Zygomatico Frontal Fracture

8/6/2019 Zygomatico Frontal Fracture

http://slidepdf.com/reader/full/zygomatico-frontal-fracture 1/50

11

Zygomatic complex fracturesZygomatic complex fractures

http://apexiondental.com/http://apexiondental.com/

Management of Maxillofacial Trauma



22

ContentsContents

Fracture of the zygomatic complex and archFracture of the zygomatic complex and arch

Orbital floor fracturesOrbital floor fractures

Traumatic injury to the frontal sinusTraumatic injury to the frontal sinus

NasoNaso--ethmoial orbital fracture (NEO)ethmoial orbital fracture (NEO)

Nasal fracturesNasal fractures



33

Zygomatic bone complexZygomatic bone complex

AnatomyAnatomy

Star Star- -shape like with four processesshape like with four processes

Frontal processFrontal process

Temporal processTemporal process

ButtressButtress

Orbital floor (Maxilla and GWSB)Orbital floor (Maxilla and GWSB)

Temporal fascia and muscleTemporal fascia and muscle

Masseter muscleMasseter muscle



44

Zygomatic complex and archZygomatic complex and arch

fracturefractureThe malar bone represent The malar bone represent

a strong bone on fragilea strong bone on fragilesupports, and it is for supports, and it is for

this reason that, thoughthis reason that, thoughthe body of the bone isthe body of the bone israrely broken, the four rarely broken, the four

processes processes- - frontal,frontal,orbital, maxillary and orbital, maxillary and

zygomatic are frequent zygomatic are frequent sites of fracture.sites of fracture.

HD Gillies, TP Kilner and D Stone,HD Gillies, TP Kilner and D Stone,1927 1927

Zygomatic bone fractured as a

block near its principle three suture

lines and often displaces inwards to

a greater or lesser extent.



55

OccurrenceOccurrence

Observed in (>50%) of middle thirdObserved in (>50%) of middle third

fracturefracture ( in developed countries due to assaults)( in developed countries due to assaults)

The zygomatic arch fracture can beThe zygomatic arch fracture can be

isolated in most of the casesisolated in most of the cases

�As isolated fracture

�In combination with other middle third fracture

�With internal orbital fracture (blow out)



66

Signs and symptomsSigns and symptoms

Periorbital ecchymosis and edemaPeriorbital ecchymosis and edema

Flattening of the malar prominenceFlattening of the malar prominence

Flattening over the zygomatic archFlattening over the zygomatic arch

Pain and tenderness on palpationPain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcusEcchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of theDeformity at the zygomatic buttress of themaxillamaxilla

Deformity at the orbital marginDeformity at the orbital margin



77

TrismusTrismus

Abnormal nerve sensibility Abnormal nerve sensibilityEpistaxisEpistaxis

Subconjunctival ecchymosisSubconjunctival ecchymosis

Crepitation from air Crepitation from air

emphysemaemphysema

Displacement of palpebralDisplacement of palpebral

fissurefissure ( pseudoptosis)( pseudoptosis)

Unequal pupillar y levelsUnequal pupillar y levelsDiplopiaDiplopia

enophthalmosenophthalmos



88

Clinical examinationClinical examination

InspectionInspection

PalpationPalpation

Visual examinationVisual examinationEye movementEye movement

DiplopiaDiplopiaPupil reactionPupil reaction



99

Radiographical evaluationRadiographical evaluation

N othing is more valuable to the surgeon inN othing is more valuable to the surgeon in

determining the extent of injury and thedetermining the extent of injury and the position of the fragments position of the fragments- -both before and both before and

after operationafter operation- - than a good skiagramthan a good skiagram

( radiograph)( radiograph)

D Gillies, TP Kilner and D Stone, 1927HD Gillies, TP Kilner and D Stone, 1927



1010

Occipitomental viewOccipitomental view

(Posterioanterior oblique)(Posterioanterior oblique)

(water¶s view)(water¶s view)



1111

submentovertexsubmentovertex

Recommended for isolated

zygomatic arch fracture



1212

CT scanCT scan

Coronal sectionsCoronal sections

Axial sections

Axial sections



1313

TreatmentTreatment

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

Preiorbital edema and ecchymosis obscure thePreiorbital edema and ecchymosis obscure the

fine details of the fracture, intervention can befine details of the fracture, intervention can bepostponed but not more than a weekpostponed but not more than a week

Indications:

�Diplopia

�Restriction of mandibular movement

�Restoration of normal contour

�Restoration of normal skeletal protection for the eye



1414

ClassificationsClassifications

DisplacementDisplacement

Rotation along the axis of FZ processesRotation along the axis of FZ processes Anterio Anterio- -posterior displacement posterior displacement

Rotation along the prominence of the boneRotation along the prominence of the boneMedioMedio- -lateral displacement lateral displacement

Extension of the fracture along processesExtension of the fracture along processes

points of fracturespoints of fractures

Combination with other injuriesCombination with other injuries



1515

TreatmentTreatment

The methods of treating a fractured malar boneThe methods of treating a fractured malar bonerecommended by the various writers who haverecommended by the various writers who have

reported cases include simple digital manipulationreported cases include simple digital manipulationunder genre real anesthesia, external manipulationunder genre real anesthesia, external manipulation

by means of a cowby means of a cow--horn dental forceps grasping thehorn dental forceps grasping theedges of the bone, traction and elevation by meansedges of the bone, traction and elevation by means

of wire or heavy bone elevators passed throughof wire or heavy bone elevators passed throughsmall local external incisions, and elevation viasmall local external incisions, and elevation via

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

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

HD Gillies, TP Kilner and D Stone, 1927 HD Gillies, TP Kilner and D Stone, 1927



1616

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



1717


Percutaneous approach (malar hook,Percutaneous approach (malar hook,

CarrollCarroll--Girard bone screw)Girard bone screw)

Suitable for displaced zygomatic

fracture with high

Stability after reduction



1818


Buccal sulcusBuccal sulcusapproach (Keenapproach (Keen1909)1909)

Elevation fromElevation from

eyebrow approacheyebrow approach( the same principle of Gillies( the same principle of Gillies

approach)approach)



1919

Open reduction and fixationOpen reduction and fixation

Transosseous wiring atTransosseous wiring at

± ±Frontozygomatic sutureFrontozygomatic suture

± ±Infraorbial rimInfraorbial rim

Surgery:

�Lateral eyebrow incision

�Infraorbital approach



2020

Open reduction and fixationOpen reduction and fixation

Rigid fixation using plate and screws atRigid fixation using plate and screws atFrontozygomatic 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



2121

Infraorbital

rim and

buttress

Lateral

orbital rim

Buttress of

zygoma

Points of fixation:



2222

Other methods of fixationOther methods of fixation

Kirschener wireKirschener wire

Pin fixationPin fixation

Antral pack Antral pack



2323

Internal orbital fracturesInternal orbital fractures

In conjunction with other In conjunction with other

facial fracturesfacial fractures

As isolated type (Blow outAs isolated type (Blow out

fracture)fracture)



2424

AnatomyAnatomy

The floor is made of:The floor is made of:

Maxillary bone and Maxillary bone and

part of zygoma part of zygomabounded laterally by bounded laterally by

the inferior orbital the inferior orbital

fissure and small fissure and small

part of the ethmoid part of the ethmoid bonebone



2525

Cli i l r i gr i l r t tiCli i l r i gr i l r t ti

Subconjunctival ecchymosisSubconjunctival ecchymosis

Crepitation from air emphysemaCrepitation from air emphysema

Displacement of palpebral fissureDisplacement of palpebral fissure

Unequal pupillary levelsUnequal pupillary levels

DiplopiaDiplopia

enophthalmosenophthalmos



2626

Diplopia andDiplopia and

enophthalmousenophthalmous

Superior orbitalSuperior orbital

fissure syndromefissure syndrome



2727

TreatmentTreatment

Rational for intervention:Rational for intervention:

Small defect with no clinical consequenceSmall defect with no clinical consequencemay not warrant the surgical intervention.may not warrant the surgical intervention.

Large defect with handicapping symptomsLarge defect with handicapping symptoms

should be operated.should be operated.



2828

Method of reconstructionMethod of reconstruction

IntraIntra--sinus approachsinus approach

to the orbital floor to the orbital floor

External approach toExternal approach to

the internal orbitalthe internal orbitalfloor floor



2929

Materials in orbital reconstructionMaterials in orbital reconstruction

Autologous graftAutologous graftBone ( cranial, rib, iliac)Bone ( cranial, rib, iliac)

CartilageCartilageAllogenic materialsAllogenic materials

Lyophilized duraLyophilized dura

Alloplastic materialsAlloplastic materialsSiliastic and proplast Siliastic and proplast

implantsimplants

TeflonTeflon

hydroxyapatitehydroxyapatite

Titanium mishTitanium mish



3030

NasalNasal--orbital ethmoid injuriesorbital ethmoid injuries

They represent a wide spectrum of injuriesThey 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



3131

DiagnosisDiagnosis

Clinical examination:Clinical examination:Obliterating swellingObliterating swelling

Canthus detachmentCanthus detachment

Lacrimal apparatus damageLacrimal apparatus damage

Deformity of nasal bridgeDeformity of nasal bridge

CSF leakCSF leak

Radiographical examinationRadiographical examination::

Occipitomental viewsOccipitomental viewsLateral skull viewsLateral skull views

CT and 3D CTCT and 3D CT



3232

Fracture classificationFracture classificationN asal N asal- -orbital ethmoid fracturesorbital ethmoid fractures

Type IType IUnilateral or bilateral, involves only one portion of theUnilateral or bilateral, involves only one portion of the

medial orbital rim with the attached canthal tendonmedial orbital rim with the attached canthal tendon

Type IIType IIUnilateral or bilateral, may be large segments of Unilateral or bilateral, may be large segments of

comminuted type and the canthus remains attachedcomminuted type and the canthus remains attachedto the large central segmentto the large central segment

Type IIIType IIIUnilateral or bilateral, comminution involves the centralUnilateral or bilateral, comminution involves the central

segment of the attached tendon results in avulsionsegment of the attached tendon results in avulsionof medial canthusof medial canthus



3333

Management of nasalManagement of nasal--orbitalorbital

ethmoid fracturesethmoid fracturesExamination for Examination for determination of the extentdetermination of the extentof the injury (surgicalof the injury (surgicalexploration)exploration)

Nasal boneNasal bone

Orbital and ethmoidalOrbital and ethmoidalFrontal boneFrontal bone

Debridement and closure of Debridement and closure of open woundsopen wounds

Reduction and stabilizationReduction and stabilizationof bone fractureof bone fracture



3434

Principles of treatmentPrinciples of treatment

Good surgical exposure via:Good surgical exposure via:Existing lacerationExisting laceration

Coronal flapCoronal flap

Open sky approachOpen sky approach

Reduction and stabilization using:Reduction and stabilization using:Transnasal wiringTransnasal wiring

OsteosynthesisOsteosynthesis

Prompt treatment as an aid to goodPrompt treatment as an aid to goodreductionreduction

Immediate bone grafting if this isImmediate bone grafting if this isindicatedindicated



3535

Detached canthusDetached canthusTraumatic telecanthusTraumatic telecanthus

Increase in inter Increase in inter--canthal distancecanthal distance

secondary tosecondary to

canthus displacement or canthus displacement or detachmentdetachment

Seen in association to:Seen in association to:Nasal boneNasal bone

NEONEO

Le Forts fracturesLe Forts fractures



3636

Sur gical management of detachedSur gical management of detached

canthuscanthus

Transnasal wiringTransnasal wiringtechniquetechnique ( unilateral ( unilateral type)type)

CanthopexyCanthopexy ± ± Identification of theIdentification of the

ligamentligament

± ± Liberation of theLiberation of theperiorbital tissueperiorbital tissue

± ± Liberation of the lacrimalLiberation of the lacrimalpathwaypathway

± ± Nasal transfixationNasal transfixation

± ± Contralateral fixationContralateral fixation



3737

Lacrimal duct system injur yLacrimal duct system injur y

The lacrimal sac can be torn byThe lacrimal sac can be torn by

fragments of a comminuted fracturefragments of a comminuted fracture

Or Or Compressed by a mass of callusCompressed by a mass of callus

which may block the nasolacrimal canalwhich may block the nasolacrimal canal

EPIPHORAEPIPHORA DacryocystitisDacryocystitis











4242

Classification of fracturesClassification of fractures

Anterior table fracture Anterior table fracture ± ± Linear Linear

± ± DisplacedDisplaced

Posterior table fracturePosterior table fracture ± ± Linear Linear

± ± DisplacedDisplaced

Outflow tract injur y Outflow tract injur y ( naso( naso- -lacrimal duct)lacrimal duct)



4343

Sur gical managementSur gical management

Intranasal cannulationIntranasal cannulation

Frontal sinusFrontal sinustrephinationtrephination

Osteoplastic flapOsteoplastic flap

Sinus ablationSinus ablation

(obliteration)(obliteration)

CranializationCranialization

Reduction and fixationReduction and fixation





4545

Sinus ablationSinus ablation

(obliteration)(obliteration)

± ± BoneBone

± ±FatFat ± ± Muscle andMuscle and

fasciafascia

± ±AlloplasticAlloplastic

materialsmaterials



4646

FixationFixation

± ± WiresWires

± ±PlatingPlating



4747

Nasal fracturesNasal fractures

Anatomy AnatomyMidline central facialMidline central facialstructure that fulfillsstructure that fulfillsboth cosmetic andboth cosmetic and

functional purposesfunctional purposes

Formed by union of Formed by union of rigid and flexible strutsrigid and flexible struts

2 rectangle2 rectangle--shapedshapednasal bonenasal bone

ULCs, LLCs andULCs, LLCs andmidline septalmidline septal

cartilagecartilage



4848

Classification of injuriesClassification of injuries

Low ener gy injuriesLow ener gy injuriesSimple injury caused by low velocity trauma ( simpleSimple injury caused by low velocity trauma ( simple

noncomminuted)noncomminuted)

High ener gy injuriesHigh ener gy injuriesSevere injury with comminution of nasal facial Skelton due toSevere injury with comminution of nasal facial Skelton due to

higher amount of energy higher amount of energy

Patterns of injury

�Lateral injury (from the side)

�Sagittal injury (from the front)

�Inferior injury (from below)





5050

Complex injuriesComplex injuriesImmediate measures:Immediate measures:

Extra and intranasal examinationExtra and intranasal examination

Identification of extra and intranasalIdentification of extra and intranasal

lacerationslacerations

Identification and control of siteIdentification and control of site

bleedingbleeding

Surgical procedures:Surgical procedures:

Open septal proceduresOpen septal procedures

Open nasal proceduresOpen nasal proceduresOpen rhinoplastyOpen rhinoplasty

OpenOpen--sky ³H´ techniquesky ³H´ technique

Documents

Zygomatico Frontal Fracture