eMedicine Specialties > Plastic Surgery > Facial Fractures

Facial Trauma, Zygomatic Arch Fractures

Author: Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Contributor Information and Disclosures

Updated: Jan 27, 2009

Introduction

The zygomaticomaxillary complex (ZMC) is a functional and aesthetic unit of the facial skeleton. This complex serves as a bony barrier, separating the orbital constituents from the maxillary sinus and temporal fossa.

The zygoma has 4 bony attachments to the skull, and ZMC fractures are sometimes known as tetrapod fractures. Trauma to the ZMC can result in multiple fractures (ie, tetrapod), but solitary bony disruption may occur, as with isolated zygomatic arch fracture. This article focuses on the zygomatic arch fracture. For information on zygomatic complex fractures, see eMedicine article Facial Trauma, Zygomatic Complex Fractures.

History of the Procedure

In 1751, Dupuytren detailed an intraoral and external technique to reduce a medial displaced zygomatic arch. Also described was an approach to the zygomatic arch by way of a plane between the temporalis muscle and deep temporalis fascia.

In 1844, Stroymeyer described the percutaneous traction technique that is still used for repair of zygomatic arch fractures.

In 1927, Gillies was first to mask incisions within the temporal hairline.

Frequency

The zygoma is the second most commonly fractured facial bone, eclipsed in number only by nasal fractures. The vast majority of zygomatic fractures occur in men in their third decade of life.

In 1994, Covington et al reviewed 259 patients with zygoma fractures and found that ZMC fractures occurred in 78.8% of patients, isolated orbital rim fractures occurred in 10.8% of patients, and isolated arch fractures occurred in 10.4% of patients.1 Of the isolated arch fractures, 59.3% were displaced or comminuted.

Etiology

Zygoma fractures usually result from high-impact trauma. Leading causes of fractures include assault, motor vehicle or motorcycle accidents, sports injuries, and falls.

Presentation

Arch fractures may result in trismus, flattening of the midface, asymmetry of the malar regions, or a reduction in oral aperture.

Indications

Surgical exploration and fracture repair are indicated with a displaced or comminuted fracture, trismus, or significant aesthetic deformity.

Although rarely indicated, emergent surgical repair and decompression are necessary when exophthalmos or signs and symptoms of an orbital apex syndrome are present.

Relevant Anatomy

The zygomatic arch is a principal constituent of the midfacial skeleton, bound by the zygomaticotemporal suture line posteriorly and the malar eminence anteriorly.2,3

The arch, in essence, is a rim of bony armor surrounding the temporalis muscle and the coronoid process of the mandible and is the origin of the masseter muscle.

The zygomatic arch is part of the facial subunit known as the zygomaticomaxillary complex (ZMC). The ZMC has 4 bony fusion sites with the skull.

Anatomic depiction of the masseter muscle as it r...

Anatomic depiction of the masseter muscle as it relates to the zygomaticomaxillary complex and mandible.

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Anatomic depiction of the masseter muscle as it r...

Anatomic depiction of the masseter muscle as it relates to the zygomaticomaxillary complex and mandible.


Contraindications

Surgical correction is contraindicated in patients who are medically unstable or unable to tolerate anesthesia.

More on Facial Trauma, Zygomatic Arch Fractures

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References
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References

  1. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. Aug 1994;37(2):243-8. [Medline].

  2. Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. Apr 1999;103(4):1287-306; quiz 1307. [Medline].

  3. Terino EO. Alloplastic contouring in the malar-midface-middle third facial aesthetic unit. In: Terino EO, Flowers RS, eds. The Art of Alloplastic Facial Contouring. St. Louis, Mo: Mosby Year-Book; 2000:79-96.

  4. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg. Dec 2007;120(7 Suppl 2):5S-15S. [Medline].

  5. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. Jul-Aug 1993;22(4):145-88. [Medline].

  6. Turk JB, Ladrach K, Raveh J. Repair of zygomaticomalar complex fractures. The Swiss method. Arch Facial Plast Surg. Apr-Jun 1999;1(2):123-6. [Medline].

  7. Honig JF, Merten HA. Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg. Nov 2004;15(6):986-9. [Medline].

  8. 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. Jun 1990;85(6):878-90. [Medline].

  9. Czerwinski M, Lee C. The rationale and technique of endoscopic approach to the zygomatic arch in facial trauma. Facial Plast Surg Clin North Am. Feb 2006;14(1):37-43. [Medline].

  10. Gülicher D, Krimmel M, Reinert S. The role of intraoperative ultrasonography in zygomatic complex fracture repair. Int J Oral Maxillofac Surg. Mar 2006;35(3):224-30. [Medline].

  11. Cohen AJ, Mercandetti M. Facial Trauma, Orbital Floor Fractures (Blowout). eMedicine from WebMD [serial online]. December 18, 2008;Accessed January 27, 2009. Available at http://emedicine.medscape.com/article/1284026-overview.

  12. Mercandetti M, Cohen AJ. Tumors, Orbital. eMedicine from WebMD [serial online]. February 7, 2007;Accessed January 27, 2009. Available at http://emedicine.medscape.com/article/1218892-overview.

  13. Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for management of malar fractures. Trans Am Acad Ophthalmol Otolaryngol. Sep-Oct 1977;84(5):ORL818-9. [Medline].

  14. Shaw GY, Khan J. Precise repair of orbital maxillary zygomatic fractures. Arch Otolaryngol Head Neck Surg. Jun 1994;120(6):613-9. [Medline].

  15. Shumrick KA, Campbell AC. Management of the orbital rim and floor in zygoma and midface fractures: criteria for selective exploration. Facial Plast Surg. 1998;14(1):77-81. [Medline].

  16. Pham AM, Strong EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg. Aug 2006;14(4):234-41. [Medline].

  17. Donald PJ. Zygomatic fractures. In: GM English, ed. Otolaryngology. Philadelphia, Pa: JB Lippincott; 1990.

  18. Evans BG, Evans GR. MOC-PSSM CME article: Zygomatic fractures. Plast Reconstr Surg. Jan 2008;121(1 Suppl):1-11. [Medline].

  19. Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for treatment of malar fractures. Based on a 1,220- case, eight-year experience. Arch Otolaryngol. Sep 1977;103(9):535-8. [Medline].

  20. Rajesh P, Rai AB. A comparison between radiography and ultrasonography in the diagnosis of zygomatic arch fracture. Indian J Dent Res. Apr-Jun 2003;14(2):75-9. [Medline].

  21. Rodriguez-Vegas JM, Casado Perez C. Inexpensive custom-made external splint for isolated closed zygomatic arch fractures. Plast Reconstr Surg. Apr 15 2004;113(5):1517-8. [Medline].

  22. Strong EB, Sykes JM. Zygoma complex fractures. Facial Plast Surg. 1998;14(1):105-15. [Medline].

  23. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg. Aug 1992;50(8):778-90. [Medline].

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Further Reading

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Keywords

zygomatic arch fracture, isolated zygoma fracture, isolated zygomatic fracture, face trauma, zygomaticomaxillary complex fracture, ZMC fracture, motor vehicle accident, MVA, motorcycle accident, sports injury, sports-related trauma, facial fracture, traumatic facial injury, tetrapod fracture

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Contributor Information and Disclosures

Author

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
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