1) Fractures of the zygoma are commonly caused by road traffic accidents and assaults, with the left side more frequently involved than the right.
2) Classification systems categorize fractures based on the location and degree of displacement. Surgical approaches are determined by the location of the fracture.
3) Treatment may involve either closed reduction using indirect methods like traction, or open reduction using direct approaches through the eyebrow, eyelid, or oral cavity as well as fixation with wires, plates or screws to realign fragments.
2. ANATOMY
• Buttress of midfacial skeleton
• Malar eminence, lateral & inferior
portions of orbit
• Strongest attachment with frontal bone
• Muscle attachments – masseter,
Temporalis, zygomaticus M. & m.,
Levator labii superioris
• Zygomaticofacial &
Zygomaticotemporal foramen
3. Etiology
• RTA 80%
• Assault 20%
• Male:female 4:1
• 2nd – 3rd decade
• Left zygoma fracture MC than right
4. CLASSIFICATION
• KNIGHT AND NORTH CLASSIFICATION
• Group 1 – No displacement – 6%
• Group 2 – isolated displaced arch fractures – 10%
• Group 3 – Displaced body fractures (unrotated) –
33%
• Group 4 – Medially rotated body fractures – 11%
• Group 5 – Laterally rotated body fractures – 22%
• Group 6 – Additional fractures crossing main
fracture – 18%
5. Rowe’s and Killey classification (1968)
• Type I: no significant displacement
• Type II : fracture of zygomaticarch
• Type III : rotation arroundhorizontal axis –inward or outward
displacement
• Type IV: rotation around longitudinal axis –medial or lateral
• Type V: displacement of the complex block –medial/inferior/lateral
• Type VI: displacement of orbitoantralpartition
• Type VII: displacement of orbital rim segment
• Type VIII: complex comminuted fracture.
6. CLINICAL FEATURES – Orbital symptoms
• Periorbital ecchymosis
• Periorbital edema
• Downward slant of palpebral fissure (antimongoloid slant)
• Subconjunctival
ecchymosis
• Diplopia
7. Facial symptoms
• Asymmetry of the midface
• Depression/flattening of the malar prominence
• Step off or gap deformities of
infraorbital/lateral orbital rim
• Sensory deficit (hypoesthesia, anaesthesia)
in the distribution of the Infra orbital nerve
8. Oral symptoms
• Ecchymosis of the gingivobuccal maxillary sulcus
• Restriction of mandibular opening or closing
–blockage of coronoid process
•impacted zygomatic arch
•retro displaced zygoma
17. Bicoronal or hemicoronal
• Fractures with extreme
posterior displacement of
malar eminence and lateral
displacement of arch
18. –Entire calvarial vault
–Anterior and lateral skull
base
–Frontal sinus/Ethmoid
–Zygoma
–Zygomatic arch
–Orbit
(lateral/cranial/medial)
–Nasal dorsum
–Temporomandibular
joint (TMJ)
–Condyle and
subcondylar region
19. Temporal (Gillies) approach
• 2.5 cm superior and anterior to the helix
• within the hairline.
• 2 cm length
• avoid sup. temporal artery.
• Plane - deep to the temporalis fascia
superficial to the temporalis muscle.
• Instrument is advanced until it is medial
to the depressed zygomatic arch.
23. Superolateral orbital rim Approaches
Fractures with ZF suture
diastasis
• Lateral eyebrow approach
• Upper eyelid approach
24. Lateral eyebrow approach
• limited access
• zygomaticofrontal process
• immediate vicinity of suture line
25. The upper-eyelid or upper blepharoplasty
approach
• Better access to
superolateral orbital rim
26. Lower eyelid approaches
Fractures with communition of
orbital floor.
A. Subciliary
B. Subtarsal: lower or mid
eyelid
C. Infraorbital: inferior orbital
rim
D. Subciliary approach can be
extended laterally to gain
access to the lateral orbital rim
29. Areas accessible by extended subciliary approach
• the entire lateral rim
• with heavy traction even
beyond the level of the
zygomaticofrontal suture
• lateral orbital wall back to
the zygomatico-sphenoid
suture
30. Transconjunctival approach
A. Transconjunctival
(inferior fornix
transconjunctival using a
retroseptal or preseptal route)
B. Transcaruncular (medial
transconjunctival)
C. Transconjunctival with
lateral skin extension (lateral
canthotomy)
31. • Transconjunctival incision
the floor of the orbit and
infraorbital rim as well as the
upper edge of the anterior
maxilla(A).
• Transcaruncular incision, the
medial wall of the orbit
behind the posterior lacrimal
crest can be exposed (B).
32. Dingman approach
• Semi closed approach
• Medially displaced arch fractures
• 2 incisions – lateral brow and lower eyelid incision
• ZF and ZM suture lines exposed
• Elevator through upper incision (closed)
• Orbital floor exploration (open)
36. Transoral(Keen) approach –lateral maxillary
vestibular incision
• direct access to the zygomatic
arch.
• 2 cm long
• Upper gingival buccal-
mucosal incision
• just at the base of the
zygomaticomaxillary buttress
41. K-Wire or Pin fixation
• Rapid & inexpensive
• Alignment not as good as open
method
• Fracture reduced by closed
reduction
• Stabilised with K-wire to
contralateral maxilla or zygoma
• 4 weeks
44. Isolated Zygomatic arch fracture
• reduced by closed reduction by Gillies or Keen’s approach
• No need for internal fixation
• Temporalis and masseter muscle and fascia with soft tissue splint the
arch sufficiently to stabilize the fragments
45. Complications
• Acute exacerbation of sinus disease
• Non union/ Malunion
• Diplopia
• Visual loss
• Globe injury
• Enophthalmos
• Persistent infraorbital nerve numbness
• Plate exposure or screw loosening