Dentist in pune. (BDS. MDS) - Dr. Amit T. Suryawanshi. Seminar-Canine Impaction. Email ID- amitsuryawanshi999@gmail.com Contact -Ph no.-9405622455 Subscribe our channel on youtube - https://www.youtube.com/channel/UC_gylEXTrjmEbbOTSXjuZ4Q/videos?view_as=public Follow us on slideshare

1. ZYGOMATICOMAXILLARY
(ZMC) COMPLEX
FRACTURES
Dr. Amit T. Suryawanshi
Dentist, Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. CONTENTS
• INTRODUCTION
• ANATOMY
• CLASSIFICATION
• SIGNS & SYMPTOMS
• CLINICAL EXAMINATION
• RADIOLOGIC EXAMINATION
• MANAGEMENT
• COMPLICATIONS

3. INTRODUCTION
• Most common facial fractures, the second in
frequency after nasal fractures.
• The high incidence relates to the zygoma’s
prominent position within the facial skeleton.
• Male predilection, 4:1 over females.
• Peak incidence- 2nd and 3rd decades of life.

4. INTRODUCTION
• Zygomatic injury is mostly due to altercations
followed by motor vehicle accidents.
• In zygomatic fractures caused by altercations,
the left zygoma is most commonly affected.
• The zygoma plays an important role in facial
contour. Disruption of the zygomatic position
creates impairment of ocular and mandibular
function.

5. INTRODUCTION
• The zygoma or malar complex forms the
central support of the cheek and is a strong
buttress of the lateral and middle third of the
facial skeleton.
• It is for this reason, the zygoma is frequently
fractured, either alone or in combination with
other bony structures of the midface.

6. ANATOMY
• The zygoma, a major
buttress of the facial
skeleton, is the principal
structure of lateral
midface.

7. ANATOMY
• Zygoma is roughly quadrilateral in shape, with
an outer convex (cheek) surface and an inner
concave (temporal) surface.
• It forms the point of greatest prominence of
the cheek.
• Resembles a four sided pyramid, which has
temporal, orbital, maxillary and frontal
processes.

8. ANATOMY
• Zygoma articulates with four bones- the
frontal, sphenoid, maxillary and temporal.
• Body of the zygoma extensively articulates
with the maxilla along the anterior maxilla and
along the orbital floor.
• It forms the superolateral aspect and part of
the superoanterior aspect of the maxillary
sinus.

9. ANATOMY

10. ANATOMY
• The frontal process is thick and triangular in
cross section, with facial, orbital and temporal
surfaces.
• The temporal process is flat and projects
posteriorly to articulate with the zygomatic
process of the temporal bone.
• The combination of the two makes up the
zygomatic arch.

11. ANATOMY
• The zygomaticotemporal articulation is a very
thin, delicate connection, which fractures
frequently.
• The zygoma provides origin to a major portion
of the masseter muscle along the body and
temporal surface.
• The temporal fascia also attaches along the
arch and the temporal process.

12. ANATOMY

13. SURGICAL ANATOMY
‘the malar bone represents a strong bone on
fragile supports, and it is for this reason that,
though the bone is rarely broken, the four
processes – frontal, orbital, maxillary and
zygomatic – are frequent sites of fracture.’
-- H.D.Gillies, T.P. Kilner and D. Stone, 1927

14. SURGICAL ANATOMY
• 2 zygomatic bones &
their temporal processes
• Zygomatic processes of
temporal bones
Form part of the middle
third of the facial
skeleton which may be
fractured following
trauma.

15. SURGICAL ANATOMY
• Fractures involving the orbit may give rise to
alteration in the position of the globe of the
eye.
• The level of the globe is normally maintained
by the suspensory ligament of Lockwood
which passes from its medial attachment on
the lacrimal bone to be inserted laterally into
the Whitnall’s tubercle.

16. SURGICAL ANATOMY
• Zygomatic and Le fort III fractures commonly
result in drop in the level of the globe of the
eye.
• As the globe of the eye drops, the upper
eyelid follows downwards giving rise to the
physical sign ‘hooding of the eye’.

17. FRACTURE PATTERNS
• The fracture pattern of any bone depends
mainly on the direction and magnitude of the
force.
• The fracture lines pass through the areas of
greatest weakness of a bone or between
bones.

18. FRACTURE PATTERNS

19. FRACTURE PATTERNS

20. FRACTURE PATTERNS
• The inferior orbital fissure is the key to
remember the usual lines of ZMC fractures.
• Three fracture lines extend from the inferior
orbital fissure in an anteromedial, a
superolateral, and an inferior direction.

21. FRACTURE PATTERNS
1. One fracture extends from the inferior orbital
fissure anteromedially along the orbital floor
mostly through the orbital process of the
maxilla.

22. FRACTURE PATTERNS
2. Second line of fracture from the inferior
orbital fissure runs inferiorly through the
posterior(infratemporal) aspect of maxilla
and joins the fracture from the anterior
aspect of maxilla, under the zygomatico
maxillary buttress.

23. FRACTURE PATTERNS
3. Third line of fracture extends superiorly
from the inferior orbital fissure along the
lateral orbital wall posterior to the rim,
usually separating the zygomaticosphenoid
suture.

24. CLASSIFICATION
• Knight and North (1961)
• Rowe and Killey (1968)
• Yanagisawa ( 1973)
• Larsen and Thomson (1978)
• Rowe and Williams (1985)
• Poswillo (1988)

25. Knight and North (1961)
Based on the direction of displacement on a
Water’s view radiograph,
• Group I – Non displaced fractures
• Group II – Arch fractures
• Group III – Unrotated fractures
• Group IV – Medially rotated fractures
• Group V - Laterally rotated fractures
• Group VI – Complex fractures

26. Knight and North (1961)

27. ROWE AND KILLEY (1968)
• Type I – no significant displacement
• Type II – fracture of the arch
• Type III – rotation around a vertical axis
• Type IV – rotation around a longitudinal axis
• Type V – displacement of the complex en bloc
• Type VI – displacement of orbito-antral partition
• Type VII – displacement of the orbital rim
segments
• Type VIII – Complex comminuted fractures

28. Yanagisawa ( 1973)
• GROUPS I & II - Unchanged
• GROUP III - Medial or lateral rotation
around a vertical axis
• GROUP IV - Medial or lateral rotation
around a longitudinal axis
• GROUP V - Medial or lateral
displacement without rotation
• GROUP VI - Isolated arch fracture
• GROUP VII - All complex fractures

29. Larsen and Thomson (1978)
• GROUP I – Non displaced fractures
requiring no treatment
• GROUP II – All fractures requiring
treatment

30. ROWE AND WILLIAMS (1985)
• Fractures stable after elevation
a) Arch only (medially displaced)
b) Rotation around the vertical axis
i) medially
ii) laterally
• Fractures unstable after elevation
a) Arch only (inferiorly displaced)
b) Rotation around horizontal axis
i) medially
ii) laterally
c) Dislocations en bloc
i) inferiorly
ii) medially
iii) postero - laterally
d) Communited fractures

31. ROWE AND WILLIAMS (1985)

32. POSWILLO’S CLASIFICATION
• Inward and downward
displacement
• Inward and posterior
displacement
• Outward displacement
of the zygomatic complex
• Communition
• Fracture of the arch alone

33. SIGNS & SYMPTOMS
• Periorbital Ecchymosis and Edema
• Flattening of the malar prominence
• Flattening over the zygomatic arch
• Pain

34. SIGNS & SYMPTOMS
• Ecchymosis of the maxillary buccal sulcus
• Deformity at the zygomatic buttress of
the maxilla
• Deformity of the orbital margin
• Trismus

35. SIGNS & SYMPTOMS
• Abnormal nerve sensibility
• Epistaxis
• Subconjunctival Ecchymoses
• Crepitation from air emphysema

36. SIGNS & SYMPTOMS
• Displacement of the palpebral fissure
• Unequal pupillary levels
• Diplopia
• Enophthalmos

37. RADIOLOGIC EXAMINATION
• Plain films and Computed Tomography have
their place in determining the type, location,
magnitude, and direction of displacement of
zygomatic fractures.
• This includes,
Water’s view, Submentovertex view,
Computed Tomography.

38. RADIOLOGIC EXAMINATION
• A single Water’s view is an important adjunct
to clinical examination.
• If fractures are noted, CT should be the
procedure of choice.
• Two dimensional CT is now considered the
best and most useful means of radiologic
assessment of the facial skeleton.

39. RADIOLOGIC EXAMINATION
• CT scans allow complete assessment of the
orbital floor and walls.
• For ZMC injuries, it is optional to have both
axial & coronal high resolution scans.
• The axial scan is helpful in evaluating the
medial and lateral orbital walls, and the
coronal scan defines the extent of injury to the
orbital floor.

40. RADIOLOGIC EXAMINATION

41. RADIOLOGIC EXAMINATION

42. RADIOLOGIC EXAMINATION

43. RADIOLOGIC EXAMINATION

44. RADIOLOGIC EXAMINATION

45. RADIOLOGIC EXAMINATION

46. RADIOLOGIC EXAMINATION

47. END OF PART 1..

48. ZYGOMATICOMAXILLARY COMPLEX
FRACTURES
PART II
PRESENTED BY,
ASHWIN THAKARE(PART III)

49. IN THE LAST PART WE DISCUSSED….
• INTRODUCTION
• ANATOMY (SURGICAL ANATOMY)
• CLASSIFICATION
• SIGNS & SYMPTOMS
• CLINICAL EXAMINATION
• RADIOLOGIC EXAMINATION

50. CONTENTS (PART 2)
• TREATMENT.

51. TREATMENT
• Historical review:
• Various authors have given various treatment
modalities and techniques for the
management of ZMC fractures.
• Dating back to 1751, when Duverney stressed
the role of contraction of temporal muscle in
realigning the medial displacement of the
zygomatic arch.

52. HISTORICAL REVIEW
• Ferrier in 1825, attempted to reduce fracture
of zygomatic arch through an incision above
the arch.
• Dupuytren in 1847, discovered the important
relationship of the temporal fascia and the
muscle as a pathway to the zygomatic arch.

53. HISTORICAL REVIEW
• Gillies in 1927 emphasised the cosmetic value
of placing the incision within the hair line.
• Stroymeyer in 1844 described the
percuteneous hook technique.
• Cheyne and Burghard in 1901 discussed the
intraoral digital manipulation technique.
• Smith and Yanagisawa in 1961 stressed the
importance of cosmetic aspects of the
treatment.

54. GENERAL PRINCIPLES OF TREATMENT
• No treatment
• Indirect reduction with,
a. No fixation
b. Temporary support
c. Direct fixation
d. Indirect fixation
• Direct reduction and fixation

55. NO TREATMENT
• Cases with a minimal degree of displacement,
which following union, are considered unlikely
to result any cosmetic deformity, disturbance
of vision, persistent paraesthesia or
impairment of mandibular movement.

56. INDIRECT REDUCTION
• NO FIXATION:
• Includes procedures which do not involve
exposure of the fracture sites.
• The principle is to disimpact and reduce the
fracture by direct application of an
instrument, through an indirect approach
remote from the fracture line.

57. NO FIXATION
• The techniques which have been developed
for this operative approach, are based upon
the introduction of an instrument through,
a. the temporal fossa,
b. the upper buccal sulcus (intraoral),
c. the cheek (percutaneous),
d. the nose (transantral)
e. the eyebrow (lateral brow)

58. NO FIXATION
• Temporal fossa approach:
• This method was introduced by Gillies et al
(1927) for elevation of the zygomatic arch.
• Incision of about 2.5 cm long, made above
and parallel to the anterior branch of the
temporal artery.

61. NO FIXATION
• Lateral brow approach: (Dingman & Natwig
1964)
• The advantage of this technique is that the
fracture at the orbital rim is visualized directly.
• The frontozygomatic area of the lateral orbital
rim is exposed by the eyebrow incision.
• The instrument is inserted to lift the zygoma
anteriorly, laterally and superiorly.

62. NO FIXATION
• Lateral eyebrow approach:

63. NO FIXATION
• Upper buccal sulcus:
• The advantages of this technique have been
discussed by Balasubramaniam (1967) who
considers that “ less force is required by the
intraoral approach than by the extraoral,
because the force is exerted where it should
be, i.e., more at the centre of the fractured
fragment”.

64. NO FIXATION
• Upper buccal sulcus: (Keen’s approach)
• Access is gained by an incision of about 1cm in
length at the reflection of the upper buccal
sulcus immediately behind the zygomatic
buttress.

65. NO FIXATION
• Quinn in 1977 described a modification.
• This employs a lateral coronoid approach
through an incision situated over the anterior
border of ramus.

67. NO FIXATION
• Percutaneous approach: (Stroymeyer 1844)
• 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.

68. NO FIXATION
• Percutaneous approach:
• Poswillo advises that the exact location of the
initial stab wound for insertion is found at the
intersection of a perpendicular line dropped
from the outer canthus of the eye and a
horizontal line extended posteriorly from the
alar margin of the nostril.

70. NO FIXATION
• Intranasal transantral approach: (Lothrop’s
approach 1906)
• Not common in use.
• An opening is made into the antrum below
the inferior meatus, and a curved urethral
sound introduced and manipulated so that its
tip lies on the antral aspect of the zygomatic
bone. Firm outward and upward pressure is
applied to reposition the bone.

71. TEMPORARY SUPPORT
• This may be indicated, as a supplementary
measure, under the following circumstances:
• When the zygomatic complex is unstable
following reduction,
• When there is gross comminution of the
zygomatic bone.
• When there is comminution without bone loss
of the orbital floor.

72. TEMPORARY SUPPORT
• Instability following adequate reduction could
be due to:
• Rupture of the enveloping periosteum or
attached temporal fascia.
• Comminution of the zygomatic arch.
• Loss of bone from around the zygomatic
buttress.
• Residual fibrosis when treatment is delayed.

73. TEMPORARY SUPPORT
• Temporary support is a concept which is
primarily based upon the introduction of a
pack or other material into the antrum so as
to exert counter-pressure against those forces
which tend to bring about a relapse of the
position achieved by indirect reduction.

74. TEMPORARY SUPPORT
• Since the pack will bring about repositioning
of fragments by pressure from their antral
aspect it will be evident that this selective
effect can only take place if there is absolute
stability of the remainder of the antrum and
the other elements of the zygomatic complex.

75. DIRECT FIXATION
• Indirect reduction, combined with direct
fixation following exposure of the fracture
site, provides an excellent method of
treatment.
• Direct fixation is needed when the fractures
remain unstable after indirect reduction.

76. DIRECT FIXATION
• Transosseous wiring or osteosynthesis:
• Separation at the frontozygomatic suture line
with displacement in excess of 2-3 mm, is
likely to cause detachment of the periosteal
and fascial attachments, and hence the direct
fixation becomes necessary.

77. DIRECT FIXATION
• Incisions on the face should be placed parallel
to or within the skin creases.
• It is preferable to incise the skin through the
outer end of the eyebrow. The incision should
not be at right angles to the skin, but directed
downwards at the same angle as the emerging
hairs.

78. DIRECT FIXATION
• The Gillies temporal approach is preferable if
there is separation at the suture.
• A percutaneous repositioning may be
preferred.
• Access to the temporal aspect of the
zygomatic bone can be obtained through the
frontozygomatic incision by passing a curved
elevator supraperiosteally posterior to the
frontal process of the zygomatic bone.

79. DIRECT FIXATION
• Dingman and Natvig (1964) recommend that
the holes are drilled in an anteroposterior
direction and when the external angular
process is well formed. It also enables the
wires to be placed in a figure of eight pattern
which provides better lateral stability.

80. DIRECT FIXATION
• Elevation of the zygomatic bone and
transosseous wiring or boneplating at the
frontozygomatic suture will achieve a stable
realignment of the orbital rim.

81. DIRECT FIXATION
• A more severe displacement, a dislocation of
the zygomatic complex en bloc, will result in
separation of the fracture ends at the inferior
orbital margin, with the fracture passing into
the orbital floor.
• In this type of unstable fracture it is essential
to carry out an osteosynthesis (transosseous
wiring) or microplating technique.

82. DIRECT FIXATION

83. DIRECT FIXATION
• Micro-plates positioned in such a way that the
screw holes are situated well away from the
fracture sites provides a very useful
alternative to wires.
• The use of malleable micro-plating equipment
has greatly improved the management of such
cases.

84. DIRECT FIXATION
• Application of a small plate, across the fronto-zygomatic
suture will usually ensure that there
is absolute immobility, so that union can take
place. Precision alignment of the inferior
orbital margin is essential, open reduction will
be indicated.

85. DIRECT FIXATION
• Inadequate immobilisation of the fronto-zygomatic
suture where the lateral orbital wall
is displaced may lead to a loss of malar
prominence.

86. INDIRECT FIXATION
• Indirect fixation implies that the zygomatic
bone will be rigidly secured to some point
elsewhere on the facial skeleton until union
occurs.
• The required degree of firmness can only be
achieved by means of internal
(intramedullary) pins or wires or external pins
and rods which are linked together.

87. INDIRECT FIXATION
• The indirect fixation can be achieved by the
following methods:
1. Zygomatico-zygomatic (Trans-maxillary)
2. Naso-zygomatic
3. Zygomatico-palatal
4. Maxillo-zygomatic
5. Fronto-zygomatic
6. Cranio-zygomatic

88. INDIRECT FIXATION
• Indirect fixation has only limited application at
the present time in view of the greater
efficiency and comfort obtained by internal
fixation techniques.

89. COMPLICATIONS
• Infraorbital nerve disorders
• Implant extrusion, displacement and infection
• Maxillary sinusitis
• Persistent diplopia
• Enophthalmos
• Ankylosis of zygoma to coronoid process
• Malunion of the zygoma

90. CONCLUSION
• Thus, the zygomatic complex fractures are
common injuries, second in frequency after the
nasal bone fractures.
• There being a wide range of treatment modalities
and techniques for the management of
zygomaticomaxillary complex fractures.
• It is the apt judgement and knowledge of the
surgical anatomy on the part of the surgeon
enabling him to effectively manage the ZMC
fractures with the desired outcome.

91. REFERENCES
• Row and williams volume -1
• Fonseca trauma volume -2
• Peter wardbooth
• Peterson’s oral and maxillofacial surgery.

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