Fernando Giovanella
Reviewed and approved by Dr. Fernando Giovanella, CRO-SC 8237 · Lattes CVHow this guide is made →
For anyone who has heard both words and isn't sure which is theirs

Zygomatic implants or All-on-4: what changes, who each is for, and when they're combined

At Dr. Fernando Giovanella's clinic in Blumenau, Brazil, "zygomatic or All-on-4?" starts with a CBCT scan, with the bone left in the maxilla, the upper jaw. If the front has bone for the four implants, you don't need zygomatic implants: All-on-4 does the job6, and it's the smaller surgery5. With no bone even at the front, the graft-free option rests on the cheekbone7. And there's a band where the literature accepts both6.

I place zygomatic implants. Even so, when All-on-4 fits, it's where I start.

And the numbers you'll find for both have a problem almost no one mentions: they aren't about the same patient.

What this page doesn't do: it gives no prices, doesn't say one is better than the other, never shows the benefit without the risk — nor the risk without what lowers it. My conflict of interest is declared at the end.

In 1 minute

  • The difference: All-on-4 uses the bone at the front of the upper jaw1; a zygomatic implant, the cheekbone6,8.
  • What decides: with bone at the front for four implants, All-on-4 does the job; in that band, the literature also accepts zygomatic implants6.
  • The surgery: the zygomatic one is bigger and, in a non-randomized study, swelled more, with no difference in the worst pain5; the anesthesia can be the same.
  • Fixed teeth: with both, the provisional can be fixed soon after1, if the implants come out firm6,7.
  • Which lasts longer: no study compares, over the long term, how long the two last in the same kind of patient18.
  • Complications: with zygomatic implants, sinusitis weighs most10,11,12, reported less when the implant runs outside the sinus12,26; with All-on-4, the bridge3.
  • Both together: zygomatic implants at the back, conventional ones at the front, one bridge7.
  • The bridge: with both, usually a fixed, screwed-in arch; what changes is where the head of the implant comes out9.
  • Two opinions: believe whoever shows you, on your own scan, the bone they'll use6,7.

Zygomatic implants or All-on-4: what's the difference?

All-on-4 dental implants are a way of building a fixed arch — a full-arch bridge — on four implants; in the upper jaw, they sit in the jaw's own bone, with the two back ones tilted1. A zygomatic implant is a long implant that rises to the cheekbone and anchors there6,8. One isn't the opposite of the other: many arches use both.

Side by sideNumbers from studies by other surgeons and centers, not from this clinic. Each column comes from different patients.
All-on-4Two zygomatic + front implantsFour zygomatic implants
Where it anchorsfour implants in the upper jaw, the two back ones tilted1one zygomatic implant on each side, in the cheekbone, joined to at least two conventional implants at the front6two zygomatic implants on each side, in the cheekbone, all joined7
Bone that has to be there the regions, on the map belowat the front, for the straight and the tilted implants6at the front or in the premolar region; none at the back6none in any of the three regions6
Size of the surgerysmaller than with zygomatic implants one study, groups not randomized5 · anesthesia: can be sedation, oral or IV at this clinicbigger: a wider opening of the gum, close to structures in the middle of the face6,10 · anesthesia: can be the same at this clinicbigger, like any zygomatic surgery6,10 · anesthesia: can be the same at this clinic
Lower jawalso works2nono
Provisional fixed teeth right after each column measures something differentthe same day, within 3 hours retrospective series in the upper jaw, from the clinic that created the technique; only people who got them on the day were in the study1in 89.6% of implants in studies using current techniques (22.3% with the original one) · one systematic review · counts the studies' protocol9in 13 of 15 patients one small study, with no comparison group13
Reported survival doesn't compare the same patient, or the same era99.0% of implants at three years systematic review of thirteen studies3 90.7% at up to twenty years single-center retrospective series, the clinic that created the technique · 740 patients, 38.8% of them lost to follow-up495.21% at twelve years systematic review of 68 studies · zygomatic implants in general11 96.2% at six years meta-analysis · zygomatic implants in general1098% of implants two systematic reviews14, sharing many of the same studies · few patients, short follow-up15
Most reported complicationin the bridge, such as the acrylic provisional that breaks3, and inflammation around the implants4sinusitis, in about 2% to 14% of cases the reviews' averages · zygomatic implants in general10,11,12 · reported less with the implant outside the sinus reviews12,26sinusitis, in 12% (margin 4% to 23%) systematic review14

Which column is yours starts with your CBCT scan, read by the person who operates6,7; in the band where two fit, it also goes through your conversation with them.

Both exist for the same thing: to use the bone you still have, instead of rebuilding what's missing. The difference is which bone.

And how All-on-4 uses the bone at the front is on the page about missing bone.

The table shows what each one needs. It doesn't show who chooses when both fit.

What decides between zygomatic implants and All-on-4?

The bone that's left, and where. If the front has bone for the four implants, you don't need zygomatic implants: All-on-4 does the job, and it's where I start6. In that same situation, the review behind the consensus also accepts two zygomatic implants with front implants. With no bone in any of the three regions, the graft-free option is four zygomatic implants7.

What decides · the bone that’s left, region by region systematic review · 2023 · and ITI consensus · 20236,7 Front Premolars Back All-on-4 has bone may be missing front bone for straight and tilted implants Two zygomatic + front implants has bone in the front or the premolars no bone joined to at least two regular implants Four zygomatic implants no bone in any of the three two per side, in the cheekbone WHERE THE TWO OVERLAP has bone either way no bone Bone like this — either can be indicated: All-on-4 Two zygomatic + front implants The zones help screen for bone; they don’t say how much is enough. Schematic · regions, not measurements
Regions, not measurements. The map compares only the options without a bone graft in the upper jaw; a graft is a different rung of the ladder. And when the front has enough bone for the four implants, the smaller surgery comes first: All-on-4.

The three regions are the front, the premolars and the back; what each option needs in each one is in the table, from the same review6. It warns that this division is for screening and doesn't say how much bone is enough for a conventional implant.

Notice: the first two bands touch. That's why another surgeon may propose two zygomatic implants where I would propose All-on-4. Ask them to show you why on the scan.

The whole ladder, from a graft to four zygomatic implants, is on the page about missing bone.

Why start with the smaller one? Because the two surgeries aren't the same size.

Which surgery is bigger, zygomatic implants or All-on-4 — and what's the anesthesia like?

The zygomatic one. It needs a wider opening of the gum and work close to structures in the middle of the face6,10; All-on-4 stays in the upper jaw's own bone. At the clinic, both can have the same anesthesia: sedation, oral or IV. Afterward, the zygomatic one swells more and needs more painkillers5. That's why, when both fit, I start with the smaller one.

When surgery runs past four hours, which can happen when redoing earlier treatment and removing old implants, general anesthesia may be the better choice. That's assessed patient by patient.

That swelling comes from a study of 70 patients, not randomized5: the worst pain wasn't different between the groups, and at four weeks it was low for everyone.

Bigger doesn't mean worse: when the front isn't enough and a graft isn't the way, it's the zygomatic implant that steps in. And it steps in planned. I do the planning myself: a computer simulation, where I operate on the case first; a prototype, printed on the clinic's own printer; and a transfer guide, the SkinGuide Zygoma®, which carries each implant's planned position into surgery and guides the drilling and the placement. The guide marks the path; the bone stays in the surgeon's view. To me, that's what makes the surgery more predictable and safer.

Size, though, doesn't tell you when the teeth arrive.

How soon do I get fixed teeth with each one?

With both, the provisional bridge can be fixed soon after surgery1, when the implants come out firm. They don't always, and the plan can change on the day6,7. The final bridge comes months later10, with both4. The timing for your case comes from the plan and the surgery, not from an average.

For zygomatic implants, the table's number counts how many implants the studies fixed teeth to straight away, under each study's protocol9. For All-on-4, the original studies included only people who received the bridge on the day21. How many went without teeth for lack of firmness, neither number shows.

Once the teeth are in, the question changes: how long do they stay?

Which lasts longer? What the studies show for both

Both show high survival in the studies. But those numbers come from different patients, centers and lengths of follow-up, so they can't tell you which would last longer in you. The two published trials that randomized patients between one and the other are small, ran for a year and measured quality of life and satisfaction, not how long the implants last over the long term18.

On the survival row, the table sets side by side people who arrived with different bone: zygomatic implants are indicated, as a rule, for people with less of it6. Comparing the columns compares patients, not techniques.

And the longest All-on-4 numbers have an address: they come from the Lisbon clinic that created the technique, a single center, which lost track of a large share of its patients along the way4. That doesn't make them wrong. It means I read them with that label on.

Putting the two in the same kind of patient takes randomization. In the first trial, 80 patients with a severely atrophic upper jaw were split in half, and those who received zygomatic implants with front implants reported better quality of life and more satisfaction one year after the final bridge16. In the second, with 36, there was hardly any difference — except for surgery and recovery, which favored All-on-417,18.

A 2026 systematic review brought the two together and rated the certainty of these results as low to very low18. And one detail you deserve to know: one of the authors of the first trial works for a company that makes the implants used in both groups16.

I place zygomatic implants. If I showed you only the first trial, that would be advertising.

The zygomatic numbers, for and against, are all on the zygomatic implant page.

Lasting is half the sum. The other half is what takes work along the way.

What are the complications of each?

With zygomatic implants, the most reported is sinusitis, which depends heavily on technique10,11,12: in the reviews, it was reported less with the implant outside the sinus12,26. Compared with a bone graft, they probably bring more complications8. With All-on-4, what's reported most is in the bridge — a screw that loosens, a provisional that breaks3 — and inflammation around the implants. With both, maintenance never stops74.

Among the studies read for this page, only the first randomized trial puts the complications of both side by side, in the same kind of patient. Within a year, the zygomatic group had one sinusitis and one infection in the orbit, around the eye; in the All-on-4 group, three bridges broke and there was inflammation around some implants. Forty on each side is too few to make a rule. In both groups, no implant was lost16.

Whether a zygomatic implant runs inside or outside the sinus depends on each person's anatomy and on the planned bridge9,10, and I decide that in the planning, not in the chair. Some studies with the implant outside the sinus recorded no sinusitis at all: 92 patients followed for almost three years, on average, and twenty-three for one year27,28. But zero isn't the rule: with current techniques, others reported sinusitis in about ten to thirteen of every hundred cases29,30,31,32. And a recent study of 69 patients, all operated on by the same surgeon, found no difference in complications between inside and outside the sinus29,30,31,32. Those numbers aren't the SkinGuide Zygoma®'s, or mine.

And over the long term? If the longest All-on-4 numbers have an address, the zygomatic ones have a date: in the table's meta-analysis, patients were operated on up to 2012, in the studies that give the year, and in many of them the implant ran through the sinus10. More recent studies report less sinusitis9,26, but it can appear years later, with any technique10,11,31, and long studies comparing today's technique with the old one are still missing10. My reading, which those studies haven't confirmed yet: those numbers portray a zygomatic implant placed with less control than today, and I expect today's to bring fewer complications.

Zygomatic sinusitis, where it comes from and how it's reduced, has a section of its own; the other complications are in what to expect.

So far, one against the other. Often, though, the answer is both.

Can zygomatic implants and All-on-4 be used in the same arch?

Yes, and it's a common way to use zygomatic implants: one on each side, at the back, joined to conventional implants at the front, in a single bridge7. When even the front has no bone, the graft-free option is four zygomatic implants. The combination uses the bone that exists in each region of the upper jaw.

The question has an "or" in it. Many arches have an "and". The logic is All-on-4's, with the back implants swapped: instead of tilting inside the upper jaw, they rise to the cheekbone. It's the middle column of the table, and the zygomatic group in both trials.

Whatever the arrangement, a bridge goes on top. And it isn't always the same.

Is the bridge on top the same?

With both, it's usually a fixed arch, screwed onto the implants, that only the dentist removes7. What changes is where the head of the implant comes out. In the original zygomatic technique, it often came out near the roof of the mouth, and the bridge was bulkier there9; today, the path is chosen from where the tooth will be9.

This is where I do most of my work. In a clinical report I published, with two zygomatic implants at the back, I tilted the front implants to come out on the side of the lips rather than the roof of the mouth, with the aim of reducing the risk of a bulky bridge33. It's one patient only: it shows how I work, it doesn't promise your result.

With so much depending on the surgeon's reading, it's common to hear two different readings.

One dentist said All-on-4, another said zygomatic. Who do I believe?

Whoever shows you, on your own CBCT scan, where the bone they'll use is. In the band where the literature accepts both, two serious surgeons can propose different paths. Ask both: which regions of my upper jaw have bone? Why not the smaller surgery? What if the implant doesn't come out firm? Which way will the zygomatic implant go, and why?

A CT scan, not a panoramic X-ray, is the exam the consensus asks for before a zygomatic implant6,7. If whoever proposed zygomatic implants decided without one, you already have an answer. How to check the surgeon is on the zygomatic implant page.

If you'd like one of those readings to be mine, the next step is short.

I want to know which one fits me. Where do I start?

With a WhatsApp message to the clinic in Blumenau, Brazil, and your CBCT scan: Dr. Fernando Giovanella reads it himself and sends you his reading in writing.

The person who reads your scan is the person who would operate, and that written reading is preliminary until I examine you in person. It goes region by region — and if All-on-4 fits, that's what I'll tell you.

No scan yet? It's taken near home; what kind, and how to send it, is in how treatment works when you live abroad.

No commitment and no pressure: it starts with a message and ends with a clear plan for your case. The message includes your consent to how the clinic handles health data — read it first.

Questions that tend to come after the comparison

Do tilted implants last less than straight ones?

No, as far as the reviews show: in those that compared the two, tilted implants didn't fail more than straight ones19,20,21,22. On the bone around the implant, the results differ: some reviews found no difference, and one found slightly more loss around tilted implants, with no effect on how long they last19,20,21,23. Most of these studies didn't randomize patients.

If All-on-4 fails, can I still have zygomatic implants?

It can be possible, yes. The international consensus on zygomatic implants includes, among their indications, earlier treatments with grafts or implants that didn't work7. It isn't automatic: the path is decided on a new CBCT scan, read again region by region. It's the same logic as for a graft that didn't take.

Are four implants enough, or are six better?

In the reviews, fixed arches on fewer than five implants — in the upper jaw, almost always four — and on five or more, almost always six, showed no difference in survival24,25. That's a comparison between studies, not a randomized test of four against six. To me, the number is decided by the bone and the bridge in each case, not by a fixed rule.

Is "All-on-4" a brand name — and is every fixed full-arch bridge an All-on-4?

All-on-4 is a name registered by an implant manufacturer. It describes one way of placing the implants under a fixed full-arch bridge: four, with the back ones tilted1. A fixed full-arch bridge can sit on four, six or more implants, or on zygomatic implants — so not every one is an All-on-4, only the ones built that way.

How treatment at the clinic works →

Read next

References

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  34. Giovanella F, Bezerra F, Dantas Soares MA, Oliveira G, Ghiraldini B. A technical note on a modified subcrestal buccal flap approach to All-on-Four: a case report. Cureus. 2024;16(4):e58453. doi:10.7759/cureus.58453 · PMID 38765329. https://pubmed.ncbi.nlm.nih.gov/38765329/ — accessed 28 October 2026.

About this guide

Reviewed and approved by Dr. Fernando Giovanella, CRO-SC 8237 · Updated October 2026 · Next review: April 2027

Where the facts come from. Every number that comes from a study has its primary source listed under References, with the date it was checked. The numbers belong to the techniques studied, by other surgeons and centers, not by this clinic. What belongs to the clinic — the anesthesia and the planning — is stated as the clinic's, with no outcome number. Explanations without a number describe how these procedures are usually done; they were reviewed by him and are not a promise about any one case. Where an opinion is his, it's stated as opinion. What this guide does not publish: prices, patient names, before-and-after images without consent, star ratings, or comparisons with other surgeons or countries.

What he has published on both techniques. Dr. Giovanella has published on both sides of this page: a technical note, on one patient, describing a modified incision for placing the four All-on-4 implants in the upper jaw (Cureus, 2024, PMID 38765329), and a clinical report, also on one patient, of a full-arch rehabilitation without a graft, with two zygomatic implants and implants at the front (J Prosthet Dent, 2025, PMID 40221273). Two reports, one patient each: they show how he works, they don't promise your result. Neither deals with sinusitis, guides or computer planning. Two co-authors of the Cureus note are employees of the manufacturer of the implants used in it.

Conflicts of interest. Dr. Giovanella is a paid research-and-development consultant to an implant manufacturer and is the designer of surgical instruments with patent applications pending in Brazil. He also designed the SkinGuide Zygoma®, the guide described in the surgery. This page compares techniques, not brands. The full declaration is on the editorial policy page.

Found a mistake? Send it to the clinic on WhatsApp (the same button above) or by e-mail at atendimento@fernandogiovanella.com. You'll have an answer within five business days; corrections are made and dated on the page.

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