1. Zygomatic complex fractures Mid-face Injury Management of Maxillofacial Trauma dr shabeel pn [email_address] www.hi-dentfinishingschool.blogspot.com

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 (Maxilla and GWSB)

Temporal fascia and muscle

Masseter muscle

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 examination

• • Eye 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)

(waters view)

11.

submentovertex

Recommended for isolatedzygomatic 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 processes

• • Anterio-posterior displacement

• Rotation along the prominence of the bone

• • Medio-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 writerswho have reported cases include simple digital manipulation under genre real 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 isolatedzygomatic fracture withgood stability afterwards 17. Methods of reduction

Percutaneous approach (malar hook, Carroll-Girard bone screw)

Suitable for displaced zygomaticfracture 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 at

• • Frontozygomatic 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 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 graft

• • Bone (cranial, rib, iliac)

• • Cartilage

Allogenic materials

• • Lyophilized dura

Alloplastic materials

• • Siliastic 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 compoundnaso-orbital ethmoid fracture involving the baseof 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 classification Nasal-orbital ethmoid fractures

Type I

Unilateral or bilateral, involves only one portion of the medial orbital rim with the attached canthal tendon

Type II

Unilateral or bilateral, may be large segments of comminuted type and the canthus remainsattached to the large central segment

Type III

Unilateral or bilateral, comminution involves the central segment of the attached tendon results in avulsion of medial canthus

33. Management of nasal-orbital ethmoid fractures

Examination 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 canthus Traumatic 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-rhinostomy

implantation 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 respiratoryepithelium 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 evaluation

• • Occipitomental 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

Anatomy

Midline 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 injuries

Simple injury caused by low velocity trauma (simple noncomminuted)

High energy injuries

Severe 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 injuries

Reduction (close manipulation, open reduction) and stabilization

Nasal packing

External nasal splint

Adjunct septoplasty

Postoperative care

50.

Complex injuries

Immediate 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