FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 966

SURGICAL CLINIC CASE PRESENTATION

FRACTURES TREATMENT OF ZYGOMATIC

COMPLEX - SURGICAL CLINIC
CASE PRESENTATION *

TRATAMENTO DAS FRATURAS DO COMPLEXO

ZIGOMÁTICO - APRESENTAÇÃO DE CASO
CLINICO-CIRÚRGICO

Silvano Daniel GUZMÁN BOUNPENSIERE **

Edgard José Franco MELLO JÚNIOR ***
Clóvis MARZOLA ****
João Lopes TOLEDO-FILHO *****
Luiz Carlos da Silva MENDES JÚNIOR ******

___________________________________________
* Monograph presented to the São Paulo Association of Surgeons Dentists, as part of the requirements
for the conclusion of the Buco Maxillofacial Surgery and Traummatology Specialization
Course, promoted for the Regional APCD of Bauru in 2007.
** Concluding pupil of the Buco Maxillofacial Surgery and Traummatology Specialization Course,
promoted for the Regional APCD of Bauru in 2007.
*** Doctor Head of the Service of Head and Neck of the HB of the AHB and Professor of the Buco
Maxillofacial Surgery and Traummatology Specialization Course, promoted for the
Regional APCD of Bauru in 2007. Person who orientates of the monograph.
**** Titular Professor of Surgery of the FOB-USP of Bauru, Pensioner and Professor of the Buco
Maxillofacial Surgery and Traummatology Specialization Course, promoted for the
Regional APCD of Bauru in 2007.
***** Titular Professor of Anatomy of the FOB-USP of Bauru and Professor of the Buco
Maxillofacial Surgery and Traummatology Specialization Course, promoted for the
Regional APCD of Bauru in 2007.
****** Head of the Buco Maxillofacial Surgery and Traummatology Service of the Hospital
Portuguese Beneficence of Bauru and Professor of the Buco Maxillofacial Surgery and
Traummatology Specialization Course, promoted for the Regional APCD of Bauru in 2007.
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 967
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ABSTRACT
Given to its localization, the zygomatic complex is an area of High
exposition to traumas, the second higher incidence in terms of facial fractures. Injury
of this specific area of the face may generate important functional and/or aesthetic
compromising. This owes, as well, to the close relationship of the zygomatic-orbital
complex with other structures of the face, making its treatment, in various cases,
essential to the functional and aesthetic restoration. The descriptive research was
carried out from a literature review, describing the procedures employed in the
treatment, analyzing the aesthetic results and a clinical case report of a blow out type
fracture.

RESUMO
Dada a sua localização, o complexo zigomático é uma área de maior
exposição aos traumas, sendo a segunda maior incidência no quadro de fraturas da
face. A lesão desta área específica da face pode gerar comprometimentos funcionais
e/ou estéticos importantes. Isso se deve, também, ao íntimo relacionamento do
complexo zigomático-orbitário com outras estruturas da face, tornando seu
tratamento, em diversos casos, essencial para a restauração funcional e estética. A
pesquisa descritiva foi feita a partir de uma revista da literatura, descrevendo os
procedimentos empregados no tratamento e analisando os resultados estéticos, e
apresentando um caso clinico cirúrgico de uma fratura tipo blow out.

Uniterms: Zygomatic complex; Aesthetics; Fractures.

Unitermos: Complexo Zigomático; Estética; Fraturas.

INTRODUCTION
The fractures of the zygomatic complex are one of the most common
traumas for the maxillofacial surgeon. The first description of this type of fracture
come from 1,650 B.C. from the “papyrus of Edwin Smith”, but was Duverney (1751)
who publish the first scientific article describing the zygomatic complex fracture.
The high incidence of this injury could be because of the projection of the zygomatic
bone in the face (ELLIS III; EL-ATTAR; MOOS, 1985; ELLIS III, 1997; LEW;
BIRBE, 2000 and SOBOTTA; BECHER, 2000).
Considering that the form of the face is related with the osseous
skeleton, we can conclude that the zygomatic complex plays an important roll on the
facial contour. An injury of this specific area can compromise the aesthetics and the
function (ELLIS III, 1997 and MARZOLA, 2005). This can be also because the
zygomatic bone is related to others facial structures such as the orbit, the maxilla and
the mandible, making the treatment, in most of the cases, essential for the functional
and aesthetical restoration (MAKOWSKI; VAN SICKELS, 1995 and
MARZOLA, 2005).
The information about incidence, etiology, age and gender concerning
this type of fractures varies according to the social, educational, and economic
condition of the studied population. Most of the cases indicate a predilection for
males with a 4:1 proportion in relation to females. Very different causes including
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aggressions, automobilist accidents, falls, work accidents and sports are important
factors for this injury. Understanding the different types of zygomatic fractures and
the anatomic and physiological features that affects the stability, is essential for a
correct diagnostic and treatment planning (CARR; MATHOG, 1997 and
MARZOLA, 2005).
The treatment of the zygomatic complex fractures is very
controversial, as we can see in all the different philosophies in the literature (CARR;
MATHOG 1997 and MARZOLA, 2005). This treatment had varied from a simple
observation, up to a surgical approach for an internal rigid fixation. The decision of
whether or not to operate is based in the signs and symptoms of the patient, or any
functional alteration (ELLIS III, 1997 and MARZOLA, 2005). A rapid diagnostic
and treatment generally offers a better opportunity for a functional and aesthetic
restoration, but cases where the injury is not diagnose or a life threatening trauma is
present can be bad for the case finalization.

SURGICAL CASE REPORT

The Patient M. C. A., 43 years old, Female, white. Arrived to the
maxillofacial service of the “Hospital Beneficência Portuguesa” in the city of
Bauru-SP, with history of a fall from her feet, presenting trauma in the middle and
upper third of the face. Presenting edema in the left periorbitary region and sub-
conjunctival hemorrhage in the same eye. She complained of having left infraorbital
parestisia end diplopic view (Figures 1 and 2).

Figure 1 – Preoperative aspect with periorbital left edema and echimosis and subconjunctival
hemorrhage in the ipsilateral eye.
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Figure 2 – Another preoperative aspect with periorbital left edema and echimosis and subconjunctival
hemorrhage in the ipsilateral eye.

We realized a detailed radiographic exam and computerized

tomography to complete the evaluation. For the radiographic exam was asked waters
projection, Caldwell, lateral projection of the nose. In the waters radiography we
observed the maxillary sinus totally radiopaque and a trace of fracture in the left
orbital floor typical of a pure blow out fracture (Figure 3).

Figure 3 – Preoperative aspect for x-ray PA of Waters noticing itself velament of the left maxillary
sinus and radiolucid trace in the wooden floor region of the orbit, being suggested a fracture
of the pure type blow out.
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We decided to operate the patient for a complete orbital floor

reconstruction. We asked the patient laboratorial exams (hemogram, coagulogram
and glicemy), pre-anesthetic evaluation and dated the surgery under general
anesthesia.
The patient was taken for the operating room of the “Hospital
Beneficência Portuguesa” the doctor in charge where Dr. Luiz Carlos da Silva
Mendes Junior, and under general anesthesia, orotraqueal intubations, we proceed the
antisepsis with PVPI. We decided to make a sub-ciliary’s approach, approximately 2
mm under the left palpebral rim, using the langerhan lines to hide the scar (Figure
4).

Figure 4 – Subciliar incision, approximately 2 millimeters below of the inferior palpebral edge, using
to advantage a line of ruga to occult the scar.

The incision was made with number 15 blade and the muscular planes
where separated with a metzembaum scissor until reaching the periostium that cover
the infraorbital rim. The periostium is incised with a number 15 blade, and proceed
to desperiotize the infraorbit and the zygomatic wall until we saw the fracture and the
infraorbital fat herniating to the maxillary sinus (Figure 5).
The fat where removed and a W. Lorenz titanium graft is the located
in the region fixed with 5 titanium screws (Figure 6). The periostium is sutured with
a 4-o vicryl with caution to avoid ectropium and skin where sutured with an
intradermic suture with 6-0 nylon. At the end of the procedure the approach is
covered with sterilize apposite.
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Figure 5 – When arriving at the periosteun, it was incised becoming fulfilled its displacement and,
observing fracture type blow out with herning of the periorbital fat for inside of the
maxillary sinus.

Figure 6 – The fat of the space of the maxillary sinus was set free, being placed a titanium mesh W.
Lorenz® fixed for five titanium screws.
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After 113 days of post-operatory (Figure 7), we can see a facial

symmetry, the edema and ecchymosed disappeared, such as the sub conjunctival
hemorrhage. The patient told that she didn’t felt the paresticia, visual alteration, and
the scar of the sub-ciliary’s approach is almost unseen.

Figure 7 – In the 113 days of postoperative, observed face symmetry, disappearance of periorbital
edema and ecchymosed, beyond the subconjunctival hemorrhage.

In the Radiographic evaluation for the 113 days we see a clean

maxillary sinus and the titanium graph in position, the osseous tissue is repairing
(Figure 8).

Figure 8 – In the radiographic postoperative examination with 113 days the left maxillary sinus met
total radiolucid, without velament, the bone in repairing and, the titanium mesh and screws
in correct position.
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SURGICAL CLINIC CASE PRESENTATION

To finalize, a view of the patient, observing the approach and the

reduction very satisfactory, functional and aesthetic (Figure 9).

Figure 9 – A view of the patient, observing the approach and the reduction very satisfactory,
functional and aesthetic.

DISCUSSION
The zygomatic orbital complex and the zygomatic arc are important
structures of the face and, probably, given to its localization, it’s more exposed to
traumas than other facial bones, except the nasal bones (ELLIS III, 1997;
MADEIRA, 1995 and SOBOTTA; BECHER, 2000). Even though some injuries
affect the orbital rim and the maxillary sinus isolated, most of the injuries of the
facial middle third will include the zygomatic complex.
The consequences of those fractures can include visual alterations,
facial aesthetic and compromise mandible mobility (BARROS; MANGANELLO-
SOUZA, 2000; GUIMARÃES, 2000 and MARZOLA, 2005).
The term zygomatic fracture refers to a fracture involving the facial
lateral middle third, even though, anatomically speaking this region is big, because it
includes the zygomatic complex (MADEIRA, 1995; FONSECA; WALKER, 1997;
SOBOTTA; BECHER, 2000 and MARZOLA, 2005).
After a 120 cases of zygomatic fracture study, it was developed a 6
group classification for the zygomatic fractures, after that was reduced to 4 groups
(KNIGHT; NORTH, 1961; MANGANELLO-SOUZA, 1982; BARROS;
MANGANELLO-SOUZA, 2000 and MARZOLA, 2005). After was elaborated a
new classification based in computerized tomography images, but all of them can fail
owing to the professional ability or the images techniques (BARROS;
MANGANELLO-SOUZA, 2000).
This dependence can generate serious errors of diagnosis and,
consequently, aesthetic and functional sequels to the patient, being subject to wrong
choices of treatment or delayed interventions (ARONOWITZ; FREEMAN;
SPIRA, 1986; ZIDE, 1986; ZACHARIADES; PAPAVASSILIOU;
PAPADEMETRIOU, 1990 and MARZOLA, 2005).
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The computerized tomography seems to be the most indicated option

for diagnosis, based in images, of a zygomatic fracture. It provides a tri dimensional
view, different to the conventional radiograph. The only disadvantage is that
important anatomic structure can be hided because of any metallic restoration
(PETERSON; ELLIS III; HUPP, 2000 and PASLER, 2001).
Radiographic techniques, such as waters projection, Hirtz, and lateral
view of the skull, can be very useful even though its limitations (GERHARDT de
OLIVEIRA; RAMOS; OLIVEIRA, 1999; DINGMAN; NATVIG, 2001 and
MARZOLA, 2005). Another important factor it’s the socio-economic factor,
knowing that the computerized tomography are a very expensive exam
(GERHARDT de OLIVEIRA; RAMOS; OLIVEIRA, 1999; DINGMAN;
NATVIG, 2001; GOMES, 2004 and MARZOLA, 2005).
The human face it’s not perfectly symmetric. It can be notice normal
differences between both sides (MILLS; SPRUILL; KANNE et al., 2001). The
clinical examination its based in comparing both sides, look for papillary symmetry,
presence of edema, ecchymosed etc (ELLIS III, EL-ATTAR; MOSS, 1985 and
MARZOLA, 2005). It has to be palpated symmetrically with 2 or 3 fingers, making
circular movement, trough the lateral, frontal superior and inferior portions (ROWE,
1985; FONSECA; WALKER, 1997 and MARZOLA, 2005). In the case of edema
that evaluation can be performed with pressure of the area (KRUEGER, 1984;
MACHADO, 1996; MOORE, 2004 and MARZOLA, 2005).
A trauma in the zygomatic complex usually leads to visual alteration,
temporal or permanent, in near a 90% of the cases, principally in the blow out facture
(FUJIMO, 1974; MANFREDI; RAJI; SPRINKLE et al., 1981; KAWAMOTO,
1982; AL-QURAINY; STASSEN; DUTTON et al., 1991; BECELLI; RENZI;
MANNINO et al., 2004 and MARZOLA, 2005).
A complete ocular evaluation are very important to detect ocular
trauma that can compromise the vision, traumas such as, hemorrhage, corneal
abrasions, dilacerations of the globe or even a rupture of the optic nerve, frequently
injured by the trauma (JUNGELL; LINDQVIST, 1987; BAHR; BAGAMBISA;
SCHLEGEL et al., 1992; LEW; BIRBE, 2000 and MARZOLA, 2005). The early
treatment has a better prognosis, knowing that a late treatment will not fully
reestablish a dystopia and/or enophthalmia (MCCOY; CHANDLER; MAGNAN et
al., 1962; CRUMLEY; LEINSOHN, 1976 and MARZOLA, 2005).
The etiology of the zygomatic fracture is related with the population
that it’s been studied (CARR; MATHOG, 1997; GASSNER; TULI; RUDISCH et
al., 2003; MOTAMEDI, 2003 and MARZOLA, 2005). Most of the studies show
male as the most affected, mostly young, between the 21 and 30 years (UGBOKO;
ODUSANYA; FAGADE, 1998), 20 and 29 years (ANDRADE-FILHO, 2000), 11
and 30 years (REIS, MARZOLA; TOLEDO-FILHO et al., 2001 and
MARZOLA, 2005) and, between 15 and 24 years (KIESER; STEPHENSON;
LISTON et al., 2002),
Traffic accidents are reported as the principal responsible of this
injury (ANDRADE FILHO, 2000; IIDA, 2001; SÁ LIMA; KIMAID; KIMAID,
2001; KLENK; KOVACS, 2003; MOTAMEDI, 2003 and MARZOLA,
2005),with a 90,1% of the cases (AKSOY, UNLU; SENSOZ, 2002). Other causes
can be physical aggressions and falls. (REIS, MARZOLA; TOLEDO-FILHO et
al., 2001; GASSNER; TULI; RUDISCH et al., 2003 and MARZOLA, 2005).
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 975
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There are some factors to be considered in the treatment for example,

the type of fracture, region, signs and symptoms, edema, health state of the patient
(MARTIN; TRABUE; LEECH, 1956; ELLIS III, 1998 and MARZOLA, 2005).
The rigid fixation with plates and screws is much recommended for a
stable and aesthetic rehabilitation, and reducing the patients discomfort
(MICHELET; DEYMES, 1973; GRUSS; VAN WYCK; PHILLIPS et al. 1990;
ELLIS III, 1993; ARAGON; WEISMANN, 1996; GONÇALES, 1999 and
MARZOLA, 2005).
Simple fractures without dislocation do not have to be fixated with
plates; the treatment depends of the surgeon varying the techniques that can be with,
Ginestet hook, Carrold Girarg screw, or Gillies access, not compromising aesthetic
(ARAGON; WEISMANN, 1996; VRIENS; VAN DER GLAS, H.W.; MOOS et
al., 1998 and BARROS; MANGANELLO-SOUZA, 2000)
Access for the rigid fixation has to be simple and do not compromises
aesthetic, basically by a subciliar incision, or a Caldwell Luc access (MICHELET;
DEYMES, 1973; ARAGON; WEISMANN, 1996; ELLIS III, 1996; BENÍCIO;
ARUAUZ, 2002 and MARZOLA, 2005). QUIN (1977), corroborates for GRUSS;
VAN WYCK; PHILLIPS et al., (1990)

CONCLUSIONS
Based on the objectives and the case report we can conclude that:
1. The intimate relation of the zygomatic complex with other facial
structures can lead in aesthetic compromising when injured.
2. Good diagnose depends on efficient physical evaluation and a
complete radiographic examination.
3. A diagnoses by images is better by a computerized tomography.
That let evaluate, not only the osseous injury but also the soft tissue and ocular globe.
4. Principal victims of a zygomatic complex fracture are young males.
5. Traffic accidents are the principal cause of this type of injury.
6. Internal rigid fixation is very important to a fully aesthetic and
functional reestablishment.
7. Sub-ciliary’s incision is the best choice, for presenting a less
marked scar in the postoperative.
8. The use of bioabsorbables materials reduces the possibilities to
have complications and the necessity of new intervention.

REFERENCES *
AFZELIUS, L. E.; ROSÉN, C. Facial fractures: a review of 3688 cases. Int J oral
Surg. v .9, n. 1, p. 25-32, 1980.
AKSOY, E.; UNLU, E.; SENSOZ, O. A retrospective study on epidemiology and
treatment of maxillofacial fractures. J. Craniofac. Surg. v.13, n. 6, p. 772-5, 2002.
AL-QURAINY, I. A.; STASSEN, L. F. A.; DUTTON, G. N.; et al., The
characteristics of midfacial fractures and the association with ocular injury: a
prospective study. Br. J. oral Maxillofac. Surg., v. 29, n. 5, p. 291-301, 1991.
_________________________________________
* According the ABNT norms.
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 976
SURGICAL CLINIC CASE PRESENTATION

ALTONEN, M.; KOHONEN, A.; DICKHOFF, K. Treatment of zygomatic fractures:

internal wiring-antral-packing-reposition without fixation. J. Maxillofac. Surg., v. 4,
n. 2, p. 107-15, 1976.
ANDRADE-FILHO et al., Fraturas de mandíbula: análise de 166 casos. Rev. Assoc.
Méd. bras., v. 46, n. 3, p. 272-6, 2000.
ANTONYSHYN, O.; GRUSS, J. S.; KASSEL, E. E. Blow-in fractures of the orbit.
Plast. Reconstr. Surg., v. 84, n. 1, p. 10-20, 1989.
ARAGON; WEISMANN. Fixação rígida em fraturas do arco zigomático. Rev.
Odonto Ciência; v. 21, n. 1, p. 133-38, jan., 1996.
ARONOWITZ, J. A.; FREEMAN, B. S.; SPIRA, M. Long-term stability of Teflon
orbital implants. Plast. Reconstr. Surg., v. 78, n. 2, p. 166-73, 1986.
BAHR, W.; BAGAMBISA, F. B.; SCHLEGEL, G. et al., Comparison of
transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a
retrospective study. Plast Reconstr Surg., v. 90, n. 4, p. 585-91, 1992.
BALLE, V.; CHRISTENSEN, P. H.; GREISEN, O. et al., Treatment of zygomatic
fractures: a follow-up study of 105 patients. Clin. Otolaryngol., v. 7, n. 6, p. 411-16,
1982.
BARROS, J. J.; MANGANELLO-SOUZA, L. C. Traumatismo Buco-Maxilo-Facial.
2a. ed. São Paulo: Ed. Roca, 2000.
BECELLI, R.; RENZI G.; MANNINO, G. et al., Postraumatic obstruction of
lachrymal pathways: a retrospective analysis of 58 consecutive nasoorbitoethmoid
fractures. J. Craniofac. Surg., v.15, n.1, p.29-33, 2004.
BENÍCIO, F. G.; ARAUZ, R. M. Tratamento das fraturas do complexo zigomático-
maxilar. Trabalho de graduação em Odontologia. Faculdade de Ciências da Saúde.
São José dos Campos: Universidade do Vale do Paraíba, 2002.
CARR, R. M.; MATHOG, R. H. Early and delayed repair of orbitozygomatic
complex fractures. J. oral Maxillofac. Surg., v. 55, n. 3, p. 253-8, 1997.
CASTELLANI, A; NEGRINI, S.; ZANETTI, U. Treatment of orbital floor blowout
fractures with conchal auricular cartilage graft: a report on 14 cases. J. oral
Maxillofac. Surg., v. 60, n. 12, p. 1413-7, 2002.
CHAUSHU, G.; MANOR, Y.; SHOSHAMI, Y. et al., Risk factors contributing to
symptomatic plate removal in maxillofacial trauma patients. Plast. Reconstr. Surg.,
v. 105, p. 521-5, 2000.
CONVERSE, J. M.; SMITH, B. Enophtalmos and diplopia in fractures of the orbital
floor. Br. J. Plast. Surg. v. 9, p. 265, 1957.
CRUMLEY, R.L.; LEIBSOHN, J. Enophthalmos and diplopia in orbital floor
fractures. Trans. Pac. Coast Otoophthalmol. Soc. Annu. Meet. v. 57, p. 105-9, 1976.
DINGMAN, R. O.; NATVIG, P. Cirurgias das Fraturas Faciais. 2a ed, São Paulo:
Ed. Santos, 2001.
ELLIS III, E.; EL-ATTAR, A.; MOOS, K. F. An analysis of 2,067 cases of
zygomaticoorbital fracture. J. oral Maxillofac. Surg., v. 43, n. 6, p. 417-28, 1985.
ELLIS III, E. Rigid skeletal fixation of fractures. J. oral Maxillofac. Surg., v. 51, n.
2, p. 163-73, 1993.
ELLIS III, E.; ZIDE, M. F. Surgical approaches to the facial skeleton. Philadelphia:
Ed. Williams & Wilkis, 1995.
ELLIS III, E.; KITTIDUMKERNG, W. Analysis of treatment for isolated
zygomaticomaxillary complex fractures. J. oral Maxillofac. Surg., v. 54, n. 4, p. 386-
400, 1996.
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 977
SURGICAL CLINIC CASE PRESENTATION

ELLIS III, E. Fractures of the zygomatic complex and arch. In: FONSECA R.;
WALKER, R. V.; BETTS, N. J. et al., Oral and maxillofacial trauma. 2a ed.
Philadelphia: Ed. W. B. Saunders, p.571-632, 1997.
ELLIS III E. Complications of mandibular condyle fractures. Int. J. oral Maxillofac.
Surg., v. 27, p. 255-7, 1998.
ELLIS III, E.; ZIDE, M. F. Acesso Cirúrgico ao Esqueleto Facial. 2a ed. São Paulo:
Ed. Santos, 2006.
FONSECA, R. J.; WALKER, R. V. W. Oral and maxillofacial trauma. 2a ed. St.
Louis: W. B. Saunders, 1997.
FORREST, C. R.; KHAIRALLAH, E.; KUZON, W. M. Intraocular and intraorbital
compartment pressure changes following orbital bone grafting: a clinical and
laboratory study. Plast. Reconstr. Surg. v.104, n.1, p.48-54, 1999.
FUJIMO, T. Experimental blow-out fracture of the orbit. Plast. Reconstr. Surg., v.
54, 1974.
GASSNER, R.; TULI, T.; RUDISCH, A. et al., Cranio-maxillofacial trauma: a 10-
year review of 9543 cases with 21067 injuries. J. Craniomaxillofac. Surg., v. 31, n.
1, p. 51-61, 2003.
GERHARDT de OLIVEIRA, M.; RAMOS, A.; OLIVEIRA, R. B. Estudo descritivo
de sinais e sintomas das fraturas no complexo orbital e avaliação radiográfica pela
incidência de Waters. Rev. Fac. Odont. Passo Fundo. v. 4, n. 2, p. 53-6, jul.,/dez.,
1999.
GILHOOLY, M. G.; FALCONER, D. T.; WOOD, G. A. Orbital subperiosteal
abscess and blindness complicating a minimally displaced zygomatic complex
fracture. Br. J. oral Maxillofac. Surg. v. 33, n. 3, p. 185-8, 1995.
GOMES, P. P. Estudo epidemiológico das fraturas do complexo zigomático-orbitário
e arco zigomático tratadas pela Área de Cirurgia e Traumatologia Buco-Maxilo-
Faciais da Faculdade de Odontologia de Piracicaba. Tese de Doutorado em
Odontologia Clínica – Departamento de Cirurgia e Traumatologia Buco-Maxilo-
Faciais. Piracicaba: Universidade de Campinas, 2004.
GONÇALES, E. S. et al., Postoperative evaluation of unilateral zygomatic complex
fractures treated by open reduction and internal fixation. Salusvita, Bauru, v. 18, n. 1,
p. 53-68, 1999.
GRUSS, J. S.; VAN WYCK, L.; PHILLIPS, J. H. et al., The importance of the
zygomatic arch in complex midfacial fracture repair and correction of posttraumatic
orbitozygomatic deformities. Plast. Reconstr. Surg., v. 85, n. 6, p. 878-90, 1990.
GUIMARÃES, P. S. M. et al., Prevalência de fraturas maxilofaciais atendidas no
ambulatório do hospital municipal de São José dos Campos. Rev. da Assoc. paul.
Cir. Dent. São José dos Campos. v. 1, n. 2, p. 8-13, 2000.
IATROU, I.; ANGELOPOULOS, A.; THEOLOGIE-LYGIDAKIS, N., Use of
membrane and bone grafts in the reconstruction of orbital fractures. Oral Surg. Oral
Med. Oral Pathol. Oral Radiol. Endod, v. 91, n. 3, p. 281-6, 2001.
JANK, S. et al., Clinical signs of orbital wall fractures as a function of anatomic
location. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod., v. 96, p.1 49-53,
2003.
JUNGELL, P.; LINDQVIST, C. Paraesthesia of the infraorbital nerve following
fracture of the zygomatic complex. Int J oral Maxillofac Surg. v. 16, n. 3, p. 363-67,
1987.
KAWAMOTO-JUNIOR, H. K. Late posttraumatic enophthalmos: a correctable
deformity? Plast. Reconstr. Surg. v. 69, n. 3, p. 423-32, 1982.
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 978
SURGICAL CLINIC CASE PRESENTATION

KIESER, J.; STEPHENSON, S.; LISTON, P. N. et al., Serious facial fractures in

New Zealand from 1979 to 1998. Int. J. oral Maxillofac. Surg. v. 31, n. 2, p. 206-9,
2002.
KLENK, G.; KOVACS, A. Etiology and patterns of facial fractures in the United
Arab Emirates. J. Craniofac. Surg. v. 14, n. 1, p. 78-84, 2003.
KNIGHT, J. S.; NORTH, J. F. The classification of malar fractures: an analysis of
displacement as a guide to treatment. Br. J. Plast. Surg. v. 13, p. 325-39, 1961.
KOSAKA, M. et al. Orbital wall reconstruction with bone grafts from the outer
cortex of the mandible. J. Cranio Maxillofac. Surg., Stuttgart, v. 32, p. 374-80, 2004.
KRISHNAN, V.; JOHNSON, J. V.; Orbital floor reconstruction with autogenous
mandibular symphyseal bone grafts. J. oral Maxillofac. Surg., Philadelphia, v. 55, p.
327-30, 1997.
KRUGER, G. O. Fraturas dos maxilares. In: KRUGER, G. O. Cirurgia bucal e
maxilo-facial. 5a ed. Rio de Janeiro: Ed. Guanabara/Koogan,. 1984, p. 244-96
LEW, D. Midfacial trauma: Diagnosis and treatment. Selected Read in Oral and
Maxillofac Surg, v. 1, n. 6, p. 1-28. 1991.
LEW, D.; BIRBE, J. Zygomatic complex fractures. In: FONSECA, R. J. Oral and
maxillofacial surgery. Philadelphia: Ed. W. B. Saunders, 2000.
MACHADO, I. R. Tratamento tardio de fraturas do osso zigomático e suas seqüelas.
Cad. Doc. v. 5, n. 2, p. 352-63, jun.,/jul., 1996.
MADEIRA, M.C. Anatomia da face. Bases anátomo-funcionais para a prática
odontológica. São Paulo: Ed. Savier, 1995.
MAKOWSKI, G. J.; VAN SICKELS, J. E. Evaluation of results with three-point
visualization of zygomaticomaxillary complex fractures. Oral Surg. Oral Med. Oral
Patho. Oral Radiol. Endod., v. 80, n. 6, p. 624-8, 1995.
MANFREDI, S. J.; RAJI, M. R.; SPRINKLE, P. M. et al., Computerized
tomographic scan findings in facial fractures associated with blindness. Plast
Reconstr. Surg., v. 68, n. 4, p. 479-90, 1981.
MANGANELLO-SOUZA, L. C. Análise de 144 casos de fratura do Malar.
Dissertação de Mestrado em Clínica Cirúrgica. Faculdade de Medicina. São Paulo:
Universidade de São Paulo, 1982.
MARTIN, B. C.; TRABUE, J. C.; LEECH, T. R. An analysis of the etiology,
treatment and complications of fractures of the malar compound and zygomatic.
Arch. Am. J. Surg., v. 92, n. 6, p. 920-4, 1956.
MARZOLA, C. Fundamentos de Cirurgia Buco Maxilo Facial. CDR, Bauru: Ed.
Independente, 2005.
MCCOY, F. J.; CHANDLER, R. A.; MAGNAN, C. G. et al., An analysis of facial
fractures and their complications. Plast. Reconst. Surg., v. 29, n. 4, p. 381-91, 1962.
MICHELET, F. X., DEYMES, J. Osteosynthesis with screwed plates in
maxillofacial surgery. Int. Surg. v. 58, p. 249-53, 1973.
MILLS, K. C.; SPRUILL, S. E.; KANNE, R. W. et al., The influence of stimulants,
sedatives and fatigue on tunnel vision: risk factors for driving and piloting. Human
Factors. v. 43, n. 2, p. 310-27, 2001.
MOORE, U.J. Princípios de Cirurgia Bucomaxilofacial. 5a ed. Porto Alegre: Ed.
Artmed. p. 199-201, 2004.
MOTAMEDI, M. H. An assessment of maxillofacial fractures: a 5-year study of 237
patients. J. oral. Maxillofac. Surg., v. 61, n. 1, p. 61-4, 2003.
 FRACTURES TREATMENT OF ZYGOMATIC COMPLEX 979
SURGICAL CLINIC CASE PRESENTATION

OLIVEIRA, R. B.; SILVEIRA. R. L.; MACHADO, R. A. et al., Utilização de

diferentes materiais de reconstrução em fraturas do assoalho de órbita: relato de seis
casos. Rev. Cir. Traumatol. Buco-Maxilo-Fac. v. 5, n. 3, p. 43-50, jul./set., 2005.
PASLER, F. A.; VISSER, H. Radiologia Odontológica. 2a ed., Rio de Janeiro, Ed.
Artmed, 331 pgs., 2001.
PETERSON, L. J.; ELLIS III, E.; HUPP, J. R. et al., Cirurgia Oral e Maxilofacial
Contemporânea. 3a ed. Rio de Janeiro: Guanabara/Koogan, 2000.
POLLEY, J. W.; RINGLER, S. L. The use of Teflon in orbital floor reconstruction
following blunt facial trauma: a 20-year experience. Plast Reconstr Surg. v. 79, n. 1,
p. 39-43, 1987.
QUINN, J. H. Lateral coronoid approach for intra-oral reduction of fractures of the
zygomatic arch. J. oral Surg., v. 35, n. 4, p. 321-2, 1977.
REIS, L. F.; MARZOLA, C.; TOLEDO-FILHO, J. L. et al., Prevalência de fraturas
faciais na região de Bauru, no período de janeiro de 1991 a dezembro de 1995. Rev.
Odonto Ciênc., v. 16, n. 34, p. 231-40, 2001.
ROWE, N. L. Fractures of the zygomatic complex and orbit. In: WILLIAMS, J. L.;
ROWE, N. L. Maxillofacial injuries. New York: Ed. Churchill Livingstone. p. 435-
537, 1985.
SÁ-LIMA, J. R.; KIMAID, A.; KIMAID, M. I. E. Estudo da prevalência das fraturas
mandibulares em relação ao sexo, faixa etária, fator etiológico e localização na
cidade de São José dos Campos. v. 8, n. 30, p. 150-5, 2001.
SEWALL, S. R.; PERNOUD, F. G.; PERNOUD, M. J. Late reaction to silicone
following reconstruction of an orbital floor fracture. J oral Maxillofac Surg. v. 44, n.
10, p. 821-25, 1986.
SOBOTTA, J.; BECHER, H. Atlas de Anatomia Humana. 21a ed. Rio de Janeiro: Ed.
Guanabara/Koogan; 2000.
TAJIMA, S. Malar bone fractures: experimental fractures on the dried skull and
clinical sensory disturbances. J. Maxillofac. Surg., v. 5, n. 2, p. 150-6, 1977.
TANAKA, T. et al., Evaluation of coronal CT findings of rare cases of isolated
medial orbital wall blow-out fractures. Dentomaxillofac. Radiol. v. 32, p. 300-3,
2003.
UGBOKO, V. I.; ODUSANYA, S. A.; FAGADE, O. O. Maxillofacial fracture in
semi-urban Nigeria teaching hospital. A review of 442 cases. Int. J. oral Maxillofac.
Surg., v. 27, n. 4, p. 286-9, 1998.
VRIENS, J. P. M.; VAN DER GLAS, H. W.; MOOS, K. F. et al., Infraorbital nerve
function following treatment of orbitozygomatic complex fractures. A multitest
approach. Int. J. oral Maxillofac. Surg., v. 27, n. 1, p. 27-32, 1998.
WHEAR, N. M.; COUSLEY, R. R.; LIEW, C. et al., Post-operative infection of
Proplast facial implants: review. Br. J. oral Maxillofac. Surg., v. 31, n. 5, p. 292-5,
1993.
ZACHARIADES, N.; PAPAVASSILIOU, D.; PAPADEMETRIOU, I. The
alterations in sensitivity of the infraorbital nerve following fractures of the
zygomaticomaxillary complex. J Craniomaxillofac Surg. v. 18, n. 7, p. 315-8, 1990.
ZIDE, M. F. Late posttraumatic enophthalmos corrected by dense hydroxylapatite
blocks. J. oral Maxillofac. Surg., v. 44, n. 10, p. 804-6, 1986.

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