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Fabricating Dental Implants withPredesigned Structure
https://t.me/medicina_free
An alternative technique, described below, revisits the current treatment concept
by applying rapid prototyping technology.
The additively manufactured subperiosteal jaw implants (AMSJI®) have been
introduced by Mommaerts etal. [12] for times when advanced deciency in bone
volume and ridge morphology limitations extend to the anterior zone (Cawood and
Howell Class V to VIII bone atrophy [13]).
Firstly introduced in 1943, there was a great interest in subperiosteal implants
[14] although they lost their popularity over time due to a number of abnormal complications such as exposure, mobility, and loss of implant. In recent years, the use of
digital technology in routine dental practice, including cone-beam computed tomography (CBCT), three-dimensional (3D) implant planning software, and computeraided design and computer-aided manufacturing (CAD-CAM) technology, has
allowed for the customization of implant therapy [15]. The new generation of subperiosteal implants is custom-made to patients’ ridge anatomy using digital technology [16]. The additively manufactured subperiosteal jaw implants might present a
valid alternative treatment for bone grafts or zygoma quads in cases with Cawood
and Howell Class V to VIII bone atrophy. This technique is advocated to fabricate
personalized implants and to address challenges in an expeditious individualized
manner [17]. The freedom in implant design and chemical/physical manipulation
made this technique an effective alternative to the custom techniques. Some properties such as porosity, microroughness, and nanoroughness that play key roles in
promoting new bone formation and osseointegration are improved by additively
manufacturing technique [18].
Although several deciencies have been reported with this technique, collapsed
structures, dross formation, and overhanging structure of the pores have been
reported as drawbacks of this technique. Nevertheless, there have been reports of
numerous unmelted alloy particles on additively manufactured implants which
increase the chances of fatigue-based failure [17].
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4 Introducing anInnovative Design forPrefabricated
Subperiosteal Implants
In this technique, we presented a palatal anchored AMSJI; this is specically suitable for patients with inadequate keratinized mucosa as well as brotic scarring
which threaten the success of common buccal-anchored subperiosteal prosthesis;
therefore a palatal anchorage was preferred.
In the presented case, we faced inadequacy of keratinized mucosa as well as
brotic scarring which threaten the success of common buccal anchored Subperiosteal prosthesis. Therefore we designed the palatal anchored sub-periosteal
prosthesis that secured to the palatal part of the maxilla (Fig.4).
Conrmed through digital mock-up, any treatment plan for the maxilla, without modifying the mandibular occlusal plane, would result in severe anterior open bite (Fig.5).
A three-dimensional (3D)-printed guide was designed for bone reduction in
upper jaw where the history of earlier failed grafting surgery had left severe bony
undercuts. The surgical guide by removing undercuts made the proper seating of the
prosthesis achievable.
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Fig. 4 (a–d) In this case we faced inadequacy of keratinized mucosa as well as brotic scarring
which threaten the success of common buccal anchored Sub-periosteal prosthesis. Therefore we
designed the palatal anchored sub-periosteal prosthesis that secured to the palatal part of the maxilla. (designed by Kaveh Software; Azari, Abbasi, Keyhan, Iran)
S. O. Keyhan et al.
The subperiosteal implant was additively manufactured in titanium grade by
selective laser melting (SLM).
Mandibular bone reduction was crucial to create enough room for prosthesis to
be in the proper plane and to have enough space for eventually setting and processing teeth without bearing destructive forces from the opposing jaw (mandible). The
stereolithography (STL) les were used for the fabrication of three- dimensional
(3D)-printed guides for mandibular bone height reduction and endosseous tting
areas and make virtual plan for surgery available. Virtual surgery allows correct
creation of ideal vertical dimensions and intermaxillary relationship with respect to
vital structures such as inferior alveolar nerve. After ap elevation and alveolar
reduction, the AMSJI® segments have been tted on the bone and splinted with a
temporary suprastructure and xed to the alveolus using the osteosynthesis screws
(Figs.6, 7, 8, and 9).
In this case, the mandibular bone reduction was crucial to create enough room
for prosthesis to be in the proper plane and to have enough space for eventually setting and processing teeth without bearing destructive forces from the opposing jaw
(mandible). The stereolithography (STL) les were used for the fabrication of threedimensional (3D)-printed guides for mandibular bone height reduction and endosseous tting areas and make virtual plan for surgery available (Fig. 10). Also,
Fig.11 illustrates the post-prosthetic rehabilitation of patient.
Virtual surgery allows correct creation of ideal vertical dimensions and intermaxillary relationship with respect to vital structures such as inferior alveolar nerve
(Fig.12).
Fabricating Dental Implants withPredesigned Structure
https://t.me/medicina_free
229
Fig. 5 (a, b) Conrmed
through digital mock-up,
any treatment plan for
maxilla, without modifying
the mandibular occlusal
plane, would result in
severe anterior open bite
(designed by Kaveh
Software; Azari, Abbasi,
Keyhan, Iran)
a
b
Fig. 6 The subperiosteal
ap dissection both in
palatal and buccal sides is
performed (designed by
Kaveh Software; Azari,
Abbasi, Keyhan, Iran)
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https://t.me/medicina_free
Fig. 7 The alveolus bone
after bone reduction using
3D surgical template
Fig. 8 2 parts of palatal
(left & right) anchored
sub-periosteal prosthesis
have been secured on
palate using insersion
guide fr precise
implantation
S. O. Keyhan et al.
In fact, the greatest challenge was extreme atrophy accompanied by unbalanced
occlusal planes. We described the rehabilitation of the severely atrophic maxilla and
mandible with AMSJI® in the maxilla and implant-supported dental prostheses in
the mandible with digital workow. We combined multiple digital data from computerized tomography and intraoral digital impressions into a software program
which enabled virtual surgical planning, guided surgery, and permitted immediate
CAD-CAM interim prostheses from a facial perspective. No postsurgical complication was observed in this case. Figures show both osseointegration and xation of
the bone-implant bond in the postsurgical follow-up 10months after the surgery
(Figs.13 and 14).
Fabricating Dental Implants withPredesigned Structure
https://t.me/medicina_free
Fig. 9 After alveolar
reduction, the AMSJI®
segments have been tted
on the bone and splinted
with a temporary
suprastructure and xed to
the alveolus using the
osteosynthesis screws
(designed by Kaveh
Software; Azari, Abbasi,
Keyhan, Iran)
Fig. 10 The osteotomy
guides fabricated for
proper mandibular
reduction
231
232
ab
cd
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S. O. Keyhan et al.
ef
g h
Fig. 11 (a) Open tray technique with direct transfer coping and splinted impressions. (b) Teeth
selection, arrangement, and adjusting. (c) Evaluation of the smile line. (d) Smile assessment at
rest. (e) Verication template for dental implant using DuraLay resin. (f) Designing and fabricating
metal implant framework for screw-retained porcelain fused to metal xed partial denture. (g)
Final view of prosthesis. (h) Final view
Fabricating Dental Implants withPredesigned Structure
https://t.me/medicina_free
a b
Fig. 12 (a, b) Virtual pre- and postsurgical mandible
233
cba
d
ghi
Fig. 13 Final view of patient after surgery (a) frontal, (b) oblique, and (c) lateral view. Final view
of metal implant framework without nal prosthesis (d, e, f, g) and with nal prosthesis (h, i)
fe
234
ab
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S. O. Keyhan et al.
c
(a–c) Graphics showed both osseointegration and xation of the bone-implant bond in the
Fig. 14
10-month postsurgical follow-up (designed by Kaveh Software; Azari, Abbasi, Keyhan, Iran)
5 Complications withPrefabricated Implants
andPotential Causes
5.1 Technique-Related Complications
It is crucial to avoid the use of autologous bone powder around the implant as it
increases the chance of wound opening. Immidiately post-surgical photos should be
avoided till proper healing process. Post surgical photos should be retained.
5.2 Design/Manufacturing-Related Complications
The original additively manufactured subperiosteal jaw implants are a product of
zygoma/buccal bone anchorage. Our previous clinical experience with the conventional technique showed several aws; rst, the buccal anchorage requires a huge
soft tissue dissection and elevation, which is quite burdensome for patients postsurgically. Second, there is a higher risk of wound dehiscence with the conventional
technique.
When designing a prefabricated subperiosteal implants, it is highly recommended to avoid the top of bony ridge; this is possible by improving the size and
number of windows on subperiosteal implants.
Fabricating Dental Implants withPredesigned Structure
https://t.me/medicina_free
Fig. 15 The thick,
unpolished base metal,
sharp-cornered butt joints,
sharp-cornered nish lines,
and ultrashort subabutment structures can be
seen on a failed design for
AMSJI
Fig. 16 The early implant
failure
235
Likewise, thick, unpolished base metal, sharp-cornered butt joints, sharp- cornered
nish lines, and ultrashort sub-abutment structures should be avoided to improve the
success rate of the implant. The aforementioned aws were present in a failed additively manufactured subperiosteal jaw implant for the maxilla (Figs.15 and 16).
The gures show the early implant failure with the possible root causes.
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S. O. Keyhan et al.
6 Future ofDental Implant Customization
The digital technological advances are rapidly growing nowadays, and the clinical
use of prefabricated implants using different printing systems in the near future is
not out of reach.
The next generation of prefabricated implants will decrease the dependence of
dental practitioners on implant companies, reduce surgical time, and probably introduce the “homemade implants” as an alternative.
Current reports on 3D manufacturing technology give us the possibility of immediate digital fabrication right after tooth extraction and the ability to cover the
implant with a thin layer of biomaterial/bioactive drug which promotes healing
within a month. New reports have combined two techniques of selective laser melting + stereolithography for personalized implant 3D fabrication which enabled
them with modications in the exibility and resistance of customized implants
while improving the pace of osseointegration with additions of drug loading polymers in the system [19].
7 Conclusion
In complex rehabilitative occasions with extreme atrophy and unbalanced occlusal
planes, dental clinicians consider augmentation with bone transplantation, guided
bone regeneration, tilted or short implants, and implantation in remote bone (zygomatic implants, for instance). However grafting techniques are associated with
donor site morbidities and non-grafting techniques might be quite challenging to
prosthodontists. The fabrication of custom-made implants which are perfectly
adapted to the morphology and anatomy of edentulous sites in severe bone resorption, when the cases are unable/unwilling to undergo bone regeneration, this technique using modern digital technologies represents a viable treatment option. This
is specically useful for elderly who need a xed prosthetic restoration but cannot
tolerate complex regenerative surgeries. Based on the technological developments,
the future prospects for prefabricated dental implants reveal numerous benets and
capabilities for successful oral rehabilitation; immediate and personalized clinical
treatments, bioactive polymer coatings, and the possibility of choosing the base
biomaterial are among the benets.
References
1. Venet L, Perriat M, Mangano FG, Fortin T.Horizontal ridge reconstruction of the anterior
maxilla using customized allogeneic bone blocks with a minimally invasive technique-a case
series. BMC Oral Health. 2017;17(1):1–8.
2. Wessing B, Lettner S, Zechner W.Guided bone regeneration with collagen membranes and
particulate graft materials: a systematic review and meta-analysis. Int J Oral Maxillofac
Implants. 2018;33(1):87–100.
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