Published 6/29/2026.
Yotom Rabinowitz, DDS, Thomas Lee, MD
In this complex maxillofacial reconstruction case, we demonstrate a jaw-dropping alternative to massive bone grafting. Watch as Dr. Robinowitz and Dr. Lee manage a patient presenting with severe panfacial fractures and highly atrophic mandible. Instead of subjecting the patient to extensive autologous bone grafts or a microvascular free flap, we utilize custom KLS Individual Patient Solutions (IPS) preprosthetic subperiosteal implants for dental rehabilitation.
By leveraging the remaining vertical and horizontal skeletal buttresses of the face for remote anchorage, this technology allows for successful, immediate dental rehabilitation in patients with severely suboptimal bone stock.
What you’ll see in this video:
Pre-operative CT analysis of panfacial trauma.
Patient Selection: Contraindication & Indications for Preprosthetic Implants.
Step-by-step subperiosteal dissection and custom cutting guide stabilization.
Transbuccal approach for secure posterior hardware fixation.
Intraoperative management and neurorrhaphy of mental nerve.
The immediate prosthetic pickup process and immediate loading protocol using multi-unit abutments.
Authors: Yotom Rabinowitz, DDS, Thomas S. Lee, MD
Affiliations:
Department of Oral and Maxillofacial Surgery, Virginia Commonwealth University (Richmond, Virginia, USA)
Department of Otolaryngology, Virginia Commonwealth University (Richmond, Virginia, USA)
Rehabilitating patients with severe panfacial trauma and concurrent maxillo-mandibular atrophy presents a significant clinical challenge. Traditional endosseous dental implants typically require extensive horizontal and vertical ridge augmentation or microvascular free flap reconstructions in situations with near total segmental bone loss. This report describes a hardware-guided, state-of-the-art alternative utilizing custom preprosthetic subperiosteal implants (KLS Individual Patient Solutions [IPS]). By utilizing remote skeletal anchorage along the vertical and horizontal facial buttresses, dental rehabilitation can be achieved in a single operative window without autologous bone harvesting.
Virtual surgical planning (VSP) is critical to map out the customized hardware and ensure appropriate vertical restorative dimensions. The ideal prosthetic clearance zones are structured as follows:
Maxilla: 12 to 15 mm
Mandible: 15 to 18 mm
Combined Total: 30 to 35 mm
However, in this case, a total restorative space of 19 mm was achieved due to patient anatomical constraints, and working closely with your prosthodontist is essential to properly accommodate patients with challenging anatomy.
Indications: Patients desiring dental rehabilitation with intact central arches (between the canines) and adequate mucosal coverage are ideal candidates for this procedure. Must have adequate central maxilla or mandible bone present to secure hardware.
Contraindications:
Patients with full-thickness segmental bony defects of the central arch (between the canines) are still best served by a vascularized osseous free flap (often fibula free flap) to minimize the risk of hardware extrusion.
Patients with inadequate mucosa or skin present for adequate bone and hardware coverage are also not ideal candidates. In such situations, additional soft tissue flaps should be performed to provide adequate soft tissue coverage over the hardware and bone.
Step 1. Anesthesia and Maxillary Incision: Infiltrate the maxillary alveolar ridge with 1% lidocaine containing 1:100,000 epinephrine. Utilize a #15 blade to make a full-thickness crestal incision down to bare bone, adding a beveled incision along the lateral aspect. Complete bone exposure using electrocautery.
Step 2. Subperiosteal Dissection: Introduce the sharp end of a #9 periosteal elevator to identify the subperiosteal tissue plane. Reflect the tissue across the anterior arch, crossing the midline to the contralateral side. Extend the dissection superiorly along the anterior maxilla to expose the zygomaticomaxillary buttress, taking care to preserve the mucosal flap without tearing. Along the anterior surface of the maxilla, be aware of the infraorbital nerve.
Step 3. Cutting Guide Adaptation and Predictive Drilling: If pre-existing hardware needs to be removed, identify and remove the hardware first. Next, seat the patient-specific predictive cutting guide firmly against the natural bony contours. Once stabilized without toggle, secure the template bilaterally using self-drilling or self-tapping screws. Utilize the guide channels to drill predictive alignment holes into the medial and lateral buttress segments. For posterior screws where access is restricted, perform a transbuccal approach: make a small stab incision in the cheek skin, pass a blunt instrument to create a fistulous tract, and advance a trocar. Load the cheek guard to safely drill and fixate screws perpendicular to the bone.
Step 4. Alveolar Ridge Reduction: Using a 3 or 4 mm round cutting burr, reduce the excess alveolar ridge through the guide pathways until the bony surface is flush. The cutting guide only helps with buccal bone reduction. This ensures the implant piers will sit in an ideal prosthetic position without bony interference to prevent splaying of piers. Monitor carefully to ensure the reduction does not breach the maxillary sinus floor. Remove the cutting guide.
Surgical Pearl: If the dental piers are not sitting passively against the bone, it will lead to splaying of the dental piers and the dental prosthesis will not fit properly. Ensure adequate bony reduction so that the dental piers will sit passively as designed during virtual surgical planning.
Step 5. Maxillary Implant Seating: Soak the custom implant in a solution of povidone-iodine and diluted chlorhexidine solution (Irrisept) to mitigate hardware infection risks. Seat the implant passively. Loosely engage screws bilaterally into the predictive holes before final tightening to prevent rocking of the implant or displacement.
Step 6. Mucosal Closure: Water-tight mucosal closure is performed using 3-0 Vicryl sutures. Purse string sutures can be placed around the piers to create a tight seal around the implant piers. Additional cuffs of mucosa may need to be released to provide sufficient mucosal advancement in cases of mucosal scar contracture. Buccal fat pads can be draped over the hardware to provide additional soft tissue coverage if available.
Step 6. Mandibular Exposure and Mental Nerve Preservation: Execute a mandibular crestal incision with bilateral posterior vertical releasing incisions. Carefully dissect down to the subperiosteal plane. Identify, dissect, and isolate the mental nerve using a subperiosteal elevator (#9 elevator).
Surgical Pearl: Especially in patients with an atrophic mandible, the inferior alveolar nerve/mental nerve sits in close proximity to the occlusal surface where the incision is being made. The incision should be designed lingual to the mental nerve as it exits the mental foramen.
Step 7. Cutting Guide Installation: The custom cutting guide and plate should be designed to pass carefully around or beneath the mental nerve to minimize mechanical traction.
Surgical Pearl: In more recent cases, hardware is modified so that it is not designed under the mental nerve to minimize nerve traction. Instead, the hardware is designed anterior and posterior to the mental nerve with nothing under the nerve. This means the posterior mandible segment may require a transbuccal approach to get an adequate vector for screw placement. Secure the mandibular cutting guide, drill predictive holes, and then perform the buccal alveolar ridge reduction with a round burr. Excess alveolar ridge is drilled down until the dental piers can sit passively without splaying, which may interfere with dental prosthesis placement. Remove the cutting guide and then secure the custom hardware.
Step 8. Intraoperative Neurorrhaphy (Nerve Repair): In the rare event that the mental nerve is disrupted during hardware mobilization, immediate neurorrhaphy is strongly recommended. Re-align the epineurium and restore continuity using 8-0 nylon sutures in an interrupted fashion (typically requiring 3 knots), mimicking peripheral nerve repair. If the proximal nerve length is insufficient, carefully drill into the mental foramen to expose the nerve and lateralize the proximal stump so that nerve repair can be done without tension. If either nerve ending is damaged, cut back until a healthy bleeding nerve segment is identified. If scar tissue forms from a disrupted nerve end, it decreases successful axonal growth. If tension is present at the repair site, consider a cable graft to preserve tissue perfusion and nerve recovery.
Step 9. Mucosal Closure: Achieve a watertight closure using 3-0 Vicryl sutures. Around the exposed implant piers, place circumferential mattress sutures to tightly adapt the mucosa to the piers, sealing the oral cavity and preventing future hardware exposure. If tissue is tight due to previous trauma scars, create a mucosal flap via beveled undermining to slide the mucosal flap over with minimal tension.
The subperiosteal system transfers loads to the basal bone structure via fused or removable straight multi-unit abutments (MUAs). Removable MUAs are generally preferred to allow salvage and exchange if an unexpected prosthetic screw failure occurs.
Abutment Prep: Secure temporary copings (chimneys) into the MUAs using universal star-grip screws.
Torque Specifications: Tighten the copings with a calibrated driver to exactly 15 N-cm.
Mucosal Field Isolation: Isolate the surgical field around the temporary copings using a rubber dam to prevent excess acrylic resin from pooling onto the healing mucosa. This prevents excess acrylic fusing to the underlying soft tissue. Usage of a rubber dam is strongly recommended for novice surgeons.
Plug Screw Channel: Teflon tape is also placed into the screw channel of the temporary copings to prevent luting material from being displaced into the screw channel.
Prosthetic Pickup: Seat the prefabricated temporary dental prosthesis over the chimneys. Inject a temporary luting composite (e.g., Luxatemp) through the prosthetic chambers and buccal channels.
Finishing: Once the resin cures, remove the Teflon tape, back out the screws, remove the dental prosthesis, and utilize a drill to trim excess flash and smooth out the margins.
Final Delivery & Sealing: Reseat the refined prosthesis and torque to 15 N-cm. Pack Teflon tape into the access channels to protect internal screw heads, and seal the remainder of the chamber with a heavy-body elastomeric material.
Rationale for Heavy-Body Seals: Avoid using composite resin for the outer access seal. Heavy-body materials can be cleanly pulled out by the restoring dentist during maintenance visits, preventing structural damage to the prosthesis caused by drill-out procedures.
Postoperative imaging should confirm complete, passive adaptation of both the maxillary and mandibular custom frameworks against the basal bone contours, with all fixation screws securely anchored into dense skeletal buttresses.
Long-term success relies on maintaining a deliberate hygiene gap between the mucosal base and the prosthetic teeth, establishing a highly cleansable environment.
The occlusion must be adjusted to feature light or minimal heavy contacts, minimizing structural stress and preventing fractures of the provisional framework before transitioning the patient to a definitive zirconia prosthesis.
