|Year : 2015 | Volume
| Issue : 2 | Page : 113-119
Revisiting the maxillary subperiosteal implant prosthesis: A case study
Mohd Adnan Mapkar1, Ruby Syed2
1 Department of Prosthodontics, Nanded Rural Dental College, Nanded, Maharashtra, India
2 Department of Periodontics, Nanded Rural Dental College, Nanded, Maharashtra, India
|Date of Web Publication||15-Sep-2016|
Mohd Adnan Mapkar
Ruby Dental Care, Sahyog Nagar, Raj Corner, Nanded - 431 605, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
As a result of the progress made in the area of endosseous implants in the last 15 years, the value of the subperiosteal implant has been minimized. Yet endosseous implants are not appropriate for all patients in need of implants. Well-designed subperiosteal implants have been reported to function successfully for many years. Among the relevant factors contributing to the success of this method are implant design, atraumatic surgery, understanding of the involved anatomic structures, accurate impression techniques, and appropriate occlusal adaptations of the final prosthesis. This report reviews a brief outlook of the literature about subperiosteal implants till date and also presents a case of maxillary subperiosteal implant prosthesis.
Keywords: Endosseous, implant, subperiosteal
|How to cite this article:|
Mapkar M, Syed R. Revisiting the maxillary subperiosteal implant prosthesis: A case study. J Dent Implant 2015;5:113-9
| Introduction|| |
Edentulism is a predicament that has plagued man since time itself, but the phenomena became even more rampant with the introduction and consumption of soft diet that is the paradigm of our society today. Hard work and perseverance by stalwarts from the past has resulted in exhaustive data that teaches us that the alveolar processes in the absence of teeth become vestigial and hence continue to undergo resorption.  This advanced, severe bone resorption is due to long-standing edentulism and the detrimental forces from loading these jaws with soft-tissue supported dentures.  One complication that arises from this severe bone resorptive pattern is ill-fitting dentures that even after repeated relines are not stable during normal, or even soft mastication and the patients have to use massive amounts of denture adhesive to just keep them in place to speak. Besides being a quality of life issue, it becomes a health issue as the lack of proper masticatory process results in inadequate nutrition, which leads to a host of digestive disorders including acid reflux and esophageal blockage, and can even contribute to metabolic disorders. 
Chronic excessive use of denture cream containing zinc may result in hypocupremia and serious neurologic disease. ,, Another major complication is pain from direct pressure on the exposed inferior alveolar nerve a result of dehisced inferior alveolar canal and mental foramen by the mandibular denture and resulting trigeminal neuralgia.  Precaution, as they say, is better than cure, and various modalities and prototypes of implants are widely utilized today to resolve the crisis faced by patients, hence, offering them treatments that are both viable and affordable.
With very advanced jawbone resorption, there may not be enough bone width or height for the more common and routinely placed type of implant: The root form implant. With no teeth in the maxilla (upper jaw), the bone internal to the ridge tends to be lost over time. The porosity gets so great that implants have no internal bone in which to hold. Although the ridge may look sufficient from the outer surface, an X-ray may show a total lack of bone density. Many times even repeated attempts at bone grafting prove unsuccessful. , In these cases, the subperiosteal implant can be of tremendous help. After the second world war research was being conducted rapidly on either sides of the Atlantic though many names prop up as regards the origin of the subperiosteal implant; it is generally agreed that the technique was originally described in 1941 by Gustav Dahl - a Swedish doctor who placed a metal structure below the periosteum with vertical extensions that protruded through the gingiva.  Inspired by his work, Dr. Norman Goldberg  US Army dentist introduced the concept in America and later collaborated with Dr. Aaron Gershkoff; to create a new design in 1948. , The design generated interest, bringing recognition, and criticism. Eventually, a collective term of "subperiosteal implants" was given to such designs.
By definition, a subperiosteal implant is a framework specifically fabricated to fit the supporting areas of the mandible or maxilla with permucosal extensions for support and attachment of a prosthesis [Figure 1].  The framework consists of permucosal extensions with or without connecting bars and struts.  Struts are classified as peripheral, primary, and secondary.  The subperiosteal implant can be constructed as a complete arch, unilateral or universal, and is loaded immediately.  Prior to the tremendous success of the root form implants since Dr. Branemark introduced the concept of osseointegration in 1981, the subperiosteal implant along with blade  [Figure 2] and plate  [Figure 3] implants were routinely used to support either a fixed, or removable, complete, or partial prosthesis. The subperiosteal implant is custom made and designed to fit that of the patient's individual three dimensional type of jaw morphology and sit on top and around the bone but under the gums.  There are two methods for its fabrication and installation. A "dual stage surgical technique" and a "single stage surgical technique." ,
In the dual stage surgical technique, the first stage comprises of an exposure of the lower jaw followed by an impression of bony jaw. The impression is then, of course, poured into a specially designed stone-cast and thus an implant is fabricated. , Traditionally, subperiosteal implants are made from chrome cobalt or titanium alloys and often immediately loaded with a removable or fixed prosthesis similar to a system used for blade implants. ,, For "single surgery," the dentist will order a special computed tomography/cone beam volumetric tomography (CT/CBVT) scan of one's jaw bone [Figure 4]. ,, With the help of CT/CBVT scan data, as well as computer modeling techniques, a model of one's jawbone is then constructed [Figure 5]. The model is then made use of by dental laboratory to fabricate the custom subperiosteal implant to fit one's jaw. Then a surgical procedure is performed, whereby the jawbone is exposed, and the implant is placed in position. The gums are then closed up with many stitches and then the replacement teeth are put in their place.
|Figure 5: Maxillary model prepared with the help of computed tomography scan|
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Dentists and oral surgeons who have access to and perhaps more importantly, experience in subperiosteal surgeries, offer this implant device as a viable solution for patients who lack sufficient bone for traditional implants. Patients unable to successfully wear a maxillary denture who lack bone density for root form implants find great comfort in maxillary subperiosteal implants. The subperiosteal implant has been long forgotten, especially in the maxilla.  This article is a humble endeavor to probe into the possibility of reintroducing them into the mainstream in view of recent studies and advances in implantology.
| Case report|| |
A 21-year-old male with a chief complaint of ill-fitting maxillary and mandibular removable partial dentures reported to the department of periodontology. The patient gave a history of trauma 6-7 years back in which he lost his maxillary and mandibular teeth on the right side (i.e., 11, 12, 13, 14, 31, 41, 42, 43, 44). Owing to the periodontal status of the patient, fixed partial dentures were not advisable in this case. Clinical and radiological examinations revealed the resorbed status of the partially edentulous maxillary and mandibular alveolar ridges [Figure 6] and [Figure 7] explaining the cause for ill-fitting dentures. On examining, the CT scan [Figure 8], the approximation of the maxillary sinus floor and the bucco-palatal width of the bone, the option of placing endosseous implants was discarded. After considering different treatment options, subperiosteal implant treatment was considered as the treatment of choice in the maxillary region and mandibular teeth were to be replaced later with endosseous implants in combination with other bone augmenting procedures.
|Figure 6: Clinical view showing resorbed maxillary and mandibular ridges|
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|Figure 7: Orthopantomogram showing resorbed maxillary and mandibular ridges|
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A dual stage surgical procedure was planned. In the first stage, surgical impression was recorded [Figure 9] [Figure 10] [Figure 11]. The impression was then poured with plaster to fabricate a replica (model) of the jawbone and the model was used by the dental laboratory to custom cast the implant with the suprastructure to fit the jaw along with the final prosthesis that was prescribed [Figure 12] and [Figure 13]. Eight weeks after the first-stage "impression acquisition" surgery, the second stage surgery was planned. The second surgery, usually 8-10 weeks after the bone impression, allows the tissues to heal before a secondary implant placement. This allows enough time for the tissues to re-establish a blood supply and decreases the risk of incision line opening. This in turn will make the final suturing much more predictable, and primary closure will be more easily attained.  Hence, a second procedure was then carried out where the jawbone was re-exposed [Figure 14] and [Figure 15] and the implant was placed and secured into place with the help of titanium screws [Figure 16]. The gums were closed with stitches over the subperiosteal and around the suprastructures, and the prosthesis was placed into place [Figure 17] and [Figure 18]. The patient was then instructed in the usual manner for postoperative wound and prosthesis care. The patient was asked to return 24 h and 1 week for postoperatory appointments. The patient was satisfied with the retention and stability of the maxillary prosthesis [Figure 19]. He was pleased with the functional and esthetic results of the treatment [Figure 20] and [Figure 21]. The patient was placed on a 6-month hygiene recall.
|Figure 12: Model of the maxillary jaw bone with superstructure of subperiosteal implants|
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|Figure 16: Subperiosteal implants fixed in place with the help of titanium screws|
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| Discussion|| |
Subperiosteally anchored implants were already introduced by the 1940s.  Of all currently used devices, it is the type of implant that has had the longest period of the clinical trial. These implants are not anchored inside the bone as endosseous devices but are instead shaped to "ride on" the residual bony ridge. They are not claimed to be osseointegrated.  Subperiosteal implants over the years have been used in both totally/partially edentulous mandibles and maxillae. Subperiosteal implants have been a controversial subject since it was introduced. There are many studies in the literature which state both favorable ,,,,,,,, and unfavorable ,, results with the use of these type of implants.
Varying results have been described in the literature. Köle  found an average success rate of only 6% after, on average, 7 years of implantation. At the Harvard NIH conference in 1978, Goldberg  reported 10-year success figures of 36% ±6%. A similar description of the outcome of subperiosteal implants was reported by Mercier et al.,  who found a 60% success after an average observation period of 3.3 years. On the contrary, the work of Bodine and Yanase  represents the only study where a long-term follow-up (>15 years) has been published. The optimal outcome of subperiosteal implant therapy is represented by the long-term material of Bodine and Yanase whose 10-year report indicated success in the range of 66 ± 8%. In 1985, , the same authors published a 30-year report on 28 subperiosteal implants inserted between 1952 and 1959. The patients of this study were followed regularly by recalls, personal contact, telephone, and questionnaires. Not one single patient was lost in the follow-up. One of the patients had his subperiosteal implant in situ without problems for over 26 years of follow-up. The 5-year success rate was found to be as high as 93%, and the 10-year results were of about 64%. Further, the 15-year results gave a success rate of about 54%.
As a result of the progress made in the area of endosseous implants in the last 15 years, the value of the subperiosteal implant has been minimized. Yet endosseous implants are not appropriate for all patients in need of implants. Subperiosteal implants have been somewhere forgotten during the last decade owing to its relative failure rates, but on the other hand considering the study conducted by Bodine and Yanase we can still probe into the possibilities of the success of these implants. There are many factors which play a role in the success of these implants. Well-designed subperiosteal implants have been reported to function successfully for many years. Among the relevant factors contributing to the success of this method are implant design, atraumatic surgery, understanding of the involved anatomic structures, accurate impression techniques, and appropriate occlusal adaptations of the final prosthesis. Sirbu  published a report from Rumania in 2003 on design characteristics of successful subperiosteal implants and the anatomy of the areas on which subperiosteal implants rest in both mandibles and maxillae based on recent research performed in Rumania. This report gave a series of developments that can be made in the fabrication as well as the patient selection for these implants.
| Conclusion|| |
Given the choice between harvesting from the iliac crest with the associated morbidity of such grafts, along with the increased cost and time required by such an approach, the maxillary subperiosteal implant remained a more attractive treatment for this patient's severely atrophied maxilla in this case. The advantages of subperiosteal implants include the predictability of the results and the high success rate.  This technique utilizes less invasive surgery and is, therefore, preferable to the use of iliac crest or tibial grafts. Partial subperiosteal implants can be used with endosseous implants and even natural teeth with fixed bridges. The surgical technique and clinical stages are not complicated, generally being mastered by implantologists in general dental practice. Disadvantages include the frequent necessity for two surgical procedures and the initial complexity of the surgical procedures. This complexity presumes a certain level of experience that the practitioner can obtain only over a long period. However, these complications are also being overcome by the different radiological advancements, and the need of two surgical procedures is being nullified. Finally, removal of subperiosteal implants, although rarely indicated, can present difficulties. The importance and potential benefits of subperiosteal implants are undeniable, being at this time the only means of restoring jaws in situations where endosseous implants cannot be placed. Hence, by presenting this case report, it is an ardent request to the field of dentistry to not to discard this choice of treatment. Instead, there should be more and more research work on this subject to obtain better prognostic results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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