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Inserting zygomatic implants is a challenging surgery and requires special care and great precision. Piezoelectric surgery offers several advantages: more precise bone cutting with improved intraoperative visibility and a low temperature increase. The aim of this case-control study was to evaluate whether ultrasonic instruments can be as effective as standard drilling instruments for zygomatic implant surgery in terms of clinical outcomes. Ninety-two patients with atrophic maxilla were included in the study. Implant sites were prepared with the ultrasonic technique (test group = 47 patients) or traditional drilling (control group = 45 patients). In total, 368 zygomatic implants were inserted (202 with the extrasinus technique, 77 with the sinus slot technique, and 89 with the 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 were based on implant survival rates and postoperative complications. Operative time and surgeon's stress were evaluated as secondary outcomes. Implant survival rate was 100% in the test and 98.89% in the control group. Postoperative complications were seen in 9 patients (4 in the test and 5 in the control group); the difference was not statistically significant. Operative time was longer in the test group; however, surgeons were more comfortable using ultrasonic instruments. Within the limitations of this preliminary study, the ultrasonic technique was a feasible alternative to traditional drilling for zygomatic implant surgery.