Anatomic,

Clinical,

Surgical, Zygomatic
AMIL JAMES

and Radiographic Complex Fracture

GERLOCK AND DOUGLAS P. SINN2

Correlation

of the

Understanding and symptoms

rect appreciation

are

the mechanisms by which produced is a prerequisite

features.

clinical signs to the corRadiographs of

Clinical
Limitation ofJaw

and
Movement

Radiographic
and Flattening

Findings
of Cheek

of radiographic

facial trauma are no different describes the specific clinical each displaced bony fragment
fracture. Limitation of jaw

in this respect. This paper findings associated with of the zygomatic complex
and flattening of the

The
like

temporal
of bone

process
extending

of the anterior of

zygoma
posteriorly

(fig.
from

1 ), a flat
the

wingof

blade

body

the covers

zygoma, the part a long

forms lower

the portion

part the

of

the

arch fossa.

which The

movement

cheek are produced by depressed fractures of the ternporal process or zygomatic arch; unilateral epistaxis is a result of fractures of the zygomatic process of the maxilla or the floor of the orbit; paresthesia or anesthesia of the cheek results from fractures of the infraorbital process or orbital floor; unequal pupil heights is associated with fracture of the frontal process; and decreased extraocular muscle function with diplopia is caused by fractures of the orbital process, frontal process. or orbital floor. The clinical and radiographic findings are correlated with surgical management.

temporal from the projecting

posterior process,
from

of this arch thin projection bone.

is formed of bone two

zygomatic anteriorly together process tendon

the temporal

These

processes

fuse

at the zygomaticotemporal suture. The coronoid of the mandible with its attached temporalis muscle lies and within forth the temporal fossa under the zygomatic and the closed. body of the can tendon, closing one-third zygoma

and must pass freely back arch when the mouth is is depressed on the coronoid inward. process the or

opened When temporal

process

impinge

Introduction Trauma to the zygomatic or of its malar bone of the bone and injury face itself and their can

temporalis muscle ficulty opening and occurs in about

and the his mouth of patients

patient will have dif(figs. 2A and 3). This with a zygomatic

produce
acteristically, rarely

multiple
the fractured;

fractures
body instead,

and
the weaker

clinical
zygomatic

findings.

Charis

complex fracture [4]. Flattening the cheek may also be present. from Acutely which the underlying this may bony be obscured this support

of the lateral contour of since it is in part formed of the edema and it is cheek features projection for arch temporal and not or process. ecchymosis until this skin dimple are present, of the zygofractures and fracand by the

processes

surrounding Knight and entity and

attachments North [2] referred

are fractured recognized this malar fracture,

displaced [1 1. as a clinical Other names complex (1) limitation (2) unilateral distribution

accompanies

injury,

to it as the fracture. clinical and flattening or

fracture. zygomatic include cheek, in the

are zygomaticomaxillary fracture, and tripod The ofjaw epistaxis, most (3) frequent movement

swelling subsides that becomes recognized. the submental vertical

the flattened When these radiographic

findings of the anesthesia

matic arches should be examined of the temporal process (fig. 3). Isolated tures ramus
Unilateral

depressed fractures

paresthesia

depressed

zygomatic

of the infraorbital nerve, (4) unequal pupil heights, and (5) a decreasein extraocular muscle function with diplopia. By understanding the mechanisms of the fractures of the processes of the zygomatic bone which cause these clinical
findings facial treatment and by correlating can these clinical accurate findings diagnosis with the and radiographs, plan a more be formulated.

of the mandibular of the mandible

Epistaxis

condyle, coronoid process, will also limit jaw movement.

The of the process and surface tured;

maxillary body of the of the of the instead, through zygomatic of the wall of lining the

process zygoma. of the maxilla side

is the at the

medial

triangular to the below

surface zygomatic suture the orbital

It is attached maxillary sinus

zygomaticomaxillary

lies to the

Anatomy Commonly the zygoma is referred to as having a central

maxilla. The maxillary process the force from a blow to the this solid process zygomatic maxillary maxillary cavity of the nasal piece of bone maxilla. of the process sinus, sinus is divided

is rarely fraccheek is transto the maxilla the 2B, two bleeding 2D, weaker results mucous and from separate in and This

mitted adjoining a fracture lateral membrane 4). Since chambers the nose
Dallas, Health Texas Science

mass or body from which three bony processes project (fig. 1). These processes are attached by sutural junctions to the frontal, maxillary, and temporal bones and
correspondingly named [3]. and Their roles in the forming cheek will the

bony

of the tearing (figs. into

the

bony
orbit,

facial
maxillary

skeletal
sinus

framework
contour

and

the
of

temporal findings.
Health Science University

fossa,
be

described
Department
2

and

related
of Radiology.

to specific
University Department

clinical
of Texas of

by the nasal septum, is limited to the side

the resulting of injury.

Center. of Texas

75235. Center, Dallas, Texas 75235. Address reprint requests to D.

Division

of

Oral

Surgery.

Surgery.

P. Sinn. Am J Roentgeno/

128:235-238,

February

1977

235

236

GERLOCK

AND

SINN

Fig. 1-5, orbital,

1.-Anatomy of Temporal, frontal, and infraorbital

..

zygoma; 6. frontal bone; 8, temporal

zygoma. maxillary, processes of bone; 7, maxillary bone; 9, greater 10, zygobone; 11, 12, zygo13, zygo14, orbital infraorbital

the

-,-

7i

wing of sphenoid bone; matic process of temporal zygomatic temporal suture; matic process of maxilla; matic maxillary suture; surface of maxilla; 15, foramen.

,,j

Fig. 2.-A. Impingement of temporal process of zygoma on coronoid process of mandible as result of depressed zygomatic complex fracture B and C. Downward displacement of frontal process of zygoma and its attached lateral palpebral ligament with separation of zygomaticofrontal suture. Lateral canthus of eyelid and eyeball are depressed. On upward gaze. involved eyeball remains fixed due to incarceration of inferior rectus and inferior oblique muscles between bony fracture fragments of orbital floor. 0, Fractures of infraorbital process, floor of orbit, and lateral maxillary sinus involving infraorbital canal, infraorbital foramen, and nerve

ZYGOMATIC

COMPLEX

FRACTURE

237

Fig 5 -Downward and separation of zygomaticofrontal to fracture of orbital floor

medial

displacement suture (open

of arrow)

frontal Black

process arrow

with points

also cause unilateral occurring below the involve type

ing Fig. 3.-Submentovertical depressed fracture patient had of limited x-ray temporal projection process of zygomatic of zygomatic motion arches show bone (arrow)

epistaxis. level of the maxillary epistaxis

Fractures maxillary sinuses, rather

of the process as in the than

maxilla usually LeFort unslateral

the

walls

of both Bilateral
occurs.

I fracture.
then

epistaxis

Clinically,

mandibular

Paresthesia lnfraorbital The

or

Anesthesia

in

Distribution

of

Nerve infraorbital process is a sharply pointed spikelike

piece

of

bone

projecting

medially

from

the

body

of

the

zygoma and extending under the orbital cavity toward the nose. It is attached to the body of the maxilla lateral to the
orbital the the the floor

at the

zygomaticomaxillary

suture. a small to that

It forms part part tip of of of

lateral anterior
floor

half of the infraorbital rim and orbital floor lying anterolateral of the orbit formed from with with may of the
in

the

maxilla.

The

this

process men, while

from

is in close contact its base is in contact the of canal, maxilla. this and
this

the infraorbital the floor of the the

or

foraorbit

formed

Fractures foramen,
orbital nerve;

process floor
results

involve orbit, and 2D,

infraorbital the infraof

damaging lateral and

view

paresthesia

anesthesia

the
the
Fig 4 -Fracture infraorbital foramen arrow). resulted opacification of zygomatic distribution Maxillary in fracture of infraorbital process and step deformity of process of lateral is not fractured. maxillary sinus had resulting infraorbitat in disruption rim (large of open has and

cheek, upper side of the

finding

lip, lower eyelid. injury (figs. 28,

is present. the

nasal area on 4). When this

of the facial

clinical

Waters

but its displacement wall (small open arrow(

bones should rim extending 4) and for Isolated and this anterior clinical
Pupil

be evaluated for fractures of the infraorbital into the infraorbital foramen (figs. 2D and fracture fractures wall finding.
Heights

of sinus from hemorrhage arch. Clinically, patient and unilateral epistaxis

Closed arrow points to fracture paresthesia of infraorbital nerve

involvement of the orbital floor of the orbital floor, infraorbital of the maxillary sinus may also

(fig.

5). rim,

produce

The maxillary

Waters sinus,

projection with an

typically associated

displays fracture of

an the

opaque lateral Unequal

wall level

of

the

involved be seen.

maxillary Isolated

sinus orbital

(fig. floor

4).

An

air-fluid or iso-

The

frontal

process

projects

superiorly

from rim

the

body

may

fractures

lated fractures involvement

of the walls of the processes

of the maxillary sinus, without of the zygomatic bone, can

of the zygoma to the frontal lateral palpebral

to form the bone at the ligament

lateral orbital zygomaticofrontal (fig. 28) inserts

and attaches suture. The on the orbital

238

GERLOCK

AND

SINN

rim surface
of the frontal

of this
with canthus

process separation

about suture. of eyelids

1 3 mm the and

below

the

level of the

whether the

treatment

can complex

consist or if

of simple interosseous

repositioning fixation

of will

zygomaticofrontal process lateral not

Displacement zygomaticofrontal

zygomatic

be required.
eye. In clinical practice, we find that involved in the fracture are large minution tioning of the ofthe lateral wall of the into zygomatic complex if the segments of bone and there is little commaxilla, simple reposiposition its anatomical

suture
of the or may

(fig. 5) causes upon

occur

a downward
of the (fig. 2B).

displacement
globe

or sagging
of heights clinical the

Depending

malalignment
[5]

of visual
Unequal

axes,
pupil

diplopia

may
withfinding

out alteration of the visual axes not to be confused with diplopia.

present, displacement of the (fig. 5). Muscle

is a distinct

by utilizing

an external
result. internal

or internal
However, fixation the

approach

will

frequently
open reis accomsuperas the line are

When these findings are frontal process with widening

allow a stable duction with plished suture iorly, by first

more frequently, is required. This fractured

of the
the

zygomaticofrontal
view

suture

should

be looked

for

on

stablizing

zygomaticofrontal

Waters

so that once the dissection wiring the and

the zygoma has been positioned to the infraorbital rim as well at the zygomatic temporalis infraorbital complex, muscle rim fracture the and

Decreased The tension the body orbital

Extraocular process frontal zygoma

Function flat

with posterior blends

Diplopia medial inferiorly forming infraorbital the infrasphenoid of the bone exwith

interosseous

is a wide process and

less difficult.
By on the elevating masseter impingement coronoid pro-

of the

which infraorbital

of the

process, of the above of the

the lateral orbital fissure. The part orbital bone orbital fissure

floor and lateral of this process to the

edge located wing

cess
jaw until time thesia orbital time.

of the mandible

will

be reduced

and the limitation

of

attaches

greater

movement eliminated. the maxillary sinus to clear. The use of

Unilateral epistaxis has had a satisfactory decongestants

will persist length of Pares-

at the zygomaticosphenoid process with the greater

suture. This fusion wing of the sphenoid

is helpful.

at the zygomaticosphenoid suture results in the formation of a flat plate of bone which has anterior and posterior surface. The posterior surface forms the anterior wall of
the and temporal infraorbital fossa. Trauma to the cheek causing produce [6] or which depresses

and anesthesia over the distribution of the infranerve frequently remain postoperatively for some However, repositioning of the bone so that there is nerve will complex the orbital enhance its will elevate contents,

no impingement of the infraorbital recovery. Reduction of the zygomatic the lateral canthal ligament, reposition

the zygomatic the lateral

disruption

bone orbital
of the

inward wall

will displace

the orbital
them diplopia

process fracture
either by

process bony

medially,

to fracture

and
cavity,

restore
thus

the

pupil
muscle

to
will

its normal
significant resolve

height
sequela. slowly

in the
Diplopia in 5-14

orbital
from days.

and floor
orbit and and can nerves nerves

of the orbit. in the

by between

This region

eliminating

swelling

of the

producing
extraocular extraocular

edema
muscles muscles

and

hemorrhage

of
fractured

the
the

Diplopia
will usually

caused fracture.

by entrapment
with

of the extraocular
reduction of the

muscles
zygomatic

trapping the 2B-2D). patients

be eliminated

complex

bony fragments Orbital floor

of the fractures

orbital floor [7] (figs. occurred in 35 of 63

with [4]. orbital should

1
.

ACKNOWLEDGMENT We thank Ms. Billie DuVall for assistance in preparing this paper.

zygomatic complex These were surgically

fractures proven

studied by Wisenbaugh by exploration of the

floor,
When

and
diplopia

all

35
for of

patients

required
orbital and

surgical
Waters

correction.
views
Kruger GO: Textbook

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