3. ∏ Zygoma: strong buttress of
lateral midface lying
between zygomatic
processes of frontal bone &
maxilla.
∏ The high incidence of ZMC
fractures relates to the it’s
prominent position within
the facial skeleton.
10. Type 1: Displaced zygomatic bone hinged on the maxillary and
the frontal attachments
Type 2: Displaced zygoma hinged on maxillary attachments
Type 3: Displaced zygoma hinged on frontal attachments
11. Group 1: Undisplaced fractures
Group 2: Isolated displaced fractures
Group 3: Displaced body fractures
(unrotated)
Group 4: Medially rotated
4a: Outward at malar buttress
4b: Inward at the FZ suture
Group 5: Laterally rotated
5a: Upward at the infraorbital
margin
5b: Outward at the FZsuture
Group 6: Any additional fracture lines across
the main fragment
12. Type 1: No significant displacement
Type 2: Isolated fractures of zygomatic arch
Type 3: Fractures rotated around a vertical axis
3a: Internally 3b: Externally
Type 4: Fractures rotated around a horizontal axis
4a: Medially 4b: Laterally
Type 5: Fracture displacement of the complex
enbloc
5a: Medially 5b: Inferiorly
5c: Laterally
Type 6: Displacement of orbital floor
6a: Inferiorly 6b: Superiorly
Type 7: Displacement of the orbital rim segments
Type 8: Complex comminuted fractures
13. Type 1: Isolated zygomatic arch fractures
Type 2: Fractures with no significant displacement
Type 3: Partially displaced fractures medially
Type 4: Totally displaced fractures medially
Type 5: Fractures with dorsal displacement
Type 6: Fractures with inferior displacement
Type 7: Comminuted fractures
14. Type 1: Non-displaced fractures
Type 2: Isolated zygomatic arch fractures
Type 3: Zygomatic complex fractures but the frontozygomatic
suture is undisplaced
Type 4: Zygomatic complex fractures with displacement of the
frontozygomatic suture
Type 5: Pure blow-out fractures
Type 6: Fractures of the orbital rim only
Type 7: Comminuted or multiple fractures
15. Group A: Fractures showing minimal or no displacement and hence
requiring no intervention
Group B: Fractures with great displacement and disruption at the
frontozygomatic suture and comminuted fractures
Group C: Fractures of all other kinds which required reduction but
no fixation
16. Type A : fracture isolated to one component of tetrapod
structure
A 1-Zygomatic arch
A2 -Lateral orbital wall
A 3-Inferior orbital rim
Type B : # of buttresses (classical tetrapod #)
Type C : Complex # with comminution of zygomatic bone
itself.
17. Type 1: Fractures with no evidence of displacement
Type 2: Isolated fractures of the zygomatic arch
Type 3: Fractures of the body of the zygomatic complex without rotation in the
antero-posterior direction (Z axis)
Type 4: Fractures of the body of the zygomatic complex with rotation in the
antero-posterior direction
4a: Axis of rotation at the bases of the arch
4b: Axis of rotation at the zygomaticomaxillary suture
4c: Fractures involving the zygoma, main body of the
maxilla and the palate
18. Category A
Isolated fracture of one of the three processes of the zygomatic bone. These processes
are:
The temporal process, which forms zygomatic arch (A1)
Frontal process, which forms lateral orbital wall (A2)
Maxillary process, which forms infraorbital rim (A3)
Category B
Fracture of all three processes, detaching zygomatic bone from facial skeleton i.e.
Classic tripod fracture, but anatomically these fractures are actually tetrapod, because
frontal process of zygoma also communicates with greater wing of sphenoid, which also
requires to be disrupted to technically render zygoma free.
Category C
Same as type B but with fragmentation including the body of zygoma
20. a) # of body of zygoma involving orbit
a) Min displacement
b) Inward & downward
c) Inward & posterior
d) Outward
e) communited
b) # of arch Without orbit involvement
21. Isolated zygomatic arch fractures(Type I)
Dual fracture (Type I-A)
More than 2 fractures (Type I-B)
V-shaped fracture (Type I-B-V)
Displaced (Type I-B-D)
Combined zygomatic arch fractures (Type II)
A. Single fracture (Type II-A)
B. Plural fracture (Type II-B)
1) Reduced (Type II-B-R)
2) Displaced (Type II-B-D)
Irfan Ozyazran et al ;A New Proposal of Classification of Zygomatic Arch Fractures; JOMS, Volume 65, Issue
3, March 2007, Pages 462–469
22. Fractures stable after elevation
• Arch only
• Rotation around a vertical axis
Medially
Laterally
Fractures unstable after elevation
Arch only (inferiorly displaced)
Rotation around a horizontal axis
Medially
Laterally
Dislocations en bloc
Inferiorly
Medially
Laterally
Comminuted fractures of the zygomatic complex
32. ∆ Aims for surgery
1. Restore normal contour of face
2. Relieve pain
3. Precise anatomical reduction of the # fragment
4. Stable fixation of the reduced fragment
5. To correct diplopia
6. To remove any interference in range of mandibular
movement
7. To relieve pressure from infraorbital nerve
33. INDICATIONS FOR SURGERY :
1. Visual compromise
2. Extraocular muscle dysfunction
3. Displacement of globe
4. orbital floor disruption
5. Displaced fractures
6. Comminuted fractures with fragments impinging on the
surrounding structure.
7. Restricted mandibular movements
8. Infraorbital nerve dysfunction
34. Steps in surgical treatment of ZMC #
•Prophylactic antibiotics
•Anesthesia
•Clinical examination & forced duction test
•Protection of globe
•Antiseptic preparation
•# reduction
•Assessment of reduction
•Determination of necessity for fixation
•Application of fixation device
•Internal orbital reconstruction
•Asessment of ocular motility
•Reconstruction with bone grafts
•Soft tissue resuspension
•Post surgical ocular examination
•Post surgical images
35. Surgical Approaches
Indirect
Extra Oral
a. Temporal
b.Percutaneous
Intra Oral
a. Keen
b. Quin
Direct
Extra Oral
a. Upper eyelid
b. Supraorbital eyebrow
c. Lower eye lid
i. Sub cilliary
ii. Infra orbital
iii. Trans conjunctival
d. Coronal
Intra Oral
a. Maxillary
Vestibular
47. Also known as lateral coronoid approach,1977
Used for reduction of zygomatic arch #.
Place 3-4 cm i/o incision along anterior border of the
ramus through mucosa and submucosa.
Extend upto depth of temporal muscle
Place Instrument between temporalis muscle and Z arch.
51. I. Use of self threading bone screws
II. Use of hardware that will not scatter postoperative CT scans- titanium plates
and screws have the advantage of not causing scatter in CT scans.
III. Placement of atleast 2 screws through the plate on each side of the fracture
IV. Avoid damage to important anatomical structures
V. Fracture of zygomatic buttress if low then “L”, “T” or “Y” shape bone plate
should be used.
Principles of plate fixation
52. VI. Use of thin plate in the periorbital areas- to prevent visibility and
reduce palpability
VII.Placement of as many bone plates in many locations for ensuring
stability
VIII.If concomitant fractures of other midfacial bones exist to be
necessary to apply fixation devices more liberally.
IX. In areas of comminution or bone loss span the gap with bone
plates.
53. Treatment algorithm for ZMC fracture without need for internal orbital
reconstruction, by Ellis and Kittidumkerng
Reduce Fracture
Fracture Reduced and
Stable
Stop
Unsure of Reduction
Transoral Open
Reduction
Fracture Reduction
But Unstable
Bone Plate at Z-M
Buttress
Fracture Reduced and
Stable
Stop
Fracture Reduction
and Stable
Stop
Unsure of Reduction
Open Reduction
Lateral Orbit
Fracture Reduced
Bone Plate at Z-M
Buttress and/or
Lateral Orbit
Fracture Reduced and
Stable
Stop
54. To support zygomatic
complex fractures
To support reconstructed
comminuted orbital floor
Temporary packing with
penrose drains, gauze,
gelfoam, silastic, antral
balloon
58. Towel clip reduction
Todd G. Carter et al; Towel Clip Reduction of the Depressed Zygomatic Arch Fracture, J Oral Maxillofac Surg
63:1244-1246, 2005
59. With the deep temporal fascia exposed from the reflected bicoronal flap, a
1-cm horizontal incision is made within the deep temporal fascia allowing a
Gillies elevator to easily reduce the arch fracture in a plane between the deep
layer of the deep temporal fascia and the temporalis muscle.
Advantages
• Preserves fascial attachments
• Avoids neurovascular injury
• Obviate the need for rigid fixation
• Saves time and money
• Decreases morbidity.
Swanson et al ;Modified Gillies Approach for Zygomatic Arch Fracture Reduction in the Setting of
Bicoronal Exposure; Journal of Craniofacial Surgery:May 2012 - Volume 23 - Issue 3 - p 859–862
Modified Gillie’s Approach
60. 1. Mal position of soft tissue on the bone
2. Ocular complications
a. Retrobulbar hemorrhage
b. SOF syndrome
c. Persistent diplopia
d. Enophthalmos
e. Infraorbital nerve disorder
f. Blindness
3. Maxillary sinusitis
4. Ankylosis of zygoma to coronoid process
5. Infection
61. Face is the most prominent and expressive part of human body and adds
to well being of a personality. Zygoma plays an imp role in facial contour.
Moreover the importance of zygomatic complex in facial skeleton lies in
protecting globe of eye and absorbing and redistributing masticatory and
external load.
Therefore for cosmetic and functional reasons it is imperative to diagnose
and treat zygomatic fractures adequately.
62. 1. Oral & maxillofacial trauma-Fonseca & walker vol 2
2. Oral & maxillofacial surgery-Fonseca vol 3
3. Oral & maxillofacial trauma-Rowe & Williams vol 2
4. Principles of Oral & maxillofacial surgery-Peterson
5. Fractures of middle third of face-Killey & Kay
6. Oral & maxillofacial surgery-Fragiskos
7. Maxillofacial trauma & facial reconstruction-Peter Ward Booth
8. Oral & maxillofacial surgery-Peter Ward Booth: vol 2
9. Chen Lee et al ;Applications of the Endoscope in Facial fracture
Management, seminars in plastics surgery/volume 22, number 1
2008
63. 9. Manual of internal fixation-J Prein
10. Mirko S. Gilardino et al;Choice of Internal Rigid Fixation
materials in the treatment of facial fractures; craniomaxillofacial
trauma & reconstruction/volume 2, number 1 2009
11. Irfan Ozyazran et al ;A New Proposal of Classification of
Zygomatic Arch Fractures; JOMS, Volume 65, Issue 3, March 2007,
Pages 462–469
12. Todd G. Carter et al;Towel Clip Reduction of the Depressed
Zygomatic Arch Fracture; J Oral Maxillofac Surg 63:1244-1246,
2005
13. Balasubramanian Thiagarajan; Fracture zygoma and its
management our experience,Journal of otolar; Volume 3 Issue 1.5
2013
