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Zygomatic complex fracturesZygomatic complex fractures
http://apexiondental.com/http://apexiondental.com/
Management of Maxillofacial Trauma
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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
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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
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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.
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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)
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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
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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
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Clinical examinationClinical examination
InspectionInspection
PalpationPalpation
Visual examinationVisual examinationEye movementEye movement
DiplopiaDiplopiaPupil reactionPupil reaction
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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
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Occipitomental viewOccipitomental view
(Posterioanterior oblique)(Posterioanterior oblique)
(water¶s view)(water¶s view)
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submentovertexsubmentovertex
Recommended for isolated
zygomatic arch fracture
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CT scanCT scan
Coronal sectionsCoronal sections
Axial sections
Axial sections
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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
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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
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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
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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
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Methods of reductionMethods of reduction
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
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Methods of reductionMethods of reduction
Buccal sulcusBuccal sulcusapproach (Keenapproach (Keen1909)1909)
Elevation fromElevation from
eyebrow approacheyebrow approach( the same principle of Gillies( the same principle of Gillies
approach)approach)
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Open reduction and fixationOpen reduction and fixation
Transosseous wiring atTransosseous wiring at
± ±Frontozygomatic sutureFrontozygomatic suture
± ±Infraorbial rimInfraorbial rim
Surgery:
�Lateral eyebrow incision
�Infraorbital approach
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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
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Infraorbital
rim and
buttress
Lateral
orbital rim
Buttress of
zygoma
Points of fixation:
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Other methods of fixationOther methods of fixation
Kirschener wireKirschener wire
Pin fixationPin fixation
Antral pack Antral pack
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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)
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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
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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
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Diplopia andDiplopia and
enophthalmousenophthalmous
Superior orbitalSuperior orbital
fissure syndromefissure syndrome
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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Sinus ablationSinus ablation
(obliteration)(obliteration)
± ± BoneBone
± ±FatFat ± ± Muscle andMuscle and
fasciafascia
± ±AlloplasticAlloplastic
materialsmaterials
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FixationFixation
± ± WiresWires
± ±PlatingPlating
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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
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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)
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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