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90

J Gandhara Med Dent Sci

October - December 2026

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INFRAORBITAL

NERVE

INJURY

IN

ZYGOMATICOMAXILLARY

COMPLEX

FRACTURES

IN PATIENTS PRESENTING TO AYUB TEACHING HOSPITAL, ABBOTTABAD

Aqsa Munir

1

, Khurshid Alam

2

, Marium Jadoon

1

, Sidra Qadir

1

, Bakhtawer Aziz

1

, Ammara Saleem

1

, Asim Qureshi

3

Munir A, Alam K, Jadoon M, Qadir S,

Aziz B, Saleem A, et al. Infraorbital

Nerve Injury in Zygomaticomaxillary

Complex Fractures in Patients

Presenting to Ayub Teaching Hospital,

Abbottabad. J Gandhara Med Dent

Sci. 2026;13(4):90-94.

Date of Submission:

03-03-2026

Date Revised:

14-09-2026

Date Acceptance:

14-09-2026

1

Postgraduate, Resident, Department of

Oral & Maxillofacial Surgery, Ayub

College of Dentistry

3

Assistant Professor, Department of

Oral & Maxillofacial Surgery, Ayub

College of Dentistry

Correspondence

2

Khurshid Alam, Assistant Professor,

Department of Oral &

Maxillofacial

Surgery Ayub College of Dentistry

+92-333-5028636

kurshid810@gmail.com

ABSTRACT

OBJECTIVES

This

study aimed to analyse the frequency and trends of infraorbital nerve

(ION) damage in zygomaticomaxillary complex (ZMC) fractures.

METHODOLOGY

We conducted a cross-sectional analytical study at the Department of Oral

and

Maxillofacial

Surgery,

Ayub

Teaching

Hospital,

Abbottabad,

from

January 2025 to June 2025. We recruited 132 ZMC fracture patients through

non-probability consecutive sampling. Information on age, gender, aetiology

and mechanism of trauma, fracture side, and ION injury presence and type

was

obtained.

We

assessed

infraorbital

nerve

injury

using

neurosensory

testing

and

graded

it

as

paraesthesia,

anaesthesia,

or

hypoesthesia.

Data

were analysed using SPSS, with p < 0.05 considered signicant.

RESULTS

Of the 132 patients, 68 (51.52%) were male, and 64 (48.48%) were female.

ION

injury

was

seen

in

88

(66.67%)

patients,

with

paraesthesia

being

the

most

prevalent

type

(34.09%),

followed

by

anaesthesia

(23.48%)

and

hypoesthesia

(9.09%).

There

was

a

statistically

signicant

relationship

between gender and ION injury (p < 0.001), and between fracture laterality

and ION injury, with 97.5% of bilateral fractures having nerve involvement

(p

<

0.001).

However,

the

aetiology

of

trauma

was

not

signicantly

correlated with ION injury (p = 0.191).

CONCLUSION

ION

injury

is

a

common

sequel

of

ZMC

fractures,

paraesthesia

being

the

most

frequent

presentation.

Male

gender

and

bilateral

fractures

were

correlated

with

increased

injury

rates,

underlining

the

necessity

of

early

neurosensory evaluation.

KEYWORDS:

Infraorbital

Nerve

Injury,

Zmc

Fracture,

Paraesthesia,

Bilateral Fractures, Facial Trauma

INTRODUCTION

The

zygoma's

prominent,

exposed

position

makes

zygomaticomaxillary complex (ZMC) fractures among

the

most

common

midfacial

injuries.¹

High-impact

trauma, such as falls, road traic accidents (RTAs), or

interpersonal

violence,

frequently

causes

these

fractures.

The

infraorbital

nerve

(ION)

is

extremely

susceptible to damage during ZMC fractures due to the

close

anatomical

relationship

between

the

zygomatic

bone

and

the

infraorbital

foramen.

By

compromising

sensory

function

in

the

midfacial

area,

infraorbital

nerve

injury

can

cause

paresthesia,

anaesthesia,

or

hypoesthesia,

which

can

have

a

substantial

negative

impact

on

a

patient's

quality

of

life.⁴

Since

neurosensory

abnormalities

may

continue

long

after

fracture

stabilisation

and

surgical

repair,

resulting

in

functional

and

psychological

complications,

it

is

imperative

to

identify

the

patterns

and

factors

associated

with

ION

injury.⁵

Homer

et

al.

found

that

47.6%

of

the

42

patients

had

some

degree

of

infraorbital hypesthesia. Compared with isolated orbital

floor

fractures,

ZMC

fractures

had

worse

long-term

sensory

outcomes.

8

According

to

Sakavicius

et

al.,

64.4% of patients with ZMC fractures had infraorbital

nerve sensory

abnormalities.

They also

stated that the

degree of damage and the presence of infraorbital canal

damage

determine

the

dynamics

and

outcome

of

functional infraorbital nerve recovery.

9

In their study of

72

patients

in

the

Pakistani

population,

Saleem

et

al.

observed

that

75.0%

of

the

patients

had

ION

injury.

They also reported a signicant correlation between the

occurrence

of

injuries

and

gender,

with

males

predominating (62.5%).

10

There is still a dearth of data

regarding

the

frequency of ION in patients

presenting

with ZMC fractures. In addition to this, there is still a

need to learn more about how certain factors, such as

the

type

of

trauma,

laterality

of

the

fracture,

and

demographic factors, aect infraorbital nerve injury in

ZMC

fractures,

especially

in

South

Asian

populations

where trauma patterns and access to healthcare may be

dierent from those in Western countries. Few studies

have

systematically

compared

the

types

of

sensory

disturbances

or

thoroughly

examined

the

relationship

ORIGINAL ARTICLE

http://doi.org/10.37762/jgmds.13-4.881

91

J Gandhara Med Dent Sci

October - December 2026

between bilateral fractures and nerve damage. Thus, the

purpose

of

this

study

is

to

ascertain

the

types

and

frequency of infraorbital nerve injury in ZMC fractures

as

well

as

their

correlation

with

trauma

and

patient

characteristics.

A

better

understanding

of

these

relationships

can

support

early

diagnosis,

improved

surgical planning, and targeted rehabilitation to reduce

long-term neurosensory decits.

"Yes"

if

sensory

decit

was

found

in

any

way,

and

"No"

if

no

decit

could

be

identied.

The

nature

of

infraorbital nerve injury was classied as: Anaesthesia:

total loss of sensation; Paraesthesia: abnormal or altered

sensation (e.g., tingling) with no loss; and hypoesthesia:

reduced sensation. All data were recorded as soon as we

inspected them on a previously designed data collection

sheet.

The

principal

investigator

cross-checked

every

variable

for

accuracy

and

completeness.

The

study

excluded

patients

with

any

trauma,

known

neuropathies,

or

signicant

associated

neurological

injuries

to

prevent

confounding

and

assigned

each

patient

a

unique

study

ID

to

ensure

confidentiality. entered, cleaned, and analysed the data

using Statistical Package for the Social Sciences (SPSS)

version 23.0 (IBM Corp., USA). Continuous variables,

such as age, were reported as mean  SD after verifying

normality

with

the

ShapiroWilk

test.

Categorical

variables

such

as

gender,

infraorbital

nerve

injury

(yes/no),

nerve

injury

type

(anaesthesia,

paraesthesia,

hypoesthesia),

cause

of

trauma

(RTA,

fall,

assault,

others),

trauma

type

(blunt,

penetrating,

others),

and

fracture laterality (unilateral/bilateral) were presented in

terms

of

frequencies

and

percentages.

Relationships

between

categorical

variables

(e.g.,

gender,

cause

of

trauma, laterality) and infraorbital nerve injury (yes/no)

were tested by the Chi-square test or Fisher's exact test

in

cases

where

expected

cell

counts

were

<

5.

The

relationship between gender and nerve type was tested

using

the

Chi-square

test.

p-value

<

0.05

was

considered statistically signicant.

RESULTS

This

study

enrolled

132

patients

with

zygomaticomaxillary complex (ZMC) fractures, with a

mean

age

of

39.79



14.87

years,

including

68

(51.52%)

men

and

64

(48.48%)

women.

Infraorbital

nerve (ION) damage was noted in 88 patients (66.67%),

and

44

patients

(33.33%)

reported

no

sensory

deficit.

Within those who suered nerve damage, paraesthesia

was the most frequent type (34.09%), then anaesthesia

(23.48%), and hypoesthesia (9.09%) (Table 1). Gender

was

signicantly

associated

with

ION

injury

(p

<

0.001),

with

a

higher

prevalence

among

males.

No

statistically

signicant

disparity

was

noticed

between

gender and type of ION injury (p = 0.577) (Table 2). In

terms of cause of trauma, RTA was the most prevalent,

followed

by

falls

and

assault.

While

ION

injury

was

most

common

in

RTA

(70.24%),

this

did

not

reach

statistical

signicance

(p

=

0.191).

However,

fracture

laterality was signicantly correlated with nerve injury,

with 97.5% of bilateral fractures having ION injury (p

< 0.001) (Table 3).

METHODOLOGY

This

cross-sectional

study

was

conducted

in

the

accident

and

emergency

department

and

maxillofacial

OPD

(App

No.

Ref.No.RC-EA-2024/083,

Dated,

17-

04-2024) at

Ayub Teaching Hospital, Abbottabad. The

calculated sample

size

was 132 using

WHO

software,

with a 95% condence level, an absolute precision of

6%,

and

an

anticipated

infraorbital

nerve

injury

(paresthesia) rate of 14.4% in ZMC fractures (Amin et

al.). A non-probability consecutive sampling technique

was used to recruit patients. The sample-size estimation

was based on the anticipated prevalence, as this was the

available

estimate

at

the

planning

stage,

not

the

prevalence

observed

in

the

present

study.

Inclusion

criteria:

Patients

aged

18-65

years,

of

either

sex,

presenting

with

ZMC

fractures

secondary

to

facial

trauma caused by road trac accidents, falls or assault-

Glasgow

Coma

Scale

(GCS)

score

15/15,

who

gave

informed consent. Exclusion criteria: Patients with old

mid-face

trauma

of

15

days

or

more

as conrmed

on

taking

history,

having

neuropathies,

previously

operated

patients

with

any

facial

bone

fracture,

non

-

displaced

fractures

of

the

zygoma,

and

panfacial

fractures

due

to

road

trac

accident.

The

sociodemographic

data

included

age

(in

years)

and

gender (male/female). We elicited a brief history of the

mode and mechanism of injury from the patient or their

attendants. The cause of trauma was classied as road

trafc

accident

(RTA),

fall,

or

assault.

We

assessed

fracture

laterality

clinically

and

radiologically

as

unilateral

(left/right)

or

bilateral

involvement.

The

extent

and

nature

of

ZMC

fracture

were

determined

clinically

and

veried

radiographically

with

orthopantomogram

(OPG)

and/or

computed

tomography (CT) where facilities existed. The presence

of

comminution,

displacement,

and

orbital

oor

involvement

was

recorded

where

appropriate.

An

experienced

examiner

tested

infraorbital

nerve

sensation using a standardised clinical sensory test. The

infraorbital

area,

i.e.,

the

lower

eyelid,

lateral

nose,

upper

lip,

and

upper

cheek,

was

tested

by

light

touch

with a cotton wisp, pinprick with a blunt dental probe

and

two-point

discrimination

if

indicated.

Patients

compared

sensations

between

the

aected

and

unaffected

sides.

Nerve

injury

presence

was

noted

as

Infraorbital

Nerve

Injury

in

Zygomaticomaxillary

Complex

Fractures

92

J Gandhara Med Dent Sci

October - December 2026

Table 1: Baseline Distribution of Gender and Infraorbital Nerve

Injury Characteristics Among Patients With

Zygomaticomaxillary Complex Fractures (N = 132)

Variables

Categories

n (%age)

Gender

Male

68 (51.52%)

Female

64 (48.48%)

Infraorbital nerve injury

Yes

88 (66.67)

No

44 (33.33%)

Type of Infraorbital nerve

injury

paraesthesia

45 (34.09%)

anaesthesia

31 (23.48%)

hypoesthesia

12 (9.09%)

Table 2: Association Between Gender and Infraorbital Nerve

Injury (Presence and Type)

Variables

Gender

p-value

Male (n = 68)

Female (n = 64)

Infraorbital nerve injury

Yes

58 (85.29%)

30 (46.88%)

<0.001

No

10 (14.71%)

34 (53.13%)

Type of Infraorbital nerve injury

paraesthesia

27 (60.00%)

18 (40.00%)

0.577

anaesthesia

22 (70.97%)

9 (29.03%)

hypoesthesia

9 (75%)

3 (25%)

Table 3: Association Between Cause of Trauma and Laterality

with Infraorbital Nerve Injury

Variables

Infraorbital Nerve Injury

p-value

Yes

(n = 88)

No

(n = 44)

Cause of ZMC

RTA

59 (70.24%)

25 (29.76%)

0.191

Trauma

18 (69.23%)

8 (30.77%)

Assault

11 (50%)

Laterality

Unilateral

49 (53.26%)

43 (46.74%)

<0.001

Bilateral

39 (97.5%)

1 (2.5%)

DISCUSSION

In this study of 132 patients with zygomaticomaxillary

complex

(ZMC)

fractures,

infraorbital

nerve

(ION)

injury was present in 66.67% of cases. Paraesthesia was

the most common type of injury (34.09%), followed by

anaesthesia (23.48%) and hypoesthesia (9.09%). There

was

a

statistically

signicant

association

between

gender and ION injury (higher in males), and fracture

laterality

(bilateral

fractures

had

much

higher

rates

of

ION

injury)

was

also

signicantly

associated

with

nerve involvement. Several studies report a similar high

frequency

of

ION

sensory

disturbance

in

ZMC

fractures.

For example, in a

descriptive study

at Lady

Reading Hospital, Peshawar, by Shaq et al.,

with 72

patients,

69.4%

had

infraorbital

nerve

injury.

11

This

prevalence rate is close to the rate of 66.67% observed

in

the

current

study,

suggesting

that

the

study

population

lies

in

the

same

expected

range

for

this

condition.

In contrast,

larger multi‐centre/retrospective

analyses

sometimes

report

lower

rates

depending

on

what

exactly

is

measured.

For

example,

the

study

by

Dubron

et

al.,

comprising

272

patients

from

Leuven,

Belgium,

reported

an

ION

hypoaesthesia

incidence of

37.3%,

much

lower

than

66.67%,

but

their

focus

was

only

on

hypoaesthesia

rather

than

all

sensory

disturbances

(anaesthesia,

paraesthesia,

etc.).

12

Regarding

gender

association,

the

finding

of

significantly

higher

ION

injury

rates

in

males

mirrors

many

other

studies.

Shaq

et

al.

found

males

constituted

~72%

of

the

sample

and

had

signicantly

more ION injury (p = 0.026) than females. Dubron et

al. also included 169 males and 103 females among 272

patients

and

similarly

reported

that

certain

fracture

types

and

anatomical

involvement

(infraorbital

canal,

orbital

oor)

predict

nerve

injury.

Bilateral

fractures

usually

imply

higher-energy

trauma,

more

displacement,

and

possibly

more

involvement

of

the

infraorbital

canal

or

foramen

on

both

sides.

More

anatomical disruption increases the likelihood of nerve

stretching,

compression,

or

even

transection.

Bilaterality may also mean a more central fracture line,

more

connective

tissue

disruption,

and

possibly

more

bilateral

swelling

and

oedema,

which

can

compress

both

infraorbital

nerves.

Fogaa

et

al.

detailed

neurosensory

testing

after

zygoma

fractures

demonstrated

abnormal

sensibility

in

76%

of

patients

overall

and

100%

of

those

requiring

orbital

oor

reconstruction,

with

much

higher

detection

rates

in

widely

displaced

fractures13findings

that

link

displacement/complexity

(features

more

common

in

bilateral or high-energy injuries) to nerve dysfunction.

Multi-centre

data

and

reviews

also

report

statistically

significant

associations

between

displaced

zygomatic

fractures

and

ION

sensory

decits,

underscoring

that

displacement/communiton

(which

bilaterality

often

implies)

is

a

major

risk

factor

for

persistent

neurosensory

abnormality

(Boano

et

al.).

14

Anatomically,

the

infraorbital

nerve

runs

within

a

relatively

xed

canal

as

it

exits

the

orbit;

when

both

zygomatic

buttresses

are

disrupted

(as

in

bilateral

or

highly

comminuted

fractures),

the

canal

and

its

supporting bony roof are more likely to be deformed or

compressed



a

mechanism

emphasised

in

surgical/trauma

references

and

AO

surgery

guidance

describing

the

vulnerability

of

the

nerve

to

displacement

and

orbital

oor

involvement.

15

Anaesthesia

implies

more

serious

interruption

or

damage

to

the

nerve.

Hypoesthesia

(reduced

but

not

absent

sense)

lies

between.

The

consistent

pattern

across these studies underscores plausible explanations:

paresthesia

often

represents

partial

injury

(nerve

compression,

stretching,

focal

demyelination)

rather

than

complete

severance,

which

is

required

for

anaesthesia

(Meyer

et

al.).

16

In

many

fractures,

the

infraorbital nerve is not transected but is compressed or

subjected to oedema, which leads to altered sensations

rather

than

total

loss.

17

Additionally,

early

clinical

Infraorbital

Nerve

Injury

in

Zygomaticomaxillary

Complex

Fractures

93

J Gandhara Med Dent Sci

October - December 2026

examination

may

detect

transient

paresthetic

changes

more

readily

than

full

anaesthesia,

which

may

also

resolve

over

time

or

evolve.

Finally,

variability

in

fracture anatomy (esp. involvement of infraorbital canal

and orbital oor) appears to inuence

not only whether

nerve injury occurs but also its type and severity, with

more

severe

anatomical

disruption

more

likely

to

produce

hypoesthesia

or

anaesthesia.

18

Time

since

injury

and

swelling

may

inuence

detection

of

complete vs partial decits. In the French study of 81

patients

by

Devoti

et

al.,

over

half

(51.8%)

had

persistent

neurological

signs

at

6

months;

within

that

group,

isolated

hypoesthesia

was

the

most

frequent

sequela

(66.7%)

among

persistent

cases,

rather

than

complete

anaesthesia

or

dysesthesia.

19

Meanwhile,

Renzi

et

al.

showed

an

overall

70.9%

prevalence

of

trigeminal

sensory

impairment

among

facial

fractures,

but

with

a

marked

increase

in

more

severe

fractures

(88.2%

for

displaced

fractures)

and

100%

in

direct

nerve

injuries,

arguing

that

severity

and

anatomical

involvement

govern

whether

injury

is

partial

(sensory

alteration)

or

complete

loss.

20

Together,

these

data

reinforce

our

ndings:

paraesthesia

(or

sensory

alteration)

is

usually

more

common

than

complete

anaesthesia or more severe sensory loss in ION injury

following

ZMC

fractures,

because

many

injuries

are

incomplete

(compression,

stretching,

oedema)

rather

than full transection of the nerve.

LIMITATIONS

This

study

had

a

few

limitations.

First,

because

this

study was conducted in a single tertiary care centre, the

results

may be less generalisable to other populations.

Secondly, the diagnosis of ION injury following ZMC

fractures was made using clinical neurosensory testing

without

the

use

of

advanced

imaging

or

adjunctive

electrophysiological

evaluations,

which

could

have

resulted in an overestimation or underestimation of the

severity of the injury. Fourth, the cross-sectional design

made

it

impossible

to

evaluate

nerve

regeneration

or

long-term

patterns

of

sensory

recovery.

Lastly,

the

observed

associations

may

have

been

aected

by

the

lack

of

detailed

stratication

of

potential

confounders

such

as

fracture

displacement,

surgical

timing,

and

technique.

CONCLUSIONS

Our study revealed that zygomaticomaxillary complex

fractures

frequently

resulted

in

infraorbital

nerve

damage. The most frequent kind of nerve damage was

paresthesia,

and

bilateral

fractures

were

more

significantly associated

with nerve involvement, while

trauma mechanism was not a signicant predictor. The

incidence

of

ION

injury

was

signicantly

higher

in

male

patients

compared

with

female

patients.

The

reasons for this association could not be determined in

the

present

study. These results

highlight the value

of

early neurosensory assessment in ZMC fracture cases,

especially for male patients who are at higher risk and

for

bilateral

fractures.

Identifying

patterns

of

nerve

damage at presentation can guide prompt interventions,

improve

postoperative

outcomes,

and

support

patient

prognosis and counselling.

CONFLICT OF INTEREST:

None

FUNDING SOURCES:

None

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Aqsa

Munir

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/interpretation;

Drafting Manuscript; Critical Revision;

Final Approval

Khurshid

Alam

-

Concept

&

Design; Data

Acquisition;

Data

Analysis/interpretation;

Drafting Manuscript; Critical Revision;

Supervision; Final Approval

Marium Jadoon

-

Concept & Design; Data Acquisition;

Data

Analysis/interpretation;

Drafting Manuscript; Final Approval

Sidra

Qadir

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/interpretation;

Drafting

Manuscript;

Supervision;

Final Approval

Bakhtawer Aziz

-

Concept & Design; Data Acquisition;

Data

Analysis/interpretation;

Drafting

Manuscript;

Supervision;

Final Approval

Ammara Saleem

-

Concept & Design; Data Acquisition;

Data

Analysis/interpretation;

Drafting

Manuscript;

Supervision;

Final Approval

Asim

Qureshi

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/interpretation;

Drafting

Manuscript;

Supervision;

Final Approval

AUTHORS CONTRIBUTION

The authors accept responsibility

for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Infraorbital

Nerve

Injury

in

Zygomaticomaxillary

Complex

Fractures