1

Zygomatic complex fractures

Management of Maxillofacial Trauma

2

Contents

Fracture of the zygomatic complex and arch

Orbital floor fractures

Traumatic injury to the frontal sinus

Naso-ethmoial orbital fracture (NEO)

Nasal fractures

3

Zygomatic bone complex

Anatomy

Star-shape like with four processes

Frontal process

Temporal process

Buttress

Orbital floor

4

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, 1927

Zygomatic bone fractured as a

block near its principle three suture

lines and often displaces inwards to

a greater or lesser extent.

5

Occurrence

Observed in (>50%) of middle third

fracture (in developed countries due to assaults)

The zygomatic arch fracture can be

isolated in most of the cases

•As isolated fracture

•In combination with other middle third fracture

•With internal orbital fracture (blow out)

6

Signs and symptoms

Periorbital ecchymosis and edema

Flattening of the malar prominence

Flattening over the zygomatic arch

Pain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of the maxilla

Deformity at the orbital margin

7

Trismus

Abnormal nerve sensibility

Epistaxis

Subconjunctival ecchymosis

Crepitation from air

emphysema

Displacement of palpebral

fissure (pseudoptosis)

Unequal pupillary levels

Diplopia

enophthalmos

8

Clinical examination

Inspection

Palpation

Visual examinationEye movement

Diplopia

Pupil reaction

9

Radiographical evaluation

Nothing is more valuable to the surgeon in

determining the extent of injury and the

position of the fragments-both before and

after operation- than a good skiagram

(radiograph)

HD Gillies, TP Kilner and D Stone, 1927

10

Occipitomental view

(Posterioanterior oblique)

Water’s view

11

submentovertex

Recommended for isolated

zygomatic arch fracture

12

CT scan

Coronal sections

Axial sections

13

Treatment

Timing:

As early as possible unless there are ophthalmic, cranial or medical complications

Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be postponed but not more than a week

Indications:

•Diplopia

•Restriction of mandibular movement

•Restoration of normal contour

•Restoration of normal skeletal protection for the eye

14

Classifications

Displacement

Rotation along the axis of FZ processesAnterio-posterior displacement

Rotation along the prominence of the boneMedio-lateral displacement

Extension of the fracture along processes

points of fractures

Combination with other injuries

15

Treatment

The methods of treating a fractured malar bone recommended by the various writers who have

reported cases include simple digital manipulation under general anesthesia, external manipulation by means of a cow-horn dental forceps grasping the

edges of the bone, traction and elevation by means of wire or heavy bone elevators passed through small local external incisions, and elevation via

incision in the mucosa of the ginigival sulcus at the canine fossa. Our technique, which has now been

used successfully in a number of cases, differs from those mentioned.

HD Gillies, TP Kilner and D Stone, 1927

16

Methods of reduction

Temporal approach (Gillies et al

1927)

Suitable for isolated

zygomatic fracture with

good stability afterwards

17

Methods of reduction

Percutaneous approach (malar hook,

Carroll-Girard bone screw)

Suitable for displaced zygomatic

fracture with high

Stability after reduction

18

Methods of reduction

Buccal sulcus approach (Keen 1909)

Elevation from eyebrow approach

(the same principle of Gillies

approach)

19

Open reduction and fixation

Transosseous wiring at

–Frontozygomatic suture

– Infraorbial rim

Surgery:

•Lateral eyebrow incision

•Infraorbital approach

20

Open reduction and fixation

Rigid fixation using plate and screws atFrontozygomatic suture

Infraorbial rim

Inferior buttress of the zygoma

Surgery:

•Lateral eyebrow incision

•Infraorbial approach

•Subciliary (blepharoplasty) incision

•Mid-lower lid incision

•Transconjunctival approach

21

Infraorbital

rim and

buttress

Lateral

orbital rim

Buttress of

zygoma

Points of fixation:

22

Other methods of fixation

Kirschener wire

Pin fixation

Antral pack

23

Internal orbital fractures

In conjunction with other

facial fractures

As isolated type (Blow out

fracture)

24

Anatomy

The floor is made of:

Maxillary bone and

part of zygoma

bounded laterally by

the inferior orbital

fissure and small

part of the ethmoid

bone

25

Clinical and radiographical presentation

Subconjunctival ecchymosis

Crepitation from air emphysema

Displacement of palpebral fissure

Unequal pupillary levels

Diplopia

enophthalmos

26

Diplopia and enophthalmous

Superior orbital fissure syndromeSuperior orbital fissure syndrome, also known as Rochon-

Duvigneaud's syndrome, is a neurological disorder that

results if the superior orbital fissure is fractured. Involvement of

the cranial nerves that pass through the superior orbital fissure

may lead to diplopia, paralysis of extraocular motions,

exophthalmos, and ptosis. Blindness or loss of vision indicates

involvement of the orbital apex, which is more serious,

requiring urgent surgical intervention. Typically, if blindness is

present with superior orbital syndrome, it is called orbital apex

syndrome.

27

Treatment

Rational for intervention:

Small defect with no clinical consequence

may not warrant the surgical intervention.

Large defect with handicapping symptoms

should be operated.

28

Method of reconstruction

Intra-sinus approach

to the orbital floor

External approach to

the internal orbital

floor

29

Materials in orbital reconstruction

Autologous graftBone (cranial, rib, iliac)

Cartilage

Allogenic materialsLyophilized dura

Alloplastic materialsSiliastic and proplast

implants

Teflon

hydroxyapatite

Titanium mish

30

Nasal-orbital ethmoid injuries

They represent a wide spectrum of injuries

Simple nasal fracture with involvement

Of orbital bones

Grossly comminuted and compound

naso-orbital ethmoid fracture involving the base

of skull with significant displacement

31

Diagnosis

Clinical examination:Obliterating swelling

Canthus detachment

Lacrimal apparatus damage

Deformity of nasal bridge

CSF leak

Radiographical examination:

Occipitomental views

Lateral skull views

CT and 3D CT

32

Fracture classificationNasal-orbital ethmoid fractures

Type IUnilateral or bilateral, involves only one portion of the

medial orbital rim with the attached canthal tendon

Type IIUnilateral or bilateral, may be large segments of

comminuted type and the canthus remains attached to the large central segment

Type IIIUnilateral or bilateral, comminution involves the central

segment of the attached tendon results in avulsion of medial canthus

33

Management of nasal-orbital

ethmoid fracturesExamination for determination of the extent of the injury (surgical exploration)

Nasal bone

Orbital and ethmoidal

Frontal bone

Debridement and closure of open wounds

Reduction and stabilization of bone fracture

34

Principles of treatment

Good surgical exposure via:Existing laceration

Coronal flap

Open sky approach

Reduction and stabilization using:Transnasal wiring

Osteosynthesis

Prompt treatment as an aid to good reduction

Immediate bone grafting if this is indicated

35

Detached canthusTraumatic telecanthus

Increase in inter-canthal distance

secondary to

canthus displacement or

detachment

Seen in association to:Nasal bone

NEO

Le Forts fractures

36

Surgical management of detached

canthus

Transnasal wiring technique (unilateral type)

Canthopexy – Identification of the

ligament

– Liberation of the periorbital tissue

– Liberation of the lacrimal pathway

– Nasal transfixation

– Contralateral fixation

37

Lacrimal duct system injury

The lacrimal sac can be torn by

fragments of a comminuted fracture

Or

Compressed by a mass of callus

which may block the nasolacrimal canal

EPIPHORA Dacryocystitis

38

Reconstitution of the lacrimal passages

Done at the same time of canthopexy via– The original scars

– Lateral nasal incision (Lynch)

– Bi-coronal incision

Dacryocystorhinostomy If the sac remains intact, drainage of lacrimal fluid by probing

or removing of surrounded bone to allow drainage into the nose

Conjunctivo-rhinostomyimplantation of a duct-like polythene tube or glass in case of

duct damage

39

Frontal sinus fracture

Frontal sinus

Drains into nasal cavity via fronto-nasal duct

An air filled cavity lined by ciliated respiratory

epithelium encased in the frontal bone

40

Extent of the injury:

Anterior table

Posterior table

Associated injuries: mid-face or head injuries e.g.

Le Fort II, III

NOE

Neuralgic insults

Ocular injuries

41

Diagnosis

Clinical examination

Radiographical

evaluationOccipitomental views

Lateral skull view

CT scan

42

Classification of fractures

Anterior table fracture– Linear

– Displaced

Posterior table fracture– Linear

– Displaced

Outflow tract injury (naso-lacrimal duct)

43

Surgical management

Intranasal cannulation

Frontal sinus trephination

Osteoplastic flap

Sinus ablation (obliteration)

Cranialization

Reduction and fixation

44

Reduction and fixation

Surgical approaches:

– Site of penetrating injury

– Coronal approach

45

Sinus ablation

(obliteration)

– Bone

– Fat

– Muscle and

fascia

– Alloplastic

materials

46

Fixation

– Wires

– Plating

47

Nasal fractures

AnatomyMidline central facial structure that fulfills both cosmetic and functional purposes

Formed by union of rigid and flexible struts

2 rectangle-shaped nasal bone

ULCs, LLCs and midline septal

cartilage

48

Classification of injuries

Low energy injuriesSimple injury caused by low velocity trauma (simple

noncomminuted)

High energy injuriesSevere injury with comminution of nasal facial Skelton due to

higher amount of energy

Patterns of injury

•Lateral injury (from the side)

•Sagittal injury (from the front)

•Inferior injury (from below)

49

Treatment

Low energy injuriesReduction (close

manipulation, open

reduction) and stabilization

Nasal packing

External nasal splint

Adjunct septoplasty

Postoperative care

50

Complex injuriesImmediate measures:

Extra and intranasal examination

Identification of extra and intranasal

lacerations

Identification and control of site

bleeding

Surgical procedures:

Open septal procedures

Open nasal procedures

Open rhinoplasty

Open-sky “H” technique