FRACTURE

1. DR DAVIS NADAKKAVUKARAN M.D.S
READER
MALABAR DENTAL COLLEGE ,MANOOR

2. CONTENTS
• Introduction
• Classification
• Clinical features
• Investigation
• Management
• Surgical Approaches
• Reduction
• Fixation
• Complication
• References

3. INTRODUCTION
• Zygomatic bone is intimately associated with
the maxilla, frontal and temporal bones
zygomatic complex.
• The zygomatic bone fractures in the region of
the zygomatico-frontal suture, the
zygomaticotemporal suture and the
zygomatico-maxillary suture

4. 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

5. II. KNIGHT & NORTHWOOD CLASSIFICATION
ON THE BASIS OF OCCIPITOMENTAL VIEW:
1. No significant displacement
2. Fracture of zygomatic arch only
3. Unrotational body fracture
4. Medial rotational body fracture
5. Lateral rotational body fracture
6. Complete rotational body fracture

6. 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

7. • 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

8. – Subconjunctival ecchymosis
– Chemosis
– Hypoglobus
– Proptosis bulbi
– Enophthalmos
– Exophthalmos

9. – Subcutaneous periorbital air emphysema
– Pneumoexophthalmos
– Amaurosis
– Superior orbital fissure syndrome
– Diplopia

10. • 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.

12. • 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

13. • 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

14. INVESTIGATION
• Plain radiographs
water’s view or paranasal view of
zygomaticomaxillary complex fracture,floor of
orbit,infra orbital rim
submentovertex- Arch fracture
• CT scan

15. 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

16. Intra oral approach
 Transoral/keen’s approach
 Endoscopic transantral approach

17. 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.

19. 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.

21. • elevator is also used in this approach for the
reduction of the zygomatic fracture.
• 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

22. • 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

23. 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.

25. • 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.

26. REDUCTION
• Indirect method
– Gillies temporal approach
– Keen’s approach
– Percutaneous approach
• Direct method
– Coronal/bicoronal approach
– Supraorbital eyebrow approach
– Lower eyelid approach

27. • Fixation
– 1 point fixation
– 2 point fixation
– 3 point fixation
– 4 point fixation

28. • 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.

30. • 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.

32. • 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.

34. • 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

36. • Fixation is again of two types:
i. Direct fixation
• Transosseous wiring
ii. Indirect fixation
• Internal pin fixation
• Transfixation with kirshner wire

37. COMPLICATIONS
• Infraorbital paraesthesia
• Malunion and assymmetry
• Diplopia
• Traumatic hyphema
• Enopthalmos
• Traumatic optic neuropathy- mild visual deficit to complete loss of
vision
• Superior orbital fissure syndrome-include ptosis, ophthalmoplegia,
forehead anesthesia, and a fixed dilated pupil. Proptosis may be
present. Treatment may include reduction of fractures, steroids,
orbital apex exploration, and aspiration of retrobulbar hematoma if
present
• Trismus
• Retrobulbar haemorrhage

38. REFERENCE
1. Textbook of oral and maxillofacial surgery;2nd
edition- S.M Balaji
2. Textbook of oral and maxillofacial surgery;3rd
edition- Neelima Mallik
3. Textbook of oral and maxillofacial surgery-
Chithra chakravarthi
4. Oral and maxillofacial surgery-Laskin