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BACKGROUND A real-time surgical navigation system potentially increases the accuracy when used for quad-zygomatic implant placement. PURPOSE To evaluate the accuracy of a real-time surgical navigation system when used for quad zygomatic implant placement. MATERIALS AND METHODS Patients with severely atrophic maxillae were prospectively recruited. Four trajectories for implants were planned, and zygomatic implants were placed using a real-time surgical navigation system. The planned-placed distance deviations at entry (entry deviation）points, exit (exit deviation) points, and angle deviation of axes (angle deviation) were measured on fused operation images. The differences of all the deviations between different groups, classified based on the lengths and locations of implants, were analysed. A P value of < 0.05 indicated statistical significance. RESULTS Forty zygomatic implants were placed as planned in 10 patients. The entry deviation, exit deviation and angle deviation were 1.35 ± 0.75 mm, 2.15 mm ± 0.95 mm, and 2.05 ± 1.02 degrees, respectively. The differences of all deviations were not significant, irrespective of the lengths (P = .259, .158, and .914, respectively) or locations of the placed implants (P = .698, .072, and .602, respectively). CONCLUSION A real-time surgical navigation system used for the placement of quad zygomatic implants demonstrated a high level of accuracy with only minimal planned-placed deviations, irrespective of the lengths or locations of the implants.