BACKGROUND: Intraoperative cone-beam computed tomography (CBCT) during open reduction and internal fixation of zygomaticomaxillary complex (ZMC) fractures may facilitate the re-establishment of a complex 3-dimensional anatomy. PURPOSE: This study was conducted to measure the occurrence of malpositions after ZMC fracture reduction and intraoperative revision rates after conducting intraoperative CBCT. STUDY DESIGN, SETTING, SAMPLE: This retrospective case series included subjects treated for ZMC fractures with intraoperative CBCT at the Department of Maxillofacial Surgery of the University Hospital Zurich (Switzerland) over a 5-year period (January 2015 to December 2019). The exclusion criteria were a history of facial fracture and incomplete data. PREDICTOR VARIABLE: Not applicable. MAIN OUTCOME VARIABLES: The primary outcome variable was malpositioning after ZMC fracture reduction on intraoperative 3-dimensional imaging. Further variables-including intraoperative revisions of ZMC malpositions, osteosynthesis material revisions, and intraoperative assessments of orbital reconstruction-were analyzed. COVARIATES: Demographic (age and sex) and clinical (associated with facial fractures) characteristics were assessed. ANALYSES: The analyses included Spearman's rank correlations, mosaic plots, χ RESULTS: The sample included 337 subjects, and 589 intraoperative CBCT scans were obtained. ZMC malposition after reduction was observed in 154 (45.7%) subjects
the most common malpositions were caudal displacement, underprojection, and inward rotation of the ZMC. Intraoperative revisions were conducted in 150 (44.5%) subjects: 105 (31.2%) subjects exhibited a ZMC malposition, 13 (3.9%) subjects needed revisions of the osteosynthesis material placement, and 32 (9.5%) subjects required intraoperative orbital floor reconstruction. No secondary revision surgeries were required, excluding 25 secondary orbital floor reconstructions. Preoperative and intraoperative CBCT findings did not correlate regarding indications for orbital floor reconstruction. CONCLUSION AND RELEVANCE: The 44.5% intraoperative revision rate underscores the challenges of ZMC fracture surgery. Clinical evaluation of fracture reduction at the latero-orbital rim is recommended to identify caudal displacements, and intraoperative CBCT helps identify candidates for primary orbital floor reconstruction. This technique may enhance quality control and precision, thereby potentially improving patient outcomes.