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I 27 case report _ guided surgery I CAD/CAM 3_2013 plastic was used (Figs. 21 & 22). Careful polishing is required to keep plaque deposits as low as possible. ThebondinggaparoundVarioSRtitaniumcapsshould besizedfortension-freeintra-oralbonding(Fig.23). _Surgical procedure The one-piece diameter-reduced implants were explanted (Figs. 24 & 25). The drilling template was secured using four osteosynthesis screws (Fig. 26). These provided adequate stability and safety for guided implantation. In order to correctly align the insertion posts, corresponding markings were milled into the CAMLOG Guide guiding sleeves in the laboratory (Fig. 27). Implantation was flapless using the CAMLOG Guide System gingival punch (Fig. 28). The implant bed was prepared accurately with the CAMLOG GuideSystemanddepthreferencedwithdrillsofas- cendinglengthsinanintermittentdrillingtechnique (Fig. 29). After a central implant had been inserted, aterminalimplantwasinserted(Fig.30).Thesecond centrally positioned implant was then placed and thesecondterminalimplantthereafter(Figs.31–34). _Seating the immediate restoration After removing the CAMLOG Guide insertion posts, the Vario SR abutments were inserted at 20 N cm (Figs. 35 & 36). The Vario SR titanium caps wereshortenedtotherequiredlength,placedonthe Vario SR abutments and mounted with the Vario SR prosthetic screw (Fig. 37). The immediate resto- ration fabricated pre-implantation could then be bonded in the mouth tension-free (Figs. 38–41). _Discussion The procedure demonstrated here, which follows the All-on-4 technique taught by Paulo Maló from Lisbon, led to the complete disappearance of the severe facial pain about two months post-operatively. The immediate prosthetic restoration was highlighted inparticularinthepatient’sevaluation.Thisresultedin an immediate improvement in mastication, speech function, food intake and quality of life. Remission of neuralgiform symptoms protracted over two months afterseatingofthefixedprosthesisandcorresponding loadreliefofthementalforamen. This case illustrates the failure of a number- reducedimplanttreatmentconceptintheadvanced atrophied mandible and the potential of purely implant-supported prostheses to avoid pressure- induced neuropathies. The mandibular restoration was converted into a removable bar-retained su- perstructure (Figs. 42 & 43)._ Fig. 26_Fixation of the drilling template using four osteosynthesis screws. Fig. 27_The fixed drilling template. Fig. 28_Gingiva punching. Fig. 29_Implant bed preparation with the CAMLOG Guide form drill. Fig. 30_Positioning of one central and one terminal implant. Figs. 31 & 32_Implant bed preparation and insertion of the final implant. Fig. 33_All four SCREW-LINE implants CAMLOG Guide in the defined final positions. Fig. 34_Detailed view of the precisely maintained cam alignment. Figs. 35 & 36_The Vario SR abutments were inserted (Fig. 35) at 20 N cm (Fig. 36). Fig. 37_The Vario SR titanium caps were shortened according to the prosthetic unit. Fig. 38_Check of the tension-free seating of the immediate restoration on the Vario SR titanium caps. Fig. 39_The surgical procedure was stress-free and controlled. Fig. 40_A dual-hardening luting composite (combo.lign, bredent) was used for intra-oral bonding of the immediate restoration. Fig. 41_A final photograph of the immediate restoration in the mandible. Fig. 42_The final restoration was milled from a zirconium oxide bar. Fig. 43_The final mandibular restoration. Dr Ferenc Steidl obtained his degree in dentistry in 1996 from Friedrich Schiller University in Jena in Germany. He subsequently undertook specialist training in oral surgery in Bietigheim-Bissingen and at Diakonie Hospital in Schwäbisch Hall in Germany.He has been practising implant dentistry since 1997.In 2001, he qualified as a specialist in oral surgery through the Baden-Württemberg Federal Chamber of Dentists (LZK) in Germany.He is a member of the German Society of Dental,Oral and Craniomandibular Sciences (DGZMK),German Federation of Oral Surgeons (BDO),German Association of Oral Implantology (DGI),Academy of Oral and Maxillofacial Surgery (AGKi),German Society of Periodontology (DGP),and Central German Association for Dental Implantology (MVZI). In 2008,he became a fellow of the European Board of Oral Surgery (European certification).Dr Steidl works at a group practice for maxillofacial surgery in Sömmerda and Bad Frankenhausen in Germany. Praxis Dr Ferenc Steidl DRK Manniske Krankenhaus An derWipper 2 06567 Bad Frankenhausen Germany Tel.:+49 3634 317387 info@praxis-steidl.de www.dr-steidl.de Sebastian Schuldes,MDT, undertook dental technician training from 1991 to 1995, and qualified as a master dental technician in 1999.In 1999 and2000,hepursuedcontinuing education for business administration in trade.In 2004, he helped establish the Cercon technology centre. He obtained a Master of Science degree in 2008. Dental-Labor Schuldes Johann-Sebastian-Bach-Str.2 99817 Eisenach Germany Tel.:+49 3691 203950 info@zahn-neu.de www.zahn-neu.de cosmeticdentistry_about the authors