Abstract
Key Clinical Message
Digital technology significantly enhances subperiosteal implantology by enabling precise presurgical planning based on CBCT scans. This technology reduces patient trauma and ensures optimal implant fit, presenting a promising alternative to traditional analogue methods.
Abstract
In the last decades, significant progress has been made in oral implantology, particularly with endosseous implants, primarily due to advancements brought about by the digital revolution. Although their versatility and predictability have been well‐documented through clinical studies and follow‐ups (J Periodontol, 2005; 769: 1623), endosseous implants have certain limitations from the patients' perspectives, such as general health status, bone availability, and lengthy osseointegration times. Researchers have reported that well‐designed subperiosteal implants function successfully for many years and are a viable alternative to endosseous implants. The analogue method of inserting subperiosteal implants has been extensively discussed and utilized, and it represents a well‐defined protocol (Int J Sci Res, 2016; 5: 98). However, the surgical step, which involves taking an impression of the residual bone, posed challenges for clinicians. These challenges included more significant trauma to the patient, who had to undergo two surgical interventions instead of one (first for the bone impression and second for the implant insertion) and the risk of implant misfit due to the contraction of the impression material. Digital technology addresses these issues by allowing clinicians to design the implant based on the patient's Cone Beam Computed Tomography (CBCT) scan long before surgery. This case report reviews the design characteristics of 3D‐printed superiosteal implants, outlines the step‐by‐step procedure, and highlights the specific features compared to the analogue method. It also discusses the anatomy of the areas where the implants rest in the maxillae based on recent research performed in Romania in collaboration with AB Dental International (J Oral Implantol, 2003; 29: 189).
Keywords: aging, chronic diseases, dentistry
1. INTRODUCTION
Endosseous dental implants used to replace missing teeth have been a reliable solution for many years and are now one of the most common techniques in dental rehabilitation. 1 , 2 However, successful implantation requires sufficient bone quantity and quality. 3 In cases of severe bone resorption, bone regeneration techniques, zygomatic implants, nerve repositioning, and sinus lift surgeries have been proposed. 4 Unfortunately, these methods require more advanced surgical procedures, which may result in higher complication rates, increased morbidity, and longer treatment times.
Subperiosteal implants were first developed in Sweden at the beginning of the 1940s and have been used ever since. 5 However, their popularity declined with the invention of the first endosseous implants by Branemark. 6 Subperiosteal implants were custom‐made based on an impression obtained during the first stage of surgery and inserted below the periosteum, stabilized to the bone with mini‐screws, and then covered by the mucosa in the second stage of surgery. 7 , 8 This process required the patient to undergo two surgeries 21 days apart. 9 The subperiosteal implants were made of cobalt‐chrome or titanium alloys and were connected to the prosthesis using transmucosal abutments that emerged into the oral cavity. Their decline in use was due to the complexity of the production process, the imperfect fit caused by the relative instability of the impression material, and the wide range of complications. 10
In contemporary subperiosteal implant prosthodontics, integrating digital techniques presents promising avenues for enhancing treatment outcomes. While traditional subperiosteal implants have faced challenges due to their invasive nature and limited predictability, digital technologies offer new opportunities for improved precision and efficacy. Intraoral scanners enable the capture of detailed impressions, facilitating the design of customized subperiosteal implants that closely match the patient's anatomical requirements. Computer‐aided design (CAD) software allows for virtual implant placement planning, considering factors such as bone density, adjacent anatomical structures, and aesthetic considerations. Additionally, advancements in three‐dimensional (3D) printing technology enable the fabrication of patient‐specific subperiosteal implants with intricate designs, promoting optimal fit and osseointegration. These digital innovations streamline treatment workflows and enhance treatment predictability and patient satisfaction. 11
Different protocols have been proposed lately for subperiosteal implants, especially those that are 3D printed. Unfortunately, Romanian clinicians must collaborate with foreign factories or laboratories to treat these cases. Here, the authors present their experience with an innovative design of a customized subperiosteal implant manufactured by AB Dental International based on the patient's CBCT scan.
2. CASE HISTORY/EXAMINATION
A 58‐year‐old male patient with severe maxillary atrophy came to the clinic complaining about inadequate masticatory and aesthetic function. The patient reported a history of a mixed tooth‐implant supported maxillary rehabilitation with five implants and two teeth, which failed 3 years ago, after more than 15 years of use, due to peri‐implantitis and mobility. Since then, the patient has been wearing a removable acrylic denture. During the anamnesis, the patient did not report any smoking habits or related systematic diseases. To determine whether the patient was a valid candidate for a subperiosteal implant, the medical team conducted a general examination, a local clinical examination of the oral cavity, laboratory analysis, and radiographs as part of the selection process. The preoperative laboratory analysis showed a slightly elevated PDW (Platelet Distribution Width), indicating anemia or an infection. Clinical examination (Figure 1) and orthopantomography (OPG) (Figure 2) indicated a severe combined horizontal and vertical osseous atrophy, confirmed through DICOM (Digital Imaging and Communications in Medicine) images of the CBCT. 12
FIGURE 1.
Intraoral photography of the initial situation, occlusal view/axial plane.
FIGURE 2.
Orthopantomography of the initial situation.
Note: In some areas, due to the severe bone atrophy, oroantral communications covered only by the mucosa were evident on the CBCT 12 scan, in which case the patient's removable denture functioned as a protective shield.
The CBCT 12 confirmed inflammation of the sinus mucosa due to odontogenic causes (infections associated with the previous teeth) and the severe lack of alveolar bone in all the maxillary regions observed in the preliminary radiographs. The CBCT 12 scan revealed the highest points of the residual bone in the third molar region on both sides with dimensions ranging between 2.4 mm and 7.2 mm in height and 6.6 mm and 10.2 mm in width in the first quadrant (Figure 3) and between 4.8 mm and 10.2 mm in height and 5.4 mm and 9.6 mm in width in the second quadrant (Figure 4).
FIGURE 3.
Dimensions of the residual alveolar bone in the third molar region of the first quadrant.
FIGURE 4.
Dimensions of the residual alveolar bone in the third molar region of the second quadrant.
Implant placement in the posterior region of the maxilla, specifically the distal area of the maxillary alveolar process, which corresponds most frequently to the position of the third molar, has been suggested by many authors as an alternative to bone grafting. 13 The posterior maxillary region typically has type III or IV bone quality, consisting of thin cortical and low‐density trabecular bone, 14 adversely affecting primary stability. Due to inadequate primary locking and the unfavorable biomechanics of short implants, this region tends to have low success rates. Therefore, clinicians face a challenge in rehabilitating this area. 13
The second area where the significant alveolar bone was measured is the second molar region on both sides with dimensions ranging between 2.1 mm and 2.7 mm in height and 10.8 mm in width in the first quadrant (Figure 5) and between 3.0 mm and 3.9 mm in height and 9.3 mm and 9.9 mm in width in the second quadrant (Figure 6).
FIGURE 5.
Dimensions of the residual alveolar bone in the second molar region of the first quadrant.
FIGURE 6.
Dimensions of the residual alveolar bone in the second molar region of the second quadrant.
As observed in the CBCT scan, 12 in the first molar region on both sides, the residual alveolar bone height is less than 3.0 mm or insignificant (Figures 5 and 7), making implant placement without lateral window sinus lift impossible. In the first quadrant, it is essential to note the absence of the cortical vestibular bone and the oral communication with the maxillary sinus, closed only by the mucosa (where we previously mentioned that the patient's removable denture functioned as a protective shield).
FIGURE 7.
Dimensions of the residual alveolar bone in the premolar region of the first quadrant. Multiple oroantral communications can be observed (indicated by red arrows).
As observed in the figures, 12 the dimensions of the residual alveolar bone in the canine (Figure 7) and premolar (Figure 8) regions of the first quadrant reveal multiple oroantral communications. Measurements of the residual alveolar bone in the right central and lateral incisors (Figure 9) and left central and lateral incisors (Figure 10) also indicate low dimensions. Additionally, (Figure 11) depicts the dimensions of the residual alveolar bone in the canine area of the second quadrant, while (Figure 12) in the premolar area of the same quadrant. These figures 12 indicate that other areas of the alveolar bone lack significant dimensions for effective, complete implant‐prosthetic rehabilitation. Thus, the initial treatment plan proposed was bilateral window sinus lifting with delayed implant placement after 8–10 months from the initial surgery and guided bone regeneration for vertical and horizontal deficiency in the frontal area. During these 8–10 months of healing, the patient uses a removable prosthesis for aesthetic rehabilitation, with the prognosis remaining reserved. However, the clinical team had to find a more appropriate treatment solution because the functional and aesthetic demands were high, and since the edentulous ridge was already 3 years old.
FIGURE 8.
Dimensions of the residual alveolar bone in the canine region of the first quadrant. Multiple oroantral communications can be observed (indicated by red arrows).
FIGURE 9.
Dimensions of the residual alveolar bone in the right central and lateral incisors area.
FIGURE 10.
Dimensions of the residual alveolar bone in the left central and lateral incisors area.
FIGURE 11.
Dimensions of the residual alveolar bone in the premolar region of the second quadrant.
FIGURE 12.
Dimensions of the residual alveolar bone in the canine region of the second quadrant.
Note: The CBCT measurements used a 1:1 scale, but the images were magnified for a better view.
3. METHODS
Using the following protocol, the team proposed custom‐made maxillary implants with an innovative design incorporating areas of endosseous support for optimal osseointegration.
3.1. Stage 1 (2 months preoperative)—CBCT and laboratory analysis
The presurgical assessment included comprehensive radiological examinations to support the formulation of a definitive treatment plan. This phase aimed to gather surgical and prosthetic details critical for determining bone quantity, quality, and density, assessing critical structures around proposed implant sites, and identifying existing disease conditions. 15
Researchers have observed that a notable percentage of patients with otherwise satisfactory dental histories show undetected systemic diseases, ranging from 12% to 18%. 16 These conditions can influence the implant surgery protocol and long‐term success rates. Standard clinical laboratory tests include CBC (complete blood count), BMP (basic metabolic panel), CMP (comprehensive metabolic panel), and tests for bleeding disorders like PT (Prothrombin Time) or PTT (Partial Prothrombin Time). Healthcare providers may perform an A1c test on patients with prediabetes or diabetes to assess diabetes management. 15
3.2. Stage 2 (1 month preoperative)—preoperative CBCT and custom‐made implant design
DICOM data from the CBCT scan were utilized for reverse planning. Custom‐made implants were designed by AB Dental International in collaboration with the surgical team (Figure 13A,B). 17 The implants with a 0.7 mm thickness (Figure 14A,B) were designed to conform to the maxillary buttresses and secured with twenty‐eight 2 mm × 7 mm osteosynthesis screws.
FIGURE 13.
(A), (B). Custom‐made implants designed based on the CBCT scan of the patient, axial plane (A) and coronal plane (B). The A'B markings in the figure represent the manufacturer's logo.
FIGURE 14.
(A), (B). Geometry of the 3D designed implants without any representation of color, texture, or any other common attributes, left implant (A) and right implant (B).
3.3. Stage 3 (2 weeks preoperative)—custom‐made subperiosteal implants manufacturing
The manufacturer fabricated the implants using direct metal laser sintering with an EOSINT M 280 machine, ensuring high‐quality metal parts based on three‐dimensional CAD data. This rapid process requires no additional equipment, providing a streamlined manufacturing solution. 18
To facilitate surgical efficiency, the manufacturer provided the implants in a comprehensive kit 19 (Figure 15), including:
a 3D‐printed polymer model (Figure 16) to guide flap elevation, ensuring a 3–4 mm margin from the implant design outline
sterilized 3D‐printed implant
fixation screwdriver with handle and screws (Figure 17)
healing caps
prosthetic components for overdenture or screw‐retained restoration, such as transfer abutments, connection abutments, and analogs
demineralized bone matrix ready for use without hydration or mixing.
FIGURE 15.
Individualized 3D printed implant toolbox.
FIGURE 16.
3D‐printed polymer model with 3D‐printed polymer implant design.
FIGURE 17.
Fixation screw.
3.4. Stage 4—surgical procedure
Surgery commenced under local anesthesia and inhalation sedation, with continuous vital signs monitoring by an anaesthesiologist (Figure 18). The clinical team instructed the patient to take amoxicillin 875 mg plus clavulanic acid 125 mg (sold under the brand name Augmentin) every 12 h for 2 days before the operation.
FIGURE 18.
Local anesthesia to the nasopalatine nerve.
A crestal incision extended from tuberosity to tuberosity, with a midline relieving incision (Figure 19). Buccal and palatal flaps were raised, exposing the anterior nasal spine, the pyriform apertures, the canine fossae, the zygomatic buttresses, and the posterolateral maxillae. The incisions were made with precise movements to minimize bleeding and ensure optimal postoperative healing, which is critical for maintaining implant integrity, especially in subperiosteal cases.
FIGURE 19.
Elevation of the flap from one tuberosity to the other.
In cases of severe bone atrophy, clinicians may encounter two types of mucosae: hypertrophic mucosa with low resilience or thin mucosa, each requiring specific intraoperative adjustments. Mucosal management was tailored accordingly during surgery.
Following flap elevation, implants were positioned in intimate contact with residual alveolar bone (Figure 20A,B). The surgeon placed initial osteosynthesis screws at the implant extremities and tightened them gradually by hand.
FIGURE 20.
(A), (B)—Intraoral images: (A) Drilling the future screw holes; (B) partial screwing the implant.
The flap was closed using multiple single‐knot ties (Figure 21) and a hydrophobic, chemically inert synthetic suture to ensure excellent knot security and minimize the risk of dehiscence, which is crucial for aesthetic outcomes. 20
FIGURE 21.
Intraoral photography with the suture.
3.5. Stage 5—postoperative phase and prosthetic integration
Immediate post‐closure OPG (Figure 22) confirmed implant placement accuracy. On the same day, clinicians took prosthetic impressions and adjusted a provisional prosthesis (Figure 23) using the patient's existing removable denture (Figure 24), which was temporarily cemented (Figure 25A,B).
FIGURE 22.
Postoperative orthopantomography with the implant in position.
FIGURE 23.
Adjustment of the patient's old removable partial denture.
FIGURE 24.
Patient's old removable partial denture, which will be used as provisional.
FIGURE 25.
(A), (B)—Applying cement on patient's old removable partial denture(A) and patient's old removable partial denture in place(B).
After 2 months of careful healing, the final prosthesis was delivered and successfully integrated, marking a significant milestone in treatment. Mock‐ups (Figure 26) provided a preview of the aesthetic outcome, supported by control orthopantomography (Figure 27) showcasing implants and final prosthesis alignment.
FIGURE 26.
Intraoral photography with the mock‐up of the final prosthesis.
FIGURE 27.
Orthopantomography of the implant and final prosthesis in place.
3.6. Stage 6—follow‐up and long‐term stability
Subsequent examinations at 10 months demonstrated commendable stability and ongoing osseointegration, affirmed by intraoral images (Figure 28) and OPG (Figure 29). These outcomes underscore the effectiveness of subperiosteal implants in achieving both functional rehabilitation and aesthetic enhancement, solidifying their role as a viable treatment option for complex dental cases.
FIGURE 28.
Follow‐up 10 months after the surgery, intraoral photography with the final prosthesis.
FIGURE 29.
Follow‐up 10 months after the surgery—orthopantomography.
4. DISCUSSION
In recent decades, while there has been a noticeable decline in the number of edentulous patients, 21 the prevalence of edentulism remains significant. The demand for tooth replacement solutions has risen correspondingly with increasing life expectancy. Studies indicate that approximately one in five seniors 65 or older have lost all their teeth. 22 As a result, clinicians must provide effective treatment options for these patients. Endosseous implants have long been a favored solution for tooth replacement. However, their efficacy is limited in cases of severe bone atrophy. For patients with substantial bone loss, endosseous implants often fall short, necessitating alternative approaches. Subperiosteal implants, introduced over 50 years ago, were designed to address this challenge by providing support in cases where bone availability is insufficient. Despite their initial promise, subperiosteal implants faced significant complications, including implant exposure, wound dehiscences, implant mobility, and instability due to impression material issues. These issues led to a decline in their popularity. 23 Recent advancements in digital technology have revolutionized dentistry, leading to improved digital acquisition, advanced software, and more precise fabrication techniques. This digital transformation has given rise to new possibilities in fixed prosthetics, including developing custom implant solutions.
Recent studies highlight a resurgence of interest in subperiosteal implants driven by innovations in fabrication techniques. Cerea and Dolcini's study involving 70 patients with custom‐made titanium subperiosteal implants manufactured using direct metal laser sintering (DMLS) demonstrated a high survival rate of 95.8% and low complication rates over a 2‐year follow‐up period. Their findings suggest that custom‐made DMLS subperiosteal implants can be a viable alternative when endosseous implants are not feasible, particularly for prosthetic restoration of severe atrophic jaws. 24
In a similar vein, Ângelo and Ferreira's study examined a 44‐year‐old male patient with congenital dental agenesis who experienced failure of a previous implant‐based rehabilitation due to peri‐implantitis. Using bimaxillary custom‐made subperiosteal implants with a novel design that integrated both subperiosteal and endosseous support effectively addressed the patient's needs. The study concluded that custom‐made subperiosteal implants offer several advantages over traditional bone‐grafting and endosseous implant techniques. These benefits include the potential for a single‐stage procedure with immediate loading, a less complex and time‐consuming approach to atrophic jaws, and the ability to salvage failed endosseous implants. 25
5. CONCLUSION
Although subperiosteal implants are no longer the sole option for restoring atrophic jaws, they offer a less invasive solution with distinct advantages. Their high success rates and predictability have remained strong, and recent technological advancements are addressing many of their former drawbacks. Notably, the digital revolution has transformed the field, significantly reducing treatment times from two surgical interventions to just one, thus minimizing patient trauma.
The integration of digital technology allows clinicians to anticipate the outcome of the treatment plan with greater accuracy. Designing implants based on a 3D model of the patient's anatomy reduces the risk of errors during execution. This advancement has streamlined the planning process and enhanced the precision of implant placement.
Nevertheless, clinicians must remain vigilant about certain aspects of subperiosteal implants, including the healing phase and potential complications such as dehiscences, implant mobility, and framework fractures. Despite these challenges, the clinician's expertise in proposing, designing, and placing subperiosteal implants is crucial. The continued refinement of these skills will ensure that subperiosteal implants remain a valuable component of an ideal treatment plan, providing effective solutions for complex dental cases.
AUTHOR CONTRIBUTIONS
Luminita Nedelcu: Writing – original draft. Ioan Sirbu: Supervision. Valentin Daniel Sirbu: Validation. Andreea Mihaela Custura: Writing – review and editing. Adelin Radu: Writing – original draft. Vladimir Nastasie: Writing – original draft.
FUNDING INFORMATION
This research received no external funding.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
This case report complies with the ethical standards outlined in the Declaration of Helsinki. The patient gave written informed consent to publish their case details, including any accompanying images. Every effort has been made to ensure the patient's confidentiality, and all identifying information has been removed or altered. Institutional policies have protected the patient's privacy. No conflicts of interest exist related to this case report.
CONSENT
Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.
Nedelcu L, Sirbu I, Sirbu VD, Custura AM, Radu A, Nastasie V. Custom‐made 3D printed subperiosteal implant for restoration of severe atrophic jaw: A case report. Clin Case Rep. 2024;12:e9515. doi: 10.1002/ccr3.9515
DATA AVAILABILITY STATEMENT
The data supporting this study's findings are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this study's findings are available from the corresponding author upon reasonable request.