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S E M I N A R

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FRACTURES OF THE ZYGOMATICOMAXILLARY COMPLEX

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INTRODUCTIONANATOMY OF THE ZYGOMA BONE CLASSIFICATION OF THE ZMC # RADIOGRAPHIC TECHNIQUES SURGICAL APPROACHES TO ZMC# COMPLICATIONS

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ANATOMYSHAPE ARTICULATIONS WITH FACIAL BONES

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MUSCLE ATTACHMENTS

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WHY ZYGOMATICOMAXILLARY COMPLEX FRACTURE???

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CLASSIFICATION

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ROWE AND WILLIAMS1) FRACTURES STABLE AFTER ELEVATION A. ARCH ONLY(MEDIALLY DISPLACED)

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1) FRACTURES STABLE AFTER ELEVATION B. ROTATION AROUND VERTICAL AXIS

MEDIAL ROTATION

LATERAL ROTATION9

2) FRACTURES UN STABLE AFTER ELEVATION A. ARCH ONLY(INFERIORLY DISPLACED)

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2. FRACTURE UNSTABLE AFTER ELEVATION B. ROTATION AROUND HORIZONTAL AXIS. AXIS.

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2. FRACTURES UNSTABLE AFTER ELEVATION C. DISLOCATION EN BLOC

INFERIOR

MEDIAL

POSTEROLATERAL12

LARSEN AND THOMPSONGROUP A: STABLE FRACTURE- SHOWING FRACTUREMINIMUM OR NO DISPLACEMENT, REQUIRES NO TREATMENT.

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GROUP B: UNSTABLE FRACTURE- GREAT DISPLACEMENT & DISRUPTION OF F-Z SUTURE & COMMINUTED #, REQUIRES REDUCTION AND FIXATION.

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GROUP C: STABLE FRACTURES TYPES OF ZYGOMATIC FRACTURES WHICH REQUIRES REDUCTION BUT NO FIXATION.

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THE CLASSIFICATION PROPOSED BY KNIGHT AND NORTH IS EASY TO USE AND PRACTICAL. THEY CLASSIFIED ZYGOMATIC FRACTURES INTO 6 GROUPS. GROUP I: NON-DISPLACED FRACTURES NONGROUP II: ISOLATED ARCH FRACTURES GROUP III: UNROTATED BODY FRACTURES GROUP IV: MEDIALLY ROTATED BODY FRACTURES GROUP V: LATERALLY ROTATED BODY FRACTURES GROUP VI: COMPLEX (COMMINUTED) FRACTURES.J ORAL MAXILLO-FACIAL SURGERY 66:1378-1382, 2008 16

FRACTURES OF ZYGOMATIC ARCH NOT INVOLVING ORBIT -MINIMUM OR NO DISPLACEMENT -V TYPE FRACTURES -COMMINUTED FRACTURES

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DINGMANS CLASSIFICATION OF ZYGOMA FRACTURE1. FRACTURES THAT ARE STABLE FOLLOWING CLOSED REDUCTION. A. UNDISPLACED FRACTURE B. FRACTURES ROTATED MEDIALLY. 2. FRACTURES THAT ARE LATERALLY DISPLACED AND / OR COMMINUTED AND LESS STABLE BY CLOSED REDUCTION.PETER WARD BOOTH- MAXILLOFACIAL SURGERY PG 127

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HENDERSONS CLASSIFICATION OF MALAR FRACTURE0: INTACT 1: UNDISPLACED (ANY SITE) 2: ZYGOMATIC ARCH ONLY 3: TRIPOD F-Z SUTURE UNDISTRACTED F4: TRIPOD F-Z SUTURE DISTRACTED F5: PURE BLOW-OUT BLOW6: ORBITAL RIM ONLY 7: COMMINUTED--OTHER THAN ABOVE COMMINUTED--OTHER19

MODIFIED CLASSIFICATION USED IN WALTON HOSPITAL0: INTACT 1: UNDISPLACED (ANY SITE) 2: ZYGOMATIC ARCH ONLY 3: TRIPOD F Z SUTURE UNDISTRACTED 4: TRIPOD F Z SUTURE DISTRACTED 5: TRIPOD BLOW-OUT OF ORBIT BLOW6: PURE BLOW-OUT BLOW7: ORBITAL RIM ONLY 8: ORBITAL BLOW-OUT WITH ORBITAL RIM FRACTURE ONLY BLOW20

9: COMMINUTED-OTHER THAN ABOVE COMMINUTED-

ZINGG CLASSIFICATION SYSTEMBASED ON ANATOMIC POINTS AND DIVIDES FRACTURES INTO 3 CATEGORIES: CATEGORY A ISOLATED # OF 1 OF THE 3 PROCESSES OF ZYGOMATIC BONE. THESE PROCESSES ARE THE TEMPORAL PROCESS, WHICH FORMS ZYGOMATIC ARCH PROCESS, (A1), FRONTAL PROCESS, WHICH FORMS LATERAL ORBITAL WALL PROCESS, (A2), PROCESS, & MAXILLARY PROCESS, WHICH FORMS INFRAORBITAL RIM (A3).21

CATEGORY B: # OF ALL 3 PROCESSES, DETACHING ZYGOMATIC BONE FROM FACIAL SKELETON. i.e. CLASSIC TRIPOD #, BUT ANATOMICALLY THESE # ARE ACTUALLY TETRAPOD, BECAUSE FRONTAL PROCESS OF ZYGOMA ALSO COMMUNICATES WITH GREATER WING OF THE SPHENOID IN ORBITAL CAVITY, WHICH ALSO REQUIRES TO BE DISRUPTED TO TECHNICALLY RENDER ZYGOMA FREE. CATEGORY C: SAME AS TYPE B, BUT WITH FRAGMENTATION, INCLUDING THE BODY OF ZYGOMA.22

MANSON ET AL CLASSIFICATIONLOW ENERGY MEDIUM ENERGY HIGH ENERGY

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ZYGOMATIC ARCH FRACTURESCLASSIFICATION(OZYAZGANCLASSIFICATION(OZYAZGAN-2007) 1)ISOLATED ZYGOMATIC ARCH FRACTURES(TYPE 1) A)DUAL FRACTURE B)MORE THAN 2 FRACTURES -V-SHAPED FRACTURES -DISPLACED

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CONTD2) COMBINED ZYGOMATIC ARCH FRACTURES(TYPE 2) A) SINGLE B) PLURAL FRACTURES -REDUCED -DISPLACED

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INVOLVED FACIAL HALF LEFT CENTRAL YES

RIGHT LATERAL NO TYPE A DISPLACEMENT >2mm

COMPLEX/DEFECT # >5mm

ISOLATED # OF 3 UNITS YES NO

NO

YES

TYPE B

TYPE C

GROUP A1

COMBINED REGION WITH SKULL BASE INVOLVEMENT

GROUP A2

NO

YES

GROUP A326

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AO/ASIF (ARBEITSGEMEINSCHAFT FR OSTEOSYNTHESEFRAGEN/ ASSOCIATION FOR STUDY OF INTERNAL FIXATION) SCHEME

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LATERAL MIDFACIAL/CRANIOFACIAL #TYPE A/B/C: GROUPS, SUBGROUPS & SPECIFICATIONS TYPE A/B/C: NONDISPLACED/DISPLACED/COMPLEX-DEFECT # 1. GROUP: ISOLATED INVOLVEMENT OF A SINGLE UNIT 1.1. LOWER MIDFACIAL # (UNIT I) 1.2. UPPER MIDFACIAL # (UNIT II) WITH FURTHER CATEGORIES: 1.2.1. INVOLVEMENT OF A SINGLE BUTTRESS (E.G. ZYGOMATIC ARCH) 1.2.2. INVOLVEMENT OF TWO BUTTRESSES (E.G. Z-M & PT-M BUTTRESSES) 1.2.3. INVOLVEMENT OF THREE BUTTRESSES (E.G. TRIPOD #) 1.2.4. INVOLVEMENT OF FOUR BUTTRESSES (Z ARCH/F-Z, Z-M & PT-M BUTTRESSES) 1.2.5. ISOLATED INVOLVEMENT OF ORBITAL FLOOR (E.G. BLOW-OUT #) OR I-O RIM 1.3. CRANIOBASAL # (UNIT III),ISOLATED INVOLVEMENT OF CRANIOBASAL FACIAL UNIT (UNIT III) (E.G. ISOLATED # OF S-O RIM WITH ORBITAL ROOF EXTENSION)29

2. GROUP: COMBINED # OF LOWER (I) & UPPER (II) MIDFACE &/OR CRANIOBASALFACIAL UNIT (III) WITHOUT INVOLVEMENT OF SKULL BASE 2.1. COMPLETE MIDFACIAL # (I + II) (E.G. Z-M # WITH INVOLVEMENT OF ALVEOLAR PROCESS) 2.2. HIGH CRANIOFACIAL # (II + IIIF-T CALVARIUM), UPPER MIDFACIAL # TOGETHER WITH A CALVARIAL COMPONENT OF CRANIOBASAL-FACIAL UNIT & WITHOUT SKULL-BASE EXTENSION (E.G. HIGH ZYGOMATIC # WITH INVOLVEMENT OF ADJACENT F-T CALVARIUM) 2.3. COMPLETE CRANIOFACIAL # (I + II + IIIF-T CALVARIUM), COMBINED # OF LOWER & UPPER MIDFACE TOGETHER WITH CALVARIAL COMPONENT OF CRANIOBASAL-FACIAL UNIT & WITHOUT SKULL-BASE EXTENSION (E.G. COMPLETE Z-M # WITH EXTENSION TO ALVEOLAR PROCESS & F-T CALVARIUM)

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3. GROUP: COMBINED # OF LOWER (I) & UPPER (II) MIDFACE &/OR CRANIOBASALFACIAL UNIT (III) WITH INVOLVEMENT OF SKULL BASE 3.1. HIGH C-F/CRANIOBASAL & (II + III-SKULL BASE), UPPER MIDFACIAL & CRANIOBASAL-FACIAL # INCLUDING SKULL-BASE EXTENSION (E.G. HIGH ZYGOMATIC # WITH INVOLVEMENT OF ORBITAL ROOF) 3.2. COMPLETE C-F/FRONTOBASAL # (I + II + III-FRONTOBASAL), LOWER & UPPER MIDFACIAL # WITH FRONTOBASAL EXTENSION OF CRANIOBASAL-FACIAL UNIT (E.G. COMPLETE Z-M # WITH INVOLVEMENT OF ALVEOLAR PROCESS $ FRONTOBASAL EXTENSION) 3.3. COMPLETE C-F/FRONTOLATEROBASAL # (I + II + IIIFRONTOLATEROBASAL), COMBINED # OF LOWER & UPPER MIDFACE TOGETHER WITH FRONTOBASAL &/OR LATEROBASAL EXTENSION OF CRANIOBASALFACIAL UNIT (E.G. COMPLETE Z-M # WITH EXTENSION TO ALVEOLAR PROCESS & FRONTOBASAL & LATEROBASAL REGION UP TO PETROUS PART OF TEMPORAL BONE)

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DIAGNOSISINSPECTION PALPATION

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SIGNS AND SYMPTOMS

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PERIORBITAL ECCHYMOSIS AND EDEMA

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FLATTENING OF THE MALAR PROMINENCE FLATTENING OVER THE ZYGOMATIC ARCH

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PAIN ECCHYMOSIS OF THE MAXILLARY BUCCAL SULCUS DEFORMITY AT THE ZYGOMATIC BUTTRESS OF THE MAXILLA DEFORMITY OF THE ORBITAL MARGIN ABNORMAL NERVE SENSIBILITY EPISTAXIS CREPITATION FROM AIR EMPHYSEMA DISPLACEMENT OF THE PALPEBRAL FISSURE37

TRISMUS

SUBCONJUNCTIVAL ECCHYMOSIS

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UNEQUAL PUPILLARY LEVELS DIPLOPIA ENOPHTHALMOS

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RADIOLOGIC EVALUATION

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WATERS VIEWDESCRIBED BY WATERS & WALDRON ORBITO-MEATAL BASELINE ELEVATION SHOULD BE 37 DEGREE.

DEMONSTRATES ATTACHMENTS OF ZYGOMA TO ZYGOMATICO FRONTAL SUTURE, INFRA-ORBITAL RIM AND THE MAXILLARY SINUS42

MODIFIED POSTERO-ANTERIOR PROJECTION:CENTRAL RAY AIMED AT AN ANGLE OF 10 TO 20 TO CANTHOMEATAL LINE.

ENABLES A BETTER VIEW OF ORBITAL FLOOR, INFRAORBITAL RIM AND THE FZ BONES.JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 43 (1993~ 21, 120-123)

SUBMENTOVERTEX VIEW

FOR ZYGOMATIC ARCH FRACTURE44

CORONAL CT SCAN

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AXIAL CT SCAN

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THREE-DIMENSIONAL VOLUME RENDERED RECONSTRUCTION

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DVT OFFERS AN ALTERNATIVE TO CT IMAGING REGARDING HIGHHIGH-CONTRAST STRUCTURES, RESULTING IN DECREASED RADIATION EXPOSURE OF PATIENTS. PATIENTS. THE LOW LEVEL OF METAL ARTIFACTS IN PRIMARY AND SECONDARY RECONSTRUCTIONS. EVEN 3D RECONSTRUCTIONS CAN BE GENERATED, WHICH HAVE BEEN DESCRIBED AS BEING OF VALUE FOR EVALUATION OF MIDFACIAL FRACTURES DISADVANTAGE OF DVT: DURATION OF THE EXAMINATION, MAKING IT SUSCEPTIBLE TO EXAMINATION, BLURRING.48

M R I (CORONAL)

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A STEREOLITHOGRAPHIC MODEL OF THE 3D CT MODEL

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TREATMENT1. NO TREATMENT 2. INDIRECT REDUCTION WITH A) NO FIXATION B) TEMPORARY SUPPORT C) DIRECT FIXATION D) INDIRECT FIXATION51

3. DIRECT REDUCTION AND FIXATION. 4. IMMEDIATE RECONSTRUCTION BY GRAFTING. 5. DELAYED RECONSTRUCTION BY OSTEOTOMY AND/OR GRAFTING. 6. LATE RESTORATION OF CONTOUR BY ONLAY GRAFT.

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PRINCIPLES IN THE TREATMENT OF ZMC FRACTURESPROPHYLACTIC ANTIBIOTICS ANESTHESIA CLINICAL EXAMINATION AND FORCED DUCTION TEST PROTECTION OF THE GLOBE ANTIANTI-SEPTIC PREPARATION53

FORCED DUCTION TEST

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NONDISPLACED FRACTURES WITHOUT EYE INVOLVEMENT ICE PACKS AND ANALGESICS DELAYED OPERATIVE CONSIDERATION 5-7 DAYS 5 DECONGESTANTS BROAD SPECTRUM ANTIBIOTICS TETANUS55

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DUVERNEY (1751) DESCRIBED INTRAORAL & EXTRAORAL MANIPULATION OF BONE FRAGMENTS & IMPORTANCE OF CONTRACTION OF TEMPORALIS IN REALIGNING MEDIALLY DISPLACED Z-ARCH. ZFERRIER (1825) ATTEMPTED TO REDUCE ZYGOMA # THRU INCISION ABOVE ARCH. ROLLAND: ROLLAND: APONEUROSIS OF TEMPORAL FASCIA MUST BE CUT TO FACILITATE INTRODUCTION OF SPATULA FOR ELEVATION