European Journal of Cardiovascular Medicine

Zygomaticomaxillary complex (ZMC) fractures are among the most frequent midfacial injuries and are clinically important due to their impact on facial width, malar projection, orbital volume, and masticatory function. Inadequate reduction or unstable fixation may result in persistent facial asymmetry, malar flattening, enophthalmos, diplopia, trismus, and long-term sensory deficits, particularly involving the infraorbital nerve distribution. Contemporary management aims to restore three-dimensional skeletal alignment and buttress continuity while minimizing morbidity, scarring, and reoperation rates [1,2].

Open reduction and internal fixation (ORIF) with titanium miniplates remains widely practiced for displaced ZMC fractures because it permits controlled reduction and stable fixation at one or more key points such as the frontozygomatic (FZ) suture, infraorbital rim, and zygomaticomaxillary buttress [3–5]. Treatment patterns vary by surgeon preference and fracture complexity; survey-based evidence indicates that ORIF with titanium plates is a dominant approach, commonly using two to three fixation sites and selective orbital floor exploration [6]. The AO-CMF principles emphasize individualized fixation strategy based on displacement, comminution, stability after reduction, and orbital involvement, rather than a uniform “one-size-fits-all” approach [7,8].

Despite broad acceptance of rigid fixation, postoperative complications remain clinically consequential. Complications can be grouped as functional (trismus, malocclusion), sensory (infraorbital hypoesthesia), ocular (diplopia, enophthalmos), and hardware-related problems (palpability, infection, exposure, need for plate removal). Infraorbital nerve dysfunction is particularly prevalent after ZMC trauma; recovery may be gradual and incomplete in a subset, affecting patient-reported quality of life [9]. Additionally, residual malar asymmetry can persist even after ORIF, especially when reduction is suboptimal in the zygomaticosphenoid area or when fixation does not adequately control rotation [10].

Although multiple studies compare fixation strategies (e.g., one-point vs two-point vs three-point fixation), outcomes vary with fracture pattern, imaging assessment, and follow-up duration. Consequently, a clinically pragmatic question persists: in typical tertiary-care settings where titanium miniplates are used for rigid fixation, what is the postoperative complication profile and how stable is the fixation over early healing intervals? Addressing this question using standardized outcome definitions and scheduled follow-up can strengthen decision-making regarding fixation points, adjunct orbital assessment, and patient counseling.

Aim: To evaluate postoperative complications and early stability of rigid internal fixation in ZMC fractures treated with ORIF using titanium miniplates.

Objectives: (1) quantify postoperative complications over 3 months; (2) assess fixation stability clinically and radiographically; and (3) explore predictors of complications and/or instability.

Study design and setting A single-center observational cohort design was structured to evaluate patients with ZMC fractures managed by ORIF and rigid internal fixation with titanium miniplates. The clinical workflow included initial trauma assessment, maxillofacial examination, CT-based fracture characterization, operative management, and standardized postoperative follow-up. Participants Eligibility criteria (intended): • Inclusion: adults (≥18 years) with unilateral displaced ZMC fractures (tripod/tetrapod patterns) requiring ORIF; CT confirmation; surgery performed within 14 days of injury; consent for follow-up. • Exclusion: panfacial fractures needing staged reconstruction; pathological fractures; severe traumatic brain injury precluding assessment; prior midface surgery; follow-up anticipated <3 months. Preoperative assessment and fracture characterization All patients underwent clinical evaluation for malar flattening, step deformity at buttress, trismus (interincisal opening), ocular signs (diplopia, enophthalmos, dystopia), and infraorbital sensory disturbance. Maxillofacial CT (axial/coronal with 3D reconstruction) was used to document fracture sites and displacement severity. Fractures were grouped pragmatically as moderately displaced or severely displaced/comminuted based on CT displacement/rotation and buttress disruption. Surgical technique (standardized description) ORIF was performed under general anesthesia. Reduction was achieved using elevator-assisted mobilization and direct visualization at planned exposure sites. Fixation employed low-profile titanium miniplates and screws. Fixation points were chosen according to fracture characteristics (commonly zygomaticomaxillary buttress ± FZ suture ± infraorbital rim). Orbital floor exploration/reconstruction was performed selectively if CT and intraoperative assessment suggested significant floor defect/entrapment. Wounds were closed in layers with standard postoperative antibiotic/analgesic regimen. Outcomes and follow-up schedule Patients were evaluated at postoperative week 1, week 6, and month 3. • Primary outcomes: overall postoperative complication rate; and fixation stability (clinical and CT-based). • Stability definition (operational): absence of clinically appreciable mobility/step and absence of secondary displacement >2 mm on follow-up imaging (or clinically indicated CT). • Complications recorded: infection, wound dehiscence, plate exposure, plate palpability (symptomatic), persistent malar asymmetry, persistent diplopia/enophthalmos, persistent infraorbital hypoesthesia, and significant trismus. Statistical analysis plan Data were summarized using mean±SD or median (IQR) for continuous variables and frequency (%) for categorical variables. Group comparisons (e.g., by fixation points or displacement severity) were intended using chi-square/Fisher’s exact tests for categorical variables and t-tests/Mann–Whitney U tests for continuous variables. Multivariable logistic regression was planned to explore predictors of (a) any complication and (b) instability, including age, displacement severity, fixation points, smoking, and time-to-surgery. A two-sided p<0.05 was considered statistically significant.

Illustrative cohort: 120 patients with unilateral ZMC fractures treated with ORIF and titanium miniplates, followed for 3 months.

Narrative (Table 1): The illustrative sample predominantly comprised young adult males, with road-traffic injuries as the leading mechanism. Moderate displacement was more common than severe/comminuted patterns. Over half presented with infraorbital sensory disturbance preoperatively, while ocular symptoms (diplopia) affected a smaller subset. More than one-third had clinically relevant trismus at presentation, reflecting the functional burden of ZMC disruption and associated soft-tissue injury. These baseline features were used to explore predictors of postoperative complications and stability.

Table 1. Baseline characteristics and injury profile (n=120)

Table 2. Operative details and fixation strategy

Narrative (Table 2): Most patients underwent surgery within the first week. Two-point fixation (zygomaticomaxillary buttress plus frontozygomatic region) was the most frequent construct, with one-point fixation reserved for less complex patterns and three-point fixation used when additional rotational control or infraorbital rim stabilization was required. Orbital floor exploration was selective and performed in fewer than one-fifth of patients. Operative duration and short hospital stay were consistent with standard ORIF pathways for isolated unilateral ZMC injuries.

Table 3. Postoperative complications over 3 months

*among total cohort; includes those with preoperative deficit.

Narrative (Table 3): Early postoperative morbidity was dominated by transient neurosensory symptoms and functional limitation rather than major infection or ocular complications. Infection rates were low and declined over time; plate exposure was uncommon but persisted in a small subgroup. Infraorbital sensory disturbance improved substantially between week 1 and month 3, suggesting progressive nerve recovery. Residual malar asymmetry and diplopia were infrequent at 3 months, indicating generally acceptable aesthetic and orbital outcomes in the context of rigid fixation.

Narrative (Table 4): Most patients demonstrated stable fixation by week 6 and maintained alignment through 3 months. Secondary displacement exceeding the predefined threshold was uncommon and concentrated in the one-point fixation subset, consistent with the biomechanical concern that single-site constructs may inadequately control rotation in more displaced fractures. Reintervention was rare and typically associated with hardware complications rather than gross reduction failure. Overall, rigid fixation using titanium miniplates showed a high early stability rate with low revision burden.

Table 4. Fixation stability and secondary displacement (clinical/radiographic)

*CT performed when clinically indicated or per protocol in unstable cases.

This manuscript-style cohort suggests that rigid internal fixation with titanium miniplates for ZMC fractures is associated with high early stability and a generally low incidence of major complications. The dominant postoperative issues were neurosensory disturbance and early functional limitation, which improved over time, whereas infection, persistent ocular symptoms, and clinically significant malar asymmetry were comparatively infrequent by 3 months.

The observed pattern aligns with contemporary understanding that ZMC fractures carry a substantial risk of infraorbital nerve dysfunction at baseline, with recovery occurring gradually after reduction and stabilization. Clinical studies evaluating infraorbital nerve recovery demonstrate that neurosensory deficits are common at presentation and may persist in a minority, influenced by the degree of displacement and nerve contusion/compression [11]. Prospective evaluation of sensory recovery has similarly highlighted improvement trajectories over weeks to months, supporting the interpretation that the decline in persistent hypoesthesia across follow-up intervals reflects nerve regeneration and decompression after anatomical reduction [11,12]. From a counseling standpoint, patients should be informed that sensory recovery is expected but not guaranteed, and persistent deficits can occur.

Stability outcomes in this draft are consistent with the rationale for multi-point fixation in fractures with significant displacement or rotation. Evidence syntheses and clinical comparative studies emphasize that increased fixation points can improve control of rotational and translational instability, albeit with trade-offs of additional exposure and operative time. Comparative clinical work supports two-point fixation as a commonly effective balance for many ZMC patterns, while three-point fixation may be selected when additional stability is required—particularly when infraorbital rim involvement or marked displacement is present [13–15]. A broader evidence review of fixation points likewise underscores ongoing debate regarding the “optimal” fixation scheme and stresses individualized decision-making based on fracture morphology rather than rigid adherence to a fixed number of plates [16]. The finding that instability clustered within one-point constructs is biomechanically plausible, because single-point buttress fixation may not fully neutralize rotational vectors, especially in more complex injuries.

Hardware-related morbidity in this draft (palpability, rare exposure) is clinically relevant because it affects patient comfort and may necessitate plate removal. Observational reporting on ZMC fracture surgery describes that fixation is frequently placed at the zygomaticomaxillary buttress and FZ suture using low-profile titanium systems, with occasional symptomatic hardware depending on plate design, soft-tissue thickness, and incision choice [17]. Hardware issues often reflect local factors (thin soft tissue, wound care, infection) rather than “failure” of fixation strategy per se; nonetheless, they remain important endpoints when comparing approaches. Evidence comparing biodegradable and titanium osteosynthesis in maxillofacial trauma indicates broadly comparable clinical efficacy, while symptomatic plate removal may differ by material system and context, suggesting that hardware selection should consider local complication patterns and resource factors [18,19]. However, titanium remains a dependable standard where predictable rigidity and handling are prioritized.

Ocular outcomes are particularly high-stakes because inadequate reduction can alter orbital volume and lead to persistent diplopia or enophthalmos. Contemporary management frameworks recommend careful preoperative CT review and selective orbital exploration/reconstruction when defects or entrapment are suspected. Reviews focusing on optimization of ZMC management highlight that accurate three-dimensional reduction—especially at the zygomaticosphenoid region—is central to restoring orbital geometry and malar projection [20]. In practical terms, centers may improve outcomes by standardizing orbital assessment (including forced duction testing where relevant) and ensuring early follow-up for persistent diplopia.

Limitations

This draft reflects an observational approach and may be subject to confounding by injury severity and surgeon preference (e.g., three-point fixation being chosen for more complex fractures). Short follow-up can under-capture late outcomes such as delayed plate removal or subtle asymmetry. Additionally, stability assessment ideally uses standardized CT protocols for all patients; selective imaging can underestimate minor displacement. For journal submission, strengthen the manuscript by (1) clearly defining fracture classification, (2) stating imaging criteria and timing, and (3) reporting patient-reported outcomes where feasible [21-26].

Clinical implications

Within typical tertiary-care practice, ORIF with titanium miniplates appears to provide high early stability with acceptable complication rates. Two-point fixation may be adequate for many displaced ZMC fractures, while one-point fixation should be used cautiously and reserved for fracture patterns demonstrably stable after reduction. Sensory recovery should be anticipated but monitored, and the decision for additional fixation points should be driven by displacement/rotation and orbital involvement rather than routine practice alone.

Rigid internal fixation using titanium miniplates for zygomaticomaxillary complex fractures demonstrates high early stability with a low frequency of major postoperative complications. In this manuscript-style cohort, most adverse outcomes were minor and time-limited—particularly infraorbital sensory disturbance and early functional restriction—while infection, persistent ocular symptoms, and clinically significant malar asymmetry were uncommon by 3 months. Stability concerns and secondary displacement were rare overall but appeared more frequent when single-point fixation was used, supporting fixation-scheme individualization based on fracture displacement, rotational tendency, and orbital rim involvement. For clinical practice, structured follow-up focused on neurosensory recovery, ocular symptoms, wound/hardware status, and facial symmetry is recommended. For publication, final conclusions should be based on the center’s actual dataset with standardized imaging and clearly defined stability criteria.

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