Closed Reduction (Gilles/Keen) Reduction Zygomatic Arch Fracture

Back To Search

Closed Reduction (Gilles/Keen) Reduction Zygomatic Arch Fracture

Surgical Procedure
Midface and Zygoma Fracture
Trauma
Author Credentials 

Rodolfo E. Manosalva, MD
Clinical Teaching Fellow
Department of Surgery
Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center
Department of Otolaryngology - Head and Neck Surgery
Naval Medical Center Portsmouth
Portsmouth, VA

Module Summary

Fractures of the zygoma are the second most common facial injury after nasal fractures. Incidence and demographics will vary depending on the population studied but overall there is a young male predilection which results mostly from motor vehicle accidents or altercations. Due to the prominent location of the zygoma and its proximity to the orbit and mandible, fractures commonly result in functional deficits and almost always will affect cosmesis and facial contour. Adequate evaluation involves a thorough physical exam and computed tomography (CT) to assess the lines of fracture and position of the bone fragments. Although closed reduction of the zygomatic arch may play a role in the management of complex zygomatico-maxillary fractures, it is mainly indicated in the treatment of isolated fractures of the zygomatic arch. The temporal (Gillies) and transoral lateral vestibular maxillary (Keen) are two well described and time tested techniques for closed reduction of zygomatic arch fractures. Modifications and adjuncts have been reported on these two approaches and it is important to understand the nuances of the procedures so that an individualized approach can be provided. Closed reduction is overall a quick and safe technique with very few complications reported. However, it is important to understand that a cosmetic deficit may persist if proper reduction of the fracture is not achieved through a closed reduction technique.

Module Learning Objectives 
  1. Recognize the signs and symptoms of fractures of the zygomatic arch.
  2. Discuss the indications and approaches used for closed repair of zygomatic arch fractures.
  3. Describe the challenges encountered with closed reduction of zygomatic arch fractures.

Anatomy

Learning Objectives 
  1. Review skeletal anatomy as it relates to fractures of the zygomatic arch.
  2. Describe the anatomy of the soft tissue and fascial planes of the supratemporal fossa and the temporalis muscle.
  3. Recognize the course of the temporal branch of the facial nerve.
References 
  1. Strong EB, Sykes JM: Zygoma complex fractures. Facial Plast Surg. 1998;14(1):105-115
  2. Babakurban S, Cakmak O, Kendir S: Temporal branch of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg. 2010;12(1):16-23
  3. Agarwal CA, Mendenhall SD, Foreman KB, et al: The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125(2):532-537

Pathogenesis

Learning Objectives 

Review the role of forces in disrupting the facial buttresses and the resulting fracture patterns.

References 
  1. Stanley RB: Concepts and classification of craniofacial trauma: biomechanical principles. Facial Plastic Surg. 1988;5(3):193-195

Basic Science

Learning Objectives 

Recognize biomechanical factors as they relate to fracture patterns of the zygoma.

References 
  1. Rhee JS, Posey L, Yoganandan N, et al: Experimental trauma to the malar eminence: fracture biomechanics and injury patterns. Otolaryngol Head Neck Surg. 2001;125(4):351-355
  2. Pappachan B, Alexander M: Biomechanics of cranio-maxillofacial trauma. J Maxillofac Oral Surg. 2012;11(2):224-230

Incidence

Learning Objectives 

Review the incidence or zygomatic arch fractures.

References 
  1. Turvey, TA: Midfacial fractures: a retrospective analysis of 593 cases. J Oral Surg. 1977;35(11):887-891
  2. Ellis E, el-Attar A, Moos KF: An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg. 1985;43(6):417-428

Patient Evaluation

Learning Objectives 

Recognize the signs and symptoms associated with fractures of the zygoma.

References 
  1. Birgfeld CB, Mundinger GS, Gruss JS: Evidence-based medicine: evaluation and treatment of zygoma fractures. Plast Reconstr Surg. 2017;139(1):168e-180e
  2. Ellstrom CL, Evans GR: Evidence-based medicine: zygoma fractures. Plast Reconstr Surg. 2013;132(6):1649-1657

Imaging

Learning Objectives 

Demonstrate an understanding of the role and importance of computed tomography in the evaluation and preoperative planning of zygomatic fractures.

References 
  1. Hopper RA, Salemy S, Sze RW: Diagnosis of midface fractures with CT: what the surgeon needs to know. Radiographics. 2006;26(3):783-793.
  2. Laine FJ, Conway WF, Laskin DM: Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. 1993;22(4):145-188
  3. Griffin JE, Max DP, Frey BS: The use of the C-arm in reduction of isolated zygomatic arch fractures: a technical overview. J Craniomaxillofac Trauma. 1997;3(1):27-31

Treatment

Learning Objectives 
  1. Express the goals of treatment when managing fractures of the zygoma.
  2. Discuss situations in which observation may be appropriate.
  3. Explain the timing of repair for zygomatic fractures.
References 
  1. Ellis, E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 1996;54(4):336-400
  2. Rohrich RJ, Hollier LH, Watumull D: Optimizing the management of orbitozygomatic fractures. Clin Plast Surg. 1992;19(1):149-165
  3. Carr RM, Mathog RH: Early and delayed repair of orbitozygomatic complex fractures. J Oral Maxillofac Surg. 1997;55(3):253-258

Surgical Therapies

Learning Objectives 
  1. Understand the indications for closed reduction of zygomatic arch fractures
    1. impingement on coronoid process of mandible
    2. correction of facial deformity
  2. Describe the surgical approaches used for closed reduction of zygomatic arch fractures
    1. Temporal (Gillies) approach
    2. Transoral (Keen) approach
References 
  1. Ellis E, Zide M. Transoral approaches to the facial skeleton. In: Surgical approaches to the facial skeleton. 2nd ed. Lippincott Williams & Wilkins; 2005. p. 114-121
  2. Ellis E. Fractures of the zygomatic complex and arch. In: Fonseca R, editor. Oral & maxillofacial trauma. 4th ed. St Louis. Elsevier Saunders; 2013. p. 383-388
  3. Cornelius CP, Gellrich N, Hillerup S, Kusumoto K, Schubert W: Indirect approaches to the zygomatic arch (temporal and transoral approaches). Retrieved March 25, 2017www.aofoundation.org

Staging

Learning Objectives 

Review various proposed classifications for fractures of the zygomatic arch.

References 
  1. Ozyasgan I, Gunay G, Eskitascioglu T, Ozkose M, Coruh A: A new proposal of classification of zygomatic arch fractures. J Oral Maxillofac Surg. 2007;65(3):462-469
  2. Honig J, Merten H: Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg. 2004;15(6):986-989
  3. Zingg M, Laedrach K, Chen J, Chowdjury K, Vuillemin T, Sutter F, Raveh J; Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg. 1992;50(8):778-790

Case Studies

References 
  1. A 19-year-old man presents with right facial swelling and pain after being struck in the face with an elbow during a game of basketball. He denies diplopia or difficulty with mouth opening. On exam there is a visible depression of the left zygomatic arch with crepitus on palpation but no depression of the malar region. There is no periorbital swelling or ecchymosis, trismus, or malocclusion. A CT scan confirms an isolated depressed fracture of the right zygomatic arch. The patient is very concerned about the way the side of his face looks and about the possibility of facial scars. How would you counsel this patient? How would you elect to treat this patient?
  2. A 32-year-old man is brought to the emergency room for evaluation of blunt trauma to the face sustained during an altercation. No loss of consciousness is reported. He endorses epistaxis which has now resolved and pain in his left cheek. He denies visual symptoms or malocclusion. Exam demonstrates swelling and ecchymosis over the left malar eminence region with significant tenderness to palpation. A CT scan reveals a left zygomatic arch depression with overlying soft tissue swelling and no other facial fractures. The patient defers to your expertise for a recommendation on how to proceed. How would you elect to treat this patient?

Complications

Learning Objectives 

Describe complications associated with closed reduction of zygomatic arch fractures.

References 
  1. Longmore RB, McRae DA: Middle temporal veins – a potential hazard in the Gillies operation. Br J Oral Surg. 1981;19(2):129-131
  2. Zachariades N, Papavassiliou D: Iatrogenic epidural hematoma complicating reduction of a zygomaticomaxillary complex fracture. J Oral Maxillofac Surg. 1987;45(6):524-525
  3. Hwang K, Kim DH: Analysis of zygomatic fractures. J Craniofac Surg. 2011;22(4):1416-1421
  4. Yamamoto K, Murakami K, Sugiura T, et al: Clinical analysis of isolated zygomatic arch fractures. J Oral Maxillofac Surg. 2007;65(3) 457-461

Review

Review Questions 
  1. List the signs and symptoms of a zygomatic arch fracture?
  2. Discuss the indications for closed reduction of a zygomatic arch fracture.
  3. Describe step-by-step the closed reduction of a zygomatic arch fracture using the temporal approach (Gillies).
  4. Describe step-by-step the closed reduction of a zygomatic arch fracture using the transoral approach (Keen).
    1. List the signs and symptoms of a zygomatic arch fracture?
    2. Discuss the indications for closed reduction of a zygomatic arch fracture.
    3. Describe step-by-step the closed reduction of a zygomatic arch fracture using the temporal approach (Gillies).
    4. Describe step-by-step the closed reduction of a zygomatic arch fracture using the transoral approach (Keen).
References 
  1. Ellis E. Fractures of the zygomatic complex and arch. In: Fonseca R, editor. Oral & maxillofacial trauma. 4th ed. St Louis. Elsevier Saunders; 2013.