Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements. Continuing Education 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 Volume 33 No. 7 Page 134
Transcript
Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and
courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to
contact their state dental boards for continuing education requirements.
Continuing Education
Placement of a ModifiedSubperiosteal 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
Volume 33 No. 7 Page 134
ABOUT THE AUTHORDr. Nazarianmaintains a private practice inTroy, Mich, with an emphasis on compre-hensive and restorative care. He hasearned a Fellowship and Mastership in theInter national Congress of Oral Implant-ologists. His articles have been published
in many of today’s popular dental publications. He is thedirector of the Reconstructive Dentistry Institute and hasconducted lectures and hands-on workshops on aestheticmaterials and dental implants throughout the United States,Europe, New Zealand, and Australia. He is also the creator ofthe DemoDent patient education model system. He can bereached by calling (248) 457-0500 or by visiting the Web sitelocated at reconstructivedentistryinstitute.com.
Disclosure: Dr. Nazarian reports no disclosures.
INTRODUCTIONThe baby boomer population is aging, and because tooth lossand age are closely related, the number of edentulouspatients is also increasing. Patients are presenting topractices all over North America with their teeth alreadyextracted (due to neglect, caries, medications, or othersystemic reasons), wearing some type of removableprosthetic device(s).
Patients who have been wearing removable prostheticsfor several years may soon discover the common dentureproblems of instability, sores, and pain that are associatedwith resorption. Their dentures may no longer fit very well,unless they incorporate some type of implants into thetreatment plan. Implants, whether small or traditional, allowpatients with dentures to eat and function like they once did
when they had teeth.However, there are some patients who are not good
candidates for traditional or small-sized dental implants dueto deficiencies in the remaining bone. These patients mayneed to undergo major surgery to graft these areas withparticulate grafts, block grafts, and sinus lifts, usually takingseveral months of healing and recovery. In addition, thecosts associated with these types of grafts may be toocostly for the patients to endure. More importantly, there areconcerns with reports of infection or failure.
When bone in the maxilla (upper jaw) is atrophied somuch that standard- and small-diameter dental implantscannot be placed without major grafting, I will recommenda subperiosteal dental implant embedded in bone as analternative option.
Subperiosteal ImplantsSubperiosteal implants have actually been around since theearly 1940s. They were invented by a Swedish dentist, Dr.Gustav Dahl, and then brought to the United States by Drs.Aaron Gershkoff and Norman Goldberg. These implantswere made of a lightweight and inorganic metal that thebody accepted. The usual material was Vitallium, a cobaltchrome alloy that is completely inert in human tissue.
The subperiosteal implant was designed to rest on top ofthe bone and beneath the periosteum. Its design was createdto distribute stress from the prosthesis to large areas ofsupporting bone. Retention was obtained by themucoperiosteum; when it became reattached, it would stabilizethe infrastructure casting. However, throughout time, thesesubperiosteal implants became sources of infection becausetissue would grow into the grooves of the framework. Whenthese complications arose, treatment or intervention wasnecessary, including curettage and irrigation of struts orabutments, pocket elimination, addition of grafting material, orsectioning of any portion of the subperiosteal struts.
Modified Subperiosteal Implant Design and TechniqueThroughout the years, many clinicians have modified thetechnique and design of this implant primarily in the UnitedStates. Coating of the subperiosteal implant with hydroxyapatite(HA) was introduced by Rivera1 in the 1980s to improve thelikelihood of direct implant to bone contact. Several authors
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Placement of a ModifiedSubperiosteal Implant: A Clinical Solution to Help Those WithNo BoneEffective Date: 7/1/2014 Expiration Date: 7/1/2017
reported2-4 very successful data on the use of HA-coatedsubperiosteal implants during that time period (1980 to 1990s).
Today, it has been observed and reported that HA-coatingimproves the chance of direct bone-to-implant interface, to de crease strut dehiscence and to improve the soft-tissueenvironment.5 A consensus re port of the American Academyof Implant Dentistry presented by clinicians Weiss, Linkow,Clark, and Nathan concluded that both maxillary andmandible, full and unilateral, HA-coated subperiosteal implantswere viable and recommended techniques for both fixed andremovable prostheses.6
The technique of placing generous amounts ofnonresorbable artificial bone (HA) around the HA-coatedsubperiosteal implant to create an implant embedded in bone(also called custom endosteal implant or custom embeddedimplant) was introduced by W. D. Nordquist and D. Naisbitt.7
This technique helps eliminate any open areas for bacteria todevelop and allows the subperiosteal dental implant torestore function and stay in use without developing generalinfection in the jawbone. The primary purpose of embeddingthe HA-coated subperiosteal implant is to prevent soft-tissuemigration under the casting before osseointegration betweenthe implant and natural bone is complete. Any furtherosseointegration that takes place is considered secondary.Some of the examples of benefits of this technique includeelimination of soft-tissue sequestration between implants andbone, functional forces are distributed more evenlythroughout the jaw, and alternative solution when there is nobone available due to extensive resorption.
CASE REPORTDiagnosis and Treatment PlanningA woman in her late 60s presented to our office frustratedwith her upper complete denture of 27 years that opposedher natural dentition from teeth Nos. 19 to 29. Shecomplained that her upper denture was currentlynonretentive, and always moving around during eating andspeaking.
Palpation and radiographic examination revealed amoderately narrowed maxillary ridge that would not allowadequate width for traditional-sized or small-sized dentalimplants (Figure 1). Because of this, a CT scan wasobtained to accurately detect the amount and quality of bone
remaining in the maxilla. Using a dual-scan technique, thepatient’s denture was scanned individually as well as in thepatient’s mouth. It is important to note the denture hadradiographic markers (gutta-percha points) placed on thefacial and palatal aspects of her existing denture held bysticky wax.
The DICOM file was then seamlessly uploaded to3ddx.com (3D Diagnos tics) for a custom conversion and atreatment planning session using SimPlant (Materialise)—thiswas done so we could rotate the image and evaluate it 3-dimensionally (Figure 2). With the assistance of the doctor onstaff, we identified that this patient indeed did have extensivebone loss in the maxilla. Major grafting utilizing block grafts,particulate grafts, and sinus lifts would be required in order tohave root form implants into the maxillary arch.
When the patient returned for review of the CT scan, all
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risks, benefits, and alternatives to the various treatment optionswere discussed. The pa tient decided that she did not want toundergo extensive grafting. Instead, she opted for the HA-coatedsubperiosteal implant procedure with corresponding palate-freemaxillary overdenture.
Once informed consent was ob tained from the patient, a 3-D model was fabricated from 3D Diagnostics (Figure 3) andforwarded to the dental laboratory team.
Dental Laboratory WorkA duplicate of this model was poured up in stone by our dentallaboratory (Dutton Dental Concepts) for designing thesubperiosteal framework. The dental lab team designed thesubperiosteal implant so that the framework would tightly fit thesupporting areas of the maxilla including the area directlyunder the nose, areas on either side of the dental archextending up the zygomatic arches, the roof of the mouth, andthe pterygohamular processes. The framework consisted ofpermucosal extensions with a connecting bar and struts.Addition ally, the subperiosteal framework had 2 countersunkscrew holes for rigid fixation using bone screws.
Clinical ProtocolUtilizing intravenous sedation, the jawbone was exposed bymaking an incision at the crest of the ridge, from the distalincline of one tuberosity around the arch to the contralateralside. A sharp periosteal elevator was used to reflect thepalatal tissue cleanly from the bone (Figure 4). The incisiveneurovascular bundle is always severed when performingthis procedure; however, with no significant harm. Oncecomplete, the palatal tissue was temporarily suturedtogether to assist in clearly visualizing the ridge for implantplacement. On the labiobuccal aspects, the muco-periosteum was elevated starting from the anterior sectionand proceeding posteriorly on both sides. The structuresthat needed to be exposed included the anterior nasal spine,canine fossa (up to the lower rim of the infraorbital foramina),zygomatic buttresses, and the entire bony tuberositiesextending toward the pterygohamular complexes. Oncecompletely re flected, any residual connective tissue on thebony ridge was removed so that the subperiosteal framewould only be in contact with bone.
The subperiosteal implant was inserted into the surgical
site with careful attention not to allow saliva to contaminatethe framework (Fig ure 5). Once inserted, the frameworkwas inspected to confirm there was no space between itand the underlying bone. Each strut and component waschecked to confirm that the subperiosteal implant wasfirmly and accurately seated. Two bone fixation screws(Salvin Dental) were placed into the appropriate recessed
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Figure 7. The HA bonegrafting placed oversubperiosteal implant.
areas of the zygomatic portion of the framework to furtherenhance the stability of the subperiosteal implant onto theunderlying bone.
The use of dense HA (Osteogen [Impladent]) was thenplaced over the entire framework to completely cover and fillany voids between the framework and the underlying bone(Fig ures 6 and 7). This would aid in the prevention of tissuegrowing into the openings of the framework, resulting in apossible infection. Once the subperiosteal implant wascompletely covered in HA, the tissue flaps were coaptedwithout tension and sutured together using 4.0 black silksutures. The area was inspected to confirm that it wasproperly closed; otherwise, more sutures would be added.
A provisional restoration had already been fabricated in 2parts by our dental laboratory team. One part resembled apalate-free record base that already had Hader Clips (PREAT)in it, while the other segment was an arch of denture teeth setin a base of pink acrylic. The record base portion was snappedonto the prosthetic bar of the subperiosteal implant. Im me -diately after, the arch of denture teeth was connected to therecord base with pink Triad (DENTSPLY Pros thetics) material.The patient was instructed to bite together in centric occlusion.Once it was confirmed that all the teeth in the provisional werein contact with the opposing dentition, a curing light (Demetron[Kerr]) was used to polymerize the pink Triad material[DENTSPLY Trubyte, DENTSPLY Inter national] to join the 2portions of the provisional. Any voids in the provisional werefilled with a pink, light-cured composite (Quick Up LC [VOCOAmerica]) material.
Postoperative instructions were reviewed with thepatient in regard to biting and function as well as foods toeat. The patient was primarily instructed to eat a soft diet forthe next 2 months. She was given a prescription forantibiotics (amoxicillin 500 mg, 28 tabs QID) and for painmedication (Vicodin ES, 15 tabs, one tab every 6 hours forpain). Oral hygiene instructions using a mouth rinse werealso reviewed.
The patient returned 72 hours later for her postoperativevisit. Al though she had some swelling, she complained ofvery little discomfort at this time. She mentioned when shedid have pain that the medication was sufficient in keepingher comfortable. The area was inspected to ensure that therewere no signs of infection, edema, or suture line opening.
Since everything looked within normal limits, the patient wasinstructed to return in 10 days for suture removal.
Using topical anesthetic, we re moved the sutures 10days after her first postoperative appointment. The patientwas very pleased with her palate-free provisionalrestoration and commented how excited she was for thedefinitive restoration.
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Figure 8. Bar extensionof the subperiostealimplant after healing.
After 4 to 5 months of healing (Figure 8), the patientreturned to the dental office for impressions to fabricate herfinal restoration: a palate-free overdenture utilizing HaderClips for retention. Now that the tissue had healed, anaccurate impression of the bar and surrounding tissues couldbe taken. In order to block out any undercuts in the bar of theframework, a silicone material (Fit Test C & B [VOCOAmerica]) was injected under the bar and allowed to set. Onceset, a customized tray (Goodfit) was used with a vinylpolysiloxane impression material (Take 1 Advanced [Kerr]) totake a full-arch impression. From this impression, our dentallab team fabricated the final restoration (Figure 9).
Within 2 weeks of the impression, the palate-freeoverdenture with Hader Clips and BlueLine denture teeth(Ivoclar Vivadent) was delivered to the patient (Figure 10).The patient was very pleased that she could smile andfunction without the em barrassment of her teeth falling out,thanks to the integrated subperiosteal implant (Figure 11).
CLOSING COMMENTSHaving the ability to provide an HA-coated subperiostealim plant embedded in bone for patients who have otherwisebeen told they cannot have im plants is very re warding to notonly the patient, but also the provider. Profes sionally, it is agreat accomplishment to be able to deliver an implant-retained res toration that allows patients the ability to speakand function regularly without discomfort or embarrassmentwhen others previously told them there was no solution butcomplete dentures.
ACKNOWLEDGMENT The author would like to thank Ryan Dutton, CDT, and the labteam at Dutton Dental Con cepts Laboratory, Ohio, for thefabrication of the subperiosteal implant and overdenture.
REFERENCES1. Rivera E. HA castings on the subperiosteal im plant.Presented at: International Congress of OralImplantologists; San Juan, Puerto Rico; 1983.
2. Kay JK, Golec TS, Riley RL. Hydroxyapatite coatedsubperiosteal dental implants status and four yearclinical experience. J Oral Implantol. 1991;8:11-16.
3. Misch CE, Dietsh F. The unilateral mandibularsubperiosteal implant—indications and technique. J Oral Implantol. 1991;8:21-27.
4. Golec TS, Krauser JT. Long-term retrospective studieson hydroxyapatite coated endosteal and subperiostealimplants. Dent Clin North Am. 1992;36:39-65.
5. Benjamin LS. Long-term retrospective studies on the CT-scan, CAD/CAM, one-stage surgery hydroxyapatite-coatedsubperiosteal implants, including human functionalretrievals. Dent Clin North Am. 1992;36:77-93.
7. Nordquist WD, Krutchkoff DJ. The custom endostealimplant (CEI): histology and case report of a retrievedmaxillary custom osseous-integrated implant nine yearsin service. J Oral Implantol. 2014;40:195-201.
FURTHER STUDY/RESOURCESFor detailed step-by-step instructions on the protocol for aone-stage subperiosteal implants and accompanyingprosthetics, please visit the Web sites located ataranazariandds.com and at duttondental.com.
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Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone
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POST EXAMINATION QUESTIONS
1. There are some patients who are not goodcandidates for traditional or small sized dentalimplants due to deficiencies in the remaining bone.
a. True b. False
2. The subperiosteal implant was designed to rest ontop of the bone and beneath the periosteum.
a. True b. False
3. Subperiosteal implants rarely become sources ofinfection due to tissue growth into the grooves of theframework.
a. True b. False
4. Today, it has been observed and reported that HA-coating improves the chance of direct bone-to-implant interface, to decrease strut dehiscence, andto improve the soft-tissue environment.
a. True b. False
5. In the clinical procedure, as described by the author,the incisive neurovascular bundle is never severedwhen performing this procedure, to preventsignificant harm.
a. True b. False
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Placement of a Modified Subperiosteal Implant: A Clinical Solution to Help Those With No Bone
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