Fracture of zygomatico maxillary complex. helpful for dental student.

2.  Introduction
 Fracture pattern
 Classification
 Clinical features
 Investigation
 Management
 Surgical Approaches
 Reduction
 Fixation
 Complication
 References

3.  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 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 i.e., antrum, orbital floor.
This structure makes up the
zygomaticomaxillary complex.

6. FRACTURE PATTERN

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.

13. I. Row and Killey classification(1968)
Type I – no significant displacement
Type II – Fracture of zygomatic arch
Type III – rotation around vertical axis (inward or
outward displacement)
Type IV – rotation around longitudinal axis(medial or
lateral displacement)
Type V – displacement of complex bloc
Type VI – displacement of orbitoantral partition
Type VII – displacement of orbital rim segment
Type VIII – complex comminuted fractures

14.  GROUP A: stable fracture-showing minimum or
no displacement, requires no treatment.
 GROUP B: unstable fracture-great
displacement & disruption of frontozygomatic
suture & comminuted fractures , require
reduction & fixation.
 GROUP C: stable fracture-types of zygomatic
fracture which require reduction but no fixation.

15.  Minimum or no displacement
 Comminuted fracture
 V-type in fracture
 W-type fracture

16.  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

17.  OCULAR /OPHTHALMIC SYMPTOMS
› Periorbital edema
› Downward slant of palpebral fissure
› Malposition of the lateral canthus
› Vertical shortening of the lower eye lid

18. › Subconjunctival ecchymosis
› Hypoglobus
› Enophthalmos
› Exophthalmos

19. • Diplopia is a very common complication of the
zygomatic fracture where patients experiences
blurred double vision.
• Types of diplopia: - temporary & permanent
- monocular &
binocular

20.  Haematoma or oedema around the extraocular
muscles.
 Disruption in the attachments of inferior rectus
or inferior oblique muscle causes displacement
of muscle attachment.
 Orbital floor fracture which leads to herniation of
the periorbital fat into the maxillary sinus.
 Neuromuscular injury resulting in paralysis of
the muscle.
 Fibrous tissue formation & adhesion between
the globe & orbital floor.

21. 1. Finger gaze:-
Finger moved infront of eye in all nine directions of gaze at a distance of
30cm.
2. Forced duction test:-
- Diplopia caused due to oedema or hematoma of the extraocular
muscles resolves in 5 to 7 days but diplopia as a result of failure to
rotate the eyes superiorly indicates paralysis or muscle entrapment
within the fracture segment.
- To differentiate these 2 causes force duction test/
traction test is carried out under topical anaesthetic
with the tissue holding forcep hold the tendon of the inferior rectus
muscle & rotate the eyeball superiorly with other movements.
- A failure to rotate eyes superiorly indicates paralysis or entrapment
of muscle within the fracture segment.

23.  HESS DIPLOPIA CHART (LEES SCREEN ) :
- Helps in identifying the nonfunctioning extraocular muscle
- In this test, dissimilar images are projected for each eye
at 1 metre distance with the patient wearing green or red
goggles.
- A red test object is held against a screen & the patient tries
to indicate the position of the object by touching it with a
green tipped wand.
- The result of pt. effort is charted when pt. head is held still
& pt. moves pt. eyes from the primary position to the
horizontal right & left extremes of movements.
- This is repeated when looking above, & left above.
- The equivalent lower positions are also charted.

24.  DIPLOPIA CHART :
- This can be a simple useful tool for diagnosis
of diplopia especially in the absence of a
Hess chart.
- Vertical bar of light is viewed through red &
green goggles at a fixed distance from the
eye.
- The bar light is moved into each direction of
gaze & the pt. describes the image
separation & appearance.

25.  FIELD OF BINOCULAR SINGLE VISION (BSV) :
- Used to describe the area of BSV, & hence diplopia.
- The pt. is seated at the perimeter, with the chin central to
fixation.
- The target is moved outwards until the pt. recognises
diplopia & the point is marked.
- The target is then moved further until one image
disappears, normally due to occlusion by facial contours &
this point is marked.
- The inner ring describes the area of BSV ; the outer ring
describes the limits of the binocular field of fixation.

26.  NEUROLOGICAL SYMPTOMS
› Paresthesia of infraorbital nerve
› Parethesia of supra orbital and supra trochlear
nerve
› Paresthesia of zygomatico temporal and
zygomatico facial nerve
› Paralysis of facial nerve
› Paralysis of extraocular muscles

27.  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

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

29. WATERS VIEW
SUBMENTOVERTEX
VIEW

30.  Surgical approach:-
A. Extra oral approach
 Gillies temporal fossa approach
 Suprolateral
 Supraorbital approach; lateral eyebrow
 Upper eyelid
 Lower eyelid
 Infra orbital
 Subtarsal
 Subcilliary
 Transconjunctival
 Percutaneous
 Bicoronal/ hemicoronal

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

32.  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.

33.  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.

34.  Bristow’s elevator has a disadvantage 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.

35.  Also known as 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.

37.  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.

38.  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.

40. › 1 point fixation
› 2 point fixation
› 3 point fixation
› 4 point fixation

41.  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
zygomaticomaxillary butress region can avoid
unsightly scars and give high satisfaction with
surgical outcome in selected patients with zygoma
fractures.

42.  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.

43.  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.

44.  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 kirschner wire

46.  Complication of periorbital incision
 Infraorbital nerve paresthesia
 Implant extrusion/displacement and infection
 Persistent diplopia
 Enophthalmos
 Blindness
 Retrobulbar hemorrhage
 Ankylosis of zygoma to coronoid
 Malunion
 Orbital dystopia