SAVE THE ZYGOMA: ANATOMY-DRIVEN INDICATIONS AND RESPONSIBLE USE OF ZYGOMATIC IMPLANTS IN FULL-ARCH REHABILITATION

P. Poliçi¹, S. Piccolo², L.M. Laudiero^2*, F. Ferrantini², M.C. Palumbo², S. Barbaro² and M. Benegiamo³

¹ Catholic University Our Lady of Good Counsel, Tirana, Albania;
² Department of System Medicine, University of Rome “Tor Vergata”, Rome, Italy;
² Department of Experimental Medicine, University of Salento, Italy.

*Correspondence to:
Lorenzo Maria Laudiero,
Department of System Medicine,
University of Rome “Tor Vergata”,
Rome, Italy.
e-mail: laudiero.lm@gmail.com

Received: 14 January, 2026 Accepted: 31 March, 2026

ISSN 2279-5855 print / 2974-6345 [online] Copyright 2026 © by Biolife-publisher This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties. Disclosure: All authors report no conflicts of interest relevant to this article.

ABSTRACT

Introduction: The role of the zygomatic bone in implant dentistry has undergone significant transformation over recent years. Originally reserved for cases of extreme maxillary atrophy, zygomatic implants are increasingly employed as first-line solutions, reflecting a shift in clinical philosophy. While their biomechanical reliability is well established, the progressive normalization of their use raises important concerns regarding anatomical preservation, functional balance, and long-term sustainability. Discussion: Zygomatic implants provide effective anchorage in dense cortical bone when conventional alveolar support is insufficient. However, survival rates alone do not fully capture treatment success, as functional overload, neuromuscular conditions, and temporomandibular disorders may significantly influence long-term biomechanical stress. Contemporary anatomy-guided protocols, including the ZAGA approach and advanced digital workflows, allow individualized implant trajectory planning and improved prosthetic integration. Biomechanical considerations, such as implant macro- and nanostructure, rigid prosthetic frameworks, and controlled load distribution, remain critical in preventing peri-implant complications. At the same time, the availability of alternative basal anchorage strategies underscores the importance of selective indication rather than routine zygomatic consumption. Conclusions: The expanding use of zygomatic implants represents a major advancement in the management of maxillary atrophy, yet it requires careful biomechanical, functional, and ethical evaluation. Preserving the integrity of the zygomatic bone through anatomy-driven and patient-specific decision-making is essential to ensure long-term functional stability. The zygoma should be regarded not merely as an anchorage resource, but as a strategic anatomical asset whose protection is fundamental to responsible and sustainable implant rehabilitation.

KEYWORDS: Zygomatic implant, maxillary atrophy, zygomatic bone preservation, anatomy-guided implantology, full-arch rehabilitation, digital workflow, zaga protocol, implant biomechanics, temporomandibular disorder, basal bone anchorage

INTRODUCTION

In recent years, the use of the zygomatic bone in implant dentistry has undergone significant evolution. Once reserved exclusively for cases of extreme maxillary atrophy, zygomatic implants are now increasingly adopted as a first-line therapeutic approach, reflecting a substantial shift in both clinical practice and treatment philosophy. This growing utilization of the zygomatic structure reflects not only increased confidence in surgical techniques, but also a broader reconsideration of rehabilitative strategies, which must carefully balance functional demands with esthetic considerations. The traditional full-arch rehabilitation paradigm, centered on bone preservation and controlled load distribution, is being challenged by this emerging trend, which favors a less conservative anchorage strategy. Although zygomatic implants have demonstrated remarkable biomechanical robustness, the consideration of functional and neuromuscular factors remains essential to ensure long-term stability. Emerging technologies, such as the ZAGA protocol and advanced digital methodologies, offer new opportunities to personalize treatment planning and improve clinical outcomes. However, the progressive normalization of zygomatic implant therapy raises important questions regarding indication criteria and the potential risk of compromising zygomatic bone integrity. This trend calls for careful reflection and prudent clinical management. It is therefore necessary to reconsider the way the zygoma is employed—not merely as an instrumental anchorage resource, but as an anatomical structure to be protected and strategically preserved within comprehensive dental rehabilitation. This paper explores recent developments in zygomatic implantology, emphasizing the importance of a strategic, anatomy-driven approach aimed at ensuring functional stability and the long-term health of the stomatognathic system.

MATERIALS AND METHODS

Study Design

Focusing on indication criteria, anatomical preservation, biomechanical implications, digital integration, and functional considerations, this study examines the current development of zygomatic implant therapy through a structured narrative review and critical analysis of the international scientific literature. The objective was to examine the shift from a strictly necessity-driven use of the zygomatic bone toward its increasing normalization as a primary anchorage option, evaluating both the clinical rationale and the potential biological and ethical implications.

Sources and Search Criteria

Databases: A comprehensive literature search was performed using major biomedical databases, including PubMed (MEDLINE) and Scopus.

Keywords and Search Terms: Search strategies were developed through combinations of relevant keywords and MeSH terms related to “zygomatic implants,” “maxillary atrophy,” “zygoma anatomy-guided approach,” “full-arch rehabilitation,” “implant biomechanics,” “primary stability,” “digital workflow,” “virtual patient protocols,” “temporomandibular disorders,” and “soft tissue management.” Boolean operators were employed to refine and combine search queries in order to ensure comprehensive coverage of the topic.

Reference Period: Particular emphasis was placed on publications from the last 10–15 years to reflect current clinical paradigms and technological advancements; however, seminal studies describing the original zygomatic surgical techniques, anatomical classifications, and foundational biomechanical principles were also included when considered essential for contextual and historical interpretation.

Types of Studies Included

Eligible publications encompassed systematic reviews and meta-analyses addressing zygomatic and alternative basal anchorage strategies, as well as prospective and retrospective clinical studies reporting survival rates, biological and mechanical complications, and long-term functional outcomes. Clinical case series and technical reports detailing surgical modifications, anatomy-guided approaches such as the ZAGA protocol, and digital planning methodologies were incorporated to provide insight into practical clinical applications. In addition, in vitro and in vivo investigations examining implant macro- and nanostructural design, biomechanical behavior, and bone–implant interface dynamics were considered when relevant to load distribution and structural stability. Studies focusing on temporomandibular disorders, neuromuscular balance, and functional risk assessment in implant-supported full-arch rehabilitation were also evaluated to contextualize the broader functional implications of irreversible zygomatic anchorage. Publications lacking methodological clarity or scientific support were excluded.

Data Extraction

For each selected study, relevant data were systematically extracted and analyzed according to thematic domains including surgical indication criteria, implant trajectory and stabilization principles, biomechanical load distribution, prosthetic framework rigidity, digital planning accuracy, peri-implant tissue management, and strategies aimed at minimizing surgical trauma and biological burden. Special attention was devoted to discussions addressing the preservation of the zygomatic bone as a finite anatomical resource and to the ethical considerations associated with its routine use.

Synthesis and Interpretation

The collected data were analyzed through a qualitative approach and organized into key thematic domains to outline current developments in zygomatic implant therapy. The interpretation was framed within a clinically oriented translational model, focusing on the interplay between anatomical considerations, biomechanical principles, functional outcomes, digital workflows, and long-term treatment predictability. As no quantitative meta-analysis was undertaken, this review instead aimed to develop a conceptually structured, anatomy-based model to guide case selection and promote the responsible and targeted use of the zygomatic bone in complex implant-supported rehabilitations.

DISCUSSION

The zygomatic bone has progressively become one of the most extensively utilized anatomical structures in contemporary implant dentistry. What was once conceived as a solution reserved exclusively for extreme maxillary atrophy is increasingly adopted as a first-line option, often driven by procedural confidence rather than strict anatomical or functional necessity. This shift contrasts with prosthetically guided full-arch rehabilitation concepts, which historically emphasized selective anchorage, controlled load distribution, and preservation of strategic bone rather than its consumption (1).

Zygomatic implants were originally developed to manage cases in which conventional alveolar anchorage was no longer feasible. Their biomechanical rationale, anchorage in dense cortical bone, extended implant length, and cross-arch stabilization, is solid and well documented (1). However, survival rates alone provide an incomplete measure of treatment success, as they fail to account for functional overload, parafunctional habits, and neuromuscular conditions that may significantly influence long-term biomechanical stress.

Primary stability represents a fundamental biological prerequisite for long-term success. Controlled clinical studies have demonstrated that initial mechanical conditions directly affect osseointegration dynamics and peri-implant tissue stability over time (2). This principle remains highly relevant in zygomatic implantology, where extended implant length and complex load distribution amplify the importance of precise surgical execution.

P-I Brånemark developed the original surgical technique (OST), which involved palatal access and an intra-sinus pathway to achieve zygomatic anchorage through a two-stage protocol. However, this methodology presented several limitations, including the frequent creation of bulky prostheses and the risk of oroantral communication (3). The original technique began with penetration through the cortical plate of the maxillary alveolar bone, followed by access to the sinus floor. The drilling direction could vary depending on the morphology of the lateral sinus wall, ultimately reaching the zygomatic body and engaging the lateral cortical plate. Zygomatic implants benefit from stabilization through both maxillary and zygomatic cortical plates, providing quadricortical anchorage and enhanced mechanical support (4).

In 2011, a classification system describing the relationship between the zygomatic buttress and the alveolar crest was introduced, leading to the development of the ZAGA (Zygoma Anatomy-Guided Approach) protocol (5). The objective of ZAGA is to personalize implant positioning according to individual anatomical variations, allowing for intra-sinus or extra-sinus trajectories and influencing implant design selection. Tunnel osteotomy techniques were conceived to promote long-term stability and enhance osseointegration at the implant neck by ensuring adequate bone support, optimized thread design, and rigid prosthetic connection. Accurate biomechanical preparation is essential to maintain the implant head within the alveolar crest perimeter, avoiding palatal emergence that may compromise both tissue health and prosthetic rehabilitation.

Traditional indications for zygomatic implants included extreme atrophy, previous graft or implant failures, avoidance of multi-stage grafting procedures, and systemic conditions complicating conventional augmentation approaches, such as benign cysts, amelogenesis imperfecta, trauma, or oncologic resections (6).

The zygoma, therefore, should not be regarded as expendable bone. It represents a finite and non-regenerative anatomical resource, essential for facial support, sinus integrity, and future reconstructive options. The progressive normalization of zygomatic implants has blurred the boundary between necessity and convenience. Patients presenting with moderate atrophy, residual alveolar bone, or alternative basal anchorage options, such as pterygoid or transnasal implants (7), are increasingly treated with zygomatic implants as a primary solution, often facilitated by newer surgical methodologies (8).

In parallel, biologically oriented surgical approaches aimed at preserving alveolar volume and minimizing surgical trauma have shown promising outcomes even in complex clinical scenarios, emphasizing the importance of conservative planning whenever feasible (9).

Contemporary digital workflows and virtual patient protocols now enable a far more refined evaluation of skeletal, facial, occlusal, and functional parameters, supporting selective and anatomy-respectful anchorage strategies (10). Advanced digital planning allows clinicians to simulate implant trajectory, prosthetic emergence, and load distribution before committing to irreversible surgical decisions, particularly in patients presenting with complex functional profiles (11,12). In such cases, preserving the zygoma whenever alternative anchorage solutions can ensure functional stability represents a rational and biologically sound decision.

Even surgical details often perceived as secondary, such as flap design, soft-tissue handling, and suturing technique, play a decisive role in limiting surgical trauma and promoting peri-implant tissue stability, even when innovative approaches are adopted (13,14). Contemporary reviews on suturing materials and techniques in dentistry further highlight how meticulous soft-tissue management contributes significantly to wound integrity and long-term tissue preservation, particularly in anatomically demanding and high-risk procedures (15).

Biomechanically, the macro- and nano-structural design of implants may influence force distribution and tissue response at the bone–implant interface, especially under complex loading conditions (16). This consideration becomes particularly relevant in zygomatic rehabilitation, where implant length and load vectors differ substantially from conventional alveolar implants.

Within this context, functional disorders of the stomatognathic system deserve particular attention. Statistical analyses of the frequency distribution of signs and symptoms in patients with temporomandibular disorders (TMD) have demonstrated that altered muscular activity, joint dysfunction, and parafunctional behaviors are common, and often underdiagnosed, among patients requiring complex oral rehabilitation (17). Ignoring these factors when planning irreversible anchorage in the zygomatic bone may expose this non-regenerative structure to excessive and uncontrolled biomechanical loading.

Provisional prostheses play a crucial role in zygomatic implant therapy. They must provide satisfactory esthetics and allow proper masticatory and phonetic function during healing. They also serve as diagnostic tools to verify occlusion and tooth positioning, as well as to compensate for soft-tissue deficiencies. The definitive rehabilitation must rigidly connect the implants in an arch form to ensure stability and appropriate load distribution. Insufficient prosthetic rigidity may lead to implant deformation, peri-implant bone loss, or screw loosening. Bending forces are particularly detrimental to long-term stability. The final prosthesis should respect Beyron’s occlusal principles, ensuring neuromuscular stability without excessive strain and allowing physiological adaptation over time (18). The use of CAD/CAM technologies is recommended to enhance precision and predictability in definitive prosthetic fabrication, improving structural rigidity, gingival adaptation, material selection, and esthetic integration.

CONCLUSIONS

In conclusion, the increasing use of zygomatic implants in implant dentistry represents a significant evolution in the management of maxillary atrophy. However, this innovative approach requires careful consideration of biomechanical and functional implications to ensure sustainable and long-term stability of the rehabilitation. The need to preserve the integrity of the zygomatic bone, avoiding indiscriminate or convenience-driven implant placement, underscores the importance of a personalized, anatomy-driven approach. Advances in digital technologies and protocols such as ZAGA provide valuable tools to optimize surgical planning and execution, yet the clinician’s responsibility to critically evaluate each individual case remains paramount. A strategic and conscientious management of the zygomatic bone not only ensures functional stability but also promotes the long-term health of the stomatognathic system. In this perspective, the zygoma should not be viewed merely as an anchorage option, but as a valuable anatomical resource whose preservation is integral to responsible and sustainable implant rehabilitation.

Conflict of interest

The authors declare that they have no conflict of interest.

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