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Zygomatic complex fracturesZygomatic complex fractures

Management of Maxillofacial Trauma

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Contents Contents

Fracture of the zygomatic complex and archFracture of the zygomatic complex and arch

Orbital floor fracturesOrbital floor fractures

Traumatic injury to the frontal sinusTraumatic injury to the frontal sinus

Naso-ethmoial orbital fracture (NEO)Naso-ethmoial orbital fracture (NEO)

Nasal fracturesNasal fractures

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Zygomatic bone complexZygomatic bone complex

AnatomyAnatomyStar-shape like with four processesStar-shape like with four processes

Frontal processFrontal process

Temporal processTemporal process

ButtressButtress

Orbital floor (Maxilla and GWSB)Orbital floor (Maxilla and GWSB)

Temporal fascia and muscleTemporal fascia and muscle

Masseter muscleMasseter muscle

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Zygomatic complex and arch Zygomatic complex and arch fracturefracture

The malar bone represent The malar bone represent a strong bone on fragile a strong bone on fragile

supports, and it is for supports, and it is for this reason that, though this reason that, though the body of the bone is the body of the bone is rarely broken, the four rarely broken, the four

processes- frontal, processes- frontal, orbital, maxillary and orbital, maxillary and

zygomatic are frequent zygomatic are frequent sites of fracture.sites of fracture.

HD Gillies, TP Kilner and D Stone, HD Gillies, TP Kilner and D Stone, 19271927

Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.

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Occurrence Occurrence

Observed in (>50%) of middle third Observed in (>50%) of middle third fracture fracture (in developed countries due to assaults)(in developed countries due to assaults)

The zygomatic arch fracture can be The zygomatic arch fracture can be isolated in most of the casesisolated in most of the cases

•As isolated fracture•In combination with other middle third fracture

•With internal orbital fracture (blow out)

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Signs and symptomsSigns and symptoms

Periorbital ecchymosis and edemaPeriorbital ecchymosis and edema

Flattening of the malar prominenceFlattening of the malar prominence

Flattening over the zygomatic archFlattening over the zygomatic arch

Pain and tenderness on palpationPain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcusEcchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of the Deformity at the zygomatic buttress of the maxillamaxilla

Deformity at the orbital marginDeformity at the orbital margin

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TrismusTrismus

Abnormal nerve sensibilityAbnormal nerve sensibility

EpistaxisEpistaxis

Subconjunctival ecchymosisSubconjunctival ecchymosis

Crepitation from air Crepitation from air emphysemaemphysema

Displacement of palpebral Displacement of palpebral fissure fissure (pseudoptosis)(pseudoptosis)

Unequal pupillary levelsUnequal pupillary levels

DiplopiaDiplopia

enophthalmosenophthalmos

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Clinical examinationClinical examination

InspectionInspection

PalpationPalpation

Visual examinationVisual examinationEye movementEye movement

DiplopiaDiplopia

Pupil reactionPupil reaction

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Radiographical evaluationRadiographical evaluation

Nothing is more valuable to the surgeon in Nothing is more valuable to the surgeon in determining the extent of injury and the determining the extent of injury and the

position of the fragments-both before and position of the fragments-both before and after operation- than a good skiagram after operation- than a good skiagram

(radiograph)(radiograph)

HD Gillies, TP Kilner and D Stone, 1927HD Gillies, TP Kilner and D Stone, 1927

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Occipitomental viewOccipitomental view

(Posterioanterior oblique)(Posterioanterior oblique)

(water’s view)(water’s view)

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submentovertexsubmentovertex

Recommended for isolated zygomatic arch fracture

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CT scanCT scanCoronal sectionsCoronal sections

Axial sectionsAxial sections

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Treatment Treatment

Timing:Timing:As early as possible unless there are ophthalmic, As early as possible unless there are ophthalmic, cranial or medical complicationscranial or medical complications

Preiorbital edema and ecchymosis obscure the Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be fine details of the fracture, intervention can be postponed but not more than a weekpostponed 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 Classifications

DisplacementDisplacement

Rotation along the axis of FZ processesRotation along the axis of FZ processesAnterio-posterior displacementAnterio-posterior displacement

Rotation along the prominence of the boneRotation along the prominence of the boneMedio-lateral displacementMedio-lateral displacement

Extension of the fracture along processesExtension of the fracture along processes

points of fracturespoints of fractures

Combination with other injuriesCombination with other injuries

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Treatment Treatment

The methods of treating a fractured malar bone The methods of treating a fractured malar bone recommended by the various writers who have recommended by the various writers who have

reported cases include simple digital manipulation reported cases include simple digital manipulation under genre real anesthesia, external manipulation under genre real anesthesia, external manipulation

by means of a cow-horn dental forceps grasping the by means of a cow-horn dental forceps grasping the edges of the bone, traction and elevation by means edges of the bone, traction and elevation by means

of wire or heavy bone elevators passed through of wire or heavy bone elevators passed through small local external incisions, and elevation via small local external incisions, and elevation via

incision in the mucosa of the ginigival sulcus at the incision in the mucosa of the ginigival sulcus at the canine fossa. Our technique, which has now been canine fossa. Our technique, which has now been

used successfully in a number of cases, differs from used successfully in a number of cases, differs from those mentioned. those mentioned.

HD Gillies, TP Kilner and D Stone, 1927HD Gillies, TP Kilner and D Stone, 1927

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Methods of reductionMethods of reduction

Temporal approach (Gillies et al Temporal approach (Gillies et al 1927)1927)

Suitable for isolated zygomatic fracture with good stability afterwards

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Methods of reductionMethods of reduction

Percutaneous approach (malar hook, Percutaneous approach (malar hook, Carroll-Girard bone screw)Carroll-Girard bone screw)

Suitable for displaced zygomatic fracture with highStability after reduction

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Methods of reductionMethods of reduction

Buccal sulcus Buccal sulcus approach (Keen approach (Keen 1909)1909)

Elevation from Elevation from eyebrow approacheyebrow approach

(the same principle of Gillies (the same principle of Gillies

approach)approach)

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Open reduction and fixationOpen reduction and fixation

Transosseous wiring atTransosseous wiring at–Frontozygomatic sutureFrontozygomatic suture– Infraorbial rimInfraorbial rim

Surgery:

•Lateral eyebrow incision

•Infraorbital approach

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Open reduction and fixationOpen reduction and fixation

Rigid fixation using plate and screws atRigid fixation using plate and screws atFrontozygomatic sutureFrontozygomatic suture

Infraorbial rimInfraorbial rim

Inferior buttress of the zygomaInferior buttress of the zygoma

Surgery:

•Lateral eyebrow incision•Infraorbial approach•Subciliary (blepharoplasty) incision•Mid-lower lid incision•Transconjunctival approach

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Infraorbital rim and buttress

Lateral orbital rim

Buttress of zygoma

Points of fixation:

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Other methods of fixationOther methods of fixation

Kirschener wireKirschener wire

Pin fixationPin fixation

Antral packAntral pack

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Internal orbital fracturesInternal orbital fractures

In conjunction with other In conjunction with other facial fracturesfacial fractures

As isolated type (Blow out As isolated type (Blow out fracture)fracture)

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AnatomyAnatomy

The floor is made of: The floor is made of: Maxillary bone and Maxillary bone and part of zygoma part of zygoma bounded laterally by bounded laterally by the inferior orbital the inferior orbital fissure and small fissure and small part of the ethmoid part of the ethmoid bonebone

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Clinical and radiographical presentationClinical and radiographical presentation

Subconjunctival ecchymosisSubconjunctival ecchymosis

Crepitation from air emphysemaCrepitation from air emphysema

Displacement of palpebral fissureDisplacement of palpebral fissure

Unequal pupillary levelsUnequal pupillary levels

DiplopiaDiplopia

enophthalmosenophthalmos

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Diplopia and Diplopia and enophthalmousenophthalmous

Superior orbital Superior orbital fissure syndromefissure syndrome

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Treatment Treatment

Rational for intervention:Rational for intervention:

Small defect with no clinical consequence Small defect with no clinical consequence may not warrant the surgical intervention.may not warrant the surgical intervention.

Large defect with handicapping symptoms Large defect with handicapping symptoms should be operated.should be operated.

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Method of reconstructionMethod of reconstruction

Intra-sinus approach Intra-sinus approach to the orbital floorto the orbital floor

External approach to External approach to the internal orbital the internal orbital floorfloor

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Materials in orbital reconstructionMaterials in orbital reconstruction

Autologous graftAutologous graftBone (cranial, rib, iliac) Bone (cranial, rib, iliac) CartilageCartilage

Allogenic materialsAllogenic materialsLyophilized duraLyophilized dura

Alloplastic materialsAlloplastic materialsSiliastic and proplast Siliastic and proplast

implantsimplantsTeflonTeflonhydroxyapatitehydroxyapatiteTitanium mishTitanium mish

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Nasal-orbital ethmoid injuriesNasal-orbital ethmoid injuries

They represent a wide spectrum of injuriesThey represent a wide spectrum of injuries

Simple nasal fracture with involvementOf orbital bones

Grossly comminuted and compound naso-orbital ethmoid fracture involving the base

of skull with significant displacement

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Diagnosis Diagnosis

Clinical examination:Clinical examination:Obliterating swellingObliterating swellingCanthus detachmentCanthus detachmentLacrimal apparatus damageLacrimal apparatus damageDeformity of nasal bridgeDeformity of nasal bridgeCSF leakCSF leak

Radiographical examinationRadiographical examination::Occipitomental viewsOccipitomental viewsLateral skull viewsLateral skull viewsCT and 3D CTCT and 3D CT

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Fracture classificationFracture classificationNasal-orbital ethmoid fracturesNasal-orbital ethmoid fractures

Type IType IUnilateral or bilateral, involves only one portion of the Unilateral or bilateral, involves only one portion of the

medial orbital rim with the attached canthal tendonmedial orbital rim with the attached canthal tendon

Type IIType IIUnilateral or bilateral, may be large segments of Unilateral or bilateral, may be large segments of

comminuted type and the canthus remains attached comminuted type and the canthus remains attached to the large central segmentto the large central segment

Type IIIType IIIUnilateral or bilateral, comminution involves the Unilateral or bilateral, comminution involves the

central segment of the attached tendon results in central segment of the attached tendon results in avulsion of medial canthusavulsion of medial canthus

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Management of nasal-orbital Management of nasal-orbital ethmoid fracturesethmoid fractures

Examination for Examination for determination of the extent determination of the extent of the injury (surgical of the injury (surgical exploration)exploration)

Nasal boneNasal boneOrbital and ethmoidalOrbital and ethmoidalFrontal boneFrontal bone

Debridement and closure of Debridement and closure of open woundsopen wounds

Reduction and stabilization Reduction and stabilization of bone fractureof bone fracture

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Principles of treatmentPrinciples of treatment

Good surgical exposure via:Good surgical exposure via:Existing lacerationExisting lacerationCoronal flapCoronal flapOpen sky approachOpen sky approach

Reduction and stabilization using:Reduction and stabilization using:Transnasal wiringTransnasal wiring

OsteosynthesisOsteosynthesis

Prompt treatment as an aid to good Prompt treatment as an aid to good reductionreduction

Immediate bone grafting if this is Immediate bone grafting if this is indicatedindicated

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Detached canthusDetached canthusTraumatic telecanthusTraumatic telecanthus

Increase in inter-canthal distance Increase in inter-canthal distance secondary to secondary to

canthus displacement or canthus displacement or detachmentdetachment

Seen in association to:Seen in association to:Nasal boneNasal bone

NEONEO

Le Forts fracturesLe Forts fractures

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Surgical management of detached Surgical management of detached canthuscanthus

Transnasal wiring Transnasal wiring technique technique (unilateral (unilateral type)type)

Canthopexy Canthopexy – Identification of the Identification of the

ligamentligament– Liberation of the Liberation of the

periorbital tissueperiorbital tissue– Liberation of the lacrimal Liberation of the lacrimal

pathwaypathway– Nasal transfixationNasal transfixation– Contralateral fixationContralateral fixation

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Lacrimal duct system injuryLacrimal duct system injury

The lacrimal sac can be torn by The lacrimal sac can be torn by fragments of a comminuted fracturefragments of a comminuted fracture

OrOr

Compressed by a mass of callus Compressed by a mass of callus

which may block the nasolacrimal canalwhich may block the nasolacrimal canal

EPIPHORAEPIPHORA DacryocystitisDacryocystitis

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Reconstitution of the lacrimal passagesReconstitution of the lacrimal passages

Done at the same time of canthopexy viaDone at the same time of canthopexy via– The original scarsThe original scars– Lateral nasal incision (Lynch) Lateral nasal incision (Lynch) – Bi-coronal incisionBi-coronal incision

Dacryocystorhinostomy Dacryocystorhinostomy If the sac remains intact, drainage of lacrimal fluid by probing If the sac remains intact, drainage of lacrimal fluid by probing

or removing of surrounded bone to allow drainage into the or removing of surrounded bone to allow drainage into the nosenose

Conjunctivo-rhinostomyConjunctivo-rhinostomyimplantation of a duct-like polythene tube or glass in case of implantation of a duct-like polythene tube or glass in case of

duct damageduct damage

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Frontal sinus fractureFrontal sinus fracture

Frontal sinusFrontal sinus

Drains into nasal cavity via fronto-nasal ductDrains into nasal cavity via fronto-nasal duct

An air filled cavity lined by ciliated respiratory epithelium encased in the frontal bone

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Extent of the injury:Extent of the injury:

Anterior tableAnterior table

Posterior tablePosterior table

Associated injuries: Associated injuries: mid-face or head mid-face or head injuries e.g.injuries e.g.

Le Fort II, IIILe Fort II, IIINOENOENeuralgic insultsNeuralgic insultsOcular injuriesOcular injuries

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Diagnosis Diagnosis

Clinical examinationClinical examination

Radiographical Radiographical evaluationevaluation

Occipitomental viewsOccipitomental views

Lateral skull viewLateral skull view

CT scanCT scan

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Classification of fracturesClassification of fractures

Anterior table fractureAnterior table fracture– LinearLinear– DisplacedDisplaced

Posterior table fracturePosterior table fracture– LinearLinear– DisplacedDisplaced

Outflow tract injury Outflow tract injury (naso-lacrimal duct)(naso-lacrimal duct)

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Surgical management Surgical management

Intranasal cannulationIntranasal cannulation

Frontal sinus Frontal sinus trephinationtrephination

Osteoplastic flap Osteoplastic flap

Sinus ablation Sinus ablation (obliteration)(obliteration)

Cranialization Cranialization

Reduction and fixationReduction and fixation

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Reduction and fixationReduction and fixation

Surgical approaches:Surgical approaches:

– Site of penetrating injurySite of penetrating injury

– Coronal approachCoronal approach

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Sinus ablation Sinus ablation (obliteration)(obliteration)

– BoneBone– FatFat– Muscle and Muscle and

fasciafascia– Alloplastic Alloplastic

materialsmaterials

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FixationFixation– WiresWires– PlatingPlating

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Nasal fracturesNasal fractures

AnatomyAnatomyMidline central facial Midline central facial structure that fulfills structure that fulfills both cosmetic and both cosmetic and functional purposesfunctional purposes

Formed by union of Formed by union of rigid and flexible strutsrigid and flexible struts

2 rectangle-shaped 2 rectangle-shaped nasal bonenasal bone

ULCs, LLCs and ULCs, LLCs and midline septal midline septal

cartilagecartilage

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Classification of injuriesClassification of injuriesLow energy injuriesLow energy injuries

Simple injury caused by low velocity trauma (simple Simple injury caused by low velocity trauma (simple noncomminuted)noncomminuted)

High energy injuriesHigh energy injuriesSevere injury with comminution of nasal facial Skelton due to Severe injury with comminution of nasal facial Skelton due to

higher amount of energyhigher 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 Treatment

Low energy injuriesLow energy injuriesReduction (close Reduction (close manipulation, open manipulation, open reduction) and stabilizationreduction) and stabilization

Nasal packingNasal packing

External nasal splintExternal nasal splint

Adjunct septoplastyAdjunct septoplasty

Postoperative carePostoperative care

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Complex injuriesComplex injuriesImmediate measures:Immediate measures:

Extra and intranasal examinationExtra and intranasal examination

Identification of extra and intranasal Identification of extra and intranasal lacerationslacerations

Identification and control of site Identification and control of site bleedingbleeding

Surgical procedures:Surgical procedures:Open septal proceduresOpen septal procedures

Open nasal proceduresOpen nasal procedures

Open rhinoplastyOpen rhinoplasty

Open-sky “H” techniqueOpen-sky “H” technique