ZYGOMATIC COMPLEX FRACTURE DAVISpptx

FRACTURE

1. ZYGOMATIC COMPLEX FRACTURE DR DAVIS NADAKKAVUKARAN M.D.S READER MALABAR DENTAL COLLEGE ,MANOOR

2. CONTENTS Introduction Classification Clinical features Investigation Management Surgical Approaches Reduction Fixation Complication References

3. INTRODUCTION Zygomatic bone is intimately associated with the maxilla, frontal and temporal bones zygomatic complex. The zygomatic bone fractures in the region of the zygomatico -frontal suture, the zygomaticotemporal suture and the zygomatico -maxillary suture

4. CLASSIFICATION Row and Killey classification(1968) Type I – no significant displacement Type II – Fracture of zygomatic arch Type III – rotation around horizontal axis (inward or outward displacement) Type IV – rotation around vertical axis(medial or lateral displacement) Type V – displacement of complex enblock Type VI – displacement of orbitoantral partition Type VII – displacement of orbital rim segment Type VIII – isolated fracture of orbital wall

5. II. KNIGHT & NORTHWOOD CLASSIFICATION ON THE BASIS OF OCCIPITOMENTAL VIEW: No significant displacement Fracture of zygomatic arch only Unrotational body fracture Medial rotational body fracture Lateral rotational body fracture Complete rotational body fracture

6. CLINICAL FEATURES SKELETAL DEFORMITIES Asymmetry of the mid face Depression or flattening of malar prominence Flattening , hollowing or broadening over the zygomatic arch Step deformity of orbital margins

7. OCULAR /OPHTHALMIC SYMPTOMS Periorbital edema Pseudoptosis Increased visibility of sclera Downward slant of palpebral fissure Malposition of the lateral canthus Vertical shortening of the lower eye lid

8. Subconjunctival ecchymosis Chemosis Hypoglobus Proptosis bulbi Enophthalmos Exophthalmos

9. Subcutaneous periorbital air emphysema Pneumoexophthalmos Amaurosis Superior orbital fissure syndrome Diplopia

10. Test for diplopia Finger gaze:- Finger moved infront of eye in all nine directions of gaze at a distance of 30cm. 2. Forced duction test:- Tissue holding forceps are used to hold tendon of inferior fornix . The globe is manipulated through its entire range of motion. Inability to rotate the globe superiorly signifies entraptment of muscle in orbital floor.

11. NEUROLOGICAL SYMPTOMS Paresthesia of infraorbital nerve Parethesia of supra orbital and supra trochlear nerve Paresthesia of zygomatico temporal and zygomatico facial nerve Paresis of facial nerve Paresis of extraocular muscles

12. ORAL SYMPTOMS Ecchymosis in the buccal sulcus of maxillary arch Deformity of zygomatic buttress of maxilla Trismus Pain Impacted /flattened zygomatic arch NASAL SYMPTOMS Ipsilateral epistaxis Ipsilateral hematosinus

13. INVESTIGATION Plain radiographs water’s view or paranasal view of zygomaticomaxillary complex fracture,floor of orbit,infra orbital rim submentovertex - Arch fracture CT scan

14. MANAGEMENT Surgical approach:- Extra oral approach Bicoronal / hemicoronal Gillies temporal approach Superolateral Supraorbital approach;lateral eyebrow Upper eyelid Lower eyelid Infra orbital Subtarsal Subcilliary Transconjunctival percutaneous

15. Intra oral approach Transoral /keen’s approach Endoscopic transantral approach

16. Bicoronal / hemicoronal approach The zygoma fracture reduction is complete if the sphenozygomatic suture is reduced. This suture can be visualized only by this approach. Moreover, this approach is ideal in zygomatic complex fracture involving the frontal bone,orbital roof reconstruction ,arch fracture requiring fixation and laterally displaced zygoma fracture requiring 3 or 4 point fixation.

17. Gillies temporal approach(1927) An incision about 2.5cm length is made between the two branches of the superficial temporal artery at an angle of 45˚ to the upper limit of the attachment of the external ear.

18. elevator is also used in this approach for the reduction of the zygomatic fracture. Dissection is carried out till the temporal fascia. A Bristow’s elevator is passed down through this incision beneath the zygomatic bone which is then gradually reduced to its position. The incision is then closed in layers. Rowe pattern zygomatic

19. Bristow’s elevator has adisadvantage of using the temporal bone as fulcrum causing risk of fracturing the temporal bone during the procedure. This was overcome by the design in Rowe zygoma elevator

20. Transoral /keen’s approach Also known as buccal sulcus incision /lateral maxillary vestibular incision A bone hook can be passed from a transverse incision made in the region of buccal sulcus and the fractured segment can be reduced. An incision 1cm in length is made in the buccal sulcus behind the zygomatic buttress.

21. A bone hook or curved elevator is passed behind supraperiosteally,to contact the deep part of the zygomatic bone.here an upward outward and forward pressure is exerted. The advantage of this method is that less amount of force is required for reduction.

22. REDUCTION Indirect method Gillies temporal approach Keen’s approach Percutaneous approach Direct method Coronal/ bicoronal approach Supraorbital eyebrow approach Lower eyelid approach

23. Fixation 1 point fixation 2 point fixation 3 point fixation 4 point fixation

24. One point fixation Indication Undisplaced fracture at frontozygomatic suture Simple non comminuted zygomatic complex fracture Approach Frontozygomatic suture approached through supraorbital eyebrow approach. Zygomaticomaxillary buttress approached through maxillary vestibular approach. One point fixation with miniplates in the zygomatico maxillary butress region can avoid unsightly scars and give high satisfaction with surgical outcome in selected patients with zygoma fractures.

25. Two point fixation Indication Displaced fracture unstable after reduction Fracture at frontozygomatic suture,infraorbital rim and buttress. Approach Exposure of frontozygomatic suture through lower eyelid incision or maxillary vestibular incision. A 2 point fixation using low profile plate at zygomaticomaxillary buttress or at the infra orbital rim suffice.

26. Three point fixation Fixation is done at frontozygomatic suture,zygomaticomaxillary buttress and the infraorbital rim. Good reduction of these 3 sites mostly reduces the arch fracture which is not fixed.

27. Four point fixation Unique from 3 point technique in that the surgeon visualizes the zygomatic arch. The order of placement of the plates will be dependant on the least damaged landmarks. The zygomatic arch is an excellent reference to restore proper anteroposterior projection of the midface

28. Fixation is again of two types: Direct fixation Transosseous wiring Indirect fixation Internal pin fixation Transfixation with kirshner wire

29. COMPLICATIONS Infraorbital paraesthesia Malunion and assymmetry Diplopia Traumatic hyphema Enopthalmos Traumatic optic neuropathy- mild visual deficit to complete loss of vision Superior orbital fissure syndrome-include ptosis , ophthalmoplegia , forehead anesthesia , and a fixed dilated pupil. Proptosis may be present. Treatment may include reduction of fractures, steroids, orbital apex exploration, and aspiration of retrobulbar hematoma if present Trismus Retrobulbar haemorrhage

30. REFERENCE Textbook of oral and maxillofacial surgery;2 nd edition- S.M Balaji Textbook of oral and maxillofacial surgery;3 rd edition- Neelima Mallik Textbook of oral and maxillofacial surgery- Chithra chakravarthi 4. Oral and maxillofacial surgery- Laskin