COMFOUR Special Issue

now the COMFOUR

™

System, regarding sourc-

es of error. We were therefore able to resolve as a

team all those surgical and prosthetic difficulties

that arose.

MDT S. Schuldes,

M.Sc

When providing

treatment using the Maló concept, you must un-

derstand the principle and have a precise under-

standing of the prosthetic challenges you will face.

Pre-implantation planning taking into account

the surgical and prosthetic requirements is given

special priority. Computer-aided, three-dimensional

planning in the form of backward planning has

proven its worth here. The implants can be posi-

tioned in the planning software in the precise 0°,

17°, or 30° angle relative to one another. From the

prosthetic perspective, it is particularly important

to position the implants so that the screw chan-

nels of the screw-retained immediate restoration

– but even more importantly those of the subse-

quent definitive restoration – do not negatively

impact either the esthetics or the function.

On this basis, we then fabricate a CAD/CAM bridge

from a polymer that is bonded free of tension in

the mouth of the patient following the fully gui-

ded insertion of the implants using the CAMLOG

Guide System. In our opinion, this procedure in-

volves considerably fewer compromises than the

traditional procedure in which impressions are tak-

en of the inserted implants intraoperatively and a

temporary restoration is then prepared using cold-

curing acrylic resin.

How often did something go wrong?

Dr. F. Steidl:

The implant loss rate during the

healing phase with VARIO SR in our patient pop-

ulation does not differ significantly from that of

other implant treatment modalities. We will defi-

nitely be able to maintain this success rate using

the COMFOUR

™

System. The COMFOUR

™

System

offers us even more treatment options. We do not

consider there to be an increased risk associated

with fully guided, immediate temporary restora-

tions after 3D planning.

Tricky and important is the question regarding

the reproducible fixation of the drill templates in-

traorally if provisional implants are not used. We

had a considerable learning curve in this area go-

ing from fixation by the assistant to osteosynthesis

screws to multiple template operations.

MDT S. Schuldes,

M.Sc

As already mentioned,

thorough planning prior to the implantation is

very important. A fracture in the immediate resto-

ration can also lead to complications during the

osseointegration. In light of this, materials with a

high fracture toughness should be used. This is the

only way to reduce failures to a minimum.

You actively participated in the develop-

ment of the new angled bar abutments

in the COMFOUR

™

System and even

treated some of the first patients with

this system. Could you describe your

impressions of the implementation

from a surgical and technical perspec-

tive, and what are the differences to

VARIO SR?

Dr. F. Steidl:

From a implant surgery perspective,

nothing has changed in the treatment sequence.

The insertion of the angled bar abutments is fun.

This is because of the handle that ensures safe

transfer of the abutments into the mouth and

makes correct alignment easier. The flexibility of the

handle and the help of the sophisticated screw-

driver means that the abutment screws can be

screwed in without any difficulty.

MDT S. Schuldes,

M.Sc.

The 17° and 30°

angled bar abutments in the A and B versions

with various gingival heights provide a generous

leeway for the treatment. All the components of

the COMFOUR

™

System have a slender design

and low profile. This makes the prosthetic resto-

ration considerably easier. For improved soft tissue

augmentation, the new design of the abutment

with the “bend” makes itself felt. Thanks to the

impression posts and the titanium caps with the

anti-rotation mechanism, occlusal screw-retained

single-tooth and telescope restorations at the

abutment level are also possible.

If the implants are not inserted under full guidance,

the new aligning tools to make fine adjustments of

the rotation cams during implantation are an excep-

tional tool.

Will this type of therapy establish itself

extensively in practices?

Dr. F. Steidl:

Certainly not extensively. Angled

implantation, where necessary also with an imme-

diate restoration, is surgically, prosthetically, and

technically demanding. I therefore believe that

practices and clinics with a focus on implantology

should at least carry out the surgical part.

For general practitioners, the COMFOUR

™

System

is an interesting option if they are involved

in prosthetics. To be able to rehabilitate an

edentulous patient not just dentally but also

often psychosocially in a single treatment session

without repeated impression taking or fittings is

an inspirational therapeutic tool.

Thank you for the interview.

[1] Ledermann, P., D.: Über 20-jährige Erfahrung mit der sofor-

tigen funktionellen Belastung von Implantatstegen in der Regio

interforaminalis. Z Zahnärztl Implantol 12, 123–136 (1996).

[2] Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina 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;142:310–320.

[3] Schley J-S, Terheyden H, Wolfart S. Implantatprothetische

Versorgung des zahnlosen Oberkiefers S3-Leitlinie AWMF-Regis-

ternr. 083–010: DZZ 08/2013.

[4] Crespi R, Vinci R, Capparé P, Romanos GE, Gherlone E. A cli-

nical study of edentulous patients rehabilitated according to the

"all on four" immediate function protocol. Int J Oral Maxillofac

Implants. 2012 Mar-Apr;27(2):428-34.

The concept popularized by Professor

Paulo Maló for occlusal screw-re-

tained immediate restorations requires

at least four implants in the edentulous

lower jaw and edentulous upper jaw.

The Implantology Consensus Con-

ference recommends six implants in

the lower jaw and eight implants in

the upper jaw for fixed restorations.

Dr. Steidl, what should guide the

clinician’s choices here?

Dr. F. Steidl

: The Consensus Conference draws up

principles or guidelines for implantology treatment.

In our opinion, these form a therapeutic corridor

with flexible limits which vary depending on the

individual situation of a patient and/or clinician.

For example, the “one implant per tooth” concept

favored and publicized by some colleagues for

fixed restorations with eight implants in some cas-

es and ten or twelve in others must be mentioned.

This is contrasted by fixed reconstructions with

four implants, which is a therapeutic option that

saves both effort and costs.The scientific foundation

of these treatment strategies ranges from studies

conducted by P. Ledermann on immediate restora-

tions on four implants in the interforaminal region

in the lower jaw [1] to studies by Professor P. Maló

with obliquely inserted distal implants in the up-

per and lower jaws [2]. The current S3 guidelines

from the DGI/ DGZMK (AWMF REGISTER NO. 083-

010) do not include any recommendations for or

against the Maló concept [3]. The authors believe

this to be a highly promising approach.

We consider the Maló treatment method to be a

valid concept for fixed immediate oral rehabilitation

in our practice and clinic [4]. Consequently, we

provide a full 5-year warranty for restorations

using the COMFOUR

™

System, as we do for other

implant treatments.

Many years ago you and your team

started to treat your patients using

this concept. How steep was the learn-

ing curve for this type of treatment?

Dr. F. Steidl:

Like every new therapeutic

approach, there are details of the surgery and den-

tal prosthesis that are only worked out over many

treatments. What was surprising to us, however,

was the tolerance of the VARIO SR System, and

CAMLOG has worked closely with its customers and invested in new machinery in order to expand the range of bar abut-

ments by adding angled versions with a slender, pointed design. This new system is called COMFOUR

™

. Dr. Ferenc Steidl

and MDT Sebastian Schuldes

M.Sc

., users during the test phase, were asked by the logo editorial team about their

impressions of and their first experience with the new system.

FIRST EXPERIENCE WITH THE COMFOUR

™

SYSTEM

LITERATURE

PRODUCTS