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16: Fractures of the Zygomatic Complex and Arch

Chapter16

Fractures of the Zygomatic Complex and Arch

EdwardEllis,III

Outline

Anatomy

TerminologyandFracturePatterns

ClassificationofZygomaticomaxillaryComplexFractures

DiagnosisofZygomaticomaxillaryComplexFractures

ClinicalExamination

RadiologicEvaluation

TreatmentofZygomaticomaxillaryComplexFractures

DeterminingWhethertheZygomaHasBeenProperlyReduced

NeedforFixation

NeedforInternalOrbitalReconstruction

PrinciplesintheTreatmentofZygomaticomaxillaryComplexFractures

SurgicalApproachestoZygomaticomaxillaryComplexFractures

ReductionTechniques

FixationTechniques

InternalOrbitalReconstruction

IntrasinusApproachtotheOrbitalFloor

PatientsTreatedforZygomaticomaxillaryComplexFractures

ZygomaticArchFractures

Complications

PeriorbitalIncisionProblems

InfraorbitalNerveDisorders

ImplantExtrusion,Displacement,andInfection

PersistentDiplopia

Enophthalmos
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Blindness

RetrobulbarandIntraorbitalHemorrhage

MalunionoftheZygoma

If excuses are needed for the writing of the present paper, they are to be found in the comparatively common occurrence of the fracture discussed, in the
extremescarcityofmentionofitoritstreatmentinsurgicalliterature,andinthefactthatevenwellknownpathologicmuseumsdonotcontainasingleexample.
Modern textbooks of surgery and fractures deal with fractures of the malarzygomatic compound so sparingly that one must be content with a few stray
referencesoraparagraphonmaxillaryfracturesorbeguidedbyatersesentenceortwocoveringthissubject.

H.D.Gillies,T.P.Kilner,andD.Stone,19271

Zygomaticfracturesarecommonfacialinjuries,representingthemostcommonfacialfracture214orthesecondinfrequencyafternasalfractures.3,1517The
highincidenceofthesefracturesprobablyrelatestothezygomasprominentpositionwithinthefacialskeleton,whichfrequentlyexposesittotraumaticforces.
Theincidence,cause,age,andgenderpredilectionofzygomaticinjuriesvary,dependinglargelyonthesocial,economic,political,andeducationalstatusofthe
population studied. Most studies indicate a male predilection, with a ratio of approximately 4 : 1 over females.1827 Most authors also agree that the peak
incidenceofsuchinjuriesoccursaroundthesecondandthirddecadesoflife.28,29 The causes of zygomatic injury in some studies are mostly altercations,
whereasinothers,motorvehicleaccidents(MVAs)accountforamoresubstantialnumber.30,30aThecauseoftheinjuriessustainedisgreatlyaffectedbythe
nature of the population in these studies in the former studies, the populations were from industrialized areas with high rates of unemployment, in which
interpersonalviolenceisveryhigh.

In zygomatic fractures caused by altercations, the left zygoma is most commonly affected,* presumably because of the greater incidence of righthanded
individuals.ThispredilectiondisappearsinunilateralfracturescausedbyMVAs.Bilateralfracturesofthezygomaareuncommonandaccountforapproximately
4% of 2067 cases of zygomatic fracture in a 10year review by Ellis et al.26 Bilateral fractures in that study were more commonly the result of MVAs than
altercations,indicatingthatthetraumainflictedinMVAsismoreseverethanthatinflictedinaltercations.

Becausethegrossshapeofthefaceisinfluencedlargelybytheunderlyingosseousstructure,thezygomaplaysanimportantroleinfacialcontour.Disruption
of zygomatic position also has great functional significance because it causes impairment of ocular and mandibular function. Therefore, for cosmetic and
functionalreasons,itisimperativethatzygomaticinjuriesbeproperlyandfullydiagnosedandadequatelytreated.

Anatomy
Thezygoma,amajorbuttressofthefacialskeleton,istheprincipalstructureofthelateralmidface.Athickstrongbone,thezygomaisroughlyquadrilateralin
shape,withanouterconvex(cheek)surfaceandaninnerconcave(temporal)surface.Theconvexityontheoutersurfaceofthezygomaticbodyformsthepoint
ofgreatestprominenceofthecheek.Therefore,thezygomaplaysamajorroleinfacialcontour.

The zygoma is roughly the equivalent of a foursided pyramid (Fig.161). It has temporal, orbital, maxillary, and frontal processes, and articulates with four
bonesthefrontal,sphenoid,maxillary,andtemporal(Fig.162).Thebodyofthezygomaextensivelyarticulateswiththemaxillaalongtheanteriormaxillaand
alongtheorbitalfloor(seeFig.162B).Thesuturebetweenthesetwobonesliesjustlateraltotheinfraorbitalforamenandrunslaterallyfromtheinfraorbitalrim
to the undersurface of the zygomaticomaxillary buttress. It forms the superolateral aspect and part of the superoanterior aspect of the maxillary sinus. The
zygomaalsohasanarrowweakarticulationwiththezygomaticcrestofthegreaterwingofthesphenoidboneatthelateralaspectoftheinferiororbitalfissure
(Fig.163A).Itformsamajorportionofthelateralaspectandflooroftheorbit.Thefrontalprocessisthickandtriangularincrosssection,withfacial,orbital,and
temporal surfaces. Because of its thickness, it is a frequent site for wire or boneplate fixation following fracture. The temporal process is flat and projects
posteriorlytoarticulatewiththezygomaticprocessofthetemporalbonethecombinationofthetwomakesupthezygomaticarch.Thezygomaticotemporal
articulationisathindelicateconnection,whichfracturesfrequentlyandwithminimalforce.

FIGURE161Thedisarticulatedzygomahasfourprocessesthefrontal,temporal,orbital,andmaxillaryandconstitutesthelateralportionoftheorbit.

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FIGURE162Anatomicpositionofthezygoma.A,Lateralskulldemonstratingitsarticulationwiththetemporal,frontal,andmaxillarybones.B,Frontalskull
demonstrating its articulation with the maxillary, frontal, and sphenoid bones. The hatchmarks demonstrate the extent of the maxillary sinus. Note that the
zygomaformsthesuperolateralaspectofthesinus.

FIGURE 163 Common fracture pattern in ZMC injury. A, Frontal view of skull showing fracture medial to a zygomaticomaxillary suture and along a
zygomaticosphenoid suture within orbit. B, Oblique frontal view of skull showing fractures through a frontozygomatic suture and posterior to a
zygomaticotemporalsuture.C,Temporalviewofskullshowingfracturesextendingfromtheinferiororbitalfissuresuperiorlythroughthezygomaticosphenoid
sutureandinferiorlythroughthezygomaticbuttressofthemaxilla.D,Inferiorskullshowingatriplefracturethroughthezygomaticarch.Notethattheorbital
floor,medialorbitalwall,andzygomaticomaxillarybuttressarefrequentlycomminutedinadditiontothefracturepatternsdescribed.

Thezygomaprovidesanorigintoamajorportionofthemassetermusclealongthebodyandtemporalprocess.Inaddition,thetemporalfasciaattachesalong
the arch and posterolateral edge of the temporal process. The zygoma also provides attachments for the temporal and zygomatic muscles. The strong
infraorbitalandlateralorbitalrimsprovideprotectiontotheorbitalcontents.

Terminology and Fracture Patterns

Themalarbonerepresentsastrongboneonfragilesupports,anditisforthisreasonthat,thoughthebodyoftheboneisrarelybroken,thefourprocesses
frontal,orbital,maxillary,andzygomaticarefrequentsitesoffracture.

H.D.Gillies,T.P.Kilner,andD.Stone,19271

Thefracturepatternofanybonedependsonseveralfactors,includingthedirectionandmagnitudeoftheforce.Fracturelinesthuscreatedpassthroughthe
areas of greatest weakness of a bone or between bones. Because of the strong buttressing nature of the zygoma and the thin bones surrounding it, most
injuriesinvolvingthezygomaareaccompaniedbydisruptionofadjacentarticulatingbones.Thisdisruptionoccursbecausewhenaforceisappliedtothebody
ofthezygoma,itisdistributedthroughitsfourprocessestotheadjacentarticulatingbones,manyofwhichareweakerthanthezygoma.Althoughthezygomatic

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bone is involved, it is rare to have an isolated fracture of the zygoma in which the fracture lines are completely within this bone or through only the sutures
surroundingit.

Zygomaticormalarfracturesarethetermscommonlyusedtodescribefracturesthatinvolvethelateralthirdofthemiddleface.Becauseoftheimpurenatureof
zygomatic fractures, other terms have been adopted in describing such fractures. Zygomaticomaxillary complex, zygomaticomaxillary compound,31
zygomaticoorbital,26zygomaticcomplex,32,33malar,trimalar,andtripodfractures are terms that have been used to describe the clinical entity of fractures
involvingthezygomaandadjacentbones.Thelattertwotermsaremisnomersbecausethezygomahasnotthreebutfourprocesses,andtheiruseshouldbe
condemned. Zygomatic, zygomatic complex, or zygomaticomaxillary complex (ZMC) are perhaps the most commonly used. They are used throughout this
chapterbecausethezygomaisthemajorboneinvolvedinsuchfracturesandforthesakeofsimplicity.ThetermzygomaticorZMChelpsdistinguishfractures
thatinvolvethezygomaandadjacentbonesfromisolatedzygomaticarchfractures,andtheyareusedwhenthisdistinctionisnecessary.

The inferior orbital fissure is the key to remembering the usual lines of ZMC fractures. Three lines of fracture extend from the inferior orbital fissure in an
anteromedial, superolateral, and inferior direction (see Fig.163). One fracture extends from the inferior orbital fissure anteromedially along the orbital floor,
mostlythroughtheorbitalprocessofthemaxillatowardtheinfraorbitalrim.Theorbitalfloorandmedialwallareoftencomminuted,creatingmultiplelinesof
fracturewithintheinternalorbit.Theinfraorbitalcanalisusuallycrossedbythefractureline(s)becausethefracturefrequentlyextendsthroughtheinfraorbital
rim to the facial surface of the maxilla, above or even slightly medial to the infraorbital foramen. The fracture extends from the infraorbital rim in the maxilla
laterally and inferiorly under the zygomatic buttress of the maxilla. Comminution of the infraorbital rim and bone along the anterior and lateral maxilla is
common,withfrequentinvolvementoftheinfraorbitalforamen.Therefore,thefracturerarelyinvolvesthezygomaticbonealongtheorbitalfloorandtheanterior
andlateralaspectsoftheface.Thefracturelinesaremostlywithinthemaxilla.

Asecondlineoffracturefromtheinferiororbitalfissurerunsinferiorlythroughtheposterior(infratemporal)aspectofthemaxillaandjoinsthefracturefromthe
anterioraspectofthemaxilla,underthezygomaticomaxillarybuttress(seeFig.163C).

The third line of fracture extends superiorly from the inferior orbital fissure along the lateral orbital wall posterior to the rim, usually separating the
zygomaticosphenoidsuture(seeFig.163AandC).Extendingsuperiorly,laterally,andanteriorlytowardthelateralorbitalrim,thefracturefrequentlyseparates
thefrontozygomaticsutureatthelateralorbitalrim.However,thefracturethroughthelateralorbitalrimisoccasionallysuperiororinferiortothefrontozygomatic
suture.

AZMCfracturethatfollowsthispatternusuallyhasoneadditionalfracturelinethroughthezygomaticarch.Becausethepointofleastresistancetofractureis
notatthezygomaticotemporalsuture,butapproximately1.5cmmoreposteriorly,thepointoffracturewhenasinglefractureexistsisusuallyintheapproximate
middleofthezygomaticarch,inthezygomaticprocessofthetemporalbone.Frequently,however,threefracturelinesexistthroughthearch,producingtwofree
segmentswhenthefracturesarecomplete(seeFig.163D).Thesesegmentscanbedisplacedbyassociatedmusclepullormaybepushedmediallyintothe
infratemporalfossa.Often,thefracturesareincomplete,orgreenstick,fractures,producingamedialorlateralwarpingofthezygomaticarchwithoutnotable
upwardordownwarddisplacement.

This description is for the common or usual ZMC fracture. However, the variability of these fractures is great because of the differences in magnitude and
directionofforce,amountofsofttissuecoveringthezygoma,anddensityoftheadjacentbones.Frequently,thelinesoffractureareinlocationsdifferentfrom
thosedescribedearlier.Usingradiographstosummarizethecourseoffracturelinesin100isolatedzygomaticinjuries,Meyeretal11havefoundfracturesinthe
bodyofthezygomainalmost40%ofcases,comparedwiththemorecommonmediallocationalongtheanteriormaxillarysurface.Singleormultiplelinesof
fracture(i.e.,comminution)mayexist.Grossdisplacementmayoccur,ornodisplacementatall.Becauseoftheinfinitenumberofpossiblevariations,onemust
assesseachzygomaticfractureindependentlyanddeterminetheextentandlocationofthefracturespresent.

Classification of Zygomaticomaxillary Complex Fractures

Itisprobablyfairtosaythatclassificationofzygomaticfracturesaccordingtotheindividualwhotriestodescribethem.Theresulthasbeenaconfusingarrayof
classification systems that try to describe the anatomic position of the displaced bone or to classify fractures using position and criteria for postreduction
stability.6,22,3339Whetherapatientreceivesbettertreatmentfrombeingclassifiedintoonesystemoranotherisdoubtful,andoneshouldnotdwellonthe
manyclassificationsystemsavailable.Asistrueformanyotheraspectsofsurgery,itisextremelyraretofindtwopatientswhohaveexactlythesamecondition.

In1990,Mansonetal40publishedaclassificationofmidfacialfracturesthatwasbasedontheamountofenergydissipatedbythefacialbonessecondarytothe
traumatic force. Their classification of high, moderate, or lowenergy fractures was based on findings on computed tomography (CT) scans. Highenergy
fractureshadextremedisplacement,comminutionofthearticulations,andsegmentationofthebones.Theynotedthattheserequiredextensiveexposureand
fixationforasatisfactoryoutcome.Ontheotherhand,lowerenergyfractureswerecharacterizedbydisplacementbutwithoutcomminutionofbonyarticulations.
Theynotedthatthesecouldbetreatedbylessaggressivemeans.UsingpreoperativeCTfindingsmaybethemostusefulwaytodecidehowmuchintervention
mayberequiredbeforesurgery.

Itbehoovesclinicianstoevaluateeachcaseindividually.Whethertheychoosetoprescribetreatmentbasedontheexperienceofothersforagivenclassof
fractureistheirchoicehowever,withpropersurgicalmanagement,thenatureofthetreatmentshoulddependmoreonthepreoperativeimaginganalysisand
surgicalfindingsthanonstatisticalprescription.

Diagnosis of Zygomaticomaxillary Complex Fractures

Inatypicalcase,diagnosismaybemadeatsightoncethecharacteristicappearancehasbeenfullyrecognized.Apeculiarfaciesispresent,duechieflytoa
certainflatnessofcontourandanabsenceofexpressionontheaffectedside.

H.D.Gillies,T.P.Kilner,andD.Stone,19271

Thediagnosisofzygomaticfracturesisprimarilybasedonclinicalandradiologicexamination,althoughthehistoryfrequentlyraisesastrongsuggestionofthe
possibilitythatafracturemayexistandgivesanindicationaboutthenature,direction,andforceoftheblow.Itshouldbestressedthattheclinicalexaminationis
frequently difficult to perform adequately because of the nature of the patients mental state and/or the amount of facial edema and pain. The swelling may

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concealfacialdeformitythatappearsonlyaftertheswellinghassubsided.Iftheexaminationcanbeperformedimmediatelyfollowingtheinjuryandbeforethe
onsetofedema,moreinformationcanbeobtainedfromtheclinicalexaminations.Becausetherearenosensitiveindicatorsofzygomaticfractures(e.g.,those
thattheteethprovideinmaxillaryormandibularfractures),andbecausetheconcomitantsofttissueedemaandcontusionthatfrequentlyaccompanyzygomatic
injuriescanobscureclinicalexamination,theuseofimagingandclinicalfindingsisimportantinthediagnosisofZMCfractures.

Clinical Examination
AftertheclinicianhasascertainedtheneurologicstatusofapatientwithsuspectedZMCfracture,thefirstpriorityisdeterminationofthevisualstatusofthe
involved eye. A thorough ocular and funduscopic examination should be performed, with complete documentation of the findings. Ocular injuries, such as
vitreoushemorrhage,hyphema,globelaceration,severanceoftheopticnerve,andcornealabrasions,werefoundin4%ofpatientswithmidfacialtraumaby
Turvey12 and in 5% of zygomaticoorbital fractures by Livingston et al.41 Ophthalmologic consultation was deemed necessary in approximately 5% of 2067
casesofzygomaticoorbitalinjuriesreportedbyEllisetal.26Ioannidesetal42foundsignificantocularandadnexalinjuriesin26%oforbitalfractures.AlQurainy
etal43 prospectively performed ophthalmologic examinations in 363 patients who had sustained midfacial fractures. Minor or transient eye injuries, such as
cornealabrasion,chemosis,mildimpairmentofaccommodationandvisualacuity,andorbitalemphysema,werefoundin63%ofpatients.Moderateinjuries,
suchasenophthalmos,conjunctivalabrasion,traumaticpupillarychanges,iridodialysis,lensdamage,macularedema,andmoderatetosevereimpairmentof
accommodation and visual acuity, were noted in 16% of patients. Severe ophthalmic disorders, such as gross proptosis, retrobulbar hemorrhage, corneal
laceration, hyphema, angle recession, severe reduction or loss of vision, visual field loss, choroidal tear involving the macula, and optic nerve injuries, were
foundin12%ofpatients.OnethirdofallpatientswithcomminutedZMCfracturessufferedasevereoculardisorder.Therefore,ifthecliniciandiscoversany
significantorquestionablefindingsinpatientswithmidfacialfractures,ophthalmologicconsultationshouldbeobtained.

Examination of the zygoma involves inspection and palpation. Inspection is performed from the frontal, lateral, superior, and inferior views. One should note
symmetry,pupillarylevels,presenceoforbitaledemaandsubconjunctivalecchymosis,andanteriorandlateralprojectionofthezygomaticbodies.Themost
usefulmethodforevaluatingthepositionofthebodyofthezygomaisfromthesuperiorview.Thepatientcanbeplacedinarecumbentpositionorreclineina
chair.Thesurgeoninspectsfromasuperiorposition,evaluatinghowthezygomaticbodiesprojectanteriorlyandlaterallytothesupraorbitalrims,comparing
onesidewiththeother.Thesurgeonshouldlayhisorherindexfingerbelowtheinfraorbitalmargins,alongthezygomaticbodies,pressingintotheedematous
tissuetopalpateandreducethevisualeffectofedemasimultaneouslywhenperformingthisexamination(Fig.164).44Thesuperiorviewisalsohelpfulfor
evaluating possible depression of the zygomatic arches. One should not forget to perform an intraoral examination, because zygomatic fractures are often
accompaniedbyecchymosisinthesuperiorbuccalsulcusandmaxillarydentoalveolarfractures.

FIGURE 164 Method of assessing posterior displacement of the ZMC from behind the patient. The clinician should firmly depress the fingers into the
edematoussofttissuewhilepalpatingalonginfraorbitalareas.

Palpationshouldbesystematicandthorough,andonesideshouldbecomparedwiththeother.Theorbitalrimsarepalpatedfirst.Thesurgeonpalpatesthe
infraorbitalrimswiththeindexfinger,movingthefingerrhythmicallyfromsidetosidealongtherim.Thelateralorbitalrimsarepalpatedwiththeindexfinger
andthumb.Oneshouldalsousetheindexfingeralongtheinneraspectofthelateralorbitalrimbecausefracturesmayfrequentlybedetectedbypalpating
inside the orbital rim, as opposed to palpating along the lateral aspect. When fractures are present, palpation frequently is accompanied by exquisite
tenderness. The body of the zygoma and zygomatic arch are best palpated with two or three fingers in a circular motion, with the surgeon comparing this
palpationwiththatoftheoppositeside.Thezygomaticbuttressofthemaxillaispalpatedintraorallywithonefinger,andhematomaorirregularitiesaresought.

Signs and Symptoms

Severalsignsandsymptomsaccompanyzygomaticfractures.Thepresenceandmagnitudeoftheirseveritygreatlydependontheextentandtypeofzygomatic
injury.Forexample,facialflatteningismorepronouncedininjuriesinwhichthezygomaticbodyhasbeengreatlydisplaced,asopposedtothoseinwhichthe
bodyhasnotbeendisplaced.Similarly,zygomaticarchfracturesmaybeexpectedtoproducelessoculardisruptionthanZMCfractures.Thefollowingsigns
andsymptomscanaccompanyzygomaticfracturesandthereforeshouldbeevaluated.

Periorbital Ecchymosis and Edema.

Edemaandbleedingintothelooseconnectivetissueoftheeyelidsandperiorbitalareasisthemostcommonsignfollowingfractureoftheorbitalrim.45,46
Swelling,oftenmassive,maybepresentandismostdramaticintheperiorbitaltissue,wheretheeyelidsmaybeswollenclosed.Theecchymosismaybeinthe
inferiorlidandinfraorbitalareaonlyoraroundtheentireorbitalrim.

Flattening of the Malar Prominence.

Acharacteristicsignandstrikingfeatureofzygomaticinjuryisaflatteningofthenormalprominenceinthemalararea.AnespeciallycommonfindinginZMC
injuries,thisflatteningisreportedin70%to86%ofcases,22,26,29especiallythoseinwhichdistractionofthefrontozygomaticsutureandmedialrotationand/or
comminutionhaveoccurred.Ifedemaispresent,flatteningmaybedifficulttodiscernsoonafterinjuryhowever,onecanusuallygainanappreciationofthis
signbydepressingtheindexfingersintothesofttissueofthezygomaticareasandcomparingonesidewiththeotherfromabovethepatient(seeFig.164).

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Flattening over the Zygomatic Arch.

A characteristic indentation or loss of the normal convex curvature in the temporal area accompanies fractures of the zygomatic arch. Visual and digital
comparisonwiththeoppositesideisextremelyhelpfulfordetectionofdepressionsofthezygomaticarch.

Pain.
Severepainisnormallynotafeatureofzygomaticinjuriesunlessthefracturedsegmentismobile.Patientsdo,however,complainofdiscomfortassociatedwith
theattendantbruising.Palpationofthefracturesitesalsoelicitsapainfulresponse.

Ecchymosis of the Maxillary Buccal Sulcus.

Animportantsignofzygomaticormaxillaryfractureisecchymosisinthemaxillarybuccalsulcus.Ecchymosismayoccurevenwithasmalldisruptionofthe
anteriororlateralmaxillaandshouldbesoughtinpatientswithsuspectedzygomaticfractures.

Deformity at the Zygomatic Buttress of the Maxilla.

Intraoralpalpationoftheanteriorandlateralaspectsofthemaxillafrequentlyrevealsirregularitiesofthenormallysmoothcontour,especiallyintheareaofthe
zygomatic buttress of the maxilla. Crepitation from comminuted fragments of bone is also frequently palpable. If no tenderness is experienced during this
maneuver,thechancesarethatnofractureexists.Theabsenceofpainmakesazygomaticfractureunlikely,butitspresencedoesnotestablishonebecause
thepaincanbearesultofsofttissueinjuryand/ormaxillaryfracture.

Deformity of the Orbital Margin.

Fracturesrunningthroughtheorbitalrimoftenresultinagap,orstepdeformity,ifdisplacementhasoccurred.Thisfindingisfrequentlynotedattheinfraorbital
andlateralorbitalrimswhenzygomaticfracturesarepresent.45,46Theseareasmayalsobetendertotouch.

Trismus.
Limitationofmouthopeningfrequentlyaccompanieszygomaticinjuriesandispresentinapproximatelyonethirdofcases.26,46,47Thisconditionoccurswith
anevenhigherincidenceinisolatedfracturesofthezygomaticarch(45%).Thereasonoftencitedforpostfracturetrismusisimpingementofthetranslating
coronoidprocessofthemandibleonthedisplacedzygomaticfragments.Whetherthiscontactactuallyoccursinmostcasesisdoubtful,becausetheamountof
displacement necessary for producing actual mechanical interference is great. A more likely explanation is muscle spasm secondary to impingement by the
displacedfragments,especiallyonthetemporalmuscle(Fig.165).Anassociatedfindingisdeviationofthemandibletowardthefracturedsidewhenthemouth
isopened.

FIGURE165Depressedzygomaticarchimpingingonthetemporalmuscleand/orcoronoidprocess,limitingmandibularexcursions.

Abnormal Nerve Sensibility.

An important symptom, present in approximately 50% to 90% of ZMC injuries, is impaired sensation of the infraorbital nerve.22,26,4552 Infraorbital nerve
paresthesiaismorecommoninfracturesthataredisplacedthanthosethatarenot.Itisdifficulttodifferentiatetrueanesthesiafromthealteredsensationof
swollen edematous tissue but, as the swelling decreases, infraorbital nerve anesthesia becomes apparent. Infraorbital anesthesia occurs when the fracture
through the orbital floor and/or the anterior maxilla causes tearing, shearing, or compression of the infraorbital nerve along its canal or foramen (Fig. 166).
Frequently,theentireorbitalflooriscomminuted,whichresultsinmultiplefragmentsofbonestrungtogetherbytheinfraorbitalneurovascularbundle.Whenthe

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line of fracture is lateral to the infraorbital groove and foramen (less common), the infraorbital nerve is spared. Disruption of the infraorbital nerve causes
anesthesiaofthelowereyelid,upperlip,andlateralaspectofthenose.

FIGURE166Typicalfractureextendsalongorthroughtheinfraorbitalgrooveorcanalalongtheorbitalfloorandfrequentlyacrosstheinfraorbitalforamenon
the facial surface of the maxilla. The orbital floor medial wall is frequently comminuted, with multiple lines of fracture crossing the infraorbital neurovascular
bundle.

A related symptom may be altered sensitivity of the maxillary teeth and gingiva.53 When this altered sensitivity is present, the clinician should suspect a
disruptionoftheinfraorbitalnervewithinitscanal,wherethemiddleandanteriorsuperioralveolarnervestakeorigin.

Epistaxis.
Wheneverthesinusmucosaisdisrupted,hemorrhageintothesinusispossible.Mostfracturesthroughthesinuswallthathavehadevenaminoramountof
displacementteartheliningmucosa,producinginternalbleeding.Becausethemaxillarysinusdrainsintothenoseviathemiddlemeatus,unilateralhemorrhage
fromthenoseispossibleandoccursinapproximately30%to50%ofZMCinjuries.26,46

Subconjunctival Ecchymoses.
Subconjunctival hemorrhage, a frequent finding in zygomatic fractures, is present in 50% to 70% of cases.26,46 It may accompany even a hairline crack
through the orbital rim if the periosteum has been torn. Its absence does not exclude an orbital rim fracture because if no disruption of the periosteum has
occurred,bleedingcanaccumulateinasubperiosteallocationandmaynotbevisibleundertheconjunctiva.Whenpresent,subconjunctivalecchymosesusually
havenoposteriorlimitandwillbebrightredbecauseoftheabilityofoxygentodiffusethroughtheconjunctivatothecollectionofblood.

Crepitation from Air Emphysema.

Fracturethroughasinuswallwithtearingoftheliningmucosaallowsairtoescapeintothefacialsofttissueifthepressurewithinthesinusisgreaterthanthat
withinthetissue.Thesofttissueoftheperiorbitalarea,especiallytheeyelids,ispronetoinflationwithairbecauseofitslooseareolarnature.Wheninflation
occurs,onecanpalpatecrepitation,indicatingsubcutaneousemphysema.Crepitationismosteasilyappreciatedbyalternativelyrollingtwofingersgentlyover
thetissue,whichproducesacharacteristiccracklingsensation.Itisanuncommonfindingfollowingzygomaticfractures,butthepotentialforairemphysemais
constant.Whenpresent,however,crepitationcanbealarmingtothepatient.Theemphysemadisappearsspontaneouslyin2to4dayswithouttreatment.The
significanceofemphysemaisthepotentialforinfectionthroughthecommunicationbetweenthesinusandthesofttissue.

Displacement of the Palpebral Fissure.

Thelateralpalpebralligamentisattachedtothezygomaticportionoftheorbitalrim.Displacementofthezygomacarriesthepalpebralattachmentwithitand
thusproducesadramaticvisualdeformity.Whenthezygomaisdisplacedinaninferiordirection,thelateralpalpebralligamentisalsodepressed,causinga
downwardslopetothefissure(antimongoloidslant)(Fig.167).Becausetheorbitalseptumisattachedtotheinfraorbitalrim,inferiororposteriordisplacement
oftheinferiororbitalrimcausesdepressionofthelowereyelid,givingitashortenedappearance.54Thisdepressionmaycausemorescleratobeexposed
belowtheirisandanapparentectropion.

FIGURE167Inferiordisplacementofthezygomaresultsindepressionofthelateralcanthusandpupilbecauseofdepressionofthesuspensoryligamentsthat
attachtothelateralorbital(Whitnalls)tubercle.

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Unequal Pupillary Levels.

Withthedisruptionoftheorbitalfloorandlateralaspectoftheorbitthatfrequentlyaccompanieszygomaticfractures,lossofosseoussupportfortheorbital
contentsanddisplacementofTenonscapsuleandthesuspensoryligamentsoftheglobepermitdepressionoftheglobe.55Thisdisplacementismanifested
clinicallyasunequalpupillarylevels,withtheinvolvedpupilatalevellowerthanthatofthenormalside(seeFig.167).

Diplopia.
Diplopiaisthenamegiventothesymptomofblurredvision.Twovarietiesofdiplopiaexistitisimportanttodistinguishbetweenthem.Monoculardiplopia,or
blurringofvisionthroughoneeyewiththeotherclosed,requirestheimmediateattentionofanophthalmologist,becauseitusuallyindicatesadetachedlens,
hyphema, or other traumatic injury to the globe. Binocular diplopia, in which the blurring of vision occurs only when the patient looks through both eyes
simultaneously, is common and occurs in approximately 10% to 40% of zygomatic injuries.* AlQurainy et al65 have found that the severity of diplopia is
associated with the severity of midfacial injuries. Almost 30% of patients with comminuted fractures of the ZMC experienced diplopia, 22% of patients with
noncomminuteddisplacedZMCfractureshaddiplopia,andonly8%ofpatientswithminimallydisplacedornondisplacedZMCfractureshaddiplopia.Binocular
diplopia that develops following trauma can be the result of soft tissue (muscle or periorbital) entrapment, neuromuscular injury, intraorbital or intramuscular
hematomaoredema,orachangeinorbitalshape,withdisplacementoftheglobecausingamuscleimbalance.Enophthalmosandglobeptosisassociatedwith
markeddisplacementoftheglobecanalsocausediplopia.

A useful point in differentiating the cause of diplopia is the finding that general edema of the orbit usually causes diplopia in the extremes of upward and
downward gaze. Almost complete lack of eye movement in one direction is present with mechanical interference or neuromuscular injury, most commonly
muscleentrapment.Thediagnosisofdiplopiacanbedifficultintheearlystagesofaninjury,whensevereedemaoftheorbitandeyelidsispresent.Diplopiaof
edemaorhemorrhagicoriginshouldresolveinafewdays,whereasdiplopiacausedbyentrapmentoforbitaltissuedoesnot.

Onecandeterminethepresenceofentrapmentoforbitalcontentsbythefracturethroughtheorbitalfloorwithaforcedductiontest.Smallforcepsareusedto
graspthetendonoftheinferiorrectusthroughtheconjunctivaoftheinferiorfornixandtheglobeismanipulatedthroughitsentirerangeofmotion(Fig.168).
Inability to rotate the globe superiorly signifies entrapment of the muscles in the orbital floor. This test should differentiate between entrapment of orbital
contents and paralysis as a result of neuromuscular injury or edema. The test should be performed routinely in those who cannot rotate the globe into an
upwardgaze.

FIGURE168Theforcedductiontestdetermineswhetherthereisaphysicalimpedimenttoocularmotility.A,Graspingoftheinferiorrectusmuscle.B,Clinical
photograph.(FromWardBoothP,EppleyBL,SchmelzeisenR:Maxillofacialtraumaandestheticfacialreconstruction,ed2,WBSaunders,St.Louis,2012.)

Enophthalmos.
Ifthezygomaticinjuryhasproducedanincreaseinorbitalvolume,usuallybylateralandinferiordisplacementofthezygomaand/ordisruptionoftheinferior,
medial,and/orlateralorbitalwalls,orhasresultedinadecreaseinorbitalsofttissuevolumebyherniationoforbitalsofttissue,enophthalmoscanresult.This
diagnosisisdifficulttomakeacutelyunlesstheenophthalmosisseverebecauseadjacentsofttissueedemaalwaysproducesarelativeenophthalmos.Afterthe
swellinghasdissipated,enophthalmosbecomesmoreobviousandisfrequentlyassociatedwithptosisoftheglobe.Theclinicalmanifestationsofenophthalmos
areaccentuationofthesulcusoftheupperlidandnarrowingofthepalpebralfissure,causingpseudoptosisoftheupperlid.Theanteriorprojectionoftheglobe
as viewed from above is reduced on the side of injury. Zygomatic fractures are associated with enophthalmos in approximately 5% of cases before
treatment.22,26,46Ifenophthalmosispresentduringtheinitialexamination,itislikelythatagreatincreaseinbonyorbitalvolumehasoccurred.66,67

Radiologic Evaluation

Nothingismorevaluabletothesurgeonindeterminingtheextentofinjuryandthepositionofthefragmentsbothbeforeandafteroperationthanagood
skiagram.

H.D.Gillies,T.P.Kilner,andD.Stone,19271

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By1992,CTessentiallysupplantedotherradiologicmethodsintheassessmentofpatientswithmidfacialinjuries.68TwodimensionalCTisnowconsideredthe
bestandmostusefulmeansofradiologicassessmentoftheinjuredfacialskeleton.69TheamountofinformationthatcanbeobtainedwithCTismuchgreater
thanthatwhichcanbeobtainedfromaseriesofplainfilms.CTaccuratelyidentifieslinesoffracture,positionanddisplacementoftheZMC,andstatusofthe
zygomaticarch(Fig.169).CTscansareespeciallyhelpfulinthattheyallowacompleteassessmentofthestatusoftheorbitalfloorandwallsandthedepthto
which one must dissect to reach stable bone. CT has eliminated the question about whether the orbit should be explored. With the accurate image of the
internalorbitprovidedbyCT,onecanmakeadecisionregardingthenecessityforinternalorbitalreconstructionbeforesurgery.

FIGURE169AD, CT scans showing exquisite detail of a patient without a ZMC fracture demonstrating normal anatomy. A, Coronal CT scan through the
medial orbital rim. One should be alert to the possibility of fractures in this area. If lateral displacement of the medial orbital rim goes unnoticed, proper
alignmentoftheinfraorbitalrimwillcausetheZMCtobelaterallydisplaced.B,CoronalCTscanjustposteriortotheglobe.Thecoronalscanisparticularly
usefulforassessingthestatusofthemedialwallandflooroftheorbit.Oneshouldcarefullycomparethesizeoftheorbitsandthecontourofthefloorandwalls.
Thecoronalscanisalsoextremelyusefulforassessingthepositionofthemalareminence.Onecanfollowthecontourofthemalareminenceinferiorlyalong
thezygomaticomaxillarybuttress.ZMCfractureshavedisruptionofthisareaandthemalareminenceoftenrotatesinferomediallyintothemaxillarysinus.C,
Axial CT scan at the level of the midglobe. This allows assessment of the medial wall, lateral wall, and lateral orbital rim, and the position of the globes in
relationtothebonyorbitandoneanother.Notethatthelateralorbitalwallisfairlystraightinitscourse.ZMCfracturesusuallyshowdisplacementofthezygoma
inrelationtothegreaterwingofthesphenoidwithinthelateralportionoftheorbit.ManyZMCfracturesassociatedwithsignificantorbitalfloorandmedialwall
fracturesshowfracturesofthemedialwallinthisview,withtheorbitalcontentsherniatingintothetopofthemaxillarysinusandethmoids.D,AxialCTscanjust
belowtheinfraorbitalrim,atthelevelofthezygomaticarch.Thisviewisusefulforshowingthestatusofthezygomaticarch,projectionofthemalareminences,
andfracturesalongtheinfratemporalsurfaceoftheZMC.Ifscansaretakenwiththeheadproperlypositionedsothatsimilarcutsaremadebilaterally,one
should compare the right and left sides for symmetry. E and F, Coronal CT scans of the orbit showing a common location of orbital floor and medial wall
fractures.Notetheincreaseinorbitalvolumethataccompaniestheseinjuries.Fracturedefectsmaybesmallandhavelittleorbitaltissueherniatingintothe
sinuses.ManydefectsassociatedwithZMCfracturesarelargerthantheoneshown.Examinationofseveralcutsidentifiestheposteriorextentofthefracture,
allowingthesurgeontodeterminepreoperativelyhowfarposteriorlytodissectandthesizeofmaterialnecessaryforreconstructingthedefect.

ThestatusoftheorbitalsofttissuecanalsobeassessedbecauseofthegreatcontrastprovidedbyCT.Comparisonofglobeprojectionfromonesidewiththe
otherhelpsidentifyenophthalmosinunilateralinjuries.66,67,70,71Also,CTscansallowidentificationofassociatedcraniofacialinjuries.72ForZMCinjuries,it
isoptimaltoobtainaxialandcoronalhighresolutionscans.Theaxialscanisextremelyhelpfulinevaluatingthemedialandlateralorbitalwalls,andthecoronal
scandefinestheextentofinjurytotheorbitalfloor(seeFig.169).Reformattedcoronalviews(fromaxialscans)arenotashelpfulbutmaybenecessaryifthe
patient cannot be properly positioned because of injury. Threedimensional CT scans offer no additional information beyond what is already present in two
dimensionalscansbutareusefultounderstandthedisplacementandfracturepatterns.73,74

Treatment of Zygomaticomaxillary Complex Fractures

Themethodsoftreatingafracturedmalarbonerecommendedbythevariouswriterswhohavereportedcasesincludesimpledigitalmanipulationundergeneral
anesthesia,externalmanipulationbymeansofacowhorndentalforcepsgraspingtheedgesofthebone,tractionandelevationbymeansofwireorheavy
boneelevatorspassedthroughsmalllocalexternalincisions,andelevationviaincisioninthemucosaofthegingivalsulcusatthecaninefossa.

Ourtechnique,whichhasnowbeenusedsuccessfullyinanumberofcases,differsfromthosementioned.

H.D.Gillies,T.P.Kilner,andD.Stone,19271

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Since Duverney75 first described the fractured zygoma, numerous methods have been suggested for treating it. These range from nonintervention and
observation to open reduction and internal fixation (ORIF). Because many fractures are nondisplaced or minimally displaced, intervention is not always
necessary.Studieshaveshownthatbetween9%and50%ofZMCfracturesdonotrequireoperativetreatment(Table161).

TABLE161

ReportedIncidenceofZygomaticFracturesNotRequiringSurgicalTreatment

Thedecisiontointerveneshouldbebasedonsigns,symptoms,andfunctionalimpairment.ThedecisionneednotbemadehastilybecauseZMCfracturesare
notemergenciesandtreatmentcanbedelayed,ifnecessary.However,duringthefirstweekfollowingtrauma,thesofttissueundergoeschangesconsistent
withtheusualsequenceofwoundhealing.Theformthattheywillultimatelytakedependsontheunderlyingbonyarchitecture.IfacomminutedZMCisnot
treatedforseveraldaysfollowinginjury,anexcellentreductionmaybecompromisedbythesofttissuescarringandchangeinmorphologythatoccurbetween
thetimeofinjuryandfracturerepair.Optimally,fracturesaretreatedbeforetheonsetofedemafromthetraumaticincident.Inpractice,however,suchtimingof
treatmentisrarelypossible.Whenedemaismoderatetosevere,postponementofsurgeryforseveraldaysmakesthoroughexaminationandsurgicaltreatment
reliable and much easier tasks. Therefore, postponement of the decision to operate until facial edema resolves is recommended when the necessity for
interventionisquestionable.Thisapproachmaybeusedinfracturesthatareminimallydisplaced,whenradiographicexaminationoftheinternalorbitshowsno
major defects. However, if the radiographic findings are so dramatic that intervention is definitely necessary, it may be advantageous to perform the surgery
regardlessofthefacialedemapresent,becausethefinalsofttissuecontourmaybesuperiortothatwhichmayoccurwhensurgeryispostponed.Ifthesurgeon
decidesnottointervene,thepatientshouldbeobservedfor2to3weeksandasoftdietshouldbeprescribed.

Oneshouldalwaysrememberthatifaforceissufficienttoproduceafractureofthezygoma,itisalsosufficienttoproduceintracranialinjuries.ZMCfractures
arenotlifethreateninginjuriesandshouldnotbegivenpriorityovermoreacuteproblems.Treatmentneednotbehastenediftheneurologicstateofthepatient
isinquestionbecausezygomaticfracturescanbesatisfactorilytreatedinseveraldays,afterthefacialedemahasresolved.

Anotherimportantconsiderationindecidingwhethertointerveneisthestatusoftheoppositeeye.Ifthepatienthasdiminishedvisionintheeyeontheside
oppositethefractureforanyreason,onemaydecidenottotreatthedisplacedZMCfractureassociatedwiththeonlynormallyfunctioningeye.Althoughtherisk
tovisionisminimalwhenZMCfracturesaretreated,lossofsightintheonlyfunctioningeyewouldbeacatastrophe.Therefore,thepatientmustbeeducatedso
thataninformeddecisioncanbemade.

Ifinterventionisdeemednecessary,propertreatment,asforanydisplacedfracture,requiresreductionand,ifnecessary,fixation.Becauseclosedreduction
using external manipulation is impossible, all reduction techniques are operative procedures (i.e., open) in the sense that the skin or mucosal surfaces are
violated.

OnemustbeawarethatZMCfracturescanresultfromhighandlowenergyinjuries.40Thoseresultingfromaltercationsseemtobemorelinearincharacter
and displaced en bloc (Fig. 1610). These fractures can frequently be treated with limited exposure, simple reduction, and simple methods of fixation, if
necessary.Conversely,highenergyinjuries,suchasthosesustainedinMVAs,producemorecomminution,especiallyoftheadjacentbones,wheretheZMC
abuts, and are much less amenable to simple methods of treatment (Fig.1611). These fractures usually require extended open reduction and rigid fixation
techniques.Thesurgeonmustthereforebeawareofthenatureandextentoftheinjuryastreatmentisplanned.

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FIGURE 1610 CT scans of a lowenergy ZMC fracture. A, Coronal scan shows rotation of the ZMC around the zygomaticofrontal suture downward and
mediallyintothemaxillarysinus.Notethedifferenceinthepositionofthemalareminencefromonesidetotheotherandthedisruptionanddisplacementofthe
zygomaticomaxillary buttress. However, note that the fracture through the orbital floor is noncomminuted. B, Axial scan of the same patient shows posterior
displacementofthemalareminenceandrotationoftheposterior(infratemporal)surfaceoftheZMCmediallyintothemaxillarysinus.Thisfracturewastreated
byopenreductionviaanintraoralapproachandfixationwithasingleboneplateappliedalongthezygomaticomaxillarybuttress.Theorbitwasnotentered.

FIGURE1611CTscansofahighenergyZMCfracture.A,Coronalscanoftheposteriororbitshowingdisruptionoftheorbitalfloorandlateralwall.Notealso
thecomminutionofthemalareminenceandzygomaticomaxillarybuttress.B,Axialscanatthelevelofthemidglobeshowingcomminutionofthelateralorbital
wall (sphenozygomatic suture) and notable posterior displacement of the lateral orbital rim. C, Axial scan at the level of the zygomatic arch showing severe
displacementofthemalareminenceposteriorlyintomaxillarysinus.Notealsothedegreeofcomminutionandbowingofthezygomaticarch.D,Axialscanat
thelevelofthemalareminenceshowingsevereposteriorandmedialdisplacementoftheZMC.Thisfracturewastreatedbyopenreductionusingintraoral,
coronal,andlowereyelidapproaches.Severalboneplateswereusedforfixationandtheorbitalfloorandwallswerereconstructedwithbonegrafts.

Manymethodsareavailableforthereductionandfixationofzygomaticfractures,whichindicatesthatnoonetechniqueisalwayssuperiortotheothers.Fewif
anyproceduresarealwayssatisfactoryforeverytypeofzygomaticfracture,sothesurgeonsjudgmentandabilitytoapplyasatisfactorymodalitytoagiven
fracturearethedecidingfactorsinwhetherthepatientreceivesappropriatetreatment.Itshouldbestressedthatsatisfactoryresultscanbeachievedusinga
numberoftechniques.Itisnotsomuchtheactualtechnique,buttheproperapplicationofprinciples,thatproducessatisfactoryresults.

Thefracturedzygomaisperhapstheleastunderstoodandmostfrequentlymistreatedfacialfracture.Muchofthedifficultyintreatingthesefracturesstemsfrom
thecomplexandmultipleanatomicrelationshipsthatthezygomamaintainswithinthefacialskeleton.Themostcommonmistakemadeinclinicalpracticeisto
assumethattheZMCwillbeinitsproperpositioniftheinfraorbitalandlateralorbitalrimshavebeenreduced.OnemustrememberthatthefracturedZMChas
fourmajorprocessesthatarticulatewithadjacentbones.Onlywhenthreeareproperlypositionedcanonebesureofanaccuratereduction.Itmaybemore
helpfultothinkofthezygomaasafourleggedchair.Ifthreeofthefourlegsareonthefloor,theothermustalsobeonthefloor.Ontheotherhand,iftwolegs
areonthefloor,twomayalsobeoffthefloor.Therefore,reducingorbitalrimfractures(twolegsofthechair)doesnotguaranteethattheentirecomplexhas
beenproperlyreduced,becausethezygomacanrotateinferiorlyandmedially(Fig.1612).Inthiscase,fracturesthroughthezygomaticbuttressofthemaxilla
andzygomaticarchareleftimproperlyaligned,80producingaflattenedappearancetothefaceintheareainwhichthebodyofthezygomanormallygivessoft
tissuesupport.

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FIGURE1612TheZMCcanrotateinferiorlyandmedially,evenwhenreducedatthefrontozygomaticandinfraorbitalareas.

BecauseoftheZMCsdifficultanatomicdetails,andbecausetherearenosensitivecluestoaccurateandstablereduction,somesurgeonshavesuggestedthat
eachZMCfracturebetreatedaggressively,withORIFofatleasttwoofitsfourmajorprocesses.17,8185DingmanandNatvig,81forexample,havestatedthat
Whileclosedreductiontechniquesarepopularandattractiveinthemanagementoffracturesinthisregion,theexperiencedsurgeonwillbequicktosee,in
manycases,thelimitationsthatclosedmethodsimpose.ThemaincontroversiesinthetreatmentofZMCfracturesarethefollowing:

1.Shouldsurgicalexposureofthezygomaintwoorthreelocationsroutinelybeperformedtodeterminewhetherthereductionhasbeenadequate?

2.Shouldfixationdevicesberoutinelyapplied?

3.Doestheinternalorbitrequirereconstruction?

Itisnoteworthythatthemostcommontreatmenterrorsthatleadtopoorresultsalsocenteronthesesametopics.

Determining Whether the Zygoma Has Been Properly Reduced

Thereshouldbenodoubtthatobservationofthefractureinthreeofitsfourprocesseswillallowthesurgeontodeterminethepostreductionpositionaccurately.
Karlan and Cassisi80 have shown this to be true in a clinical review of their patients. The question therefore becomes whether this is always necessary.
RecommendationsintheliteratureforreductionofZMCfracturesrangefromclosedreductiontechniques7879tothreeorfourpointsurgicalexposure.8992
Incisions used to expose the lateral orbital, infraorbital, and zygomaticomaxillary buttress (intraorally) areas not only take time but also have the potential to
producecomplicationsoftheirown,regardlessofthezygomaticfractureforwhichtheyarebeingused(seelater,Complications).

Inseveralcases,however,surgicalexposurebecomeshelpful.First,whenpreoperativesignsandsymptomsand/orradiographsindicatetheneedforinternal
orbitalreconstruction,itisprudenttogainaccesstotheinfraorbitalrimandorbitalfloorbeforeelevationofthezygoma.Second,ifsurgerymustbeperformed
whileexcessivefacialedemaispresent,surgicalexposuretodeterminethepositionoftheZMCishelpful.Third,ifonecannotdeterminewhetherthereduction
has been adequate during the surgery, exposure will provide the necessary verification. Fourth, surgical exposure is helpful if fixation devices are deemed
necessaryfromthepreoperativeassessmentofthefracture.Thus,theuseofsurgicalexposuredependsonthecircumstancesandexperienceofthesurgeon
however,giventheseexamples,itwillbefrequentlyperformed.IfthereisanydoubtaboutthepostreductionZMCposition,oneshouldverifyitwithexposure,
remembering that even though the orbital rims are reduced, the body of the zygoma can be rotated medially. Exposure and exploration of other areas help
determinewhenthezygomahasbeenproperlyreduced.Fracturesatthezygomaticarchandinternalorbitalongthegreaterwingofthesphenoid(Fig.1613A)
aresensitiveindicatorsofZMCposition.However,exposureofthezygomaticomaxillarybuttress(intraorallyseeFig.1613B)providesoneofthemostvaluable
cluesabouttheadequacyofZMCposition,ifitisnotseverelycomminuted.Withthisexposure,onewillalsohaveexcellentexposureoftheinfraorbitalrim.It
shouldberealizedthatareciprocalrelationshipexistsbetweenmalarprojectionandfacialwidth.Ifthezygomaticarchisbowedlaterally,themalareminenceis
posteriorlydisplaced(Fig.1614).ReductionofZMCfracturesshouldensurethatthemalareminenceisproperlyprojectedanteriorlyand,ifthezygomaticarch
isreconstructed,theprocedureisdonebykeepingitflat.

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FIGURE1613AnatomicareasfordeterminingtheproperreductionofZMCfracture.A,RotationoftheZMCintheverticalaxisismosteasilydeterminedbyits
alignmentwiththegreaterwingofthesphenoidalongtheinternalorbit(straightarrow).B,Thezygomaticomaxillarybuttressprovidesasensitiveindicatorof
malarprojection.

FIGURE1614A,Thereciprocalrelationshipbetweenfacialwidthandmalarprojectionisdemonstrated.Notethatthenormalcontourofthezygomaticarchis
straight,notcurved.Ifthezygomaticarchisreconstructedwithabow,themalareminencewilllackanteriorprojection.Frontal(B)andsubmental(C)viewsofa
patient who had open reduction and internal fixation of a right ZMC fracture 2 years previously. Note the increase in facial width and the decrease in malar
projection.Alsonotetheenophthalmosoftherightglobe.D,AxialCTscanshowinglateralbowingofthezygomaticarchandtheposteriorpositionofthefrontal
processofthezygoma.Onecanseethatthemedialorbitalwallwasalsoinadequatelyreconstructedwhenthecontouriscomparedwiththeoppositeorbit.
Coronal CT scan of the anterior (E) and posterior (F) orbit showing inadequate orbital reconstruction (arrow). The bone grafts in the anterior orbit do not
maintainnormalorbitalshape.Thegraftsalsodidnotextendfarenoughposteriorly.Notethegreatincreaseinorbitalvolume.

Ifthesurgeonhasnavigationand/orintraoperativeCTscanningavailable,theamountofsurgicalinterventioncanoftenbeminimized.Eitherofthesetoolscan
assessthepositionoftheZMCandinternalorbitalfloorreconstructionsintheoperatingroom.Thus,onecanoftenuseamorelimitedexposure,reducethe
fracture,anddeterminewhethertheZMCisinproperposition.

AnotherimportantpointthatshouldbestressedinthetreatmentofZMCfracturesisthestatusofthemedialorbitalrim.Occasionally,aunilateralnasalorbital
ethmoidfractureoccursonthesideoftheZMCfracture,displacingthemedialportionoftheinfraorbitalrimlaterally.Thisportionofbonemayseemtobevery
stableandthefactthatitismalpositionedmaygounnoticed.IftheZMCisreducedintoappositionwiththislaterallydisplacedfragmentofinfraorbitalrim,the
ZMCwillbelaterallypositioned,increasingorbitalvolumeandwideningtheface(Fig.1615).Becauseaunilateralnasalorbitalethmoidfracturemaybedifficult
to diagnose clinically, preoperative CT scans are the best diagnostic tool (see Fig.169A). Therefore, one should always search for fractures of the medial
orbitalrimswhenassessingpreoperativescans.

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FIGURE1615ThispatientwastreatedforaleftZMCfracture.NotelateraldisplacementoftheZMCandslighttelecanthusontheleft.Thispatienthadan
undiagnosedleftnasalorbitalethmoidfracture,withlateraldisplacementofthefrontalprocessofthemaxilla.TheleftZMCfracturewasreducedtothisbone,
resultinginlateraldisplacementoftheZMC.

Need for Fixation

One of the most controversial topics in maxillofacial surgery is the amount of fixation necessary to prevent postreduction displacement of the fractured
ZMC.9395 Some have noted that reduction, by itself, does not produce adequate stability of the fractured zygoma, claiming that the downward pull of the
masseter muscle will cause a medial rotation of the zygomatic body before healing.* Albright and McFarland96 went so far as to recommend intermaxillary
immobilization following fracture reduction to help reduce the pull of the masseter muscle on the repositioned ZMC. The masseter muscle has often been
implicatedasaprimarycauseofpostreductiondisplacementofthefracturedZMC.Itwasassumedtobecapableofexertingsufficientinferiorlydirectedforce
on the fractured ZMC to cause movement, even after surgical insertion of fixation devices. However, this contention has never been proven. There is no
evidence in the literature that postreduction displacement of a ZMC fracture has occurred in patients. Previous clinical studies simply evaluated patients
clinicallyandradiographicallymonthsaftersurgeryandnotedanoccasionalpatientwithpoorZMCposition.Itwasassumedthatbecausethefractureswere
simply elevated, or perhaps stabilized with wire fixation, postsurgical displacement had occurred. Therefore, recommendations for fixation have varied from
nonetotheplacementofthreeorfourboneplatesatdifferentlocationsaroundthefracturedZMC.

EllisandKittidumkerng99havereviewedaseriesofisolatedZMCfracturestreatedbydifferentapproachesandfixationschemes,bothimmediatelyandseveral
weeksafterrepair,andfoundnoevidenceofpostreductioninstabilityinanypatient.Basedontheirexperienceandthedatageneratedfromtheirstudy,various
methodscanbeusedsuccessfullytostabilizeZMCfractures.Theserangefromreductionwithoutfixationtoreductionwiththreeorfourpointfixationusing
boneplates.

Suchadiversityoftreatmentoptionsshouldnotbesurprising,giventheresultsofastudybyDalSantoetal.95Thierstudycomparedmassetermuscleforcein
10malecontrolsubjectswiththatin10malepatientswhohadsustainedunilateralZMCfractures.Thecalculationofmuscleforcewasbasedonmeasuredbite
force,electromyograms,andradiographicdeterminationofmusclevectors.Itwasfoundthatthemassetermuscledevelopednotablylessforceinpatientswith
ZMCfracturesthanincontrolsubjects.Followingfracture,massetermuscleforceslowlyincreased,butat4weeksaftersurgery,mostpatientswerestillwell
belowcontrollevels.TheresultsofthatstudycastdoubtontheroleofthemassetermuscleinpostreductiondisplacementofthefracturedZMCandindicate
thatpotentiallyminimumamountsoffixationarerequiredforsuchinjuries.

Mosthavedisagreedwiththeconceptthatfixationshouldberoutinelyappliedfollowingreductionofzygomaticfractures.*Thesesurgeonsappliedfixationto
zygomaticfracturesonlywhereindicated.Theindicationsfortheapplicationoffixationseemtovarywiththesurgeonandtypeoffracture,sotheincidenceof
fixationapplicationvarieswidelyintheliterature(8%to100%)(Table162).

TABLE162

ReportedIncidenceoftheNeedforFixationinAdditiontoReduction

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*Onlythosecasesthatweresurgicallytreatedinthesestudiesareincludedinthistable.

The efficacy of using simple elevation (without fixation) when indicated has been demonstrated by Larsen and Thomsen.22 They reexamined 87 patients
severalmonthstoyearsafterelevationoftheirfracturesbytheGilliestemporalapproachandfoundonly2patientswithresidualdeformity.Similarly,Fischer
BrandiesandDielert25reexamined41casesofzygomaticfracturetreatedwithelevationusingahookandfoundnopostsurgicaldisplacement.Severalother
studiesintheliteraturehaveusedZMCrepositioningwithoutfixation,withgoodresults,29,7879verifyingthatfixationrequirementsarelessthanadvocatedby
some. Fixation with one bone plate has been advocated by several surgeons in a certain percentage of ZMC fractures, either at the zygomaticomaxillary
buttress*or,morecommonly,atthefrontozygomaticarea.Champyetal111usedasingleboneplateatthefrontozygomaticareain342isolatedZMCfractures
andfoundthatonly6(1.8%)hadanunsatisfactoryresult.Tarabichi100treated17consecutivelowvelocityZMCfracturesbyatransoralopenreductionand
internalboneplatefixationofthezygomaticomaxillarybuttress,withexcellentresultsinallbut2patients,whohadcomminutionoftheorbitalrim.Covingtonet
al79wereabletostabilize30%to40%ofZMCfracturesbyonepointfixation.EllisandKittidumkerng99wereabletouseonepointfixationin31%ofZMC
fracturesreportedintheirstudy.SimilarresultswereshownbyShumricketal.114

AnimportantpointregardingthestabilityofZMCfracturereductionisthestateofthefractureends.Wheretheosseousprocessesarenotcomminuted,the
fracture is more likely to remain stable without fixation devices. However, when comminution of the fragments has occurred, instability usually results and
fixationdevicesbecomenecessary.Thus,comminutedfracturesbehavedifferentlyfromlinearfractures.Ifthereisanyquestionaboutthestabilityofareduced
zygomaticfracture,itisprudenttoapplyfixation.

Need for Internal Orbital Reconstruction

By definition, the orbital floor is fractured in ZMC fractures. However, the magnitude and extent of orbital floor disruption vary from a linear crack to
fragmentationoftheentirefloorandmedialandlateralwalls.Many,perhapsmost,lowenergyZMCfracturesdonothaveherniationofperiorbitalcontentsinto
thesinuswithentrapmentofocularmusclesorenophthalmos.However,theseproblemsdooccurinacertainpercentageofcases.Davies115notedsignificant
orbitalfloordisruptionin47%ofpatientswithzygomaticfractures.SacksandFriedland116notedthiscomplicationintwothirdsofZMCfractures.Crewe117
notednotabledisruptioninmostzygomaticfractures.CrumleyandLeibsohn64notedthat39%ofzygomaticfractureshadcomminutedfracturesoftheorbital
floor. The need for orbital floor reconstruction to support the periorbital tissue was necessary in two of three cases of orbital floor exploration performed by
Pozateketal76andWiesenbaugh.46Ellisetal26founditnecessarytoplaceimplantsinoneofthreecasesonexplorationoftheorbitalfloor.Theorbitalfloor
andwallswerereconstructedin44%ofisolatedZMCfracturesinastudybyEllisandKittidumkerng.99AsimilarstudybyShumricketalfoundthenecessityto
reconstructtheinternalorbitinonly30%ofZMCfractures.114

AlthoughsomesurgeonsbelievethatsocalledexplorationoftheinternalorbitshouldbeperformedroutinelywhenoperatingonZMCfractures,*mostdonot.
Thesesurgeonswouldarguethatexplorationoftheorbitshoulddependonpreoperativeandintraoperativefindings.Fortunately,CTscanshaveeliminatedthe
debateaboutwhenanorbitshouldbeexplored.Itisnowpossibletoobtainanaccurateassessmentofthestatusoftheinternalorbitbeforesurgerysothat
adequatetreatmentcanbeproscribedandplanned.114,118Ifcomminutionoftheorbitalfloorandwallsand/orprolapseoforbitalsofttissueintothemaxillary

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andethmoidsinusesisnoted,oriforbitalvolumehasincreasedfromblowoutofthefloorandwalls,reconstructionshouldbeperformed.119,120Usingsimilar
criteriainthepreoperativeCTscans,ReddyandElliswereabletoclassifypatientssuccessfullyintothosewhorequiredandthosewhodidnotrequireinternal
orbitalreconstruction.118 They showed that in those who were determined not to need internal orbital reconstruction, good radiographic and clinical results
wereobtained.

With the availability of intraoperative CT scanning in some operating rooms, the question about whether to reconstruct the internal orbit in those patients in
whomthepreoperativeCTscandoesnotshowgrossdisruptioncanbeansweredintheoperatingroom.AftertheZMChasbeenreduced,ascanistakenand
anassessmentoftheinternalorbitismade.Thesurgeoncanthendecidewhetheritisnecessarytoreconstructtheorbitalwalls(Fig.1616).

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FIGURE1616UseofintraoperativeCTscanning.A,B,PreoperativethreedimensionalCTscansshowamoderatelydisplacedrightZMCfracture.Notethe
lateral displacement of zygomatic arch and posterior displacement of malar eminence. C, D, Preoperative coronal CT scans show fractures of the orbital
floor.TheZMCfracturewasexposedusingmaxillaryvestibular(E)anduppereyelidapproaches(F).G,TheZMCwasreducedusingaCarrollGirardscrew.H,
An intraoperative CT scan was then obtained to determine whether the reduction of the ZMC was adequate and to determine whether internal orbital
reconstruction was necessary.I, J, Intraoperative threedimensional reconstructions demonstrated good reduction of the ZMC. Coronal (K) and sagittal (L)
imagesoftheorbitindicatedthattheorbitalfloorwasingoodposition,sonointernalorbitalreconstructionwasdeemednecessary.TheZMCwasstabilizedwith
bone plates across the zygomaticomaxillary buttress (M) and frontozyomatic suture areas (N) and the incisions closed. O, P, Q, Postoperative CT scans
demonstrategoodpositionoftheZMCandorbitalfloor(R,S,T).

Principles in the Treatment of Zygomaticomaxillary Complex Fractures

In the treatment of any ZMC fracture that requires surgical intervention, consideration should be given to each of several steps in a sequential and orderly
manner(Box161).

Box161StepsinSurgicallyTreatingaZygomaticomaxillaryComplexFracture

1.Prophylacticantibiotics

2.Anesthesia

3.Clinicalexaminationandforcedductiontest

4.Protectionoftheglobe

5.Antisepticpreparation

6.Reductionofthefracture

7.Assessmentofreduction

8.Determinationofnecessityforfixation

9.Applicationoffixationdevice

10.Internalorbitalreconstruction

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11.Assessmentofocularmotility

12.Bonegraftextraorbitalosseousdefects

13.Softtissueresuspension

14.Postsurgicalocularexaminations

15.Postsurgicalimages

Prophylactic Antibiotics.
TheincidenceofinfectionfollowingZMCfractureorfracturereductionisextremelylowhowever,suchaninfectionisdifficulttodiscernbecausemanysurgeons
routinelyuseprophylacticantibiotics.Thispracticealsomakesitdifficulttodeterminetheeffectivenessofantibioticsinpreventinginfectionofthesefractures.
Becausethemaxillarysinusisinvolved,ZMCfracturescanbeconsideredcompound,andprophylacticantibioticsareprobablyappropriate,especiallygiventhe
factthattheorbitalcontentsarealsofrequentlyviolated.Thechoiceofantibioticsshouldcoverroutinesinusbacteria(e.g.,ampicillin,amoxicillin,clindamycin,
cephalosporin).

Anesthesia.
ForisolatedZMCfractures,generalanesthesiawithoralintubationishelpful.Theanesthesiologistoranesthetistshouldbepositionedsothatthesurgeonhas
accesstothesideofthefractureandheadofthetable.Itisveryimportanttohavecompleteaccesstothetopofthepatientsheadforvisualcomparisonofone
sidewiththeother.(Reductionofisolatedzygomaticarchfracturescanbeperformedwiththepatientunderlocalanesthetic,withorwithoutsedationwhenthe
patientiscooperative,andanintraoralorapercutaneousapproachisused.)

Clinical Examination and Forced Duction Test.

Followinginductionofgeneralanesthesia,thesurgeonshouldtaketheopportunitytoexaminethepatientmorecarefully.Withthepatientunderanesthesia,the
surgeon has more freedom in the examination and can use more digital force than is possible with the patient awake. This examination can help confirm
previous diagnoses and may reveal new information. It is very important to look at the patient from the superior view and to visualize both zygomas
simultaneously.Unlesstheswellingismarked,oneshouldbeabletodetermineanasymmetry.Layingtheindexfingeracrosstheinfraorbitalareaoronthe
malarprominenceshouldhelpdiscerntheasymmetry(seeFig.164).Aforcedductiontestshouldalsobeperformedatthistime(seeFig.168).

Protection of the Globe.

Thecorneamustbeprotectedfrominadvertenttrauma.Oftheseveralwaysofprovidingthisprotection,perhapsthesimplestisplacementofascleralshell
(corneal shield) after application of an ophthalmic ointment (Fig.1617A). Temporary tarsorrhaphy can also be used by suturing the dermal surfaces of the
upperandlowereyelidstogetherwith50nylonsutures(seeFig.1617BandC).

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FIGURE1617A,Scleralshellusedforocularprotection.B,C,Techniqueoftemporarytarsorrhaphy.

Antiseptic Preparation.
Thetypeofpreparationnecessarydependslargelyonthetypeofapproach(es)thatareanticipated.Itisgoodpractice,however,topreparetheforehead,both
periorbitalareasandcheekstothelevelofthemouth,andbothsidesofthepreauriculararea.Suchpreparationallowscomparisonoftheaffectedsidewiththe
oppositesideduringsurgery.Anotherusefulsuggestionisalwaystopreparethemouthwiththroatpackandantisepticrinse,becauseanoralapproachtothe
sinusand/orzygomaisfrequentlyuseful.Ifthepreoperativeclinicalandradiographicexaminationssuggestthatacoronalapproachmaybenecessary,thehair
andearsarepreparedanddraped.

Reduction of the Fracture.

Thefractureshouldbereducedbywhatevermeansthesurgeondeemsappropriate(techniquesdescribedlater).

Assessment of Reduction.
The most important step in the management of ZMC fractures is to determine at the table whether the fracture has been properly reduced. The success or
failureofreductionwillbeobviousforthosewhohaveopenedthefractureatthreesites.Ifexposureatthreesiteshasnotbeenperformed,theorbitalmargins
aretheareasthatshouldbepalpatedfirsttodeterminereduction.Ifreductionhasbeensatisfactory,thesemarginswillbesmoothandcontinuous.Thisfinding
byitself,however,isinadequateverificationthatthezygomaisproperlypositioned.Althoughthezygomaticofrontalsutureareaprovidesthestrongestpillarof
thezygoma,itisoneoftheworstindicatorsofproperreductionoftheentirecomplex,evenwhensurgicallyexposedandevaluateddirectly.Oneshouldalso
palpateinthemaxillaryvestibule.Ifthereisanyflatnessstillvisible,thezygomahasnotbeenproperlyelevated.Ifthereisanydoubtaboutproperreduction,
exposureismandatory.Inthiscase,anincisioninthemaxillaryvestibuleoffersexcellentexposureofthezygomaticomaxillarybuttressandtheinfraorbitalrim.

ForsurgeonswhohavenavigationorintraoperativeCTscanningavailable,assessmentofthereductionisrelativelyeasy.

Determination of the Necessity for Fixation.

Thesecondmostimportantstepinsurgicallytreatingzygomaticfractures(followingdeterminationofwhetherthereductionhasbeensatisfactory)isdetermining
whetherthereductionwillbestablebyitselforneedssomeformoffixation.IfconstantreductionforceisnecessaryformaintainingZMCposition,theZMC
shouldbestabilizedwithsomeformoffixationdevice(s).Ifthezygomaticpositionisdeemedappropriateanddoesnotrequireconstantapplicationofreduction
force,oneshouldpresswithmoderatepressureonthemalareminencewiththefingersandseewhetherdisplacementresults.Ifitdoesnot,fixationdevices
maybeunnecessary.Manyminimallydisplacedcasesarestableaftertheyhavebeenreduced.However,ifthereisanydoubtaboutpostreductionstability,the
applicationoffixationdevicesisprudent.

Application of a Fixation Device.

ThemethodsofstabilizingthefracturedZMCvarywiththeimaginationandexperienceofthesurgeon.Generalprinciplesareinvolved,however(seelater).

Internal Orbital Reconstruction.

Whenindicated,reconstructionshouldbecarriedoutafterrepositioningandstabilizingtheZMCfracture.Insuchcases,theorbitalfloorandwallsshouldbe
exposedbeforeelevationoftheZMCsothattheopenorbitalrimcanalsoserveasaguidetoreduction.However,itisunwiseatthispointtotrytofreeany
trappedtissue,becauseelevationofthezygomamayseparatebonefragmentsandmakethismaneuvermucheasierfollowingreduction.Assessmentofthe
magnitudeofthedefecttobereconstructedismadefollowingreduction,becausetheactualdefectwillthenberevealed(techniquesdescribedlater).

Inminimallydisplacedcasesinwhichnoocularsignsofentrapmentorenophthalmosarenotedpreoperatively,andinwhichthefractureistreatedbysimple
reduction,internalorbitalexplorationand/orreconstructionisunnecessaryunlessapostreductionforcedductiontestproducespositivefindings(rare).Inmost
of these cases, reduction of the zygoma results in adequate alignment of the orbital floor.33,114,118 However, one should never avoid reconstructing the
internalorbitforfearofcausingharmtoorbitaltissue.Thisoccurrenceisextremelyrare.ForthosesurgeonswhohaveintraoperativeCTscanningcapability,

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thestatusoftheinternalorbitafterreductionoftheZMCisknownandthedecisionabouttheneedforinternalorbitalreconstructioncanbemadeduringthe
surgery.

Assessment of Ocular Motility.

Anotherforcedductiontestshouldbeperformedattheendofallactivetreatment,withthepossibleexceptionofsuturing,toverifythatthetreatmentdidnot
createentrapmentoforbitalcontents(seeFig.168).

FIGURE1618A,AnteriormaxillarywalldefectafterreductionandfixationofaZMCfracture.B,Bonegraftplacedovertheareaofdefect.

Bone Graft for Extraorbital Osseous Defects.

Considerationshouldbegiventograftingareasofmissingbonealongtheanteriormaxillaandzygomaticomaxillarybuttress.Eventhoughboneplatefixation
mayprovidestabilizationoftheZMCbyspanningsuchdefects,itisunclearhowlongboneplateswillprovidesuchstability.Reconstructionoftheskeletonwith
bonegraftspreventssofttissueprolapsefromthecheekintothemaxillarysinusandpromotesosseousunionacrossthedefect,providinglongtermstability
(Fig.1618).

Soft Tissue Resuspension.

In 1991, Phillips et al121 described a method of soft tissue suspension of infraorbital and malar soft tissues before closing incisions after treating midfacial
fractures.Theyhypothesizedthatthesesofttissuesdroopifnotresuspendedthedroopingresultsinfacialasymmetryandprovidestractiononthelowereyelid,
causing ectropion. Yaremchuk and Kim122 have confirmed this hypothesis and found a 20% incidence of scleral show when the facial soft tissue was not
resuspendedbutnoscleralshowwhenthetissuewasresuspended.Thus,forfracturesinwhichthesofttissuewascompletelystrippedfromthebone,sutures
shouldbepassedthroughthedeepsurfaceofthesofttissueofthecheekandsecuredtostructuressuchastheorbitalrimandtemporalfasciatoraisethem
intotheirproperlocationontheunderlyingbone(Fig.1619seealsoFig.1625F).

FIGURE1619A,Appearanceofmalarsofttissuebeforeresuspension.Notethe30polyglycolicacidsuture,whichentersthroughthesubciliaryincisionand
passesthroughtheperiosteumandmalarsofttissue.Itisshownwithoutbeingtied.B,Appearanceofthemalarsofttissueafterthesuturehasbeenpulled
superiorly.Notetheelevationofthemalarsofttissuemassandthesupportprovidedtothelowereyelid.Thissuturecanbetiedtooneofthescrewsinabone
plateonthelateralorbitalrim,throughaholethroughtheorbitalrim,orthroughthetemporalfascia.

Postsurgical Ocular Examination.

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The pupillary reflexes should be monitored postoperatively and the fundus examined periodically. Visual acuity must also be checked. Because of surgical
edema,binoculardiplopiawillprobablybepresent,dependingonthesurgicalprocedure.

Postsurgical Images.
Postoperativeimagesshouldbeobtainedwheneverthepatientisstable.AxialandcoronalCTscansarerecommendedtoassessadequacyofreductionand
internalorbitalreconstruction,ifperformed.

Surgical Approaches to Zygomaticomaxillary Complex Fractures

Many techniques have been advocated for reducing and stabilizing ZMC fractures. These approaches will be described after a discussion of the surgical
approachesusedtogainaccesstotheZMC.Techniquesoforbitalexplorationandreconstructionwillthenbepresented.

AstandardseriesofapproacheshasbeenusedextensivelyforapproachingthefracturedZMCandorbit.Existinglacerationsareoftenusedforthispurpose.In
theabsenceoflacerations,properlyplacedincisionsofferexcellentaccess,withminimalmorbidityandscarring.

Protection of the cornea during operative procedures is mandatory in all operations in the vicinity of the orbit. If one is operating on the dermal side of the
eyelidstoapproachtheorbitalrimand/ororbitalfloor,a/>

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