Virtually Planned Subperiosteal Implants: A 3-Year Follow-up. Technical Tips and Practical Considerations for Optimal Clinical Management

Paolo Cariati, Fernando Pérez Salazar, Lydia Fraile Ruíz, Carlos Hugo Martínez Martínez, Ildefonso Martinez Lara

Full text link: https://pubmed.ncbi.nlm.nih.gov/40835492/

Virtually Planned Subperiosteal Implants: A 3-Year Follow-up. Technical Tips and Practical Considerations for Optimal Clinical Management

1. Scientific Reference

• Study Title: Virtual surgical planned subperiosteal implants. 3 years of follow up. Tips and tricks for a proper management
• Authors: Paolo Cariati, Fernando Pérez Salazar, Lydia Fraile Ruíz, Carlos Hugo Martínez Martínez, Ildefonso Martinez Lara
• Journal: Journal of Cranio-Maxillofacial Surgery
• Publication Year: 2025
• DOI: 10.1016/j.jcms.2025.08.008

2. Scientific Background

Managing severe maxillary atrophy remains one of the greatest challenges in implant dentistry and oral rehabilitation. In patients with advanced bone resorption, conventional treatment often relies on extensive bone augmentation procedures before implant placement. These protocols may involve prolonged healing periods, increased surgical morbidity, and, in some cases, general anesthesia—factors that some patients are unwilling to accept.

Recent advances in digital workflows have renewed interest in customized subperiosteal implants manufactured from virtual surgical planning. Modern imaging, CAD/CAM technologies, and patient-specific implant design have expanded the potential indications of this historical treatment concept. Within this context, the present study investigates the medium-term clinical performance of digitally designed subperiosteal implants in patients with extreme maxillary atrophy while also highlighting technical aspects that may contribute to improved surgical execution and complication management.

3. Study Objective

The primary objective of this study was to assess the three-year clinical outcomes of digitally planned custom-made subperiosteal implants placed in patients with severe maxillary atrophy who declined conventional implant therapy or bone grafting procedures.

In addition, the authors sought to document the complications encountered during follow-up and to identify practical surgical recommendations that could improve treatment predictability.

4. Methodology

This investigation was designed as a retrospective case series.

Twelve patients presenting with Cawood and Howell Class V or VI maxillary atrophy were included after refusing conventional bone augmentation or traditional implant therapy. Virtual surgical planning combined facial CT imaging with intraoral scanning to fabricate patient-specific subperiosteal implant frameworks.

Following osteotomy, the customized frameworks were secured with self-tapping screws, and all patients underwent immediate prosthetic loading within 24 hours under local anesthesia.

Clinical outcomes focused on implant survival over a three-year follow-up period, while postoperative complications were evaluated using frequency-based analysis. Additional methodological details were not specified in the available abstract.

5. Main Findings

Immediate prosthetic rehabilitation was successfully achieved in all twelve patients within 24 hours after surgery.

Complications were reported in four patients during follow-up. Two cases involved framework exposure and were managed conservatively without indication of implant removal. One anticoagulated patient experienced postoperative bleeding, while one implant failed because of inadequate bone reshaping; this case was successfully revised surgically.

After three years, the reported implant survival rate reached 91.7%.

Although complications occurred in approximately one-third of the treated patients, the authors indicate that these events were generally manageable and did not appear to compromise long-term clinical function in most cases. Based on their experience, the study also emphasizes several technical considerations intended to optimize surgical execution.

6. Clinical Analysis

This case series contributes to the growing body of evidence supporting digitally planned subperiosteal implants as a potential treatment option for carefully selected patients with severe maxillary atrophy who are unwilling to undergo conventional reconstructive procedures.

Rather than positioning this technique as a replacement for established augmentation protocols, the findings suggest that modern digital planning and customized implant manufacturing may allow immediate implant-supported rehabilitation in highly challenging anatomical situations. The reported technical recommendations—including avoidance of lateral incisions, the use of dual surgical guides, and pilot hole preparation—highlight the importance of meticulous surgical planning and execution when performing these procedures.

However, these observations should be interpreted within the context of the study design. A retrospective case series involving only twelve patients cannot establish comparative effectiveness against alternative treatment strategies such as bone grafting or other implant-based rehabilitation techniques. Consequently, while the reported outcomes are encouraging, they primarily demonstrate clinical feasibility rather than definitive therapeutic superiority. Larger prospective comparative studies will be necessary to validate these preliminary observations and determine their reproducibility across broader patient populations.

7. Clinical Applications

The findings may be particularly relevant for patients with advanced maxillary atrophy who decline bone grafting procedures, prolonged healing protocols, or treatment under general anesthesia.

The study also illustrates the potential contribution of digital implant planning, guided surgery, CAD/CAM manufacturing, and customized subperiosteal implant frameworks in complex implant rehabilitation requiring immediate loading. Furthermore, the technical recommendations described by the authors may assist clinicians in optimizing surgical workflow and minimizing procedure-related complications. These applications should remain limited to clinical scenarios consistent with the study population.

8. Level of Evidence, Limitations, and Transparency

This publication represents a retrospective case series, corresponding to a low level of clinical evidence when compared with controlled clinical trials or systematic reviews.

Several methodological limitations should be considered, including the small sample size, the absence of a control group, and the retrospective design. These factors restrict the generalizability of the findings and prevent direct comparison with alternative rehabilitation strategies.

The information provided does not mention any declared conflicts of interest or financial relationships with implant manufacturers.

Accordingly, the results should be interpreted as observational clinical data obtained from a carefully selected patient cohort rather than definitive evidence supporting widespread clinical adoption.

9. Key Study Highlights

• Study design: Retrospective case series
• Level of evidence: Low
• Study population: Patients with Cawood and Howell Class V–VI maxillary atrophy
• Number of patients: 12
• Number of implants: Not specified in the available information
• Follow-up period: 3 years
• Primary outcome: Implant survival and postoperative complications
• Main result: 91.7% implant survival after three years with immediate loading achieved in all patients
• Scientific conclusion: Digitally planned customized subperiosteal implants may represent a viable treatment alternative for carefully selected patients refusing conventional reconstructive procedures when combined with meticulous surgical planning and execution.
• Main limitations: Small sample size, retrospective design, and absence of a control group.

10. Scientific Impact

This study adds further clinical evidence supporting the contemporary use of customized subperiosteal implants within a fully digital workflow. Rather than introducing a completely new concept, it demonstrates how advances in virtual surgical planning and patient-specific implant fabrication have modernized a historical treatment modality for complex maxillary rehabilitation.

Its contribution extends beyond survival outcomes by providing practical surgical recommendations derived from clinical experience, which may help optimize treatment protocols in highly atrophic maxillae. Although the study does not establish comparative superiority over conventional reconstructive approaches, it strengthens the growing body of literature suggesting that digitally manufactured subperiosteal implants can represent a realistic option for selected patients with limited therapeutic alternatives.

Future prospective investigations involving larger patient populations and comparative study designs will be necessary to determine the long-term role of this technique within contemporary implant dentistry.

11. Editorial Conclusion

This retrospective case series suggests that digitally planned customized subperiosteal implants may provide a clinically feasible solution for selected patients with severe maxillary atrophy who refuse conventional bone augmentation procedures. The reported three-year outcomes, together with practical surgical recommendations, support the potential value of this approach when meticulous digital planning and precise surgical execution are employed. Nevertheless, the limited level of evidence warrants cautious interpretation, and larger comparative studies remain necessary before broader clinical recommendations can be established.