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Zigomaticus Fracture

By :

Dika IsnainiIzzatul Muna

Nurul Fitri S.

Eka Dewi P.

Fifianan Dewi P.

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About The Patient

The identity of the patientName : Miss. E

Age : 23 years old

Sex : woman

The religi : Moeslem

Addres : Kradenan-GroboganDate of came to the hospital : July 28th 2012

Date of the examination : July 28th 2012

The number of medical record : 01027498

The room : Mawar 2/ 4B

The Main Complaint

Patient wants to operation again on the left side of her face

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The History of present illnes The disease of Now history

The patient came to the poly plastic surgery wantsto operation again on the left of her face. She hadpreviously undergone such an operation in September2010 because she has a accident (she ridings a

motorcycle and accident with a truck in the oppositedirection). Because the accident resulted in damage istoo severe on the left face of the patient, the doctordecided to hold repeat operation with distance of 1-2years again after the first operation.

Now, patient only complained of hard drinkingwith glasses. For drinking, she needs a straw. Thepatient didntt complain to difficulty to eat the foodand not pain in her face.

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The Past medical history of patient

The same disease : denied

Hipertension :denied

Diabetes mellitus :denied

Asthma :denied

Allergy :denied

The family history of disease

The same : denied

Hipertension : denied

Asthma : deniedAllergy : denied

The physical Examination :

Compos mentis, nutrition a good impression

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Status Localist1. R. Left Zygoma

Inspection : no found scar

Palpation : no pain2. R. Left Midfacial

Inspection : there is a scar, deformity to the left

Palpation : no pain, no crepitus

3. R. The left labium oris inferior

Inspection : there is a scarPalpation : no pain, no crepitus

4. R. The left mentale

Inspection : no found scar

Palpation : no pain, no crepitus

5. R. The left mandibleInspection : no found scar

Palpatin : no pain

** For r. Right zygoma, r. Right Midfacial, r. Right labium oris inferior, r. Rightmentale and r. Right mandible : within normal limits, no abnormalities

found, there is no scar and no pain

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The Patient

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Preliminary

Maxillofacial fracture is fracture of facial bones (os

frontal, tempotal, orbitozigomaticus, nasal, maxillary

and mandibular)

Etiology : traffic accident, sports trauma adnviolance

Zigomaticus fracture is one of the most common

fracture midfacial

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Anatomy

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Anatomy

Zygoma has four projections, the shape of

quadrangular or tetrapod

1. The frontal plane

2. Temporal

3. Maxillary

4. Sphenoid

Zygoma compleks fracture involving the orbital basisZygoma nervous system : nerves V, VII

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Anantomy

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Distribution of Fracture Le Fort

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Le Fort 1

Fracture of the lower horizontal between the maxillary andpalate / alveolar arch complex. Fracture line goes backthrough the lamina pterigoid

Fracture can be unilateral or bilateral

Trauma of the anteroposterior direction can be in :Nasomaxilla and vertical zigomaticomaxilla buttress

The bottom of the lamina pterigoid

Anterolateral maxillary

Palate durum

The basisc of nose

Septum

Apertura Piriformis

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Le Fort II

Line of Le Fort II fracture (fracture of thepyramid) runs through the nasal bones and

forward to the bone of lacrimalis, basic orbit,

infraorbita adn crossing to the top of the

maxillary sinus is also the direction to the

lamina pterigoid and pterigopalatina fossa.

Fracture of the lamina kribiformis etmoid cells

can damage the roof of system lakrimalis

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Le Fort III

The line fracture runs through the nasofrontalsuture passed along the line superior orbitalfissure etmoid through transversely foward

the lateral wall of the orbit, zygomatico suturatemporo frontal and zygomatic

Le Fort III maxillary fracture often causecamplications such as the emergence of intracranial brain via the roof of the effusion cellsand lamina cribiformis etmoid.

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Classification of Fractures Manson et all (1990)

Based on segmentation and shift patterns1. A low energy zygoma fractures

Fractures that show little or no shift

2. Middle energy zygoma fractures

Complete fracture of the entire articulation with mild tomoderate shift

3. High energy zygoma fractures

Characterized by lateral and orbital debris on the lateral

shift of the segmentation of the arch zygomatic. AxialCT Scan image can see on the lateral bowing andsegmentation on the zygomaticus arch.

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Axial CT Scan image seen on the lateral bowing and segmentation on zygomaticus

arch.

Coronal CT image reconstruction comminution visible on zygomaticomaxillary

buttress, infraorbital rim and orbital basis

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Enforcement of DiagnosisSymptoms :

1. Pain, periorbital edema and ecchymoses

2. Paresthesia / anesthesia. Above the cheeks,nore, lateral, upper lip and maxillary anteriorteeth

3. Trismus

4. Epistaxis

5. Diplopia

6. Coronal CT Scan, the picture looks right andbuttress zygomaticomaxillary base fracture withherniation of the orbital on the maxillary sinus

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Physical Examination

1. Evaluation of bone and soft tissue injuries2. Visual acuity, status of the eyeball and the

retina

3. Examination of Nn craniales ( N II, III, IV, V,VI)

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The Sign

1. Edema and ecchymoses

2. Depression decreased cheeks eminence rim

infraorbita

3. Hemorrhage subkonjungtiva

4. Lateral canthal dystopia

5. Diplopia and enophthalmus

6. Mandibular movement disorders

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Radiological Examination

CT Scan as gold standard

We can also use :

a. Waters Viewb. Caldwells View

c. Submentovertex View

CT i l f th bit d t ti di ti f th

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CT scan axial of the orbit demonstrating disruption of the

zygomatic arch.

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Coronal CT Scan, the pictures looks right and butters

zygomaticomaxillary base fracture with herniation of the orbital

of the on the maxillary sinus

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A. Schematic showing positioning for a Caldwell projection. (CM, canthomeatal line;

CR, central ray) B. Radiograph of a Caldwell projection. The petrous ridge is positioned

at the orbital floor. Detail of the orbital floor and maxillary sinus is blocked. C. The

radiograph is taken at a steeper angle so the petrous ridge is now positioned lower

within the maxillary antrum. (a, frontal sinus; b, innominate line; c, inferior orbital rim;d, posterior orbital floor; e, superior orbital fissure; f, greater wing of sphenoid;g,

ethmoid sinus; h, medial orbital wall; i, petrous ridge; j, zygomatic-frontal suture; k,

foramen rotundum))

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The Treatment

Treatment of complex fractures and arch zygomaticdepend on the level and the resultant shift in aestheticand functional deficits

Fractures of zygomatic arch

Zygomatic arch fracture is not displaced and minimallydisplaced (low-energy) with conservative

Middle/ High Energy zygoma fractures

1. Gilies temporal approach

2. Supraorbital approach3. Buccal sulcus approach to less popular

4. Internal fixation to reconstruction

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Pharmacological

Analgesik

Ibuprofen (Motrin, Ibuprin)

feverall, Tylenol, Aspirin FreeAnacin)

Acetaminophen andhydrocodone (Lortab, Norcet,Vicodin, Lorcet HD)

Aspirin and oxycodone(Percodan, Roxiprin, Codoxy)

Ketorolac (Toradol)

Morphine (Duramorph,Astramorph, MS Contin)

Anti-emetics

Promethazine (Phenergan,

Anergan, Prorex, Phenazine)

Ondansetron (Zofran)

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