Zygomatico maxillary complex fractures ppt 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

2. contentscontents
IntroductionIntroduction
Surgical anatomySurgical anatomy
ClassificationClassification
EtiologyEtiology
DiagnosisDiagnosis
ManagementManagement
ConclusionConclusion
ReferencesReferences

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.