ZYGOMATICO MAXILLARY COMPLEX

FRACTURE

Submitted by Josna Thankachan

Final year part IIAl-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.

CLASSIFICATIONI. Row and Killey classification(1968)

Type I – no significant displacementType II – Fracture of zygomatic archType III – rotation around horizontal axis (inward or outward

displacement)Type IV – rotation around vertical axis(medial or lateral displacement)Type V – displacement of complex enblockType VI – displacement of orbitoantral partitionType VII – displacement of orbital rim segmentType VIII – isolated fracture of orbital wall

II. Spiessel and Schroll(1972)Type I – zygomatic arch fractureType II – zygomatic complex fracture;no significant displacementType III - zygomatic complex fracture;partial medial

displacementType IV - zygomatic complex fracture;total medial displacementType V - zygomatic complex fracture; dorsal displacementType VI - zygomatic complex fracture; inferior displacementType 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 diplopia1. 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 water’s 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/keen’s 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 Bristow’s 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.

• Bristow’s 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/keen’s 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– Keen’s 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