Zygomatic “tetrapod” as it maintains four points of

Zygomatic complex fracture 

Type of manuscript- review article 

Running title- zygomatic complex fracture 

Swetaa.A
Undergraduate student 
Saveetha Dental College,
Saveetha university 
Chennai,
India.

Mr. K. Yuvaraj Babu
Assistant professor 
Department of Anatomy 
Saveetha Dental College 
Saveetha university, 
Corresponding author
Chennai,
India.

Corresponding author-

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. 

INTRODUCTION 

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 animation, 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. 

Discussion-

The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, it 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 

Diagnosis- 
1. CT scan imaging 
2. Endoscopy 
3. Enophthalmos 
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  
fixation.
It has gillies procedure, two point fixation, three point fixation and many.

Gillie’s procedure:
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. 

Conclusion- 
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. 

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