Zmc fracture

ZYGOMATICOMAXILLARY
COMPLEX (ZMC)
FRACTURE

Contents
• Introduction
• Anatomy
• Classification
• Signs and Symptoms
• Clinical Examinations
• Radiological Examinations
• Management
• Complications

Introduction
• Second most common facial fracture, after nasal fracture
• The high incidence relates to zygoma’s prominent position within the facial skeleton
• Male predilection, 4:1 ratio
• Peak incidence - 2nd to 3rd decades of life
• Mostly due to altercations followed by motor vehicle accidents
• During altercations left zygoma is most commonly affected
• Zygoma plays an important role in facial contour. Disruption of the zygomatic position
creates impairement of ocular and mandibular function
• Zygoma or the malar complex forms the central support of the cheek an is a strong
buttress of the lateral and middle third of the facial skeleton.

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.

• 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 supero-anterior aspect of the maxillary
sinus.

• The zygomatico-temporal 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.

The inferior orbital fissure is the key to remember the usual lines of
ZMC fracture
Three fracture lines extend from the inferior orbital fissure in an
antero-medial, a supero-lateral, and an inferior direction.
FRACTURE PATTERNS

1. One fracture extends from the
inferior orbital fissure antero-
medially along the orbital floor
mostly through the orbital process of
maxilla.

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

3. Third line of fracture extends
superiorly from the inferior
orbital fissure along the lateral
orbital wall posterior to the rim,
usually separating the
zygomatico-sphenoid suture. A
ZMC fracture that follows this
pattern usually has one
additional fracture line through
the zygomatic arch.

Classification
Knight and North (1961)
Rowe and Killey (1968)
Yanagisawa (1973)
Larsen and Thomson (1978)
Rowe and Williams (1985)
Poswillo (1988)

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 Ill - Un-rotated fractures
• Group IV - Medially rotated fractures
• Group V - Laterally rotated fractures
• Group VI - Complex fractures

ROWE AND KILLEY (1968)
Type I : No significant displacement
Type II : Fracture of the zygomatic arch
Type III : Rotation around vertical axis
- Inward displacement of orbital rim
- Outward displacement of orbital rim
Type IV : Rotation around longitudinal axis
- Medial displacement of frontal process
- Lateral displacement of frontal process
Type V : Displacement of the complex en bloc
- Medial
- Inferior
- lateral (Rare)
Type VI : Displacement of orbitoantral partition
- Inferiorly
- Superiorly
Type VII : Displacement of orbital rim segments
Type VIII : Complex comminuted fractures.

Type I : no significant displacement

Type II . Fracture of the zygomatic arch

Outward Displacement
Inward Displacement
Type III. Rotation around vertical axis

Type IV. Rotation around longitudinal axis

Type V. Displacement of the complex en bloc

Type VI. Displacement of orbitoantral partition

Type VII. Displacement of orbital rim segments

Type VIII. Complex comminuted fractures

Yanagisawa ( 1973 )
GROUPS I & II - Unchanged
GROUP Ill - 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

Larsen and Thomson (1978)
Group I – Non displaced fractures requiring no treatment
Group II – All fractures requiring treatment

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

Poswillo’s classification (1988)
Inward and downward displacement
Inward and posterior displacement
Outward displacement of the zygomatic complex
Communition
Fracture of the arch alone

Deformity at the zygomatic buttress of the maxilla
Deformity of the orbital region
Trismus
Abnormal nerve sensibility
Epistaxis
Crepitation from air emphysema

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.

• A single Water 1
s view is an important adjunct to clinical examination.

Submento vertex : “Jug handle view”

• 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.

• CT scans allow complete assessment orbital
floor and walls.
• The axial scan is helpful in evaluating the medial and
lateral walls, and the coronal scan defines the extent of
injury to the orbital floor

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

• 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.

• Gillies in 1927 emphasized the cosmetic value of placing the incision
within the hair line.
• Stroymeyer in 1844 described the percutaneous
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.

GENERAL PRINCIPLES OF TREATMENT
• No treatment
• Indirect reduction with,
1. No fixation
2. Temporary support
3. Direct fixation
4. Indirect fixation
• Direct reduction and fixation

Surgical Approaches
Indirect reduction with
No fixation
1. the temporal fossa (gillies)
2. the upper buccal sulcus (intraoral),
keens and balasubramanium
3. the cheek (percutaneous),
4. the nose (transantral)
5. the eyebrow (lateral brow), dingman
& natwig
Temporary support- packing into the
antrum
Direct fixation – transosseous wiring,
miniplates
Indirect fixation
Zygomatico-zygomatic (Trans-maxillary)
Naso-zygomatic
Zygomatico-palatal
Maxillo-zygomatic
Fronto-zygomatic
Cranio-zygomatic
Direct reduction and fixation
Extra oral
a. Upper eyelid
b. Supra orbital eyebrow
c. Lower eyelid
i. Subciliary
ii. Infra orbital
iii. Trans conjunctival
d. Coronal
Intra oral
a. Maxillary vestibular
No treatment

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

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.

The techniques which have been developed for this operative
approach, are based upon the introduction of an instrument
through,
1. the temporal fossa,
2. the upper buccal sulcus (intraoral),
3. the cheek (percutaneous),
4. the nose (transantral)
5. the eyebrow (lateral brow)

Temporal fossa approach
• 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.

Upper buccal sulcus - Balasubramaniam (1967)
• 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''.

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.
Quinn in 1977 described a modification –
Which employs a lateral coronoid approach through an incision situated over
the anterior border of ramus.

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.
• 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.
Percutaneous approach: (Poswillo)

Intra nasal transantral approach: (Lathrop's approach 1906)
• Not common in use.
• An opening is made into the antrum below the inferior meatus, and a
curved instrument (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.

Lateral brow approach: (Dingman & Natwig 1964)
• The advantage of this technique is that the
fracture at the orbital rim is visualized
directly.
• The fronto-zygomatic area of the lateral
orbital rim is exposed by the eyebrow
incision.
• The instrument is inserted to lift the
zygoma anteriorly, laterally and
superiorly.

• 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.
TEM PORARY 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.

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.

Transosseous wiring or osteosynthesis
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.

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

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

Intra-oral
Gingival Buccal Sulcus Incision
• The transoral approach was
popularized by Keen in 1909
with later modifications by
Goldthwaite and Quinn.
Direct reduction and fixation

Direct reduction and fixation – Extra oral
2-For Infra - Orbital Rim Fracture.
Infraorbital approach.
Subciliary incision.
Transcongunctival Approach.
3-For the fractured Maxillary Buttress
Gingival buccal sulcus approach. (transoral
approach).
1-For ZF Frcature.
Lateral eyebrow approach.
Upper blepharoplasty incision.
4-For comminuted Fracture.
Coronal approach.

Plate Fixation
The first two screws should be
placed in the plate holes
closest to the fracture, one on
each side of the fracture. Make
sure that the fracture is
adequately spanned so that
each screw is placed in solid
bone.

Approaches to
Infraorbital
Rim
•Transconjunctival approach.
• Subciliary incision.
•Infraorbital approach.

Transconjunctival Approach
 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.

Tranconjunctival approaches
• is that they produce excellent cosmetic
results
• no skin or muscle dissection is necessary.
Advantage:

 limited medial extension by the lacrimal drainage
system.
Disadvantage:

Subciliary Approach
1
2
1
•2nd Incision:
•periorbital fat to
herniate into the wound.
•The skin and muscle
flap, maintains a better
blood supply to the skin,
and pigmentation of the
lower lid has not been
seen.
3
1•1ST Incision:
•"buttonhole" dehiscence.
•slight darkening of the skin in this
area after healing.
• An increase in the incidence of
ectropion has also been noted by
some investigators with this
approach.
3rd Incision:
•the pretarsal fibers of the
orbicularis oculi can be kept
attached to the tarsal plate,
presumably assisting in
maintaninig the position of
the eyelid and its contact
with the globe
postoperatively.

Approaches to ZF suture
• Upper eye lid
Approach.
• Lateral Brow
Approach.
• Hemicoronal
Approach.

• also called upper
blepharoplasty, upper
eyelid crease, and
supratarsal fold
approach.
Upper eye lid Approach

Upper eye lid Approach
• Technique:
1-globe protection.
2-Identification of and marking
Incision Line.
3-incision.
4-Disection
5-closure.

Lateral eye brow Approach
• Technique:
1-Vasoconstriction.
2-Skin Incision.
3-Periosteal Incision.
4-Subperiosteal
Dissection of Lateral
Orbital Rim and
Lateral Orbit.
5. Closure.

Lateral eye brow
Approach
•Gives simple and rapid access to the
frontozygomatic
• area.
•If the incision is made almost entirely within
the confines of the eyebrow, the scar is usually
imperceptible.
Advantage:

•extremely limited access.
•Occasionally, some hair loss occurs, making the
scar perceptible.
•Incisions made along the lateral orbital rim
outside of the eyebrow are very conspicuous in
such individuals, and another type of incision
may be indicated.
Disadvantage:
Lateral eye brow
Approach

Bicoronal Approach
 surgical approach to
the upper and middle
regions of the facial
skeleton, including the
zygomatic arch.
 It provides excellent
access to these areas with
minimal complications
and scar.

Skin Layer
•S = skin
•C = subcutaneous tissue
•A = aponeurosis and muscle
•L = loose areolar tissue
•P = pericranium (periosteum)

A thick layer arises from the
superior temporal line, where it
fuses with the pericranium .
 At the level of the superior
orbital rim, the temporalis fascia
splitts into the superficial & deep
layer.
Temporalis Fascia
Superficial Temporal Fat Pad
Buccal Fat Pad

COMPLICATIONS
• lnfraorbita l nerve disorders
• Implant extrusion,displacement and infection
• Maxilla ry sinusitis
• Persistent diplopia
• Enophthalmos
• Ankylosis of zygoma to coronoid process
• Malunion of the zygoma

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 zygomaticomaxiIlary
complex fractures.
• It is the a patient 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.

REFERENCES
• Rowe and Williams volume – 1
• Fonseca trauma volume – 2
• Maxillofacial surgery - Peter ward booth – 2nd edition
• Peterson’s Principles of oral and maxillofacial surgery – 3rd edition
• Surgical Approaches to Facial Skeleton, 2nd edition

Surgical Approaches
Indirect
Extra oral
a. Temporal
b. Percutaneous
Intra oral
a. Keen
b. Quin
Direct
Extra oral
a. Upper eyelid
b. Supra orbital eyebrow
c. Lower eyelid
i. Subciliary
ii. Infra orbital
iii. Trans conjunctival
d. Coronal
Intra oral
a. Maxillary
vestibular

Zmc fracture

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