• 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
• It can affect facial contour ,ocular and mandibular functioning.
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)
 It is roughly equivalent of a four sided pyramid sides are
represented by four processes
1. Temporal
2. Orbital
3. Maxillary
4. Frontal
• 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
•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
A zygomatic complex fracture causes disruption of four
articulating sutures:

•Zygomatico- frontal
•Zygomatico-temporal
•Zygomatico -maxillary
•Zygomatico- sphenoid
Common fracture pattern in ZMC injury:
1. Fracture medial to a zygomatico-maxillary
suture and along a zygomatic-sphenoid
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.
•Knight and North (1961)
•Rowe and Killey (1968)
•Larsen and Thomson (1978)
•Rowe and Williams (1985)
•Poswillo (1988)
GROUP I – Non displaced fractures requiring no treatment

GROUPII – All fracturesrequiring treatment

 Fractures stable after elevation
a) Arch only (medially displaced)
b) Rotation around the vertical axis
i) medially
ii) laterally
 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
•Inward and downward displacement
•Inward and posterior displacement
•Outward displacement of the
zygomatic complex
•Comminution
•Fracture of the arch alone
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.
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.
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.
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.
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.
Trismus:

• Limitation of mouth opening in approximately one

third of 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.
Subconjunctival Ecchymosis :
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.
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.

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 deformity.

Inferior displacement of zygoma produces

downward slope to the fissure (antimongoloid
slant).
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
Diplopia :- 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.
Causes:
Muscle entrapment: doesnt resolve by itself.
Edema or hemorrhage: Resolve in few days.
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.
1. Neurological status
2. Visual status
3. Examination of zygoma
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.
RADIOLOGICAL EVALUATION
WATERSVIEW :Waters’ view is the most useful view to evaluate for zygomaticinjuries
because it defines the injury involving the arch, lateral wall of the maxillary sinus,
inferior orbital rim, and floor of the orbit
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

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
Treatment types:
1. No treatment
2. Delayed treatment
3. Immediate treatment
Medical contraindications

Non-displaced fractures-9-50 % zmc #

Minimal degree of displacement Unlikely to result in -
◦ Cosmetic deformity
◦ Disturbance of vision
◦ Paresthesia
◦ Mandibular movements impaired
CRITICAL PERIOD

Advantages:
Oedema resolves-detailed examination of eye

Antrum clears-better radiograph

Haematoma still not organised –dissection easier

Delay >5-10 DAYS

•Difficulty in disimpacting & reducing

•Physiological resorption of # margins
•Interdigitation less accurate
•Inelasticity of fibrous tissue at site of malunion
 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
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 .
5) Antiseptic preparation:

It depends largely on the type of approach

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 frequentlyuseful.
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
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.
• 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.
Supraorbital EyebrowApproach
A popular approach used to gain access to the lateralorbital
rim is the eyebrow incision.
No significant neurovascular bundle present.
Advantage: Scar is usually imperceptible.
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.
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.
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 .
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.
• 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.
• 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
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 Miller have
developed the transconjunctival retroseptal
incision and Tessier elaborated on the
transconjunctival preseptal incision
2. retroseptal :. The retroseptal approach is
more direct than the preseptal approach and
is easier to perform.
7)Reduction of fracture:
Temporal Approach : First described by Gillies et al in 1971 for usein
zygomatic arch fractures
Advantage: large amount of controlled force can beapplied.
Disadvantage :hemorrhage due to temporal vessels.
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.
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.
Buccal Sulcus Approach:
Described by keen in year 1909.
Approach is through the maxillary buccalsulcus.
Advantage: prevention of any externalscar.
This can be used for both ZMC and zygomatic archfractures.
Technique: small incision of 1 cm in mucobuccalfold.
Sharp end no. 9 periosteal elevator or curved freeris inserted.
Use side to side sweeping motion cant with infratemporalsurface
of maxilla , zygoma and arch and dissect soft tissue in supra
periosteal plane.
Advantage : fracture at the orbital rim is
visualized directly and fixation can be
done through same incision.
Disadvantage: difficult to generatea Dingmans elevator
large amount of force.
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.
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.
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.
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:

First orbital 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 notbeen properly
elevated
If there is any doubt about proper reduction, exposure is mandatory.
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.
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:

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.

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 scre
ws should be used to minimize CT artifacts.
 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.

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.
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.

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.
Types of fixation:
One-point fixation can be done by ORIF at the ZMB or by ORIFat 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 theZMC
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
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
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 .
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.
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
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.
Incidence of postoperative retrobulbar hemorrhageand
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 nerveitself.
◦Retrobulbar hemorrhage
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
Greenstick-Medial Type.

Greenstick-Lateral Type
Shear-Medial Type.

Shear-Lateral Type
Face is the most prominent and expressive part of human body and adds towell
being of apersonality.
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 externalload.