ZYGOMATIC FRACTURES

THOMAS W. ALBERT, M.D., D.M.D.

ZYGOMATIC FRACTURES 3
 Zygomatic fractures are the second most common
fractures of the facial bones, with nasal bone fractures
being the most common.
PERTINENT ANATOMY
The zygomatic complex is highlighted in Figure 1-1.
The zygoma forms a highly visible portion of the
midfacial contour, giving support to the prominence
of the cheek. It is this very prominent position that
contributes to its high frequency of fracture. The
zygoma has four articulations: frontal, maxillary, and
temporal bones (zygomatic process) and the greater
wing of the sphenoid. The major contact areas are
with the maxilla and frontal bone. The zygoma also
forms a portion of the floor and lateral wall of the
orbit and serves as a major protection against orbital
injury.
Lateral canthal tendons attach to the lateral portion
of the zygoma. A small foramen allows for passage of
zygomaticofacial and zygomaticotemporal nerves,
branches of cranial nerve (CN) V that supply sensa-
tion to the cheek and anterior temple. The infraorbital
nerve lies in close proximity to the zygoma as it runs
along the floor of the orbit and exits through the
infraorbital foramen. Medial and inferior zygomatic
displacement frequently results in anesthesia and/or
paresthesia in the infraorbital nerve distribution.
Muscle attachments include masseter muscle origin,
levator labial superior, zygomaticus major, and tem-
poralis fascia, which attaches along the superior
surface of the zygomatic arch.
The most common fracture involves separation at
the (1) frontozygomatic suture, (2) infraorbital rim,
and (3) junction of the zygomatic arch and temporal
bone as well as fracture of the floor of the orbit.
Isolated fractures of the arch or orbital floor may also
occur but are less common. Orbital floor fractures
require special considerations regarding indications
for repair. These indications generally include en-
ophthalmos, persistent diplopia, and/or limitation of
the inferior oblique muscle movement.
The most common findings with zygomatic com-
plex fracture include the following:
• Periorbital ecchymosis ;
-
• Subconjunctival ecchymosis < ,!-r,
• Depression of the malar eminence
• Depression and step deformity of the infraorbital rim
• Tenderness or step deformity at the frontozygomatic
suture
• Paresthesia/anesthesia of the infraorbital nerve
and/or zygomaticofacial and zygomaticotemporal
nerves
Other findings may include the following:
• Enophthalmos or proptosis
• Diplopia
Figure 1-1
4 ZYGOMATIC FRACTURES
• Decreased range of extraocular motion, particularly
in upward gaze
• Injury to the globe
• Limitation of mandibular movement (impingement
of the zygomatic arch against the coronoid process)
• Surgical emphysema
• Canthal ligament disruption (medial or lateral) with
traumatic telecanthus
PREOPERATIVE EXAMINATION
Physical Examination
Several regions should be assessed for symmetry.
The orbital rims should be bilaterally palpated firmly,
feeling for step deformities, crepitus, and tenderness.
The most prominent portion of the malar eminences
should be bilaterally palpated to determine any
asymmetry. Press down to bone, particularly if the
patient has swelling. It is often helpful to stand above a
seated patient and look down from directly overhead.
Placing tongue blades on the eminences may also help
assess symmetry. The zygomatic arches should be
palpated firmly down to bone. Standing above the
patient may be helpful. Palpate for steps, crepitus, and
symmetry.
Globe position should be checked frontally and lat-
erally. With significant edema, light palpation against
the globe may be helpful. Computed tomography
(CT) scans are helpful if there is any question of
orbital floor fractures. Look for vertical depression of
the globe below the normal interpupillary line as well
as posterior depression (enophthalmos) or protrusion
(exophthalmos).
Voluntary movement should be examined in the six
cardinal positions of gaze, as this tends to isolate the
individual muscles.
Gross movement is evaluated by observation.
Forced duction testing of the inferior rectus muscle
can also be used to assess for possible muscle en-
trapment. After a topical anesthetic is dropped on the
eye, the insertion of the muscle can be grasped gently
with a forcep and the globe rotated superiorly (the
opposite direction of the normal pull of the muscle) to
ensure that there is no muscle entrapment. Fine
movement distortions can be evaluated by assessing
for diplopia. This may require an ophthal-mologic
examination, particularly when there are small
distortions and if the patient has significant swelling.
The globe should also be assessed for lacerations or
ruptures. Examine the anterior chamber for traumatic
hyphema and lens dislocation. Examine the fundus for
papilledema and retinal detachments. Assess CN II for
level of function.
Cranial Nerve Examination
Particular attention should be paid to CN II, III, IV,
V, VI, and VII. The sensory portion of CN V
examination should include light touch, directional
discrimination, and sharp vs dull. Paresthesia or
anesthesia of CN V2 almost always indicates fracture
of the orbital floor or rim. Examination of CN II, III,
IV, and VI should be carried out in both eyes in
relation to vision and extraocular movements. CN III
also elevates the upper lid. Function of CN VII is
rarely affected in simple fractures but may be injured
in extensive injuries and particularly with penetrating
injuries. Visual acuity must be rechecked carefully
after surgery as well.
Patency of the lacrimal system should be assessed
by clinical examination. If patency is questionable, a
probe can be placed.
Radiographs
The most useful radiographs for initial evaluation
include (1) upright Waters, (2) submentovertex, and
(3) Caldwell views. More detail can be seen on a CT
scan, and this technique should be used if there are
any questions. Tomography can be helpful but gen-
erally is less detailed than a CT scan. Magnetic
resonance imaging (MRI) may also be useful.
INDICATIONS FOR SURGERY
The following are the major reasons for considering
surgical reduction of a zygomatic fracture:
1. Alteration in facial contour
2. Globe displacement—enophthalmos, exophthal-
mos
3. Muscle and/or nerve entrapment
4. Mechanical restriction of mandibular movement
from impingement on the coronoid process
Ideally, surgery should be performed before signifi-
cant swelling has occurred or after most swelling has
resolved. If possible, surgery should be done within 7
to 14 days, before significant healing has occurred.
Stable nondisplaced fractures with no muscle or nerve
entrapment can be observed weekly for several weeks
to ensure normal healing.
Closed (Indirect) Reduction vs
Open Reduction
Closed reduction is generally reserved for simple
displacements that have a reasonable chance of being

reduced from an indirect approach (e.g., Gillies pro-
cedure) and not requiring fixation. This most com-
monly is found in simple arch fractures. Closed
reduction can be done under local anesthesia. Simple
arch fractures do not generally require antibiotic
coverage postoperatively.
Nonfixation vs Fixation * pin; (2) temporary packing with a Penrose drain,
Direct fixation should be used in any fracture that is
likely to be unstable, e.g., Rowe and Williams group
2 (see hereafter) or even those in group 1 that are
clinically unstable after reduction (Rowe and
ZYGOMATIC FRACTURES 5
Williams, 1985). One or two point fixation may be
adequate for relatively stable fractures, but additional
fixation may be necessary for very unstable fractures.
Direct fixation (at the fracture site) involves (1)
wiring with 24- to 30-gauge stainless steel, and fixa-
tion with (2) mini bone plates and (3) a Steinmann
pin. Indirect fixation (at an area removed from the
fracture site) involves (1) placement of a Steinmann
gauze, Gelfoam, or Silastic; and (3) attachment to an
external frame. The extent of fixation is most often
dictated by the degree of instability encountered at the
time of surgery. Mini plate fixation is generally the
most stable means of direct fixation.
6 ZYGOMATIC FRACTURES
SURGICAL GOALS AND
CONSIDERATIONS
Reduction and stabilization of the fracture are the
goals. In comminuted fractures, stabilization may be
difficult. The surgical approaches are designed to
allow access for reduction and/or fixation. The ad-
vantages/disadvantages of each approach are dis-
cussed along with the operative technique.
Classification of Fractures
Rowe and Williams (1985) have classified zygo-
matic fractures into two major groups based on
fracture anatomy as demonstrated by the upright
Waters and submentovertex radiographs. Group 1
fractures are usually stable after elevation. These
include fractures of the arch only (medial displace-
ment) (Fig. 1-2A) and medial and lateral rotation
around the vertical axis (Fig. 1-2B and C).
Group 2 fractures often remain unstable after ele-
vation. These include fractures of the arch only
(inferior displacement) (Fig. 1-2D); medial and lateral
rotations around the horizontal axis (Fig. 1-2E); in-
ferior, medial, and posterolateral dislocations en bloc
(Fig. 1-2F and G); and comminuted fractures (Fig. 1-
2H and I). In addition, isolated orbital wall fractures
(blow-out fractures) can be classified as follows: roof,
floor, medial wall, and lateral wall.
Anesthesia
General anesthesia is usually preferred for adequate
reduction and fixation. Orotracheal intubation usually
affords the best access to both sides of the face,
which is helpful for comparison of symmetry. Some
reductions can be accomplished with local anesthesia,
which may allow for reduction before significant
swelling has occurred. This is most often considered
for simple arch fractures (e.g., Rowe and Williams
group la) (Rowe and Williams, 1985).
Position
The patient is placed in the supine position and
should be prepped and draped so the surgeon has
access to both sides of the face to aid in re-establishing
symmetry. Eyebrows and hairlines need not be
shaved. Eye protection is imperative. Temporary
tarsorraphy is often employed. Eye patches need to be
well contoured so as not to interfere with access and
palpation for bony symmetry. Eye ointments offer
extra protection.
 ZYGOMATIC FRACTURES 7

Figure 1-2
8 ZYGOMATIC FRACTURES
SURGICAL APPROACH AND
INTRAOPERATIVE
CONSIDERATIONS
Open Reduction—Indirect
Approach
Temporal Fossa Approach
(Gillies)—Nonfixation
This approach (Fig. 1-3) is used for (1) isolated
arch fractures and (2) zygomatic complex fractures
that have a reasonable chance of remaining reduced
without fixation. Direct wiring cannot be accom-
plished via this approach.
A 2- to 3-cm incision is made within the hairline
below and parallel to the anterior branch of the
temporal artery (Fig. 1-4). The incision is taken down
to the deep portion of the superficial temporalis fascia,
which is incised. A Gillies elevator or urethral sound is
passed along the potential space just medial to the
arch.
For arch fractures the instrument can be swept
along the arch with upward and outward force. Most
arch fractures will be stable. However, if the fracture is
comminuted and continues to collapse, packing can be
placed utilizing a Penrose drain, which must be
removed in 5 to 8 days, or Gelfoam, which usually
does not require removal.
Figure 1-3
For medially rotated zygomatic complex fractures,
the elevator should be swept as anteriorly as possible
with upward and lateral force being applied. For
medially rotated fractures some slight posterior force
should be applied to help disimpact the fracture
before moving upward and outward. Again, the
Gillies approach does not allow for direct fixation if
the reduction is unstable. The infraorbital rim and
frontozygomatic suture areas are palpated to assess
reduction.
Intraoral Approach for Isolated Arch
Fracture (Fig. 1-5)
An incision is made in the maxillary buccal sulcus
in the region of the canine sulcus, the periosteum is
elevated, and the elevator is passed deep to the arch.
For isolated fractures, the arch is swept on the medial
surface with lateral pressure. Medially displaced zy-
gomatic complex fractures can be reduced by utilizing
upward and lateral force as anteriorly as possible
under the arch. This approach alone does not provide
enough access for direct fixation and is used only for
fractures that can be easily reduced and remain stable.
However, it is possible to place a bone plate across
the fracture line near the zygomatic buttress for
stabilization. At least one other point of stabilization
will usually need to be used (e.g., infraorbital,
frontozygomatic, or possibly transantral pin fixation).
Figure 1-4
 ZYGOMATIC FRACTURES 9

Open Reduction—Direct
Internal Fixation ;

Approach to Frontozygomatic
Suture
EYEBROW INCISION (Fig. 1-6) • ; ; ;
This incision allows for direct visualization of the
frontozygomatic suture area as well as placement of
an elevator under the arch to reduce the fracture. A
1.5- to 2.0-cm incision is made in the lateral third and
inferior aspect of the brow, parallel to the hair shafts,
and carried to the bone. The frontozygomatic suture
area is cleared to expose the fracture. Through this
incision an elevator (urethral sound) can be passed
posterior to the lateral rim to engage the major portion
of the malar eminence (Fig. 1-7).
Reduction of the fracture is carried out with lateral
and upward force. The reduction at the frontozygo-
matic suture area can be observed directly. Palpation
is used to determine alignment at the infraorbital rim.
The elevator can be repositioned to sweep more
posteriorly along the arch to reduce the arch fracture.
Fixation at the frontozygomatic suture can be accom-
plished with either direct wiring or a mini bone plate.
Figure 1-5
The tail of the wire should always be placed laterally.
Care must be taken to ensure that the screws do not
penetrate into the orbit.
Figure 1-6 Figure 1-7
10 ZYGOMATIC FRACTURES
INFRAORBITAL INCISION
Several incisions are commonly used for approaching
the infraorbital rim as well as the orbital floor.
INFRACILIARY (BLEPHAROPLASTY) INCISION.
This incision is cosmetically pleasing but may slightly
increase the risk of ectropion or lid edema. The skin
incision is made just below the tarsal plate beginning
just lateral to the lacrimal puncta and extending 2 to 3
cm laterally. It should be curved downward as it
approaches the lateral can thus. Once through the skin
the dissection is carried to below the level of the
infraorbital rim, which should be below the orbital
septum (Fig. 1-8). A horizontal incision about 5 mm
below the palpable rim is made through orbicularis
oculi muscle down to the orbital rim, which is cleared
to visualize the fracture. It is useful to use a "step"
incision so that the skin and muscle incisions are at
different levels to reduce the risk of ectropion. The
orbital floor can also be adequately explored and
repaired through this incision (Fig. 1-9). Once the
fracture has been reduced, the rim can be fixed with
28- or 30-gauge wire or a mini plate.
To drill holes for wires the periosteum of the
anterior orbital floor must be elevated and the globe
Figure 1-8
protected. Direct and/or figure-of-eight wires can be
used. If the rim is comminuted, a mini bone plate
extending from solid bone medially to solid bone
laterally may be necessary.
INFRAORBITAL CREASE INCISION. Generally
the most prominent infraorbital crease is selected for
incision placement. The incision is stepped once
through the skin so that the muscle and skin incisions
are at different levels. The rim is exposed as in the
infraciliary approach.
SUBCONJUCTIVAL INCISION. An incision in
the conjunctiva of the lower lid can be used for direct
access to the infraorbital rim fracture. The lid is pulled
forward and an incision made directly down to the
rim. Access tends to be more limited, especially for
placing wires or plates. All sutures should be buried
to avoid corneal irritation.
SUPRATARSAL FOLD. In addition to the eye-
brow incision for exposure of the frontozygomatic
suture area, an incision can be made in the lateral
third of the supra tarsal fold. Dissection is then carried
down to the orbital rim, avoiding the lacrimal sac.
"CROW'S FOOT" INCISION. An incision through
prominent skin creases above the lateral canthus of
some individuals also affords access to the
frontozygomatic suture area.
Figure 1-9
ZYGOMATIC FRACTURES 11
Other Approaches
Unstable isolated arch fractures rarely but occa-
sionally require open reduction. These can be ap-
proached with a horizontal incision over the arch.
Careful dissection is required to avoid the upper
branches of the facial nerve. The arch as well as the
frontozygomatic suture area can also be approached
via a hemicoronal incision and craniofacial approach.
To reduce the trimalar fracture, the major force
usually needs to be applied via the frontozygomatic
approach with an urethral sound, a Gillies elevator, or
a similar elevator. Reduction at the frontozygomatic
suture and infraorbital rim can be accomplished under
direct visualization. Transosseous wires or mini
plates should be placed at both the frontozygomatic
and infraorbital fracture lines. Care must be taken to
protect the globe while drilling holes and passing
wires. Wiring or plating at both the frontozygomatic
and infraorbital areas usually gives adequate stability.
If the fracture is still unstable other approaches, such
as antral packing or Steinmann pin fixation, may be
necessary.
Antral packing is placed into the sinus via a canine
fossa approach. This usually allows for good visual-
ization of the orbital floor (Fig. 1-10). Large pieces
of the floor can be repositioned and held in place
with packing. A 1- or 2-inch-wide gauze pack im-
pregnated with iodoform, balsam of Peru, or other
bacteriostatic agent should be layered back and forth
across the sinus. It can be brought out through the
incision or a nasal antrostomy and should be re-
moved in 7 to 10 days. Appropriate antibiotics should
be used during this time.
Steinmann pin fixation can also provide additional
stability for unstable tripod fractures (Fig. 1-11). Two
approaches are most often used. The first is to drill a
small threaded pin through the anterior zygomatic
prominence into the hard palate. This is done
through a small stab incision in the skin. The second
approach is to drill from the anterior maxilla from
the opposite side of the face, across the floor of the
nose and the sinus on the side of the fracture, into
the zygomatic prominence. The pins are generally
left for 2 to 3 weeks and can be removed by backing
them out under local anesthesia. The use of mini
plates usually eliminates the necessity for pin fixa-
tion.
Postoperative Management
Care must be taken to avoid undue pressure against
the reduced fractures; an orthognathic splint can be
applied. Ice packs should be applied lightly. The head
should be elevated 30 degrees to reduce edema. The
eye is examined postoperatively to assess for any
change, paying particular attention to visual acuity
and signs of acute bleeding, especially intraor-bital,
which can rapidly compromise vision. Cranial nerve
function should be examined carefully. Reduction and
symmetry should be evaluated both radio-graphically
and clinically.
Figure 1-10 Figure 1-11
12 ZYGOMATIC FRACTURES
Antibiotics
Simple fractures with no sinus involvement gen-
erally call for short-term antibiotic therapy (a first
generation cephalosporin is usually employed). Frac-
tures involving the sinus generally require antibiotics
preoperatively and for 5 to 7 days postoperatively.
Compound fractures require vigorous local debride-
ment and appropriate antibiotic therapy for 7 to 10
days. If there is any sign of infection the organism
should be cultured and antibiotic therapy altered as
necessary.
ZYGOMATIC FRACTURES IN
CHILDREN
Isolated zygomatic fractures are very uncommon
in young children, with the incidence increasing
during adolescence. The surgical approaches are es-
sentially the same as in the adult with the exception
of antral approaches, which are limited in the young
child because of small antral size and mixed denti-
tion.
Sinus Care KEY REFERENCES
Dingman, R.O., Natvig, P.: Surgery of Facial Fractures. Philadelphia,
In fractures involving the sinus the patients should W.B. Saunders Co., 1964.
use decongestant medications and nasal spray to help Habal, M., Ariyan, S.: Facial Fractures. Philadelphia, B.C. Decker
Inc., 1989.
promote sinus drainage postoperatively. Kaban, L.: Pediatric Oral and Maxillofacial Surgery. Philadelphia,
W.B. Saunders Co., 1990.
Mathog, R.: Maxillofacial Trauma. Baltimore, Williams & Wilkins,
1984.
Long-Term Prognosis Peterson, L.J., et al.: Contemporary Oral and Maxillofacial Surgery.
St. Louis, C.V. Mosby, 1988.
The long-term prognosis depends greatly on the Rowe, N.L., Williams, J.L.: Maxillofacial Injuries. New York,
Churchill Livingstone, 1985.
extent of the initial injury and the ability of the initial
procedure to correct the defect.