Zygomatic arch fracture

Presented by / Mostafa Heeba

Introduction

The zygoma has four projections, which create a quadrangular shape: the frontal, temporal, maxillary, and the infraorbital rim .

The zygoma articulates with four bones: the frontal, temporal, maxilla, and sphenoid.

The zygomatic arch includes the temporal process of the zygoma and the zygomatic process of the temporal bone.

Regional AnatomyThe zygomatic arch is formed by the

zygomatic process of temporal bone and the temporal process of the zygomatic bone

the two processes being united by an oblique suture( zygomaticotemporal suture)

The upper border of the arch gives attachment to the temporal fascia; the lower border and medial surface give origin to the Masseter ms .

EtiologyRDA

Assault

Sports injuries

Radiographic Evaluation

Radiographic Evaluation

The diagnosis of zygomatic fractures is usually established by history and physical examination .

CT scan of the facial bones, in axial and coronal planes, is standard forall patients with suspected zygomatic fractures .

Radiographs are helpful for confirmation and for medicolegal documentation and to establish the extent ofthe bony injury .

Computed Tomography

CT is the gold standard for radiographicevaluation of zygomatic fractures .

Axial and coronal images are obtained to definefracture patterns, degree of displacement, and comminution.

Submentovertex viewdemonstrating displaced left zygomatic arch fracture.

Plain x-ray (Submentovertex view)

Management

Indirect approaches Common indirect approaches for reduction of the zygomatic arch include:

Temporal (Gillies) approach Trans-oral (Keen) approach

Quinn’s approach Towel clip technique

Temporal (Gillies) approach

The Gillies technique describes a temporal incision (2 cm in length), made 2.5 cm superior and anterior to the helix, within the hairline.

A temporal incision is made. Care is taken to avoid the superficial temporal artery.

Temporal (Gillies) approach - Deep dissection The dissection continues through the

subcutaneous tissue and superficial temporal fascia down to the deep portion of the deep temporal fascia.

Deep fascia is then incised to expose the temporalis muscle.

The temporal fascia is incised horizontallyto expose the temporalis muscle

Temporal (Gillies) approach - Exposure An instrument is inserted deep to The deep temporalis fascia and superficial to 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 .

Great care should be taken not to fulcrum off the squamous

portion of the temporal bone.

The arch should be palpated at all times as a guide to

proper reduction.

Temporal (Gillies) approach - Wound closure

The wound is closed in layers.

Trans-oral (Keen) approach – lateral maxillary vestibular incision provides the most direct access to the zygomatic arch.

allows for an intraoral incision, and therefore does not have the risk of scar alopecia that will result from a temporal (Gillies) approach.

A 2 cm lateral maxillary vestibular incision (upper gingival buccal incision) is made with a scalpel or a cautery device just at the base of the zygomaticomaxillary buttress .

The incision is made through mucosa only.

Trans-oral (Keen)

approach

Trans-oral (Keen) approach - Exposure

Because of the direct proximity of the incision to the arch ,

an instrument can easily be placed deep to the fractures to allow elevation of a depressed zygomatic arch.

the depressed arch can often be palpated and elevated with a digital exam.

Quinn’s approach Also known as lateral coronoid approach.

Used for reduction of Zygomatic arch.

making an incision in the mucosa at the level of the maxillary alveolus and extending it inferiorly along the anterior border of the ramus.

The dissection continues along the lateral aspect of the coronoid process, ending at the level of the maxillary alveolus and extending it inferiorly along the anterior border of the ramus.

The dissection continues along the lateral aspect of the coronoid process, ending at the level of the zygomatic arch at the site of the fracture.

An elevator is placed between the coronoid processes and zygomatic arch, and the

fracture is reduced

Towel Clip Reduction of the DepressedZygomatic Arch Fracture

The lateral orbital rim, malar prominence, and arch are then outlined with

a marking pen .

The area of depression is then palpated. The area immediately superior and inferior to the fracturesite is infiltrated with a local anesthetic with vasoconstrictor.

A No. 11 blade is then used to make a small stab incision through the skin approximately 1 cm superior to the fracture site .

A large penetrating towel clip is opened widely, and one tine is introduced and passed deep to the depressed arch .

The towel clip is then partially closed, and the site for the inferior stab incision is identified to make the second stab incision.

Placement of inferior stab incision after rotation of towel clip.

Placement of superior stab incision.

The inferior tine of the towel clip is then passed, and the clip is closed and latched into position .

The patient’s head is stabilized, and firm but steady lateral force is applied .

The fragments can be felt reducing into appropriate position, and a click may or may not be appreciated .

Steady force is maintained for several seconds to ensure that the fragments are reduced laterally as much as possible as there may be a tendency for some relapse as the force is diminished .

The area is then palpated for symmetry with the contralateral arch, and the esthetics evaluated .

The clip is removed when adequate reduction has been ensured.

Application of lateral reducing force while stabilizing patient’s head.

Passage of superior tine deep to depressed arch.

• The zygoma fracture reduction is complete if the spheno-zygomatic suture is reduced.

• This suture can be visualized only by this approach. Moreover, this approach is ideal in zygomatic complex fracture involving the frontal bone, orbital roof reconstruction, arch fracture requiring fixation and laterally displaced zygoma fracture requiring 3 or 4 point fixation.

Bi-coronal/hemi-coronal approach

Direct approach :

Bi-coronal/hemi-coronal approach

Thank you