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The fractured malar
CHARLES B. BINGRAM,
D.D.S., FRESNO, CALIF.
F
RACTURES of the m&r-zygomatic arch complex (Fig. 1) constituted 16 per cent of 497 fractures of the external facial bones treated in the Oral and Maxillofacial Surgery Section of the 98th General Hospital during the four-year period beginning January, 1949. The fractures treated ranged from simple fractures involving depression of the body of the malar to compound, comminuted, multiple fractures involving all the facial bones. The more severe injuries causing the latter type of fractures fortunately are not common. Their treatment is involved and complicated by SO many extraneous factors that it is not within the scope o-f this article to deal with their therapy; rather, it will be my purpose to deal with the more common type of fracture of the malar bone and mention only incidentally the more complicated injuries. The first axiom in treatment of the depressed malar, and perhaps the most important that must be stressed, is: “DO not overlook. these injuries.” Often a person is hit with a ball or fist, runs into a door, or slips and falls on an icy walk, receiving an injury that causes edema and a “black eye,” which mask an underlying fracture of the malar bone. In many instances these patients are seen by a physician or dental surgeon and, after a ca,sue.l examination, are told that the injury is not serious and tha,t no treatment is indicated. Many times roentgenograms are ordered which are inadequate or which are not properly evaluated, and extremely displaced fractures of the malar bone are overlooked. Even in hospitals where the staff is alerted to the possibility of this type of injury, severely displaced fractures have been overlooked until the swelling has subsided and then it is often the pa,tient who calls attention to the facial deformity, the diplopia, or the interference with mandibular function, which are the ordinary results of untreated malar fractures (Fig. 2). Another distressing occurrence is the correct diagn.osis of the injury, but failure to rea,lize its importance and hence failure to afford treatment for the patient. Diagnosis of malar fractures requires the combination of careful clinical examination and adequate roentgenographic views. Clinical examination is best performed with the patient seated and the examiner standing immediately behind the patient. Then, by careful bimanual digital palpation with the thumbs and forefingers, the infraorbital ridges, the lateral wall of the orbit and maxilla, and the zygomatic arch are carefully palpated throughout their external extent. In most malar fractures the fracture line can be located 13
14
CEXARLES
B.
BINUHAM
with Fel.ative ea.se about midwa,y in the ~~l~~~,~r~~~~~l ridge and also in the intera,? wall of the orbit. Often a fracture cannot be definitely ascertained by palpation, hut, by pressing wit’n the index finp?rs at mn7~Rra,hic! points
Fig. Z.--A, Facial deformity resulting ‘Y. The patient was examined shortly La and he was told that no treatment
from depressed after the injury, was indicated.
left malar as seen eight days after but the depression was masked by B, Same patient after treatment.
bilaterally, a depression will be noted on the injured side as compared visua.lly to the uninjured side. Intraoral exa.minntion also is indicated, and many fractures not discovered by extraoral examination will be found by this examination. The
FRACTURED
Il.5
MALWR
index finger is directed into the buccal vault and used to palpate the lateral and posterior walls of the maxilla and the zygomatic process of the maxilla. A fracture line often is evident in this area. Many times, in the absence of marked edema or hematoma, a suspected. fracture of the malar or zygomatie arch ma,y be ruled out by careful digital examination alone, but whenever there is any question of a fracture or where edema makes the clinical examination inadequate, roentgcnographic examination should be undertaken. Three standard views are recommended: (I) posteroanterior view of the facial bones, (2) modified Waters’ projection (Fig. 3), and (3) submento vertex or zygomatic arch view (Fig. 4). Originally, this latter view was not included as part of the routine examination, but it
Fig.
3.--A,
fragment
Preoperative is evident
roentgenogram taken in Waters’ position. in arcas indicated by arrows. B, The smne
Uisplacernent of case, postoperative.
malar
has been found to be invaluable in diagnosis and treatment planning so that Occasionally other views will now it is incorporated in the initial request. be indicated in evaluation of more complicated fractures, and stereoscopic Waters’ projections a.re found to be of utmost value. It should be remembered that roentgenographic and clinical examination are complementary and that either is inadequate alone. M-any cases have been seen that revealed considerable displacement of the malar bone clinically, with little evidence of displacement roentgenographically. The converse is true, also : clinical examination may fail to reveal a fracture, and examination of roentgenograms will identify one. Because of the superimposition of many structures on roentgenograms of the facial bones, esperience is required to evaluate fractures in this area correctly. Good judgment is essen.tial in evaluation of cases to determine those which require treatment. There are occasional cases of minimal depression or
dislocation of m&r-zygoma.tic arch fragments, for which no treatment is indicated. However, if there is any dipl.opia, significant facial deformity, or ktcrfercncc~ with manilibutar function, treatment should be instituted withOIJ!; clelay. Oceasiona,lly, a patient will be observed who does not complain of di~)iopio, but holds his head lo (me side or the other in an attempt to overcome diplopia, which is present -when he is looking st,raightaway Snth patient,s require early treatmen~t.
R. Fig.
4.--A,
Roentgenogmm
illustrating
fractured postoyrrativc.
zygomatic
arch,
preoperative
: R,
same
case,
After the diagnosis has been made, the second axiom in the handling of malar fractures is : “They must be given as early treatment as possible.” The longer the treatment is delayed, the more difficult it will be to effect a
‘Il’RACTURl3D
17
MALAR
gootl reduction and to maintain that reduction, A good rule to follow is to see that all rnalar fra,ctures are reduced as early as possible and not delayed except in those cases beyond seven or eight days from the time of injury, where the patient’s other injuries are o-f such nature as to contraindicate this procedure. In such cases, usually cranioeerebral injuries, active treatment should be instituted at the first practicable moment consistent with the general welfare of the patient, There are many a,pproaches to the treatment of uncomplicated depressed malar fractures, and the proponents of different methods point out the advantages of their preferred methods. As long as a satisfactory result is obtained with as little surgical trauma a,s possible, the approach is unimportant. In fact, the same approach is not applicable to all cases. The important element in treatment is to standardize a, technique for the usual case and become adept in that technique. In my hands the approach accredited to Gillie+ has been found to be the most universally successful in
A. Fig.
5.-A
Malar
elevator held lateral to malar bone to illustrate tration of position of malnr clcvator in reduction
B. relative of fracture.
position;
R,
illus-
reduction of ordinary malar fractures. In this approach, a preauricular incision is made to expose the temporal fascia and a small vertical cut is made Through this incision an Ivy elevator is inserted bethrough the fascia. neath the fascia in such a manner that it rides on the fibers of the temporal muscle. The elevator is advanced in this plane until it is inferior to the malar bone and zygoma,tic arch (Fig. 5). With lateral and superior force directed on the elevator and. digital pressure on the bones externally, the reduction is accomplished and no other treatment is required. Often an audible snap is into an heard as the reduction occurs. A gauze roll ma,y be incorporated elastic head bandage superior to the fracture, so that the weight of the head will be taken off the fra,cture area in the event the patient rolls onto the injured. side during the recovery period, thereby preventing possible postreduction dislocation of the fragments (Fig. 6). In cases that are difficult to reduce or in cases that are more than one week ol.d, it may be necessary to make a small incision over the infraorbitad
Fig.
7:-~--Postrcduction
traction
appliance.
For those fractures which require some form of traction to maintain reduction, a simple method is to insert a pin into the body of the maJar and attach it by traction to a headcap appliance (Fig. 7). l'ra.ction maintained ten to fourteen days is usually adequate.
FRACTURED
MALAR
19
Fig. 8.-Open reduction of malar and sygomatic arch fragments by means of wiring. This procedure was accomplished in this case without extension of existing lacerations.
Fig.
S.--iksults
of untreated
multiple
fractures
of malar-zygomatic
arch
complex.
direct facial
20
CHATZLBX If. lX~Nt.ll‘ABf
The more severe injuries of the malas-zygomatic arch complex arc complicated by numerous compound Pra.ctures. Iii those cases, best treated ea.rl.y, prirriary closure of the soft tissues is indical cd but should not, be peri’nrmwi trntii the nnderlyiug possible. Often, by little,
Fractured
bones
have
bun
positioned
2~swell
as
if any, extension of existing lacerations and minimal surgical trauma, fragments of hone can he identified and fixed in normal position by direct fixation if necessary (Fig. 8). Such procedures can he combined with a.n antrnm pack extending into the oral cavity via a (IaIdwell-Luc opening. The pack facilitates molding and positioning the thin bony fragments of the anterior an.d la’terai walls of the nmxilla into their normal positions, as well a.s the fragments of the rnalar-zygoaratic arch comI)lex. Tf the soft tissues are closed over multiple unreduced fractures in this area and the reduction delayed, a satisPa.ctory conclusion to the ca,se may never be effected. Ilate, refracture and repositioning or tissue implants atternpting to correct the deformity are gratifying,2 but not colnpletely sat%fa,ctory. Facial deformity accompanyin g unreduced fractures of the malnr-zygomatic arch complex causes not only decreased ocular ability and occasionally mandibular interference, but, more important perhaps, it causes extreme trauma to the psychic welfare of the patient (Fig. 9). With these disturbances in mind, it is perha,ps superfluous to add that the patient with a. fractured malar or zygonmtic, a.rch dema.nds early and a.dequate care.
References Fractures of the Malar Zygomatic ComD., Kilner, T. I’., and Stone, D.: a. Description of a New X-Ray Position, Bit. J. Rnrg. i4: 651, ,192~. 2. Dingman, R. O., and Harding, R. IA.: Treatment of Malnnion Fractures of the Facial Bones, Plast. $ Reconstruct. 8urg. 7: 505, :ISFil. 1. Gillies,
II.
pound With
510 Row~r.r,
RT,l>G.
D.D.S., FRESNO, CALIF.
F
RACTURES of the m&r-zygomatic arch complex (Fig. 1) constituted 16 per cent of 497 fractures of the external facial bones treated in the Oral and Maxillofacial Surgery Section of the 98th General Hospital during the four-year period beginning January, 1949. The fractures treated ranged from simple fractures involving depression of the body of the malar to compound, comminuted, multiple fractures involving all the facial bones. The more severe injuries causing the latter type of fractures fortunately are not common. Their treatment is involved and complicated by SO many extraneous factors that it is not within the scope o-f this article to deal with their therapy; rather, it will be my purpose to deal with the more common type of fracture of the malar bone and mention only incidentally the more complicated injuries. The first axiom in treatment of the depressed malar, and perhaps the most important that must be stressed, is: “DO not overlook. these injuries.” Often a person is hit with a ball or fist, runs into a door, or slips and falls on an icy walk, receiving an injury that causes edema and a “black eye,” which mask an underlying fracture of the malar bone. In many instances these patients are seen by a physician or dental surgeon and, after a ca,sue.l examination, are told that the injury is not serious and tha,t no treatment is indicated. Many times roentgenograms are ordered which are inadequate or which are not properly evaluated, and extremely displaced fractures of the malar bone are overlooked. Even in hospitals where the staff is alerted to the possibility of this type of injury, severely displaced fractures have been overlooked until the swelling has subsided and then it is often the pa,tient who calls attention to the facial deformity, the diplopia, or the interference with mandibular function, which are the ordinary results of untreated malar fractures (Fig. 2). Another distressing occurrence is the correct diagn.osis of the injury, but failure to rea,lize its importance and hence failure to afford treatment for the patient. Diagnosis of malar fractures requires the combination of careful clinical examination and adequate roentgenographic views. Clinical examination is best performed with the patient seated and the examiner standing immediately behind the patient. Then, by careful bimanual digital palpation with the thumbs and forefingers, the infraorbital ridges, the lateral wall of the orbit and maxilla, and the zygomatic arch are carefully palpated throughout their external extent. In most malar fractures the fracture line can be located 13
14
CEXARLES
B.
BINUHAM
with Fel.ative ea.se about midwa,y in the ~~l~~~,~r~~~~~l ridge and also in the intera,? wall of the orbit. Often a fracture cannot be definitely ascertained by palpation, hut, by pressing wit’n the index finp?rs at mn7~Rra,hic! points
Fig. Z.--A, Facial deformity resulting ‘Y. The patient was examined shortly La and he was told that no treatment
from depressed after the injury, was indicated.
left malar as seen eight days after but the depression was masked by B, Same patient after treatment.
bilaterally, a depression will be noted on the injured side as compared visua.lly to the uninjured side. Intraoral exa.minntion also is indicated, and many fractures not discovered by extraoral examination will be found by this examination. The
FRACTURED
Il.5
MALWR
index finger is directed into the buccal vault and used to palpate the lateral and posterior walls of the maxilla and the zygomatic process of the maxilla. A fracture line often is evident in this area. Many times, in the absence of marked edema or hematoma, a suspected. fracture of the malar or zygomatie arch ma,y be ruled out by careful digital examination alone, but whenever there is any question of a fracture or where edema makes the clinical examination inadequate, roentgcnographic examination should be undertaken. Three standard views are recommended: (I) posteroanterior view of the facial bones, (2) modified Waters’ projection (Fig. 3), and (3) submento vertex or zygomatic arch view (Fig. 4). Originally, this latter view was not included as part of the routine examination, but it
Fig.
3.--A,
fragment
Preoperative is evident
roentgenogram taken in Waters’ position. in arcas indicated by arrows. B, The smne
Uisplacernent of case, postoperative.
malar
has been found to be invaluable in diagnosis and treatment planning so that Occasionally other views will now it is incorporated in the initial request. be indicated in evaluation of more complicated fractures, and stereoscopic Waters’ projections a.re found to be of utmost value. It should be remembered that roentgenographic and clinical examination are complementary and that either is inadequate alone. M-any cases have been seen that revealed considerable displacement of the malar bone clinically, with little evidence of displacement roentgenographically. The converse is true, also : clinical examination may fail to reveal a fracture, and examination of roentgenograms will identify one. Because of the superimposition of many structures on roentgenograms of the facial bones, esperience is required to evaluate fractures in this area correctly. Good judgment is essen.tial in evaluation of cases to determine those which require treatment. There are occasional cases of minimal depression or
dislocation of m&r-zygoma.tic arch fragments, for which no treatment is indicated. However, if there is any dipl.opia, significant facial deformity, or ktcrfercncc~ with manilibutar function, treatment should be instituted withOIJ!; clelay. Oceasiona,lly, a patient will be observed who does not complain of di~)iopio, but holds his head lo (me side or the other in an attempt to overcome diplopia, which is present -when he is looking st,raightaway Snth patient,s require early treatmen~t.
R. Fig.
4.--A,
Roentgenogmm
illustrating
fractured postoyrrativc.
zygomatic
arch,
preoperative
: R,
same
case,
After the diagnosis has been made, the second axiom in the handling of malar fractures is : “They must be given as early treatment as possible.” The longer the treatment is delayed, the more difficult it will be to effect a
‘Il’RACTURl3D
17
MALAR
gootl reduction and to maintain that reduction, A good rule to follow is to see that all rnalar fra,ctures are reduced as early as possible and not delayed except in those cases beyond seven or eight days from the time of injury, where the patient’s other injuries are o-f such nature as to contraindicate this procedure. In such cases, usually cranioeerebral injuries, active treatment should be instituted at the first practicable moment consistent with the general welfare of the patient, There are many a,pproaches to the treatment of uncomplicated depressed malar fractures, and the proponents of different methods point out the advantages of their preferred methods. As long as a satisfactory result is obtained with as little surgical trauma a,s possible, the approach is unimportant. In fact, the same approach is not applicable to all cases. The important element in treatment is to standardize a, technique for the usual case and become adept in that technique. In my hands the approach accredited to Gillie+ has been found to be the most universally successful in
A. Fig.
5.-A
Malar
elevator held lateral to malar bone to illustrate tration of position of malnr clcvator in reduction
B. relative of fracture.
position;
R,
illus-
reduction of ordinary malar fractures. In this approach, a preauricular incision is made to expose the temporal fascia and a small vertical cut is made Through this incision an Ivy elevator is inserted bethrough the fascia. neath the fascia in such a manner that it rides on the fibers of the temporal muscle. The elevator is advanced in this plane until it is inferior to the malar bone and zygoma,tic arch (Fig. 5). With lateral and superior force directed on the elevator and. digital pressure on the bones externally, the reduction is accomplished and no other treatment is required. Often an audible snap is into an heard as the reduction occurs. A gauze roll ma,y be incorporated elastic head bandage superior to the fracture, so that the weight of the head will be taken off the fra,cture area in the event the patient rolls onto the injured. side during the recovery period, thereby preventing possible postreduction dislocation of the fragments (Fig. 6). In cases that are difficult to reduce or in cases that are more than one week ol.d, it may be necessary to make a small incision over the infraorbitad
Fig.
7:-~--Postrcduction
traction
appliance.
For those fractures which require some form of traction to maintain reduction, a simple method is to insert a pin into the body of the maJar and attach it by traction to a headcap appliance (Fig. 7). l'ra.ction maintained ten to fourteen days is usually adequate.
FRACTURED
MALAR
19
Fig. 8.-Open reduction of malar and sygomatic arch fragments by means of wiring. This procedure was accomplished in this case without extension of existing lacerations.
Fig.
S.--iksults
of untreated
multiple
fractures
of malar-zygomatic
arch
complex.
direct facial
20
CHATZLBX If. lX~Nt.ll‘ABf
The more severe injuries of the malas-zygomatic arch complex arc complicated by numerous compound Pra.ctures. Iii those cases, best treated ea.rl.y, prirriary closure of the soft tissues is indical cd but should not, be peri’nrmwi trntii the nnderlyiug possible. Often, by little,
Fractured
bones
have
bun
positioned
2~swell
as
if any, extension of existing lacerations and minimal surgical trauma, fragments of hone can he identified and fixed in normal position by direct fixation if necessary (Fig. 8). Such procedures can he combined with a.n antrnm pack extending into the oral cavity via a (IaIdwell-Luc opening. The pack facilitates molding and positioning the thin bony fragments of the anterior an.d la’terai walls of the nmxilla into their normal positions, as well a.s the fragments of the rnalar-zygoaratic arch comI)lex. Tf the soft tissues are closed over multiple unreduced fractures in this area and the reduction delayed, a satisPa.ctory conclusion to the ca,se may never be effected. Ilate, refracture and repositioning or tissue implants atternpting to correct the deformity are gratifying,2 but not colnpletely sat%fa,ctory. Facial deformity accompanyin g unreduced fractures of the malnr-zygomatic arch complex causes not only decreased ocular ability and occasionally mandibular interference, but, more important perhaps, it causes extreme trauma to the psychic welfare of the patient (Fig. 9). With these disturbances in mind, it is perha,ps superfluous to add that the patient with a. fractured malar or zygonmtic, a.rch dema.nds early and a.dequate care.
References Fractures of the Malar Zygomatic ComD., Kilner, T. I’., and Stone, D.: a. Description of a New X-Ray Position, Bit. J. Rnrg. i4: 651, ,192~. 2. Dingman, R. O., and Harding, R. IA.: Treatment of Malnnion Fractures of the Facial Bones, Plast. $ Reconstruct. 8urg. 7: 505, :ISFil. 1. Gillies,
II.
pound With
510 Row~r.r,
RT,l>G.