This document discusses zygomatic complex fractures, including: - The anatomy and composition of the zygomatic complex. - Common causes and characteristics of zygomatic complex fractures. - Clinical signs and symptoms of zygomatic complex fractures. - Evaluation methods including radiography and CT imaging. - Surgical and non-surgical treatment approaches depending on the severity and displacement of the fracture. - Post-operative care considerations and potential complications.

1. Mohamed khames hemeda khames
salouma
ID.201500901

2.  The term “zygomatic complex” refers to zygomatic bone
and parts of maxilla, frontal, temporal and sphenoid bone.
It plays a key role not only in the structure and function
but
also in the aesthetic appearance of the facial skeleton. It
occupies a key position in the anterolateral aspect of the
face, contributing to set the width of the midface, and to
define the shape and contour of the inferior and lateral
orbital borders as well as the cheek prominence. Moreover,
it separates the orbital contents from the infra temporal
fossa and the maxillary antrum . Further, it represents the
major buttress for the face and transmits the occlusal
stress to the base of skull along its vertical and horizontal
struts

3.  The zygomatic complex consists of zygomatic bone
and parts of
maxilla, frontal, temporal and sphenoid bone

4. Zygomatic complex fracture is the second most common
fracture of facial region just behind isolated nasal
fractures. Forty-five percent of trauma to the midface
constitutes fractures of the zygomatic complex . The
prominent convex shape of the zygoma makes it prone
to
trauma. The most common etiologic factors involved in
these injuries are interpersonal violence, road traffic
accidents, falls, and sports injuries .The incidence of
zygomatic complex in males is four times that in
females.
Most cases occur in young people in their second and
third
decades of life

5.  Fracture of the zygomatic complex, also known as a
quadripod fracture, and formerly referred to as a tripod
fracture, varies in severity from a simple crack to major
disruption. The severity of the injury is directly
proportional to force of the impact. Among the four
articulating surfaces of the zygoma, the
zygomaticomaxillary suture line is relatively stronger
than the
zygomatico-frontal, the zygomatico-temporal or
zygomatico-sphenoidal suture line. So the
zygomaticomaxillary suture line frequently remains
intact even after
multiple fractures of the complex.

6.  Zygomatic Arch Fractures
 Zygomatic Body Fracture
 Zygomatic Complex Fractures

7.  In majority of the cases of zygomatic complex fractures,
the fractured part displaces inward. This results in the
flattening of the cheek. But, this may be masked under the
swelling of the overlying soft tissues soon after injury.
Flattening becomes obvious when swelling dissipates .
Periorbital oedema and ecchymosis develops within few
hours of injury. Ecchymosis in the maxillary buccal sulcus
is also an important sign. Subconjunctival hemorrhage is
another common feature. Acute loss of sensory function of
the infraorbital nerve is often seen. Numbness of the
infraorbital nerve involves the upper lip and side of the
nose along with the anterior teeth. Traumatic injury to the
infraorbital nerve may be due to compression, oedema,
ischemia or laceration

8.  Motion of the mandible may be inhibited because of
impingement of fractured zygomatic arch on the
coronoid
process. Ipsilateral epistaxis may occurs because of
hemorrhage within maxillary sinus . If there is a
significant component of an orbital fracture,
impairment of
the extraocular muscles may be noted or the position of
the globe altered. Enophthalmos can occur secondary to
loss of orbital floor support. Evaluation for entrapment
of
the globe is critical along with diplopia if the patient is
alert and able to respond . Step deformities of the
orbital
rim may also be palpable

10.  Radiographic examination provides important evidence to
confirm the findings of the physical examination .This
occurs through plain radiographs and includes a Water’s
view, Townes view, posteroanterior (Caldwell) view, lateral
skull film, and Panorex examination. Although these plain
films are important, computed tomographic examination
with or without three-dimensional reconstruction has
replaced most of these early radiographs. Advances in
ultrasonography and computed tomography allows better
visualization of orbital fractures, often associated with
zygomatic fractures, for better preoperative evaluation,
planning, and intraoperative repair .The creation of
models based on these computed tomographic
examinations may assist with preoperative planning

14.  Indications
• Diplopia
• Restriction of mandibular movement
• Restoration of normal contour
• Restoration of normal skeletal protection
for the eye

15.  The management of zygomatic complex fracture depends
on
the degree of displacement and the resultant esthetical
and
functional deficit. Management may therefore range from
simple observation of resolving edema, diplopia and
paresthesia to a more aggressive open reduction and
internal
fixation. Although it has been suggested that all displaced
fractures require surgical intervention, conservative
management is frequently employed in cases of minimal
displacement, asymptomatic injury, patient
noncompliance,
or medical contraindication to surgery . As a general rule,
non- displaced or minimal displaced fracture can usually
be
treated conservatively and regular follow up should be
done
to assess for any late displacement

16.  The decision to intervene surgically should be primarily
based on displacement and rotation of the malar complex.
Fractures with functional or esthetic impairments in the
form of diplopia, extraocular muscle entrapment,
malocclusion, restricted mouth opening and/or depression
of the malar prominence often necessitate surgical
intervention. The first and most critical step in
management of zygomatic complex fractures is achieving
adequate reduction . Questions still remain about the
best approach for reducing zygomatic complex fractures.
When fractures are not significantly comminuted, the
entire zygoma may be reduced as a single unit. In such
cases, fractures may be managed through the use of
limited intraoral and extraoral incisions

17.  Surgical reduction of zygomatic fractures by an intraoral
surgical approach was first described in 1909 by Keen .
The intraoral approach offers several advantages
compared to the extraoral approach including no visible
skin scar, visualization of the fracture line at the
zygomaticomaxillary buttress and the infraorbital nerve,
placement of fixation plates at the zygomaticomaxillary
buttress through the same intraoral incision, and
diminished morbidity. However, further exposure of the
zygomaticofrontal junction or of the inferior orbital rim is
necessary for severely displaced zygomatic complex
fractures, which require additional rigid fixation or
reconstruction of the orbital floor

19.  In 1927, Gillies was the first to create an incision made
behind the hairline and over the temporal muscle to reach
the malar bone . He described the use of a periosteal
elevator that is slid under the depressed bone below the
temporalis fascia and to use the leverage of the elevator
for reducing the fracture. The technique has been a
commonly used for the reduction of zygomatic complex
fractures. However, this surgical approach is associated
with a facial scar in the hairline and risk of facial nerve
palsy. Moreover, further exposure of the zygomaticofrontal
junction or of the inferior orbital rim is required for
placement of mini-plates fixation in case of an unstable
zygomatic complex fracture

22.  Alternatively, reduction could be performed directly
percutaneously with a bone hook or with threaded pins
for simple, speedy and effective reduction of
noncomminuted mono fragmented zygoma fractures. A
snapping sound is heard once the fracture is reduced into
its
position. It is expected that the reposition remains stable
even without osteosynthesis. Contraindications for closed
reduction are complex or comminuted fractures of the
zygomatic complex as well as doubts of the surgeon
regarding the stability of the reposition. Furthermore,
closed treatment of zygomatic fractures is automatically
contraindicated if surgical revision of the orbital floor is
necessary

24.  Open reduction and internal fixation is generally applied
in all dislocated, instable, and comminuted fractures of
the
zygomatic bone. The purpose of fixation is to restore the
normal appearance of the face and to provide adequate
anatomic alignment of the zygomatic complex. Intraoral
sublabial vestibular incision is used to expose and
reduce the zygomatic maxillary buttress region. Lateral
brow incision is used to expose and reduce the fracture
at the fronto-zygomatic suture. The lower eyelid,
subciliary incision was selected to expose and reduce
the infra orbital margin.

28.  • It can be done in 4 methods depending on
severity of fracture
– 1 point fixation
– 2 point fixation
– 3 point fixation
– 4 point fixation

29.  • Indication
– simple noncomminuted ZMC
– patients where CT has
revealed no separation at the
fracture of the
zygomaticofrontal suture,
– and with good intraoperative
visualization, and reduction
of the lateral maxillary
buttress and the inferior
orbital rim,
– 1-point fixation with a plate
between the maxilla and
zygoma may be adequate.

30.  • When zygoma is not
adequately reduced by
visualizing only through
a single approach
• a second point of
exposure can help
determine if the
zygomatic complex has
been properly reduced.
• bone plates placed
across the
frontozygomatic
suture and the
zygomaticomaxillary
buttress provide stable
internal fixation.

31.  Indication
–Comminution of
the
zygomaticomaxillary
buttress and/or the
frontozygomatic
region, making
assessment of
reduction difficult.
–reconstruction of
the internal orbit

32.  • Only placing the
plate at infraorbital
rim will help align
the zygoma but will
not provide much
additional stability.
• 3 different
approach for direct
visualization

33.  • complex fracture of the zygoma and
uncertainty as to
adequate reduction of the fracture.
– Zygomaticofrontal suture
– Infraorbital rim
– Zygomaticomaxillary buttress,
– Zygomatic arch
• It require cornoal incision which has its own
complication
– scar alopecia
– injury to the temporal branch of the facial
nerve
– temporal hollowing : depression within the soft
tissues
overlying the temporal fossa

34.  But its
absolutely
indicated in
patient with
multiple
fractures
• frontal sinus
fractures
• NOE fractures
• Necessity to
harvest split
calvarial bone graft

35.  • Evaluation of vision
– as soon as they are awakened from anesthesia
– regular intervals until they are discharged from the
hospital
• Postoperative positioning : upright position -
improve
periorbital edema and pain
• Nose-blowing: avoided for 10 days - orbital
emphysema
• Medication : Nasal decongestant, Antibiotics,
Analgesia, Steroids, Ophthalmic ointment excluding
NSAID’S and aspirin
• Ophthalmological examination
• Postoperative imaging: 3-D imaging (CT, cone
beam

36. • Wound care: suture removal within 5 days, ice packs,
avoid sun
exposure
• Diet
• Soft diet: after healing of the maxillary vestibular
incision.
• Intranasal feeding: oral bone exposure and soft-tissue
defects.
• liquid diet : Patients in MMF
• Clinical follow-up: complexity of the surgery
• Eye movement exercises
• Oral hygiene : use of soft tooth brush and oral rinse
• MMF: duration of MMF is controversial and is dependent
on
– Fracture morphology
– Type and stability of fixation (including palatal splints)
– Dentition
– Coexistence of mandibular fractures
– Premorbid occlusion

37.  Retrobulbar haemorrhage
 Malar assymetry
 Visual disturbance
 Loss of vision
 Persisten diplopia
 Orbital dystopia
 Enopthalmos
 Sensory deifict
 Persitant occular-cardiac reflex
 Compromised occular function

38.  Principles of Internal Fixation of the Craniomaxillofacial
Skeleton - Trauma and Orthognathic Surgery by AO
foundation
 Textbook of oral and maxillofacial surgery 2nd edition: S
M Balaji
 Text book of oral and maxillofacial surgery 3rd
edition_neelima Mallik
 Contemporary oral and maxillofacial surgery
_hupp_ellis_tucker
 clinical handbook of oral and maxillofacial
surgery_lashkins
 Netter’s Atlas version 5.1