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

Luminita Nedelcu, Ioan Sirbu, Valentin Daniel Sirbu, Andreea Mihaela Custura, Adelin Radu, Vladimir Nastasie.

Full text link: https://pubmed.ncbi.nlm.nih.gov/39670079/

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

1. Scientific Reference

• Study title: Custom-made 3D printed subperiosteal implant for restoration of severe atrophic jaw: A case report
• Authors: Luminita Nedelcu, Ioan Sirbu, Valentin Daniel Sirbu, Andreea Mihaela Custura, Adelin Radu, Vladimir Nastasie.
• Journal: Clinical Case Reports
• Year of publication: 2024
• DOI: 10.1002/ccr3.9515

2. Scientific Background

Managing patients with advanced maxillary bone atrophy remains one of the greatest challenges in contemporary implant dentistry. Conventional endosseous implants require adequate bone volume and quality, meaning that severe alveolar resorption often necessitates additional surgical procedures such as bone augmentation or sinus floor elevation before implant placement can be considered. Although these reconstructive approaches are well established, they frequently increase treatment complexity, surgical morbidity, healing time, and overall rehabilitation duration.

Subperiosteal implants were originally introduced as an alternative for patients with insufficient bone support, but their use gradually declined because of limitations associated with traditional manufacturing techniques, particularly the need for direct intraoperative bone impressions and a two-stage surgical protocol. Advances in digital implantology—including cone beam computed tomography (CBCT), computer-aided design (CAD), and metal additive manufacturing—have renewed interest in patient-specific subperiosteal implants. Within this technological context, the present case report describes the clinical workflow and rehabilitation of a patient treated using a custom-designed 3D-printed subperiosteal implant.

3. Study Objective

The primary objective of this case report was to describe the clinical management of a patient with severe maxillary atrophy using patient-specific, 3D-printed subperiosteal implants designed from CBCT imaging. The authors sought to present the complete digital workflow, including preoperative planning, implant design, manufacturing, surgical placement, prosthetic rehabilitation, and postoperative follow-up. In addition, the report discusses how contemporary digital technologies may overcome several technical limitations historically associated with conventional subperiosteal implant fabrication.

4. Methodology

This publication is a single-patient case report describing the treatment of a 58-year-old male presenting with severe maxillary atrophy following the failure of a previous implant-supported rehabilitation affected by peri-implantitis. The patient had been wearing a removable maxillary denture for approximately three years before treatment.

The diagnostic work-up included clinical examination, panoramic radiography, CBCT imaging, and routine laboratory investigations. Three-dimensional CBCT data (DICOM files) were used for virtual treatment planning and the CAD design of two patient-specific subperiosteal implants. The implants were manufactured using Direct Metal Laser Sintering (DMLS) and stabilized with osteosynthesis screws during surgery. Prosthetic impressions were taken immediately after surgery, allowing fabrication of a provisional restoration using the patient’s existing removable prosthesis, followed by delivery of the definitive prosthesis after approximately two months of healing. Clinical and radiographic evaluations were performed during a 10-month follow-up period.

5. Main Findings

Preoperative imaging demonstrated extensive horizontal and vertical maxillary bone resorption, with several areas exhibiting minimal residual bone volume and multiple oroantral communications. According to the authors, these anatomical conditions considerably limited the feasibility of conventional implant placement without extensive bone reconstruction procedures.

The digital workflow enabled the design of customized subperiosteal implants precisely adapted to the patient’s remaining maxillary anatomy. Each implant was secured using a total of 28 osteosynthesis screws measuring 2 × 7 mm, providing mechanical stabilization immediately after placement. Postoperative panoramic radiography confirmed accurate implant positioning, while the patient’s existing removable denture was modified to serve as a provisional prosthesis on the day of surgery. A definitive prosthetic restoration was delivered after the healing phase.

Clinical and radiographic assessments performed 10 months after surgery demonstrated satisfactory implant stability and continued functional integration of the rehabilitation. The authors considered these findings encouraging within the context of this individual clinical case. However, the report does not provide quantitative survival rates, comparative outcome measures, or long-term performance data beyond the documented follow-up period.

6. Clinical Analysis

This case report illustrates how digital technologies may redefine the role of subperiosteal implants in the management of severe maxillary atrophy. Rather than relying on conventional manufacturing techniques that required direct bone impressions during an initial surgical procedure, the treatment described here was entirely planned from CBCT imaging. The integration of digital imaging, CAD software, and metal additive manufacturing allowed the surgical team to produce implants tailored to the patient’s residual anatomy before entering the operating room.

From a clinical perspective, the most notable contribution of this report is the demonstration of a fully digital workflow for a patient who would otherwise have required extensive reconstructive surgery. The CBCT examination revealed severe horizontal and vertical bone loss throughout the maxilla, accompanied by multiple oroantral communications and insufficient residual bone for predictable placement of conventional endosseous implants. Under these anatomical conditions, the authors selected customized subperiosteal implants to obtain mechanical support from the remaining maxillary buttresses rather than relying on alveolar bone volume alone.

Another clinically relevant aspect concerns treatment simplification. Historically, traditional subperiosteal implants required two separate surgical interventions because implant fabrication depended on an intraoperative impression of the exposed maxillary bone. By replacing this analogue workflow with digital planning based on CBCT data, the protocol described in this report eliminated the preliminary surgical impression stage. According to the authors, this approach has the potential to reduce surgical trauma while improving the anatomical adaptation of the implant framework.

Despite these encouraging observations, the findings should be interpreted within the limitations of the study design. This publication reports the outcome of a single patient followed for ten months and therefore cannot establish treatment predictability, long-term biological behavior, or superiority over alternative rehabilitation strategies. Likewise, the report does not include direct comparisons with bone grafting procedures, zygomatic implants, or other advanced implant protocols. Consequently, the clinical value of this article lies primarily in demonstrating the technical feasibility of a personalized digital workflow rather than providing definitive evidence for routine clinical practice.

7. Clinical Applications

The clinical experience described in this report may be relevant for carefully selected patients presenting with severe maxillary atrophy, particularly when conventional endosseous implant placement would require extensive bone augmentation procedures. In such situations, patient-specific subperiosteal implants designed from CBCT data may represent an alternative reconstructive strategy when supported by comprehensive digital planning.

The article also highlights the practical integration of a complete digital implant workflow, combining three-dimensional imaging, CAD-based implant design, and metal 3D printing. This approach may improve the anatomical adaptation of customized implant frameworks while eliminating the need for intraoperative bone impressions associated with traditional analogue techniques.

However, because the publication reports only a single clinical case, these findings should not be interpreted as evidence supporting widespread adoption of the technique. Instead, they provide a detailed example of how digital technologies can be incorporated into the rehabilitation of exceptionally complex anatomical situations and serve as a foundation for future clinical investigations.

8. Level of Evidence, Limitations, and Transparency

This publication is a case report, representing a low level of clinical evidence within the hierarchy of evidence-based medicine. While case reports are valuable for describing innovative treatment approaches and generating clinical hypotheses, they cannot establish treatment efficacy, predictability, or superiority over existing therapeutic options. The findings presented here should therefore be interpreted as descriptive observations rather than definitive clinical recommendations.

Several methodological limitations should be acknowledged. The report describes the management of a single patient, without a control group or statistical analysis, and includes a 10-month follow-up only. Consequently, the study cannot provide information regarding long-term implant survival, biological stability, prosthetic maintenance, or complication rates beyond the observation period. Furthermore, no direct comparison was performed with alternative treatment modalities such as bone grafting, zygomatic implants, or conventional implant rehabilitation following bone reconstruction.

Regarding transparency, the authors state that no external funding was received for the study and explicitly declare no conflicts of interest. They also report that written informed consent was obtained from the patient and that the case complied with the ethical principles outlined in the Declaration of Helsinki. The article additionally describes a collaboration with AB Dental International, which designed and manufactured the customized implants used in this case. This collaboration is reported factually, while the authors maintain that no conflicts of interest exist.

9. Key Study Highlights

• Study design: Case report.
• Level of evidence: Low.
• Study population: One patient with severe maxillary atrophy.
• Patient age: 58 years.
• Number of implants: Two patient-specific 3D-printed subperiosteal implants.
• Manufacturing technique: CBCT-based digital planning, CAD design, and Direct Metal Laser Sintering (DMLS).
• Implant fixation: Twenty-eight osteosynthesis screws (2 × 7 mm).
• Follow-up duration: 10 months.
• Primary endpoint: Clinical feasibility of a fully digital workflow and postoperative implant stability.
• Main finding: Clinical and radiographic examinations demonstrated satisfactory implant stability and functional rehabilitation during the 10-month follow-up period.
• Scientific conclusion: The authors suggest that digitally designed, patient-specific subperiosteal implants may represent a viable treatment alternative for selected cases of severe maxillary atrophy while emphasizing the importance of careful postoperative monitoring.
• Main limitations: Single-patient design, absence of a control group, and limited follow-up duration.

10. Scientific Impact

This case report contributes to the growing body of literature exploring the renewed role of subperiosteal implants in the digital era. Rather than presenting a novel implant concept alone, the study demonstrates how the integration of CBCT imaging, computer-aided design (CAD), and metal additive manufacturing can modernize a treatment modality that had largely fallen out of routine clinical practice because of the limitations of conventional fabrication techniques.

A noteworthy aspect of the publication is the comprehensive description of the digital workflow, encompassing diagnosis, virtual implant design, manufacturing, surgical placement, and prosthetic rehabilitation. By documenting each phase of the clinical protocol, the authors provide practical insight into how customized subperiosteal implants can be incorporated into complex implant rehabilitation when conventional endosseous approaches are severely limited by bone deficiency.

The article also aligns with recent research cited by the authors reporting encouraging outcomes for digitally manufactured subperiosteal implants. Although the present publication does not increase the overall level of clinical evidence, it supports the ongoing shift toward patient-specific implant solutions enabled by digital technologies. Its principal contribution lies in illustrating the feasibility of a personalized treatment workflow rather than establishing clinical effectiveness or long-term predictability. Future prospective studies involving larger patient cohorts and extended follow-up periods will be necessary to determine the durability, complication profile, and comparative performance of these customized implant systems.

11. Editorial Conclusion

This case report demonstrates how digital planning and additive manufacturing can expand the therapeutic options available for patients with severe maxillary atrophy. The successful rehabilitation described in this individual case highlights the potential of patient-specific 3D-printed subperiosteal implants to address complex anatomical situations while simplifying certain aspects of the traditional surgical workflow. However, because the evidence is limited to a single patient with a 10-month follow-up, the findings should be interpreted cautiously. Overall, the publication represents a valuable technical and clinical contribution that supports continued investigation of digitally customized subperiosteal implant rehabilitation in larger clinical studies.