COMFOUR Special Issue

8 9 After the alveolar ridge incision and the flap formation, the three molars were extracted and the wisdom tooth 18 was extracted using osteotomy (Fig. 34) . Sufficient autologous bone chips were harvested in the process,which were then ground in the bone mill and mixed with xenogenous bone substitute material (Bio-Oss ® , Geistlich) [7] to augment the bone defects identified virtually beforehand. We covered the augmentation ma- terial with a resorbable collagen membrane (Bio- Gide ® , Geistlich) and closed the soft tissue with individual button sutures (Fig. 35 to 37) . Insertion of the immediate temporary restoration To prevent the polymer entering the screw channels of the titanium caps, we covered these prior to polymerization with cotton pellets and then “adhered” the temporary restoration tension free (Fig. 38 and 39) . The patient left the practice on the day of the surgical procedure with a screw- retained, temporary, fixed denture and detailed instructions on food intake. This means a diet con- sisting of only soft foods for the first two weeks and in the subsequent four weeks slowly shifting to more solid food. During the procedure the patient was administered 1000 mg amoxicillin as antibioticprophylaxis.Hewas repeatedlyandclearly instructed to abstain from nicotine as much as possible in the postoperative period. Figure 40 shows soft tissue completely free of signs of irritation just a few days after surgery. After two weeks the sutures were removed. A follow-up radiograph was prepared and the occlu- sion of the temporary restoration was checked and minor corrections were made (Fig. 41 and 42). Conclusion The screw-retained, fixed reconstruction on four implants is a treatment concept that reduces both effort and costs. Immediate temporary restoration using the Maló Clinic protocol has been scienti- fically documented. Pre-implantation planning taking into account the surgical and prosthetic re- quirements is given special priority. With the help of 3D planning in the form of backward planning [8], implants can be positioned in the software in the precise angle (0°, 17°, and 30°) relative to one another, and the screw channels do not have any negative effects on either the esthetics or the function. The new COMFOUR ™ System is highly suitable for using with this treatment concept [9]. The angled bar abutments are available in different gingival heights and as type A or B. The insertion of the abutments in the correct position is safe and easy using the attached handle. To screw the abutment screws in, the flexible handle can be simply pushed to one side. The new design of the bar abutments, which omits the bend, has a positive effect on the soft tissue augmentation. An additional feature is the align- ing tools that are helpful for precisely positioning the cams. The concept is exceptionally well suited for providing edentulous patients with fixed, im- mediate temporary restorations in one surgical procedure. [1] Maló P, de Araújo Nobre M, Lopes A, Moss SM, Molin GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142(3):310−20. [2] Sheng L, Silvestrin T, Zhan J, Wu L, Zhao Q, Cao Z, Lou Z, Ma Q, Replacement of severely traumatized teeth with immediate im- plants and immediate loading: literature review and case reports. Dent Traumatol. 2015 Jul 14. doi: 10.1111/edt.12201. [3] Agliardi E, Panigatti S, Clericó M, Villa C, Maló P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: interim results of a single cohort pros- pective study. Clin. Oral Impl. Res. 21, 2010; 459–465. [4] Ackermann KL, Kirsch A, Nagel R, Neuendorff G. Mit Backward Planning zielsicher therapieren. Teil 1: Implantat-prothetische Be- handlungsbeispiele teamwork J Cont Dent Educ 2008: 466−484. [5] Kirsch A, Nagel R, Neuendorff G, Fiderschek J, Ackermann KL. Backward Planning und dreidimensionale Diagnostik, Teil 2: Scha- blonengeführte Implantation nach CT-basierter 3D-Planung mit sofortiger Eingliederung des präfabrizierten Zahnersatzes – ein erweitertes Backward Planning-Konzept. teamwork J Cont Dent Educ 2008: 734−754. [6] Maló P, de Araújo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil. 2015 Aug;42(8): 615-23. doi: 10.1111/joor.12291. Epub 2015 Mar 10. [7] Pang C1, Ding Y, Zhou H, Qin R, Hou R, Zhang G, Hu K. Al- veolar ridge preservation with deproteinized bovine bone graft and collagen membrane and delayed implants. J Cra- niofac Surg. 2014 Sep;25(5):1698–702. doi: 10.1097/ SCS.0000000000000887. [8] Venezia P, Lacasella P, Cordaro L, Torsello F, Cavalcanti R. The BARI technique: a new approach to immediate loading. Int J Est- het Dent. 2015 Autumn;10(3):428–43. [9] Randelzhofer P, Cacaci C. Verschraubte Lösung - implantatge- tragene Restauration im zahnlosen Oberkiefer. teamwork J Cont Dent Educ 2011: 294−300. LITERATURE Fig. 31: The titanium caps were screwed onto the bar abutments. Fig. 32: To check the esthetics and occlusion, the provisional PMMA bridge was inserted… Fig. 33: … and the tension-free fit around the titanium caps was checked. Fig. 37: The augmentation material was covered with a resorbable membrane (Bio-Gide ® , Geistlich). Fig. 39: The titanium caps of the COMFOUR ™ system were polymerized free of tension in the immediate temporary restoration. Fig. 38: Using individual button sutures, the soft tissue was closed, and the screw channels were covered with cotton pellets prior to the cold-cure polymerization. Fig. 34: The remaining teeth were extracted and the osteotomy of the displaced wisdom tooth was carried out. Fig. 35: The bone chips obtained during the osteotomy were ground and mixed with bone substitute material (Bio-Oss ® , Geistlich). Fig. 36: The virtually identified bone deficits were augmented with the bone mixture. Fig. 40: At the follow-up three days after the surgical procedure, the soft tissue was free of inflammation and well adapted. Fig. 41: The follow-up radiograph shows the angulated, well-anchored implants with the angled COMFOUR™ bar abutments. Fig. 42: The occlusal screw-retained temporary restoration forms an harmonious and esthetic lip line. CASE STUDY CASE STUDY