This document discusses zygomatic complex fractures, which involve breaks in the zygomatic bone and its connections to the maxilla, frontal, and temporal bones. It covers the anatomy of the zygomatic bone, classification systems for fractures, common signs and symptoms, causes, and importance of radiological evaluation in determining the nature and extent of injuries.

2. ZYGOMATICO-MAXILLARYZYGOMATICO-MAXILLARY
COMPLEX FRACTURESCOMPLEX FRACTURES
Presenter- Dr.Itart HussainPresenter- Dr.Itart Hussain

3. INTRODUCTION:INTRODUCTION:
Zygomatic bone is closely associated with maxilla,Zygomatic bone is closely associated with maxilla,
frontal and temporal bones and thus are commonlyfrontal and temporal bones and thus are commonly
involved in zygomatic complex fractures.involved in zygomatic complex fractures.
 Also known asAlso known as TRIPOD FRACTURESTRIPOD FRACTURES
 Involves three sutures:Involves three sutures:
Zygomatico frontal sutureZygomatico frontal suture
Zygomatico temporal sutureZygomatico temporal suture
Zygomatico maxillary sutureZygomatico maxillary suture

5. APPLIEDAPPLIED
ANATOMY:ANATOMY:
 Zygomatic bone is a dense, strong structuresZygomatic bone is a dense, strong structures
appears as a "appears as a " FOUR POINTED STARFOUR POINTED STAR ":":
 Upper point: frontal process.Upper point: frontal process.
 Distal point: temporal processDistal point: temporal process
 Medial point: forming outer half of inferior orbitalMedial point: forming outer half of inferior orbital
rim.rim.
 Lower point: constituting zygomatic buttress.Lower point: constituting zygomatic buttress.
 Convexity on outer surface forms prominence ofConvexity on outer surface forms prominence of
cheek.cheek.
 It articulates with four bones:It articulates with four bones:
 FrontalFrontal
 SphenoidSphenoid
 MaxillaMaxilla
 temporaltemporal

6.  Thickness & strength areThickness & strength are
evident atevident at zygomatico-zygomatico-
maxillary suture.maxillary suture.
 Medial to this- area ofMedial to this- area of
extremely thin boneextremely thin bone
comprising thecomprising the lateral wall oflateral wall of
antrum,antrum,
 Buttress distributesButtress distributes
masticatory stress to cranialmasticatory stress to cranial
base.base.
 Temporal process extendsTemporal process extends
posteriorly to form alongwithposteriorly to form alongwith
the zygomatic process ofthe zygomatic process of
temporal bone, thetemporal bone, the zygomaticzygomatic
arch.arch.
 coronoid process of mandiblecoronoid process of mandible
moves between the arch andmoves between the arch and

7.  TEMPORALIS FASCIATEMPORALIS FASCIA is attached to superioris attached to superior
border of zygomatic bone and arch, whereasborder of zygomatic bone and arch, whereas
TEMPORALIS MUSCLETEMPORALIS MUSCLE is inserted via its tendonis inserted via its tendon
into the tip and anteromedial surface of coronoidinto the tip and anteromedial surface of coronoid
process of mandible and anterior border ofprocess of mandible and anterior border of
ramus.ramus.
 This natural space is between fascia and muscle provides aThis natural space is between fascia and muscle provides a
route to approach posterior surface of zygomatic bone androute to approach posterior surface of zygomatic bone and
mesial aspect of arch, utilized for elevation of bone duringmesial aspect of arch, utilized for elevation of bone during
reduction process.reduction process.
 VERTICAL AXIS:VERTICAL AXIS: is an imaginary line drawn fromis an imaginary line drawn from
frontozygomatic suture which passes downwardsfrontozygomatic suture which passes downwards
through the centre of the body to the buttress.through the centre of the body to the buttress.
 a blow received in front of vertical axis will result ina blow received in front of vertical axis will result in inwardinward
displacement of orbital rim and outward movement ofdisplacement of orbital rim and outward movement of
centre of arch.centre of arch.
 A blow received behind the vertical axis will result inA blow received behind the vertical axis will result in
outward displacement of orbital rim and inwardoutward displacement of orbital rim and inward
displacement of centre of archdisplacement of centre of arch

8.  LONGITUDINAL AXIS:LONGITUDINAL AXIS: line at the level ofline at the level of
infraorbital foramen which passes from in frontinfraorbital foramen which passes from in front
horizontally backward through the centre of thehorizontally backward through the centre of the
body of the bone and the zygomatic arch.body of the bone and the zygomatic arch.
 Impact above this level leads toImpact above this level leads to medial displacement of themedial displacement of the
frontal process and outward movement of buttress.frontal process and outward movement of buttress.
 Impact directly on the axis will beImpact directly on the axis will be en-block displacement.en-block displacement.
 Impact below this level leads toImpact below this level leads to lateral movement of frontallateral movement of frontal
process and medial displacement of buttress into antralprocess and medial displacement of buttress into antral
cavity.cavity.

9. Horizontal and vertical axisHorizontal and vertical axis

10. CLASSIFICATION OF ZYGOMATICCLASSIFICATION OF ZYGOMATIC
COMPLEX FRACTURES:COMPLEX FRACTURES:
Was given by Rowe and Killey in 1968:Was given by Rowe and Killey in 1968:
 Type I:Type I: no significant displacementno significant displacement
 Type II:Type II: Fractures of zygomatic archFractures of zygomatic arch
 Type III:Type III: Rotation around vertical axis:Rotation around vertical axis:
 Inward displacement of orbital rim.Inward displacement of orbital rim.
 Outward displacement of orbital rim.Outward displacement of orbital rim.
 Type IV:Type IV: Rotation around longitudinal axis.Rotation around longitudinal axis.
 Medial displacement of frontal process.Medial displacement of frontal process.
 Lateral displacement of the frontal processLateral displacement of the frontal process

11.  Type V:Type V: Displacement of the complex en bloc;Displacement of the complex en bloc;
 MedialMedial
 InferiorInferior
 Lateral ( rare)Lateral ( rare)
 TYPE VI:TYPE VI: Disturbance of the orbitoantral partition.Disturbance of the orbitoantral partition.
 Inferiorly.Inferiorly.
 Superiorly( rare)Superiorly( rare)
 TYPE VII:TYPE VII: Displacement of orbital rim segments.Displacement of orbital rim segments.
 TYPE VIII:TYPE VIII: Complex comminuted fractures.Complex comminuted fractures.

12. Larsen and thomsen in 1968 gave anotherLarsen and thomsen in 1968 gave another
classification:classification:
 GROUP A:GROUP A: Stable fracture- showing minimal or noStable fracture- showing minimal or no
displacement and requires no interventiondisplacement and requires no intervention
 GROUP B:GROUP B: Unstable fracture- with greatUnstable fracture- with great
displacement and disruption at thedisplacement and disruption at the
frontozygomatic suture and comminutedfrontozygomatic suture and comminuted
fractures. Requires redution as well as fixationfractures. Requires redution as well as fixation
 GROUP C:GROUP C: Stable fractures- other types ofStable fractures- other types of
zygomatic fractures, which require reduction, butzygomatic fractures, which require reduction, but
no fixation.no fixation.

13. Fractures of body of zygomatic complexFractures of body of zygomatic complex
involving the orbit:involving the orbit:
 Minimal or no displacementMinimal or no displacement
 Inward and downward displacementInward and downward displacement
 Inward and posterior displacementInward and posterior displacement
 Outward displacementOutward displacement
 Comminution of the complex as a wholeComminution of the complex as a whole
Fractures of zygomatic arch alone notFractures of zygomatic arch alone not
involving the orbit:involving the orbit:
 Minimal or no displacementMinimal or no displacement
 V - type in fractureV - type in fracture
 comminutedcomminuted

14. C- Outward displacement of the zygomatic complex in conjunction with
impacted central middle third fractures
A-Inward and downward
Displacement; Whitnall's tubercle
Is depressed together with the
suspensory ligament of the eye
B-Inward and posterior
displacement,
Level of suspensory ligament of the
eye is unchanged floor of orbit is
damaged

15. D-D-Comminution of the whole zygomatic complex withComminution of the whole zygomatic complex with
considerable depression,considerable depression, E-E- Fracture of the zygomatic archFracture of the zygomatic arch
alone not involving the orbital walls.alone not involving the orbital walls.

16. AETIOLOGY:AETIOLOGY:
 Road side accidentsRoad side accidents
 Inter-personal violence.Inter-personal violence.
 Sports injuriesSports injuries
 FallFall

17. Signs and symptoms:Signs and symptoms:
EXTRAORALLY:EXTRAORALLY:
 Flattening of cheekFlattening of cheek
 Swelling of cheekSwelling of cheek
 Periorbital haematomaPeriorbital haematoma
 Subconjunctival haemorrhageSubconjunctival haemorrhage
 Limitation of ocular movementsLimitation of ocular movements
 DiplopiaDiplopia
 EnophthalmosEnophthalmos
 Lowering of pupil levelLowering of pupil level
 Unilateral epistaxisUnilateral epistaxis
 Tenderness over orbital rim and frontozygomaticTenderness over orbital rim and frontozygomatic
suturesuture
 Step deformity at infraorbital marginStep deformity at infraorbital margin
 Anaesthesia of cheekAnaesthesia of cheek

18. INTRAORALLINTRAORALL
YY
 Ecchymosis and tenderness intraorally overEcchymosis and tenderness intraorally over
zygomatic buttress.zygomatic buttress.
 Limitation of mandibular movementLimitation of mandibular movement
 Paraesthesia of upper teeth and gingivaParaesthesia of upper teeth and gingiva
 Posterior gagging of back teethPosterior gagging of back teeth

19. CIRCUMORBITAL ECCHYMOSIS AND OEDEMACIRCUMORBITAL ECCHYMOSIS AND OEDEMA

20. UNILATERAL EPISTAXISUNILATERAL EPISTAXIS

21. SUBCONJUNCTIVAL ECCHYMOSISSUBCONJUNCTIVAL ECCHYMOSIS

22. Radiographical evaluationRadiographical evaluation
Nothing is more valuable to the surgeon inNothing is more valuable to the surgeon in
determining the extent of injury and the positiondetermining the extent of injury and the position
of the fragments-both before and afterof the fragments-both before and after
operation- than a good skiagram (radiograph)operation- than a good skiagram (radiograph)

23. •Occipitomental viewOccipitomental view
(Posterioanterior oblique)(Posterioanterior oblique)
•(water’s view)(water’s view)

24. •submentovertexsubmentovertex
Recommended for
isolated
zygomatic arch fracture

25. CT scanCT scan
 Coronal sectionsCoronal sections
 Axial sectionsAxial sections

26. MANAGEMENTMANAGEMENT
Fractures of zygomatic complex require reductionFractures of zygomatic complex require reduction
and if necessary fixation for the followingand if necessary fixation for the following
reasons:reasons:
 To restore normal contour of the face- cosmeticTo restore normal contour of the face- cosmetic
reasons and protection for the globe of eyereasons and protection for the globe of eye
 To correct diplopiaTo correct diplopia
 To remove any interference with the range ofTo remove any interference with the range of
movement of the mandiblemovement of the mandible
 To treat the parasthesia of the cheekTo treat the parasthesia of the cheek

27.  For stable fractures:For stable fractures: simple reduction issimple reduction is
sufficient, because of high degree of stabilitysufficient, because of high degree of stability
due to integrity of temporalis fascia anddue to integrity of temporalis fascia and
interdigitation of the fracture lineinterdigitation of the fracture line
 For unstable fractures:For unstable fractures: requires open reductionrequires open reduction
and transosseus fixation or bone platingand transosseus fixation or bone plating

28. GILLIES TEMPORAL APPROACHGILLIES TEMPORAL APPROACH
 Hair is shaved from the temporal region ofHair is shaved from the temporal region of
scalpscalp
 External auditory meatus is plugged with cottonExternal auditory meatus is plugged with cotton
to prevent any fluid or blood getting insideto prevent any fluid or blood getting inside
 Palpate and mark the superficial temporalPalpate and mark the superficial temporal
artery and its anterior and posterior branchesartery and its anterior and posterior branches
 An incision 2-2.5 cm is placed inclining forwardAn incision 2-2.5 cm is placed inclining forward
at an angle of 45 degreesat an angle of 45 degrees
 Care is taken to avoid injury to superficialCare is taken to avoid injury to superficial
teporal vesselsteporal vessels

29.  Incision is given through skin, subcutaneousIncision is given through skin, subcutaneous
tissue and temporal fascia is reached.tissue and temporal fascia is reached.
 Temporal fascia is exposed which can beTemporal fascia is exposed which can be
identified as white glistening structure.identified as white glistening structure.
 Place an incision over it, temporalis musclePlace an incision over it, temporalis muscle
protrudes out soon is after the incision isprotrudes out soon is after the incision is
placed.placed.
 Temporal fascia is attached to the zygomaticTemporal fascia is attached to the zygomatic
bone and zygomatic arch , whereas temporalisbone and zygomatic arch , whereas temporalis
muscle is inserted via its tendon into the tip andmuscle is inserted via its tendon into the tip and
anteromedial surface of coronoid process andanteromedial surface of coronoid process and
anterior border of ramus of mandible.anterior border of ramus of mandible.

30.  There exist a natural space between temporalThere exist a natural space between temporal
fascia and temporalis muscle which provides afascia and temporalis muscle which provides a
route to approach the posterior surface ofroute to approach the posterior surface of
zygomatic bone and medial aspect of the arch ,zygomatic bone and medial aspect of the arch ,
which is utilized for elevation of the bone duringwhich is utilized for elevation of the bone during
reduction process.reduction process.
 LongLong BRISTOW’S ELEVATOR OR ROWE’SBRISTOW’S ELEVATOR OR ROWE’S
ZYGOMATIC ELEVATORZYGOMATIC ELEVATOR is passed into thisis passed into this
spacespace
 Once this correct plane is identified andOnce this correct plane is identified and
instrument is inserted through it downwards andinstrument is inserted through it downwards and
forward, tip of instrument is adjusted mediallyforward, tip of instrument is adjusted medially
to the displaced fracturev segment.to the displaced fracturev segment.
 Thick gauze pad is placed on the lateral aspectThick gauze pad is placed on the lateral aspect
of the skull to protect it from the pressure ofof the skull to protect it from the pressure of

31.  operator has to grasp the handle with both theoperator has to grasp the handle with both the
hands and the assistant has to stabilize thehands and the assistant has to stabilize the
head of the patienthead of the patient
 Tip of the elevator is manipulated upwardTip of the elevator is manipulated upward
forward and outwardforward and outward
 Snap sound will be heard as soon as reductionSnap sound will be heard as soon as reduction
is completeis complete
 Wound is closed in layers after withdrawing theWound is closed in layers after withdrawing the
elevatorelevator
 Care is taken that after surgery atleast for 5-7Care is taken that after surgery atleast for 5-7
days, no pressure is exerted on the areadays, no pressure is exerted on the area

33. KEEN’S APPROACHKEEN’S APPROACH
 It was given in 1909It was given in 1909
 Intraoral buccal vestibular incision is taken inIntraoral buccal vestibular incision is taken in
first and second molar region behind thefirst and second molar region behind the
zygomatic buttresszygomatic buttress
 A pointed curved elevator is passedA pointed curved elevator is passed
supraperiosteally up beneath the zygomaticsupraperiosteally up beneath the zygomatic
bonebone
 Depressed bone is then elevated with anDepressed bone is then elevated with an
upward, forward and outward movement.upward, forward and outward movement.

34. KEEN’S APPROACHKEEN’S APPROACH

35. OTHER TECHNIQUESOTHER TECHNIQUES
 QUINN’S APPROACH (Anterior ramal incision)QUINN’S APPROACH (Anterior ramal incision)
 DINGMAN’S APPROACH(Lateral brow incision)DINGMAN’S APPROACH(Lateral brow incision)
OTHER INCISIONS TO EXPOSE THE INFERIOROTHER INCISIONS TO EXPOSE THE INFERIOR
ORBITAL MARGINORBITAL MARGIN
 Transconjunctival approachTransconjunctival approach
 Subcilliary approachSubcilliary approach
 Lower blepheroplastyLower blepheroplasty

36. TRANSOSSEOUS WIRINGTRANSOSSEOUS WIRING
 Transosseous wiring at frontozygomaticTransosseous wiring at frontozygomatic
suture line:suture line:
 The fracture line is exposed by bluntThe fracture line is exposed by blunt
dissection via an oblique incision above ,dissection via an oblique incision above ,
below or just whithin the outer one-third ofbelow or just whithin the outer one-third of
the eyebrowthe eyebrow
 Small holes are drilled in the zygomaticSmall holes are drilled in the zygomatic
process of the frontal bone and frontalprocess of the frontal bone and frontal
process of the zygomatic boneprocess of the zygomatic bone
 After reduction zygomatic bone is fixed inAfter reduction zygomatic bone is fixed in
position by a piece of 0.45 mm soft stainlessposition by a piece of 0.45 mm soft stainless
steel wire passed through the two holes andsteel wire passed through the two holes and
twisted uptwisted up

37. Plating at the frontozygomatic suture linePlating at the frontozygomatic suture line
 Miniature plates may sometimes be employedMiniature plates may sometimes be employed
to establish fixation at reduced frontozygomaticto establish fixation at reduced frontozygomatic
suture or lateral orbital rimsuture or lateral orbital rim
 There is tendency for fractures which areThere is tendency for fractures which are
comminuted along the orbital floor to contractcomminuted along the orbital floor to contract
inwards during healinginwards during healing
 This can be prevented by miniplatesThis can be prevented by miniplates
 Plates are bulkierPlates are bulkier

38. Transosseous wiring at infraorbital rim
 Fracture line is exposed
 Holes are drilled in adjacent fragments
 Fracture is reduced and fixation is achieved by
transosseous wiring.
 Since the bone of infraorbital margin is
delicate, 0.35 mm soft stainless steel wire is
the most useful size to employ.

39. 3939
Infraorbital
rim and
buttress
Lateral
orbital rim
Buttress of
zygoma
Points of fixation:

40. Fixation with a pack in the maxillary sinus
 Pack placed whithin the maxillary sinus used
for two purposes:
 To support a comminuted fracture of the body of
zygomatic complex- thus pack is directed to the outer
aspect of antrum beneath zygomatic bone.
 To support a reconstituted comminuted orbital floor
 Approach is made through an incision in the
buccal sulcus
 Bone is exposed, a hole into the maxillary sinus
is seen as a result of fracture or a window is
made through the canine fossa.

41.  Opening into the maxillary sinus is enlarged ,
and the blood clot and fragments of bone are
evacuated.
 Frequently buccal pad of fat herniates into the
sinus through its fractured lateral wall and should
not be mistaken for orbital fat.
 Zygomatic bone is either reduced from KEEN'S
APPROACH or GILLIE'S TEMPORAL
APPROACH.
 Operator gently repositions fragments of orbital
floor with his fingers and then antrum is packed.
 Pack should be composed of 5cm ribbon gauze

42.  WHITEHEAD'S WARNISH consists of:
 This warnish pack remains uninfected during the
period needed for stabilization of the fracture
segments
 It has number of aromatic resins which slowly
broke down to release benzoic acid ( potent
antiseptic) togethr with waterproofing property of
compound
Iodoform 10 gm
Benzoin 10 gm
Prepared storax
7.5 gm
Balsam of tolu 5
gm
Solvent 100 ml

43.  It is placed enclosed within the sinus , beneath the
suture line in the buccal sulcus, by which route
they are easily removed
 Pack should be placed until the bone it is
supporting is stable, around 3 wks.
 Great care must be taken not to displace any bony
spicule of orbital floor against optic nerve and
ophthalmic artery leading to blindness
 BALLOONS and FOLEY'S CATHETER in antrum
can also be used but there is an disadvantage of
expanding uniformly in all directions so that
pressure cannot be exerted in the desired location
with accuracy

44. Pin fixation from the zygomatic bone to the
supra-orbital rim
 Bone pin with self tapping thread is inserted into
the zygomatic bone and other into the bone of the
lateral aspect of the supra-orbital ridge.
 Fracture is reduced and two pins are connected
by a rod and two universal joints
 Useful for the zygomatic bone which is
excessively mobile and is a valuable adjunct to
fixation .

45. COMPLICATIONS
 Retrobulbor haemorrhage leading to blindness
 Persistent infraorbital nerve parasthesia.
 Persistant cosmetic deformity.
 Maxillary sinusitis
 Deranged occlusion
 Persistant trismus
 Infection
 Malunion
 Non-union