ZYGOMATICOMAXILLARY (ZMC) COMPLEX

FRACTURES

Dr. Amit T. Suryawanshi

Dentist, Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.comMobile No - 9405622455

CONTENTS

• INTRODUCTION

• ANATOMY

• CLASSIFICATION

• SIGNS & SYMPTOMS

• CLINICAL EXAMINATION

• RADIOLOGIC EXAMINATION

• MANAGEMENT

• COMPLICATIONS

INTRODUCTION

• Most common facial fractures, the second in frequency after nasal fractures.

• The high incidence relates to the zygoma’sprominent position within the facial skeleton.

• Male predilection, 4:1 over females.

• Peak incidence- 2nd and 3rd decades of life.

INTRODUCTION

• Zygomatic injury is mostly due to altercations followed by motor vehicle accidents.

• In zygomatic fractures caused by altercations, the left zygoma is most commonly affected.

• The zygoma plays an important role in facial contour. Disruption of the zygomatic position creates impairment of ocular and mandibular function.

INTRODUCTION

• The zygoma or malar complex forms the central support of the cheek and is a strong buttress of the lateral and middle third of the facial skeleton.

• It is for this reason, the zygoma is frequently fractured, either alone or in combination with other bony structures of the midface.

ANATOMY

• The zygoma, a major

buttress of the facial

skeleton, is the principal

structure of lateral

midface.

ANATOMY

• Zygoma is roughly quadrilateral in shape, with an outer convex (cheek) surface and an inner concave (temporal) surface.

• It forms the point of greatest prominence of the cheek.

• Resembles a four sided pyramid, which has temporal, orbital, maxillary and frontal processes.

ANATOMY

• Zygoma articulates with four bones- the frontal, sphenoid, maxillary and temporal.

• Body of the zygoma extensively articulates with the maxilla along the anterior maxilla and along the orbital floor.

• It forms the superolateral aspect and part of the superoanterior aspect of the maxillary sinus.

ANATOMY

ANATOMY

• The frontal process is thick and triangular in cross section, with facial, orbital and temporal surfaces.

• The temporal process is flat and projects posteriorly to articulate with the zygomatic process of the temporal bone.

• The combination of the two makes up the zygomatic arch.

ANATOMY

• The zygomaticotemporal articulation is a very thin, delicate connection, which fractures frequently.

• The zygoma provides origin to a major portion of the masseter muscle along the body and temporal surface.

• The temporal fascia also attaches along the arch and the temporal process.

ANATOMY

SURGICAL ANATOMY

‘the malar bone represents a strong bone on fragile supports, and it is for this reason that, though the bone is rarely broken, the four processes – frontal, orbital, maxillary and zygomatic – are frequent sites of fracture.’

-- H.D.Gillies, T.P. Kilner and D. Stone, 1927

SURGICAL ANATOMY• 2 zygomatic bones &

their temporal processes

• Zygomatic processes of temporal bones

Form part of the middle

third of the facial

skeleton which may be

fractured following

trauma.

SURGICAL ANATOMY

• Fractures involving the orbit may give rise toalteration in the position of the globe of theeye.

• The level of the globe is normally maintainedby the suspensory ligament of Lockwoodwhich passes from its medial attachment onthe lacrimal bone to be inserted laterally intothe Whitnall’s tubercle.

SURGICAL ANATOMY

• Zygomatic and Le fort III fractures commonly result in drop in the level of the globe of the eye.

• As the globe of the eye drops, the upper eyelid follows downwards giving rise to the physical sign ‘hooding of the eye’.

FRACTURE PATTERNS

• The fracture pattern of any bone depends mainly on the direction and magnitude of the force.

• The fracture lines pass through the areas of greatest weakness of a bone or between bones.

FRACTURE PATTERNS

FRACTURE PATTERNS

FRACTURE PATTERNS

• The inferior orbital fissure is the key to remember the usual lines of ZMC fractures.

• Three fracture lines extend from the inferior orbital fissure in an anteromedial, a superolateral, and an inferior direction.

FRACTURE PATTERNS

1. One fracture extends from the inferior orbital fissure anteromedially along the orbital floor mostly through the orbital process of the maxilla.

FRACTURE PATTERNS

2. Second line of fracture from the inferior orbital fissure runs inferiorly through the posterior(infratemporal) aspect of maxilla and joins the fracture from the anterior aspect of maxilla, under the zygomaticomaxillary buttress.

FRACTURE PATTERNS

3. Third line of fracture extends superiorly

from the inferior orbital fissure along the

lateral orbital wall posterior to the rim,

usually separating the zygomaticosphenoid

suture.

CLASSIFICATION

• Knight and North (1961)

• Rowe and Killey (1968)

• Yanagisawa ( 1973)

• Larsen and Thomson (1978)

• Rowe and Williams (1985)

• Poswillo (1988)

Knight and North (1961)

Based on the direction of displacement on a

Water’s view radiograph,

• Group I – Non displaced fractures

• Group II – Arch fractures

• Group III – Unrotated fractures

• Group IV – Medially rotated fractures

• Group V - Laterally rotated fractures

• Group VI – Complex fractures

Knight and North (1961)

ROWE AND KILLEY (1968)

• Type I – no significant displacement

• Type II – fracture of the arch

• Type III – rotation around a vertical axis

• Type IV – rotation around a longitudinal axis

• Type V – displacement of the complex en bloc

• Type VI – displacement of orbito-antral partition

• Type VII – displacement of the orbital rim

segments

• Type VIII – Complex comminuted fractures

Yanagisawa ( 1973)

• GROUPS I & II - Unchanged

• GROUP III - Medial or lateral rotation around a vertical axis

• GROUP IV - Medial or lateral rotation

around a longitudinal axis

• GROUP V - Medial or lateral

displacement without rotation

• GROUP VI - Isolated arch fracture

• GROUP VII - All complex fractures

Larsen and Thomson (1978)

• GROUP I – Non displaced fractures requiring no treatment

• GROUP II – All fractures requiring treatment

ROWE AND WILLIAMS (1985)• Fractures stable after elevation a) Arch only (medially displaced)b) Rotation around the vertical axis

i) mediallyii) laterally

• Fractures unstable after elevationa) Arch only (inferiorly displaced)b) Rotation around horizontal axis

i) mediallyii) laterally

c) Dislocations en bloci) inferiorlyii) mediallyiii) postero - laterally

d) Communited fractures

ROWE AND WILLIAMS (1985)

POSWILLO’S CLASIFICATION

• Inward and downward displacement

• Inward and posterior displacement

• Outward displacement

of the zygomatic complex

• Communition

• Fracture of the arch alone

SIGNS & SYMPTOMS

• Periorbital Ecchymosis and Edema

• Flattening of the malar prominence

• Flattening over the zygomatic arch

• Pain

SIGNS & SYMPTOMS

• Ecchymosis of the maxillary buccal sulcus

• Deformity at the zygomatic buttress of the maxilla

• Deformity of the orbital margin

• Trismus

SIGNS & SYMPTOMS

• Abnormal nerve sensibility

• Epistaxis

• Subconjunctival Ecchymoses

• Crepitation from air emphysema

SIGNS & SYMPTOMS

• Displacement of the palpebral fissure

• Unequal pupillary levels

• Diplopia

• Enophthalmos

RADIOLOGIC EXAMINATION

• Plain films and Computed Tomography have their place in determining the type, location, magnitude, and direction of displacement of zygomatic fractures.

• This includes,

Water’s view, Submentovertex view,

Computed Tomography.

RADIOLOGIC EXAMINATION

• A single Water’s view is an important adjunct to clinical examination.

• If fractures are noted, CT should be the procedure of choice.

• Two dimensional CT is now considered the best and most useful means of radiologic assessment of the facial skeleton.

RADIOLOGIC EXAMINATION

• CT scans allow complete assessment of theorbital floor and walls.

• For ZMC injuries, it is optional to have bothaxial & coronal high resolution scans.

• The axial scan is helpful in evaluating themedial and lateral orbital walls, and thecoronal scan defines the extent of injury to theorbital floor.

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

RADIOLOGIC EXAMINATION

END OF PART 1..

ZYGOMATICOMAXILLARY COMPLEX FRACTURES

PART II

PRESENTED BY,

ASHWIN THAKARE(PART III)

IN THE LAST PART WE DISCUSSED….

• INTRODUCTION

• ANATOMY (SURGICAL ANATOMY)

• CLASSIFICATION

• SIGNS & SYMPTOMS

• CLINICAL EXAMINATION

• RADIOLOGIC EXAMINATION

CONTENTS (PART 2)

• TREATMENT.

TREATMENT

• Historical review:

• Various authors have given various treatment modalities and techniques for the management of ZMC fractures.

• Dating back to 1751, when Duverney stressed the role of contraction of temporal muscle in realigning the medial displacement of the zygomatic arch.

HISTORICAL REVIEW

• Ferrier in 1825, attempted to reduce fracture of zygomatic arch through an incision above the arch.

• Dupuytren in 1847, discovered the important relationship of the temporal fascia and the muscle as a pathway to the zygomatic arch.

HISTORICAL REVIEW

• Gillies in 1927 emphasised the cosmetic value of placing the incision within the hair line.

• Stroymeyer in 1844 described the percuteneous hook technique.

• Cheyne and Burghard in 1901 discussed the intraoral digital manipulation technique.

• Smith and Yanagisawa in 1961 stressed the importance of cosmetic aspects of the treatment.

GENERAL PRINCIPLES OF TREATMENT

• No treatment

• Indirect reduction with,

a. No fixation

b. Temporary support

c. Direct fixation

d. Indirect fixation

• Direct reduction and fixation

NO TREATMENT

• Cases with a minimal degree of displacement, which following union, are considered unlikely to result any cosmetic deformity, disturbance of vision, persistent paraesthesia or impairment of mandibular movement.

INDIRECT REDUCTION

• NO FIXATION:

• Includes procedures which do not involve exposure of the fracture sites.

• The principle is to disimpact and reduce the fracture by direct application of an instrument, through an indirect approach remote from the fracture line.

NO FIXATION

• The techniques which have been developed for this operative approach, are based upon the introduction of an instrument through,

a. the temporal fossa,

b. the upper buccal sulcus (intraoral),

c. the cheek (percutaneous),

d. the nose (transantral)

e. the eyebrow (lateral brow)

NO FIXATION

• Temporal fossa approach:

• This method was introduced by Gillies et al (1927) for elevation of the zygomatic arch.

• Incision of about 2.5 cm long, made above and parallel to the anterior branch of the temporal artery.

NO FIXATION

• Lateral brow approach: (Dingman & Natwig1964)

• The advantage of this technique is that the fracture at the orbital rim is visualized directly.

• The frontozygomatic area of the lateral orbital rim is exposed by the eyebrow incision.

• The instrument is inserted to lift the zygoma anteriorly, laterally and superiorly.

NO FIXATION

• Lateral eyebrow approach:

NO FIXATION

• Upper buccal sulcus:

• The advantages of this technique have been discussed by Balasubramaniam (1967) who considers that “ less force is required by the intraoral approach than by the extraoral, because the force is exerted where it should be, i.e., more at the centre of the fractured fragment”.

NO FIXATION

• Upper buccal sulcus: (Keen’s approach)

• Access is gained by an incision of about 1cm in length at the reflection of the upper buccalsulcus immediately behind the zygomatic buttress.

NO FIXATION

• Quinn in 1977 described a modification.

• This employs a lateral coronoid approach through an incision situated over the anterior border of ramus.

NO FIXATION

• Percutaneous approach: (Stroymeyer 1844)

• This method consists of inserting a hook through the skin below and behind the zygomatic bone so that it engages the deep aspect and allows reduction by strong outward traction on the handle of the instrument.

NO FIXATION

• Percutaneous approach:

• Poswillo advises that the exact location of the initial stab wound for insertion is found at the intersection of a perpendicular line dropped from the outer canthus of the eye and a horizontal line extended posteriorly from the alar margin of the nostril.

NO FIXATION

• Intranasal transantral approach: (Lothrop’s approach 1906)

• Not common in use.

• An opening is made into the antrum below the inferior meatus, and a curved urethral sound introduced and manipulated so that its tip lies on the antral aspect of the zygomatic bone. Firm outward and upward pressure is applied to reposition the bone.

TEMPORARY SUPPORT

• This may be indicated, as a supplementary measure, under the following circumstances:

• When the zygomatic complex is unstable following reduction,

• When there is gross comminution of the zygomatic bone.

• When there is comminution without bone loss of the orbital floor.

TEMPORARY SUPPORT

• Instability following adequate reduction could be due to:

• Rupture of the enveloping periosteum or attached temporal fascia.

• Comminution of the zygomatic arch.

• Loss of bone from around the zygomatic buttress.

• Residual fibrosis when treatment is delayed.

TEMPORARY SUPPORT

• Temporary support is a concept which is primarily based upon the introduction of a pack or other material into the antrum so as to exert counter-pressure against those forces which tend to bring about a relapse of the position achieved by indirect reduction.

TEMPORARY SUPPORT

• Since the pack will bring about repositioning of fragments by pressure from their antralaspect it will be evident that this selective effect can only take place if there is absolute stability of the remainder of the antrum and the other elements of the zygomatic complex.

DIRECT FIXATION

• Indirect reduction, combined with direct fixation following exposure of the fracture site, provides an excellent method of treatment.

• Direct fixation is needed when the fractures remain unstable after indirect reduction.

DIRECT FIXATION

• Transosseous wiring or osteosynthesis:

• Separation at the frontozygomatic suture line with displacement in excess of 2-3 mm, is likely to cause detachment of the periosteal and fascial attachments, and hence the direct fixation becomes necessary.

DIRECT FIXATION

• Incisions on the face should be placed parallel to or within the skin creases.

• It is preferable to incise the skin through the outer end of the eyebrow. The incision should not be at right angles to the skin, but directed downwards at the same angle as the emerging hairs.

DIRECT FIXATION

• The Gillies temporal approach is preferable if there is separation at the suture.

• A percutaneous repositioning may be preferred.

• Access to the temporal aspect of the zygomatic bone can be obtained through the frontozygomatic incision by passing a curved elevator supraperiosteally posterior to the frontal process of the zygomatic bone.

DIRECT FIXATION

• Dingman and Natvig (1964) recommend that the holes are drilled in an anteroposteriordirection and when the external angular process is well formed. It also enables the wires to be placed in a figure of eight pattern which provides better lateral stability.

DIRECT FIXATION

• Elevation of the zygomatic bone and transosseous wiring or boneplating at the frontozygomatic suture will achieve a stable realignment of the orbital rim.

DIRECT FIXATION

• A more severe displacement, a dislocation of the zygomatic complex en bloc, will result in separation of the fracture ends at the inferior orbital margin, with the fracture passing into the orbital floor.

• In this type of unstable fracture it is essential to carry out an osteosynthesis (transosseouswiring) or microplating technique.

DIRECT FIXATION

DIRECT FIXATION

• Micro-plates positioned in such a way that the screw holes are situated well away from the fracture sites provides a very useful alternative to wires.

• The use of malleable micro-plating equipment has greatly improved the management of such cases.

DIRECT FIXATION

• Application of a small plate, across the fronto-zygomatic suture will usually ensure that there is absolute immobility, so that union can take place. Precision alignment of the inferior orbital margin is essential, open reduction will be indicated.

DIRECT FIXATION

• Inadequate immobilisation of the fronto-zygomatic suture where the lateral orbital wall is displaced may lead to a loss of malar prominence.

INDIRECT FIXATION

• Indirect fixation implies that the zygomatic bone will be rigidly secured to some point elsewhere on the facial skeleton until union occurs.

• The required degree of firmness can only be achieved by means of internal (intramedullary) pins or wires or external pins and rods which are linked together.

INDIRECT FIXATION

• The indirect fixation can be achieved by the following methods:

1. Zygomatico-zygomatic (Trans-maxillary)

2. Naso-zygomatic

3. Zygomatico-palatal

4. Maxillo-zygomatic

5. Fronto-zygomatic

6. Cranio-zygomatic

INDIRECT FIXATION

• Indirect fixation has only limited application at the present time in view of the greater efficiency and comfort obtained by internal fixation techniques.

COMPLICATIONS

• Infraorbital nerve disorders

• Implant extrusion, displacement and infection

• Maxillary sinusitis

• Persistent diplopia

• Enophthalmos

• Ankylosis of zygoma to coronoid process

• Malunion of the zygoma

CONCLUSION

• Thus, the zygomatic complex fractures are common injuries, second in frequency after the nasal bone fractures.

• There being a wide range of treatment modalities and techniques for the management of zygomaticomaxillary complex fractures.

• It is the apt judgement and knowledge of the surgical anatomy on the part of the surgeon enabling him to effectively manage the ZMC fractures with the desired outcome.

REFERENCES

• Row and williams volume -1

• Fonseca trauma volume -2

• Peter wardbooth

• Peterson’s oral and maxillofacial surgery.

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