RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE

KARNATAKA,INDIA

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT OF DISSERTATION

1 NAME OF THE DR.ADITI UDAY RAO,

CANDIDATE AND POST GRADUATE STUDENT,
ADDRESS(IN BLOCK DEPARTMENT OF ORAL , MAXILLOFACIAL AND
LETTERS) RECONSTRUCTIVE SURGERY,
BAPUJI DENTAL COLLEGE AND HOSPITAL,
DAVANAGERE-577004
KARNATAKA.

2 NAME OF THE BAPUJI DENTAL COLLEGE AND HOSPITAL,

INSTITUTION DAVANAGERE-577004

3 COURSE OF THE STUDY MASTER OF DENTAL SURGERY IN ORAL AND

AND THE SUBJECT MAXILLOFACIAL SURGERY

4 DATE OF ADMISSION TO 20TH APRIL 2009

COURSE

5 TITLE OF THE TOPIC “A COMPARATIVE STUDY OF THREE TECHNIQUES

FOR THE REDUCTION OF THE DEPRESSED
ZYGOMATIC COMPLEX FRACTURES- UPPER
BUCCAL SULCUS TECHNIQUE,GILLIE’S
TEMPORAL APPROACH,LATERAL EYEBROW
INCISION TECHNIQUE”
6 BRIEF RESUME OF THE INTENDED WORK

6.1 Need for the study:

With the advent of faster technology a sudden rise in the maxillofacial trauma has been
noticed. The complexity of maxillofacial region and the physiological aspect associated
with it often leads to confusion in the minds of the maxillofacial surgeon.
One injury that often creates doubt is the fractured zygomatic complex. Over the years
several techniques for the reduction of fractured zygomatic complex including Gillie’s
temporal approach, hook elevation, the upper buccal sulcus technique, the intranasal
transantral approach reduction through the sigmoid notch and the modified lateral
coronoid technique have been put forward.
Elevation of the zygoma can also be accomplished by lateral or coronal eyebrow incision.
In most occasions a combination of these techniques is used for the satisfactory reduction
of fractured zygomatic complex. Though each technique has its own advantages,
keeping the physiological aspect of treatment in mind it is important to find out a
versatile intraoral approach.
The upper buccal sulcus technique was originally described by Keen in 1909.1 In 1927,
Gillie’s described the temporal approach for reduction of the fractured zygoma.2 This
technique has been used by 74% surgeons as reported in a recent survey. Similarly many
surgeons believe that the lateral eyebrow approach is the logical method of initial surgical
management of zygomatic arch fractures. It has been used successfully for many years
even as a outpatient technique under local anaesthesia. However in recent surveys it has
been published that the intraoral approach is a preferred method only in 9% of cases.
Thus there is a need to revisit these three techniques for the management of the fractures
of zygomatic complex and hence the need of this study.
6.2 Review of literature

A retrospective study was conducted on 50 consecutive cases of fractures of the

zygomatic complex reduced by the upper buccal sulcus approach. All were treated with
simple elevation, elevation with intraoral plating at the zygomatic buttress or extra oral
placement of bone plates. In no case was the approach deemed unsuitable or abandoned
in favour of another technique. There was minimal morbidity (one case each of mild
diplopia, trismus and swelling all of which settled spontaneously).The upper buccal
sulcus approach was a safe, rapid and effective technique for the reduction of zygomatic
body and arch fractures.1

In a prospective study, 105 cases were treated using the Gillie’s temporal approach for
fractures of the zygoma. In 97 cases this was sufficient. Only 8 cases required open
reduction. It was suggested that the Gillie’s method should be used more frequently as it
was associated with minimal morbidity and a short duration of general anaesthesia.2

From July 1, 1969, through June 30, 1972, 85 patients with displaced fractures of the
zygomatic complex were treated by the oral surgical service at the Massachusetts General
Hospital. All fractures were grouped according to the Knight and North classification.
The predominant reduction approach was via the lateral eyebrow; 55.8% of all surgical
cases were treated in this fashion. Of the 45 cases that required stabilization, 20 remained
stable after internal wire fixation in the frontozygomatic suture region. 16 cases required
a combined eyebrow and infraorbital approach for stabilization. It is advocated that the
lateral eyebrow approach, with internal wire fixation if necessary, be used as the initial
surgical approach in the management of zygomatic complex fractures.3

A technique was described for reduction of zygomatic complex fractures under local
anaesthetic, intravenous sedation and analgesia on an outpatient basis. The author had
performed this procedure on 20 occasions on a majority of male patients with a mean age
of 30 years. The postoperative amnesia was variable but the procedure was always
acceptable according to the patients. Postoperative recovery was complete in all cases
with eventual resolution of paraesthesia and diplopia. Complications to note were an
early infratemporal infection which was treated by antibiotics and incision and drainage.
However no pus accumulated and the patient had recovered almost completely in 4 days
with only slight residual trismus at 1 week. Another patient suffered respiratory
depression which was quickly recognized and reversed. The procedure was completed,
the patient suffered no ill effects and was discharged the same day.4

A survey was undertaken to investigate the current practises in the UK in the

management of zygomatic fractures. The study was in the form of a questionnaire sent to
210 practising oral and maxillofacial surgeons and completed replies were received from
148 of them. In moderately displaced fractures 69% surgeons preferred Gillie’s
technique, 23% used the hook technique and 8% used the intra oral method. For severely
displaced fractures 74% preferred the Gillie’s technique, 17% used hook technique and
only 9% used the intra oral technique.5

6.3 Objectives of the study

The main aim of the study is to bring to light the effectiveness of this technique.
The criteria evaluated are
1. Ease of the technique
2. Relative safety of the technique
3. Time taken for the procedure
4. Patient comfort
5. Post operative healing
6. Complications associated
7 MATERIALS AND METHODS

7.1 Source of data

30 patients with zygomatic fractures reporting to the Department of oral, maxillofacial

and reconstructive surgery Bapuji Dental college and hospital Davanagere during the
period 2009-2012.

Inclusion criteria:

1. Patients with ASA 1 and relatively healthy ASA class II

2. Patients with zygomatic fractures requiring surgical intervention
3. Patients presenting with depressed fractures of zygomatic complex

Exclusion criteria:

1. Medically compromised patients not fit for surgery

2. Patients not willing or unable to give informed consent
3. Patients presenting with malunited fractures

Study design:

A prospective study of 30 patients with zygomatic complex fractures

7.2 Methods of collection of data

The study will include 30 patients .Each patient will be randomly selected for a
group. The groups will be based on the approaches that would be taken for the
management of depressed zygomatic arch fractures.
Group A will consist of 10 patients treated by upper buccal sulcus approach wherein a
horizontal incision will be placed into the upper buccal sulcus in the region of the second
molar tooth, in the free gingival for a distance of approximately 2 cms over the
zygomatic buttress.
Group B will consist of 10 patients treated by the Gillie’s temporal approach wherein a
straight incision approximately 2.5 cms long will be made at an angle of 30 to 40 degrees
to the horizontal, approximately 1-2 cms anterosuperior to the helix of the ear.
Group C will consist of 10 patients treated by lateral eyebrow approach where in 1.5 cms
curvilinear incision will be made at the lateral inferior portion of the eyebrow.
A questionnaire would be given to the operating surgeon containing multiple responses to
the questions to evaluate the ease of the technique, relative safety of the technique and
the complications associated with the technique.
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 final closure. The assessment of
postoperative scarring and healing would be made by visual and photographic evaluation
on the seventh day postoperatively (t1), one month postoperatively (t2), three months
postoperatively (t3). The treatment outcome and satisfactory reduction of fractures will
be evaluated radiographically.

The results will be verified by the Anova or the Chi square test.

7.3 Does the study require any investigations or interventions to be conducted on

patients or other humans or animals? If so, please describe briefly.

1. Routine blood investigation

2. Orthopantomograph
3. Para nasal sinus view
4. Sub mento vertex view
5. Postero-anterior skull view

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes
Ethical clearance has been obtained and a copy of the same is attached herewith
8

LIST OF REFERENCES

1. 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

2. Ogden GR. The Gillies method for fractured zygomas: An analysis of 105 cases.
J Oral Maxillofac Surg 1991;49:23-25

3. Pozatek ZW, Kaban LB, Guralnick WC. Fractures of the zygomatic complex: an
evaluation of surgical management with special emphasis on the eyebrow approach.
J Oral Surg 1973;31:141-14

4. Schnetler JFC. A technique for reducing fractures of the zygomatic complex under
local anaesthesia. Br J Oral Maxillofac Surg 1990;28:168-171

5.McLoughlin P, Gilhooly M, Wood G. The management of zygomatic complex

fractures-results of a survey Br J Oral Maxillofac Surg 1994;32:284-288