COMFOUR Special Issue

4 5 IMMEDIATE RESTORATION OF AN UPPER JAWWITH FOUR IMPLANTS USING THE COMFOUR TM SYSTEM Dr. Ferenc Steidl, Sömmerda and Bad Frankenhausen, and MDT Sebastian Schuldes, M.Sc., Eisenach Offering edentulous patients a fixed restoration on four or six implants is not new and has been easily achievable to date using the CAMLOG ® VARIO SR System. In close dialogue with its customers, CAMLOG developed new system components with sophisticated features for the bar abutments. The range was expanded by bar abutments angled at 17° and 30° as types A or B. CAMLOG presented the new COMFOUR ™ System components to VARIO SR users and made the components available to users for the clinical test phase. The therapeutic concept underlying the following case report is a temporary immediate restoration after extraction of non-preservable and periodontally compromised teeth in the upper jaw on four implants, based on the concept developed by Professor Paolo Maló [1, 2, 3], using the new components of the COMFOUR ™ System. For the long-term success of an immediate resto- ration, the experience of the clinical team com- prising the surgeon, prosthodontist, and dental technician is of critical importance. Thorough preliminary examinations and carefully determi- ning the indication, knowing how to handle the system components, and positioning the implants to obtain a sufficiently large load polygon without damaging the anatomic structures are criteria that must be met. The implants inserted for an imme- diate restoration must have a high degree of pri- mary stability and must be splinted or blocked. If these criteria are met, the concept provides a safe and predictable treatment outcome using only a single surgical procedure. The initial findings The 37-year-old patient, smoker, came to our practice in January 2015 after referral by his dentist. The initial intraoral situation was char- acterized by a inadequate plastic clasp-retained denture and periodontally compromised teeth in the upper jaw. Despite therapy that was promptly initiated, no significant improvement could be seen. The highly mobile teeth could not be pre- served.The patient expressed a wish for a permanent fixed restoration and a considerable improvement in the esthetic appearance. It was equally impor- tant to him to have a temporary fixed denture during the healing phase of the implants. After a meticulous case analysis and a diagnostic setup, we discussed our therapeutic concept with the patient. The concept is based on the Maló Clinic protocol. In our practice it has proven itself to be an outstanding concept following extraction of non-preservable teeth combined with immediate implantation and an immediate, fixed, temporary restoration with a reduced number of implants in the edentulous jaw. The preoperative phase After a thorough explanation for the patient and making the decision, we prepared the following treatment plan: • Professional teeth cleaning with deep scaling in the lower jaw • Guided surgery after three-dimensional implant planning and template preparation • Fabrication of a long-term temporary restora- tion using CAD/CAM high-performance polymer • Extraction, implantation, and immediate restoration on the bar abutments from the COMFOUR ™ System in one treatment session under general anesthetic For the preparation of a scanning template, we made an impression of the upper and lower jaws in February 2015. The teeth in the lower jaw were professionally cleaned by a dental hygienist inclu- ding deep scaling, and the tooth color was deter- mined for the maxillary restoration. The fabrication of the temporary restoration Because the setup met the esthetic and function- al requirements, it was converted into polymer with added barium sulfate using the “backward planning” procedure [4, 5]. In order to visualize the prosthetic tooth axis in the DVT data set, holes were drilled through the radiopaque teeth in this axis (see Fig. 8) . The DVT imaging was carried out in the practice. The digital data were fed into the implant plan- ning system and the optimal implant position and length were determined, taking into ac- count the anatomic structures and the prosthe- tic requirements (Fig. 5) . The prerequisite for a successful outcome using this treatment con- cept is achieving a sufficiently large support for the restoration. The positioning of the dorsally angled implants is a critical requirement for the success of this treatment concept (Fig. 6) . After the 3D planning, a precise drilling template was prepared in the laboratory for fully guided surgery using the guide sleeves from the CAMLOG Guide System. The template should be stably fixed intraorally over the natural teeth and the palate. In order to precisely position the angled bar abutments of the COMFOUR ™ System the indexing of the inner implant configuration must be aligned with the marking on the guide sleeve. After pre- paring the template, the plaster teeth were re- moved and we used the drilling template for model implantation. The model was ground away around the im- plants taking the axis alignment into account (Fig. 7 and 8) . Figure 9 shows the use of the aligning tool that is placed on the Guide inser- tion aid for precise positioning of the cam in rela- tion to the 17° and 30° angled bar abutments. The lab analogs screwed onto the CAMLOG ® Guide insertion posts were fixed in the model, corresponding to the aligning tool (Fig. 10 and 11) . Near the lateral incisors, we insert- ed 17° and 30° angled bar abutments in regions 15 and 25. The abutments were supplied pre-mounted on an insertion handle. This handle makes the positioning of the short bar abutments easier and ensures that the screwdriver has free access to the abutment screw (see Fig. 28) . Fig. 6: Optimal use was made of the original jaw bone thanks to angled implants. Fig. 5: Taking the anatomic structures into account, the implant positions were planned virtually. Fig. 4: The dentition in the lower jaw: Free-end situation on the left and a shortened row of teeth in the 4th quadrant. Fig. 1: The patient presented in the dental practice with an inadequate denture. Fig. 2: The current oral situation shows periodontally compromised and non-preservable teeth. Fig. 3: The model of the situation in the upper jaw was prepared by etching tooth 22 for the creation of a Guide template. Fig. 9: The lab analogs were screwed in using the Guide insertion aid and the loose fit was checked in the model. Fig. 8: The implant areas were ground away for insertion of the lab analogs. Fig. 7: To prepare the pre-fabricated immediate restoration, the anterior teeth were etched for bridge retention. Fig. 10: With the help of the aligning tool of the COMFOUR ™ System, the inner configuration of the implant can be aligned. Fig. 11: The extension of the aligning tool shows the screw channel of the prosthetic restoration. CASE STUDY CASE STUDY