It asseses complex zygomatic and maxillary fractures types, prevention and management.

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Management of ZMC Fractures
Dr. Kemer K. OMFS (R4)

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Contents
• Introduction
• Anatomy
• Etiology
• Classifications
• Diagnosis
• Indications
• Treatment
• Complications
• Conclusion
• References

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Introduction
• The gross shape of the face is influenced
largely by the underlying osseous structures,
the zygoma plays an important role in facial
contour
• Strong buttress of lateral midface lying
between zygomatic processes of frontal bone
& maxilla

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• Zygomatic fractures are common facial
injuries due to its prominent position within
the facial skeleton.
• It is the 2nd
in frequency after nasal fractures
• a male predilection, with a ratio of 4 : 1 over
females
• The peak incidence of such injuries occurs
around the 2nd
& 3rd
decades of life

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Anatomy
• A thick strong bone,
roughly quadrilateral
in shape, with an
outer convex (cheek)
surface and an inner
concave (temporal)
surface
• Major buttress of the
facial skeleton

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Classification
• Manson and his colleagues proposed a
method of classification based on the pattern
of segmentation and displacement
low-energy injuries- # with little or no
displacement
- Incomplete fractures of one or more
articulations may be present

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Middle-energy fractures- complete # of all
articulations with mild to moderate
displacement

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High-energy injuries- comminution in the lateral
orbit and lateral displacement with segmentation
of the zygomatic arch

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Zingg and coworkers classification
Type A fractures- incomplete low-energy
fractures with fracture of only one zygomatic
pillar
Type B fractures- complete “monofragment”
fractures with fracture and displacement
along all four articulations
Type C “multifragment” fractures- included
fragmentation of the zygomatic body

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Diagnosis
History & PE
• The nature, force, and direction of the injuring blow
should be determined
• Pts. complains of pain, periorbital edema, and
ecchymosis
• Paresthesia or anesthesia over the cheek, lateral nose,
upper lip, and maxillary anterior teeth resulting from
injury to the zygomaticotemporal or infraorbital nerves
• Trismus, Epistaxis and diplopia

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• Ecchymosis
• Edema early clinical signs (61%)
• Flattening of the cheek
• Subconjunctival hemorrhage
• Downward displacement an antimongoloid
slant to the lateral canthus
• enophthalmos

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• Examination of the zygoma involves inspection and
palpation
• Tenderness, a step-off, or separation at the sutures
• Ecchymosis of the maxillary buccal sulcus
• Deformity at the zygomatic buttress of the maxilla
• The range of mandibular motion

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• Evaluation of the eye includes documentation
of visual acuity, pupillary response to light,
fundoscopic examination, ocular movement,
and globe position
• Neurologic examination CN-II, III, IV, V, and VI

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Radiographic Evaluation
• CT scan (axial & coronal)
• Waters’ View ( reverse waters’ view)
• Caldwell’s View(evaluation of rotation around
a horizontal axis).
• Submentovertex View
(jug handle)

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Indication For Surgery
• Indications for surgery are cosmetic
deformities and functional deficit

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Treatment
• The surgeon must individualize Rx based on a
combination of Hx, P/E, radiographic findings, and
sound clinical judgment.
• Rx depends on the degree of displacement and the
resultant aesthetic and functional deficits
• Rx may, therefore, range from simple observation of
resolving swelling, extraocular muscle dysfunction, and
paresthesia to ORIF.

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Zygomatic Arch Fractures
• Nondisplaced and minimally displaced zygomatic arch
fractures may require no surgical correction (observation)
• Duverney was the first surgeon to describe an operative
technique for treatment of a fractured zygomatic arch.
• He used intraoral finger pressure to elevate the depressed
arch.
• Alternatively, bite on a block of wood, which results in
temporalis muscle and tendon tension.
• This force, along with finger pressure in an outward
direction, reduces the fracture.

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• Goldthwaite in 1924 was the first to describe an
intraoral approach to the zygomatic arch through a
stab wound in the buccal sulcus.
• A sharp elevator is passed superiorly through the
vestibule and behind the maxillary tuberosity and
forward pressure is applied to reduce the arch.

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Lateral Coronoid Approach
• Also called Quinn’s approach(modificn)
• Place 3-4 cm i/o incision at the level of the maxillary
alveolus and extending it inferiorly along the anterior
border of the ramus through mucosa and submucosa
• Extend up to depth of temporal muscle
• Place instrument b/n temporalis muscle and Z arch

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Gillie’s Temporal Approaches
• The standard technique for treatment of
zygomatic arch fractures, first described by
Gillies and colleagues in 1927, can also be
used to reduce zygomatic complex fractures.

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NB; The arch should be palpated at all times as
a guide to proper reduction. The wound is
closed in layers.

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• methods of stabilization for zygomatic arch
• include temporarily packing the temporal
fossa with 1/2-inch gauze, a nasogastric tube,
or a urinary catheter
• More conveniently, a transcutaneous
circumzygomatic arch wire can be passed and
tightened over a foam-backed aluminum eye
shield to suspend the arch

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Zygomatic Complex Fractures
Low-Energy Zygomatic Complex Fractures
• Low-energy, non-displaced or minimally displaced
zygomatic complex fractures may require no
operative correction.
• The patient should be observed longitudinally for
signs of displacement, extraocular muscle
dysfunction, and enophthalmos after swelling
resolves.

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Middle-Energy Zygomatic Complex Fractures
• Middle-energy, displaced zygomatic complex fractures
require reduction and internal fixation.
• In 1996, Ellis and Kittidumkerng25 proposed an algorithm of
Rx for isolated middle-energy zygomatic complex fractures
that didn’t require orbital reconstruction.
• The initial step in this algorithm is reduction of the fracture.
Ellis and others recommend the use of a Carroll- Girard screw
(3D control in redn), which is inserted into the malar eminence

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• Other authors recommend routine exposure
of 2/more of the three anterior buttresses for
middle-energy injuries: the ZM buttress, ZF
buttress, and the infraorbital rim .
• In this manner, multiple buttresses are
visualized and the three dimensional accuracy
of the reduction can be confirmed

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High-Energy Zygomatic Complex Fractures
• A more aggressive surgical approach should be planned to
treat high-energy fractures.
• There is often significant comminution of the anterior
buttresses, making anatomic reduction difficult. With
segmentation of the ZA, it’s impossible to control this
posterior buttress.
• In addition, these fractures often require orbital reconstruction.
• To restore proper projection, facial width, and orbital volume,
exposure of the zygomatic arch and orbital floor is often
required in addition to exposure of the anterior buttresses.

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Percutaneous Approach
• A direct route to elevation of the depressed
zygoma is through the skin surface of the face
overlying the zygoma

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BONE HOOK
• Applied at a point just inferior and posterior to
the prominence of the zygoma so that it
engages the infratemporal aspect

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Carroll-Girard screw
• Advantage controlled ZMC positioning in all
three planes of space.

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Buccal Sulcus Approach

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• The major advantage, as in most intraoral
approaches, is no external scar.
• Used for both ZMC and zygomatic arch fractures
• Several different instruments can be used Monks or
Cushing (joker) elevator, simple dental extraction
forceps, large Kelly hemostat, right angle retractor,
bone hook
• Avoid using the anterior maxilla as a point of fulcrum

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Elevation from Eyebrow Approach

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• Advantage the fracture at the orbital rim is
visualized directly
• Disadvantage is that it is difficult to generate a
large amount of force, especially in the
superior direction

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Maxillary Vestibular Approach
• Approaches for open treatment of ZMC #
• Access to zygomatic arch, infraorbital rim &
frontal process of the maxilla
Advantage
hidden intraoral scar
Relatively rapid & simple
complications are few

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Supraorbital Eyebrow Approach
• Used to gain access to the lateral orbital rim
• Provides simple and rapid access to the
frontozygomatic area

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• Disadvantages
Scar will not be hidden in those who have no
eyebrows
 Does not afford a great amount of surgical
access
There is no reason to shave the eyebrow before
incision because the hair may not grow back

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Upper Eyelid Approach
• The upper eyelid approach to the
superolateral orbital rim is also called the
upper blepharoplasty, upper eyelid crease,
and supratarsal fold approach.

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Advantage
• it creates inconspicuous scar

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Lower Eyelid Approaches
Subtarsal Approach
• For approaching to infraorbital rim & orbital floor
• Incision is made in a natural skin crease at or below
the level of the tarsus, approximately half the
distance between the lash margin and orbital rim

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Advantages
(1) it is relatively easy;
(2) the incision is placed in a natural skin crease
so that the scar is imperceptible; and
(3) it is associated with minimal complications

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Subciliary Approach
• Also called the infraciliary approach, or
blepharoplasty
• The skin incision is made approximately 2 mm
inferior to the gray line of the lower eyelid, along the
entire length of the lid
• The incision may be extended laterally approximately
1 to 1.5 cm in a natural crease inferior to the lateral
canthal ligament

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Advantage
• imperceptible scar
Disadvantages
• the procedure is technically difficult for the
novice (beginners)
• higher risk of postoperative ectropion exists

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Transconjunctival Approach
• Also called the inferior fornix approach
• used for orbital floor and rim fractures
• Two basic transconjunctival incisions
1 Preseptal
2 Retroseptal approaches

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• The retroseptal approach is more direct than
the preseptal approach and is easier
• Lateral canthotomy for improved lateral
exposure but its controversial
• Advantage- produce superior cosmetic results
scar is hidden behind the lower lid
– no skin or muscle dissection is necessary

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Coronal Approach
• is an extremely useful incision for surgery of
the zygoma and arch
• it provides excellent access to the orbits,
zygomatic bodies, and zygomatic arches, with
almost no complications
• Indicated for comminuted #
• The scar is hidden within the hairline

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Fixation Techniques
1. Transosseous wiring
2. Miniplates
3. External fixators

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Complications Of Zygomatic
Complex Fractures
• Infraorbital Paresthesia
• Malunion and Asymmetry
• Enophthalmos
• Diplopia
– causes of diplopia include edema and hematoma,
entrapment of the extraocular muscles and orbital
tissue, and injury to cranial nerve III, IV, or VI

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• Traumatic Optic Neuropathy
– May range from mild visual deficit to complete visual
loss
• Superior Orbital Fissure Syndrome
– Presentation may include ptosis, ophthalmoplegia,
forehead anesthesia, and a fixed dilated pupil
– Rx-reduction of fractures, steroids, orbital apex
exploration
• Traumatic Hyphema (collection of fluid in
anterior chamber i.e b/n cornea & iris)

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• Retrobulbar Hemorrhage
– may be the result of either the initial injury or the
operative correction
– Rx decompression with lateral canthotomy and cantholysis
• Trismus
– cause is impingement of the zygomatic body on the
coronoid process of the mandible & fibro-osseous
ankylosis
– Rx Coronoidectomy

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References
• Oral & maxillofacial trauma – Fonseca 3rd
edition
• Principles of oral & maxillofacial surgery –
Peterson 3rd
edition

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Thank you