Zygomatic complex fractures

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Management of Maxillofacial Trauma
Mid-face Injury

• Zygomatic complex fractures

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Contents

• Fracture of the zygomatic complex and arch
• Orbital floor fractures
• Traumatic injury to the frontal sinus
• Naso-ethmoial orbital fracture (NEO)
• Nasal fractures

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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

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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.
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Occurrence

• As isolated fracture
• In combination with other middle third fracture
• With internal orbital fracture (blow out)

• Observed in (gt50) of middle third fracture (in
  developed countries due to assaults)
• The zygomatic arch fracture can be isolated in
  most of the cases

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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

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• Trismus
• Abnormal nerve sensibility
• Epistaxis
• Subconjunctival ecchymosis
• Crepitation from air emphysema
• Displacement of palpebral fissure (pseudoptosis)
• Unequal pupillary levels
• Diplopia
• enophthalmos

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Clinical examination

• Inspection
• Palpation
• Visual examination
• Eye movement
• Diplopia
• Pupil reaction

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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

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• Occipitomental view
• (Posterioanterior oblique)
• (waters view)

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• submentovertex

Recommended for isolated zygomatic arch fracture
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• CT scan
• Coronal sections
• Axial sections

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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

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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

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Treatment

• The methods of treating a fractured malar bone
  recommended by the various writers who 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

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Methods of reduction

• Temporal approach (Gillies et al 1927)

Suitable for isolated zygomatic fracture with
good stability afterwards
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Methods of reduction

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

Suitable for displaced zygomatic fracture with
high Stability after reduction
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Methods of reduction

• Buccal sulcus approach (Keen 1909)
• Elevation from eyebrow approach
• (the same principle of Gillies approach)

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Open reduction and fixation

• Transosseous wiring at
• Frontozygomatic suture
• Infraorbial rim

• Surgery
• Lateral eyebrow incision
• Infraorbital approach

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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

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Points of fixation
Infraorbital rim and buttress
Lateral orbital rim
Buttress of zygoma
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Other methods of fixation

• Kirschener wire
• Pin fixation
• Antral pack

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Internal orbital fractures

• In conjunction with other facial fractures
• As isolated type (Blow out fracture)

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• 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

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Clinical and radiographical presentation

• Subconjunctival ecchymosis
• Crepitation from air emphysema
• Displacement of palpebral fissure
• Unequal pupillary levels
• Diplopia
• enophthalmos

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• Diplopia and enophthalmous
• Superior orbital fissure syndrome

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Treatment

• Rational for intervention
• Small defect with no clinical consequence may not
  warrant the surgical intervention.
• Large defect with handicapping symptoms should be
  operated.

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Method of reconstruction

• Intra-sinus approach to the orbital floor
• External approach to the internal orbital floor

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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

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Nasal-orbital ethmoid injuries

• They 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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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

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Fracture classificationNasal-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 remains attached
  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

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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

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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

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Detached canthusTraumatic telecanthus

• Increase in inter-canthal distance secondary to
• canthus displacement or detachment
• Seen in association to
• Nasal bone
• NEO
• Le Forts fractures

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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

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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

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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

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Frontal sinus fracture

• Frontal sinus
• Drains into nasal cavity via fronto-nasal duct

An air filled cavity lined by ciliated
respiratory epithelium encased in the frontal
bone
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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

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Diagnosis

• Clinical examination
• Radiographical evaluation
• Occipitomental views
• Lateral skull view
• CT scan

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Classification of fractures

• Anterior table fracture
• Linear
• Displaced
• Posterior table fracture
• Linear
• Displaced
• Outflow tract injury (naso-lacrimal duct)

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Surgical management

• Intranasal cannulation
• Frontal sinus trephination
• Osteoplastic flap
• Sinus ablation (obliteration)
• Cranialization
• Reduction and fixation

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Reduction and fixation

• Surgical approaches
• Site of penetrating injury
• Coronal approach

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• Sinus ablation (obliteration)
• Bone
• Fat
• Muscle and fascia
• Alloplastic materials

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• Fixation
• Wires
• Plating

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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

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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)

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Treatment

• Low energy injuries
• Reduction (close manipulation, open reduction)
  and stabilization
• Nasal packing
• External nasal splint
• Adjunct septoplasty
• Postoperative care

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• 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