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A four-membered heterocycle synthesis offers a thorough exploration of these unstable organic compounds, systematically introducing the synthesis and reactions of all standard four-membered heterocycles while showcasing various methods for creating unique variants. Due to their inherent strain, four-membered heterocyclic compounds are classified as unstable organic compounds, which makes them valuable as precursors for synthesizing a wide range of complex heterocyclic molecules. These compounds have become essential frameworks in medicinal chemistry, providing unique properties that enhance drug design and development. The incorporation of heteroatoms like nitrogen, oxygen, and sulfur into four-membered rings (such as azetidines, oxetanes, and thietanes) leads to diverse electronic, steric, and metabolic characteristics that can improve therapeutic efficacy, selectivity, and pharmacokinetics. Despite the challenges posed by their ring strain, recent advancements in chemical synthesis and functionalization techniques have made these compounds more accessible for various therapeutic applications. These strained ring structures offer increased metabolic stability, controlled lipophilicity, and the potential for advantageous binding interactions, making them suitable for multiple therapeutic uses, including oncology, infectious diseases, and CNS disorders. This review examines the key properties of four-membered heterocyclic rings, their role in drug development, recent synthetic advancements, and the potential of these compounds to yield next-generation medications with enhanced efficacy and precision.