Management of zygomaticomaxillary complex fractures ih

2. MANAGEMENT OF
ZYGOMATICOMAXILLARY
COMPLEX FRACTURES
PRESENTER : DR. ITRAT HUSSAIN

3. INTRODUCTION:
Zygomatic bone is closely associated with maxilla,
frontal and temporal bones and thus are
commonly involved in zygomatic complex
fractures.
Also known as TRIPOD FRACTURES
Involves three sutures:
 Zygomatico frontal suture
 Zygomatico temporal suture
 Zygomatico maxillary suture

5. APPLIED ANATOMY:
Zygomatic bone is a dense, strong structures appears
as a "FOUR POINTED STAR":
 Upper point: frontal process.
 Distal point: temporal process
 Medial point: forming outer half of inferior orbital rim.
 Lower point: constituting zygomatic buttress.
Convexity on outer surface forms prominence of cheek.
It articulates with four bones:
 Frontal
 Sphenoid
 Maxilla
 temporal

6. Thickness & strength are evident at
zygomatico-maxillary suture.
Medial to this- area of extremely thin
bone comprising the lateral wall
of antrum,
Buttress distributes masticatory
stress to cranial base.
Temporal process extends
posteriorly to form alongwith the
zygomatic process of temporal
bone, the zygomatic arch.
coronoid process of mandible
moves between the arch and
infratemporal fossa.

7. FUNCTION
Provides cheek prominence
Helps to maintain the facial height and facial width
To protect the globe of the eye
For the attachment of masseter muscle
To direct masticatory forces to the cranium
To absorb force of an impact before it reaches the
cranium.

9. HOW IS THE ZYGOMATIC BONE WEAK?

10. FRACTURE LINE

12. AXIS OF ROTATION
Vertical axis- is drawn by extending a line from the fz
suture, zygomatic buttress and the maxillary third
molar.
Horizontal axis- is drawn by taking two parallel lines,
one from the inferior orbital margin and the other on
the zygomatic buttress.

13. ROWE AND KILLEY 1968- TYPE OF AXIAL
ROTATION & DISPLACEMENT
Type
I. No significant displacement
II. Fracture of zygomatic arch
III. Rotation around vertical axis-
a. Internally b. Externally
iv. Rotation around longitudinal / horizontal axis
a. Medially b. Laterally
v. Displacement of complex enbloc-
a. Medially b. Inferiorly c. laterally
vi. Displacement of orbito-antral portion-
a. Inferiorly b. Superiorly
vii. Displacement of orbital rim segments
viii. Complex comminuted fracture

15. CLINICAL EXAMINATION- ON INSPECTION
Periorbital Tissue :
Edema
Circumorbital ecchymosis
Subconjunctival haemorrhage
Surgical emphysema

16. Abnormality of the palpebral fissure
Unequal pupillary levels

17.  Diplopia
CAUSES OF DIPLOPIA-
•Physical interference-
- Extravasation of blood into and
around the muscles
- Impinging of bone spicules
-Displacement of bony origin
-Avulsion from the bony origin
-Entrapment of muscle within the
fracture line
-Incarceration of periorbital fat in
a bony defect
-Formation of fibrous adhesion
•Physiological imbalance
•Neurological defects
-supra-nuclear
-Nuclear lesion
-Infra-nuclear & intra-
cranial injury
-Cavernus sinus
compression
-Superior orbital fissure
contusion
-Intra-orbital damage

18. Forced duction test

19. Neurological deficit
Paraesthesia- infra-orbital , supra orbital / supra – trochlear
nerves

20. Mandible
Limited opening + deviation to the opposite side
Restricted lateral excursion to the affected side

21. On palapation-
Flattening over the malar prominence
Flattening over the zygomatic arch

22. Orbit
Pain on palpation
Superior margin
F-Z suture
Inferior margin
Naso-frontal & naso-maxillary
sutures
Zygomatic bone &/ arch
(intraorally)
Zygomatic buttress
Lateral antral wall

23. RADIOLOGICAL
Plain Radiographs
• PNS view
Water’s view
ZMC#
Floor of the orbit #
Infraorbital rim
Submentovertex
CT scan

24. •submentovertex
Recommended for
isolated
zygomatic arch fracture

25. MCGREGOR, CAMPBELL & TRAPNELL’S LINES

26. Dolan & Jacob’s lines

28. MANAGEMENT OF ZMC FRACTURE
• No treatment
• Indirect reduction with
- No fixation
- Temporary support
- Direct fixation
- Indirect fixation
• Direct reduction & fixation
• Immediate reconstruction with bone grafting
• Delayed reconstruction with osteotomy or
grafting
• Late restoration of contour using onlay grafts.

29. Optimum time for the treatment …
The following factors have to be considered :
I)The presence of any ophthalmic injuries.
II)Progressive proptosis
III)Deterioration in visual acuity
IV)Visual integrity on the unaffected side
V)The necessity for immediate operation in relation to other
facial or general injuries
VI)The medical condition of the patient.
The optimal time for treatment is after 5 – 7 days of trauma.
During 5-7 days- there is no fibrous tissue formation
During second week- hematoma formation- dissection difficult
After 3-4 weeks- there is union of the fractured bones.

30. APPROACHES – CLOSED RX
Temporal Fossa
Upper Buccal Sulcus
Percutaneous

31. TEMPORAL FOSSA APPROACH
• Introduction- Gilles (1927)
• Rationale
• Technique

37. KEEN’S/ BALASUBRAMANIAM(1967) INTRA
ORAL APPROACH
• Incision
• Application of pressure
• Heavy instruments :
 Monk’s Elevator

38. LATERAL CORONOID APPROACH
1977 – Quinn
Simple method – isolated # of the arch ( medially displaced)
Incision-3-4 cm long intraoral incison along the anterior border of
the ramus through mucosa & submucosa
Dissection- Supraperiosteal dissection is carried out followed by
dissection of the lateral part of the coronoid process
through the tendon of temporal muscle
reaching the medial aspect of the zygomatic arch

39. PERCUTANEOUS APPROACH
Advantages:
 Produce force laterally & superiorly in direct manner
Disadvantage :
 Scar on the face

40. SEVERAL INSTRUMENTS
Stroh meyer ( 1844) – Bone hook
Posswillos Hook
Carroll – Girard Bone screw

41. TEMPORARY SUPPORT
Indications :
 ZMC is unstable following reduction
 Gross communition of zygomatic
bone
 Communition with out bone loss of
orbital floor
 Orbital floor fractures

42. INDIRECT FIXATION
Securing the zygoma bone -elsewhere on the facial skeleton until union
occurs
 Internal pin fixation
 To utilize opposite sound zygoma & nasal structures for cantilever support
 Transfixation with Krishner wire

43. DIRECT FIXATION
Transosseous wiring
 Incision parallel to skin creases / langer lines
 Stainless steel wire
Bony Plating

44. APPROACHES
Existing Laceration
Maxillary Vestibular Approach
Supra orbital eyebrow approach ( Bhepharoplasty)
Lower eyelid
 Subciliary
 Transconjunctival
Coronal Approach

45. EXISTING LACERATION

46. MAXILLARY VESTIBULAR APPROACH

47. SUPEROLATERAL RIM
A- Lateral Eye brow
Approach
B- Upper-eyelid
Approach

48. A-Sub Ciliary
B- Sub Tarsal
C-Infra orbital
D-Subciliay- lateral rim
Transconjuctival

49. Coronal approach
 Anterior cranial
vault
 Forehead
 Upper & middle
regions of the facial
skeleton

51. 1-POINT FIXATION
Simple noncomminuted zygomatic-complex fracture
•Stronger plate - zygomaticomaxillary buttress
•Leg of the L-plate be placed on the most lateral portion of
the lateral maxillary buttress

52. 2-POINT FIXATION
First plate –F- Z # area
A larger L-shaped plate
zygomaticomaxillary buttress

53. 3 POINT FIXATION
Comminution of the
zygomaticomaxillary buttress
and/or the frontozygomatic
region
Infraorbital rim-more anatomic
reduction
Thin bone plates must be used in
this location

54. 1. Zygomatic arch
2. Fronto-zygomatic
suture
3. Zygomaticomaxillary
buttress
4. Orbital rim fixation
4 point fixation

55. COMPLICATIONS
• Complication of periorbital incisions
• Infra orbital Nerve injuries
• Persistent Diplopia
• Enopthalmos
• Blindness
• Ankylosis of zygoma to coronoid
• Malunion