Zygomatic maxillary complex fracture
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The document summarizes the zygomaticomaxillary complex fracture, including its anatomy, fracture patterns, classification systems, clinical features, investigations, management approaches, reduction techniques, fixation methods, and potential complications. Key points include that the fracture pattern typically involves 3 lines extending from the inferior orbital fissure in different directions, and management often involves open reduction and internal fixation using either a transoral/Keen's approach, Gillies temporal approach, or bicoronal approach depending on the fracture type and displacement. Complications can include nerve damage, malunion, enophthalmos, and infection.
Zygomatic maxillary complex fracture
- 1. ZYGOMATICO MAXILLARY COMPLEX FRACTURE Submitted by Josna Thankachan Final year part II Al-Azhar Dental College
- 2. CONTENTS • Introduction • Fracture pattern • Classification • Clinical features • Investigation • Management • Surgical Approaches • Reduction • Fixation • Complication • References
- 3. 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.
- 5. • 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.
- 7. • 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.
- 8. • 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.
- 9. 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
- 10. • 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.
- 11. • 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.
- 12. 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
- 13. 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
- 14. 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
- 15. • 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
- 16. – Subconjunctival ecchymosis – Chemosis – Hypoglobus – Proptosis bulbi – Enophthalmos – Exophthalmos
- 17. – Subcutaneous periorbital air emphysema – Pneumoexophthalmos – Amaurosis – Superior orbital fissure syndrome – Diplopia
- 19. • 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.
- 21. • 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
- 22. • 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
- 23. INVESTIGATIONS • Plain radiographs water’s view or paranasal view of zygomaticomaxillary complex fracture,floor of orbit,infra orbital rim submentovertex- Arch fracture • CT scan
- 24. 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
- 25. B. Intra oral approach Transoral/keen’s approach Endoscopic transantral approach
- 26. 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.
- 28. 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.
- 30. • 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.
- 31. • 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.
- 32. 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.
- 34. • 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.
- 35. REDUCTION • Indirect method – Gillies temporal approach – Keen’s approach – Percutaneous approach • Direct method – Coronal/bicoronal approach – Supraorbital eyebrow approach – Lower eyelid approach
- 36. • Fixation – 1 point fixation – 2 point fixation – 3 point fixation – 4 point fixation
- 37. • 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.
- 39. • 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.
- 41. • 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.
- 43. • 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.
- 45. • Fixation is again of two types: i. Direct fixation • Transosseous wiring ii. Indirect fixation • Internal pin fixation • Transfixation with kirshner wire
- 46. 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
- 47. 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