Zygomaticomaxillary complex (ZMC) fractures are frequently seen injuries of the midfacial skeleton, and are often seen with road traffic accidents, falls, interpersonal violence and sports-related trauma.[1] The zygomatic bone has a significant contribution to facial width, malar prominence, orbital integrity and lateral midfacial contour.[2] If the ZMC is displaced, it can lead to asymmetry of the face, paraesthesia of the infraorbital nerve, diplopia, inability to open the mouth widely, reduced mastication and enophthalmos.[3] Therefore, good anatomical reduction is crucial for adequate facial aesthetics and function and to reduce post-op complications.[4] ZMC fractures are considered the second most frequent facial bone fracture with significant clinical importance and the necessity for efficient surgical management strategies.[4]

Traditional surgical treatment usually consists of open reduction and internal fixation, which relies on the preoperative computed tomography (CT) scan, anatomical landmarks, direct visual inspection, and in-situ facial symmetry evaluation.[5] This is still a commonly used method, but reconstructing the three-dimensional position of the zygomatic bone can be difficult, especially in comminuted fractures, fractures with significant displacement, or complex fractures.[6] Routine surgical exposure, swelling, loss of normal surgical landmarks, and the inability to visualize the posterior bony alignment may lead to residual displacement and lack of facial contour restoration.[7] These restrictions have stimulated the use of computer-assisted surgical methods that aim to enhance the accuracy and reliability of fracture reduction.[8]

Intraoperative surgical navigation is one of the most sophisticated techniques, combining the use of conventional CT imaging, 3D virtual planning, and real-time tracking of surgical instruments to aid the surgeon in the reduction of fractures.[9] The technology allows the surgeon to compare the actual position of the zygomatic complex during surgery with the intended position of the complex, which may help enhance the accuracy of the zygomatic complex reduction and restoration and facial symmetry.[10] In 2022, a systematic review was published that identified 17 studies that assessed virtual planning and navigation in ZMC fracture management, with some studies demonstrating increased linear or rotational accuracy, or restoration of orbital volume, but with inconclusive results on the time taken and extra costs involved in the procedure.[7] The results indicate that when the use of standard anatomical assessment is challenging, navigation can be particularly useful, but its practical benefits must be assessed in conjunction with resource use and the efficiency of the surgery.

The results of comparative studies have been encouraging, but not uniformly consistent, to date. Cheng et al. conducted a randomized controlled trial (RCT) in 2022 that compared navigation-assisted and conventional reduction in 38 patients with unilateral type B ZMC fractures.[10] A subsequent 2023 systematic review and meta-analysis, which included five studies and 189 patients, reported that computer-assisted navigation showed a mean difference of −0.86 mm in fracture-reduction error compared with conventional surgery (95% confidence interval: −1.58 to −0.14 mm), with no statistically significant difference observed for blood loss or operative time.[11]

Although the use of computer-assisted maxillofacial surgery has improved, it is unclear if intraoperative navigation offers a clinically significant benefit when compared with traditional surgical navigation for routine ZMC fracture surgery. Several factors, including fracture complexity, surgeon expertise, equipment availability, surgical time, and cost of navigation systems, can affect its overall value. Therefore, it is appropriate to directly compare both techniques to determine if better anatomical precision equates with better postoperative alignment and clinical outcome. The purpose of this study was to assess the precision of fracture reduction, facial symmetry restoration, surgery time, and postoperative complications between the use of intraoperative navigation and conventional surgical guidance in the treatment of ZMC fracture. The results can be used to guide evidence-based surgical guidance methods and to explain the importance of surgical navigation in modern maxillofacial trauma surgery.

A comparative study was done in the Department of Oral and Maxillofacial Surgery, Ayub Teaching Hospital Abbottabad, Pakistan for 6 months period from February 01, 2026 to July 30, 2026. The study compared the outcomes of intraoperative navigation-assisted surgical reduction with those of conventional surgical guidance in patients undergoing operative management of zygomaticomaxillary complex (ZMC) fractures. The sample size was calculated using the OpenEpi online sample size calculator for comparing two independent means. This was based on a previous study that found mean surgical deviation at the zygomaticomaxillary landmark of 0.69 ± 0.37 mm in the navigation-assisted group, and of 1.12 ± 0.28 mm in the conventional surgery group.[12] With 95% confidence, 80% power, an equal number of patients in each group, and a mean difference of 0.43 mm, the estimated sample size was 10 patients per group. After allowing for a 10% potential loss to follow-up or incomplete outcome assessment, the final target sample size was 22 patients, with 11 patients in each group. Eligible patients were recruited by non-probability consecutive sampling during the study period. Patients were randomly allocated to the navigation-assisted or conventional surgery groups based on the type of surgical guidance technique used. Each group consisted of 11 patients, with the number available to join the group and complete the outcome assessment. Randomization of group allocations was not described since the study protocol did not specify random assignment. Patients aged 18–65 years with radiologically confirmed unilateral ZMC fractures requiring open reduction and internal fixation were included. Informed consent and medical fitness for surgery were prerequisites for participation. Patients with displaced fractures that could be reduced using either navigation or conventional methods were eligible. Bilateral ZMC fractures, associated panfacial fractures that prevented evaluation of the affected ZMC, previous facial skeletal deformity or reconstructive surgery, pathological fractures or contraindications to surgery were excluded. Patients with incomplete preoperative/postoperative imaging, those who failed to register the navigation, or those without primary outcome measurements were not included in the relevant outcome analysis. Ethical approval and written informed consent were obtained from the institutional review committee and from each participant, respectively and data were collected by using a structured proforma. Demographic data and clinical data such as mechanism of injury, involved side, fracture classification, time to surgery, and facial injuries were obtained. Fracture pattern and displacement were determined by pre-operative clinical examination and computed tomography (CT) scans. The navigation-assisted patients received planning and guidance for the surgery before and during the procedure using a navigation system. The system was registered to the patient's anatomy and the location of the zygomatic complex and surgical instruments was evaluated against the desired location during reduction. Patients in the conventional group had open reduction and internal fixation with conventional techniques that involved standard surgical exposure, anatomical landmarks, direct visualization, and routine intraoperative evaluation without computer-assisted navigation. Surgical procedures were performed by appropriately trained surgeons using the institutional standard of care. The main outcome was the quality of the fracture reduction, which was evaluated by the deviation of the postoperative positioning with respect to the planned position and the contralateral (normal) side on CT scans. Three-dimensional comparison of pre- and post-operative CT datasets was performed in cases where appropriate imaging and software were available to quantify the displacement at predefined anatomical landmarks. The millimetre deviation of the average value of the landmarks was noted, and the smaller the deviation, the more accurate the reduction. Secondary outcomes included restoration of facial symmetry, operative duration in minutes, and postoperative complications, including infraorbital nerve paraesthesia, diplopia, infection, and residual facial deformity. The duration of the operation was recorded from its onset to its completion. Postoperative clinical findings and imaging were examined at a specific time point at follow-up, and complications recorded in both groups were reported using the same criteria. The data gathered were then entered and analyzed by the software IBM SPSS Statistics version 26. The Shapiro–Wilk test was used to evaluate the distribution of quantitative variables, such as age, operative duration, and landmark deviation. The data of normally distributed variables were expressed as mean ± standard deviation and median (IQR). Frequencies and percentages were used for the categorical variables such as sex, fracture characteristics, restoration of facial symmetry, and postoperative complications. Normally distributed continuous outcomes were compared between the two groups using the independent-samples t-test and Mann-Whitney U test. Categorical variables were compared using Fisher's exact test. The main comparison was between the deviation from the postoperative landmarks between navigation-assisted surgery and conventional surgery. The p-value was taken as significant for both sides with <0.05.

A total of 22 patients were included in the analysis, with 11 patients in each group. There were no significant differences in mean age between the navigation and conventional groups (35.4 ± 7.3 years vs. 35.9 ± 7.0 years). Both groups had more males than females. Demographic features were similar in both groups. (Table 1)

Road traffic accidents were the most common mechanism of injury in both groups, accounting for 54.5% of cases in the navigation group and 45.5% in the conventional group. A few more fractures were observed on the right side in the navigation group, and a few more on the left side of the body in the conventional group. Both groups had displaced or comminuted fractures and facial injuries. The median time between injury and surgery five days in each group. (Table 2)

The mean deviation of postoperative landmarks was less in the navigation group than in the conventional group (0.69 ± 0.24 mm versus 1.12 ± 0.22 mm), demonstrating that navigation-assisted surgery provides improved anatomical reduction accuracy. The percentage of patients with deviation of 1.0 mm or less was 81.8% in the navigation group and 36.4% in the conventional group. (Table 3)

The mean operative duration was longer in the navigation group compared to the conventional group (109.6 ± 9.5 minutes versus 96.3 ± 7.8 minutes). The success of achieving satisfactory restoration of facial symmetry was demonstrated in 81.8% of patients treated with navigation-assisted surgery and 54.5% of patients treated with conventional surgery. Diplopia and infraorbital nerve paraesthesia were reported in both groups and were less frequently reported in the navigation group. (Table 4)

In total, 27.3% of the patients in the navigation group and 45.5% in the conventional group had postoperative complications. No surgical site infections were observed in the navigation group, compared with one case in the conventional group. There were also fewer cases of residual facial deformity in the navigation group (9.1% vs 27.3%). These results indicated that navigation-assisted surgery had a lower numerical occurrence of postoperative complications. (Table 5).

Table 1. Sociodemographic characteristics of the study participants

Table 2. Injury and fracture characteristics

Table 3. Comparison of fracture-reduction accuracy (primary outcome)

Table 4. Operative and postoperative clinical outcomes

Table 5. Postoperative complications by surgical guidance technique

This study investigated the difference between surgeon-assisted and navigation-assisted reduction in the treatment of zygomaticomaxillary complex (ZMC) fractures. The most important outcome was that the mean deviation between postoperative and preoperative landmarks was less in the navigation group as compared to the conventional group (0.69±0.24 mm vs 1.12±0.22 mm). The navigation group also had a higher rate of satisfactory restoration of facial symmetry and longer operative time. In this data set, the navigation group had lower rates of complications following surgery. The results indicate a potential benefit of navigation in anatomical precision, but the small sample size and the limited amount of data limit the conclusions that can be drawn and do not prove that navigation is clinically superior. The lower landmark deviation in the navigation group is similar to the results of Gong et al. (2023), who performed a systematic review and meta-analysis of five studies with 189 patients. Their analysis showed that the mean fracture-reduction error was 0.86 mm less with computer-assisted navigation than with conventional surgery (p=0.02).[13] Likewise, Bănărescu et al. (2025) found that the interventions with surgical navigation during the surgery resulted in a reduction in zygomatic bone deviation of 0.64 mm in the postoperative phase, with no significant difference for the majority of other clinical outcomes.[8] Cheng et al. (2022), on the other hand, performed a randomized controlled trial on 38 patients who had unilateral type B ZMC fractures, and they did not find any statistically significant difference between the accuracy of translation or rotation with and without the use of navigation. They concluded that anatomical reduction could be obtained with satisfactory results in selected fractures using conventional surgery.[14] The variations in their results and those of the present findings could be due to fracture complexity, registration of the navigation, surgeon skill, and outcome measurement. Therefore, navigation is not a better alternative in all circumstances, but may be regarded as a potentially useful adjunct. Dubron et al. (2022) conducted a systematic review that included 17 studies, which also concluded that several investigations showed improved linear accuracy, rotational alignment, or orbital volume restoration using virtual planning and navigation.[7] The review, however, noted inconsistent findings with respect to the operative time and cost-effectiveness. Combined, the results of these studies confirm the promise of computer-assisted methods to enhance anatomical assessment, while also highlighting the need to be aware of the potential for benefit to differ depending on the clinical context. In the present results, satisfactory restoration of facial symmetry was observed in 81.8% of patients in the navigation group compared with 54.5% in the conventional group. This numerical difference in favor of navigation should be interpreted with caution, as only 11 patients were included in each group. In patients with ZMC fractures, Franke et al. (2025) evaluated the postoperative symmetry by the intraoperative cone-beam computed tomography (CBCT) scan. Their work highlighted the need for 3D assessment of the patient to detect any residual asymmetry that may not be fully captured using traditional clinical assessment. These findings validate the importance of objective anatomical assessment, which is a different technology from CBCT-guided assessment and real-time surgical navigation.[15] In a separate study, Van et al. (2025) compared quantitative and qualitative symmetry after open reduction and fixation in 16 patients and 10 controls who had no injuries. Symmetry increased towards control values, but some postoperative differences persisted in some patients, especially those with more complicated fractures.[16] This finding is important in the present study as it shows that without successful fixation, total facial symmetry cannot be restored. The study, however, only compared conventional fracture treatment, not navigation vs. conventional guidance. The mean duration of the operation was higher in the navigation group compared to the conventional group (109.6±9.5 minutes vs. 96.3±7.8 minutes). This difference could be attributed to the extra time that was needed for the image registration, system calibration, virtual planning, and verification of anatomical alignment. The findings do not, however, conclude that this was due to navigation itself. In this randomized study, Eswari et al. (2022) studied ultrasonography during surgery in 24 patients suffering from unilateral zygomatic complex fracture. Their results confirmed that ultrasound could be used to evaluate the fracture alignment in three dimensions, and that using ultrasound to assess fracture alignment would decrease the operative time when compared to the use of conventional methods [7]. This study validates this approach, but does not provide equivalence with computer-assisted navigation and cannot be directly applied to navigation-assisted surgery.[17] In 2025, Korner et al. published their experience of 5 years of using CBCT during treatment of 337 patients with ZMC fractures. In 2025, Korner et al. reported their experience of 5 years using CBCT for the treatment of 337 patients with ZMC fractures. In 44.5% of cases, the remaining malposition was detected and corrected intraoperatively, while apparently satisfactory reduction was obtained.[18] It is important to note that the use of intraoperative CBCT is not the same as the use of surgical navigation, but this study demonstrates the benefit of objective measurement of fracture alignment. However, it does not prove that navigation decreases post-op complications or the need for additional surgery. Brierly et al. (2026) recently performed a randomized controlled trial of 133 patients who were treated for zygomatic arch fractures (ZAFs) with and without the assistance of intraoperative computed tomography (CT). They reported no statistically significant differences when it comes to postoperative radiographic results (p = 0.618) and revision surgery (p = 0.653).[19] The results are a significant offset to the report of increased anatomic accuracy with computer-assisted techniques. In addition, they recommend that the advantages of increased intraoperative imaging may vary based upon the experience of the surgical team and the type of fractures being treated. The authors of Postoperative Outcomes and Complication Risk Factors in Zygomaticomaxillary Complex (ZMC) Fractures conducted a retrospective study of 77 patients who underwent surgery for ZMC fractures in 2025 and looked at postoperative results and risk factors for complications.[10] This study confirms the relevance of taking patient and injury factors into consideration when evaluating surgery outcomes. It did not directly establish the superiority of navigation over conventional guidance; therefore, its findings do not give direct evidence for either technique but do give wider clinical context. Limitations There were a few limitations in the study. The small sample size of 22 patients limited the statistical power to detect differences in postoperative complications and other clinical outcomes. Selection bias and differences in baseline fracture complexity between groups could have been introduced through non-probability consecutive sampling and non-random allocation. Moreover, the accuracy of fracture reduction was assessed only if there were standardized postoperative imaging and consistent anatomical reference points. A relatively brief follow-up period might also have restricted the evaluation of late facial symmetry and sensory abnormalities and late complications. Lastly, the results may not be applicable to institutions with different surgical experiences and access to navigation technology.

Intraoperative navigation-assisted surgery demonstrated lower postoperative landmark deviation and a higher proportion of satisfactory facial symmetry than conventional surgical guidance. In terms of operative time, however, navigation was linked to a longer operative time, but the differences in postoperative complications were not large enough to prove clinical superiority. The results imply that navigation might be superior when it comes to anatomical accuracy, but the clinical advantages need to be verified with sufficiently powered comparative research on a standardized outcome measure with extended follow-up.