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Zygomatic process

The zygomatic processes are bony projections extending from several cranial bones—the temporal bone, maxilla, and frontal bone—that articulate with the zygomatic bone to contribute to the structural framework of the face, including the zygomatic arch, orbital rim, and lateral facial walls.^[1] These processes are essential for supporting the cheeks, facilitating mastication through muscle attachments, and protecting the orbital contents.^[2]

Embryological development

The zygomatic bone and its articulating processes develop from neural crest cells associated with the first pharyngeal arch through intramembranous ossification. This process begins around the 6th to 8th week of embryonic development, forming the membranous bones of the face without a cartilaginous precursor. The zygomatic processes of the adjacent bones (frontal, maxillary, and temporal) similarly arise via intramembranous ossification, contributing to the lateral facial skeleton.^[2]

Introduction

Definition and overview

The zygomatic processes are bony projections extending from the frontal, maxillary, and temporal bones, named for their articulation with the zygomatic bone and their role in forming the lateral facial and orbital framework.^[2] These processes contribute to the structural integrity of the midface by bridging adjacent cranial elements. The term "zygomatic" derives from the Greek zygōma, meaning "yoke," which reflects the bridging or connecting function of these structures across the face, akin to a yoke linking draft animals.^[3] These processes are situated in the superolateral aspect of the skull, primarily along the lateral orbital region and temporal fossa. They participate in key sutures, including the frontozygomatic suture (between the frontal and zygomatic bones), the zygomaticomaxillary suture (between the maxilla and zygomatic bone), and the temporozygomatic suture (between the temporal and zygomatic bones).^[4] This positioning allows them to integrate seamlessly with the zygomatic bone, forming stable articulations that support facial contour and protect underlying neurovascular structures. Collectively, the zygomatic processes contribute to essential craniofacial structures: the zygomatic arch is formed by the union of the temporal bone's zygomatic process and the zygomatic bone's temporal process, providing attachment for the masseter muscle; the lateral orbital wall arises from the frontal bone's zygomatic process and the zygomatic bone's frontal process, enclosing the orbital contents; and the inferior orbital rim is delineated by the maxillary bone's zygomatic process and the zygomatic bone's maxillary process, reinforcing the orbital floor.^[2]^[5]

Embryological development

The zygomatic processes originate from mesenchymal condensations derived primarily from neural crest cells migrating from the first pharyngeal (branchial) arch, contributing to the formation of the viscerocranium during early embryonic development.^[2] These multipotent neural crest cells delaminate from the dorsal neural tube around the 4th week of gestation and populate the facial primordia by weeks 5-6, where they differentiate into osteogenic precursors under the influence of signaling pathways such as BMP and FGF.^[6] The processes of the zygomatic bone—frontal, maxillary, and temporal—emerge as distinct mesenchymal outgrowths that articulate with adjacent bones, while the zygomatic processes of the frontal, maxillary, and temporal bones develop in coordination to form the zygomatic arch and orbital framework.^[7] Ossification of the zygomatic processes proceeds via intramembranous ossification, beginning with the appearance of primary centers in the 8th week of gestation for the core zygomatic bone and its frontal and maxillary processes.^[8] The zygomatic bone ossifies from a single center appearing around the 8th week of gestation, with the temporal process of the zygomatic bone articulating with the zygomatic process of the temporal bone to form the zygomatic arch, the latter's ossification center also appearing around the 8th week.^[9] These centers expand and fuse progressively throughout the fetal period, achieving structural integrity and articulation with adjacent processes by birth, though minor sutural refinements continue postnatally.^[10] Genetic regulation is critical for proper patterning and differentiation of the neural crest mesenchyme in the zygomatic region, with homeobox genes playing key roles.^[2] Developmental anomalies uniquely impacting the zygomatic processes include isolated hypoplasia, often linked to disruptions in neural crest migration or survival, as seen in Treacher Collins syndrome (mandibulofacial dysostosis). This autosomal dominant disorder, caused by mutations in TCOF1, POLR1D, or POLR1C, reduces neural crest cell proliferation, leading to severe underdevelopment of the zygomatic bone, maxillary process, and zygomatic arch, resulting in midfacial hypoplasia.^[11] Such defects highlight the vulnerability of these processes to genetic perturbations during the critical 6-8 week window.

Zygomatic processes of adjacent bones

Zygomatic process of the frontal bone

The zygomatic process of the frontal bone is a bony projection that extends inferolaterally from the lateral aspect of the supraorbital margin of the frontal bone, arising from the temporal surface of the frontal squama. This process contributes to the superolateral portion of the orbital rim as part of the overall facial skeleton.^[12] It articulates directly with the frontal process of the zygomatic bone via the frontozygomatic suture (also termed the zygomaticofrontal suture), helping to stabilize the lateral orbital wall.^[12] The orbital surface of the process is smooth, forming a continuous superolateral margin of the orbit that provides structural support for orbital contents. Its posterior border marks the origin of the temporal line, which serves as an attachment for the temporal fascia.^[12]

Zygomatic process of the maxilla

The zygomatic process of the maxilla is a short, robust, triangular eminence projecting laterally from the anterolateral aspect of the maxilla, located at the junction where the anterior, orbital, and infratemporal surfaces converge.^[13] This structure, also known as the malar process, is thick and rough in texture, providing a stable base for articulations and contributing to the overall contour of the midface.^[14] Its pyramid-like form reinforces the superolateral border of the maxillary sinus, positioned above the first maxillary molar.^[5] The process articulates laterally with the maxillary process of the zygomatic bone via the zygomaticomaxillary suture, a serrated junction that enhances midfacial stability.^[15] Superiorly, it borders the infraorbital foramen, separating it from the orbital margin, while its inferior margin blends with the zygomaticoalveolar crest.^[5] The anterior surface of the process forms part of the facial contour, and its posterior aspect is concave, contributing to the infratemporal fossa. The inferior aspect integrates into the zygomatic buttress, a thickened bony ridge that supports masticatory forces and midface projection.^[13] Additionally, the process contains small nutrient foramina that transmit branches of the maxillary artery, supplying vascularization to the surrounding bone.^[5] Morphological variations in the zygomatic process include increased thickness and width in skulls exhibiting greater robusticity. Anthropological studies indicate ethnic differences in prominence, with more pronounced processes observed in Asian populations compared to others, influencing facial width and the overall zygomatic framework.^[16]

Zygomatic process of the temporal bone

The zygomatic process of the temporal bone is a long, slender, arcuate projection that originates from the lower portion of the squamous part (squama) of the temporal bone, extending anteriorly and laterally for approximately 2.5 cm in adults to contribute to the posterior segment of the zygomatic arch.^[17] Its base integrates smoothly with the articular tubercle, forming part of the anterior boundary of the mandibular fossa in the temporomandibular joint. The process begins as a flat, triangular plate with a concave superior surface that gradually twists forward, reorienting its medial and lateral aspects as it bows outward.^[18]^[19] The superior border of the zygomatic process provides an attachment site for fibers of the temporalis muscle, while the roughened inferior border serves as the origin for the masseter muscle. The medial surface is hollowed to accommodate masseter attachments. The lateral surface is rounded and smooth, contributing to the external contour of the arch.^[18]^[19]^[17] Articulation occurs primarily at the distal end, where the zygomatic process joins the temporal process of the zygomatic bone via the temporozygomatic suture, thereby completing the zygomatic arch as a key structural element of the lateral skull. The posterior root of the process blends into the supramastoid crest, and in some cases, it may contain a squamosal foramen related to venous drainage.^[18]^[19] Anatomical variations in the zygomatic process include differences in curvature and length, with the structure often appearing straighter and relatively shorter in Caucasian populations compared to more pronounced bowing and greater elongation in Mongoloid groups; overall length shows correlation with skull base width.^[20]^[21]

Processes of the zygomatic bone

Frontal process

The frontal process of the zygomatic bone is a narrow, vertically oriented plate that extends superiorly from the superolateral aspect of the zygomatic body, contributing to the lateral margin and wall of the orbit.^[22] It features a rough medial margin adapted for ligamentous and sutural attachments, while its overall structure supports the bony framework of the orbit alongside adjacent bones.^[2] Dimensions vary with individual skeletal proportions.^[16] Superiorly, the frontal process articulates with the zygomatic process of the frontal bone via the frontozygomatic suture, a serrated junction that provides stability to the lateral orbital rim.^[23] This articulation also reinforces the orbital roof's lateral extension.^[22] Posteriorly, it may interface with the greater wing of the sphenoid through the sphenozygomatic suture, though this articulation is sometimes obscured by sutural fusion.^[23] On its orbital surface, the frontal process forms a smooth component of the lateral orbital wall and bears Whitnall's tubercle, a small elevation approximately 10-11 mm inferior to the frontozygomatic suture that serves as an attachment site for the lateral palpebral ligament, the suspensory ligament of the eyeball, and the aponeurosis of the levator palpebrae superioris muscle.^[22] The anterior surface may include the zygomaticofacial foramen near its base, transmitting the zygomaticofacial nerve and vessels to innervate the skin of the cheek.^[24] Although not directly housing the lacrimal sac, the process's posterior aspect aligns with the orbital framework adjacent to the lacrimal fossa formed by the maxilla and lacrimal bone.^[25] Anatomical variations in the frontal process include occasional bipartition due to an accessory suture line extending from the zygomaticomaxillary junction, observed in a subset of skulls and potentially influencing surgical approaches.^[2] Height and prominence can differ by sex and population ancestry, with males often exhibiting greater overall zygomatic projection, while orbital volume correlations influence process dimensions across individuals.^[21] Rare instances of orbital bridging may occur via supplementary bony struts connecting the process to adjacent orbital elements, though such features are infrequent.^[26] These variations underscore the process's role in the adaptive orbital architecture.^[23]

Maxillary process

The maxillary process of the zygomatic bone projects downward and medially from the main body of the bone, contributing to the prominence of the cheek and forming key structural elements of the midface. This process integrates closely with the surrounding facial architecture, particularly by constituting the anterior and lateral segments of the infraorbital rim and the anterior portion of the lateral wall of the maxillary sinus. As part of the zygomaticomaxillary buttress system, it provides essential support against masticatory forces in the midface.^[2] In terms of articulations, the maxillary process connects inferiorly with the zygomatic process of the maxilla via the zygomaticomaxillary suture, ensuring stable integration between the two bones, while contributing to the lateral infraorbital rim for continuity with orbital structures. The medial surface of this process directly forms the lateral boundary of the maxillary sinus, facilitating the sinus's extension laterally, and its inferior margin includes a crest-like ridge that serves as an attachment site for the superficial head of the masseter muscle, aiding in jaw elevation during mastication.^[2]^[27] Anatomical variations in the maxillary process include a tendency for greater breadth in males compared to females, reflecting overall sexual dimorphism in midface width and prominence. Additionally, the degree of pneumatization of the maxillary sinus into the zygomatic bone via this process can vary, often resulting in reduced bone thickness where sinus extension is more extensive, which has implications for surgical planning in the region.^[28]^[29]

Temporal process

The temporal process of the zygomatic bone is a thin, posterolateral projection that extends posteriorly from the posterior aspect of the zygomatic bone, originating from its lower half and directing slightly superiorly toward the temporal bone.^[22]^[30] It forms a slender, roughly quadrilateral plate that tapers superiorly, with its terminal end appearing oblique and jagged or serrated.^[22]^[23] This process articulates posteriorly with the zygomatic process of the temporal bone via the temporozygomatic suture, thereby completing the anterior portion of the zygomatic arch.^[22]^[23]^[30] Its superior margin contributes to the boundary of the temporal fossa, aligning with the temporal line of the skull.^[2] Key surface features include the inferior border, which forms the lower edge of the zygomatic arch, and the zygomaticotemporal foramen located on its temporal surface, through which the zygomaticotemporal nerve and vessels pass.^[23] The process also provides attachment sites along its inferior aspect for the lateral ligament of the temporomandibular joint.^[2] Anatomical variations in the temporal process include differences in arch height and projection, with higher and more laterally arched structures observed in populations such as Eastern Asians and Arctic groups, potentially linked to broader facial morphology.^[16] Rare cases involve bipartite division of the zygomatic bone due to an accessory suture, which may extend to the temporal process, or duplication leading to accessory bony arches.^[2]^[26]

Functions and clinical significance

Biomechanical roles

The zygomatic processes form critical structural buttresses in the facial skeleton, transmitting masticatory forces from the mandible to the cranium while maintaining facial integrity. The zygomatic arch, composed of the temporal process of the zygomatic bone and the zygomatic process of the temporal bone, primarily resists parasagittal bending and mediolateral torsion generated during jaw adduction.^[31] This configuration allows the arch to endure compressive and shear loads from biting, preventing deformation of the midface.^[32] In mammalian crania, including humans, the arch's cross-sectional shape—ranging from cylindrical to blade-like—influences local strain distribution, with stiffer forms elevating stresses at zygomatic roots but enhancing overall load-bearing capacity.^[31] Muscle attachments on the zygomatic processes are integral to masticatory biomechanics. The masseter muscle originates from the inferior border of the zygomatic arch, spanning the zygomatic process of the maxilla and the temporal process of the zygomatic bone, before inserting on the mandibular ramus to generate forceful elevation of the jaw.^[33] The temporalis muscle, originating from the temporal fossa, passes deep to the zygomatic arch en route to its insertion on the mandibular coronoid process, with the arch providing lateral constraint and protection during contraction.^[34] These attachments enable coordinated force production, where masseter contraction induces arch torsion, while temporalis activity contributes to anteroposterior stability.^[31] The zygomatic processes also fulfill protective roles by forming the lateral and inferior orbital rims, which shield the ocular globe and orbital contents from direct trauma.^[35] This bony framework absorbs impact forces, dissipating energy to minimize penetration or displacement of the eye. Additionally, the zygomatic arch safeguards the underlying temporalis muscle and adjacent neurovascular structures, such as the superficial temporal artery and vein, from lateral blows.^[36] Finite element models of the craniofacial complex demonstrate that the zygomatic processes play a key role in load distribution during mastication, experiencing peak Von Mises stresses of 7–12 MPa at the zygomaticoalveolar crest under molar biting forces.^[32] These models reveal that the complex dissipates loads through bending and shear rather than pure axial compression, channeling forces away from the maxilla to reduce fracture risk in adjacent regions.^[32] In nonhuman primates and human simulations, this mechanism ensures balanced strain energy absorption, with the arch contributing to global cranial stiffness without localized failure.^[31]

Pathologies and surgical relevance

Zygomatic arch fractures represent a common traumatic pathology involving the zygomatic processes, often occurring as part of the zygomaticomaxillary complex (ZMC) injury pattern referred to as a tripod or tetrapod fracture. This fracture disrupts the attachments at the zygomaticotemporal suture (temporal process of zygomatic bone), frontozygomatic suture (frontal process), infraorbital rim and zygomaticomaxillary buttress (maxillary process), and zygomatic arch itself, typically resulting from high-impact blunt trauma to the malar region.^[36]^[37]^[38] Congenital hypoplasia of the zygomatic processes is frequently observed in hemifacial microsomia (HFM), a developmental disorder characterized by unilateral underdevelopment of craniofacial structures derived from the first and second branchial arches. In HFM, the zygomatic complex, including its frontal and maxillary processes, exhibits asymmetric hypoplasia, leading to facial asymmetry and orbital dystopia.^[39]^[40] Clinical manifestations of zygomatic process pathologies include orbital floor blowout fractures associated with maxillary process involvement, where increased intraorbital pressure causes inferior displacement of orbital contents, potentially resulting in enophthalmos, diplopia, and infraorbital nerve paresthesia. Fractures of the temporal process or zygomatic arch can lead to masseter muscle dysfunction due to mechanical impingement or displacement, manifesting as trismus, reduced masticatory force, and temporomandibular joint limitations.^[41]^[42]^[36] Surgical interventions for zygomatic process pathologies often target the zygomaticomaxillary buttress in Le Fort osteotomies, particularly Le Fort I procedures, which mobilize the maxilla while fixating plates along the buttress to restore midfacial projection and occlusion in corrective or reconstructive contexts. For isolated zygomatic arch fractures, the Gillies temporal approach provides minimally invasive reduction by accessing the arch through a scalp incision above the temporalis fascia, elevating the depressed segment without direct exposure.^[43]^[44] Recent advances in zygomatic process reconstruction post-2020 emphasize patient-specific 3D-printed implants, such as polyetheretherketone (PEEK) scaffolds, which enable precise anatomical restoration in complex ZMC defects, improving fit and reducing operative time compared to autologous grafts.^[45] Three-dimensional planning and printing have also facilitated secondary reconstructions of mistreated fractures by guiding refracturing and implant placement for optimal symmetry.^[46]

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