Dr. Shahzad HussainBDS, FCPS (resident)

Nishtar Institute of DentistrySNDENTALCare.co

Contents Introduction

Surgical Anatomy

Classification

Etiology

Diagnosis

Management

Complications

Conclusion

Introduction Zygoma: Strong buttress of lateral midface lying

between zygomatic process of frontal bone and maxilla.

The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.

Surgical Anatomy 4 process: temporal, orbital, maxillary, frontal

Forms lateral wall and floor of orbit

Articulations of zygoma:

1. angular process of frontal bone

2. orbital floor

3. greater wing of sphenoid

4. Maxilla

5. zygomatic bone of temporal bone.

Soft Tissue Attachments Muscular attachments:

Malar surface – zygomatic major, minor, levator labiisuperioris

Temporal surface – masseter muscle

Temporal process - Temporal fascia

Temporalis muscle passes beneath the arch

• Lateral Canthal Ligament

• Lockwood Suspensory Ligament

Sensory Nerves •Zygomatico Temporal nerve.

•Zygomatico facial nerve.

Zygomatic Fractures These Include the fractures of

1. Zygomaticofacial Suture

2. Zygomaticomaxillary Buttress

3. Zygomatic arch

4. Zygomaticosphenoid Suture

5. Infraorbital rim

Classification Schjelderup classification

Knight and north classification

Rowe and killey classification

Spissel and schroll classification

Henderson classification

Ellis classification

Rowe and killey classification Type 1: no significant displacement.

Type 2: isolated fracture of zygoma.

Type 3: fracture rotated around a vertical axis.

Type 4: fracture rotated around a horizontal axis.

Type 5: fracture displacement of complex in block.

Type 6: displacement of orbital floor.

Type 7: displacement of orbital rim.

Type 8: complex comminuted fracture

Henderson’s Classification

Aitiology Physical Assault

Road Traffic accidents

Sports Related Injuries

Incidence

Mechanism Of Injury Direct

Indirect (contra lateral

lefort fracture)

Diagnosis History

Clinical Examination

Radiological Examination

Signs & Symptoms1. Orbital

2. Neurological

3. physical

Orbital1. Proptosis

2. Enophthalmos

3. Double vision

4. Scleral show

5. Subconjuctival hemorrhage

6. Periorbital oedema

Neurological Contusion or compression of nerve

Physical Flatness of face

Limitation of jaw movement

Epistaxis

Radiological Evaluation Plain films:

waters view (P-A Skull) reverse reverse waters view(A-P Skull)

submentovertex view

C.T Scan: Axial sectionsCoronal sections

Three Dimensional C.T Scan

Treatment Goals Restore Normal Contour of the face

Relieve pain

Precise anatomical reduction of the fractured segment

Stable fixation of the reduced segment

To correct associated diplopia

To remove any interference in the range of mandibularmovement

To relieve pressure from infraorbital nerve

Indications For Surgery Visual compromise

Extraocular muscle dysfunction

Displacement of globe

Orbital floor disruption

Displaced fracture

Communated fracture with the segments impinging on the surrounding structures

Restricted mandibular movements

Infraorbital nerve dysfunction

Steps of Surgical treatment Pre surgical Images Prophylactic antibiotic Anesthesia Detailed Clinical Examination and forced duction test Protection of the globe Antiseptic preperation Fracture reduction Assessment of the reduction Determination of the necessarity of the fixation Application of the fixation device Internal orbital reconstruction Assessment of ocular mobility Reconstruction with bone grafts Soft tissue management Post surgical ocular examination Post surgical images

Surgical Approaches Indirect

Direct

Direct ApproachExtra oral:

1. Upper eyelid

2. supra orbital eyebrow

3. Coronal

4. Lower eye lid: 1. Subcilliary

2. Transconjuctival

3. Infraorbital

Intra oral

1. Maxillary vestibular

Indirect Approach Intra Oral:

1. Keen’s Approach

2. Quin’s Approach

Extra Oral:

1. Temporal

2. Percutaneous

Dingman’s approach

Vestibular Approach

Vestibular Approach Advantages:

Less force is required for reduction

No Skin incision

Less dissection

Technique:

Incision-1cm

Elevator- Taylor monks or Rows

Temporal fossa approachRemains best technique.

Rationale:

Temporal fascia

Zygomatic bone

Zygomatic arch

Temporal muscle

Instrument

Technique Hair is shaved

Baseline gauge - external auditory meatus

Incision – 2.5cm

Identification of temporal fascia

Elevator – Row zygomatic elevator or Bristow’s orthopaedicperiosteal Reduction

Audible click

Elevator is withdrawn

Closure by layers

Post operative care

elevator

Technique

Lateral coronoid approach Technique:

Incision

Anterior border of ramus

Blunt dissection

Elevator

Upper Eyelid Approach

KEEN’s Approach

Surgical Approaches in relation to Fracture

Approaches to infraorbital rim:1. Existing skin laceration2. Subtarsal incision3. Blephroplasty incision4. Transconjunctival incision (pre-septal or post- septal) Approaches to lateral orbital rim:1. Eye brow incision2. Upper lid incision Approaches to zygomatic arch:1. Pretragal incision2. Coronal flap incision.

Fixation Methods Most common methods of fixation:

1. Wire osteosynthesis

2. Rigid fixation – mini – plates.

Less common methods:

1. External pin fixation

2. Maxillary antral support

Trans osseous wiring Technique:

No.2 round bur

5mm apart from the fractured ends

0.35mm diameter soft stainless steel wire

Fig of 8 fashion

Transosseous wiring

Carrol – Girard screw Useful in laterally displaced zygoma fractures.

Temporary support

Unstable following reduction

Gross contamination

Communition

Antral pack

Wire -Splint

Inflateable balloon

Plaster head cap

Silicon elastomer wedge.

Principles of Plate Fixation Use of self threading bone screws.

Use of the material that will not scatter the Post operative CT scans . Titanium is the meterial of the choice

Placement of at least 2 screws through the plate on each side of the fracture

Avoid damage to anatomical structures

Use of thin plates in the periorbital region to prevent visibility and reduce palpability.

Placement of as many bone plates in locations to ensure stability

Mini Plates 2mm plates – zygomatic arch

1.5mm – zygomaticomaxillary buttress

1.3mm infra orbital rim

Order of fixation

Zygomatic arch

Zygomaticofrontal suture

Infraorbital rim

Zygomatic buttress

Miniplates and screws

Fixation with a pack in maxillary sinus To support zygomatic complex fracture

To support reconstructed comminuted orbital floor.

Technique:

Incision

Window into sinus

Bone pack – ribbon gauge

Complications Malposition of soft tissue on bone

Complications of bone malposition

Occular complications

Malposition of soft tissue on bone:

Closure of periosteal incision

Refixation of the tissue on facial skeleton

Complication of bone malposition:

Maxillary sinusitis

Inaccurate alignment: orbital rim , zygomatic arch

Reconstructed flat rather than as a curve to achieve a satisfactory reduction.

Ocular Complications :

Traumatic diplopia

Enophthalmos

Retrobulbar hemorrhage and blindness

Superior orbital fissure syndrom

Neurologic Complications : damage to infraorbital nerve.