Maxillofacial fractures are generally addressed for function, aesthetics, and quality of life. The trauma evaluation protocol varies among different centers, but the clinical parameters of concern are roughly the same.

We observed that the severity of trauma was more significant in patients under the influence of alcohol, thus increasing the risk of morbidity [6, 7]. This finding was more prevalent in the younger age groups (below 40 years). In the elderly, slip and falls were the primary causative factor, and injuries sustained could be attributed to age-related bone changes [8, 9]. Our study found a high incidence of facial soft tissue injuries associated with ZMC fractures. This was similar to the findings of Lim et al., who, in their study, found an association between facial fractures and concomitant injuries [10].

The decision to treat ZMC fractures surgically or conservatively is vital. Indications for surgical intervention include fracture displacement, malar depression, the presence of step deformity, or limited mouth opening [1, 11,12,13]. As per existing literature, mildly displaced fractures with minimal to no symptoms generally formed the criteria for conservative management of facial fractures [14]. But non-surgical treatment outcomes, especially of ZMC fractures, have rarely been discussed [14, 15]. In this study, we included patients with varying degrees of ZMC fracture based on the Zingg et al. classification. Due to varied reasons like associated neurological, abdominal, or thoracic injuries, some displaced fractures that traditionally warrant surgical intervention had to be managed conservatively in this study. Thus, for the first time, we have presented a comprehensive evaluation and enlisted the outcomes of non-surgical management of different grades of ZMC fractures.

Regarding the Zingg et al. classification, in our study, Type A fractures occurred more frequently than Type B but only marginally. Brucoli et al. (7) reported a higher incidence of Type B fractures, which may be attributed to their large sample size (1406). Among Type A fractures, the higher incidence of A3 and low incidence of A2 in our study similar to that of Brucoli et al. (7). The lower incidence of A2 fractures indicates that isolated fractures of the lateral orbital wall rarely occur. The low incidence of Type C fractures may be because patients in this group often seek surgical intervention to improve obvious functional and aesthetic deformities [16, 17].

Pain in the affected area reduces significantly over time [4]. Neuropathic pain can lead to chronic pain, which can affect the patient psychologically and influence the individual’s quality of life [18]. In our study, Type A had an 80.4% improvement after 6 months, followed by Type B (60.5%). We noticed that in non-surgical management, the lesser the fracture severity and displacement, the better the prognosis for pain reduction. The multi-fragmented Type C fracture group showed only a 27.3% improvement in pain reduction after 6 months (Table 3). These findings were similar to a study by Dubron et al., who reported a higher incidence of neuropathic pain symptoms in Type B and C fractures [18].

Restriction in mouth opening posed a significant concern for us. Thirty-three patients in the final evaluation, thirty (90.9%) did not report any restriction until clinical evaluation. This may be attributed to the dietary modifications made to cope with the same and the lack of awareness about the minimal requisites of a standard mouth opening. Coronoid fracture or impingement of the zygomatic arch is the usual cause of restricted mouth opening [19]. In our study, some fractures involving the zygomatic arch also showed restriction in mouth opening. The restriction may also be due to the damage of anatomical soft tissue attachments [1].

Altered nerve deficit is a well-documented phenomenon following fractures of the ZMC region [7]. Authors have attributed this to the involvement of the infraorbital canal/foramen within the ZMC fracture line, which acts as a “chink in one’s armor” [20, 21]. The vulnerability of this anatomic landmark leads to traction–compression or rupture of the nerve resulting in paresthesia [22, 23]. In minimally displaced fractures, quick resolution happens once edema or the hematoma settles [4, 24]. Ironically, surgically managed groups of patients too may suffer from nerve injury due to iatrogenic causes [25]. However, it is not discussed as it is beyond the scope of this study. As noted by Back et al., “there is no justification for surgical treatment of these fractures if altered nerve sensitivity is the only complication” [14]. In our study, while the infraorbital rim fracture (A3) is the most prevalent Type A fracture, its minimal displacement resonates with maximum improvement (77.3%) in 6 months. Significant correlations between Type B and increased nerve paresthesia were noted. 54.5% of patients reported resolution, while the rest continued to have paresthesia. These findings bear similarity to the study by Brucoli et al., who said that increased severity of the mono-bloc displaced ZMC fracture results in increased nerve paresthesia [7]. Type C, with possible nerve rupture, exhibited a minor resolution (36.4%) (Table 3).

Aesthetic deformity with or without malar flattening is a thoroughly documented finding [20] and is of aesthetic concern to patients. Some patients reported it affecting their personal or professional life. This could be due to the purely subjective nature of the deformity [26, 27]. Post-traumatic malar edema masks this deformity during the initial evaluation. Comparable improvement was noted in the Type A and B groups during the final review after 6 months but was not statistically significant (Table 3). The improvement was evident in only those cases of aesthetic deformity not associated with malar flattening.

One of the most frequent signs of a ZMC fracture is step deformity of the bony margin [28]. There can be associated tenderness on palpation of this region. No significant resolution of tenderness on palpation of the step deformity and the persistence of the step in all our reported cases suggests the possible need for surgical intervention (Table 3). Studies have similarly indicated that infraorbital rim deformity is one of the factors affecting prognosis and warrants surgical intervention for the same [1, 20].

In our study, diplopia was a noted complication, with one patient reporting painful gazes. Most subjects reporting diplopia were late presentation cases following trauma (more than 2 months). Popular literature documents diplopia as one of the common complications post ZMC fractures [7]. One patient had sought an ophthalmology consultation and is currently on prescription glasses. We found pain during lateral gazes in one patient, which persisted even after 6 months. There may be involvement of the III, IV, or VI cranial nerve, which warrants a complete ophthalmology evaluation [7]. Nevertheless, in Type B or C, it is essential to recognize the entrapment of the inferior rectus muscle into the orbital floor, which would warrant prompt surgical management [1]. The results of our study justify this fact, as no significant improvement of the ophthalmic condition was noted in any of the groups after 6 months (Table 3).

In our study, Type A benefitted the most from non-surgical management. We observed satisfactory improvement in parameters such as pain reduction, mouth opening, and infraorbital nerve paresthesia. Isolated fractures with minimal displacement could have aided adequate healing with time. Type A with nerve/muscle injury, infraorbital step, or diplopia exhibited slight improvement. Even mild fractures can lead to lasting deformity if not thoroughly diagnosed.

In Type B fractures, the mono-bloc zygoma is separated from its surrounding articulating bones. The deformities depend on the degree of displacement. It is known that the lesser the displacement, the better the non-surgical outcomes. However, few cases with appreciable fracture separation had satisfactory results with time, as noted with the improvement of pain, nerve paresthesia, and mouth opening. Self-healing capability is vital, but such observation demands long-term research for justification. Large sample size is required to identify suitable candidates for conservative management. This factor is a limitation of the present study.

This study reveals that Type C with comminution shows no significant improvement in any parameters. (P > 0.05). The severity of the fracture in this group demands surgical intervention to restore function and aesthetics.

Another notable observation was significant inter-variable relationships (Table 4). As one variable among the pair improves, the other factor improves and vice versa. These inter-variable relationships could give the surgeon insight and help decide to wait and watch or intervene promptly for the patient’s overall well-being.