This document discusses fractures of the zygomatic bone complex. It begins by describing the anatomy of the zygomatic bone and its connections. It then discusses the different types of zygomatic fractures based on the location and degree of displacement. The clinical features, investigations, classification systems, and approaches for open reduction and internal fixation are described. Complications from zygomatic fractures include infraorbital numbness, diplopia, enophthalmos, and traumatic optic neuropathy.

1. PRESENTED BY-
MAHAK RALLI
FINALYEAR

2.  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.
 The zygomatic arch may be fractured
without displacement of the zygomatic
bone.

3.  BASED ONTHE EXTENT OF INVOLVEMENT OF
STRUCTURESWITHINTHE ORBIT- all fractures
of the body of the zygomatic complex must
involve the orbit but the importance of that
involvement depends on the degree and
direction of displacement.
1. Minimal or no displacement
2. Inward and downward displacement
3. Inward and posterior displacement
4. Outward displacement
5. Comminution of the complex as a whole.

4. INWARD AND DOWNWARD
DISPLACMENT
Whitnall’s tubercle is depressed
together with suspensory ligament of
the eye.
INWARD AND POSTERIOR
DISPLACEMENT
The level of suspensory ligament is
unchanged but the floor of orbit may
be extensively damaged

5. OUTWARD DISPLACEMENT of the
zygomatic complex occurring in
conjunction with impacted central
middle third fractures.
COMMINUTION
of the whole zygomatic complex
with considerable depression.

6. Fracture of the zygomatic arch alone, not
involving the orbital walls.

7.  Minimal or no displacement
 V-type fracture
 Comminuted
Displacement of ZMC around vertical axis through
frontozygomatic suture is more stable than
displacement around horizontal axis through infra
orbital foramen and zygomatic arch.
Comminuted fractures are highly unstable.

8.  ONTHE BASIS OF OCCIPITOMENTALVIEW:
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

9. Type I No significant displacement
Type II Fractures of the zygomatic arch
Type III Rotation around vertical axis
a. Inward displacement
b. Outward displacement
Type IV Rotation around longitudinal axis
a. Medial displacement of frontal process
b. Lateral displacement of frontal bone
TypeV Displacement of complex bloc
a. Medial
b. Inferior
c. Lateral
TypeVI Displacement of orbito-antral partition
a. Inferiorly
b. Superiorly (rare)
TypeVII Displacement of orbital rim segment
TypeVIII Complex comminuted fractures

10.  Low energy
 Middle energy
 High energy

11.  Circumorbital oedema and ecchymosis and
subconjuctival haemorrhage
 Tenderness

12.  Flattening of the malar prominence and
zygomatic arch

13.  Trismus
 Epistaxis- Maxillary sinus drains into the nose through
middle meatus, unilateral haemorrhage is possible
whenever there is haemorrhage into the sinus as a
result of disruption of the sinus mucosa.

14.  Nerve damage- Neuropraxia or neurotmesis
of the infraorbital nerve causing anaesthesia
and paraesthesia of the temple, cheek, one
side of the upper lip and side of the nose.
 Enopthalmos

15.  Lateral or inferior displacement of zygoma
 Inferior displacement of eyeball within he orbit
due to increase in the volume of orbit due to
fracture of its walls (worsened by herniation of
fat)
 Restriction of eye movement due to entrapment
of inferior rectus and inferior oblique muscles
 Sunken eye appearance

16.  Blurred double vision
 Maybe : temporary/permanent
monocular/binocular
Temporary Haematoma/oedema of extraocular muscles
Lasts 5-7days
Permanent Paralysis or muscle entrapment in the fractured segments
Monocular Double vision through one eye with the other eye closed
Caused due to detached lens or traumatic injury to the globe of eye
Binocular Double vision is experienced when looking through both eyes
simultaneously

17.  Finger gaze test
 Traction test
 Hess diplopia chart
 Diplopia chart
 Field of binocular single vision

18.  Initial evaluation of the patient with a
zygomatic fracture includes documentation
of the bony injury and the status of
surrounding soft tissue (eyelids, lacrimal
apparatus, canthal tendons and globe) and
cranial nerves II toVI.
 Visual acuity and the status of the globe and
retina should be established; an
ophthalmologist should be consulted for
suspected or questionable ophthalmic injury.

19.  History
 Physical examination
 Radiographs – waters view, submentovertex
view and Caldwells view

21. Isolated
Zygomatic
arch fracture
Extraoral
Approach:
Gillie’s
Approach.
Dingman
Approach
Intraoral
approach-
Keen
approach
Percutaneo
-us method
Approaches
to ZF suture
Upper eye
lid
Approach.
Lateral
Brow
Approach.
Hemicoro-
nal
Approach
Zygomatic
buttress
fracture
Transoral
approach
Transcutan
-eous
cheek
approach
Approaches for
infraorbital rim
Transconjucti
val
Subciliary
Lowerlid
approach
Infraorbital
approach

24.  The Gillies technique
describes a temporal
incision (2 cm in
length), made 2.5 cm
superior and anterior
to the helix, within the
hairline.
 A temporal incision is
made. Care is taken to
avoid the superficial
temporal artery

25.  An instrument is inserted
deep over the temporalis
muscle. Using a back-and-
forth motion the instrument
is advanced until it is medial
to the depressed zygomatic
arch.
 A Rowe zygomatic
elevator is inserted just
deep to the depressed
zygomatic arch and an
outward force is applied.

27. Gillies
approach
using Rowe’s
zygoma
elevator

28.  It involves an incision near the ZF suture with dissection
beneath the temporal fascia and place an elevator along the
frontal process of the zygoma and underneath the
zygomatic arch .

29. An incision 1cm in length is made in the buccal sulcus behind the zygomatic
buttress
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
Advtg- less amount of force is required for reduction

30.  Making an incision in the mucosa at the level of the
maxillary alveolus and extending it inferiorly along the
anterior border of the ramus.
 The dissection continues along the lateral aspect of
the coronoid process, ending at the level of the
maxillary alveolus and extending it inferiorly along the
anterior border of the ramus.
 The dissection continues along the lateral aspect of
the coronoid process, ending at the level of the
zygomatic arch at the site of the fracture. An elevator
is placed between the coronoid process and the
zygomatic arch, and the fracture is reduced.

31.  Stacey bone hook andCaroll-Girard screw

32.  This method consists of inserting a hook
through the skin below and behind the
zygomatic bone so that it engages the deep
aspect and allows reduction by strong
outward traction on the handle of the
instrument.

33.  Retroseptal method: In
this method an incision
is sited 2mm below the
tarsal plate to reach the
orbital rim.
 Preseptal method: In
this method incision is
made at the edge of the
tarsal plate to create a
space infront of the
orbital septum to reach
the orbital rim

37.  Direct fixation through open reduction- plate
and screw technique
 Internal orbital reconstruction-
transantral/endoscopic approach

38. Type of fixation Indication Approach
One point fixation Undisplaced fracture at
frontozygomatic suture, simple
noncomminuted zmc fracture
ZF suture-through
supraorbital eyebrow
approach.
Two point fixation Displaced fracture unstable after
reduction. Fracture at ZF suture,
infraorbital rim, buttress
Through lower eyelid
incision (infraorbital) or
maxillary vestibular incision.
Three point fixation Grossly displaced zygoma fracture
at ZF suture, ZM buttress and
infraorbital rim
Through lateral eyebrow,
infraorbital and Maxillary
vestibular incision.
Four point fixation- fixation at ZF suture, infraorbital rim, ZM buttress and zygomatic arch.
In cases of complex fracture of zygoma

39.  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

40.  CF- pain, proptosis,
dilation of the pupil,
opthalmoplegia and
decreasing visual
acuity.
 RX- IV mannitol,
acetozolamide
+steroids along with
surgical
decompression to
reduce intra-ocular
pressure