Incision and Flap Design in Zygomatic Implant Surgery: A ZAGA-Based Decision Tree.

Rehabilitation of severely atrophic maxillae with zygomatic implants requires wide surgical access and precise soft tissue management to minimize dehiscence and promote long-term stability. The ZAGA Concept emphasizes individualized incision and flap design based on anatomical and prosthetic parameters.

Materials and methods: A decision tree was constructed to guide incision and flap selection during primary surgery, based on five anatomical factors: bone discontinuities identified on CBCT, palatal mucosa thickness, expected implant platform position (channel vs. tunnel), buccal keratinized tissue width, and skeletal or dental Class III relationships. Five flap types were defined: ZAGA Palatal Roll Flap, Partial Thickness Flap, Double Pedicle Flap, Buccal Fat Pad Flap, and Scarf Graft.

Results: Each flap showed specific indications depending on the anatomical context. When properly selected, incision and flap designs improved soft tissue coverage, preserved or increased keratinized mucosa, and reduced soft tissue complications. The decision tree enabled systematic and reproducible selection of main incision and flap type based on patient-specific anatomy.

Conclusions: Integrating incision and flap design into surgical planning allows for individualized soft tissue management in zygomatic implant therapy. The proposed decision tree offers a practical, anatomy-driven protocol to optimize outcomes in the rehabilitation of the atrophic maxilla.