Zygomatic complex fractures Management of Maxillofacial Trauma Mid-face Injury Zygomatic complex fractures

Contents Fracture of the zygomatic complex and arch Orbital floor fractures Traumatic injury to the frontal sinus Naso-ethmoial orbital fracture (NEO) Nasal fractures

Zygomatic bone complex Anatomy Star-shape like with four processes Frontal process Temporal process Buttress Orbital floor (Maxilla and GWSB) Temporal fascia and muscle Masseter muscle

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.

Occurrence As isolated fracture In combination with other middle third fracture With internal orbital fracture (blow out) 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

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

Trismus Abnormal nerve sensibility Epistaxis Subconjunctival ecchymosis Crepitation from air emphysema Displacement of palpebral fissure (pseudoptosis) Unequal pupillary levels Diplopia enophthalmos

Clinical examination Inspection Palpation Visual examination Eye movement Diplopia Pupil reaction

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

Occipitomental view (Posterioanterior oblique) (water’s view)

submentovertex Recommended for isolated zygomatic arch fracture

CT scan Coronal sections Axial sections

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

Classifications Displacement Extension of the fracture along processes Rotation along the axis of FZ processes Anterio-posterior displacement Rotation along the prominence of the bone Medio-lateral displacement Extension of the fracture along processes points of fractures Combination with other injuries

Treatment The methods of treating a fractured malar bone recommended by the various writers who have reported cases include simple digital manipulation under genre real 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

Methods of reduction Temporal approach (Gillies et al 1927) Suitable for isolated zygomatic fracture with good stability afterwards

Percutaneous approach (malar hook, Carroll-Girard bone screw) Methods of reduction Percutaneous approach (malar hook, Carroll-Girard bone screw) Suitable for displaced zygomatic fracture with high Stability after reduction

(the same principle of Gillies approach) Methods of reduction Buccal sulcus approach (Keen 1909) Elevation from eyebrow approach (the same principle of Gillies approach)

Open reduction and fixation Transosseous wiring at Frontozygomatic suture Infraorbial rim Surgery: Lateral eyebrow incision Infraorbital approach

Open reduction and fixation Rigid fixation using plate and screws at Frontozygomatic suture Infraorbial rim Inferior buttress of the zygoma Surgery: Lateral eyebrow incision Infraorbial approach Subciliary (blepharoplasty) incision Mid-lower lid incision Transconjunctival approach

Points of fixation: Infraorbital rim and buttress Lateral orbital rim Buttress of zygoma

Other methods of fixation Kirschener wire Pin fixation Antral pack

Internal orbital fractures In conjunction with other facial fractures As isolated type (Blow out fracture)

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

Clinical and radiographical presentation Subconjunctival ecchymosis Crepitation from air emphysema Displacement of palpebral fissure Unequal pupillary levels Diplopia enophthalmos

Diplopia and enophthalmous Superior orbital fissure syndrome

Treatment Rational for intervention: Small defect with no clinical consequence may not warrant the surgical intervention. Large defect with handicapping symptoms should be operated.

Method of reconstruction Intra-sinus approach to the orbital floor External approach to the internal orbital floor

Materials in orbital reconstruction Autologous graft Bone (cranial, rib, iliac) Cartilage Allogenic materials Lyophilized dura Alloplastic materials Siliastic and proplast implants Teflon hydroxyapatite Titanium mish

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

Diagnosis Clinical examination: Radiographical 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

Fracture classification Nasal-orbital ethmoid fractures Type I Unilateral or bilateral, involves only one portion of the medial orbital rim with the attached canthal tendon Type II Unilateral or bilateral, may be large segments of comminuted type and the canthus remains attached to the large central segment Type III Unilateral or bilateral, comminution involves the central segment of the attached tendon results in avulsion of medial canthus

Management of nasal-orbital ethmoid fractures Examination 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

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

Detached canthus Traumatic telecanthus Increase in inter-canthal distance secondary to canthus displacement or detachment Seen in association to: Nasal bone NEO Le Forts fractures

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

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

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-rhinostomy implantation of a duct-like polythene tube or glass in case of duct damage

Frontal sinus fracture Drains into nasal cavity via fronto-nasal duct An air filled cavity lined by ciliated respiratory epithelium encased in the frontal bone

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

Diagnosis Clinical examination Radiographical evaluation Occipitomental views Lateral skull view CT scan

Classification of fractures Anterior table fracture Linear Displaced Posterior table fracture Outflow tract injury (naso-lacrimal duct)

Surgical management Intranasal cannulation Frontal sinus trephination Osteoplastic flap Sinus ablation (obliteration) Cranialization Reduction and fixation

Reduction and fixation Surgical approaches: Site of penetrating injury Coronal approach

Sinus ablation (obliteration) Bone Fat Muscle and fascia Alloplastic materials

Fixation Wires Plating

2 rectangle-shaped nasal bone Nasal fractures Anatomy Midline 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

Classification of injuries Low energy injuries Simple injury caused by low velocity trauma (simple noncomminuted) High energy injuries Severe 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)

Treatment Low energy injuries Reduction (close manipulation, open reduction) and stabilization Nasal packing External nasal splint Adjunct septoplasty Postoperative care

Complex injuries Immediate measures: Surgical procedures: 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