Immediate mandibular rehabilitation with only 3 implants and a prefabricated titanium bar.

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Posted on By José Ferreira In Implants

This video try to show the workflow for a new cutting edge technic for immediate rehabilitation of the mandible with a prefabricated adaptive titanium bar using only 3 implants. This new technic saves a considerable amount of chair time for the surgeon and patient allowing the delivery of the final prosthesis in the same chair time of the surgery. This treatment also turns the implant rehabilitation available for more people as the final price of the rehabilitation drops considerably.


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Nice video. Thanks for sharing. What are the advantages of this technique? Dr. Salama


thank you for the question Dr. Salama.
Lets see if I can resume it. I will try to tell all the advantages according to my personal opinion:

1-Less chair time for patient and Dr., not only in surgical time but in number of appointments;

2- the use of only 3 implants makes it more affordable for the patient and less costly for the Dr. Its also better for the patient do do the hygiene.

3- High acceptance of the patient. The patient loves the fact that all the procedure could be over in 6 or 7 hours, including the final prosthesis.

4- High level of predictability as the planning (DTX Studio implant) its very exact (fig. 1) and, at the end, its a guided surgery with all the well known advantages: predictability of implants and final prosthesis, safeness, less surgical time, perfect positioning of the implants, reduction of surgical accidents. The planning also able us to have an exact measurement of the needed osteotomy (fig 2).

5-Using the same final prosthesis if, in the future, you need to substitute an implant. Imagine that the patient have problem on one implant. You can take the prosthesis and the implant out and use, for example, 2 locaters abutments on the other 2 implants. After the normal time that you find appropriate to do a new implant you will have the stander Trefoil surgical guides to help you put the implant in the same place and you can use the same final prosthesis.

6-High levels of longevity. This technic (Trefoil technic) it not an "adventure". The bases were made by Prof. Branemark in around 1990 and it was called Novum. There are literature presenting very high levels of longevity. The problem was the technology of the bar that was to complicated. This enhancement of the bar was developed and there are also literature confirming the same longevity results.

7- Its an exciting new way of mandibular rehabilitation and I personally love to do it!

exact planning
Osteotomy measurement


Do you have clinical follow-up data(how long on how many prosthesis and most important are these opposing natural teeth or denture cases) on the performance of these All on 3 Fixed denture? Also do you adhere to the prosthetic limitation on the A-P spread at 1.5 x width at the distal most implants?
I had the opportunity to place 2 transmandibular implants while in residency.The hardware(drilling jig) is very similiar to the old 5 or 7 pin transmandibular implants used for overdentures.


Thank you for the question Dr. Bistritz.

The clinical follow-up it the most fundamental thing, no doubts about it. Like I said before, this is not a "adventure" or some "crazy" experimental surgery. The 3 large diameter implant rehabilitation was first created and studied by Prof. Branemark him self. He started the Novum Protocol in 1990. The Novum system came out for the market in 2001(fig 2), by Nobel Biocare, and since then there were numerous studies confirming high results of success and longevity like for example an 2014 article called "Stress analysis of different configurations of 3 implants to support a fixed prosthesis in an edentulous jaw" by João Paulo da Silva-Neto,Marcele Jardim Pimentel and others that concludes, and I quote " The use of 3 wide implants presented lower stress values compared to the standard 5-implant technique".

The new protocol called Trefoil, is an enhancement of the old Novum, and it was studied and optimized by Kenji Higuchi, Rubén Davó, Glen Liddelow, Massimo Albanese, and Rubén Rosenberg in a multi center study in 4 continents during 5 years. At the end, they have made the first presentation of their study in the EAO congress in 2017 "An adaptive prefabricated full-arch framework on three implants in the mandible: preliminary results".
The study included 110 patients(330 implants). The implant survival rate at 6 month were 98,2 and 97,6 at the end of one year. (fig 1).

Dr Lucio Faria and I we have made about 18 cases, 2 of the in the company of Prof. Alexander Salvoni, and we didn't had any major problem until now. We have only started about one year so we only have a follow up of 1 year in the first cases. Of cours, we have the Novum long term results and they have 20 years. The Trefoil system its the same as Novum in everything including the guides created by Prof. Branemark. The only change its the new amazing adaptive titanium bar.

Do you remember when the All-on-Four concept started?

Trefoil results
Branemark Novum


The All on four was initially looked at By P.I.Branemark as you referenced. I believe the first "4 implant fixed prosthesis in the edentulous jaw" data set was published in 1977. Then early 1990's the first "angulated four implant fixed prosthesis" data was published. The "angulated distal fixture modification" data set was first published by Paula Malo et al in 2003.

Does the dentures distal extension length follow the prosthetic proportion of 1.5 x the arch width at the distal 2 implants?


Thank you for this another very good question Dr. Bistriz and for the interest in the case.

Well, the implant spread (in millimeters) can be multiplied by 1.5 (to 2.5) to give us a guideline of the acceptable length of a distal cantilever (Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:149).

In this system, the "implant spread" is 8.7 and the "bar spread" is 14.5, with a factor of 1.67 which I think its very reasonable. I am also sending a schematic drawing of the bar with the measurements.

In respect of the All-on-Four, I just refer it because a couple of months ago I have heard Paulo Malo saying that when he started the concept in 1998, and even after the publication of 2003 it was very difficult for most of the people to accept it and trust on it. Now it one of the most documented and used rehabilitation technic in the all world. I have the feeling that the same will happen with this Trefoil technic and thats why I talked about it (All-on-four).

Implants/bar spread


The successful clinical outcome of the prosthetic reconstructions is confirmation that the ratio is well tolerated when used with the prefabricated bar system. Very nice technique and system.


Thank you very much for your comment and interest Dr. Bistritz.