Maxillary Reconstruction with Subperiosteal Implants in a Cancer Patient: One-Year Follow-Up

Pablo Garrido-Martínez, Norberto Quispe-López, Néstor Montesdeoca-García, Germán Esparza-Gómez, José-Luis Cebrián-Carretero

Full text link: https://pubmed.ncbi.nlm.nih.gov/35317297/

Maxillary Reconstruction with Subperiosteal Implants in a Cancer Patient: One-Year Follow-Up

1. Scientific Reference

• Study Title: Maxillary reconstruction with subperiosteal implants in a cancer patient: A one-year follow-up
• Authors: Pablo Garrido-Martínez, Norberto Quispe-López, Néstor Montesdeoca-García, Germán Esparza-Gómez, José-Luis Cebrián-Carretero
• Journal: Journal of Clinical and Experimental Dentistry (J Clin Exp Dent)
• Year of Publication: 2022
• DOI: 10.4317/jced.59331

2. Scientific Background

Reconstructing the maxilla following oncologic surgery remains one of the greatest challenges in oral and maxillofacial surgery. Extensive tumor resections frequently result in severe loss of bone volume and profound alterations of the facial skeleton, making conventional implant-supported rehabilitation particularly demanding. Although microvascular bone grafts have become an established reconstructive option, these procedures are technically complex and may be associated with complications capable of compromising the entire rehabilitation pathway.

Recent advances in digital surgery, three-dimensional planning, CAD/CAM technology, and additive manufacturing have renewed interest in patient-specific subperiosteal implants. Unlike conventional endosseous implants, these customized frameworks are designed according to each patient’s residual anatomy, potentially offering an alternative solution when available bone is insufficient for traditional implant placement.

This case report explores the integration of digital planning, customized implant manufacturing, and prosthetic rehabilitation in a patient undergoing complex maxillary reconstruction after treatment for oral cancer, illustrating how modern technologies may expand reconstructive options in selected clinical situations.

3. Study Objective

The primary objective of this case report was to describe the complete management of a patient diagnosed with maxillary squamous cell carcinoma, from treatment planning and tumor resection to definitive implant-supported prosthetic rehabilitation. The authors aimed to demonstrate the clinical feasibility of using a custom-made subperiosteal implant following the failure of an initial reconstructive procedure. More broadly, the report investigates whether digitally designed patient-specific implants may represent an alternative reconstructive strategy for highly complex oncologic cases.

4. Methodology

This publication is a single-patient case report involving a 61-year-old man diagnosed with squamous cell carcinoma of the maxilla. Following virtual surgical planning, the patient underwent total maxillary resection and immediate reconstruction using a microvascular fibula free flap incorporating three osteotomies. The graft failed within 72 hours because of vascular anastomosis thrombosis and was subsequently removed.

Nine months later, a second digital planning procedure was performed to design a patient-specific titanium subperiosteal implant manufactured through laser sintering and equipped with machined external implant connections. The customized framework was fixed to the nasomaxillary and zygomaticomaxillary buttresses before prosthetic rehabilitation was completed using transepithelial abutments, an open-tray impression technique, CAD/CAM prosthetic fabrication, and a milled cobalt-chromium framework veneered with feldspathic ceramic. Clinical follow-up extended over one year.

5. Main Findings

Despite the failure of the initial fibula free flap reconstruction, the customized subperiosteal implant enabled successful prosthetic rehabilitation. According to the authors, placement of the patient-specific titanium framework was completed without postoperative surgical complications. Following soft tissue healing, implant-supported prosthetic rehabilitation proceeded through conventional restorative stages, ultimately restoring oral function and aesthetics.

After one year of clinical follow-up, no surgical or prosthetic complications were reported. The patient underwent quarterly maintenance visits including periodontal and prosthetic assessments. At the one-year review, the prosthetic framework was temporarily removed to allow complete cleaning of the underlying oral mucosa before being reinserted.

Although these results are encouraging, the authors emphasize that this report demonstrates the feasibility of the technique in a particularly challenging clinical scenario rather than providing evidence of long-term effectiveness. They conclude that additional clinical studies are required before broader indications for customized subperiosteal implants can be established.

6. Clinical Analysis

This case report highlights the potential role of customized subperiosteal implants in patients with extensive maxillary defects following ablative cancer surgery. The clinical significance of the publication lies not only in the successful prosthetic outcome but also in the management of a patient whose initial reconstruction with a microvascular fibula flap had failed because of vascular thrombosis. In this context, the customized implant functioned as a salvage reconstructive solution rather than as a primary treatment option.

One of the most important aspects of the study is the integration of a fully digital workflow. Three-dimensional virtual planning, CAD/CAM design, and additive manufacturing allowed the implant framework to be tailored precisely to the patient’s remaining maxillary anatomy. Such customization may improve the adaptation of the framework to available skeletal support while facilitating prosthetic rehabilitation in anatomically compromised situations.

From a clinical perspective, the absence of surgical or prosthetic complications during the one-year follow-up suggests that patient-specific subperiosteal implants may provide stable short-term outcomes in carefully selected cases. Nevertheless, these observations should be interpreted cautiously. As a single-case report, the study cannot determine treatment predictability, survival rates, or comparative effectiveness against established reconstructive approaches.

Rather than supporting a change in current clinical practice, this publication demonstrates the technical feasibility of combining digital planning, personalized implant manufacturing, and implant-supported prosthetic rehabilitation in highly complex oncologic reconstructions. Its findings are best viewed as preliminary clinical evidence that justifies further investigation through larger prospective studies with longer follow-up periods.

7. Clinical Applications

The findings presented in this report suggest that customized subperiosteal implants may be considered in selected patients requiring complex maxillary reconstruction when conventional endosseous implant placement is not feasible because of severe bone loss or extensive oncologic resection. The described workflow combines digital surgical planning, CAD/CAM technology, and patient-specific titanium implant fabrication to support definitive implant-supported prosthetic rehabilitation.

The reported indication specifically concerns a patient who experienced failure of a microvascular fibula flap reconstruction. Consequently, the study should not be interpreted as recommending this technique as a replacement for established reconstructive procedures. Instead, it illustrates a possible alternative for highly selected cases in which conventional reconstructive options have failed or are particularly challenging. Broader clinical indications cannot be established based on the evidence provided in this single case report.

8. Level of Evidence, Limitations, and Transparency

This publication is a single-patient case report, representing a low level of clinical evidence. While it provides a detailed description of an innovative reconstructive strategy, it does not allow conclusions regarding long-term effectiveness, reproducibility, or superiority over alternative treatment approaches.

Several limitations should be considered when interpreting the findings. The report includes only one patient, lacks a control group, and provides a follow-up period limited to one year. Consequently, the observations remain descriptive and exploratory rather than confirmatory. The authors themselves acknowledge that additional clinical studies are required before customized subperiosteal implants can be more broadly recommended for patients with severe maxillary atrophy or extensive oncologic defects.

Regarding transparency, the authors explicitly state that they have no conflicts of interest. No funding source or commercial relationship likely to influence the reported outcomes is identified in the published article.

9. Key Study Highlights

• Study design: Case report.
• Level of evidence: Low (single-patient clinical report).
• Study population: One patient diagnosed with maxillary squamous cell carcinoma.
• Number of patients: 1.
• Number of implants: Not specifically stated in the article. The report describes a custom-made subperiosteal implant with multiple prosthetic connections but does not specify the exact number of implant components.
• Follow-up period: One year.
• Primary outcome assessed: Clinical feasibility of maxillary reconstruction and implant-supported rehabilitation using a patient-specific subperiosteal implant following ablative cancer surgery.
• Main outcome: Successful implant-supported rehabilitation was achieved, with no surgical or prosthetic complications reported during the one-year follow-up.
• Scientific conclusion: Customized subperiosteal implants may represent a viable reconstructive alternative in selected patients with extensive maxillary defects after oncologic surgery; however, larger clinical studies are needed before broader conclusions can be drawn.
• Main limitations: Single-patient report, absence of a control group, and relatively short follow-up period.

10. Scientific Impact

This publication contributes to the growing body of literature supporting the renewed application of customized subperiosteal implants made possible by modern digital technologies. Historically, subperiosteal implants gradually disappeared from routine practice because of manufacturing limitations and poor adaptation to the underlying bone. The combination of virtual surgical planning, CAD/CAM design, and additive manufacturing has substantially changed this landscape by enabling highly individualized implant frameworks that closely match each patient’s anatomy.

Rather than introducing definitive clinical evidence, this report demonstrates the practical feasibility of applying these technologies in an exceptionally complex oncologic reconstruction. It also illustrates how personalized implantology may provide additional reconstructive options when conventional bone grafting procedures are unsuccessful or cannot be completed as initially planned.

Because this publication represents a single clinical case, its scientific contribution should be viewed primarily as hypothesis-generating. It supports continued investigation into digitally manufactured subperiosteal implants while highlighting the need for prospective clinical studies involving larger patient cohorts, standardized outcome measures, and longer follow-up periods before their role in maxillofacial reconstruction can be fully established.

11. Editorial Conclusion

This case report demonstrates that a patient-specific subperiosteal implant, designed through a fully digital workflow, can successfully support maxillary rehabilitation following extensive oncologic surgery, even after failure of an initial microvascular reconstruction. While the short-term clinical outcome was favorable, the findings should be interpreted within the context of a single-patient report and should not be considered sufficient to establish routine clinical recommendations. Nevertheless, the study provides valuable insight into the evolving role of customized implant technologies in complex maxillofacial reconstruction and highlights an area that warrants further high-quality clinical research.