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. 2021 Oct 7;35(4):256–262. doi: 10.1055/s-0041-1735812

Contemporary Management of Zygomaticomaxillary Complex Fractures

Howard D Wang 1,2, Jasjit Dillon 3,✉
PMCID: PMC8604623  PMID: 34819807

Abstract

Zygomaticomaxillary complex fracture is one of the most commonly treated facial fractures. Accurate reduction and stable fixation of the zygoma are required to restore facial symmetry and projection and avoid functional sequalae from changes in orbital volume. Achieving optimal outcome is challenging due to the complex three-dimensional anatomy and limited visualization of all affected articulations of the zygoma. This article provides an updated overview of the evaluation and management of zygomaticomaxillary complex fractures based on available evidence and clinical experience at our center. The importance of soft tissue management is emphasized, and approaches to internal orbital reconstruction are discussed. While evidence remain limited, intraoperative imaging and navigation may prove to be useful adjuncts in the treatment of zygomaticomaxillary fractures.

Keywords: zygoma fracture, zygomaticomaxillary complex, orbital fractures, facial fracture, open reduction and internal fixation

Zygoma fractures are common and can result from assault, fall, motor vehicle collisions among other etiologies. 1 Zygomaticomaxillary complex (ZMC) fractures have also been described as a tetrapod fracture, in reference to the junction of the zygoma with the frontal, maxillary, temporal and sphenoid bones. 2 In practice, there are five articulations that should be considered when treating ZMC fractures. In addition to the zygomaticofrontal (ZF), the zygomaticosphenoid (ZS) and the zygomatic arch (ZT), the zygomaticomaxillary (ZM) junction can be divided into two separate articulations at the infraorbital rim and the lateral buttress. 3 Additionally, as the zygoma makes up a significant portion of the lateral orbital wall and the orbital floor, some authors refer to these injuries as orbito-zygomaticomaxillary complex fractures to reflect the involvement of the orbit in all cases of ZMC injuries. 4

ZMC fractures may present as an isolated injury or in combination with multilevel facial fractures. The zygoma determines the facial width and projection and greatly impacts the orbital volume through its contribution to the lateral orbital wall and the orbital floor. Successful treatment of ZMC fractures requires careful assessment of the injury pattern, detailed understanding of the anatomy and accurate reduction and fixation of the fracture. Furthermore, meticulous soft tissue management and resuspension are required to avoid iatrogenic injuries. This article will focus on the management of ZMC fractures in the adult population.

Classification

Multiple classification systems for ZMC fractures have been described. 5 6 7 One practical way to approach ZMC fractures is to simply categorize them as low, middle or high energy injuries. 8 The classifications are not a sole reflection of the mechanism of injury but are rather based on the clinical characteristics of the fracture. Low energy injuries refer to those with minimal displacement and is often incomplete at one or more articulations. Surgical treatment is seldom indicated for this group of injuries ( Fig. 1A ). Middle energy injuries include the majority of ZMC fractures and are complete at all articulations with varying degrees of displacement and comminution present. Most of these injuries will require operative reduction and fixation using standard exposures that will be described below ( Fig. 1B ). High energy injuries consist of a small fraction of ZMC fractures and are often associated with other midface fractures. This group is often characterized by comminution of the lateral orbital wall and lateral displacement and comminution of the arch, allowing extensive lateral and posterior displacement of the malar eminence and zygomatic arch ( Fig. 1C ). In addition to the commonly used approaches, a coronal approach to reduce and fixate the arch can be considered in these complex injury patterns.

Fig. 1.

Fig. 1

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Examples of low, middle and high energy zygoma fractures. ( A ) Low energy injury with minimal displacement at the infraorbital rim and lateral buttress and nondisplaced or incomplete fractures at the zygomaticofrontal and zygomatic arch. ( B ) Middle energy injury characterized by complete fractures at all articulations with depression and lateral rotation of the zygoma. ( C ) High energy injury with severe comminution of the lateral orbital wall and significant posterolateral displacement.

Evaluation/Diagnosis

Patient evaluation should include detailed ocular exam as all ZMC fractures include involvement of the orbit. Assessment of visual acuity and evaluation for evidence of entrapment, enophthalmos, exophthalmos, or orbital dystopia should be performed. A formal ophthalmology consultation should be considered. Loss of malar projection and facial widening may be present but may be masked by the presence of edema in the acute phase. Neurosensory changes in the infraorbital nerve distribution is common as the fracture near the ZM suture invariably traverses through or near the infraorbital foramen. 9 Most commonly, patients will report numb cheek and teeth. Occasionally, they will have dysesthesia. Bony step-offs may be palpable at the infraorbital rim, lateral orbital rim and/or zygomatic arch. The patient's mouth opening should be assessed because depressed arch fractures could impinge on the temporalis muscle insertion onto the coronoid and result in severe trismus.

Maxillofacial computed tomography (CT) imaging should be obtained to confirm diagnosis and assist with operative planning. Concomitant facial fractures should be noted. Ipsilateral naso-orbito-ethmoid (NOE) fractures may be missed and can affect treatment outcome ( Fig. 2 ). 10 The presence of concomitant NOE fractures has been shown to be associated with worse outcomes after treatment of ZMC fractures, which may be related to inadequate reduction of the NOE fracture leading to malalignment of the ZMC at the infraorbital rim. 11 Similarly, fractures at the sphenoid or frontal bone could makes reduction of the ZMC fracture more challenging and should be noted during review of the imaging.

Fig. 2.

Fig. 2

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( A ) Note the presence of an ipsilateral, depressed fracture of the naso-orbito-ethmoid complex. ( B ) Worms-eye view demonstrates the disruption of the S-shaped contour that is normally present when a line is traced from the nasofrontal region to the zygomatic arch.

Operative planning should include careful assessment of the degree of displacement and comminution at each articulation of the zygoma. Three-dimensional reconstruction of the CT images is helpful to fully appreciate the severity and orientation of displacement. The surgeon should also assess the preoperative status of the orbital floor to determine whether internal orbital reconstruction will be required.

Indications for Operative Intervention

The Indications for treatment of ZMC fractures include both functional and aesthetic considerations. Functional sequelae of ZMC fractures include the effects on ocular and masticatory functions. In terms of the orbit, displacement of the ZMC affects orbital volume and globe position and can lead to diplopia resulting from enophthalmos and/or hypoglobus. Impingement of the coronoid process by a severely impacted zygomatic arch fracture could lead to trismus and is another functional indication for reduction of ZMC fractures. As with management of orbital fractures, the presence of entrapment or retrobulbar hematoma represent surgical emergencies that require immediate intervention. Otherwise, treatment may be delayed for one to two weeks until resolution of edema. However, delayed treatment beyond 3 weeks often necessitates performing osteotomies to mobilize the zygoma and may be associated with worse outcomes. 12

From an aesthetic standpoint, ZMC fractures can be associated with decreased malar projection and increased facial width. Its effect on globe position can result in clinically noticeable enophthalmos, all of which can be disfiguring. The severity of the facial deformity should be weighed against the risks of surgery to determine whether operative repair is indicated when functional impairments are absent.

In cases of isolated zygomatic arch fractures, treatment is indicated when trismus is present or significant depression has caused a noticeable deformity. It is important to recognize that not all ZMC fractures require treatment. Those that are minimally displaced without any functional or aesthetic deformities will not benefit from surgical treatment. 13

Surgical Exposure

Reduction of an isolated zygomatic arch fractures can be achieved via either a Gilles approach through the temporal scalp or a Keen approach through an intraoral incision. The Gilles approach hides the scar within the hair-bearing scalp and requires dissection under the superficial layer of the deep temporal fascia to approach the deep surface of the arch and avoid injury to the frontal branch of the facial nerve. The Gilles approach may provide a more direct access to the posterior portion of the zygomatic arch. The Keen approach can provide access to the zygomatic arch or body along the lateral buttress and has the advantage of avoiding external scars all together. The Keen approach is generally the preferred option at our institution.

For complete ZMC fractures, the incisions required for adequate exposure depends on the severity of displacement at each site of articulation. Common approaches used to gain access to fractured sites include the upper brow or lateral blepharoplasty incision for the ZF and ZS region, lower eyelid incisions for the infraorbital rim, and upper gingivobuccal sulcus incision for access to the lateral buttress. In terms of the choice of lower eyelid incisions, multiple options are available. Our preferred approach is the mid-lid (subtarsal) incision, which lies within the first crease below the tarsal plate. The mid-lid incision provides access to both the infraorbital rim and the orbital floor, allowing easy access for placement of fixation at the infraorbital rim, reconstruction of the orbital floor, and performance of midface resuspension prior to closure ( Fig. 3 ). The subciliary incision is an alternative with a more concealed scar but a higher risk of ectropion. 14 The tranconjunctival incision provides excellent access to within the orbit but is more limited in terms of access to the infraorbital rim and for midface resuspension.

Fig. 3.

Fig. 3

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Mid-lid or subtarsal approach to the infraorbital rim with application of miniplate fixation.

In certain cases, accurate reduction of the zygomatic arch can be an important adjunct to accurately restoring facial projection and width. 15 This is especially true in high energy injuries with severe comminution at multiple articulations and associated midface fractures, making accurate reduction challenging. 16 However, exposure of the zygomatic arch is not commonly performed in isolated ZMC fractures because of the need for a coronal incision and the risk of injury to the frontal branch of the facial nerve which crosses the zygomatic arch in its course to innervate the frontalis muscle. 17 In cases of panfacial fractures where a coronal incision may be required to address frontal sinus fractures or mixed Le Fort fractures, then the zygomatic arch can be exposed to assist with reduction and fixation of the zygoma ( Fig. 4 ). An alternative approach to the zygomatic arch is through a preauricular incision ( Fig. 5 ). With either approach, care must be taken to avoid injury to the facial nerve.

Fig. 4.

Fig. 4

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Coronal approach for open reduction and internal fixation of a comminuted zygomatic arch.

Fig. 5.

Fig. 5

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( A and B ) Intraoperative photograph of preauricular approach for open reduction and internal fixation of the zygomatic arch. ( C ) Preoperative CT image demonstrating lateral displacement of the zygomatic arch at the root of the arch. ( D ) Postoperative CT showing reduction and fixation of the zygomatic arch.

The decision of which incisions to perform for each individual fracture depends on the severity of the injury and which articulations need to be exposed to achieve accurate reduction and stable fixation. Multiple surgical incisions and wide periosteal dissection can have significant functional and cosmetic complications. Therefore, the risk and benefit of making each incision should be considered when treating ZMC fractures. While the approaches to the lateral orbital rim and lateral buttress rarely cause significant deformities, lower eyelid incisions can be associated with lid retraction and ectropion, which can be functional and cosmetically debilitating. 14 Given the risk of iatrogenic injury with lower lid incisions, it should only be utilized when it is required for adequate reduction of the ZMC fractures or internal orbital reconstruction. 18

Fracture Reduction and Fixation

Careful evaluation of the CT images will reveal that ZMC fractures are often impacted and/or rotated ( Fig. 6 ). Less commonly, the zygoma can be laterally displaced, such as in cases of ballistic injury ( Fig. 7 ). The reduction maneuver required to achieve anatomic reduction will depend on the orientation of displacement. While achieving anatomic alignment at all five articulations is the general approach, this task is made challenging by difficulty with visualizing these articulations simultaneously with limited incisions. In cases with severe comminution, reduction should be guided by the overarching goal of restoring facial projection and facial width while keeping in mind the three-dimensional position of the zygoma.

Fig. 6.

Fig. 6

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A common pattern of displacement due to blunt trauma where the zygoma is depressed and rotated.

Fig. 7.

Fig. 7

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Lateral displacement of the zygoma due to ballistic injury.

The following is one approach taken at the author's institution for reduction of an impacted ZMC fracture. 3 All planned exposures are performed first based on which articulations will be used for reduction and fixation. For an impacted ZMC fracture, disimpaction of the zygoma is first performed by applying an anterolateral force to the body of the zygoma with an elevator or curved mayo scissors inserted through the intraoral incision. In cases of severe impaction at the zygomaticofrontal region limiting mobility, a small osteotome can be used to osteotomized the fracture along the lateral orbital wall to improve mobility. Another helpful adjunct is the use of a Carroll-Girard screw inserted into the body of the zygoma to improve leverage. It can also be used as a handle to manipulate a freely mobile or laterally displaced ZMC fracture.

Once the zygoma has been disimpacted, reduction at the lateral orbital wall or ZS suture is then performed. The ZS suture serves as the most important point of reference for reduction of ZMC fractures given its natural curvature, which provides information on the vertical, horizontal and rotational position of the zygoma. 19 The ZF articulation is a poor landmark for reduction, but does provide easy access and strong bone for fixation. Loose fixation at the ZF is then applied using a miniplate. This way, the vertical position of the zygoma is maintained while still allowing enough mobility for the ZMC to be rotated and translated to achieve reduction at the other points of articulation.

Next, the fracture at the infraorbital rim is reduced and can be fixated with another miniplate, which helps to correct the rotational and horizontal vectors. Reduction at the lateral orbital wall and lateral buttress can be checked again as movement at one articulation can lead to displacement at another region. In most cases, anatomic alignment at both the ZS and infraorbital rim reliably restores facial projection and width.

Finally, the lateral buttress alignment is assessed and reduced if needed. While thin plates are used at the lateral and infraorbital rim to minimize palpability in areas with thin skin, a stronger plate should be used at the lateral buttress to provide more stability as palpability is not a concern in this region with the amount of overlying soft tissue ( Fig. 8 ). At this stage, orbital floor reconstruction should be performed if indicated. An intraoperative CT or direct orbital floor exploration can be performed to determine whether orbital floor reconstruction is required.

Fig. 8.

Fig. 8

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Fixation at the lateral buttress applied through an upper gingivobuccal sulcus incision.

This represents one treatment approach to ZMC fractures used at our institution. Other algorithmic approaches have also been described. 20 21 22 How much fixation is required for ZMC fractures has been a frequently studied subject, with recommendations ranging from one point to four points of fixation. 23 24 25 The overarching goal should be to apply the minimum amount of fixation necessary to achieve stability of the ZMC to allow for bony union. Therefore, lower energy injuries with no comminution may only require one or two plates at the lateral buttress and the ZF suture. 24 If additional stability is required, an additional miniplate can be used at the infraorbital rim to obtain three points of fixation. The lower eyelid skin overlying the rim is thin, and patients can complain of palpability or sensitivity related to hardware in this region.

In high energy injuries with severe comminution and multiple associated fractures, the zygomatic arch can be fixated as well through to establish facial width and projection. It is important to keep in mind that the arch is straight in its midsection during open reduction and fixation of the arch fracture, therefore, the plate should not be bent to create a nonanatomic curvature.

Orbital Floor Reconstruction

Every ZMC fracture is associated with an orbital floor fracture component. Some present as a linear pattern with minimal comminution whereas others have a large blow-out pattern with herniation of intra-orbital soft tissue. As such, only a subset of ZMC fractures, ranging from 30% to 40%, will require internal orbital reconstruction. 4 18 Preoperative CT scans can be used to predict whether internal orbital reconstruction will be required and has been shown to be mostly reliable. 4 Alternatively, intraoperative exploration can be performed to assess the orbital floor. The advantage of the latter approach is that it would take into account the effect of the zygoma being reduced, which can potentially increase the size of the orbital floor defect. 26 This does commit the patient to having a lower eyelid incision and intra-orbital dissection with their associated iatrogenic risks.

The use of intraoperative CT after reduction and fixation of the ZMC fracture can be used as an adjunct to assess the status of the orbital floor and quality of reduction. In some cases, reduction of the zygoma will lead to realignment of the orbital floor fracture without causing any herniation of intra-orbital soft tissue. This can be confirmed by intraoperative CT performed after reduction of the zygoma prior to committing the patient to a lower eyelid incision. 27

Intraoperative Imaging and Navigation

In addition to helping to make the decision of whether to reconstruct the orbital floor, intraoperative CT can be used to assess the accuracy of the zygoma reduction as well, which may be particularly useful in cases with severe displacement or adjacent fractures. 28 The use of intraoperative CT imaging gives the surgeon the ability to assess unexposed articulations and the status of the orbital floor, which has the potential to reduce the number of incisions required to accurately treat ZMC fractures. 29 In cases where internal orbital reconstruction is performed, intraoperative CT can help the surgeon assess the choice and positioning of the orbital implant and allows for intraoperative adjustments to be made such as repositioning, recontouring or exchanging the implant. 30

In addition to intraoperative imaging, surgical navigation is another technology with increasing adoption in the management of facial trauma to provide real-time information on reduction and implant positioning. 31 The evidence surrounding the use of navigation in the management of acute ZMC fractures are limited, but further investigation may prove substantial benefit in certain complex cases or cases of secondary zygomatic repositioning. 32 Computer-assisted planning and design has also been used to create individualized patient-specific implants to help achieve more accurate reconstruction of the internal orbit and zygomatic repositioning for secondary reconstruction. 33

Soft Tissue Management

An underestimated aspect of ZMC fractures is the importance of proper soft tissue management, which deserves equal emphasis as accurate bony reduction and fixation and plays an essential role in the success of the clinical outcome. Soft tissue disruption from surgical access to the zygoma can cause significant deformities including visible scars, lid mal-positioning, contour deformities and premature soft tissue descent. 34

Avoiding unnecessary incisions and limiting dissection to what is necessary for accurate reduction and fixation should always be the goal. Additionally, careful tissue handling and meticulous dissection should be performed during access to the fractures to minimize tissue trauma and injury or displacement of critical structures. It is important to avoid detachment of the lateral canthus during the approach to the lateral orbit and injury to the frontal branch during the approach to the arch. 35 At the conclusion of the case, re-approximation of the deep temporalis fascia if a coronal incision was made should be performed to avoid contour deformities at the temporal region. If an external eyelid lid incision was performed, careful repair of orbicularis oculi muscle and eyelid skin is essential to minimize the risk of lid retraction, increased scleral show and ectropion.

Prior to that, midface resuspension to the orbital rim must be performed to avoid midface descent and increased tension on the lower eyelid incision that can result in an appearance of premature aging and lid malposition. 36 This can be performed by resuspending the divided midface periosteum to a plate at the infraorbital rim or drill holes into the bone at the orbital rim with an absorbable suture.

Clinical Outcomes

Complications after ZMC fractures include facial asymmetry due to inadequate reduction, hardware problems from exposure or palpability, neuropraxia from injury to the infraorbital nerve, and dental injuries from mal-positioned screws. Complications common to all surgery such as bleeding, scarring, and infection occur as well. Ocular-related complications are more common when there is a large orbital floor component associated with the ZMC fracture or an eyelid incision was performed and include enophthalmos, lid retraction/ectropion/entropion, double vision, orbital dystopia, and blindness. Post-traumatic enophthalmos can result from not performing internal orbital floor reconstruction when it is indicated or inadequate reconstruction of the orbital floor defect. Lateral displacement of the ZMC can also lead to significant increase in the orbital volume and subsequent enophthalmos. Malunions of zygoma can result in significant aesthetic and functional deformities that require challenging secondary correction.

Summary

The management of ZMC fractures requires careful review of CT imaging to formulate a thoughtful treatment plan. The number of surgical incisions and fixation required for each fracture is dependent on the characteristics of the fracture pattern, with the overall goal of achieving accurate reduction and stable fixation while minimizing the risk of introducing iatrogenic injuries. In addition to bony reduction and fixation, careful soft tissue management during surgery is essential to optimize functional and aesthetic outcomes. Internal orbital reconstruction is often required and is a critical component of management of ZMC fractures. The advent of intraoperative imaging and navigation may present opportunities for surgeons to achieve increased accuracy while minimizing surgical exposures.

Footnotes

Conflict of Interest Dr. Dillon received research support from Osteoscience and Oral & Maxillofacial Surgery foundation grants. No conflict of interest to disclose.

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