Contemporary Management of Zygomaticomaxillary Complex Fractures

Abstract

Zygomaticomaxillary complex fracture is one of the most commonly treated facial fractures. Accurate reduction and stable fixation of the zygoma are required to restore facial symmetry and projection and avoid functional sequalae from changes in orbital volume. Achieving optimal outcome is challenging due to the complex three-dimensional anatomy and limited visualization of all affected articulations of the zygoma. This article provides an updated overview of the evaluation and management of zygomaticomaxillary complex fractures based on available evidence and clinical experience at our center. The importance of soft tissue management is emphasized, and approaches to internal orbital reconstruction are discussed. While evidence remain limited, intraoperative imaging and navigation may prove to be useful adjuncts in the treatment of zygomaticomaxillary fractures.

Keywords

zygoma fracture - zygomaticomaxillary complex - orbital fractures - facial fracture - open reduction and internal fixation

Publication History

Article published online:
07 October 2021

• References

• 1 Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003; 31 (01) 51-61
• 2 Louis M, Agrawal N, Kaufman M, Truong TA. Midface Fractures I. Semin Plast Surg 2017; 31 (02) 85-93
• 3 Birgfeld CB, Mundinger GS, Gruss JS. Evidence-Based Medicine: Evaluation and Treatment of Zygoma Fractures. Plast Reconstr Surg 2017; 139 (01) 168e-180e
• 4 Ellis III E, Reddy L. Status of the internal orbit after reduction of zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 2004; 62 (03) 275-283
• 5 Cornelius CP, Audigé L, Kunz C, Buitrago-Téllez CH, Rudderman R, Prein J. The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial. Craniomaxillofac Trauma Reconstr 2014; 7 (Suppl. 01) S068-S091
• 6 Donat TL, Endress C, Mathog RH. Facial fracture classification according to skeletal support mechanisms. Arch Otolaryngol Head Neck Surg 1998; 124 (12) 1306-1314
• 7 Zingg M, Laedrach K, Chen J. et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg 1992; 50 (08) 778-790
• 8 Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M. Toward CT-based facial fracture treatment. Plast Reconstr Surg 1990; 85 (02) 202-212 , discussion 213–214
• 9 Kurita M, Okazaki M, Ozaki M. et al. Patient satisfaction after open reduction and internal fixation of zygomatic bone fractures. J Craniofac Surg 2010; 21 (01) 45-49
• 10 Nissen NJ, Okhah ZI, Basta MN. et al. Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury. Plast Reconstr Surg 2020; 145 (04) 1001-1008
• 11 Buchanan EP, Hopper RA, Suver DW, Hayes AG, Gruss JS, Birgfeld CB. Zygomaticomaxillary complex fractures and their association with naso-orbito-ethmoid fractures: a 5-year review. Plast Reconstr Surg 2012; 130 (06) 1296-1304
• 12 Carr RM, Mathog RH. Early and delayed repair of orbitozygomatic complex fractures. J Oral Maxillofac Surg 1997; 55 (03) 253-258 , discussion 258–259
• 13 Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma 1994; 37 (02) 243-248
• 14 Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg 2009; 124 (05) 1578-1586
• 15 Gruss JS, Van Wyck L, Phillips JH, Antonyshyn O. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg 1990; 85 (06) 878-890
• 16 Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg 2007; 120 (07, Suppl 2): 5S-15S
• 17 Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989; 83 (02) 265-271
• 18 Shumrick KA, Kersten RC, Kulwin DR, Smith CP. Criteria for selective management of the orbital rim and floor in zygomatic complex and midface fractures. Arch Otolaryngol Head Neck Surg 1997; 123 (04) 378-384
• 19 De Ruiter BJ, Levin A, Nash D. et al. Defining the Zygomaticosphenoidal Angle as a Guide to Anatomic Zygomaticomaxillary Complex Fracture Reduction. J Craniofac Surg 2019; 30 (07) 2030-2033
• 20 Marinho RO, Freire-Maia B. Management of fractures of the zygomaticomaxillary complex. Oral Maxillofac Surg Clin North Am 2013; 25 (04) 617-636
• 21 Ellis III E, Perez D. An algorithm for the treatment of isolated zygomatico-orbital fractures. J Oral Maxillofac Surg 2014; 72 (10) 1975-1983
• 22 Ellis III E, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 1996; 54 (04) 386-400 , discussion 400–401
• 23 Yonehara Y, Hirabayashi S, Tachi M, Ishii H. Treatment of zygomatic fractures without inferior orbital rim fixation. J Craniofac Surg 2005; 16 (03) 481-485
• 24 Fujioka M, Yamanoto T, Miyazato O, Nishimura G. Stability of one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg 2002; 109 (02) 817-818
• 25 O'Hara DE, DelVecchio DA, Bartlett SP, Whitaker LA. The role of microfixation in malar fractures: a quantitative biophysical study. Plast Reconstr Surg 1996; 97 (02) 345-350 , discussion 351–353
• 26 Czerwinski M, Izadpanah A, Ma S, Chankowsky J, Williams HB. Quantitative analysis of the orbital floor defect after zygoma fracture repair. J Oral Maxillofac Surg 2008; 66 (09) 1869-1874
• 27 Wilde F, Lorenz K, Ebner AK, Krauss O, Mascha F, Schramm A. Intraoperative imaging with a 3D C-arm system after zygomatico-orbital complex fracture reduction. J Oral Maxillofac Surg 2013; 71 (05) 894-910
• 28 Cuddy K, Dierks EJ, Cheng A, Patel A, Amundson M, Bell RB. Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol. J Oral Maxillofac Surg 2021; 79 (01) 177-182
• 29 van Hout WM, Van Cann EM, Muradin MS, Frank MH, Koole R. Intraoperative imaging for the repair of zygomaticomaxillary complex fractures: a comprehensive review of the literature. J Craniomaxillofac Surg 2014; 42 (08) 1918-1923
• 30 Borad V, Lacey MS, Hamlar DD, Dresner HS, Yadava GK, Schubert W. Intraoperative Imaging Changes Management in Orbital Fracture Repair. J Oral Maxillofac Surg 2017; 75 (09) 1932-1940
• 31 Ellstrom CL, Evans GRD. Evidence-based medicine: zygoma fractures. Plast Reconstr Surg 2013; 132 (06) 1649-1657
• 32 Watzinger F, Wanschitz F, Wagner A. et al. Computer-aided navigation in secondary reconstruction of post-traumatic deformities of the zygoma. J Craniomaxillofac Surg 1997; 25 (04) 198-202
• 33 Zimmerer RM, Ellis III E, Aniceto GS. et al. A prospective multicenter study to compare the precision of posttraumatic internal orbital reconstruction with standard preformed and individualized orbital implants. J Craniomaxillofac Surg 2016; 44 (09) 1485-1497
• 34 Czerwinski M, Martin M, Lee C. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures. Plast Reconstr Surg 2005; 115 (07) 1848-1854 , discussion 1855–1857
• 35 Yaremchuk MJ, Kim WK. Soft-tissue alterations associated with acute, extended open reduction and internal fixation or orbital fractures. J Craniofac Surg 1992; 3 (03) 134-140
• 36 Phillips JH, Gruss JS, Wells MD, Chollet A. Periosteal suspension of the lower eyelid and cheek following subciliary exposure of facial fractures. Plast Reconstr Surg 1991; 88 (01) 145-148