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March 2016, Volume 66, Issue 3

Case Reports

Reduction of isolated zygomatic arch fractures using dental instrument: Report of 2 cases and review of the literature

Yavuz Tolga Korkmaz  ( Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey. )
Ummugulsum Coskun  ( Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey. )
Mustafa Cenk Durmuslar  ( Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bulent Ecevit University, Zonguldak, Turkey. )
Zeynep Fatma Zor  ( Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Ankara, )
Turgay Peyami Hocaoglu  ( Cumhuriyet University, Sivas, Turkey. )
Nuray Yilmaz Altintas  ( Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey. )

Abstract

To assess the effectiveness of a dental instrument for reduction of isolated zygomatic arch fractures. Two patients were admitted to our clinic representing isolated unilateral zygomatic arch fracture. The common presenting complaints were pain, swelling and difficulty in mouth opening. Fractures were confirmed with plain radiography and computerized tomography. The fractures were reduced with upper buccal sulcus approach by dental instrument. Patients achieved satisfactory maximum mouth opening within 10 days. At follow up after 6 months, there was complete healing without any complication. This procedure is cost effective, time saving, safe and effective to manage isolated zygomatic arch fractures under local anaesthesia with satisfactory outcomes.
Keywords: Zygomatic arch, dental instrument, forceps, treatment, trauma, prognosis.


Introduction

Isolated zygomatic arch fracture is rare in zygomaticomaxillary complex fracture, representing approximately 10% of all cases in the literature.1-3
There are several conventional techniques that can be used for reducing isolated zygomatic arch fractures such as: the Gillies temporal approach, hook elevation, upper buccal sulcus technique, intranasal transantral approach, and open reduction.2,4,5 Besides, many devices such as; elevators, towel, curved mosquito, different types of hooks, aqua splint and percutanous wire suture technique were defined to immobilize the repositioned fragments.6,7 Although these techniques are noninvasive, treatment of zygomatic arch fractures depends on aesthetic and functional defect and the degree-types of displacement.1,3,5,6 However, there is limited information about the effectiveness of extraction forceps in reducing zygomatic arch fractures in the literature.
The purpose of documenting this case is to present the simplicity and outcomes of reduction of isolated zygomatic arch fractures using extraction forceps as a reduction instrument through upper buccal sulcus technique.


Case Report

Two patients were admitted to our clinic for facial trauma along with isolated zygomatic arch fractures. Two cases were performed in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University from January 2012 to May 2013. The first one had unilateral isolated zygomatic arch fracture on the left side because of interpersonel assault the week before and the second one had unilateral zygomatic arch fracture on the right side because of industrial accident ten days ago. The common complaints of the patients were pain, swelling, diffuculty in mouth opening and zygomatic arch region sensitiveness on palpation. However fracture mobility was not observed in both patients. The zygomatic arch fractures were confirmed with a plain radiograph and computarized tomography (CT) images (Figure-1 A,B,C,D)

and classified according to Yamamoto classification system2 into Type II (displacement with bone contact at all fracture lines). Each patient was informed about the possible risks and benefits of the procedure and signed a detailed consent form.
The patients with isolated zygomatic arch fractures were treated with upper buccal sulcus technique by using dental instrument (extraction forceps) for internal reduction. After local anaesthesia, a horizontal incision was made in the free gingiva for a distance of approximately 2 cm over the zygomatic buttress extending through the mucosa, submucosa, and any buccinator muscle fibers (Figure-2A).

After the mucoperiosteal elevation, zygomatic arch was felt and one handle of a extraction forceps was inserted into the wound under the fractured area and advanced posteriorly, as well as superiorly (Figure-2B). The depressed zygomatic arch was elevated into its proper anatomical position by the forceps with controlled force while the reduced area was palpated by the surgeon\\\'s other hand extraorally (Figure-2C). And then, the forceps were moved back and forth to check whether the arch was in the correct position. The wound area was closed with 3/0 silk suture after the symmetry of two zygomatic arches had been confirmed.
Postoperative radiographs were taken immediately to confirm the adequacy of zygomatic arch reduction (Figure-1E). The patients were then discharged after the operation and suggested avoiding direct force on the operated site and not to sleep on the affected side for a period of 8 weeks. All of the patients gained satisfying mouth opening within 10 days and no complications such as infections, trismus and nerve damage were observed. The patients were followed up for the following 6 months and no additive operation was neccesary.


Discussion

Different techniques and devices have been described by many authors concerning the evaluation and treatment of zygomatic arch fractures.3 Besides, it is important to select the adequate technique and instrument in treatment of zygomatic arch fracture because inadequate stabilization and reduction of zygomatic arch may result in malunion or asymetry.1,8 In the present study, we used extraction forceps for reduction of depressed zygomatic arch fracture by upper buccal sulcus approach as closed reduction due to minimal displacement with bone contact at all fracture lines (Class II). As a result, the patients were treated with satisfactory results without any complication.
Temporal approach by Gilles widely used for the treatment of zygomatic arch fracture due to several benefits such as; easy to achieve under local anaesthesia, little risk of nerve damage or direct trauma to globe exists.3 But it has more complications risk and needs large forces to reduce the fragments.1 Recently, the upper buccal sulcus technique of Keen has become quite an effective technique in the management of zygomatic arch fractures because of advantages of no visible scar and minimal surgical procedures over the Gilles temporal approach.2,3,9
Courtney9 was of the opinion that upper buccal sulcus technique using Bristow\\\'s or Rowe\\\'s elevator was succesful in elevating the depressed zygomatic complex and arch regardless of the time lag between injury and surgical reduction. Krishnan B et al8 treated twenty five patients with unilateral isolated zygomatic arch fractures by reduction of fractures by using a dental forceps through an upper buccal sulcus approach with pleasant results. They stated that performing this procedure under sedation or local anaesthesia in clinic setting or an emergency department makes it a highly cost-effective and time-saving tool in the armamentarium of an oral and maxillofacial surgeon.
Researchers proposed the use of a towel for reducing depressed zygomatic arch fractures as a quick, simple and effective technique.10 They stated that this tecnique is also minimally invasive, has little risk of infection or neurovascular injury. Mezitis et al5 described the use of a curved mosquito for reducing isolated zygomatic arch fractures as a less invasive method. However it requires an experienced and skillful surgeon and has a limitation of using force to reduce the fractures.
Different types of hooks have also been used for the reduction of those fractures.5,7 J shaped curved hook elevator, most frequently used, can be performed intraorally and extraorally, but it needs a preauricular stab incision and general anaesthesia and it may damage the facial nerve branches.7
Dong-Kyu Kim et al3 informed aqua splint and suture techique for isolated zygomatic arch fractures with good facial contour and functional results. In addition, percutaneous reduction using a wire suture extraorally was described as a minimally invasive and excellent reduction method.6 However these techniques have a risk of weakness of facial nerve by pressure and may be more complicated compared to the other techniques.3,10
Our method has notable avantages in the management of isolated zygomatic arch fractures. Using of extraction forceps as a reduction instrument allows reduction of the fracture effectively without requiring any other special instrument. Extraction forceps is a blunt equipment so there is low risk of damage to soft tissues and less force is required for elevation of depressed fragment compared to using the elevators. The surgeon can control the force and feel the reduction of fracture easily. However, this technique may not be used for reduction of comminuted arch fractures.


Conclusion

Reduction of isolated zygomatic arch fractures using extraction forceps is a simple, quick and cost effective technique. The patients had good functional, aesthetic and radiological outcomes. So this technique can be preferred for surgical treatment of isolated zygomatic arch fractures instead of complex procedures.
Conflict of interest: The authors declare that they have no conflict of interest.
Funding: No manufacturers provided any support in this study.


References

1. Miloro M, Ghali GE, Larsen PE. Management of Zygomatic Complex Fracture. In: Bailey JS, Goldwasser MS, eds. Pterson\\\'s Principles Of Oral And Maxillofacial Surgery. 2nd ed. London: BC Decker Inc, 2004; pp 445-62.
2. Yamamoto K, Murakami K, Sugiura T, Fujimoto M, Inoue M, Kawakami M, et al. Clinical analysis of isolated zygomatic arch fractures. J Oral Maxillofac Surg 2007; 65: 457-61.
3. Kim DK, Kim SK, Lee JH, Park CH. Aqua splint suture technique in isolated zygomatic arch fractures. Eur Arch Otorhinolaryngol 2014; 271: 707-11.
4. Robiony M, Tenani G, Bellini P, Salgarelli AC. Intraoral Approach for Aesthetic Restoration of Posttraumatic Zygomatic Arch Deformities. J Craniofac Surg 2012; 23: 1418-20.
5. Mezitis M, Stathopoulos P, Rallis G. Use of a Curved Mosquito for Reducing Isolated Zygomatic Arch Fractures. J Craniofac Surg 2010; 21: 1281-3.
6. Giudice A, Colangeli W, Cristofaro MG. Percutaneous reduction of an isolated zygomatic fracture using a wire suture. Br J Oral Maxillofac Surg 2013; 51: 201-2.
7. Zingg M, Laedrach K, Chen J, Chowdhury K, Vuillemin T, Sutter F, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg 1992; 50: 778-90.
8. Krishnan B, El Sheikh MH. Dental Forceps Reduction of Depressed Zygomatic Arch Fractures. J Craniofac Surg 2008; 19: 782-4.
9. Courtney DJ. Upper Buccal Sulcus Approach to Management of Fractures of the Zyogomatic Complex: A Retrospective Study of 50 Cases. Br J Oral Maxillofac Surg 1999; 37: 464-6.
10. Hwang K, Lee SI. Reduction of zygomatic arch fracture using a towel clip. J Craniofac Surg 1999; 10: 439-41.

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