Which maxillofacial fractures warrant the use of intraoperative CT? A systematic review and meta-analysis

Purpose The introduction of intraoperative CT (iCT) has provided a new tool that may improve outcomes in the surgical management of maxillofacial fractures (MFFs). This systematic review and meta-analysis evaluated the clinical value of iCT in MFFs and identified the fracture types and circumstances in which it provides notable benefit. Methods PubMed, Scopus, and ClinicalTrials.gov were searched for clinical studies published or registered from January 2020 to November 2025. Random-effect models pooled the intraoperative CT revision rate and post-operative bilateral orbital volume difference across various fracture types. Results Eighteen studies (1165 patients; 12 cohorts, 1 case-control, and 5 case series) were included across zygomaticomaxillary complex, orbital, mandibular, and nasal fractures. Of these, 11 studies ( n = 493) provided extractable quantitative data for the intraoperative revision meta-analysis, which yielded a pooled revision rate of 36% ( I 2 = 77%), with a fracture-type gradient (orbital 58% > other MFFs 49% > zygomaticomaxillary complex 26%; subgroup p < 0.001). High revision yield in orbital fractures suggests that iCT may enhance intraoperative verification of reduction and implant positioning during orbital reconstruction; however, evidence for post-operative volumetric symmetry remains limited and largely derived from observational studies. Mean iCT acquisition time was 4.2 to 18.9 min, and comparative data suggested no significant increase in total operative time. Conclusions Overall, iCT appeared most valuable when 3-dimensional reduction accuracy or implant seating could not be confidently assessed before closure, especially in orbital reconstruction and anatomically constrained, symmetry-critical MFFs.