Chapter 14 

–  Unilateral Subperiosteal Implants

Treatment of Partial Edentulism With Severe Alveolar Ridge
Resorption Diagnosed for a Fixed Prosthesis With Natural Co-
Abutments BENEFITS AND DESCRIPTION OF THE MODALITY USED
IN THE TEACHING CASE

When the volume of the residual alveolar ridge is insufficient to receive endosteal implants, use of
the unilateral subperiosteal implant is the treatment of choice [1] ( Fig. 14-1 ). Subperiosteal
implants require more maintenance than endosteal implants but have comparable success and
survival rates.[2][3] They were specifically developed to treat patients with insufficient available
bone in the alveolar ridge for the insertion of endosteal implants. They should not be used for
patients with overabundant bone.

Figure 14-1  Mainstream unilateral subperiosteal implant serving as a distal abutment for a fixed
prosthesis.

Figure 14-1 Mainstream unilateral subperiosteal implant serving as a distal

abutment for a fixed prosthesis.

Mode of Tissue Integration

Subperiosteal implants heal in the periosteal mode of tissue integration. They are enveloped in a
dense fibrous collagenous tissue sheath constituting the outer layer of the periosteum. Functional
forces are absorbed by the underlying bone through the periosteum. [4][5]

Planning for Treatment

Diagnosis and treatment planning is routine. Periapical radiographs, supplemented by panoramic

radiographs if desired, are all that are required. Out-of-office radiography is not required for
mainstream cases.

Technique-Permissive Implant Fabrication and Insertion

In many respects, mainstream unilateral subperiosteal implant fabrication and insertion protocols
are simpler than those for endosteal implants. The implants are custom made, designed and cast
from wax-ups on models of the supporting bone. In mainstream cases these models are poured
from direct bone impressions obtained following tissue reflection. Tissue reflection, though more
extensive, is essentially the same as that for endosteal implants. No osteotomy is required.
During what is termed the stage one visit, taking the direct bone impression is easier than
preparing osteotomies for endosteal implants.[6] In stage two, following laboratory fabrication of
the implant, insertion is simple as well. The entire protocol is technique-permissive.

Restorative Simplicity

In mainstream cases, the final prosthesis is almost always a fixed bridge supported by the
unilateral subperiosteal implant posteriorly and natural co-abutments anteriorly. In such cases,
the implant abutment, which extends into the oral cavity through attached gingiva, is treated as
one would treat the abutment of a plate/blade form implant ( Fig. 14-2 ). The prosthesis is
fabricated in the same way, with the same simplicity. The prosthodontics are conventional. [7]

Figure 14-2  Abutments of healed mandibular (left, note flossing) and maxillary (right) subperiosteal
implants.

Figure 14-2 Abutments of healed mandibular (left, note flossing) and maxillary
(right) subperiosteal implants

Proven Long-Term Success/Survival Rates

Subperiosteal implants are custom made. They are therefore exempt from Food and Drug
Administration (FDA) governance, and not applicable to the American Dental Association (ADA)
Acceptance Program, which focuses on manufactured products. [8] This implant modality has been
in wide use for well over 40 years. The ADA Council on Education has declared subperiosteal
implantology to be a viable treatment option for correctly diagnosed and fully informed patients in
the hands of a trained practitioner. Long-term survival rates are high, although as previously
mentioned, maintenance and reversible complication rates are higher than for endosteal implants.
[9]
Research confirming these points is presented in Chapter 8 .

Unique Features

Unilateral subperiosteal implants are used with natural co-abutments. Cases can be completed in
4 to 7 weeks of elapsed treatment time. In mainstream cases, fixed bridges are the restoration of
choice. One can create posterior abutments in the maxilla within weeks and avoid the in-vasive,
time-consuming protocols for subantral augmentation procedures. In the mandible as well,
subperiosteal implant treatment renders bone augmentation, grafting, or nerve repositioning
unnecessary. In many severely resorbed edentulous cases, unilateral subperiosteal implantology
is the only mainstream abutment-providing treatment that can help the patient.

Configuration and Nomenclature of Subperiosteal Implants

The primary support for subperiosteal implants is derived from main bearing struts that rest over
basal bone ( Fig. 14-3 ). Basal bone is defined as the relatively fixed and unchangeable
framework of the mandible and maxilla. [10] Alveolar bone, which rests on basal bone, is bone that
invested the roots of teeth when they were in position, and transmitted their functional forces.
Buccal and lingual main bearing struts are joined by connecting struts, which cross over the
resorbed residual alveolar ridge ( Figs. 14-4 and 14-5 ). The implant abutment arises from a
connecting strut that provides ideal mesio-distal and bucco-lingual prosthodontic positioning for
the planned restoration. In the maxilla, in cases with thick overlying soft tissue, a pergingival strut
may be interposed between a connecting strut and the abutment. One or two screw holes may be
provided within the main bearing struts, to permit insertion of bone screws that enhance initial
fixation of the implant during early healing. These screws may remain in position passively or be
removed, their function accomplished. Specific configurations of abutments and the anatomy of
struts are discussed later in this chapter.

Figure 14-3  Labial/left buccal view of mandibular subperiosteal model.

Figure 14-3 Labial/left buccal view of mandibular subperiosteal model

Figure

Figure 14-4 Labial/right buccal view of mandibular subperiosteal model

Figure 14-5  Lingual/crestal view of mandibular subperiosteal model. Dotted line represents ridge
crest.

Figure 14-5 Lingual/crestal view of mandibular subperiosteal model. Dotted line

 represents ridge crest

Incorporating Unilateral Subperiosteal Implant Dentistry into One’s

Practice

As a rule, subperiosteal implantology should be pursued after a practitioner has performed

mainstream treatment in several cases using the abutment-providing endosteal implant
modalities. Unilateral subperiosteal implants are applicable in a smaller percentage of cases, but
this minority is of great importance, for these patients have lost not only their teeth but also most
or all of their residual alveolar ridge. Also, in most cases in which mainstream treatment can be
performed using a unilateral subperiosteal implant, no other abutment-providing modality can
offer mainstream treatment

DIAGNOSIS, TREATMENT PLAN, AND END RESULTS

Case as Presented
Patient’s Story.

A typical case presents with posterior edentulism, either in the maxilla or mandible. As in
mainstream cases correctly diagnosed for endosteal implants, the patient may have a removable
unilateral or bilateral free-end saddle partial denture that is prone to complications because of
significant ridge resorption. Complaints associated with clasped or semi-precision or
precisionattached natural abutments are common. Odor, poor function, gingival tissue
complications, and compromised esthetics often lead to implant treatment. Removable
appliances may not be well tolerated, and patients may wish not to wear one when they become
aware that alternatives exist. One often observes loss of function, sunken hollow cheeks, and
reduced facial height.

Clinical Appearance.

Examination reveals what is observed in endosteal implant candidates, but often more severely
because cases suitable for subperiosteal implant treatment exhibit more bone resorption.
Potential natural co-abutments may be more traumatized and require careful evaluation. The
edentulous portion of the alveolar ridge is severely resorbed, hollowed out, and flat in the
mandible. Edentulous areas in the posterior maxilla are more variable. Sinuses may be deep and
quite near the crest, and yet clinically the ridge may appear to be large, full, and broad as a result
of the presence of a substantial amount of overlying soft tissue. It is not unusual to see shallow,
flat ridges and excessive interocclusal clearance. Another factor to consider is that the buccal
plate in the highly resorbed maxilla has lost a substantial amount of bone. Thus, the position of
the healed ridge crest is lingual to the opposing dentition, whereas it was once buccal. This poses
occlusal challenges in restoring function, such as the potential need to establish an edge-to-edge
or cross-bite tooth arrangement, as well as possible esthetic problems. All such difficulties can be
overcome.

Radiographic Interpretation.
The radiograph reveals severely resorbed residual alveolar ridges, with insufficient bone for the
insertion of endosteal implants ( Fig. 14-6 ). Landmarks and borders are clearly shown.
Inconsistent overlying soft-tissue thickness is observed in both the maxilla and mandible.

Figure

Figure 14-6 Limited available bone (outlined) ideal for placement of unilateral
subperiosteal implant

Rejected Alternative Treatment Plans

The patient feels that neither adjustments to an existing removable prosthesis nor the fabrication
of a new one would be satisfactory. The status quo is also not acceptable, because conditions
causing the patient complaints would remain and become exacerbated over time. Implant support
and fixed prostheses are desired, yet no endosteal implant modality is indicated because of
insufficient available bone. Extensive bone augmentation, subantral augmentation, and nerve
repositioning are not mainstream options.

Accepted Treatment Plan—An Overview of Visit-By-Visit Case

Sequencing

The objectives of each of the treatment visits for the teaching case in this chapter are shown in
Box 14-1 . It is important to have a basic understanding of the entire course of treatment, so that
one can appreciate how each treatment step contributes to ultimate success.

Box 14-1
VISIT-BY-VISIT TREATMENT OBJECTIVES

   Preoperative procedures
Visit 1: Stage one direct bone impression and interarch occlusal registration for implant
  
fabrication
   Visit 2, week 1: Suture removal
   Visit 3, week 2: Stage two implant placement
   Visit 4, week 3: Suture removal
Visit 5, week 4: Master impression and interarch occlusal registration for prosthesis
  
fabrication
   Visits 6 to 7, weeks 5 to 7: Fabrication, try-in, and adjustment of final prosthesis
   Visits 8 to 9, weeks 8 to 9: Cementation of final prosthesis
Completed Case

Having the goal of treatment firmly in mind during each patient visit is important. Every procedure
is directed toward successful completion of the case. For this reason, the end result is presented
here, to help the reader understand how each step of treatment contributes to the final objective,
and to convey the satisfaction and benefits of treatment for the patient and the practitioner.

Patient’s Story.

The treatment goals have been achieved. Nonremovable tooth restorations are in function. The
patient is comfortable, with an easily cleansable restoration that is efficient and does not interfere
with normal control of speech and salivation. The patient is pleased and grateful.

Clinical Appearance.

The completed restoration resembles a conventionally fabricated fixed bridge supported

exclusively by natural abutments. Because of the significant ridge resorption that prompted the
treatment, the first molar pontic and second molar co-abutment may exhibit greater clinical crown
height than usual. Rarely does this interfere with the esthetic result. Because the implant
abutment’s pergingival site is within attached gingiva, ridge lapping is easily achieved, yielding
significant esthetic advantages.[11] If the second molar overcasting is in a nonesthetic area, one
may elect to fabricate a bullet-shaped pontic rather than ridge lap. [7] Taking into account the
patient’s desires when making this choice is advisable.

Radiographic Interpretation.

The postoperative radiograph reveals a well-positioned, fully seated implant. The landmarks and
borders limiting the extent of the implant are not abridged. The prosthetic restoration has correct
margins against both the implant abutment and natural co-abutments. The postoperative
radiograph reveals harmony of the axial inclination of the implant and natural co-abutments, the
result of careful planning and execution of treatment ( Fig. 14-7 ).

Figure 14-7  Postoperative radiographs of maxillary (A) and mandibular (B) unilateral subperiosteal
implants.
 Figure 14-7 Postoperative radiographs of maxillary (A) and mandibular (B)
unilateral subperiosteal implants

Microscopic Interpretation at the Interface.

Light microscopy following healing reveals a dense fibrous sheath constituting the outer layer of
the periosteum enveloping each implant strut. This organized fibrous envelopment, acting as both
attachment mechanism and shock-absorbing agent to protect the supporting osseous tissue, is
an example of the periosteal mode of tissue integration [12]( Fig. 14-8 ). A detailed explanation of
periosteal tissue integration is given in Chapter 6 .

Figure 14-8  Periosteal tissue integration.  (From McKinney RV, Lemons JE, editors: The dental
implant, Littleton, Mass, 1985, PSG Publishing.)

Figure 14-8 Periosteal tissue integration. (From McKinney RV, Lemons JE, editors:
 The dental implant, Littleton, Mass, 1985, PSG Publishing.)

PLANNING AND PROCEDURES BEFORE IMPLANT FABRICATION

The steps that are performed before the implant fabrication visit are shown in Box 14-2 .

Box 14-2
PREOPERATIVE PROCEDURES

   Prepare and temporize natural co-abutments

   Choose single- or double-abutment option
   Evaluate interocclusal clearance
   Prescribe preoperative medication
Prepare and Temporize the Natural Co-Abutments

The natural co-abutments that are used in conjunction with the unilateral subperiosteal implant for
support of the restoration are prepared and temporized before direct bone impressioning, often
during the same visit under the same local anesthetic. In one’s first few cases, it may be
advisable to prepare and temporize the natural co-abutments in a separate session before the
direct bone impressioning visit. In cases being referred to another practitioner for implant
fabrication, the referring practitioner should prepare and temporize the natural co-abutments
before the referral. This gives the inserting practitioner guidance for parallelism when viewing the
prepared teeth, and allows greater visibility of and access to the surgical field.

Natural co-abutment preparation and temporization is the same as that for conventional fixed
bridgework. Use of one’s preferred conventional technique is recommended.

Single- and Double-Abutment Options

Many of the considerations in determining whether to use a single- or a double-abutment

plate/blade form apply to subperiosteal implant treatment. An important concern is to ensure that
each abutment is placed under a crown of the planned prosthesis. Each abutment should pass
through its pergingival site into the oral cavity to harmonize with the opposing dentition, dictating
the positioning of the teeth in the planned prosthesis. Insofar as possible, abutments should not
be located in embrasures. This is not difficult to achieve in mainstream cases.

The use of two abutments usually is indicated in cases in which the interocclusal clearance is
relatively small, resulting in compromised abutment height. Using two abutments in such cases
doubles the cementation area, improving retention.

Every subperiosteal implant is uniquely configured. Therefore, preoperatively, one simply

determines whether to fabricate the implant with one or two abutments. This influences the
design phase, when one determines the exact location of the connecting strut(s) from which the
abutment(s) will arise. This and other design considerations are discussed later in this chapter.
Evaluate Opposing Occlusal Plane for Adequate Interocclusal
Clearance

In the case of unilateral subperiosteal implants, because ridge resorption is severe, there is
almost always adequate interocclusal clearance to enable fabrication of an abutment with
sufficient surface area to provide reliable cement fixation for the final prosthesis. One exception
occurs when the opposing dentition, over time, has extruded into the edentulous area. One must
then shorten extruded teeth as conservatively as possible. In extreme cases, these teeth may
require endodontic treatment for this purpose. These considerations are discussed with the
patient during the case presentation. Perhaps the greatest benefit of bringing extruded teeth back
into a harmonious relationship with the more anterior occluding teeth is the enhanced capability of
fabricating a more optimal restoration in terms of function, esthetics, and cleansability. Because
the unilateral subperiosteal implant is custom made, it is fabricated with abutments of ideal
interocclusal clearance, so adjustment rarely is required.

Prescribe Preoperative Medication

Prescribe preoperative medication for the insertion visit as discussed in Chapter 9 . Recall that
preoperative administration of anti-edema medication is generally not required for mainstream
cases, unless the patient’s history suggests that edema may be greater than normal. Nor is
preoperative sedation recommended. Patients who take prophylactic aspirin daily are advised to
discontinue doing so for at least 3 weeks preoperatively, to allow for normal clotting at the
insertion visit.

PRINCIPLES OF MAINSTREAM SUBPERIOSTEAL IMPLANT DESIGN

Osseous Exposure and Evaluation of Available Bone

Because the primary support for subperiosteal implants is provided by main bearing struts that
rest on basal bone, tissue reflection for adequate osseous exposure is essential. Underexposure
compromises the ability to design an ideal implant. Overexposure may lead to unnecessary tissue
trauma, bleeding, edema, and postoperative discomfort. The solution is to design the implant
mentally as tissue is reflected. When reflecting the buccal flap to expose to the level of basal
bone, stop when enough basal bone is visible in terms of length and depth to permit the
placement of an ideal main bearing strut in that area ( Fig. 14-9 ). The same principles apply
when reflecting to locate the lingual main bearing strut, connecting struts, and pergingival struts (
Figs. 14-10 and 14-11 ). One must evaluate while exposing the osseous implant support
structures whether enough support can be designed to ensure that the final implant will function
within physiologic limits of health.[13]

Figure 14-9  Buccal main bearing strut at extent of reflection (arrows).

Figure 14-9 Buccal main bearing strut at extent of reflection (arrows).

Figure 14-10  Lingual main bearing strut at extent of reflection (arrows).

Figure 14-10 Lingual main bearing strut at extent of reflection (arrows).

Figure 14-11 Ideal positioning of connecting struts (arrows).

4-11  Ideal positioning of connecting struts (arrows).

Anatomy of Resorbed Edentulous Alveolar Ridges

In the posterior mandible, the residual alveolar ridge is at least two thirds resorbed. In extremely
resorbed cases, the medial border of the edentulous area may be higher than the ridge crest,
which may be resorbed to concavity ( Fig. 14-12 ). The inferior alveolar nerve may be dehiscent
through the roof of the canal ( Fig. 14-13 ). The relationship between the mental foramen and the
inferior border of the mandible, for all clinical purposes, remains fairly constant. Resorption occurs
at the expense of the alveolar ridge, at times to the point at which the mental foramen appears at
or near the ridge crest ( Fig. 14-14 ). The ascending ramus, mylohyoid ridge, and portions of the
lateral border of the ramus are other limiting landmarks for mainstream subperiosteal implants (
Fig. 14-15 ). Compared with ridges that have adequate available bone for endosteal implant
insertion, mandibular ridges appropriate for mainstream subperiosteal implants exhibit greatly
reduced bone contours. Dehiscence of the nerve makes the treatment non-mainstream. [14]

Figure 14-12  Resorbed ridge crest (dotted line) inferior to medial border of mandible.

Figure 14-12 Resorbed ridge crest (dotted line) inferior to medial border of mandible

Figure 14-13  Crestal dehiscence (arrow) of inferior alveolar nerve.

Figure 14-13 Crestal dehiscence (arrow) of inferior alveolar nerve

Figure 14-14  Mental foramen (arrow) near ridge crest in severely resorbed mandible.

Figure 14-14 Mental foramen (arrow) near ridge crest in severely resorbed
mandibl

Figure 14-15  Variations in anatomy of ascending rami.

 Figure 14-15 Variations in anatomy of ascending ram

The maxilla is far more variable. Resorption often is greater than in the mandible ( Fig. 14-16 ).
Other times, a clinically full or even wide ridge is observed ( Fig. 14-17 ) that reveals little bone
below the base of the sinus radio-graphically, thus making the case ideal for mainstream
subperiosteal implant treatment ( Fig. 14-18 ). In the maxilla, because of the variability of
resorption, there may be a well-defined tuberosity with a firm distal border ( Fig. 14-19 ), or little or
no residual tuberosity ( Fig. 14-20 ). Toward the distal of the hard palate, slightly medial to the
junction of the hard palate and the alveolar ridge, the posterior palatine foramina are located.
These provide passage for the blood and nerve supply to the palate, and are to be avoided.

Figure 14-16  Severely resorbed maxillary ridge.

Figure 14-16 Severely resorbed maxillary ridge

Figure 14-17  Broad maxillary ridge.

Figure 14-17 Broad maxillary ridge

Figure 14-18  Radiograph showing minimal bone depth under sinus.

Figure 14-18 Radiograph showing minimal bone depth under sinus

Figure 14-19  Tuberosity with sufficient distal border to place a main bearing strut.

Figure 14-19 Tuberosity with sufficient distal border to place a main bearing strut
 Figure 14-20  Tuberosity with extensively resorbed distal border.

Figure 14-20 Tuberosity with extensively resorbed distal border

Main Bearing Struts Defined

Main bearing struts of a unilateral subperiosteal implant absorb the functional forces applied to
the overlying prosthesis. There are buccal and lingual main bearing struts. They are placed
against basal bone.

Connecting Struts Defined

Connecting struts connect and unify the buccal and lingual main bearing struts into a cohesive
functioning unit. They usually are placed to cross over residual alveolar ridges.

Pergingival Struts Defined

Pergingival struts pass from connecting struts through the overlying soft tissues, preferably
through attached gingiva. They are contiguous with the implant abutments.

Abutment Design Options

In many cases the base of the abutment is actually against the connecting strut. The base of the
abutment rests on or slightly buccal or lingual to the ridge crest, depending on the preferred
prosthodontic positioning. The abutment is best designed to be octagonal, faceted, and tapered
to enhance cement retention. Millimeter adjustment lines are not needed because the implants
are custom fabricated for ideal interocclusal clearance.

Functional Force Components Defined

Functional forces are transmitted through the overlying prosthesis and the implant for ultimate
absorption by supporting bone. These functional force components are multidirectional,
depending on the occlusal anatomy of the final prosthesis and the dynamics of the chewing cycle,
and on whether the implant is in the posterior maxilla or mandible. The basic functional force
directions are vertical, anterior, posterior, right lateral, and left lateral. For clarity, the figures
related to this discussion of force components and strut placement show models of total arch
subperiosteal implants.

Vertical Force Components Defined.

The vertical component of applied functional force is applied approximately in the long axis of the
residual ridge. It tends to compress the implant firmly over bone during function ( Fig. 14-21 ).

Figure 14-21  Arrows in the direction of vertical force components.

Figure 14-21 Arrows in the direction of vertical force components

Anterior and Posterior Force Components Defined.

The anterior and posterior functional force components act to displace the implant anteriorly or
posteriorly during function. Appropriately placed main bearing struts absorb these force
components to prevent displacement ( Fig 14-22 ).

Figure 14-22  Arrows in the direction of posterior force com-ponents.

Figure 14-22 Arrows in the direction of posterior force com-ponent

Right and Left Lateral Force Components Defined.

Right and left lateral functional force components act to dislodge the implant toward the right or
toward the left ( Fig. 14-23 ). Appropriately placed main bearing struts prevent this.

Figure 14-23  Arrows in the direction of right and left lateral force components.

Figure 14-23 Arrows in the direction of right and left lateral force component

Locations of Main Bearing Struts to Absorb the Components of Force

The decisions made at the time of implant design are critical to the implant prognosis. [15] In the
right mandible, the buccal main bearing strut is positioned to withstand both vertical and left
lateral force components. The lingual main bearing strut withstands vertical and right lateral force
components. When possible, a forward extension of the lingual main bearing strut is positioned
anteriorly to pass to the point at which the mandible narrows, or turns the arch, to withstand the
anterior force component. The buccal and lingual main bearing struts diverge as they extend
distally, thereby resisting the distal component of functional force. Connecting struts may initially
help resist some or even all of the force components, but because of the possibility of continuing
alveolar ridge resorption, they cannot be relied upon to do so long-term. Main bearing struts on
the anterior portion of the lateral surface of the ascending ramus may help resist the left lateral
force component. These struts may be in shear during the exertion of vertical force components,
and their action during mandibular flexion is undetermined. In all but the most resorbed
mainstream unilateral mandibular subperiosteal cases, struts against the lateral surface of the
ascending ramus may be unnecessary.

In the posterior right maxilla, the buccal main bearing strut is positioned superiorly on the lateral
border of the temporal bone, against the inferior border of the zygomatic arch. This strut
withstands left lateral forces as well as vertical forces. If a distal surface is present on the
tuberosity, a buccal main bearing strut is extended around it to connect with the lingual main
bearing strut, to absorb anterior force components. The lingual main bearing strut is positioned at
the junction of the hard palate and the resorbed alveolar ridge, anterior to the posterior palatine
foramina. This strut counters vertical and right lateral force components. The posterior force
component is absorbed by the anterior border of the zygomatic arch, against which the buccal
main bearing strut is placed as it extends anteriorly from the inferior border of the zygomatic arch.
Location of Connecting and Pergingival Struts

In the mandible, the first connecting strut location to be designed is the one that gives rise to the
pergingival strut and abutments. This is positioned as close as possible to where the second
molar abutment for the final prosthesis would be most optimally located. Place connecting struts
in depressions or valleys in the edentulous ridge anatomy, where they will be protected, and/or in
areas of maximum resorption to minimize the chance of complications related to a change in
residual alveolar ridge contours. Other connecting struts for strength and support are placed from
buccal to lingual, over residual ridges in areas of maximum resorption and/or depressed areas of
bone.

Sectional Contours and Dimensions of Struts

Main bearing struts are generally ribbonlike in configuration. They are generally 1 mm thick, 2 to 3
mm wide, have rounded edges, and a flat base that rests against bone. In some anatomic
locations, a main bearing strut must be designed to absorb various functional force components.
For example, a main bearing strut passes under the zygomatic buttress to absorb the vertical
force components, and proceeds toward the canine fossa to absorb right and left lateral force
components. This is also the case with main bearing struts passing along the hard palate as it
joins the residual alveolar ridge. Connecting struts are also generally ribbonlike in configuration.
Their base lies against the residual alveolar ridge. Connecting struts are generally 1 mm thick and
approximately 2 mm wide. In cases in which the overlying soft tissue is only 1 to 2 mm thick, as is
commonly observed in the mandible and less often in the maxilla, no pergingival strut is required.
In such cases, the connecting strut melds directly with the abutment. When at least 3 mm of soft
tissue is present, a round pergingival strut, generally 1.5 to 2 mm in diameter, arises from a
connecting strut and broadens to form the same configuration as the safety stop found at the
base of a plate/blade form abutment. The safety stop configuration is positioned to be at least 2
mm beneath the gingival crest, and functions in the same manner as an emergence profile collar
for certain root form implant systems. Following loading, it is optimal when the tapered, faceted
sides of the implant abutment pass to a depth of approximately 2 mm beneath the gingival crest

VISIT 1: STAGE ONE DIRECT BONE IMPRESSIONING

The steps that are performed during the stage one direct bone impressioning visit are shown in
Box 14-3 .

Box 14-3
VISIT 1: STAGE ONE DIRECT BONE IMPRESSION AND INTERARCH OCCLUSAL
REGISTRATION FOR IMPLANT FABRICATION

   Confirm use of prophylactic antibiotic

   Set up instrumentation
   Administer anesthetic
   Make incision
   Reflect tissue
   Fix tissue flaps for impressioning access
Take one-piece direct bone and opposing arch impression in centric occlusion for implant
  
fabrication
   Cleanse and inspect impressioned area
   Release flap fixation sutures
   Suture
   Provide home care instruction
   Schedule follow-up visit
Confirm That Preoperative Medication Has Been Taken

As discussed in Chapter 9 , it is not necessary to postpone the case if the patient has not taken
his or her preoperative prophylactic antibiotic medication. The practitioner should have antibiotics
on hand for preoperative administration in such cases. If a patient on an aspirin regimen has not
discontinued its use, treatment may nonetheless be performed, with delayed clotting expected.

Instrumentation Setup— The Armamentarium

The sterilized instrument setup is placed in the operating area. In contrast with endosteal implant
insertion procedures, only one tray setup is required. It consists of a mirror and explorer, scalpel
(No. 15 blade preferred), regular and large periosteal elevators, tissue scissors, bone rongeurs,
bone file, curette, needle holder, 3-0 atraumatic black silk sutures, needle forceps, suture
scissors, tissue retractors, topical anesthetic, local anesthetic and syringes with appropriate
needles, a supply of gauze squares, and suction tips ( Fig. 14-24 ).

Figure 14-24  Selection of instruments for use during direct bone impressioning visit.

Figure 14-24 Selection of instruments for use during direct bone impressioning
visit

Presurgical Treatment

Prepare the surgical field, administer local anesthetic containing vasoconstrictor to promote
comfort and control bleeding, and prepare the oral cavity and targeted tissues according to the
principles and procedures described in Chapter 9 .

Incision

Evaluate the attached gingiva, plan the incision line, incise, and ensure hemostasis according to
the principles and procedures described in Chapter 9 .

To take a stage one direct bone impression for a subperiosteal implant in the mandible, the
incision is made through the retromolar pad to the base of the anterior wall of the ascending
ramus. It extends anteriorly along the ridge crest to the distal of the most distal remaining tooth. In
the maxilla, the incision starts against the distal of the tuberosity, with care to incise buccal to the
pterygomandibular raphe, and extends anteriorly along the crest of the alveolar ridge through the
distal of the most distal remaining tooth.

   Tissue reflection for direct bone impressioning for subperiosteal implant

design and placement requires wider access than that required for endosteal implant
insertion.
Tissue Reflection and Preparation Before Stage One Direct Bone
Impressioning

Reflect the tissue using the periosteal elevator, trim the tissue flap edges to ensure healing by
primary intention, and cleanse and alter the exposed alveolar ridge as required according to the
procedures and principles described in Chapter 9 .

To take a direct bone impression for the design of a subperiosteal implant, and for its subsequent
placement, the extent of tissue reflection is greater than that required for endosteal implants. On
the lingual of the mandible, extend the reflection inferiorly until the mylohyoid ridge is exposed to
the extent that its inserting mylohyoid muscle fibers can be observed. Extend the lingual reflection
distally until the anterior wall of the ascending ramus is visible, and mesially until the lingual
gingival cuff around the closest natural co-abutment is reflected halfway around the tooth. Reflect
the tissue to expose bone inferior and anterior to the anterior border of the mylohyoid ridge.

   At the time of reflection, one must think of the main bearing strut that will be
placed on the exposed bone, exactly where it will be placed, and whether enough
bone is exposed to place it properly. The main bearing strut starts anteriorly below
the level of the mylohyoid ridge against the bone opposite the lingual of the natural
co-abutments, and passes superiorly at the anterior border of the mylohyoid ridge to
cross over into the depression just buccal to the ridge crest.

The buccal mandibular flap is extended down toward the base of the mandible ( Fig. 14-25 ).
Distally expose the bone at the ascending ramus and its lateral surface no more than 10 mm
posterior to the lateral border of its anterior ascending wall. Carefully reflect mesially until the
mental foramen is visualized.

Figure 14-25  Reflection of buccal flap to base of mandible (arrow)

 .

Figure 14-25 Reflection of buccal flap to base of mandible (arrow).

   Visualize the design of the buccal main bearing strut. Is there enough
exposure to place it over basal bone? If struts on the lateral anterior portion of the
ascending ramus are required, is sufficient bone exposed? Is there room over the
mental foramen, with 2 mm clearance, to place an anterior extension of the buccal
main bearing strut, if required? The object is to design the implant mentally while
reflecting tissue.

In the posterior maxilla, the lingual flap is reflected only down to the junction of the hard palate
and the alveolar ridge to avoid the posterior palatine foramina. Expose the distal of the tuberosity.
[16]
About 10 mm anterior to the tuberosity, the reflection may be carried onto the hard palate
approximately 5 mm toward the median suture ( Fig. 14-26 ). This reflection is carried anteriorly
toward the closest natural co-abutment, and ends no farther anteriorly than its mesial border.

Figure 14-26  Reflection of distal of tuberosity and junction of alveolar ridge with hard palate (arrows).
 Figure 14-26 Reflection of distal of tuberosity and junction of alveolar ridge with hard
palate (arrows

The lingual main bearing strut is placed at the junction of the hard palate and alveolar ridge, with
a distal portion positioned against the distal of the tuberosity if enough osseous structure exists
there to do so, and a mesial extension against the lingual of the alveolar ridge opposite the
closest natural co-abutment.

The buccal maxillary flap is reflected until the inferior border of the zygomatic arch is exposed (
Fig. 14-27 ), and then its distal border is exposed as one reflects tissue distally to expose the
buccal and disto-buccal of the tuberosity. Reflecting mesially, the mesial border of the zygomatic
arch is exposed, and moving superior and mesial to it, bone is exposed anteriorly to the mesial
border of the closest natural co-abutment.

Figure 14-27  Reflection to inferior border of zygomatic arch (arrow).

 Figure 14-27 Reflection to inferior border of zygomatic arch (arrow).

   Continue to design mentally as tissue reflection proceeds. The labial main

bearing strut starts distally at the distal of the tuberosity, if osseous structure exists
there, and continues anteriorly and superiorly to the distal of the zygomatic arch,
where it passes inferiorly and anteriorly under the arch to proceed superiorly and
anteriorly against the buccal bone opposite the root of the closest natural co-
abutment. The bone for the design of all other struts is exposed according to this
procedure, and will therefore be evident on the master model poured from the direct
bone impression.
Tissue Flap Fixation for Enhanced Impressioning

Hold the buccal tissue flap against the cheek. With a 3-0 black silk suture with an atraumatic
needle, attach the edge of the flap to the inner surface of the cheek with carefully placed sutures
spaced 5 to 10 mm apart. Pass the needle through the mucosal lining of the cheek ( Fig. 14-28 ).
Avoid the area at the opening of Stenson’s duct.
 Figure 14-28  Suture fixation (arrows) of buccal flap to cheek to facilitate direct impressioning.

Figure 14-28 Suture fixation (arrows) of buccal flap to cheek to facilitate direct
impressionin

   Suturing the tissue flap to the inner surface of the cheek facilitates
impressioning the buccal basal bone exposed for the placement of main bearing
struts. Gently grasping the cheek between thumb and forefinger and extending it
laterally draws the attached buccal flap with it, resulting in wide exposure of bone.
This reduces the chance of tissue interference as impression material is introduced
for the direct bone impression.

The lingual flap is held open with a series of sutures that wrap around teeth on the opposite side
of the arch, or pass through the gingiva in an edentulous area on the opposite side of the arch. In
the latter case, infiltration with a few drops of local anesthetic is advised.

   Holding the lingual flap open in this manner facilitates impressioning the
lingual aspect of the exposed bone, again opening the area wide and precluding
loose tissue from becoming incorporated in the impression material.

The exposed areas are kept moist with coolant.

One-Piece Master Impression of Exposed Bone, Opposing Dentition,
and Jaw Relation for Implant Design

With the flaps properly fixed away from the impressioning area, have the patient close in centric
occlusion. Observe how the remaining teeth meet clinically, particularly in the areas that are not
being impressioned.

   This rehearsal is important. One is able to confirm that the patient will close
into the desired occlusal relationship when the master bone impression is taken.

Position the patient horizontally to take advantage of gravity during the introduction of impression
material. Set up two separate mixes. Inspect the exposed moistened bone, and retract the cheek
to rehearse and determine the direction of lateral cheek movement that retracts the buccal flap
best for access. Remove the provisional crowns from the natural co-abutments, and cleanse. Mix
the first batch of impression material. Insert the impression material into the buccal space, then
over the ridge, and then lingually using gentle finger pressure.

   A fine impression material is Kerr Citricon heavy body silicone. It is stiff

enough when set that it becomes its own tray. Setting time is controlled by adding
the desired amount of accelerator at room temperature.

The first batch is portioned to set slowly. The practitioner may insert the bulk of the material first
toward the buccal, then over the crest, and then lingually. If some areas are hard to impress,
pieces of impression material may first be inserted directly into these areas, and then the bulk of
the first impression material mix can be placed. They will merge. Include the prepared natural co-
abutments in the impression.

   While the initial mix is being inserted against the exposed bone, have the
second batch mixed. Add enough accelerator such that it will set faster than the first
batch. As the practitioner completes seating the first batch, the second batch should
be ready for use.

Place the second batch, rolled into a tubelike shape, over the first batch, and have the patient
close down firmly into and maintain centric occlusion ( Fig. 14-29 ). Compress the softer second
batch against the setting first batch to join them together. With gentle finger pressure, compress
the buccal impression material against the opposing dentition.

Figure 14-29  One-piece direct bone impression and opposing dentition in centric occlusion.
 Figure 14-29 One-piece direct bone impression and opposing dentition in centric
occlusion

   Closing into centric occlusion accomplishes two things. First, it exerts

pressure on the first batch of impression material, forcing it into all areas of exposed
bone and natural co-abutments. Second, it records an impression of the opposing
arch within the same unified mass of impression material.

After the materials have set, hold the buccal of the impression against the area of exposed bone,
not against the opposing teeth, and have the patient open slowly in the path of least resistance.

   This leaves the impression in the mouth, against the exposed bone and
natural co-abutments, free of the opposing dentition.

Gently release the impression from the exposed bone. Ask the patient to stay relaxed and open.

   As the impression starts to work free, the patient may help dislodge it from
the oral cavity with his or her tongue.
The completed master impression is washed and inspected. The exposed bone, opposing arch,
and natural co-abutments, all related in centric occlusion, have been recorded in one solid
impression. Using a heavy-body rubber base impression material such as Permalastic (Kerr), the
inferior buccal border of the mandible, mental foramen, and lingual fibers of the mylohyoid muscle
are clearly visible ( Fig. 14-30 , A). Heavy-body rubber base impression mate-rial lacks the
stiffness required to take a one-piece impression, and therefore requires the use of a custom tray
and separate opposing arch and bite registrations. In a Citricon impression, the zygomatic border,
junction of the hard palate and alveolar ridge, and opposing arch in the maxilla are clearly visible (
Fig. 14-30 , B). The impression is set aside.

Figure 14-30  A, Rubber base impression showing turn of mandible and mental foramen (left) and
mylohyoid muscle fibers and turn of mandible (right). B, Citricon impression showing inferior zygomatic
border, junction of alveolar ridge and hard palate, and natural co-abutment (left), in centric occlusion
(right).

Figure 14-30 A, Rubber base impression showing turn of mandible and mental
foramen (left) and mylohyoid muscle fibers and turn of mandible (right). B, Citricon
impression showing inferior zygomatic border, junction of alveolar ridge and hard
palate, and natural co-abutment (left), in centric occlusion (right).
Thorough Cleansing Before Closure

Suction, wash, suction again, and carefully inspect the impression site. Look at the deepest
extent of the reflection, and examine the entire surface of bone. Remove any residual impression
material. Particularly in the maxilla, check bone porosities for retained material.

   Thorough inspection of the exposed bone and investing tissues is critical. No

residual impression material may be left behind.
Release Flap Fixation

Using a suture or Noyes scissors, clip and remove each suture that holds the edges of the buccal
and lingual flaps against the cheek. Inspect to ensure that no silk suture remnants are left behind.
Coapt the flap edges together, and inspect to determine whether the trimming of the tissue edges
performed earlier was adequate. If not, correct them now.

   Although these steps eventually become routine, they should not be taken
for granted. Failure to meticulously check after every step of the procedure can lead
to complications.
Stage One Final Closure—Suturing

Suture according to the principles and procedures described in Chapter 9 .

After impressioning for a subperiosteal implant, compress the flaps against bone with wet gauze
to express all excess fluids from between the flap and the bone. This keeps the overlying tissues
firm and free of unwanted bulk that could result if retained blood clots and turns into fibrous tissue
during healing.

Provisional Prosthesis

Replace the provisional crowns over the premolar coabutments. If the patient had a removable
partial denture, reinsert it. It will serve as a stent to further compress and hold tissue in position.

   The clinical portion of stage one is now complete.

Post–Stage One Home Care Instructions

As discussed in Chapter 9 , advise the patient about the effects that can result from the trauma of
the surgery, and prescribe prophylactic antibiotic and analgesic medications. Instruct the patient
in proper maintenance of postoperative cleanliness and the need for a soft diet to ensure that the
sutures are not disturbed, which could result in dehiscence.

VISIT 2: POST–STAGE ONE FOLLOW-UP AND SUTURE REMOVAL

The steps that are performed during the post–stage one follow-up visit are shown in Box 14-4 .

Box 14-4
VISIT 2, WEEK 1: SUTURE REMOVAL AND INTERIM EVALUATION

   Conduct general evaluation

   Remove sutures
   Evaluate soft-tissue healing
   Check and adjust co-abutment temporization as required
General Evaluation

The patient is examined after 7 to 10 days. Patient progress and experiences are evaluated.

   Generally, patients report little edema, with resolution before the follow-up
visit. Hematomas are rare. Most often, little or no medication is needed for comfort.
Be sure that the antibiotic regimen has been followed, the no-smoking rule observed,
and a soft diet maintained.
Suture Removal

With rare exceptions, no dehiscence is observed. The soft tissues heal quickly. The sutured area
is gently cleansed with water spray, and the sutures are removed carefully. No anesthetic is
necessary. A Noyes or suture scissors that slips gently under a suture promotes comfort during
this process. Apply tincture of benzoin to the area following suture removal.

   If healing seems slow, one may remove alternating sutures and wait for
another week to remove the rest. If healing is tenuous and tension seems to be the
cause in an area, wait for another week to remove the sutures there.
Healing

Mucosal tissue heals rapidly in these cases. The chief cause of slow healing is smoking, and the
second most common cause is excessive alcohol consumption.

   Advise the patient in clear terms that the prognosis of any case may be
seriously compromised if he or she cannot refrain from smoking or excessive alcohol
consumption, at least throughout the course of treatment.
Case Sequencing—Scheduling Stage Two

The optimum sequencing for stage two, the implant insertion visit, is 2 to 4 weeks after stage one
is completed. However, honoring this timeframe is not critical. Many unilateral subperiosteal
implants are inserted 2, 3, or 4 months following stage one if such a delay is unavoidable.
    During the interim, the patient is advised to eat and brush cautiously in the area
of the implant site. The case sequencing for subperiosteal implants between stage one
and stage two is not critical. In the interest of kindness, and because it is true, share this
with the patient to alleviate anxiety.

SUBPERIOSTEAL IMPLANT DESIGN AND FABRICATION

Pour and Mount Master Models

The one-piece direct bone impression that captures opposing dentition and interocclusal
registration in centric occlusion simplifies the design phase. After this impression is removed from
the oral cavity, it is handled gently, with particular care not to touch or compress thin flanges.
Cleanse the impression under cold water, gently blow it dry, and select an articulator for
mounting.

Quick-setting gray rock is a model material of choice. It sets quickly, like snow-white impression
plaster, but is harder and retains dimensional stability. Do not box the impression, because doing
so may distort the flanges. The impression is poured and mounted in four stages, with four
separate small mixes of gray rock. First, make a small, loose mix and, holding the impression
gently in hand with the bone surface facing up, gently tease a small amount of gray rock into
place with a small spatula or brush. Be sure that the loose mix is against the entire bony surface
to the height of the flanges. Because the mix is loose, doing so will not distort the flanges. Hold
the impression until the first batch of gray rock initially sets. If the gray rock starts to set too soon,
make another loose mix and continue filling the impression. After preliminary setting, turn the
impression over and with another loose mix of gray rock, fill in the opposing dentition. Allow the
mix to set in hand. Next, orient the impression within the articulator, and rehearse its placement.
Adjust the articulator opening as desired. Pour another gray rock mix, and join the mandibular
portion of the impression to the base of the articulator in the selected orientation. When this sets,
the final gray rock mix is made, and the maxillary portion is joined to the articulator in its selected
locked-in position.

Following hardening of the final gray rock mix, carefully open the articulator and tease the models
from the elastic impression material. Some impression material may have to be scored and
removed from undercuts. With all impression material removed, cleanse the models, blow dry,
and close the articulator into centric occlusion. This bone impression is the master model for
implant fabrication only. The centric occlusion recording is solely to determine optimal abutment
location and height. If possible, the anterior natural coabutment(s) was captured in the mold to aid
in achieving abutment parallelism in the design phase ( Fig. 14-31 ).

Figure 14-31  Articulated models. Arrow indicates anterior tooth with marked long axis for parallelism
guidance.
 Figure 14-31 Articulated models. Arrow indicates anterior tooth with marked long
axis for parallelism guidance

Design the Main Bearing and Connecting Struts

Mandibular Posterior Subperiosteal Implant.

The practitioner should design the implant. First, pencil in the buccal main bearing strut. Place it
on basal bone as close to the base of the mandible as possible. Distally stop at the point at which
the ascending ramus rises from the residual alveolar ridge. In unilateral posterior mandibular
cases, stop as anteriorly on the model as possible, but posterior to the mental foramen ( Fig. 14-
32 ). Next, pencil in the lingual main bearing strut. Anteriorly it extends against lingual basal bone,
as far inferiorly as possible, alongside the roots of the premolar natural co-abutments. Try to
place this strut slightly into an undercut area for additional primary retention of the implant. As it
extends posteriorly, it is limited by the anterior border of the mylohyoid ridge, where it rises
superior to the ridge and then passes over the alveolar ridge crest toward the buccal ( Fig. 14-
33 ). Connecting struts are now penciled in. The first to be designed is the one that will give rise
to the abutment ( Fig. 14-34 ). To determine the optimal location for the abutment, close the
articulator to observe the location of the opposing dentition as a guide, and visualize the ideal
position of the planned second molar in the final fixed bridge. This is the position at which the
implant abutment should be located. Mark the corresponding location on the bone model. Also
consider the bucco-lingual position of the abutment. Whereas in the case of endosteal implants
the abutment must always arise at or near the ridge crest, this is not the case with subperiosteal
implants. In most cases, one is able to position the abutment bucco-lingually to be centered under
the occlusal surface of the planned restoration. Once the location of the abutment is marked,
pencil in a connecting strut joining the mark to the buccal and to the lingual main bearing struts.
Next, pencil in a connecting strut anteriorly that curves distally and passes over the ridge crest at
least 3 mm from the distal natural co-abutment, to join the anterior extents of the buccal and
lingual main bearing struts. The distal connecting strut may need special attention. As the distal
extent of the lingual main bearing strut rises superiorly at the anterior border of the mylohyoid
ridge and then crosses the ridge crest, the connecting strut attached to it may run distally in a
hollow just buccal to the ridge crest where it joins the distal extent of the buccal main bearing
strut. Auxiliary connecting struts may be added if required to ensure strength ( Fig. 14-35 ).
Figure 1

Figure 14-32 Arrows indicate position of buccal main bearing strut distal to mental
foramen in mandible

Figure 14-33  Arrow indicates position of lingual main bearing strut in area anterior and then superior
to mylohyoid ridge in mandible.

Figure 14-33 Arrow indicates position of lingual main bearing strut in area anterior
and then superior to mylohyoid ridge in mandible
 Figu

Figure 14-34 Arrows indicate position of connecting strut and abutment in

mandible

Figure 14-35  Arrows indicate positions of connecting struts in mandible.

Figure 14-35 Arrows indicate positions of connecting struts in mandible

Maxillary Posterior Unilateral Subperiosteal Implant.

First, pencil in the buccal main bearing strut. Start anteriorly against basal bone, along the buccal
surface of the natural co-abutments, as far superiorly as possible on the model. Proceed
posteriorly to the anterior border of the zygomatic arch, inferiorly and then posteriorly against its
inferior border, continuing superiorly behind its distal border and then posteriorly and inferiorly
toward the area of the tuberosity ( Fig. 14-36 ). Try to place the buccal and lingual main bearing
struts into slight undercut areas to increase primary retention of the implant. Next, pencil in the
lingual main bearing strut on basal bone starting anteriorly at the lingual surface along the natural
co-abutments at the junction of the hard palate and the alveolar ridge. Move distally toward the
tuberosity, being careful to avoid impingement upon the area of the posterior palatine foramina (
Fig. 14-37 ). Connecting struts are now penciled in. Again, the first to be designed gives rise to
the pergingival strut and implant abutment. To determine the optimal location for the abutment,
close the articulator to determine the position of the opposing dentition as a guide, and visualize
the ideal location of the planned second molar overcasting on the final fixed bridge. This is where
the implant abutment will be located. Mark the corresponding location on the model. Remember
that the buccal plate of bone in the edentulous posterior maxilla most often reveals substantial
resorption toward the lingual, to the extent that the ridge crest often is in cross-bite relative to the
occlusal surfaces of the mandibular dentition. In such cases it is wise, when possible, to place the
abutment toward the buccal to preclude or at least minimize the potential for cross-bite in the final
restoration ( Fig. 14-38 ). Once the position of a projected abutment is marked, pencil in a
connecting strut from it to the buccal main bearing strut, and another to the lingual main bearing
strut. If additional abutments are desired, they are penciled in at appropriate locations in the same
manner. Next, connect the anterior extent of the buccal and lingual main bearing struts with a
connecting strut that curves distally to pass over the ridge crest at least 3 mm from the distal of
the distal natural co-abutment. The location of the distal connecting strut depends on the osseous
anatomy. If there is a distal surface on the tuberosity, and in many resorbed cases there may not
be, carry the distal connecting strut from the distal of the buccal main bearing strut, around the
distal of the tuberosity, to join the distal of the lingual main bearing strut. If there is no distal to the
tuberosity against which one can rest a connecting strut, cross over the ridge as distally as
possible, running the strut along a hollow, depression, or over the most resorbed area of bone.
Auxiliary connecting struts may be added if required to ensure strength and rigidity ( Fig. 14-39 ).

Figure 14-36  Arrows indicate position of buccal main bearing strut in maxilla.

Figure 14-36 Arrows indicate position of buccal main bearing strut in maxilla
Figure 1

Figure 14-37 Arrows indicate position of lingual main bearing strut in area of
junction of alveolar ridge and hard palate in maxilla

Figure 14-38  Arrows indicate position of connecting struts and abutment in maxilla.

Figure 14-38 Arrows indicate position of connecting struts and abutment in

maxilla

Figure 14-39  Arrows indicate positions of all connecting struts in maxilla.

 Figure 14-39 Arrows indicate positions of all connecting struts in maxilla

Design the Abutment(s)

The optimal abutment design is discussed earlier in this chapter. Because the desired abutment
configuration cannot be drawn on the implant model, it is important for the fabricating laboratory
to have exact instructions regarding its fabrication. A sample drawing of the desired abutment
configuration will suffice, with the caveat that at least 2 mm of interocclusal clearance is desired.

Position Initial Retention Screw Hole

A 3- to 4-mm screw fabricated of the same metal as the implant often is used to ensure initial
stability during the early stages of healing. When periosteal integration is established, the screw
no longer functions, but may remain in position. Only rarely is it removed.

Mandibular Posterior Unilateral Subperiosteal.

In the mandible, position the screw along the buccal border, usually at the junction of the buccal
main bearing strut and distal connecting strut ( Fig. 14-40 ). The strut is widened in this area to
accommodate the hole through which the screw will pass.

Figure 14-40  Screw hole (arrow) in mandible.

 Figure 14-40 Screw hole (arrow) in mandible

Maxillary Posterior Unilateral Subperiosteal.

In the maxilla, position the screw hole in the buccal main bearing strut at the junction of the distal
connecting strut, providing that this junction is at an area of solid bone distal to the sinus ( Fig. 14-
41 ). The strut is widened to accommodate the hole through which the screw will pass.

Figure 14-41  Screw holes (arrows) in maxilla.

Figure 14-41 Screw holes (arrows) in maxilla

Laboratory Prescription

The laboratory should have instructions regarding the cross-sectional configuration and
dimensions of the main bearing and connecting struts. One need only instruct the laboratory to
fabricate and finish a unilateral subperiosteal implant as designed on the articulated master
model enclosed with the case, according to previously agreed upon instructions.

Laboratory Fabrication

This section outlines the basic procedure followed by the laboratory, to enable the practitioner to
understand any questions or complications that may arise at the laboratory and provide
appropriate input. After laboratory staff review the prescription for complete understanding,
fabrication begins.

Investment Model.

Subperiosteal implants are one-piece castings fabricated of various accepted biocompatible

metal alloys. The process is similar to that used to fabricate removable partial denture
frameworks. The master model is duplicated and poured in a unique casting investment material.
This investment model is checked, trimmed, and cleansed.

Wax-Up.

Using the penciled design on the master model as a guide, the implant is waxed up on the
investment model. The configurations and dimensions required for the main bearing struts,
connecting struts, and abutment are on file at the laboratory. In waxing up the abutment, the
occluding articulated counter model is the guide for height. The guide for parallelism is the long
axis of the prepared natural co-abutments on the master model. This step reconfirms the value of
capturing these co-abutments at the impression stage. The completed wax-up is sprued liberally
to ensure adequate metal flow to all areas of the implant.

Investment.

The waxed-up sprued implant on the investment model is invested in a casting ring with the
companion investment material, and allowed to set.

Casting.

The first step is burn-out of the wax-up, just as in all lost-wax casting techniques. The implant
must be cast in a biocompatible material, usually a cobalt-chromium-molybdenum alloy such as
surgical Vitallium. Following burn-out, casting begins. There are several sophisticated casting
techniques, each requiring specific timing and heat level sequences and usually performed in a
vacuum or an inert gas such as argon.

Finishing Process.

Following casting, the investment material is removed from around the implant casting. The
casting is cleansed, and its sprues and buttons are cut away. Flash, if any, is removed. The
finished casting usually is given a sand-blasted surface. A consensus conference conducted by
10 practitioners with long experience in subperiosteal implant dentistry concluded that evidence is
lacking that coatings contribute to the safety, efficacy, or longevity of subperiosteal implants,
although a coating may be used if desired.[17]

Passivation.

The passivation procedure, unique to the formula of any biocompatible metal, oxidizes the
surface of the implant. The laboratory follows the appropriate protocol. Following passivation, the
implant is cleansed and packaged. A prefabricated initial retention set-screw of compatible metal
is included.

Materials and Biocompatibility.

Subperiosteal implants tend to be cast in surgical Vitallium. This material is biocompatible and is
available in many variations around the world.

Implant Sterilization

When received from the laboratory, the implant and its initial retention set screw(s) are pouched,
sterilized, and set aside with the stage two armamentarium. Sterilization is accomplished in the
conventional manner. Guidelines for gravity air displacement steam sterilization are for an
exposure time of 30 minutes at 250° F (121° C) or 15 minutes at 270° F (132° C). For prevacuum
steam sterilization, an exposure time of 4 minutes is required at 270° F (132° C). The sterilized
implant in its pouch is transferred to the stage two implant insertion surgical tray setup. These
implants may be cleansed and resterilized as required.

VISIT 3, WEEK 2: STAGE TWO IMPLANT PLACEMENT

The steps that are performed during the stage two implant placement visit are shown in Box 14-
5.

Box 14-5
VISIT 3, WEEK 2: STAGE TWO IMPLANT PLACEMENT

   Confirm use of prophylactic antibiotic

   Set up instrumentation
   Administer anesthetic
   Make incision
   Reflect tissue
   Seat implant
   Check abutment for prosthodontic parallelism and interocclusal clearance
   Adjust and reseat implant, if required
   Set retaining screw(s)
   Perform soft-tissue treatment
   Suture
   Check temporization of premolar co-abutments
   Temporize provisional implant abutments, if required
   Provide home care instruction
   Schedule follow-up visit
Confirm That Preoperative Medication Has Been Taken

The preoperative prophylactic antibiotic should have been taken as prescribed. Confirm this when
the patient arrives for treatment. If it has not been taken, administer it preoperatively.

Instrumentation Setup— The Armamentarium

The sterilized instrument setup is placed in the treatment area. It contains all the instruments
required for the stage one procedure, as well as a tissue punch to help contour tissue around
abutments before final closure, a screwdriver of compatible metal to set the initial retention screw
following implant insertion, and an XL high-speed bone bur to create a pilot hole for the retention
screw.

Preoperative Tissue Preparation

Again, as in stage one, a bactericidal solution such as povidone-iodine (Betadine) is applied to

the operating field and its surrounding tissues. Professional prophylaxis should be performed
before the procedure. Before applying povidone-iodine, remove any debris that may be present.

Local Anesthetic, Promotion of Comfort, and Control of Bleeding

The local anesthetic regimen for stage one surgery is followed again.

Incision

Remove the partial denture, if there is one, and the provisional prosthesis over the prepared
natural co-abutments. The incision is made along the same incision line made for stage one, to
the same extent mesially and distally.

   The tissues coapted at stage one usually are not yet fully healed. Therefore,
an incision line parallel to but not through the original incision line would require that
the fragile healing line be reflected with one of the new flaps. The healing tissue
along the original incision line may tear away because it is still weak. This
complication to suturing and healing can be avoided by incising along the original
incision line. Healing after the second incision is uneventful.
Tissue Reflection

Tissue reflection is accomplished exactly as for stage one, and to the same extent.

   However, reflection is accomplished in stage two with greater ease and less
bleeding. The tissue reflected at stage one is not yet fully reattached to the
underlying bone. It lifts away with ease. Remember to keep one’s eyes on the
juncture at which the periosteum is lifting from bone to be sure to stay under it.
 Confirm that the tissue is reflected as far as it was in stage one.
Trim Tissue Flap Edges

The edges of the tissue flaps are carefully inspected and trimmed with a serrated edge tissue
scissors in the same way as described for stage one.

   Because of the greater ease of tissue reflection, less trimming is required at

this stage.
Trial Seat the Implant—Check Fit to Osseous Contours

There is no need to affix the reflected tissue flaps to the cheek or across the arch to maintain
access to the exposed area, as was done for impressioning in stage one. The implant is removed
from its sterilization pouch for trial seating. The tissue flaps are held away with a periosteal
elevator or tissue forceps. The implant is gently seated on the exposed bone ( Fig. 14-42 ).

Figure 14-42  Seating of mandibular (A, B) and maxillary (C) unilateral subperiosteal implants.

Figure 14-42 Seating of mandibular (A, B) and maxillary (C) unilateral

subperiosteal implants

   This procedure is much the same as fitting the framework of a removable

partial denture over clasped teeth. One varies the angles of approach, and by trial
and error, the path of insertion that permits greatest ease of seating is determined. If
the implant seats fully on the supporting bone, the trial seating is successful, the
implant remains in place, and the procedure continues.
In the rare instance in which an implant cannot fully seat because of a protuberance of bone near
an undercut area, even after trying various paths of insertion, place an orangewood stick against
the occlusal surface of the abutment and try tapping it into position with a mallet. Most often, this
will solve the problem. If not, reduce the protuberance. Remove and rinse the implant and set it
aside on the sterile tray. With a bone file or rongeur, remove the smallest amount of bone that will
allow full seating of the implant. Repetition of this procedure may be required.

   This removal of bone does not compromise the case. No main bearing or
connecting strut will rest against the reduced bone, because the implant moves past
the protuberance to its final position to achieve full seating.
Check Abutment(s) for Prosthodontic Parallelism and Interocclusal
Clearance

Confirm that the abutment on the seated implant is in parallelism with the prepared natural co-
abutments. Also confirm that adequate interocclusal clearance is present when the patient closes
into centric occlusion.

   These conditions are almost always correct if the implant was designed
properly and laboratory instructions were followed.

If lack of parallelism or interocclusal clearance is apparent at this time, note what adjustments are
required. Remove the implant, rinse, and with sterile heatless wheels or stones, followed by a
rubber polishing wheel, make the adjustments. The implant is cleansed, reinserted, and
rechecked.

   This procedure may need to be repeated until acceptable parallelism and

clearance are achieved. Be aware that this process is almost never needed when the
laboratory follows its instructions correctly.
Final Seating of the Implant—Set Initial Retention Screws

With the implant firmly seated against the supporting bone and held immobile with pressure
applied to the abutment, the tissue is reflected to expose the screw hole. With an XL bone bur in
a high-speed contra angle with coolant, a pilot hole is made through the screw hole to a depth of
approximately 1.5 to 2 mm.

   Do not make the hole too deep or wide, to preserve the initial retentiveness
of the set screw.

Place and turn the initial retention set screw clockwise with a screwdriver until it is fully seated
and tight against the implant framework. Final seating is complete ( Fig. 14-43 ).
 Figure 14-43  Placement of a set screw with compatible driver.

Figure 14-43 Placement of a set screw with compatible driver

Gingival Flap Plastic Surgery

If required because of the presence of flabby tissue over the incision site preoperatively or in the
case of excessively thick maxillary gingiva, remove any excess tissue that will interfere with
coapting the flaps, decrease flap thickness if required, and reduce flabby tissue according to the
procedures and principles described in Chapter 9 .

Whether or not these plastic surgery procedures are required, tissue punch to remove any tissue
that bunches around the pergingival strut upon final coapting, again according to the procedures
described in Chapter 9 . When the soft tissue is ready for suturing, take a periapical radio-graph
for the patient record. For an implant with one abutment, place the first suture just mesial to it.
Penetrate first on the buccal flap even with the mesial border of the abutment, and pass the
needle through the lingual flap at the mid-point of the abutment. Penetrate next on the buccal flap
even with the distal border of the abutment and pass the needle through the lingual flap at the
mid-point of the abutment, and tie.

In the case of a double-abutment implant, the first suture is placed at the mesial of the mesial
abutment, the second at the distal of the distal abutment, the third at the distal of the mesial
abutment, and the fourth at the mesial of the distal abutment.

The next suture is placed carefully to secure closure of the gingival flap against the distal of the
nearest natural co-abutment, followed by a suture 2 mm mesial to the distal extent of the gingival
flaps.

   These sutures secure the reflected flaps at the mesial and distal borders of
the abutments, and provide important flap orientation to guide placement of the
remainder of the required sutures.

Now, spacing sutures 2 to 3 mm apart, fill in all unsutured areas carefully. Compress the flaps
against the underlying bone with wet gauze, and inspect. Add sutures if required.
    Always, with each suture, secure a good bite of tissue, preferably within the
band of attached gingiva. Successful suturing is an important aspect of implant
insertion. Securely sutured flaps heal rapidly by primary intention, with reduced
edema.
Check Temporization of Premolar Co-Abutments

Reseat the premolar provisional crowns and recheck margins, embrasures, and occlusion. Again
check for adequate clearance of the implant abutment(s). Adjust intraorally if required.

   The provisional crowns over the natural co-abutments were removed before
implant insertion to provide clear observation and access to the field of operation. In
checking the marginal fit, pay attention to the distal of the nearest natural co-
abutment, particularly where the incision passed through the distal of its gingival cuff.
Provisional Implant Temporization
In Nonesthetic Areas.

Posteriorly, in nonesthetic areas, no provisional teeth are placed.

   In mainstream posterior unilateral subperiosteal treatment, provisional

restorations are placed only if required for esthetics. The implant is initially held
immobile by the set screw, and in many cases by additional frictional fit if the implant
seats into an undercut area. The abutments are out of occlusion. The implant is in a
state of hypofunction, in which only cheek and tongue movement or a stray bolus of
soft food can apply load. This hypofunctional state enhances periosteal integration
through the formation of an enveloping collagenous connective tissue sheath that is
part of the periosteum and is attached to bone through Sharpey’s fibers.
In Esthetic Areas.

In the posterior, provisional teeth are placed only in esthetic areas. These are splinted to the
existing provisionals on the natural co-abutments. Provisional prostheses are conventionally
fabricated as if for a fixed bridge supported exclusively by natural abutments. The occlusal
surfaces are kept narrow and just out of occlusion.

   The natural co-abutments ensure implant immobilization. The portion of the

restoration over the implant and pontic is kept just out of occlusion, and the need to
maintain a soft diet is emphasized. The most carefully made provisional prosthesis
can be weak, break, or have delicate margins. Any one of these may interfere with
healing. When esthetics is not a consideration, only the natural coabutments are
temporized.

The provisional prosthesis is placed with sedative cement applied only to the natural co-abutment
crowns. No cement is placed around the implant abutment. Frictional fit is adequate.
    This procedure protects the implant from being disturbed during healing, or
when the provisional prosthesis is removed to facilitate suture removal or the
fabrication of the final prosthesis.
Radiographic Record

A panoramic or series of two or three periapical radio-graphs is taken of the area with the seated
implant ( Figs. 14-44 and 14-45 ).

Figure 14-44  Mandibular postoperative radiograph.

Figure 14-44 Mandibular postoperative radiograph

Figu

Figure 14-45 Maxillary postoperative radiograph

   The radiographs are taken to complete the patient record. They are not
obtained to check full seating of the implant. The best check for correct seating is
direct observation before closure. The vagaries of radiography should not undermine
confidence in one’s direct observation.
Immediate Post–Stage Two Home Care Instructions

The considerations at this time are identical to those after stage one surgery
VISIT 4: POST–STAGE TWO FOLLOW-UP VISIT, SUTURE REMOVAL

The steps that are performed during the stage two implant placement follow-up visit are listed in
Box 14-6 .

Box 14-6
VISIT 4, WEEK 3: SUTURE REMOVAL AND INTERIM EVALUATION

   Conduct general evaluation

   Remove sutures
   Evaluate soft-tissue healing
   Check and adjust co-abutment and implant temporization as required
General Evaluation

This follow-up visit is scheduled 7 to 10 days after insertion. Earlier visits are generally not
required. Evaluate the progress and experiences of the patient.

   Patients generally report minimal edema that has already resolved.

Hematoma rarely is reported, and most often the pain medication was not used.
Always confirm that the antibiotic regimen was followed, that the no-smoking rule
was observed, and that diet was appropriate.
Suture Removal

If required, gently remove the provisional prosthesis for better access to facilitate suture removal.
Often it can be left in place. Use a Noyes or suture scissors and fine forceps. The scissors slip
under and sever each suture with little trauma to the underlying tissue. Apply a medicament such
as tincture of benzoin. No anesthetic is necessary.

   Suture removal should cause little or no discomfort. Discomfort only occurs

when a forceps is used to pull the suture up to sever it. Using a suture or Noyes
scissors obviates this.
Healing

Check that soft-tissue healing is by primary intention. Observe the pergingival cuff around the
nearest natural co-abutment and the healing around the implant abutments, and medicate if
necessary.

   Problems with soft-tissue healing rarely are observed at this time.

Check Provisional Restoration
Before replacing the provisional restoration if it was removed for suture removal, examine for
gingival signs of overextended margins or pontic, and adjust accordingly. Recheck the occlusion,
and adjust if necessary.

   These details are important. Anything that promotes gingival health is worth
doing. Ideal case sequencing always can be followed if every step of the procedure
is performed carefully, and then checked and adjusted as required.
Post–Stage Two General Considerations

In cases of normal healing, to follow ideal case sequencing, make the next appointment 7 to 10
days following suture removal.

   This time span allows sufficient healing of the overlying soft tissues and
around the incised gingival cuff of the natural co-abutment before the first
appointment to fabricate the final prosthesis. Almost always, the site is ready for final
impressioning 1 week after suture removal.

VISIT 5: MASTER IMPRESSIONING AND INTERARCH OCCLUSAL

REGISTRATION FOR PROSTHODONTIC RESTORATION

The steps that are performed during the master impressioning and interarch occlusal registration
for prostho-dontic restoration visit are shown in Box 14-7 .

Box 14-7
VISIT 5, WEEK 4: MASTER IMPRESSION AND INTERARCH OCCLUSAL REGISTRATION
FOR PROSTHESIS FABRICATION

   Expose natural co-abutments

   Take master impression
   Perform interarch occlusal registration
   Select shade
General Considerations

The prosthodontic restoration of mainstream unilateral subperiosteal implant cases is essentially

the same as that of conventional nonimplant cases. Simply fabricate the required three- to five-
unit fixed prosthesis as one would for a fixed bridge supported entirely by natural abutments.
Remember that although it is perceived that implant dentistry prosthodontics are complicated, this
is not true for all modalities. For subperiosteal restorative dentistry, one need not take special
courses or use special laboratories or an array of specialized components.

Although the restorative regimen is conventional, there is an ideal time sequencing that should be
followed insofar as possible. This sequencing is not as critical as that for the endosteal implant
modalities, but following it promotes successful case completion with the best possible prognosis.
It is important to understand how the healing cycle works, and its timing, to fully understand why
the schedule of restoration described hereafter is considered ideal. Reserve 2 to 4 weeks for
complete fabrication of the final prosthesis.

Master Impressioning/Master Model

Taking the master impressions and pouring master models is best accomplished using one’s
conventional technique of choice for tooth-supported fixed bridges. Retraction cord usually is
placed to promote hemostasis and provide space for one’s elastic impression material of
preference. Carefully inspect the site for any residual material after the impression is removed,
and cleanse as necessary.

Recording Jaw Relationships

Again, one’s preferred technique for recording jaw relationships in the fabrication of a
conventional prosthesis should be used

VISITS 6 TO 7: TRY-IN AND ADJUSTMENT OF FINAL

PROSTHESIS

The steps that are performed during the visits for try-in and adjustment of the final prosthesis are
shown in Box 14-8 .

Box 14-8
VISITS 6 TO 7, WEEKS 5 TO 7: FABRICATION, TRY-IN, AND ADJUSTMENT OF FINAL
PROSTHESIS

Try in bisque-baked bridge directly, or try in copings and/or assembled framework before
  
bisque-bake try-in
   Check occlusion, tooth contours, embrasures, and margins, and reconfirm shade
Timing of Prosthesis Fabrication

One’s customary sequencing of prosthesis fabrication should be followed. Remember that ideally,
the final prosthesis should be fixed 2 to 4 weeks following master impressioning and bite
registration. Many practitioners write their laboratory prescription for a return of an assembled
bisque-baked prosthesis try-in, while others try a one-piece frame casting first, and then bisque
bake. Another option is to try in individual copings, assemble them, and then bisque bake and go
to completion. Each of these methods requires a different number of patient visits. As long as the
2 to 4 weeks completion time is honored, any of these methods can be successfully used.

Implant-Related Prosthodontic Considerations

Central Fossae/Ridge Crest Relationships.

When teeth are removed or lost, resorption occurs at the expense of the buccal and labial plates
of bone. Thus, ridges resorb medially, toward the lingual, as they lose height. The resorbed ridge
crest is lingual to the location of the original, unresorbed ridge crest when teeth were present.
Thus, the abutment of the subperiosteal implant often is placed as far buccal to the resorbed
ridge crest as possible, but in most cases will remain lingual to the position of the teeth when they
were present.
In positioning replacement teeth, the central fossae generally should replicate those of the
original teeth to help ensure ideal occlusion, esthetics, and the dimensional and functional
integrity of the vestibule. Therefore, the replacement teeth will be positioned partially buccal to the
healed ridge crest, and the implant abutment will project under the lingual portion of the overlying
crown. In the maxilla it sometimes is necessary to establish an edge-to-edge occlusion, or even a
cross-bite. In the mandible, occlusion may be established primarily between the tip and buccal
incline of the maxillary lingual cusp and the central fossa and lingual incline of an extremely
narrowed mandibular buccal cusp. Because of resorption patterns, it may be necessary for proper
function and esthetics to ridge lap the buccal border of the implant abutment crown, especially in
esthetic areas.

Ridge Lapping Implant Abutments.

In conventional fixed bridges, the ridge lap is important. To provide an esthetic lineup of pontics in
the area of the gingival margin, a passively placed ridge lap is formed labial or buccal to the ridge
crest. These pontics are fabricated to provide esthetic gingival curvature, and thus appear to be
growing out of the gingiva. In conventional fixed prostheses, this cannot be successfully
accomplished with crowns over natural teeth. The gingival sulcus of the tooth becomes
periodontally involved, no matter how diligently home care is performed.

However, ridge lapping is an important, predictable, and effective option for subperiosteal implant
abutments with attached gingiva at the buccal or labial border. Although there is a peri-implant
gingival sulcus with hemi-desmosomes, there is no direct fiber insertion into the implant. [4]
Nonetheless, in mainstream cases, the abutment margins are almost always in attached gingiva.
This is why ridge lapping in these cases succeeds. For more than 30 years, subperiosteal implant
prostheses have successfully functioned with ridge-lapped implant abutments. The esthetic result
and ease of cleansability are materially enhanced when this restorative option is chosen.

In forming a ridge lap, note that all proximal and lingual implant abutment casting margins are
created as they would be against natural teeth. Only the buccal areas are extended. This is best
accomplished in the laboratory by esthetically positioning replacement teeth over the implant
abutments as though they were pontics. The implant abutments are positioned within the casting,
governed by the dictates of esthetic contouring of the ridge lap. It is desirable that the implant
abutments rise through the gingiva at a central point under the overlying crown, but it is neither
hygienically nor esthetically essential that they do so. In the area of the ridge lap, place the metal
casting margin at or slightly above the gingiva and extend metal 2 mm shy of the expected
contour to allow ample room to adjust the resin or porcelain ridge lap for esthetics at try-in without
exposing metal in the process.

In nonesthetic areas, ridge lapping is optional. Bullet-shaped crowns with wide embrasures may
be used, depending on practitioner preference and patient acceptance.

Finishing Lines Against Abutments/Embrasures.

In the area of the ridge lap, the finishing line of the crown is placed at or up to 1 mm above the
gingival margin, to allow for proper flossing and flow of fluids during lavage. All margins are
placed above, at, or below the free gingival crest, in accordance with one’s preference when
working with crowns over natural abutments.

Occlusion.

Occlusion is also established in accordance with the techniques and principles with which one is
most familiar and comfortable when fabricating a conventional fixed prosthesis. Narrow bucco-
lingual dimensions, anatomic or semi-anatomic noninterfering cuspid relations, group function,
cuspid protection, long centric, gnathologic principles, and other concepts of occlusion are all
successfully used with subperiosteal implants.[7]

Restorative Materials.

Most conventional materials can be used, such as porcelain-to-metal prostheses, gold occlusals
with acrylic veneers, and gold superstructures with acrylic teeth. Gold and acrylic occlusal
surfaces transmit less force through the implant into the investing tissues than porcelain. Use of
an alternative restoration material is not required in mainstream cases but may be of some
advantage in cases offering a more marginal prognosis

VISITS 8 TO 9: CEMENTATION OF FINAL PROSTHESIS

The steps that are performed at the visits related to cementation of the final prosthesis are shown
in Box 14-9 .

Box 14-9
VISITS 8 TO 9, WEEKS 8 TO 9: CEMENTATION OF FINAL PROSTHESIS

   Remove provisional restoration

   Try in completed prosthesis
   Check previous adjustments and shade
   Perform provisional cementation
   Evaluate patient comfort and gingival adaptation to pontic and crowns
   Perform final cementation
Provisional Placement

The final restoration may be placed provisionally for up to 1 week. Provisional cement is not
applied to the implant abutment. Provisional cement is conventionally applied to the natural co-
abutment only.

Final Placement

The final restoration is seated with one’s crown and bridge cement of preference. Zinc
oxyphosphate, polycarbonate, and acrylic cements are all successfully used.

Postoperative Radiographic Record

A postoperative radiographic record is obtained. A pan-oramic radiograph and/or two or three

periapical radio-graphs are sufficient for this purpose.

COMPLICATING AND ATYPICAL CONDITIONS

Common Complicating and Atypical Conditions

Many of the complicating and atypical conditions that are common to the mainstream treatment
procedures using the abutment-providing implant modalities, as discussed in Chapter 9 , are
applicable here. These include minimal width of attached gingiva, frayed or torn flaps, excessive
bleeding, retained root tip, presence of a cyst or granulomatous tissue, friable tissue at suturing,
excessive postoperative edema, and retained impression material. Each of these conditions is
rare. Handling such complications properly is covered in Chapter 9 .

Areas of Excessive Ridge Height

Occasionally, one encounters limited areas of overabundant bone for the placement of a
subperiosteal implant. These limited areas deserve special consideration. First, while mentally
designing the implant as the tissue is reflected, determine whether a connecting strut should be
placed across an area of excessive ridge height ( Fig. 14-46 ). If so, reduce that height at the time
of ridge crest cleaning and alteration either by cutting a groove into the ridge toward basal bone,
or removing the entire area of excessive ridge. Whereas endosteal implants place residual
alveolar ridges back into function and thereby preserve them, subperiosteal implants do not.
Overabundant ridges therefore will resorb over time. If a connecting strut passes over such an
area, it will in time work its way through the gingiva and dehisce into the oral cavity. Removing
this excess bone in advance and seating the connecting strut on basal bone avoids this problem.
Excess bone may need to be removed, even if a crossover strut need not be passed over it,
when there is insufficient interocclusal clearance over it. Reduction can help make the final
prosthesis more esthetic and cleansable.

Figure 14-46  Arrow indicates position of incorrect placement of connecting struts on alveolar ridge of
excessive height.

Figure 14-46 Arrow indicates position of incorrect placement of connecting struts on

alveolar ridge of excessive height

Knife-Edge Ridge Areas

Knife-edge ridge areas are always removed, where and whenever observed. If left in place, the
overlying healed tissue is tender to compression. The knife-edge bone ridges resorb and alter the
fit of the overlying prosthesis. These areas are easy to reduce. Finish the process with gentle
smoothing using a bone file or sharp curette.

Inadequate Soft-Tissue Closure—Dehiscence

Dehiscence is not always the result of inadequate suturing. The patient may traumatically
separate the tissues. Whatever the etiology, anesthetize, debride the edges of tissue, suture
deeply, and repeat important home care instructions. When suturing will not suffice, any
periodontal pack may be applied over the exposed area, and healing, though retarded, will
progress. This delays the recommended case sequencing.

Inadequate Impression

The master impression is cleansed and inspected following removal during the stage one
procedure. Consider the final implant design and relate it to one’s ability to identify on the
impression sufficient anatomy to support each planned strut. If the impression is adequate, pour
the model. If not, identify the cause of the inadequacy. First, reexamine the patient to be sure that
in fact adequate tissue reflection was performed. If the reflection was inadequate, or if the
impression material failed to reach all exposed areas, retake the master impression, remove it,
and confirm the corrections.

In some cases, what seemed adequate at the time seems questionable when examining the
master model. By this time the patient is sutured and on the way home. Be sure that as much
exposed bone as possible is used for appropriate support. Almost always, this will suffice,
because the model typically has much more exposure than the required minimum.

Incomplete Final Seating of Implant

Depending on the degree, incomplete final seating of the implant may or may not be a
complication. If portions of the implant do not fully seat, even after protuberances or bulges are
removed, and if under a small area of one or two struts there is a lack of contact with bone, there
is little reason for concern. The area will heal with dense, fibrous connective tissue. A small
amount of nonresorbable alloplastic bone augmentation material may be used in such cases.

If major portions of the implant do not fully seat, the master impression must be retaken and the
implant refabricated. This rarely occurs in mainstream cases.

Inadequate Retention of Seated Implant

Inadequate retention of a seated implant is caused by insufficient anatomic undercut areas and/or
small-sized implants. A retention screw solves the problem. Keep the initial pilot hole for the set
screw narrow to ensure adequate grip for the set screw threads in the bone. When tightening set
screws, be sure not to strip the bone threading, which can compromise early retention.

Home care instruction is important. The implant remains in as little function as possible

VARIATIONS AND ALTERNATIVES

Various Abutment Connections

In the case of mainstream unilateral subperiosteal implants, the abutment design replicates that
of the plate/ blade form.

Total and circumferential subperiosteal implant cases are not considered mainstream. Their
overlying prostheses may be fixed or removable. If a removable overdenture is placed on the
implant, various ball, O-ring, and clip and bar attachments and assemblies can be used.

Restorative Procedure Options

Two unilateral subperiosteal implants can be used for bilateral distal support of a complete arch
fixed bridge. The stage one implant procedure is identical to the mainstream procedures already
discussed. Only the overlying prosthesis is different in that it includes more teeth, up to the entire
arch.

Precision and Semi-Precision Attachments

The use of precision and semi-precision attachments sometimes is considered to facilitate the
fabrication of a new prosthesis should the implant fail. However, the long-term survival of these
implants is commonly up to 15 years or longer. Should an implant fail, the prosthesis is separated
at the distal of the pontic closest to the natural co-abutment. The implant is removed, and
following healing a new one is fabricated and seated. Restoration follows with the fabrication of a
two-unit restoration supported by the new implant and an overcasting on the pontic of the original
bridge.

Stress-Breaking

The use of stress-breaking components in mainstream unilateral subperiosteal prostheses may

be counterproductive. One objective of the final prosthesis is to provide rigidity, especially during
the healing phase, and shared loading in function. Posteriorly, functional load is up to four times
greater than anteriorly. In posterior mainstream cases, the implant is almost always posterior to
the natural co-abutments. The stress breaker protects the natural co-abutments more than the
implant, which is subjected to added load. A rigid prosthesis offers the best prognosis.

Coatings

A consensus conference of 10 practitioners with long experience in subperiosteal implant

dentistry concluded that evidence is lacking to confirm that coatings are of benefit. Complications
such as coatings that crack, delaminate, dissolve, or may act as pathways for infection are
observed. Coated implants cannot be handled easily, resterilized, or cleansed. They may
complicate the procedure, with no confirmed benefit.

Various Strut Dimensions and Designs

The strut dimensions discussed in the teaching case are recommended. Variations in width,
height, and crosssectional dimensions sometimes are observed. No research exists to establish
benefit of one set of dimensions over another. Some practitioners design certain main bearing
struts with fenestrations to enhance fibrous tissue envelopment of the implant ( Fig. 14-47 ).
 Figure 14-47  Fenestrated main bearing struts.

Figure 14-47 Fenestrated main bearing struts

Various Basic Designs

In all areas of technology, new designs, protocols, and materials always are being developed. [18]
[19]
Although innovations are attractive, clinical use is what counts. Only long-term clinical trials
and general use can determine the value of a new design. The basic mainstream posterior
unilateral subperiosteal designs taught in this chapter have been used for many years and are
known to work. In the maxilla, some alternative designs offer more lingual support and fewer
labial struts. In the mandible, struts are sometimes extended onto the lateral border of the
ascending ramus. The long-term benefits of such variations in design weighed against long-term
complications are as yet unknown.

Implant Insertion Over New or Partially Healed Extraction Sites

Implant insertion over new or partially healed extraction sites is not mainstream subperiosteal
implant dentistry. It is better to be patient and wait for complete healing before seating a
subperiosteal implant. Additional resorption that may occur at the extraction site is not a concern,
and in some subperiosteal cases can be considered a benefit.

CAD-CAM Design of Subperiosteal Implants

Computer-assisted design–computer-assisted manufacture (CAD-CAM) design of subperiosteal

implants is not considered a mainstream procedure because of techniquesensitivity and cost, and
because CAD-CAM generated models may not be as accurate as direct bone impressions. [20] In
the hands of highly trained technicians and practitioners, accurate models can be predictably
fabricated, but direct bone impressioning is more predictable in mainstream cases.

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