The insertion of zygomatic implants is a challenging surgery and requires special care and great precision. Piezoelectric surgery offers several advantages, since it provides a more precise bone cutting with an improved intraoperative visibility and a low temperature increase.The aim of this case-control study was to evaluate if the use of ultrasonic instruments for zygomatic implant surgery can be as effective as standard drilling instruments in terms of clinical outcomes. Ninety-two patients with atrophic maxilla were included in the study. Implant sites were prepared either with ultrasonic technique (Test group- 47 patients) or with traditional drilling (Control group- 45 patients). In total, 368 zygomatic implants were inserted (202 with "extrasinus technique", 77 with "sinus slot technique" and 89 with "Brånemark technique"). Complete arch provisional prostheses were delivered 3 to 5 hours after the surgical operations. The mean follow-up after surgery was 24 months (range 12-32 months). The primary outcome evaluations based on implant survival rates and postoperative complications. The operative time and surgeon's stress were evaluated as secondary outcomes. According to the results, implant survival rate was 100% in Test, and 98.89% in Control group. The postoperative complications were seen in 9 patients (4 in Test, 5 in Control group), and the difference was not statistically significant. The operative time was longer in the Test group, however surgeons were more comfortable while using ultrasonic instruments. Within the limitations of this preliminary study, ultrasonic technique can be considered as a feasible alternative to traditional drilling for zygomatic implant surgery.