Management of Maxillofacial Trauma

Zygomatic complex fractures

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 Contents
Fracture of the zygomatic complex and arch

Orbital floor fractures

Traumatic injury to the frontal sinus

Naso-ethmoial orbital fracture (NEO)

Nasal fractures

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 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

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 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.
Zygomatic bone fractured as a
block near its principle three suture
HD Gillies, TP Kilner and D Stone,
lines and often displaces inwards to
1927
a greater or lesser extent.
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 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
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 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

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

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Clinical examination

Inspection

Palpation

Visual examination
Eye movement
Diplopia
Pupil reaction

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 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

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 Occipitomental view

(Posterioanterior oblique)

(water’s view)

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 submentovertex

Recommended for isolated

zygomatic arch fracture

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CT scan
Coronal sections
Axial sections

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 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
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 Classifications
Displacement

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

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 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

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 Methods of reduction
Temporal approach (Gillies et al
1927)

Suitable for isolated

zygomatic fracture with
good stability afterwards
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Methods of reduction

Percutaneous approach (malar hook,

Carroll-Girard bone screw)

Suitable for displaced zygomatic

fracture with high
Stability after reduction

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Methods of reduction

Buccal sulcus
approach (Keen
1909)

Elevation from
eyebrow approach
(the same principle of Gillies
approach)

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 Open reduction and fixation
Transosseous wiring at
– Frontozygomatic suture
– Infraorbial rim

Surgery:

•Lateral eyebrow incision

•Infraorbital approach
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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
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Points of fixation:

Lateral Buttress of Infraorbital

orbital rim zygoma rim and
buttress 21
 Other methods of fixation

Kirschener wire

Pin fixation

Antral pack

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 Internal orbital fractures
In conjunction with other
facial fractures

As isolated type (Blow out

fracture)

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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

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Clinical and radiographical presentation

Subconjunctival ecchymosis

Crepitation from air emphysema

Displacement of palpebral fissure

Unequal pupillary levels

Diplopia
enophthalmos

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Diplopia and
enophthalmous
Superior orbital
fissure syndrome

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 Treatment
Rational for intervention:

Small defect with no clinical consequence

may not warrant the surgical intervention.

Large defect with handicapping symptoms

should be operated.
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 Method of reconstruction
Intra-sinus approach
to the orbital floor

External approach to
the internal orbital
floor

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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

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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

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 Diagnosis
Clinical 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

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 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

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 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

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 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
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 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

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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
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 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

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 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

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 Frontal sinus fracture
Frontal sinus

An air filled cavity lined by ciliated respiratory

epithelium encased in the frontal bone

Drains into nasal cavity via fronto-nasal duct

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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

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 Diagnosis
Clinical examination

Radiographical
evaluation
Occipitomental views
Lateral skull view
CT scan

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 Classification of fractures
Anterior table fracture
– Linear
– Displaced

Posterior table fracture

– Linear
– Displaced

Outflow tract injury (naso-lacrimal duct)

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 Surgical management
Intranasal cannulation

Frontal sinus
trephination

Osteoplastic flap

Sinus ablation
(obliteration)

Cranialization

Reduction and fixation

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 Reduction and fixation
Surgical approaches:

– Site of penetrating injury

– Coronal approach

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

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Fixation
– Wires
– Plating

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 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

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 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)

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 Treatment

Low energy injuries

Reduction (close
manipulation, open
reduction) and stabilization

Nasal packing

External nasal splint

Adjunct septoplasty

Postoperative care
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Complex injuries
Immediate measures:
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

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