Zygomatic maxillary complex fracture
-
Upload
josna-thankachan -
Category
Education
-
view
1.481 -
download
6
Transcript of Zygomatic maxillary complex fracture
![Page 1: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/1.jpg)
ZYGOMATICO MAXILLARY COMPLEX
FRACTURE
Submitted by Josna Thankachan
Final year part IIAl-Azhar Dental College
![Page 2: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/2.jpg)
CONTENTS
• Introduction • Fracture pattern• Classification• Clinical features• Investigation• Management• Surgical Approaches• Reduction• Fixation• Complication• References
![Page 3: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/3.jpg)
INTRODUCTION
• Zygoma is a major buttress of facial skeleton is the principle structure of lateral midface.
• It is equivalent of a four sided pyramid.• It has temporal process which articulates with
temporal process which articulates with sphenoid bone, maxillary process which articulates with maxillary bone and frontal process which articulates with frontal bone.
![Page 4: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/4.jpg)
![Page 5: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/5.jpg)
• Fracture of zygoma is usually not present alone, it finds mostly in conjunction with adjacent structures ie, antrum, orbital floor. This structure makes up the zygomaticomaxillary complex.
![Page 6: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/6.jpg)
FRACTURE PATTERN
![Page 7: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/7.jpg)
• Fracture pattern follows a line which commence at frontozygomatic suture,passes downward close to or between the greater wing of sphenoid and the frontal process of zygomatic bone to reach anterior limit of inferior orbital fissure and then turns anteromedially to cross the inferior orbital margin above or in close proximity to the infraorbital canal.
![Page 8: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/8.jpg)
• From this point the fracture continues inferolaterally to cross the outer wall of antrum and pass beneath the zygomatic buttress turning upward across the posterior wall of antrum to rejoin the anterior limit of inferior orbital fissure.
![Page 9: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/9.jpg)
Inferior orbital fissure is the key to remembering the usual lines of zygomaticomaxillary complex fracture 3 lines extending from inferior orbital fissure in 3 direction-anteromedially
superolaterally inferiorly
![Page 10: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/10.jpg)
• One fracture line extend from inferior orbital fissure anteromedially along orbital floor mostly through orbital process of maxilla towards the infraorbital rim.
• Second line of fracture run from inferior orbital fissure to inferiorly towards the posterior aspect of maxilla(infra temporal)and joins the fracture from the anterior aspect of maxilla under the zygomatic buttress.
![Page 11: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/11.jpg)
• Third line of fracture extend superiorly from the inferior orbital fissure along the lateral orbital wall posterior to the rim,usually separating the zygomatico sphenoid suture.
• An additional fracture line runs through the zygomatic arch.
• frequently ; however 3 fracture lines exist through the arch,producing 2 free segments when the fracture are complete.
![Page 12: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/12.jpg)
CLASSIFICATIONI. Row and Killey classification(1968)
Type I – no significant displacementType II – Fracture of zygomatic archType III – rotation around horizontal axis (inward or outward
displacement)Type IV – rotation around vertical axis(medial or lateral displacement)Type V – displacement of complex enblockType VI – displacement of orbitoantral partitionType VII – displacement of orbital rim segmentType VIII – isolated fracture of orbital wall
![Page 13: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/13.jpg)
II. Spiessel and Schroll(1972)Type I – zygomatic arch fractureType II – zygomatic complex fracture;no significant displacementType III - zygomatic complex fracture;partial medial
displacementType IV - zygomatic complex fracture;total medial displacementType V - zygomatic complex fracture; dorsal displacementType VI - zygomatic complex fracture; inferior displacementType VII - zygomatic complex fracture; comminuted fracture
![Page 14: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/14.jpg)
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
![Page 15: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/15.jpg)
• 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
![Page 16: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/16.jpg)
– Subconjunctival ecchymosis– Chemosis– Hypoglobus– Proptosis bulbi– Enophthalmos– Exophthalmos
![Page 17: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/17.jpg)
– Subcutaneous periorbital air emphysema– Pneumoexophthalmos– Amaurosis– Superior orbital fissure syndrome– Diplopia
![Page 18: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/18.jpg)
![Page 19: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/19.jpg)
• Test for diplopia1. 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.
![Page 20: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/20.jpg)
![Page 21: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/21.jpg)
• 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
![Page 22: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/22.jpg)
• 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
![Page 23: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/23.jpg)
INVESTIGATIONS
• Plain radiographs water’s view or paranasal view of
zygomaticomaxillary complex fracture,floor of orbit,infra orbital rim
submentovertex- Arch fracture• CT scan
![Page 24: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/24.jpg)
MANAGEMENT• Surgical approach:-
A. Extra oral approach Bicoronal/hemicoronal Gillies temporal approach Superolateral
Supraorbital approach;lateral eyebrow Upper eyelid
Lower eyelid Infra orbital Subtarsal Subcilliary
Transconjunctival percutaneous
![Page 25: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/25.jpg)
B. Intra oral approach Transoral/keen’s approach Endoscopic transantral approach
![Page 26: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/26.jpg)
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.
![Page 27: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/27.jpg)
![Page 28: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/28.jpg)
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.
![Page 29: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/29.jpg)
![Page 30: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/30.jpg)
• 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 elevator is also used in
this approach for the reduction of the zygomatic fracture.
![Page 31: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/31.jpg)
• 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.
![Page 32: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/32.jpg)
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.
![Page 33: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/33.jpg)
![Page 34: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/34.jpg)
• 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.
![Page 35: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/35.jpg)
REDUCTION
• Indirect method– Gillies temporal approach– Keen’s approach– Percutaneous approach
• Direct method– Coronal/bicoronal approach– Supraorbital eyebrow approach– Lower eyelid approach
![Page 36: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/36.jpg)
• Fixation– 1 point fixation– 2 point fixation– 3 point fixation– 4 point fixation
![Page 37: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/37.jpg)
• 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.
![Page 38: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/38.jpg)
![Page 39: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/39.jpg)
• 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.
![Page 40: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/40.jpg)
![Page 41: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/41.jpg)
• 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.
![Page 42: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/42.jpg)
![Page 43: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/43.jpg)
• 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.
![Page 44: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/44.jpg)
![Page 45: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/45.jpg)
• Fixation is again of two types:i. Direct fixation • Transosseous wiring
ii. Indirect fixation• Internal pin fixation• Transfixation with kirshner wire
![Page 46: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/46.jpg)
COMPLICATIONS• Complication of periorbital incision• Infraorbital nerve paresthesia• Implant extrusion/displacement and infection• Persistent diplopia• Enophthalmosis• Blindness• Retrobulbar hemorrhage• Ankylosis of zygoma to coronoid• Malunion• Orbital dystopia
![Page 47: Zygomatic maxillary complex fracture](https://reader034.fdocuments.us/reader034/viewer/2022042501/587fe2541a28ab46228b4aaf/html5/thumbnails/47.jpg)
REFERENCES
1. Clinical handbook of oral and maxillofacial surgery- Laskins
2. Textbook of oral and maxillofacial surgery;2nd edition- S.M Balaji
3. Textbook of oral and maxillofacial surgery;3rd edition- Neelima Mallik