## 3 Discussion  
Since 2017, subperiosteal implants have been gaining renewed popularity for the rehabilitation of maxillary atrophies [18; 19; 20; 21; 22; 23; 24; 25; 26; 27; 28; 29; 30; 31]. This increased attention has been based on the possibilities introduced by CAD/CAM technology, which allows for the attainment of implants that precisely fit the bone surfaces. Moreover, the introduction of the technique of rigid fixation on the maxilla's resistance pillars has enabled a balanced distribution of the masticatory forces on the osteosynthesis screws, making the contribution to the stability provided by the alveolar bone less important [19; 21; 32]. This provides the rationale for the use of subperiosteal implants in patients undergoing maxillary resection without reconstructing the crestal bone lining. [PERSON] et al. [23] and [PERSON] et al. [26] have previously reported two cases of the secondary reconstruction of the maxilla with subperiosteal implants. These two patients had wide oroantral communications and the subperiosteal implant, positioned without being covered with local or distant flaps, had the dual function of rehabilitating the patient from a prosthetic point of view, and provided support to the palatal obturator. [PERSON] et al. [25] reported their experience with four patients, primarily reconstructed with a free fibula flap and subsequently rehabilitated with custom-made subperiosteal implants. The largest series of secondary reconstructions was published by [PERSON] et al. [27] and includes 19 patients who had undergone maxillectomy and reconstruction with microvascular flaps which had subsequently failed. According to [PERSON] et al., middle-third reconstructions after cancer resection should always include a fixed prosthetic rehabilitation and correct soft tissue support, which both enhance definitely the quality of life of these patients. In this sense, subperiosteal customized implants, in combination with soft tissue flaps to reconstruct the oronasal layer, could speed up the reconstructive process, in comparison with free bone flaps in combination with conventional endosseous implants [24; 27]. The surgical time, donor site morbidity, osseointegration time, and ease of reconstruction have, in fact, an incomparably smaller effect. This case report demonstrates how in selected cases, when even fascio-cutaneous free flaps are not feasible and it is necessary to fall back on local reconstructive solutions, the simultaneous adoption of a subperiosteal CAD/CAM titanium implant with a dental connection can provide the patient with the possibility of an implant-prosthetic rehabilitation prosthetic and, at the same time, adequate support for the soft tissues of the middle-third of the face. Additionally, implant connections can provide solid support for palatal obturators where oroantral communications are present. In this way, it is possible to reduce considerably the size of the obturator, making it more comfortable, and guaranteeing, at the same time, a much more watertight closure of the oroantral communication compared to that provided by mobile devices [33; 34]. This is very important as maxillectomies can negatively impact the patient's quality of life in several ways. Difficulty in chewing and swallowing, speech impairment, and changes in facial appearance can lead to psychological distress and social isolation. Furthermore, the formation of an oroantral fistula, which allows the passage of food from the mouth to the nose, can cause further discomfort and embarrassment [35; 36]. In this report, the possibility of performing a primary reconstruction with subperiosteal implants and local flaps is described in patients who cannot undergo reconstructions with bone flaps. In the design of the implant, some critical points must be considered. First, the bone resection must be carefully planned through an assessment of pre-operative investigations, ensuring radical excision of the tumor.