Injuries to the zygomaticomaxillary complex, also known as ZMC, may be one of the most frequent type of facial injury because of the important location and function of zygomatic bone since zygomatic bone serves the purpose of supporting the orbit and maintaining the contour of the face.1 ZMC injuries usually occur as a result of major accidents including, car accidents, violence, falls, and accidents while playing sports.2 Considering the type and severity of ZMC injuries, the patients can experience problems connected with both aesthetics and function of their face including facial asymmetry, loss of prominence of cheeks, dysfunction of the infraorbital nerve, double vision, limitation in the opening of the mouth, and various eye problems.3,4 The best diagnostic method to define ZMC injury is considered ultrasound diagnostic method which gives the information about the location of the injury, its severity, and involvement of other facial structures and orbit.5 Although there are new ways of treatment and imaging methods, the epidemiology, radiological characteristics, and clinical manifestations of ZMC injuries differ in different populations, thus showing the necessity of having region-oriented data regarding this type of injury.6,7 In a cross-sectional study conducted by Alamgir et al. on 40 cases of zygomaticomaxillary complex fractures, there was found to be a strong male preponderance as 77.5% of patients were males while 22.5% of them were females. The cause of injury was found to be road traffic accident in 42.5%, followed by fall (20.0%), interpersonal violence (7.5%), and sports (5.0%). As far as the clinical manifestations were concerned, periorbital ecchymosis was the most common one (32.5%), followed by infraorbital paresthesia (20.0%), malar flattening (15.0%), and subconjunctival ecchymosis (12.5%).8 Likewise, in another study done by Rohit et al., 57.1% of ZMC fractures were caused by road traffic accidents, while self-fall (16.3%) and interpersonal violence (12.3%) were relatively uncommon causes. According to the findings of the CT assessment, 83.7% of patients had displaced fractures and needed open reduction and internal fixation.9 In a study conducted by Yamsani et al. on 101 patients of displaced ZMC fractures, road traffic accident was again found to be the commonest cause of injury, and 77% of the patients required surgical management due to displaced fractures.10 In spite of the existence of literature on a global level regarding this topic, information about the clinical and radiological aspects of ZMC fractures in the population of Pakistan is scarce, especially from tertiary care hospitals in Khyber Pakhtunkhwa province. The majority of the available literature in this region has mainly concentrated on the prevalence rate of fractures of the face along with the treatment results, with very few details regarding the CT aspects of fractures and the relation of such findings to clinical features. Also, the variation in factors such as trauma mechanism, availability of health care facilities, and injury severity makes it unsuitable to apply the results obtained from other settings. Therefore, there is a need to develop epidemiological and radiological information locally. This study was carried out to identify the cause, CT fracture features, and clinical features of zygomatico-maxillary complex fractures in Ayub Teaching Hospital, Abbottabad.

This study has been designed as a cross-sectional analysis and was performed in the Department of Oral and Maxillofacial Surgery of Ayub Teaching Hospital (ATH), Abbottabad, during the period of six months between January 2025 and June 2025. This study has been approved by IRB Ref.No.RC-EA-2024/214. Informed written consent has been taken from all the participants prior to the study and patient confidentiality has been kept. Sample size for this research has been calculated with the help of WHO sample size calculator on the basis of 3.1% expected prevalence of ZMC fractures as described by Rohit et al.,9 with 95% confidence level and 3% margin of error that resulted into required sample size of 129 patients. Non probability consecutive sampling technique was used in order to select participants. Inclusion criteria for this study include patients with age ranging from 18-60 years of either gender with clinically and radiographically proven cases of zygomaticomaxillary complex (ZMC) fractures. Exclusion criteria for this study include patients with injuries caused due to firearms, pathological fractures, fractures for more than six weeks and history of previous facial fractures/surgeries involving zygomatic complex. The data was gathered utilizing a structured proforma. Age and gender along with the etiology of trauma (RTA, fall, assault or other) were noted. A thorough clinical examination was conducted to determine whether there was the presence or absence of periorbital swelling, flattening of cheeks, subconjunctival hemorrhage, infraorbital anesthesia, ecchymosis, diplopia and restricted mouth opening (trismus). Radiological investigations involved the use of computed tomography (CT) scan of facial bones together with Orthopantomogram (OPG) and Paranasal Sinuses (PNS) when necessary for routine clinical investigations. A consultant oral and maxillofacial surgeon with a minimum of five years of post-fellowship experience reviewed the CT scans. The factors considered were: side of fracture (unilateral - right, left or bilateral), whether fracture is displaced (yes/no), fracture of zygomatic arch, floor of orbit, infra orbital rim, zygomaticomaxillary buttress, frontozygomatic suture and communited fracture (yes/no). The data were analyzed using SPSS version 25.0. Normality of quantitative variables, such as age, was tested via the Shapiro-Wilk test while the results were presented in mean ± SD. The categorical variables included gender, etiology, clinical manifestations, and CT characteristics of fractures and were described in terms of frequency and percentages. Chi-square test was used to test the associations between etiology and clinical manifestations, etiology and CT characteristics of fractures, and CT characteristics of fractures and clinical manifestations if expected cell count was < 5. P value < 0.05 was considered statistically significant.

A total of 129 patients had a mean age of 32.69 ± 8.41 years including 96 (74.42%) male and 33 (25.58%) female. In this study, out of 129 patients with ZMC fractures, road traffic accidents represented the most common cause of injury, impacting 84 (65.1%). Second on the list of causes was interpersonal violence, which affected 25 (19.4%) patients, followed by falls in 16 (12.4%) patients, and other causes in 4 (3.1%). Most (41.1%) cases involved left-sided fractures, while 31.0% of cases were bilateral and the remaining 27.9% were right-sided. Finally, 70.5% of cases were associated with fracture displacement. From a radiological perspective, the most common finding was the involvement of the zygomatic arch (86.0%), followed by the zygomaticomaxillary buttress (82.9%) and the frontozygomatic suture (80.6%). Finally, orbital floor fractures occurred in 50.4% of patients, while 26.4% of patients suffered from comminuted fractures (Fig. 1). From a clinical point of view, the most common presentation of these patients was periorbital edema, which was observed in 89.1% of cases. The flattening of the malar area occurs in 76.7% of the cases in addition to subconjunctival hemorrhaging has occurred in 65.9% of the cases. Infratemporal facial numbness was noted in 43.4% of patients and ecchymosis, diplopia, and trismus were noted in 38.8%, 27.1%, and 19.4% of patients respectively (Fig. 2). Although it is found that the road traffic accidents occur frequently among the people having these symptoms, no significant association between the cause and the symptoms was observed (all p > 0.05) (Table 1). More cases of displaced fractures were significantly seen after RTA (p = 0.019), but there were no significant relationships found between the cause and other CT findings (Table 2). Diplopia was significantly related to orbital floor fracture, infraorbital paresthesia to infraorbital rim fracture, malar flattening to displaced fracture, and limited mouth opening to comminuted fractures (p < 0.001) (Table 3). Table 1. Association between etiology of injury and clinical findings among patients with zygomaticomaxillary complex (ZMC) fractures (n = 129). Clinical Findings Etiology p-value Fall (n = 16) RTA (n = 84) Assault (n = 25) Other (n = 4) Periorbital Edema Yes 15 (93.8%) 75 (89.3%) 21 (84.0%) 4 (100.0%) 0.677 No 1 (6.2%) 9 (10.7%) 4 (16.0%) 0 (0.0%) Trismus Yes 3 (18.8%) 16 (19.0%) 6 (24.0%) 0 (0.0%) 0.726 No 13 (81.2%) 68 (81.0%) 19 (76.0%) 4 (100.0%) Diplopia Yes 1 (6.2%) 27 (32.1%) 6 (24.0%) 1 (25.0%) 0.193 No 15 (93.8%) 57 (67.9%) 19 (76.0%) 3 (75.0%) Ecchymosis Yes 7 (43.8%) 32 (38.1%) 8 (32.0%) 3 (75.0%) 0.411 No 9 (56.2%) 52 (61.9%) 17 (68.0%) 1 (25.0%) Infraorbital Paresthesia Yes 5 (31.2%) 37 (44.0%) 11 (44.0%) 3 (75.0%) 0.457 No 11 (68.8%) 47 (56.0%) 14 (56.0%) 1 (25.0%) Subconjunctival Hemorrhage Yes 13 (81.2%) 54 (64.3%) 16 (64.0%) 2 (50.0%) 0.519 No 3 (18.8%) 30 (35.7%) 9 (36.0%) 2 (50.0%) Malar Flattening Yes 12 (75.0%) 66 (78.6%) 18 (72.0%) 3 (75.0%) 0.917 No 4 (25.0%) 18 (21.4%) 7 (28.0%) 1 (25.0%) Table 2. Association between etiology of injury and radiological (CT) characteristics among patients with zygomaticomaxillary complex (ZMC) fractures (n = 129). CT Characteristics Etiology p-value Fall (n = 16) RTA (n = 84) Assault (n = 25) Other (n = 4) Side Bilateral 3 (18.8%) 23 (27.4%) 13 (52.0%) 1 (25.0%) 0.070 Left 5 (31.2%) 38 (45.2%) 9 (36.0%) 1 (25.0%) Right 8 (50.0%) 23 (27.4%) 3 (12.0%) 2 (50.0%) Displacement Yes 9 (56.2%) 67 (79.8%) 13 (52.0%) 2 (50.0%) 0.019 No 7 (43.8%) 17 (20.2%) 12 (48.0%) 2 (50.0%) Zygomatic arch involvement Yes 14 (87.5%) 72 (85.7%) 22 (88.0%) 3 (75.0%) 0.914 No 2 (12.5%) 12 (14.3%) 3 (12.0%) 1 (25.0%) Orbital floor involvement Yes 4 (25.0%) 48 (57.1%) 12 (48.0%) 1 (25.0%) 0.080 No 12 (75.0%) 36 (42.9%) 13 (52.0%) 3 (75.0%) Infraorbital rim involvement Yes 12 (75.0%) 56 (66.7%) 15 (60.0%) 2 (50.0%) 0.694 No 4 (25.0%) 28 (33.3%) 10 (40.0%) 2 (50.0%) Zygomaticomaxillary buttress involvement Yes 14 (87.5%) 69 (82.1%) 20 (80.0%) 4 (100.0%) 0.741 No 2 (12.5%) 15 (17.9%) 5 (20.0%) 0 (0.0%) Frontozygomatic suture involvement Yes 13 (81.2%) 70 (83.3%) 18 (72.0%) 3 (75.0%) 0.644 No 3 (18.8%) 14 (16.7%) 7 (28.0%) 1 (25.0%) Comminution Yes 2 (12.5%) 25 (29.8%) 7 (28.0%) 0 (0.0%) 0.314 No 14 (87.5%) 59 (70.2%) 18 (72.0%) 4 (100.0%) Table 3. Association between CT fracture characteristics and clinical findings among patients with zygomaticomaxillary complex (ZMC) fractures (n = 129). CT characteristics Clinical Findings Yes n (%) No n (%) p-value Orbital floor involvement Diplopia Present 30 (46.2%) 5 (9.1%) <0.001 Diplopia Absent 35 (53.8%) 50 (90.9%) Infraorbital rim involvement Infraorbital paresthesia Present 47 (55.3%) 9 (20.5%) <0.001 Infraorbital paresthesia Absent 38 (44.7%) 35 (79.5%) Malar Flattening Displacement Present 78 (85.7%) 13 (34.2%) <0.001 Displacement Absent 21 (14.3%) 17 (65.8%) Comminuted fracture Restricted mouth opening Present 16 (47.1%) 9 (9.5%) <0.001 Restricted mouth opening Absent 18 (52.9%) 86 (90.5%)

This study sought to evaluate the etiological factors, clinical features, and radiological features of ZMC fractures among patients visiting Ayub Teaching Hospital, Abbottabad. Results showed that the majority of ZMC fractures involved young adult males, whereby RTAs constituted more than half (65.1%) of all injuries. Malar flattening, periorbital edema, and subconjunctival hemorrhage were common clinical features of ZMC fractures. Radiologically, fracture displacement, involvement of the zygomatic arch, and involvement of the frontozygomatic suture were common. Besides, RTAs significantly correlated with ZMC displacement, while orbital floor involvement, infraorbital rim involvement, fracture displacement, and comminution had a correlation with their respective clinical manifestations. The epidemiology and presentation of ZMC fractures vary greatly among different populations. A retrospective analysis conducted by Dubron et al. on 272 patients found that infraorbital nerve hypoaesthesia was seen in 37.3% of patients, whereby orbital floor fractures, fracture displacement, and crossing of the fracture line through the infraorbital canal were strong predictors of sensory deficits.11 Recently, Mehta et al. determined that the occurrence of infraorbital nerve deficits amongst individuals suffering from ZMC fractures was 51.9% (95% confidence interval, 48.0 to 55.0%), showing that sensory impairment is the most frequent complication in ZMC fractures.12 In addition, the systematic review and meta-analysis performed by Alanazi et al. on the incidence of ocular complications among 7,998 individuals with maxillofacial fractures revealed that subconjunctival hemorrhage is the most prevalent ocular trauma (31.1%), followed by periorbital trauma (including edema and ecchymosis), which amount to 24.1% of cases. According to the review, road traffic accident and interpersonal violence were the most common causes of facial trauma around the world.13 These results indicate the necessity of recording both radiologic fracture types and clinical manifestations. These results are in agreement with those of the current study, where road traffic accidents were the major cause of ZMC fractures, and periorbital edema, subconjunctival hemorrhage (65.9%), and infraorbital paresthesia (43.4%) were the most common clinical manifestations. Regarding clinical findings in the current study, periorbital edema (89.1%), malar flattening (76.7%), and subconjunctival hemorrhage (65.9%) were found to be predominant. Additionally, it was noted in 43.4% of patients with infraorbital paresthesia, in 38.8% of patients with ecchymosis, in 27.1% of patients with diplopia, and in 19.4% of patients with trismus. These findings reveal similarities with findings of prior studies. In a recent research study in Lahore conducted by Khan et al. periorbital ecchymosis was seen in 80.8% of patients, subconjunctival hemorrhage in 74.0% and diplopia in 41.1% of patients with ZMC fractures indicating that periocular soft tissue injuries are one of the most seen findings in such cases, which results were corroborated by other studies.14 For instance, Lin et al. documented periorbital edema in 74.1% of patients, subconjunctival hemorrhage in 67.2% of patients, and infraorbital paresthesia in 46.6% of patients in a study assessing the involvement of the orbit in maxillofacial trauma which can also be compared with the findings of this study.15 The radiological analysis revealed that there was a significant correlation between the fracture displacement and road traffic accidents (p = 0.019), but not with other CT findings. This is backed up by Obayemi et al., who noted that there is more kinetic energy involved in high-velocity motor vehicle accidents, leading to displaced ZMC fractures that require surgery.16 While RTAs were the primary cause of injury in the current research, Prabhu et al. found interpersonal violence to be the major cause of ZMC fractures rather than road traffic accidents. Likewise, while diplopia occurred in 27.1% of cases in this research, this rate is less than the one reported by Prabhu et al., in their study on the causes of orbital floor fractures where 52% of patients had isolated orbital floor injuries with diplopia.17 The dominance of RTAs in the cause of ZMC fractures could be attributed to the higher energy forces involved in motor vehicle accidents since the zygoma is the primary support of the midface that projects outwards from the face.18 Thus, it receives all the force during the traumatic event, and thus there is displacement of the bone and comminution with several joints being involved at once. The results found in this study are supported by the injury mechanism and anatomy behind it. In fact, orbital floor fractures are responsible for limiting the movement of the eye and causing diplopia due to the eye muscle being trapped in the fracture or orbit tissues being pushed into the sinus.19 The infraorbital nerve that is compressed or traumatized while accessing the canal can cause infraorbital nerve dysfunction. Injuries/displacement that occur with fractures may be responsible for the abnormal position of the zygoma.20 Also, it should be noted that comminuted fractures are caused by severe trauma and have a bigger impact on surrounding soft tissue compared to other injuries.21 The results of this study are indicative of the relationship between the CT findings and the abnormalities occurring in the presence of the fractures. In terms of clinical practice, the inclusion of CT characteristics of the fractures together with the clinical examination will improve diagnosis and allow clinicians to predict any functional limitations prior to the start of treatment. Recognition of orbital floor involvement will require an ophthalmologic evaluation, while infraorbital rim fractures will require thorough sensory examination to diagnose infraorbital nerve damage. Limitations There are a few limitations associated with this study. First, it was carried out within one tertiary healthcare facility; therefore, it may not be applicable to other populations. Second, being cross-sectional in nature, the study fails to assess treatment effectiveness and the degree of functional recovery. Third, while radiology was done by experienced clinicians, observer variability may not be ruled out. Finally, the absence of analysis of postoperative recovery, fixation technique, and possible complications makes the research less useful from the standpoint of functional recovery of patients. The results of the study have considerable practical and public health significance. Timely identification of typical radiologic signs in association with certain clinical symptoms can help make the diagnosis quicker and plan surgical procedures, thus reducing the risk of functional and aesthetic problems in the future. Since the leading cause of injury is RTA, there is a need for legislative measures that will increase road safety and compliance with helmet and seatbelt use.

Fractures of the zygomaticomaxillary complex were mostly seen in young adult men, with road traffic accidents serving as the main cause of trauma. Periorbital edema, flatness of the cheekbone, and subconjunctival bleeding were the most common clinical signs seen, whereas the CT scan showed that there was a higher incidence of displaced fractures as well as those involving the zygomatic arch. The correlations between particular fracture features found by the radiologic evaluation and their respective clinical features show the importance of both clinical and CT evaluations in the diagnosis and management of ZMC fractures.

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