- Email: [email protected]
A splint for the unstable zygomatic arch fracture
British Journal of Oral and Maxillofacial Surgery (1986) 24, 269-271 0 1986 The British Association of Oral and Maxillofacial Surgeons
G.
A SPLINT
FOR THE UNSTABLE
M.
M.B.,
JONES,
B.S.,
B.D.s.,
F.D.S.
F.F.D.,
AND
F.R.A.C.D.S.,
Frenchay Summary. anaesthetic
ZYGOMATIC
Hospital,
B.
ARCH
FRACTURE
SPECULAND*,
M.D.s.,
F.D.s.,
D.O.S.
Bristol
A ease report is presented in which circumferential wires tied over a short length of tubing on the face were used for the fixation of an unstable fracture of the zygomatic arch.
Introduction
Fractures of the zygomatic arch can occur alone or together with fractures of the body of the zygoma. The isolated arch fracture typically presents as a pond-shaped depression on the side of the face accompanied by a ‘V’ shaped radiographic deformity. The depressed arch may limit mandibular movements by impinging on the coronoid process. Rarely, the zygomatic arch may be displaced outwards (Bloem & deMan, 1973). Depressed arch fractures can be reduced from above by the Gillies’ temporal approach or from below via the intraoral route. The majority are stable when reduced because of interdigitation of the bone ends and because the fragments are held in a vertical plane by the temporal fascia above and the attachment of the masseter muscle below. Occasionally such fractures are unstable and require additional support. This paper presents a simple method of overcoming this problem. Case Report A 53 year-old man presented at the Accident Centre, Bristol Royal Infirmary, in November 1984 complaining of limitation of mouth opening after receiving a blow to the left side of the face that morning. Radiographs (Fig. 1) showed a depressed fracture of the left zygomatic arch. The following morning, under general anaesthesia, the fracture was reduced via submento-vertex the Gillies’ temporal approach: However, a post-operative radiograph showed that the fracture of the zygomatic arch was still in a depressed position (Fig. 2). He was readmitted to hospital and returned to the operating theatre 4 days after the first operation. When the depressed zygomatic arch was re-elevated it was found to be quite unstable. A large curved awl was passed under the zygomatic arch from above, exiting on the skin below the arch. The awl was then withdrawn back under the arch after picking up the end of a length of soft stainless steel wire. Two such circumferential wires were placed around the zygomatic arch and tied over a short piece of 8.0 plastic nasoendotracheal tubing* (Fig. 3). The temporal incision was re-sutured. *Portex
Ltd, Hythe, Kent, CT21 6JL., (Received
*Correspondence Birmingham.
to:
Department
U.K
29 May of
Oral
1985; accepted 17 June and
Maxillo-facial
269
198.5)
Surgery,
Dudley
Road
Hospital,
270
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
Fig. I
SURGERY
Fig. 2
Figure 1-Pre-operative occipito-mental radiograph showing depressed fracture of the left zygomatic arch. Figure ~-LOW exoosure submento-vertex radiograph taken after first operation showing unstable depressed left zygomatic arch
I
Fig. 4
Fig. 3 Figure 3-Left
profile view demonstrating position of splint. Figure 4--Occipito-mental taken with splint in place over left zygomatic arch.
radiograph
He made an uneventful post-operative recovery. Radiographs confirmed that the fracture was satisfactorily reduced and splinted (Fig. 4). The tubing and wires were well tolerated and removed 2 weeks later. His mouth opening had returned to normal. Discussion
Isolated fractures of the zygomatic arch represent 2-20X of zygomatic complex
ZYGOMATIC
AKCH
FRACTURE
271
1981). Unstable arch fractures are fractures (van der Wal & de Visscher, uncommon but are more likely to be encountered if treatment has been delayed such that the bone ends become rounded (Gorman, 198O), or if a large segment of the midportion of the arch is displaced medially (Blevins & Gross, 1979). The use of circumferential wires tied over a convenient object on the face is not new. Previous reports have described wires tied over part of an oral airway (van der Wal & de Visscher, 1981) or over a metal eye shield (Blevins & Gross, 1979) and left in situ for one to two weeks. Other methods of fixation include placing a Foley balloon catheter under the zygomatic arch (Podoshin & Fradis, 1974), packing rubber dam under the arch via the temporal fossa (Dingman & Natvig, 1964) and direct wiring (osteosynthesis) (Rowe & Killey. 1968). The passing of an awl and tightening of wires in this region of the face might be expected to damage branches of the facial nerve. However, this complication was not encountered in 119 recalled patients treated for TMJ dysfunction by blind condylotomy, although the awl was passing in a different direction (Banks & Mackenzie, 1975). Other reported complications of circumferential wiring elsewhere on the face include a false aneurysm of the facial artery (van der Akker & van der Lijn, 1974) and a mucous extravasation cyst in the submandibular region (Morton, 1980). The use of wires tied over a piece of anaesthetic tubing to splint an unstable zygomatic arch fracture is recommended as being simple, effective and inexpensive. The present case illustrates that sometimes the fascial attachments of the arch are not sufficient to maintain it in a reduced position. Acknowledgements We would like to thank Mr J. W. Ross. Consultant Oral and Maxillofacial Bristol report this case and the Department of Medical Illustration, photographs.
Surgeon. for permission to Royal Infirmary, for the
References Banks, P. & Mackenzie, I. (1975). Condylotomy: a clinical and experimental appraisal of a surgical technique. Journal of Maxillofacial Surgery, 3, 170. Blevins, C. & Gross. R. D. (1979). A method of fixation of the unstable zygomatic arch fracture. Journal of Oral Surgery, 37, 602. Bloem, J. J. & de Man, K. (1973). Outward displacement of zygomatic arch fractures. Journal of Oral Surgery, 31, 790. Dingman, R. 0. & Natvig. P. (1964). Surgery of Fuciul Fructures. 1st ed. p. 226 Philadelphia & London: Saunders (1980). German, J. M. (1980). Malar fractures: silicone wedge stabilisation. British Journal of Oral Surgery, 17, 244. Morton, M. E. (1980). An unusual complication of circumferential wiring. British Journal of Oral Surgery, 17, 248. Podoshin, L. & Fradis, M. (1974). The use of the Foley balloon catheter in zygomatic arch fractures. British Journal of Oral Surgery, 12, 246. Rowe, N. L. & Killey, H. C. (1968). Fractures of the Facial Skeleton. 2nd ed. p. 325-326. Edinburgh: Livingstone. van der Akker, H. P. & van der Lijn. F. (1974). A false aneurysm of the facial artery as a complication of circumferential wiring. Oral Surgery, Oral Medicine, Oral Pathology, 37, 514. van der Wal, K. G. H. & de Visscher, J. G. A. M. (1981). Fixation of the unstable zygomatic arch fracture. Journal of Oral Surgery, 39, 783.
G.
A SPLINT
FOR THE UNSTABLE
M.
M.B.,
JONES,
B.S.,
B.D.s.,
F.D.S.
F.F.D.,
AND
F.R.A.C.D.S.,
Frenchay Summary. anaesthetic
ZYGOMATIC
Hospital,
B.
ARCH
FRACTURE
SPECULAND*,
M.D.s.,
F.D.s.,
D.O.S.
Bristol
A ease report is presented in which circumferential wires tied over a short length of tubing on the face were used for the fixation of an unstable fracture of the zygomatic arch.
Introduction
Fractures of the zygomatic arch can occur alone or together with fractures of the body of the zygoma. The isolated arch fracture typically presents as a pond-shaped depression on the side of the face accompanied by a ‘V’ shaped radiographic deformity. The depressed arch may limit mandibular movements by impinging on the coronoid process. Rarely, the zygomatic arch may be displaced outwards (Bloem & deMan, 1973). Depressed arch fractures can be reduced from above by the Gillies’ temporal approach or from below via the intraoral route. The majority are stable when reduced because of interdigitation of the bone ends and because the fragments are held in a vertical plane by the temporal fascia above and the attachment of the masseter muscle below. Occasionally such fractures are unstable and require additional support. This paper presents a simple method of overcoming this problem. Case Report A 53 year-old man presented at the Accident Centre, Bristol Royal Infirmary, in November 1984 complaining of limitation of mouth opening after receiving a blow to the left side of the face that morning. Radiographs (Fig. 1) showed a depressed fracture of the left zygomatic arch. The following morning, under general anaesthesia, the fracture was reduced via submento-vertex the Gillies’ temporal approach: However, a post-operative radiograph showed that the fracture of the zygomatic arch was still in a depressed position (Fig. 2). He was readmitted to hospital and returned to the operating theatre 4 days after the first operation. When the depressed zygomatic arch was re-elevated it was found to be quite unstable. A large curved awl was passed under the zygomatic arch from above, exiting on the skin below the arch. The awl was then withdrawn back under the arch after picking up the end of a length of soft stainless steel wire. Two such circumferential wires were placed around the zygomatic arch and tied over a short piece of 8.0 plastic nasoendotracheal tubing* (Fig. 3). The temporal incision was re-sutured. *Portex
Ltd, Hythe, Kent, CT21 6JL., (Received
*Correspondence Birmingham.
to:
Department
U.K
29 May of
Oral
1985; accepted 17 June and
Maxillo-facial
269
198.5)
Surgery,
Dudley
Road
Hospital,
270
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
Fig. I
SURGERY
Fig. 2
Figure 1-Pre-operative occipito-mental radiograph showing depressed fracture of the left zygomatic arch. Figure ~-LOW exoosure submento-vertex radiograph taken after first operation showing unstable depressed left zygomatic arch
I
Fig. 4
Fig. 3 Figure 3-Left
profile view demonstrating position of splint. Figure 4--Occipito-mental taken with splint in place over left zygomatic arch.
radiograph
He made an uneventful post-operative recovery. Radiographs confirmed that the fracture was satisfactorily reduced and splinted (Fig. 4). The tubing and wires were well tolerated and removed 2 weeks later. His mouth opening had returned to normal. Discussion
Isolated fractures of the zygomatic arch represent 2-20X of zygomatic complex
ZYGOMATIC
AKCH
FRACTURE
271
1981). Unstable arch fractures are fractures (van der Wal & de Visscher, uncommon but are more likely to be encountered if treatment has been delayed such that the bone ends become rounded (Gorman, 198O), or if a large segment of the midportion of the arch is displaced medially (Blevins & Gross, 1979). The use of circumferential wires tied over a convenient object on the face is not new. Previous reports have described wires tied over part of an oral airway (van der Wal & de Visscher, 1981) or over a metal eye shield (Blevins & Gross, 1979) and left in situ for one to two weeks. Other methods of fixation include placing a Foley balloon catheter under the zygomatic arch (Podoshin & Fradis, 1974), packing rubber dam under the arch via the temporal fossa (Dingman & Natvig, 1964) and direct wiring (osteosynthesis) (Rowe & Killey. 1968). The passing of an awl and tightening of wires in this region of the face might be expected to damage branches of the facial nerve. However, this complication was not encountered in 119 recalled patients treated for TMJ dysfunction by blind condylotomy, although the awl was passing in a different direction (Banks & Mackenzie, 1975). Other reported complications of circumferential wiring elsewhere on the face include a false aneurysm of the facial artery (van der Akker & van der Lijn, 1974) and a mucous extravasation cyst in the submandibular region (Morton, 1980). The use of wires tied over a piece of anaesthetic tubing to splint an unstable zygomatic arch fracture is recommended as being simple, effective and inexpensive. The present case illustrates that sometimes the fascial attachments of the arch are not sufficient to maintain it in a reduced position. Acknowledgements We would like to thank Mr J. W. Ross. Consultant Oral and Maxillofacial Bristol report this case and the Department of Medical Illustration, photographs.
Surgeon. for permission to Royal Infirmary, for the
References Banks, P. & Mackenzie, I. (1975). Condylotomy: a clinical and experimental appraisal of a surgical technique. Journal of Maxillofacial Surgery, 3, 170. Blevins, C. & Gross. R. D. (1979). A method of fixation of the unstable zygomatic arch fracture. Journal of Oral Surgery, 37, 602. Bloem, J. J. & de Man, K. (1973). Outward displacement of zygomatic arch fractures. Journal of Oral Surgery, 31, 790. Dingman, R. 0. & Natvig. P. (1964). Surgery of Fuciul Fructures. 1st ed. p. 226 Philadelphia & London: Saunders (1980). German, J. M. (1980). Malar fractures: silicone wedge stabilisation. British Journal of Oral Surgery, 17, 244. Morton, M. E. (1980). An unusual complication of circumferential wiring. British Journal of Oral Surgery, 17, 248. Podoshin, L. & Fradis, M. (1974). The use of the Foley balloon catheter in zygomatic arch fractures. British Journal of Oral Surgery, 12, 246. Rowe, N. L. & Killey, H. C. (1968). Fractures of the Facial Skeleton. 2nd ed. p. 325-326. Edinburgh: Livingstone. van der Akker, H. P. & van der Lijn. F. (1974). A false aneurysm of the facial artery as a complication of circumferential wiring. Oral Surgery, Oral Medicine, Oral Pathology, 37, 514. van der Wal, K. G. H. & de Visscher, J. G. A. M. (1981). Fixation of the unstable zygomatic arch fracture. Journal of Oral Surgery, 39, 783.