Outcomes of transconjunctival approach and its modifications for the treatment of orbito-zygomatic complex fractures: A pilot study


1 Department of Oral and Maxillofacial Surgery, Rural Dental College, Ahmednagar, Maharashtra, India

2 Department of Periodontics, Rural Dental College, Ahmednagar, Maharashtra, India


Background and Objectives: Transconjunctival incision is used to access the floor of orbit and infraorbital rim; however, when continued with lateral canthotomy, it becomes a versatile approach to treat various types of zygomaticomaxillary fractures. The aim of this study was to evaluate the outcomes of transconjunctival approach and its modifications in terms of accessibility, esthetic outcome, and postoperative complications for the treatment of patients of orbito-zygomaticomaxillary complex fractures. Methods: In the hospital, a total of five cases of zygomatic complex fractures were operated from October 2019 to December 2019. The transconjunctival approach was assessed on the following criteria: adequacy and ease of exposure, time required for exposure of fracture site, accuracy of reduction of fracture, esthetic outcome, and postoperative complications (e.g., ectropion, entropion, chemosis, infection, and scarring). The patients were kept on follow-up for 6 weeks. Results: The average age of the patients was 26 years. The average time required for exposure of fracture site was 25.2 min. Exposure obtained in all the cases was adequate according to the operating surgeon. During postoperative follow-up, all the patients were evaluated for ectropion, entropion, chemosis, and infection. None of the patients reported with any complications, and the postoperative esthetic results were satisfactory (according to the patient). Conclusion: The transconjunctival approach is an efficient approach to gain surgical access to infraorbital rim and zygomatic complex fractures. With good exposure and nonvisible scar, transconjunctival approach is superior to other techniques. The numerous advantages of this approach nullify the longer time taken for the procedure.


1. Ellis E 3rd. Fractures of the zygomatic complex and arch. In: Fonseca RJ, Walker RF, editors. Oral and Maxillofacial Trauma. Philadelphia, U. S: WB Saunders; 1991. p. 583‑94.
2. Dawson RL, Fordyce GL. Complex fractures of the middle third of the face and their early treatment. Br J Surg 1953;41:255‑68.
3. Middleton DS. Management of injuries of the nose and upper jaw. Proc R Soc Med 1953;46:476‑9.
4. Kumar S, Shubhalaksmi S. Clinical outcome following use of transconjunctival approach in reducing orbit zygomaticomaxillary complex fractures. Contemp Clin Dent 2016;7:163.
5. Hazrati E, Waite P, Carr DD. The transconjunctival approach for treating orbital trauma. Plast Reconstr Surg 1992;90:151.
6. Rajkumar K, Mukhopadhyay P, Sinha R, Bandyopadhyay TK. ‘Y’ modification of the transconjunctival approach for management of zygomatic complex fractures: A prospective analysis. J Maxillofac Oral Surg 2016;15:45‑51.
7. Tenzel RR, Miller GR. Orbital blow‑out fracture repair, conjunctival approach. Am J Ophthalmol 1971;71:1141‑2.
8. Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1973;1:3‑8.
9. Converse JM, Firmin F, Wood‑Smith D, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg 1973;52:656‑7.
10. Wray RC, Holtmann B, Ribaudo JM, Keiter J, Weeks PM. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 1977;30:142‑5.
11. Manganello‑Souza LC, Rodrigues de Freitas R. Transconjunctival approach to zygomatic and orbital floor fractures. Int J Oral Maxillofac Surg 1997;26:31‑4.
12. Sullivan GM, Artino AR Jr. Analyzing and interpreting data from likert‑type scales. J Grad Med Educ 2013;5:541‑2.
13. Miloro M, Ghali GE, Larsen P, Waite PD. Peterson’s Principles of Oral and Maxillofacial Surgery. 3rd ed. USA: People’s Medical Publishing House; 2011. p. 465‑69.
14. Leech TR, Martin BC, Trabue JC. An analysis of the etiology, treatment and complications of fractures of the malar compound and zygomatic arch. Am J Surg 1956;92:920‑4.
15. Chang EL, Hatton MP, Bernardino CR, Rubin PA. Simplified repair of zygomatic fractures through a transconjunctival approach. Ophthalmology 2005;112:1302‑9.
16. Yamsani B, Gaddipati R, Vura N, Ramisetti S, Yamsani R. Zygomaticomaxillary complex fractures: A review of 101 Cases. J Maxillofac Oral Surg 2016;15:417‑24.
17. Starch‑Jensen T, Linnebjerg LB, Jensen JD. Treatment of zygomatic complex fractures with surgical or nonsurgical intervention: A retrospective study. Open Dent J 2018;12:377‑87.
18. Santosh BS, Giraddi G. Transconjunctival preseptal approach for orbital floor and infraorbital rim fracture. J Maxillofac Oral Surg 2011;10:301‑5.
19. Wesley RE. Transconjunctival approaches to the lower lid and orbit. J Oral Maxillofac Surg 1998;56:66‑9.
20. Baumann A, Ewers R. Use of the preseptal transconjunctival approach in orbit reconstruction surgery. J Oral Maxillofac Surg 2001;59:287‑91.
21. Novelli G, Ferrari L, Sozzi D, Mazzoleni F, Bozzetti A. Transconjunctival approach in orbital traumatology: A review of 
56 cases. J Craniomaxillofac Surg 2011;39:266‑70.
22. Barcic S, Blumer M, Essig H, Schumann P, Wiedemeier DB, Rücker M, et al. Comparison of preseptal and retroseptal 
transconjunctival approaches in patients with isolated fractures of the orbital floor. J Craniomaxillofac Surg 2018;46:388‑90.
23. Bruneau S, Scolozzi P. Preseptal transconjunctival approach to the orbital floor fractures. Surgical technique. Rev Stomatol Chir Maxillofac Chir Orale 2015;116:362‑7.
24. Ellis E 2nd, Zide M. Transconjunctival Approaches. In: Surgical Approaches to Facial Skeleton, Ellis E III, Zide M, editors. Philadelphia, U. S; Lipincott Williams and Wilkins; 2006. p. 41‑64.
25. Martinez AY, Bradrick JP. Y modification of the transconjunctival approach for management of zygomaticomaxillary complex fractures: A technical note. J Oral Maxillofac Surg 2012;70:97‑101.
26. GanderT, RostetterC, BlumerM, WagnerM, SchumannP, WiedemeierDB, et al. Use of a monopolar microneedle device in a transconjunctival, retroseptal approach. J Craniomaxillofac Surg 2017;45:1934‑7.
27. Saluja H, Sachdeva S, Shah S, Dadhich A, Singh M, Mishra S. Ten‑year review of facial bone fractures in rural population at a teaching institute in central India (Maharashtra). J Head Neck Physicians Surg 2020;8:23.
28. Saluja H, Sachdeva S, Shah S, Dadhich A, Tandon P. Autogenous grafts for orbital floor reconstruction: A review. Int J Oral Craniofac Sci 2017;3:046‑52.
29. Rudagi BM, Halli R, Mahindra U, Kharkar V, Saluja H. Autogenous mandibular symphysis graft for orbital floor reconstruction: A preliminary study. J Maxillofac Oral Surg 2009;8:141‑4.
30. Pausch NC, Sirintawat N, Wagner R, Halama D, Dhanuthai K. Lower eyelid complications associated with transconjunctival versus subciliary approaches to orbital floor fractures. Oral Maxillofac Surg 2016;20:51‑5.