Additively Custom-Made 3D-Printed Subperiosteal Implants for the Rehabilitation of the Severely Atrophic Maxilla: A Case Report

Mahnaz Arshad, Nourin Khoramshahi, Gholamreza Shirani

Full text link: https://pubmed.ncbi.nlm.nih.gov/37942187/

Additively Custom-Made 3D-Printed Subperiosteal Implants for the Rehabilitation of the Severely Atrophic Maxilla: A Case Report

1. Scientific Reference

• Study title: Additively custom-made 3D-printed subperiosteal implants for the rehabilitation of the severely atrophic maxilla (a case report)
• Authors: Mahnaz Arshad, Nourin Khoramshahi, Gholamreza Shirani
• Journal: Clinical Case Reports
• Publication year: 2023
• DOI: 10.1002/ccr3.8135

2. Scientific Background

Rehabilitating patients with severe maxillary bone atrophy remains one of the greatest challenges in modern implant dentistry. Conventional endosseous implants require sufficient bone volume and quality to achieve long-term stability, making treatment particularly difficult in cases of advanced alveolar bone resorption. Although bone augmentation procedures have become standard practice for many complex cases, they frequently involve additional surgery, prolonged healing periods, increased morbidity, and variable clinical outcomes.

Recent advances in digital implant planning, cone-beam computed tomography (CBCT), computer-aided design (CAD), and additive manufacturing have renewed interest in patient-specific subperiosteal implants. Unlike historical designs that suffered from poor adaptation and high complication rates, modern custom-made titanium frameworks are digitally engineered to match each patient’s anatomy with greater precision. This case report illustrates how these contemporary technologies can be integrated into a prosthetically driven workflow to rehabilitate a severely resorbed maxilla after failure of a previous implant-supported restoration.

3. Study Objective

The purpose of this case report was to describe the digital design, additive manufacturing, surgical placement, and prosthetic rehabilitation of a patient-specific 3D-printed subperiosteal implant used to restore a severely atrophic maxilla. In addition, the authors aimed to document the clinical outcome and prosthetic performance of this customized rehabilitation during a three-year follow-up period.

4. Methodology

This publication is a single-patient case report describing the management of a 25-year-old male with complete maxillary edentulism following aggressive periodontitis. The patient had previously undergone full-arch rehabilitation with endosseous implants, which failed five years later because of peri-implantitis associated with extensive alveolar bone loss.

The treatment followed a fully customized digital workflow. Conventional impressions, jaw relation records, and a diagnostic tooth arrangement were completed before CBCT imaging using a radiographic stent. These digital records enabled prosthetically driven reverse engineering of a patient-specific subperiosteal implant. The implant was manufactured by additive manufacturing using Grade 23 titanium alloy (Ti6Al4V-ELI) and verified on a 3D-printed skull model before surgery. Following implant placement under general anesthesia, a provisional implant-supported prosthesis was delivered after two weeks, while the definitive CAD/CAM ceramic restoration was inserted three months later. Clinical follow-up was performed over a period of three years.

5. Main Findings

The customized subperiosteal implant enabled complete rehabilitation of the severely atrophic maxilla without bone grafting. Following surgery, a provisional implant-supported restoration was delivered after two weeks and subsequently replaced with a definitive three-piece CAD/CAM full-ceramic prosthesis three months later.

During the three-year follow-up period, the implant remained clinically stable. Minor soft tissue dehiscence developed in the left premolar region and the palatal aspect of the left incisor area shortly after surgery; however, the authors report that these defects did not progress over time. No implant fracture, prosthetic fracture, or additional biological complications were observed throughout the follow-up period. The patient maintained satisfactory oral hygiene through a dedicated maintenance protocol including tooth brushing, water irrigation, and super floss, and reported improvements in function, aesthetics, speech, and overall quality of life following treatment.

Within the discussion, the authors also place their findings in the context of previously published evidence. They reference a retrospective study reporting an approximately 96% survival rate after two years for customized subperiosteal implants, as well as a more recent case series describing 100% survival at 12 months for ten implants placed in partially edentulous patients. These figures originate from external studies cited by the authors and should not be interpreted as results generated by the present case report.

6. Clinical Analysis

This case report demonstrates the potential role of digitally designed, patient-specific subperiosteal implants in managing severe maxillary atrophy when conventional implant therapy becomes difficult or impossible without extensive bone reconstruction. In this patient, advanced alveolar bone resorption following peri-implantitis prevented placement of new endosseous implants unless an extraoral bone graft was performed—a treatment option that the patient declined. Under these circumstances, a customized subperiosteal implant provided an alternative rehabilitation strategy based on the patient’s residual anatomy rather than bone augmentation.

One of the most important clinical messages of this report is the central role of prosthetically driven digital planning. The implant was not designed solely according to the available bone but was engineered from the desired prosthetic outcome using CBCT imaging, radiographic stents, reverse engineering, CAD software, and additive manufacturing. This integrated workflow illustrates how digital technologies can improve the precision of implant adaptation while facilitating prosthetic rehabilitation in anatomically challenging cases.

The three-year clinical follow-up also highlights the importance of long-term maintenance. Although localized soft tissue dehiscence occurred postoperatively, the authors opted for careful monitoring rather than additional surgery because the lesions remained stable and the implant continued to function successfully. Their management emphasizes that meticulous oral hygiene and regular follow-up appointments are essential components of treatment with customized subperiosteal implants.

Despite these encouraging observations, the findings should be interpreted with caution. As a single case report, this publication cannot establish comparative effectiveness or demonstrate superiority over alternative approaches such as bone grafting, zygomatic implants, or conventional implant rehabilitation. Instead, it provides evidence of technical feasibility and suggests that patient-specific subperiosteal implants may represent a valuable treatment option for carefully selected patients with severe maxillary bone loss when conventional solutions are not appropriate.

7. Clinical Applications

The findings presented in this report are primarily applicable to patients with severe maxillary atrophy who cannot be predictably rehabilitated with conventional endosseous implants because of insufficient bone volume. The described approach may be particularly relevant for individuals who are not suitable candidates for extensive bone grafting or who decline additional reconstructive procedures.

The report also illustrates the clinical value of a fully digital treatment workflow, integrating CBCT imaging, prosthetically driven implant planning, CAD design, additive manufacturing, and CAD/CAM prosthetic fabrication. Together, these technologies enable the production of a patient-specific titanium subperiosteal implant designed to fit the individual’s anatomy while supporting immediate prosthetic rehabilitation. Nevertheless, because this publication represents a single clinical observation, its applications should be considered exploratory rather than definitive, and broader clinical recommendations require validation through larger prospective studies.

8. Level of Evidence, Limitations and Transparency

This publication is a single-patient case report, representing a low level of clinical evidence within the hierarchy of evidence-based medicine. Its primary purpose is to demonstrate the technical feasibility of a patient-specific 3D-printed subperiosteal implant rather than to establish the effectiveness of this treatment compared with alternative rehabilitation strategies. Consequently, the findings should be interpreted as observational rather than confirmatory.

Several methodological limitations should be considered. The report describes the outcome of only one patient, includes no control group, and does not compare the proposed technique with conventional treatment options such as bone grafting combined with endosseous implants, zygomatic implants, or other reconstructive procedures. Although the three-year follow-up provides valuable information regarding medium-term clinical stability, it is insufficient to determine long-term implant survival or predict outcomes across broader patient populations.

Regarding transparency, the authors state that the study received no external funding and declare no financial or other conflicts of interest that could have influenced the scientific content of the publication. They acknowledge BONASH (Tehran, Iran) for manufacturing the customized subperiosteal implant, but this contribution is reported in the acknowledgments rather than as a declared conflict of interest. The patient provided written informed consent for publication of the case report.

9. Key Study Highlights

• Study design: Case report.
• Level of evidence: Low (single clinical case).
• Study population: One patient with severe maxillary atrophy following failure of previous endosseous implant rehabilitation.
• Number of patients: 1.
• Number of implants: One customized full-arch subperiosteal implant.
• Follow-up period: 3 years.
• Primary outcome evaluated: Clinical feasibility and medium-term performance of a patient-specific additively manufactured subperiosteal implant supporting full-arch maxillary rehabilitation.
• Main findings: The implant remained clinically stable throughout the three-year follow-up. Minor soft tissue dehiscence occurred without progression, no implant or prosthetic fractures were reported, and the patient expressed satisfaction with functional and aesthetic outcomes.
• Scientific conclusion: The report suggests that customized 3D-printed subperiosteal implants may represent a feasible treatment option for selected patients with severe maxillary atrophy when conventional endosseous implant placement would require extensive bone grafting.
• Main limitations: Single-patient design, absence of a control group, no direct comparison with alternative treatment modalities, and limited generalizability of the findings.

10. Scientific Impact

This case report contributes to the growing body of literature supporting the renewed interest in customized subperiosteal implants enabled by digital technologies. Rather than revisiting historical implant designs, the study demonstrates how contemporary digital workflows—including CBCT imaging, prosthetically driven planning, CAD engineering, additive manufacturing, and CAD/CAM prosthetic fabrication—can be integrated into a personalized rehabilitation strategy for patients with severe maxillary bone loss.

Its scientific value lies in documenting the complete clinical workflow, from digital planning to medium-term follow-up, while illustrating the practical application of reverse engineering principles in implant dentistry. The report also reinforces previously published observations suggesting that modern manufacturing techniques may overcome some of the limitations associated with earlier generations of subperiosteal implants by improving anatomical fit and prosthetic planning.

Although the evidence remains limited because of the study design, this publication supports continued investigation into patient-specific subperiosteal implants as a potential alternative for carefully selected patients with advanced alveolar bone resorption. Larger prospective studies, comparative clinical trials, and long-term follow-up data will be necessary to clarify their indications, survival, biological behavior, and role within contemporary implant rehabilitation protocols.

11. Editorial Conclusion

This case report presents a carefully documented example of full-arch rehabilitation using a patient-specific 3D-printed subperiosteal implant in a patient with severe maxillary atrophy following failure of conventional implant therapy. The three-year clinical follow-up demonstrates the technical feasibility of this digitally planned, prosthetically driven approach while highlighting the importance of meticulous case selection, precise digital planning, and structured maintenance. Given its low level of evidence, the findings should be viewed as preliminary and hypothesis-generating rather than practice-changing. Nevertheless, the study provides valuable insight into an emerging treatment option that warrants further investigation through larger clinical studies.