CRANIOMAXILLOFACIAL TRAUMA

Interfragmentary Screw Fixation of the

Zygomatic Arch in Complex Midface and
Zygomaticomaxillary Fractures
Andr
e Luis Ribeiro Ribeiro, DDS, MSc,* T^ania Maria de Souza Rodrigues, DDS, MSc, PhD,y
S
ergio de Melo Alves-Junior, DDS, MSc, PhD,z
and Jo~ ao de Jesus Viana Pinheiro, DDS, MSc, PhDx

Zygomatic arch reduction and fixation is a key point in the treatment of complex midface and zygomatico-
maxillary fractures. High-impact frontal trauma can cause posterior displacement of zygomatic bone, with a
sagittal fracture of the root of the zygomatic arch extending posteriorly to the glenoid fossa. Miniplate and
screw fixation of this fracture requires a large detachment of soft tissue, thus being technically more difficult
for proper fixation and increasing the risk of soft tissue damage. This report describes an operative
approach for fixation of this type of fracture using an adaptation of the lag screw technique. After the initial
reduction of zygomatic bone, the proximal segment of the zygomatic arch containing the sagittal fracture is
anatomically reduced and a 2.0-mm titanium screw is placed with an inferior inclination of 10 to 15 into
the mastoid cells of the temporal bone, thus avoiding intracranial screw placement. This technique showed
excellent results in reduction and long-term stability. It facilitates the surgical procedure, decreases the risk
of soft tissue damage, and can lower costs compared with conventional miniplate and screw fixation.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:494-498, 2015

The surgical repair of zygomatic arch fractures is a key
point in the treatment of complex fractures of the
midface and zygomaticomaxillary complex.1,2 The
zygomatic arch is crucial in the anteroposterior
positioning of the midface and for maintenance of facial
width after complex fractures.1,2 Malpositioning of the
zygomatic arch is a major cause of unsatisfactory results
in this type of fracture and compromises the position of
all other facial structures.1 Traditionally, fixation of the
zygomatic arch is carried out using titanium miniplates
and screws. However, in certain fracture types, the use
of miniplates can be difficult to apply and the surgeon
should use different resources for proper fixation.
The authors have observed in their surgical practice a
pattern of fractures of the zygomatic arch that is usually
associated with complex fractures involving the mid-
face and zygomaticomaxillary region. It occurs mainly
because of a high-impact frontal trauma, where there
is a force of posterior displacement that compresses
the zygomatic arch, causing at least 2 lines of fracture:
1 fracture of the zygomatic arch that shows lateral
displacement (Fig 1A, white arrow; Fig 1B) and the
other 1, the subject of this study, that occurs in a sagittal
direction at the root of the zygomatic arch and can
extend into the outer cortical bone above the glenoid
fossa (Fig 1A, red arrow). In this situation, the use of min-
iplates and screws requires a large posterior displace-
ment of the surrounding soft tissues, thus increasing
surgical difficulty and the risk of soft tissue damage.
For these reasons, the authors have adapted the use
of the lag screw technique for fixation of this type of
fracture. Details of the technique are described below.

*Associate Professor, Department of Oral and Maxillofacial
Surgery, School of Dentistry, University Center of Par
a, Bel
em, Brazil.
yAssociate Professor, Department of Periodontology, School of
Dentistry, University Center of Par
a, Bel
em, Brazil.
zAssociate Professor, Department of Oral Pathology, School of
Dentistry, Federal University of Par
a, Bel
em, Brazil.
xAssociate Professor, Department of Oral Pathology, School of
Dentistry, Federal University of Par
a, Bel
em, Brazil.
Dr Ribeiro received scholarship funding from the CAPES Founda-
tion, Ministry of Education of Brazil (grant 0698130).
Address correspondence and reprint requests to Dr Ribeiro
Ribeiro: Travessa 9 de Janeiro, 927, Faculdade de Odontologia, De-
partamento de Cirurgia e Traumatologia Buco-Maxilo-Facial, Centro
Universit
ario do Par
a, Bel
em, PA, Brazil; e-mail: ribeiroalr@ig.com.br
Received July 25 2014
Accepted September 25 2014
Ó 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01595-X
http://dx.doi.org/10.1016/j.joms.2014.09.028

494
RIBEIRO RIBEIRO ET AL 495

FIGURE 1. A, Axial computed tomographic view and B, 3-dimensional reconstruction. A, Fracture in the sagittal direction of the zygomatic
arch in the zygomatic process of the temporal bone (red arrow). The posterior border of this fracture is near the external auditory canal (blue
arrow). A second line of fracture is observed with lateral displacement of the zygomatic arch (white arrow). B, The body of the zygoma is
posteriorly displaced, leading to lateral displacement of the zygomatic arch and facial enlargement.
Ribeiro Ribeiro et al. Interfragmentary Screw Fixation. J Oral Maxillofac Surg 2015.
496 INTERFRAGMENTARY SCREW FIXATION

Technical Report One or 2 self-drilling 2.0-mm screws with a length of

This technique requires surgical access to the zygo-
matic arch and a coronal approach was carried out, as
previously described.2 In cases of unilateral involve-
ment of the arch, the hemicoronal approach also
can be used. Owing to the retrospective nature of
this study, it was granted an exemption in writing
by the University Center of Par
a institutional review
board.
Treatment was conducted according to the outside-
to-inside principle based on the authors’ preference;
however, this technique can be used in any treatment
sequence. After exposure of the zygoma and zygo-
matic arch, the zygomatic bone is initially reduced in
the zygomaticofrontal suture and adjustable fixation
is carried out using a 4-hole miniplate with 1 screw
on each side of the fracture. This allows further adjust-
ment of the position of the zygoma after reconstruc-
tion of the zygomatic arch.
Regardless of the number of fractures in the zygo-
matic arch, the second step is reduction and fixation
of the sagittal arch fracture. The bone fragment is
anatomically reduced through visualization of the
roof of the glenoid fossa. Drilling is performed only
in the displaced fragment of the zygomatic arch with
an angle of 10 to 15 in the inferior direction. The
thread of the screws is positioned in the thin bone of
the mastoid cells, and for this reason no drilling into
this bone is required.
10 to 12 mm are used. The screw should be inserted
carefully until it touches the outer cortical bone, and
the fragment of the arch is kept reduced by a Kelly
clamp. After fixation of this fragment of the zygomatic
arch, the remaining fragments are reduced and fixed
with miniplates and screws, as in the conventional
technique (Fig 2). After reconstruction of the zygo-
matic arch, the anteroposterior position of the zygo-
matic bone can be set correctly. The anteroposterior
manipulation of the zygomatic bone is possible owing
to the adjustable initial fixation of the zygomaticofron-
tal suture. After these steps, the outer facial frame is
positioned and surgery continues, with the properly
reduced zygoma serving as a reference for restoring
the anterior projection of the midface.
If there is maxillary involvement, it will be the next
bone to be reduced and fixated. The maxilla is mobi-
lized, reduced, and placed in intermaxillary fixation.
Afterward, reduction of the naso-orbito-ethmoid re-
gion and rigid internal fixation is carried out as
required, including fixation of the infraorbital rim.
The remaining screws of the zygomaticofrontal region
are inserted and stabilization of the zygoma is
completed. Then, reconstruction of the orbital walls
is performed.
This technique showed excellent results in short-
and long-term stability of the zygomatic arch. All pa-
tients were followed for at least 1 year after surgery.

FIGURE 2. Intraoperative clinical images after fixation of the zygomatic arch. Two interfragmentary screws are used for fixation of the
proximal segment of the zygomatic arch fracture (arrows). After fixation of this fragment, the remaining fractures of the zygomatic arch are
reduced and fixated and the zygomatic bone recovers its anterior projection.
Ribeiro Ribeiro et al. Interfragmentary Screw Fixation. J Oral Maxillofac Surg 2015.
RIBEIRO RIBEIRO ET AL 497

FIGURE 3. Computed tomograms in A, axial and B, coronal views. A, Excellent fracture reduction can be observed, with no gaps in the sagittal
fracture line (arrow). B, The screw is appropriately placed in the temporal bone (arrow). There is proper spatial positioning of the zygoma and
zygomatic arch after fixation. A, The facial width and anterior projection of the face are restored.
Ribeiro Ribeiro et al. Interfragmentary Screw Fixation. J Oral Maxillofac Surg 2015.
498
Table 1. SUMMARY OF KEY POINTS FOR LAG SCREW
FIXATION OF SAGITTAL FRACTURES OF THE ROOT OF
THE ZYGOMATIC ARCH
Indications
Complex midface and zygomaticomaxillary fractures
that show sagittal fracture of the root of the zygomatic
arch for which surgical repair of zygomatic arch is
required
Limitations
May require use of miniplates and screws for fixation of
other zygomatic arch fractures
Temporal bone fracture with intracranial involvement
Technique details
Anatomic reduction of zygomatic arch with surgical
clamp
Drilling with 10 -15 inferior inclination only in
displaced fragment
Fixation with 1 or 2 self-drilling 2.0-mm screws with
10- to 12-mm length
Rationale for its use
Decreases soft tissue displacement because it does not
require fixation in non-fractured stable temporal bone
Facilitates a straightforward and fast surgical procedure
during surgical access, reduction, and fixation
Potentially can lower costs of treatment by decreasing
the total number of screws and possibly avoid use of
miniplates
Ribeiro Ribeiro et al. Interfragmentary Screw Fixation. J Oral
Maxillofac Surg 2015.
No complications were observed, including any
related to the surgical technique, or insufficient stabil-
ity of the zygomatic arch (Fig 3). Table 1 presents the
key points of this technique.
Discussion
Achieving satisfactory results in the treatment of
complex midface and zygomaticomaxillary fractures
involves a series of decisions that include the approach
of the zygomatic arch as a key point of treatment.1,2 In
addition, a distinct pattern of fractures can generate
more challenges for achieving satisfying results. In
this report, the authors have described a pattern of
sagittal fracture of the root of the zygomatic arch and
the surgical technique for stable and easy fixation of
this special type of fracture. This technique was used
in 15 cases with the same pattern of sagittal fractures,
showing its reproducibility.
In this region, the use of miniplates can be difficult
because the posterior border of the fracture is located
posteriorly in the temporal bone, which requires wide
displacement of soft tissue to accommodate the mini-
plate and at least 2 screws in the skull base. It can in-
crease surgical difficulty and the risk of soft tissue
INTERFRAGMENTARY SCREW FIXATION
damage. For this reason, the authors adapted the
lag screw technique for suitable fixation of this type
of facial fracture. Lag screw fixation has been
described as a suitable technique for zygomatic frac-
tures with some similar advantages.3-6 To the
authors’ knowledge, it is the first full description of
this technique for fixation of sagittal fractures of the
zygomatic arch.
This technique uses 2.0-mm screws with a length of
10 to 12 mm. Thinner screws (1.5 or 1.3 mm) do not
provide adequate stability owing to the smaller
threads. The screw is anchored in the mastoid cells,
which have a fragile bone structure, being unstable
when using thin screws. In contrast, larger screws
(2.3 to 2.7 mm) are very thick and can lead to bone
fracture of the zygomatic arch.
Furthermore, the usually poor quality of bone in
mastoid cells requires the use of long screws to
achieve adequate stability. For this reason, insertion
of the screw must be performed carefully to avoid
unwanted intracranial penetration. Thus, the authors
use an inclination of 10 to 15 in the inferior direction
at the time of drilling and screw insertion in the zygo-
matic arch fragment associated with self-drilling screw
insertion in the mastoid region. This set of simple
precautions is sufficient for correct application of
this technique.
This report has presented an alternative technique
for the fixation of sagittal fractures of the root of the
zygomatic arch in complex midface and zygomatico-
maxillary fractures. This technique enables stable
fixation and avoidance of excessive posterior displace-
ment of soft tissues. It also facilitates the execution of
the surgical procedure, decreases possible complica-
tions associated with extensive manipulation of soft
tissues, and can incur a lower cost4-6 compared with
conventional miniplate and screw fixation.
References
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zygomatic arch in complex midfacial fracture repair and correc-
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Surg 85:878, 1990
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of tripod fractures of the zygoma with microcompressive screws.
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