Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497

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The clinical and radiographical characteristics of zygomatic complex

fractures: A comparison between the surgically and non-surgically
treated patients
Erik G. Salentijn a, Jolanda Boverhoff a, Martijn W. Heymans b, Bart van den Bergh a,
Tymour Forouzanfar a, *
a
Department of Oral and Maxillofacial Surgery/Oral Pathology (Head: Tymour Forouzanfar, MD, DDS, PhD), VU University Medical Center,
Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
b
Department of Epidemiology and Biostatistics, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Background: In this retrospective study we evaluated the epidemiological data and the clinical and
Paper received 20 December 2012 radiographical differences between surgically and non-surgically treated patients with zygomatic com-
Accepted 6 June 2013 plex fractures at their initial assessment in our clinic over a period of 5 years. More knowledge of the
clinical similarities and/or differences between the non-surgical and the surgical group will provide us a
Keywords: more complete view and may help physicians to develop any future methods in clinical decision making
Zygomatic
or even methods in distinguishing patients benefiting from a surgical treatment.
Fracture
Methods: Surgically and non-surgically treated patients were included in the study, if clinical and
Trauma
Treatment
radiographical confirmation of zygomatic complex fractures were present at initial assessment. The
Surgical patient groups were divided into surgically treated zygomatic complex fractures, and non-surgically
Non-surgical treated fractures, with and without displacement. The groups were compared according to age,
gender, degree of fracture displacement and clinical signs.
Results: In total 283 patients were diagnosed with zygomatic complex fractures, with a mean age of 43
years (
20 years) and a domination of male patients. The mean age was higher in the non-surgically
treated group and contained more female patients. Overall type C fractures and the majority of the
type B fractures were treated surgically. Only 2.1% of the type A fractures were treated surgically. Overall
facial swelling and paraesthesia of the infraorbital nerve were found as most common clinical findings.
Additionally, malar depression and extraoral steps were frequently found in the surgically treated group,
as in the non-surgically treated group only facial swelling was found frequently, whether there was
fracture displacement or not. The clinical characteristics ’extraoral steps’, ’intraoral steps’, and ’malar
depression’ were found to be significantly related to surgical treatment.
Conclusion: Extraoral steps, intraoral steps, and malar depression were significantly related to surgical
treatment. The group of non-surgically treated zygomatic complex fractures is a valuable group to
investigate as this group also consists of patients with displaced fractures (i.e. surgical indication) and
thus, could provide us more insight in future clinical decision methods. Therefore, we highly recommend
more research of the non-surgically treated group.
Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction traumatic injury (Covington et al., 1994; Gassner et al., 2003;

Trivellato et al., 2011; van den Bergh et al., 2011). Early diagnosis
Fractures of the zygomatic complex are commonly seen after of these fractures is essential for optimal treatment and is directly
facial trauma and are frequently associated with additional dependent on appropriate initial evaluation, correct injury assess-
ment and timely initiation of the chosen therapy. Displacement of
* Corresponding author. Tel.: þ31 204441031.
zygomatic complex fractures is in principle a surgical indication,
E-mail addresses: t.forouzanfar@vumc.nl, bartvdbergh@yahoo.com unless there is clinical contradictory, such as being medically unfit
(T. Forouzanfar). for surgery, patient refusal or the absence of functional and/or

1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2013.06.008
 E.G. Salentijn et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497
aesthetic problems (Evans and Evans, 2008; Kelley et al., 2007).
However, a suspected and/or displaced zygomatic complex fracture
could be easily missed clinically at the initial assessment, due to the
additional associated symptoms of the trauma injury, such as facial
swelling. Subsequently, computed tomography is routinely used to
determine zygomatic complex fractures and their potential
displacement, but this radiographic examination is ‘supersensitive’:
showing minor zygomatic complex fractures that are clinically not
relevant. Evaluation of clinical signs is therefore not replaceable by
radiological imaging and still remains essential for an adequate
treatment management. In their study, Forouzanfar et al.
(2013) demonstrated their treatment protocol for zygomatic com-
plex fractures. An important aspect of a treatment protocol con-
cerns the decision making, whether or not to treat a patient
surgically or non-surgically in case of a zygomatic complex fracture.
This decision is based on clinical signs and radiographic analysis.
The absence of knowledge of the similarities and differences of the
clinical characteristics of zygomatic complex fractures could
hamper the development of any future clinical decision making in
treatment methods or even to distinguish patients benefiting from
a surgical treatment.
Literature of the preoperative assessment and in particular the
clinical differences between the surgically and non-surgically
indicated treatment groups is lacking. Numerous studies only
evaluated the surgical treatment management (Carr and Mathog,
1997; Zingg et al., 1992). To our knowledge only one study inves-
tigated the non-surgically treated patients with facial fractures
(Back et al., 2007).
Neglecting this non-surgically treated group in studies and
solely describing the surgically treated patient group could be
considered as a data gap in the literature. Standardized and com-
parable studies including non-surgically treated patients, and more
specifically comparing the non-surgically treated group with the
surgically treated group, are therefore highly required.
The aim of the present study was to investigate the clinical
characteristics of the surgically and non-surgically treated patients
with zygomatic complex fractures in our department. Thereby, we
attempted to provide physicians a more complete view of the clinical
presentation of patients with fractures of the zygomatic complex.
2. Material and Methods
2.1. Subjects
The hospital and outpatient records of 283 patients diagnosed
with a zygomatic complex fracture, from January 2007 to January
Surgically
treated
(133)
Displacement No displacement
(133) (0)
Symptoms No symptoms Missing Symptoms
(116) (6) (10) (49)
( ) = number of patients in each patient group.
Fig. 1. Overview of the different patient groups.
493
2012, were reviewed and analyzed retrospectively. These patients
were identified using the hospital database. Data collected were age,
gender, degree of fracture displacement, clinical signs, radiographical
analysis and treatment management (surgical or non-surgical).
Diagnosis and the degree of fracture displacement of all patients
were established at the same day of initial assessment by plain
radiographic analysis (submentovertex and occipitomental radio-
graphs) and/or a CT-scan. Exclusion-criteria were the presence of a Le
Fort fracture, or other facial bone fractures that were associated with
the (four-sided) fractured zygomatic complex (e.g. isolated orbital
rim and/or wall, orbital floor or zygomatic arch), and/or a bilaterally
fractured zygomatic complex. Furthermore patients were excluded if
the initial clinical assessment was more than one week after trauma
and if radiographical analyses (e.g. plain radiographs or CT-scan)
were not available. In all patients the department’s protocol was used
for the decision making process in the treatment of zygomatic
complex fractures, as demonstrated below:
1) zygomatic complex fracture without/with mild displacement
and without paraesthesia infraorbital nerve: no surgical
treatment
2) zygomatic complex fracture without/with mild displacement
and with paraesthesia infraorbital nerve: no surgical treatment
and a follow-up period for 10 days;
- if there is an increase in sensibility after ten days: no surgical
treatment
- if there is no increase in sensibility after 10 days: surgical
treatment
3) zygomatic complex fracture with moderate/severe displace-
ment and with/without paraesthesia infraorbital nerve: surgi-
cal treatment
4) zygomatic complex fracture with moderate/severe displace-
ment, with/without paraesthesia infraorbital nerve and
entrapment of inferior rectus muscle: surgical treatment (ORIF
and reconstruction of the orbital floor)
In our department absolute criteria for surgical treatment of
zygomatic complex fractures are displacement, diplopia due to
rectus muscle entrapment, enophthalmus and impingement of the
coronoid process with the zygomatic arch. Relative criteria for
surgical treatment are cosmetic reasons, paraesthesia of the
infraorbital nerve and patient related reasons, such as age- and
health-related causes.
After data retrieval patients were divided into groups according
to the treatment management (surgical or non-surgical treatment),
as shown in Fig. 1. These groups were further subdivided into
All
(283)
Non-surgically
Treated
(150)
Displacement No displacememt
(55) (95)
No symptoms Missing Symptoms No Missing
(5) (1) (48) symptoms (8)
(39)
494 E.G. Salentijn et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497

groups based on the presence of displacement (displacement vs no Table 1

displacement). Overview of the demographic characteristics of the patient groups.

Furthermore the patient groups (surgical and non-surgical) Treatment group Surgical Non-surgical Non-surgical
were classified according to the degree of zygomatic complex (n ¼ 133) Displacement No displacement
fracture displacement, using the classification according to Zingg (n ¼ 55) (n ¼ 95)

et al. (1992). Age (mean (yrs)
SD) 39 (
16) 51 (
24) 43 (
21)

In this classification zygomatic complex fractures are classi- Gender (%)
Male 77% 66% 66%
fied into 3 types: incomplete (isolated zygomatic arch, lateral
Female 23% 34% 34%
orbital rim or infraorbital rim) fractures (type A), complete
n: total number of patients.
(classic) fractures (type B) and multifragmented fractures (type
C) (Fig. 2).
Type A fractures were considered as mild fracture displace-
ment, type B fractures were considered as moderate fracture 3. Results
displacement and type C fractures were considered as severe
fracture displacement. It should be mentioned that the non- 3.1. Demographic factors of all patient groups
displaced zygomatic complex fractures were all classified as
type A fractures. In Table 1 the patient demographics are shown. The mean age of
all patients was 43 years (
20 years) and was dominated by male
2.2. Statistical analyses patients (71% male vs 29% female).
The mean age and relative share of males/females were little in the
Nominal data were presented as frequencies, metric data as surgically treated group compared to the overall results, as described
mean and standard deviation (SD). Comparisons between the above. However, the mean age was higher in the non-surgically
treatment groups were done by the chi-square test for nominal treated group and this group also had a higher share of females
data and the ManneWhitney U-test for age, because age was not compared to the surgically treated group and the overall results.
normally distributed. A logistic regression model was used in
which treatment was the dependent variable and the different 3.2. Radiographical findings
clinical symptoms were the independent variables, to further
explore which clinical symptoms were most indicative for a As the zygomatic complex fractures are radiographically diag-
specific treatment group. The p-values < 0.05 were considered nosed with conventional radiographs (submentovertex and occi-
to be significant. All calculations were made using IBM SPSS pitomental radiographs) and/or a CT-scan, this classification is
Statistics 19. demonstrated in Table 2.

Fig. 2. Classification system for zygomatic complex fractures: Isolated fractures including types A1, A2, and A3. Type A1 (A) are isolated zygomatic arch fractures; type A2 (B) are isolated lateral
orbital wall fractures, A3 (C) are isolated infraorbital rim fractures. Type B (D) fractures are tetrapod fractures and type C (E) fractures are multifragmented zygomatic complex fractures.
 E.G. Salentijn et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497 495

Table 2 Table 4
Classification of patients according to the type of radiographical analysis. Overview of the clinical characteristics of all zygomatic complex fractures according
to the degree of fracture displacement.
Radiographical analysis No. of patients
Degree of displacement Mild Moderate Severe
CT-scan 196
displacement displacement displacement
Conventional radiographs 48
(type A) (97) (type B) (175) (type C) (11)
CT-scan and conventional radiographs 39
Total 283 Extraoral steps 6 (6.2%) 96 (54.9%) 2 (18.2%)
Available data 89 151 4
Missing data 8 24 7
Intraoral steps 4 (4.1%) 56 (32.0%) 2 (18.2%)
Available data 89 143 8
Table 2 shows that 196 (69.3%) of the patients were diagnosed Missing data 8 32 3
radiographically with CT-scan and that only 48 (17.0%) of the pa- Malar depression 7 (7.2%) 87 (49.7%) 6 (54.5%)
Available data 88 149 10
tients were diagnosed using conventional radiographs, In 39 pa- Missing data 9 26 1
tients (13.7%) both conventional radiographs and CT-scans were Facial swelling 79 (81,4%) 126 (72.0%) 3 (27.3%)
performed for radiographic examination, due to the fact that in Available data 90 143 7
certain cases conventional radiographs were not accurate enough Missing data 9 32 4
Subconjunctival ecchymosis 22 (22.7%) 36 (20.6%) 1 (9.1%)
for exact radiographical examination of the zygomatic complex
Available data 88 120 4
fracture. Missing data 9 55 7
In Table 3 the zygomatic complex fractures according to the Paraesthesia infraorbital 31 (32.0%) 107 (61.1%) 7 (63.6%)
degree of fracture displacement in the surgical and non-surgical nerve
treatment groups are demonstrated. Available data 90 159 8
Missing data 7 16 3
It shows that all of the type C fractures and the majority (68.6%)
Restricted mouth opening 6 (6.2%) 13 (7.4%) 0 (0.0%)
of the type B fractures were treated surgically. Only 2.1% of the type Available data 86 117 5
A fractures were treated surgically. Missing data 11 58 6
Restricted extraocular 9 (9.3%) 15 (8.6%) 3 (27.3%)
movements
3.3. Clinical findings Available data 92 146 7
Missing data 5 29 4
Table 4 demonstrates an overview of the clinical characteristics Diplopia 12 (12.4%) 15 (8.6%) 3 (27.3%)
Available data 91 150 7
of zygomatic complex fractures according to the degree of fracture
Missing data 6 25 4
displacement. Enophthalmus 0 (0%) 4 (2.3%) 2 (18.2%)
Although not significant, as described in Table 4, enophthalmus, Available data 89 115 4
diplopia, restricted extraocular movements and paraesthesia of the Missing data 8 60 7
infraorbital nerve are more frequently seen in het severely dis- Data are presented as absolute and % presence.
placed fracture group (type C), whereas intraoral and extraoral
steps are more frequently seen in the moderately displaced fracture
Table 5
group (type B). Probably this is due to the loss of bony landmarks in Overview of the clinical characteristics of the patient groups.
the severely displaced (multifragmented) zygomatic complex
Treatment group All Surgical Non-surgical
fractures. Furthermore it should be noted that regarding to the
important clinical signs as restricted mouth opening, enoph- Extraoral steps 104 (42%) 70 (65%) 34 (24%)
thalmus and extraoral steps, data of 6 and 7 patients (of in total 11 Available data 249 107 142
Missing data 34 26 8
patients) are missing, which could explain the relatively low per-
Intraoral steps 62 (26%) 46 (47%) 16 (11%)
centages in the severely displaced fracture group. Available data 239 97 142
Table 5 demonstrates an overview of the clinical characteristics Missing data 44 36 8
of zygomatic complex fractures in all of the patient groups ac- Malar depression 98 (39%) 74 (70%) 24 (17%)
Available data 249 106 143
cording to the treatment type (surgical vs non-surgical).
Missing data 34 27 7
As shown in Table 5 the two symptoms that have a very high Facial swelling 208 (87%) 78 (80%) 130 (92%)
frequency in the ‘all patients’ group were facial swelling (87%) and Available data 238 97 141
paraesthesia of the infraorbital nerve (56%). These two symptoms Missing data 45 36 9
were also frequently found in the surgically treated patient group, Subconjunctival ecchymosis 60 (28%) 22 (31%) 38 (27%)
Available data 211 70 141
respectively 80% and 84%. Additionally, malar depression (70%) and
Missing data 72 63 9
extraoral steps (65%) were also frequently found in this group. In Paraesthesia infraorbital nerve 145 (56%) 97 (84%) 48 (34%)
the non-surgically treated patients group only facial swelling (92%) Available data 257 115 142
was frequently found. The symptoms frequently found in the sur- Missing data 26 18 8
Restricted mouth opening 19 (9%) 12 (17%) 7 (5%)
gically treated patient group were found less common in the non-
Available data 208 69 139
surgically treated patient group. For example, malar depression Missing data 75 64 11
Restricted extraocular 27 (11%) 10 (10%) 17 (12%)
movements
Table 3 Available data 246 101 145
Zygomatic complex fractures classified according to the degree of fracture Missing data 37 32 5
displacement. Diplopia 30 (12%) 12 (12%) 18 (13%)
Available data 248 104 144
Degree of fracture displacement No. of patients Surgical Non-surgical
Missing data 35 29 6
Type A (mild) 97 2 (2.1%) 95 (97.9%) Enophthalmus 6 (3%) 5 (8%) 1 (1%)
Type B (moderate) 175 120 (68.6%) 55 (31,4%) Available data 208 66 142
Type C (severe) 11 11 (100%) 0 (0%) Missing data 75 67 8
Total 283 133 150
Data are presented as absolute and % presence.
496 E.G. Salentijn et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 492e497
accounted for 17% and extraoral steps accounted for 24% in the non-
surgically treated patient group. Two symptoms were almost
equally distributed over all patient groups: restricted extraocular
motility and diplopia. Enophthalmus was the only symptom solely
present in the patient groups (surgical and non-surgical) with
displacement.
The chi-square test conformed a significant relation between
clinical symptoms and surgical treatment (p < 0.001). The logistic
regression model demonstrated that extraoral steps, intraoral steps
and malar depression were significantly associated with surgical
treatment (p < 0.05). Disturbances of the infraorbital nerve seemed
not to be associated with surgical treatment.
After a period of 6 weeks post-operatively all of the patients,
surgically treated or not, were reassessed. As far as could be
analyzed none of the patients had disagreed with the chosen
therapy (surgical or non-surgical treatment), as all of the trauma
patients had been informed well about the advantages and disad-
vantages of surgical or non-surgical treatment of zygomatic com-
plex fractures. Overall, patients were treated non-surgically if they
did not feel like treatment for aesthetic purposes (mostly older and
medically unfit patients) or if treatment could not predict an in-
crease in functional behaviour, such as a decrease of paraesthesia
after fracture reduction. Further follow-up of this would be useful.
4. Discussion
This retrospective study aimed as an analysis of the clinical
differences between the surgically and non-surgically treated pa-
tients with a fracture of the zygomatic complex at their first
consultation. In our patients population surgical treatment was
significantly associated with the presence of intraoral steps,
extraoral steps and a malar depression, which suggests that sur-
gical treatment was particularly performed for aesthetic reasons.
Patients in the non-surgically treated group with fracture
displacement were generally aged higher. Hypothetically, a non-
surgical treatment was advised, as in this group aesthetics were
less important. Furthermore in this group more patients were
thought to be medically unfit, causing surgical treatment to be
hazardous.
In the “Material and methods” section the absolute and relative
criteria for surgical treatment of zygomatic complex fractures in
our department are described. To our knowledge no publications
exist in which the absolute indications for surgical treatment of
zygomatic complex fractures are described or studied. However,
the publications of Kaufman et al. (2008) and Hollier et al. (2003)
mention that the most common criterion for the treatment of
zygomatic complex fractures is fracture displacement. Further-
more, Ceallaigh et al. (2007) suggest that surgical treatment is
indicated when there is a limited mouth opening, and/or when
there are aesthetic problems. They suppose that paraesthesia is not
specifically an indication for surgical treatment of zygomatic
complex fractures. As in line with other previous studies (Calderoni
et al., 2011; Naveen Shankar et al., 2012; Salentijn et al., 2013; van
den Bergh et al., 2011) the sex distribution was markedly higher for
males compared to females, and a relative higher share of males in
the surgically treated group. As expected clinical assessment
showed that there was a significant association between the clinical
findings, referred to as the palpatory assessment of deformity
(palpable extraoral and intraoral steps) and the visual assessment
of deformity (malar depression), and the surgical treatment of the
fractured zygomatic complex. As facial swelling was almost present
in all patients, it might mask the clinical findings, particularly if the
displacement was minimal. Swelling of the soft-tissues, due to the
injury, could conceal any depression of the malar eminence or
disturbance within the orbital anatomy, such as enophthalmus.
Furthermore, posttraumatic swelling could cause a transitory nerve
paraesthesia of the infraorbital nerve. In the literature the incidence
of posttraumatic sensory disturbances following fractures of the
zygomatic complex is reported to be between 33% and 82% (Jungell
and Lindqvist, 1987; Sakavicius et al., 2008; Vriens and Moos, 1995;
Westermark et al., 1992). We found a higher incidence of paraes-
thesia in the surgically treated patients (84%), compared to the non-
surgically treated patients (34%), with an overall incidence of 56% in
the ‘all patients’ group. However, paraesthesia was not significantly
related to the treatment method (surgical or non-surgical).
Follow-up records of the patients are required to determine the
duration and frequency of paraesthesia and furthermore relating
this to radiological scans.
At last, posttraumatic swelling could cause intraorbital pressure
on the globe and/or extraocular muscles, leading to diplopia or a
disturbed extraocular motility. As these symptoms were almost
equally distributed in our study, it could be expected that swelling
contributes most likely to a large amount of the disturbed eye
movements and/or diplopia. However, it is highly important to
identify those patients with entrapment of the rectus inferior
muscle in orbital floor fractures, as the orbital floor is always part of
the zygomatic complex, which requires immediate surgical treat-
ment in these cases.
One could argue that a shortcoming of this study is the retro-
spective nature of recording the clinical findings and therefore the
results being more subject to subjective measurements and regis-
tration between physicians. Like other retrospective studies, this
retrospective analysis may lead to information bias. Nevertheless,
due to the large amount of patients the results still give valuable
information concerning the characteristics of surgically and non-
surgically treated zygomatic complex fractures. Prospective
studies are necessary to standardize clinical examination and
reporting style of these symptoms.
5. Conclusion
Management of zygomatic complex fractures remains a chal-
lenging problem and lacks an accepted consensus internationally.
In the present study the surgically treated zygomatic complex
fractures are compared with the non-surgically treated fractures,
and furthermore both groups are divided into fractures with mild,
moderate and severe displacement. We found that the mean age of
non-surgically treated patients, even with fracture displacement,
compared to the surgically treated group was higher and had a
higher share of female patients. Concerning the clinical character-
istics, malar depression, intraoral and extraoral steps were found to
be significantly related with zygomatic fracture treatment.
Paraesthesia of the infraorbital nerve was not related with the
surgical treatment policy of zygomatic complex fractures. In sum-
mary we state that the non-surgically treated patient group is a
valuable group to investigate, as this group also consists of patients
with displaced fractures, and thus could provide us more insight in
future clinical decision methods. Therefore, we highly recommend
more research of the non-surgically treated patient group.
Acknowledgements
None.
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