Two-Point Versus Three-Point Fixation in Zygomaticomaxillary Complex (ZMC) Fractures: A Narrative Review

Zygomaticomaxillary complex (ZMC) fractures are among the most prevalent facial injuries encountered during maxillofacial surgery because of the anatomical prominence and structural significance of the zygoma. These fractures often result from high-energy impacts, such as road traffic accidents, assaults, falls, and sports injuries, predominantly affecting males in their third to fourth decades of life. The management of ZMC fractures requires restoring facial aesthetics, orbital integrity, and masticatory function while minimizing surgical morbidity. Open reduction and internal fixation (ORIF) remains the primary approach, with two- and three-point fixation being the most commonly employed techniques.  This narrative review evaluates and compares the clinical outcomes, stability, aesthetic results, and complications associated with two- and three-point fixation methods. Three-point fixation, involving stabilization at the frontozygomatic suture, infraorbital rim, and zygomaticomaxillary buttress, offers superior mechanical stability, particularly in displaced or comminuted fractures. It provides better control over rotational displacement and ensures improved malar projection and facial symmetry. However, this approach is invasive and may lead to increased surgical time and tissue trauma. Two-point fixation, typically involving the frontozygomatic suture combined with either the infraorbital rim or zygomaticomaxillary buttress, is less invasive and is suitable for minimally displaced or non-comminuted fractures. It is associated with a reduced operative time and morbidity, although it may offer less control over rotational forces and result in a higher incidence of malar asymmetry in complex fractures. Although both techniques showed comparable complication rates in select cases, three-point fixation demonstrated better outcomes in terms of malar height restoration and stability under functional loads. Alternative fixation strategies, such as single- or four-point fixation, are reserved for specific clinical scenarios but carry their own limitations and risks. The decision-making process must consider the fracture classification, displacement severity, and patient-specific factors. Ultimately, individualized treatment planning, guided by clinical assessment and evidence-based practice, is essential.  Three-point fixation remains the standard for complex fractures, whereas two-point fixation is a reliable option for simpler injuries, offering a balance between functional recovery and minimal invasiveness. This review aims to evaluate and compare the clinical outcomes, stability, aesthetic results, and complications of two-point versus three-point fixation techniques in the management of zygomaticomaxillary complex fractures, guiding evidence-based treatment decisions.