Anatomic, Clinical, Surgical, and Radiographic Correlation of the

Zygomatic Complex Fracture

AMIL JAMES GERLOCK’ AND DOUGLAS P. SINN2

Understanding the mechanisms by which clinical signs Clinical and Radiographic Findings
and symptoms are produced is a prerequisite to the cor-
Limitation ofJaw Movement and Flattening of Cheek
rect appreciation of radiographic features. Radiographs of
facial trauma are no different in this respect. This paper The temporal process of the zygoma (fig. 1 ), a flat wing-
describes the specific clinical findings associated with like blade of bone extending posteriorly from the body of
each displaced bony fragment of the zygomatic complex the zygoma, forms the anterior part of the arch which
fracture. Limitation of jaw movement and flattening of the
covers the lower portion of the temporal fossa. The
cheek are produced by depressed fractures of the tern-
posterior part of this arch is formed from the zygomatic
poral process or zygomatic arch; unilateral epistaxis is a
process, a long thin projection of bone projecting anteriorly
result of fractures of the zygomatic process of the maxilla
or the floor of the orbit; paresthesia or anesthesia of the from the temporal bone. These two processes fuse together
cheek results from fractures of the infraorbital process or at the zygomaticotemporal suture. The coronoid process
orbital floor; unequal pupil heights is associated with frac- of the mandible with its attached temporalis muscle tendon
ture of the frontal process; and decreased extraocular lies within the temporal fossa and must pass freely back
muscle function with diplopia is caused by fractures of the and forth under the zygomatic arch when the mouth is
orbital process, frontal process. or orbital floor. The opened and closed.
clinical and radiographic findings are correlated with When the body of the zygoma is depressed inward. the
American Journal of Roentgenology 1977.128:235-238.

surgical management.
temporal process can impinge on the coronoid process or
temporalis muscle tendon, and the patient will have dif-
Introduction ficulty opening and closing his mouth (figs. 2A and 3). This
occurs in about one-third of patients with a zygomatic
Trauma to the zygomatic or malar bone of the face can
complex fracture [4]. Flattening of the lateral contour of
produce multiple fractures and clinical findings. Char-
the cheek may also be present. since it is in part formed
acteristically, the body of the zygomatic bone itself is
from the underlying bony support of the temporal process.
rarely fractured; instead, its weaker processes and their
Acutely this may be obscured by the edema and ecchymosis
surrounding attachments are fractured and displaced [1 1.
which accompanies this injury, and it is not until this
Knight and North [2] recognized this injury as a clinical
swelling subsides that the flattened cheek or skin dimple
entity and referred to it as the malar fracture. Other names
becomes recognized. When these features are present,
are zygomaticomaxillary fracture, zygomatic complex
the submental vertical radiographic projection of the zygo-
fracture, and tripod fracture.
matic arches should be examined for depressed fractures
The most frequent clinical findings include (1) limitation
of the temporal process (fig. 3).
ofjaw movement and flattening of the cheek, (2) unilateral
Isolated depressed zygomatic arch fractures and frac-
epistaxis, (3) paresthesia or anesthesia in the distribution
tures of the mandibular condyle, coronoid process, and
of the infraorbital nerve, (4) unequal pupil heights, and
ramus of the mandible will also limit jaw movement.
(5) a decreasein extraocular muscle function with diplopia.
By understanding the mechanisms of the fractures of the
Unilateral Epistaxis
processes of the zygomatic bone which cause these clinical
findings and by correlating these clinical findings with the The maxillary process is the medial triangular surface
facial radiographs, a more accurate diagnosis and of the body of the zygoma. It is attached to the zygomatic
treatment plan can be formulated. process of the maxilla at the zygomaticomaxillary suture
and lies to the side of the maxillary sinus below the orbital
surface of the maxilla. The maxillary process is rarely frac-
Anatomy
tured; instead, the force from a blow to the cheek is trans-
Commonly the zygoma is referred to as having a central mitted through this solid piece of bone to the weaker
bony mass or body from which three bony processes pro- adjoining zygomatic process of the maxilla. This results in
ject (fig. 1). These processes are attached by sutural junc- a fracture of the zygomatic process of the maxilla and
tions to the frontal, maxillary, and temporal bones and lateral wall of the maxillary sinus, tearing the mucous
correspondingly named [3]. Their roles in forming the membrane lining of the maxillary sinus (figs. 2B, 2D, and
bony facial skeletal framework and the temporal fossa, 4). Since the nasal cavity is divided into two separate
orbit, maxillary sinus and contour of the cheek will be chambers by the nasal septum, the resulting bleeding from
described and related to specific clinical findings. the nose is limited to the side of injury.

Department of Radiology. University of Texas Health Science Center. Dallas, Texas 75235.
2 Division of Oral Surgery. Department of Surgery. University of Texas Health Science Center, Dallas, Texas 75235. Address reprint requests to D.
P. Sinn.

Am J Roentgeno/ 128:235-238, February 1977 235

 236 GERLOCK AND SINN

Fig. 1.-Anatomy of the zygoma.

1-5, Temporal, frontal, maxillary,
orbital, and infraorbital processes of
zygoma; 6. frontal bone; 7, maxillary
/‘ .. bone; 8, temporal bone; 9, greater
wing of sphenoid bone; 10, zygo-
matic process of temporal bone; 11,
zygomatic temporal suture; 12, zygo-
matic process of maxilla; 13, zygo-
-,- “7i matic maxillary suture; 14, orbital
surface of maxilla; 15, infraorbital
foramen.
American Journal of Roentgenology 1977.128:235-238.

,,j

Fig. 2.-A. Impingement of tem-

poral process of zygoma on coronoid
process of mandible as result of de-
pressed 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 pro-
cess, floor of orbit, and lateral maxil-
lary sinus involving infraorbital canal,
infraorbital foramen, and nerve
 ZYGOMATIC COMPLEX FRACTURE 237

Fig 5 -Downward and medial displacement of frontal process with

separation of zygomaticofrontal suture (open arrow) Black arrow points
to fracture of orbital floor

also cause unilateral epistaxis. Fractures of the maxilla

American Journal of Roentgenology 1977.128:235-238.

occurring below the level of the maxillary process usually

involve the walls of both maxillary sinuses, as in the LeFort
type I fracture. Bilateral epistaxis rather than unslateral
Fig. 3.-Submentovertical x-ray projection of zygomatic arches show
epistaxis then occurs.
ing depressed fracture of temporal process of zygomatic bone (arrow)
Clinically, patient had limited mandibular motion

Paresthesia or Anesthesia in Distribution of

lnfraorbital Nerve

The 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 floor at the zygomaticomaxillary suture. It forms
the lateral half of the infraorbital rim and a small part of
the anterior orbital floor lying anterolateral to that part of
the floor of the orbit formed from the maxilla. The tip of
this process is in close contact with the infraorbital fora-
men, while its base is in contact with the floor of the orbit
formed from the maxilla.
Fractures of this process may involve the infraorbital
foramen, canal, and floor of the orbit, damaging the infra-
orbital nerve; this results in paresthesia or anesthesia of
the cheek, upper lip, lower eyelid. and lateral nasal area on
the side of the injury (figs. 28, 2D, and 4). When this
clinical finding is present. the Water’s view of the facial
Fig 4 -Fracture of infraorbital process resulting in disruption of
infraorbital foramen and step deformity of infraorbitat rim (large open bones should be evaluated for fractures of the infraorbital
arrow). Maxillary process is not fractured. but its displacement has rim extending into the infraorbital foramen (figs. 2D and
resulted in fracture of lateral maxillary sinus wall (small open arrow( and
4) and for fracture involvement of the orbital floor (fig. 5).
opacification of sinus from hemorrhage Closed arrow points to fracture
of zygomatic arch. Clinically, patient had paresthesia of infraorbital nerve Isolated fractures of the orbital floor, infraorbital rim,
distribution and unilateral epistaxis and anterior wall of the maxillary sinus may also produce
this clinical finding.

The Water’s projection typically displays an opaque

Unequal Pupil Heights
maxillary sinus, with an associated fracture of the lateral
wall of the involved maxillary sinus (fig. 4). An air-fluid The frontal process projects superiorly from the body
level may be seen. Isolated orbital floor fractures or iso- of the zygoma to form the lateral orbital rim and attaches
lated fractures of the walls of the maxillary sinus, without to the frontal bone at the zygomaticofrontal suture. The
involvement of the processes of the zygomatic bone, can lateral palpebral ligament (fig. 28) inserts on the orbital
 238 GERLOCK AND SINN

rim surface of this process about 1 3 mm below the level whether treatment can consist of simple repositioning of
of the zygomaticofrontal suture. Displacement of the the zygomatic complex or if interosseous fixation will
frontal process with separation of the zygomaticofrontal be required.
suture (fig. 5) causes a downward displacement or sagging In clinical practice, we find that if the segments of bone
of the lateral canthus of the eyelids and globe of the eye. involved in the fracture are large and there is little com-
Depending upon malalignment of visual axes, diplopia may minution of the lateral wall of the maxilla, simple reposi-
or may not occur [5] (fig. 2B). Unequal pupil heights with- tioning ofthe zygomatic complex into its anatomical position
out alteration of the visual axes is a distinct clinical finding by utilizing an external or internal approach will frequently
not to be confused with diplopia. When these findings are allow a stable result. However, more frequently, open re-
present, displacement of the frontal process with widening duction with internal fixation is required. This is accom-
of the zygomaticofrontal suture should be looked for on plished by first stablizing the fractured zygomaticofrontal
the Water’s view (fig. 5). suture so that once the zygoma has been positioned super-
iorly, the dissection to the infraorbital rim as well as the
Decreased Extraocular Muscle Function with Diplopia interosseous wiring at the infraorbital rim fracture line are

The orbital process is a wide flat posterior medial ex- less difficult.
By elevating the zygomatic complex, the impingement
tension of the frontal process which blends inferiorly with
on the masseter and temporalis muscle and coronoid pro-
the body of the zygoma and infraorbital process, forming
the lateral orbital floor and lateral edge of the infraorbital
cess of the mandible will be reduced and the limitation of
fissure. The part of this process located above the infra- jaw movement eliminated. Unilateral epistaxis will persist
until the maxillary sinus has had a satisfactory length of
orbital fissure attaches to the greater wing of the sphenoid
time to clear. The use of decongestants is helpful. Pares-
bone at the zygomaticosphenoid suture. This fusion of the
American Journal of Roentgenology 1977.128:235-238.

orbital process with the greater wing of the sphenoid bone thesia and anesthesia over the distribution of the infra-
orbital nerve frequently remain postoperatively for some
at the zygomaticosphenoid suture results in the formation
time. However, repositioning of the bone so that there is
of a flat plate of bone which has anterior and posterior
no impingement of the infraorbital nerve will enhance its
surface. The posterior surface forms the anterior wall of
recovery. Reduction of the zygomatic complex will elevate
the temporal fossa. Trauma to the cheek which depresses
the zygomatic bone inward will displace the orbital process the lateral canthal ligament, reposition the orbital contents,

and infraorbital process medially, causing them to fracture

and restore the pupil to its normal height in the orbital
cavity, thus eliminating significant sequela. Diplopia from
the lateral orbital wall and floor of the orbit. This fracture
disruption of the bony orbit can produce diplopia either by swelling of the muscle will resolve slowly in 5-14 days.

producing edema and hemorrhage in the region of the Diplopia caused by entrapment of the extraocular muscles
extraocular muscles and nerves [6] or by trapping the will usually be eliminated with reduction of the zygomatic

extraocular muscles and nerves between the fractured complex fracture.

bony fragments of the orbital floor [7] (figs. 2B-2D).
ACKNOWLEDGMENT
Orbital floor fractures occurred in 35 of 63 patients with
zygomatic complex fractures studied by Wisenbaugh [4]. We thank Ms. Billie DuVall for assistance in preparing this paper.
These were surgically proven by exploration of the orbital
floor, and all 35 patients required surgical correction. REFERENCES

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be examined for fractures involving the orbital process, Mosby. 1964
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an analysis
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