Technical Note

Craniomaxillofacial Trauma &

Reconstruction
1-3
Management of Zygomatic Arch ª The Author(s) 2020
Article reuse guidelines:
Fractures by Intraoral Open Reduction sagepub.com/journals-permissions
DOI: 10.1177/1943387520911866

and Transbuccal Fixation: A Technical journals.sagepub.com/home/cmt

Note

Elavenil Panneerselvam, MDS, MBA, FAM, FDS RCPS(Glasg)1,

Sasikala Balasubramanian, MDS1, Jaghandeep Kempraj, BDS1,
Vijitha Ravindira Babu, BDS1, and V. B. Krishna Kumar Raja, MDS1

Abstract
Fractures of the zygomatic arch are common due to its anatomical prominence. The post-traumatic restoration
of the arch form is important to maintain the midfacial symmetry and anteroposterior projection of the face.
Open reduction and internal fixation (ORIF) of fractured arch is indicated in specific clinical presentations. The
traditional methods of ORIF of zygomatic arch fractures require cutaneous incisions, which are associated with
complications such as scarring and facial nerve injury. This article presents a simple technique of “intraoral
reduction and transbuccal fixation” of the arch that negates the problems associated with the conventional
approaches to ORIF.

Keywords
zygomatic arch fracture, transbuccal, intraoral, fixation

Introduction
Zygomatic arch fractures in isolation or associated with
fractures of other bones are common. The arch is prone
to fracture due to its long and thin structural framework
which projects outside the facial skeleton.1 Restoration of
the arch form is important to maintain the symmetry of
midface and its anteroposterior projection. Most often, they
are managed by closed reduction without any fixation
because of the thick periosteal envelope which holds the
fragments together.
However, open reduction and internal fixation (ORIF)
of the fractured arch is indicated for the following:1
(1) comminuted fractures which are unstable after reduc-
tion, (2) malunited arch fractures, and (3) failed closed
reduction. The traditional methods of ORIF of zygo-
matic arch fractures require either a cutaneous incision,
such as a preauricular incision, or an extensive approach
using a coronal incision, both of which are associated
with potential complications.1 This article presents a
simple technique that negates the problems associated
with the conventional approaches to ORIF of the zygo-
matic arch.
Technique
The procedure was planned for a 26-year-old male patient
who presented with zygomatic arch fracture (Figure 1) fol-
lowing road traffic accident. The patient had reported to our
unit 2 weeks after trauma and required surgical intervention
to treat complaints of facial asymmetry and restricted
mouth opening. Under general anesthesia, the fracture was
exposed using an intraoral vestibular incision which
extended from 13 to 17 regions. Transoral reduction of the
fracture was achieved with a zygomatic elevator. A 2-hole,
1.5-mm titanium miniplate was adapted intraorally across
the reduced zygomatic arch fracture. A stab incision was
placed on the facial skin corresponding to the arch through
1
Department of Oral and Maxillofacial Surgery, SRM Dental College and
Hospital, Ramapuram Campus, Ramapuram, Chennai, Tamil Nadu, India
Corresponding Author:
Sasikala Balasubramanian, MDS, Department of Oral and Maxillofacial
Surgery, SRM Dental College and Hospital, Ramapuram Campus,
Ramapuram, Chennai 600089, Tamil Nadu, India.
Email: elavenilomfs@gmail.com
2 Craniomaxillofacial Trauma & Reconstruction XX(X)
Figure 1. CT demonstrating arch fracture. CT indicates com-
puted tomography.
Figure 2. Transbuccal instrumentation.
which a trocar was introduced to facilitate insertion of a
transbuccal cannula (Figure 2). The miniplate was fixed
transbuccally by inserting 6-mm screws through the can-
nula (Figure 3).
Closure of the intraoral wound was done with 3-0 Vicryl
and transbuccal entry wound with a single, 5-0 Prolene
suture. Postoperatively, the patient demonstrated good
mouth opening, facial symmetry, and an imperceptible scar
on the skin over the zygomatic arch. Postoperative com-
puted tomography taken 4 weeks after the procedure
demonstrated optimal reduction and fixation in axial view
(Figure 4).
Discussion
Restoration of the zygomatic arch anatomy is essential for
aesthetic purpose and functional stabilization of midface.1
The approaches commonly followed to access the frac-
tured arch for open reduction and fixation involve cuta-
neous incisions,1 namely (1) suprazygomatic Dingman’s
incision (above the zygomatic arch and parallel to it),
(2) suprazygomatic arch incision, along the skin crease,
Figure 3. Mini plate fixation on the zygomatic arch.
Figure 4. Postoperative CT taken 4 weeks after fixation—axial
view. CT indicates computed tomography.
(3) preauricular, and (4) coronal. However, these
approaches are associated with limitations; scarring is a
major concern related to all skin incisions.1,2 In addition,
suprazygomatic incisions and preauricular incision pose
potential risks to the facial nerve1 and inability to access
the arch fracture, which is located at the anterior third of
the zygomatic arch (near the zygomaticotemporal suture).
Coronal approach is a relatively extensive procedure
with increased surgical time and blood loss. It is generally
indicated in the management of arch fractures with conco-
mitant midface injuries. The associated risks of coronal
approach are temporal hollowing, scalp numbness, and
facial nerve injury. Further, the resultant scar may lead to
alopecia and unesthetic scarring in bald patients.1
Endoscopic-assisted approach to reduce and fix zygo-
matic arch fractures has been practiced for decades, with
the aim of minimizing surgical morbidity and injury to the
facial nerve. However, the endoscopic access to the arch
also requires incisions which may be restricted to the tem-
poral region or a preauricular incision with a scalp exten-
sion and are associated with 7% to 13% of temporary
Panneerselvam et al.
frontal weakness.3 Further, endoscopic fixation requires
special armamentarium, training, and expertise. Xie et al4
used a modified endoscopic-assisted approach with a pre-
auricular incision but used a different plane of dissection
that negated facial nerve injury. The use of “z instrument”
along with endoscopy has been claimed to facilitate fixa-
tion with better vision and less nerve damage, but the tech-
nique requires 3 cutaneous incisions as well as special
armamentarium.5
Author’s Approach Versus Conventional Approaches
The transbuccal approach is ideal to fix the fractured arch,
which is displaced at the zygomaticotemporal suture or
anterior one-third of the arch. As compared with the other
techniques, the observed advantages of the author’s tech-
nique are as follows: (1) avoiding scarring due to cutaneous
approaches, (2) prevention of facial nerve injury, (3) mini-
mizing blood loss, (4) ease and rapidity of technique, and
(5) facilitates correct angulation of screw placement. How-
ever, a prospective study involving a large sample of cases
would validate the advantages of this technique.
The possibility of facial nerve damage (especially the
temporal branch) during trocar placement may be an aspect
of concern to surgeons. Nerve injury can be avoided using
safe anatomical landmarks, as described by Dahlke and
Murray.6 The temporal branch of the facial nerve lies in
the danger zone, which is bounded by 2 imaginary lines:
inferior line extending from the lateral eyebrow to the ear-
lobe and superior line connecting the tragus to the upper
forehead crease. Introducing the trocar just below this zone
would ensure safe transbuccal instrumentation and protec-
tion of the temporal branch of the facial nerve. Limitation
of the technique includes inadequate access for fixation of
fracture involving the posterior third of the arch, which
may necessitate a preauricular incision.
Conclusion
The management of zygomatic arch fractures by intraoral
open reduction and transbuccal fixation is an effective
3
method to address zygomatic arch fractures. The technique
is simple and less invasive with reduced risk of facial nerve
injury.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Patient Consent
Patient consent was obtained to publish the clinical intraoral
photographs without any patient identification.
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