J Oral Maxillofac Surg

68:28-34, 2010

Navigation-Guided Reduction and

Orbital Floor Reconstruction in the
Treatment of Zygomatic-Orbital-Maxillary
Complex Fractures
Hongbo Yu, DDS, MD,* Guofang Shen, DDS, MD,†
Xudong Wang, DDS, MD,‡ and Shilei Zhang, DDS, MD§

Purpose: To evaluate the effectiveness of image-guided navigation on open reduction and orbital floor
reconstruction as treatment for zygomatic-orbital-maxillary complex fractures.
Patients and Methods: Six patients with zygomatic-orbital-maxillary complex fractures were enrolled
in the present study. With preoperative planning and 3-dimensional simulation, the normal anatomic
structures of the deformed area were recreated by superimposing and comparing the unaffected side
with the affected side. The position of dislocated bone for reduction was defined, and surgical simulation
was performed. All patients underwent open reduction and orbital floor reconstruction under the
guidance of the navigation system.
Results: A fairly accurate match between the intraoperative anatomy and the computed tomography
images was achieved through registration, with a systematic error of 1-mm difference. With guidance of
the navigation system, open reduction of zygomatic-orbital-maxillary complex fractures and orbital floor
reconstruction were performed in all cases. The reduction was checked by postoperative computed
tomography scans, with a good match with preoperative planning noted. The maximal deviation
between the reduction and preoperative planning was less than 2 mm. The symptoms associated with
the orbital floor defects were eliminated, and the postoperative facial appearance of the patients was
clearly improved.
Conclusion: Navigation-guided open reduction of zygomatic-orbital-maxillary complex fractures with
orbital floor reconstruction can be regarded as a valuable treatment option for this potentially compli-
cated procedure.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:28-34, 2010

The zygomatic-orbital-maxillary complex fracture is
known as one of the most prevailing facial injuries. It
can cause secondary morphologic disfigurement and
functional impairment, including ocular motility re-
striction, facial asymmetry, and so forth.1 Inadequate
treatment or the absence of initial treatment can re-
sult in a decrease in the anteroposterior projection of
the zygomatic body and a increase of the facial width
resulting from collapse and outward bowing of the
zygomatic arch.2 Enophthalmos and diplopia are com-
plications in post-traumatic orbital deformities due to
the enlargement of the orbital volume.3 As a conse-
quence of the remodeling process, no obvious edges
of the fracture are available that could serve as land-

Received from the Department of Oral and Maxillofacial Surgery,
Ninth People’s Hospital, Shanghai Jiao Tong University School of
Medicine, Shanghai, People’s Republic of China.
*Attending Doctor.
†Professor.
‡Associate Professor.
§Associate Professor.
This study was supported by grant 30872906 from the Na-
tional Natural Science Foundation of China and grant 074119511
from Key Project of Shanghai Scientific and Technological Com-
mission.
Address correspondence and reprint requests to Dr Shen: Department
of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao
Tong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011
People’s Republic of China; e-mail: maxillofacsurg@163.com
© 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6801-0006$36.00/0
doi:10.1016/j.joms.2009.07.058

28
YU ET AL 29

Table 1. PATIENT CHARACTERISTICS

Clinical Examination Findings

Age Trauma Facial Ocular Motility Infraorbital
Pt. No. (yrs) Gender Trauma Side Etiology Duration (mo) Asymmetry Diplopia Enophthalmos Restriction Hypoesthesia

1 21 Male Right Traffic 3 Yes Yes Yes No No

2 24 Female Left Traffic 1 Yes No Yes Yes Yes
3 31 Male Right Assault 10 Yes Yes Yes Yes Yes
4 39 Female Right Traffic 6 Yes Yes Yes Yes Yes
5 27 Male Left Traffic 5 Yes No Yes No No
6 23 Male Right Traffic 3 Yes Yes Yes Yes No
Yu et al. Navigation-Guided Reduction and Orbital Floor Reconstruction. J Oral Maxillofac Surg 2010.

marks for correct repositioning.4 Furthermore, surgi-
cal exposure does not offer surgeons an unobstructed
view of the entire facial skeleton.5 These conditions
could result in over- or underestimation of the dis-
placement, leading to unsatisfactory outcomes caused
by over- or undercorrection.6 Precise repositioning of
the fractured bones, especially for the zygomatic-or-
bital-maxillary complex fractures, is key to ultimately
restore the normal function and esthetics of the mid-
face, a surgical challenge.4,7,8 Image-guided naviga-
tion has shown great potential for clinical appli-
cations, particularly when precise location of any
instrument or bony anatomic landmark is required.
In maxillofacial surgery, navigation technology was
extensively introduced in procedures such as foreign
body removal, tumor resection, deformity correction,
craniomaxillofacial reconstruction, and implanta-
tion.9-12 With the help of surgical navigation, precise
and predictable results were achieved in the recon-
struction of the medial orbital wall and floor.7 Com-
puter-assisted navigation was also used to reposition
the zygoma.2,13,14 For real-time instrument position-
ing and clear anatomic identification, computer-as-
sisted navigation is exceptionally helpful in maxillo-
facial fracture reduction. However, few reports have
documented the application of navigation-guided re-
duction and orbital floor reconstruction in the treat-
ment of zygomatic-orbital-maxillary fractures.
In the present report, we have described our expe-
rience and results using navigation-guided open re-
duction of displaced comminuted bones and orbital
floor reconstruction as treatment of zygomatic-orbital-
maxillary complex fractures in various clinical cases.
The 6 patients (4 men and 2 women) had a median
age of 27 years (range, 21 to 39), and the trauma had
occurred 1 to 10 months before surgery. Five of the
fractures had been caused by vehicular accidents and
1 by an assault. The treatment was delayed for 4
patients because of concomitant craniofacial or mul-
tisystemic injuries. Malunion had occurred in 2 pa-
tients secondary to previous improper reduction. All
patients had facial asymmetry (flattened malar emi-
nence and increased facial width on the affected side)
and enophthalmos. Of the 6 patients, 4 had diplopia
and ocular motility restriction, 3 had infraorbital hy-
poesthesia (Table 1).
Five positioning screws as navigation markers had
been implanted on maxillary alveolar bone (Fig 1). A
preoperative thin-cut (0.625-mm), spiral, computed
tomography (CT) scan (Light speed 16, GE, Glouces-
tershire, United Kingdom) was obtained for all 6 pa-
tients. The patients’ individual anatomy was assessed
using Mimics software, version 8.11 (Materialise, Leu-
ven, Belgium) in multiplanar (axial, coronal, and sag-
ittal) and 3-dimensional (3D) views. The median sag-
ittal plane was used as reference plane. The normal

Patients and Methods

Six patients with functional disabilities and esthe-
tic deformities caused by zygomatic-orbital-maxillary
complex fractures were admitted to the Department
of Oral and Maxillofacial Surgery, Ninth People’s Hos-
pital, Shanghai Jiao Tong University School of Medi-
cine, Shanghai, China, from July 2007 to August 2008.
FIGURE 1. Positioning screws as navigation markers implanted in
maxillary alveolar bone.
Yu et al. Navigation-Guided Reduction and Orbital Floor Recon-
struction. J Oral Maxillofac Surg 2010.
30 NAVIGATION-GUIDED REDUCTION AND ORBITAL FLOOR RECONSTRUCTION

parison, the position of the displaced segments to be

FIGURE 2. Preoperative simulation showing normal contour and
position of displaced bone to be as defined on 3D virtual model
using a mirror tool.
Yu et al. Navigation-Guided Reduction and Orbital Floor Recon-
struction. J Oral Maxillofac Surg 2010.
anatomic structures of the target area were mirrored
from the unaffected side, such that the desired con-
tour of the affected zygomatic-orbital-maxillary com-
plex could be visualized. With the side-to-side com-
reduced was defined and displayed on a 3D recon-
struction image with different colors (Fig 2). Virtual
osteotomy and reduction was performed on the 3D
model. Once the simulation was completed, the original
and simulated virtual data sets were imported into an
intraoperative navigation system (TBNavis multifunc-
tional surgical navigation system, Shanghai, China).
Intraoperative navigation was performed using
frameless stereotaxy, with infrared cameras tracking the
navigation pointer and trackers. The patient’s position
was identified using a digital reference frame, which
was rigidly fixed to the patient’s forehead (Fig 3A).
Instrument orientation was determined by reference
markers (light-reflecting balls), which were attached to
the handle of the surgical instrument. The light-reflect-
ing balls of the digital reference frame and those on the
instruments reflected the infrared rays emitted by cam-
eras, allowing the system to track their position. The
virtual image on the workstation was matched with the
patient by individual registration using the 5 positioning
screws, which had been implanted in the maxillary

FIGURE 3. Intraoperative navigation. A, Digital reference frame fixed rigidly on the patient’s forehead. B, Patient and virtual image on
workstation matched by individual registration with 5 positioning screws. C, Fracture reduction performed with guidance of TBNavis
navigation system.
Yu et al. Navigation-Guided Reduction and Orbital Floor Reconstruction. J Oral Maxillofac Surg 2010.
YU ET AL
alveolar bone preoperatively (Fig 3B). Tracking informa-
tion was then processed by the TBNavis system and
merged with the 3D craniomaxillofacial model, provid-
ing surgeons with continuous 3D positioning of the
instruments. Registration accuracy was checked visually
for every patient by repeatedly pinpointing the ana-
tomic landmarks (eg, maxillary incisor point, dental
cusp).
All patients underwent anatomic reduction of the
fracture fragments and orbital floor reconstruction
using the guidance of the TBNavis system. The zygo-
matic-orbital-maxillary complex of affected side was
exposed by semicoronal, subconjunctival, and in-
traoral incisions. A preauricular approach was also
required in 1 patient. The dislocated bone segments
were released and repositioned according to the pre-
operative plan and simulation. The intraoperative nav-
igation probe was then placed on multiple different
areas of the mobilized bone segment to precisely
confirm or modify the reduction (Fig 3C). Once the
actual reduction accurately approximated the pre-
planned position, internal fixation was applied. Tita-
nium mesh was used to reconstruct the orbital floor in
3 patients with orbital floor defects.
Ophthalmologic examinations were performed on
the first and fifth postoperative day, and the facial
symmetry was evaluated 4 weeks after surgery. A
postoperative CT scan was obtained 3 to 5 days after
surgery. Quantitative postoperative evaluation of the
intervention was performed. The postoperative 3D
image of the unaffected side was mirrored and super-
imposed on the affected side. The maximal deviation
of the reduction between the virtual plan and the
achieved results was analyzed.
Results
The preoperative planning, including the genera-
tion of virtual models and intraoperative navigation,
was successfully achieved in all cases. The registration
discrepancy was less than 1 mm, as verified by ana-
tomic landmark visual checking. After surgical explo-
ration, the proposed osteotomies were localized with
the intraoperative navigation system. Dislocated bone
segments were mobilized with a sagittal saw and os-
teotome. Using the guidance of the navigation system,
the position of the probe and surgical instruments was
shown real-time on a screen. The probe of the TBNavis
system was used not only to navigate the deformed
contour of the affected side, but also to check the
desired position to which the displaced bone was to be
reduced. According to the preplanned virtual contour,
the titanium mesh was modeled into patient-specific
implant. Next, it was used to reconstruct the orbital
floor in 3 patients with a bony defect.
31
All patients underwent uneventful healing without
any serious complications. The ophthalmologic exam-
ination performed 4 weeks after surgery verified the
elimination of diplopia, enophthalmos, and ocular
motility restriction in all cases. The previous fac-
ial asymmetry caused by zygomatic-orbital-maxillary
complex malunion was completely corrected (Fig 4).
The sensitivity of the infraorbital area had improved
by 4 weeks after surgery. The reduction of the frac-
ture segments was checked by postoperative CT, and
good matching with the preoperative planning was
achieved (Fig 5). The maximal deviation between the
preoperative design and actual surgical results for
each patient was less than 2 mm (Fig 6).
Discussion
Navigation technology is based on the synchroniza-
tion of the intraoperative position of the instruments
with the imaging of the patient’s anatomy previously
obtained by CT or magnetic resonance imaging.15 The
synchronization is realized through image registra-
tion, the process of computing and mapping the sys-
tem coordinates of the preoperative planning CT im-
ages and that of the actual patient during the surgical
procedure. After the registration is performed, the
orientation and position of any tracked instrument
can be displayed on-screen, showing its real-time re-
lationship to the preoperative images and actual sur-
gical anatomy.
Using image-guided navigation, interactive, intra-
operative application of 3D image data has been
realized.16 By matching the contours of the mobile
segment with the preoperative plan, computer-as-
sisted navigation can be used to guide the reduc-
tion. Navigation-aided procedures have proved to be
an essential precondition for achieving precise and
predictable results in the treatment of zygomatic-or-
bital-maxillary complex fractures.
The protocols in the present report were for uni-
lateral maxillofacial fractures. Because most traumatic
or tumor-related facial deformities are unilateral, us-
ing the described mirror tool (normal side to affected
side) in navigation-aided surgery is an ideal adjunct to
precise rehabilitation of the facial symmetry. It is
based on the assumption that the facial bony contour
of any given individual is symmetric. Although studies
have shown measurable differences exist in the or-
bital volume for any given individual, the differences
are small and have no significant effect on facial ap-
pearance and function.17
The technical system accuracy has been widely
reported to be less than 1 mm, and the intraoperative
precision for a patient has been 1 to 2 mm.18-20 A
number of factors influence the accuracy of a naviga-
tion system, including the imaging data resolution,
32 NAVIGATION-GUIDED REDUCTION AND ORBITAL FLOOR RECONSTRUCTION

FIGURE 4. Comparisons between preoperative and postoperative portraits. A, B, Preoperative photographs reveal facial asymmetry and
enophthalmos on the left side. C, D, Postoperative photographs show improved facial symmetry and elimination of enophthalmos.
Yu et al. Navigation-Guided Reduction and Orbital Floor Reconstruction. J Oral Maxillofac Surg 2010.

registration precision, computer algorithm accuracy,
and so forth.16 However, image drift is one of the
most indispensable factors influencing system accu-
racy. It results from systematic image drift and struc-
tural image drift. The former is related to framework
loosening and the markers gliding during registration.
The latter is caused by intraoperative topographic
changes resulting in discrepancies between the pre-
operative image data and the surgical site. As long as
surgeons were aware of the limitations of the system
and regularly performed a recalibration using ana-
tomic landmarks, the TBNavis navigation system
proved to be a useful supplement in the treatment of
zygomatic-orbital-maxillary complex fractures.
The registration mode used also has a decisive in-
fluence on the precision of the system. Registration
errors can be caused by shifting, or unfavorable spa-
tial distribution of the markers. Calibration using an-
atomic landmarks is not precise enough and could
lead to 2 to 5-mm divergence.21 Five cortical fixed
screws on maxillary alveolar bone were used for reg-
istration because of the benefits of immobility, high
accuracy, and minimal invasiveness. Also, bone is
always regarded as rigid and has minimal deformation.
Thus, both systematic and structural image drift were
decreased, and system accuracy was guaranteed. The
postoperative CT scan verified that the maximal devi-
ation between the preoperative plan and the actual
surgical results for each patient was less than 2 mm.
Numerous reconstruction methods are available for
the orbital floor, including the use of alloplastic ma-
terials, autogenous bone grafts, and others.3,22,23 Ap-
propriate reconstruction of the orbital floor must aim
to both restore the volume and shape of the orbit and
achieve stability of the reconstruction with time.3
Convenience, stability, lack of donor site morbidity,
YU ET AL 33

FIGURE 5. Comparisons between preoperative and postoperative CT scans. Preoperative A, 3D and B, coronal view of CT images showing
malposition of the zygomatic-orbital-maxillary complex. Postoperative C, 3D and D, coronal view of CT images showing reduction and orbital
floor reconstruction.
Yu et al. Navigation-Guided Reduction and Orbital Floor Reconstruction. J Oral Maxillofac Surg 2010.

and a reduction of the operative duration have per-
suaded many surgeons to use alloplastic materials.24
Titanium mesh was found to be more accurate in repair-
ing orbital defects, especially in the orbital posterior
regions.25 Titanium mesh might have provided more
optimal reconstruction because of the ease with which
titanium mesh can be contoured to adapt to the intricate
contour of the internal orbit. With navigation guidance,
titanium mesh was precisely contoured and positioned
to restore the orbital volume and shape.
Overall, our experience revealed that the use of the
TBNavis system was of great benefit in fracture reduc-
tion as a treatment of maxillofacial cases. It is helpful
for precise anatomic reduction, asymmetry correc-
34 NAVIGATION-GUIDED REDUCTION AND ORBITAL FLOOR RECONSTRUCTION
FIGURE 6. Accuracy evaluation. Anatomic contour of unaffected
side was mirrored and superimposed on postoperative affected
side. Discrepancy between preoperative simulation and postoper-
ative result was calculated.
Yu et al. Navigation-Guided Reduction and Orbital Floor Recon-
struction. J Oral Maxillofac Surg 2010.
tion, and safe manipulation in close proximity to del-
icate structures.
Acknowledgments
The authors thank Professor Chengtao Wang and Dr Yanping Lin
(Shanghai Jiao Tong University School of Mechanical and Power
Engineering, Shanghai, China) for their valuable advice and assis-
tance with respect to the navigation aspects of this report.
References
1. Morgan BDG, Madan DK, Bergerot JPG: Fractures of the middle
third of the face—A review of 300 cases. Br J Plast Surg 25:147,
1972
2. Watzinger F, Wanschitz F, Wagner A, et al: Computer-aided
navigation in secondary reconstruction of post-traumatic defor-
mities of the zygoma. J Craniomaxillofac Surg 25:198, 1997
3. 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 60:1413, 2002
4. Hammer B, Prein J: Correction of post-traumatic orbital defor-
mities: Operative techniques and review of 26 patients. J Crani-
omaxillofac Surg 23:81, 1995
5. Freihofer HPM, Borstlap WA: Reconstruction of the zygomatic
area: A comparison between osteotomy and onlay techniques.
J Craniomaxillofac Surg 17:243, 1989
6. Klug C, Schicho K, Ploder O, et al: Point-to-point computer-
assisted navigation for precise transfer of planned zygoma os-
teotomies from the stereolithographic model into reality. J Oral
Maxillofac Surg 64:550, 2006
7. Schmelzeisen R, Gellrich NC, Schoen R, et al: Navigation-aided
reconstruction of medial orbital wall and floor contour in
craniomaxillofacial reconstruction. Injury Int J Care Injured
35:955, 2004
8. Manson PN, Ruas EJ, Iliff NT: Deep orbital reconstruction for
correction of post-traumatic enophthalmos. Clin Plast Surg
14:113, 1987
9. Guven O: A clinical study on temporomandibular joint anky-
losis. Auris Nasus Larynx 27:27, 2000
10. Malis DD, Xia JJ, Gateno J, et al: New protocol for 1-stage
treatment temporomandibular joint ankylosis using surgical
navigation. J Oral Maxillofac Surg 65:1843, 2007
11. Horsley V, Clarke RH: The structure and function of the cere-
bellum examined by a new method. Brain 31:35, 1908
12. Hassfeld S, Zoller J, Albert FK, et al: Preoperative planning and
intraoperative navigation in skull base surgery. J Craniomaxil-
lofac Surg 26:220, 1998
13. Watzinger F, Wagner A, Enislidis G, et al: Computer aided
navigation in secondary reconstruction of posttraumatic defor-
mities of the zygoma. J Craniomaxillofac Surg 25:198, 1997
14. Marmulla R, Niederdellmann H: Surgical planning of computer-
assisted reposition osteotomies. Plast Reconstr Surg 104:938,
1999
15. Casap N, Wexler A, Eliashar R: Computerized navigation for
surgery of the lower jaw: Comparison of 2 navigation systems.
J Oral Maxillofac Surg 66:1467, 2008
16. Hassfeld S, Mühling J: Computer assisted oral and maxillofacial
surgery—A review and an assessment of technology. Int J Oral
Maxillofac Surg 30:2, 2001
17. Forbes G, Gehring DG, Gorman CA, et al: Volume measure-
ments of normal orbital structures by computed tomographic
analysis. AJR Am J Roentgenol 145:149, 1985
18. Marmulla R, Hilbert M, Niederdellmann H: Inherent precision
of mechanical, infrared and laser-guided navigation systems for
computer-assisted surgery. J Craniomaxillofac Surg 25:192,
1997
19. Wanschitz F, Birkfellner W, Watzinger F, et al: Evaluation of
accuracy of computer-aided intraoperative positioning of en-
dosseous oral implants in the edentulous mandible. Clin Oral
Implants Res 13:59, 2002
20. Chiu WK, Luk WK, Cheung LK: Three-dimensional accuracy of
implant placement in a computer-assisted navigation system.
Int J Oral Maxillofac Implants 21:465, 2006
21. Helm PA, Eckel TS: Accuracy of registration methods in frame-
less stereotaxis. Comput Aid Surg 3:51, 1998
22. Morrison AD, Sanderson RC, Moos KF: The use of Silastic as an
orbital implant for reconstruction of orbital wall defects: Re-
view of 311 cases treated over 20 years. J Oral Maxillofac Surg
53:412, 1995
23. Johnson PE, Raftopoulos I: In situ splitting of a rib graft for
reconstruction of the orbital floor. Plast Reconstr Surg 103:
1709, 1999
24. Courtney DJ, Thomas S, Whitfield PH: Isolated orbital blowout
fractures: Survey and review. Br J Oral Maxillofac Surg 38:496,
2000
25. Ellis E, Tan Y: Assessment of internal orbital reconstructions for
pure blowout fractures: Cranial bone grafts versus titanium
mesh. J Oral Maxillofac Surg 61:442, 2003