What is the treatment for a right zygomaticomaxillary complex (ZMC) fracture?

Treatment of Right Zygomaticomaxillary Complex Fracture

Surgical intervention with open reduction and internal fixation (ORIF) is the treatment of choice for displaced ZMC fractures, while nondisplaced fractures can be managed conservatively with observation. 1, 2

Initial Assessment and Imaging

CT maxillofacial without contrast is the essential diagnostic modality for evaluating ZMC fractures, providing high-resolution imaging of osseous structures, multiplanar reconstructions, and 3-D reformations critical for surgical planning. 3, 4 This imaging is superior to plain radiography, which misses approximately 12% of maxillofacial fractures. 3

Key Diagnostic Features on CT:

• Zygomaticosphenoid suture status - critical indicator of asymmetry and orbital volume changes 3
• Degree of displacement and comminution 3
• Associated orbital floor fractures (most common associated injury) 5
• Infraorbital nerve involvement 3

Associated Injuries to Evaluate:

• Cervical spine injury occurs in 6-19% of significant maxillofacial trauma cases 3
• Intracranial injury present in 9% of patients with orbital wall fractures 3
• Blunt cerebrovascular injury (BCVI) screening not typically required for isolated ZMC fractures (unlike Le Fort II/III) 3

Treatment Algorithm

Surgical Indications:

Operate when there is displacement of bony fragments, comminution, or fracture instability. 1

Surgical Approach - Two-Point Fixation Standard:

Most ZMC fractures (73%) are successfully treated with two-point fixation, typically at the zygomaticomaxillary buttress plus one additional site. 5

Incision Options (surgeon preference):

• Intraoral approach alone - sufficient for most depressed ZMC fractures with fixation at zygomaticomaxillary buttress 2
• Additional exposure sites for severely displaced fractures:
  • Lateral eyebrow or upper blepharoplasty 5
  • Transconjunctival or subciliary for inferior orbital rim 5
  • Zygomaticofrontal junction access 2

Nonsurgical Management:

Nondisplaced fractures without functional impairment can be observed without surgical intervention. 2 This approach showed satisfactory outcomes in 74 patients at 1-year follow-up. 2

Expected Outcomes and Complications

Surgical Success Rates:

• Satisfying facial contour achieved in 98% of cases (45/46 patients) 2
• Normal ocular movement and globe position in all patients 2
• Mean mouth opening 49mm without pain 2

Common Complications to Monitor:

Infraorbital nerve dysfunction - most frequent complication, with persistent neurosensory disturbance in approximately 41% of surgical patients at 1-year follow-up. 2 This is expected given the anatomic relationship between ZMC fractures and the infraorbital nerve (V2). 3

Wound infection - occurs in approximately 11% of cases (5/46 patients), typically resolves with oral antibiotics and local wound care. 6, 2

Critical pitfall: Inadequate postoperative wound management can lead to severe complications including oroantral fistula formation, particularly if absorbable plates become exposed and untreated. 6

Orbital Considerations:

When orbital floor reconstruction is required, dissimilar orbital floor position may occur in some cases (3/46 patients) despite adequate ZMC alignment, though this rarely requires secondary correction. 2

Postoperative Management

Proper postoperative treatment and close follow-up are essential to prevent disastrous complications such as soft tissue dehiscence, plate exposure, and fistula formation. 6 Early recognition and treatment of wound complications prevents progression to permanent defects requiring complex reconstruction with bone grafting and mucosal flaps. 6