Background <p>Zygomatico-Maxillaris Complex (ZMC) fractures are the second most common fractures after nasal fractures. Open Reduction Internal Fixation (ORIF) is the most preferable treatment option in the management of ZMC fractures, mainly aiming at achieving maximum reduction and stability to prevent micromovement. There is no consistency in the number of fixation points required to achieve stability. The study was aimed at evaluating the difference in the number of fixation points on radiographic symmetry after ORIF.</p> Methods <p>This retrospective study used Water’s radiographic data from patients who had undergone ORIF, with predetermined patient inclusion criteria. The data were grouped into group A (1-point fixation), group B (2-point fixation), and group C (3-point fixation), each of which comprised 20 samples, and observations were made on day 3 postoperatively. Symmetry was analyzed using the symmetry index and Bland-Altman analysis by comparing the non-fracture side and the fracture side after ORIF in unilateral ZMC fractures.</p> Results <p>The smallest symmetry index was found in group B (0.42 ± 0.16). Tukey statistical tests showed that there was no significant difference between group B and group C (0.45 ± 0.18) (<i>p</i> &lt; 0.8). However, the difference was found between group A (0.79 ± 0.22) and group B and group C, with <i>p</i> &lt; 0.001, respectively. Bland-Altman analysis with a 95% limit of agreement showed the smallest limit also in group B, which means that group B had the best symmetry, followed by group C and group A, but overall all groups showed symmetry.</p> Conclusion <p>The number of point fixations affects the symmetry of post-ORIF reduction in ZMC fracture in early radiographic assessment. The use of 2-point and 3-point fixation showed no difference and appeared better compared with 1-point fixation.</p> Clinical trial number <p>Not applicable.</p>