J Oral Maxillofac Surg

66:2322-2329, 2008

Zygomatic Arch Deformation:

An Anatomic and Clinical Study
Marcin Czerwinski, MD,* Stephanie Ma, BSc,†
and H. Bruce Williams, MD, FRCS(C)‡

Purpose: Trauma to the zygomatic arch classically leads to 1 of 3 injury patterns: fracture with medial
displacement, fracture with posterior telescoping, or explosive burst with lateral displacement. We
identified an additional injury pattern whereby the arch undergoes significant bending in the axial plane
without fracture.
Patients and Methods: In the anatomical part of the study, computed tomography (CT) scans of patients
with arch deformation without fracture were analyzed for location, degree, and type of arch bending. In the
clinical part, patients were divided into “arch deformation without fracture” and “arch fracture” groups and
their demographic characteristics compared. Three patients from each group, all treated with the Gillies’
technique, underwent postoperative CT scanning to compare accuracy of zygoma repair.
Results: Bending occurred most commonly in the middle and posterior thirds of the zygomatic arch,
with average deformation of 11°. Post-Gillies’ repair, average residual arch deformation was 2°. Patients
with arch deformation without fracture were significantly younger than those with arch fracture (24 yrs
vs 42 yrs, P ⬍ .05). Unlike patients with arch fractures, all those with arch bending treated with the
Gillies’ maneuver had near anatomic zygoma realignment.
Conclusion: Zygomatic arch deformation without fracture occurs in 19% of zygoma injuries in our group
and is likely elastic in nature. We believe this injury pattern is important clinically as it may decrease the need
for coronal exposure, facilitate anatomic repair, and provide stability without hardware fixation.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:2322-2329, 2008

Fractures of the zygomatic arch may occur due to aforementioned classical patterns. The arch may un-
trauma to the arch itself or to the midface, resulting in dergo significant bending in the axial plane, with a
isolated arch or classic zygoma and Le Fort III level resultant decrease in its radius of curvature, without
injuries, respectively. Several classifications for arch frac- an identifiable fracture line. It is unclear whether this
tures have been described. Mechanistically, however, 3 deformation is elastic (reversible, the arch seeks to
patterns are seen. First, a direct lateral force will displace regain its original form) or plastic (irreversible, the
the arch medially. Second, an anterior force vector fo- arch does not seek to regain its original form). We
cused on the malar prominence will usually cause a have observed this injury in zygoma and Le Fort III
posterior telescoping pattern of injury. At times, how- fractures, but not in isolated arch trauma.
ever, a posteriorly directed force can result in an explo- This injury pattern, depending on its mechanical
sive burst with displacement of the arch fragments lat- characteristics, may have several significant clinical
erally.1 The degree of comminution and displacement consequences stemming directly from the role of the
depends on the traumatic energy and the quality of the zygomatic arch in facial trauma management.2,3 First,
craniofacial skeleton. if the deformation is elastic, a nonvisualized reduction
In our experience, an additional type of zygomatic of the arch in zygoma fractures, guided by its inherent
arch injury may occur that does not resemble the ability to return to original shape, may serve to accu-
rately restore midfacial projection and transverse
*Craniofacial Fellow, The Craniofacial Center, Dallas, TX. width without anterior exposure. Second, in both
†Medical Student, McGill University, Montreal, Quebec, Canada. zygoma and Le Fort III injuries, the intact reduced
‡Professor of Plastic Surgery, McGill University, Montreal, Que- arch may be an important stabilization point decreas-
bec, Canada. ing the need for fixation hardware.
Address correspondence and reprint requests to Dr Czerwinski: This study involved anatomic and clinical objectives.
6550 Shady Brook Lane #1310, Dallas, TX 75206; e-mail: marcin. Our anatomic objectives were to delineate the precise
czerwinski@mail.mcgill.ca location, degree, and hypothesize on the mechanical
© 2008 American Association of Oral and Maxillofacial Surgeons type of zygomatic arch deformation. Our clinical objec-
0278-2391/08/6611-0021$34.00/0 tives were to define the epidemiology of these injuries
doi:10.1016/j.joms.2008.01.022 and further understand the clinical consequences of this

2322
CZERWINSKI, MA, AND WILLIAMS 2323

injury pattern in zygoma fractures by objectively com-

paring postoperative facial symmetry of patients with
arch deformation or arch fracture.

Patients and Methods

Retrospective review of zygoma fractures treated at
the McGill University Health Center between 2003 and
2006 was carried out. Admission forms, computed to-
mography (CT scans), and the operative notes were
reviewed to collect demographic data, fracture anat-
omy, and surgical procedure details, respectively.

ANATOMIC STUDY
Based on the preoperative CT scans (1.25-mm slice
thickness), patients with arch deformation without
fracture were identified.
The location of the maximal deformation was de-
scribed in each patient (posterior, middle, or anterior
one-third of the zygomatic arch) as seen on the axial
CT scan section through the arch.
The degree of arch bending was quantified as the
FIGURE 2. A 34-year-old male who slipped on ice and fell from his
difference in arch curvatures between the injured and own height. Preoperative axial CT scan shows a posteriorly dis-
uninjured sides of the face. This was carried out by first placed zygoma body. Although the zygomatic arch did not frac-
transferring outer arch contours from preoperative CT ture at any point along its length, it did sustain a 7° deformation in
the middle third of its course.
images onto transparency films, then overlapping the 2
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation.
J Oral Maxillofac Surg 2008.

sides of the face and measuring the difference using a

goniometer.
The mechanical type of arch deformation (elastic or
plastic) was hypothesized through the following. Three
patients with zygoma fractures with arch deformation
who were treated using nonvisualized reduction (Gillies

Table 1. DEMOGRAPHIC CHARACTERISTICS OF

PATIENTS WITH ZYGOMATIC ARCH DEFORMATION
ONLY AND THOSE WITH ARCH FRACTURE

Zygomatic Arch Zygomatic Arch

Deformation Fracture
(n ⫽ 10) (n ⫽ 42)

Average age (yr) 24.6 41.3

Gender (%)
Male 100 (10) 83.3 (5)
Female 0 (0) 16.7 (7)
MOI (%)
Assault 50 (5) 31.0 (13)
Fall (⬍14 feet) 30 (3) 38.1 (16)
FIGURE 1. A 16-year-old male who sustained a fist blow to the Sports 10 (1) 4.8 (2)
right cheek. Preoperative axial CT scan shows a fracture at the MVA 0 (0) 19.0 (8)
anterior buttresses of the right zygoma with posteromedial dis- Other 10 (1) 7.1 (3)
placement of the zygoma body. Although there is no fracture in the
zygomatic arch, one can appreciate a 13° deformation of the arch Abbreviations: MOI, mechanism of injury; MVA, motor ve-
most evident in the middle third of its course. hicle accidents.
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation. Czerwinski, Ma, and Williams. Zygomatic Arch Deformation.
J Oral Maxillofac Surg 2008. J Oral Maxillofac Surg 2008.
2324 ZYGOMATIC ARCH DEFORMATION

graph above. Due to the nonvisualized nature of the

repair, the exact postoperative arch form was assumed
to be guided mainly by the forces within the arch,
released by reduction of the anterior buttresses. Thus,
based on the definition of elastic deformation, if the

FIGURE 3. A, An 18-year-old male who was punched on the right

side of his face. Preoperative axial CT scan shows a 7° deformation in
the middle third of the right zygomatic arch in an otherwise structurally
intact arch, and a significant step-off at the inferior orbital rim resulting
from posterior displacement of the zygoma body. B, Postoperative
axial CT scan shows accurate realignment of the right zygomatic arch
contour with only 3° of residual deformation. Furthermore, the zy-
goma body projection and midface width have been restored cor-
rectly as compared with the uninjured side of the face. FIGURE 4. A, A 15-year-old male who was kicked with a steel-toe
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation. J Oral boot in the right side of his face. Preoperative axial CT scan shows
Maxillofac Surg 2008. posterior displacement of the zygoma body after fracture at the
anterior buttresses of the zygoma. There is no evidence of fracture
along the right zygomatic arch. However, there is a 13° deforma-
tion in the posterior third of its course. B, Postoperative axial CT
technique) were selected randomly to undergo postop- scan shows accurate realignment of the anterior buttresses as well
as the zygomatic arch, with only 3° of arch deformation. Cheek
erative CT imaging. The difference in the curvature of projection and midface width have been restored correctly in
the zygomatic arches between the injured and unin- comparison to the uninjured side of the face.
jured sides of the face on the postreduction CT scan was Czerwinski, Ma, and Williams. Zygomatic Arch Deformation.
measured using the technique described in the para- J Oral Maxillofac Surg 2008.
CZERWINSKI, MA, AND WILLIAMS 2325

difference in postoperative arch curvatures is insignifi- was carried out using independent variable Student’s t
cant, the deformation is more likely elastic. test with a significance level of 0.05.
Three patients who showed arch deformation
CLINICAL STUDY injury pattern and 3 patients with arch fracture, all
Based on the preoperative CT scans (1.25 mm slice treated using nonvisualized reduction (Gillies tech-
thickness), patients were divided into 2 groups: arch nique), were selected randomly to undergo postop-
deformation without fracture or arch fracture. Inci- erative CT imaging to compare the accuracy of
dence of zygomatic arch deformation was calculated. zygoma reduction. All of the patients sustained a
For both groups, patient age, gender, and mechanisms moderate type of zygoma fracture. Accuracy of realign-
of injury were collected. Statistical analysis of the age ment was carried out by comparison of side-to-side zy-

FIGURE 5. A, A 21-year-old male who sustained a sports injury to

the left side of his face with a football. B, Preoperative axial CT
scans show a posteromedially displaced left zygoma, with signifi-
cant overlap at the inferior orbital rim and a 4° deformation in the
posterior third of the left zygomatic arch, but no fracture. C, Post-
operative axial CT scan shows satisfactory realignment of the left
zygomatic arch contour, with only a 1° residual deformation. More-
over, the zygoma body projection and midface width have been
restored anatomically.
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation.
J Oral Maxillofac Surg 2008.
2326 ZYGOMATIC ARCH DEFORMATION

goma projection, width, and rotation. Projection was Results

defined as the distance between the axial midline and
In total, 54 cases of zygoma fractures were iden-
the most anterior point on the zygoma body, width as
tified. Nineteen percent (10/54) of the patients
the distance between the sagittal midline and the
showed zygomatic arch deformation without frac-
most lateral point on the zygoma body. Rotation was
ture.
defined by the presence of separation or overlap at
the level of the sphenozygomatic suture without sig-
nificant change in zygoma body projection or width. ANATOMIC STUDY
Discrepancy between the repaired and unaffected The deformation of the zygomatic arch occurred
sides of the face greater than 2 mm in any of the 3 most commonly in the middle (6/10 patients) and
parameters indicated inaccurate reduction. posterior (4/10 patients) thirds of the zygomatic arch.

FIGURE 6. A, A 50-year-old male who fell down the steps onto the
right side of his face. B, Preoperative axial CT scans show a medially
displaced fracture of the right zygomatic arch with some outward
rotation of the zygoma body. C, Post-Gillies reduction axial CT scan
shows persistent deformity of the arch and outward rotation of the
zygoma body. Although cheek projection is adequate, there remains a
marked asymmetry of the lateral facial contour.
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation. J Oral
Maxillofac Surg 2008.
CZERWINSKI, MA, AND WILLIAMS 2327

The average degree of zygomatic arch bending was CLINICAL STUDY

11° (span of 4° to 14°). Representatives of deformed Demographic characteristics of the 2 groups are pre-
arches are shown in Figures 1 and 2. sented in Table 1. Importantly, the average age of pa-
The difference in zygomatic arch curvatures be- tients in the deformation group was 24 years compared
tween the injured and noninjured sides of the face in with 42 years in the fracture patients (P ⫽ .004). The
the 3 patients with deformed arches who underwent incidence of severe mechanism of injury was 30%
nonvisualized repair averaged 2°. greater in the fracture sample.

FIGURE 7. A, A 39-year-old male who was punched in the left side of his face. B, Preoperative axial CT scans show a medially displaced
fracture of the left zygomatic arch and an outward-rotated zygoma body. Three-dimensional reformatted (C) and postoperative axial (D) CT
scans show evident malalignment of the left zygomatic arch contour, mostly unchanged from the preoperative defect. The degree of left
zygoma body projection is satisfactory; however, there is flattening of the lateral aspect of the left cheek that resulted from failure of the
zygoma body to rotate inward during the Gillies reduction maneuver.
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation. J Oral Maxillofac Surg 2008.
2328 ZYGOMATIC ARCH DEFORMATION

Postoperative CT scans of the patients with deformed Discussion

but unfractured arches showed anatomic realignment in
all (Figs 3-5). Postoperative CT scans of the patients with We have identified a new type of zygomatic arch
classically fractured arches showed imperfect fracture injury in which the arch bends in the axial plane, de-
reduction in all (Figs 6-8). creasing its radius of curvature without the disruption of

FIGURE 8. A, A 72-year-old male who was burglarized and pushed to the ground, falling face-forward on the pavement. B, Preoperative
axial CT scans show severely medially displaced fracture of the left zygomatic arch, as well as a significant outward rotation of zygoma body.
C, Postoperative CT axial scans shows residual malalignment of the left zygomatic arch contour. D, Consequent to the overlap of the arch
fragments and sphenozygomatic suture is a deficit in zygoma projection.
Czerwinski, Ma, and Williams. Zygomatic Arch Deformation. J Oral Maxillofac Surg 2008.
CZERWINSKI, MA, AND WILLIAMS 2329

osseous continuity. The deformation occurs most com- collagen fiber orientation and increasing amount of
monly at the middle third of the arch and averages 11°, denatured collagen.5
compared with the uninjured side of the face. Elastic deformation of the zygomatic arch seems to
Our work suggests that this deformation may be be clinically important. Because the arch seeks to regain
elastic in nature. The curvature of the blindly reduced its resting configuration, a nonvisualized reduction is
arch was similar to the uninjured side of the face, often sufficient to restore its preinjury shape and thus
suggesting that the intrinsic forces within the osseous accurately realign midfacial projection and width with-
arch structure guided it to preinjury form once the out the drawbacks associated with arch exposure
tension at interdigitating anterior fracture interfaces through the coronal incision. All of the zygoma fracture
was released by the reduction maneuver. The zygo- patients with deformed arches in our sample (3/3) re-
matic arch may be more capable of elastic deforma- gained normal facial symmetry compared with 0/3 of
tion than other components of the facial skeleton. zygoma fracture patients with fractured arches. Further-
The long, cylindrical, and thin structures of the arch more, the nonfractured arch may provide an important
all increase the amount of deformation possible for point of stability for zygoma and Le Fort III level injuries,
any given load, according to the mechanical bending potentially decreasing the requirements for excessive
theory.4 As well, most of the energy in moderate anterior hardware fixation.
midfacial impacts is dissipated by fracturing of the Facial fractures are thought to occur through a
anterior buttresses, transmitting only sub-threshold limited number of general pathways of energy dissi-
forces posteriorly that tend to only deform the arch. pation. However, it is important when assessing each
Finally, the presence of the cartilaginous zygomatico- injury to be critical of the specific pattern of fracture
temporal suture in the mid third of the arch likely interface and bone displacement, as these may often
serves as an additional point of increased deforma- have significant impact on the surgical approach and
tion. patient outcome.
Zygomatic arch deformation is not uncommon, be-
ing present in 19% of zygoma fractures in our sample. References
The majority resulted from moderate mechanism of 1. Czerwinski M, Lee C: The rationale and technique of endoscopic
injury (MOI), compared with a greater incidence of approach to the zygomatic arch in facial trauma. Facial Plast Clin
arch fractures in patients sustaining a severe MOI. N Am 14:37, 2006
2. Stanley RB Jr: The zygomatic arch as a guide to reconstruction of
Average patient age in the deformation group, 24 comminuted malar fractures. Arch Otolaryngol Head Neck Surg
years, was smaller than in the fracture group, 42 years 115:1459, 1989
(age span of 15 to 41 and 18 to 76 years old, respec- 3. Gruss JS, Van Wyck L, Phillips JH, et al: The importance of the
zygomatic arch in complex midfacial fracture repair and correc-
tively). The difference was statistically significant tion of posttraumatic orbitozygomatic deformities. Plast Recon-
(P ⬍ .05). This is perhaps not unexpected given that str Surg 85:878, 1990
elastic modulus of bone has been shown to degrade 4. Cordey J: Introduction: Basic concepts and definitions in me-
chanics. Injury 31:SB1, 2000
by 2% per decade and is related to increasing bone 5. Augat P, Schorlemmer S: The role of cortical bone and its
mineralization and porosity, decreased variability in microstructure in bone strength. Age Aging 35:ii27, 2006