COMFOUR Special Issue

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.Hewasrepeatedlyandclearly

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