Currently, the rehabilitation of the atrophic jaws continues to be a challenge for surgeons. Atrophic jaws are a result of bone volume loss due to multiple factors, hindering their rehabilitation with conventional implant therapy. Many surgical techniques published in the scientific literature for these cases depend on the treated area. Reconstructive procedures such as autogenous bone grafting are generally applied, but a second donor site, sinus lift, and guided bone regeneration are all required, increasing co-morbidity of the procedure. Therefore, these procedures are frequently limited in gain, requiring several months for graft maturation.
Alternative techniques include tilted implants, pterygoid implants, zygomatic implants, short implants, and lateralization of the inferior alveolar nerve among others. [Ref 1,2,3]
These techniques play a fundamental role in the surgical armamentarium surgeons, who are in charge of selecting the ideal treatment option according to the particular case indication for the patients.
Many of these surgical techniques can be combined according to individualized cases. This is done by obtaining optimal results, performing protocols with less morbidity and invasiveness, thereby shortening treatment times for the patients.
Alternative implant techniques to bone reconstructive and regenerative procedures for atrophic jaws allow precisely these less invasive protocols and shortening treatment times, making it possible to carry out immediate loading procedures (provisional fixed teeth in a day). This significantly improves the patient’s quality of life. Logically, whether to apply one or other techniques will depend on the individual case. This is done by all the existing parameters and variables to decide which treatment option is the best for the patient but also most fitting to a surgeon’s skill set.
Classical subperiosteal implants as an alternative technique were first described in 1943. However, they were soon associated with abnormally high complications, such as implant exposure, implant mobility, and implant loss. These complications are mainly due to inaccurate manufacturing, impression techniques, wrong materials used, lack of retention elements, and general poor knowledge regarding the interaction between biological structures and implants at that time (biofunctionalization).
Recently, there has been a great digital evolution in medicine, related to new technologies, such as computer aid design/computer aid manufacturing (CAD/CAM), 3D printing, digital designing with improved processing software, and modern manufacturing techniques with biocompatible materials. These advancements allow the beginning of a new era in reconstructive rehabilitations with 3D printing custom-made implants.
Custom-made implants for the reconstruction of craniomaxillofacial defects have gained great importance with the development of new technologies. This is because of increased precision in the adaptation of the area to be implanted, a reduction in surgical treatment times, and lower morbidity for patients.
The application of 3D printing in reconstructive surgery is changing the way surgeons are planning and designing these surgeries using custom-made implants. Advances in the manufacturing processes of these biomedical devices with 3D printing have eliminated the problems of shape, size, adaptation, optimizing the internal structure and mechanical properties with a high dimensional accuracy of these implants. That’s because these implants are created according to the physical, mechanical, and biological requirements of the area to be implanted.
The materials commonly used for 3D printing custom-made implants are titanium (Ti6AL4V) and PEEK. These materials have great biocompatibility and properties widely studied in the scientific literature with clinical trials.
For all these reasons previously exposed, it is possible to take the old concepts of classical subperiosteal and apply these new technologies and new knowledge regarding the biological interaction with custom-made implants. Therefore we can further the evolution, optimization, and biofunctionalization of these biomedical devices with 3D printing and apply them in complex cases of atrophic jaw rehabilitations.
A deep anatomical and biological knowledge are necessary to plan and design custom-made implants that are functional.
The treatment planning takes into account the keratinized gingiva and mucosas. We need the good thickness of the gingiva and mucosa to avoid tissue dehiscence of the custom implant, protect vital structures like muscles in the implanted area, ensure screw fixation anchor points to avoid movement of the implant due to stress masticatory and occlusion forces.
Treatment planning should also include material and implant surface consideration. For example, we typically recommend biocompatible titanium (TI6AL4V), high polish external surface in contact with the soft tissues, and internal SLA acid etching surface treatment to increase bone-implant contact.
All these features regarding the good interaction between biological structures and the custom made implant biofunctionalization.
Currently, custom-made 3D printed subperiosteal implants are promising innovative alternative treatments that can be used in selected cases for atrophic jaw rehabilitation. In comparison to large reconstructive and regenerative bone grafting procedures, the less invasive technique of custom-made subperiosteal implants utilizing 3D printing can lead to reduced treatment time and improve the patient’s quality of life.
However, like any other techniques, long-term follow-up clinical trials will be necessary to establish the suitability of this emerging and innovative procedure.
I express my thanks to our strategic partner for this protocol of custom-made implants, BoneEasy for their contribution to expanding the possibilities on 3D printing healthcare.
 Garcia Lozada V. Use of quadruple zygoma implants technique for atrophic maxilla rehabilitation with immediate loading – A clinical case report. J Oral Health Dent 2018;2:206.
 Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atrophic posterior maxilla with pterygoid implants: A review. J Oral Implantolol. 2012;38 Spec No:461-6.
 Krekmanov L, Rangert B, Khan M, Lindstrom H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants.2000;15(3):405-14
About the Author:
Dr. Vladimir Garcia Lozada graduated in Dentistry, Oral Surgery, and Maxillofacial Implantology internationally in many programs of Universities and Hospitals obtaining his specialist, fellowship, and Master degree. He went through a residency program in Oral and Maxillofacial Surgery in Brazil, and he qualified for the degree Doctor of Philosophy in Oral and Maxillofacial Implantology Ph.D. program at the Cambridge International University. His research interests and clinical activity include the techniques for the treatment of severe atrophies of the jaws with a special focus in complex cases using zygomatic and pterygoid implants, full-arch implant rehabilitation, and new technologies with CAD/CAM 3D printing medical devices in the field of maxillofacial applications.
Lecturer of different Universities Programs in oral implantology as in training courses, webinars, and conferences on implant surgery for complex cases.
He is the author of several articles in national and international
journals, and is a member of various scientific societies
(IAOMS, SECIB, SEI, ICOI).
Founder & CEO of Cibumax / Expert Surgical Services