THOMPSONGROUP A: STABLE FRACTURE- SHOWING MINIMUM OR NO

DISPLACEMENT, REQUIRES NO TREATMENT.

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GROUP B: UNSTABLE FRACTURE- GREAT DISPLACEMENT & DISRUPTION OF F-Z SUTURE & COMMINUTED #, REQUIRES REDUCTION AND FIXATION.

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GROUP C: STABLE FRACTURES – TYPES OF ZYGOMATIC FRACTURES WHICH REQUIRES REDUCTION BUT NO FIXATION.

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THE CLASSIFICATION PROPOSED BY KNIGHT AND NORTH IS EASY TO USE AND PRACTICAL.

THEY CLASSIFIED ZYGOMATIC FRACTURES INTO 6 GROUPS.

GROUP I: NON-DISPLACED FRACTURES

GROUP II: ISOLATED ARCH FRACTURES

GROUP III: UNROTATED BODY FRACTURES

GROUP IV: MEDIALLY ROTATED BODY FRACTURES

GROUP V: LATERALLY ROTATED BODY FRACTURES

GROUP VI: COMPLEX (COMMINUTED) FRACTURES. J ORAL MAXILLO-FACIAL SURGERY 66:1378-1382, 2008

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FRACTURES OF ZYGOMATIC ARCH NOT INVOLVING ORBIT

-MINIMUM OR NO DISPLACEMENT

-V – TYPE FRACTURES

-COMMINUTED FRACTURES

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1. FRACTURES THAT ARE STABLE FOLLOWING CLOSED REDUCTION.

A. UNDISPLACED FRACTURE

B. FRACTURES ROTATED MEDIALLY.

2. FRACTURES THAT ARE LATERALLY DISPLACED AND / OR COMMINUTED AND LESS STABLE BY CLOSED REDUCTION. PETER WARD BOOTH- MAXILLOFACIAL SURGERY PG 127

DINGMAN’S CLASSIFICATION OF ZYGOMA FRACTURE

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0: INTACT

1: UNDISPLACED (ANY SITE)

2: ZYGOMATIC ARCH ONLY

3: TRIPOD F-Z SUTURE UNDISTRACTED

4: TRIPOD F-Z SUTURE DISTRACTED

5: PURE BLOW-OUT

6: ORBITAL RIM ONLY

7: COMMINUTED--OTHER THAN ABOVE

HENDERSON’S CLASSIFICATION OF MALAR FRACTURE

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0: INTACT

1: UNDISPLACED (ANY SITE)

2: ZYGOMATIC ARCH ONLY

3: TRIPOD F Z SUTURE UNDISTRACTED

4: TRIPOD F Z SUTURE DISTRACTED

5: TRIPOD BLOW-OUT OF ORBIT

6: PURE BLOW-OUT

7: ORBITAL RIM ONLY

8: ORBITAL BLOW-OUT WITH ORBITAL RIM FRACTURE ONLY

9: COMMINUTED-OTHER THAN ABOVE

MODIFIED CLASSIFICATION USED IN WALTON HOSPITAL

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BASED ON ANATOMIC POINTS AND DIVIDES FRACTURES INTO 3 CATEGORIES:

CATEGORY A ISOLATED # OF 1 OF THE 3 PROCESSES OF ZYGOMATIC BONE. THESE PROCESSES ARE THE TEMPORAL PROCESS, WHICH FORMS ZYGOMATIC ARCH (A1), FRONTAL PROCESS, WHICH FORMS LATERAL ORBITAL WALL (A2), & MAXILLARY PROCESS, WHICH FORMS INFRAORBITAL RIM (A3).

ZINGG CLASSIFICATION SYSTEM

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CATEGORY B: # OF ALL 3 PROCESSES, DETACHING ZYGOMATIC BONE FROM FACIAL SKELETON. i.e. CLASSIC TRIPOD #, BUT ANATOMICALLY THESE # ARE ACTUALLY TETRAPOD, BECAUSE FRONTAL PROCESS OF ZYGOMA ALSO COMMUNICATES WITH GREATER WING OF THE SPHENOID IN ORBITAL CAVITY, WHICH ALSO REQUIRES TO BE DISRUPTED TO TECHNICALLY RENDER ZYGOMA FREE. CATEGORY C: SAME AS TYPE B, BUT WITH FRAGMENTATION, INCLUDING THE BODY OF ZYGOMA.

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MANSON ET AL CLASSIFICATION

LOW ENERGY

MEDIUM ENERGY

HIGH ENERGY

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ZYGOMATIC ARCH FRACTURESCLASSIFICATION(OZYAZGAN-2007)1)ISOLATED ZYGOMATIC ARCH FRACTURES(TYPE 1)

A)DUAL FRACTURE B)MORE THAN 2 FRACTURES -V-SHAPED FRACTURES -DISPLACED

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CONTD2) COMBINED ZYGOMATIC ARCH FRACTURES(TYPE

2) A) SINGLE B) PLURAL FRACTURES -REDUCED -DISPLACED

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INVOLVED FACIAL HALF

RIGHTDISPLACEMENT >2mm

COMPLEX/DEFECT# >5mm

NO YES

AO cla

ssifi

catio

n sy

stem

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AO/ASIF (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN/ASSOCIATION FOR STUDY OF INTERNAL FIXATION) SCHEME

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LATERAL MIDFACIAL/CRANIOFACIAL #

TYPE A/B/C: GROUPS, SUBGROUPS & SPECIFICATIONSTYPE A/B/C: NONDISPLACED/DISPLACED/COMPLEX-DEFECT #

1. GROUP: ISOLATED INVOLVEMENT OF A SINGLE UNIT 1.1. LOWER MIDFACIAL # (UNIT I)

1.2. UPPER MIDFACIAL # (UNIT II) WITH FURTHER CATEGORIES: 1.2.1. INVOLVEMENT OF A SINGLE BUTTRESS (E.G. ZYGOMATIC ARCH) 1.2.2. INVOLVEMENT OF TWO BUTTRESSES (E.G. Z-M & PT-M BUTTRESSES) 1.2.3. INVOLVEMENT OF THREE BUTTRESSES (E.G. “TRIPOD” #) 1.2.4. INVOLVEMENT OF FOUR BUTTRESSES (Z ARCH/F-Z, Z-M & PT-M BUTTRESSES) 1.2.5. ISOLATED INVOLVEMENT OF ORBITAL FLOOR (E.G. BLOW-OUT #) OR I-O RIM

1.3. CRANIOBASAL # (UNIT III),ISOLATED INVOLVEMENT OF CRANIOBASAL FACIAL UNIT (UNIT III) (E.G. ISOLATED # OF S-O RIM WITH ORBITAL ROOF EXTENSION)

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2. GROUP: COMBINED # OF LOWER (I) & UPPER (II) MIDFACE &/OR CRANIOBASAL- FACIAL UNIT (III) WITHOUT INVOLVEMENT OF SKULL BASE

2.1. COMPLETE MIDFACIAL # (I + II) (E.G. Z-M # WITH INVOLVEMENT OF ALVEOLAR

PROCESS)

2.2. HIGH CRANIOFACIAL # (II + III—F-T CALVARIUM), UPPER MIDFACIAL # TOGETHER WITH A CALVARIAL COMPONENT OF CRANIOBASAL-FACIAL UNIT & WITHOUT SKULL-BASE EXTENSION (E.G. HIGH ZYGOMATIC # WITH INVOLVEMENT OF ADJACENT F-T CALVARIUM)

2.3. COMPLETE CRANIOFACIAL # (I + II + III—F-T CALVARIUM), COMBINED # OF LOWER & UPPER MIDFACE TOGETHER WITH CALVARIAL COMPONENT OF CRANIOBASAL-FACIAL UNIT & WITHOUT SKULL-BASE EXTENSION (E.G. COMPLETE Z-M # WITH EXTENSION TO ALVEOLAR PROCESS & F-T CALVARIUM)

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3. GROUP: COMBINED # OF LOWER (I) & UPPER (II) MIDFACE &/OR CRANIOBASAL- FACIAL UNIT (III) WITH INVOLVEMENT OF SKULL BASE

3.1. HIGH C-F/CRANIOBASAL & (II + III-SKULL BASE), UPPER MIDFACIAL & CRANIOBASAL-FACIAL # INCLUDING SKULL-BASE EXTENSION (E.G. HIGH ZYGOMATIC # WITH INVOLVEMENT OF ORBITAL ROOF)

3.2. COMPLETE C-F/FRONTOBASAL # (I + II + III-FRONTOBASAL), LOWER & UPPER MIDFACIAL # WITH FRONTOBASAL EXTENSION OF CRANIOBASAL-FACIAL UNIT (E.G. COMPLETE Z-M # WITH INVOLVEMENT OF ALVEOLAR PROCESS $ FRONTOBASAL EXTENSION)

3.3. COMPLETE C-F/FRONTOLATEROBASAL # (I + II + III- FRONTOLATEROBASAL), COMBINED # OF LOWER & UPPER MIDFACE TOGETHER WITH FRONTOBASAL &/OR LATEROBASAL EXTENSION OF CRANIOBASAL- FACIAL UNIT (E.G. COMPLETE Z-M # WITH EXTENSION TO ALVEOLAR PROCESS & FRONTOBASAL & LATEROBASAL REGION UP TO PETROUS PART OF TEMPORAL BONE)

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GROUP A1

• A1.1: CAUDAL MIDFACE UNIT

• A1.2: CRANIAL MIDFACE UNIT

• A1.3: CRANIOBASAL FACIAL UNIT

GROUP A2

• A2.1: I+II• A2.2:

II+III(CALOTTE F-T)

• A2.3:I+II+III(CALOTTE F-T)

GROUP A3

• A3.1: II+III(SKULLBASE)

• A3.2: I+II+III(FRONTAL SKULL BASE)

• A3.3: I+II+III(FRONTOLATERAL SKULL BASE)

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DIAGNOSISINSPECTION

PALPATION

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SIGNS AND SYMPTOMS

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PERIORBITAL ECCHYMOSIS AND EDEMA

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FLATTENING OF THE MALAR PROMINENCE

FLATTENING OVER THE ZYGOMATIC ARCH

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PAIN

ECCHYMOSIS OF THE MAXILLARY BUCCAL SULCUS

DEFORMITY AT THE ZYGOMATIC BUTTRESS OF THE MAXILLA

DEFORMITY OF THE ORBITAL MARGIN

ABNORMAL NERVE SENSIBILITY

EPISTAXIS

CREPITATION FROM AIR EMPHYSEMA

DISPLACEMENT OF THE PALPEBRAL FISSURE

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TRISMUS

SUBCONJUNCTIVAL ECCHYMOSIS

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UNEQUAL PUPILLARY LEVELS

DIPLOPIA

ENOPHTHALMOS

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RADIOLOGIC EVALUATION

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WATER’S VIEW

DEMONSTRATES ATTACHMENTS OF ZYGOMA TO ZYGOMATICO FRONTAL SUTURE, INFRA-ORBITAL RIM AND THE MAXILLARY SINUS

DESCRIBED BY WATERS & WALDRON

ORBITO-MEATAL BASELINEELEVATION SHOULD BE 37 DEGREE.

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ENABLES A BETTER VIEW OF ORBITAL FLOOR, INFRAORBITAL RIM AND THE FZ BONES.JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

(1993~ 21, 120-123)

CENTRAL RAY AIMED AT AN ANGLE OF 10 ° TO 20 ° TO CANTHOMEATAL LINE.

MODIFIED POSTERO-ANTERIOR PROJECTION:

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FOR ZYGOMATIC ARCH FRACTURE

SUBMENTOVERTEX VIEW

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CORONAL CT SCAN

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AXIAL CT SCAN

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THREE-DIMENSIONAL VOLUME RENDERED RECONSTRUCTION

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DVT OFFERS AN ALTERNATIVE TO CT IMAGING REGARDING HIGH-CONTRAST STRUCTURES, RESULTING IN DECREASED RADIATION EXPOSURE OF PATIENTS.

THE LOW LEVEL OF METAL ARTIFACTS IN PRIMARY AND SECONDARY RECONSTRUCTIONS.

EVEN 3D RECONSTRUCTIONS CAN BE GENERATED, WHICH HAVE BEEN DESCRIBED AS BEING OF VALUE FOR EVALUATION OF MIDFACIAL FRACTURES

DISADVANTAGE OF DVT: DURATION OF THE EXAMINATION, MAKING IT SUSCEPTIBLE TO BLURRING.

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M R I (CORONAL)

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A STEREOLITHOGRAPHIC MODEL OF THE 3D CT MODEL

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TREATMENT1. NO TREATMENT

2. INDIRECT REDUCTION WITH

A) NO FIXATION

B) TEMPORARY SUPPORT

C) DIRECT FIXATION

D) INDIRECT FIXATION

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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 GRAFT.

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PRINCIPLES IN THE TREATMENT OF ZMC FRACTURES

PROPHYLACTIC ANTIBIOTICS

ANESTHESIA

CLINICAL EXAMINATION AND FORCED DUCTION TEST

PROTECTION OF THE GLOBE

ANTI-SEPTIC PREPARATION

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FORCED DUCTION TEST

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NONDISPLACED FRACTURES WITHOUT EYE INVOLVEMENT

– ICE PACKS AND ANALGESICS

– DELAYED OPERATIVE CONSIDERATION 5-7 DAYS

– DECONGESTANTS

– BROAD SPECTRUM ANTIBIOTICS – TETANUS

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DUVERNEY (1751) DESCRIBED INTRAORAL & EXTRAORAL MANIPULATION OF BONE FRAGMENTS & IMPORTANCE OF CONTRACTION OF TEMPORALIS IN REALIGNING MEDIALLY DISPLACED Z-ARCH.

FERRIER (1825) ATTEMPTED TO REDUCE ZYGOMA # THRU INCISION ABOVE ARCH.

ROLLAND: APONEUROSIS OF TEMPORAL FASCIA MUST BE CUT TO FACILITATE INTRODUCTION OF SPATULA FOR ELEVATION & REDUCTION OF #ed SEGMENT.

DUPUYTREN (1874): RELATIONSHIP OF TEMPORAL FASCIA & MUSCLE AS A PATHWAY TO Z-BONE & ARCH WHEN TREATING COMPOUND #

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GILLIES ET AL (1927) EMPHASIZED THE COSMETIC VALUE OF PLACING THE INCISION WITHIN THE HAIRLINE.

STROYMEYER (1844): PLACEMENT OF SHARP HOOK BEHIND ARCH THROUGH SKIN WITHOUT INCISION & BRINGING THE FRAGMENTS BACK TO NORMAL POSITION

CHEYNE & BURGHARD (1901) PLACING INCISION ANTERIOR TO MASSETER & INTRODUCING A RASPATORY BENEATH BONE TO LEVER IT BACK TO POSITION, OR PUTTING A HORIZONTAL INCISION OVER ARCH TO EXPOSE # & SECURING IT BY SILVER WIRE.

TREVES (1896): PERFORATE CANINE FOSSA & FORCE THE ANTRAL WALL OUTWARD.

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SHEA (1931) INTRODUCING INSTRUMENT THRU AN INTRANASAL ANTROSTOMY TO ANTRAL ASPECT OF DEPRESSED ZYGOMATIC BONE.

SHEA & ANTHONY (1952) DEVISED ANTRAL BALLOON WHICH WAS INTRODUCED VIA INTRANASAL ANTROSTOMY & FILLED WITH WATER TO DISPLACE # DISLOCATED BONES OF ORBIT BEYOUND NORMAL POSITION REQ 1-5 MIN PRESSURE.

GILL (1928): # SEGMENT ELEVATED BY TRACTION & CALLUS #ed WITH CHISEL & RETAINED & REDUCED IN POSITION BY SILVER WIRE SUTURES.

SMITH & YANAGISAWA(1961): EARLY ATTEMPTS TO CORRECT DISPLACEMENT WERE CONCERNED WITH SEPSIS PREVENTION FOLLOWED LATER BY CONSIDERATION FOR COSMESIS.

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SURGICAL APPROACHES

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TEMPORAL APPROACH

MAXILLARY VESTIBULAR APPROACH

SUPRAORBITAL EYEBROW APPROACH

LOWER EYELID APPROACH -SUB CILIARY & SUBTARSAL

TRANSCONJUNCTIVAL APPROACH

CORONAL APPROACH

PERCUTANEOUS APPROACH

TRANSANTRAL

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GILLIES TECHNIQUE OF ZYGOMA REDUCTION

GILLIES, KILNER & STONE(1927)

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KEEN’S APPROACH (1909)

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UPPER BUCCAL SULCUS APPROACH

TAYLOR MONK PATTERN ELEVATOR

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‘LESS FORCE IS REQUIRED THAN BY EXTRAORAL , AS FORCE IS EXERTED WHERE IT SHOULD BE i.e. MORE AT THE CENTRE OF # SEGMENT.

INCISION AT 1cm AT REFLECTION OF UPPER BUCCAL SULCUS JUST BEHIND Z-BUTTRESS.

MONKS ELEVATOR IS PASSED UPWARDS SUPRAPERIOSTEALLY TO CONTACT INFRATEMPORAL SURFACE OF Z-BONE. UPWARD, FORWARD & OUTWARD PRESSURE IS EXERTED.

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LATERAL CORONOID APPROACH THRU INCISION OVER ANTERIOR BORDER OF RAMUS.

BLUNT DISSECTION IN SUPRAPERIOSTEAL PLANE FOLL LATERAL ASPECT OF CORONOID PROCESS UNTIL MEDIAL ASPECT OF ARCH IS REACHED.

SIUTABLE ELEVATOR IS PLACED & ARCH PALPATED EXTRAORALLY TO RESTORE CONTOUR.

QUINN (1977) MODIFICATION

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TRANSANTRAL APPROACH

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ADVANTAGES: NO VISIBLE SCARRING.USED TO SIMULTANEOUSLY TO TREAT ZMC & ORBITAL BLOW OUT #.RELATIVELY EASY.

INSERTION OF A URETHRAL BALLOON CATHETER INTO MAXILLARY SINUS FOR REDUCTION & MAINTENANCE OF HERNIATED ORBITAL CONTENTS

DISADVANTAGE:NECESSITY TO REMOVE THE CATHETER 2 WEEKS AFTER SURGERY POSSIBILITY OF RECURRENT PROLAPSE OF ORBITAL CONTENT AFTER REMOVING CATHETER. J ORAL MAXILLOFAC SURG 66:2488-2492, 2008

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PERCUTANEOUS APPROACH

INSERTING HOOK THRU SKIN INCISIONREDUCTION BY STRONG OUTWARD TRACTION REPOSITIONING OF MEDIALLY DISPLACED ISOLATEDZ-ARCH #

LOCATING STAB WOUNDINTERSECTION OF PERPENDICULAR LINE DROPPED FROM OUTER CANTHUS OF EYE AND HORIZONTAL LINE FROM ALAR MARGIN OF NOSTRILHOOK INSERTED VERTICALLY & ROTATED IN 90*POINT OF CONTACT SHUD B WID BONE

POTENTIAL COMPLICATIONINSERTION INTO INFERIOR ORBITAL FISSURE

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TRANSCUTANEOUS

CHEEK APPROACHINCISION 3mm IN CHEEK DIRECTLY OVER INF TUBERCLE OF MALAR EMINENCE.CLAMP IS SPREAD IN THE DIRECTION OF FACIAL NERVE TO REACH PERIOSTEUM.CARROLL GIRARD SCREW IS INSERTED TO MANIPULATE AND POSITION ZYGOMAMAY BE USED WITH OPEN AND CLOSED REDUCTION TECHNIQUESSPECIALLY USEFUL IN LATERALLY DISPLACED #, OLD #.

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DINGMAN & NATIVE SUPRA-ORBITAL APPROACH

(1964)

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THE LATERAL BROW AND UPPER BLEPHAROPLASTY

APPROACHES

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THE LATERAL BROW AND UPPER BLEPHAROPLASTY APPROACHES ARE USEFUL FOR ACCESSING THE Z-F AND Z-S SUTURES.

THE LATERAL PORTION OF THE SUPERIOR ORBITAL RIM ALSO CAN BE EXPOSED

ADVANTAGE: SIMPLICITY OF THE TECHNIQUE. DISADVANTAGES: POSSIBILITY OF VISIBLE SCARRING AND BROW ALOPECIA.

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SUBCILIARY APPROACH

LOWER EYE LID INCISION

SUBTARSAL APPROACH

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ADVANTAGES :

EASY TO LEARN AND OFFER BROAD ACCESS TO ORBITAL FLOOR. DISADVANTAGES :

GREATER RATES OF POSTOPERATIVE LOWER LID MALPOSITION & VISIBLE SCARRING WHEN COMPARED WITH THE TRANSCONJUNCTIVAL APPROACH

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TRANSCONJUNCTIVAL APPROACH

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BOURQUETT FIRST DESCRIBED INFERIOR FORNIX CONJUNCTIVAL OR TRANSCONJUNCTIVAL APPROACH FOR BLEPHAROPLASTY IN 1924.

TENZEL AND MILLER LATER USED THIS APPROACH IN 1970S FOR THE REPAIR OF ORBITAL FLOOR DEFECTS.

ADVANTAGES : NO VISIBLE SCARRING

DECREASED RISK OF ECTROPION WHEN COMPARED WITH THE SUBCILIARY APPROACH.

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LOWER BLEPHAROPLASTY INCISION

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CORONAL APPROACH

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INDICATIONS

(1) MULTIPLE FRACTURES OF ZYGOMATIC COMPLEX OR OTHER MIDFACIAL BONES;

(2) COMMINUTED FRACTURES OF ZYGOMATIC COMPLEX;

(3) OLD FRACTURES OF MIDFACIAL BONES WITH MAL- OR NONUNION

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ADVANTAGE COMPLETE & UNINTERRUPTED VISUALIZATION OF

WHOLE ZYGOMATIC COMPLEX INCLUDING F-Z & Z-T

SUTURES. PLATING AND GRAFTING CAN BE ACCOMPLISHED

WITHOUT ANY LIMITATIONS RELATING TO EXPOSURE.

PROVIDE AN OPPORTUNITY TO HARVEST CRANIAL BONE THROUGH SAME INCISION WHEN IMMEDIATE BONE GRAFTING IS INDICATED.

ELIMINATES THE NEED FOR A SECOND DONOR SITE.

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COMPLICATIONS

IMMEDIATE

HAEMATOMA, HAEMORRHAGE, NERVE INJURY, INFECTION AND OEDEMA

LONG TERM

1. ALOPECIA WITH THE SCAR BEING WIDER THAN 0.5 CM

2. PARAESTHESIA IN THE OPERATIVE AREA

3. DEPRESSION OF THE TEMPORAL FOSSA

4. PARALYSIS OF THE FACIAL NERVE JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY (2006) 34, 182–185

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THE SUPRATARSAL FOLD APPROACH

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CHUONG AND KABAN FIRST DESCRIBED THE SUPRATARSAL FOLD APPROACH FOR Z-M FRACTURE IN1986.

ELLIS & ZIDE AND FONSECA DESCRIBED THE SUPRATARSAL FOLD APPROACH AS AN AESTHETICALLY VIABLE ALTERNATIVE FOR EXPOSURE OF Z-F SUTURE.

IT GIVES AN EXCEPTIONAL AESTHETIC RESULTS THAT CREATE AN INCONSPICUOUS SCAR.

COMPLICATIONS : EXPOSURE OF ORBITAL FAT AND LACRIMAL GLANDS BY DISSECTION OF THE ORBITAL SEPTUM, BUT THIS CAN BE AVOIDED BY CAREFUL DISSECTION IN THE SUBPERIOSTEAL PLANE. BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 46 (2008) 226–228

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ENDOSCOPIC REPAIR

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INDICATION

EXPLORATION OF ORBITAL FLOOR AFTER ZYGOMA FRACTURE REDUCTION TO EVALUATE THE NEED FOR ORBITAL FLOOR REPAIR.

PATIENTS WITH A HYPHEMA AND EXTRAOCULAR MUSCLE ENTRAPMENT.

DISADVANTAGE

“TECHNOLOGY”- DRIVEN TECHNIQUE WITH A MODERATE LEARNING CURVE. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY (2008) 19, 209-213

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COMPLICATIONS

COMPLICATIONS OF PERIORBITAL INCISIONS

-DEHISCENCE -HEMATOMA -LYMPHEDEMA -VERTICAL SHORTENING OF LOWER EYELID -ECTROPION -ENTROPION

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INFRA ORBITAL NERVE DISORDERS

PERSISTENT DIPLOPIA

BLINDNESS

MAXILLARY SINUSITIS

ANKYLOSIS OF ZYGOMA TO CORONOID PROCESS

MAL UNION

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MAXILLO FACIAL INJURIES: ROWE AND WILLIAMS, II EDITION.

MAXILLOFACIAL SURGERY: PETER WARD BOOTH, II EDITION

MF TRAUMA & ESTHETIC FACIAL RECONSTRUCTION: PETER WARD BOOTH, BARRY EPPLEY, RAINER SCHMELZEISEN.

TEXTBOOK OF OMFS: NEELIMA MALIK, II EDITION.

SURGICAL APPROACHES TO FACIAL SKELETON: EDWARD ELLIS, SECOND EDITION

REFERENCES

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ARTICLE REFERENCES1. J ORAL MAXILLOFAC SURG 66:1378-1382, 2008 ORBITOZYGOMATIC COMPLEX FRACTURE REDUCTION UNDER LOCAL ANESTHESIA AND LIGHT ORAL SEDATIONERIC BISSADA, MD, DMD, ZAHI ABOU CHACRA, MD,CHRISTIAN AHMARANI, MD, JEAN POIRIER, DMD, ANDAKRAM RAHAL, MD

2. BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY 46 (2008) 226–228 ACCESS TO FRONTAL SINUS AND ZYGOMATICO FRONTAL SUTURE THROUGH THE SUPRATARSAL FOLDBRUNO FELIPE GAIA , HIGOR LANDGRAF, SHAJADI CARLOS PARDO-KABA, ELIO HITOSHI SHINOHARA

3. JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY (2006) 34, 182–185CORONAL INCISION FOR TREATING ZYGOMATIC COMPLEX FRACTURESQING-BIN ZHANG, YAO-JUN DONG, ZU-BING LI, JI-HONG ZHAO

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4. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY (2008) 19, 132-139SURGICAL APPROACHES TO THE ORBITCLINTON D. HUMPHREY, MD, J. DAVID KRIET, MD

5. BR J OF ORAL & MAXILLOFACIAL SURGERY (1984) 22, 261-268 REVIEW OF LOWER BLEPHAROPLASTY INCISION AS A SURGICAL APPROACH TO ZYGOMATIC-ORBITAL FRACTURES0. A. POSPISIL, M.D, F.D.S.R.C.S.L AND T. D. FERNANDO, B.D.S., F.D.R.C.S.

6. JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY (93~ 21, 120-123)COMPARATIVE EVALUATION OF DIFFERENT RADIOGRAPHIC PROJECTIONS OF ZYGOMATIC COMPLEX FRACTURESLEON ARDEKIAN, ISRAEL KAFFE, SHLOMO TAICHER.

7. J ORAL MAXILLOFAC SURG 66:2488-2492, 2008A SIMPLE TECHNIQUE FOR TREATMENT OF INFERIOR ORBITAL BLOW-OUT FRACTURE: A TRANSANTRAL APPROACH, OPEN REDUCTION, AND INTERNAL FIXATION WITH MINIPLATE & SCREWSJAE-HYUNG KIM, DDS, PHD, MIN-SUK KOOK, DDS, MS, SUN-YOUL RYU, DDS, PHD, HEE-KYUN OH, DDS, PHD, HONG-JU PARK, DDS, PHD,