management of zygomatic complex fractures
TRANSCRIPT
Dr. Shahzad HussainBDS, FCPS (resident)
Nishtar Institute of DentistrySNDENTALCare.co
Contents Introduction
Surgical Anatomy
Classification
Etiology
Diagnosis
Management
Complications
Conclusion
Introduction Zygoma: Strong buttress of lateral midface lying
between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Surgical Anatomy 4 process: temporal, orbital, maxillary, frontal
Forms lateral wall and floor of orbit
Articulations of zygoma:
1. angular process of frontal bone
2. orbital floor
3. greater wing of sphenoid
4. Maxilla
5. zygomatic bone of temporal bone.
Soft Tissue Attachments Muscular attachments:
Malar surface – zygomatic major, minor, levator labiisuperioris
Temporal surface – masseter muscle
Temporal process - Temporal fascia
Temporalis muscle passes beneath the arch
• Lateral Canthal Ligament
• Lockwood Suspensory Ligament
Sensory Nerves •Zygomatico Temporal nerve.
•Zygomatico facial nerve.
Zygomatic Fractures These Include the fractures of
1. Zygomaticofacial Suture
2. Zygomaticomaxillary Buttress
3. Zygomatic arch
4. Zygomaticosphenoid Suture
5. Infraorbital rim
Classification Schjelderup classification
Knight and north classification
Rowe and killey classification
Spissel and schroll classification
Henderson classification
Ellis classification
Rowe and killey classification Type 1: no significant displacement.
Type 2: isolated fracture of zygoma.
Type 3: fracture rotated around a vertical axis.
Type 4: fracture rotated around a horizontal axis.
Type 5: fracture displacement of complex in block.
Type 6: displacement of orbital floor.
Type 7: displacement of orbital rim.
Type 8: complex comminuted fracture
Henderson’s Classification
Aitiology Physical Assault
Road Traffic accidents
Sports Related Injuries
Incidence
Mechanism Of Injury Direct
Indirect (contra lateral
lefort fracture)
Diagnosis History
Clinical Examination
Radiological Examination
Signs & Symptoms1. Orbital
2. Neurological
3. physical
Orbital1. Proptosis
2. Enophthalmos
3. Double vision
4. Scleral show
5. Subconjuctival hemorrhage
6. Periorbital oedema
Neurological Contusion or compression of nerve
Physical Flatness of face
Limitation of jaw movement
Epistaxis
Radiological Evaluation Plain films:
waters view (P-A Skull) reverse reverse waters view(A-P Skull)
submentovertex view
C.T Scan: Axial sectionsCoronal sections
Three Dimensional C.T Scan
Treatment Goals Restore Normal Contour of the face
Relieve pain
Precise anatomical reduction of the fractured segment
Stable fixation of the reduced segment
To correct associated diplopia
To remove any interference in the range of mandibularmovement
To relieve pressure from infraorbital nerve
Indications For Surgery Visual compromise
Extraocular muscle dysfunction
Displacement of globe
Orbital floor disruption
Displaced fracture
Communated fracture with the segments impinging on the surrounding structures
Restricted mandibular movements
Infraorbital nerve dysfunction
Steps of Surgical treatment Pre surgical Images Prophylactic antibiotic Anesthesia Detailed Clinical Examination and forced duction test Protection of the globe Antiseptic preperation Fracture reduction Assessment of the reduction Determination of the necessarity of the fixation Application of the fixation device Internal orbital reconstruction Assessment of ocular mobility Reconstruction with bone grafts Soft tissue management Post surgical ocular examination Post surgical images
Surgical Approaches Indirect
Direct
Direct ApproachExtra oral:
1. Upper eyelid
2. supra orbital eyebrow
3. Coronal
4. Lower eye lid: 1. Subcilliary
2. Transconjuctival
3. Infraorbital
Intra oral
1. Maxillary vestibular
Indirect Approach Intra Oral:
1. Keen’s Approach
2. Quin’s Approach
Extra Oral:
1. Temporal
2. Percutaneous
Dingman’s approach
Vestibular Approach
Vestibular Approach Advantages:
Less force is required for reduction
No Skin incision
Less dissection
Technique:
Incision-1cm
Elevator- Taylor monks or Rows
Temporal fossa approachRemains best technique.
Rationale:
Temporal fascia
Zygomatic bone
Zygomatic arch
Temporal muscle
Instrument
Technique Hair is shaved
Baseline gauge - external auditory meatus
Incision – 2.5cm
Identification of temporal fascia
Elevator – Row zygomatic elevator or Bristow’s orthopaedicperiosteal Reduction
Audible click
Elevator is withdrawn
Closure by layers
Post operative care
elevator
Technique
Lateral coronoid approach Technique:
Incision
Anterior border of ramus
Blunt dissection
Elevator
Upper Eyelid Approach
KEEN’s Approach
Surgical Approaches in relation to Fracture
Approaches to infraorbital rim:1. Existing skin laceration2. Subtarsal incision3. Blephroplasty incision4. Transconjunctival incision (pre-septal or post- septal) Approaches to lateral orbital rim:1. Eye brow incision2. Upper lid incision Approaches to zygomatic arch:1. Pretragal incision2. Coronal flap incision.
Fixation Methods Most common methods of fixation:
1. Wire osteosynthesis
2. Rigid fixation – mini – plates.
Less common methods:
1. External pin fixation
2. Maxillary antral support
Trans osseous wiring Technique:
No.2 round bur
5mm apart from the fractured ends
0.35mm diameter soft stainless steel wire
Fig of 8 fashion
Transosseous wiring
Carrol – Girard screw Useful in laterally displaced zygoma fractures.
Temporary support
Unstable following reduction
Gross contamination
Communition
Antral pack
Wire -Splint
Inflateable balloon
Plaster head cap
Silicon elastomer wedge.
Principles of Plate Fixation Use of self threading bone screws.
Use of the material that will not scatter the Post operative CT scans . Titanium is the meterial of the choice
Placement of at least 2 screws through the plate on each side of the fracture
Avoid damage to anatomical structures
Use of thin plates in the periorbital region to prevent visibility and reduce palpability.
Placement of as many bone plates in locations to ensure stability
Mini Plates 2mm plates – zygomatic arch
1.5mm – zygomaticomaxillary buttress
1.3mm infra orbital rim
Order of fixation
Zygomatic arch
Zygomaticofrontal suture
Infraorbital rim
Zygomatic buttress
Miniplates and screws
Fixation with a pack in maxillary sinus To support zygomatic complex fracture
To support reconstructed comminuted orbital floor.
Technique:
Incision
Window into sinus
Bone pack – ribbon gauge
Complications Malposition of soft tissue on bone
Complications of bone malposition
Occular complications
Malposition of soft tissue on bone:
Closure of periosteal incision
Refixation of the tissue on facial skeleton
Complication of bone malposition:
Maxillary sinusitis
Inaccurate alignment: orbital rim , zygomatic arch
Reconstructed flat rather than as a curve to achieve a satisfactory reduction.
Ocular Complications :
Traumatic diplopia
Enophthalmos
Retrobulbar hemorrhage and blindness
Superior orbital fissure syndrom
Neurologic Complications : damage to infraorbital nerve.