Fractures of The Zygomaticomaxillary Complex

Fractures of
the Zygomaticomaxillary
Complex 56
Elavenil Panneerselvam, Poornima Ravi, and B. Sasikala
56.1 Introduction 56.2 Surgical Anatomy
The zygomaticomaxillary complex (ZMC) refers to the skel- The term zygoma denotes a “yoke or bar,” in Greek. Quite aptly,
etal unit [1] formed by the zygomatic bone and maxilla the zygoma extends as a prominent, sturdy bar across the face,
(Fig. 56.1). These two bones are referred to as a complex, contributing to its transverse width and anteroposterior projec-
because of the structural and functional relationship between tion. The clinical significance of this bony complex is attributed
them; they articulate with each other over a wider area, and to its role in defining facial esthetics and globe function.
any traumatic impact on one bone generally influences the
other. This duo complex also constitutes a major part of the
orbit, spanning the infra-orbital rim, lateral wall, and floor. 56.2.1 Articulations
Hence the ZMC is also termed orbitozygomaticomaxillary
complex [2]. Because of its multiple articulations, various The zygoma articulates with four bones [5]; superiorly fron-
names are commonly used to describe ZMC fractures such tal, medially maxilla, laterally temporal bone, and posteri-
as “tripod, tetrapod, or pentapod” [3, 4] fractures. orly sphenoid, through five processes [4] (Fig. 56.1), namely,
Fractures of the ZMC commonly result in severe cosmetic the zygomaticotemporal (ZT), zygomaticomaxillary (ZM),
and functional deficits because of the prominent anatomical infra-orbital (IOR), fronto-zygomatic (FZ), and sphenozygo-
position of the zygoma and its proximity to adjacent vital matic (SZ) or zygomaticosphenoid (ZS). These processes are
structures such as the globe. Precise reduction and fixation of clinically significant in establishing the three-dimensional
these fractures is challenging due to their complex anatomic structural integrity of the upper lateral face.
form, multiple articulations, and deformation in multiple Fractures of the ZMC have been traditionally called the
planes. The scope of this chapter encompasses the biody- “tripod or trimalar fractures” because it involved separation
namics of ZMC fractures, clinical implications, and guide- at the three processes of the zygoma—the FZ, IOR, and the
lines for successful management. ZM processes (Fig. 56.2a). The terminology was later modi-
fied to “quadripod or quadramalar fracture” to include sepa-
ration at the fourth point of articulation, the ZT process
(Fig. 56.2b). However, the importance of SZ articulation
Disclosure: Authors have no financial conflicts to disclose. along the lateral wall of the orbit has been recognized lately,
and, hence, ZMC fracture is currently called a pentapod frac-
Electronic Supplementary Material The online version of this chap-
ter (https://doi.org/10.1007/978-981-15-1346-6_56) contains supple- ture (Fig. 56.2c), to emphasize the necessity of restoring the
mentary material, which is available to authorized users. five articulations during fracture management.
E. Panneerselvam (*)
Department of Oral and Maxillofacial Surgery, 56.2.2 Relations
SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India
Department of Orbit and Oculoplasty, Aravind Eye Hospital, • Zygoma and orbit: ZMC forms the lateral and inferior
Chennai, Tamil Nadu, India part of the orbit, protecting as well as supporting the globe
P. Ravi · B. Sasikala and associated soft tissues. The Whitnall’s tubercle pres-
Department of Oral and Maxillofacial Surgery, SRM Dental ent on the zygoma (inferior to the FZ suture) provides
College, Ramapuram, Chennai, Tamil Nadu, India
© The Association of Oral and Maxillofacial Surgeons of India 2021 1151

K. Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician, https://doi.org/10.1007/978-981-15-1346-6_56
1152 E. Panneerselvam et al.
attachment to the suspensory ligament of Lockwood that related to the zygoma and may be affected in fractures of
maintains the horizontal axis of the globe [6] (Fig. 56.3a). the ZMC or its surgical manipulation.
A fracture line located above the Whitnall’s tubercle leads • Zygoma and mandible: The zygoma and zygomatic arch
to inferior displacement of zygoma as well as the lateral are anatomically close to the coronoid process of the
attachment of Lockwood ligament resulting in anti- mandible. Therefore, a fractured zygoma or arch, when
mongoloid slant to the eye (Fig. 56.3b). Thus ZMC frac- retro/medially positioned, may impede mandibular move-
tures greatly influence the structure and function of the ments [7]. A displaced and untreated fracture of zygoma/
orbit. Further, the contents of the orbit including the arch which is in close proximity to the coronoid process
globe, extraocular muscles, and orbital fat are intimately can result in extra-articular ankylosis [8].
• Zygoma and maxillary sinus: Fractures of the ZMC
(except the isolated zygomatic arch fractures) involve the
maxillary sinus and show features of hemosinus [4] or
sinusitis [3].
56.2.3 Muscle and Fascia Attachments
The muscles attached to ZMC are the zygomaticus major, zygo-

maticus minor, orbicularis oculi, and masseter [9]. Masseter is
attached to the zygomatic arch on the lateral and inferior aspect
as well as the zygomatic tuberosity (Fig. 56.4a). The downward
displacing forces of the masseter have been considered by many
as the principal cause of post-reduction instability [10].
The temporal fascia attached to the arch superiorly plays
a major role in resisting the downward displacement of frac-
tured ZMC or arch due to the inferior pull of the masseter
(Fig. 56.4b) [1].
56.2.4 Zygomatic Arch
The arch is the key parameter for re-establishing the sagittal

projection as well as transverse width of the face [11]. An
©Association of Oral and Maxillofacial Surgeons of India
arch which is bent outward or inward gets shortened [4].
Fig. 56.1 ZMC skeletal unit. Articulations of zygoma with facial skel- This leads to retrodisplacement of zygoma resulting in
eton and articulating processes altered facial width (Fig. 56.5b). It is important to remember
a b c
Fig. 56.2 Types of ZMC fractures. (a) Tripod fracture. (b) Tetrapod fracture. (c) Pentapod fracture
56 Fractures of the Zygomaticomaxillary Complex 1153
Fig. 56.4 Displacing forces acting on the zygoma and arch. (a)
Masseter exerting downward force. (b) Temporalis with a superior
vector
ION canal giving off the superior dental plexus of nerves

before exiting through the ION foramen onto the face. Here
b it innervates the lower eyelid, lateral aspect of the nose, and
upper lip of the ipsilateral side. The zygomatic nerve which
enters the orbit through the inferior orbital fissure divides
into two branches, the zygomatico-facial and zygomatico-
temporal which emerge onto the face through their respec-
tive foramina. The zygomaticofacial nerve innervates the
skin over the malar area, while the zygomaticotemporal
nerve supplies the skin over the anterior temporal region.
These nerves may be injured due to trauma or during surgery.
The severity of paresthesia which arises is generally propor-
tional to the degree of displacement of a fractured zygoma
©Association of Oral and Maxillofacial Surgeons of India [13]. The other nerves whose function may be affected in
ZMC fractures are the optic nerve [14] and facial nerve [15].
Fig. 56.3 Relation of suspensory ligament to zygoma. (a) Displacement Blood vessels of importance related to the ZMC are infra-
of suspensory ligament of Lockwood leading to anti-mongoloid slant.
(b) Clinical appearance of anti-mongoloid slant
orbital artery and vein [16] (Fig. 56.6b) which accompany
the infra-orbital nerve. Uncontrolled forces delivered during
elevation of zygoma may injure these vessels resulting in
that in spite of being referred to as an arch, it does not have severe intra-op bleeding.
an exaggerated curvature. Therefore, overzealous contouring
during reduction of zygomatic arch fractures can result in
compromised esthetics. The arch is encased by a thick peri- 56.3 Classification
osteal and fascial envelope which counteracts the displacing
forces of the masseter [1]. However, when the periosteal
envelope is damaged due to high-velocity injuries, the frac- 56.3.1 Classification of ZMC Fractures
ture segments show more displacement.
Numerous classifications have been proposed for ZMC frac-
tures; this chapter would discuss the most practical ones which
56.2.5 Nerves and Blood Vessels help in understanding the biodynamics of fracture as well as
facilitate quick decision-making regarding the treatment.
The nerves in close proximity to the ZMC are (1) infra-
orbital nerve and (2) zygomatic nerve [12] (Fig. 56.6a). The • The classification proposed by Rowe and Williams [1]
infra-orbital nerve runs along the ION groove and enters the (Fig. 56.7) is based on the axis of rotation of ZMC and the
a b
Fig. 56.5 Change in facial dimension in zygomatic arch fractures. (a) Inward bowing of arch. (b) Outward bowing of arch
stability after reduction. Following trauma, the zygoma ture, and types A2 and A3 are separation at the FZ suture
may undergo rotation along two axes: vertical axis and IOR, respectively. Type B is a complete monofrag-
extending through the FZ suture and first molar and hori- ment type with separation at all five sites of articulation
zontal axis running across the infra-orbital foramen and and type C which is multifragmented.
zygomatic arch. According to this classification, fractures
were considered as stable after elevation when they dem- A special and rare variant of zygoma injuries includes avul-
onstrated (1) arch only fracture with medial displacement sion of zygoma [18] (Fig. 56.11). These injuries result from tan-
and (2) rotation around vertical axis (medially/laterally), gentially directed forces with high velocity or greater energy.
while fractures were categorized as unstable after reduc- The fractured zygomatic fragment characteristically becomes a
tion when the following features were observed: (1) arch non-vascularized-free graft whose management is complex.
only fracture with inferior displacement (Fig. 56.8), (2)
ZMC fracture rotated around horizontal axis (Fig. 56.7),
(3) dislocated en bloc (inferiorly/laterally/medially) 56.3.2 Classification of Arch Fractures
(Fig. 56.9a), and (4) comminuted (Fig. 56.9b).
This classification provides clinical guidance regard- The fractures involving the zygomatic arch constitute a sepa-
ing the stability of fracture after reduction and the neces- rate entity.
sity for fixation. The various patterns of zygomatic arch fractures have
• ZMC fractures have also been classified on the basis of been described by Ozyazgan et al. [19] (Fig. 56.12) based
“severity of traumatic impact” [4] into low-, medium-, on the number of fracture lines and displacement of fracture
and high-energy patterns, as demonstrated on CT; low- fragments:
energy type is associated with non-displaced/minimally
displaced “en bloc” fractures, medium-energy type is dis- • Type 1 constitutes the isolated zygomatic arch fractures
placed fractures with or without fragmentation, and high- which are subdivided into (1) dual fracture (type I A) and
energy type is associated with fractures with massive (2) more than two fractures (type I B). This is further clas-
displacement, comminution, or fragmentation. sified into V-shaped (type I B-V) and displaced fracture
• Zing et al.’s [17] classification (Fig. 56.10a−e) is a simple (type I B-D).
but practically useful method based on the anatomic site • Combined zygomatic arch fractures are referred to as type
involved; type A1 refers to isolated zygomatic arch frac- II, which can present as two variants: single (type II A)
class III a combined fracture of the malar bone and the

a
zygomatic arch.
56.4 Clinical Assessment
The clinical assessment of ZMC fractures is performed by a

thorough examination of the face and the eye. As the zygoma
forms an integral part of the orbit (floor and lateral wall), any
trauma to the ZMC may have profound impact on the integ-
rity of the globe and vision [2, 22]. This mandates a primary
ophthalmic examination prior to facial examination.
b 56.4.1 Examination of the Eye
The globe is meticulously assessed for its form, position, and

function. This is performed by a comprehensive examination
protocol called “8-point eye exam” [23] provided by the
American Academy of Ophthalmology (refer to Chap. 57).
56.4.2 Examination of the Face
The facial examination should focus on assessment of (1)

facial symmetry and morphology and (2) functions such as
mouth opening, vision, sensory perception, and occlusion.
The clinical characteristics of ZMC fractures [1, 4, 5]
may be divided based on their cosmetic and functional impli-
cations (Box 56.1) .
Box 56.1: Clinical Features of ZMC Fractures

Cosmetic deficits Functional deficits
Fig. 56.6 a, b Neurovascular structures related to ZMC fractures. OA,
• Facial asymmetry due to • Vision
ophthalmic artery; nb, nasal branch; zmb, zygomatico-malar branch;
– Periorbital edema – Diplopia
vb, vestibular branch
– Hematoma – Loss of vision (partial/
– Emphysema total)
• Facial asymmetry due to • Restricted mouth opening
and plural fracture (type II B). Plural fractures are termed malpositioned zygoma • Malocclusion
type II B-R when they are approximated or reduced and – Depression of malar • Neurological deficit
prominence – Paresthesia
type II B-D, when displaced. – Transverse facial widening (i) Infra-orbital nerve
– Changes in AP projection (ii) Zygomaticofacial
Yamamoto et al. classification [20] (Fig. 56.13) dif- – Orbital dystopia nerve
ferentiates fractures based on displacement: type I, no dis- • Discoloration (iii) Zygomaticotemporal
– Subconjunctival nerve
placement; type II, displacement with bone contact at all hemorrhage – Paresis/palsy
fracture lines; type III, displacement without bone contact – Periorbital ecchymosis (i) Facial nerve
at one fracture line; type IV, displacement without bone • Altered morphology/position • Epistaxis/nasal congestion
contact at two fracture lines; and type V, comminution or of eye • Compartment syndromes
– Anti-mongoloid slant – SOF syndrome
displacement without bone contact at three or more frac- – Increased scleral show – Orbital apex syndrome
ture lines. Honig Merten et al. [21] (H-M classification) – Hypoglobus/hyperglobus
(Fig. 56.14) classified zygomatic arch fractures based on – Enophthalmos/
CT findings as class I which indicated isolated tripod frac- exophthalmos
ture, class II as an isolated stick fracture of the arch, and
Fig. 56.7 Axes of rotation of ZMC fractures
A description of clinical features with their associated fractures does not have a posterior limit in contrast to
pathophysiology is provided below. SCH due to globe injuries [24]. It is important to note that
SCH without a posterior limit is also seen in skull base
• Periorbital edema and ecchymosis: The edema and fractures [25].Chemosis and hyphema are also seen in
ecchymosis in ZMC fractures are more dramatic due to some cases.
the loose connective tissue in the periorbital region. • Epistaxis: Occasional epistaxis may be observed due to
Ecchymosis is commonly seen in the circumorbital region escape of pooled blood from the maxillary sinus follow-
and maxillary buccal sulcus (Fig. 56.15). ing ZMC fracture. This is typically ipsilateral. Resultant
• Subconjunctival hemorrhage (SCH): Subconjunctival nasal congestion is a common clinical finding.
hemorrhage or hyposphagma (Fig. 56.15) often occurs in • Loss of facial prominence: Displacement of zygoma due
ZMC fractures due to collection of the blood into the sub- to trauma leads to the characteristic flattening of malar
conjunctival space, secondary to hemorrhage from the prominence (Fig. 56.16). This is well observed in bird’s
surrounding periosteum. Characteristically, SCH in ZMC eye and worm’s view. Examination by palpation is done
from behind the patient to detect malar depression. The commonly observed variations in globe position
However, the flattening cannot be appreciated in the pres- are exophthalmos in posteriorly/medially displaced
ence of moderate or severe edema. zygoma (Fig. 56.18a−c) and enophthalmos in laterally
• Eye signs: The eye signs are a very striking feature of and inferiorly displaced zygoma (Fig. 56.19). En/exoph-
zygomatic injury especially when rotated and inferiorly thalmos resulting from ZMC fractures must be differenti-
displaced. Inferior displacement of zygoma results in ated from enophthalmos arising from blow-out fractures
hypoglobus and an anti-mongoloid slant to the eye involving the orbital floor. The clinical implications of the
(Fig. 56.3b). Inferior or posterior displacement of the above are explained under “preoperative planning.” Also,
infra-orbital rim also causes lowering of the lower eyelid it is important to remember that the traditional assessment
leading to increased scleral show (Fig. 56.17). of en/exophthalmos by Hertel’s exophthalmometer does
not reflect the true position of the globe in displaced ZMC
fractures because it uses the orbital rim as a point of refer-
ence. Naugle’s which utilizes supraorbital rim as a refer-
ence is ideal in such cases [26]. However CT evaluation is
the most preferred modality [27] (refer Chap. 57 on
orbital fractures).
• Tenderness and step deformity: When edema is severe and
inspectory findings are not conclusive, palpation gives
more details. Tenderness on digital palpation, step defor-
mity at the fronto-zygomatic, zygomatic buttress, and
IOR are good indicators of fracture.
• Air emphysema: Palpation also helps to elicit air emphy-
sema in the form of subcutaneous crackling. This occurs
when there is a fracture through a sinus wall which allows
air escape into the facial soft tissues. It usually disappears
spontaneously, in 2–4 days [28]. However, this can be a
potential cause of infection [29].
• Reduced mouth opening: Restriction in mouth opening
can arise because of two reasons [30]: (1) mechanical
obstruction to movement of the mandible by a retrodis-
placed zygoma or a fractured zygomatic arch (Fig. 56.20a,
b) and (2) a fractured arch impinging on the temporalis
muscle causing reflex spasm/trismus. Likewise, injury to
Fig. 56.8 Inferior displacement of zygomatic arch the masseter also can lead to trismus.
a b
Fig. 56.9 En bloc and comminuted ZMC fractures. (a) En bloc displacement of the right ZMC. (b) Comminuted ZMC of left side
Fig. 56.10 Zing’s classification of ZMC fractures. (a) arch only (Type A1), (b) separation at fronto-zygomatic suture (Type A2), (c) separation at
infra-orbital rim (Type A3), (d) complete mono-fragment (Type B) and (e) multi-fragment (Type C)
for altered occlusion is the flexing of the ipsilateral

maxillary alveolus leading to premature molar contact
[31]. Paresthesia involving the zygomaticofacial and
zygomaticotemporal nerves may be present. In rare occur-
rences, injury to the facial nerve leading to paresis has
been observed in severely displaced or high-velocity inju-
ries of the zygoma [15].
• Altered/loss of vision: Binocular diplopia is a common
finding. The diplopia that develops following trauma
can be the result of soft tissue (muscle or periorbital)
entrapment, neuromuscular injury, intra-orbital or intra-
muscular hematoma/edema, or a change in orbital
shape, with displacement of the globe [32]. A forced
duction test (FDT) (Fig. 56.21) would confirm any
physical impediment to ocular motility [4]. Diplopia
due to edema/hematoma resolves in a few days, while
that due to muscle entrapment does not, necessitating
Fig. 56.11 Avulsion of zygoma surgical correction.
Another rare but serious sequel to ZMC fractures is
traumatic optic neuropathy which may present as total or
• Paresthesia: Infra-orbital nerve being closely related to partial loss of vision [33].
the zygoma gets compressed or pulled in displaced or
comminuted ZMC fractures leading to paresthesia along
the lower eyelid, upper lip, and lateral aspect of the nose. 56.5 Imaging for ZMC Fractures
Occasionally, a patient may also have altered sensation
involving the maxillary teeth leading to a perception of Radiological assessment is essential for accurate diagnosis
altered dental occlusion [5]. The other theory put forward and assessment of severity of the fracture.
Fig. 56.12 Ozyazgan et al. classification of zygomatic arch fractures
• Plain radiographs [31]: Conventional radiographs con- [35] are useful in identification of fractures on the Water’s
tinue to remain the mainstay of imaging at some centers. view (Box 56.2).
Conventional radiographs may also be useful in the post-
operative phase, to assess fracture reduction. However Box 56.2 (Fig. 56.22): Radiographic Appearance in
conventional radiographs are limited by superimposition ZMC Fracture
of structures.
The commonly used views include the waters view • Disruption of the Dolan’s lines
(37° occipitomental) (Fig. 56.22) which provides good Orbital line
visualization of the fractured zygoma and helps in com- Zygomatic line
paring with the contralateral side. Tracing the McGrigor- Maxillary line
Campbell lines [34] (refer Chap. 55) or the Dolan’s lines • Loss of elephant trunk appearance
Fig. 56.13 Yamamoto et al. classification of zygomatic arch fractures

Class I Class II Class III
Fig. 56.14 Hönig Merten (HM) et al. classification of zygomatic arch fractures
©Association of Oral and Maxillofacial Surgeons of India ©Association of Oral and Maxillofacial Surgeons of India
Fig. 56.15 Periorbital edema, ecchymosis, and subconjunctival Fig. 56.16 Loss of facial prominence in right malar region
hemorrhage
Fig. 56.17 Increased scleral show on right side
Fig. 56.19 Enophthalmos. (a) Frontal view showing enophthalmos on

left side. (b) Basal view of the same patient showing enophthalmos on
left side. (c) Axial CT section demonstrating enophthalmos of the left
eye
• Computed tomograms: CT remains the gold standard

[31]. It enables a three-dimensional assessment of the
fracture along with demonstration of soft tissue entrap-
ment between the fracture fragments. Identification of
sphenozygomatic diastasis is best appreciated on CT
scans. They also aid in volumetric analysis of the orbital
cavity and deficits of the orbital floor. The features dem-
©Association of Oral and Maxillofacial Surgeons of India onstrated in different CT sections are highlighted
(Fig. 56.24a−d). Figure 56.25 demonstrates CT scan
Fig. 56.18 Exophthalmos. (a) Frontal view demonstrating exophthal-
image with volume rendering, which is useful in assess-
mos and hyperglobus on right side. (b) Basal view of the same patient
showing exophthalmos on right side. (c) Axial CT section demonstrating the spatial orientation of fractured ZMC.
ing exophthalmos of the right eye • USG is a useful tool for diagnosis of ZMC fractures with
high degree of sensitivity for fractures of the arch and
infra-orbital rim with the significant advantage of “zero”
• The submentovertex/jug handle view [31] (Fig. 56.23) radiation exposure [36].
offers the best representation of fractures of the arch. Loss
of elephant trunk appearance which is indicative of arch The role of intra-operative imaging is discussed in the
fracture is well appreciated in this view. later segments of the chapter.
a b
Fig. 56.20 Restricted mouth opening in ZMC fractures. (a) noid. Process, blue arrow demonstrating normal space. (b) Fractured
Retrodisplaced zygoma impinging on the coronoid. Yellow arrow dem- arch impinging on the coronoid (Here, blue arrow demonstrates reduced
onstrating restriction of space between the body of zygoma and coro- space)
Fig. 56.21 Forced duction test
Fig. 56.22 Waters view with Dolan’s lines. (A) Orbital line, (B)
Zygomatic line and (C) Maxillary line. The yellow arrows indicate frac-
ture separations noted on the right ZMC
56.6.2 Timing of Intervention [39]
ZMC fractures are not emergencies, and treatment can be

delayed, if necessary.
• When the decision is “no immediate intervention,” sur-

gery may be postponed for up to 2 weeks, following
which a reassessment may be made.
• When the indications are questionable, for example, pres-
ence of severe edema or fractures with minimal displace-
ment, it is advisable to wait for the edema to subside so
that the deformity may be assessed better.
• When the indications are definite, immediate intervention
provides better outcomes due to minimal soft tissue scar-
ring and easier reduction of fractures.
56.6.3 Surgical Objectives

Fig. 56.23 Submentovertex view demonstrating fractured arch on left Management of ZMC fractures is aimed at achieving the sur-
side gical objectives highlighted in Box 56.3 [37].
56.6 Principles of Management Box 56.3: Surgical Objectives in ZMC Fracture

• Restoration of facial esthetics
56.6.1 Indications and Contraindications • Restoration of premorbid ocular function
for Intervention [5, 37] • Correction or prevention of enophthalmos/
exophthalmos
Surgical outcome of ZMC fractures is greatly influenced by • Restoration of premorbid antral function
two important factors: (1) choosing the right indications for • Restoration of mandibular range of motion
intervention and (2) ideal time for surgery. Not all fractures Mouth opening of 40 mm, excursion – 4–6 mm
of the ZMC require surgical intervention. The decision to
intervene should be based on signs and symptoms and pres-
ence of functional impairment (Fig. 56.26).
1. It is not necessary to intervene surgically if the fracture is 56.6.4 Need for Prophylactic Antibiotics
incomplete, undisplaced, or minimally displaced with no
compromise in esthetics or function. But such patients ZMC fractures may be categorized into three classes based on
must be advised to follow soft, non-chewy diet for 2–6 their propensity to develop postsurgical infection: clean frac-
weeks and monitored to identify displacement [38]. tures (isolated arch fractures), clean-contaminated (ZMC frac-
2. Indications for surgery include (1) presence of cosmetic tures compound into the antrum), and dirty (fracture which is
defects in the form of facial deformity, loss of lower eyelid open to exterior). While type three fractures require regular
support, or ocular dystopia; (2) functional deficits such as antibiotic prophylaxis, types 1 and 2 show minimal rates of
limitation of mouth opening, sensory nerve deficit, and infection and may either need “no” antibiotic prophylaxis [40]
impaired ocular movements; and (3) ZMC fracture associ- or a modified single-day postsurgical regimen [41].
ated with OCR reflex in children (please refer to Chap. 57).
3. Postponement of surgical intervention is considered when
the general neurologic status of the patient is questionable. 56.7 Preoperative Planning [42]
4. Surgical intervention is relatively contraindicated when
the involved side has the only seeing eye. In a patient ZMC fractures show high propensity for over or under reduc-
willing for surgery, “potential loss of vision” has to be tions due to lack of objective intra-operative measures to
included in the informed consent. assess reduction. This may be overcome with accurate pre-
Fig. 56.24 CT scan of patient with left ZMC fracture. (a) Axial view medial displacement of the body of zygoma. (d) Sagittal section dem-
demonstrating overriding of fracture fragments at SZ suture. (b) Axial onstrating posterior displacement of IOR and large blow-out fracture of
section demonstrating fracture at the IOR and buckling of arch. (c) orbital floor
Coronal section showing separation at the FZ and ZM sutures with
operative planning which helps in realizing surgical objec- 56.7.1 CT Evaluation
tives in a predictable manner.
Preoperative planning includes three vital steps: Proper CT evaluation is absolutely essential for choosing
the ideal treatment; CT plays a very important role in dif-
(i) CT evaluation ferentiating en/exophthalmos due to ZMC fractures from
(ii) Model surgery those due to orbital fractures. This helps in arriving at a
(iii) Soft tissue analysis decision regarding internal orbit reconstruction (Box 56.4).
Box 56.4: Relative vs. Absolute En/Exophthalmos
Enophthalmos in
Enophthalmos ZMC +orbit
in ZMC fracture
Relative Absolute
Etiology Change in globe Change in globe
position due to position due to
displaced zygoma fracture of orbital
floor
Surgical Restoration of orbital Restoration of
management rims by reduction and orbital rims by ©Association of Oral and Maxillofacial Surgeons of India
fixation of ZMC reduction of ZMC
fracture alone fracture as well as Fig. 56.26 Indications and contraindications for intervention
reconstruction of
orbital floor
The repositioned fragments are stabilized temporar-
ily with wax. The fixation devices (miniplates) are
then pre-contoured over the model. Such pre-
contoured implants are used to guide intra-operative
fracture reduction as well as fixation. Figure 56.28a−d
demonstrates the sequence described.
2. STL model after mirroring: CT scan is used to
generate a virtual model wherein the normal side is
mirrored onto the fractured side. The virtual model is
used to print a physical model which demonstrates
the skull which is bilaterally symmetrical, mimick-
ing ideal reduction status. Similar to the earlier
method, implants for fixation are pre-contoured over
this model to help achieve optimal results intra-oper-
atively. Figure 56.29a−d demonstrates a similar clin-
ical scenario.
(B) Planning Using Virtual Models
©Association of Oral and Maxillofacial Surgeons of India This method utilizes the complete spectrum of computer-
assisted surgical planning. A CT scan is obtained to create
Fig. 56.25 CT with 3D volume rendering demonstrating medially a virtual model on which the entire surgical sequence of
rotated right ZMC fracture
reduction is performed and on which the stents for intra-
operative guidance are designed. Intra-operative stents are
56.7.2 Model Surgery printed from these virtual designs. There is no physical
“handheld” model here (Refer Chap. 41).
The process begins with obtaining CT scans of the patient • In the case of a unilateral ZMC fracture, the normal
with minimum slice thickness of 0.6 mm. This is followed by side is mirrored to the fractured side to obtain bilat-
two different sequences of workflow (Fig. 56.27) which are eral symmetry. CAS technology is then utilized to
described below. design “guidance stents” on the mirrored side. These
stents can be utilized intra-operatively to (1) verify
(A) Planning Using Physical Models ideal reduction position in primary trauma or (2)
The first step involves generation of a physical stereo- design the osteotomy and repositioning, in second-
lithographic model (STL) from the CT scan of the ary corrections. Another important advancement in
patient. There are two methods by which this can be recent years is the design and printing of
done. “patient-specific implants” (PSI) using virtual plan-
1. STL model with the actual deformity: This model ning. These customized fixation devices double up
presents the post-traumatic deformity, as observed as guidance stents also (Refer Fig. 57.54).
clinically. A routine model surgery is then per- • In bilateral ZMC fractures [43], mirroring is not an
formed, by which the displaced fragments are cut option, and the ideal sequencing for such cases is
and repositioned to obtain optimal anatomical form. discussed in Sect. 56.14, of this chapter.
Fig. 56.27 Flow chart for

preoperative planning in ZMC
fractures
Fig. 56.28 Model surgery for pre-contouring of implants. (a) CT image demonstrating fractured ZMC of right side. (b) STL model demonstrating
deformity. (c) Repositioning of fracture fragments to anatomical position. (d) Pre-contouring of implants
Fig. 56.29 Use of mirrored models for pre-contouring of implants. (a) 3D CT image of fracture. (b) Mirroring of zygoma of normal side to frac-
tured side. (d) Generation of mirrored STL model and pre-contouring of implants
56.7.3 Soft Tissue Analysis Fracture reduction may be done either by direct or indi-
rect method, and the approaches may be extraoral or intra-
Li et al. [44] have described a technique for 3D simulation oral [1].
and prediction of soft tissue—outcome analysis in ZMC
fractures. This process enables prediction of postoperative
soft tissue changes in patients with ZMC fractures who are 56.8.1 Direct vs. Indirect Method
indicated for primary/secondary surgical interventions. The
planning involves utilization of CT data and 3D stereopho- The indirect method is a blind technique where fracture is
tography for the analysis. The technique may also be utilized reduced without exposure of the fracture site (e.g., Gillies
for evaluation of postsurgical results. reduction), while direct method involves reduction of the
fracture under direct visualization (e.g., coronal approach to
reduce arch fracture). The differences between the two meth-
56.8 Reduction of ZMC Fractures ods are shown in Fig. 56.30. However, indirect method is
more commonly practiced. Open method is resorted to when
Reduction of zygoma is unique in two aspects: the ZMC fracture is (1) severely displaced, (2) complex or
comminuted, (3) when stable reduction is doubtful, and (4)
1. Unlike the other facial bones, “reduction alone” may be there is a need for internal orbit reconstruction. However, no
the sole treatment in many cases of ZMC fractures. “single technique” is superior, and sometimes, a combina-
2. The surgical approach for reduction may be different tion of techniques is more effective.
from that for fixation.
56.8.2 Extraoral Techniques as well as the zygoma. The technique is based on the ana-
tomical basis that the plane between the temporalis fascia
The extraoral reduction techniques may be either percutane- and the temporalis muscle offers direct access to the
ous, temporal, or endoscopic [1, 45]. zygomatic arch and zygoma. The only contraindication to
this approach is the presence of concomitant temporal
• Temporal approach [46], commonly called the Gillie’s bone fracture. The incision is placed at a level 2 cm above
(Figs. 56.31a−f and 56.32a), is the most popular method the helix of the ear, paralleling the anterior branch of the
of ZMC reduction. This approach is favored because the superficial temporal artery, well within the hairline
incision is placed within the hairline which does not leave (Fig. 56.33). Dissection is carried down through the skin,
a visible scar. It also offers a very predictable force during subcutaneous tissue, and galea aponeurotica (temporopa-
reduction and may be used for reduction of both the arch rietal fascia—TPF) to reach the temporalis fascia.
A B
Fig. 56.30 (A) Indirect vs (B) direct reduction

Fig. 56.31 Gillies temporal approach. (a) Marking of incision parallel temporal fascia exposing temporalis muscle. (e) Developing plane of
to frontal branch of superficial temporal artery. (b) Placement of inci- elevation with periosteal elevator. (f) Placement of Rowe’s zygomatic
sion. (c) Exposure of deep temporal fascia. (d) Incision through deep elevator for elevation
An incision is made through the temporalis fascia to collapsed arch form. Care is taken not to lever the elevator
reveal the underlying temporalis muscle. A Howarth’s against the skull (Video 56.1).
elevator is inserted between the temporalis fascia and the
muscle, to create a plane for the zygomatic elevator. Two
Clinical Tip
types of zygomatic elevators, namely, the Bristow’s and
1. It is good practice to keep a roll of gauze under the
Rowe’s (Fig. 56.34a), are commonly used; the Bristow’ s
zygomatic elevator to prevent injury to the temporal
has a single flat and elongated working tip attached to a
bone.
handle and is used like a spatula for elevation, while the
2. Instead of extensive shaving of the temporal hair
Rowe’s elevator has an additional arm attached to the
for a Gille’s approach, a small patch (1cm by 3cm)
working tip which serves two purposes: (1) to provide the
of shaving/close trimming of hair can be done for
necessary countertraction during elevation so that it
better cosmesis.
relieves the fulcrum off the temporal bone and (2) to eval-
uate the approximate depth of insertion of the working tip
when inserted into the tissue. The zygomatic elevator is • Percutaneous methods make use of a minimal facial skin
positioned in the plane created, directed inferiorly to incision, usually right over the zygoma or the lateral brow
reach the deeper surface of the zygoma and carefully (Dingman’s method) through which instruments may be
elevated, while an ironing motion is used to smoothen the inserted to manipulate and elevate the displaced zygoma.
Fig. 56.32 Different approaches for reduction of fractured ZMC. (a) Gillie’s. (b) Poswillo. (c) Dingman. (d) Balasubramaniam. (e) Quinn
–– Poswillo’s approach. This involves a stab incision beneath it to lift the arch or the body of the zygoma in
made at the point of intersection of two imaginary an upward, forward, and outward fashion. The original
lines—a horizontal from the base of the nose and a description by Dingman utilized trans-osseous wiring
vertical from lateral canthus (Fig. 56.35a, b). The inci- for stabilization of the front-zygomatic suture.
sion is oriented along the skin crease, just enough for a However current methods incorporate the use of mini-
Poswillo hook [47] to be engaged underneath the body plate osteosynthesis through this approach.
of the zygoma (Fig. 56.32b and Fig. 56.34b). And the
impacted zygoma is pulled upward or outward. Skin
incision is closed with a single suture. Reduction
through a zygoma approach may also be performed by 56.8.3 Intraoral Techniques
using a Carroll-Girard screw [48]/universal bone
reduction screw (Fig. 56.34c). The greatest advantage of intraoral techniques is “no skin
–– Dingman’s lateral brow approach [49] (1964) incision.” Commonly followed methods are:
(Fig. 56.32c)
This technique is performed through a standard lat- • Balasubramaniam’s/Keen’s approach (upper buccal sul-
eral brow approach where the fracture is visualized by cus approach) [50] (Fig. 56.32d)
a direct approach to the bone after incising through the This approach uses a vestibular incision behind the
skin, subcutaneous tissue, and periosteum. An elevator zygomatic buttress. A Howarth’s periosteal elevator is
is then passed laterally and posterior to the orbital rim inserted in a supraperiosteal plane to engage the infratem-
into the temporal fossa. The temporal aponeurosis poral surface of the zygoma. Reduction is achieved with
(attachment of the deep temporal fascia to the lateral an upward, forward, and outwardly directed force. When
orbital rim) is incised, and the elevator is passed greater force is needed to elevate as in impacted zygomas
Fig. 56.34 Instruments for reduction. (a) Rowe’s . (b) Poswillo hook.
©Association of Oral and Maxillofacial Surgeons of India (c) Universal bone reduction screw
Fig. 56.33 Gillie’s correct plane for elevation. It is important to under-

stand that the deep temporal fascia divides into two, to enclose the
zygomatic arch and the fat above, approximately 2 cm above the arch.
56.8.5 Intra-operative Assessment
An incision placed too low may mislead the young surgeon into the fat of Reduction
plane (b, lateral to the arch) rather than the subfascial plane (a, medial
to the arch) (Also refer Fig. 85.1a) The intra-operative assessment of reduction is a critical step
in zygoma management, especially in closed reduction. The
or delayed presentation, a Bristow’s/Rowe’s zygomatic methods commonly used are (1) clinical assessment, (2)
elevator (Fig. 56.36) or the arm of an upper anterior for- imaging, and (3) use of prefabricated guides/stents.
ceps may be used. The technique offers more mechanical
advantage than the extraoral method; less force is needed 1. Clinical assessment is usually done by eyeballing, com-
to elevate, because the force is directed entirely at the cen- paring with the normal side or palpation of the rims for
ter of the zygomatic body, which is considered more steps. However, the adequacy of reduction may be diffi-
effective. cult to assess intra-operatively because of edema as well
• Quinn’s procedure (lateral coronoid approach) [51] as patient position. Audible click during manipulation is
(Fig. 56.32e) employs an incision over the anterior border also indicative of reduction [58]. Surgical exposure of
of the ramus. An elevator is inserted in a supraperiosteal multiple suture sites is the other method to confirm reduc-
plane, lateral to the coronoid process and paralleling the tion [59] but is less favored because of surgical morbidity.
temporalis tendon to reach the medial surface of the zygo- However, exposure at all sites of articulation is not
matic arch. Elevation of the arch may be done in an iron- required; two sites are considered perfect indicators of
ing fashion. accurate reduction [5] (Box 56.5).
2. Intra-operative imaging [58] such as C-arm [60]
Both the abovementioned intraoral techniques are supra- (Fig. 56.37a, b), CT [59], O arm [61], or endoscopes [45]
periosteal methods. are valuable guides in confirming reduction of ZMC frac-
tures. However, use of intra-op imaging other than
endoscopes mandates use of lead aprons by operating
56.8.4 Reduction of Zygomatic Arch room personnel to prevent radiation exposure.
3. Prefabricated guides/ stents [62] are valid tools which
Elevation of the depressed arch is usually performed in an ensure accuracy of reduction, intra-operatively.
indirect manner, using the Gillie’s technique. However
numerous techniques have been advocated in literature.
These include the “roller-coaster” lateral brow technique Box 56.5: Indicators of Accurate Reduction of ZMC #
[52] and methods using percutaneous towel clip [53], trac- Reduction along the vertical axis—SZ suture
tion suture [54], Foley’s catheter [55], K wire [56], and Reduction along the horizontal axis—ZM suture
Dingman elevator [57] to restitute the arch anatomy.
a b
Fig. 56.35 Percutaneous reduction with Poswillo’s technique. (a) Marking on skin. (b) Percutaneous insertion of bone hook
56.8.6 Precautions During and After

Reduction
Manipulation of zygoma during reduction has been known

to cause certain complications such as bleeding from
infra-orbital vessels [16]. Use of controlled force during
indirect reduction greatly reduces such complications. It
is prudent to watch out for stimulation of Oculocardiac
reflex (OCR) [63] as described later in the text. OCR may
also be prevented by administering regional blocks before
elevation [64].
Once the reduction is completed and found satisfactory,
the fracture fragments need to be maintained in the reduced
state. A Zimmer splint [65] (preformed aluminum splint with
foam on the undersurface) may be adapted to the reduced
arch and secured with sutures. It is maintained in situ for 2–3
weeks.
Finally, it is mandatory to do a force duction test (FDT)
after elevation of zygoma [5] (Box 56.6).
Box 56.6: FDT Is Mandatory After Reduction of ZMC

Fractures (Fig. 56.21)
During reduction of ZMC fractures, as the fractured

bones get realigned to normal anatomical position,
entrapment of surrounding soft tissue or muscles may
occur between the fragments
This may lead to port-surgical diplopia, necessitat-
Fig. 56.36 Balasubramaniam’s technique ing a surgical revisit.
Fig. 56.37 Intra-operative assessment of reduction using C-arm. (a) Intra-operative positioning of C-arm. (b) Image demonstrating zygomatic
arch after reduction
56.9 F
ixation and Stabilization of Box 56.7: Ideal Sequence of Fixation
ZMC Fractures
1. Vertical buttress—to restore facial height
56.9.1 Need for Fixation 2. Zygomatic arch—to restore anteroposterior
projection
Fixation needs of ZMC fractures depend on the post-
reduction stability. Classification of fracture patterns by
Rowe and Williams [1] provides guidance on assessment 56.9.2 Fixation Principles
of fracture stability after reduction. Any fracture classified
as stable after reduction does not require fixation, while The current dictum is “any zygoma which when fractured
those considered unstable, mandate fixation. However, a and displaced must be fixed” [37]. The objectives are to
practical method would be to apply moderate digital pres- achieve a 3D reconstruction (transverse width, vertical
sure on the malar eminence after reduction. Displacement height, and anteroposterior projection) and establish the but-
secondary to this maneuver, requires fixation [59]. The tresses. Attention needs to be given to the order of restoration
algorithm proposed by Rodrigo and Belini et al. is also a [66, 67]. The results of various biomechanical experiments
practical guide to manage ZMC fractures which are not indicate that the vertical buttress needs to be fixed first, to
associated with orbital component [3]. For ZMC fractures restore the facial height. Then, the anteroposterior projection
with orbital involvement, Ellis and Perez advocate guide- may be achieved by restoring the arch (Box 56.7).
lines for orbital reconstruction based on CT evaluation.
Most of the studies indicate increase of fixation points
from 1 to 2, 3, and 4 points based on the status of intra- 56.9.3 Surgical Access to Fixation
operative stability after reduction. Involvement of orbit
leading to changes in intra-orbital volume requires orbital Surgical approaches for ZMC fixation are chosen based on
reconstruction [59]. the fracture pattern and fixation needs. A single or multiple
incision may be used for the surgical exposure of ZMC frac-

tures [30, 68, 69]. Box 56.8: Approaches to ZMC Fractures
Intraoral vestibular incision ZM, IOR

Lower eyelid cutaneous incisions IOR, orbital floor
The incisions may be broadly classified as: (Subtarsal, subciliary, infraorbital)
Transconjunctival SZ, FZ, IOR, floor
• Cutaneous (upper eyelid, lateral brow, subciliary, Lateral brow FZ, SZ
subtarsal, infra-orbital, preauricular, and coronal Upper eyelid SZ, FZ
incisions) Coronal SZ, FZ, arch
Preauricular Arch
• Conjunctival (transconjunctival with canthotomy/
transcaruncular)
• Mucosal (intraoral vestibular)
56.9.3.1 Supraorbital/Lateral Brow Incision
(Fig. 56.38)
The list of incisions and the exposure achieved (green The lateral brow incision is otherwise called as “in the brow”
shaded areas on Fig. 56.38) by each are highlighted in Box incision and offers a fast and direct access to the fronto-
56.8 (Fig. 56.38) zygomatic suture and lateral part of the supraorbital rim. The
The following is a description of the various incisions extensions for the incision must be well within the eyebrow
used to access the fixation points in ZMC fractures. It is which provides an ideal camouflage (Fig. 56.41a). However,
important to take adequate measures for globe protection this incision may not be ideal in people who are cosmetically
while placing any periorbital incisions [70]. The commonly inclined to maintain a higher eyebrow. Absence of any
followed methods include either a temporary tarsorrhaphy important neurovascular structures in this area makes this
(Fig. 56.39) or a corneal shield (Fig. 56.40). The tarsorrha- incision easy to perform, even by beginners.
phy also offers the additional advantage of being used as a After infiltration of LA solution containing vasoconstric-
retraction suture during surgery. tor, a 2 cm long incision is placed along the curve of the
Fig. 56.38 Incisions to

access ZMC fractures


Fig. 56.40 Corneal shield
Fig. 56.39 Tarsorrhaphy
crow’s feet wrinkle which is restricted to the skin only, is
utilized to provide a much wider access [70] (Fig. 56.41b).
This extension must remain 6 mm superior to the lateral can-
thus. Inferior limit of the incision along the lateral orbital rim
should not cross the RSTL (resting skin tension lines) to
avoid unaesthetic scars.
Closure is performed in layers with approximation of the
periosteum and subcutaneous tissues (Video 56.2).
56.9.3.2 Upper Eyelid Blepharoplasty Incision

(Fig. 56.38)
The upper lid blepharoplasty incision is otherwise called as
the supratarsal fold or upper eyelid crease incision. It offers
the most esthetically favorable approach to the fronto-
zygomatic suture region. The incision is made along the eye-
lid crease, 10 mm above the free margin of the eyelid
(Fig. 56.41c). As the incision extends laterally, it should be at
least 6 mm above the lateral canthus. When eyelid anatomy
is distorted with edema or hematoma, the contralateral lid
©Association of Oral and Maxillofacial Surgeons of India crease measurements are used to mark the incision.
The incision is placed through the skin and muscle and is
Fig. 56.41 Periorbital incisions for FZ suture. (a) Lateral brow inci-
raised as a skin-muscle flap for good viability of the overly-
sion. (b) Lateral brow extension (shown in dotted lines). (c) Upper lid
blepharoplasty ing skin. The plane of dissection is below the orbicularis
oculi in a superior and lateral fashion to reach the periosteum
superolateral part of the orbital rim. Care is taken to incline (Fig. 56.43a, b). The periosteum is sharply incised to expose
the blade parallel to the hair so that the shafts are not tran- the bone underneath. Further dissection along the bony mar-
sected. Failure to do so may cause linear alopecia along the gins is strictly subperiosteal; any violation of the periosteum
incision line, which may be unaesthetic. Incision is carried may cause herniation of the lacrimal gland which is present
through the skin, subcutaneous tissue, and the orbicularis in the superolateral concavity of the orbit. Closure of the
oculi muscle. The flap is undermined in the supraperiosteal incision is done in layers, starting with periosteum, followed
plane to permit ease of retraction. A periosteal incision is by the orbicularis oculi, and the skin.
then placed above the fronto-zygomatic suture for reduction An important advantage of the upper lid blepharoplasty
and fixation (Fig. 56.42a, b). incision is the extensive access it offers to the entire supero-
When additional exposure is needed on the medial aspect, lateral aspect of the orbit. It also permits good visualization
the incision is extended up to the supraorbital nerve. For and access to the spheno-zygomatic suture which is the most
additional inferior extension, a gradual 90° turn into the important indicator of reduction of ZMC fractures.
Fig. 56.42 Lateral brow incision—intra-operative. (a) Marking. (b) Exposure
Fig. 56.43 Upper lid blepharoplasty intra-operative. (a) Marking. (b) Exposure demonstrating ORIF
56.9.3.3 Subciliary Incision [71, 72] (Figs. 56.38,

56.44a and 56.45a, b)
The subciliary incision is a commonly used transcutaneous
approach which offers good exposure of the infra-orbital rim
along with the entire orbital floor. This may be a very useful
approach in the management of ZMC fractures which involve
the orbital floor also.
The skin incision is placed along the entire length of the
lower eyelid, 2 mm below the level of the eye lashes to con-
ceal the future scar.
The incision must not be extended more than 2 cm lateral
to the lateral canthal ligament. This prevents any inadvertent
damage to the temporal branch of the facial nerve which is
present about 3 cm lateral to the lateral canthal ligament.
Once the skin is incised, the dissection may proceed in
three different ways [30, 70] (Fig. 56.45b) (Box 56.9):
(i) “Skin-alone” flap technique where the plane of dissec- ©Association of Oral and Maxillofacial Surgeons of India
tion is along the subcutaneous plane between the skin of
Fig. 56.44 Lower eyelid incisions. (a) Subciliary. (b) Extended sub-
ciliary showing area of exposure shaded. (c) Subtarsal incision. (d)
Infra orbital
Box 56.9: Comparison of Variants of Subciliary Incisions
Skin- the eyelid and the orbicularis oculi. On reaching the

muscle Stepped
Skin flap flap skin-muscle flap
facial surface of the infra-orbital rim, the orbicularis
Skin incision 2 mm below 2 mm 2 mm below the muscle along with the periosteum is incised to reach the
the cilia below the cilia rim. The periosteal incision is generally placed at least
cilia 3–4 mm below the level of the infra-orbital rim
Muscle Just below Same level 2–3 mm below (Fig. 56.45a and 56.45b1).
incision the infra- as skin the skin incision
orbital rim incision
(ii) “Skin-muscle” technique: the incision is carried down
Periosteum Just below Just below Just below the from the skin into the pre-tarsal fibers of the orbicularis
incision the infra- the infra-orbital rim oculi, and the flap is dissected along the plane deep to
orbital rim infra- the muscle but superficial to the tarsal plate. The dis-
orbital rim
section is then carried out superficial to the orbital sep-
Plane of Between skin Between • Stepped
dissection and orbicularis • Between skin tum till the rim is reached. Exposure of the rim is
orbicularis muscle and orbicularis performed after sharp dissection of the periosteum just
muscle and muscle in below the level of the rim (Fig. 56.45b2).
septum pre-tarsal (iii) “Step” approach is performed in two different levels
region
• Between and is considered the best approach as it prevents most
orbicularis of the complications which are associated with the two
muscle and former approaches. The incision is first placed through
septum— the skin, and the plane of dissection is carried in the
inferior to the
tarsal region subcutaneous plane, maintaining the pre-tarsal fibers
Preservation Preserved Incised Preserved of the orbicularis oculi. As the lower end of the tarsal
of pre- tarsal plate is reached, the orbicularis oculi muscle is divided,
fibers of and the plane is changed to include the muscle along
orbicularis
oculi
with the skin as a “skin-muscle” flap (Fig. 56.45b3).
Complications Skin Septal Lesser incidence The development of a skin-alone flap at the marginal
buttonholing, perforation of complications level and a “skin-muscle” flap at the subtarsal level cre-
discoloration Ectropion ates a step in the plane of dissection. The dissection then
Lid
proceeds caudally toward the infra-orbital rim in a sub-
shortening
Scleral muscular plane superficial to the orbital septum. On
show reaching the rim, the periosteum is incised sharply about
3–4 mm below the level of the rim on the facial aspect.
b1 b2 b3
Fig. 56.45 Lower eyelid incisions—sagittal view. (a) Subciliary, sub tarsal and infra-orbital (b) Variants of sub-ciliary incision
The incision of the periosteum at this level not only helps 56.9.3.4 Extended Lateral Exposure with
preserve the attachment of the orbital septum along the the Subciliary Approach Fig. 56.46 [70]
rim margin but also lies above the level of the infra-orbital After placing a standard subciliary incision, supraperiosteal
foramen which is seen about 7–8 mm below the level of dissection is performed along the lateral orbital rim in the
the rim. Dissection of the periosteum can be performed cephalic direction till the FZ suture or a few millimeters
along the entire length of the infra-orbital rim, anterior beyond (Figs. 56.44b and 56.46). This releases the skin flap
maxilla, and the zygoma to provide excellent exposure. and makes it amenable to easy retraction to reach the FZ
region. The periosteum is then divided in the center of the
lateral orbital rim along its length. In most cases the lateral
Advantages of the stepped approach include (1) mini- canthal ligament may be stripped in a subperiosteal fashion
mal chances of buttonholing or darkening of the skin to facilitate comfortable access to the FZ suture. This
due to vascular compromise (2) lesser incidence of approach may be used to avoid an additional incision for
ectropion and entropion (3) reduced scarring at the exposure of the FZ suture.
eyelid margins due to preservation of the pre-tarsal
orbicularis oculi fibers. 56.9.3.5 Subtarsal Approach [73] (Figs. 56.38,
56.44c and 56.47)
Subtarsal or mid-lid incision was also described by Converse.
The differences between the three variants of subciliary The incision is marked 5–7 mm below the inferior lid margin
incision are highlighted in Box 56.9 (Figs. 56.45b). corresponding to the lower border of the tarsal plate, along
the subtarsal crease (Fig. 56.47). The lateral extension of the

incision may be extended up to 2 cm beyond the lateral can-
thal ligament similar to the subciliary incision, along one of
the resting skin tension lines. The incision is made through
the skin and subcutaneous tissue. The pre-septal fibers of the
orbicularis oculi are also divided at the same level, and the
plane of dissection is maintained superficial to the orbital sep-
tum. The dissection is carried out caudally to reach the infra-
orbital rim, and the periosteum is divided below the level of
the rim on the anterior surface of the maxilla and zygoma.
The subtarsal approach is favored more than the subcili-
ary [73] due to its easier technique and lesser incidence of
complications (Box 56.10).
Box 56.10: Subtarsal vs. Subciliary Incision
Subtarsal Subciliary
Ease of technique Easy Technically demanding
©Association of Oral and Maxillofacial Surgeons of India due to
•S tepped dissection and
Fig. 56.46 Subciliary with lateral extension demonstrating exposure closure
of the FZ suture after ORIF • I nterference of lashes in
the surgical field
Time taken for the Quick Takes almost twice the
approach amount of time
Incidence of scleral 2.7–7.7% 17–42%
show or ectropion
Cutaneous scar More Less visible
visible
Fig. 56.48 Figure demonstrates use of frost suture for ZMC fracture
approached by transconjunctival and upper lid blepharoplasty incision.
Technique for frost suture. A 4-0/5-0 nonabsorbable suture on a 3/8th
©Association of Oral and Maxillofacial Surgeons of India circle needle is passed to engage the inferior tarsal plate, at the middle
of the lower eyelid margin. The suture is taken either through the gray
Fig. 56.47 Subtarsal marking intra-operative line or through the pre-tarsal skin to include the skin, orbicularis, and
the tarsus. Appropriate tension is applied in superior direction by the
anchoring the suture ends, to the supraorbital skin, 5 mm above the
eyebrow using adhesive tapes
An important consideration following lower eyelid most direct approach to the infra-orbital rim and orbital floor,
approaches is the application of the “frost suture” [74] (tem- it is seldom preferred in contemporary surgery due to the
porary lower eyelid suspension suture) (Fig. 56.48), to pre- unsightly postoperative scar and prolonged edema of the
vent postoperative ectropion. Frost suture also permits lower lid region due to disruption of lymphatic drainage.
visualization of the globe in the postoperative phase, when
required (Refer Fig 11.13). 56.9.3.7 Transconjunctival Incision [78, 79]
Nevertheless, lower rim incisions are often associated (Figs. 56.38 and 56.49)
with postoperative ectropion and scleral show. While scleral Transconjunctival incision has gained popularity because it
show/lid traction refers to abnormal exposure of sclera completely negates the unesthetic scarring associated with
(1 mm or more) with contact between bulbar conjunctiva and skin incisions. This incision offers good access to the infra-
the lid, ectropion refers to eyelid eversion with no contact orbital rim and SZ regions with either a pre-septal or retro-
between bulbar conjunctiva and lid [75]. Ectropion requires septal approach. Refer to the Chap. 57 for a detailed
correction for cosmetic reasons as well as functional prob- description of the approach. The modified transconjunctival
lems arising from keratinization of exposed conjunctiva. incision with a cutaneous Y extension when combined with
Treatment varies from conservative modalities to surgical lateral canthotomy offers excellent exposure to the IOR, SZ,
procedures [76, 77] (Box 56.11). as well as the FZ region [80–82]. The complications of trans-
conjunctival incisions include entropion [82], in-curling of
lashes (trichiasis) [83], or growth of the eyelashes in two lay-
Box 56.11: Measures to Correct Ectropion and Scleral Show
ers (distichiasis) [84]. Malposed lateral canthus has also
• Conservative measures been observed following improper repositioning of the lat-
Corneal protection measures; artificial tears, oint- eral canthus after canthotomy [82].
ment, temporary tarsorrhaphy
• Surgical procedures 56.9.3.8 Vestibular [85] Incision (Figs. 56.50 and
Release of cicatrization, sutures, skin/mucosal 55.16)
grafts, cartilage grafts, rotation flaps The vestibular incision is the most frequently used approach
to access the ZM buttress. The popularity is due to its appli-
cation for reduction of ZMC fracture as well as fixation at the
ZM buttress. Refer to the Chap. 55 for description of the
56.9.3.6 Infra-orbital Incision (Figs. 56.38 technique. The author of this chapter (EP) uses the vestibular
and 56.44d) approach to also fix the zygomatic arch fractures which over-
This is performed as an incision which simultaneously ride at the zygomaticotemporal suture, with transbuccal
divides the skin, orbicularis muscle, and periosteum, along instrumentation (transoral arch fixation technique) (Refer to
infra-orbital rim. Though the infra-orbital incision offers the recent trends section 56.16).

Fig. 56.50 Vestibular incision demonstrating fracture at ZM buttress
Fig. 56.49 Transconjunctival intra-operative
56.9.3.9 Preauricular [86] (Figs. 56.38, 56.51, 56.9.3.10 Coronal Incision [88] (Figs. 56.38,
53.17a, b and 65.6) (Refer Video on pre 56.52a, b and 85.1)
auricular approach in Chap. 53) Tessier introduced the use of coronal incision to access the
Preauricular incision is useful for open reduction and fixa- superior and lateral orbits bilaterally along with naso-orbito-
tion of arch fractures. After the routine skin incision, adopt- ethmoid complex in congenital facial reconstruction. The
ing the deep subfascial approach provides better protection approach can be extended with a preauricular incision to
to the facial nerve as compared to the other commonly used include the exposure of the zygomatic body and the arches
approaches, namely, the subfascial and suprafascial proce- bilaterally. This incision also facilitates the temporal
dures [87]. Figure 56.51 demonstrates the use of preauricular approach to the SZ suture [82]. Disadvantages of the
incision with deep subfascial dissection to expose a mal- approach include the extensive length of incision, dissection,
united zygomatic arch fracture. temporal hollowing, scar alopecia, risk of injury to the supra-
orbital nerve, and temporal branch of the facial nerve.
56.9.4 Fixation Methods
Fixation methods for ZMC fractures have evolved through

the ages.
Three basic fixation methods are available for ZMC

fractures [1] (Table 56.1):,
1. Temporary support
2. Indirect fixation and
3. Direct fixation
©Association of Oral and Maxillofacial Surgeons of India The trend has gradually shifted from nonrigid fixation
Fig. 56.51 Preauricular approach demonstrating exposure of mal-
methods such as trans-osseous wiring, external pin fixation,
united zygomatic arch fracture and K wires to functionally rigid fixation methods including
Fig. 56.52 Coronal approach, intra-operative. (a) Exposure of arch demonstrating fractured zygomatic arch and FZ region (yellow arrows). (b)
Arch after reduction and fixation at ZT and FZ region
Table 56.1 Fixation methods for ZMC fractures minuted. But it is an inaccurate technique with high
Temporary relapse potential and increased possibility of infection.
support Indirect fixation Direct fixation Antral packing may be done either with a roller gauze
Access to Fracture is not Fracture is not Fracture is pack or balloon. The technique followed for both is simi-
fracture visualized visualized visualized by
surgical exposure lar. The anterolateral wall of the maxilla is exposed by a
Fixation Provide Indirectly fixed Directly fixed Caldwell-Luc incision in the vestibule through which the
technique support to using anchorage fracture is inspected and manipulated to achieve reduc-
reduced from a distant site tion of the fragments. A trans-nasal antrostomy port is
fragments
created in the inferior meatus. (refer Sect. 24.10, Fig.
Modalities • Antral pack • Trans-osseous • Trans-osseous
• Antral pins (K wire, wiring 24.24)
balloon Steinmann pins) • Miniplates and –– The medicated ribbon gauze pack is introduced into
• Silicone • External screws the antrum through trans-nasal antrostomy, and one
wedge fixatorsCranio- • Microcompressive
end of the gauze is packed tight in the antrum under
• Percutaneous zygomaticFronto- screws
wire with zygomatic direct visualization through the vestibular incision.
splint (arch) The oral layer is closed, once the desired level of pack-
Advantages Less surgical Less hardware • Functionally ing is achieved. The other end which is free is pulled
morbidity Less invasive stable/semi rigid/ out through the nostril and taped to the cheek. This is
rigid (lag screw)
• Anatomic later used to retrieve the pack once the healing phase is
reduction possible complete.
Limitations • Nonrigid • Poor patient • Wiring is nonrigid –– The inflatable balloon is positioned within the sinus
• Not precise compliance • Surgical cavity in a similar manner and verified through the
• Chances of• Non-precise morbidity
• Chances of pin
vestibular approach. The balloon is then inflated
infection
• Poor patient track infection with about 20cc of saline till adequate support is
compliance• Requires second obtained for the reduced fragments. The vestibular
intervention for approach is then closed meticulously without dam-
removal
aging the balloon. The balloon is left in situ for the
Indications When the • Comminuted For most fractures,
surgery must fractures unless fracture to heal. Removal is accomplished by deflat-
be delayed • Inability to contraindicated ing the balloon and pulling it out through the antros-
(eg. visualise fracture tomy port.
compromised site (Please add • Kirchner or K wires and Steinmann pins [1, 90]
systemic bullets for both
status) these points) (Fig. 56.53a–c) are still popular in some units as they
serve as tools of reduction as well as fixation. But these
techniques are associated with cutaneous scars and poor
miniplates and compressive screws. However, some of the patience compliance due to the transcutaneous presence
nonrigid fixation modalities are still applicable in certain of pins. The noteworthy advantages of external pin fixa-
clinical situations. A brief description of all fixation methods tion are the reduced cost and the possibility of adjusting
is provided below along with their indications and the fixation in the immediate postoperative period.
limitations. • K wires and Steinmann pins constitute an indirect method
of fixation whereby the fractured zygomatic bone is fixed
• Trans-osseous wiring using stainless steel wires is rarely in a secure fashion to another stable point in the craniofa-
used in current practice due to its nonrigid mode of fixa- cial skeleton. Such indirect anchorage may be obtained by
tion that compromises post-reduction stability. However, using pins (1) to secure the fractured fragment to other
it still remains a useful technique for fracture reduction by stable bones or (2) to provide anchorage for connectors of
traction, especially at the FZ and IOR. The advantages an external fixator. The different techniques of indirect
include minimal periosteal stripping and lesser hardware fixation that have been advocated for management of
as compared to use of miniplates and screws. ZMC fractures include (Fig. 56.54):
• Antral packing [89] with gauze or balloon/Foley’s cath- (A) Trans-zygomatic—by this technique, the zygoma is
eter is used in special scenarios where the ZMC is com- first reduced through an intraoral approach to
Fig. 56.53 Armamentarium
for indirect fixation. (a) K a c
wire. (b) Steinmann pin. (c)
Manual K-wire driver
enable adequate visualization of the entry of K attached to pins for anchorage. This may include
wire/pin thorough the vestibular incision. The the techniques described below.
reduced ZMC is then stabilized by transfixing it to (D) Fronto-zygomatic fixation: This technique involves
the contralateral zygoma using a K wire. The K the use of a Steinmann pin for anchorage onto the
wire is passed from the body of the reduced zygoma reduced ZMC fragment. The pin is then anchored to
in a trans-facial fashion to engage the stable cortex another pin which is fixed on the stable orbital pro-
of the contralateral zygoma by the use of a K-wire cess of the frontal bone by the use of an external
driver. fixator device.
(B) Naso-zygomatic—this method involves the use of a (E) Cranio-zygomatic fixation: This method is per-
K wire to stabilize the reduced ZMC to the frontal formed in the same fashion as the fronto-zygomatic
process of the maxilla on the contralateral side. The method, except that the stable component for
wire is driven from the frontal process of the max- anchorage is from a halo frame that is cranially
illa in a forward and downward direction to engage anchored, rather than a single pin on the frontal
the antral surface of the zygomatic body. This must bone.
be done with care to prevent any inadvertent dam- • Lag screws [91] have been found to be an effective alter-
age to the nasolacrimal duct which lies adjacent to native at the FZ region because of the additional stability
the path of pin. offered by interfragmentary compression. But this tech-
(C) Zygomatico-palatal—this procedure involves fixa- nique requires adequate bone stock for fixation.
tion of the reduced ZMC to the palatal surface of • Micro screws [92]: Micro screws are 2 mm screws which
the contralateral maxilla, by passing a K wire are used to fix sagittal zygomatic fractures by using the
through the reduced ZMC in a downward and lag screw technique. These screws also reduce hardware
oblique direction. (Fig. 56.55a–c).
Indirect fixation may also be performed by the • Miniplates [3, 4]: The principal method of fixation is
use of external fixators or a halo frame that can be miniplate osteosynthesis. Miniplates are chosen based on
a b
c d
Fig. 56.54 Techniques for indirect fixation

rigidity requirements, anatomical site involved, presence Comparative studies have shown that one-point
of bone deficits, and biological considerations pertaining fixation at the ZM buttress has been found to more
to protection of adjacent vital structures. advantageous due to many reasons: (1) absence of
Shape of plates: The plates are chosen according to the external scarring; (2) ease of surgical access; (3) unlike
contour of the bone that needs to be fixed; L plate for the the FZ region, adequate soft tissue cover is present;
ZM suture and a curved plate for the IOR. and there are no issues of plate palpability; (4) easier to
Presence of bone loss: Comminuted fractures or bone remove the plate, when needed; and most importantly
loss may result in sagging of overlying soft tissues, espe- (5) ZM buttress is a better indicator of zygoma align-
cially in the ZM buttress region. This may be negated by ment than the FZ region due to the wider area of articu-
using a broad mesh that bridges defects. lation. However, FZ may be used in fractures with
Biological considerations: Care must be taken to pro- comminuted ZM buttress.
tect the roots, infra-orbital nerve and eye during fixation. –– Two-point fixation indicates fixation at ZM and FZ/
In regions where the skin is thin, low-profile plates are IOR [93, 94].
preferred, 2 mm system for the ZM buttresses and 1.5 mm –– Three-point fixation/tripoding includes fixation at the
at the FZ, IOR, arch, and SZ suture [72]. FZ, IOR, and the ZM. A recent meta-analysis indicates
Stability requirements: For ideal stability, screws of that three-point fixation is the most effective in ensur-
6 mm length with a minimum of two screws on either side ing absolute clinical stability against displacing forces
of fracture are essential. The only exception being the SZ after reduction [94].
suture where one screw on either side of the fracture line –– Four-point fixation/tetrapoding [95] involves fixation
is adequate. at the FZ, IOR, arch, and the ZM. This may be indi-
• Fixation points: The number of fixation points is directly cated in panfacial fractures requiring fixation of the
proportional to the requirements of stability. Five differ- arch to restore the anteroposterior projection of the
ent possibilities exist (Fig. 56.56a−f): face (case scenarios 1 and 2).
–– One-point fixation [92] refers to fixation at either the –– Five-point fixation/pentapoding [4] is used to manage
FZ or ZM suture. This has been found to be adequate severely comminuted or dislocated ZMC fractures
in resisting post-reduction in-stability in simple tripod wherein the SZ suture is also fixed, in addition to the
fractures while reducing hardware and surgical other four sites of fixation. The SZ fixation may be per-
exposure. formed either through a temporal or an intra-orbital
approach
Fig. 56.55 Fixation of zygomatic arch fracture with microcompressive screws a, b, and c. (a) Preoperative CT showing diastasis at the zygomatic
root. (b) Intra-operative picture showing arch fixation with screw. (c) Postoperative CT showing adequate fracture reduction and screw fixation
a b c
d e f
Fig. 56.56 Types of fixation using miniplates. (a) One-point fixation at FZ suture; (b) one-point fixation at ZM buttress; (c) two-point fixation;
(d) three-point fixation; (e) four-point fixation; and (f) five-point fixation (the 5th articulation (SPZ) of the right is unseen and hence is depicted on
the contralateral side for better understanding)
–– ZMC fractures requiring orbital reconstruction [59]: the need for second surgery to remove plates. Limitations
irrespective of the type of fixation, when ZMC fracture associated with bio-resorbable plates are its technique
is associated with orbit, the orbital rims are fixed first. sensitivity and increased operating time.
This is important because it is safer and easier to gauge
the depth of orbital dissection from the restored infra-
orbital rim and also to facilitate floor reconstruction 56.9.5 Fixation of Zygomatic Arch
[66] (case scenario 2). Also, the size of the orbital
defect is better assessed when the rims are aligned. The ORIF of arch fracture is indicated when the fragments
• Bio-resorbable plates [96, 97] are unstable after closed reduction and in cases where re-
Though titanium miniplates are more commonly used establishment of sagittal projection of face is needed.
to fix ZMC fractures, substantial clinical success has been Fixation may be performed by one of the three methods,
obtained with use of bio-resorbable plates. They offer based on the fracture pattern (Fig. 56.57a, b, c): (1) a mini-
comparable post-reduction stability along with the added plate for an arch demonstrating a single fracture line
advantages of preventing thermal sensitivity and avoiding (Fig. 56.52b), (2) a spanning adaptation plate (Fig. 56.62b)
when the arch is multi-fragmented [98], and (3) a micro

screw for an outfractured root or sagittal fracture of the arch The various changes that may be a sequel to wide sub-
[99] (Fig. 56.55). Kim et al. proposed plating on the superior periosteal dissection of the midface include (1) cheek
surface of the upper border as an alternate line of arch fixa- ptosis, (2) descent of the lower eyelid skin and infra-
tion which negated the drawbacks associated with the con- orbital hollowness, (3) loss of malar prominence due
ventional fixation [100] (Fig. 56.57). to inferior displacement of the malar fat pad, and (4)
exaggeration of the nasolabial fold [101].
56.10 Soft Tissue Resuspension [101, 102]

Over the years many authors have documented these
Accurate reduction and fixation of ZMC fractures frequently undesirable changes and proposed soft tissue resuspension
necessitates the use of multiple incisions on the midface methods to minimize them. This can be achieved by various
which deglove the entire periosteum-muscle-fat complex of methods (Fig. 56.58a): (1) re-approximating the incised peri-
the midface and zygoma. Failure to re-approximate the dis- osteum using absorbable sutures, (2) by suspending the peri-
sected tissues may lead to undesirable changes in the soft osteum using heavy absorbable or nonabsorbable sutures to
tissue projection and form. a drill hole placed in a superiorly positioned bony landmark
a b c
Fig. 56.57 Different fixation options for zygomatic arch fractures. (a) Adaptation plate. (b) Miniplate. (c) Compressive screw
a b
Fig. 56.58 Soft tissue resuspension. (a) Graphical representation. (b) Resuspension of temporal soft tissues to deep temporal fascia (blue arrow)
such as the orbital rim [103], (3) resuspension of lateral • Post-op sinus regimen [105]: A sinus regimen including
facial and temporal soft tissues to the deep temporal fascia in prophylactic antibiotics for sinus coverage and deconges-
the temporal region [104] (Fig. 56.58b), and (4) prophylactic tants is advocated by some authors.
endoscopic midface lift [101]. • Periodic assessment of vision [66]: Periodic ophthalmic
examination for the first 2 postoperative weeks is manda-
tory, in an awake patient. In an unconscious patient, it is
56.11 Postoperative Care achieved by swinging flashlight test or VEP (visual
evoked potential).
Following reduction of ZMC fractures, with or without • Anti-edema measures: Head end elevation must be main-
fixation, the following measures are taken to maintain post- tained to prevent facial edema.
surgical stability and prevent soft tissue complications • Anti-emphysema measures, such as avoiding nose blow-
(Box 56.12): ing [106].
• Protection of eye with ophthalmic ointments.
• Physiotherapy to prevent postoperative trismus:
Box 56.12: Postsurgical Care Postoperative trismus is a common phenomenon follow-
ing ORIF of ZMC fractures due to hematoma, reflex mus-
• Soft diet cle spasms, and fibrosis. Measures such as physiotherapy,
• Protection of surgical site and eye forced mouth opening using gag [107], and kinesiologic
• Frost suture tapes [108] may be used to improve mouth opening.
• Post-op sinus regimen • Eye movement exercises are encouraged to facilitate
• Periodic assessment of vision resolution of edema and expedite restitution of move-
• Anti-edema measures ments [66].
• Anti-emphysema measures
• Physiotherapy (eye and mouth opening)
56.12 Pediatric Considerations
• Soft diet: Patients managed with conservative methods 56.12.1 Nonsurgical vs. Surgical
are advised soft diet for a period of 2 weeks. Intervention [109]
• Protection of surgical site: The reduced zygoma or the
arch must be protected with a tape labelled “do not touch” The incidence of ZMC fractures is high in pediatric popu-
to provide cognitive input to the patient and people around. lation due to its prominence [109]. In children, most
• Frost suture: This temporary suspension suture is main- authors favor a “nonsurgical” management or “reduction
tained for 3–5 days in any patient undergoing an inferior without fixation” of ZMC fractures due to concerns regard-
eyelid approach for the prevention of ectropion. ing “surgery/implant-induced” growth disturbances of
facial skeleton and injury to teeth. However, literature sup- 56.12.3 Osteosynthesis Methods
ports ORIF of zygoma fractures which are grossly dis-
placed or unstable after reduction. This is very important Fixation techniques prior to year 2000 advocated titanium
in pediatric population to (1) correct the facial asymmetry miniplates for pediatric midface. However they must be
which may cause psychological impact, (2) restitute nor- removed after 2 months to prevent any growth disturbances,
mal mouth opening to permit mastication, and (3) restitute plate migration, or burying of plate due to bone apposition.
globe position and function to enable normal vision and Microplates and self-drilling screws are also reported to give
prevent development of phthisical eye or hypoplasia of adequate stability and fixation in this age group without
zygoma, in the future. compromising vital structures [110]. Alternatively, bio-
resorbable plates may be used which became popular after
year 2004 to negate the need for re-surgery for plate removal
56.12.2 Approaches and Fixation Principles [113]. Figure 56.59a−f shows a case of displaced zygoma
fracture in a 5-year-old boy managed by ORIF. The plates
The preferred approaches include vestibular and lateral brow were removed after 2 months.
with minimal soft tissue dissection. Literature suggests one-
point fixation at FZ region as adequate for pediatric ZMC
fractures because of the short lever arm forces between the 56.13 Malunited ZMC Fractures [114]
FZ and IOR [110]. But current studies have demonstrated
that two-point fixations provide adequate stability and are Malunion of the zygoma may be a sequel to two clinical sce-
associated with the least complication rates when compared narios, (1) a neglected ZMC fracture which was never treated
with one and three-point fixations. Similarly, fixation at the and (2) an improperly treated fracture. The protocol for the
zygomaticomaxillary buttress had the least complications management of the malunited zygoma is based on the type of
when compared against the fronto-zygomatic and infra- deformity which may be either cosmetic or functional. The
orbital fixations [111]. In contrast, Defazio et al. proposed protocol followed by the author is demonstrated in Fig. 56.60.
that plating at the FZ and IOR may be done conveniently in Deformities producing aesthetic concerns may again be
children below 6 years without any risk of damage to tooth subdivided into those demonstrating facial asymmetry or
buds [112]. those showing altered globe positions.
a b c d
e f g h
Fig. 56.59 ZMC fracture management in a pediatric patient. (a) suture and lateral displacement of the body of zygoma. (e) Postoperative
Frontal view of patient with left-sided ZMC fracture. (b) Basal view frontal view. (f) Postoperative basal view demonstrating restoration of
demonstrating loss of facial projection and enophthalmos of left side. facial projection and enophthalmos correction. (g) Postoperative 3D
(c) Preoperative 3D CT image demonstrating en bloc displacement of CT. (h) Post-operative coronal section
ZMC. (d) Preoperative coronal section demonstrating separation at FZ
Fig. 56.60 Management of malunited ZMC fracture—algorithm
• The patients with asymmetries involving only the malar or infra-orbital foramen is not an uncommon finding. The
infra-orbital regions with no functional deficits can be first line of management in these patients is to perform a
treated with onlay grafts which may either be autogenous nerve release by an ostectomy around the infra-orbital
in nature (rib, iliac crest, calvarium) or alloplastic (Medpore, foramen or by repositioning of the ZMC when it is com-
PEEK (polyether ether ketone), etc.) (Fig. 56.61). pressing the nerve.
• Patients demonstrating gross facial asymmetry along with • Diplopia: The major cause for diplopia in ZMC fractures
orbital dystopia and/or anti-mongoloid slant of the palpe- may either be gross displacement of the ZMC or mechan-
bral fissure may not be amenable to treatment with onlay ical restriction due to entrapment of orbital soft tissues
augmentations. In such cases, a conventional osteotomy (muscle, orbital septum, or fat) with resultant fibrosis or
(re-fracture) and repositioning of the zygomatic complex adhesions. Correction in these instances is achieved only
is advocated (case scenario 2). by an osteotomy along with release of the entrapped tis-
• When either of the deformities are associated with large sues. These patients may also require orbital floor recon-
floor defects, they require concomitant orbital floor structions if they present with floor defects that are large
reconstructions. (>2 cm2 in area). Non-resolving diplopia may be sub-
jected to management with prism glasses and/or strabis-
Functional deficits secondary to malunited ZMC frac- mus surgery.
tures essentially fall into three categories; Restricted mouth
opening, parasthesia and diplopia.
56.14 Bilateral ZMC Fractures
• Restricted mouth opening due to retropositioned zygoma/
arch which either (1) forms a mechanical obstacle to man- Bilateral fractures of the ZMC are a rare occurrence and
dibular translation or (2) fuses to the coronoid process of present more difficulty in achieving adequate reduction. In
the mandible (extra-articular ankylosis) (Fig. 56.62a, b). contrast to unilateral fractures where the normal side is used
The choice of treatment in these patients is dictated by the as a guide to achieve symmetry on the fractured side, bilat-
presence or absence of fusion (bony/fibrous); ZMC oste- eral ZMC fractures are complex in management. Two options
otomy, and repositioning alone are indicated in the exist: (1) reducing the less displaced or comminuted side
absence of fusion, while presence of fusion mandates first and using it as a reference for the more displaced side
additional coronoidectomy [8, 115]. [116]. This may however result in compromised results, if
• Paresthesia over the infra-orbital nerve (ION) distribu- three- or four-point fixation is not achieved, and (2) meticu-
tion: The entrapment of the ION or constriction of the lous preoperative planning [43] by virtual surgical procedure
to achieve the ideal facial width and projection. This involves 56.15 Complications of ZMC Fractures [3–5]
a sequence of segmenting and virtually repositioning the
fracture fragments to the “best possible fit” position. Once The incidence of postoperative complications increases with
this is completed, the stents for intra-operative guidance can certain risk factors such as severe displacement, presence of
be generated. sinus infection, and compound/comminuted ZMC fractures
[37].
The various complications specific to surgeries of the
ZMC may be categorized as intra-operative, immediate post-
operative, and delayed postoperative complications.
• Intra-operative complications: Commonly encountered

intra-operative complications are bradycardia and bleeding.
Bradycardia due to oculocardiac/trigemino-cardiac
reflex occurs typically during elevation of the ZMC [117].
Manipulation of zygoma stimulates the trigeminal nerve
which subsequently stimulates the vagus nerve, due to the
neuronal interconnections between them. Vagal stimula-
tion is cardioinhibitory and hence results in bradycardia
of varying degrees. This complication can be prevented
by identifying risk factors and administering prophylactic
vagolytic agents or minimizing nerve stimulation by
administering regional blocks. However, management of
bradycardia after its onset involves temporary cessation
of manipulation and or medical management with atro-
Fig. 56.61 Use of Medpore onlay for malunited fracture pine or epinephrine [64].
a b
Fig. 56.62 Coronoidectomy for malunited ZMC fracture. (a) Pre-operative scan showing malunion of the right ZMC with fusion of the body of
zygoma and coronoid process, and (b) post-operative scan demonstrating reduction and fixation of the right zmc with ipsilateral
coronoidectomy.
Brisk intra-op bleeding can occur due to the sudden rup- lofacial surgery” for additional information. The margin
ture of vessels (mainly infra-orbital artery) during of error with use of intra-operative navigation is less than
reduction. 1.2 mm with accurate restoration of facial symmetry. A
• Immediate postoperative complications: In the immedi- case of deformity secondary to ZMC fracture treated
ate postoperative phase, the adverse effects range from using intra-operative navigation is illustrated in
maxillary sinusitis, meteorosensitivity [3] (discomfort Fig. 56.63.
arising due to change in weather conditions) to infra- 4. Intra-operative imaging: Intra-operative imaging greatly
orbital nerve paresthesia, diplopia, blindness, and SOF improves the accuracy of intra-operative fracture reduc-
syndrome. The incidence of postoperative infra-orbital tion. The various imaging modalities that are available
nerve paresthesia is higher with ZMC fractures which include ultrasound, conventional C-arm (videofluoros-
demonstrate more rotation, displacement, and comminu- copy), and intra-operative CT. The quality of imaging
tion [118]. Interestingly, recovery from post-trauma ION with videofluoroscopy is not accurate in reflecting the
paresthesia shows better prognosis with reduction and complex anatomy of the cranio-facial skeleton. This
fixation due to de-compression on the nerve. Blindness makes intra-operative CT a more accurate and reliable
following surgery may arise either due to direct injury to tool. However, the associated radiation doses may be a
optic nerve by impingement of fracture fragments or hem- concern. This has been surmounted with the advent of the
orrhage into the optic sheath/retro-bulbar hemorrhage intra-operative CBCT devices [125]. This device has the
(Refer Fig. 56.16) producing nerve compression [119]. significant advantages of portability, ease of use, increased
• Delayed post-op complications commonly witnessed accuracy, and reduced radiation exposure.
include enophthalmos and hypophthalmos due to inade- 5. Transbuccal Arch Fixation: A technique involving intra
quate reduction or inadequate fixation. Oroantral fistula oral reduction of zygomatic arch and its fixation by trans-
[120], TMJ dysfunction [121], and ankylosis of zygoma buccal instrumentation has been described by
to coronoid process, referred to as Jacob’s disease [1, Panneerselvam et al for fractures of the zygomatic arch
122], are also recorded in literature. which are displaced at the zygomatico temporal articula-
tion. This technique minimises the potential morbidity
associated with the coronal approach which is commonly
56.16 Recent Trends used for ORIF of zygomatic arch [126].
Fractures of the ZMC are notorious for their sub-optimal

outcomes due to over or under reductions. This may be
attributed to difficulty in simultaneous visualization of its 56.17 Conclusion
multiple articulations without increasing surgical morbidity
due to additional exposures. The ZMC fracture is one of the most complex fractures to
Technological advancements in the recent years have reduce and fix, because of its propensity to undergo displace-
added ease as well as predictability to the reduction and fixa- ments in all three planes of orientation, along its five articu-
tion of these fractures while minimizing surgical morbidity. lations. Accurate reduction is challenging due to the difficulty
The most popular methods in contemporary surgical man- in intra-operative assessment of reduction, inability to pre-
agement are discussed below. dict the rotation of the zygoma during reduction, and com-
plexity involved in concomitant orbital fractures.
1. Intra-operative reduction and fixation templates [123]
This has been discussed earlier under the section for The surgical objectives must include (1) choice of inci-
preoperative planning. sions which provide maximal exposure with minimal
2. Computer-assisted patient-specific implants (PSI) [42]: morbidity, (2) increase in number of fixation points
Another method for improving intra-operative accuracy with increase in severity of fracture displacement, (3)
is the use of virtual surgery to plan for reduction of the achieving three-dimensional stability of ZMC com-
fracture and design patient-specific implants (PSI). These plex and minimizing post- reduction complications,
PSI designs are then printed using a 3D printer which can and (4) resuspension of overlying soft tissues to pre-
double up as intra-operative reduction guides also. Refer vent sagging.
to section 57.13.2 in Chap. 57 for additional information
3. Intra-operative navigation [124]: Intra-operative naviga- Preoperative planning and intra-operative imaging play a
tion is an excellent method for obtaining intra-operative great role in improving accuracy of fracture reduction while
guidance for precise reduction. Refer to Chap. 41. minimizing surgical exposure and post-reduction
“Computer-assisted navigation surgery in oral and maxil- complications.
Fig. 56.63 Intra-operative navigation for ZMC fracture. Multiplanar sections demonstrating superimposition of patient CT (white) and surgical.
Plan (pink) with use of intra-operative navigation to verify position during surgery (blue pointer)
Acknowledgment The authors would like to acknowledge the efforts

of the postgraduate trainees Dr. Vijitha and Dr. Logitha Sri towards the
Surgical plan: Reduction of ZMC fracture with four-
illustrations. point fixation
Surgical procedure:
• The exposure of fracture sites was done by:

56.18 Case Scenarios 1. Trans-conjunctival incision with extended lateral
approach
ase Scenario 1: Fracture of right ZMC
C 2. Intraoral buccal sulcus approach
(Fig. 56.64) • Reduction of ZMC fracture and arch fracture by
Balasubramaniam’s approach
atient: 21-Year-Old Male, with History of RTA
P • Four-point fixation of fracture was performed at FZ, IOR,
Preoperative CT (Fig. 56.64a, c) showing right-sided frac- ZM, and SZ (Fig. 56.64f) regions with miniplates
ture of the ZMC and arch with undisplaced frontal bone.
The sections demonstrate: Postoperative CT (Fig. 56.64b, d, e):
CT demonstrating optimal reduction of fractured ZMC
• Medial displacement with reduction of the transverse and arch. The successful surgical outcome may be appreci-
dimension of the face ated by the approximation and fixation at the SZ suture,
• Diastasis at the FZ and ZM sutures which is the most reliable indicator of accurate ZMC
• Overriding of fragments at the IOR and SZ suture reduction.
• Medial displacement of the right zygomatic arch
a c e
b d f
Fig. 56.64 Case scenario 1. (a) Preoperative 3D CT-frontal view dem- fracture. (d) Postoperative 3D CT-basal view demonstrating arch reduc-
onstrating fractures. (b) Postoperative 3D CT-frontal view demonstrat- tion. (e) Postoperative 3D CT demonstrating fixation at SZ suture. (f)
ing fixation. (c) Preoperative 3D CT-basal view demonstrating arch Intra-operative fixation at SZ suture
ase Scenario 2: Fracture of left ZMC and

C Surgical procedure:
orbital floor (Fig. 56.65 a–h)
• Virtual surgical planning to generate a mirrored STL
atient: 27-Year-Old Male with History of RTA
P model for pre-contouring of implants (Fig. 56.65c, d)
and delayed presentation after 2 months • Surgical exposure of the fracture through a transconjunc-
Preoperative CT findings (Fig. 56.65a, b): tival (infra-orbital rim and floor), upper lid blepharoplasty
(FZ and SZ sutures), vestibular for the ZM buttress, and
• En bloc fracture of the left ZMC with diastasis at the preauricular approaches for the zygomatic arch.
left infra-orbital rim, zygomatic arch, and FZ and SZ • Mobilization of the malunited ZMC after osteotomy and
sutures. ORIF with pre-contoured implants
• The fracture shows posterior, inferior, and lateral dis- • Fixation of the fracture performed at the FZ, infra-orbital
placement and comminution at the infra-orbital rim, rim, and the zygomatic arch regions
zygomaticomaxillary buttress, and the arch. • Orbital exploration and reconstruction with pre-contoured
• The CT also demonstrates a concomitant left orbital floor left-sided anatomical titanium orbital implant
fracture with resultant enophthalmos and hypo-ophthal-
mos (Fig. 56.65g). Postoperative features (Fig. 56.65e, f and h):
The postoperative CT demonstrates optimal reduction
Surgical plan: ZMC osteotomy, repositioning, and inter- and fixation of the left ZMC with reconstruction of the left
nal fixation orbital floor defect with titanium implant.
a b
c d
e f
g h
Fig. 56.65 Case scenario 2. (a) Preoperative 3D CT-frontal view dem- view demonstrating fixation. (f) Postoperative 3D CT-basal view dem-
onstrating fractures. (b) Preoperative 3D CT-basal view. (c) STL model onstrating fixation. (g) Preoperative CT-sagittal view demonstrating
surgery with pre-contoured plate. (d) STL model demonstrating mirror- floor fracture. (h) Postoperative CT-sagittal view demonstrating recon-
ing of normal side and plate adaptation. (e) Postoperative 3D CT-frontal struction of floor with orbital mesh
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Fractures of

56.1 Introduction 56.2 Surgical Anatomy

© The Association of Oral and Maxillofacial Surgeons of India 2021 1151

56.2.3 Muscle and Fascia Attachments

The muscles attached to ZMC are the zygomaticus major, zygo-

56.2.4 Zygomatic Arch

The arch is the key parameter for re-establishing the sagittal

©Association of Oral and Maxillofacial Surgeons of India

ION canal giving off the superior dental plexus of nerves

©Association of Oral and Maxillofacial Surgeons of India

class III a combined fracture of the malar bone and the

56.4 Clinical Assessment

The clinical assessment of ZMC fractures is performed by a

b 56.4.1 Examination of the Eye

The globe is meticulously assessed for its form, position, and

56.4.2 Examination of the Face

The facial examination should focus on assessment of (1)

Box 56.1: Clinical Features of ZMC Fractures

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.7 Axes of rotation of ZMC fractures

©Association of Oral and Maxillofacial Surgeons of India

for altered occlusion is the flexing of the ipsilateral

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.12 Ozyazgan et al. classification of zygomatic arch fractures

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.13 Yamamoto et al. classification of zygomatic arch fractures

Class I Class II Class III

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.17 Increased scleral show on right side

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.19 Enophthalmos. (a) Frontal view showing enophthalmos on

• Computed tomograms: CT remains the gold standard

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.21 Forced duction test

©Association of Oral and Maxillofacial Surgeons of India

56.6.2 Timing of Intervention [39]

ZMC fractures are not emergencies, and treatment can be

• When the decision is “no immediate intervention,” sur-

56.6.3 Surgical Objectives

56.6 Principles of Management Box 56.3: Surgical Objectives in ZMC Fracture

©Association of Oral and Maxillofacial Surgeons of India

Box 56.4: Relative vs. Absolute En/Exophthalmos

Fig. 56.27 Flow chart for

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.30 (A) Indirect vs (B) direct reduction

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

Fig. 56.33 Gillie’s correct plane for elevation. It is important to under-

©Association of Oral and Maxillofacial Surgeons of India

56.8.6 Precautions During and After

Manipulation of zygoma during reduction has been known

Box 56.6: FDT Is Mandatory After Reduction of ZMC

During reduction of ZMC fractures, as the fractured

56.1 Introduction 56.2 Surgical Anatomy

56.2.3 Muscle and Fascia Attachments

56.2.4 Zygomatic Arch

56.4 Clinical Assessment

b 56.4.1 Examination of the Eye

56.4.2 Examination of the Face

56.6.2 Timing of Intervention [39]

56.6.3 Surgical Objectives

56.6 Principles of Management Box 56.3: Surgical Objectives in ZMC Fracture

56.8.6 Precautions During and After

56.9.3.2 Upper Eyelid Blepharoplasty Incision

56.9.3.3 Subciliary Incision [71, 72] (Figs. 56.38,

56.9.4 Fixation Methods

56.10 Soft Tissue Resuspension [101, 102]

ase Scenario 2: Fracture of left ZMC and