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

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

3. 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

4. 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.

5. 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

6. 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

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

8. Clinical examination Inspection Palpation Visual examination
Eye movement
Diplopia
Pupil reaction

9. 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

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

11. submentovertex
Recommended for isolated
zygomatic arch fracture

12. CT scan
Coronal sections
Axial sections

13. 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

14. 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

15. 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

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

17. 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

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

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

20. 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

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

22. Other methods of fixation
Kirschener wire
Pin fixation
Antral pack

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

24. 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

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

26. Diplopia and enophthalmous
Superior orbital fissure syndrome

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

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

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

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

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

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

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

46. Fixation
Wires
Plating

47. 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

48. 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)

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

50. 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