Zygomatic arch fracture

1. Presented by / Mostafa Heeba

2. Introduction
The zygoma has four projections, which create a quadrangular shape: the frontal,
temporal, maxillary, and the infraorbital rim.
The zygoma articulates with four bones: the frontal, temporal, maxilla, and
sphenoid.
The zygomatic arch includes the temporal process of the zygoma and the zygomatic
process of the temporal bone.

5. Regional Anatomy
The zygomatic arch is formed by the
zygomatic process of temporal bone and the temporal
process of the zygomatic bone
the two processes being united by an oblique suture
(zygomaticotemporal suture)
The upper border of the arch gives attachment to the
temporal fascia; the lower border and medial surface give
origin to the Masseter ms.

6. RDA
Assault
Sports injuries

9. Radiographic Evaluation
The diagnosis of zygomatic fractures is usually established by history and physical
examination.
CT scan of the facial bones, in axial and coronal planes, is standard for
all patients with suspected zygomatic fractures.
Radiographs are helpful for confirmation and for medicolegal documentation and to
establish the extent of
the bony injury.

10. Computed Tomography
CT is the gold standard for
evaluation of zygomatic
Axial and coronal images are
define
fracture patterns, degree of
displacement, and comminution

12. Submentovertex view
demonstrating displaced left zygomatic arch fracture.
Plain x-ray
( Submentovertex view )

14. Indirect approaches
Common indirect approaches for reduction of the
zygomatic arch include:
 Temporal (Gillies) approach
 Trans-oral (Keen) approach
 Quinn’s approach
 Towel clip technique

15.  Temporal (Gillies) approach
 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.

16. Temporal (Gillies) approach - Deep dissection
The dissection continues through the
subcutaneous tissue and
superficial temporal fascia
down to the deep portion
of the deep temporal fascia.

17. Deep fascia is then incised to expose the
temporalis muscle.
The temporal fascia
is incised
horizontally
to expose the
temporalis muscle

18. Temporal (Gillies) approach - Exposure
An instrument is inserted deep to
The deep temporalis fascia and superficial
to the temporalis muscle.
Using a back-and-forth motion
the instrument is advanced until
it is medial to the depressed
zygomatic arch.

19. A Rowe zygomatic elevator is inserted just
deep to the depressed zygomatic arch and an
outward force is applied.
Great care should be taken
not to fulcrum off the squamous portion of
the temporal bone.
The arch should be palpated
at all times as a guide to
proper reduction.

20. Temporal (Gillies) approach - Wound closure
The wound is closed in layers.

21. Trans-oral (Keen) approach – lateral maxillary vestibular incision
provides the most direct access to the zygomatic arch.
allows for an intraoral incision, and therefore does not have the risk of scar
alopecia that will result from a temporal (Gillies) approach.
A 2 cm lateral maxillary vestibular incision (upper gingival buccal incision) is made
with a scalpel or a cautery device just at the base of the zygomaticomaxillary
buttress.
The incision is made through mucosa only.

22. Trans-oral
(Keen)
approach

23. Trans-oral (Keen) approach - Exposure
Because of the direct proximity of the incision
to the arch,
 an instrument can easily be placed deep
to the fractures to allow elevation of a
depressed zygomatic arch.
 the depressed arch can often be
palpated and elevated with a digital
exam.

24. Quinn’s approach
 Also known as lateral coronoid approach.
 Used for reduction of Zygomatic arch.
 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 processes and zygomatic arch, and the fracture is reduced

25. Towel Clip Reduction of the Depressed
Zygomatic Arch Fracture

26. The lateral orbital rim, malar prominence, and arch are then outlined with
a marking pen.
The area of depression is then palpated.
The area immediately superior and inferior to the fracture
site is infiltrated with a local anesthetic with vasoconstrictor.
A No. 11 blade is then used to make a small stab incision through the skin
approximately 1 cm superior to the fracture site.
A large penetrating towel clip is opened widely, and one tine is introduced and
passed deep to the depressed arch.
The towel clip is then partially closed, and the site for the inferior stab incision is
identified to make the second stab incision.

27. Placement of inferior stab incision after
rotation of towel clip.
Placement of superior stab incision.

28. The inferior tine of the towel clip is then passed, and the clip is closed and latched
into position.
The patient’s head is stabilized, and firm but steady lateral force is applied.
The fragments can be felt reducing into appropriate position, and a click may or
may not be appreciated.
Steady force is maintained for several seconds to ensure that the fragments are
reduced laterally as much as possible as there may be a tendency for some
relapse as the force is diminished.
The area is then palpated for symmetry with the contralateral arch, and the
esthetics evaluated.
The clip is removed when adequate reduction has been ensured.

29. Application of lateral reducing force while stabilizing
patient’s head.
Passage of superior tine deep
to depressed arch.

30. • The zygoma fracture reduction is complete if the spheno-
zygomatic 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.
Bi-coronal/hemi-coronal approach
Direct approach :

31. Bi-coronal/hemi-coronal approach