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ZYGOMATICO MAXILLARY

COMPLEX FRACTURE

Submitted by
Josna Thankachan
Final year part II
Al-Azhar Dental College
CONTENTS
Introduction
Fracture pattern
Classification
Clinical features
Investigation
Management
Surgical Approaches
Reduction
Fixation
Complication
References
INTRODUCTION
Zygoma is a major buttress of facial skeleton is
the principle structure of lateral midface.
It is equivalent of a four sided pyramid.
It has temporal process which articulates with
temporal process which articulates with
sphenoid bone, maxillary process which
articulates with maxillary bone and frontal
process which articulates with frontal bone.
Fracture of zygoma is usually not present
alone, it finds mostly in conjunction with
adjacent structures ie, antrum, orbital floor.
This structure makes up the
zygomaticomaxillary complex.
FRACTURE PATTERN
Fracture pattern follows a line which
commence at frontozygomatic suture,passes
downward close to or between the greater
wing of sphenoid and the frontal process of
zygomatic bone to reach anterior limit of
inferior orbital fissure and then turns
anteromedially to cross the inferior orbital
margin above or in close proximity to the
infraorbital canal.
From this point the fracture continues
inferolaterally to cross the outer wall of
antrum and pass beneath the zygomatic
buttress turning upward across the posterior
wall of antrum to rejoin the anterior limit of
inferior orbital fissure.
Inferior orbital fissure is the key to remembering
the usual lines of zygomaticomaxillary
complex fracture 3 lines extending from
inferior orbital fissure in 3 direction-
anteromedially
superolaterally
inferiorly
One fracture line extend from inferior orbital
fissure anteromedially along orbital floor
mostly through orbital process of maxilla
towards the infraorbital rim.
Second line of fracture run from inferior
orbital fissure to inferiorly towards the
posterior aspect of maxilla(infra temporal)and
joins the fracture from the anterior aspect of
maxilla under the zygomatic buttress.
Third line of fracture extend superiorly from
the inferior orbital fissure along the lateral
orbital wall posterior to the rim,usually
separating the zygomatico sphenoid suture.
An additional fracture line runs through the
zygomatic arch.
frequently ; however 3 fracture lines exist
through the arch,producing 2 free segments
when the fracture are complete.
CLASSIFICATION
I. Row and Killey classification(1968)
Type I no significant displacement
Type II Fracture of zygomatic arch
Type III rotation around horizontal axis (inward or outward
displacement)
Type IV rotation around vertical axis(medial or lateral
displacement)
Type V displacement of complex enblock
Type VI displacement of orbitoantral partition
Type VII displacement of orbital rim segment
Type VIII isolated fracture of orbital wall
II. Spiessel and Schroll(1972)
Type I zygomatic arch fracture
Type II zygomatic complex fracture;no significant
displacement
Type III - zygomatic complex fracture;partial medial
displacement
Type IV - zygomatic complex fracture;total medial
displacement
Type V - zygomatic complex fracture; dorsal displacement
Type VI - zygomatic complex fracture; inferior displacement
Type VII - zygomatic complex fracture; comminuted fracture
CLINICAL FEATURES
SKELETAL DEFORMITIES
Asymmetry of the mid
face
Depression or flattening
of malar prominence
Flattening , hollowing or
broadening over the
zygomatic arch
Step deformity of
orbital margins
OCULAR /OPHTHALMIC SYMPTOMS
Periorbital edema
Pseudoptosis
Increased visibility of sclera
Downward slant of palpebral fissure
Malposition of the lateral canthus
Vertical shortening of the lower eye lid
Subconjunctival ecchymosis
Chemosis
Hypoglobus
Proptosis bulbi
Enophthalmos
Exophthalmos
Subcutaneous periorbital air emphysema
Pneumoexophthalmos
Amaurosis
Superior orbital fissure syndrome
Diplopia
Test for diplopia
1. Finger gaze:-
Finger moved infront of eye in all nine
directions of gaze at a distance of 30cm.
2. Forced duction test:-
Tissue holding forceps are used to hold
tendon of inferior fornix . The globe is
manipulated through its entire range of motion.
Inability to rotate the globe superiorly signifies
entraptment of muscle in orbital floor.
NEUROLOGICAL SYMPTOMS
Paresthesia of infraorbital nerve
Parethesia of supra orbital and supra trochlear
nerve
Paresthesia of zygomatico temporal and
zygomatico facial nerve
Paresis of facial nerve
Paresis of extraocular muscles
ORAL SYMPTOMS
Ecchymosis in the buccal sulcus of maxillary arch
Deformity of zygomatic buttress of maxilla
Trismus
Pain
Impacted /flattened zygomatic arch
NASAL SYMPTOMS
Ipsilateral epistaxis
Ipsilateral hematosinus
INVESTIGATIONS
Plain radiographs
waters view or paranasal view of
zygomaticomaxillary complex fracture,floor of
orbit,infra orbital rim
submentovertex- Arch fracture
CT scan
MANAGEMENT
Surgical approach:-
A. Extra oral approach
Bicoronal/hemicoronal
Gillies temporal approach
Superolateral
Supraorbital approach;lateral eyebrow
Upper eyelid
Lower eyelid
Infra orbital
Subtarsal
Subcilliary
Transconjunctival
percutaneous
B. Intra oral approach
Transoral/keens approach
Endoscopic transantral approach
Bicoronal/hemicoronal approach
The zygoma fracture reduction is complete if
the sphenozygomatic suture is reduced. This
suture can be visualized only by this
approach. Moreover, this approach is ideal in
zygomatic complex fracture involving the
frontal bone,orbital roof reconstruction ,arch
fracture requiring fixation and laterally
displaced zygoma fracture requiring 3 or 4
point fixation.
Gillies temporal approach(1927)
An incision about 2.5cm length is made
between the two branches of the superficial
temporal artery at an angle of 45 to the
upper limit of the attachment of the external
ear.
Dissection is carried out till the temporal
fascia. A Bristows elevator is passed down
through this incision beneath the zygomatic
bone which is then gradually reduced to its
position.
The incision is then closed in layers.
Rowe pattern zygomatic elevator is also used
in this approach for the reduction of the
zygomatic fracture.
Bristows elevator has adisadvantage of using
the temporal bone as fulcrum causing risk of
fracturing the temporal bone during the
procedure. This was overcome by the design
in Rowe zygoma elevator.
Transoral/keens approach
Also known as buccal sulcus incision /lateral
maxillary vestibular incision
A bone hook can be passed from a transverse
incision made in the region of buccal sulcus
and the fractured segment can be reduced.
An incision 1cm in length is made in the buccal
sulcus behind the zygomatic buttress.
A bone hook or curved elevator is passed
behind supraperiosteally,to contact the deep
part of the zygomatic bone.here an upward
outward and forward pressure is exerted.
The advantage of this method is that less
amount of force is required for reduction.
REDUCTION
Indirect method
Gillies temporal approach
Keens approach
Percutaneous approach
Direct method
Coronal/bicoronal approach
Supraorbital eyebrow approach
Lower eyelid approach
Fixation
1 point fixation
2 point fixation
3 point fixation
4 point fixation
One point fixation
Indication
Undisplaced fracture at frontozygomatic suture
Simple non comminuted zygomatic complex fracture
Approach
Frontozygomatic suture approached through supraorbital
eyebrow approach.
Zygomaticomaxillary buttress approached through maxillary
vestibular approach.
One point fixation with miniplates in the zygomatico
maxillary butress region can avoid unsightly scars and give
high satisfaction with surgical outcome in selected patients
with zygoma fractures.
Two point fixation
Indication
Displaced fracture unstable after reduction
Fracture at frontozygomatic suture,infraorbital rim and
buttress.
Approach
Exposure of frontozygomatic suture through lower
eyelid incision or maxillary vestibular incision.
A 2 point fixation using low profile plate at
zygomaticomaxillary buttress or at the infra orbital rim
suffice.
Three point fixation
Fixation is done at frontozygomatic
suture,zygomaticomaxillary buttress and the
infraorbital rim.
Good reduction of these 3 sites mostly reduces
the arch fracture which is not fixed.
Four point fixation
Unique from 3 point technique in that the surgeon
visualizes the zygomatic arch. The order of
placement of the plates will be dependant on the
least damaged landmarks. The zygomatic arch is
an excellent reference to restore proper
anteroposterior projection of the midface.
Fixation is again of two types:
i. Direct fixation
Transosseous wiring
ii. Indirect fixation
Internal pin fixation
Transfixation with kirshner wire
COMPLICATIONS
Complication of periorbital incision
Infraorbital nerve paresthesia
Implant extrusion/displacement and infection
Persistent diplopia
Enophthalmosis
Blindness
Retrobulbar hemorrhage
Ankylosis of zygoma to coronoid
Malunion
Orbital dystopia
REFERENCES
1. Clinical handbook of oral and maxillofacial
surgery- Laskins
2. Textbook of oral and maxillofacial surgery;2nd
edition- S.M Balaji
3. Textbook of oral and maxillofacial surgery;3rd
edition- Neelima Mallik