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Zygomatic fractures

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Zygomatic fractures

  1. 1. - Dr. Dona Bhattacharya
  2. 2. 1. Introduction2. Surgical anatomy3. Classification4. Etiology5. Diagnosis6. Management7. Conclusion8. References
  3. 3. ∏ Zygoma: strong buttress oflateral midface lyingbetween zygomaticprocesses of frontal bone &maxilla.∏ The high incidence of ZMCfractures relates to the it’sprominent position withinthe facial skeleton.
  4. 4. ∏ Thick, strong, quadrilateralshaped bone∏ Surfaces:∏ Processes:∏ Temporal∏ Frontal∏ sphenoid∏ maxillaryOuter/convexinner/concave
  5. 5. ∏ Forms articulations with various bones.∏ AppliedFrontal process,usually thickest;site for plate fixation.
  6. 6. Soft tissue attachments∏ Masseter∏ Temporalis∏ Facial mimeticmuscles∏ Lateral canthalligament∏ Lockwood suspensoryligament
  7. 7. Sensory nerves transmitting zygoma
  8. 8. ∏ Zygomatic fracture include:∏ Zygomaticofrontal suture∏ Zygomaticomaxillarybuttress∏ Zygomatic arch∏ Zygomaticosphenoid suture∏ Infraorbital rim
  9. 9. Type 1: Displaced zygomatic bone hinged on the maxillary andthe frontal attachmentsType 2: Displaced zygoma hinged on maxillary attachmentsType 3: Displaced zygoma hinged on frontal attachments
  10. 10. Group 1: Undisplaced fracturesGroup 2: Isolated displaced fracturesGroup 3: Displaced body fractures(unrotated)Group 4: Medially rotated4a: Outward at malar buttress4b: Inward at the FZ sutureGroup 5: Laterally rotated5a: Upward at the infraorbitalmargin5b: Outward at the FZsutureGroup 6: Any additional fracture lines acrossthe main fragment
  11. 11. Type 1: No significant displacementType 2: Isolated fractures of zygomatic archType 3: Fractures rotated around a vertical axis3a: Internally 3b: ExternallyType 4: Fractures rotated around a horizontal axis4a: Medially 4b: LaterallyType 5: Fracture displacement of the complexenbloc5a: Medially 5b: Inferiorly5c: LaterallyType 6: Displacement of orbital floor6a: Inferiorly 6b: SuperiorlyType 7: Displacement of the orbital rim segmentsType 8: Complex comminuted fractures
  12. 12. Type 1: Isolated zygomatic arch fracturesType 2: Fractures with no significant displacementType 3: Partially displaced fractures mediallyType 4: Totally displaced fractures mediallyType 5: Fractures with dorsal displacementType 6: Fractures with inferior displacementType 7: Comminuted fractures
  13. 13. Type 1: Non-displaced fracturesType 2: Isolated zygomatic arch fracturesType 3: Zygomatic complex fractures but the frontozygomaticsuture is undisplacedType 4: Zygomatic complex fractures with displacement of thefrontozygomatic sutureType 5: Pure blow-out fracturesType 6: Fractures of the orbital rim onlyType 7: Comminuted or multiple fractures
  14. 14. Group A: Fractures showing minimal or no displacement and hencerequiring no interventionGroup B: Fractures with great displacement and disruption at thefrontozygomatic suture and comminuted fracturesGroup C: Fractures of all other kinds which required reduction butno fixation
  15. 15. Type A : fracture isolated to one component of tetrapodstructureA 1-Zygomatic archA2 -Lateral orbital wallA 3-Inferior orbital rimType B : # of buttresses (classical tetrapod #)Type C : Complex # with comminution of zygomatic boneitself.
  16. 16. Type 1: Fractures with no evidence of displacementType 2: Isolated fractures of the zygomatic archType 3: Fractures of the body of the zygomatic complex without rotation in theantero-posterior direction (Z axis)Type 4: Fractures of the body of the zygomatic complex with rotation in theantero-posterior direction4a: Axis of rotation at the bases of the arch4b: Axis of rotation at the zygomaticomaxillary suture4c: Fractures involving the zygoma, main body of themaxilla and the palate
  17. 17. Category AIsolated fracture of one of the three processes of the zygomatic bone. These processesare:The temporal process, which forms zygomatic arch (A1)Frontal process, which forms lateral orbital wall (A2)Maxillary process, which forms infraorbital rim (A3)Category BFracture of all three processes, detaching zygomatic bone from facial skeleton i.e.Classic tripod fracture, but anatomically these fractures are actually tetrapod, becausefrontal process of zygoma also communicates with greater wing of sphenoid, which alsorequires to be disrupted to technically render zygoma free.Category CSame as type B but with fragmentation including the body of zygoma
  18. 18. a) Low energyb) Middle energyc) High energy
  19. 19. a) # of body of zygoma involving orbita) Min displacementb) Inward & downwardc) Inward & posteriord) Outwarde) communitedb) # of arch Without orbit involvement
  20. 20. Isolated zygomatic arch fractures(Type I)Dual fracture (Type I-A)More than 2 fractures (Type I-B)V-shaped fracture (Type I-B-V)Displaced (Type I-B-D)Combined zygomatic arch fractures (Type II)A. Single fracture (Type II-A)B. Plural fracture (Type II-B)1) Reduced (Type II-B-R)2) Displaced (Type II-B-D)Irfan Ozyazran et al ;A New Proposal of Classification of Zygomatic Arch Fractures; JOMS, Volume 65, Issue3, March 2007, Pages 462–469
  21. 21. Fractures stable after elevation• Arch only• Rotation around a vertical axisMediallyLaterallyFractures unstable after elevationArch only (inferiorly displaced)Rotation around a horizontal axisMediallyLaterallyDislocations en blocInferiorlyMediallyLaterallyComminuted fractures of the zygomatic complex
  22. 22. ∏ Assault∏ RTA
  23. 23. IncidenceFracture Type PrevalenceZygomaticomaxillary complex (tripod fracture) 40 %LeFortI 15 %II 10 %III 10 %Zygomatic arch 10 %Alveolar process of maxilla 5 %Smash fractures 5 %Other 5 %
  24. 24. a) Direct impactb) Indirect injury(contralateral le fort #)Mechanism of injury
  25. 25. Usual lines of ZMC fracture extend ina) Anteromedialb) Inferiorc)superolateralFracture patterns
  26. 26. 1. History2. Clinical examination3. Radiological examination
  27. 27. Inspection PalpationLacerationSymmetryPupillary levelsPeriorbital edemaPeriorbital ecchymosisTendernessMalar depressioncrepitus
  28. 28. •Periorbital edema•Periorbital ecchymosis•Flattening of malar prominence•Flattening over arch•Pain•Ecchymosis of maxillary buccal sulcus•Deformity of zygomatic buttress•Deformity of orbital margin•Trismus•Paresthesia of cheek•Epistaxis•Subconjunctival hemorrhage•Crepitation•Displacement of palpebral fissure•Unequal pupillary levels•Diplopia•Enopthalmos
  29. 29. Other tests:• Snellen chart• HESS chart• Forced duction test
  30. 30. 1. OM/Water’s view2. SMV3. Caldwell projection(PA view)4. CT Scan5. 3D CT Scan
  31. 31. ∆ Aims for surgery1. Restore normal contour of face2. Relieve pain3. Precise anatomical reduction of the # fragment4. Stable fixation of the reduced fragment5. To correct diplopia6. To remove any interference in range of mandibularmovement7. To relieve pressure from infraorbital nerve
  32. 32. INDICATIONS FOR SURGERY :1. Visual compromise2. Extraocular muscle dysfunction3. Displacement of globe4. orbital floor disruption5. Displaced fractures6. Comminuted fractures with fragments impinging on thesurrounding structure.7. Restricted mandibular movements8. Infraorbital nerve dysfunction
  33. 33. Steps in surgical treatment of ZMC #•Prophylactic antibiotics•Anesthesia•Clinical examination & forced duction test•Protection of globe•Antiseptic preparation•# reduction•Assessment of reduction•Determination of necessity for fixation•Application of fixation device•Internal orbital reconstruction•Asessment of ocular motility•Reconstruction with bone grafts•Soft tissue resuspension•Post surgical ocular examination•Post surgical images
  34. 34. Surgical ApproachesIndirectExtra Orala. Temporalb.PercutaneousIntra Orala. Keenb. QuinDirectExtra Orala. Upper eyelidb. Supraorbital eyebrowc. Lower eye lidi. Sub cilliaryii. Infra orbitaliii. Trans conjunctivald. CoronalIntra Orala. MaxillaryVestibular
  35. 35. 1964
  36. 36. TechniqueAdvantagesDisadvantageIndication
  37. 37. TechniqueAdvantagesIndication
  38. 38. Poswilo: bone hook techCarrole Girald screw
  39. 39.  Also known as lateral coronoid approach,1977 Used for reduction of zygomatic arch #. Place 3-4 cm i/o incision along anterior border of theramus through mucosa and submucosa. Extend upto depth of temporal muscle Place Instrument between temporalis muscle and Z arch.
  40. 40. 1. Transosseous wiring2. Miniplates3. External fixators
  41. 41. Trans -osseous wires
  42. 42. Miniplates and screws
  43. 43. I. Use of self threading bone screwsII. Use of hardware that will not scatter postoperative CT scans- titanium platesand screws have the advantage of not causing scatter in CT scans.III. Placement of atleast 2 screws through the plate on each side of the fractureIV. Avoid damage to important anatomical structuresV. Fracture of zygomatic buttress if low then “L”, “T” or “Y” shape bone plateshould be used.Principles of plate fixation
  44. 44. VI. Use of thin plate in the periorbital areas- to prevent visibility andreduce palpabilityVII.Placement of as many bone plates in many locations for ensuringstabilityVIII.If concomitant fractures of other midfacial bones exist to benecessary to apply fixation devices more liberally.IX. In areas of comminution or bone loss span the gap with boneplates.
  45. 45. Treatment algorithm for ZMC fracture without need for internal orbitalreconstruction, by Ellis and KittidumkerngReduce FractureFracture Reduced andStableStopUnsure of ReductionTransoral OpenReductionFracture ReductionBut UnstableBone Plate at Z-MButtressFracture Reduced andStableStopFracture Reductionand StableStopUnsure of ReductionOpen ReductionLateral OrbitFracture ReducedBone Plate at Z-MButtress and/orLateral OrbitFracture Reduced andStableStop
  46. 46.  To support zygomaticcomplex fractures To support reconstructedcomminuted orbital floor Temporary packing withpenrose drains, gauze,gelfoam, silastic, antralballoon
  47. 47. Trans -maxillaryNaso-zygomaticZygomatico-palatalFronto-zygomaticMaxillo-zygomaticCranio-zygomatic
  48. 48. Indications
  49. 49. 1. Towel clip reduction2. Endoscopic management(Harold Hopkins)3. Modified gillie’s approach
  50. 50. Towel clip reductionTodd G. Carter et al; Towel Clip Reduction of the Depressed Zygomatic Arch Fracture, J Oral Maxillofac Surg63:1244-1246, 2005
  51. 51. With the deep temporal fascia exposed from the reflected bicoronal flap, a1-cm horizontal incision is made within the deep temporal fascia allowing aGillies elevator to easily reduce the arch fracture in a plane between the deeplayer of the deep temporal fascia and the temporalis muscle.Advantages• Preserves fascial attachments• Avoids neurovascular injury• Obviate the need for rigid fixation• Saves time and money• Decreases morbidity.Swanson et al ;Modified Gillies Approach for Zygomatic Arch Fracture Reduction in the Setting ofBicoronal Exposure; Journal of Craniofacial Surgery:May 2012 - Volume 23 - Issue 3 - p 859–862Modified Gillie’s Approach
  52. 52. 1. Mal position of soft tissue on the bone2. Ocular complicationsa. Retrobulbar hemorrhageb. SOF syndromec. Persistent diplopiad. Enophthalmose. Infraorbital nerve disorderf. Blindness3. Maxillary sinusitis4. Ankylosis of zygoma to coronoid process5. Infection
  53. 53. Face is the most prominent and expressive part of human body and addsto well being of a personality. Zygoma plays an imp role in facial contour.Moreover the importance of zygomatic complex in facial skeleton lies inprotecting globe of eye and absorbing and redistributing masticatory andexternal load.Therefore for cosmetic and functional reasons it is imperative to diagnoseand treat zygomatic fractures adequately.
  54. 54. 1. Oral & maxillofacial trauma-Fonseca & walker vol 22. Oral & maxillofacial surgery-Fonseca vol 33. Oral & maxillofacial trauma-Rowe & Williams vol 24. Principles of Oral & maxillofacial surgery-Peterson5. Fractures of middle third of face-Killey & Kay6. Oral & maxillofacial surgery-Fragiskos7. Maxillofacial trauma & facial reconstruction-Peter Ward Booth8. Oral & maxillofacial surgery-Peter Ward Booth: vol 29. Chen Lee et al ;Applications of the Endoscope in Facial fractureManagement, seminars in plastics surgery/volume 22, number 12008
  55. 55. 9. Manual of internal fixation-J Prein10. Mirko S. Gilardino et al;Choice of Internal Rigid Fixationmaterials in the treatment of facial fractures; craniomaxillofacialtrauma & reconstruction/volume 2, number 1 200911. Irfan Ozyazran et al ;A New Proposal of Classification ofZygomatic Arch Fractures; JOMS, Volume 65, Issue 3, March 2007,Pages 462–46912. Todd G. Carter et al;Towel Clip Reduction of the DepressedZygomatic Arch Fracture; J Oral Maxillofac Surg 63:1244-1246,200513. Balasubramanian Thiagarajan; Fracture zygoma and itsmanagement our experience,Journal of otolar; Volume 3 Issue 1.52013

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