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Zygomatic complex fractures
Management of Maxillofacial Trauma
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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
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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
Observed in (>50%) of middle third
fracture (in developed countries due to assaults)
The zygomatic arch fracture can be
isolated in most of the cases
•As isolated fracture
•In combination with other middle third fracture
•With internal orbital fracture (blow out)
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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 examinationEye 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)
Water’s 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 processesAnterio-posterior displacement
Rotation along the prominence of the boneMedio-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 general 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 atFrontozygomatic 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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Infraorbital
rim and
buttress
Lateral
orbital rim
Buttress of
zygoma
Points of fixation:
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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 syndromeSuperior orbital fissure syndrome, also known as Rochon-
Duvigneaud's syndrome, is a neurological disorder that
results if the superior orbital fissure is fractured. Involvement of
the cranial nerves that pass through the superior orbital fissure
may lead to diplopia, paralysis of extraocular motions,
exophthalmos, and ptosis. Blindness or loss of vision indicates
involvement of the orbital apex, which is more serious,
requiring urgent surgical intervention. Typically, if blindness is
present with superior orbital syndrome, it is called orbital apex
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 graftBone (cranial, rib, iliac)
Cartilage
Allogenic materialsLyophilized dura
Alloplastic materialsSiliastic 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 IUnilateral or bilateral, involves only one portion of the
medial orbital rim with the attached canthal tendon
Type IIUnilateral or bilateral, may be large segments of
comminuted type and the canthus remains attached to the large central segment
Type IIIUnilateral 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 fracturesExamination 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-rhinostomyimplantation 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
evaluationOccipitomental 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
AnatomyMidline 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 injuriesSimple injury caused by low velocity trauma (simple
noncomminuted)
High energy injuriesSevere 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 injuriesReduction (close
manipulation, open
reduction) and stabilization
Nasal packing
External nasal splint
Adjunct septoplasty
Postoperative care
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Complex injuriesImmediate 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