0 AN OPTIMAL POSTOPERATIVE SYMMETRY AFTER TWO-POINT FIXATION WITH OPEN REDUCTION IN INTERNAL FIXATION OF COMPLEX ZYGOMATICOMAXILLARY FRACTURES: A RADIOGRAPHIC ANALYSIS OriginalPaper 1 1 2018 44452 Kukuh Adhi Nastiti Poerwati Soetji Rahajoe poerwati_soetji_fkg@ugm.ac.id Didit Istadi Department of Oral and Maxillofacial Surgery Universitas Gadjah Mada Yogyakarta Indonesia Kukuh Adhi Nastiti 1 , Poerwati Soetji Rahajoe1*, Didit Istadi1 1Department of Oral and Maxillofacial Surgery, Universitas Gadjah Mada, Yogyakarta, Indonesia Corresponding author: Poerwati Soetji Rahajoe, Email address: *poerwati_soetji_fkg@ugm.ac.id ABSTRACT Background Zygomatico-Maxillaris Complex (ZMC) fractures are the second most common fractures after nasal fractures. Open Reduction Internal Fixation (ORIF) is the most preferable treatment option in the management of ZMC fractures, mainly aiming at achieving maximum reduction and stability to prevent from micromovement. There is no consistency in the number of fixation points required to achieve stability. The study was aimed at evaluating the difference in the number of fixation points on radiographic symmetry after ORIF. Methods This retrospective study used Water's radiographic data from patients who had undergone ORIF, with predetermined patient inclusion criteria. The data were grouped into group A (1-point fixation), group B (2-point fixation), and group C (3-point fixation), each of which comprised 20 samples, and observations were made on day 3 postoperatively. Symmetry was analyzed using the symmetry index and Bland Altman analysis by comparing the non-fracture side and the fracture side after ORIF in unilateral ZMC fractures. Results Post Hoc LSD statistical tests showed that the smallest symmetry index was found in group B (0.42 ± 0.16) compared to group C (0.45 ± 0.18) and group A (0.79 ± 0.22) with P value of 0.63 and 0.00, respectively. Bland-Altman analysis with a 95% limit of agreement showed the smallest limit also in group B, which means that group B had the best symmetry, followed by group C and group A, but overall all groups showed symmetry. Conclusion The number of fixation points affects the symmetry of the zygomatic bone in patients with unilateral ZMC fractures after ORIF. The use of 2 fixation points in ZMC fractures results in the best symmetry.

Keywords: ZMC fracture ORIF waters radiograph malar bone symmetry symmetry index Bland Altman Introduction Consisting of the frontal, temporal, sphenoid, and maxillary bones, the Zygomatico Maxillaris Complex (ZMC) contributes greatly to providing structural form and aesthetic function to the middle third of the face. The ZMC serves as the insertion site for the masseter muscle, protects the temporal muscle and coronoid process, separates the orbit from the temporal fossa and maxillary sinus, and absorbs forces directed toward the eye and brain in the event of trauma.2,3,4 ZMC fractures often occur in the middle third of the face, the second most frequent after nasal fractures.3,5,6,7,8 Dubron et al (2021) reported an incidence of 44.3% in Belgium, and Farber et al (2016) in Washington showed that there were more than 40% of ZMC fracture cases.5,9 In Indonesia, the relevant study is still rare. The incidence rate at Sanglah Hospital in Bali was reported to be 30.22% (Wiargitha & Wiradana., 2019), and at Mangusada Hospital in Bali, the incidence was 35.1%-40% (Wiwekananda et al, 2019). 7,8 A study by Andrian and Wibowo (2023) in Bandung reported an incidence of 34.6%.6 Open Reduction Internal Fixation (ORIF) is widely recommended due to its access for exploration of the fracture area, reduction, and more accurate fixation.2,10 There has been no consensus on the number of fixation points and surgical approach, as well as the ZMC fracture management algorithm.2,11 Several studies have been inconsistent in the number of fixation points required to achieve post-ORIF stability,12,13,14 and multiple access points may increase the risk of complications such as scarring and paresthesia.2,12 In particular, the approach to the infraorbital region carries a risk of ectropion, bradycardia due to eye pressure, and diplopia.2,11 The key purpose in ZMC fracture treatment is to achieve reduction that approximates or reaches the condition prior to fracture with maximum stability.2 Micromovement may occur if the stability achieved is not optimal, inducing changes in the height of the malar bone, resulting in asymmetry, and even leading to other complications such as orbital dystopia, enophthalmos, and diplopia..2,15,16 Jazayeri et al (2021) reported that 3-point fixation was superior to 2-point fixation in terms of orbital dystopia symmetry and malar bone symmetry.17 Degala et al (2021) found that 2-point fixation is sufficient for malar bone symmetry with minimal surgical approach,12 but Shokri et al (2020) found that 1-point fixation was sufficiently stable.14 Previous studies showed inconsistency in the number of fixation points required to achieve stability in the treatment of ZMC fractures.6,7,8 This study was aimed at evaluating the difference in the number of fixation points in the management of ZMC fractures on the symmetry of the malar bone after ORIF. Methods This retrospective study was performed on patients with unilateral ZMC fractures who were treated from 2020 to 2024 at Prof. Dr. Margono Soekarjo Regional General Hospital, Indonesia. Data were collected from medical records with the following inclusion criteria: (a) patients diagnosed with unilateral ZMC fractures, (b) patients with Waters radiograph data on day 3 postoperatively (®Instrumentarium OP300 Panorex), (c) complete medical records, (d) 11–60 years of age, and (e) presence of molar teeth for occlusion. Exclusion criteria include: (a) radiographic data ineligible for the requirements as determined by the radiology specialist (SFD). This study was approved by the Ethics Committee of the Faculty of Dentistry, Universitas Gadjah Mada (34/UNI/KEP/FKG-RSGM/EC/2025). The sample size for this study refers to the study by Choudury et al. (2020), which examined the symmetry of the vertical aspect of the malar bone involving 40 samples with 80% power estimation and a 95% confidence interval. This study used 60 samples of patients after ORIF.31 The samples were divided into three groups based on the number of fixation points: group A used 1-point fixation (n = 20 patients), group B used 2-point fixation (n = 20 patients), and group C used 3-point fixations (n = 20 patients). Medical record data which include age, gender, etiology, location of ZMC fracture displacement, and type of open or closed fracture were recorded. Similarly, surgical reports including surgical approach, plate placement location (point fixation), plate type, and preoperative and postoperative complications were also recorded. Symmetry was evaluated from Water’s radiographs taken on day 3 after ORIF by a radiology specialist. Considering as the beginning of primary healing and the end of the inflammatory phase. Symmetry was evaluated by comparing the fracture side post-ORIF with the non-fracture side, as in the study by Kim et al. (2021), and was also analyzed with the Bland-Altman test. Symmetry Analysis Symmetry analysis, the selected Water's radiographs were standardized in pixel size to 534 x 600 using Adobe Photoshop 2022, 64 bit (Adobe, San Jose, California) (Fig. 1). Subsequently, landmark points were identified using ImageJ software (Wayne Rasband NIH). In this study, the landmark points used were: (1) anterior nasal spine (2) crista galli (3) the lowest point on the orbital rim on both the fracture and non-fracture sides (Fig. 2). The three points on the fracture and non-fracture sides were then connected to form a right triangle, and each line (horizontal, vertical, and diagonal) was measured (Fig. 3). In this study, the symmetry analysis used the symmetry index (Kim et al, 2021)13 by adding the results of the subtraction of the squares of the horizontal, vertical, and diagonal lines and then the result was square rooted, where the value of the size of the fracture side after ORIF vertical, horizontal, and diagonal was subtracted from the non-fracture side on the vertical, horizontal, and diagonal Water's radiograph. The symmetry index formula = . In addition to the symmetry index (Kim et al, 2021), the symmetry analysis also used the Bland Altman test to categorize symmetry, by comparing the perimeter (between triangles formed from landmark points made on the fracture and non-fracture sides). It is said to be symmetrical if the mean difference is within the range of ± 95% limit of agreement (standard deviation).

Fig. 1 Standardization of pixel size

Fig. 2 Determination of Anatomical Landmarks with image-J software (®Wayne Rasband NIH)

Fig. 3 Triangle construction using anatomical landmarks on the fracture and non-fracture sides. Note: Blue color: fractured side after ORIF. Purple color: non-fracture side. Red line: midline, connecting crista galli and anterior nasal spine. Yellow line: imaginary horizontal line from the anterior nasal spine. Horizontal line: connecting the anterior nasal spine to the intersection of the vertical line at the lowest point of the orbital rim. Vertical line: connecting the lowest point of the orbital rim to the horizontal line extending the anterior nasal spine. Diagonal line: connecting the anterior nasal spine to the lowest point of the orbital rim. The gap in the vertical line (+) indicates a cranial shift of the orbital point compared to the non-fracture side, and (-) shows a caudal shift of the orbital point compared to the non-fracture side. The gap in the horizontal line (+) points out a lateral shift of the orbital point compared to the non-fracture side. The (-) reveals a medial shift of the orbital point compared to the non-fracture side. The diagonal gap (+) indicates a lengthened line, and (-) shows a shortened line. Data Analysis The data analysis of this study was made using IBM SPSS software version 29. The post-ORIF ZMC symmetry index based on the number of fixation points was tested using one-way ANOVA followed by the post-hoc LSD (Least Significant Difference) test. All statistical analyses used a 95% confidence level (α = 0.05), with a P value < 0.05 was considered statistically significant. Results During 2020–2024, 144 patients were treated with a diagnosis of unilateral ZMC fracture, but only 60 samples met the inclusion criteria. A total of 84 patients were excluded because of not Water’s radiograph. The eligible 60 samples were grouped into three categories based on the number of point fixation used: group A (1-point fixation), group B (2-point fixation), and group C (3-point fixation), each of which consists of 20 samples. Patients involved in the study in the three groups were predominantly male, the age group was dominated by 11–30 years, the cause of road traffic accidents (RTA) was multiple and dominated by closed fractures, but all showed no significant difference. In group A, displacement was more frequent in the zygomaticomaxillary and infraorbital (30%), while in group B and group C, displacement was more frequent in the zygomaticomaxillary, frontozygomaticus, and infraorbital, as many as 13 patients (65%) in group B and 12 patients (60%) in group C (P = 0.00) (Table 1). Characteristics 1-point fixation (Group A n = 20) 2-point fixation (Group B n = 20) 3-point fixation (Group C n = 20) P Gender Male 19 (95%) 14 (70%) 17 (85%) 0.10 Female 1 (5%) 6 (30%) 3 (15%) Age 11–30 years 13 (65%) 11 (55%) 9 (45%) 0.39 31–50 years 3 (15%) 4 (20%) 5 (25%) 51–70 years 4 (20%) 5 (25%) 6 (30%) Etiology Single RTA 1 (5%) 3 (15%) 6 (30%) 0.23 Multiple RTA 16 (80%) 16 (80%) 12(60%) Fall down 3 (15%) 1 (5%) 2 (10%) Type of Fracture Open 6 (30%) 2 (10%) 3 (15%) 0.23 Closed 14 (70%) 18 (90%) 17 (85%) Displacement Location ZM 4 (20%) 0 (0%) 0 (0%) 0.00* FZ 4 (20%) 0 (0%) 0 (0%) IO 1 (5%) 0 (0%) 0 (0%) ZM and IO 6 (30%) 2 (10%) 0 (0%) ZM and FZ 0 (0%) 1 (5%) 0 (0%) FZ and IO 2 (10%) 2 (10%) 0 (0%) ZM, FZ and IO 0 (0%) 13 (65%) 12 (60%) FZ and AZ 3 (15%) 0 (0%) 0 (0%) ZM, FZ, IO and AZ 0 (0%) 2 (10%) 8 (40%)

Description: ZM Zygomaticomaxillary, FZ frontozygomaticus, IO infraorbita, AZ arcuszygomaticus. Single KLL = accident involving only one vehicle and no other parties involved. Multiple KLL = accident involving two or more vehicles and involving other parties. P = 0.05 based on chi-square test. Based on the surgical approach performed, group A (1-point fixation) with a single approach, either intraoral (vestibule) or extraoral (lateral eyebrow) (in 8 patients), while two combinations (intraoral and extraoral) were all performed on the installation of 2-point fixation and 3-point fixation. The operation generally took 1 hour, mostly using a straight plate (Table 2). Characteristics 1-point fixation (Group A n = 20) 2-point fixation (Group B n = 20) 3-point fixation (Group C n = 20) P Surgical approach Intra oral 8 0 0 0.00* VM 8 (40%) 0 (0%) 0 (0%) Extra oral 12 0 0 IO 4 (20%) 0 (0%) 0 (0%) LE 8 (40%) 0 (0%) 0 (0%) Combination of intra oral and extra oral 0 20 20 LE, VM 0 (0%) 15 (75%) 0 (0%) IO, VM 0 (0%) 3 (15%) 0 (0%) LE, IO 0 (0%) 2 (10%) 0 (0%) LE, IO, VM 0 (0%) 0 (0%) 20 (100%) Duration of operation 1 hour 20 (100%) 15 (75%) 13 (65%) 0.01* > 1 hour 0 (0%) 5 (25%) 7 (35%) Type of Plate Straight 15 (75%) 13 (65%) 13 (65%) 0.21 Curved 2 (10%) 1 (5%) 0 (0%) L-shape 3 (15%) 2 (10%) 0 (0%) Straight and curved 0 (0%) 2 (10%) 2 (10%) Straight and L-shaped 0 (0%) 1 (5%) 4 (20%) Curved and L-shaped 0 (0%) 1 (5%) 1 (5%) Plate installation Site ZM 9 (45%) 0 (0%) 0 (0%) 0.00* IO 3 (15%) 0 (0%) 0 (0%) FZ 8 (49%) 0 (0%) 0 (0%) ZM, FZ 0 (0%) 14 (70%) 0 (0%) ZM, IO 0 (0%) 4 (20%) 0 (0%) FZ, IO 0 (0%) 2 (10%) 0 (0%) ZM, FZ, IO 0 (0%) 0 (0%) 20 (100%)

Description: ZM: Zygomaticomaxillary, FZ: frontozygomaticus, IO: infraorbita, AZ: arcuszygomaticus, VM: maxillary vestibular, LE: lateral eyebrow, P based on chi-square test with α = 95%. Preoperative and postoperative complications (Table 3) such as diplopia, dystopia, and malocclusion were not found. Preoperatively, paresthesia complications were found in all groups, the most frequent or 50% paresthesia was found in group B, followed by group C 40%, and A 15%. However, postoperative paresthesia decreased, the most frequent decrease or 35% occured in group B. There was no significant difference in all groups, with P 0.65, 0.10, and 0.40, respectively (Table 3). Complications 1-PF (Group A) n = 20 2-PF (Group B) n = 20 3-PF (Group C) n = 20 Preop Post op Preop Post op Preop Post op Diplopia 0 0 0 0 0 0 Dystopia Paresthesia 3 (15%) 2 (10%) 10 (50%) 4 (20%) 8 (40%) 5 (25%) Malocclusion 0 0 0 0 0 0 P 0.65 0.10 0.40 Description: PF: point fixation. P is based on the chi-square test with α = 95%. Postoperative observation until day 3

Distance between fracture and non-fracture sides (Table 4) The distance was seen from the vertical, horizontal, and diagonal gaps. The average result of the smallest horizontal gap in the 2-point fixation group was 0.01 mm, the largest difference in the 1-point fixation group was 0.06 mm. The smallest vertical gap in the 3-point fixation group was 0.01 mm, the largest difference in the 1-point fixation group was − 0.2 mm, but the smallest diagonal gap in the 1-point fixation group (0.01 mm), the largest gap in the 3-point fixation group (-0.05 mm), but there was no significant difference in groups A, B, and C with P value of 0.76, 0.27, and 0.88, respectively. Number of point fixation Horizontal (mm) () Vertical (mm) () Diagonal (mm) () Fracture Non Fracture Gap Fracture Non Fracture Gap Fracture Non Fracture Gap (A) 1 PF 3.97 ± 0.53 3.91 ± 0.46 0.06 ± 0.39 0.93 ± 0.4 1.13 ± 0.33 -0.2 ± 0.52 4.09 ± 0.54 4.08 ± 0.47 0.01 ± 0.45 (B) 2 PF 4.13 ± 0.46 4.12 ± 0.48 0.01 ± 0.19 0.8 ± 0.31 0.92 ± 0.29 -0.12 ± 0.32 4.21 ± 0.47 4.23 ± 0.48 -0.02 ± 0.22 (C) 3 PF 4.33 ± 0.34 4.38 ± 0.3 -0.05 ± 0.26 0.92 ± 0.22 0.91 ± 0.3 0.01 ± 0.29 4.43 ± 0.35 4.48 ± 0.32 -0.05 ± 0.27 P 0.76 0.27 0.88

Description: PF: point fixation. The gap is calculated from the fracture and non-fracture sides. Horizontal (+) experiences lateral shift, horizontal (-) experiences medial shift, vertical (+) experiences lengthened malar bone height, vertical (-) experiences shortened malar bone height. P is based on the Kruskal Wallis test, with α = 95%. Malar Bone Symmetry Index (Kim et al, 2021) The symmetry index of the malar bone (Table 5) reflects the position of the malar bone on the fractured side compared to the non-fracture side, calculated using the formula according to Kim et al, (2021). 13 The smaller the index value, the more symmetrical it was. It was found that the symmetry index of group B (0.42 ± 0.16) was smaller than group C (0.45 ± 0.18) (P = 0.63) and group A (0.79 ± 0.22) (P = 0.00), while group C was smaller than group A (P = 0.00), thus group B was the most symmetrical (Table 5, Fig. 4). Group Symmetry Index () P A (1-point fixation) 0.79 ± 0.22 0.00** B (2-point fixation) 0.42 ± 0.16 C (3-point fixation) 0.45 ± 0.18 P based on one-way Anova test, with α = 95%

Description: P based on LSD post hoc test, with α = 95%

Figure 4. Symmetry index graph based on the number of fixation points Bland-Altman Analysis Bland-Altman analysis was used to assess symmetry statistically, the calculation results of 95% limit of agreement for group A range [2.50-(-2.24)], group B [1.37-(-1.11)], group C [1.43-(-1.25)]. The largest limit was found in group A, while the smallest limit was in group B. Because the limit of agreement for group B was the smallest, group B had the best symmetry, but all groups showed symmetry in general, because the calculation results were still within the limit of agreement range (Table 6) (Fig. 5). Group Mean Standard Deviation Range Upper Limit Lower Limit A (1-point fixation) 0.128 1.21 2.50 -2.24 B (2-point fixation) 0.1295 0.63 1.37 -1.11 C (3-point fixation) 0.0885 0,.8 1.43 -1.25 Description: symmetrical values within 95% limit of agreement

Fig. 5 Bland-Altman graph (A) 1-point fixation (group A), (B) 2-point fixation (group B), (C) 3-point fixation (group C) Discussion The subjects of this study, ZMC fractures in the 1-point fixation, 2-point fixation, and 3-point fixation groups, were mostly experienced by men aged 11–30 years, with multiple traffic accidents ending up in fractures, and displacements often occurred in the zygomaticomaxillary, frontozygomaticus, and infraorbital areas.21 Similarly, studies conducted by Choudury et al. (2020); Gautam et al. (2024); Farber et al. (2016); and Wiwekanda et al. (2019) found similar findings, with young adult men engaging in more activities, work, and risky behavior.7,9,20 The most common approach in this study was intraoral (vestibule), which was superior for its effectiveness and minimal invasion.20,21,22 It also provides good access for malar bone reduction, considering aesthetics and minimal complications. 1-point fixation was often performed using a vestibule approach, while multiple-point fixation was carried out using an intraoral approach combined with an extraoral approach, mostly on the lateral eyebrows followed by the infraorbital approach, as also found in studies by Raghoebar et al. (2022); Rana et al. (2016); and Ji et al. (2016).23,24 There has been no agreed-upon algorithm for the management of ZMC fractures (in terms of the number of fixation points), but accurate reduction and stable fixation were the basis. The objective of ZMC fracture treatment was to achieve a reduction that approaches or reaches the pre-fracture condition with maximum stability.2 This study was aimed at evaluating the number of fixation points on malar bone symmetry after ORIF in unilateral ZMC fractures.23,25 The direction of fragment shift after ORIF was greatly affected by the masticatory muscles. The masseter muscle originates from the zygoma and inserts at the angle, thereby the direction of shift often leads to inferior and diagonal, due to the large tensile strength.27,28 Shabana et al, (2024) claimed the use of 2-point fixation with the main fixation key on the zygomaticomaxillary, while reinforced on the frontozigoma or infraorbita was able to resist the force of the masseter muscle.29 In contrast to the study by Chen et al, (2015) the use of 1-point fixation was strong and stable enough to endure the force of the masseter muscle.30 Kim et al, (2018) and Yang et al, (2021) stated that the number of fixation points gave no effect to the stability of the vertical horizontal shift after ORIF,27,28 Meanwhile, Latif et al, (2017) and Rana et al, (2012) assured that the use of 3-point fixation was more stable than 2-point fixation.10,31 The results of this study still showed a gap between the fracture side after ORIF and the non-fracture side, none of which was truly symmetrical with a difference of 0 radiographically, but the gap was not visible clinically, therefore, the patient still looked symmetrical (Table 5). Radiologically, there was a gap (-0.05 ± 0.26) the use of 3-point fixation, As a result, the orbital point after ORIF on the fracture side was more medial than the non-fracture side, while in 2-point fixation and 1-point fixation, the orbital point after ORIF was more lateral than the non-fracture side (gap 0.01 ± 0.19; 0.06 ± 0.39). Viewed from the vertical direction of the use of 3-point fixation, the orbital point after ORIF was more inferior (gap 0.01 ± 0.29), while in 2-point fixation and 1-point fixation, it was more superior (gap − 0.12 ± 0.32; -0.2 ± 0.52). Diagonal shift represents the distance from the orbital point to the anterior nasal spine. The use of 1-point fixation experienced lengthening (0.01 ± 0.45), on the other hand, 2 and 3-point fixation experienced shortening. Radiological asymmetry was not necessarily visible clinically as according to Brindha et al, (2024) shifts of less than 2 mm were difficult to distinguish.26 This study used a symmetry index as in Kim et al, (2021) and the Bland-Altmant statistical test. The symmetry index reflects the position of the ZMC bone after ORIF relative to the non-fracture side, a smaller index indicates more symmetry. 13,18,32 The smallest index was found in the use of 2-point fixation (0.42 ± 0.16), Despite no significant difference with 3-point fixation (0.45 ± 0.18; P = 0.635), between 1-point fixation with 2 and 3-point fixation there was a significant difference with P 0.00, respectively (Table 5). The same results were obtained from the Bland-Altmant analysis, where the best symmetry used 2-point fixation, but overall all groups showed symmetry (Fig. 5). In the study by Kim et al, (2021) which only compared 2-point fixation and 3-point fixation, the smallest symmetry index was found in the use of 2-point fixation with no significant difference, as found in this study.13 Unlike the study by Nasr et al, (2018), the use of 2-point fixation and 3-point fixation showed the same symmetry index and no significant difference.11 The key purpose of ZMC fracture treatment is to achieve function, aesthetics, and minimize complications through stable reduction and fixation.2,27 Stability is vital, without which micromovements occur and may lead to clinically visible complications such as diplopia,24 dystopia and malocclusion.34 In this study, no complications were found as previously mentioned. Paresthesia complications were found in all preoperative groups and decreased postoperatively on day 3. The top decrease in paresthesia was found in the use of 2-point fixation. This condition met with Gawande et al, (2021) that the use of 2-point fixation minimized paresthesia complications compared to 3-point fixation because of interventions in the infraorbital area.35 Meanwhile, the results of the review by Raghoebar et al (2022), with CT assistance intraoperatively, it was able to promote the quality of repositioning, minimize the number of fixations and reduce postoperative complications. Furthermore, paresthesia decreased and there was no significant difference in the use of 2- and 3-point fixation, and none of them required revision.23 Symmetry assessment in this study used a symmetry index with a formula as in Kim et al, (2021); Choudhury et al, (2020); and Degala et al, (2021),13,18,32 Additionally, symmetry was also tested with Bland-Altmant analysis, to categorize the symmetry between the fracture side after ORIF and the non-fracture side to whether or not in the symmetrical category, by evaluating the mean disparity in the range of ± 95% limit of agreement (standard deviation)36 and it was proven to support the results of the symmetry index calculation. As a cross-sectional retrospective research, this study cannot control factors that influence the overall symmetry, such as fracture severity, plate installation sequence, reduction technique. In addition to the previously-mentioned weaknesses, this study cannot control the number of holes and screws, and observations were made only on day 3 postoperatively. Conclusion The number of fixation points affects malar bone symmetry in patients with unilateral ZMC fractures after ORIF. The use of 2 fixation points can result in the best symmetry. No significant difference was found in the use of 3 fixation points (P = 0.63), However, there is a significant difference (P = 0.00), between 1 fixation point and 2 and 3 fixation points. List of Abbreviations ZMC Zygomatico Maxillary Complex ORIF Open Reduction and Internal Fixation LSD Least Significant Difference RTA Road Traffic Accident ZM Zygomatico Maxillary FZ Fronto Zygoma IO Infra Orbita AZ Arcus Zygoma VM Vestibulum LE Lateral Eyebrow PF Point Fixation SD Standard Deviation Hr Horizontal Fracture Side Hi Horzontal Non-Fracture Side Vr Vertical Fracture Side Vi Vertical Non-Fracture Side Dr Diagonal Fracture Side Di Diagonal Non-Fracture Side Declarations Consent to participate and consent for publication Not Applicable. Patient consent This study uses secondary data that obtained from medical records searches. Ethical approval Not Applicable. Data AvailabilityThe data set ad/or analysed during the current study are available from the corresponding author on reasonable request. Ethical clearance Ethical eligibility of the study was approved by the ethics committee of Faculty of Dentistry of the Mada University (34/UNI/KEP/FKG-RSGM/EC/2025). Competing interests The authors have no conflicts of interest to disclose. Funding Self-funded Author ContributionKAN wrote a manuscript, PSR designed a research method and proposed a statistical method, KAN performed data collection and analysis, and PSR, DI supervised the research. The authors read and approved the final manuscript. AcknowledgementThe author thanks to the radiology specialist (SFD) for the evaluation of the radiographic images. Clinical Trial Number Not Applicable References 1. D. Meslemani, R.M. Kellman. Zygomaticomaxillary Complex Fractures. Arch Facial Plast Surg.14, (2012), pp 62 − 6. https://doi.org/10.1001/archfacial.2011.1415 . 2. I. Raghoebar, R.F. Rozema, D.J. Lange, L. Dubois. Surgical treatment of fractures of the zygomaticomaxillary complex: effect of fixation on repositioning and stability. A systematic review. British Journal Of Oral and Maxillofacial Surgery, 60(4), (2021), pp 397–411. https://doi.org/10.1016/j.bjoms.2021.07.006 . 3. B. Yamsani, R. Gaddippati, N. Vura, S. Ramisetti. Zygomaticomaxillary Complex Fractures: A Review of 101 Cases. J Maxillofacial and Oral Surgery, 15(4), (2016), pp 417–424. https://doi.org/10.1007/s12663-015-0851-9 . 4. J.P.T.F. Ho, R. Schreurs, S. Aydi. Natural Variation of the Zygomaticomaxillary Complex Symetry in Normal Individuals. J Craniomaxillofac Surg, 45(12), (2017), pp 1927–1933. https://doi.org/10.1016/j.jcms.2017.09.017 . 5. K. Dubron, M. Verbist, E. Shaheen, J.T. Dormaar, R. Jacobs. Incidence, Aetiology, and Associated Fracture Patterns of Infraorbital Nerve Injuries Following Zygomaticomaxillary Complex Fractures: A Retrospective Analysis of 272 Patients. Craniomaxillofacial Trauma & Recontruction, 15(2), (2022), pp 139–146. https://doi.org/10.1177/19433875211022569 . 6. K. Andrian, M.D. Wibowo. Profiles of patients with maxillofacial fractures in emergency department of head and neck surgery division of Dr. Soetomo General Hospital Surabaya in 2021 during COVID-19 pandemic. 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Yes