- Email: [email protected]
Intra-oral approach for reduction of malar fractures
INTRA-ORAL APPROACH FOR REDUCTION OF MALAR FRACTURES S. BALASUBRAMANIAM,F.D.S.
Withington Hospital, Manchester PREAMBLE OF the malar fractures there are many which require only simple elevations. This may be done either by the classical extra-oral Gillies temporal approach or by the seldom used intra-oral route. Whether it is the only fracture, or is associated with other facial fractures, early reduction is desirable to correct the diplopia, to restore the facial contour and to allow for free movement of the mandible. In addition, the reduction of malar fractures usually hastens the recovery of the facial anaesthesia and corrects the sharp bony edges which may be tender and take a long time to remould, especially in older patients.
FIG. I Pre-operative X-rays.
Anatomically the zygomatic arch has a mesial hollow bordered by the lateral wall of the orbit and the greater wing of the sphenoid and is occupied chiefly by the temporalis muscle in addition to the glandular and fatty subcutaneous tissue. This hollow may be approached from either above or below. In the extra-oral approach the incision is made between the terminal branches of the superficial temporal artery through the fascia to the temporalis muscle and an elevator passed down on the temporalis muscle and under the zygomatic arch. o
I89
19o
BRITISH JOURNAL OF ORAL SURGERY
In the intra-oral approach the incision is about a centimetre in length at the reflection of the sulcus, just distal to the buttress of the zygoma along the length of the buccinator fibres. This is just between the upper first and second molars.
FIG. 2 Post-operative X-ray.
FIG. 3
FIG. 4
FIG. 3--Photograph of operative procedure. FIG. 4--Line drawing to illustrate placement of instrument on skull.
INTRA-ORAL
APPROACH
FOR REDUCTION
OF MALAR
FRACTURES
191
A Howarth's periosteal elevator easily slides up the posterior aspect of the zygomatic mass, so that the end of the elevator lies in the hollow behind it. The application of force upwards and outwards brings the depressed malar fragment into position. With older and resistant fractures the Bristow's, or Rowe's modification of Bristow's, slid up along the Howarth's periosteal elevator enables greater force to be used. One's assistant palpates extra-orally to feel the fragments m o v e into position. With this procedure the access to any point along the arch is quite satisfactory because the elevator easily swings along the inner aspect of the arch, and there is no difficulty in bringing the fractured fragments into position, whether this involves the zygomatic mass as such or any part of the arch. Ironing out comminuted fractures of the arch is also quite simple. Anatomically it is quite safe. On examining the skull it can be seen that it is not possible to enter the orbit, the maxillary sinus, or the pterygoid plexus of veins, because this latter is way behind around the lateral pterygoid muscle and medial to the temporalis. The intra-oral procedure is not only useful in simple depressed malar fractures, or that of the arch, but also when it occurs in conjunction with maxillary fractures. In these instances the malar fracture is manipulated with the other fractures, without having to adopt a separate external entry. DISCUSSION The fractures usually involve more of the zygoma including some of the lateral aspect of the maxilla and less of the arch. So a more anterior component is required of the upward, forward and lateral movement of the fractured malar. By the intra-oral approach force is exerted on the real mass of the malar fragment because of the vertical approach. On the other hand, only the anteroinferior border of the arch is caught by the external approach. This means that less force is required by the intra-oral approach than by the extra-oral, because the force is exerted where it should be, i.e. more at the centre of fractured fragment. With the reduction of force greater accuracy of movement is possible. Besides this, the intra-oral incision is so small that it need not be sutured. No previous preparation of the skin or shaving is required. This is especially important as far as the ladies and the younger generation of boys today are concerned. This procedure is quick, simple and safe. The two questions which have been uppermost in the minds of surgeons are that of: (I) Access; and (2) Infection. The author has not found any difficulty with regard to these. The author and his colleagues in the Maxillo Facial Unit saw 64 pure and simple depressed malar fractures in the last two years. Of these, 29 were cracks with minimum displacement and so were left alone. Of the rest, I7 were elevated by an extra-oral approach and I8 intra-oral. The end-result, has been quite satisfactory in all cases. ACKNOWLEDGEMENTS I amgrateful to Mr. A . IV. Moule, Consultant Oral Surgeon, for all his help and encouragement. I am most indebted to the Departments of Radiology and Medical Illustration and to the Secretary of the Dental Departmem for help given in preparing this article.
Withington Hospital, Manchester PREAMBLE OF the malar fractures there are many which require only simple elevations. This may be done either by the classical extra-oral Gillies temporal approach or by the seldom used intra-oral route. Whether it is the only fracture, or is associated with other facial fractures, early reduction is desirable to correct the diplopia, to restore the facial contour and to allow for free movement of the mandible. In addition, the reduction of malar fractures usually hastens the recovery of the facial anaesthesia and corrects the sharp bony edges which may be tender and take a long time to remould, especially in older patients.
FIG. I Pre-operative X-rays.
Anatomically the zygomatic arch has a mesial hollow bordered by the lateral wall of the orbit and the greater wing of the sphenoid and is occupied chiefly by the temporalis muscle in addition to the glandular and fatty subcutaneous tissue. This hollow may be approached from either above or below. In the extra-oral approach the incision is made between the terminal branches of the superficial temporal artery through the fascia to the temporalis muscle and an elevator passed down on the temporalis muscle and under the zygomatic arch. o
I89
19o
BRITISH JOURNAL OF ORAL SURGERY
In the intra-oral approach the incision is about a centimetre in length at the reflection of the sulcus, just distal to the buttress of the zygoma along the length of the buccinator fibres. This is just between the upper first and second molars.
FIG. 2 Post-operative X-ray.
FIG. 3
FIG. 4
FIG. 3--Photograph of operative procedure. FIG. 4--Line drawing to illustrate placement of instrument on skull.
INTRA-ORAL
APPROACH
FOR REDUCTION
OF MALAR
FRACTURES
191
A Howarth's periosteal elevator easily slides up the posterior aspect of the zygomatic mass, so that the end of the elevator lies in the hollow behind it. The application of force upwards and outwards brings the depressed malar fragment into position. With older and resistant fractures the Bristow's, or Rowe's modification of Bristow's, slid up along the Howarth's periosteal elevator enables greater force to be used. One's assistant palpates extra-orally to feel the fragments m o v e into position. With this procedure the access to any point along the arch is quite satisfactory because the elevator easily swings along the inner aspect of the arch, and there is no difficulty in bringing the fractured fragments into position, whether this involves the zygomatic mass as such or any part of the arch. Ironing out comminuted fractures of the arch is also quite simple. Anatomically it is quite safe. On examining the skull it can be seen that it is not possible to enter the orbit, the maxillary sinus, or the pterygoid plexus of veins, because this latter is way behind around the lateral pterygoid muscle and medial to the temporalis. The intra-oral procedure is not only useful in simple depressed malar fractures, or that of the arch, but also when it occurs in conjunction with maxillary fractures. In these instances the malar fracture is manipulated with the other fractures, without having to adopt a separate external entry. DISCUSSION The fractures usually involve more of the zygoma including some of the lateral aspect of the maxilla and less of the arch. So a more anterior component is required of the upward, forward and lateral movement of the fractured malar. By the intra-oral approach force is exerted on the real mass of the malar fragment because of the vertical approach. On the other hand, only the anteroinferior border of the arch is caught by the external approach. This means that less force is required by the intra-oral approach than by the extra-oral, because the force is exerted where it should be, i.e. more at the centre of fractured fragment. With the reduction of force greater accuracy of movement is possible. Besides this, the intra-oral incision is so small that it need not be sutured. No previous preparation of the skin or shaving is required. This is especially important as far as the ladies and the younger generation of boys today are concerned. This procedure is quick, simple and safe. The two questions which have been uppermost in the minds of surgeons are that of: (I) Access; and (2) Infection. The author has not found any difficulty with regard to these. The author and his colleagues in the Maxillo Facial Unit saw 64 pure and simple depressed malar fractures in the last two years. Of these, 29 were cracks with minimum displacement and so were left alone. Of the rest, I7 were elevated by an extra-oral approach and I8 intra-oral. The end-result, has been quite satisfactory in all cases. ACKNOWLEDGEMENTS I amgrateful to Mr. A . IV. Moule, Consultant Oral Surgeon, for all his help and encouragement. I am most indebted to the Departments of Radiology and Medical Illustration and to the Secretary of the Dental Departmem for help given in preparing this article.