S E M I N A R

FRACTURES OF THE ZYGOMATICOMAXILLARY COMPLEX

INTRODUCTION
ANATOMY OF THE ZYGOMA BONE CLASSIFICATION OF THE ZMC # RADIOGRAPHIC TECHNIQUES SURGICAL APPROACHES TO ZMC# COMPLICATIONS

ANATOMY
SHAPE ARTICULATIONS WITH FACIAL BONES

MUSCLE ATTACHMENTS

WHY ZYGOMATICOMAXILLARY COMPLEX FRACTURE???

CLASSIFICATION

ROWE AND WILLIAMS

1) FRACTURES STABLE AFTER ELEVATION A. ARCH ONLY(MEDIALLY DISPLACED)

1) FRACTURES STABLE AFTER ELEVATION B. ROTATION AROUND VERTICAL AXIS

MEDIAL ROTATION

LATERAL ROTATION
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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. AXIS.

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2. FRACTURES UNSTABLE AFTER ELEVATION C. DISLOCATION EN BLOC

INFERIOR

MEDIAL

POSTEROLATERAL
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LARSEN AND THOMPSON

GROUP A: STABLE FRACTURE- SHOWING FRACTUREMINIMUM 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 NONGROUP 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 16

FRACTURES OF ZYGOMATIC ARCH NOT INVOLVING ORBIT -MINIMUM OR NO DISPLACEMENT -V TYPE FRACTURES -COMMINUTED FRACTURES

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DINGMANS CLASSIFICATION OF ZYGOMA FRACTURE

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

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HENDERSONS CLASSIFICATION OF MALAR FRACTURE

0: INTACT 1: UNDISPLACED (ANY SITE) 2: ZYGOMATIC ARCH ONLY 3: TRIPOD F-Z SUTURE UNDISTRACTED F4: TRIPOD F-Z SUTURE DISTRACTED F5: PURE BLOW-OUT BLOW6: ORBITAL RIM ONLY 7: COMMINUTED--OTHER THAN ABOVE COMMINUTED--OTHER
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MODIFIED CLASSIFICATION USED IN WALTON HOSPITAL

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 BLOW6: PURE BLOW-OUT BLOW7: ORBITAL RIM ONLY 8: ORBITAL BLOW-OUT WITH ORBITAL RIM FRACTURE ONLY BLOW20

9: COMMINUTED-OTHER THAN ABOVE COMMINUTED-

ZINGG CLASSIFICATION SYSTEM

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 PROCESS, (A1), FRONTAL PROCESS, WHICH FORMS LATERAL ORBITAL WALL PROCESS, (A2), PROCESS, & MAXILLARY PROCESS, WHICH FORMS INFRAORBITAL RIM (A3).
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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 FRACTURES

CLASSIFICATION(OZYAZGANCLASSIFICATION(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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CONTD
2) COMBINED ZYGOMATIC ARCH FRACTURES(TYPE 2) A) SINGLE B) PLURAL FRACTURES -REDUCED -DISPLACED

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INVOLVED FACIAL HALF LEFT CENTRAL YES

RIGHT LATERAL NO TYPE A DISPLACEMENT >2mm

COMPLEX/DEFECT # >5mm

ISOLATED # OF 3 UNITS YES NO

NO

YES

TYPE B

TYPE C

GROUP A1

COMBINED REGION WITH SKULL BASE INVOLVEMENT

GROUP A2

NO

YES

GROUP A3
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AO/ASIF (ARBEITSGEMEINSCHAFT FR OSTEOSYNTHESEFRAGEN/ ASSOCIATION FOR STUDY OF INTERNAL FIXATION) SCHEME

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LATERAL MIDFACIAL/CRANIOFACIAL #
TYPE A/B/C: GROUPS, SUBGROUPS & SPECIFICATIONS TYPE 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 CRANIOBASALFACIAL 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 + IIIF-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 + IIIF-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 CRANIOBASALFACIAL 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 + IIIFRONTOLATEROBASAL), COMBINED # OF LOWER & UPPER MIDFACE TOGETHER WITH FRONTOBASAL &/OR LATEROBASAL EXTENSION OF CRANIOBASALFACIAL 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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DIAGNOSIS
INSPECTION 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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WATERS VIEW
DESCRIBED BY WATERS & WALDRON ORBITO-MEATAL BASELINE ELEVATION SHOULD BE 37 DEGREE.

DEMONSTRATES ATTACHMENTS OF ZYGOMA TO ZYGOMATICO FRONTAL SUTURE, INFRA-ORBITAL RIM AND THE MAXILLARY SINUS
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MODIFIED POSTERO-ANTERIOR PROJECTION:

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

ENABLES A BETTER VIEW OF ORBITAL FLOOR, INFRAORBITAL RIM AND THE FZ BONES.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 43 (1993~ 21, 120-123)

SUBMENTOVERTEX VIEW

FOR ZYGOMATIC ARCH FRACTURE

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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 HIGHHIGH-CONTRAST STRUCTURES, RESULTING IN DECREASED RADIATION EXPOSURE OF PATIENTS. 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 EXAMINATION, 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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TREATMENT
1. 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 ANTIANTI-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 5 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. ZFERRIER (1825) ATTEMPTED TO REDUCE ZYGOMA # THRU INCISION ABOVE ARCH. ROLLAND: 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 ZCOMPOUND #
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GILLIES ET AL (1927) EMPHASIZED THE COSMETIC VALUE OF PLACING THE INCISION WITHIN THE HAIRLINE. 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. 1GILL (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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KEENS 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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QUINN (1977) MODIFICATION

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.

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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 66:248871

PERCUTANEOUS APPROACH
INSERTING HOOK THRU SKIN INCISION REDUCTION BY STRONG OUTWARD TRACTION REPOSITIONING OF MEDIALLY DISPLACED ISOLATED Z-ARCH # LOCATING STAB WOUND INTERSECTION OF PERPENDICULAR LINE DROPPED FROM OUTER CANTHUS OF EYE AND HORIZONTAL LINE FROM ALAR MARGIN OF NOSTRIL HOOK INSERTED VERTICALLY & ROTATED IN 90* POINT OF CONTACT SHUD B WID BONE POTENTIAL COMPLICATION INSERTION INTO INFERIOR ORBITAL FISSURE

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TRANSCUTANEOUS CHEEK APPROACH

INCISION 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 ZYGOMA MAY BE USED WITH OPEN AND CLOSED REDUCTION TECHNIQUES SPECIALLY USEFUL IN LATERALLY DISPLACED #, OLD #.

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DINGMAN & NATIVE SUPRASUPRA-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. ZZTHE 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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LOWER EYE LID INCISION

SUBCILIARY APPROACH 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. 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; MAL(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. FZ 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, 182185 CRANIO182 85

THE SUPRATARSAL FOLD APPROACH

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CHUONG AND KABAN FIRST DESCRIBED THE SUPRATARSAL FOLD APPROACH FOR Z-M FRACTURE IN1986. ZELLIS & ZIDE AND FONSECA DESCRIBED THE SUPRATARSAL FOLD APPROACH AS AN AESTHETICALLY VIABLE ALTERNATIVE FOR EXPOSURE OF Z-F SUTURE. ZIT 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) 226228 226
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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 TECHNOLOGYTECHNOLOGY- DRIVEN TECHNIQUE WITH A MODERATE LEARNING CURVE.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY (2008) 19, 209-213 20989

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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REFERENCES
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
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ARTICLE REFERENCES 1. J ORAL MAXILLOFAC SURG 66:1378-1382, 2008

ORBITOZYGOMATIC COMPLEX FRACTURE REDUCTION UNDER LOCAL ANESTHESIA AND LIGHT ORAL SEDATION ERIC BISSADA, MD, DMD, ZAHI ABOU CHACRA, MD, CHRISTIAN AHMARANI, MD, JEAN POIRIER, DMD, AND AKRAM RAHAL, MD 2. BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY 46 (2008) 226 226228 ACCESS TO FRONTAL SINUS AND ZYGOMATICO FRONTAL SUTURE THROUGH THE SUPRATARSAL FOLD BRUNO FELIPE GAIA , HIGOR LANDGRAF, SHAJADI CARLOS PARDOPARDOKABA, ELIO HITOSHI SHINOHARA 3. JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY (2006) 34, 182185 CRANIO182 CORONAL INCISION FOR TREATING ZYGOMATIC COMPLEX FRACTURES QINGQING-BIN ZHANG, YAO-JUN DONG, ZU-BING LI, JI-HONG ZHAO YAOZUJI93

4. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY (2008) 19, 132-139 132SURGICAL APPROACHES TO THE ORBIT CLINTON D. HUMPHREY, MD, J. DAVID KRIET, MD 5. BR J OF ORAL & MAXILLOFACIAL SURGERY (1984) 22, 261-268 261REVIEW OF LOWER BLEPHAROPLASTY INCISION AS A SURGICAL APPROACH TO ZYGOMATIC-ORBITAL FRACTURES ZYGOMATIC0. 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) CRANIO-MAXILLO120COMPARATIVE EVALUATION OF DIFFERENT RADIOGRAPHIC PROJECTIONS OF ZYGOMATIC COMPLEX FRACTURES LEON ARDEKIAN, ISRAEL KAFFE, SHLOMO TAICHER. 7. J ORAL MAXILLOFAC SURG 66:2488-2492, 2008 66:2488A SIMPLE TECHNIQUE FOR TREATMENT OF INFERIOR ORBITAL BLOWOUT FRACTURE: A TRANSANTRAL APPROACH, OPEN REDUCTION, AND INTERNAL FIXATION WITH MINIPLATE & SCREWS JAE-HYUNG KIM, DDS, PHD, MIN-SUK KOOK, DDS, MS, SUN-YOUL 94 RYU, DDS, PHD, HEE-KYUN OH, DDS, PHD, HONG-JU PARK, DDS, PHD,

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