Dr.Hanan Shanab

The zygomaticomaxillary

complex (ZMC) plays a key

role in the structure, function,

and aesthetic appearance of

the facial skeleton.

It provides normal cheek

contour and separates the

orbital contents from the

temporal fossa and the

maxillary sinus.

It also has a role in vision and

mastication.

ANATOMY

•The zygomaticomaxillary complex is a

quadrupled structure,

•It relates to 4 different bones:

•Temporal bone,,by

zygomaticotemporal

suture.

•maxilla,,by

zygomaticomaxillary

suture.

•frontal bone,,by

frontozygomatic suture.

•skull base,,by

zygomaticosphenoidal

suture.

A zygomatic complex fracture is a fracture that involves the

zygoma and its surrounding bones. The typical lines of a

zygomatic complex fracture are:

At least 3 points of fixation in order to achieve a good

anatomical reduction of ZMC Fx

Facial Buttress system

•The buttresses represent areas

of relative increased bone

thickness that support the

functional units of the face

(muscles, eyes, dental occlusion)

in an optimal relation.

From :Stanley RB. Maxillary and Periorbital Fractures. In :Bailey BJ ed., Head and Neck Surgery-Otolaryngology, third edition, Philadelphia, Lippincott Williams & Wilkins 2001, pg 777.

•define the form of the face by

projecting the overlying soft-

tissue envelope.

• Owing to the reliance of facial

form and function on these

buttresses, as well as the

mechanical force exerted on

them

Facial buttress

Buttresses have sufficient bone thickness to

accommodate metal screw fixation.

Buttresses are all linked either directly or through

another buttress to the cranium or cranial base as a

stable reference point.

Some authors describe the zygomaticomaxillary and

zygomaticosphenoidal suture lines as a single unit. Using this

definition, ZMC fractures are called tripod fractures. However,

the term tetrapod fracture is a more accurate description

because 4 suture lines are disrupted.

The frontozygomatic and zygomaticosphenoidal

buttresses are very strong. Isolated injuries in these

areas are uncommon. When displaced fractures are

noted, a high velocity injury with other associated

fractures is likely.

•The inferior orbital rim is a

common location for

displaced and comminuted

fractures. These injuries

can be isolated, but they

are often associated with

orbital floor fractures.

•Isolated injuries often

occur in the zygomatic

arch because of its length

and unprotected location.

ZMC Fracture involves:

Lateral orbital wall (zygomaticofrontal region). Infraorbital rim.

Zygomatic buttress. Isolated zygomatic arch

Frequency of ZMC Fracture

A much higher percentage of zygomaticomaxillary

complex (ZMC) fractures occur in males (80%) than in

females (20%).

Incidence of ZMC fractures peaks in persons aged 20-

30 years.

Women who have been domestically abused are

more likely to suffer ZMC fractures and orbital blow-

out fractures.

Etiology

Assault (age 18-25y/o)

RTA, MVA

Gunshot wounds

Sports..

Falls..

Industrial accidents

War and civil disorder.

Associated Injuries

Haug et al 1990

(402 patients with midfacial trauma)

with Zygoma fractures:

Lacerations 43%

Orthopedic injuries 32%

Additional facial fractures 22%

Neurologic injury 27%

Pulmonary, abdominal, cardiac 7%, 4.1%, 1%

Maxillary fractures:

Lacerations and abrasions 75%

Orthopedic injury 51%

Other facial fractures 42%

Neurologic injury 51%

Pulmonary 13%, abdominal 5.7%,

cardiac 3.8%

Ocular injury

Al-Qurainy et al 1991

363 patients with midface fractures

63 - 90.6% of patients had ocular injury

Classification

Zingg (1992) separates these injuries into types A, B, and C.

Type A injuries are isolated to one component of the tetrapod structure,

zygomatic arch (type A1),

the lateral orbital wall (type A2), and

the inferior orbital rim (type A3).

Type B fractures involve all 4 buttresses (ie, classic tetrapod fracture).

Type C injuries are complex fractures with comminutionof the zygomatic bone itself.

LeFort fractures Rene LeFort 1901 in cadaver skulls

Frequently different levels on either side

LeFort I

LeFort II

LeFort III

LeFort fractures

Le Fort I Le Fort II Le Fort III

Initial

Assessment

The initial evaluation of facial trauma patients is focused on

areas that can result in the greatest morbidity.

Airway control and hemodynamic stability are the primary

concerns.

Next, spinal cord injury must be ruled out by a thorough

clinical and/or radiological examination.

Finally, any overt globe injury should be evaluated.

Often midface fracture patients are admitted to the hospital unconscious and intubated. Special regard has to be given to foreign bodies obstructing the airways such as dislocated partial or full dentures or teeth fragments

As well as hard-tissue considerations, severe bleeding and/or cerebrospinal fluid (CSF) leakage may accompany and aggravate the treatment outcome.

General considerations

To clinically evaluate possible midfacial injuries a standard examination protocol is strongly recommended and has to include full examination of the head, eyes, ears, nose, throat, and neck.

Eye examination

Ophthalmic evaluation..

•Globe integrity.

•Occular motility.

•Visual acuity and light

perception.

Retrobulbar hemorhage:

Signs and Symptoms:

•non-pulsating exophthalmous

with resistance to retropulsion.

•elevated IOP.

•EOM restriction.

• Central retinal artery pulsation (indicating a possible

impending central retinal artery occlusion),

• choroidal folds, and possibly signs of optic

neuropathy.

Management

medically lower the patients IOP.

Immediate surgical consult for a lateral canthotomy

and cantholysis to reduce orbital pressure.

An emergent orbital decompression.

Signs and symptoms of ZMC fractures:

•Bilateral periorbital

ecchymosis is termed Owl’s

sign and typically is

representative of a Le Fort II

or III fracture.

•pain, edema, and

ecchymosis of the cheek

and eyelids.

Clinical Findings

Physical findings such as

severe conjunctival

hemorrhage or hyphema

are suggestive of direct

globe injury, rupture, and

visual loss.

Clinical Findings

• Fractures of the zygomatic

bone evoke pain on

palpation in 70% of

patients.

• Significant malar

depression

• Step deformity

•Orbital floor disruption can result in

subcutaneous emphysema and

ecchymosis.

• (enophthalmos) globe

displacement.

Epistaxis on the side of the fracture

due to blood draining from involved

maxillary sinus.

Evaluation

initial documentation

Hess screen field of binocular vision.

forced duction test under sedation, local, or general anesthesia.

Electromyography

orbital CT scan

Diplopia

Mechanisms

There are three principal

mechanisms causing diplopia

in trauma cases

1- Edema and hematoma

2- Restrictive motility disorder

(mechanical)

3- Cranial nerve injury

(neurogenic)

Management of diplopia

Conservative treatment

Motility exercises.

patching.

prisms.

SURGICAL:

Bone repair 6-12 months

Muscles surgery .

Botulinum toxin.

Trismus

The traumatic force and pull of the masseter muscle may result in

medial, inferior, and posterior rotation of the zygoma result in:

• Compression of the zygomatic arch on the temporalis muscle and coronoid process result in trismus

Pseudoptosis

Inferior displacement of the lateral canthal angle may indicate inferior migration of the fractured zygomatic bone.

Guerin’s Sign:

Guerin's sign is characterised by

ecchymosis in the region of greater

palatine vessels

Nerve injury

Facial trauma is associated with an increased risk of optic nerve injury and visual loss.

According to Al-Qurainy et al.

The mechanisms of trauma

Ocular globe.

1- Rupture

2- Intraocular hemarrhage

Optic never

1- Edema

2- Bleeding

3- Vasospasm

Visual function impairment

Orbit

1- Retrobulbar hematoma

2- Blow in fracture

Optic canal

1- Shearing of nerve

2- Contusion

3- Bone fragment injury

Infraorbital nerve injury

may result in anesthesia

or paresthesias of the

cheek, nose, upper lip,

and lower eyelid.

Radiographic

Studies

1- Plane Films:

Water’s view : (occipitomental view )

Submental vertex view:

Fractured zygomatic

arch (M).

Rotation of zygoma

around vertical axis.

Lines of Dolan and the

elephants of Rogers1-orbital line.

2-zygomatic line.

3-maxillary line.

McGrigor and Campbells’ lines

McGrigor’s line 1

McGrigor’s line 2

McGrigor’s line 3

Campbell’s line 4

Campbell’s line 5

2- CT scan:

Axial and coronal view & 3D

Areas of fracture are camouflaged by the overlying soft tissues. However, this CT scan nicely shows contour differences between different parts of the face.

MRI

MRI might be indicated to better detect soft-

tissue problems such as:

* Optic nerve edema or hematoma

* Ocular muscle disorders (incarceration,

hematoma, disruption)

* Intraocular disorders (hematoma)

* Foreign bodies in the orbit

Treatment modalities

Most maxillofacial injuries involve

extensive soft tissue violation.

Adequate tetanus vaccination

and coverage with oral or

intravenous broad spectrum

antibiotics is the rule.

Any associated life

threatening injuries must

be addressed first.

TIMING:

As early as possible

unless there are

ophthalmic, cranial or

medical complications

Until the edema to

decrease.

Treatment modalities

Restore pre-injury facial configuration

Prevent cosmetic deformity and visual disturbances.

Closed Vs. ORIF with plating and screws.

Soft diet and malar protection.

Possible need for bone grafting.

Soft tissue injury.

Surgical approaches

2-For Orbital Rim Fracture.

Infraorbital approach.

Subciliary incision.

Transcongunctival Approach.

3-For the fractured Maxillary Buttress

Gingival buccal sulcus approach. (transoral

approach).

1-For ZF Frcature.

Lateral eyebrow approach.

Upper blepharoplasty incision.

4-For Isolated Zygomatic Arch Fractrue.

Extraoral Approach:

Gillie’s Approach.

Dingman Approach.

Intraoral Approach:

Keen Approach( lateral vestibular approach).

5-For comminuted Fracture.

Coronal approach.

Correct anatomical reduction is required to reproduce

the original structure of the zygomaticomaxillary

complex and the proper alignment of the orbital walls.

In order to achieve proper reduction of the lateral

orbital wall the greater wing of the sphenoid and the

zygoma must be properly aligned.

The aim is to restore the proper orbital volume and to

restore proper width, AP projection, and height of the

midface.

GENERAL CONSEDERATION

One must consider 2 needs in analyzing a ZMC Fx:

Need to expose a particular Fx site for confirmation of

alignment.

Need to expose a particular Fx site for application of

fixation.

Plate Fixation

The first two screws should be placed

in the plate holes closest to the

fracture, one on each side of the

fracture. Make sure that the fracture is

adequately spanned so that each

screw is placed in solid bone.

Approaches to Infraorbital Rim

•Transcongunctival approach.

• Subciliary incision.

•Infraorbital approach.

Approaches to Infraorbital

Rim

*Transconjunctival Approach. *Subciliary approach.

*Lower lid Approach. *Infraorbital approach.

Transcongunctival Approach

Retroseptal

method:

In this method an

incision is sited

2mm below the

tarsal plate to

reach the orbital

rim.

Preseptal method: In this

method incision is made

at the edge of the tarsal

plate to create a space

infront of the orbital

septum to reach the

orbital rim.

Tranconjunctival approaches

is that they produce excellent cosmetic results

no skin or muscle dissection is necessary.

Advantage:

limited medial extension by the lacrimal drainage

system.

Disadvantage:

TECHNIQUE

•Protection of the globe.•Tarsorrhaphy.

•Lateral Canthotomyand Inferior Cantholysis.

Transconjunctival Incision

Subperiosteal Orbital DissectionPeriosteal elevators are used to strip the periosteum over the orbital rim and anterior surface of the maxilla and zygoma, and orbital floor. A broad malleable retractor should be placed as soon as feasible to protect the orbit and to confine any herniatingperiorbital fat.

Suturing

1- A running 6-0 gut suture is initially placed through the conjunctiva (and lower lid retractors).

2-A 4-0 polyglactin or other long lasting suture for the canthopexy. The bulk of the lateral canthal tendon attaches to the orbital tubercle, 3 to 4 mm posterior and superior to the orbital margin.

3-Finally, subcutaneous sutures and 6-0 skin suture are placed along the horizontal lateral canthotomy.

Subciliary Approach

1

21

•2nd Incision:•periorbital fat to herniate into the wound. •The skin and muscle flap, maintains a better blood supply to the skin, and pigmentation of the lower lid has not been seen.

3

1•1ST Incision:•"buttonhole" dehiscence.•slight darkening of the skin in this area after healing.• An increase in the incidence of ectropion has also been noted by some investigators with this approach.

3rd Incision:•the pretarsal fibers of the orbicularis oculi can be kept attached to the tarsal plate, presumably assisting in maintaninig the position of the eyelid and its contact with the globe postoperatively.

Technique

Technique

Materials used for Reconstruction

Avoid risk of infected implant.

✘ Additional operative time.

✘ donor site morbidity .

✘ Graft resorption.

Examples:

Calvarial bone, iliac crest, rib, septal or auricular cartilage

Autogenous Tissues

Alloplastic implants

Decreased operative time,

easily available,

no donor site morbidity,

can provide stable support

✘Risk of infection 0.4-7%.✘invisible on postoperative radiological imaging.

Examples:Gelfilm, polygalactin film, silastic, marlex mesh, teflon, prolene, polyethylene, titanium

Ellis and Tan 2003

58 patients, compared titanium mesh with cranial bone graft

Used postoperative CT to assess adequacy of reconstruction

Titanium mesh group subjectively had more accurate reconstruction

Approaches to ZF Suture

Approaches to ZF suture

Upper eye lid

Approach.

Lateral Brow

Approach.

Hemicoronal

Approach.

Extended Subciliary Approach

Technique used to obtain increased exposure of the lateral orbital rim. The initial incision is extended laterally 1 to 1,5 cm, and supraperiosteal dissection along the lateral orbital rim proceeds

Upper eye lid composed of:

1-Skin.

2-Orbicularis Oculi muscle.

3-Orbital Septum/Levator

Aponeurosis Complex.

4-Müller's Muscle/Tarsus

Complex.

5-Congunctiva.

also called upper

blepharoplasty, upper

eyelid crease, and

supratarsal fold

approach.

Upper eye lid Approach

Upper eye lid Approach

Technique:

1-globe protection.

2-Identification of and marking

Incision Line.

3-incision.

4-Disection

5-closure.

Technique:

1-Vasoconstriction.

2-Skin Incision.

3-Periosteal Incision.

4-Subperiosteal Dissection

of Lateral Orbital Rim

and Lateral Orbit.

5. Closure.

Lateral eye brow Approach

Lateral eye brow Approach

Technique:

1-Vasoconstriction.

2-Skin Incision.

3-Periosteal Incision.

4-Subperiosteal Dissection

of Lateral Orbital Rim

and Lateral Orbit.

5. Closure.

Lateral eye brow

Approach

•Gives simple and rapid access to the frontozygomatic

• area.

•If the incision is made almost entirely within the confines of the

eyebrow, the scar is usually imperceptible.

Advantage:

•extremely limited access.

•Occasionally, some hair loss occurs, making the scar perceptible.

•Incisions made along the lateral orbital rim outside of the

eyebrow are very conspicuous in such individuals, and another

type of incision may be indicated.

Disadvantage:

Lateral eye brow

Approach

Zygomatic Buttress Fracture

Zygomatic Buttress Fracture

Gingival Buccal Sulcus

Incision

The transoral approach was

popularized by Keen in 1909

with later modifications by

Goldthwaite and Quinn.

Advantages :

avoiding any skin incision

avoiding any visible scaring.

Allow for minimal dissection and

an excellent vector for reduction.

Disadvantage:

✘ they may result in

increased rates of infection

by introducing oral flora

into the infratemporal

fossa.

Transcutaneous Cheek

Approach

Reduction by inserting a bone

screw (Carroll-Girard screw) after

drilling a small hole .

By using a hook.

By making 3 mm incision in the cheek

directly over the inferior tubercle of

malar eminence with a blade.

Subperiosteum dissection over the

zygoma body.

Isolated Zygomatic Arach Frcature

Isolated Zygomatic Arach

Frcature

Closed Reduction:

1-Extraoral Approach:

Gillie’s Approach.

Dingman Approach.

2-Intraoral Approach:

Keen Approach( lateral

vestibular approach).

3- percutaneous method.

Isolated Zygomatic Arach

Frcature

Open Reduction and

Internal Fixation:

Periauricular Approach.

Extraoral Approach

1-Gillies Approach.

Gillies et al described

the temporal fossa

approach in 1927.

By using a Rowe

zygoma elevator

Technique

•A temporal incision is

made. Care is taken to

avoid the superficial

temporal artery.

•The Gillies technique

describes a temporal

incision (2 cm in length),

made 2.5 cm superior

and anterior to the helix,

within the hairline.

•An instrument is inserted

deep over the temporalis

muscle. Using a back-and-

forth motion the instrument is

advanced until it is medial to

the depressed zygomatic

arch.

A Rowe zygomatic

elevator is inserted just

deep to the depressed

zygomatic arch and an

outward force is applied.

Advantage:

Minimal dissection.

Save time.

Disadvantage:

✘ significant scar alopecia.

✘ temporal hollowing.

✘ remote chance of injury to the temporal branch of facial

nerve.

Extraoral Approach

2- Dingman Approach

Dingman and Native described the supraorbital

approach as an extraoral alternative in 1964.

It involves an incision near the ZF suture with

dissection beneath the temporal fascia and place

an elevator along the fronatl process of the

zygoma and underneath the zygomatic arch .

Intraoral Approach

•Insert an elevator shortly

under the malar eminence .

•Care should be taken not to

inter the the orbit or

Keen Approach.1909

through

zygomaticomaxillary

incision.

Percutaneous Methods

Hwang and Lee in 1999

less invasive.

These include the using of a towel clip

to directly grasp the bone fragments

and allow for lateral force to be applied.

Towel Clip MethodAdvantages:

Quick, simple, and effective

technique.

It is minimally invasive,

Carries little risk of infection

or neurovascular injury.

No visible scarring.

This technique may be

performed under local

anesthesia or sedation in an

emergency department or

clinic setting, making it a

highly cost effective.

addition to the oral and

maxillo- facial surgeon’s

armamentarium.

Disadvantages :

✘ include a lack of direct

visualization of the bony

insult.

✘ imprecise reduction.

✘ lack of fracture

stabilization.

Open Reduction &Internal

Fixation

Open Reduction &Internal Fixation

Bicoronal Approach

surgical approach to the upper

and middle regions of the facial

skeleton, including the zygomatic

arch.

It provides excellent access to

these areas with minimal

complications and scar.

Skin Layer

•S = skin

•C = subcutaneous tissue

•A = aponeurosis and muscle

•L = loose areolar tissue

•P = pericranium (periosteum)

Anatomical Relation

A thick layer arises from the superior temporal line, where it fuses with the pericranium . At the level of the superior orbital rim, the temporalis fascia splitts into the superficial & deep layer.

Temporalis Fascia

Superficial Temporal Fat Pad

Buccal Fat Pad

Temporal Branch of Facial Nerve

TECHNIQUE

TECHNIQUE

Conclusions

High index of suspicion for associated injuries- especially ocular

Assessment of buttress system.

Wide exposure via cosmetically acceptable incisions

Open reduction and Rigid fixation with plates and screws.

Soft tissue resuspension.

With early, accurate repair of these injuries more patients will be returned to their pretraumatic state.

THANK YOU

THANK YOU