Original

RESEARCH

A comparative study of Upper buccal sulcus approach, Gillies temporal approach & Lateral eyebrow approach for the reduction of the depressed zygomatic arch fracture
Subhash Rai, Aditi Rao, Rajesh Kumar B.P.

Contact Author
Subhash Rai
e-mail: subhash.rai@gmail.com

ABSTRACT
OBJECTIVE: To compare and evaluate Upper buccal sulcus approach, Gillies temporal approach & Lateral eyebrow approach for the reduction of zygomatic complex (arch) fractures. METHODS: Group A will consist of 10 patients treated by upper buccal sulcus approach. Group B will consist of 10 patients treated by the Gillies temporal approach. Group C will consist of 10 patients treated by lateral eyebrow approach. A questionnaire would be given to the operating surgeon containing multiple responses to the questions to evaluate the ease of the approach, relative safety of the approach and the complications associated with the approach. Similarly patient comfort following surgery will be evaluated by a questionnaire given to the patient at the time of discharge. The time taken for the procedure will be recorded from the time of placement of incision to the nal closure. The assessment of postoperative scarring and healing would be made by visual and photographic evaluation on the seventh day postoperatively, one month postoperatively, three months postoperatively. The treatment outcome and satisfactory reduction of fractures will be evaluated radiographically. RESULTS: The upper buccal sulcus approach was signi cantly better than the Gillies temporal approach and the lateral eyebrow approach in terms of time taken for the procedure, force applied for the reduction and with the advantage of no extra oral scar and xation through the same incision. CONCLUSION: The upper buccal sulcus approach is more superior to the Gillies temporal approach and the lateral eyebrow approach. KEY WORDS: Zygomatic arch fracture, Gillies temporal, Lateral eyebrow approach, upper buccal sulcus approach.

ractures of the zygomatic complex are among the most frequent in maxillofacial trauma. e zygomatic complex is responsible for the mid-facial contour and for the protection of the orbital contents. e etiology of zygomatic complex fractures includes road tra c accidents, assaults, and falls, sports and missile injuries.
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Over the years several approaches for the reduction of fractured zygomatic complex including Gillies temporal approach, hook elevation, the upper buccal sulcus approach, the intranasal transantral approach reduction through the sigmoid notch and the modi ed lateral coronoid approach have been put forward.

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Given that all approaches have been the potential of postoperative sequelae, the approach selection must balance perioperative risks with the requirements of treatment. e approach must also be based in part on the ability of the surgeon not only to perform the approach but also to manage the complications that might result from the approach. e goal of any surgical approach in the maxillofacial region is to provide the access necessary to accomplish the primary surgical objective and leave little or no sign that the surgeon has visited this area. AIMS AND OBJECTIVES To compare and evaluate Upper buccal sulcus approach, Gillies temporal approach & Lateral eyebrow approach for the reduction of zygomatic arch fractures. e criteria evaluated are Ease of the approach Relative safety of the approach Time taken for the procedure Patient comfort Post operative healing Complications associated METHODOLOGY Sequential enrolment of 30 patients with zygomaticomaxillary complex fractures reporting from November 2009 to March 2011 to the unit for treatment were evaluated using three di erent approaches:a. Gillies temporal approach, b. Upper buccal sulcus approach and c. Lateral eyebrow anesthesia. Inclusion criteria: 1. Patients with ASA (American Society of Anesthesiology) 1 and relatively healthy ASA class II. 2. Patients with zygomatic fractures requiring surgical intervention. 3. Patients presenting with depressed fractures of ZMC (zygomatic complex). Exclusion criteria: 1. Medically compromised patients not surgery. t for approach under general

Sequence of patient care: On initial presentation, patients were clinically, radiographically evaluated and photographs were taken. Clinical examination included: 1. Extra oral examination in which any laceration, abrasion, edema and area of echymosis on the face were evaluated. Examination also included for any step deformities or bony crepitus in the region of infraorbital rim. 2. Intraoral examination included mouth opening, occlusion, tenderness, step deformity at the Zygomaticomaxillary buttress region. Study design: In this study 30 patients with age ranging 18-50 years with ZMC fractures were included. Preoperative radiographs done were OPG, PNS and SMV views. Among 30 patients, in 10 patients the Gillies temporal approach was used for arch reduction, in 10 patients the lateral eyebrow approach was used for arch reduction and in 10 patients the upper buccal sulcus approach was used. All 30 patients were subjected to routine hematological and biochemical investigations. Patients were explained about the procedure and informed consent was obtained. Surgical approach: e zygoma has four projections, which create a quadrangular shape: the frontal, temporal, maxillary, and the infraorbital rim. e zygoma articulates with four bones the frontal, temporal, maxilla, and sphenoid. A zygomatic complex fracture includes disruption of the four articulating sutures zygomaticofrontal, zygomaticotemporal, Zygomaticomaxillary and the zygomaticosphenoid suture. e zygomatic arch includes the temporal process of the zygoma and the zygomatic process of the temporal bone. e glenoid fossa and articular eminence are located at the posterior aspect of the zygomatic process of the temporal bone. e sensory nerve associated with the zygoma is the second division of the trigeminal nerve. e zygomatic, facial, and temporal branches exit the foramina in the body of the zygoma and supply sensation to the cheek and anterior temporal region. e infraorbital nerve passes through the orbital oor and exits at the infraorbital foramen. It provides sensation to the anterior cheek, lateral nose, upper lip, and maxillary anterior teeth. Muscles of facial expression originating from the zygoma include the zygomaticus major and labii superioris. ey are innervated by cranial nerve VII. e masseter muscle inserts along the temporal surface of the zygoma and arch and is innervated by a branch of the mandibular nerve. e temporalis fascia attaches to the frontal process of the zygoma and zygomatic arch. e fascia produces resistance
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2. Patients not willing or unable to give informed consent. 3. Patients presenting with malunited fractures.

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to inferior displacement of a fractured fragment by the downward pull of the masseter muscle. e position of the globe in relation to the horizontal axis is maintained by Lockwoods suspensory ligament. is attaches medially to the posterior aspect of the lacrimal bone and laterally to the orbital (Whitnalls) tubercle (which is 1 cm below the zygomaticofrontal suture on the medial aspect of the frontal process of the zygoma). e shape and location of the medial and lateral canthi of the eyelid are maintained by the canthal tendons. e lateral canthal tendon is attached to Whitnalls tubercle. e medial canthal tendon is attached to the anterior and posterior lacrimal crests. Gillies temporal approach:

eminence or the infraorbital rim, or both are palpated, the zygoma can be elevated

Pic. 2 - Reduction through the Lateral eyebrow approach.

Courtesy: Surgical Approaches to the facial skeleton, 2nd edition Edward Ellis III & Michael F. Zide, Lippincott William & Wilkins, Philadelphia.

Upper buccal sulcus approach

Pic. 1 - Reduction through the temporal (Gillies) approach.

Courtesy: Carl-Peter Cornelius, Nils Gellrich et al AO Surgery reference, Online reference in clinical life.

A temporal incision (2 cm in length) is made behind the hairline. e dissection continues through the subcutaneous and super cial temporal fascia down to the glistening white deep temporal fascia. e temporal fascia is incised horizontally to expose the temporalis muscle. A sturdy elevator, Rowe zygomatic elevator, is inserted deep to the fascia, underneath the temporal surface of the zygoma. e elevator must pass between the deep temporal fascia and temporalis muscle or it will be lateral to the arch. e bone should be elevated in an outward and forward direction, with care taken not to put force on the temporal bone. e arch should be reduction. e wound is closed in layers while palpating constantly as a guide to proper reduction. Lateral eyebrow approach: A lateral brow incision is performed by rst palpating the frontozygomatic suture. A 1.5 cm incision is made within the con nes of the lateral eyebrow parallel to the superior lateral orbital rim. Dissection is continued through the orbicularis oris and the periosteum to the fracture site. e entire lateral rim can also be explored. An elevator can be passed through the incision to engage the zygoma on its medial surface. When the zygomatic
International Journal of Dental Update 2012;2(1):16-23

Pic. 3 - Reduction through the Upper buccal sulcus approach.

Courtesy: Carl-Peter Cornelius, Nils Gellrich et al AO Surgery reference, Online reference in clinical life.

A horizontal incision is made in the free gingiva about 2 cms over the zygomatic buttress. Howarths periosteal elevator is passed supraperiosteally and acts as a guide for insertion of a Rowes elevator which is oriented under the zygomatic arch or body. e zygoma is elevated into its proper anatomical position in a gentle sweeping motion while the infraorbital margin and frontozygomatic suture are palpated. Intraoperative assessment: Accessibility to the surgical site, ease of the approach, amount of force used for the procedure, bleeding and other complications were assessed through all the approaches. Presence of an audible click during reduction was noted and whether xation could be done was also noted.

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SCAR ASSESSMENT SCALE (1st WEEK )

Table I. Access to site. Table VIII. Scar Assesment 1st Week

SCAR ASSESSMENT SCALE (1st MONTH )

Table II. Force used. Table IX. Scar Assesment 1st Month.

SCAR ASSESSMENT SCALE (3rd MONTH )

Table III. Bleeding encountered.

Table X. Scar Assesment 3rd Month

Table IV. Audible click

Table XI. Patient Satisfaction

Table V. Trauma to globe.

Table VI. Fixation required or not.

Table VII. Time required to access the fracture site

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Postoperative assessment: e assessment of postoperative scarring and healing was made by visual and photographic evaluation on the seventh day post-operatively, one month postoperatively, three months postoperatively. e treatment outcome and satisfactory reduction of fractures was evaluated radiographically. Results and Observations: e study consisted of 30 patients with 28 males & 2 females with age ranging from 18-50 years. Among 30 patients, 15 patients were diagnosed with le sided ZMC fracture, 15 patients with right sided ZMC fracture. e causes of ZMC fractures were found to be road tra c accidents in 18 cases, self fall in 7 patients and other causes in 5 cases. Among 30 patients, 10 fractures were reduced by Gillies temporal approach, 10 fractures were reduced by upper buccal sulcus approach and 10 fractures were reduced by lateral eyebrow approach. Intra operatively the ease of the approach was evaluated as easy, moderate or di cult. e Gillies approach was found to be easy in 7 cases and moderate in 3 cases, the upper buccal sulcus approach was easy in 7 cases and moderate in 3 cases, the lateral eyebrow approach was found to be easy in 4 cases, moderate in 5 cases and di cult in 1 case. e access of the approaches was evaluated as good, moderate or di cult. e access was good in 7 cases and moderate in 3 cases in the Gillies approach, good in 9 cases and moderate in 1 case, in the upper buccal sulcus approach, good in 5 cases and moderate in 5 cases in the lateral eyebrow approach. e amount of force used during the procedure was recorded as being less or more. e amount of force used was less in 8 cases and more in 2 cases in the Gillies approach, less in 10 cases in the upper buccal sulcus approach and less in 3 cases and more in 7 cases in the lateral eyebrow approach. e bleed during the procedure was recorded as being mild, moderate or severe. e bleed was found to be mild in 7 cases and moderate in 3 cases during the Gillies approach, mild in 8 cases and moderate in 2 cases during the upper buccal sulcus approach, mild in 8 cases and moderate in 2 cases during the lateral eyebrow approach. An audible click was noted if present. It was present in 7 cases in Gillies approach, was present in 6 cases each in the upper buccal sulcus approach and the lateral eyebrow approach. Possibility of trauma to the globe by instruments used in the procedure was also recorded. ere was no possibility of trauma to the globe by instruments used in the Gillies approach and the upper buccal sulcus approach but in 2 cases there was possibility of trauma to the globe by instruments used in the lateral eyebrow approach.

Any possibility of injury to the facial nerve or any major artery were also recorded which was present in 1 case in the Gillies approach only. It was also noted that xation could be done through the upper buccal sulcus approach and the lateral eyebrow approach. e average time for the procedures was 73.5 minutes for Gillies approach, 68.5 minutes for the upper buccal sulcus approach and 101.5 minutes for the lateral eyebrow approach. Extra oral scar was also evaluated at 1 week, 1 month and 3 months. ere was no extra oral scar visible in the upper buccal sulcus approach. In the Gillies approach the scar was visible in the rst week but was hidden at the end of the rst and third month.In the lateral eyebrow approach. e scar was visible in all the cases at 1 week and 1 month but was hidden in 6 cases at the third month. Discussion: e etiology of ZMCs includes road tra c accidents, assaults, falls, sports and missile injuries. In western countries, inter personal violence is the commonest cause, whereas in developing countries road tra c accidents result with more facial trauma than any other cause. Other causes of the facial trauma include industrial, accidentals, sports injuries, falls.1,2,3,4 e reason for this is that there is lack of road sense amongst road user, poor condition of the vehicles and roads and increased tra c load. ere is a clear need of educating the road users about the protection measures and necessary seat belt and helmet legislation enforcement, which will decrease the number of maxillofacial injuries including isolated Zygomatic bone fractures.1 In our study we found that 60% of the fractures were due to road tra c accidents, 24% were due to self falls and the rest were due to causes like interpersonal violence and sports injuries. is study results are similar to the previous ndings that most of the fractures are unilateral. Injury to the le side of the face showed more predominance in the cases of trauma due to assaults. is may be due to the fact that majority of the population is right handed.1,4 In our study we found that 50% cases were fractures of right ZMC and 50% were of the le side. e method of treatment varies, depending on the type of fracture, the delay in treatment, the associated injuries (particularly of the globe), the general condition of the patient, and the surgeons armamentarium and experience. As in most surgical endeavors, successful management of the orbital zygomatic complex fracture requires thorough anatomic knowledge to gain excellent exposure to accurately reduce fractures. e approaches described are based on sound surgical precepts. We have tried to compare three approaches that is Gillies temporal
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approach, intraoral approach and the lateral eyebrow approach. ere is no consensus on the employment of the di erent possible surgical accesses to the zygomatic complex. It was considered that less force was required by the intraoral approach than the extra oral approach because the force is exerted where it should be that is more at the centre of the fractured fragment closer and more precise force application by the operator. In the lateral eyebrow approach the elevator is in direct contact with bone so large amount of force can be applied and in more directions.5 We found that less force was required to reduce the fracture with the upper buccal sulcus approach as compared to the other two approaches which was statistically signi cant. It has been said that there is minimal bleeding with the upper buccal sulcus approach.6 While comparing the three approaches we found that there was no statistically signi cant di erence between the three approaches in terms of bleeding during the procedure. Another advantage is that the upper buccal sulcus approach can be performed within minutes.1 e Gillies approach is said to be a quick method for reduction of arch fractures.7,8 e dissection is less in the upper buccal sulcus approach where in an incision is made through the mucosa, sub mucosa and any buccinator bers a er which an elevator can be applied. e buccal pad of fat is rarely encountered as the incision is very small so dehiscence cannot occur during surgery.9 e Gillies temporal approach took more time because more dissection was required comparatively. Following the placement of the incision blunt dissection had to be done to reach the temporal fascia to get the correct plane. In the lateral eyebrow approach a er the incision dissection was carried both sharply and bluntly through the subcutaneous tissues to the bone. Our results show that the mean time for the upper buccal sulcus approach was 68.5 minutes as opposed to Gillies approach which took 73.5 minutes and the lateral eyebrow approach took 101.5 minutes which was statistically signi cant. Similarly the Gillies temporal approach is said to be an easy approach8 and the upper buccal sulcus approach was said to be an easy approach.1 is study shows that in terms of ease all the three approaches were comparable. e use of ORIF approaches in the management of complex maxillofacial fractures o ers many advantages, including easier airway management, improved anatomical alignment and facilitates treatment of the edentulous patient. However, for less complex fractures of the zygomaticofacial skeleton, the case for ORIF remains to be proved. In a recent survey of British maxillofacial surgeons, almost all voiced a preference for traditional methods as their initial choice for management of
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moderately or severely displaced fractures of the zygomatic complex. Unlike any of the previously available surgical options, miniplate xation permits accurate reduction and maintains fracture stability in three dimensions.10 e Gillies method is a closed method and if used alone no xation is provided which is appropriate only for recent fractures of the zygomatic arch and relatively easy ZMC fractures.8 Some authors prefer an initial approach through an intraoral incision, arguing that greater stability is achieved by xing the Zygomaticomaxillary buttress, and only if necessary access the remaining fracture sites. e bone in the buttress region is generally of adequate thickness for the application of bone plate.1 Hence in our study we found that if the fracture was not stable a er reduction we could do miniplate xation through the same incision in the case of upper buccal sulcus approach and the lateral eyebrow approach wherein a er the closed reduction by Gillies approach we had to give a second incision to plate the buttress or the FZ region. Access to the fracture site is considered to be the best through the upper buccal sulcus method.6 Possibility of trauma to the globe was found in only one case in which the lateral eyebrow approach was used. During the surgical approach bleeding was encountered from a major artery in only one case where Gillies approach was used. One of the biggest advantages of the upper buccal sulcus method is absence of an extra oral scar.1 Similarly the advantage of the Gillies temporal approach is that the scar is hidden by the hairline and for the lateral eyebrow approach it is hidden by the brow line.3 Also an additional advantage of the lateral eyebrow approach is that we could gain access to the fracture site in two cases through the pre existing lacerations.5 We assessed the presence of extraoral scar at the end of 1 week, 1 month and 3 months. ere was no extra oral scarring in the upper buccal sulcus approach where as in the Gillies temporal approach it was well hidden by the hair growth by the end of one month. But in cases of the lateral brow approach extra oral scars were visible in four cases. In two of the cases it could be due to the pre existing lacerations. Hence in terms of aesthetics the upper buccal sulcus approach is comparable to the Gillies temporal approach, but both these methods are superior to the lateral eyebrow approach. Another advantage of the upper buccal sulcus approach is that there is no need of placing a skin incision. Hence shaving the hair as in the Gillies approach is unnecessary. e lateral eyebrow approach has its own advantages like incarcerated tissue in the fracture, which may hinder proper reduction, can easily be released and retracted. e
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elevator is in direct contact with bone so large amount of force can be applied and in more directions. As the fracture is directly exposed with this approach an assessment of the anatomical reduction can be made directly and it o ers the opportunity for xation at the time of reduction. For all these reasons the lateral eyebrow is also applicable for old and malunited fractures.5 Postoperative radiographs showed symmetry of the zygomatic complex in all patients. A er resolution of facial swelling and at every follow-up visit, all patients felt that they had facial symmetry. Clinically, this subjective assessment was veri ed visually and by palpation (lack of bony steps, especially at the Zygomaticomaxillary crest. e zygomatic bone was absolutely stable with regard to lateral pressure at the last follow-up date. All patients with zygomatic fractures did not develop secondary diplopia or any ocular motility disturbance. e Gillies approach is by far the most practiced method of elevation.3,11,12 At the end of this study we conclude that the upper buccal sulcus approach proved to be better than the Gillies temporal approach and the lateral eyebrow approach considering the various parameters that we assessed. A thorough knowledge of anatomy, precise approach followed and good postoperative care will de nitely provide excellent results with the upper buccal sulcus approach. SUMMARY & CONCLUSION: Many approaches are available for the treatment of zygomatic fractures but one approach has not been clearly demonstrated to be superior to another. e Gillies approach o ers the advantage of being quick, decreasing the possibility of facial nerve damage or direct trauma to the globe of the eye and not being associated with a visible scar. It can be used for fractures of the zygomatic arch and, in selected cases with no signi cant comminution, for fractures of the Zygomaticomaxillary complex. e lateral eyebrow approach has its own advantages like incarcerated tissue in the fracture, which may hinder proper reduction, can easily be released and retracted. e elevator is in direct contact with bone so large amount of force can be applied and in more directions. For all these reasons the lateral eyebrow is also applicable for old and malunited fractures. e upper buccal sulcus approach has several advantages over it like no skin scar, closer and more precise force application by the operator, and placement of bone plates through the same incision, minimal bleeding, simpli ed antral bone harvest if required and simple mucosal closure. Another advantage is that this approach can be performed within minutes.
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At the end of this study we conclude that, upper buccal sulcus approach is better than the Gillies temporal approach and the lateral eyebrow approach. A thorough knowledge of anatomy, precise approach followed and good postoperative care will de nitely provide excellent results with the with the upper buccal sulcus approach. References: 1. Punjabi S.K, Rehman H, Ali Z, Ahmed S. Causes and management of zygomatic bone fractures at Abbasi Shaheed Hospital Karachi (Analysis of 82 Patients). J Pak Med Assoc 2011;61(1):36-39. Obuekwe O, Owotade F, Osaiyuwu O. Etiology and pattern of zygomatic complex fracture : A Retrospective study. J Natl Med Assoc. 2005;97(7):992-996.

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3. Gomes P.P, Passeria L.A, Barbosa J.R.A. A 5 year retrospective study of zygomatic-orbital complex and zygomatic arch fractures in Sao Paulo State. Brazil J Oral Maxillofac Surg 2006;64:63-67. 4. Hitchin A.D, Shuker S.T. Some observations on zygomatic fractures in the Eastern region of Scotland. British Journal Of Oral Surgery 1973;11(2):114-117. 5. Ogden G.R. e Gillies method for fractured zygomas : An analysis of 105 cases. J Oral Maxillofac Surg 1991;49:23-25.

6. Courtney DJ. Upper buccal sulcus approach to management of fractures of zygomatic complex: a retrospective study of 50 cases. Br J Oral Maxillofac Surg 1999;37:464-466. 7. Pozatek Z.W, Kaban L.B, Guralnick W.C. Fractures of the zygomatic complex : an evaluation of surgical management with special emphasis on the eyebrow approach. J Oral Surg 1973;31(2):141-148. Zachariades N, Mezitis M, Anagnostopoulos D. Changing Trends in the Treatment of Zygomaticomaxillary Complex Fractures: A 12-Year Evaluation of Methods Used. J Oral Maxiilofac Surg 1998;56(10):1152-1156. Schnetler J.F.C. A approach for reducing fractures of the zygomatic complex under local anaesthesia. Br J Oral Maxillofac Surg 1990;28:168-171.

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10. OSullivan S.T, Panchal J, ODonoghue J.M. et al. Is there still a role for traditional methods in the management of fractures of the zygomatic complex? Injury 1998;29(6):413-415. 11. Lund K. Fractures of the zygoma : A follow up study on 62 patients . J Oral Surg 1971;29(8):557-560. 12. Chuong R, Kaban L.B. Fractures of the zygomatic complex. J Oral Maxillofac Surg 1986;44(4):283-288.

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Authors
Subhash Rai Professor, Dept.of Oral & Maxillo-Facial Surgery, Bapuji Dental College & Hospital, Davangere-577004. Aditi Rao PG Student, Dept.of Oral & Maxillo-Facial Surgery, Bapuji Dental College & Hospital, Davangere-577004. Rajesh Kumar B.P. Professor, Dept.of Oral & Maxillo-Facial Surgery, Bapuji Dental College & Hospital, Davangere-577004.

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