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Zygomatic Arch Fracture

What is Zygomatic arch fracture?

A zygomatic arch fracture is a break in the bony ridge that forms the cheekbone, extending from the temporal bone (near the ear) to the maxilla (upper jaw). The arch gives the face its lateral contour and provides attachment for the masseter muscle, which is essential for chewing. When this structure breaks, the cheek may appear flattened, sunken, or asymmetrical, and the patient often experiences pain, swelling, and difficulty opening the mouth.

These fractures are classified as mid‑facial skeletal injuries and are usually part of a broader pattern of facial trauma. In isolation, they are called “isolated zygomatic arch fractures,” but they frequently coexist with other facial bone injuries, orbital fractures, or more severe skull base trauma.

Sources: Mayo Clinic, Facial Trauma; American Academy of Craniofacial Surgery (2023)【1】.

Common Causes

• Motor‑vehicle collisions – especially when a passenger is not wearing a seatbelt.
• Falls – slipping from a height or landing on the side of the head.
• Assaults – punches, kicks, or blunt objects striking the cheek.
• Sports injuries – contact sports (football, rugby, boxing, martial arts).
• Motorcycle or bicycle accidents – lack of helmet protection.
• Work‑place accidents – construction sites, heavy machinery, or falling objects.
• Gunshot or penetrating trauma – though less common, can shatter the arch.
• Electrical shock – sudden muscle contraction can cause a fracture.
• Sudden increase in intranasal pressure (e.g., forceful nose blowing in rare cases).
• Underlying bone disease (osteoporosis, osteogenesis imperfecta) that weakens the arch.

Associated Symptoms

When the zygomatic arch is fractured, additional signs often appear because of damage to surrounding structures:

• Visible flattening or depression of the cheek.
• Swelling and bruising (often spreading to the lower eyelid – “raccoon eyes”).
• Severe pain when touching the cheek or moving the jaw.
• Difficulty opening the mouth (trismus) due to masseter muscle spasm.
• Numbness or tingling in the cheek, upper lip, or lower eyelid (injury to the infraorbital nerve).
• Clicking, grinding, or a “popping” sensation when moving the jaw.
• Bleeding from the mouth or nose if the fracture extends into the maxillary sinus.
• Double vision (diplopia) if the fracture involves the orbital floor.
• Hearing changes or a feeling of fullness in the ear if the fracture transmits force to the temporal bone.

When to See a Doctor

Because the face houses delicate structures (eyes, nerves, sinuses), prompt evaluation is essential. Seek medical care if you notice any of the following:

• Severe or worsening facial pain after a blow.
• Visible depression, asymmetry, or a “step-off” in the cheekbone.
• Swelling or bruising that spreads rapidly.
• Inability to open the mouth wider than a few centimeters.
• Numbness, tingling, or loss of sensation in the face.
• Clear fluid leaking from the nose or ear (possible cerebrospinal fluid leak).
• Vision changes, double vision, or eye pain.
• Bleeding that does not stop after applying pressure for 10‑15 minutes.

Diagnosis

Evaluation involves a combination of clinical examination and imaging studies.

Physical Examination

• Inspection for swelling, bruising, or deformity.
• Palpation of the arch to locate tenderness or a palpable step-off.
• Assessment of jaw range of motion and muscle tenderness.
• Neurologic check of facial sensation (infraorbital nerve).
• Eye examination for visual acuity, pupil reaction, and extra‑ocular movements.

Imaging

• Plain facial X‑rays – limited utility, may miss nondisplaced fractures.
• CT scan (computed tomography) with bone windows – gold standard; provides 3‑D detail, shows displacement, comminution, and involvement of adjacent sinuses or orbit.
• 3‑D reconstruction – useful for surgical planning.
• In rare cases, MRI may be ordered to evaluate soft‑tissue injury (e.g., muscle or nerve involvement).

Special Tests

• Dental occlusion analysis if the fracture affects the maxilla.
• Endoscopic sinus examination if there is concern for sinus involvement or CSF leak.

Treatment Options

Treatment depends on the severity of displacement, presence of associated injuries, and functional impairment.

Non‑Surgical (Conservative) Management

• Analgesia – acetaminophen, ibuprofen, or short‑course opioids for severe pain.
• Cold compresses – 15‑minute intervals for the first 48 hours to reduce swelling.
• Soft‑diet – avoid hard or chewy foods for 2‑3 weeks to limit masseter strain.
• Physical therapy – gentle jaw exercises after pain subsides to prevent trismus.
• Observation – many nondisplaced fractures heal spontaneously within 4‑6 weeks.

Surgical Intervention

Surgery is indicated when the arch is displaced >2 mm, there is functional impairment, or cosmetic deformity is significant.

• Open reduction and internal fixation (ORIF) – the most common technique. Small titanium plates and screws are placed via a small incision (often a temporal or intra‑oral approach) to realign and stabilize the arch.
• Closed reduction – in selected cases, the surgeon can manipulate the bone back into place without an incision, using a Gillies or Keen method.
• Bone grafting – reserved for comminuted (multiple‑fragment) fractures where bone loss occurs.
• Post‑operative care – analgesics, antibiotics (usually a single dose of a second‑generation cephalosporin), and a soft diet for 1‑2 weeks. Sutures are removed after 5–7 days.

Follow‑up

Patients typically have a follow‑up visit at 1 week, 4 weeks, and 3 months to assess healing, jaw function, and cosmetic outcome. Imaging may be repeated if healing is uncertain.

Prevention Tips

• Always wear a properly fitted seatbelt and airbag when traveling in a vehicle.
• Use a helmet designed for the activity (bicycle, motorcycle, ski, skateboarding).
• Engage in strength and flexibility training for neck and facial muscles to reduce impact forces.
• Practice safe techniques in contact sports; use mouthguards and face shields when appropriate.
• Maintain a clutter‑free environment at home and work to prevent accidental falls.
• Adhere to occupational safety guidelines – wear hard hats where required.
• Address osteoporosis or other bone‑weakening conditions with your physician; calcium, vitamin D, and appropriate medications can improve bone density.
• Avoid excessive alcohol or drug use that impairs balance and reaction time.

Emergency Warning Signs

Key Takeaways

A zygomatic arch fracture is a potentially serious facial injury that can affect appearance, chewing, and facial sensation. While many low‑energy fractures may heal with rest and pain control, displaced or complex fractures often require surgical fixation to restore function and symmetry. Prompt evaluation—especially after high‑impact trauma—is essential to rule out accompanying orbital, sinus, or cranial injuries. Early treatment, combined with preventive measures like proper protective equipment, can markedly reduce the risk of long‑term complications.

References:

1. Mayo Clinic. “Facial Fractures.” Accessed May 2024. https://www.mayoclinic.org
2. American Academy of Craniofacial Surgery. “Management of Zygomatic Arch Fractures.” 2023 Clinical Guidelines.
3. Cleveland Clinic. “Zygomatic Bone Fracture.” Updated 2024. https://my.clevelandclinic.org
4. National Institutes of Health (NIH). “Trauma to the Midface.” 2022. https://www.ncbi.nlm.nih.gov
5. World Health Organization. “Road Safety and Helmet Use.” 2023 Fact Sheet.

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