Contemporary zygomatic implant rehabilitation: A critical review of the evidence and clinical recommendations

BACKGROUND: Zygomatic implant (ZI) therapy has evolved over the past two decades into an established modality for the rehabilitation of the severely atrophic maxilla, avoiding extensive bone augmentation procedures. AIM: While the efficacy of ZI therapy is well established, variability in its clinical implementation and remaining knowledge gaps continue to influence its application in clinical practice. METHODS: This critical review, based on a focused PubMed/MEDLINE search, synthesized higher-level and long-term evidence on surgical approaches, loading protocols, indications and outcomes, complications, prosthetic considerations, digital workflows, and current consensus recommendations. RESULTS: Current evidence demonstrates favorable long-term survival across a broad range of ZI indications. The Quad Zygoma Protocol has further expanded graftless rehabilitation for the severely atrophic edentulous maxilla. Surgical approach selection should be guided by maxillozygomatic anatomy and prosthetically driven planning, while digital technologies have progressively shifted ZI surgery toward precision-oriented workflows. Nevertheless, heterogeneous complication profiles, inconsistent definitions of treatment success, and limited reporting of patient-reported and long-term biological and prosthetic outcomes remain important limitations. CONCLUSIONS: Contemporary ZI rehabilitation represents an established treatment modality for complex maxillary rehabilitation, with the current focus shifting from demonstrating efficacy toward improving treatment predictability and long-term outcomes. CLINICAL RECOMMENDATIONS: Appropriate case selection is fundamental to successful ZI rehabilitation. Surgical planning should integrate anatomical feasibility, implant emergence, and restorative design, while structured maintenance and patient compliance support long-term success. Digital workflows can enhance surgical accuracy and reproducibility but require surgical experience and clinical judgment.