Patients affected by severe maxillary atrophy and skeletal malocclusion have been widely treated by simultaneous orthognathic surgical procedures, interpositional bone insertion and immediate or delayed implant placement. Although several authors have described that the "quad" technique using 4 zygomatic fixtures as an effective way to fully rehabilitate the severe atrophic maxilla, there are still no experiences relative to the use of zygomatic fixtures associated to maxillary osteotomies in case of large skeletal discrepancy. The aim of this study is to report a 1-step surgical rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary forward repositioning and simultaneous insertion of 4 zygomatic implants with immediate prosthetic loading.