Orbital floor repair and three-point fixation of zygomaticomaxillary complex fractures to restore orbital morphological features and ocular functions: a retrospective observational cohort study

Abstract

Background

Despite numerous investigations on how to manage zygomaticomaxillary complex fractures (ZMCFs), the best treatment option remains uncertain. The purpose of this study was to investigate the efficacy of three-point fixation with orbital floor reconstruction in restoring orbital morphology and managing post-traumatic ocular complications associated with ZMCFs, as well as to measure the postoperative reduction in orbital volume (OV).

Methods

A retrospective observational cohort study was conducted on patients with unilateral ZMCFs and orbital floor fractures with a completely intact contralateral orbit. The primary variable was the efficacy of three-point fixation of ZMCFs with orbital floor reconstruction in reducing enlarged OV and restoring ocular functions. The manual segmentation method was used to measure the OV of both orbits on CT scans. The measurements were categorized into OV_Intact, OV_Fractured, and OV_Repaired. The outcome variables were the percentages of OV difference and OV change between both orbits, the resolution rate of diplopia, the improvement in restricted extraocular muscle movements (EOMs), and the correction of post-traumatic enophthalmos.

Results

The study included 63 patients (mean age: 28.1 ± 2.6 years), with a male predominance of 60.3%. Post-traumatic enophthalmos and diplopia were observed in 49 (77.8%) patients, while restricted EOMs in upward gaze was noted in 33 (52.4%). The treatment protocol significantly reduced the OV_Fractured from 26.8 ± 1.6 cc to 21.9 ± 1.3 cc, achieving a correction rate of 97.3% (p < 0.021). Comparison between OV_Repaired and OV_Fractured showed a 20.12% difference and 18.28% change, whereas comparison with the OV_Intact revealed a minimal asymmetry, with a 2.78% difference, 2.82% change, and a mean volume difference of 0.6 ± 2.3 cc. Ocular complications were significantly resolved, with a p-value < 0.001. Postoperatively, 54 patients had normal globe position, while three showed enophthalmos and six showed exophthalmos. At the end of the postoperative first month, the resolution rate of diplopia and restricted EOMs were 52.4% and 98.4%, respectively. Diplopia was completely resolved at the end of the postoperative third month.

Conclusion

Three-point fixation of zygomaticomaxillary buttresses with orbital floor reconstruction should be considered the standard of treatment for ZMCFs due to its high success rate in restoring orbital morphology and ocular function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-025-03343-4.

Background

Zygomaticomaxillary complex fractures (ZMCFs) occur frequently because the prominent facial position of the zygomatic bone makes it susceptible to fractures. The zygomatic bone prominence also has an important role in social interactions, so any asymmetry caused by ZMCFs has significant aesthetic and functional complications [1]. These complications may involve facial deformities, malocclusion, orbital fractures, and sensory nerve impairments, as well as post-traumatic ocular problems, including traumatic telecanthus, diplopia, eyelid lacerations, and displacement of the eye globe (enophthalmos, hypoglobus, or exophthalmos [2, 3]. A disparity more than two millimeters between orbital contents and orbital volume (OV) is called enophthalmos. Whereas hypoglobus indicates posterior and inferior displacement of the eye globe. Displacement of the eye globe may lead to binocular diplopia and restricted extraocular muscle movements (EOMs) [4, 5].

ZMCFs are managed either conservatively or surgically with open reduction and internal rigid fixation (ORIF) [6]. In terms of ORIF, ZMCFs can be fixed after reduction using two-, three-, or four- points according to the number of zygomatic buttresses which are fixed [7]. It is yet uncertain if increasing the points of fixation for ZMCFs would result in more effective and predictable outcomes [8–10]. It is proved that the three- point fixation, in which ZMCFs are fixed at frontozygomatic suture, inferior orbital rim, and zygomaticomaxillary buttress, provides a three-dimensional stability zygomatic bone, and it also allows addressing orbital floor defects [10]. Although numerous studies have assessed the effectiveness of the three-point fixation technique, the majority of these investigations concentrated on postoperative problems and zygomatic bone stability. To the best of our knowledge, there is no solid evidence that three-point fixation of ZMCFs can restore OV and ocular functioning to their pre-injury state. Furthermore, it is currently underreported to what extent this therapy approach can restore OV. So, this study was conducted to assess the OV difference between the intact and repaired orbits after orbital floor reconstruction and three-point fixation of ZMCFs, in order to assess the effectiveness of this procedure in returning the orbital morphology and ocular functions. The study also aimed to contribute to the body of knowledge on ZMCF management by giving the authors' experience to confirm this treatment strategy to be the first treatment option.

Methods

Study design

A retrospective cohort study was conducted between January 2020 and August 2022. The study involved the review of patient records from Al-Zahraa Educational Hospital, Faculty of Dentistry for Girls, Al-Azhar University, Egypt, for individuals who had undergone treatment for ZMCFs between January 2017 and December 2021. Adults above 18 years who diagnosed with unilateral monofragment ZMCFs (type B) and orbital floor fracture, ZMCFs fixed with titanium miniplates and preformed orbital plates; CT scans obtained one week after trauma and one month after surgery (to allow resolution of soft tissue edema that provides more accurate pre- and postoperative assessment of OV) [11]; and available data on pre- and postoperative enophthalmos were the inclusion criteria. Traumatic telecanthus, ZMCFs corrective procedures, and/or orbital diseases prior to injury were all considered reasons to exclude a case. The patients were also excluded if they had been treated or assessed by different surgical teams or if they had concomitant head and neck fractures, such as mandible, nasal, frontal bone, or superior orbital wall fractures.

Study variables

The effectiveness of three-point fixation of ZMCFs with orbital floor reconstruction in restoring the orbital morphology and resolving post-traumatic ocular complications was the primary variable. The outcome variables were: 1) the change in OV measurements before and after management; 2) the OV difference between repaired and intact orbits; 3) the correction rate and the percent of change between the preoperative and postoperative records; and 4) the improvement in post-traumatic ocular complications after fracture fixation. The three categories for the ocular complications were diplopia, restricted EOMs, and globe displacement, which was classified as no, enophthalmos, or exophthalmos. The globe displacement was calculated by comparing the positions of the eye globes in fractured and repaired orbits to those in intact orbits [12].

Data collection

All files were reviewed to collect and record patients’ demographic data and surgical outcomes as follow:

Measurement of orbital volume (OV)

All axial, coronal, and sagittal views were reviewed (Figs. 1 and 2) and the measurements were performed by two independent investigators who were the same for each patient to estimate the interobserver variability, and the average of their records was documented as a final record. The OV of both orbits was measured on pre- and postoperative CT scans (Siemens, Erlangen, Germany, bony threshold). The OV of intact orbits was measured on both pre- and postoperative CT scans for comparison, then the records of the postoperative scans were marked as OV_Intact. For the fractured orbits, the OV was measured on preoperative CT scans and categorized as OV_Fractured. After surgery, the OV measurements were calculated and recorded as OV_Repaired. The OV_Fractured and OV_Intact were used as a control group to evaluate the efficacy of the study’s treatment protocol.

Fig. 1.

Preoperative CT scans (axial, coronal, and sagittal views) showing a right-side type B zygomaticomaxillary complex fracture (ZMCF) with a trap-door orbital floor fracture, highlighting displacement and orbital volume increase

Fig. 2.

Postoperative CT scans showing three-point fixation of the ZMCF on the right side and restoring orbital morphology and globe position

Using mimic software (Materialise, Leuven, Belgium, version 9), the orbital walls were considered within the following boundaries: a) The anterior aspect of the optic canal was regarded as the posterior boundary of the orbital cavity; and b) The orbital cavity's anterior boundary was defined as the line between the lateral orbital rim and the lacrimal bone. The region of interest was defined by removing and deleting undesirable structures and including those of interest in all three planes (axial, coronal, and sagittal). Then, segmentation was performed from the anterior lacrimal crest to the lateral orbital wall to reconstruct 3D structure. The OV was measured in cubic centimeters (cc) by using the built-in measuring tool of the software. The difference between intact and fractured or repaired orbits was referred to as OV change. The following equations was used to calculate the study’s variables:

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Assessment of globe position

The same ophthalmologist evaluated all patients for posttraumatic ocular problems. They conducted a case history review and full ophthalmic examinations pre- and postoperatively. Each patient was subjected to the following ophthalmic tests: visual acuity test, fundoscopy, ocular motility test, and determining globe displacement. Globe displacement was clinically determined and quantified using the following equation:

The Hertel values were calculated by measuring the distance from the lateral orbital rim of the examined eye to its corneal apex using Hertel exophthalmometer (Oculus Inc, Wetzalr, Germany). No globe displacement was taken into consideration if the equation's results were ranged from zero to less than 2 mm. Enophthalmos, a sign of posterior globe displacement, was noted if the results were greater than 2 mm. Exophthalmos, which denotes anterior displacement of the eye globe, was recorded if the Hertel values of the fractured or repaired orbits were greater than those of the intact orbits.

Assessment of eye globe functions

Diplopia was identified by taking a case history, and if the patients reported it, they were asked if it disappeared after closing one eye during the visual acuity test. To detect restricted EOMs and gaze direction at which diplopia was present, patients were instructed to cover the unaffected eyes and maintain their heads motionless while moving their affected eyes to follow the ophthalmologist's finger. To the left, right, and center, the ophthalmologist moved the testing finger up and down in a modified “H” pattern [13].

Surgical managements

All patients were treated surgically under general anesthesia with endotracheal intubation. All fractures were fixed via three-point fixation of ZMCFs with orbital floor reconstruction. Maxillary vestibular approaches were used to repair maxillary-zygomatic buttresses, lateral lower brow incisions to approach zygomatico-frontal sutures, and subciliary incisions to access inferior orbital rims and orbital floors. Subperiosteal reflection was then performed to expose bony segments. Bony hooks or periosteal elevators were used to elevate displaced bone fragments and restore them to their proper positions. To compare the two zygomas, the zygomatic reduction was observed from behind the patient to the zygomatic projection on both sides. Miniplates (2.0 mm) were used at the inferior orbital rim, zygomatico-frontal suture, and zygomatic buttress to stabilize the zygoma (Fig. 3). Then, the orbital floor was restored using a prefabricated titanium plate. The forced duction test was used to assess limits in eye movements following plate fixation. Additionally, we examined the horizontal position and protrusion of both eyes to identify any asymmetry. Periosteal wounds were repaired using 3–0 vicryl interrupted sutures. Running sutures were used to reposition the vestibular incisions using 3–0 vicryl suture material. Finally, skin incisions were closed with subcuticular sutures, which were removed after 3 days.

Fig. 3.

Intra-operative pictures demonstrating ZMMCFs at zygomaticomaxillary buttress and inferior orbital rim

Follow-up

The patients were monitored weekly for the first month and then monthly for the next three months. All patients had their surgical wounds checked for healing. Ophthalmic outcomes were assisted at the end of the postoperative first and third months. The glob displacement was clinically evaluated at the end of the third month following surgery with a Hertel exophthalmometer.

Statistical analysis

All the data were analyzed using SPSS software version 25.0. The descriptive data were formulated as a percentage and mean ± standard deviation. A paired t-test was used to compare changes in the mean volume before and after surgery. The results obtained by the two observers were analyzed using the Pearson correlation test, and the interobserver variability was calculated by calculate the intraclass correlation coefficient (Two- way random effect ICC). P-values less than 0.05 were considered significant at 95% confidence interval (CI). ICC of 0 indicates no agreement, 1 denotes perfect agreement, and values above 0.75 indicates a good agreement.

Human ethics and consent to participate declarations

This retrospective study was approved by the Dental Ethics Committee of the College of Dentistry, Qassim University (reference number: EA/F-2020–3009). The study adhered to all principles outlined in the Helsinki Declaration (2024). Clinical trial number was not required because of the retrospective design of the study and does not include clinical trial. The Institutional Review Board waived the need for written informed consent, as the study utilized clinical data collected during routine medical care. An opt-out approach was implemented to ensure that participants and their guardians could decline the use of their clinical information for research purposes.

Results

Demographic data

Out of 130 files, sixty-three fulfilled the study's inclusion criteria; Table 1 displays the patient demographics, clinical, and radiographic characteristic. Patients ranged in age from 20 to 55 years, with an average age of 28.1 ± 2.6 years. The female to male ratio was 1:1.5, indicating male predominance. Road traffic accidents were the leading cause of ZMCFs, followed by first or second floor falls and sports-related injuries. The intact orbits had a maximum OV of 23.8 cc, while the fractured orbits had a maximum OV of 28.9 cc. There was an insignificant volume difference between the two records of intact orbits, with a mean volume difference of 0.2 ± 0.5 cc and a p- value of 0.9. As a result of trauma, there was a significant volume difference between the OV_Fractured and the OV_Intact, with an average of 5.5 ± 2.3 cc, a p-value below 0.0001, a change percentage of 25.82, and an increase percentage of 22.87 (Table 2).

Table 1.

Preoperative patients demographic data

Variables	Descriptive Data
Age (In years):
▪ Mean ± SD	28.1 ± 2.6
▪ Range	20- 55
Sex (n, %):
▪ Male	38 (60.3%)
▪ Female	25 (39.7%)
Races (n, %):
▪ Middle East Arabians	36 (57.1%)
▪ Asian	19 (30.2%)
▪ Others	8 (12.7%)
Side (n, %):
▪ Left	29 (46%)
▪ Right	34 (54%)
Cause (n, %):
▪ Road Traffic Accidents	38 (60.3%)
▪ Falls	12 (19.1%)
▪ Sports Injuries	13 (20.6%)
Signs and Symptoms (n, %):
▪ Diplopia	49 (77.8%)
▪ Restricted EOMs*	33 (52.4%)
▪ Infraorbital nerve affection	25 (39.7%)
▪ Periorbital hematoma	57 (90.5%)
▪ Subconjunctival hemorrhage	61 (96.8%)
▪ Visual Defect	4 (6.3%)
Radiographic orbital floor findings (n, %):
▪ Displaced orbital floor fracture	48 (76.2%)
▪ Trap-door orbital fractures	15 (23.8%)
Timing of surgery (in days):
▪ Mean ± SD	13.21 ± 1.55
▪ Range	10- 15
Means of fixation:
▪ Orbital floor	Prefabricated orbital floor titanium miniplate
▪ Buttress	2.0 mm titanium miniplate

n Patients number, SD Standard deviation; and EOMs^* Extraocular muscle movements

Table 2.

Orbital volume (OV) changes in fractured orbits relative to intact and repaired orbits

Variable	Parameter	Records (In cc)	Volume Difference Mean ± SD (In cc)	Percentage of Difference	Percentage of Change	T- Test
						t- value	P- value
Volumetric Measurements of Orbits	OVIntact Mean ± SD Range	21.3 ± 1.9 19.7—23.8	---------	---------	---------	---------	---------
	OVFractured Mean ± SD Range	26.8 ± 1.6 23.8—28.9
	OVRepaired Mean ± SD Range	21.9 ± 1.3 19.9—23.5
OVFractured Versus OVIntact	OVFractured	26.8 ± 1.6	5.5 ± 2.3	22.87%*	25.82%	~ 18.98	< 0.0001
	OVIntact	21.3 ± 1.9
OVFractured Versus OVRepaired	OVFractured	26.8 ± 1.6	4.9 ± 0.9	20.12%#	18.28%	~ 43.2	< 0.0001
	OVRepaired	21.9 ± 1.3
OVRepaired Versus OVIntact	OVRepaired	21.9 ± 1.3	0.6 ± 2.3	2.78%*	2.82%	~ 2.7	< 0. 021
	OVIntact	21.3 ± 1.9		Correction Rate: 97.3%

OV Orbital volume, CC Cubic centimeters, SD Standard deviation

*: A percent of increase; and ^#: A percent of decrease

Surgical results

The postoperative surgical results showed that all ZMCFs and surgical wounds healed without challenges, with the exception of sixteen patients. The following complications were noted in 16 patients: three patients experienced a postoperative infection that included wound dehiscence and plate exposure at the intraoral vestibular incisions; five patients experienced temporary infraorbital nerve paresthesia following surgery; and eight cases developed lower eyelid ectropion and sclera show, which resolved within six months. Nevertheless, soft tissue healing proceeded rapidly after the administration of antibiotics and good dental hygiene, and all exposed plates had soft tissues replaced on them in three months.

Orbital volume restoration

A significant correlation was found between the two observers' OV measurements; all r- values fell between 0.96 and 0.98, and p < 0.001. The findings also showed a high level of interobserver agreement, with ICC values at 95% CI ranging from 0.81 to 0.89 (Table 3). The treatment significantly reduced orbital volume in fractured orbits, restoring it close to the intact orbit’s volume, with all p values less than 0.05. As shown in Table 2, the mean OV_Fractured reduced from 26.8 ± 1.6 cc to 21.9 ± 1.3 cc. The mean volume differences between the OV_Fractured and OV_Repaired were 4.9 ± 0.9 cc, with a 20.12% drop and a 18.28% change (p value < 0.0001). The results also revealed a mean volume difference between OV_Repaired and OV_Intact of 0.6 ± 2.3 cc, with a correction rate of 97.3%, a 2.78% increase, and a 2.82% change. These results were statistically significant with p value less than 0.021.

Table 3.

Interobserver variability test and Pearson’s correlation coefficient for orbital volume (OV) measurements

OV Measurements	Intraclass correlation coefficient (ICC)	95% Confidence Interval (CI)	r	P-value
OVIntact	0.87	0.25—0.91	0.97	< 0.001
OVFractured	0.81	0.03—0.95	0.98	< 0.001
OVRepaired	0.86	0.04—0.96	0.96	< 0.001

OV Orbital volume, ICC Intraclass correlation coefficient, CI Confidence interval, r Pearson’s correlation coefficient

Ophthalmic results

The results showed that the post-traumatic ophthalmic complications were significantly improved in all patients (Table 4). By the end of the postoperative third month, the enophthalmos of 46 patients (73.02%) out of 49 were completely corrected, resulting in a zero Hertel value. In the remining three patients (4.8%), their Hertel value was significantly reduced with p- value was less than 0.05. They had enophthalmos ranged from 0.3 mm to 0.5 mm with a mean of 0.4 ± 0.1 mm. The remaining of patients (6 subjects, 9.5%) developed exophthalmos ranging between 0.2 mm and 0.7 mm. Both of enophthalmos and exophthalmos had no effect on ocular functions and were not clinically noticed.

Table 4.

Ophthalmic outcomes in relation to ocular signs and symptoms before surgery

Variables	Preoperative	Postoperative	Statistical Test
Globe Displacement* (n, %):			Chi-square	P
▪ Normal	14 (22.2%)	54 (85.7%)	51.12	< 0.00001
▪ Displaced:	49 (77.8%)	9 (14.3%)
• Enophthalmos	49 (77.8%)	3 (4.8%)
• Exophthalmos	-----	6 (9.5%)
Quantitative Measurements of Enophthalmos:			Paired t-test	P
▪ Mean ± SD (mm)	3.26 ± 0.39	0.4 ± 0.1	50.58	< 0.00001
▪ Range (mm)	2.4- 3.8	0.3—0.5
▪ Measures:
< 0.3	14 (22.2%)	2 (3.2%)
≥ 0.3	35 (55.6%)	1 (1.6%)
Quantitative Measurements of Exophthalmos:			NA
▪ Mean ± SD (mm)	---------------	0.4 ± 0.2
▪ Range (mm)		0.2—0.7
▪ Measures:
< 0.3		4 (6.3%)
≥ 0.3		2 (3.2%)
Diplopia (n, %):	49 (77.8%)	16 (25.4%)	Chi-square	P
▪ Resolution Rate at the end of the first month	----	52.4%	34.61	< 0.00001
▪ Resolution Rate at the end of the third month	-----	100%
Restricted EOMs^ (n, %):	33 (52.4%)	1(1.6%)#	Chi-square	P
▪ Resolution Rate at the end of the first month		98.4%	41.25	< 0.00001

 n Patients number, SD Standard deviation, EOMs^ Extraocular muscle movements, NA None applicable

^*The eye ball position was measured one week after trauma and at the end of the postoperative third month;

^#Correction surgery was performed to correct limitations in eye movement

Forty- nine patients had diplopia preoperatively, which was resolved in 33 patients at the end of the first month with a resolution rate 52.4%. The diplopia was completely disappeared in all patients by the end of the postoperative third month. All patients experienced the recovery of eye movements in all directions, except for one who was unable to raise his eye upward. The restricted EOMs had been resolved with a resolution rate of 98.4%.

Discussion

Successful repair of ZMCFs is crucial for both function and aesthetics, yet there is no consensus on optimal management [10–12]. Restoring preinjury OV is key for good outcomes [13, 14], but data on how treatment affects OV differences between both orbits are lacking. This study aimed to quantify OV reduction using three-point fixation with orbital floor reconstruction and to evaluate its effectiveness in restoring orbital morphology and addressing post-traumatic ocular issues.

Assessment strategy

A number of strategies, including clinical and radiographic evaluations, have been described to assess the postoperative results of the surgical approach utilized for managing ZMCFs [15]. OV measurements are used to assess ZMCFs’ treatment outcomes as reported by many studies [16–18]. Most of these studies advocated the use of postoperative CT scans to record the volume difference between both orbits. Our study found insignificant OV difference (0.2 ± 0.5 cc) in OV_Intact between pre- and postoperative CT scans. While some authors [17] reported no difference, our results align with Chepurnyi et al., [6] who noted deviations up to 1 cc. This discrepancy may be owed to manual segmentation method, which is the most examiner-dependent and variable tool for OV assessment. Nevertheless, our study found that the manual segmentation method provides a reliable indirect estimate of the OV. In line with earlier research [19–22], the interobserver tests demonstrated great reliability and repeatability of CT-based OV measures, with ICC values of 0.81—0.89 (all values above 0.75) and significant correlations between observers (r = 0.96—0.88, p < 0.001). However, the wide 95% confidence intervals (0.03—0.95) suggest some imprecision, which could be due to small sample size and data variability.

Effectiveness of the study treatment protocol

Restoring orbital volume

The overall difference between the intact and fractured orbits is 22.87%, with the fractured orbit being 25.82% larger, indicating a marked asymmetry. After surgery, the OV_Repaired values (mean: 21.9 ± 1.3 cc) are restored to the normal adult range of 16—30 cc. This demonstrates that the study’s treatment protocol has a proved highly effectiveness, achieving a 97.3% correction rate. The volumetric analysis also shows that the OV_Repaired is significantly smaller than the OV_Fractured (26.8 ± 1.6 cm³), with an 18.28% reduction, indicating effective volume restoration. Similar encouraging results have also been reported by other researchers [23, 24].

Compared to OV_Intact (21.3 ± 1.9 cm³), the OV_Repaired is slightly larger by 0.6 ± 2.3 cc, showing a minimal asymmetry of 2.78%. Nevertheless, this difference lies in the normal variations between left and right orbits in the same person. Many authors [25] reported a range of 0.01 to 1.9 cc between the right and left orbital volumes in an individual. Numerous factors, such as anatomical differences [4, 16], CT scan quality, slice thickness, type of cut, and methods used to identify orbital boundaries, especially anterior boundaries, could be the cause of this volume difference between the two orbits [23]. Issues pertaining to those aspects have not yet been resolved [19–21].

Resolving ocular complications

Post-traumatic ocular complications result from the displacement of orbital contents into paranasal sinuses, increased OV, atrophy of the orbital fats, or inadequate fixation of orbital fractures [26, 27]. Our study’s results illustrated that its treatment protocol is significantly resolve the post-traumatic ocular problems, which are in align with the results of other studies [26–28]. It was reported that increased OV and extraocular muscle entrapment are the main cause for post- traumatic globe displacement and diplopia [29]. In our study, the resolution rate was 100% for diplopia at the end of the postoperative third month. Regarding the restricted EOMs, the correction rate is 98.4% with one patient has limited movement in the upward gaze.

Out of 63 patients, nine individuals had eye globe displacement. Three of those patients had postoperative enophthalmos, nevertheless the study's treatment strategy is effective in reducing the Hertel values of the enophthalmos (0.3 to 0.5 mm). The remaining six patients (9.5%) developed exophthalmos after surgery. Fortunately, there were no visible clinical evidence of enophthalmos or exophthalmos, and vision was completely unaffected. The favorable ocular results, in our study, could be due to its treatment protocol. This is in align with Widodo et al., [15] who found that three-point fixation improves enophthalmos outcomes by enabling three-dimensional reduction and enhancing zygomatic bone stability through its three sutures (sphenozygomatic sutures, zygomaticomaxillary sutures, and zygomaticofrontal sutures). Thus, as reported by others [15], proper ZMCF reduction and fixation are essential for restoring OV and improving ocular functions.

Orbital floor reconstruction is another factor that aids in improvement of posttraumatic ocular complications. This is in agreement with other authors who reported that the orbital floor reconstruction has positive functional and aesthetic effects, especially for enophthalmos [30]. On the other hand, other authors [31] found no discernible difference between ZMCFs repair with orbital floor reconstruction and ZMCFs repair without orbital floor repair in terms of the short-term ophthalmologic outcomes which indicates that the points of ZMCFs of fixation have the greatest role in resolving the post-traumatic complications via restoring the OV.

Despite several advantages of the study’s treatment option, it appeared to have some drawbacks, including significant periosteal stripping, severe bone edge retraction, and the need for professional assistance when applying miniplate across the zygomatico-maxillary buttress. Other drawbacks included a longer operating time, the presence of more hardware, and higher surgical costs are also recorded. Many authors also documented the same findings [32].

Study limitations and strengths

The study has some limitations, such as its retrospective design, and it does not adhere to the favorable comparative study design, which compares between various treatment options. Nevertheless, the study has the following strength points: 1) the study involves self-control from each patient, which strengths the validity of its conclusions and could address the limitation of its non-comparative design; 2) the same surgeon operated on every patient, and the same investigators performed every measurement; and 3) the study performed at a single institution.

Conclusion

Base on the results of the study, the three-point fixation of ZMCFs with orbital floor reconstruction is able to restore normal OV and reduce the volume difference between intact and repaired orbits up to 0.6 ± 2.3 cc. Therefore, we recommend three-point fixation with orbital floor reconstruction as the primary treatment for ZMCFs to restore pre-injury orbital morphology and achieve reliable surgical outcomes for associated ocular complications.

Abbreviations

OV

Orbital volume

ZMCFs

Zygomatic complex fractures

ICC

Intraclass correlation coefficient

CI

Confidence interval

Authors’ contributions

Ghada Amin Khalifa: Conceptualized and designed the study, collected data, performed statistical analysis, and drafted the manuscript. Gharam Mefleh Alharbi: Contributed to data interpretation, critically revised the manuscript for important intellectual content, and approved the final version. Khalid Zabin Alotaibi: Supervised the research process, provided guidance during study development, and reviewed and approved the final manuscript. All authors meet the ICMJE criteria for authorship and agree to be accountable for all aspects of the work.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was conducted using the authors’ own institutional resources without external financial support.

Data availability

The data used to support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This retrospective study was approved on April 19, 2023, by the Dental Ethics Committee of the College of Dentistry, Qassim University (reference number: EA/F-2020–3009). The study adhered to all principles outlined in the Declaration of Helsinki (2024). The Institutional Review Board waived the requirement for written informed consent, as the study utilized clinical data obtained during routine medical care. An opt-out approach was implemented to ensure that participants and their guardians had the opportunity to decline the use of their clinical information for research purposes.

Financial support for publication

Not applicable...The Researchers would like to thank the Deanship of Graduate Studies and Scientific Research at Qassim University for (2025-QU-APC) Financial Support for publication

Competing interests

The authors declare no competing interests.