Group I encompassed fractures with no significant displacement.

While fracture lines may be evident on

imaging, their recommendation was observation and soft diets. Group II fractures include isolated arch
fractures. Fracture is indicated when trismus or aesthetic deformities are present.

Unrotated body fractures, medially rotated body fractures, laterally rotated body fractures, and complex
fractures (defined as the presence of additional fracture lines across the main fragment) belong to groups
III, IV, V, and VI, respectively. Knight and North defined these groups by their stability after reduction. They
found that 100% of group II and group V fractures were stable after a Gillies reduction, and no fixation was
required. However, 100% of group IV, 40% of group III, and 70% of group VI were unstable after reduction
and required some form of fixation.[9]

A study by Pozatek et al concurred with the findings of Knight and North except for group V
fractures.[10] This group was found to be unstable in 60% of cases. Dingman and Natvig studied patients
who were treated by closed methods of zygomatic elevation.[4] In a significant number of patients, they
found concomitant fractures along other suture lines and within the orbit after exposing the site through a
brow or lower lid incision. They postulated that these fractures were overlooked because of the edema and
hematomas present at the time of evaluation and reduction. A significant number of patients suffered from
displacement of the zygoma after reduction without fixation. This displacement recurrence may occur
because of masseteric displacing forces.

Lund found that all group III fractures were stable after reduction, disagreeing with the findings of Knight
and North.[11] It now seems apparent that displaced fractures require open reduction and fixation.

Manson and colleagues have proposed a more modern classification system in which CT scan is used to
assess and classify zygomatic fractures.[8] CT provides information about facial structures, including both
bone segmentation and displacement, allowing for complete repair of the fractures. This system divides
fractures into low-energy, medium-energy, and high-energy injuries.

Low-energy zygoma fractures result in minimal or no displacement. These types of fractures often are seen
at the zygomaticofrontal suture, and inherent stability usually obviates reduction.

Middle-energy zygoma fractures result in fractures of all buttresses, mild-to-moderate displacement, and
comminution. Often, an eyelid and intraoral exposure is necessary for adequate reduction and fixation.

High-energy zygoma fractures frequently occur with Le Fort or panfacial fractures. The zygomatic fractures
often extend through the glenoid fossa and permit extensive posterior dislocation of the arch and malar
eminence. A coronal exposure, in addition to the oral and eyelid incisions, usually is necessary to properly
reposition the malar eminence.

Preoperative Assessment
Although isolated zygomatic complex (ZMC) fractures occur, fractures of this nature are usually
associated with other facial skeletal and soft-tissue injury.

Initially, assessment of a zygomatic fracture in an emergent setting should be directed at prevention

of life-threatening complications including major bleeding, airway compromise, aspiration, and
identification of other fractures. Cervical spine injury should always be considered if the injury is the
result of a high velocity event or if the patient has altered mental status. Intracranial, thoracic,
extremity, and pelvic injuries require proper evaluation and management.

Once other more pressing injuries have been dealt with and the patient is stable, a thorough
preoperative assessment of facial skeletal architecture can be performed. Symptoms include
paresthesias in the distribution of the maxillary branch of the trigeminal nerve, trismus, diplopia, and
flattening of the zygoma.

Signs classically include subconjunctival and periorbital hemorrhage and hypesthesias in the
distribution of the maxillary branch of the trigeminal nerve. Flattening of the malar eminence, lateral
canthal dystopia, and reduction in mandibular movement may be present. Ipsilateral epistaxis and
buccal sulcus hematomas may occur. Reduced extraocular muscle function, diplopia, and
enophthalmos can occur secondary to orbital floor fractures, resulting in entrapment of orbital
contents.

A thorough ophthalmologic examination is required to evaluate and document ocular status. If a

ruptured globe, retinal detachment, or traumatic optic neuropathy exists, treatment of these
supersedes repair of a ZMC fracture.

Since mandibular fractures are most often associated with ZMC fractures, tooth roots can be injured,
necessitating a thorough intraoral examination.