Abstract

Subperiosteal implants have played a significant role in the field of dental implantology, particularly for patients with insufficient bone mass to support traditional endosteal implants. These implants, placed beneath the gum line but above the jawbone, offer an alternative for patients who are not candidates for endosteal implants due to severe bone loss. Although once a common solution, the use of subperiosteal implants has significantly declined with the advent of more advanced bone grafting techniques and the development of other implant options. This paper explores the historical evolution of subperiosteal implants, the current indications for their use, and the reasons for their decreasing popularity. In doing so, it reviews the scientific literature on subperiosteal implants, bone grafting, and the advancements that have made endosteal implants a more viable and preferred option for many patients.

Introduction

Dental implants have revolutionized the treatment of edentulism and provide a reliable and long-lasting solution for replacing missing teeth. The most common type of dental implant used today is the endosteal implant, which is placed directly into the jawbone. However, not all patients have sufficient bone volume to support these implants due to factors such as periodontal disease, trauma, congenital defects, or the natural loss of bone associated with aging. For such patients, alternative implant solutions are necessary. One such solution, the subperiosteal implant, is placed just beneath the gum line but above the jawbone, offering a viable treatment option when adequate bone mass is lacking.

While subperiosteal implants were once considered a standard treatment for patients with inadequate jawbone, the rise of bone grafting techniques and the development of newer implant designs have led to a decline in their use. This paper aims to discuss the clinical applications of subperiosteal implants, their historical context, and the contemporary alternatives available for patients with insufficient bone mass.

Historical Context of Subperiosteal Implants

Early Development and First Use

The concept of dental implants dates back to ancient civilizations, with the earliest evidence of tooth replacement found in the remains of ancient Egyptians and Mayans, who used various materials such as ivory, wood, and metal to replace missing teeth. However, it was not until the 20th century that modern dental implants began to take shape. In the 1950s, Swedish dentist Per-Ingvar Brånemark's discovery of osseointegration—the process by which titanium integrates with bone—paved the way for the development of endosteal implants, which are now the gold standard in implant dentistry (Brånemark, 1983).

Subperiosteal implants, on the other hand, have their origins in the early 20th century. In 1940, Dr. J.R. Cooke, an American dentist, first introduced the idea of a subperiosteal implant as a solution for patients with insufficient jawbone mass. These implants were designed to be placed under the periosteum (the connective tissue membrane covering the bone) and were primarily used for edentulous patients who could not support traditional endosteal implants due to significant bone loss (Terry & Terry, 2006).

Initially, subperiosteal implants were a promising solution for patients with severe bone atrophy, especially in the maxillary arch. The first successful subperiosteal implant was placed in 1941 by Dr. J.R. Cooke, and its success led to increased use of this technique throughout the mid-20th century. During this period, subperiosteal implants were often the only option for patients who had insufficient bone height and width to support endosteal implants, especially in cases of total maxillary or mandibular edentulism (Block, 2014).

Evolution of Techniques and Materials

The design and materials used for subperiosteal implants evolved over time. Early subperiosteal implants were made of metals such as gold and stainless steel, which were prone to corrosion and did not integrate well with bone. In the 1960s, titanium became the material of choice for subperiosteal implants due to its superior biocompatibility and ability to integrate with bone through osseointegration (Albrektsson et al., 1981).

The surgical procedure for placing subperiosteal implants also evolved. Initially, the implants were placed through large, invasive surgeries that required significant tissue removal and bone exposure. As surgical techniques improved, the procedures became less invasive, and the success rate of subperiosteal implants improved as well. However, the advent of new bone regeneration techniques and endosteal implants gradually diminished the popularity of subperiosteal implants.

Indications for Subperiosteal Implants

Clinical Indications

Subperiosteal implants are typically indicated for patients with severe bone loss or atrophy that precludes the placement of endosteal implants. Bone loss can occur due to a variety of factors, including periodontal disease, tooth extraction, trauma, or age-related resorption. In cases where there is insufficient bone mass to support an endosteal implant, a subperiosteal implant may be considered as an alternative treatment.

Subperiosteal implants are generally placed when other options, such as bone grafting or sinus lifts, are not viable or if the patient is unwilling to undergo more complex procedures. For example, patients who have resorbed maxillary bone due to prolonged edentulism or those who are unable to undergo bone grafting due to systemic conditions (e.g., osteoporosis, uncontrolled diabetes) may be candidates for subperiosteal implants (Dursun et al., 2014). Furthermore, subperiosteal implants can provide a solution for patients who require multiple tooth replacements, particularly in cases of complete edentulism in the upper or lower jaw.

Comparison to Endosteal Implants

Endosteal implants, which are placed directly into the jawbone, are the most commonly used type of dental implant. They are typically indicated for patients who have adequate bone volume to support the implant. In contrast, subperiosteal implants are used in patients who lack sufficient bone mass, often due to resorption following tooth loss. The primary advantage of subperiosteal implants is that they do not require bone augmentation, which can be a lengthy and expensive process.

However, subperiosteal implants do have certain limitations compared to endosteal implants. One significant disadvantage is that subperiosteal implants do not integrate as well with the bone as endosteal implants, which can affect their long-term stability and success. Furthermore, the placement of subperiosteal implants requires a more invasive surgical procedure, which increases the risk of complications and prolongs the recovery period (Block et al., 2012).

Decline in Popularity and the Rise of Bone Grafting Techniques

Advancements in Bone Grafting

The decline in the use of subperiosteal implants can largely be attributed to the advancements in bone grafting techniques that have allowed for the regeneration of bone in patients with insufficient jawbone. Bone grafting procedures, such as autografts, allografts, xenografts, and alloplastic materials, have revolutionized the treatment of bone loss in dental implantology (Jiang et al., 2016).

One of the most significant breakthroughs in bone grafting was the development of the sinus lift procedure, which allows for the augmentation of bone in the posterior maxilla, enabling the placement of endosteal implants even in cases of severe resorption. Additionally, techniques such as guided bone regeneration (GBR) and the use of growth factors and stem cells have further improved the ability to regenerate bone and create a stable environment for implant placement (Kok et al., 2012).

These advancements have significantly reduced the need for subperiosteal implants, as patients who were previously unable to undergo endosteal implant placement due to bone loss can now benefit from bone grafting procedures. As a result, subperiosteal implants are now considered a last resort for patients who cannot benefit from bone grafting techniques or those who are unwilling to undergo more complex procedures (Piconi et al., 2010).

Development of Modern Implant Designs

In addition to advancements in bone grafting, the development of modern implant designs has also contributed to the decline of subperiosteal implants. The use of tapered and surface-modified implants has improved the success rates of endosteal implants, even in patients with compromised bone quality. Furthermore, mini-implants and short implants have made it possible to place implants in areas with limited bone height, further reducing the need for subperiosteal implants (Wagner & Bormann, 2017).

Contemporary Applications of Subperiosteal Implants

Although subperiosteal implants are no longer the first-line treatment for patients with insufficient bone mass, they are still used in specific clinical situations. In cases where bone grafting is not feasible due to systemic health conditions, or in cases of extreme bone resorption, subperiosteal implants may remain a viable alternative. Additionally, in cases of compromised bone volume in the maxillary anterior region, where grafting procedures may be more challenging, subperiosteal implants can provide a more predictable solution (Pistilli et al., 2013).

Furthermore, subperiosteal implants have been used in patients with severe systemic diseases, such as osteoporosis or uncontrolled diabetes, where bone grafting may not be an option due to poor healing potential. In such cases, subperiosteal implants can offer a solution without the need for additional bone augmentation (Lindh et al., 2015).

Conclusion

Subperiosteal implants have played an important role in the history of dental implantology, offering a solution for patients with insufficient bone mass who could not benefit from endosteal implants. However, the development of bone grafting techniques and modern implant designs has led to a decline in the use of subperiosteal.

Versi Bahasa Indonesia

Implant Subperiosteal dalam Kedokteran Gigi Implant

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