Clinical Performance of Subperiosteal Implants in Full-Arch Rehabilitation of Severely Resorbed Edentulous Jaws: A Systematic Review and Meta-Analysis

Luis Sánchez-Labrador, Santiago Bazal-Bonelli, Fabián Pérez-González, Tomás Beca-Campoy, Carlos Manuel Cobo-Vázquez, Jorge Cortés-Bretón Brinkmann, José María Martínez-González

Full text link: https://pubmed.ncbi.nlm.nih.gov/40559143/ 

Clinical Performance of Subperiosteal Implants in Full-Arch Rehabilitation of Severely Resorbed Edentulous Jaws: A Systematic Review and Meta-Analysis

1. Scientific Reference

• Study Title: Clinical Performance of Subperiosteal Implants in the Full-Arch Rehabilitation of Severely Resorbed Edentulous Jaws: A Systematic Review and Metanalysis
• Authors: Luis Sánchez-Labrador, Santiago Bazal-Bonelli, Fabián Pérez-González, Tomás Beca-Campoy, Carlos Manuel Cobo-Vázquez, Jorge Cortés-Bretón Brinkmann, José María Martínez-González
• Journal: Dentistry Journal (Dent. J.)
• Publication Year: 2025
• DOI: 10.3390/dj13060240

2. Scientific Background

Managing completely edentulous patients with advanced jaw atrophy remains one of the greatest challenges in modern implant dentistry. Conventional endosseous implants generally require sufficient bone volume and quality to achieve predictable outcomes. In cases of severe maxillary or mandibular resorption, clinicians often rely on complex bone augmentation procedures, including guided bone regeneration, block grafting, sinus floor elevation, or distraction osteogenesis. While effective in selected cases, these approaches may increase surgical morbidity, treatment duration, cost, and technical complexity.

Against this background, subperiosteal implants have experienced renewed clinical interest. Although originally introduced decades ago and later abandoned because of manufacturing limitations and frequent complications, advances in digital imaging, CAD/CAM design, additive manufacturing, and biomaterials have fundamentally changed their clinical application. Patient-specific implants can now be digitally designed and manufactured with greater anatomical precision, allowing placement through a single surgical procedure. This systematic review explores whether these technological developments have translated into improved clinical outcomes compared with traditional two-stage subperiosteal implant protocols.

3. Study Objective

The primary objective of this systematic review and meta-analysis was to assess the clinical performance of subperiosteal implants used for full-arch rehabilitation of severely resorbed edentulous maxillae and mandibles. The investigators focused on two key clinical outcomes: implant survival and treatment-related complications.

In addition, the review sought to compare outcomes between two distinct surgical concepts. The first involved contemporary patient-specific subperiosteal implants designed using digital workflows and placed during a single surgical procedure. The second included traditional subperiosteal implants manufactured using conventional techniques that required two separate surgical interventions. Through this comparison, the authors aimed to determine whether modern digital technologies have improved the predictability and safety of subperiosteal implant rehabilitation.

4. Methodology

This study was conducted as a systematic review and meta-analysis following the PRISMA reporting guidelines and was prospectively registered in the PROSPERO database (CRD42022372736), ensuring methodological transparency.

A comprehensive literature search was performed across four electronic databases—MEDLINE/PubMed, Scopus, Web of Science, and the Cochrane Library—supplemented by a manual search of relevant journals and reference lists. Publications available up to 28 February 2025 were considered.

Eligible studies included clinical investigations involving at least four human patients treated with subperiosteal implants supporting full-arch prosthetic rehabilitation. Randomized clinical trials, cohort studies, case-control studies, cross-sectional studies, and case series were eligible, whereas case reports, animal studies, and in vitro investigations were excluded.

Fourteen studies fulfilled the inclusion criteria, representing 958 patients who received 973 subperiosteal implants. Five studies evaluated contemporary single-stage protocols, while nine investigated historical two-stage procedures. The primary outcomes were implant survival and complication rates. Study quality and risk of bias were assessed using the Newcastle–Ottawa Scale for cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for case series.

5. Main Results

The review analyzed data from 973 subperiosteal implants placed in 958 patients with severe maxillary or mandibular atrophy requiring full-arch rehabilitation.

Studies evaluating digitally designed implants placed during a single surgical procedure reported an overall 100% implant survival rate, with follow-up periods ranging from 4 to 38 months. In contrast, studies involving traditional two-stage subperiosteal implants demonstrated an overall survival rate of 85%, with substantially longer follow-up periods ranging from 3 to 22 years. Meta-analysis showed that this difference between the two treatment approaches was statistically significant.

The incidence of complications also differed between the two groups. Single-stage digital protocols reported only a small number of implant exposures and one case of gingival inflammation. Historical two-stage protocols presented a broader spectrum of adverse events, including implant exposure, paresthesia, gingival inflammation, peri-implantitis, bone screw sequestration, epulis formation, and prosthetic fractures.

Although these findings appear favorable for modern digitally manufactured implants, the authors emphasize that the results should be interpreted cautiously because the studies differed considerably in design, patient populations, and especially duration of follow-up. The shorter observation periods available for contemporary implants prevent definitive conclusions regarding their long-term performance.

6. Clinical Analysis

This systematic review highlights the renewed role of subperiosteal implants as a potential treatment option for patients with advanced jaw atrophy who cannot be predictably rehabilitated using conventional endosseous implants without extensive bone augmentation. Rather than presenting these implants as a replacement for established implant therapies, the evidence suggests they may expand the range of available solutions for carefully selected clinical situations.

One of the most significant findings concerns the impact of technological evolution. The favorable outcomes reported for single-stage subperiosteal implants should be interpreted within the context of modern digital workflows. Advances in cone beam computed tomography (CBCT), intraoral scanning, virtual surgical planning, and CAD/CAM manufacturing have enabled the fabrication of patient-specific titanium frameworks with improved anatomical adaptation. According to the authors, eliminating the initial surgical procedure previously required to obtain a bone impression may reduce surgical complexity while improving implant fit and potentially lowering complication rates.

However, these encouraging findings should not be interpreted as definitive evidence of superiority. The studies evaluating modern digital implants include relatively small patient populations and considerably shorter follow-up periods than the historical investigations. Consequently, the apparent improvement in survival rates may partially reflect the limited observation time currently available for these newer devices rather than an unequivocal long-term clinical advantage.

Another important consideration is the methodological quality of the available evidence. Most included studies were observational cohorts or case series, with only limited high-level comparative evidence. The authors therefore emphasize that current findings should be viewed as promising rather than conclusive. Additional randomized clinical trials with standardized protocols and extended follow-up are necessary before firm clinical recommendations can be established.

Overall, this review suggests that digitally manufactured subperiosteal implants may represent a valuable alternative for selected patients with severe maxillary or mandibular atrophy, particularly when conventional implant placement would require extensive reconstructive surgery. Nevertheless, careful patient selection, thorough digital planning, and continued clinical monitoring remain essential given the current level of evidence.

7. Clinical Applications

The findings of this review indicate that patient-specific subperiosteal implants may be considered in the management of completely edentulous patients with severe maxillary or mandibular bone resorption when conventional implant placement is not feasible without extensive bone reconstruction.

The study also supports the integration of digital workflows—including three-dimensional imaging, virtual surgical planning, and CAD/CAM manufacturing—in the design of customized subperiosteal implants. According to the reviewed evidence, these technologies allow implant placement through a single surgical procedure while potentially reducing complications associated with earlier techniques.

The authors also note that subperiosteal implants may provide an alternative treatment option for patients with extensive maxillofacial defects resulting from oncologic resection or severe trauma, although this indication was discussed as clinical context rather than evaluated directly within the review. Importantly, the available evidence does not support considering digitally manufactured subperiosteal implants as a new standard of care, and further long-term clinical research remains necessary before broader recommendations can be made.

8. Level of Evidence, Limitations, and Transparency

This publication is a systematic review with meta-analysis, representing a high level of evidence within evidence-based dentistry. However, the strength of its conclusions depends on the methodological quality of the studies included.

Several important limitations are acknowledged by the authors. Considerable heterogeneity existed among the included studies regarding study design, patient populations, implant manufacturing methods, and follow-up duration. Contemporary single-stage digital protocols were evaluated primarily in recent observational studies with relatively small sample sizes and limited follow-up, whereas historical two-stage protocols included substantially longer observation periods. These differences make direct comparisons challenging.

Quality assessment using the Newcastle–Ottawa Scale and the Joanna Briggs Institute Critical Appraisal Tool indicated that many included studies were of low to moderate methodological quality, limiting the certainty of the pooled estimates.

Regarding transparency, the authors state that the study received no external funding and declare no conflicts of interest. They also emphasize that the encouraging results observed for digitally designed subperiosteal implants should be interpreted cautiously until supported by well-designed randomized clinical trials with longer follow-up periods.

9. Key Study Highlights

• Study type: Systematic review with meta-analysis.
• Level of evidence: High-level evidence based on study design, although the certainty of the conclusions is moderated by the quality and heterogeneity of the included studies.
• Studies included: 14 clinical studies.
• Patient population: 958 completely edentulous patients presenting with severe maxillary and/or mandibular bone atrophy.
• Number of implants evaluated: 973 subperiosteal implants.
• Follow-up period:
  • Single-stage protocols: 4 to 38 months.
  • Two-stage protocols: 3 to 22 years.
• Primary outcomes assessed:
  • Implant survival.
  • Treatment-related complications.
• Main findings:
  Digitally designed subperiosteal implants placed during a single surgical procedure demonstrated a reported 100% survival rate throughout the available follow-up period, whereas conventional two-stage implants showed an overall survival rate of 85%. This difference was statistically significant in the meta-analysis.
• Reported complications:
  Contemporary single-stage protocols were mainly associated with a small number of implant exposures and one case of gingival inflammation. Historical two-stage procedures reported a broader range of complications, including implant exposure, paresthesia, gingival inflammation, peri-implantitis, bone screw sequestration, epulis formation, and prosthetic fractures.
• Scientific conclusion:
  Patient-specific digitally manufactured subperiosteal implants appear to represent a promising treatment option for full-arch rehabilitation in patients with severe jaw atrophy. Nevertheless, the authors stress that additional high-quality randomized clinical trials with longer follow-up are required before definitive conclusions can be drawn.
• Major limitations:
  • Considerable heterogeneity among included studies.
  • Predominantly observational study designs.
  • Limited number of contemporary digital implant studies.
  • Short follow-up for modern single-stage protocols.
  • Lack of randomized controlled trials directly comparing treatment modalities.

10. Scientific Impact

This publication represents one of the first comprehensive systematic reviews specifically dedicated to the clinical performance of subperiosteal implants used for full-arch rehabilitation of severely resorbed edentulous jaws. Rather than simply summarizing historical experience, it places renewed attention on how digital technologies have transformed a treatment concept that had largely fallen out of clinical practice.

A notable contribution of the review is the distinction between traditional two-stage subperiosteal implant protocols and contemporary patient-specific implants designed through digital workflows. By separating these two generations of implants, the authors provide a clearer understanding of how advances in CBCT imaging, virtual planning, CAD/CAM manufacturing, and additive production may have influenced clinical outcomes.

The review also contributes to the ongoing discussion regarding treatment options for patients with severe jaw atrophy who may otherwise require extensive bone grafting procedures. While the findings suggest encouraging survival rates and relatively few complications for digitally manufactured implants, the authors appropriately avoid overstating their conclusions. Instead, they identify significant gaps in the current literature, particularly the absence of randomized clinical trials and long-term prospective data.

Consequently, this study strengthens the scientific foundation supporting renewed interest in customized subperiosteal implants while simultaneously defining the future research priorities necessary to establish their long-term role within contemporary implant dentistry.

11. Editorial Conclusion

This systematic review and meta-analysis provides an updated and balanced assessment of customized subperiosteal implants for the rehabilitation of severely resorbed edentulous jaws. The currently available evidence suggests that digitally designed, patient-specific implants placed in a single surgical procedure may achieve encouraging short-term clinical outcomes with relatively few reported complications. However, the available evidence remains limited by heterogeneous study designs and the relatively short follow-up of contemporary protocols. As a result, these findings should be viewed as promising rather than definitive, underscoring the need for robust long-term clinical investigations before broader clinical recommendations can be established.