Zygomaticomaxillar Y Complex Fracture: Deepak Kgupta

Zygomaticomaxillar
y complex Fracture
Deepak KGupta
• Zygoma or cheek bone
• Fracture of zygoma is not usually present
alone, its find mostly in the conjunction with
adjacent structure i.e.
– antrum,
– orbital walls including the infraorbital canal,
– rim
– orbital floor
This structure makes up the zyogmaticomaxillary
complex
www.facebook.com/notesdental
Applied Anatomy
• Zygomatic bone
separated from the
craniofacial skeleton.
Five articulations are
identified:
1. Frontal process
2. Zygomaticomaxillary
buttress
3. Infraorbital rim
4. Zygomatic arch
5. Lateral orbital wall
Frontal process
Zygomaticomaxillary
buttress
Infraorbital rim
Zygomatic arch
Lateral orbital wall
Rowe’s and Killey classification (1968)
• Type I : no significant displacement
• Type II : fracture of zygomaticarch
• Type III : rotation arround horizontal axis – inwardor
outward displacement
• Type IV: rotation around longitudinal axis – medial or
lateral
• Type V : displacement of the complex block–
medial/inferior/lateral
• Type VI: displacement of orbitoantral partition
• Type VII: displacement of orbital rim segment
• Type VIII: complex comminuted fracture.
Axis of rotation
• Vertical axis : Line passing through
frontozygomatic suture and first molar tooth
– Medial or lateral movement
• Horizontal Axis : infraorbital foramen and
horizontal arch
– Upward or downward movement of broken
segment
Clinical features: Skeletal deformities
• Asymmetry of the
midface
• Depression/flattening
of the malar
prominence
• Flattening, hollowing
(bony indentation) or
broadening over the
zygomatic arch
• Palpable step offs or
gap deformities of
orbital margins
(infraorbital/lateral)
Clinical features : ocular/opthalmic
•
sypmtoms
Periorbital edema or hematoma
(“monocle hematoma”)
• Pseudoptosis - inability to elevate the eyelid
• Increased scleral show
• Downward slant of palpebral
fissure or horizontal lid axis
respectively
• Malposition of the lateralcanthus
• Vertical shortening of the lower
eyelid (ectropion)
• Subconjunctival ecchymosis
(temporal/medial)
• Chemosis – edema of conjuctiva
• pupillary or globe leveldisparity
(hypoglobus)
• Proptosis bulbi
Clinical features : ocular/opthalmic
sypmtoms
• Enophthalmos (outward
displacement of zygoma)
• Exophthalmos (inward
displacement of zygoma)
• Subcutaneous periorbital
air emphysema (skin
crepitation)
• Pneumoexophthalmos
• Amaurosis - vision lossor
weakness that occurs
without an apparent
lesion affecting the eye
• Superior orbital fissure
syndrome
Diplopia
• Neurogenicocular motility disorder –classic
symptom of ZMCfracture
• Classified
– Monocular: double vision with 1eye
– Binocular : double vision with both eyesopen
– Permanent : paralysis or muscle entrapment
– Temporary : last for 5-7 days
Diplopia: cause
• Haeomotoma or
edema arround
extraoccular
muscle
• Neuromuscular
injury
• Disruption of
attatchment of
inferior rectus
or inferior
oblique muscle
Diplopia : test
• Finger Gaze: finger moved in front of eye inall
nine direction of gaze at a distance 30 cm.
Reporting of double vision –positive.
• Forced duction test: differentiate between
permanent and temporary diplopia – carried
out under topical LA.
– Tendons of inferior rectus muscle is held with
tissue holding forceps and eyeball is rotated
superiorly with other movement
– failure to rotate indicates paralysis or entrapment
of muscle in fracture
Forced Duction test
Clinical feature : Sensory
• Sensory deficit
(hypoesthesia,
anesthesia) in the
distribution of the
following nerves:
1. Infraorbital nerve:
lower eyelid, upper lip, 3
ala and lateral sidewall
of the nose
1. Zygomatiofacial nerve:
malar eminence, cheek 2
2. Zygomaticotemporal
nerve: lower lateral
orbital rim anterior 1
temporal/lateral/frontal
region www.facebook.com/notesdental
Clinical feature: Oral symptoms
• Ecchymosis of the gingivobuccal maxillarysulcus
• Subjective occlusal disorder due to altered
sensation of the maxillary premolars/molars and
gingiva, no objective malocclusion
• Palpable contour disturbance of
zygomaticomaxillary buttress
• Restriction of mandibular opening (trismus) or
closing
– blockage of temporal muscle or coronoidprocess
• impacted zygomatic arch
• retrodisplaced zygoma
Clinical feature : Nasalsymptoms
• Ipsilateral epistaxis
• Ipsilateral hematosinus
Investigation
• Conventional plain x-rays in combination with
a detailed clinical examination in absence of
CTscan
• high-resolution CTscans in axial, coronal, and
sagittal reconstructions provide complete
radiological visualization of the fracture
sections with bone and soft-tissue windows
The apex of the V-shaped
fracture is indented toward the
coronoid mandibular process
Surgical Approach
• Extra-oral approach
– Bicoronal or hemicoronal
– Gillies : Temporal
– Superolateral
• Supraorbital approach : lateral eyebrow
• Upper eyelid
– Lower eyelid
• Infraorbital
• Subtarsal
• Subcilliary/infracilliary : lower blepheroplasty
– Transconjuctival
– Percutaneous
• Intra-oral approach
• Transoral : maxillary vestibular
• Endoscopic transantral
Bicoronal or hemicoronal
• The coronal or
bi-temporal
approach is used
to expose the
anterior cranial
vault, the
forehead, and
the upper and
middle regions
of the facial
skeleton
Bicoronal : Access
The following areas
can be exposed:
–Entire calvarial vault
–Anterior and lateral
skull base
–Frontal
sinus/ Ethmoid
–Zygoma
–Zygomatic arch
–Orbit
(lateral/cranial/medi a
–Nasal dorsum l
–Temporomandibular
joint (TMJ)
–Condyle and
subcondylar region
Temporal (Gillies) approach - Skin
incision
• The Gillies
technique describes
a temporal incision
(2 cm in length),
made 2.5 cm
superior and
anterior to thehelix,
within the hairline.
• A temporal incision
is made. Care is
taken to avoid the
superficial temporal
artery.
Temporal (Gillies) approach - Deep
dissection
• The dissection
continues
through the
subcutaneous
tissue and
superficial
temporal fascia
down to thedeep
portion of the
deep temporal
fascia.
• This fascia is then
incised to expose
the temporalis
muscle. www.facebook.com/notesdental
Temporal (Gillies) approach -
Exposure
An instrument is
inserted deep to
the temporalis
fascia and
superficial to the
temporalis
muscle. Using a
back-and-forth
motion the
instrument is
advanced until it
is medial to the
depressed
zygomatic arch.
Temporal (Gillies) approach
• A Rowe
zygomatic
elevator is
inserted just
deep to the
depressed
zygomatic
arch and an
outward
force is
applied.
Superolateral orbital rim Approaches
• There are two
periorbital
approaches:
A. Lateral eyebrow
approach :
supraorbital
eyebrow
approach
B. Upper-eyelid
approach :
upper
blepharoplasty
or supratarsal
fold approach
lateral eyebrow approach
•gives rather limited
access to
zygomaticofrontal
process and the
immediate vicinity
of suture line
(superolateral
orbital rim).
•brow skin is thick
and the wound
edge
The upper-eyelid or upper
blepharoplasty approach
• greater versatility
and enhanced
accessibility to
the superolateral
rim compared to
the lateral
eyebrow
approach.
• upper lid arethin,
resilient
Lower eyelid approaches
A. Subciliary : lower
blepharoplasty
B. Subtarsal : lower
or mideyelid
C. Infraorbital :
inferior orbital rim
D. The subciliary
approach can be
extended laterally
to gain access to
the lateral orbital
rim
Accessible area with a, b, c,approach
• lower
circumference
of the orbital
cavity and/or for
the
subperiosteal
elevation of the
upper midface
and release of
the cheek area
Accessible area with (d) approach
• With a lateral
extension of the
subciliary incision
however, the entire
lateral rim- with
heavy traction even
beyond the level of
the zygomaticofrontal
suture, as well the
lateral orbital wall
back to the
zygomaticosphenoid
suture become
accessible
Transconjunctival
• Transconjunctival lower-
eyelid approaches are
performed in severalways.
A. Transconjunctival (inferio
r fornix transconjunctival
using a retroseptal or
preseptal route)
B. Transcaruncular (=media
l transconjunctival)
C. Transconjunctival with
lateral skin
extension(lateral
canthotomy/swinging
eyelid
D. Combination of (A) and
(B)
A. C-shaped incision:
Combination (a), (b), (c)
Transconjunctival : Acess area
the floor of the orbit and
infraorbital rim as well as
the upper edge of the
anterior maxilla(A).
Via a pre- or
transcaruncular incision, the
medial wall of the orbit
behind the posterior
lacrimal crest can be
exposed (B).
The combination of the
lower fornix and the medial
transconjunctival approach
provides access to both
previously mentioned areas
at atime.
Percutaneous: Stacey bone hook
Percutaneous: screw and traction method
Percutaneous : Carroll-Girard screw
Transoral (Keen) approach – lateral
maxillary vestibular incision
• The transoral (Keen)
approach provides the
most direct access to
the zygomatic arch.
• A 2 cm lateral maxillary
vestibular incision
(upper gingival buccal
incision) is made with a
scalpel or a cautery
device just at the base
of the
zygomaticomaxillary
buttress. The incision is
made through mucosa
only.
Transoral (Keen) approach - Exposure
• Because of the direct proximity of the incision
to the arch,
– an instrument can easily be placed deep to the
fractures to allow elevation of a depressed
zygomatic arch.
– the depressed arch can often be palpated and
elevated with a digital exam.
Transoral (Keen) approach - Exposure
• An instrument is
inserted deep to
the temporalis
fascia and
superficial to the
temporalis muscle.
Using a back-and-
forth motion the
instrument is
advanced until it is
medial to the
depressed
zygomatic arch.
Reduction
Indirect method
1. Gillies temporal fossa approach
2. Transverse maxillary buccal sulcus incision :
Keen’s or Balasubramanyam approach
3. Percutaneus approach
Direct method
Done through various approaches as
explained earlier
Fixation
• It can be done in 4 methods dependingon
severity of fracture
– 1 point fixation
1 point fixation
• Indication
– simple noncomminuted ZMC
– patients where CThas
revealed no separation at the
fracture of the
zygomaticofrontal suture,
– and with goodintraoperative
visualization, and reduction
of the lateral maxillary
buttress and the inferior
orbital rim,
– 1-point fixation with aplate
between the maxilla and
zygoma may be adequate.
2 point fixation
• When zygoma is not
adequately reduced by
visualizing only through
a single approach
• a second point of
exposure can help
determine if the
zygomatic complex has
been properly reduced.
• bone plates placed
across the
frontozygomatic
suture and the
zygomaticomaxillary
buttress provide stable
internal fixation.
3 Point Fixation
Indication
–Comminution of the
zygomaticomaxillary
buttress and/or the
frontozygomatic
region, making
assessment of
reduction difficult.
–reconstruction of
the internal orbit
3 point fixation
• Only placing the
plate at infraorbital
rim will help align
the zygoma but will
not provide much
additional stability.
• 3 different
approach for direct
visualization
4 point Fixation
• complex fracture of the zygoma and uncertaintyas to
adequate reduction of thefracture.
– Zygomaticofrontal suture
– Infraorbital rim
– Zygomaticomaxillary buttress,
– Zygomatic arch
• Itrequire cornoal incision which has its own
complication
– scar alopecia
– injury to the temporal branch of the facial nerve
– temporal hollowing : depression within the soft tissues
overlying the temporal fossa
4 point Fixation
But its
absolutely
indicated in
patient with
multiple
fractures
• frontal sinus
fractures
• NOE fractures
• Necessity to
harvest split
calvarial bone graft
Zygomatic arch fracture
• Isolated Zygomatic arch fracture may be
effectively reduced by closed reduction by
Gillies or Keen’sapproach
• No need for rigid internal fixation : temporalis
and masster muscle and fascia along soft with
soft tissue splint the arch sufficiently to
stabilize the fragments
Aftercare
• Evaluation of vision
– as soon as they are awakened from anesthesia
– regular intervals until they are discharged fromthe
hospital
• Postoperative positioning : upright position - improve
periorbital edema and pain
• Nose-blowing: avoided for 10 days - orbital
emphysema
• Medication : Nasal decongestant, Antibiotics,
Analgesia, Steroids, Ophthalmic ointment excluding
NSAID’S and aspirin
• Ophthalmological examination
• Postoperative imaging: 3-D imaging (CT, conebeam)
Afercare
• Wound care: suture removal within 5 days, ice packs, avoid sun
exposure
• Diet
• Soft diet: after healing of themaxillary vestibular incision.
• Intranasal feeding: oral bone exposure and soft-tissue defects.
• liquid diet : Patients inMMF
• Clinical follow-up: complexity of the surgery
• Eye movementexercises
• Oral hygiene : use of soft tooth brush and oral rinsetds
• MMF: duration of MMF is controversial and is dependent on
– Fracture morphology
– Type and stability of fixation (including palatalsplints)
– Dentition
– Coexistence of mandibular fractures
– Premorbid occlusion
Post operative complication
• Retrobulbar haemorrhage
• Malar assymetry
• Visual disturbance
• Loss of vision
• Persisten diplopia
• Orbital dystopia
• Enopthalmos
• Sensory deifict
• Persitant occular-cardiac reflex
• Compromised occular function
Refrences
• Principles of Internal Fixation ofthe Craniomaxillofacial
Skeleton - Trauma and Orthognathic Surgery by AO
foundation
• Textbook of oral and maxillofacial surgery 2nd edition: S
M Balaji
• Text book of oral and maxillofacial surgery3rd
edition_neelima Mallik
• Contemporary oral and maxillofacial surgery
_hupp_ellis_tucker
• clinical handbook of oral andmaxillofacial
surgery_lashkins
• Netter’s Atlas version 5.1
THANKS……
Feedback if any : dr.dkg07@gmail.com
Like, share and comment on
https://www.facebook.com/notesdental

Zygomaticomaxillar Y Complex Fracture: Deepak Kgupta

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Zygomaticomaxillar Y Complex Fracture: Deepak Kgupta

Uploaded by

Copyright:

Available Formats

Zygomaticomaxillar

You might also like