Dr.

Shahzad Hussain
BDS, FCPS (resident)
Nishtar Institute of Dentistry
SNDENTALCare.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 labii
superioris
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 & Symptoms
1. Orbital
2. Neurological
3. physical
Orbital
1. 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 sections
Coronal 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 mandibular
movement
 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 Approach
Extra 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 approach
Remains 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 orthopaedic
periosteal 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 laceration
2. Subtarsal incision
3. Blephroplasty incision
4. Transconjunctival incision (pre-septal or post- septal)
 Approaches to lateral orbital rim:
1. Eye brow incision
2. Upper lid incision
 Approaches to zygomatic arch:
1. Pretragal incision
2. 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.