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. 2026 Apr 28;88(6):3189–3197. doi: 10.1097/MS9.0000000000004994

W2 Technique for the placement of zygomatic implants and the new guidelines for optimal implant surgical approach: a technical note

Paulo Henrique Teles de Almeida 1,*
PMCID: PMC13236229  PMID: 42254122

Abstract

There are several published scientific articles warning about the risks and complications of penetration of zygomatic implants into the orbital cavity, some of which lead to irreversible consequences. Digital dentistry is a reality, with positive impact on the manufacture of surgical guides for the placement of zygomatic implants, which should decrease orbital iatrogenesis. However, contemporary literature has revealed that there is still a minimal difference between the planned position and positioning of the implants, resulting in small deviations. Within this context, it is necessary to follow protocols that support the digital workflow so that the zygomatic implant placement technique can be performed safely by a higher number of surgeons, who still feel confident about performing the technique freehand. The purpose of this technical note is to present a safe freehand surgical protocol for the placement of zygomatic implants, entitled the W2 Technique, in cases where there is anatomically no buccal bone tissue at the head of the zygomatic implant and the middle and cervical thirds of the implant are exteriorized, with part of the zygomatic implant body visible and outside the maxillary sinus, and to present new guidelines for the surgical approach to optimal implants, based on the radiographic zones of the maxilla. The surgical protocol presented is a safe protocol for the placement of zygomatic implants freehand, with the aim of reducing the risk of ocular complications and adjacent tissues.

Keywords: atrophic maxilla, orbital penetration, Quad Zygoma, technical note, zygomatic implants

Introduction

Bedrossian et al proposed a classification, based on the radiographic zones of the maxilla, for the rehabilitation of edentulous patients[1]. According to the authors, the maxilla is divided into three zones: Zone 1, Zone 2, and Zone 3. Zone 1 covers the canines and incisors, Zone 2 the premolars, and Zone 3 the molars. At that time, depending on the presence and/or absence of bone tissue in each of these zones, there were some treatment options and types of implants that were restricted exclusively to traditional straight and/or inclined, and zygomatic implants, and bone grafts.

With the passage of time, new surgical techniques such as different types of implants have emerged, increasing the possibility of offering patients a larger number of treatment options, especially those with severe bone atrophy[2].

HIGHLIGHTS

  • Present new guidelines for the surgical approach to optimal implants, based on the radiographic zones of the maxila.

  • Present a safe freehand surgical protocol for the placement of zygomatic implants.

  • Reducing the risk of ocular complications and adjacent tissues.

  • Recommended to perform surgical planning using software, simulate the surgery virtually as well as on a stereolithographic model of the patient, and possess extensive knowledge of facial anatomy.

  • Always having the help of experienced mentors in the first operated cases.

One of the greatest challenges in implant dentistry has always been the rehabilitation of patients with atrophic jaws. In the early 2000s, large autogenous bone grafts were still performed, such as grafts from the iliac crest, cranial calvari, mandibular body and ramus, and chin[3]. These surgical procedures caused morbidity in patients[4] with a consequent decrease in oral health-related quality of life and health-related quality of life[5]. Gradually, biomaterials were introduced to replace the autogenous bone harvesting procedures[6].

With a view to achieving faster treatments, with lower morbidity and without the need for bone grafts, it is now possible to rehabilitate these patients with the use of remote anchorage implants, positioning implants in positions such as the zygomatic bone and paranasal bones of the maxilla[7], inferior nasal concha and frontal process of the maxilla[2,8], the composite bone pillar of the maxillary tuberosity, pyramidal process of the palatine bone, and pterygoid process of the sphenoid bone[9].

For borderline cases, with significant maxillary bone atrophy, implant loss, and advanced patient age, we still have the option of using additively manufactured subperiosteal jaw implants (AMSJI), made with computer-aided design/computer-aided manufacturing technology, to rehabilitate these patients with immediate loading after surgery[10].

With the increasing number of surgical treatment options, at present available for rehabilitating patients with atrophic jaws, it is necessary to present surgeons with new guidelines for ideal implant placement based on radiographic zones of Bedrossian et al[1], proposed by this author. This is required for disseminating various surgical protocols[9] that will help surgeons plan their surgeries with improved prognoses, by promoting the longevity of prosthetic rehabilitations.

Within this scenario, we will present the surgical protocol entitled “W2 Technique,” with a view to creating a safe freehand surgical protocol, to assist the digital workflow, for all experienced surgeons who are qualified to rehabilitate patients with major maxillary bone atrophy. Furthermore, we expect fewer new complications related to these implants to occur, especially those related to perforation of the orbital cavity and injury to adjacent tissues[11]. All patients who are indicated for zygomatic implant placement using the “W2 Technique” surgical protocol will benefit.

The purpose of this technical note is to describe new guidelines for an optimal surgical approach to implant placement, based on radiographic zones of the maxilla and to present the surgical protocol entitled “W2 Technique” for safe freehand placement of zygomatic implants in cases where there is anatomically no buccal bone tissue at the head of the zygomatic implant and the middle and cervical thirds of the implant are exteriorized, with part of the zygomatic implant body visible and outside the maxillary sinus. The author declares that they did not use any AI tools or technologies in the preparation of this manuscript, thus complying with the TITAN Guidelines 2025[12].

New guidelines for optimal implant surgical approach, based on radiographic zones of the maxilla

At present, it is possible to classify several treatment techniques with remote anchorage implants for patients with atrophic jaws, according to the availability of bone found in each radiographic zone, and without the need for performing complex autogenous bone grafts[9,13]. This classification allows the combination of several types of surgical techniques used in the same patient, which we call All on X[9,13].

Presence of bone in Zones 1, 2, and 3

When rehabilitating a patient with a totally edentulous maxilla, with the use of dental implants, the best condition we can hope for when performing the tomographic examination is to find sufficient height and thickness of bone tissue in Zones 1, 2, and 3. In these cases, conventional straight implants are used to support fixed prostheses, hybrid prostheses such as the Branemark protocol, or removable prostheses (overdenture)[1].

Presence of bone in Zones 1 and 2

In this configuration, it is possible to use conventional straight and/or inclined anterior implants, using the paranasal bones of the maxilla, directed to points M or V[14,15], depending on the degree of bone atrophy of the maxilla. Conventional nasopalatine implants[9] and conventional straight implants directed toward the nasal crest/vomer junction can also be used[14]. In the posterior region, conventional inclined implants, tangential to the anterior wall of the maxillary sinus, which is generally pneumatized, can be used (point M)[15], and their trajectory can also be trans-sinus[16]. Extra-long implants directed toward the nasal cavity (trans-sinus) can also be used[17]. It is possible to use conventional implants in the tuberosity and/or pterygoid implants, with the aim of reducing the free end of prostheses[9,18].

Presence of bone in Zone 1

In this configuration, it is possible to use conventional straight and/or inclined anterior implants, directed toward the points M or V[14,15]. Moreover, conventional nasopalatine implants[9] and conventional straight implants directed toward the nasal crest/vomer junction can be used[14]. In the posterior region, unilateral zygomatic implants, conventional implants used in the tuberosity, and/or pterygoid implants are used to reduce the free end of the prostheses[9,18].

Presence of bone in Zone 2

In this configuration, transnasal implants and/or zygomatic implants are used in the anterior region[1,13]. In the posterior region, conventional inclined implants, tangential to the anterior wall of the maxillary sinus, can be used (point M)[13,15], and their trajectory can be trans-sinus[16]. Extra-long implants directed toward the nasal cavity (trans-sinus) can also be used[13,17]. It is possible to use conventional implants in the tuberosity and/or pterygoid implants, with the aim of reducing the free end of prostheses[9,18].

Absence of bone in Zones 1, 2, and 3

In this configuration, it is possible to use transnasal anterior implants[2,13], unilateral posterior zygomatic implants[8,13], Quad Zygoma[1,9], conventional tuberosity implants and/or pterygoid implants[9,18], and AMSJI[10].

Table 1 presents the new guidelines for optimal implant surgical approach.

Table 1.

New guidelines for optimal implant surgical approach.

Bone present for implants Posterior surgical approach
Zones 1, 2, and 3 Traditional straight implants
Zones 1 and 2 Traditional previous straight implants; traditional previous inclined implants (point M and point V); nasopalatine implants; straight implants nasal crest/vomer junction; posterior inclined traditional implants (M/Trans-Sinus point); posterior extralong implants (Trans-Sinus); traditional implants in tuberosity; pterygoid implants
Zone 1 only Traditional previous straight implants; traditional previous inclined implants (point M and point V); nasopalatine implants; straight implants nasal crest/vomer junction; unilateral zygomatic implants; traditional implants in tuberosity; pterygoid implants
Zone 2 only Transnasal implants; anterior zygomatic implants; posterior inclined traditional implants (M/Trans-Sinus point); posterior extralong implants (Trans-Sinus); traditional implants in tuberosity; pterygoid implants
Insufficient bone in any zone Transnasal implants; unilateral zygomatic implants; Quad Zygoma; traditional implants in tuberosity; pterygoid implants; additively manufactured subperiosteal jaw implants
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Description of the technique

The surgical protocol presented is intended for patients with facial anatomy in which the head of the zygomatic implant lacks vestibular bone tissue and a concavity of smaller or larger size forms between the zygomatic bone and the alveolar crest, rendering all or part of the zygomatic implant exteriorized. The surgery should preferably be performed in hospital under general anesthetic, with nasal intubation. Infiltrative anesthesia with a vasoconstrictor must be administered to contain local bleeding and postoperative pain. Experienced surgeons can perform the procedure in an outpatient setting, with local anesthesia and intravenous or oral sedation[19].

The procedure begins with an incision in the crest of the alveolar ridge, slightly palatinized, going toward the distal direction of the first molars. Relaxing incisions are made going toward the midline and in the distal direction to the first molars. Subsequently, the palatine and vestibular flaps are detached, exposing the nasal cavity, infraorbital foramen, zygomatic arch and bone, and the inferior rim of the orbit. When necessary, bone regularization is performed on the crest of the alveolar ridge. At all times, the cutting line should be left above the patient’s upper lip (smile line) to hide the transition zone between the hybrid implant-supported prosthesis and the patient’s gum tissue. Then, the lines that will be used as entry points for the anterior and posterior zygomatic implants are marked[20]. The lowest point P1 of the maxillary alveolar ridge intersects with a perpendicular line L1 extending from the lateral margin of the nasal incisure. The lowest point P2 of the alveolar crest was identified by taking a line L2 at a tangent to the lateral margin of the infraorbital foramen (Fig. 1). Entry points P1 and P2 can also be determined by multifunctional surgical guides[2], with the most anterior implant located in the lateral incisor/canine region and the posterior one in the second premolar region[9], aiming for a better anteroposterior distribution of the zygomatic implants. Using a compass calibrated at 8 mm (Fig. 2), whose lower tip should rest on the most anterior point P3 of the lower border of the zygomatic bone (Fig. 3), the first marking M1 is made on the zygomatic bone (Fig. 4). This process is then repeated, now with the compass calibrated at 12 mm (Fig. 5), making the second marking M2 on the zygomatic bone (Fig. 6). After these two markings have been made on the zygomatic bone, two lines are drawn toward points P1 and P2. The most posterior line L3 is made from the middle of the 8-mm marking to the point P2 (Fig. 7). The most anterior line L4 is made from the middle of the 8 at 12-mm markings to the point P1 (Fig. 8). These will be the paths of the zygomatic implants, which may be 1 or 2, depending on the surgical planning. Clinically, at this time, the letter W is observed, in the case of using two zygomatic implants (Fig. 9), and if four zygomatic implants are placed, we will observe two letters W (Fig. 10), origin of the name of the surgical protocol presented (W2 Technique). After this, spherical markings M3 and M4 are made on the anterior wall of the maxillary sinus, close to the zygomatic bone, for subsequent drilling with a spherical diamond drill (Figs 11–13) creating a niche for the insertion of the cylindrical diamond drill. After feeling that the maxillary sinus has been entered, the sinus membrane is detached around the niche with a maxillary sinus lifting curette (Fig. 14) and then the cylindrical diamond drill is used to make the grooves on the pre-drawn lines L3 and L4, up to the alveolar ridge crest, creating a niche to accommodate the head of the zygomatic implant (Figs 15 and 16). With the use of diamond drills, in the majority of cases, due to increased wear resistance and reduced friction, the maxillary sinus membrane is preserved, thereby preventing possible rhinosinusal complications due to the fact that it was not ruptured (Fig. 17). The drill is used with a 20-1 handpiece at 800–1200 revolutions per minute and abundant irrigation. From this time onward, the sequence of drills and placement of implants is performed (Figs 18 and 19). Techniques such as use of the Bichat ball[2] or connective tissue should be performed to avoid tissue dehiscence around the head of the zygomatic implant[21]. For the safe use of two zygomatic implants, on each side of the arch, the recommendation is to leave a safety measurement of between 5 and 6 mm from the lower base of the orbit.

Figure 12.

Figure 12.

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Perforation performed with spherical diamond drill.

Figure 1.

Figure 1.

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Marking of lines L1 and L2 and entry points P1 and P2 for anterior and posterior zygomatic implants.

Figure 2.

Figure 2.

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Caliper calibrated at 8 mm.

Figure 3.

Figure 3.

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Compass support point P3.

Figure 4.

Figure 4.

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First marking M1 on the zygomatic bone.

Figure 5.

Figure 5.

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Caliper calibrated at 12 mm.

Figure 6.

Figure 6.

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Second marking M2 on the zygomatic bone.

Figure 7.

Figure 7.

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Posterior line L3 going toward the point P2.

Figure 8.

Figure 8.

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Previous line L4 going toward the point P1.

Figure 9.

Figure 9.

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Letter W formed on the left side for placement of two zygomatic implants.

Figure 10.

Figure 10.

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Two letters W formed for placement of Quad Zygoma (W2 Technique).

Figure 11.

Figure 11.

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Spherical markings M3 and M4 on the anterior wall of the maxillary sinus.

Figure 13.

Figure 13.

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Perforations finalized.

Figure 14.

Figure 14.

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Elevation of the mucosal flap showing the displaced sinus membrane around the niche with a maxillary sinus lifting curette.

Figure 15.

Figure 15.

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Creating the channel osteotomies (grooves) on the L3 and L4 guide lines for placement of zygomatic implants.

Figure 16.

Figure 16.

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Channel osteotomies made on the right side.

Figure 17.

Figure 17.

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Maxillary sinus membrane preserved.

Figure 18.

Figure 18.

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Milling finalized on right side.

Figure 19.

Figure 19.

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Quad Zygoma installed.

The surgical protocol presented may undergo variations in the positioning of the zygomatic implants, related to the patient’s facial anatomy[22], width of the zygomatic bone[20], improved AP spread[9], and professional experience. The zygomatic implant technique is complex, requiring extensive anatomical knowledge and surgical experience[9]. By following this protocol, the risk of orbital perforation is reduced and the protocol can be used by experienced surgeons who have been newly accredited in the technique under the supervision of mentors. When considering a reduction in the free end of the prosthesis or even helping with the loss of zygomatic implants, experienced surgeons can place zygomatic implants (HESIAn protocol) located dorsal to the buttress and crossing the anterior third of the infratemporal fossa (A-frame)[9]. After the placement of zygomatic implants, other implants may be inserted[2,9,18], according to the new guidelines proposed by this author (Fig. 20). The markings made on the stereolithographic model in this technical note are for educational purposes only and may undergo changes in the patient, depending on each person’s facial anatomy and the surgeon’s experience. Over 50 patients have already undergone surgery following this surgical protocol. The greatest difficulty encountered by some newly certified surgeons in the technique is the precise execution of lines and markings on the patient’s bone tissue, as well as the linear creation of grooves on the pre-drawn L3 and L4 lines, when they encounter the technique for the first time. The sinus membrane can also be drilled at the M3 and M4 markings when creating the niche with the diamond spherical drill bit. It is always recommended to perform surgical planning using software, simulate the surgery virtually as well as on a stereolithographic model of the patient, and possess extensive knowledge of facial anatomy, in addition to always having the help of experienced mentors in the first operated cases.

Figure 20.

Figure 20.

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Radiological control with four zygomatic implants, one transnasal implant, and one conventional implant in the tuberosity installed.

Discussion

The risk of irreversible injuries to the orbital cavity due to the penetration of zygomatic implants has been shown to be a reality[11]. Several studies have been published in recent years reporting the harm caused to patients[11,23]. The orbital cavity was penetrated during the drilling procedure performed by an experienced surgeon in one patient, with no relevant clinical consequences[24]. It is essential for new surgical techniques and protocols to be standardized with the aim of minimizing or even eliminating these types of complications, mainly related to the use of four zygomatic implants in an attempt to rehabilitate patients with severe bone atrophy[2,8,13,18,25]. It is now possible to place zygomatic implants using surgical guides manufactured by means of virtual planning and digital workflow, with the aim of introducing safer surgical procedures[26–29]. This approach, however, still presents small deviations in the final positioning of the implants in relation to the virtual planning[28]. Therefore, comparative studies are required concerning the efficacy of surgery performed with surgical guides when compared with surgery performed freehand. Therefore, it is necessary to follow protocols. The freehand placement of zygomatic implants requires far more than surgical skills alone. It requires talent, and talent is something that is acquired over time. The surgical protocol presented is a tool that is an auxiliary to existing virtual surgical planning[2]. Moreover, it will help experienced surgeons to place zygomatic implants freehand with greater predictability, especially for those who are experiencing their first contact with zygomatic implants. It is strictly recommended for surgeons that their first zygomatic implant surgeries, whether with the presented surgical protocol or using other surgical techniques, be performed under the supervision of mentors. By following this surgical protocol, it is possible to decrease the risk of injuries to the eyeball and adjacent tissues[11]. After placement of the zygomatic implants using the surgical protocol presented, whether unilateral[30] or Quad Zygoma[31], other implants can be placed, depending on the bone availability present or absent in the Radiographic Zone 1 of the maxilla, such as in the tuberosity region[2,9,13,18], according to the new guidelines for the ideal surgical approach to implants proposed in this technical note. The “W2 Technique” is being promoted for the placement of zygomatic implants in cases where there is anatomically no buccal bone tissue at the head of the zygomatic implant[22], the middle and cervical thirds of the implant are exteriorized, and its L1 and L2 lines[20] and M1 and M2 markings can also serve as support for surgeons in patients with ZAGA 0–4 facial patterns[22].

With the new guidelines for the ideal surgical approach to implants, there will be cases in which it will be possible to rehabilitate patients without the need for zygomatic implants[13], especially when using extra-long dental implants anchored in the paranasal bones of the maxilla[2,7,17,18,32]. In 2008, there were few options of techniques and implants for rehabilitating patients with atrophic jaws[1]. Today there is a much wider range of options that offers faster and less invasive options for rehabilitation, such as the PATZi protocol[32]; however, if the use of zygomatic implants is necessary, surgeons can also rely on the protocol presented, for the safe placement of these implants.

The surgical protocol presented, whose nomenclature (W2 Technique) was named by this author, is based on preexisting scientific knowledge about the maxilla and zygomatic region, is a natural evolution of procedures already established in the medical and dental literature[33–38], and does not aim to replace techniques and protocols already established in the literature, but rather to serve as support for surgeons who work with freehand zygomatic implants and to avoid hyatrogenic injuries to the orbital cavity and adjacent tissues. Alveolar bone resorption does not affect the bone–implant contact (BIC) for Quad Zygoma[20]. Anchoring the apex of the anterior zygomatic implant in the anterior section of the zygomatic bone deserves a warning and a great deal of surgical experience, especially at point A3[9,20], which is closest to the orbital cavity, which may present a high risk of orbital penetration[20] and, according to a recent study[20], may not be recommended in a Quad Zygoma approach[20], despite offering a high value of BIC[20]. It is concluded that the surgical protocol presented is a safe protocol for the placement of zygomatic implants freehand with the aim of reducing the risk of ocular complications and adjacent tissues.

Acknowledgements

Not applicable.

Footnotes

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Ethical approval

Not applicable.

Consent

Written informed consent was obtained from the patient for publication of this technical note report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal on request.

Sources of funding

Not applicable.

Author contributions

Study design: P.H.T.A.: Data collection: P.H.T.A.: Data analysis: P.H.T.A.: Manuscript preparation: P.H.T.A.: Critical revision: P.H.T.A.

Conflicts of interest disclosure

Not applicable.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Paulo Henrique Teles de Almeida.

Provenance and peer review

Not commissioned, externally peer reviewed.

Data availability statement

The data used in this study are available upon reasonable request to the corresponding author.

Use of AI for writing assistance

The author declares that they did not use any AI tools or technologies to prepare this manuscript.

References

  • [1].Bedrossian E, Sullivan RM, Fortin Y, et al. Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J Oral Maxillofac Surg 2008;66:112–22. [DOI] [PubMed] [Google Scholar]
  • [2].Almeida PHT, Cacciacane SH, Arcazas Junior A. Extra-long transnasal implants as alternative for Quad Zygoma: case report. Ann Med Surg (Lond) 2021;68. doi: 10.1016/j.amsu.2021.102635 [DOI] [Google Scholar]
  • [3].Deppe H, Mücke T, Wagenpfeil S, et al. Sinus augmentation with intra- vs extraorally harvested bone grafts for the provision of dental implants: clinical long-term results. Quintessence Int 2012;43:469–81. [PubMed] [Google Scholar]
  • [4].Joshi A, Kostakis GC. An investigation of post-operative morbidity following iliac crest graft harvesting. Br Dent J 2004;196:167–71. [DOI] [PubMed] [Google Scholar]
  • [5].Reissmann DR, Dietze B, Vogeler M, et al. Impact of donor site for bone graft harvesting for dental implants on health-related and oral health-related quality of life. Clin Oral Implants Res 2013;24:698–705. [DOI] [PubMed] [Google Scholar]
  • [6].Vidote RM, Guastaldi FPS, Klüppel LE, et al. Uso da proteína morfogenética óssea recombinante humana2 em levantamento de assoalho de seio maxilar. ImplantNews 2013;10:613–17. [Google Scholar]
  • [7].Jensen OT, Adams MW, Smith E. Paranasal bone: the prime factor affecting the decision to use transsinus vs zygomatic implants for biomechanical support for immediate function in maxillary dental implant reconstruction. Int J Oral Maxillofac Implants 2014;29:e130–8. [DOI] [PubMed] [Google Scholar]
  • [8].Oh S, Zelig D, Aalam AA, et al. Case report: utilization of Z-Point fixture “Trans-nasal” implants. Ann Med Surg (Lond) 2023;85:1959–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [9].Holtzclaw D. Remote Anchorage Solutions for Severe Maxillary Atrophy. Rock R, ed. Texas, USA: Zygoma Partners LLLC; 2022. [Google Scholar]
  • [10].Van den Borre C, Rinaldi M, De Neef B, et al. Radiographic evaluation of bone remodeling after Additively Manufactured Subperiosteal Jaw Implantation (AMSJI) in the Maxilla: a one-year follow-up study. J Clin Med 2021;10:3542. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [11].Weber MI, Koschitzki E. Ocular complications of zygomatic dental implants: a systematic review. Cureus 2024;16:e67535. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [12].TITAN Group, Agha RA, Mathew G, Rashid R, et al. Transparency In The reporting of Artificial INtelligence– the TITAN guideline. Prem J Sci 2025;10:100082. [Google Scholar]
  • [13].Almeida PHT. Transnasal implants as an alternative to zygomatic Implants. Av En Odontoestomatología 2024;40.SPE:146–51. [Google Scholar]
  • [14].Jensen OT, Cottam JR, Ringeman JL, et al. Angled dental implant placement into the vomer/nasal crest of atrophic maxillae for All-on-Four immediate function: a 2-year clinical study of 100 consecutive patients. Int J Oral Maxillofac Implants 2014;29:e30–5. [DOI] [PubMed] [Google Scholar]
  • [15].Jensen OT, Adams MW. The maxillary M-4: a technical and biomechanical note for all-on-4 management of severe maxillary atrophy-report of 3 cases. J Oral Maxillofac Surg 2009;67:1739–44. [DOI] [PubMed] [Google Scholar]
  • [16].Jensen OT, Cottam J, Ringeman J, et al. Trans-sinus dental implants, bone morphogenetic protein 2, and immediate function for all-on-4 treatment of severe maxillary atrophy. J Oral Maxillofac Surg 2012;70:141–48. [DOI] [PubMed] [Google Scholar]
  • [17].Nicoli G, Piva S, Ferraris P, et al. Extra-long nasal wall-directed dental implants for maxillary complete arch immediate function: a pilot study. Oral Maxillofac Surg Clin North Am 2019;31:349–56. [DOI] [PubMed] [Google Scholar]
  • [18].Şahin O. Treatment of severely atrophic maxilla by using zygomatic, pterygoid, and transnasal implants. J Craniofac Surg 2024;35:e145–e146. [DOI] [PubMed] [Google Scholar]
  • [19].Almeida PHT, Salvoni AD, França FMG. Evaluation of satisfaction of individuals rehabilitated with zygomatic implants as regards anesthetic and sedative procedure: a prospective cohort study. Ann Med Surg (Lond) 2017;22:22–29. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [20].Wang J, Chen B, Zhao Y, et al. The optional apex sites for quad zygomatic implant placement in edentulous patients with severe alveolar bone resorption: a CBCT anatomical analysis. BMC Oral Health 2024;24:1393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [21].Aparicio C, Antonio S. Zygoma anatomy-guided approach “scarf graft” for prevention of soft tissue dehiscence around zygomatic implants: technical note. Int J Oral Maxillofac Implants 2020;35:e21–e26. [DOI] [PubMed] [Google Scholar]
  • [22].Aparicio C. A proposed classification for zygomatic implant patient based on the zygoma anatomy guided approach (ZAGA): a cross-sectional survey. Eur J Oral Implantol 2011;4:269–75. [PubMed] [Google Scholar]
  • [23].Van Camp P, Vrielinck L, Gemels B, et al. Intraorbital hemorrhage following a secondary intervention at integrated zygomatic implants: a case report. Int J Surg Case Rep 2018;43:21–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [24].Davo R, Pons O, Rojas J, et al. Immediate function of four zygomatic implants: a 1-year report of a prospective study. Eur J Oral Implantol 2010;3:323–34. [PubMed] [Google Scholar]
  • [25].Eshoiee N, Aalam AA, Zelig D, et al. Trans-nasal dental implants: indication and the report of 10 cases. Ann Med Surg (Lond) 2025;87:1814–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [26].Ghantous Y, Nashef A, Mohanna A, et al. Three-dimensional technology applications in maxillofacial reconstructive surgery: current surgical implications. Nanomaterials (Basel) 2020;10:2523. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [27].Grecchi F, Stefanelli LV, Grivetto F, et al. A novel guided zygomatic and pterygoid implant surgery system: a human cadaver study on accuracy. Int J Environ Res Public Health 2021;18:6142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [28].Gallo F, Zingari F, Bolzoni A, et al. Accuracy of Zygomatic Implant Placement Using a Full Digital Planning and Custom-Made Bone-Supported Guide: a Retrospective Observational Cohort Study. Dent J (Basel) 2023;11:123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [29].Prytula M, Broumand V. Static zygomatic guides: digital ZAGA concept. Oral Maxillofac Surg Clin North Am 2025;37:383–401. [DOI] [PubMed] [Google Scholar]
  • [30].Almeida PHT, Cacciacane SH, França FMG. Stresses generated by two zygomatic implant placement techniques associated with conventional inclined anterior implants. Ann Med Surg (Lond) 2018;30:22–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [31].Davó R, David L. Quad zygoma: technique and realities. Oral Maxillofac Surg Clin North Am 2019;31:285–97. [DOI] [PubMed] [Google Scholar]
  • [32].Ponnusamy S, Gonzalez J, Holtzclaw D. A systematic approach to restoring full arch length with maxillary fixed implant reconstruction: the PATZi protocol. Int J Oral Maxillofac Implants 2023;38:996–1004. [DOI] [PubMed] [Google Scholar]
  • [33].Brånemark PI, Gröndahl K, Ohrnell LO, et al. Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results. Scand J Plast Reconstr Surg Hand Surg 2004;38:70–85. [DOI] [PubMed] [Google Scholar]
  • [34].Stella JP, Warner MR. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants 2000;15:889–93. [PubMed] [Google Scholar]
  • [35].Migliorança RM, Coppedê A, Dias Rezende RC, et al. Restoration of the edentulous maxilla using extrasinus zygomatic implants combined with anterior conventional implants: a retrospective study. Int J Oral Maxillofac Implants 2011;26:665–72. [PubMed] [Google Scholar]
  • [36].Camargo VB, Baptista D, Manfro R. Implante transnasal (técnica vanderlim) como opção ao segundo implante zigomático. In: Coppedê A, ed. Soluções Clínicas Para Reabilitações Totais Sobre Implantes Sem Enxertos Ósseos. 1st ed. Quintessence Publishing Company, Inc; 2019: 198–214. [Google Scholar]
  • [37].Maló P, Nobre Mde A, Lopes I. A new approach to rehabilitate the severely atrophic maxilla using extramaxillary anchored implants in immediate function: a pilot study. J Prosthet Dent 2008;100:354–66. [DOI] [PubMed] [Google Scholar]
  • [38].Le JM, Chen PH, Seidenfaden JC, et al. Zygomatic implants for restoration of complex nasal defects - a case report and outcome. J Diagn Treat Oral Maxillofac Pathol 2020;4:152–61. [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data used in this study are available upon reasonable request to the corresponding author.

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