ZYGOMATIC BONE

FRACTURE
 ZYGOMATIC BONE FRACTURE

The malar bone represents a strong bone on a fragile supports,

and it is this reason that though the body of the bone is rarely
broken, the four processes

–frontal, orbital, maxillary, and zygomatic –

are frequent sites of fracture.

H.D. Gillies, T. P. Kilner, and. D. Stone, 1927

ZYGOMATIC BONE
ANATOMY & RELATION
MUSCLES ATTACHED

• 1. Masseter muscle

• 2. Temporalis fascia

• 3. Zygomaticus major

• 4. Zygomaticus labialis
 FUNCTION
1. Provides origin to major portion of masseter muscle,

2. Temporal fascia attaches along the arch and

posterolateral part of temporal process,

3. Provides attachment to zygomatic muscles,

4. Protect orbital contents from lateral injury.

 CLASSIFICATION
OF
ZYGOMATIC COMPLEX
FRACTURES
AXIS OF ROTATION
 ROWE AND KILLEY 1968 CLASSIFICATION
TYPE I NO SIGNIFICANT DISPLACEMENT
TYPE II FRACTURES OF ZYGOMATIC ARCH
TYPE III ROTATION AROUND VERTICAL AXIS
ORBITAL RIM a. INWARD DISPLACEMENT
b. OUTWARD DISPALCEMENT
TYPE IV ROTATION AROUND LONGITUDINAL AXIS
FRONTAL PROCESS a. MEDIAL DISPLACEMENT
b. LATERAL DISPLACEMENT
TYPE V DISPLACEMENT OF THE COMPLEX EN BLOC
a. MEDIAL
b. INFERIOR
c. LATERAL
TYPE VI DISPLACEMENT OF THE ORBITO-ANTRAL PARTITION
a. INFERIORLY
b. SUPERIORLY
TYPE VII DISPLACEMENT OF ORBITAL RIM SEGMENTS

TYPE VIII COMPLEX COMMINUTED FRACTURES

 ROWE MODIFICATION 1985

GROUP A STABLE NO INTERVENTION

GROUP B UNSTABLE REDUCTION AND

FIXATION

GROUP C STABLE REDUCTION ONLY

 MANSON AND COLLEGUES 1990

1. Low energy – little or no displacement

2. Middle energy- complete fracture of all articulation with

minimal displacement

3. High energy –comminution in lateral orbit , lateral

displacement with segmentation , zygomatic arch fracture
 LARSEN & THOMPSON 1968

Group I Group II

Non-displaced fractures no All fractures requiring treatment

treatment

During the initial evaluation, if there is This is further subdivided into

any doubt about stability, revaluation fractures that are stable and fractures
should occur 1 week after injury. that are unstable after reduction.

Peterson. (Principles of Oral & Maxillofacial Surgery).

Zygomatic Based on direction of
displacement in waters
complex fractures view radiograph.

Group I
KNIGHT & NORTHNo 1961
Non displaced fractures
CLASSIFICATION
clinical or radiographic No treatment required.
evidence of displacement

Group II Arch fractures A pure fracture of the zygomatic Classical three fracture lines produce a ‘V’
arch. shaped deformity.

Group III Un rotated body fractures Zygoma is driven posteriorly Direct blow to the zygomatic prominence
and medially, producing a
flattening of the cheek.

Group IV Medially rotated body Zygomatic bone is driven Blow from above the horizontal axis of
fractures medially, inferiorly and Zygoma
posteriorly with rotation.
Inferior displacement of infraorbital rim,
. Either outward or inward displacement at
at the malar buttress and frontozygomatic
suture

GroupV Laterally rotated body Blow below the horizontal axis of the bone.
fractures Medial and posterior displacement with
lateral rotation.

Group VI Complex fractures These have additional fractures

across the body of zygoma

Peterson. Principles of Oral & Maxillofacial surgery)

 ZING ET AL CLASSIFICATION
(1992)
• Type A 1 – isolated zygomatic arch fracture
A2 – fz suture
A3- infraorbital rim
• Type B- complete monofragment type
• Type C- multifragmeneted

Classification and treatment of zygomatic arch fractures ,a review of 1025

cases: J oral Maxillofac surg 1992;50:778-90
 ZYGOMATIC COMPLEX
FRACTURE

DIAGNOSIS

In a typical case, diagnosis may be made at sight once the

characteristic appearance has been fully recognized. A peculiar
facies is present, due chiefly to a certain flatness of contour and
absence of expression on the affected side.

H.D. Gillies, T. P. Kilner, and. D. Stone, 1927

 DIAGNOSIS

• History
• Clinical examination
• Assessment of visual status
• Ocular & fundoscopic
• Inspection
• Palpation
 FIRST PRIORITY

1. Visual status

2. Ocular & Fundoscopic examination

 INSPECTION
FRONTAL VIEW SUPERIOR VIEW INFERIOR VIEW
(BIRD’S VIEW) (WORM’S VIEW)
 INSPECTION

REDUCED OPENING ALTERATION OF PUPILARY LEVEL

 PALPATION

SUPRAORBITAL
RIM

ZYGOMATIC LATERAL
BUITTRESS ORBITAL RIM

ZYGOMATIC INFRAORBITAL
ARCH RIM
 SIGNS & SYMPTOMS
1. Pain
2. Edema
3. Epistaxis
4. Abnormal nerve sensibility
5. Crepitation from air emphysema
6. Ecchymosis of maxillary buccal sulcus
PERIORIBITAL ECCHYMOSIS &
EDEMA
FLATTENING OF MALAR PROMINENCE
FLATTENING OR V SHAPED
DEPRESSION OF ARCH
 DEFORMITY OF ZYGOMATIC
BUTTRESS

• I/O Crepitations
• Ecchymosis
• Palpate anterolateral
region and compare
with opposite side
SUBCONJUNCTIVAL HAEMORRHAGE
 TRISMUS

In isolated arch fracture

Impingment of translating coronoid process leading to spasm of

muscles.
DISPLACEMENT OF PALPEBRAL FISSURE
ALTERED VISION
0.

DIPLOPIA ASSESSEMENT
RED GREEN GLASS HARM TANGENT
TEST SCREEN

The clear area marks the area of binocular single vision and the stripped background , the area
of binocular double vision. The example shows double vision in upgaze starting from 200 within
a a lateral view of 20 0 and double vision in downgaze starting from 300 within a lateral view of
30
GLOBE POSITION

Hertel exophthalmometer
FORCED DUCTION TEST
 REMEMBER!!!
6 P’S OF ZMC #

1. Periorbital swelling
2. Pain in extremes of gaze
3. Perception: Diplopia and lateral subconjunctival blood
4. Paraesthesia in V2 distribution
5. Projection: lack of malar prominence
6. Protusion: Enophthalmos or exophthalmos
 RADIOLOGICAL
EVALUTION
Nothing is more valuable to a surgeon in determining the extent
of injury and the position of the fragments -both before and after
operation-
than a good skiagram

H.D. Gillies, T. P. Kilner, and. D. Stone, 1927

• Plain radiograph
• C T scans
• CBCT
 PLAIN RADIOGRAPH
PNS VIEW

PNS VIEW

SUBMENTOVERTEX
WATERS VIEW

McGrigor and Campbell

1950
• First line- from zygomatico frontal suture,along superior orbital margin
across glabella to supra orbital margin and f z suture of opposite side.

• Second line- Zygomatic arch to zygomatic bone along the inferior orbital
margin across the frontal process of maxilla and lateral wall of nose through
the septum to a similar course on the opposite side.

• Third line- from the condyle of mandible across mandibular

notch,coronoid process to lateral antral wall through medial anteral wall to
a level of nasal floor to opposite side

• Fourth line- from the ramus through the occlusion of teeth to the opposite
side

• Fifth line-Lower border of the mandible

DOLANS AND JACOBYS LINE
C T SCANS
AXIAL VIEWS
CORONAL VIEW
3D CT
DID I MISS ANYTHING???
 TREATMENT OPTIONS
1. NO TREATMENT

2. INDIRECT REDUCTION

3. OPEN REDUCTION & FIXATION

 PRINCIPLES IN TREATMENT

• Prophylatic antibiotics

• Anesthesia

• Clinical examination & force duction test

• Protection of globe
• Reduction of fracture

• Assessment of reduction

• Determination of necessity for fixation

• Application of fixation device

• Internal orbital reconstruction

• Assessment of occular motility

• Bone graft for extraorbital osseous defect

• Soft tissue suspension

• Post surgical ocular examination

• Post surgical images

 REDUCTION TECHNIQUES

1. Temporal approach (Gillies temporal.)

2. Buccal sulcus(Keen technique1909).

3. Lateral coronoid(Quinn).

4. Upper Eyebrow .

5. Percutaneous(Strohmeyer 1844,Poswillo).
 PERCUTANEOUS
(STROHMEYER 1844, POSWILLO).

Zygoma Hook

J Hook
 TEMPORAL APPROACHE
(GILLIES TEMPORAL.)

BRISTOS ELEVATOR

One handle for grasping & flat

blade on its working end for
insertion medially to
zygomatic arch and body

Needs skull as a fulcrum

therefore should be used with
care
 ROWES

• One handle is in direct line

with working end for
insertion medially to
zygomatic arch and body

external lifting lever, its

length is almost equal to that of
working blade (used for
activation)
TEMPORAL APPROACHE
(GILLIES TEMPORAL.)
 BUCCAL SULCUS
(KEENS TECHNIQUE1909).
LATERAL CORONOID(QUINN).

Reduction of zygomatic arch

UPPER EYEBROW .

Posteriorly to the zygoma along its temporal surface

through the incision & elevated
anteriorly,laterally,superiorly
 SURGICAL APPROACHES

• Existing laceration.
• Maxillary vestibular.
• Supra orbital eye brow incision.
• Upper eyelid.
• Lower eyelid.
-Infraorbital
-Subciliary
-Transconjunctival
• Coronal .
 SURGICAL APPROACHES

• UPPER EYELID INCISION • SUPRA ORBITAL EYEBROW

INCISION
SUBCILIARY INCISION
INFRAORBITAL INCISION
TRANSCONJUNCTIVAL
 FIXATION
Three basic fxation methods are available for ZMC fractures

• 1. Temporary support

• 2. Indirect fxation and

• 3. Direct fxation
FRONTOLATERAL PLATING
 FRONTOLATERAL AND
INFRAORBITAL PLATING
THREE POINT FIXATION
FOUR POINT FIXATION
 FIVE POINT FIXATION ??????

SPHENOZYGOMATIC SUTURE!!
ZYGOMATIC ARCH FRACTURES

PREOPERATIVE

POSTOPERATIVE
 COMPLICATIONS

• Incision related
• Infra orbital nerve disorder
• Implant extrusion, Displacement, Infection
• Enophalmos
• Blindness
• Retrobulbar & Intraorbital hemorrhage
• Malunion & Nonunion
 RETROBULBAR & INTRAORBITAL
HEMORRHAGE

Reduction in visual acuity

Tense Proptosis
Periorbital swelling
Retro orbital pain
Dilated pupil
Ophthalmoplegia
 CONCLUSION

Shape of face is influenced by the underlying osseous structures,

Zygoma plays an important role in facial contour.

Position of zygoma has great functional impairment on ocular and

mandibular function.

Therefore, for cosmetic and functional reason, it is imperative that

zygomatic injuries be properly and fully diagnosed and adequately
treated
BOOKS TO READ
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 IF YOU CAN’T
CONVINCE YOUR
EXAMINERS,
 DR RAVI RAJAN AREEKKAL
MDS, FIBCSOMS, FIBOMS
PUSHPAGIRI COLLEGE OF DENTAL SCIENCES