FRACTURES OF THE ZYGOMATIC COMPLEX AND ORBIT.pptx.pptx

fractures of ZMC region cause disfigurement of face which leads to facial deformity

1. CONTENTS

2. INTRODUCTION Zygomatic fractures are common facial fractures and the second in frequency after nasal fractures . Fractured Zygoma was Noted as early as 1650 BC The highest incidence of fractures probably relates to the Zygoma’s prominent position within the facial skeleton . Most studies indicate male predilection with a ratio of approximately 4:1 over females.

3. ANATOMY

4. FUNCTIONS OF ZYGOMA Protect the globe. Give origin to Masseter muscle. Transmit masticatory force to the cranium. Absorb the force of an impact before it reaches brain.

5. ANATOMY of ORBIT LATERAL WALL : Dense zygomatic bone and greater wing of sphenoid at 45 degree to the long axis of the skull. Junctions of this wall with the roof and floor of the orbit are smooth and rounded anteriorly. Weakened by superior and inferior orbital fissure.

6. MEDIAL WALL Half the height of lateral wall Floor of the orbit meets the wall at 45 degress Formed by thin plates of ethmoid bone. Anteriorly: wall continues as lacrimal bone and weakened by naso -lacrimal canal

7. FLOOR OF THE ORBIT Triangular which is narrow posteriorly , Floor is not horizontal; slopes upwards 45degree medially and ascends 30degrees posteriorly Floor is very thin: 0.5mm thick; further weakened by infra-orbital groove and canal. Blow-out fractures occur immediately medial to this line

8. PRINCIPAL COMPARTMENTS

9. EPIDEMIOLOLGY AND ETIOLOGY AGE: 20-30 years. SEX Males (80%) Females(20%) Women who have been domestically abused are more likely to suffer ZMC fractures and orbital blow-out fractures

10. FRACTURE PATTERN

11. CLASSIFICATIONS KNIGHT AND NORTHWOOD - 1961 ROWE AND KILLEY- 1968 LARSEN AND THOMSEN - 1978 ROWE AND WILLIAMS - 1985 MANSON AND COLLEAGUES - 1990 ZINGG et al - 1992.

12. KNIGHT AND NORTHWOOD

13. ROWE AND KILLEY’S CLASSIFICATION

14. ROWE AND WILLIAMS CLASSIFICATION

15. MANSON AND COLLEAGUES Based on the amount of “ ENERGY ” dissipated by the facial bones secondary to traumatic force. They classified fractures based on findings in C.T. Scan High energy fractures Moderate energy fractures Low energy fractures High energy fractures had extreme displacement communition of the articulations segmentation of the bones. These fractures required extensive exposure and fixation for satisfactory outcome. Low-energy fractures were characterized by displacement but without comminution of bony articulations. These fractures could be treated by less aggressive means. `

16. DIAGNOSIS OF ZYGOMATICO - MAXILLARY COMPLEX FRACTURES

17. CLINICAL EXAMINATION Neurological status Rapid assessment should be done noting the 4point AVPU scale GCS – secondary survey Pupillary response.

18. INSPECTION AND PALPATION Examine and palpate the entire face Note assymetry , ecchymosis , cuts, and lacerations Nerves Examination of the eye

19. CLINICAL FEATURES

20. TRISMUS Occurs due to medial displacement and/or posterior displacement of zygoma impinging coronoid process. Seen in isolated fractures of zygomatic arch

21. ABNORMAL NERVE SENSIBILITY Anesthesia or paresthesia are common in displaced fractures due to neuropraxia or neurotemesis . Anesthesia of the temple and cheek Injury to the zygomatico -temporal and zygomatico -facial nerves Anesthesia of upper lip and upper teeth injury to infraorbital never The recovery depends on the degree of nerve injury and usually it takes 6-9 months.

22. ALTERATION OF GLOBE LEVEL Depends on the level at which lateral orbital rim fracture occurs. Fracture at FZ or above the Whitnall’s tubercle: Bone displaced downwards along with which there is hooding of upper eyelids DISPLACEMENT OF PALPEBRAL FISSURE Lateral canthal ligament is attached to the Whitnall ’s tubercle, therefore displacement of zygoma displaces the palpebral fissure along with it producing antimongloid slant

23. AIR EMPHYSEMA Following sinus wall or roof fractures, tearing of the lining mucosa of the maxillary sinus, air escapes into the facial soft tissues if pressure within the sinus is greater than that within the tissues. This can result in crepitation on palpation

24. DIPLOPIA Serious complication of zygomatic complex fractures Patient experiences blurred double vision Types: Temporary or Permanent Monocular or Binocular Temporary diplopia : results from hematoma or oedema of the extraocular muscles and lasts only for 5 to 7 days Permanent diplopia : results from paralysis or muscle entrapment within the fractured segments. If left untreated can lead to permanent diplopia

25. Monocular diplopia : Double vision through one eye with the other eye closed Indicates detached lens or traumatic injury of the globe Binocular diplopia : Double vision is experienced when looking through both eyes simultaneously

26. CAUSES FOR DIPLOPIA Hematoma or oedema around extraocular muscles interfering with their actions Disruption in attachment of Inferior Rectus and Inferior Oblique muscles Orbital floor fracture and subsequent herniation of periorbital fat into maxillary sinus Fibrous tissue formations and adhesions between the globe and orbital floor

27. TESTS FOR DIPLOPIA Finger gaze Forced duction test Hess diplopia chart Diplopia chart Field of binocular single vision test

28. RADIOGRAPHIC EXAMINATION Fronto-zygomatic suture zygomatico-maxillary buttress inferior orbital rim WATERS VIEW

29. CALDWELL’S POSTERO-ANTERIOR VIEW Shows the Frontozygomatic suture Inferior orbital rim Zygomatico -maxillary buttress

30. SUBMENTOVERTEX VIEW Detects fractures of zygomatic arch

31. Mc GRIGOR- CAMPBELL LINES

32. COMPUTED TOMOGRAMS The coronal section Medial wall Floor of the orbit Malar eminence Zygomatico -maxillary buttress Orbital volume One should carefully compare the size of the orbits and the contour of the floor and walls.

33. Coronal section of the orbit showing common location of orbital floor and medial wall fractures. Examination of several cuts identifies the posterior extent of the fracture allowing the surgeon to know before surgery how far posteriorly to dissect and the size of material necessary for reconstructing the defect.

34. THE AXIAL SECTION AT THE LEVEL OF MID GLOBE Medial wall Lateral wall Lateral orbital rim Position of the globe in relation to the bony orbit and one another. Zygomatic arch The projection of malar eminences. Fracture along the infratemporal surface of the ZMC.

35. GENERAL PRINCIPLES

36. INDICATIONS FOR OPEN REDUCTION

37. TIMING OF REPAIR INTERVENTION SCENARIO Immediate Diplopia- due to muscle or periorbital tissue entrapment with non resolving Oculocardiac reflex White-eyed blow out fractures Early enophthalmos/ hypoglobus causing facial asymmetry Within 2 weeks Symptomatic diplopia with positive forced duction test and CT based evidence of entrapments and minimal clinical improvement Large floor fracture causing latent enophthalmus Significant hypo- ophthalmos Progressive infraorbital hypoesthesia Observation Minimal diplopia , good ocular motility and no significant enophthalmos or hypophthalmos Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Current opinion in ophthalmology. 2003 Oct 1;14(5):236-40

38. SURGICAL APPROACHES

39. INTRAORAL APPROACH

40. DINGMAN APPROACH OR LATERAL EYEBROW APPROACH Simple and rapid access to supero -lateral orbital rim No functionally important neurovascular structures are at risk Scar is usually well concealed in the eyebrow

41. UPPER EYELID APPROACH The upper-eyelid approach, also called upper blepharoplasty , upper-eyelid crease, and supratarsal fold approach is direct and usually aesthetically acceptable.

42. TRANSCUTANEOUS LOWER-EYELID APPROACHES Subciliary (lower blepharoplasty ) Subtarsal (lower or mideyelid ) Infraorbital (inferior orbital rim) Subciliary approach can be extended laterally to gain access to the lateral orbital rim (D).

43. SUBCILIARY APPROACH

44. SUBTARSAL APPROACH

45. INFRAORBITAL APPROACH Infraorbital incisions lie at the transition between the thin eyelid skin and the thicker cheek skin. They are therefore predisposed to edema and increased visibility of the scars, even when the incision runs curvilinear within the resting skin tension lines. That is why the infraorbital approach has lost its former popularity.

46. TRANSCONJUNCTIVAL APPROACH Surgical routes The typical inferior fornix transconjunctival approach can use two different routes to access the infraorbital rim: Retroseptal Preseptal These two approaches vary in relation to the orbital septum on the pathway to the infraorbital rim.

47. RETROSEPTAL APPROACH

48. PRESEPTAL APPROACH The preseptal route requires entering the suborbicularis oculi / preseptal space above the fusion of the lower lid retractors and the orbital septum. This allows direct visualization of the septum.

49. CORONAL OR HEMICORONAL APPROACH

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

51. PERCUTANEOUS APPROACH

52. CARROL-GIRARD BONE SCREW

53. USING EXISTING LACERATIONS

54. TRANSORAL MAXILLARY VESTIBULAR APPROACH Keen’s approach or Balasubramanium approach

55. Pitfall: too high an incision In the anterior region the incision line should not be placed too high in order not to lose the bone contact and to avoid entrance into a low piriform aperture. Palpation of the piriform rim and anterior nasal spine ensures incision placement below these structures. In the edentulous maxilla, where the alveolar crest and the nasal floor converge due to progressive bone atrophy, the incision should be placed along the base of the alveolar crest.

56. Edentulous patients In edentulous patients, make sure to use a crest of the ridge incision rather than a vestibular incision.

57. KEEN’S APPROACH- REDUCTION TECHNIQUE

58. ENDOSCOPIC TRANSANTRAL APPROACH Ducic Y, Verret DJ. Endoscopic transantral repair of orbital floor fractures. Otolaryngology—Head and Neck Surgery. 2009 Jun;140(6):849-54.

59. INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION Infraorbital nerve compression (numbness). Impingement on coronoid process or temporal muscle (trismus) Diplopia due to entrapment of extraocular muscle(s) Exophthalmos or orbital apex syndrome Enophthalmos Aesthetic deformity (i.e., depressed ZMC)

60. NEED FOR INTERNAL ORBITAL RECONSTRUCTION

61. ISOLATED ZYGOMATIC ARCH FRACTURE Closed treatment Open reduction without fixation Open reduction with fixation

62. ZYGOMATIC COMPLEX FRACTURES Closed treatment ORIF – 1 point fixation (without orbital reconstruction) ORIF – 2 point fixation (without orbital reconstruction) ORIF – 3 point fixation (without orbital reconstruction) ORIF – 3 point fixation (with orbital reconstruction) ORIF – 4 point fixation (with orbital reconstruction)

63. CLOSED TREATMENT MAIN INDICATION Displaced fracture amenable for minimally invasive reduction techniques such as bone hook or a Carroll-Girard type screw. CONTRAINDICATIONS Displaced comminuted injury of the zygomatic complex Stable reduction is not achievable using a closed technique The need for internal orbital reconstruction ADVANTAGE Less invasive technique DISADVANTAGES Difficult assessment of proper reduction Risk of displacement due to the absence of fixation hardware Possible injury to soft tissues, due to poor placement of bone

64. ORIF,1-POINT FIXATION (WITHOUT ORBITAL RECONSTRUCTION) MAIN INDICATION Displaced simple noncomminuted fracture with minimal separation of zygomaticofrontal suture. FURTHER INDICATION Stable reduction is not achievable using a closed technique CONTRAINDICATIONS Displaced comminuted injury of the zygomatic complex Stable reduction is not achievable using one point fixation The need for internal orbital reconstruction ADVANTAGE Less invasive technique if fragment "snaps" into place with reduction DISADVANTAGE Difficult assessment of proper reduction at nonvisualized sites ( frontozygomatic , internal orbit, zygomatic arch)

65. ORIF, 2-POINT FIXATION (WITHOUT ORBITAL RECONSTRUCTION) MAIN INDICATION Displaced fracture requiring 2-point exposure to verify reduction. FURTHER INDICATION Anatomic reduction cannot be confirmed using one point fixation CONTRAINDICATIONS Displaced comminuted injury of the zygomatic complex Anatomic reduction cannot be confirmed using two point fixation The need for extended internal orbital reconstruction ADVANTAGE Allows for visualization of the sphenozygomatic and frontozygomatic sutures in addition to the zygomaticomaxillary buttress DISADVANTAGE Difficult assessment of proper reduction at nonvisualized sites ( orbital floor, medial orbital wall, and zygomatic arch) Alternatively, a second point of exposure can be the infraorbital rim.

66. ORIF, 3-POINT FIXATION (WITHOUT ORBITAL RECONSTRUCTION) MAIN INDICATION Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction. FURTHER INDICATION Anatomic reduction cannot be confirmed using two point exposure CONTRAINDICATIONS The need for extended internal orbital reconstruction Anatomic reduction cannot be confirmed using three point exposure ADVANTAGE Allows for visualization of the infraorbital rim, in addition to the sphenozygomatic and frontozygomatic sutures, and the zygomaticomaxillary buttress DISADVANTAGE Difficult assessment of proper reduction at nonvisualized sites (orbital floor, medial orbital wall, and zygomatic arch)

67. ORIF, 3-POINT FIXATION (WITH ORBITAL RECONSTRUCTION) MAIN INDICATION Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction and need for orbital reconstruction. CONTRAINDICATION Need for arch reduction and fixation ADVANTAGE Allows for visualization of the relevant regions of the internal orbit, , in addition to the infraorbital rim, sphenozygomatic and frontozygomatic sutures, and the zygomaticomaxillary buttress DISADVANTAGE Difficult assessment of the zygomatic arch fracture

68. ORIF – 4 POINT FIXATION WITH ORBITAL RECONSTRUCTION MAIN INDICATION Complex zygomatic fractures where exposure of the zygomatic arch (4th point) is necessary to ensure proper reduction of the zygomatic complex. FURTHER INDICATION Associated multiple fractures that require a coronal approach (frontal sinus fractures, NOE fractures, or a necessity to harvest split calvarial bone graft) ADVANTAGE Allows for the visualization of the zygomatic arch (to ensure restoration of facial projection and facial width) in addition to all other zygomatic complex fracture lines DISADVANTAGES Visible scar Time consuming Risk of temporal hollowing Risk of injury to temporal branch of the facial nerve

69. TOWEL CLIP REDUCTION OF THE DEPRESSED ZYGOMATIC ARCH FRACTURE Todd G. Carter, DMD,* Shahrokh Bagheri , DMD, MD, and Eric J. Dierks , DMD, MD Placement of superior stab incision. Placement of inferior stab incision after rotation of towel clip Passage of superior tine deep to depressed arch . Application of lateral reducing force while stabilizing patient’s head.

70. INDIRECT FIXATION The zygomatic bone will be rigidly secured to some point elsewhere on the facial skeleton until union occurs after which the connecting apparatus may be removed. The technique provides a means of fixation when there has been gross loss of bone in the region of FZ suture and Inferior orbital rim. Zygomatico-zygomatic Naso-zygomatic Zygomatico -palatal Maxillo-zygomatic Front- zygomatic Cranio-zygomatic

71. ZYGOMATICO-ZYGOMATIC Utilizes sound zygoma of opposite side and nasal structures for cantilever support. After reduction of ZMC in reduced position and held with with a hook, a K wire is driven across with a hand drill ( McKelvie’s or Toller’s drill) through the zygoma, walls of nasal cavity and septum and engages the antral surface of fractured zygoma. Alternatively a Steinmann pin can be used. Removed after 3weeks but in severe cases it can be kept in position for upto 6 weeks. Kruger (1959) and Vero (1968) recommended elevation of ZMC should be performed intraorally to get a direct visualization of the pin and the bone

72. NASO-ZYGOMATIC Brown and Barnard (1983) recommended using a trans-nasal K wire of 1.5 mm diameter which is inserted with a hand drill to pass from the frontal process of the maxilla on the contra-lateral aspect of the nose to engage the antral surface of the Zygoma Care must be taken to traverse the bone anterior to the nasolacrimal canal.

73. ZYGOMATICO-PALATAL Matsunaga et.al (1977) transfixed fractured zygoma with K wire which was directed obliquely downwards to engage the palatal process of the contra-lateral maxilla at the junction with the lateral wall of the nose.

74. MAXILLO-ZYGOMATIC Upper jaw is used as the fixed point through the medium of a cast silver cap splint cemented to the teeth pre-operatively. A two-screw locking plate, to which a length of rod has been soldered, forms the link between the cap splint and the pin ( Moule or Toller type) which is inserted into the body of zygomatic bone.

75. FRONTO-ZYGOMATIC Utilises two pins connected with a rod and universal joints After reduction, one pin is inserted into the zygomatic process of the frontal bone and the other on the body of zygoma If the body is fractured transversely,the principal lower fragment is utilised for insertion of the pin.

76. CRANIO-ZYGOMATIC Before the introduction of Halo-frames, pins were inserted into the zygoma and were connected by rods and universal joints to a plaster of Paris headcap . Because of the mobility of the scalp the head cap could become displaced. Halo frames are now employed for fixation of the fractures segments as it gives better stability than plaster of Paris as it engages the outer plate of cranium. Can be helpful if LeFort type fractures coexist.

77. PRINCIPLES OF FIXATION Use self-threading bone screws. Use hardware that will not scatter postoperative ct scans. Place at least two screws through the plate on each side of the fracture. Avoid important anatomic structures . Use as thin a plate as possible in the periorbital areas. Place as many bone plates in as many locations as necessary for ensuring stability. If concomitant fractures of other midfacial bones exist, it will be necessary to apply fixation devices more liberally. In areas of comminution or bone loss, span the gap with the bone plate. Use Y,L,T shaped plates where fracture line in the Zmc Buttress region is low . Prevents damage to the roots and nerve bundle.

78. AFTERCARE CLOSED TREATMENT OF ZYGOMATIC ARCH FRACTURES EVALUATION OF THE PATIENT’S VISION performed as soon as they are awakened from anesthesia and then at regular intervals until they are discharged from the hospital. A swinging flashlight test may serve in the unconscious and/or noncooperative patient POSTOPERATIVE POSITIONING Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain

79. Nose-blowing To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following orbital fracture repair. Nasal decongestant may be helpful for symptomatic improvement in some patients.

80. OPHTHALMOLOGICAL EXAMINATION Vision (except for alveolar ridge fracture, palatal fracture) Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture) Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture) Globe position Lid position If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked. Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.

81. Postoperative imaging Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging. Diet Diet depends on the fracture pattern. Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects. Patients in MMF will remain on a liquid diet until such time the MMF is released.

82. MMF The duration and/or use of MMF is controversial and highly dependent on the particular patient and complexity of the trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases the surgeon may choose to place the patient in MMF after these concerns have been resolved. The need and duration of MMF is very much dependent on: Fracture morphology Type and stability of fixation (including palatal splints Dentition Coexistence of mandibular fractures Premorbid occlusion

83. COMPLICATIONS Retrobulbar haemorrhage Maxillary sinusitis The cause is probably inflammation of the sinus membrane causing occlusion of the ostium Post-traumatic maxillary sinusitis usually responds to antibiotic and decongestant therapy within a day or two. Ankylosis of zygoma to coronoid process Cause of extracapsular ankylosis may be improper reduction of the zygoma, leaving the arch in close proximity to the coronoid process. When a patient develops limited mandibular motion following a fracture of the zygoma, one must consider the possibility of extracapsular ankylosis between the mandible and the zygoma. Treatment- coronoidectomy and aggressive physiotherapy.

84. COMPLICATIONS Complication of periorbital incision Infraorbital nerve paresthesia Implant extrusion/displacement and infection Persistent diplopia Enophthalmosis Blindness

85. Malunion of the Zygoma Improper reduction, Improper fixation, Nonintervention when surgery was indicated. TREATMENT MALAR IMPLANTS AND TRANSPLANTS . OSTEOTOMY MEDIAL ROTATION OF RT.ZMC BUTTRESS INTO SINUS FOLLOWING REPOSITIONING AND STABILISATION BONE GRAFTING OF ZMC BUTTRESS IS DONE.

86. Reasons for low incidence Prominence of calavarium Relative retrusions of the midface . Lack of development of the maxillary sinus. Elasticity of facial bones Treatment… Wire fixation is advocated in preference to ORIF because wire placement requires much smaller incision, less likely to injure developing tooth buds. Experimental studies have shown ORIF application interferes with growth and results in facial deformity. PEDIATRIC ZYGOMATIC COMPLEX FRACTURES.

87. ONE-POINT VS. TWO-POINT VS. THREE-POINT FIXATION FOR UNSTABLE PEDIATRIC ZYGOMATICOMAXILLARY COMPLEX FRACTURES JD Luck, Joseph Lopez, et.al AIM: The purpose of this study was to assess ZMC fracture management and associated complications in the pediatric trauma population. Methods A retrospective cohort review was performed of all patients younger than 15 years of age presenting to the Johns Hopkins Hospital with ZMC fractures from 1990-2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites. Results A total of 36 patients with 44 unique ZMC fractures met our inclusion criteria. Twelve ZMC fractures were labeled as Type-I (27.3%) while 32 ZMC fractures were categorized as Type-II (72.7%). Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate when compared to one- and three-point fixation (0% vs. 75% and 75%, p = 0.01). Furthermore, rigid plate and screw fixation at the zygomaticomaxillary buttress (ZMB) was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40% vs. 50%, p = 0.76). Conclusions Our results suggest that two-point fixation (ZM and ZF) may be optimal in the deciduous dentition population. Our results also demonstrated no association between complication rate and rigid plate and screw fixation at the ZMB in children with deciduous dentition. Future multi-center, prospective trials will be necessary to fully corroborate our results and provide conclusive recommendations regarding these important clinical questions.

88. CONCLUSION The challenge in ZMC fracture treatment is to balance suitable bone fixation against the potential sequelae of numerous soft tissue approaches. Fixation highly depends on fracture type and can include immobilizing any combination of the following five sites: ZF suture, inferior orbital rim, zygomaticosphenoid suture, ZM buttress, and zygomatic arch. There is disagreement as to which of these four points provides the best stability when fixated is seen throughout the literature. Ellis and Kittidumkerng demonstrated that with proper reduction and stabilization of the fracture, there were no differences in the presence of post-reduction displacement related to the number of fixation plates used. Rohner et al advocate placing a plate on the ZS suture in addition to two other points after their cadaveric biomechanical studies revealed improved structural strength compared with that of four-point fixation.

89. When treating ZMO fractures, there are three critical components that must be addressed. performing an anatomic reduction of the displaced segment. assuring that the segment is stable once reduced. performing adequate internal orbital reconstruction, when indicated. All three of these require clinical and/or radiographic judgment Whether or not intraoperative CT is available, the treatment of ZMO fractures can be individualized and most can be treated without the need for three- or four-point exposure and fixation, or internal orbital reconstruction. When required, however, such treatment must be provided. Knowing when to do what is the key and studying the preoperative CT scans and using a methodical, structured approach to the surgery can provide good results with minimal surgical intervention in most cases.

90. REFERENCES Maxillofacial Injuries - Rowe and Williams Maxillofacial Surger - Peter ward booth Killey’s fractures of the middle third of the facial skeleton – Peter Banks Oral and Maxillofacial Surgery – Trauma; Fonseca Ducic Y, Verret DJ. Endoscopic transantral repair of orbital floor fractures. Otolaryngology—Head and Neck Surgery. 2009 Jun;140(6):849-54. Nishiike S, Nagai M, Nakagawa A, Konishi M, Kato T, Sakata Y, Yasukura T, Harada T. Endoscopic transantral orbital floor repair with antral bone grafts. Archives of Otolaryngology–Head & Neck Surgery. 2005 Oct 1;131(10):911-5. Tarabichi M. Transsinus reduction and one-point fixation of malar fractures. ARCHIVES OF OTOLARYNGOLOGY HEAD AND NECK SURGERY. 1994 Jun 1;120:620-. Baek JE, Chung CM, Hong IP. Reduction of zygomatic fractures using the carroll-girard T-bar screw. Archives of plastic surgery. 2012 Sep;39(5):556. Farber SJ, Nguyen DC, Skolnick GB, Woo AS, Patel KB. Current management of zygomaticomaxillary complex fractures: a multidisciplinary survey and literature review. Craniomaxillofacial trauma & reconstruction. 2016 Nov;9(4):313. Phan LT, Piluek WJ, McCulley TJ. Orbital trapdoor fractures. Saudi Journal of Ophthalmology. 2012 Jul 1;26(3):277-82. Carter TG, Bagheri S, Dierks EJ. Towel clip reduction of the depressed zygomatic arch fracture. Journal of oral and maxillofacial surgery. 2005 Aug 1;63(8):1244-6. Olate S, Lima Jr SM, Sawazaki R, Moreira RW, de Moraes M. Surgical approaches and fixation patterns in zygomatic complex fractures. Journal of Craniofacial Surgery. 2010 Jul 1;21(4):1213-7. Salinas JB, Vira D, Hu D, Elashoff D, Abemayor E, John MS. Steimann pin repair of zygomatic complex fractures. International Journal of Otolaryngology and Head & Neck Surgery. 2013 Mar 29;2(02):74. Zygomaticomaxillary Complex Fracture ; Srinivas M. Susarla , DMD, MD, MPH,a and Zachary S. Peacock, DMD, MD Shao Y, Xie L, Li H, Gao L, Gu ZC, Ye XH, Hu Y. Endoscope-assisted repair of zygomatic arch fracture via a short hidden preauricular incision. Zhonghua zheng xing wai ke za zhi = Zhonghua zhengxing waike zazhi = Chinese journal of plastic surgery. 2007 Jul;23(4):288-90. Choi KY, Ryu DW, Yang JD, Chung HY, Cho BC. Feasibility of 4-point fixation using the preauricular approach in a zygomaticomaxillary complex fracture. Journal of Craniofacial Surgery. 2013 Mar 1;24(2):557-62. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Current opinion in ophthalmology. 2003 Oct 1;14(5):236-40