COMFOUR Special Issue

IMMEDIATE RESTORATION OF AN UPPER JAWWITH

FOUR IMPLANTS USING THE COMFOUR

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