| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Zygomaticomaxillary Complex Fracture E.S. is a 37-year-old Hispanic male who presented to Ben Taub General Hospital's emergency department on September 13, 2004, with a chief complaint of right malar depression and numbness. Two weeks prior to his presentation, he sustained blunt trauma to his right face. He, since then, has had some difficulty chewing on the right side as well. He denies any loss of consciousness, and no diplopia was reported either. His past medical history and surgical history were otherwise negative. He is currently on Augmentin and ibuprofen. On physical exam, the right malar depression and tenderness were noted, and on palpation he had a bony step off in the right inferior orbital rim, and also he did have some numbness over the right cheek. He otherwise, however, did not have any edema or ecchymosis. The ear exam was notable for a clear right TM. The left TM exam was limited secondary to cerumen impaction. His visual exam was benign, and nasal exam was also benign. On oropharyngeal exam, there was no apparent malocclusion, although he did have some mild difficulty opening his right jaw. Otherwise, he had no loose teeth, any internal oral bleeding lesions, and neck exam was benign as well. So, a maxillofacial CT was done on this patient as you can see here, and 3D reconstruction is shown here in this slide, and you can see a right ZMC fracture as you can see here, and there is some diastasis noted on the frontal zygomatic suture line, and the zygomatic arch was intact. There is some inferior orbital rim displacement, as well as you can see on the CT scan, and there is some possible infraorbital foramen involvement as well. So, today I would like to go over several different aspects of the ZMC fracture. First I would like to go over the relevant anatomy, and then briefly review the epidemiology of the fractures, and then like to review the approach to diagnosis both from the physical exam and radiology, and then focus on the management of fractures, first looking at the different surgical approaches and then looking at different reduction and fixation principles. Lastly, I would like to review some complications associated with ZMC fracture repair. First, I would like to discuss briefly the facial buttress system, which offers structural support to the face not only under traumatic conditions, but also during everyday function such as mastication; and realignment and fixation along the facial buttresses are crucial in any type of facial fracture repair. The facial buttresses are composed of both the vertical and the horizontal buttresses as shown here in this diagram. You can see the vertical buttress consists of the paranasal maxillary buttresses, zygomaticomaxillary buttresses, and the pterygomaxillary buttresses. Vertical buttresses are linked together by the system of horizontal buttresses; and you can see here the frontal bar, which consists of the thickened glabella bone and the superior orbital rim, the inferior orbital rim, the zygomatic arches, and the maxillary alveolus along with the hard palate. Now, we look at the anatomy of the ZMC more closely itself. The central portion of the ZMC is the malar prominence, and its convex shape is partially responsible for its vulnerability to traumatic injuries. From the central portion of the malar prominence, there are four attachments to the skull; the first superiorly, and there is the frontal zygomatic suture line that connects to the frontal bone and, laterally, as shown here in number two, there is a connection to temporal bone from zygomaticotemporal suture line. Medially we have a connection to the maxillary bone through the zygomaticomaxillary suture line; and, lastly, there is a deep attachment to the greater sphenoid bone from the zygomaticosphenoidal suture. Therefore, even though a ZMC fracture is commonly referred to as a trimalar or tripod fracture, a “complete ZMC fracture” technically should be really called a tetrapod fracture. The reason being that number three and number four here are often considered together as one unit and, therefore, the name tripod fractures. ZMC fracture is most often sustained as a result of lateral impact force resulting in a medial displacement, as you can see in diagram B here, and a result of the strong inferior pull by the masseter muscle, you also have inferior displacement resulting in inferomedial rotation. Next, if you look briefly at the epidemiology associated with the ZMC fractures, it is the second most common type of facial fracture second only to nasal bone fracture. This diagram just illustrates the amount of force needed for the fractures to occur in different facial bones and, as you can see, the amount of force needed for zygoma is close to that needed for a fracture of the nasal bone to occur. In addition, more than 80 percent of the ZMC fractures occur in males, and also more than 80 percent of all ZMC fractures occur between the ages of 18-45, with peak incidence between 20-30 years of age. The prevalence of ZMC fractures in the younger age group is explained partially by the mechanism of injury. In one recent retrospective analysis of 263 ZMC fractures, it was found that assault was responsible for about 40 percent, followed by sport injuries, MVA, and fall in prevalence. Also, ETOH was found to be associated with about 30 percent of all fracture incidence. Given the mechanism of injury, most patients with ZMC fractures also have other associated injury as well. In one retrospective analysis, 43 percent of the patients had other open lacerations. In decreasing frequencies are orthopedic injuries, other facial fractures, most commonly mandible fractures, and also neurologic injury, pulmonary injury, abdominal injury, and lastly and least frequent, cardiac injuries. Next, we will look at the approach to diagnosis from physical exam and then through radiology and, of course, the diagnosis should always begin with a complete history and physical. A complete head and neck exam will, in fact, often reveal most of the bony and soft tissue defects. Some of the most common findings on initial inspection are listed here; first periorbital ecchymosis and edema, subconjunctival hemorrhage, and epistaxis is also sometimes found as well. Malar depression can be appreciated often and, on palpation, you can often feel bony step off in the infraorbital rim and the frontal zygomatic suture line. Sometimes, intraoral palpation can feel step off in the zygomaticomaxillary buttress as well. Anther often observed symptom that relates to malar is malar anesthesia and hypoanesthesia. ZMC fracture can often involve the maxillary branch of the trigeminal nerve, most commonly the infraorbital branch as it exits from the infraorbital foramen, and also the zygomaticotemporal branch exiting from the zygomaticofacial foramen and the body of the zygoma bone. The incidence of this varies anywhere between about 10 to 76 percent, depending on the literature that you look at, most commonly in the distribution as shown here in this diagram in the paranasal region, upper lip, and zygomaticotemporal region. Occasionally, in 25 percent, it is presenting as heat or cold intolerance as sometimes being reported as well. A patient with ZMC fracture can often have trismus as well, presenting with pain and difficulty opening the mouth. The prevalence has been quoted to vary anywhere between 15 to 27 percent in the literature. The most common cause is thought to be secondary to impingement of coronoid process of the mandible as the fracture placement experiences inferomedial rotation that we discussed earlier, nicely illustrated here in this diagram. In addition, extracapsular fibrous ecchymosis of the mandible secondary to the healing the fracture has been quoted as a possible cause as well. Probably the most important portion of physical exam in a patient with a ZMC fracture is the eye exam, because the zygoma constitutes the floor and the lateral orbital bulb. The orbit is almost always involved to some extent. Enophthalmos secondary to increase in orbital volume can often by seen; however, proptosis can sometimes be observed as well. Diplopia secondary to change in pupillary alignment, as seen in this figure here, is sometimes responsible for the diplopia. Also, there is a possibility of inferior rectus muscle entrapment with the orbital wall fracture; and the patient may complain of diplopia on upward gaze, as you can see here, secondary to inferior rectus entrapment on the left eye. Of course, globe injury needs to be ruled out as well. Traumatic optic neuropathy is another complication that has been reported in about 2 to 5 percent of severe facial trauma. Afferent pupillary defect is sometimes observed; however, it can sometimes mask as a less obvious sign as diminished color perception; therefore, underscoring the importance of the complete ophthalmology exam during the evaluation. The mechanism was thought to be an indirect one, secondary to the firm attachment of the dural sheath to the optic nerve as it exits from the optic foramen, making the nerves exceptionally susceptible to sheer force in a trauma situation. Treatment options are controversial, although steroids have appeared to be somewhat helpful. In this slide, we would like to present a patient who sustained a right ZMC fracture about 48 hours prior to when this picture was taken. This slide illustrates a number of the physical exam findings that one can often appreciate on the physical exam. This patient, as you can see, has a subconjunctival hemorrhage. On exam he had complaint of diplopia as well; and he has some malar prominence flattening, coupled with ipsilateral epistaxis. In addition, he also has some limited ipsilateral mandibular movement. The traditional radiographic evaluation of facial trauma is the facial bone series, which is being largely replaced by the wide availability of the CT scans. Nevertheless, the plain films can sometimes still be helpful, and one of the more helpful views in a facial bone series in the submental vertex view for its detailed projection of the zygomatic arches, as you can see here, showing a view of the left zygomatic arch fracture. Another useful view is probably the Waters view, which shows the zygomatic arch to a certain extent, as shown in this example, in number four; however, it is more useful in delineating other associated facial fractures such as the orbital wall or floor and also maxillary fractures. The evolution of science and technology in medicine has really changed what is considered to be the standard of care. While 90s literature often regards CT as an infrequently utilized gold standard, recently many authors have advocated that all patients with suspected ZMC fractures should undergo CT scan for a couple of reasons. First, CT scan is often necessary for evaluation of other possible intracranial injuries, and also it is very helpful in the planning of surgery as well. Coronal view is probably the most important and gives a good evaluation of the overall components; however, in order to give this test, the patient needs to hyperextend the neck, which is not always possible, in which case a 1-1.5 mm ultra thin axial cut should be asked for, which can be reconstructed into coronal views. Here, I would like to present another example of how a CT can be useful in diagnosis of ZMC fracture. This is a patient, who is also from Ben Taub, status post assault to the left ZMC. As you can see here, he sustained a left ZMC fracture, extending from the left zygomatic arch here into the lateral orbital wall. He also has left nondisplaced level 4 fracture. There is some intraorbital air. Otherwise, the extraocular muscles and globe are intact. Also, on the axial view you can see the left lateral anterior maxillary wall fracture as well. The 3D reconstruction on CT of this patient gives you a better appreciation of the focally depressed nature of this left ZMC fracture. In addition, like we talked about earlier, trismus is a presenting complaint of this patient because you can see there is impingement on the coronoid process of the mandible. Next, I would like to go over the management of ZMC fractures, firstly focusing on the surgical approaches and then looking at a few of the reduction and fixation principles involved. As in any trauma situation, the first step is always to stabilize the patient; and sometimes tracheotomy may be necessary if there is significant edema or a hemorrhage. In addition, before proceeding with any surgery, you need to rule out cervical spine injuries. Not all ZMC fractures need intervention, of course. In fact, nondisplaced or minimally displaced fractures may often need only observation. In one retrospective analysis of over 2,000 patients by Ellis and others, it was found that 23 percent of patients did not require any surgical intervention and, it depends on the literature you look at, this number can vary anywhere between 9 and 50 percent. In Ellis’ study, 70 percent of nondisplaced fractures were treated with observation alone and, if this approach is taken, it is important to let patients know that obviously they need to avoid excessive pressure on the fractured side. So, which fractures do need surgical intervention? Although not absolute indications, displaced or comminuted fractures would be ones to lean more toward surgical options, obviously. The indications include facial contour alteration and also visual changes secondary to either muscle entrapment, globe displacement, or orbital floor disruptions. Also, mechanical disruption of mandibular movement is another indication as well. Now, I would like to review some of the surgical approaches for reduction and fixation of ZMC fractures. For isolated zygomatic arch fractures, the most simple one, the most commonly utilized surgical reduction approach is probably the Gillies approach. It can be done under either local anesthesia with sedation or under general anesthesia. A vertical incision is made in the temporal hairline, and the elevator is then tunneled underneath the temporalis fascia, keeping in mind the superficial temporal artery branches and the temporal division of facial nerve, which is nearby. Then lateral pressure with superior anterior rotation is exerted to pop the fracture back in place. Next, for fractures involving the lateral orbital rim or the orbital wall, lower eyelid incisions are usually required for exposure. The type of incision really depends on the surgeon’s experience, as well as the amount of exposure needed. There are really two broad categories, the first of which is the transcutaneous approach. The advantage of this approach is that it gives you direct and good exposure. You can also excise skin if necessary with this approach. The disadvantages obviously are that it gives a visible scar and also it has a higher risk of ectropion on the literature compared to the transconjunctival approach. The two major approaches for the transcutaneous incision really include the lower lid crease incision and also the subciliary or the blepharoplasty incision. The second major category, as I mentioned earlier, is the transconjunctival approach, which is becoming more popular recently for the advantages including the well hidden incision. Also, it has been quoted to offer lower risk of ectropion and the scleral show; however, lateral canthotomy is often necessary. With this transconjunctival incision, you can take two approaches; first the preseptal approach in which the dissection is carried out in a plane superficial to the orbital septum just deep to orbicularis oculi muscle. This offers a lower risk of injury to inferior oblique muscle and also preserves the periosteum as well. The retroseptal approach is the other one in which the incision is carried directly into the orbital fat and, therefore, a septal dissection is not needed in this case and it is often faster; however, as a result, you get increased risk of injury to inferior oblique muscle and sometimes have to deal with the fact that orbital fat can collapse into a surgical field in this approach as well. Here are just pictures showing transconjunctival approach with lateral canthotomy in this figure and then this figure, which shows transconjunctival approach with preseptal incision and postseptal approach. In the classic tetrapod ZMC fracture where all the bony attachments are involved, the combination incision may be necessary for proper reduction. Typically,, the brow incision is carried out first and this is done parallel to the brow hair follicles to avoid damaging the hair follicles for frontal zygomatic suture exposure and then anterolateral force exerted for reduction. At this point, the fracture stability and reduction adequacy should be reassessed. If the exposure and reduction are not adequate, you may need additional exposure through additional incisions. One of these additional incisions is a sublabial incision, which is used for zygomaticomaxillary buttress exposure. This incision is carried out about 1.5-2.0 cm above the gingiva for facilitation of closure later on. It is important during the process to avoid damaging the infraorbital nerve. Lower eyelid incisions, as we mentioned briefly before, can be used for additional exposure as needed for the infraorbital rim and orbital floor exposure. Lastly, in a comminuted ZMC fracture where a wide surgical exposure may be needed, hemicoronal incision can be helpful, in addition to all of the previous incisions that we have discussed. Although this is rarely used, but just to talk about it briefly, this is carried out 5 cm behind the hairline, and again you bevel the incision to avoid injury to the hair follicles. Plane dissection is deep to the temporal parietal fascia, but just superficial to the temporalis muscle fascia to elevate the temporal branch of the facial nerve to avoid injury. To review some of the principles in reduction of ZMC fractures, first and foremost, aggressive mobilization of fracture fragment is often necessary to pop the fracture back in place for correct realignment. Granulation tissue and debris removal along the fracture edges is also important as well to facilitate healing later on. Bow hook and towel clip can be very helpful in mobilizing a fracture fragment back in place. In difficult cases, the percutaneous approach of a bone screw has been suggested for use as a handle to disimpact the fracture. Also, proper reduction should be insured prior to fixation. Even in the hands of experienced surgeons, the rate of inadequate reduction can range anywhere from 10 to 13 percent. Interestingly, intraoperative and mobile CT scan has been suggested as a possible way to improve the outcome of reduction and fixation in ZMC fracture repair. In a study by Stanley and others, 25 patients underwent repair of ZMC fractures with evaluation of intraoperative CT scan after the reduction. As a result of the CT scan, they found major readjustment was needed in four patients, and minor readjustment was needed in three patients. The conclusion from their study was that the opportunity for immediate revision during the surgery as a result of CT scan can decrease the need for take-backs in the future. Since their introduction in the 1980s, plate and screw fixation have really gained favors over the wires for fracture reduction for a number of reasons. Wires are certainly cheap; however, you often need exposure on deep surfaces of fracture in order to use the wires, and often it is difficult to use the wires in a comminuted fracture as well. Most importantly, the wires really offer you stability in only one plane, as you can see in this diagram, but still allows rotation of the two planes. The plates on the other hand offer three-plane fixation and are easy to use; however, with placing screws, often you need broader exposure and sometimes literature has suggested that there can be more hardware complications associated with the use of plates and screws as well. Davis and others in their study evaluated a complex question of how many and what type of fixation is really best in achieving proper reduction and fixation. In their study, they tested 25 combinations of wire and plates of ZMC fracture on human skulls, and they tried to use different rotational displacement to see how the different combinations did. In their study, they found that three-point fixation with miniplates or wires offered the greatest stability. Two-point fixation with miniplates also offered acceptable fixation. Plates offer greater stability than the wires with less points of fixation, mainly with two-point and one-point fixations. They also found that clinically stable fixation can also be achieved with either one miniplate at the frontal zygomatic suture line and the wire on the second buttress. In addition, they concluded that acceptable stability can be achieved with a single point fixation with a miniplate at the frontal zygomatic suture line or the infraorbital rim. There has been some innovation in the treatment of ZMC fractures. In a biomechanical study, it is being shown that modified microplates without undulation, as shown in this picture right here, offers high resistance to rotational displacement over the traditional miniplate and microplate. In addition, the recent study has suggested that, endoscopically assisted, a ZMC fracture is a viable alternative surgical approach as well. In a study from UCSF, 15 cadaver heads with ZMC fractures were tested and they made three minimal access incisions in the preauricular, lateral orbital, and the buccal surface area. Four-point fixation with adequate reduction was reported to be achieved with a mean surgery time of 4.9 hours. Lastly, I would like to review some of the complications that have been associated with ZMC fracture repair. Diplopia has been quoted to occur between 3.4 and 8 percent, most often thought to be secondary to extraocular muscle contusion, swelling, and occasionally entrapment as well. As a result, forced duction test, as shown in this diagram here, is recommended prior to closure to make sure there is no muscle entrapment, and when in doubt CT can be used. Anesthesia/dysesthesias, usually in the infraorbital nerve region, has been reported between 0.4 and 11.6 percent postoperatively as well; however, usually they resolve on their own, but if they last more than three to twelve months, then one may suspect impingement as a possible cause. Enophthalmos, as you see in this picture here, is most often secondary to inadequate fracture reduction. This patient had inadequate left ZMC fracture reduction, as you can see here ,and this has been reported to occur anywhere between 1 and 23 percent postoperatively. If enophthalmos is noted during the early postoperative period, reoperation is a viable option. Most often, the enophthalmos is thought to be due to the fact that the zygoma has been fixed too far posteriorly and laterally; however, in the late postoperative period, reoperation will often require osteotomy, in which case one may consider implants for orbital volume augmentation as a potential solution as well. Lastly, complications related to hardware eventually requiring removal is also not uncommon status post repair of ZMC fractures. It is the second most commonly affected site after the mandible status post facial fracture reduction and fixation. In a recent study, ZMC plates accounted for about 28.6 percent of the fracture hardware complications, as shown in this diagram. The most commonly cited reason for needing removal is palpability, specifically in the infraorbital rim and the frontal zygomatic suture region. In this study, they also saw an isolated case of plate fracture. Finally, I would like to summarize some of the major points from today’s presentation. First, ophthalmologic evaluation is important during the initial evaluation of ZMC fractures. The CT scan is often essential in the evaluation for surgery, and also multiple incisions can be needed depending on the extent of the fracture, and lastly, accurate reduction with awareness of key facial reconstruction principles prior to fixation coupled with postoperative radiological evaluation can improve surgical outcome. Case Presentation E. S. is a 37-year old Hispanic male who presented to the Ben Taub emergency department on 9/13/04 with the chief complaint of right malar depression and numbness. Patient sustained blunt trauma to his right cheek in his backyard two weeks ago while working on woodwork repairs. He had acute swelling which had since resolved. He reported noticeable right malar depression after resolution of the right cheek edema and persistent numbness of his right cheek. He also reported some difficulty chewing particularly on the right side. He denied any loss of consciousness both during and after the incident. He also denied any diplopia or other visual changes. Patient denied any past medical and surgical history. He has been taking Augmentin as prescribed by his PMD. He has no known drug allergies. He denies any use of alcohol, tobacco, or any illicit substance. On physical exam patient was in no acute distress. Right malar depression and hypoesthesia in the distribution of right infraorbital nerve was noted. He had no edema or ecchymosis. He was tender to palpation over the right malar region. His extraocular movement was intact and visual field grossly intact to confrontation bilaterally. His right tympanic membrane is clear, and left tympanic membrane was not completely visualized secondary to cerumen impaction. His septum was midline with no epistaxis. No apparent dental malocclusion on oropharyngeal exam though he complained of mild difficulty in opening the jaw on right side. His neck exam was benign. Maxillofacial CT scan done in the emergency department revealed right zygomaticomaxillary (ZMC) fracture involving the right inferior orbital rim. The zygomatic arch was intact. There was no orbital floor depression. The globes were intact. E.S. underwent ORIF of his right ZMC fracture on September 17, 2004. The patient tolerated the procedure well. On follow-up appointment on September 27, 2004, the patient was doing well with satisfactory reduction and fixation. Bibliography: Bosniak SL, Tizes, BR. Trimalar fractures: diagnosis and treatment. Adv Ophthalmic Plast Reconstr Surg 1987;6:403-414. Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN (ed.), Operative Otolaryngology Head and Neck Surgery. WB Saunders Co. Philadelphia: 1997; pp1143-1192. Chuong RL, Kaban B. Fractures of the zygomatic complex. J Oral Maxillofac Surg 1986;44:283-288. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. 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