Facial Trauma, Zygomatic Complex Fractures

Author: Adam J Cohen, MD, Consulting Surgeon, Myers Wyse Center for the Eye; Director,
Center for Facial Rejuvenation
Coauthor(s): Zachary Segal, MD, Staff Physician, Department of Ophthalmology, Washington
National Eye Center; W Scott McDonald, MD, Private Practice, Miami, Florida; Seth R
Thaller, MD, DMD, FACS, FAAP, Professor, Chief, Department of Surgery, Division of Plastic
Surgery, University of Miami School of Medicine

History
Attempts to treat facial fractures were recorded in the 25-30 centuries BC. The Smith Papyrus is
likely the first document in which treatment of several types of zygomatic fractures are
described.
In 1751, du Verney described the anatomy, type of fractures observed, and approach to reduction
in two cases. Recognizing the importance of reduction for proper healing, du Verney took
advantage of the mechanical forces of the masseter and temporalis muscles on the zygoma in his
approach to closed reduction techniques.
In 1906, Lothrop was the first to describe an antrostomy reaching the fractured zygoma through a
Highmore antrum below the inferior turbinate.1 This allowed for rotation of the fractured zygoma
upward and outward for a proper reduction. This transantral approach is known today as the
Caldwell-Luc approach. This method avoids external incisions, with access to the maxillary
sinus for drainage and for debridement of pulverized bone and mucosal debris.
In 1909, Keen categorized zygomatic fractures as those of the arch, the body, or the sutural
disjunction.2 He was the first to describe an intraoral approach to the zygomatic arch via a
gingivobuccal sulcus incision.
In 1927, Gillies was the first to create an incision made behind the hairline and over the temporal
muscle to reach the malar bone.3 Gillies further described the use of a small, thin elevator that is
slid under the depressed bone enabling the surgeon to use the leverage of the elevator to reduce
the fracture. The Gillies method remains in use today to elevate the arch.
Adams recognized the need for greater stabilization in more comminuted fractures and was one
of the first to write of internal wire fixation. This technique, described by Adams in 1942,
remained the mainstay treatment at many institutions for years. A study performed by Dingman
and Natvig demonstrated that many zygoma fractures treated with a closed reduction technique
and then later re-examined were more severe than they had appeared clinically or by
roentgenographic evaluation.4 It appeared that although the fracture was reduced at one point, the
bone became displaced again because of extrinsic forces. Therefore, they concluded that most
displaced fractures of the zygoma should be treated by open reduction and direct wire fixation.

Other advocates of internal wire-pin fixation were Brown, Fryer, and McDowell.5 In their
publication in 1951, they described the use of Kirschner wires, either alone or in combination
with direct wiring, for the purpose of stabilizing middle-third facial fractures.
Osteosynthesis became a reality for facial fractures in the 1970s. The Swiss AO group and
Association for the Study of Internal Fixation developed miniplate fixation. The success of
miniplates was supported further by Michelet et al and others, who continued to develop
techniques for reduction and fixation of facial fractures using miniplates.6 For unstable, displaced
fractures of the zygoma, miniplates were found to efficiently stabilize the bones with minimal
complications. The complications noted were attributed to surgical technique rather than the
plating system.
One can appreciate readily that the treatment of facial fractures has progressed. This article
discusses the most current methods of diagnosis and treatment of zygoma fractures.

Anatomy
The integrity of the zygoma is critical in maintaining normal facial width and prominence of the
cheek. The zygomatic bone is a major contributor to the orbit. From a frontal view, the zygoma
can be seen to articulate with 3 bones: medially by the maxilla, superiorly by the frontal bone,
and posteriorly by the greater wing of the sphenoid bone within the orbit. From a lateral view,
one clearly can see the temporal process of the zygoma join the zygomatic process of the
temporal bone to form the zygomatic arch. Attached to the zygoma anteriorly are the
zygomaticus minor and major muscles, as well as part of the orbicularis oculi muscle. Laterally,
the masseter muscle from below attaches to the zygomatic arch and produces displacing forces
on the zygoma.
Sicher and DeBrul were the first to depict facial anatomy in terms of structural pillars or
buttresses.7 This concept allows consideration of an approach for reduction of midface fractures
and, ultimately, the production of a stable reconstruction. Manson et al have elucidated this
concept further by emphasizing the idea that the mid face is made of sinuses that are supported
fully and fortified by vertical and horizontal buttresses of bone.8
Three principal buttresses need to be considered in midface fractures. The medial or
nasomaxillary buttress reaches from the anterior maxillary alveolus to the frontal cranial
attachment. The second is the pterygomaxillary or posterior buttress, which connects the maxilla
posteriorly to the sphenoid bone. The third is the lateral or zygomaticomaxillary buttress. This
important buttress connects the lateral maxillary alveolus to the zygomatic process of the
temporal bone. These buttresses help give the zygoma an intrinsic strength such that blows to the
cheek usually result in fractures of the zygomatic complex at the suture lines, rarely of the
zygomatic bone.
Fracture lines usually run through the infraorbital rim, involve the posterolateral orbit, and
extend to the inferior orbital fissure. The fracture line then continues to the zygomatic sphenoid
suture area and on to the frontozygomatic suture line. All zygomatic complex fractures involve
the orbit, making visual complications a frequent occurrence.

Another important landmark with respect to zygomatic fractures is the sphenozygomatic junction
(especially laterally displaced fractures). The alignment of the zygoma with the greater wing of
the sphenoid in the lateral orbit is critical for determining adequate reduction of zygomatic
fractures. Reducing the 3 points that make up the buttresses also helps ensure proper alignment
of the zygoma and proper reduction of other facial fractures present. This graduated approach
helps preserve facial height and width.
Lastly, the branches of the fifth and seventh cranial nerves lie within the bounds of the mid face.
Particularly, the temporal and zygomatic branches of the seventh nerve and the
zygomaticotemporal and zygomaticofacial branches of the fifth nerve must be identified
carefully upon surgical dissection of the area to prevent complications of paresis and
paresthesias, respectively.

Classification
In 1961, Knight and North described a classification system of zygoma fractures, hoping to
better determine the prognosis and treatment of these injuries.9
Group I encompassed fractures with no significant displacement. While fracture lines may be
evident on imaging, their recommendation was observation and soft diets. Group II fractures
include isolated arch fractures. Fracture is indicated when trismus or aesthetic deformities are
present.
Unrotated body fractures, medially rotated body fractures, laterally rotated body fractures, and
complex fractures (defined as the presence of additional fracture lines across the main fragment)
belong to groups III, IV, V, and VI, respectively. Knight and North defined these groups by their
stability after reduction. They found that 100% of group II and group V fractures were stable
after a Gillies reduction, and no fixation was required. However, 100% of group IV, 40% of
group III, and 70% of group VI were unstable after reduction and required some form of
fixation.9
A study by Pozatek et al concurred with the findings of Knight and North except for group V
fractures.10 This group was found to be unstable in 60% of cases. Dingman and Natvig studied
patients who were treated by closed methods of zygomatic elevation.4 In a significant number of
patients, they found concomitant fractures along other suture lines and within the orbit after
exposing the site through a brow or lower lid incision. They postulated that these fractures were
overlooked because of the edema and hematomas present at the time of evaluation and reduction.
A significant number of patients suffered from displacement of the zygoma after reduction
without fixation. This displacement recurrence may occur because of masseteric displacing
forces.
Lund found that all group III fractures were stable after reduction, disagreeing with the findings
of Knight and North.11 It now seems apparent that displaced fractures require open reduction and
fixation.

Manson and colleagues have proposed a more modern classification system in which CT scan is
used to assess and classify zygomatic fractures.8 CT provides information about facial structures,
including both bone segmentation and displacement, allowing for complete repair of the
fractures. This system divides fractures into low-energy, medium-energy, and high-energy
injuries.
Low-energy zygoma fractures result in minimal or no displacement. These types of fractures
often are seen at the zygomaticofrontal suture, and inherent stability usually obviates reduction.
Middle-energy zygoma fractures result in fractures of all buttresses, mild-to-moderate
displacement, and comminution. Often, an eyelid and intraoral exposure is necessary for
adequate reduction and fixation.
High-energy zygoma fractures frequently occur with Le Fort or panfacial fractures. The
zygomatic fractures often extend through the glenoid fossa and permit extensive posterior
dislocation of the arch and malar eminence. A coronal exposure, in addition to the oral and eyelid
incisions, usually is necessary to properly reposition the malar eminence.

Biomechanics
While 2-point fixation of zygomatic fractures may be used commonly, it often leaves an axis of
rotation for the zygoma following an adequate reduction. Forces such as the masseter muscle
often displace the zygoma postoperatively. Thus, making the diagnosis and then choosing the
correct approach to establish 3-point fixation and ultimate stability is essential for obtaining a
successful outcome. Since biomechanical properties are of primary importance underlying the
treatment of zygoma fractures, a brief discussion is warranted.
Primary bone healing allows quicker and stronger healing of a fracture than callous healing. A
study by Lin et al reported that rigidly fixated bone grafts maintain their position and volume
better than mobile grafts.12 Furthermore, rigid fixation helps the bone heal by primary processes
rather than by fibroelastic processes. In terms of postoperative stability of a reduced zygoma
fracture, 3-point fixation is undoubtedly best. However, at times, 2-point stabilization is perfectly
adequate.
Some biomechanical models predict downward, backward, and medial rotation of the zygoma
with 2-point alignment. Furthermore, the superiority of miniplates over interfragmentary wiring
is observed only when fewer points of fixation are used. In this study, the authors found that one
miniplate could be used as effectively as 3 points of wire fixation. However, only 5 kg of force
were used in the study (normal sustained forces of up to 50 kg are seen in vivo).
In a study by Rinehart et al, mechanical loads that better approximate the actual sustained forces
observed physiologically were used.13 Deforming forces of this magnitude require at least 2
miniplates (with 1 miniplate stronger than 3 points of wire fixation and slightly weaker than 3
plates).

In a retrospective study by Rohrich et al, rigid miniplate fixation achieved consistently better
malar and global symmetry than did interosseous wires.14 Furthermore, fewer complications
occurred, including infraorbital nerve sensory abnormalities. Long-term experimental studies
demonstrate that miniplates maintain the osseous volume of bone grafts and prevent nonunion at
bone graft contact points better than wires. Rigid fixation with plates and screws is the best form
of bony fixation; it restores 3-dimensional stability and allows for the least amount of motion
between ends of fragments, the main cause of bone resorption and instability.
Presently, several types of microplating systems are available to choose from when rigid fixation
is needed for stabilization. A study by Gosain et al directly compared titanium plates with
biodegradable plate and screws and cyanoacrylate glue fixation systems.15 Titanium miniplates
were the strongest in distraction and compression across a central gap.
However, in many situations, resorbable plates and screws are believed to be adequate. Such
situations may include the presence of primarily compressive forces of relapse and sturdy bone
fragments that can be fixed in direct contact, since forces of relapse are absorbed by bone
fragments and not the fixation system. Resorbable plates and screw fixation systems can be used
when standard titanium midface and microplate systems are believed to be adequate. Resorbable
plates fixed with cyanoacrylate glue may be used if forces of relapse are primarily compressive
and titanium midface or microplate and screw fixation systems are believed to be adequate.

Preoperative Assessment
Although isolated zygomatic complex (ZMC) fractures occur, fractures of this nature are usually
associated with other facial skeletal and soft-tissue injury.
Initially, assessment of a zygomatic fracture in an emergent setting should be directed at
prevention of life-threatening complications including major bleeding, airway compromise,
aspiration, and identification of other fractures. Cervical spine injury should always be
considered if the injury is the result of a high velocity event or if the patient has altered mental
status. Intracranial, thoracic, extremity, and pelvic injuries require proper evaluation and
management.
Once other more pressing injuries have been dealt with and the patient is stable, a thorough
preoperative assessment of facial skeletal architecture can be performed. Symptoms include
paresthesias in the distribution of the maxillary branch of the trigeminal nerve, trismus, diplopia,
and flattening of the zygoma.
Signs classically include subconjunctival and periorbital hemorrhage and hypesthesias in the
distribution of the maxillary branch of the trigeminal nerve. Flattening of the malar eminence,
lateral canthal dystopia, and reduction in mandibular movement may be present. Ipsilateral
epistaxis and buccal sulcus hematomas may occur. Reduced extraocular muscle function,
diplopia, and enophthalmos can occur secondary to orbital floor fractures, resulting in
entrapment of orbital contents.
A thorough ophthalmologic examination is required to evaluate and document ocular status. If a

ruptured globe, retinal detachment, or traumatic optic neuropathy exists, treatment of these
supersedes repair of a ZMC fracture.
Since mandibular fractures are most often associated with ZMC fractures, tooth roots can be
injured, necessitating a thorough intraoral examination.

Imaging
Noncontrast computed tomography (CT scan) with three-dimensional reconstruction is most
commonly used to confirm the presence of a fracture and optimize pre-surgical planning.
Ultrasonography has been used and found to identify lateral orbital wall fractures with high
sensitivity and specificity. Combining this modality with CT allows for excellent visualization of
fractures, leading to maximal perioperative planning and repair.

Management and Surgical Repair

Isolated zygomatic arch fractures
Optimal repair of isolated zygomatic arch fractures is within 72 hours of the injury. Within this
time frame, the arch is easily reduced without the need for internal fixation or external splints.
Arch fractures resulting in decreased mandibular motility can be dealt with via a Gillies temporal
approach or supraorbital approach described by Dingman and Natvig in 1964.4 The temporal
approach allows for surgical reduction of a depressed zygomatic arch while leaving a wellcamouflaged scar within the hairline. Dissection exposes the deep temporalis fascia followed by
creation of a plane between the fascia and temporalis muscle. The lateral eyebrow incision of the
supraorbital approach allows for additional access to the frontozygomatic suture line. A
supraperiosteal dissection plane allows for access to the arch. Both approaches provide safe and
direct access to the zygomatic arch, since the seventh cranial nerve lies above the dissection
planes.
An instrument such a Rowe zygomatic elevator or Kelly clamp is placed beneath the arch. Once
the instrument is properly positioned, the arch is elevated in a superolateral vector taking care to
not use surrounding facial bones as a fulcrum. Proper placement of the instrument can be
confirmed with palpation by the surgeon's free hand placed within the intraoral, posterior buccal
sulcus. A cracking sound is heard when the convexity of the arch is restored with full reduction.
The surgeon should be cognizant of the normal flattening of the middle of the arch. A persistent
protuberance will occur if care is not taken not to avoid fracture overcorrection. The wounds are
closed, and the patient is advised to avoid direct contact to the area for several weeks.
A less popular buccal sulcus approach can used. Masseter muscle bleeding may occur along with
ocular insult if the instrument is placed too high.
Studies by Kobienia et al of intraoperative portable fluoroscopy have demonstrated improved
results with the use of a temporal or supraorbital approach for arch fractures.16 Fluoroscopy

allows for visualization of the arch and confirmation of fracture reduction, reducing the need for
postoperative CT scanning in patients with isolated zygomatic arch fractures.
Zygomatic complex fractures
ZMC fractures are usually repaired with open reduction and internal fixation within 3-4 weeks
following injury. Plating systems are used to fixate the zygomaticomaxillary buttresses,
zygomaticofrontal suture, and zygomatic arch. Osteotomies are indicated for fractures older than
1 month with onlay bone grafting for fractures present for 4 months or longer.
Various approaches to ZMC fractures have been well described in the literature. These include
coronal, eyebrow, upper eyelid, transconjunctival and infraciliary lower eyelid, and maxillary
vestibular approaches. The approach to the ZMC is dictated by the degree of injury and need for
exposure for open reduction and internal fixation.
In most instances, 2 areas of internal fixation are necessary to provide rigidity and satisfactory
malar contour and eminence. The frontozygomatic suture and maxillary buttresses are the usual
fixation points, with plating of the inferior orbital rim when reconstruction of the orbital floor is
necessary.
Many materials, both autogenous and allogenic, are used for plating. Description of these
materials is beyond the scope of this article. Typically, miniplating systems are used for fixation.
When fixating the frontozygomatic suture, the plates should be placed posterior to the orbital rim
to avoid prominence and easy palpation by the patient. The author has used an AlloDerm overlay
to reduce visibility and palpability of orbital rim fixation devices.

Complications
Infraorbital nerve dysesthesia
Fractures of the zygomatic complex frequently result in sensory disturbances in the infraorbital
nerve distribution. These symptoms include dysesthesia of the skin of the nose, cheek, lower
eyelid, upper lip, gingiva, and teeth of the affected side. These arise because fractures generally
occur in the vicinity of the infraorbital foramen and canal. This incidence can range from 5094% with long-term dysfunction of 20-50%, depending on the technique of sensory
measurement.
Several authors have noted significant improvement in sensory function after open reduction and
internal fixation with plates versus a closed reduction technique.17,18,19,20 This does not make
infraorbital nerve dysfunction after a nondisplaced zygoma fracture a sole indication for
exploration and decompression, since sensory function returns in most patients.
Trismus
Trismus is also a common finding (45%), particularly after a fracture involving the zygomatic
arch. It results from impingement upon the coronoid process of the mandible by a depressed

zygomatic arch. This may indicate a need for elevation of the depressed arch, accurate reduction,
and fixation. If new bone has formed in the space below the zygomatic arch and restricts the
movement of the mandible, an intraoral approach for coronoidectomy may be required to permit
mandibular movement.
Diplopia
Diplopia may occur after zygoma fractures for numerous reasons. These include, but are not
limited to, hematoma, muscle injury, motor nerve injury to the extraocular muscles, entrapment
of extraocular muscles, or damage to the fine connective tissue system described by Koornneef.21
In Ellis et al's series of 2067 zygomatico-orbital fractures (1985), diplopia was noted in
approximately 12% of patients.22 Diplopia that occurs after zygoma fractures not associated with
significant orbital floor fractures and entrapment is usually transitory and is probably associated
with hematomas. Barclay reported an 8.4% incidence of diplopia; 60% were transitory.23
A symptomatic diplopia associated with a positive forced duction test and CT evidence of
entrapped muscle or soft tissue with no improvement over 1-2 weeks may be an indication for
surgery. When diplopia is associated with enophthalmos, an improvement in vision can be
predicted after correction of the enophthalmos. Diplopia associated with zygomatico-orbital
fractures may persist longer, and young patients may recover more slowly than adults.
Enophthalmos
A study of over 1000 patients by Zingg et al (1992) demonstrated a 3-4% incidence of acute
enophthalmos. The eye is supported by intramuscular cone fat, a network of intraorbital
ligaments, and the bony orbit. The displacement of orbital contents into an enlarged bony orbit
with subsequent change to a more spherical orbital soft-tissue shape is thought to be the principal
underlying mechanism behind the development of enophthalmos.
The most common causes of enophthalmos include the failure to properly reduce displaced
zygoma fractures and malunited zygoma fractures. Blowout fractures of the orbit, especially
those of the medial wall and those of floor fractures behind the axis of the globe, and highvelocity comminuted fractures involving combinations of lateral wall, posterior floor, and medial
wall fractures are other causes of enophthalmos. Other theories of possible causes of
enophthalmos include fat atrophy, soft-tissue contracture, and fibrosis.
Before surgical correction of enophthalmos, examine the patient to assess visual function,
extraocular eye movement, and the sensory function of the infraorbital nerve. Both thin coronal
and axial slices on CT scans are helpful in determining the extent of orbital damage.
Infection
While an infrequent occurrence, infection is a problem that threatens all postoperative patients. A
study by Zachariades et al of 223 patients treated with rigid internal fixation of facial bone
fractures reported that interosseous wiring resulted in a greater rate of infection when compared
to bone plates.24 While 4.5% of patients suffered from both late and early infection, only 0.8% of

infections were located in the mid face. Sinusitis has been found to be the most common type of
infection seen in postoperative patients; preseptal cellulitis and dacryocystitis also can occur.
Complications with plates and/or screws
Since microplate development in the late 1980s, wire fixation techniques have been used less in
zygoma fractures. However, no matter how well these plates and screws work, occasions exist in
which their removal is required. The usual cause is a palpable plate, although a pain syndrome
may occur. More rarely, infections may occur. Very rarely, screws can fracture into bone and
create problems for removal.
These problems may be limited by a broad availability of drill sizes for use in thin or dense bone.
In a review of 55 patients who had internal fixation devices removed after many types of
craniomaxillofacial surgery, including trauma, Orringer et al found palpable plates and screws to
be the most common reason (35%), followed closely by pain, infection, or loosening of the
fixation device (approximately 25%).25 The authors' experience with complications of fixation of
zygoma fractures is limited mainly to palpable plates and screws at the frontozygomatic suture
and infraorbital rim.

Summary
Zygomatic complex (ZMC) fractures remain the most common facial fracture behind nasal
fractures. Advances in imaging, surgical technique, and materials for fixation have allowed for
improved functional and aesthetic outcomes.
For excellent patient education resources, see eMedicine's Breaks, Fractures, and Dislocations
Center and eMedicine article Facial Fracture.