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3. Zygomatico-maxillary complex fractures: A retrospective study on etiology,

pattern and management

Article · December 2016

DOI: 10.18320/JIMD/201603.03140

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 Original article
DOI: https://doi.org/10.18320/JIMD/201603.03140
Journal of International Medicine and Dentistry 2016; 3(3): 140-150

JOURNAL OF INTERNATIONAL MEDICINE AND DENTISTRY

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Zygomatico-maxillary complex fractures: A retrospective study on

etiology, pattern and management
Kalappa TM 1, Pramod Krishna B2, Santhosh Kumaran3, Saritha Maloth4,
Yashavanth Kumar DS5, Lakshith Bidappa MA6

Abstract:
The aim of the study was to record the etiology, pattern and management of zygomatico-maxillary
complex (ZMC) fractures seen in two centres in Mysore and to compare the findings with other
studies in literature. A fifteen year retrospective study involving 123 patients with ZMC fractures
were selected from a pool of 219 patients who sustained maxillofacial fractures during the period
under study. The age distribution, gender distribution, etiology, associated injuries, associated
maxillofacial fractures, clinical features, distribution of radiographic investigation, radiographic
findings associated with ZMC Fractures, pattern of fractures and various modalities of management
and surgery were recorded. In this study, 86.17% were males and 13.83% females. Most (39.02%)
patients were aged 21-30 years. There was highly significant association between road traffic
accidents and ZMC fractures. (Chi square value 291.512, P < 0.001). The most frequently associated
maxillofacial fracture was nasal bone fracture (28.45%). Circumorbital edema was the commonest
clinical feature (88.61%); Keene’s approach was the commonest method of zygoma elevation (78%).
Two point internal fixation was commonly used (46.83%). Among two point fixation, fronto-
zygomatic suture and zygomatico-maxillary suture were commonly plated (64.86%). Among one
point internal fixation, zygomatico-maxillary suture was most commonly plated (40.74%). This study
has shown that road traffic accidents have been responsible for most of the ZMC fractures in our
geographical area and two point fixation at zygomatico-maxillary suture and fronto-zygomatic suture
has been the commonest method of fixation and Keene’s approach has been the choicest method for
elevation of zygoma.

Key words: Zygomatico-maxillary complex, fractures, internal fixation, road traffic accident

Introduction: Due to the prominent mid face location of

The zygomatic bone is a prominent and
strong bone contributing stability to the
lateral midface and protection to the
orbital contents. The zygomatic bone is
anatomically a ‘tetrapod’ structure, as it
maintains four points of articulation with
the frontal bone, temporal bone, maxilla
and greater wing of sphenoid at the
zygomatico-frontal (ZF) suture,
zygomatico-temporal (ZT) suture,
zygomatico-maxillary buttress (ZMB) and
zygomatico-sphenoid (ZS) suture
respectively. This tetrapod configuration
then lends itself to complex fractures, as
fractures here rarely occur in isolation.1
the cheek, the fracture of the zygomatico-
maxillary complex represents the second
most common fracture of the maxillofacial
skeleton.2,3 The etiology of zygomatico-
maxillary complex fractures includes road
traffic accidents, assaults, accidental falls,
sports and missile injuries.4-9 The relative
contribution of these factors varies from
region to region.6, 9
Zygomatico-maxillary complex fractures
most commonly occur in young adult
males.7, 9-11 The frequently encountered
clinical features of the zygomatico-
maxillary complex fractures include
circumorbital edema, subconjunctival
hemorrhage, flattening
Kalappa TM et al: Zygomatico-maxillary complex fractures
of the cheek, sensory disturbances,
limitation of mandibular movements,
enopthalmos and diploplia.8, 12-14 Clinical
diagnosis is confirmed with radiographs
and CT scan.15
Majority of zygomatico-maxillary
complex fractures are closed, displaced
and non -communited.16 Fractures of the
zygomatico-maxillary complex may have
a substantial functional deficit including
orbital injury with ophthalmological
impairment and are often associated with
concomitant injuries to the other parts of
the craniofacial skeleton or spine. 3, 17, 18
Though it has been suggested that all
displaced zygomatico-maxillary complex
fractures require surgical intervention,
conservative management is frequently
employed in case of minimal
displacement, asymptomatic injury, patient
non-compliance or medical
19,20
contraindications to surgery.
This retrospective study analyses the
etiology, pattern of fracture, associated
injuries, associated maxillofacial fractures,
commonly seen clinical features,
radiographs for investigation and its
interpretation and various modalities of
management of zygomatico-maxillary
complex fractures.
Materials and Methods:
Over a 15-year period (August 1998 to
August 2013), 123 patients with fractures
of the zygomatico-maxillary complex were
retrospectively studied at two centers.
These patients were selected from a pool
of 219 patients with maxillofacial fractures
during the period under study.
All the patients who sustained zygomatico-
maxillary complex fractures during the
period of the study were included in the
study while those patients with incomplete
medical records were excluded.
Data documented were the patients age,
sex and etiology of the fracture. Other data
recorded were the associated injuries of
head and neck, associated maxillofacial
fractures, clinical presentation,
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
www.jimd.in
radiographic findings, distribution of
radiographic investigations, pattern of
zygomatic fractures, management and
different modalities of surgical treatment
of the zygomatico-maxillary complex
fractures.
Statistical testing was done with Chi
squared test using SPSS version 17
software. P values less than 0.05 were
regarded as significant.
Results:
A total of 123 patients who reported with
zygomatico-maxillary complex fractures
during the study period were selected. Of
these, 106 (86.17%) were males and 17
(13.83%) females giving a male to female
ratio of 6.2:1. A Chi square value was
64.398 (p<0.001) showing highly
significant association between males and
zygomaticomaxillary complex fractures.
The patients ranged in age from 16 to 68
years, with a mean age of 29 years.
Patients in the 21-30 age group (48 or
39.02%) were most often involved (Figure
I). The etiology of zygomatico-maxillary
complex fractures is shown in Table I.
There was a highly significant association
between road traffic accidents and
zygomatico-maxillary complex fractures
[Chi square value 291.512, P<0.001].
Among the total number of patients in the
study, 69 patients (56.09%) had associated
head injuries, 5 patients (4.06%) had loss
of vision and 49 patients (39.83%) had no
associated head and neck injuries (Figure
II). Table II shows distribution of
associated maxillofacial fractures.
Table I: Etiology
Number Percentage
Cause
Road Traffic 100 81.30
Accident
Accidental Fall 12 09.75
Assault 06 04.88
Occupational 04 03.25
Injury
Sports Injury 01 00.82
Total 123 100
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Kalappa TM et al: Zygomatico-maxillary complex fractures www.jimd.in

Table II: Distribution of associated was recorded at 64.86% of the 37 patients.

maxillofacial fractures Fixation at the zygomatico-maxillary
Associated Number Percentage buttress seemed to be the choice (40.74%)
fracture among 27 patients treated with one point
Nasal 35 28.45 fixation. Keene’s intraoral approach has
Mandible 23 18.69 been the preferred method of zygomatic
Dentoalveolar 22 17.88
arch elevation (78% of 9 cases).
Lefort II 18 14.63
Temporal bone 10 08.13 Discussion:
Frontal bone 09 07.31
Lefort III 02 01.62 The esthetic projection of the face is given
by the zygomatic bone. The bone with its
Table III: Clinical Features
other articulations forms the zygomatico-
maxillary complex, which serves as a bony
Clinical Feature Number Percentage
Circumorbital 109 88.61 barrier separating the contents of the orbit
oedema from the maxillary sinus and temporal
Subconjuctival 105 85.36 bone and hence becomes a key functional
haemorrhage unit of the facial skeleton. Thus, the goal
Flattening of the 49 39.83 of management of zygomatico-maxillary
cheek complex fractures is restoration of
Depression over 32 26.01 esthetics and function. Zygoma is the
the arch second most commonly fractured facial
Infraorbital 31 25.20 bone.18, 21
paraesthesia Most important considerations in treating
Limitation of 29 23.57 ZMC fractures are proper reduction,
mandibular adequate stabilization, adequate
movement
positioning of periorbital soft tissues. Most
Enopthalmos 07 05.69
retrospective studies have issues like a
Diplopia 03 02.43
limited sample size, uncontrolled
variables, inconsistent data accumulation
The clinical presentation of zygomatico-
and lack of availability of records. 22 This
maxillary complex fractures are shown in
study also invariably had these
Table III and Figure III shows the
shortcomings and hence it did not answer
radiographic views requested for diagnosis
all questions regarding ZMC fractures, but
of these fractures. The radiological
it reinforces certain observations of
findings are shown in Table IV. The
previous studies.
pattern of zygomatico-maxillary complex
This study recorded that more males than
fractures is recorded as per Figure IV. The
females sustained zygomatico-maxillary
approaches and methods of management
complex fracture, which is consistent with
of zygomatico-maxillary complex
other studies.23-26 Patients in the age group
fractures are shown in Table V. Figure V
of 21-30 years were most often involved
represents, various interventions carried
and road traffic accidents were the leading
out for these patients. The modalities of
etiological factor (p<0.001). Many studies
surgical management ranged from
have shown that young adult males were
zygomatic arch elevation by either Gillie’s
commonly affected.7, 9, 10, 24, 26 The role of
Temporal or Keene’s Intraoral methods, to
road traffic accidents as a very common
fixation at one point, two point or three
etiology for zygomatico-maxillary
point fixation of which two point fixation
complex fractures has been well
was recorded at 46.83%. Among two
documented by several studies 6, 15, 24, 26-28
point fixation, frontozygomatic and
which is consistent with our study.
zygomatico-maxillary buttress fixation

142
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
Kalappa TM et al: Zygomatico-maxillary complex fractures www.jimd.in

Table IV: Radiographic findings associated with ZMC

Radiographic Findings Number Percentage

Zygomatic arch fracture 42 34.14
Antral opacity 35 28.45
Fracture at the FZ suture, ZMB & infraorbital rim 31 25.20
Fracture at the FZ and ZMB 25 20.32
At ZMB only 19 15.44
Communition of the zygomatic bone 11 08.94
Orbital floor fracture 10 08.13
Fracture at the infraorbital rim only 09 07.31
Fracture at the infraorbital rim & FZ suture 08 06.50
Fracture at FZ suture only 04 03.25
Communition of the zygomatic arch 00 00

Table V: Management of Zygomatico-maxillary complex fractures

Treatment Number Percentage

Conservative Management 31 25.20
Keene’s approach 07 05.69
Zygomatic Arch Elevation Gillie’s approach 02 01.62
ZM buttress 11 08.94
One Point Fixation FZ suture 08 06.50
Infraorbital rim 08 06.50
FZ & ZM buttress 24 19.51
Two Point Fixation Infraorbital rim & FZ Ssture 08 06.50
Infraorbital rim & ZMB 05 04.06
Three Point Fixation 06 04.87
Patient Refused Treatment 13 10.56
Total 123
• FZ – Frontozygomatic
• ZMB – Zygomaticomaxillary Buttress

Figure I: Age Distribution (Total=123)

143
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
Kalappa TM et al: Zygomatico-maxillary complex fractures
Figure II: Associated injuries (n=123)
Figure III: Distribution of radiographic
investigation
Figure IV: Pattern of zygomatic fractures
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
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Figure V: ZMC fracture management
Other etiologies in our study included
accidental fall, interpersonal violence,
occupational injury and sports injury. In
one case, the patient sustained
zygomatico-maxillary complex fracture
due to an accidental fall during an attack
of myocardial infarction. In one case of
occupational injury, a jockey was kicked
by a horse resulting in zygomatico-
maxillary complex fracture and rest of the
three occupational injuries were due to
recoil of bore well pipes while securing a
submerged bore well pump used for
agriculture. This kind of injury usually
results in fracture of maxillofacial skeleton
and is common in rural India. One case of
sports injury recorded in our study was due
to a hit by a cricket ball, which also
resulted in associated fracture of nasal
bone.
There were 69 patients (56.09%) who had
associated head injury along with
zygomatico-maxillary complex fracture,
wherein the treatment was done after
neurosurgical stabilization. Among the
series of patients, 5 patients (4.06%) had
loss of vision.
There is a close association of zygomatico-
maxillary complex with rest of the
maxillofacial skeleton and hence
concomitant fractures of other bones of
maxillofacial skeleton are not uncommon.
In our study, we had 35 patients (28.45%)
who had associated nasal fracture which
was the most common associated
maxillofacial fracture, with mandibular
fractures being second most common with
23 patients (18.69%) accounting for the
144
Kalappa TM et al: Zygomatico-maxillary complex fractures
same. The involvement of nasal bone in
most of the middle third fracture may be
attributed to its prominent location on the
face and relative structural weakness, as
reported in the studies of Le et al. 29 This
finding was different from other studies
reported by Afzelius4, Ellis et al23,
Obuekwe 26 and Nam 30 where mandibular
fractures were most often associated with
zygomatico-maxillary complex fractures.
Other associated maxillofacial fractures
noted in our study were dentoalveolar
fracture (17.88%), Lefort II fracture
(14.63%), temporal bone fracture (8.13%),
frontal bone fracture (7.31%) and Lefort
III fracture (1.62%).
There are several distinct clinical features
of zygomatico-maxillary complex
fractures among which, certain self
limiting findings like circumorbital edema
(88.61%) and subconjunctival hemorrhage
(85.36%) were the ones more often seen in
our study similar to a study reported by
Obuekwe. 26 Flattening of the cheek was
encountered among 39.83% patients in the
study and was one of the major findings
for which surgical treatment was
undertaken. This is usually seen in tripod
fractures that most often are displaced
inwards.6 Depression over the arch was
seen in 26.01% of patients and limitation
of mandibular movements occurred in
23.57% patients and is usually a result of
the fractured zygomatic arch and/or
zygomatico-maxillary complex impinging
on the coronoid process of the mandible.6
Infraorbital paraesthesia was seen in
25.20% of patients in our study which is
consistent with other studies which have
reported a range of 18 to 83% of
infraorbital paraesthesia.23, 31-33 Infraorbital
nerve paraesthesia is most commonly seen
in displaced zygomatico-maxillary
complex fractures. 34 Enopthalmos was
seen in 5.69 % of cases in our study. Other
studies have reported 5% of enopthalmos
in zygomatico-maxillary complex fractures
before treatment. 23, 35 Diploplia was
observed in 2.43% patients in our study.
A study reported diploplia in 19.8% of
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
www.jimd.in
patients with mid-face fractures and found
that zygomatic fractures were a principle
risk factor in the development of
diploplia.13
Bank and Brown 6 have summarized the
indications for treatment as follows: to
restore the normal contour of the face,
both for cosmetic reasons and to establish
skeletal protection for the globe of the eye,
to correct diplopia and to remove any
interference in the range of movement of
the mandible.
Paranasal sinus view radiograph (30°
Occipitomental radiograph) (Figure VI)
and computed tomography (CT) scans
(Figure VII, VIII) were the most
commonly advised radiographic
investigation, followed by submentovertex
view (jug handle view). A study had
evaluated the efficacy of single radiograph
to screen for midface fractures and
concluded that a single 30° Occipitomental
radiograph, along with CT scans whenever
indicated can identify all midface fractures
requiring treatment. 36 In our study, as
there were 56.09 % of associated head
injuries, CT scans were taken in all these
cases and wherever CT was not available,
30° occipitomental radiographs were taken
for the diagnosis, thereby reducing the
need for any other radiograph for the
diagnosis of zygomatico-maxillary
complex fractures.
A classification of midfacial fracture based
on the amount of ‘energy’ dissipated by
the facial bones secondary to the traumatic
force classified them as high energy
fracture, moderate energy fracture and low
energy fracture, which was based on
findings on CT scans. 37 In our study, there
were 11 patients (8.94%) with
communition of the zygomatic bone
indicating high energy fractures. These
high energy fractures required extensive
exposure and fixation for a satisfactory
outcome, whereas on the other hand a
higher percent of low energy fractures in
our study could be an indication of lower
145
Kalappa TM et al: Zygomatico-maxillary complex fractures
incidences of high speed road traffic
crashes in our geographical area.
Figure VI: PNS radiograph showing
fractures at frontozygomatic suture,
zygomatico-maxillary suture and body
Figure VII: CT Scan showing fracture at
the frontozygomatic suture
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
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Figure VIII: CT scan showing fracture at
anterior wall of maxilla extending to
zygomatic buttress through body of zygoma
and also showing antral opacity
The management of zygomatico-maxillary
complex is based primarily on whether
there is displacement of the malar
complex. Undisplaced fractures are treated
by first allowing for the edema to subside
and managed conservatively by putting the
patient on soft non-chewable diet for 6
weeks, protection of the malar eminence
and patient is followed up in 2 weeks to
assess for displacement and enopthalmos,
which if present are indications for
delayed intervention, whereas displaced
fracture is surgically reduced and
stabilized. The degree of displacement is
assessed by looking at the normal
articulations of the zygomatico-maxillary
complex with the craniofacial skeleton on
radiographs.1 In our study, 64.22 % of
patients were treated surgically, 25.2%
were managed conservatively, whereas
10.56% patients who required surgical
intervention refused treatment.
The surgical modalities of treatment in our
study included zygomatic arch elevation,
either by Keene’s intraoral approach or by
Gillie’s temporal approach, one point
internal fixation (either at zygomatico-
maxillary buttress, frontozygomatic suture
146
Kalappa TM et al: Zygomatico-maxillary complex fractures
or infraorbital rim), two point internal
fixation (either at frontozygomatic and
zygomatico-maxillary buttress, infraorbital
rim and frontozygomatic suture or
infraorbital rim and zygomatico-maxillary
buttress) and three point internal fixation .
The surgical approaches were ‘Transoral’
for zygomatico-maxillary buttress fixation,
lateral brow incision for frontozygomatic
suture fixation and ‘Subciliary’ incision
for infraorbital rim fixation. In one
extensive laterally displaced and
communited zygomatic arch and complex
fracture, there was a necessity to use a
‘Coronal’ approach.
Certain studies reported Gillie’s temporal
approach as the commonest method of
arch reduction,25, 26, 30, 38 but in our study
we have mostly used Keene’s upper buccal
sulcus approach (78 %) as it eliminated the
necessity of an extra oral incision and at
the same time provided good access to the
arch. The fixation was carried out
according to the treatment
recommendation given by Edward Ellis
III, 22 wherein after transoral reduction and
fixation of the zygomatico-maxillary
buttress if still the fracture is unstable, then
frontozygomatic suture is accessed and
plated. Among two point fixation, plating
at frontozygomatic and the zygomatico-
maxillary buttress was most commonly
performed (64.86%), which is in
accordance to a study conducted by
Davidson et al, wherein he suggests that if
two point fixation is done, one of the
points of fixation should be the
frontozygomatic suture. 39 Zygomatico-
maxillary buttress fixation (40.74%) was
most commonly done among one point
fixation, which gave adequate stability in
minimally displaced fractures. This is
consistent with other reports.40, 41
In conclusion, road traffic accident has
been responsible for most of the
zygomatico-maxillary complex fractures in
our geographical area. Most of these
fractures were low energy fractures and
hence the displacement was also minimal.
In only one case, coronal approach was
Journal of International Medicine and Dentistry 2016; 3(3): 140-150
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required for reduction and fixation of an
extensively displaced zygomatico-
maxillary complex fracture. Satisfactory
reduction of the malar prominence was
achieved in all cases, except in two cases
wherein there was over reduction of the
zygoma.
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Acknowledgment:
The authors would like to thank the Director and the Medical Records Department of Holdsworth
Memorial Mission Hospital, Mysore for their valuable help for this study.

**********************************************************************************
Conflict of interests: Nil Date of submission: 21-09-2016
Source of funding: Nil Date of acceptance: 26-10-2016

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 Kalappa TM et al: Zygomatico-maxillary complex fractures www.jimd.in

Authors details:

1. Professor, Department of Oral and Maxillofacial Surgery, Farooqia Dental

College & Hospital, Mysore -570 021, Karnataka, India
2. Corresponding author: Professor, Department of Oral and Maxillofacial
Surgery, Farooqia Dental College & Hospital, Mysore -570 021, Karnataka,
India; E-mail: drpramodkrishna2001@yahoo.co.in
3. Reader, Department of Oral and Maxillofacial Surgery, Farooqia Dental College
& Hospital, Mysore -570 021, Karnataka, India
4. Assistant Professor, Department of Oral Medicine and Radiology, Koppal
Institute of Medical Sciences, Koppal -583 231, Karnataka, India
5. Reader, Department of Oral and Maxillofacial Surgery, College of Dental
Sciences Davangere -577 004, Karnataka, India
6. Senior Lecturer, Department of Oral and Maxillofacial Surgery, Farooqia Dental
College & Hospital, Mysore -570 021, Karnataka, India

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Journal of International Medicine and Dentistry 2016; 3(3): 140-150

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