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I 21 clinical technique _ TRIPOD I CAD/CAM 3_2011 might also consider changing from drills to bone spreaders; this would compact the surrounding bone and provide additional stability to the corresponding implant. Finally, the implant could be adapted to a re- cipientsitebychoosinganappropriatediameter,length and even profile (e.g. from conical to conical-cylindri- cal)oncesitepreparationhasalmostbeencompleted. The previously placed implants provide not only useful precision to implant site preparation with the guide,butalsoessentialstabilitytoimmediatelyloaded bridgeworkinanareawherestabilityintheinitialheal- ingphaseisprobablyvitaltosuccess.Mostpatientsare alreadyolder,withahistoryofperiodontitis,toothloss and associated impaired medical conditions, and pos- sibly reduced healing capacity. Therefore, it is of major interesttobeabletoassessthehealingcapacitybythe stability of previously placed implants, before under- takingafull-archmaxillarybridgeimmediatelyloaded on implants, preferably with advanced surface tech- nology. Most of the cases require some sort of bone graftingintheposteriorareasandthistechniqueleaves time for initial healing before occlusal loading. In fact, someoftheimplantscouldbesubjectedtoimmediate loading, while others—the most critical in terms of bonevolumeavailabilityandlocation—couldbeloaded according to a classical schedule. This should be con- sidered when making a comparison with other pro- cedureswithsurgicalguides. TheINICELLsurfaceofThommenMedicalimplants showed more bone-to-implant contact and a higher removaltorqueattwoweeksthanunconditionedim- plantsdid.15 Thisaspectshouldbeparticularlyusefulin the early stages of healing and providing additional stabilityinthiscrucialphase.Inaddition,thiscompany provides implants of various diameters, length and profiles to satisfy various implant site requirements andwhichprovidethebestpossiblestability. _Conclusion The TRIPOD protocol is based on our latest clinical experience.ItutilisesCBCTandthevastdevelopments of implant placement planning software and com- puter-guided implant dentistry. The efficiency of the techniquemuststillbevalidatedbyanalysisofimplant survivalindifferentclinicalenvironments,specifically investigating adequate positioning between planned and final implant position, and the need to verify the surgical guide after the learning process has been completed. Finally, a study on patients’ satisfaction withtheprocedureintermsofpainandaestheticout- come needs to be performed. We must still determine whether the benefits of open flap surgery in combi- nation with surgical guides outweigh the related dis- comfort and pain for the patient: does this pose a major problem for patients, is the final aesthetics im- provedbypreservingkeratinisedtissue,anddoessuch a technique fulfil expectations, considering that bone volumelossisoftendifficulttolimitintheseareas? The proposed TRIPOD procedure is certainly more labourintensivethancurrentflaplessguidesystems, since a flap has to be raised and no definitive pros- thesis is placed right after surgery. Nevertheless, it is also more versatile because maintaining or increas- ing bone volume is considered in the treatment plan andisadaptedtotheindividualsituations.Theriskof failureisconsiderablyreducedbyconnectingimme- diately placed implants to osseointegrated implants. Furthermore, this procedure allows use of the last millimetre, as typical cases show reduced bone vol- ume and require the widest and longest implants within anatomical restrictions. Although knowledge and close collaboration with the laboratory techni- cian are required, this procedure adds fundamental security and predictability for success, and can cer- tainlybeadaptedtodifferentpracticesituationsand one-day procedures._ Editorial note: A complete list of references is available fromthepublisher. Figs. 13a & b_Initial provisional bridgework in place. Dr Jean-Nicolas Hasson 5 Rue duWerkhof 68100 Mulhouse France hasson@hrnet.fr CAD/CAM_contact Fig. 13a Fig. 13b