Zmc fracture..by Dr.GPK/ Dr.G.P.Kumar/Dr.G.Padmanabha Kumar
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1) Zygomatic fractures are the second most common fractures of the facial bones. The zygomatic bone forms a prominent part of the cheek and is susceptible to fractures. 2) Diagnosis involves clinical examination to identify deformities, step defects, and numbness as well as radiological imaging like CT scans. 3) Treatment aims to restore facial contour and nerve function through either closed or open reduction and fixation methods depending on the fracture pattern and degree of displacement.
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Zmc fracture..by Dr.GPK/ Dr.G.P.Kumar/Dr.G.Padmanabha Kumar
- 1. Zygomatic complexZygomatic complex fracturesfractures Dr.G.P.Kumar,Dr.G.P.Kumar, Dept of OMFSDept of OMFS
- 3. Introduction Zygoma: Strong buttress of lateral midface lying between the zygomatic process of frontal bone and maxilla Zygomatic buttress: The structural pillar of the mid-facehe structural pillar of the mid-face that extends superiorly from thethat extends superiorly from the maxillary ridge through the zygomaticmaxillary ridge through the zygomatic bone to the frontal and temporalbone to the frontal and temporal bones.bones. (Buttress – a structure built or projecting from a wall which serves to support or reinforce the wall
- 4. Surgical anatomySurgical anatomy • Also known as Malar bone, Tripod, quadrilateral shaped boneAlso known as Malar bone, Tripod, quadrilateral shaped bone • Thick, strong,Thick, strong, • Surfaces:Surfaces: outer – convexouter – convex Inner – concaveInner – concave • Processes: The zygomatic bone articulates withProcesses: The zygomatic bone articulates with TemporalTemporal FrontalFrontal MaxillaryMaxillary SphenoidalSphenoidal
- 5. Surgical anatomy…..Surgical anatomy….. Forms articulation with various bonesForms articulation with various bones Frontozygomatic Zygomaticotemporal Zygomaticomaxillary The high incidence of ZMC fractures relates to its prominent position within the facial skeleton
- 6. Soft tissue attachmentsSoft tissue attachments MasseterMasseter TemporalisTemporalis Facial musclesFacial muscles Lateral canthal ligamentLateral canthal ligament Suspensory ligament of LockwoodSuspensory ligament of Lockwood Nerve supply:Nerve supply: Zygomatico temporal nerveZygomatico temporal nerve Zygomatico facial nerveZygomatico facial nerve Infra orbital nerveInfra orbital nerve
- 7. Zygomatic complex fracturesZygomatic complex fractures Second most common fracture of the facial bones behind nasal bone fractures Zygoma forms prominence of cheek which subsequently contributes to frequency of fractures Major contact areas are with the maxilla and frontal bones Also forms portion of lateral wall and floor of the orbit
- 8. 88 Zygomatic complex and arch fracture The malar bone represent a strong bone on fragile supports, and it is for this reason that, though the body of the bone is rarely broken, the four processes- frontal, orbital, maxillary and zygomatic are frequent sites of fracture. HD Gillies, TP Kilner and D Stone,HD Gillies, TP Kilner and D Stone, 19271927 Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.
- 9. COMMON FRACTURE SITESCOMMON FRACTURE SITES 1.1. FrontozygomaticFrontozygomatic suturesuture 2.2. Infraorbital rimInfraorbital rim 3.3. Junction of theJunction of the zygomatic arch andzygomatic arch and temporal bonestemporal bones 4.4. Orbital floorOrbital floor 5.5. Maxillary buttressMaxillary buttress
- 11. ClassificationClassification Knight and NorthKnight and North Rowe and KilleyRowe and Killey Spissel and SchrollSpissel and Schroll HendersonHenderson
- 16. EtiologyEtiology RTARTA AssaultAssault Sports injurySports injury Gun shot injuries (comminuted)Gun shot injuries (comminuted)
- 19. DiagnosisDiagnosis HistoryHistory Clinical examinationClinical examination Radiological examinationRadiological examination
- 20. 2020 Clinical examinationClinical examination Inspection Palpation Visual examination Eye movement Diplopia Pupil reaction
- 23. Clinical features of Zygomatic FracturesClinical features of Zygomatic Fractures Common clinical featuresCommon clinical features:: Edema Circumorbital ecchymosis Subconjunctival hemorrage Malar depression Step defect at infraorbital rim Step defect at frontozygomatic suture Unilateral Epistaxis
- 24. Clinical features of Zygomatic FracturesClinical features of Zygomatic Fractures Step defect at zygomatic buttress of maxilla intraorally Ecchymosis at maxillary buttress region V2/infraorbital nerve paraesthesia or anesthesia
- 25. Clinical features of Zygomatic FracturesClinical features of Zygomatic Fractures LESS COMMON FINDINGS Enopthalmos or Proptosis Diplopia (monocular vs. binocular) Decreased mobility of extraocular muscles -- upward gaze due to its entrapment . Injury to globe itself -- ophtho. consultation should be obtained on all midface fracture patients
- 26. Limitation of mandibular movement secondary to zygomatic arch impingement on the coronoid process Crepitation from air emphysema Unequal pupillary level
- 27. Clinical features of Zygomatic FracturesClinical features of Zygomatic Fractures Intra-oral inspectionIntra-oral inspection Ecchymosis in the upper buccal sulcus in the region of zyg. Buttress. Anesthesia of teeth and gum. Intra-oral palpationIntra-oral palpation Tenderness over zyg. Buttress. Crepitus may be felt.
- 28. Zygomatic arch fracturesZygomatic arch fractures May exist alone or with zygomatic bone orMay exist alone or with zygomatic bone or with other facial bone fractures.with other facial bone fractures. Specific clinical findings:Specific clinical findings: 1.1. Visible depression over the zyg. arch area. 2. Limitation of mandibular movements. 3. Classified as a- triple or V-shaped fracture b- comminuted fractures
- 29. 2929 Radiographical evaluationRadiographical evaluation Nothing is more valuable to the surgeon in determining theNothing is more valuable to the surgeon in determining the extent of injury and the position of the fragments-bothextent of injury and the position of the fragments-both before and after operation- than a good skiagrambefore and after operation- than a good skiagram (radiograph)(radiograph) HD Gillies, TP Kilner and D Stone, 1927HD Gillies, TP Kilner and D Stone, 1927
- 30. RADIOGRAPHSRADIOGRAPHS Water's view :Water's view : a PA projection w/ the head positioned ata PA projection w/ the head positioned at 27 degree angle to the vertical with the chin resting on27 degree angle to the vertical with the chin resting on the cassettethe cassette Submentovertex :Submentovertex : "jug handle""jug handle" Caldwell viewCaldwell view :: PA projection w/ the face at a 15 degreePA projection w/ the face at a 15 degree angle to the cassetteangle to the cassette CT ScanCT Scan :: for more detail usually obtain axial andfor more detail usually obtain axial and coronal 3-5mm cutscoronal 3-5mm cuts
- 31. 3131 Occipitomental viewOccipitomental view (water’s view)(water’s view) Caldwell projectionCaldwell projection (PA oblique view)(PA oblique view)
- 32. 3232 submentovertexsubmentovertex Recommended for isolated zygomatic arch fracture
- 33. 3333 CT scanCT scan Coronal sectionsCoronal sections Axial sectionsAxial sections 3D CT3D CT
- 34. Definitive treatmentDefinitive treatment Aim for surgeryAim for surgery 1. Restore normal contour of face 2. Relieve pain 3. Precise anatomical reduction of the fractured segment 4. Stable fixation of the reduced fragment 5. To remove any interference with the mandibular movement 6. To correct diplopia 7. To relieve pressure from infra orbital nerve
- 35. Treatment of Zygomatic FracturesTreatment of Zygomatic Fractures Zygomatic bone requires reduction for the followingZygomatic bone requires reduction for the following reasons:.reasons:. Globe displacement - enophthaimus /Globe displacement - enophthaimus / exophthaimus / diplopiaexophthaimus / diplopia Alteration in facial contourAlteration in facial contour Muscle/Fat/Nerve entrapmentMuscle/Fat/Nerve entrapment Mechanical restriction of mandibular movementMechanical restriction of mandibular movement Displaced fracturesDisplaced fractures Comminuted fractures with fragments impinging onComminuted fractures with fragments impinging on the surrounding structuresthe surrounding structures Cosmetic.Cosmetic.
- 36. Treatment of Zygomatic FracturesTreatment of Zygomatic Fractures Methods:Methods: Reduction alone.Reduction alone. Reduction & fixation.Reduction & fixation.
- 37. Reduction of Zygomatic FracturesReduction of Zygomatic Fractures Methods of reduction:Methods of reduction: Closed reduction usingClosed reduction using - Bristow’s elevator- Bristow’s elevator - Rowe’s zygomatic elevator- Rowe’s zygomatic elevator * Open reduction ( surgical )* Open reduction ( surgical )
- 49. 4949 Methods of reductionMethods of reduction Temporal approach (Gillies et alTemporal approach (Gillies et al 1927)1927) Suitable for isolated zygomatic fracture with good stability afterwards
- 51. GILLIE’S APPROACHGILLIE’S APPROACH NONFIXATIONNONFIXATION Isolated arch fractures/minimally displaced ZMC fractures -- no direct visualization 2-3cm incision in hairline below and parallel to anterior branch of temporal artery To and through superficial temporalis fascia Bristow’s elevator is passed medial to arch for elevation in a sweeping upward and outward direction
- 53. 5353 Methods of reductionMethods of reduction Percutaneous approach (malar hook, Carroll-Girard bone screw)Percutaneous approach (malar hook, Carroll-Girard bone screw) Poswillo bone hook techniquePoswillo bone hook technique Suitable for displaced zygomatic fracture with high Stability after reduction
- 55. 5555 Methods of reductionMethods of reduction Buccal sulcusBuccal sulcus approach (Keenapproach (Keen 1909)1909) Elevation fromElevation from eyebrow approacheyebrow approach (the same principle of Gillies(the same principle of Gillies approach)approach)
- 59. 5959 Open reduction and fixationOpen reduction and fixation Transosseous wiring atTransosseous wiring at –Frontozygomatic sutureFrontozygomatic suture –Infraorbial rimInfraorbial rim Surgery: •Lateral eyebrow incision •Infraorbital approach
- 60. 6060 Open reduction and fixationOpen reduction and fixation Rigid fixation using plate and screws atRigid fixation using plate and screws at Frontozygomatic sutureFrontozygomatic suture Infraorbial rimInfraorbial rim Inferior buttress of the zygomaInferior buttress of the zygoma Surgery: •Lateral eyebrow incision •Infraorbial approach •Subciliary (blepharoplasty) incision •Mid-lower lid incision •Transconjunctival approach
- 64. 6464 Infraorbital rim and buttress Lateral orbital rim Buttress of zygoma Points of fixation:
- 65. 6565 Other methods of fixationOther methods of fixation Kirschener wireKirschener wire Pin fixationPin fixation Antral packAntral pack
- 73. ConclusionConclusion Face is the most prominent and expressive part of the body and adds more value to the personality. Zygoma plays an important role in the contour of the face. Also plays a vital role in protecting the eye globe Therefore the proper diagnosis and treatment of zygomatico maxillary complex fracture is very important.