Zygomatic Arch Anatomy, Fracture, and Titanium Plate Stabilization

Understanding the Zygomatic Arch: Anatomy, Fractures, and Treatment Options

Warning: some images on this page may be disturbing!

The zygomatic arch is an important component of the facial skeleton and plays an important role in facial aesthetics and function. Sometimes it can be damaged by blunt and penetrating trauma to the face. Treatment options ranging from closed reduction or conservative follow-up to open reduction and stabilization with titanium screws may be required. One of the most effective surgical interventions in comminuted and displaced zygomatic arch fractures is the use of titanium plates for stabilization. In this article, I wanted to tell you about the displaced left zygomatic arch fracture that occurred in a female patient who fell on the slippery floor while leaning in the bathroom and the stabilization of the zygomatic arch using titanium screws. The patient, who described it as just a simple slip and fall, applied to our clinic when she noticed the asymmetry on her face and the sunken area just above her left cheek when she looked in the mirror. Since the image may be disturbing, it is shared as a small image, when you click on it, the image will open in a larger size.

Where is the Zygomatic Arch?

Zygomatic Arch Anatomy

The zygomatic arch is a bony structure formed by the temporal process of the zygomatic bone and the zygomatic process of the temporal bone, located just above the cheek area on our face. It serves as the attachment site for the masseter muscle, which is very important for chewing. In addition, the zygomatic arch contributes to the lateral contour of the face and provides structural integrity to the midface region. Traumatic damage to this arch can lead to functional and cosmetic deformities.

Zygomatic Arch Fracture

Zygomatic arch fractures may occur for various reasons. The patient I shared with you here had a zygomatic arch fracture after she slipped in the bathroom and hit her face on the corner of the sink. Zygomatic arch fractures are common in facial trauma and can occur as a result of motor vehicle accidents, sports injuries, falls, and physical assaults. These fractures are usually isolated, but can also be part of a more complex zygomatic-maxillary complex (ZMC) fracture.

Types of Zygomatic Arch Fractures

• Isolated Zygomatic Arch Fracture – It involves only the zygomatic arch without affecting the other facial bones. Our patient here also has an isolated fracture.
• Zygomatic-Maxillary Complex (ZMC) Fracture – Also known as a three-legged fracture, it involves the zygomatic arch, infraorbital rim, lateral orbital wall, and maxilla. It is a more complicated injury than an isolated arch fracture.
• Depressed Fracture – The fractured segment is displaced inward and usually impinges on the coronoid process, restricting jaw movement.
• Comminuted Fracture – Multiple fragments of bone, usually seen in high-impact trauma.

Zygomatic Arch Fracture Symptoms

Both aesthetic and functional problems may occur in zygomatic arch fractures. Symptoms may increase as the severity of the trauma causing the fracture increases. Symptoms of zygomatic arch fractures can be listed as follows:

• Facial asymmetry and flattening of the cheek (you can note the sunken area on the upper left cheek of our patient)
• Pain and tenderness in the fracture area
• Swelling and bruising
• Restriction of mouth opening due to masseter muscle compression
• Diplopia (double vision) if associated with orbital fractures (our patient did not have orbital floor fracture and diplopia)
• Numbness in the cheek due to infraorbital nerve involvement (our patient did not have injury in this area and this symptom)

Zygomatic Arch Fracture Diagnosis

• Clinical examination and imaging studies are essential for the diagnosis of zygomatic arch fractures. Our patient applied to our clinic after noticing the asymmetry on his face when he looked in the mirror after falling.
• Physical Examination – Palpation of the zygomatic arch may reveal stepping deformities or tenderness. During palpation, palpation from inside and outside the mouth may reveal a sunken area, crepitation.
• Plain Radiography (X-ray) – The submentovertex (SMV) view is useful for detecting zygomatic arch fractures.
• Computed Tomography (CT) Scan – The gold standard for assessing fracture displacement, comminution, and associated injuries. In the photos I have shared, the zygomatic arch fracture area on the CT scan slices is marked with arrows.

Treatment of Zygomatic Arch Fractures

Treatment depends on the severity of the fracture and the functional impairment. Our patient had an isolated zygomatic arch fracture. It was found to be displaced and fractured in several lines. The following treatment options are available for zygomatic arch fractures:

Non-Surgical Management

Conservative Treatment – ​​Indicated for non-displaced or minimally displaced fractures. Includes pain management, cold compresses, and limited jaw movement to allow healing.

Closed Reduction – Manual or percutaneous reduction technique used to realign the fractured arch without open surgery. The Gillies approach is a common method in which a small incision is made in the temporal region and an instrument is used to elevate the collapsed bone. More information see the source link for "Gillies approach for zygomatic arch fracture" >> https://surgeryreference.aofoundation.org/cmf/trauma/midface/approach/indirect-approaches-to-the-zygomatic-arch-temporal-and-transoral-approaches

Surgical Treatment of Zygomatic Arch Fractures

Open Reduction and Internal Fixation (ORIF) – Indicated for severely displaced or comminuted fractures. Titanium plates and screws provide rigid fixation by restoring anatomic contour and function.

Coronal Approach – Used in complex fractures involving the zygomatic arch and other facial structures.

Fixation of Zygomatic Arch Fracture with Titanium Plates

Titanium plates have revolutionized the management of zygomatic arch fractures by providing rigid and stable fixation. The main advantages of titanium plates include biocompatibility, corrosion resistance, and excellent strength-to-weight ratio. In our patient, after a mucosal incision was made through the mouth, the arch fracture area was reduced with the help of an elevator. After the fracture lines were brought end to end, titanium plates and screws were used to fix the fracture lines as seen in the images. The mucosal incision area was then sutured with absorbable sutures.

Titanium Plate Fixation Procedure

Preoperative Planning – A CT scan is used to assess the extent of the fracture and plan the incision and plate placement.

Surgical Exposure – An intraoral or coronal approach is used to access the fracture site. We performed an intraoral fracture reduction and fixation procedure on our patient.

Fracture Reduction – The fracture segments are repositioned to restore normal anatomy. In our patient, the fracture lines were reduced by applying traction force from the inside out (in the opposite direction of the trauma force) with the help of an elevator. In such patients with displaced fracture lines and multiple fracture lines, titanium plate and screw fixation is very important.

Placement of Titanium Plates – One or more titanium plates are contoured and secured using screws to stabilize the fracture. As seen in the images, two titanium plates were used for fracture fixation.

Closure and Postoperative Care – The soft tissues are sutured and the patient is monitored for healing and complications.

Advantages of Titanium Plates in Zygomatic Arch Fracture Treatment

Titanium screws and plates allow surgeons to fix bone fractures much more easily. The advantages of these plates can be listed as follows:

Rigid Fixation – Provides stability and prevents secondary displacement. Rigid fixation has become easier thanks to the production of screws and plates in different sizes and their durability.

Biocompatibility – Minimizes risk of infection or immune response.

Long-Term Durability – Ensures permanent stabilization without degradation.

Minimal Interference with Imaging – Unlike other materials, titanium does not cause significant artifacts on CT or MRI scans. Newly produced titanium metals allow patients to undergo MRI imaging.

Postoperative Care and Recovery

The following can be considered for patients to have a comfortable postoperative period:

• Antibiotics and pain management: Patients can be given prophylactic antibiotic treatment and various analgesic drugs for pain control during and after surgery.
• Avoidance of excessive jaw movement: Eating soft, warm foods may be beneficial.
• Cold compression and elevation may be beneficial in reducing edema and bruising.
• Avoiding excessively salty and hot foods may be beneficial in reducing edema.
• Regular follow-up with imaging to assess healing
• Monitoring for complications such as infection, plate exposure, or malunion

Zygomatic arch fractures can occur frequently in facial traumas. Rapid diagnosis and appropriate treatment are required for these fractures. While closed reduction techniques may be sufficient for small fractures; severe cases require surgical intervention using titanium plates for optimum stabilization. Titanium plates provide effective long-term results by offering superior strength, durability and biocompatibility. Developments in surgical techniques and materials continue to improve the prognosis and functional restoration in patients with zygomatic arch fractures. You can pay attention to the post-operative images of our patient. No problems were observed in the long-term follow-ups of the patient. Try not to hit your face and not to fall😉.

Similar links >> Nasal Fractures - Causes, Symptoms, Diagnosis, Treatment / Closed Technique Nasal Fracture Reduction

Source links >> Zygomatic Arch Fracture - StatPearls - NCBI Bookshelf / Zygomatic arch fractures | Radiology Reference Article | Radiopaedia.org

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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