▋ Introduction
Cleft lip and palate (CLP) is a common congenital craniofacial anomaly frequently associated with congenitally missing teeth, malocclusion, and extensive maxillary defects. For such patients, full-mouth implant-supported rehabilitation often requires extensive bone grafting. Compared to conventional grafting procedures, zygomatic implants offer a more efficient and minimally invasive alternative for maxillary reconstruction.

▋ Case Presentation
A 41-year-old female presented with severe maxillary periodontitis seeking occlusal rehabilitation. Her medical history revealed prior cleft lip and palate repair and a LeFort I osteotomy. She has hypothyroidism managed with medication and denied any history of bisphosphonate or steroid use. No smoking or bruxism habits were reported.

▋ Patient Status
Intraoral examination revealed severe maxillary bone defects. Notably, due to complications from the previous LeFort I osteotomy, partial non-union of the maxilla was observed, rendering the bilateral alveolar bone unstable under occlusal loading. After consultation, the patient opted for four zygomatic implants to facilitate reconstruction and avoid the prolonged healing time associated with extensive bone grafting. Clinical photos showed an ill-fitting anterior bridge, generalized periodontitis, and scar tissue from previous CLP surgeries.

▋ Diagnosis and Planning
Panoramic Radiograph: Demonstrated generalized maxillary periodontitis, severe ridge resorption, and retained L-shaped plates and screws from previous orthognathic surgery.

CBCT Analysis: Confirmed defects in the alveolar ridge and hard palate due to the congenital cleft, leading to poor connectivity between the maxilla, zygoma, and nasal bones. Furthermore, the non-union post-LeFort I osteotomy compromised the three primary pillars of maxillary stress distribution: the canine buttress, zygomatic buttress, and pterygoid buttress. This left the bilateral maxillary alveolar segments essentially “floating.”

▋ Zygomatic Implant Design
Conventional implantation combined with bone grafting was deemed unlikely to achieve primary stability. While an extensive reconstruction using a free fibula osteocutaneous flap could provide sufficient hard and soft tissue, the patient preferred a less invasive approach. Consequently, a treatment plan involving four zygomatic implants (Quad Zygoma) was established.

▋ Surgical Procedure and Techniques
To mitigate the risk of creating an oroantral communication (OAC) or reopening the cleft, the flap design was conservative; the palatal tissue over the non-union cleft area was preserved, only reflecting the flap at the site of the zygomatic implant trajectory. To ensure an unobstructed path for the implants, several titanium screws and L-plates from the previous LeFort I surgery were removed. Four zygomatic implants were then successfully placed into the maxilla.

▋ Post-operative Follow-up
A temporary full-mouth fixed provisional prosthesis was delivered within two weeks post-surgery. The definitive prosthesis was completed within one year, successfully correcting the patient’s original crossbite. At the 4.5-year follow-up, the implants show stable osseointegration with excellent occlusal function and oral hygiene.

▋ Conclusion
Patients with extensive jaw defects—whether due to congenital conditions or tumor resection—pose significant challenges for traditional full-mouth rehabilitation. Historically, these cases required autologous bone harvesting from the iliac crest or a free fibula flap, involving complex and lengthy procedures.

The All-on-4 concept (utilizing zygomatic implants) provides these patients with a viable alternative for functional recovery. However, due to the extent of bone deficiency and anatomical variations, treatment planning is highly complex. Each case requires a customized implant strategy. In future posts, I will continue to share more cases of full-mouth reconstruction in special needs patients.