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Annali di Stomatologia | 2026; 17(3): 655-665

ISSN 1971-1441 | DOI: 10.59987/ads/2026.3.655-665

Articles

Piezosurgery in zygomatic implantology: a case report

Alberto Gasbarri1, Alessio Danilo Inchingolo2, Sofia Rastelli1, Giulia Caporro1, Gianluca Botticelli1, Giulia Ciciarelli1, Mario Capogreco1, Beatrice Marzo1, Maurizio D’Amario1, Marco Severino3, Alfredo De Rosa4, Angelo Michele Inchingolo3, Gianna Dipalma2,5

1Department of Life, Health and Environmental Sciences, University of L’Aquila, Italy

2Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Bari, Italy

3Department of Medicine and Surgery, University of Perugia, Italy

4Dipartimento di Scienze della Vita, della Salute e delle Professioni Sanitarie, Università Link Campus University Roma, Italy

5Department of Life Science, Health and Health Professional, Link Campus, Roma, Italy.

*Corresponding author: Gianluca Botticelli - gianluca.botticelli@univaq.it

Article History

Received: May 21, 2026

Accepted: July 21, 2026

Published: July 30, 2026

Abstract

Zygomatic implants provide a graftless option for the rehabilitation of patients with severe maxillary atrophy. This case report describes the use of piezoelectric instrumentation for extrasinus implant-site preparation in a 76-year-old woman with severe maxillary atrophy and masticatory impairment. A hybrid maxillary rehabilitation was performed with two zygomatic implants and two anterior axial implants using a minimally invasive ultrasonic protocol; the mandibular arch was rehabilitated separately according to an All-on-4 treatment concept. The maxillary prosthesis was delivered 48 hours after surgery. No postoperative complications were reported at the 1-week review, and the 2-year clinical and radiographic follow-up showed stable implant-supported rehabilitation without procedure-related complications. Within the limits of a single case, piezoelectric implant-site preparation offered controlled osteotomy, good intraoperative visibility, and preservation of adjacent soft tissues. Comparative studies are required before superiority over conventional drilling can be established.

Keywords: piezosurgery; zygomatic implants; ultrasonic osteotomy; extrasinus approach; severe maxillary atrophy; case report.

1. Introduction

Piezoelectric bone surgery, developed by Tomaso Vercellotti in the late 1980s, is an ultrasonic method used in oral and maxillofacial surgery [1,2]. Experimental studies have reported favorable early bone-healing and remodeling responses after piezoelectric osteotomy [3,4]. These findings supported the extension of piezoelectric bone surgery to other bone-surgery disciplines, including otolaryngology, neurosurgery, traumatology, and orthopedics.

1.1 Overview of Piezoelectric Surgery

Unlike conventional rotary cutting with diamond or tungsten-carbide burs, piezoelectric surgery uses dedicated ultrasonic inserts. It permits precise osteotomy while limiting macroscopic bone loss and, when used with adequate irrigation and pressure, can reduce thermal and mechanical trauma [1–2,5].

Piezosurgery is based on the inverse piezoelectric effect: piezoelectric transducers deform in response to an alternating electric field and generate ultrasonic micromovements that are transmitted to a surgical insert [1,5]. Light pressure on mineralized tissue produces a selective cutting action. Because part of the mechanical energy is converted into heat, continuous irrigation is required; irrigation also contributes to cavitation, removal of debris, hemostasis, and operative-field visibility [1,5–6].

The linear micromovements of piezoelectric inserts permit micrometric osteotomies and selective cutting of mineralized tissue, reducing the risk of injury to adjacent soft tissues [1–2,7]. Accurate and conservative osteotomy may also reduce postoperative edema and hematoma compared with more traumatic instrumentation. The change in sound produced during cutting can provide the operator with additional acoustic feedback.

These advantages derive from both the piezoelectric mechanism and the ergonomic design of the handpiece and dedicated inserts, which can facilitate access to restricted surgical fields [1].

1.2 Applications of Piezoelectric Surgery in Dentistry

In dentistry, piezoelectric surgery is used when precise bone cutting and protection of adjacent soft tissues are required. Orthodontic applications include corticotomy-assisted tooth movement, traction of impacted mandibular third molars, and management of selected edentulous spaces [8–10].

In oral surgery, reported applications include simple and third-molar extractions, particularly when roots are close to the inferior alveolar nerve, germectomy, implant surgery, endodontic surgery, and removal of selected cystic or osseous lesions [11–15].

Piezoelectric devices have also been used in maxillofacial, orthognathic, oncologic, and reconstructive surgery [7,16].

1.3 Piezoelectric Surgery in Implant Surgery

In implant dentistry, piezoelectric instrumentation has been used for maxillary sinus elevation, implant-site preparation, and alveolar-ridge expansion [17].

Placement of an endosseous implant triggers an inflammatory and reparative response that contributes to osseointegration. Excessive thermal, mechanical, or vascular trauma can enlarge the zone of peri-implant bone injury. Experimental evidence indicates that maintaining bone at approximately 47 °C for 1 minute may cause irreversible thermal damage; temperature and exposure time therefore require strict control during osteotomy [18–19].

Conventional implant-site preparation generally uses internally or externally irrigated steel drills mounted on a surgical motor; osteotomes may be used in selected low-density bone sites. Heat generation is influenced by operator pressure, drilling time and motion, rotational speed, drill design and sharpness, irrigation, cortical thickness, and osteotomy depth [18–19].

Ultrasonic implant-site preparation combines micrometric cutting with continuous irrigation and may facilitate intraoperative correction of the osteotomy axis. Cavitation and irrigation remove debris from cancellous trabeculae and improve visibility. Available evidence indicates that piezoelectric site preparation is a clinically acceptable alternative to conventional drilling, although operative time and thermal performance depend on the device, insert, pressure, and irrigation protocol [6,17,20].

In an animal study, Vercellotti et al. compared bone healing after osteotomy and osteoplasty performed with rotary burs or piezoelectric inserts. Histologic and immunohistochemical analyses showed fewer inflammatory cells and more active early osteogenesis in piezoelectric sites [3]. These observations were subsequently supported by biomolecular analyses showing earlier expression of osteogenic mediators and lower expression of selected proinflammatory cytokines [4].

Preti et al. evaluated BMP-4, TGF-β2, TNF-α, IL-1β, and IL-10 during early peri-implant healing. Piezoelectric preparation was associated with earlier increases in BMP-4 and TGF-β2 and reduced expression of proinflammatory cytokines in the experimental model [4].

Clinical resonance-frequency analysis has also shown that implant stability after piezoelectric preparation is at least comparable with that achieved after conventional drilling, with possible differences during secondary stability [21].

1.4 Piezoelectric Surgery in Zygomatic Implantology

Implant-supported rehabilitation is predictable in appropriately selected patients, but severe alveolar resorption may limit conventional implant placement. Treatment alternatives include bone augmentation, short or tilted implants, zygomatic implants, maxillary sinus elevation, and, in selected mandibular cases, inferior alveolar nerve transposition [22].

Zygomatic implants are indicated principally for severe maxillary atrophy when conventional implant anchorage is insufficient or extensive grafting is undesirable [22–24]. The zygomatic fixture was introduced clinically by Brånemark and subsequently developed for rehabilitation of the severely resorbed maxilla [25–26]. Systematic reviews report high survival rates, but complication profiles and follow-up periods vary across techniques and studies [23–24,27].

A common indication is adequate anterior maxillary bone for conventional implants combined with marked posterior maxillary resorption, for which zygomatic implants can provide posterior anchorage [22,24].

Zygomatic implants are long implants, commonly approximately 30–55 mm, that obtain anchorage in the zygomatic bone and usually emerge in the premolar region [24,26].

Surgical approaches are commonly classified as intrasinus, extrasinus, or anatomy-guided variants according to the relationship between the implant trajectory and the maxillary sinus [23–24].

Despite technical developments and computer-assisted planning, zygomatic implant placement remains complex and may injure the infraorbital nerve, orbit, or infratemporal fossa. Reported postoperative complications include sinusitis, sensory disturbances, oroantral fistula, soft-tissue dehiscence, and implant failure [23–24,27].

Contemporary protocols aim to improve control of the implant trajectory and bone-implant interface while limiting flap elevation and postoperative morbidity [23–24].

This case report describes, where permitted by the patient-specific anatomy, an extrasinus implant-site preparation performed with dedicated ultrasonic instrumentation. The objective was to document the operative sequence and the potential advantages and limitations of a minimally invasive piezoelectric approach compared with conventional rotary preparation [28–29].

2. Materials and Methods

2.1 Case Description

A 76-year-old female patient presented to the authors’ attention, wearing a complete upper removable denture and a lower partial denture, with masticatory difficulties. The patient’s medical history revealed she was being treated with Ramipril 10 mg tablets for hypertension.

The patient underwent clinical and radiographic evaluation. Intraoral examination and panoramic radiography (Figures 1 and 2) indicated the need for implant-prosthetic rehabilitation.

After cone-beam computed tomography (CBCT), the treatment options were discussed with the patient. Because of severe maxillary atrophy and the patient’s request for a fixed rehabilitation, a hybrid maxillary treatment was planned with two zygomatic implants and two axial implants at sites 1.2 and 2.2. The mandibular arch was planned for rehabilitation according to an All-on-4 treatment concept.

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Figure 1. Preoperative intraoral view of the edentulous maxilla.
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Figure 2. Preoperative panoramic radiograph.

The maxillary and mandibular procedures were performed separately after written informed consent for treatment had been obtained. [MANCANTE: explicit statement confirming consent for publication of clinical images and case details.] The maxillary procedure was performed under general anesthesia after anesthesiology assessment and preoperative testing.

The dental procedure began with regional anesthesia of the infraorbital, greater palatine, and nasopalatine nerves using 3% mepivacaine, together with local infiltration using 2% mepivacaine with epinephrine 1:100,000.

A full-thickness mucoperiosteal flap was raised through a paramarginal crestal incision extending palatally from the midline to the region of the second molar, with a posterior vertical releasing incision.

The flap was carefully elevated buccally and palatally to expose the anterolateral maxilla, piriform aperture, infraorbital foramen and nerve, and zygomatic body. A horizontal reference line was marked above the infraorbital foramen toward the zygomatic body to define the operative safety zone and reduce the risk of orbital injury.

Implant-site preparation was performed with a piezoelectric unit. Osteotomy began on the anterolateral maxillary surface along the planned trajectory from the residual alveolar crest to the zygomatic body, without entering the maxillary sinus. Dedicated inserts were used to prepare the residual crest and create a buccal groove supporting the coronal third of the implant; longer inserts were then used to complete preparation in the zygomatic bone (Figures 3 and 4). The cortical preparation was continued along the established trajectory while maintaining the planned angulation.

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Figure 3. Initial extrasinus implant-site preparation with ultrasonic instrumentation.
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Figure 4. Progression of the zygomatic implant osteotomy with ultrasonic instrumentation.

Preparation depth was confirmed with a calibrated millimeter probe. The zygomatic implants were inserted manually with a minimum insertion torque of 35 N·cm, and the crestal emergence was oriented to permit prosthetic abutment access. In each hemiarch, one zygomatic implant (3.5 mm diameter, 42.5 mm length) and one axial implant (4.0 mm diameter, 11.5 mm length) were placed (Figure 5).

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Figure 5. Zygomatic implant placement at site 2.5 and axial implant placement at site 2.2.

The flap was closed with interrupted 3-0 polyglactin 910 (Vicryl) resorbable sutures. The same surgical sequence was then performed in the contralateral hemiarch.

After hemostasis had been confirmed, the patient was discharged with postoperative hygiene and dietary instructions and prescriptions for antimicrobial and analgesic therapy.

The prescribed postoperative regimen was:

  • Amoxicillin/clavulanic acid 1 g orally twice daily for 6 days, beginning 3 days before surgery;
  • Metronidazole 250 mg orally twice daily for 10 days, beginning 3 days before surgery;
  • Pantoprazole 40 mg orally once daily for 6 days, beginning the day before surgery;
  • Dexamethasone sodium phosphate 0.2% oral drops from the day after surgery according to a tapering regimen [MANCANTE: exact dose and taper schedule];
  • Naproxen sodium 550 mg orally as needed, up to one tablet every 12 hours for a maximum of 3 days;
  • Chlorhexidine digluconate gel 0.5% twice daily after oral hygiene, beginning 24 hours after surgery and continuing for 15 days.

The maxillary prosthesis was delivered 48 hours after surgery (Figures 6 and 7).

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Figure 6. Occlusal view of the maxillary implant-supported prosthesis delivered 48 hours after surgery.
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Figure 7. Extraoral view of the implant-prosthetic rehabilitation.

At the 1-week postoperative review, the patient reported no complications.

At the 2-year follow-up, clinical and panoramic radiographic examinations showed no procedure-related complications (Figures 8 and 9).

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Figure 8. Peri-implant soft-tissue appearance at the 2-year follow-up.
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Figure 9. Panoramic radiograph at the 2-year follow-up.

3. Discussion

Zygomatic implants permit graftless rehabilitation of the severely atrophic maxilla and may support immediate loading when adequate primary stability is achieved. Implant-site preparation is performed on an oblique trajectory between the residual maxillary crest and the zygomatic body, often across different planes. The anatomy and degree of atrophy therefore make lateral zygomatic osteotomy and trajectory control technically demanding [23–24,29].

The minimally invasive technique described by Tedesco uses an extrasinus trajectory, when anatomically feasible, and dedicated piezoelectric inserts. The intended advantages are controlled osteotomy, preservation of residual crestal bone, improved visibility, and reduced exposure of the maxillary sinus [28–29,32]. These potential benefits must be balanced against the need for specific training and the absence of high-level comparative evidence for every step of the protocol.

The protocol divides preparation into three controllable phases: maxillary bone preparation, crestal preparation, and zygomatic bone preparation. Each phase permits reassessment and correction of the trajectory. After the initial groove has been created on the maxillary surface, the instrument is advanced toward the zygomatic body while maintaining contact with bone and avoiding inadvertent sinus entry. Preparation depth is measured with a calibrated probe before the osteotomy is enlarged to the selected implant diameter [28–29].

Conventional protocols use long rotary drills. Their length and continuous rotation can make control difficult and may increase the risk of unintended contact with adjacent soft tissues or deviation from the planned trajectory [29–30].

The ultrasonic protocol uses nonrotating, vibrating inserts for preparation of the residual alveolar crest and zygomatic bone. The insert tip can provide tactile and acoustic feedback and permits incremental correction of direction. Nevertheless, piezoelectric osteotomy may require longer operative time, and cutting efficiency depends on adequate irrigation, low pressure, and correct insert selection [17,29–30].

Ultrasonic osteotomy can provide precise cutting and continuous visualization of the entry point. Because the active movement is concentrated at the insert tip, bone removal can be controlled more locally than with a long rotary bur. These characteristics may help preserve bone structures contributing to implant stability, although clinical superiority cannot be inferred from a single case [1,17,29].

Selective cutting of mineralized tissue may reduce accidental injury to the Schneiderian membrane, nerves, and vascular structures. The inserts should be used with light pressure and adequate irrigation because excessive pressure dampens vibration, reduces cutting efficiency, and may increase heat generation [1,6,17].

Systematic reviews and clinical studies support piezoelectric preparation as a viable alternative to conventional drilling for implant osteotomy; survival appears comparable, while some studies report differences in early secondary stability and post-operative morbidity [20,30–31,33]. Continuous irrigation and cavitation also improve removal of bone debris and visibility of the osteotomy site.

Long rotary drills may contact the surrounding soft tissues, including the lip. Piezoelectric inserts reduce the risk associated with rotary motion but can still cause thermal injury if an inappropriate insert, inadequate irrigation, excessive pressure, or prolonged contact is used [1,29].

4. Conclusions

Piezoelectric surgery is a feasible method for implant-site preparation in selected zygomatic implant cases. Its principal potential advantages are controlled micrometric cutting, operative-field visibility, and selective action on mineralized tissue. In this patient, the procedure was completed without reported complications and the rehabilitation remained clinically and radiographically stable at 2 years. Because this is a single case without a conventional-drilling control, the findings do not establish lower complication rates or superior outcomes. Prospective comparative studies are required.

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