Two Plates May Be Enough: Study Finds Sweet Spot for Rebuilding Cheekbone Fractures

When the cheekbone shatters, the goal of surgery sounds deceptively simple: put the pieces back exactly where they were and hold them there. In practice, surgeons have argued for decades about how many titanium plates it takes to do that reliably. A new radiographic study from Indonesia now adds a compelling data point to that debate, suggesting that two-point fixation of complex zygomaticomaxillary fractures achieves facial symmetry that is statistically indistinguishable from three-point fixation, and clearly better than a single plate.

The zygomaticomaxillary complex, or ZMC, is the bony buttress that anchors the middle third of the face, articulating with the frontal, temporal, sphenoid, and maxillary bones. It is far more than a cosmetic structure. It 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 during trauma. Fractures of this region are the second most common facial fractures after nasal fractures, accounting for more than 40 percent of midface trauma cases reported in Washington, 44.3 percent in Belgium, and roughly 30 to 40 percent of midface fractures in Indonesia.

The standard surgical treatment is open reduction and internal fixation, known as ORIF, in which the fractured bone is directly visualized, repositioned, and secured with miniplates. The rationale is to achieve maximum reduction and stability to prevent micromovement of the bone fragments. If fixation is inadequate, even tiny shifts in the position of the malar bone can produce visible asymmetry and serious functional complications, including orbital dystopia, enophthalmos, and diplopia. Yet despite the stakes, there has never been a settled consensus on how many fixation points are needed, and previous studies have pointed in conflicting directions.

Some evidence favored more hardware. A systematic review by Jazayeri and colleagues reported that three-point fixation was superior to two-point fixation in terms of orbital dystopia symmetry and malar bone symmetry. Degala and colleagues, working with CT scans, found that two-point fixation was sufficient for malar symmetry with a more minimal surgical approach, while Shokri and colleagues went further, arguing that a single fixation point at the zygomaticomaxillary buttress was adequately stable in non-comminuted fractures. Each additional surgical approach, however, carries a price: more scarring, more risk of nerve injury and paresthesia, longer operating times, and more extensive stripping of periosteum.

To resolve the question, researchers at Universitas Gadjah Mada and Prof. Dr. Margono Soekarjo Regional General Hospital conducted a retrospective analysis of patients treated between 2020 and 2024. From 144 patients with unilateral ZMC fractures, 60 met strict inclusion criteria: non-comminuted fractures, adequate Waters-view radiographs, complete medical records, ages between 11 and 60, and the presence of molar teeth for occlusion. Patients were excluded if their radiographs were of inadequate quality or if they had additional mandibular fractures that could affect occlusion. The final cohort was divided into three groups of 20 patients each: one-point, two-point, and three-point fixation.

The methodological centerpiece was a symmetry analysis performed on Waters radiographs taken three days after surgery, a time point chosen because it marks the beginning of primary healing and the end of the inflammatory phase. The images were standardized to a fixed pixel size and analyzed in ImageJ software. Anatomical landmarks, including the anterior nasal spine, the crista galli, and the lowest point of the orbital rim on both sides of the face, were connected to form right triangles on the fractured and non-fractured sides. Horizontal, vertical, and diagonal line lengths were then compared using a modified version of Kim’s symmetry index, in which the squared differences between the two sides are summed and square-rooted. A smaller index means a more symmetrical result. The team added a second layer of statistical rigor with Bland-Altman analysis, which assesses agreement between paired measurements by calculating 95 percent limits of agreement.

The results were striking. The smallest mean symmetry index, 0.42 plus or minus 0.16, was found in the two-point fixation group, followed closely by the three-point group at 0.45 plus or minus 0.18. The one-point group lagged well behind at 0.79 plus or minus 0.22. Tukey post-hoc testing showed no statistically significant difference between the two-point and three-point groups, with a p value of 0.8, but both differed significantly from the one-point group, with p values below 0.001 and large effect sizes. The Bland-Altman analysis told the same story: the two-point group had the narrowest 95 percent limits of agreement, spanning roughly 1.37 to minus 1.11, compared with wider limits in the three-point and especially the one-point group. All three groups nonetheless fell within the range considered symmetrical overall.

The patient population reflected the epidemiology of facial trauma in a developing country. The cohort was predominantly male, mostly aged 11 to 30, and road traffic accidents were the dominant cause, with closed fractures predominating, a pattern the authors attribute to the high-risk activity profiles of young men and the prevalence of motorcycles as a primary mode of transportation in Indonesia. The intraoral vestibular approach was the most common surgical route in all groups, valued for being effective, minimally invasive, and cosmetically favorable. Two-point fixation was most often placed at the zygomaticomaxillary and frontozygomatic regions, while three-point fixation added the infraorbital rim. Notably, paresthesia was the only complication observed, present preoperatively in all groups and decreasing by postoperative day three, with the largest decrease, 35 percent, seen in the two-point group.

The authors are careful about what their findings do and do not prove. The measurements capture the accuracy of reduction in the immediate postoperative period, not long-term stability, and masticatory forces from the masseter and temporalis muscles can cause secondary malposition over time. No diplopia, dystopia, or malocclusion was found, but the short follow-up cannot exclude delayed complications. The team also acknowledges technical limitations: a single radiologist performed the assessments, and the reported gaps of 0.01 to 0.06 millimeters fall below the approximate 0.2 to 0.4 millimeter spatial resolution of conventional radiography, meaning some measured differences may be smaller than the imaging can reliably resolve. Radiological asymmetry below two millimeters, other work suggests, is generally not visible clinically.

Even with those caveats, the clinical message is pragmatic and potentially practice-changing. Theoretically, more fixation points should mean better stability, but each additional plate demands wider surgical access, more periosteal stripping, greater risk of nerve injury, and longer anesthesia time. This study indicates that if adequate reduction and stability can be achieved with two plates, adding a third offers no measurable symmetry benefit in early radiographic assessment while increasing surgical burden. The authors conclude that the number of fixation points should be tailored to each case, considering displaced fragments, the number of fracture locations, and the stability achieved after reduction, and they call for longer follow-up studies to confirm that the early symmetry advantage of two-point fixation translates into durable, complication-free outcomes.

Subject of Research: Radiographic comparison of one-, two-, and three-point fixation for postoperative malar symmetry in zygomaticomaxillary complex fracture repair

Article Title: Optimal postoperative symmetry after two-point fixation with open reduction in internal fixation of complex zygomaticomaxillary fractures: a radiographic analysis

Article References: Nastiti, K. A., Rahajoe, P. S., & Istadi, D. (2025). Optimal postoperative symmetry after two-point fixation with open reduction in internal fixation of complex zygomaticomaxillary fractures: a radiographic analysis. BMC Plastic and Reconstructive Surgery, 1(1), Article 10. https://doi.org/10.1186/s44452-025-00010-8

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00010-8

Keywords: zygomaticomaxillary complex fracture, open reduction internal fixation, fixation points, facial symmetry, Waters radiograph, symmetry index, Bland-Altman analysis, maxillofacial surgery, malar bone, facial trauma, miniplate fixation, retrospective study