Zygomatic Implants (Zygoma All-on-4): For Severe Bone Loss

In some patients who have worn an upper denture for years, the upper jaw has resorbed so far that there is simply nothing left for conventional implants to hold on to. The bone is thin, the sinuses have dropped, and the standard answer used to be lengthy grafting or a sinus lift with months of waiting. Zygomatic implants change that calculation: instead of building bone, we anchor into bone the patient already has, the cheekbone (the zygomatic bone).

What a zygomatic implant is

A zygomatic (Zygoma) implant is longer than a standard one, typically between 30 and 55 millimetres. It does not rely on the alveolar ridge of the upper jaw; instead it passes through it or alongside it and finds its anchorage in the body of the cheekbone. That bone is dense and in most people stays preserved even when the alveolar ridge is severely resorbed. That is the key to why this approach works where an ordinary implant has nothing to grip.

The technique was introduced in the late 1980s by Per-Ingvar Brånemark, the same researcher who described osseointegration. Since then it has developed into a well documented method for rehabilitating the severely atrophic edentulous upper jaw.

How Zygoma fits into the All-on-4 concept

All-on-4 means a complete fixed bridge on the upper or lower jaw carried by four implants. In an upper jaw without enough bone, the front section (the premaxilla) often still has some bone left, while the back section, beneath the sinus, is empty. This is where the zygomatic variant comes in.

In practice it most often looks like this:

• Two zygomatic implants at the back, one on each side, anchored in the cheekbone.
• Two standard implants at the front, if there is enough bone in the premaxilla.

When the bone at the front has been lost as well, a Quad Zygoma is performed, that is, four zygomatic implants, two on each side. The choice depends entirely on how much bone is left and where, and we only see that on the CBCT scan.

Who zygomatic implants are a solution for, and who they are not

We consider the zygomatic approach in patients for whom conventional implant placement is not feasible without extensive bone grafting. The typical profile:

• a severely resorbed edentulous upper jaw with too little bone for standard implants;
• a previous graft or sinus lift that did not hold;
• bone loss after a tumour, a cyst or trauma to the upper jaw;
• patients who want to avoid repeated bone grafting procedures and long waiting.

It is not for everyone. Active sinusitis, some bone diseases and uncontrolled general health problems can be a contraindication or call for preparation before surgery. That is why we plan every case individually, on the basis of an examination and a scan, rather than to a template.

Fixed teeth in 24 hours: how that is possible without bone

The cheekbone is dense and allows the implant to achieve high primary stability at the moment it is placed. That is why in most patients a temporary fixed bridge can be fitted within 24 hours, following an immediate loading protocol. The patient arrives at the practice with a denture or without teeth, and leaves with fixed teeth.

This is not only a matter of comfort. In a 2023 meta-analysis (18 studies, 1,349 zygomatic implants in 623 patients), immediate loading showed survival of 98.1% against 95% for delayed loading. Early function, with good primary stability, does no harm, and for some patients it actually helps.

How reliable the method is

The data are encouraging, even for a technique that sounds dramatic. The same 2023 meta-analysis reports a mean survival of zygomatic implants of 96.2% at six years, with an average follow-up of more than six years. A 2021 systematic review and meta-analysis that compared zygomatic and conventional implants in the upper jaw found comparable survival, with a range of 94.1% to 100% for the zygomatic ones.

In other words, with a properly selected patient and an experienced surgeon, the long-term results come close to those of standard implants, with the major advantage of avoiding extensive bone grafting.

Risks that deserve an honest mention

The most common biological complication is sinusitis. The 2023 meta-analysis mentioned above reports a prevalence of around 14.2% over five years. Importantly, sinusitis usually responds well to antibiotics or, where needed, to surgery, but it can also appear years after placement, which is why follow-up matters.

A great deal depends on surgical technique. A 2023 systematic review showed that the anatomy-guided approach has lower complication rates than the original surgical technique. Sinusitis with the anatomy-guided approach was around 4.4% against 9.5% with the original surgical technique. This is why, with zygomatic implants, the right indication, precise 3D planning and correct execution of the procedure are decisive for the long-term success of the treatment.

How we do this at Ortoimplant DENTAL SPA

Zygomatic implants are part of our narrower niche for patients without enough bone, alongside pterygoid, trans-sinus, subperiosteal and transnasal implants. Our position is simple: there is practically no patient who cannot be offered a fixed solution, as long as there is a safe surgical option and a clear indication for using it.

We plan every Zygoma case precisely from a 3D CBCT scan, so that the path of each implant is determined before we begin surgery. For procedures of this complexity we routinely use potentiated intravenous analgosedation, the depth of which is adjusted to the patient and to the procedure, so that the whole process goes calmly and comfortably. We support recovery further with individually tailored DENTAL SPA treatments, which are an integrated part of our perioperative protocol and are aimed at creating the most favourable possible conditions for healing, postoperative recovery and the processes that matter for osseointegration.

The procedure is led by dr. Zdenko Trampuš, DDS, who introduced zygomatic implants to Croatia and the region back in 2011, is a certified Zygoma instructor and today has the longest clinical experience with zygomatic implants in the region. He is joined in treatment by a team that includes dr. Martin Trampuš. Zygomatic surgery calls for exactly this level of experience and routine because, as the literature shows, results depend heavily on the right indication, precise planning and the surgeon’s experience.

The first examination and the assessment of whether zygomatic implants are an option for you are free of charge. If it turns out that a conventional approach is not feasible, Zygoma All-on-4 is often the shortest route to fixed teeth without lengthy bone grafting.

Frequently asked questions