ASSOCIATION FOR STUDY OF INTERNAL FIXATION

Basically, the midface equates to a tent, where the tent poles represent the bony
midface and the tarpaulin represents the overlying soft tissues , which makes it
much more demanding than the construction plan of a tent. Means if the tent poles
are in correct position, automatically tarpaulin gets its shape.
Manson et al :- sinuses of the midface are supported fully and fortified by
vertical and horizontal buttresses of bone. Nasofrontal :- bridge b/w Ant. hard
palate & frontal bone which includes frontal process of maxilla, nasal bone,
nasofrontal suture) Zygomatic :- body of zygoma and its frontal process
Ptergomaxillary :- pterygoid process and plates of the sphenoid bone & transmit
forces from post. Hard plate & alveolar ridge to cranium. Nasoethmoidal
buttresses :- composed of ethmoid and vomer bone . It’s a important osseous bridge
b/w lower facial skeleton and the cranium
Superior(orbital plate of frontal bone, cribriform plate) Middle( zygomatic process
of temporal bone, the body and temporal process of zygoma, infraorbital process of
zygoma, orbital surface of maxilla and segments of frontal process of maxilla.)
Function :- provides lateral stability to facial skeleton. And also protect central
facial skeleton from horizontal forces. Inferior ( alveolar ridge and hard palate
acts as stablizing bridge b/w maxilla)
maxillary process of zygomatic bone articulates with maxilla at its anterior
surface and forms Zygomaticomaxillary suture : ZM suture runs lateral to
infraorbital foramen and runs downward from inferior orbital rim to under surface
of zygomaticomaxillary buttress . Frontal process is thick and triangular in cross
secton …….. Articulates with zygomatic portion of the frontal bone . Because of its
thickness it is a frequent site for wire or bone plate fixation . Temporal process
of zygomatic bone is thin, flat and projects posteriorly to articulate with the
zygomatic process of temporal bone . Both join to form zygomatic arch ……. Very thin
delicate connection …… fracture very frequently with minimal force . Zygoma has a
narrow weak articulation with zygomatic crest of greater wing of sphenoid . Forms
the major portion of the lateral aspect and floor of the orbit
the masseter muscle originates across the inferior surface of the zygomatic arch
and zygomatic buttress. the zygomaticus major and minor muscles support the oral
commissure, taking origin from the anterior face of the malar eminence. The
zygomatic head of the quadratus labii superioris muscle originates just below the
infraorbital rim. the temporal fascia also attaches along the arch and
posterolateral edge of the temporal process. The temporalis muscle passes beneath
the arch
Via various butresses
With increasing age and development of paranasal sinuses, the face becomes less
flexible In fact, for a child patient, the cranium-face ratio is 8:1, whereas for
an adult patient, this ratio decreased to 2:1. Given this relationship, if the
infant receive a direct trauma, he is more likely to present a fracture of the
cranium when compared with an older child or adolescent who will likely to present
a face fracture. The Journal of Craniofacial Surgery & Volume 22, Number 4, July
2011
This disruption occurs because when a force is applied to the body of the zygoma,
it is distributed through its four processes to the adjacent articulating bones,
many of which are weaker than the zygoma.
Inferior orbital fissure key to remember the usual lines of ZMC fractures. Three
lines of fracture extend from inferior orbital fissure in anteromedial
superolateral and inferior direction A fracture emanating from the inferior orbital
fissure superiorly along the sphenozygomatic suture to the frontozygomatic suture
where it crosses the lateral orbital rim# A fracture emanating from the inferior
orbital fissure anteriorly along the orbital plate of the maxilla, crossing the
infraorbital rim and extending inferiorly along the anterior face of the maxilla
underneath the zygomaticomaxillary buttress# A fracture emanating from the inferior
orbital fissure passing inferiorly along the infratemporal surface of the maxilla,
passing anteriorly underneath the zygomaticomaxillary buttress to meet fracture 2
above# One or more fractures through the zygomatic arch.
The point of # when a single # exist is usually middle of the arch . Frequently
however three # lines exist through the arch …… producing 2 free segments
Rowe has suggested that displacement of the zygomatic bone can be best understood
when it is measured AROUND different axis Vertical axis - imaginary line drawn from
FZ suture passes vertically downward through the center of the body and buttress of
zygomatic bone .
Horizontal line at the level of infraorbital foramen passes horizontally through
the center of zygomatic bone and the zygomatic arch.
Based on the direction of displacement on a waters view, classify in 6 groups No
treatment necessary Classical 3 fracture lines produces a v shaped deformity
Upward displacement at infraorbital rim, lateral displacement at the fz
1985 modified his classification giving it more clinical significance by dividing
fractures into stable and unstable
CATEGORY B: ## Of all 3 processes, detaching zygomatic bone from facial skeleton.
I.E. Classic tripod #, but anatomically these # are actually tetrapod, because
frontal process of zygoma also communicates with greater wing of the sphenoid in
orbital cavity, 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.
Primarily based on clinical and radiologic examination Clinical examination is
frequently difficult to perform cos of the amount of facial edema and pain Swelling
may conceal the facial deformity hence imaging is very imp Even a good history can
give a strong suggestion of the possibility of zmc # by knowing the nature,
direction and force of the blow Complete documentation
The most useful method of evaluating the position of the body of the zygoma is from
the superior view. The patient can be placed in a recumbent position / can recline
in a chair. The surgeon inspects from a superior position, evaluating how the
zygomatic bodies project anterior and lateral to the supra orbital rims, comparing
one side to the other. – one should also inspect intraorally , since the zygomatic
#rs are often accompanied by ecchymosis in superior buccal sulcus and max.
dentoalveolar # .
Compared to most other fractures trauma in the zmc region presents with a diverse
clinicsal presentation such as..
Diplopia and decreased or blurred vision is noted. The presence of diplopia is
assessed in all nine cardinal positions of gaze similar to the evaluation of the
visual fields. Snellen eye chart.
SEE CAREFULLY FOR ALL OCULAR MOVEMENTS IN 9 GAZES WHICH DIRECTLY CO RELATES TO THE
EXTRA OCULAR MUSCLE FUNCTION.
In case of # zyg arch a characterstic indentation or loss of convex curvature in
temporal area . It should be visually and digitally compared with other side .
Associated with approximately 1/3 rd of zyg bone injuries .mostly in case of
isolated arch # . This trismus is due to impingement of the translating coronoid
process of mand on the displaced zyg fragment . More common in # that r displaced n
communited Fracture through the obital floor and/or ant maxilla ------ tearing ,
shearing or compresssion of infraorbital nerve along its canal or foramen .----
result in anasthesia/ paraesthesia of lower eyelid , lateral aspect of nose and
upper lip . ION anaesthesia reduced down as oedema and swelling decreased. When
nerve get injured withn canal where psa n msa take origin then there will be
peresthesia of max teeth and gingiva
Normal P-A oblique (waters view) F-Z suture Lateral maxillary wall Maxillary
sinuses Orbital wall. Zygomatic arch. Systematic approach to read a occipito mental
view similar to dolons lines Orbital outline- step or discontinuties Sinus outline-
opacifications of sinus Elephants trunk- zygomatic line n maxillary line Coronoid
process- tip should be equidistant from max line on each side
Orbital floor fracture
Jug handle view Specific for arch fractures Typical # has a classical V shaped
depression
Multiplanar images would be useful in knowing the exact location of the fracture
Direction of displacement of zygoma can be visualized on 3d reconstruction Complete
assesment of status of the orbital floor and depth to which one must dissect to
reach stable bone
Popular through years for reduction of both ZMC & arch # Hemorrhage encounterd r
rarely of ant consequence
A 2.5cm incision is made through skin and sub cut tissue at an angle running from
anterosuperior to postero-inferior Incision is placed Superior to the bifurcation
of the superficial temporal artery. Glistening surface of the temporalis fascia is
visualized. At this level one should be above the point where temporalis fascia
splits into 2 layers, one attaching lateral and one medial to the arch, it splits
approx 2-3 cm above the arch A deeper incision is made throughe the fascia, one
should see the underlying temporal muscle bulge through the incision
A flat instrument, such as a large freer elevator or the broad end of No.9
periosteal elevator is then inserted between the temporalis muscle and the
temporalis fascia. The instrument is swept back and forth until the medial surface
of arch is reached Glide quite freely Originally bristows elevator was used-
superior margin of wound n adjacent skull was used as fulcrum Exert large amount of
controlled force First handle- stabilization and second handle is for elevation 2
arms r approximately same length so the operator is constantly aware of position by
closing Firm anterior sup n lateral elevation is applied Once elevated the working
blade should be swept post n lat reducing or ironing out any arch fractures
Incision was made for direct reduction of arch in case were arch is inferiorly
displaced Modified curved incision is placed 1 cm above the arch Incision is safe
cos it is posterior to temporal brch of facial nerve and below the anterior branch
of superficail temporal artery CONCLUSION Although the isolated fracture of the
zygomatic arch is rare and even rarer is the need for the open reduction and
internal fixation, this alternative approach to the arch is useful. The operative
time is reduced and the complications are minimized through this approach
both arch and zmc Can be reduced Incision is made through mucosa, submucosa and any
buccinator fibres A sharp end of a no 9 periosteal elevator or a curved freer
elevator Using a side to side sweeping motion the infra temporal surface of
maxilla, zygoma and zygomatic arch is reached and dissect the soft tissue in supra
periosteal manner Dental extraction forceps can be used similar to rowes zygomatic
elevator
SELDIN RETRACTOR
This technique described by quinn in 1977 Not useful for zmc The wound is deepened
superiorly following the lateral aspect of the temporal muscle with blunt
dissection With proper Placement lateral to the coronoid process Buccal fat pad
will probably be encountered which is not of concern
Popular technique IN U.S. Both arch and ZMC FRACTURES can be reduced as well as to
fix FZ suture Around 1.5 – 2 cm incision has to be given over lateral brow region
to the depth of periosteum and 2nd incision made through the perosteum And
instrument is inserted posterior to the zygoma along its temporal surface Lift the
zygoma in ant, lateral n superior direction Dingman zygomatic elevator
However scarring is more theorotical and in practice incision sites are rarely
visible 2-3 weeks following surgery
One horizontally in lateral direction from ala of nose One vertically downward from
lateral canthus of eye Precaution –slippage into the inferior orbital fissure
CHAMPION S TECHNIQUE ( peter ward booth We can use even CARROL GIRARD SCREW THROUGH
2-3 mm extra ORAL INCISION over cheek
Can be placed in the body of the zygoma as a handle to reduce displaced zygoma Can
control zmc position in all three planes
A No. 11 blade is used to make a small stab incision through the skin approximately
1 cm superior to the fracture site (Figs 3-6). 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. A No. 11 blade is used to make the second 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.
Deep local infiltration is needed to anesthetize skin, subcutaneous tissues,
periosteum of the zygomatic arch, and masseter muscle fibers attached to the arch
With a no. 15 blade, a short (G5-mm length) stab incision through the skin at the
area immediately inferior to the fracture site is carried out. Using the curved
mosquito forceps, blunt dissection of subcutaneous tissues and masseter muscle
fibers is achieved until the tip of the instrument is positioned underneath the
arch at the exact depression site, already marked (Fig. 3). Once the zygomatic arch
is felt and stabilization of the head is accomplished, a controlled, steady, and
lateral force is applied outward.
Before the slide---One of the most controversial topic in maxfac surg ….. Is the
amount of fixation that is necessary to prevent post reduction displacement of #rd
Zmc. Some surgeons ….. Reduction itself doesn’t provide adequate stability ….. So
fixation required some says every # is does not require fixation Downward pull of
masseter is the reason for instability following reduction ….. Medial rotation of
the zyg before healing
Undisplaced fractures and in stable fractures of rows classification
Outer to inner orbital portion no2 round bur, 5mm away from the fracture ends Guard
such as periosteal elevator is placed at the medial orbit to protect the globe 0.35
mm wire is used Bone in infra orbital margin is thin n antrum is in close proximity
5 mm below the outer aspect of the rim obliquely upward and backwards 3- 5 mm away
from the fracture line
When drilling in this region , always take care Not to injure the palpabral lobe of
lacrimal gland or inadverent removal of it May lead to dry eye. Dingman and natvig
in 1964 suggested holes be drilled in an antero posterior direction and figure of 8
pattern which provides better lateral stability
Now a days this kind of fixation is of historical interest as plating systeam has
better advantage of three dimentional stability Here fracure reduction is done by
taking traction from other stable structure on the face through wire Mostly
Krischner wire is used for indirect fixation
When plate n screw fixation is used there r several general principles in its
application to zmc # Self threading bone screws have more holding power in thin
bones Titanium plates have advantage of not causing scatter in CT scans Infra
orbital nerve n tooth roots
Skin overlying the orbital rims is thin Many fractures can adequately be reduced
with with single bone plate in fz o zm butress region However when articulations of
zygoma are communited it ll be necessary to apply additional plates When gap is
more than few mm bone grafts can be attached to the bone plate or laid over the
bone plate to promote osseous healing
Indicated in Tripod fracture
Here 3 butttreses are secured as it provides stable fixation of fracture
n a zygomatic fracture that requires orbital floor reconstruction, after exposing
the zygoma and orbital floor, the zygoma should be disimpacted prior to dissecting
herniated orbital soft tissues from the maxillary sinus.#In a fracture of this
nature, the reduction and fixation of the zygoma should be performed first.
Reconstruction of the orbital floor should be performed after the zygoma has been
reduced and stabilized. Note: Check the proper alignment of the repositioned
zygomatic complex along the lateral wall of the orbit (sphenozygomatic junction)
before performing the fixation at the other points.
The first plate is placed across the frontozygomatic fracture area.#We recommend a
minimum of a 5-hole plate with one hole spanning the fracture line. The plate
should be properly adapted. In this illustration, the first screw is placed in the
unstable zygomatic fracture. An instrument is then used to pull the plate and
zygomatic fragment in the cephalad direction to further reduce the fracture.
Only one screw should be placed on each side of the fracture in the holes nearest
to the fracture, until the surgeon has verified the proper 3-D reduction of the
zygoma at the other two points. Looking through the upper eyelid incision, it is
very difficult to determine the 3-D rotation of the zygoma. While drilling holes in
the periorbital area, it may be desirable to use a drill bit with a stop (commonly
6 mm stop). The final two screws in the zygomaticofrontal plate should be placed at
the end of the intervention. #
When looking through the lower eyelid incision, the orbital rim plate should be
properly adapted. Use a minimum of a 5-hole plate with the extra hole spanning the
fracture line. Reconfirm that the lateral orbital wall (greater wing of the
sphenoid and zygoma) has been properly reduced prior to placing this plate. A
minimum of two screws should be placed on each side of the fracture.
Looking through the maxillary vestibular approach, the fracture of the
zygomaticomaxillary buttress is aligned. A larger L-shaped plate is ideal for the
fixation of this fracture. This is the most difficult plate to properly adapt in a
zygoma fracture. It is important that the leg of the L-plate be placed on the most
lateral portion of the lateral maxillary buttress, where the bone is fairly thick.
Several complications can occur from the incisions approaching for the infraorbital
rim, orbital floor and walls *due to scarring between tarsal plate and periosteum,
shortening of the orbital septum. $outward curl to lower eyelid . Ectropion Mild-
slight lifting of the eyelid from the glob Moderate-lifting of the lid from the
globe and shortening of the vertical hight of the eyelid Severe-combination of
shortening of the eyelid and true eversion of the eyelid
In case of persistent dysaesthesia – disruption of infraorbital nerve within the
canal can be suspected.
Binocular diplopia is double vision arising as a result of the misalignment of the
two eyes relative to each other, while the fovea of one eye is directed at the
object of regard, the fovea of the other is directed elsewhere, and the image of
the object of regard falls on an extra-foveal area of the retina
Decrease in vol of orbital contents increase in vol of bony orbit Loss of
ligamentry support Scar contracure Or combintion
if diagnosis of ankylosis is made then surgery will be necessary i.e.
coronoidectomy
- results from improper reduction / improper fixation / non intervention when
surgery was indicated . Minor deformity with limted flattening of malar
prominence . Little orbital involvement Comminuted ZMC # so it can not be mobilized
and repositioned in one piece