Rehabilitation of a Severely Atrophic Maxilla Using a CAD/CAM-Assisted Customized Subperiosteal Implant: A Digital Workflow Case Report

Pablo Revuelta-Cortés, Dorsaf Sahli, Mónica Serrano Torrecilla, Natalia Martínez-Rodríguez, Juan Santos Marino, José María Martínez-González.

Full text link: https://pubmed.ncbi.nlm.nih.gov/41707925/ 

Rehabilitation of a Severely Atrophic Maxilla Using a CAD/CAM-Assisted Customized Subperiosteal Implant: A Digital Workflow Case Report

1. Scientific Reference

• Study Title: CAD/CAM-assisted subperiosteal implant rehabilitation of a severely atrophic maxilla: A digital workflow case report.
• Authors: Pablo Revuelta-Cortés, Dorsaf Sahli, Monica Serrano Torrecilla, Natalia Martínez-Rodríguez, Juan Santos Marino, José María Martínez-González.
• Journal: Journal of Stomatology, Oral and Maxillofacial Surgery.
• Year of Publication: 2026.
• DOI: 10.1016/j.jormas.2026.102762.

2. Scientific Background

Managing patients with severe maxillary bone atrophy remains one of the most demanding challenges in implant dentistry. Extensive bone loss following peri-implantitis may leave insufficient residual bone for conventional endosseous implant placement, often requiring complex reconstructive procedures before oral rehabilitation can be considered. These approaches may increase treatment time, surgical morbidity, and overall complexity.

Advances in digital implantology have renewed interest in customized subperiosteal implants. Modern workflows combining cone-beam computed tomography (CBCT), intraoral scanning, three-dimensional planning, and CAD/CAM manufacturing now enable the fabrication of patient-specific titanium frameworks that closely match individual anatomy. Rather than revisiting historical subperiosteal implant concepts, these technologies have introduced a new generation of highly customized devices intended for carefully selected patients with advanced jaw atrophy. This case report illustrates how a fully digital workflow can be incorporated into the rehabilitation of a severely resorbed maxilla after implant failure caused by advanced peri-implantitis.

3. Study Objective

The primary objective of this case report was to describe the complete digital workflow involved in designing, manufacturing, and surgically placing a customized CAD/CAM-assisted subperiosteal implant following the removal of failed maxillary implants affected by peri-implantitis. The authors also aimed to document the subsequent prosthetic rehabilitation and short-term clinical outcomes achieved with this individualized treatment approach.

4. Methodology

This publication is a single-patient clinical case report involving a 53-year-old woman presenting with advanced peri-implantitis affecting multiple maxillary implants that had been placed seven years earlier. The patient’s medical history was largely unremarkable, although she reported smoking approximately fifteen cigarettes per day. Smoking reduction was recommended because of its potential influence on soft-tissue healing and peri-implant health.

The treatment protocol consisted of removing hopeless implants while preserving stable posterior implants to support a provisional fixed prosthesis during healing. After a six-month healing period, CBCT imaging and intraoral digital scans were obtained. DICOM and STL datasets were merged to design a patient-specific titanium subperiosteal implant using a CAD/CAM digital workflow. The implant was surgically placed under conscious sedation and stabilized with multiple fixation screws according to the preoperative digital plan. Following soft-tissue maturation, a definitive titanium-composite hybrid prosthesis was fabricated and delivered. Clinical and radiographic follow-up extended over two years.

5. Main Findings

The digital workflow enabled the fabrication of a customized titanium subperiosteal implant specifically designed to match the patient’s residual maxillary anatomy. According to the authors, this individualized design facilitated passive adaptation during surgery while avoiding the need for additional bone grafting procedures before fixed implant rehabilitation.

Following implant placement, a provisional fixed prosthesis was connected to both the retained posterior implants and the subperiosteal implant abutments, allowing functional rehabilitation during healing. Once the peri-implant soft tissues had stabilized, a definitive hybrid prosthesis consisting of a titanium framework layered with esthetic composite materials was fabricated after successful evaluation of a PMMA prototype for occlusion, biomechanics, and esthetics.

Throughout the two-year follow-up period, the patient experienced no reported soft-tissue complications or prosthetic failures. Based on this individual clinical outcome, the authors suggest that CAD/CAM-assisted customized subperiosteal implants may represent a feasible salvage solution for carefully selected patients with severe maxillary atrophy when conventional endosseous implant placement is no longer possible. However, they explicitly emphasize that these observations should be interpreted cautiously because they are derived from a single clinical case.

6. Clinical Analysis

Rather than attempting to establish the superiority of customized subperiosteal implants over conventional implant therapy, this case report demonstrates how a fully digital treatment pathway can expand rehabilitation possibilities for highly complex patients. Its principal contribution lies in illustrating the integration of digital planning, patient-specific implant design, and prosthetic-driven surgery into a single coordinated workflow.

One of the most relevant aspects of the report is the emphasis placed on individualized treatment planning. Instead of adapting standard implants to compromised anatomy, the implant itself was engineered according to the patient’s residual maxillary bone and the planned definitive prosthesis. This prosthetically driven approach reflects an increasingly important concept in contemporary implant dentistry, where restorative objectives influence surgical planning from the earliest stages of treatment.

The case also highlights the potential role of customized subperiosteal implants in situations where conventional alternatives become extremely challenging. Extensive bone loss following peri-implantitis often limits the feasibility of additional endosseous implants without major reconstructive procedures. In this clinical scenario, the customized framework allowed fixed rehabilitation without performing bone augmentation, demonstrating a possible treatment pathway for selected salvage cases. Nevertheless, the study does not compare this strategy with grafting procedures, zygomatic implants, or other reconstructive approaches, and therefore cannot support comparative clinical recommendations.

Another important observation concerns patient selection. The authors underline the need to control inflammation before surgery, allow an adequate healing period after implant removal, and carefully manage risk factors such as smoking, which may negatively influence soft-tissue healing and postoperative complications. These considerations reinforce that successful outcomes depend not only on digital technology but also on comprehensive biological and clinical management.

Finally, the discussion places this clinical experience within the broader scientific literature. Although recent publications have renewed interest in CAD/CAM-assisted subperiosteal implants, available evidence remains limited by heterogeneous methodologies, inconsistent definitions of implant success, relatively small patient cohorts, and limited long-term follow-up. Consequently, this report should be viewed as a valuable clinical illustration rather than definitive evidence supporting widespread adoption of the technique.

7. Clinical Applications

The findings presented in this case report suggest that CAD/CAM-assisted customized subperiosteal implants may have a role in highly selected clinical situations involving severe maxillary atrophy, particularly when conventional endosseous implant placement is no longer feasible because of extensive bone loss following peri-implantitis. Rather than representing a routine treatment option, the technique is described as a potential salvage solution for complex rehabilitation cases.

This report also highlights the value of a fully digital implant workflow, integrating CBCT imaging, intraoral scanning, CAD/CAM design, and prosthetically driven planning into a single treatment protocol. Such an approach allows the implant framework to be individually manufactured according to the patient’s residual anatomy while simultaneously considering prosthetic requirements. The digital workflow therefore supports precise surgical planning and customized prosthetic rehabilitation without additional bone augmentation in the presented case.

Nevertheless, the authors do not propose this technique as a replacement for conventional implant therapy or established reconstructive procedures. Instead, they present it as a possible alternative when traditional treatment options are contraindicated, technically impractical, or declined by the patient. Broader clinical indications will require stronger evidence from prospective studies involving larger patient populations and standardized outcome measures.

8. Level of Evidence, Limitations and Transparency

This publication is a single clinical case report, representing a low level of scientific evidence. Although it provides a detailed description of an innovative treatment protocol, its findings cannot be generalized to the wider patient population or interpreted as proof of clinical superiority over other rehabilitation strategies.

The authors acknowledge several important limitations. They note that the current literature on customized subperiosteal implants remains dominated by case reports and small case series with heterogeneous success criteria and variable follow-up durations. In addition, long-term biological outcomes, particularly regarding peri-implant health and implant survival, remain insufficiently documented. These limitations emphasize the need for cautious interpretation of the reported clinical success.

Regarding research transparency, the authors declare no known financial or personal conflicts of interest that could have influenced the reported work. They also state that the study was conducted without public or private research funding, supporting the transparency of the publication.

9. Key Study Points

• Study Design: Single clinical case report.
• Level of Evidence: Low.
• Study Population: One 53-year-old female patient presenting with severe maxillary atrophy following implant failure caused by advanced peri-implantitis.
• Number of Patients: 1.
• Number of Customized Subperiosteal Implants: 1.
• Follow-up Period: 2 years.
• Primary Outcome Evaluated: Clinical feasibility of rehabilitating a severely atrophic maxilla using a CAD/CAM-assisted customized subperiosteal implant and subsequent prosthetic restoration.
• Main Clinical Outcome: Successful fixed rehabilitation with no reported soft-tissue or prosthetic complications during the two-year follow-up period.
• Scientific Conclusion: Within the limitations of a single-patient case report, customized CAD/CAM-assisted subperiosteal implants may represent a feasible salvage option for carefully selected patients in whom conventional endosseous implant placement is not possible.
• Study Limitations: Single-case design, absence of a control group, inability to generalize findings, heterogeneous evidence available in the literature, and limited long-term clinical data.

10. Scientific Impact

This case report contributes to the growing body of literature exploring the renewed clinical application of CAD/CAM-assisted customized subperiosteal implants in the management of severe jaw atrophy. Rather than introducing a new implant concept, the study demonstrates how contemporary digital technologies—including CBCT imaging, intraoral scanning, virtual treatment planning, and patient-specific manufacturing—can transform a historical implant design into a modern, digitally driven rehabilitation solution.

A notable contribution of this publication is its detailed presentation of an integrated digital workflow, illustrating how surgical planning and prosthetic design can be coordinated from the earliest stages of treatment. This prosthetically driven approach reflects the ongoing evolution of digital implant dentistry, where individualized planning seeks to optimize anatomical adaptation while reducing the need for additional reconstructive procedures in selected patients. Although the report focuses on a single clinical case, it provides practical insight into the implementation of personalized implant rehabilitation in a challenging clinical scenario.

The discussion also identifies several unresolved issues that remain relevant for future research. The authors highlight the lack of standardized definitions of implant success across published studies, the variability of reported survival outcomes, and the limited availability of long-term prospective clinical data. These methodological inconsistencies currently prevent definitive conclusions regarding the long-term predictability of customized subperiosteal implants.

Consequently, this study should be regarded as an important clinical contribution to an emerging field rather than evidence supporting widespread adoption. It reinforces the need for prospective cohort studies with standardized success criteria, larger patient populations, and extended follow-up to better define the role of CAD/CAM-assisted subperiosteal implants within contemporary implant rehabilitation.

11. Editorial Conclusion

This clinical case illustrates how a CAD/CAM-assisted customized subperiosteal implant can be incorporated into the rehabilitation of a severely atrophic maxilla following implant failure associated with advanced peri-implantitis. Within the limitations of a single-patient report, the described digital workflow achieved successful functional and prosthetic rehabilitation without reported biological or prosthetic complications during a two-year follow-up period. While these findings are encouraging, they should not be interpreted as definitive evidence of clinical effectiveness. Instead, the study provides valuable documentation of an emerging digital treatment strategy and underscores the importance of generating higher-level clinical evidence before broader recommendations can be established.