Continuing Education

Volume 33 No. 7 Page 134

Placement of a Modified
Subperiosteal Implant:
A Clinical Solution to Help Those
With No Bone
Authored by Ara Nazarian, DDS

Upon successful completion of this CE activity 1 CE credit hour will be awarded

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 Continuing Education

Placement of a Modified when they had teeth.

However, there are some patients who are not good
Subperiosteal Implant: candidates for traditional or small-sized dental implants due
to deficiencies in the remaining bone. These patients may
A Clinical Solution to Help Those With need to undergo major surgery to graft these areas with
particulate grafts, block grafts, and sinus lifts, usually taking
No Bone several months of healing and recovery. In addition, the
Effective Date: 7/1/2014 Expiration Date: 7/1/2017 costs associated with these types of grafts may be too
costly for the patients to endure. More importantly, there are
concerns with reports of infection or failure.
ABOUT THE AUTHOR When bone in the maxilla (upper jaw) is atrophied so
Dr. Nazarian maintains a private practice in much that standard- and small-diameter dental implants
Troy, Mich, with an emphasis on compre- cannot be placed without major grafting, I will recommend
hensive and restorative care. He has a subperiosteal dental implant embedded in bone as an
earned a Fellowship and Mastership in the alternative option.
International Congress of Oral Implant-
ologists. His articles have been published Subperiosteal Implants
in many of todays popular dental publications. He is the Subperiosteal implants have actually been around since the
director of the Reconstructive Dentistry Institute and has early 1940s. They were invented by a Swedish dentist, Dr.
conducted lectures and hands-on workshops on aesthetic Gustav Dahl, and then brought to the United States by Drs.
materials and dental implants throughout the United States, Aaron Gershkoff and Norman Goldberg. These implants
Europe, New Zealand, and Australia. He is also the creator of were made of a lightweight and inorganic metal that the
the DemoDent patient education model system. He can be body accepted. The usual material was Vitallium, a cobalt
reached by calling (248) 457-0500 or by visiting the Web site chrome alloy that is completely inert in human tissue.
located at reconstructivedentistryinstitute.com. The subperiosteal implant was designed to rest on top of
the bone and beneath the periosteum. Its design was created
Disclosure: Dr. Nazarian reports no disclosures. to distribute stress from the prosthesis to large areas of
supporting bone. Retention was obtained by the
INTRODUCTION mucoperiosteum; when it became reattached, it would stabilize
The baby boomer population is aging, and because tooth loss the infrastructure casting. However, throughout time, these
and age are closely related, the number of edentulous subperiosteal implants became sources of infection because
patients is also increasing. Patients are presenting to tissue would grow into the grooves of the framework. When
practices all over North America with their teeth already these complications arose, treatment or intervention was
extracted (due to neglect, caries, medications, or other necessary, including curettage and irrigation of struts or
systemic reasons), wearing some type of removable abutments, pocket elimination, addition of grafting material, or
prosthetic device(s). sectioning of any portion of the subperiosteal struts.
Patients who have been wearing removable prosthetics
for several years may soon discover the common denture Modified Subperiosteal Implant Design and Technique
problems of instability, sores, and pain that are associated Throughout the years, many clinicians have modified the
with resorption. Their dentures may no longer fit very well, technique and design of this implant primarily in the United
unless they incorporate some type of implants into the States. Coating of the subperiosteal implant with hydroxyapatite
treatment plan. Implants, whether small or traditional, allow (HA) was introduced by Rivera1 in the 1980s to improve the
patients with dentures to eat and function like they once did likelihood of direct implant to bone contact. Several authors

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

reported2-4 very successful data on the use of HA-coated

subperiosteal implants during that time period (1980 to 1990s).
Today, it has been observed and reported that HA-coating
improves the chance of direct bone-to-implant interface, to
decrease strut dehiscence and to improve the soft-tissue
environment.5 A consensus report of the American Academy
of Implant Dentistry presented by clinicians Weiss, Linkow,
Figure 1. Edentulous
Clark, and Nathan concluded that both maxillary and maxillary ridge with
excessive resorption.
mandible, full and unilateral, HA-coated subperiosteal implants
were viable and recommended techniques for both fixed and
removable prostheses.6
The technique of placing generous amounts of
nonresorbable artificial bone (HA) around the HA-coated
subperiosteal implant to create an implant embedded in bone
(also called custom endosteal implant or custom embedded
implant) was introduced by W. D. Nordquist and D. Naisbitt.7
This technique helps eliminate any open areas for bacteria to Figure 2. A 3-D image
of the maxillary ridge.
develop and allows the subperiosteal dental implant to
restore function and stay in use without developing general
infection in the jawbone. The primary purpose of embedding
the HA-coated subperiosteal implant is to prevent soft-tissue
migration under the casting before osseointegration between
the implant and natural bone is complete. Any further
osseointegration that takes place is considered secondary.
Some of the examples of benefits of this technique include
Figure 3. A 3-D model
elimination of soft-tissue sequestration between implants and of the maxillary ridge.
bone, functional forces are distributed more evenly
throughout the jaw, and alternative solution when there is no remaining in the maxilla. Using a dual-scan technique, the
bone available due to extensive resorption. patients denture was scanned individually as well as in the
patients mouth. It is important to note the denture had
CASE REPORT radiographic markers (gutta-percha points) placed on the
Diagnosis and Treatment Planning facial and palatal aspects of her existing denture held by
A woman in her late 60s presented to our office frustrated sticky wax.
with her upper complete denture of 27 years that opposed The DICOM file was then seamlessly uploaded to
her natural dentition from teeth Nos. 19 to 29. She 3ddx.com (3D Diagnostics) for a custom conversion and a
complained that her upper denture was currently treatment planning session using SimPlant (Materialise)this
nonretentive, and always moving around during eating and was done so we could rotate the image and evaluate it 3-
speaking. dimensionally (Figure 2). With the assistance of the doctor on
Palpation and radiographic examination revealed a staff, we identified that this patient indeed did have extensive
moderately narrowed maxillary ridge that would not allow bone loss in the maxilla. Major grafting utilizing block grafts,
adequate width for traditional-sized or small-sized dental particulate grafts, and sinus lifts would be required in order to
implants (Figure 1). Because of this, a CT scan was have root form implants into the maxillary arch.
obtained to accurately detect the amount and quality of bone When the patient returned for review of the CT scan, all

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

risks, benefits, and alternatives to the various treatment options

were discussed. The patient decided that she did not want to
undergo extensive grafting. Instead, she opted for the HA-coated
subperiosteal implant procedure with corresponding palate-free
maxillary overdenture.
Once informed consent was obtained from the patient, a
3-D model was fabricated from 3D Diagnostics (Figure 3) and
Figure 4. Reflection of
forwarded to the dental laboratory team. the periodontal
tissue.
Dental Laboratory Work
A duplicate of this model was poured up in stone by our dental
laboratory (Dutton Dental Concepts) for designing the
subperiosteal framework. The dental lab team designed the
subperiosteal implant so that the framework would tightly fit the
supporting areas of the maxilla including the area directly
under the nose, areas on either side of the dental arch
extending up the zygomatic arches, the roof of the mouth, and Figure 5. Subperiosteal
the pterygohamular processes. The framework consisted of implant.

permucosal extensions with a connecting bar and struts.

Additionally, the subperiosteal framework had 2 countersunk
screw holes for rigid fixation using bone screws.

Clinical Protocol
Utilizing intravenous sedation, the jawbone was exposed by
making an incision at the crest of the ridge, from the distal Figure 6. The
incline of one tuberosity around the arch to the contralateral hydroxyapatite (HA)
bone grafting material.
side. A sharp periosteal elevator was used to reflect the
palatal tissue cleanly from the bone (Figure 4). The incisive
neurovascular bundle is always severed when performing
this procedure; however, with no significant harm. Once
complete, the palatal tissue was temporarily sutured
together to assist in clearly visualizing the ridge for implant
placement. On the labiobuccal aspects, the muco-
periosteum was elevated starting from the anterior section Figure 7. The HA bone
and proceeding posteriorly on both sides. The structures grafting placed over
subperiosteal implant.
that needed to be exposed included the anterior nasal spine,
canine fossa (up to the lower rim of the infraorbital foramina), site with careful attention not to allow saliva to contaminate
zygomatic buttresses, and the entire bony tuberosities the framework (Figure 5). Once inserted, the framework
extending toward the pterygohamular complexes. Once was inspected to confirm there was no space between it
completely reflected, any residual connective tissue on the and the underlying bone. Each strut and component was
bony ridge was removed so that the subperiosteal frame checked to confirm that the subperiosteal implant was
would only be in contact with bone. firmly and accurately seated. Two bone fixation screws
The subperiosteal implant was inserted into the surgical (Salvin Dental) were placed into the appropriate recessed

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

areas of the zygomatic portion of the framework to further

enhance the stability of the subperiosteal implant onto the
underlying bone.
The use of dense HA (Osteogen [Impladent]) was then
placed over the entire framework to completely cover and fill
any voids between the framework and the underlying bone
(Figures 6 and 7). This would aid in the prevention of tissue
Figure 8. Bar extension
growing into the openings of the framework, resulting in a of the subperiosteal
possible infection. Once the subperiosteal implant was implant after healing.
completely covered in HA, the tissue flaps were coapted
without tension and sutured together using 4.0 black silk
sutures. The area was inspected to confirm that it was
properly closed; otherwise, more sutures would be added.
A provisional restoration had already been fabricated in 2
parts by our dental laboratory team. One part resembled a
palate-free record base that already had Hader Clips (PREAT)
Figure 9. Internal
in it, while the other segment was an arch of denture teeth set connection of the
denture.
in a base of pink acrylic. The record base portion was snapped
onto the prosthetic bar of the subperiosteal implant. Imme-
diately after, the arch of denture teeth was connected to the
record base with pink Triad (DENTSPLY Prosthetics) material.
The patient was instructed to bite together in centric occlusion.
Once it was confirmed that all the teeth in the provisional were
in contact with the opposing dentition, a curing light (Demetron
[Kerr]) was used to polymerize the pink Triad material Figure 10. Palate-free
[DENTSPLY Trubyte, DENTSPLY International] to join the 2 overdenture seated
intraorally.
portions of the provisional. Any voids in the provisional were
filled with a pink, light-cured composite (Quick Up LC [VOCO
America]) material.
Postoperative instructions were reviewed with the
patient in regard to biting and function as well as foods to
eat. The patient was primarily instructed to eat a soft diet for
the next 2 months. She was given a prescription for
Figure 11. Panoramic
antibiotics (amoxicillin 500 mg, 28 tabs QID) and for pain radiograph (Panorex) of
medication (Vicodin ES, 15 tabs, one tab every 6 hours for the subperiosteal
implant.
pain). Oral hygiene instructions using a mouthrinse were
also reviewed. Since everything looked within normal limits, the patient was
The patient returned 72 hours later for her postoperative instructed to return in 10 days for suture removal.
visit. Although she had some swelling, she complained of Using topical anesthetic, we removed the sutures 10
very little discomfort at this time. She mentioned when she days after her first postoperative appointment. The patient
did have pain that the medication was sufficient in keeping was very pleased with her palate-free provisional
her comfortable. The area was inspected to ensure that there restoration and commented how excited she was for the
were no signs of infection, edema, or suture line opening. definitive restoration.

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

After 4 to 5 months of healing (Figure 8), the patient REFERENCES

returned to the dental office for impressions to fabricate her 1. Rivera E. HA castings on the subperiosteal implant.
final restoration: a palate-free overdenture utilizing Hader Presented at: International Congress of Oral
Implantologists; San Juan, Puerto Rico; 1983.
Clips for retention. Now that the tissue had healed, an
2. Kay JK, Golec TS, Riley RL. Hydroxyapatite coated
accurate impression of the bar and surrounding tissues could subperiosteal dental implants status and four year
be taken. In order to block out any undercuts in the bar of the clinical experience. J Oral Implantol. 1991;8:11-16.
framework, a silicone material (Fit Test C & B [VOCO 3. Misch CE, Dietsh F. The unilateral mandibular
America]) was injected under the bar and allowed to set. Once subperiosteal implantindications and technique.
set, a customized tray (Goodfit) was used with a vinyl J Oral Implantol. 1991;8:21-27.
4. Golec TS, Krauser JT. Long-term retrospective studies
polysiloxane impression material (Take 1 Advanced [Kerr]) to
on hydroxyapatite coated endosteal and subperiosteal
take a full-arch impression. From this impression, our dental implants. Dent Clin North Am. 1992;36:39-65.
lab team fabricated the final restoration (Figure 9). 5. Benjamin LS. Long-term retrospective studies on the CT-
Within 2 weeks of the impression, the palate-free scan, CAD/CAM, one-stage surgery hydroxyapatite-coated
overdenture with Hader Clips and BlueLine denture teeth subperiosteal implants, including human functional
(Ivoclar Vivadent) was delivered to the patient (Figure 10). retrievals. Dent Clin North Am. 1992;36:77-93.
6. Minichetti JC. Analysis of HA-coated subperiosteal
The patient was very pleased that she could smile and
implants. J Oral Implantol. 2003;29:111-116.
function without the embarrassment of her teeth falling out, 7. Nordquist WD, Krutchkoff DJ. The custom endosteal
thanks to the integrated subperiosteal implant (Figure 11). implant (CEI): histology and case report of a retrieved
maxillary custom osseous-integrated implant nine years
CLOSING COMMENTS in service. J Oral Implantol. 2014;40:195-201.
Having the ability to provide an HA-coated subperiosteal
FURTHER STUDY/RESOURCES
implant embedded in bone for patients who have otherwise
For detailed step-by-step instructions on the protocol for a
been told they cannot have implants is very rewarding to not
one-stage subperiosteal implants and accompanying
only the patient, but also the provider. Professionally, it is a
prosthetics, please visit the Web sites located at
great accomplishment to be able to deliver an implant-
aranazariandds.com and at duttondental.com.
retained restoration that allows patients the ability to speak
and function regularly without discomfort or embarrassment
when others previously told them there was no solution but
complete dentures.

ACKNOWLEDGMENT
The author would like to thank Ryan Dutton, CDT, and the lab
team at Dutton Dental Concepts Laboratory, Ohio, for the
fabrication of the subperiosteal implant and overdenture.

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

POST EXAMINATION INFORMATION POST EXAMINATION QUESTIONS

To receive continuing education credit for participation in 1. There are some patients who are not good
this educational activity you must complete the program candidates for traditional or small sized dental
post examination and answer 4 out of 5 questions correctly. implants due to deficiencies in the remaining bone.

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 Continuing Education
Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone

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