Zygomatic complex fracture
Type of manuscript- review article
Running title- zygomatic complex fracture
Saveetha Dental College,
Mr. K. Yuvaraj Babu
Department of Anatomy
Saveetha Dental College
Email- [email protected]
Telephone number- 9566047924
Author name- Swetaa.A
Guide Name- Mr. K. Yuvaraj Babu
Telephone number- 9840210597
Year of the study- I BDS 2017-2018
Total no.of words- Abstract-
Aim- To create awareness on zygomatic complex fracture.
Objective- To review and establish about zygomatic complex fracture.
Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation. However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications.
The zygomaticomaxillary complex (ZMC) functions as a buttress for the face and it gives a person’s aesthetic appearance, by both setting midfacial width and providing prominence to the cheek. It can best be anatomically described as a “tetrapod” as it maintains four points of articulation with the frontal bone, temporal bone, maxilla, and greater wing of the sphenoid, at the zygomaticofrontal (ZF) suture, zygomaticotemporal (ZT) suture, zygomaticomaxillary buttress (ZMB), and zygomaticosphenoid (ZS) suture.
This tetrapod configuration then lends itself to complex fractures, as fractures here rarely occur in isolation. Additionally, the zygoma serves as the attachment point for muscles of both mastication and facial expression ,but among these, it is the masseter that provides the most significant intrinsic deforming force on the zygomatic body and arch, albeit a small one. The zygoma plays an integral role with the orbit, as it buttresses the orbit and forms the majority of the lateral orbital wall and floor. The cause is usually a direct blow to the Malar eminence of the cheek during assault. The paired zygomas each have two attachments to the cranium, and two attachments to the maxilla, making up the orbital floors and lateral walls. These complexes are referred to as the zygomaticomaxillary complex. The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures.
The formerly used ‘tripod fracture’ refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture.
There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity.
Materials and methods-
A total of 140 articles were identified through the database searches. Data relevant to the demographic profile of the patients such as age and gender, cause of injury, other associated injuries (noncranio-facial), and surgical treatment provided was collected. Only those patients with iZMC fractures without any other facial bone injury were included in this study. Patients who presented with displaced iZMC fractures causing aesthetic or functional problems that needed surgical intervention underwent standard preoperative . Every article identified checked by one reviewer and subjected to pre-determined inclusion/exclusion criteria. Where abstracts were ambiguous, the article was obtained. These were found to be a review papers, summaries of other studies, or contained no data to inform the research questions. A total 42 articles were included in the review.
Key words- zygomatic complex fracture, trauma, surgical procedure, patients.
The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, has four components: the lateral orbital wall ,inferior wall, separation of the maxilla and zygoma along the anterior maxilla , the zygomatic arch, and the orbital floor near the infraorbital. A patient with maxillofacial injuries presents with a clinical picture of gross facial swelling, usually from oedema and bleeding into the tissues. Clinical examination augmented with radiological investigation gives an accurate diagnosis regarding the extent of injuries. The rise in the motorized population accompanied by rash driving and disregard to traffic rules has resulted in a rise of zygomatic complex fracture . The increase in interpersonal violence and accidental falls are also contributing to maxillofacial injuries.
The Armed Forces are predisposed to various kinds of injuries. High-speed vehicles and increased violence account for a large number of maxillofacial injuries. Zygomaticomaxillary complex, due to its prominent position in the face bears the brunt of trauma in majority of the cases and has shown to have the highest incidence of fractures in the maxillofacial region in various studies, including this study. Facial bones, especially of the middle third of the face, are composed of a network of fragile bones held together across sutures which give way in case of force to a lesser extent than other parts of the body. It is imperative to educate people regarding the importance of restraints and use of protective headgear/ seat belts while travelling in motorised transport, which will go a long way in preventing injuries to the facial region.
BUTTRESS-The buttress system of the mid face is formed by strong frontal, maxillary, zygomatic and sphenoid bones and their attachments to one another. The central mid face contains fragile bones.These fragile bones are surrounded by thicker bones of the facial buttress system lending it some strength and stability.
Horizontal buttress system- These buttresses interconnect and provide support for the vertical buttresses. They include: 1. Frontal bar 2. Infraorbital rim nasal bones 3. Hard palate maxillary alveolus
Vertical buttress system- These buttresses are very well developed. They include: 1. Nasomaxillary 2. Zygomaticomaxillay 3. Pterygomaxillay 4. Vertical mandible. Majority of the forces absorbed by midface are masticatory in nature. Hence the vertical buttresses are well developed in humans.
CLASSIFICATION-Non displaced,Displaced,Comminuted,Orbital wall fracture,Zygomatic arch fracture Knight North classification.
Under Knight and north classification there are types of fractures.
Types of fractures-
There are six types of fracture.
Group one fracture
Group two fracture
Group three fracture
Group four fracture
Group five fracture
Group six fracture
Among these fractures group six fracture is complex fracture. Majority of the patients belong to group 1 and group 2 fractures.
CLINICAL FEATURES- 1. Anaesthesia / Paraesthesia of that side of the face 2. Inability to open the mouth 3. Flattening of zygomatic area 4. Diplopia 5. Subconjunctival haemorrhage 6. Eye lid oedema 7. Periorbital haemorrhage 8. Lateral canthal dystopia 9. Ipsilateral epistaxis 10. Buccal sulcus haematomas 11. Enopthalmos in orbital floor fractures.
Masons classification of fracture zygoma:
It is based on CT images to classify the different types of fractured zygoma. It has 3 types
Low energy injury
Medium energy injury
High energy injury
1. CT scan imaging
4. Floor orbital fracture
5. Globe retraction
6. Medial wall orbital fracture
TREATMENT- It is always done in a surgical procedure.Majority of the patients were managed
conservatively or Gillie’s procedure.Only few patients needed open reduction with three point
It has gillies procedure, two point fixation, three point fixation and many.
Small incision is made in temporal area. Superficial temporal artery is avoided dissection is continues deep temporal fascia.
Two point fixation:
It involves micro plates in zygomatico- frontal and zygomatic areas.
Three point fixation:
It includes frontozygomatic suture, infraorbital rim, zygomatico maxillary buttress.
Facial bones are fragile bones most of the cases are caused due to trauma. Management of facial trauma is to treat as soon as possible. Surgical technique results in good bony alignment and esthetics. As told before lots of accidents lead to zygomatic complex fracture that to majority of the cases are bike accidents so awareness of wearing helmet is very important to avoid facial fractures.
1. Balasubramanian Thiagarajan ,Seethalakshmi Narashiman , Karthikeyan Arjunan,Fracture zygoma and its management our experience,Stanley Medical College,otolaryngology online journal,2013
2. H. Kobashi, S. Ishii, N. Yakushiji, Huge nasopalatine duct cyst treatment with the help of cystectomy and bilateral fenestration surgery of the nasal cavity: A case report,Oral and Maxillofacial Surgery Cases, 28 sept 2017.
3. Edward E, Winai K (1996) Analysis of treatment of the isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54(4):386–400
4. Chowdhury SKR, Menon PS: Etiology and management of zygomatico maxillary complex fractures in the armed forces. MJAFI 2005, 61:238-240.
5. Nayyar MS: Management of zygomatic complex fracture. J Coll Physicians Surg Pak 2002, 12:700-705.
6. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: An approach to the management of Le Fort fractures. Plast Reconstr Surg 1980; 66:54–7.
7. Knight JS, North JF. The classification of malar fractures: An analysis of displacement as a guide to treatment. Br J Plast Surg. 1961;13:325.
8. Manson PN, Markowitz B, Mirvis S, et al. Toward CTbased facial fracture treatment. Plast Reconstr Surg. Feb 1990;85(2):20212; discussion 2134
9. Lin KY, Bartlett SP, Yaremchuk MJ, et al. The effect of rigid fixation on the survival of onlay bone grafts: an experimental study. Plast Reconstr Surg. Sep 1990;86(3):44956.
10. Gosain AK, Song L, Corrao MA, et al. Biomechanical evaluation of titanium, biodegradable plate and screw, and cyanoacrylate glue fixation systems in craniofacial surgery. Plast Reconstr Surg. Mar 1998;101(3):58291
11. Dingman RO, Natvig P. Surgery of Facial Fractures. Philadelphia: WB Saunders Co; 1964.
12. Kobienia BJ, Sultz JR, Migliori MR, et al. Portable fluoroscopy in the management of zygomatic arch fractures. Ann Plast Surg. Mar 1998;40(3):2604.
13. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg. Aug 1992;50(8):77890.
14. Longaker MT, Kawamoto HK. Evolving thoughts on correcting posttraumatic enophthalmos. Plast Reconstr Surg 1998 Apr;101(4):899-906.
15. Karyouti SM. Maxillofacial injuries in Jordan University hospital; Int J Oral Maxillofacial Surgery 1987:16,262-5.
16. Ajagbe HA and Daramola JO. Pattern of facial bone fracture seen at University College Hospital, Ibadan, Nigeria, East Africa Med J 1980,57:267-72.
17. Oji C. Jaw fractures in Enugu, Nigeria, 1985-1995. British Journal of Oral and Maxillofacial Surgery (1999) 37,106-9.
18. NL Rowe and JLI Williams. Maxillofacial injuries. Vol I Churchill Livingstone 1985:363-558.
19. Mwaniki D, Radol JWO, Miniu E, Manji F. The occurance and pattern of facial bone fractures in Nairobi. East Afr Med J 1988:65,759-63.
20. Akama MK, Chindiu ML, Ndungu FI. Occurance and pattern of facial bone factures at Kissi District Hospital Kenya; East Afr. Med J 1993;70:732-3.
21. O’Hara DE, Del Vecchio DA, Bartlett SP, Whitaker LA. The role of micro fixation in malar fractures: a quantitative biophysical study. Plast Reconstr Surg 1996 Feb;97(2):34550;discussion 351-3.
22. Lee CH, Lee C, Trabulsy PP, et al. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair. Plast Reconstr Surg 1998 Feb; 101(2): 333-45; discussion 346-7.
23. Swanson KS, Kaugars GE, Gunsolley JC. Nasopalatine duct cyst: an analysis of 334 cases. J Oral Maxillofac Surg 1991;49:268e71.
24. Falci SGM, Verli FD, Consolaro A, Dos Santos CRR. Morphological characterization of the nasopalatine region in human fetuses and its association to pathologies. J Appl Oral Sci 2013;21:250e5.
25. Escoda Francolí J, Almendros Marques N, Berini Aytes L, Gay Escoda C. Nasopalatine duct cyst: report of 22 cases and review of the literature. Med Oral Patol Oral Cir Bucal 2008;13:E438e43.
26. Aldelaimi TN, Khalil AA. Diagnosis and surgical management of nasopalatine duct cysts. J Craniofac Surg 2012;23, e472e4.
27. Suter VG, Sendi P, Reichart PA, et al. The nasopalatine duct cyst: an analysis of the relation between clinical symptoms, cyst dimensions, and involvement of neighboring anatomical structures using cone beam computed tomography. J Oral Maxillofac Surg 2011;69:2595.
28. Elliott KA, Franzese CB, Pitman KT. Diagnosis and surgical management of nasopalatine duct cysts. Laryngoscope 2004;114:1336.
29. Honkura Y, Nomura K, Oshima H, Takata Y, Hidaka H, Katori Y. Bilateral endoscopic endonasal marsupialization of nasopalatine duct cyst. Clin Pract 2015;5:748.
30. Kang JW, Kim HJ, Nam W, Kim CH. Endoscopic endonasal marsupialization of nasopalatine duct cyst. J Craniofac Surg 2014;25, e155e6.
31. Wu PW, Lee TJ, Huang CC, Huang CC. Transnasal endoscopic marsupialization for a huge nasopalatine duct cyst with nasal involvement. J Oral Maxillofac Surg 2013;71:891e3
32. Lieblich SE, Piecuch JF. Orbital-zygomatic trauma. In: Kelly JP (Ed). Oral and maxillofacial surgery knowledge update. Vol 1, part II. Rosemont, Ill: AAOMS, 1995; pp 165-176.
33. Stewart MG (Ed). Head, neck, and face trauma. New York: Thieme, 2005; pp 68-76.
34. Bailey JS, Goldwasser MS. Management of zygomatic complex fractures. In: Miloro M, (Ed). Peterson’s principles of oral and maxillofacial surgery, Hamilton: BC Decker, 2004; pp 445-462.
35. Wong MEK, Johnson JV. Management of mid face injuries. In: Fonseca R, Marciani R, Hendler B (Eds). Oral and maxillofacial surgery. Vol 3. Philadelphia: WB Saunders, 2000; pp 245-299.
36. Prein J. Manual of internal fixation in the craniofacial skeleton. New York: Springer-Verlag, 1998; pp 133-148.
37. Chotkowski G, Eggleston TI, Buchbinder D. Lagscrew fixation of a nonstable zygomatic complex fracture: A case report. J Oral Maxillofac Surg, 1997; 55:183-185.
38. Gruss JS, Van Wyck L, Phillips JH, et al. The importance of the zygomatic arch in complex midfacial fracture repair and correction of post-traumatic orbitozygomatic fracture deformities. Plast Reconstr Surg, 1990; 85:878-890.
39. Kushner GM. Surgical approaches to the infraorbital rim and orbital floor: the case for the transconjunctival approach. J Oral Maxillofac Surg, 2006; 64:108-110.
40. Ellis E, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg, 1996; 54:386-400, discussion 400-401.
41. Hoelzle F, Klein M, Schwerdtner O, et al. Intraoperative computed tomography with the mobile CT Tomoscan M during surgical treatment of orbital fractures. Int J Oral Maxillofac Surg, 2001; 30:26-31.
42. Bagheri SC, Meyer RA, Khan HA, et al. Microsurgical repair of peripheral trigeminal nerve injuries from maxillofacial trauma. J Oral Maxillofac Surg, 2000
43. Gokulnath B.V, Gokul.V, SCALP, Anatomy,Saveetha Dental College,2010
44. Jothika Mohan, stem cell research, Anatomy, Saveetha Dental College, 2010