Facial Fractures I

FACIAL
FRACTURES
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

OUTLINE
• Zygomatic Complex Fractures
• Orbital and Ocular Trauma
• Frontal Sinus and Naso-Orbito-Ethmoid Complex Fractures
• Gunshot Injuries
• References

ZYGOMATIC COMPLEX FRACTURES
• The zygoma articulates with the frontal, sphenoid, temporal, and maxillary bones.
• Tri-malar or tripod fracture are inaccurate.
• Zygomatic complex fracture includes disruption of the four articulating sutures:
zygomatico-frontal, zygomatico-temporal, zygomatico-maxillary and the
zygomatico-sphenoid sutures.
• All zygomatic complex fractures involve the orbital floor.
• Nerve supply.

ZYGOMATIC COMPLEX FRACTURES
• The temporalis fascia attaches to the frontal process of the zygoma and zygomatic arch.
The fascia produces resistance to inferior displacement of a fractured fragment by the
downward pull of the masseter muscle.

DIAGNOSIS
• Zygomatic fractures are not life threatening.
• Initial evaluation of the patient with a zygomatic fracture includes documentation of the
bony injury and the status of surrounding soft tissue (eyelids, lacrimal apparatus, canthal
tendons, and globe) and cranial nerves II to VI.

SIGNS AND SYMPTOMS
• Pain
• Periorbital edema and Ecchymosis [most common early clinical signs and present in 61% of
all zygomatic injuries]
• Paresthesia or anesthesia over the cheek, lateral nose, upper lip and maxillary anterior teeth
resulting from injury to the zygomaticotemporal or infraorbital nerves.
• Nerve injury occurs in 18 to 83% of all patients with zygomatic trauma.
• When the arch is medially displaced, the patient may complain of trismus.
• Epistaxis and diplopia may be present.
• Malar Depression

SIGNS AND SYMPTOMS
• Downward displacement of the zygoma produces an Antimongoloid slant to the
lateral canthus, enophthalmos, and accentuation of the supra-tarsal fold of the
upper eyelid.
• Radiographs: CT scan of the facial bones, in axial and coronal planes, is standard
for all patients with suspected zygomatic fractures.

DOLAN’S LINES
• Dolan's lines are the collective name given to three lines that aid in evaluating
for maxillofacial fractures on an occipitomental skull radiograph. They are usually
used as an adjunct to McGrigor-Campbell lines.
• orbital line traces the inner margins of the lateral, inferior, and medial orbital walls,
and the nasal arch
• zygomatic line traces the superior margin of the zygomatic arch and body, extending
along the frontal process of the zygoma to the zygomaticofrontal suture
• maxillary line traces the inferior margin of the zygomatic arch, body, and buttress,
and the lateral wall of the maxillary sinus

RADIOGRAPHIC EVALUATION
• Waters’ View
• The single best radiograph for evaluation of zygomatic complex fractures.
• Postero-anterior projection with the head positioned at a 27˚ angle to the vertical and the
chin resting on the cassette.
• This projects the petrous pyramids off the maxillary sinuses, permitting visualization of
the sinuses, lateral orbits and infraorbital rims
• In patients who are unable to assume a facedown position, a reverse Waters’ projection
provides similar information.

RADIOGRAPHIC EVALUATION
• Caldwell’s View; Postero-anterior projection with the face at a 15˚ angle to the
cassette. This study is helpful in the evaluation of rotation (around a horizontal
axis).
• Submentovertex View; (jug-handle) from the submandibular region to the vertex
of the skull. It is helpful in the evaluation of the zygomatic arch and malar
projection.

CLASSIFICATION OF FRACTURES
• Pattern of segmentation and displacement.
• Low-Energy Fractures; fractures that demonstrated little or no displacement, incomplete
fractures of one or more articulations may be present.
• Middle-Energy Fractures; fractures that demonstrated complete fracture of all articulations
with mild to moderate displacement.
• High-Energy Fractures; characterized by comminution in the lateral orbit and lateral
displacement with segmentation of the zygomatic arch.

CLASSIFICATION OF FRACTURES
• Type A fractures; incomplete low-energy fractures with fracture of only one zygomatic
pillar: the zygomatic arch, lateral orbital wall, or infraorbital rim.
• Type B fractures; designated complete “mono-fragment” fractures with fracture and
displacement along all four articulations.
• Type C “multi-fragment” fractures included fragmentation of the zygomatic body.

TREATMENT
• Management of zygomatic complex and zygomatic arch fractures depends on the degree
of displacement and the resultant esthetic and functional deficits.
• Treatment may therefore range from simple observation of resolving swelling,
extraocular muscle dysfunction, and paresthesia to open reduction and internal fixation
of multiple fracture.

TREATMENT
• Nondisplaced and minimally displaced zygomatic arch fractures may require no surgical
correction.
• The first operative treatment described was by usage of intraoral finger pressure [ Wood
block – tension]
• Incision in the mucosa at the level of the maxillary alveolus and extending it inferiorly along
the anterior border of the ramus. An elevator is placed between the coronoid processes and
zygomatic arch, and the fracture is reduced.

GILLIE’S APPROACH
• Standard technique
• A temporal incision (2 cm in length) is made behind the hairline. [Temporalis Fascia]
• The temporal fascia is incised horizontally to expose the temporalis muscle.
• A sturdy elevator, such as a urethral sound or Rowe zygomatic elevator is inserted
underneath the temporal surface of the zygoma.
• The bone should be elevated in an outward and forward direction, with care taken not to
put force on the temporal bone.
• The arch should be palpated at all times as a guide to proper reduction.
• The wound is closed in layers.

TREATMENT
• Pre-Auricular Incision – J- Shaped Elevator
• Aluminum Foam Rubber Splint – 3 – 5 days
• Open reduction with internal fixation is seldom necessary for treatment of
isolated zygomatic arch fractures.

ZYGOMATIC COMPLEX FRACTURE
TREATMENT
• Middle-Energy Zygomatic Complex Fractures Middle-energy, displaced zygomatic
complex fractures require reduction and internal fixation.
• Carroll-Girard screw, which is inserted trans-cutaneously into the malar
eminence.
• Excellent three dimensional control to reduce the fracture.
• The zygomatico-maxillary buttress is exposed first, zygomatico-frontal buttress is
exposed next and also stabilized with a plate if required.

HIGH-ENERGY ZYGOMATIC COMPLEX
FRACTURES MANAGEMENT
• Coronal Flap
• Transcutaneous or trans-conjunctival incision is used to explore and reconstruct the
internal orbit.
• Intraoral approach; maxillary vestibule incision 3 to 5 mm above the mucogingival
junction. [ 3-7]
• Periosteal incision.
• Supra-tarsal fold incision or Lateral Eyebrow incision.

COMPLICATIONS
• Infraorbital Paresthesia – 13 – 83%
• Mal-union and Asymmetry
• Enophthalmos
• Diplopia – 17 – 83%
• Traumatic Hyphema
• Traumatic Optic Neuropathy
• Superior Orbital Fissure Syndrome
• Retrobulbar Hemorrhage

RETROBULBAR
HEMORRHAGE
• Rare but severe complication
• Result of either the initial injury or the operative correction.
• Disruption of the retinal circulation may lead to irreversible ischemia and
permanent blindness.
• An emergent ophthalmologic consultation is necessary
• Decompression with lateral canthotomy and cantholysis should not be delayed

REFERENCES
• Chapter 23: Management of Zygomatic Complex Fractures

Facial Fractures I

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Facial Fractures I