Complete presentation on zygoma fractures, clinical features and management.

1. FRACTURES OF ZYGOMA
Dr.Satish Kumar.S

2. ANATOMY
• Buttress of midfacial skeleton
• Malar eminence, lateral & inferior
portions of orbit
• Strongest attachment with frontal bone
• Muscle attachments – masseter,
Temporalis, zygomaticus M. & m.,
Levator labii superioris
• Zygomaticofacial &
Zygomaticotemporal foramen

3. Etiology
• RTA 80%
• Assault 20%
• Male:female 4:1
• 2nd – 3rd decade
• Left zygoma fracture MC than right

4. CLASSIFICATION
• KNIGHT AND NORTH CLASSIFICATION
• Group 1 – No displacement – 6%
• Group 2 – isolated displaced arch fractures – 10%
• Group 3 – Displaced body fractures (unrotated) –
33%
• Group 4 – Medially rotated body fractures – 11%
• Group 5 – Laterally rotated body fractures – 22%
• Group 6 – Additional fractures crossing main
fracture – 18%

5. Rowe’s and Killey classification (1968)
• Type I: no significant displacement
• Type II : fracture of zygomaticarch
• Type III : rotation arroundhorizontal axis –inward or outward
displacement
• Type IV: rotation around longitudinal axis –medial or lateral
• Type V: displacement of the complex block –medial/inferior/lateral
• Type VI: displacement of orbitoantralpartition
• Type VII: displacement of orbital rim segment
• Type VIII: complex comminuted fracture.

6. CLINICAL FEATURES – Orbital symptoms
• Periorbital ecchymosis
• Periorbital edema
• Downward slant of palpebral fissure (antimongoloid slant)
• Subconjunctival
ecchymosis
• Diplopia

7. Facial symptoms
• Asymmetry of the midface
• Depression/flattening of the malar prominence
• Step off or gap deformities of
infraorbital/lateral orbital rim
• Sensory deficit (hypoesthesia, anaesthesia)
in the distribution of the Infra orbital nerve

8. Oral symptoms
• Ecchymosis of the gingivobuccal maxillary sulcus
• Restriction of mandibular opening or closing
–blockage of coronoid process
•impacted zygomatic arch
•retro displaced zygoma

9. Nasal symptoms
• Ipsilateral epistaxis
• Ipsilateral hemosinus

10. DIAGNOSIS
• History
• Clinical examination
• X-ray
Water’s view - Zygoma buttresses, orbital floor, inf. orbital rim, ZF
suture, ZM buttress
Caldwell view – ZF suture
• CT- Facial bones – gold standard
• 3D CT – normal vs abnormal rim and malar eminence

13. MANAGEMENT
POINTS TO NOTE
• Presence of fracture
• Displacement
• Degree of comminution
POINTS OF ALIGNMENT
• ZF suture
• Infraorbital rim
• ZM buttress
• Zygomatic arch
• Greater wing of sphenoid
(Lat .wall of orbit)
• Orbital floor

14. Conservative management
• Non-displaced fractures- 9-50 %
• Minimal degree of displacement
Unlikely to result in -
◦ Cosmetic deformity
◦ Disturbance of vision
◦ Paraesthesia
◦ Mandibular movements impaired

15. Surgical approaches
Extra-oral approach
–Bicoronal or hemicoronal
–Gillies: Temporal
• Supra orbital approach :
Lateral eyebrow
Upper eyelid
• Infraorbital
Sub tarsal
Sub ciliary/infra ciliary
Transconjunctival
• Percutaneous

16. Surgical approaches
• Intra-oral approach
Transoral: maxillary vestibular
Endoscopic transantral

17. Bicoronal or hemicoronal
• Fractures with extreme
posterior displacement of
malar eminence and lateral
displacement of arch

18. –Entire calvarial vault
–Anterior and lateral skull
base
–Frontal sinus/Ethmoid
–Zygoma
–Zygomatic arch
–Orbit
(lateral/cranial/medial)
–Nasal dorsum
–Temporomandibular
joint (TMJ)
–Condyle and
subcondylar region

19. Temporal (Gillies) approach
• 2.5 cm superior and anterior to the helix
• within the hairline.
• 2 cm length
• avoid sup. temporal artery.
• Plane - deep to the temporalis fascia
superficial to the temporalis muscle.
• Instrument is advanced until it is medial
to the depressed zygomatic arch.

20. Gillies approach

21. Bristow Elevator Rowe elevator

22. Gillies Lift

23. Superolateral orbital rim Approaches
Fractures with ZF suture
diastasis
• Lateral eyebrow approach
• Upper eyelid approach

24. Lateral eyebrow approach
• limited access
• zygomaticofrontal process
• immediate vicinity of suture line

25. The upper-eyelid or upper blepharoplasty
approach
• Better access to
superolateral orbital rim

26. Lower eyelid approaches
Fractures with communition of
orbital floor.
A. Subciliary
B. Subtarsal: lower or mid
eyelid
C. Infraorbital: inferior orbital
rim
D. Subciliary approach can be
extended laterally to gain
access to the lateral orbital rim

27. Lower eyelid approaches

28. Areas accessible
• lower circumference of
the orbital cavity

29. Areas accessible by extended subciliary approach
• the entire lateral rim
• with heavy traction even
beyond the level of the
zygomaticofrontal suture
• lateral orbital wall back to
the zygomatico-sphenoid
suture

30. Transconjunctival approach
A. Transconjunctival
(inferior fornix
transconjunctival using a
retroseptal or preseptal route)
B. Transcaruncular (medial
transconjunctival)
C. Transconjunctival with
lateral skin extension (lateral
canthotomy)

31. • Transconjunctival incision
the floor of the orbit and
infraorbital rim as well as the
upper edge of the anterior
maxilla(A).
• Transcaruncular incision, the
medial wall of the orbit
behind the posterior lacrimal
crest can be exposed (B).

32. Dingman approach
• Semi closed approach
• Medially displaced arch fractures
• 2 incisions – lateral brow and lower eyelid incision
• ZF and ZM suture lines exposed
• Elevator through upper incision (closed)
• Orbital floor exploration (open)

33. Percutaneous: Stacey bone hook

34. Percutaneous: screw and traction method

35. Percutaneous: Carroll-Girard screw

36. Transoral(Keen) approach –lateral maxillary
vestibular incision
• direct access to the zygomatic
arch.
• 2 cm long
• Upper gingival buccal-
mucosal incision
• just at the base of the
zygomaticomaxillary buttress

37. Transoral arch elevation

38. Endoscopic assisted repair
• Orbital floor defects
• Visualising zygomatic arch reduction
• - Through maxillary sinus
• - Through intraoral buccal sulcus incision

39. Indirect reduction methods
1.Gillies temporal approach
2.Transoral: Keen’s approach
3.Percutaneus approach
4.Dingman approach

40. Fixation methods
• K-wire or pin fixation
• Inter fragmentary wiring
• Plate and screw fixation

41. K-Wire or Pin fixation
• Rapid & inexpensive
• Alignment not as good as open
method
• Fracture reduced by closed
reduction
• Stabilised with K-wire to
contralateral maxilla or zygoma
• 4 weeks

42. Plate and Screw Fixation

43. MANSON APPROACH

44. Isolated Zygomatic arch fracture
• reduced by closed reduction by Gillies or Keen’s approach
• No need for internal fixation
• Temporalis and masseter muscle and fascia with soft tissue splint the
arch sufficiently to stabilize the fragments

45. Complications
• Acute exacerbation of sinus disease
• Non union/ Malunion
• Diplopia
• Visual loss
• Globe injury
• Enophthalmos
• Persistent infraorbital nerve numbness
• Plate exposure or screw loosening