Zygomaticomaxillary Complex Fractures
Meslemani D, Kellman RD. Zygomaticomaxillary complex
fractures. Arch Facial Plast Surg. 2012;14(1):62-66.
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Zygomaticomaxillary complex (ZMC) fractures can result in disfigurement;
even after reduction and fixation, there is a high risk for asymmetry.
This review presents the classification, morbidities and complications,
diagnostic evaluation, and treatment of ZMC fractures.
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Study Design: literature review.
Referenced publications were retrospective studies of patients with ZMC
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ZMC fractures are the second most common facial fracture (second to nasal
The ZMC’s 3-dimensional configuration and the anatomic approximation of
the ZMC to the orbit and infraorbital foramen contribute to orbital and
neuropathic morbidities and asymmetry frequently seen with ZMC fractures,
even after reduction.
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ZMC Fracture Classifications
– Knight and North, with groups I through VI based on anatomic
• I: No significant displacement.
• II: Inward buckling of malar eminence.
• III: Unrotated body fractures.
• IV: Medially rotated body fractures.
• V: Laterally rotated body fractures.
• VI: Complex fractures.
– Knight and North indicated that groups II and V required only closed
reduction without fixation, whereas groups III, IV, and VI required
– However, Pozatek et al determined that up to 60% of group V cases
were unstable for closed reduction.
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ZMC Fracture Classifications
– Manson et al devised a computed tomographic scan–based
classification system.
• Low-energy fractures: incomplete fractures with minimal
• Medium-energy fractures: complete fractures with moderate
• High-energy fractures: associated with other midface fractures,
most severe type.
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ZMC Fracture Classifications
– Zingg et al developed a system based on site and quantity of fractures:
• Type A: only 1 site (ie, arch, lateral orbital rim, or inferior orbital rim).
• Type B: fractures in all 4 suture lines of the ZMC.
• Type C: comminuted fractures.
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Epidemiology of ZMC Fractures
– Ellis et al reported that most ZMC fractures are the result of assaults,
falls, sporting activities, and motor vehicle crashes.
– Incidence decreased as a result of seatbelt laws.
– Air bags did not change the incidence of ZMC fractures.
– 25% of ZMC fractures are associated with other facial fractures.
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Clinical Presentation
– Swelling, edema, ecchymosis, and/or subcutaneous emphysema in the
ZMC region.
– Depression of the ZMC may not be evident until the swelling and edema
– Pain, tenderness, and/or numbness (infraorbital nerve dysfunction).
– Trismus may be present (likely due to impingement of the temporal
muscle or coronoid process by a depressed zygomatic arch).
– Diplopia (fracture through zygomaticosphenoid suture with entrapment
of extraocular muscle[s]).
– Enophthalmos (herniation of orbital content).
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– Computed tomographic scan (gold standard).
• High resolution.
• 3-Dimensional computed tomography enables better visualization of
malpositioned bone, but does not replace 2-dimensional computed
• Axial and coronal.
• 2-Dimensional computed tomography is better for orbital fractures
and soft-tissue deformities.
– Plain radiography is not the current standard.
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Treatment Options
– Observation.
– Closed reduction without fixation.
– Open reduction with fixation at 1 or more buttresses.
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Treatment of ZMC Fractures
– Indications for open reduction and internal fixation:
• Infraorbital nerve compression (numbness).
• Impingement on coronoid process or temporal muscle (trismus).
• Diplopia due to entrapment of extraocular muscle(s) (urgent).
• Exophthalmos or orbital apex syndrome (emergent).
• Enophthalmos.
• Aesthetic deformity (ie, depressed ZMC).
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Open Reduction And Internal Fixation Treatment
– 4 Principles:
• Adequate exposure.
• Proper reduction.
• Stable fixation.
• Minimize complications.
– Common philosophy:
• Treat each fracture individually.
• Fixate the fracture with the least amount of plating and
disruption of soft tissue.
• Preoperative ophthalmologic evaluation in cases with an
orbital component.
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Surgical Approaches
– Sublabial-vestibular.
– Orbital approaches (avoid if possible):
• Subciliary (transient ectropion [12% of patients], permanent scleral
show [28% of patients]).
• Transconjunctival (permanent scleral show [3% of patients], low risk
of entropion).
• Subtarsal (unless there is an existing laceration, avoid entirely
because of poor cosmesis and prolonged edema).
– Gilles or hemicoronal for the zygomatic arch.
– Endoscopic.
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Surgical Reduction
– Bone hook.
– Carroll-Girard screw.
– Finger palpation of fracture lines.
– Gilles, hemicoronal.
– Stability examined sequentially during reduction and fixation to
determine the extent of needed fixation.
– Zygomaticomaxillary buttress, frontozygomatic suture, infraorbital rim,
zygomatic arch, and nasomaxillary buttress should all be examined for
changes and stability during reduction.
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ZMC fractures can be challenging to manage.
The complex 3-dimensional appearance and location result in difficulty
with reduction and fixation.
There is no consensus regarding proper management.
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Contact Information
If you have questions, please contact the corresponding author:
– Robert M. Kellman, MD, Department of Otolaryngology and
Communicative Sciences, State University of New York Upstate
Medical University, 241 Campus W, 750 E Adams St, Syracuse,
NY 13210 ([email protected]).
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