OMFS-0112Maxillofacial traumaTraumaintermediateZygomaticomaxillary complex

Flattened cheek and diplopia after assault

29-year-old male

Draft — educational study aid, pending faculty review.

§Chief complaint

Depressed cheek and double vision after being punched

§Medical & dental history

01Healthy, no ocular history
02No dental injury

§Clinical examination

01Flattening of the right malar prominence, periorbital ecchymosis and subconjunctival haemorrhage
02Step at the infraorbital rim and zygomaticofrontal suture
03Infraorbital nerve paraesthesia
04Diplopia on upward gaze; visual acuity 6/6 bilaterally

§ figuresFigures (1)

Zygomatic Complex Fracture — radiology image: CT brain bone window showing right zygomatic arch and anterior wall of right maxillary sinus fracture. Haemosinus is seen within the right maxillary sinus. — Fig. 1CT brain bone window showing right zygomatic arch and anterior wall of right maxillary sinus fracture. Haemosinus is seen within the right maxillary sinus.
“CT brain bone window showing right zygomatic arch and anterior wall of right maxillary sinus fracture” · Cerevisae · CC BY-SA 4.0 · Wikimedia Commons

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Zygomatic Complex Fracture figures pending faculty review.

§Differential diagnosis

Zygomatic complex fractureMalar flattening, rim step, infraorbital paraesthesia

Isolated orbital floor blowoutRims intact, enophthalmos and diplopia

Nasoethmoid fractureTelecanthus, nasal deformity

Soft tissue haematoma onlyNo step, no paraesthesia

§Final diagnosis

Right zygomaticomaxillary complex fracture with orbital floor involvement

The triad of malar flattening, palpable steps at two or more articulations, and infraorbital nerve paraesthesia distinguishes a ZMC fracture from an isolated floor blowout, where the rims are intact.

§Investigations

01CT face axial and coronal — fractures at ZF suture, infraorbital rim, zygomatic arch and orbital floor
02Formal ophthalmology review with forced duction test
03Visual acuity documented before and after surgery

§Treatment plan

01Urgent surgery if globe-threatening; otherwise operate at 5-7 days once oedema settles
02Open reduction and internal fixation at two or three points
03Orbital floor reconstruction with a titanium mesh or PDS sheet
04Nose-blowing avoidance and antibiotic cover

§Surgical procedure

01Upper buccal sulcus, lateral brow and transconjunctival approaches
02Reduction with a Rowe elevator, fixation at ZF suture and infraorbital rim with 1.5 mm plates
03Orbital floor explored, herniated fat reduced, titanium mesh placed
04Forced duction repeated at the end of surgery

§Follow-up & outcome

01Diplopia resolved by 6 weeks
02Infraorbital paraesthesia improving at 3 months
03Symmetrical malar projection on review

§Clinical pearls / learning points

01Always record visual acuity before and after any orbital surgery — retrobulbar haemorrhage is a sight-threatening emergency.
02Malar flattening can be masked by swelling; assess from above and behind the patient.
03Two-point fixation is usually enough for a stable ZMC; comminuted arch fractures need more.

§ evidenceReferences & Evidence

Current Classification

WHO Classification of Tumours Online — Head and Neck

IARC / WHO · 2022

Continuously updated online edition of the WHO head and neck tumour classification.

View official source

Evidence summary

Highest level of evidence linked to this page: WHO / Official Classification.

L1 · Classification — 1
L6 · Textbook — 5

1 linked source was published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.

Content last reviewed

September 2026

Evidence last reviewed

September 2026

Next scheduled review

September 2027

Review status

EVIDENCE REVIEWED

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Last literature search: 7 September 2026

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Current Classification