Clinical Outcomes, Survival, and Complications of Customized Computer-Aided Design and Manufacturing (CAD/CAM) 3-Dimensional-Printed Titanium Subperiosteal Implants

Saverio Cosola, Ernesto Vatteroni, Mohammadreza Asadi, Ugo Covani, Angelo Cardarelli, Giovanni-Battista Menchini-Fabris

Full text link: https://pubmed.ncbi.nlm.nih.gov/41831830/

Clinical Outcomes, Survival, and Complications of Customized Computer-Aided Design and Manufacturing (CAD/CAM) 3-Dimensional-Printed Titanium Subperiosteal Implants

1. Scientific Reference

• Study Title: Clinical Outcomes, Survival, and Complications of Customized Computer-Aided Design and Manufacturing (CAD/CAM) 3-Dimensional-Printed Titanium Subperiosteal Implants
• Authors: Saverio Cosola, Ernesto Vatteroni, Mohammadreza Asadi, Ugo Covani, Angelo Cardarelli, Giovanni-Battista Menchini-Fabris
• Journal: Journal of Oral and Maxillofacial Surgery
• Year of Publication: 2026
• DOI: 10.1016/j.joms.2026.02.019

2. Scientific Background

Managing patients with severe maxillary or mandibular atrophy continues to represent one of the greatest challenges in implant dentistry and oral surgery. Conventional rehabilitation frequently relies on extensive bone augmentation procedures, which may not be appropriate or feasible for every patient. Advances in digital workflows, computer-aided design and manufacturing (CAD/CAM), and additive manufacturing have renewed interest in customized titanium subperiosteal implants as an alternative treatment strategy.

Unlike traditional approaches that depend on sufficient bone volume for endosseous implant placement, patient-specific subperiosteal implants are designed to conform to the existing jaw anatomy, potentially allowing immediate implant-supported rehabilitation without major reconstructive surgery. This systematic review and meta-analysis examines the current clinical evidence supporting these modern customized implants by assessing their survival rates, reported complications, and overall clinical performance in patients with advanced jaw atrophy.

3. Study Objective

The primary objective of this systematic review and meta-analysis was to evaluate the clinical outcomes associated with customized CAD/CAM and 3D-printed titanium subperiosteal implants. The authors specifically investigated implant survival and treatment-related complications in order to determine the predictability and clinical reliability of this rehabilitation approach for patients with severe jaw atrophy.

4. Methodology

This investigation was conducted as a systematic review and meta-analysis following PRISMA guidelines and was prospectively registered in PROSPERO. Electronic searches were performed in PubMed/MEDLINE, Scopus, Web of Science, the Cochrane Library, and Google Scholar through November 2025.

Eleven eligible studies were included, comprising randomized controlled trials, cohort studies, and case series. Overall, the analysis involved 268 patients who received 369 customized titanium subperiosteal implants. A random-effects meta-analysis was performed to calculate pooled implant survival rates with 95% confidence intervals. The primary outcomes assessed were implant survival and the occurrence of clinical complications.

5. Main Findings

The pooled evidence indicates highly favorable short-term outcomes for customized subperiosteal implants. Studies with follow-up periods of three years or less demonstrated a pooled implant survival rate of 97.8%, suggesting excellent early clinical performance.

When all included studies were analyzed together, the overall pooled survival rate reached 92.4%. However, the authors identified substantial heterogeneity among the included studies, largely attributable to longer-term follow-up data. The study reporting the longest observation period, extending to six years, documented a survival rate of 54.1%, highlighting a marked reduction in long-term implant retention.

Soft tissue complications emerged as the predominant adverse events. Implant exposure and soft tissue dehiscence were the most frequently reported biological complications and represented the principal causes of late implant failure.

6. Clinical Analysis

This review provides an important perspective on the contemporary use of customized CAD/CAM subperiosteal implants by distinguishing early treatment success from long-term clinical stability. While short-term outcomes appear highly predictable, the available evidence suggests that implant survival alone should not be regarded as a comprehensive indicator of treatment success.

The findings emphasize the critical role of peri-implant soft tissue health in maintaining long-term function. Biological complications affecting the surrounding soft tissues may progressively compromise otherwise stable implants, underscoring the importance of careful postoperative monitoring and maintenance.

From a clinical standpoint, these patient-specific implants may represent a valuable treatment alternative for individuals with severe jaw atrophy when conventional bone augmentation procedures are unsuitable. Nevertheless, patient selection remains essential, and clinicians should interpret the reported survival rates within the broader context of biological complications and functional outcomes.

It is also important to recognize that the available evidence originates from studies with varying methodological designs, introducing heterogeneity that limits direct generalization of the results.

7. Clinical Applications

The findings of this review are particularly relevant for the rehabilitation of patients presenting with advanced maxillary or mandibular atrophy requiring complex implant-supported restoration.

Customized CAD/CAM and 3D-printed titanium subperiosteal implants may serve as a salvage treatment option when extensive bone grafting or conventional implant placement is not considered appropriate. The study also highlights the importance of long-term follow-up, with particular attention to peri-implant soft tissue management, as biological complications appear to be the primary determinant of long-term treatment success.

8. Level of Evidence, Limitations, and Transparency

As a systematic review with meta-analysis, this publication represents a high level of scientific evidence. However, the overall strength of its conclusions depends on the methodological quality and consistency of the included studies.

The authors report substantial heterogeneity across the available literature, primarily driven by differences in long-term follow-up outcomes. This variability should be considered when interpreting pooled survival estimates. Additional methodological limitations are not detailed in the abstract provided.

No conflicts of interest or financial relationships with implant manufacturers are reported within the information available.

9. Key Study Highlights

• Study design: Systematic review and meta-analysis.
• Level of evidence: High.
• Studies included: 11.
• Patients: 268.
• Implants: 369 customized titanium subperiosteal implants.
• Maximum follow-up: Up to 6 years.
• Primary outcomes: Implant survival and clinical complications.
• Principal finding: Excellent short-term implant survival (97.8% within three years), with declining survival reported in the longest follow-up study and soft tissue complications representing the main cause of late implant failure.
• Scientific conclusion: Customized subperiosteal implants provide predictable short-term rehabilitation but demonstrate limitations in long-term performance due to soft tissue-related complications.
• Reported limitations: Significant heterogeneity among included studies; additional methodological limitations are not specified in the available abstract.

10. Scientific Impact

This systematic review contributes valuable evidence regarding the contemporary application of digitally designed and additively manufactured customized subperiosteal implants. Rather than focusing exclusively on implant survival, the analysis broadens the discussion by emphasizing the influence of biological complications on long-term clinical success.

The review supports the growing body of literature suggesting that modern CAD/CAM technology has improved the feasibility of patient-specific subperiosteal implant rehabilitation for severe jaw atrophy. At the same time, it highlights that durable clinical success depends on factors extending beyond initial implant stability, particularly the long-term maintenance of healthy peri-implant soft tissues.

By identifying the limitations of currently available evidence and the variability of long-term outcomes, the study also underscores the need for further high-quality investigations with standardized protocols and extended follow-up periods.

11. Editorial Conclusion

This systematic review and meta-analysis indicates that customized CAD/CAM 3D-printed titanium subperiosteal implants can achieve highly predictable short-term outcomes in patients with severe jaw atrophy. However, the available evidence also demonstrates that long-term clinical performance may be compromised by soft tissue-related complications. Consequently, these patient-specific implants should be viewed as a carefully selected salvage treatment option, with long-term maintenance and biological monitoring playing a central role in overall treatment success.