Classification & management of zygomatic complex fractures including lateral wall of the orbit /certified fixed orthodontic courses by Indian dental academy

Classification and
management of zygomatic
complex fractures including
lateral wall of the orbit.

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents
Introduction
 Surgical anatomy
 Mechanism of zygomatic injury
 Classification
 Signs and symptoms
 Clinical examination
 Radiographic examination
 Treatment
 complications.



Introduction
ZYGOMA
 Central

support of the cheek
 Strong buttress
 Stabilizing bridge
 Frequently fractured.


Surgical anatomy

Quadrilateral in shape
 Four process:
Temporal, Orbital, Maxillary, Frontal
 Lateral wall and floor of the orbit.



Surgical anatomy
 Articulations

of

zygoma:
Angular process of
the frontal bone,
orbital floor, greater
wing of the sphenoid,
maxilla, zygomatic
process of the
temporal bone.


Surgical anatomy
Muscular attachments:
Malar surface – zygomatic major, minor, levator
labii superioris.
Temporal surface – masseter muscle
Temporal process – temporal fascia
Temporalis muscle passes beneath the arch.
Nerves:


Zygomatico temporal nerve



Zygomatico facial nerve.


Surgical anatomy


Mechanism of zygomatic injury
 Direct

blow – malar eminence

 Violent

face -

blows – contra lateral mid-

causes a fracture
dislocation of the zygoma by
reciprocal transfer of forces from
the opposite side of the facial
skeleton.

Classification
 Larsen

and Thomsen:

– A: Stable #, no/minimal displacement
,no intervention
– B: Stable #, with displacement,
reduction, no fixation
– C: unstable #, displacement, reduction
and fixation
 Fracture

of zygomatic arch:

– Minimum/no displacement
– V-type #
– Communiated #

Rowe and Killey’s Classification
Type
 Type
 Type


I – no significant displacement
II - # of zygomatic arch
III – rotation around vertical axis

– Inward displacement of orbital rim
– Outward displacement of orbital rim



Type IV – rotation around longitudinal axis
– Medial displacement of frontal process
– Lateral displacement of frontal process

Type V – displacement of complex enblock
 Type VI – displacement of orbital floor
 Type VII – displacement of orbital rim
 Type VIII – complex communited #



Mechanism of zygomatic injury

•Direction of dislocation:
several planes.

Classification


Signs and symptoms of zygomatic
fractures
Orbital signs and
symptoms:
 Proptosis
 Enopthalmous
 Double vision
 Scleral show
 Subconjuctival
hemorrhage
 Periorbital oedema.

Signs and symptoms of zygomatic fractures
 Neurological

signs &

symptoms:
contusion or compression
of infra orbital nerve:
•Others:

•Flatness of the face
•Limitation of the jaw
movement
•Epistaxis

Clinical examination:
Face examination.
 Tenderness.
 Greenstick fracture.
 Step deformity.
 Intra oral palpation.
 Drooping of the upper lip.
 Facial nerve examination.



Radiographic examination:


Plain films:
Waters view (P-A Skull)
Reverse waters view
(A-P Skull)
Submentovertex view.



C.T. Scans:
Axial sections
Coronal sections



3-D C.T.Scans:

Treatment
 Should

one surgically intervene ?
 When is the optimal time ?
 What is the most effective
method ?
- closed reduction without fixation ?
- open reduction and fixation ?
 Demann

& Dortzbach
recommended early intervention
for muscle entrapment injuries.

Treatment
Reduction










Temporal fossa approach
Gillies et al (1927)
Buccal sulcus approach
Keen (1907)
Lateral coronoid approach
Quinn (1977)
Percutaneus approach.
Poswillo
Intranasal transantral approach.


Treatment
Temporal fossa approach :


Remains a best technique



RATIONALE :

- Temporal fascia
- Zygomatic bone
- Zygomatic arch
- Temporal muscle
- Instrument

Treatment
Technique :
 Hair is shaved
 Vaseline gauge – external auditory
meatus
 Incision – 2.5 cm
 Identification of temporal fascia
 Definitive elevator:
1 Bristow’s orthopaedic periosteal elevator
2 Rowe zygomatic elevator

Treatment

Temporal fossa approach

Gillies Temporal Approach


Treatment
u

Reduction

u

Audible click

u

Elevator is withdrawn

u

Closure by layers

u

Post operative care.

Treatment
Upper buccal sulcus approach :
• Intra oral approach
Advantages:
• less force is recquired for reduction
• Sparing a skin incision
• Less dissection
Technique :
• Incision – 1 cm
• Elevators:
Taylor monks
Rows.

Treatment

Upper buccal sulcus approach

Treatment

Lateral coronoid approach :
 Technique:
- Incision
- Anterior border of ramus
- Blunt dissection
- Elevator
- Herniation of the buccal pad.

Treatment
Percutaneous approach :
 Technique: Incison
Instruments:
Crowe (1952)
Ginestat & Dautrey (1960)
Poswillo (1976)


Treatment
Percutaneous
approach :
 Insertion of hook
 Rotation : 90
degrees
0.5 cm
 Note :
The point of
instrument
must be kept in close
contact with the bone
all the times.
Complication: blindness

Treatment
Carrol – Girard screw :


Useful in laterally displaced zygoma
fractures.


Treatment
Intranasal transantral
approach :
 Not commonly used
 Rotation around vertical axis
Technique:
opening – inferior meatus
curved urethral sound
firm upward and downward
pressure

Treatment
Temporary support :
Unstable following reduction
 Gross contamination
 Communition
- Antral pack,
- Wire – splint
- Inflatable balloon
- Plaster head cap
- Silicon elastomer
wedge



Treatment
Fixation
Approaches to the infra orbital rim:
Existing skin lacertions
 Infra orbital rim incision
 Subtarsal incision
 Blepharoplasty incison
 Transconjuctival incision
A. Pre septal
B. Post septal.



Treatment

Approaches to the infra orbital rim:

Treatment


Approaches to the lateral orbital rim :
Eye brow
incison
Upper lid
incision



Approaches to the zygomatic arch:
Pretragal incision
Coronal flap incision

Treatment
 Most

common methods of
fixation:

plates


Wire osteosynthesis
Rigid fixation-mini-

Less common methods are :

support.

External pin fixation
Maxillary antral

Treatment
1.

Trans osseous wiring or
osteosynthesis :
Technique :






No.2 round bur,
5mm apart from the fracture ends
0.35 mm diameter soft stainless steel
wire
Figure of eight fashion

Treatment
2. Bone plates :
 2 mm plates – Zygomatic arch
 1.5 mm – Zygomatico-Maxillary
buttress.
 1.3 mm – Infra orbital rim
Order of fixation :
Zygomatic arch
 Zygomatico frontal suture
 Infraorbital rim
 Zygomatic buttress.



Treatment
4. Fixation with a pack in the
maxillary sinus :

To support zygomatic complex fractures
 To support reconstructed comminuted
orbital floor.


Technique :

Incision
 Window into the sinus
 Bone pack – ribbon gauge
 Concertina pattern



Treatment
White head varnish :











Iodoform -10 g
Benzoin -10 g
Storax - 7.5 g
Balsam of tolu - 5 g
Solvent ether to 100 ml.
Aromatic resins – benzoic acid – potent
anticeptic and water proofing pack.
3 weeks
Easy to remove
Balloon or a foley’s catheter.

Complications
 Malpositions

the bone

of the soft tissue on

 Complications

 Ocular

of bone malposition

complications

Complications
Malposition of the soft tissue on the
bone :
Closure of periosteal incisions
 Refixation of the tissue on the facial
skeleton.



Complications
Complications of bone
Malpositions :
 Maxillary sinusitis
 Inaccurate alignment :
orbital rim
zygomatic arch
Reconstructed flat rather than as a
curve to achieve a satisfactory
reduction.

Complications
:

Ocular complications

Traumatic diplopia
 Enopthalmos
 Retrobulbar hemorrhage &
blindness
 Superior orbital fissure syndrome
 Neurologic complications :
Damage to the infrawww.indiandentalacademy.com
orbital nerve.


MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Shape: Pyramidal Apex
Optic foramen
Roof, Lateral wall,
floor & medial wall
Direct injury to globe
 intraoccular pressure
Fracture floor/medial wall

(blow out #s)
• Applied anatomy
• Clinical features
• Radiographic features
• Management

(blow out #s)
Applied anatomy
Floor : Zygoma & Maxilla
Entrapment
“Trap door effect”
Diplopia , Enophthalmos


(blow out #s)
Clinical features
Pain
Edema
Ecchymosis
Proptosis
Paraesthesia
Emphysema
Diplopia

(blow out #s)
Radiographic features
Occipito-mental view
( PNS, Water’s View)
“Hanging Drop”
CT Scan:
Coronal cuts: Floor
Axial cuts: Medial wall

(blow out #s)
Management
Diplopia & Enophthalmos
Surgical & surgical only
Create a new floor
Bone
Cartilage
Metal: titanium

(blow out #s)
Management
Incidence – 2 / 62
Reconstruct floor to prevent
enophthalmos & diplopia


Leader in continuing dental education


Classification & management of zygomatic complex fractures including lateral wall of the orbit /certified fixed orthodontic courses by Indian dental academy

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Classification & management of zygomatic complex fractures including lateral wall of the orbit /certified fixed orthodontic courses by Indian dental academy

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