Restorative driven implant solution

Inclusive®

Restorative Driven Implant Solutions

A publication of Glidewell Laboratories

Vol. 1, Iss. 1

Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edenulous Arches with the All-on-4 TechniqueIn this case report, Dr. Irfan Atcha details the process and ben-efits of utilizing digital treatment planning and guided surgery to restore fully edentulous arches using the All-on-4 Technique. Dr. Atcha explains that this technology can be used to rehabilitate a fully edentulous patient in just one appointment.

Screw-Retained Denture with CAD/CAM FrameworkDr. Kenneth Hebel and Victor Rodriguez, CDT, present this photo essay on delivery of a screw-retained denture featuring a preci-sion-milled CAD/CAM framework. In this piece, the clinician offers step-by-step instructions on delivering such a case, complete with details on how to proceed at each appointment.

The Restorative-Driven Surgical PracticeWhat is the “restorative-driven surgical practice”? Dr. George V. Duello describes it as a dentist, specialist or laboratory that uses a menu of services to provide patients and referrals with their implant services. Find out more about Dr. Duello’s philosophy on implant dentistry in this excerpt from a video lecture you’ll find at www.inclusivemagazine.com.

Cone Beam Computed Tomography: Applications in Diagnostic Oral and Maxillofacial Radiology and PathologyDr. Parish Sedghizadeh discusses the benefits and increased utili-zation of Cone Beam CT scanning. Three-dimensional imaging is rapidly becoming the standard of care in dentistry, he explains, and its applications are increasing. Dr. Sedghizadeh also offers a refresher on pathology, as well as a discussion on medical-legal liability and CBCT.

Determining Implant FeesDr. Samuel Strong provides a strategy to help clinicians decide what to charge for their implant cases. Taking into account lab costs, implant component costs and overhead costs, Dr. Strong de-termines: Are you charging too little for your implant cases? Read his fee analysis to find out.

Contents

6

13

30

31

33

22 R&D Corner: Mechanical Testing of Inclusive® Custom Abutments by Grant Bullis

24 Product Spotlight: BruxZir® Solid Zirconia and Inclusive® Titanium Abutments by Dr. Richard Seberg

26 My First Implant by Dr. Michael DiTolla

27 Guided Surgery with Grafting and Ridge Expansion by Dr. Richard Seberg

32 Removable and Digital Treatment Planning Instructions for Use

FEATURES

– Contents – 1

Implant dentistry is one of the fastest-growing fields in our profession. With to-day’s technologies and materials, implant placement is now truly a restoratively-driven procedure. To provide you with the latest information in this field, Glidewell Laboratories is pleased to present this inaugural issue of Inclusive, a new print and online magazine focused on implant dentistry. Inclusive will be a multimedia publication, offering printed articles in this magazine and complementary videos and expanded content online at www.inclusivemagazine.com.

As your laboratory partner, our goal is to provide you with the most up-to-date, practical information available from some of the most knowledgeable, experi-enced educators, clinicians and technicians in the field. From tips on obtaining more accurate implant impressions to the prosthetic benefits of digital treatment planning and guided surgery, we will cover an array of subjects related to implant reconstruction in our new quarterly publication. Included will be reviews of the latest technologies and materials, along with information on how to utilize these tools to provide a higher quality of care to your patients, improve your productiv-ity and increase your profitability.

In our premiere issue, you’ll find an informative photo essay by Dr. Irfan Atcha on “Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Eden-tulous Arches with the All-on-4 Technique.” You’ll also learn about “Cone-Beam Computed Tomography: Applications is Diagnostic Oral and Maxillofacial Radiol-ogy and Pathology” in a piece by Dr. Parish Sedghizadeh, an expert in the field who serves as an assistant professor at the USC School of Dentistry. Also, find out how to determine fees for your overdenture cases in a practice management article by Dr. Samuel Strong.

At Glidewell, we are committed to continuing education. That’s why we offer you the opportunity to earn CE credits by taking the online test that accompanies des-ignated articles. We’ll also provide you with information on how to access other continuing educational opportunities that may be of interest to you.

We are eager to hear your feedback. Let us know what topics, products and proce-dures you would like to see discussed in future issues. We welcome your questions and comments, as well. Contact us at [email protected]

Letter From the Editor

Yours in quality dentistry,

Dr. Bradley C. Bockhorst Editor in Chief, Clinical Editor [email protected]

– www.inclusivemagazine.com –2

Contributors

■ GRANT BULLIS

Grant Bullis, Glidewell Laboratories’ Research & Development Depart-ment Manager, began his career in the dental industry at Steri-Oss in 1997. After Nobel Biocare acquired Steri-Oss, Grant worked in the R&D department, where he was responsi-ble for the development of implants, prosthetics, surgical tools and pack-aging. Today, Grant manages CAD/

CAM, implant product development and manufacturing at Glidewell. Since joining the lab in March 2007, he has obtained FDA 510K clearances for Inclusive Titanium and Zirconia Custom Abutments on six major implant platforms and now directs manufacturing for more than 150 implant laboratory and prosthetic components. Grant has a degree in mechanical CAD/CAM from Ir-vine Valley College in Orange County, Calif., and an MBA from Keller Graduate School of Management. To contact Grant, call 800-521-0576 or e-mail [email protected].

■ IRFAN ATChA, DDS, DICOI, DADIA

Dr. Irfan Atcha graduated from the University of Illinois College of Den-tistry in 1996. Today, he operates a private practice in Dyer, Ind., that focuses on general, cosmetic, seda-tion and implant dentistry. Dr. Atcha owns the Center of Implants, Seda-tion and Cosmetic Dentistry and the No Dentures Chicago Dental Implant Center. He is a Diplomate

of the International Congress of Oral Implantologists and American Dental Implant Association and board of directors member of the American Dental Implant Asso-ciation. An expert on implantology, occlusion and TMJ, Dr. Atcha specializes in one-day implants and lectures across the U.S. Contact Dr. Atcha at www.NoDentures- Chicago.com, [email protected] or 888-416-4109.

■ BRADLEy C. BOCkhORST, DMD

Dr. Bradley Bockhorst is known for his unique perspective, which incor-porates both clinical and industrial backgrounds. After receiving his dental degree from Washington Uni-versity School of Dental Medicine, Dr. Bockhorst served as a Navy Den-tal Officer. Dr. Bockhorst has held positions as Director of Marketing and Education for several leading

implant companies. He is currently Director of Clini-cal Technologies at Glidewell Laboratories, where he oversees Inclusive® Digital Implant Treatment Planning Services and acts as editor in chief and clinical editor of Inclusive magazine. A member of the CDA, ADA, the Academy of Osseointegration, International Congress of Oral Implantologists and the American Academy of Implant Dentistry, Dr. Bockhorst continues to lecture internationally while maintaining a private practice in Mission Viejo, Calif. Contact him at 800-521-0576 or [email protected].

■ MIChAEL C. DITOLLA, DDS, FAGD

Dr. Michael DiTolla is Director of Clinical Education & Research at Glidewell Laboratories in Newport Beach, Calif. Here, he performs clin-ical testing on new products in con-junction with the company’s R&D Department. Glidewell dental tech-nicians have the privilege of rotat-ing through Dr. DiTolla’s operatory and experience his commitment to

excellence through his prepping and placement of their restorations. He is a CR evaluator and lectures nation-wide on both restorative and cosmetic dentistry. Dr. Di-Tolla has several clinical programs available on DVD through Glidewell Laboratories. For more information on his articles or to receive a free copy of Dr. DiTol-la’s clinical presentations, call 888-303-4221 or e-mail [email protected].

– Contributors – 3

PublisherJim Glidewell, CDT

editor in ChiefBradley C. Bockhorst, DMD

Managing editorsJim Shuck, Mike Cash, CDT

Creative direCtorRachel Pacillas

CliniCal editorBradley C. Bockhorst, DMD

Contributing editorGreg Minzenmayer

CoPy editorsMelissa Manna, Kim Watkins

Magazine CoordinatorsLindsey Lauria, Vivian Tsang

graPhiC designers/Web designersJamie Austin, Deb Evans, Joel Guerra, Lindsey Lauria, Phil Nguyen, Gary O’Connell, Rachel Pacillas,

staff PhotograPhers/CliniCal iMagesSharon Dowd, Kevin Keithley, Jennifer Brunst, RDAEF, James Kwasniewski

illustratorsPhil Nguyen

ad rePresentativeVivian Tsang ([email protected])

If you have questions, comments or suggestions, e-mail us at [email protected]. Your comments may be featured in an upcoming issue or on our Web site.

© 2010 Glidewell Laboratories

Neither Inclusive magazine nor any employees involved in its publica-tion (“publisher”), makes any warranty, express or implied, or assumes any liability or responsibility for the accuracy, completeness, or useful-ness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe proprietary rights. Reference herein to any specific commercial products, process, or services by trade name, trademark, manufacturer or otherwise does not necessar-ily constitute or imply its endorsement, recommendation, or favoring by the publisher. The views and opinions of authors expressed herein do not necessarily state or reflect those of the publisher and shall not be used for advertising or product endorsement purposes. CAUTION: When viewing the techniques, procedures, theories and ma-terials that are presented, you must make your own decisions about specific treatment for patients and exercise personal professional judg-ment regarding the need for further clinical testing or education and your own clinical expertise before trying to implement new procedures.

Inclusive is a registered trademark of Glidewell Laboratories.

■ kENNETh S. hEBEL, DDS, MS

Dr. Kenneth Hebel received his den-tal degree from the University of Western Ontario in 1979 and a mas-ter of science degree in anatomy at the University of Rochester in 1985. Dr. Hebel has the appointment of Adjunct Professor at the School of Dentistry, University of Western On-tario. He also maintains a private practice in London, Ontario. He is

a certified prosthodontist, a Diplomate of the Interna-tional Congress of Oral Implantology and a fellow of the American Academy of Implant Dentistry. Dr. Hebel is a published author and lectures on implant dentistry. E-mail him at [email protected].

■ GEORGE V. DUELLO, DDS, MS

Dr. George Duello graduated from UMKC School of Dentistry in 1979 and received a master’s degree in oral biology at UMKC School of Dentistry in 1981. He has been in private practice in St. Louis, Mo., since 1983. Dr. Duello was named a Diplomate of the American Board of Periodontology in 1987 and is a member of the American Dental So-

ciety, Academy of Osseointegration and the American Academy of Periodontology, among others. Dr. Duello serves on the Professional Advisory Committee for No-bel Biocare. Contact him at 314-965-3271 or [email protected]

■ GREG MINzENMAyER

Glidewell Laboratories Director of Business Development Greg Min-zenmayer joined the lab in 2006. With a career in the dental indus-try that spans nearly 15 years, Greg has a proven track record in sales, product management, marketing and business development. Greg attended Chapman University in Orange, Calif. In 1994, he began at

Den-Mat and in 1996 moved to Steri-Oss. In 1998, Steri-Oss was acquired by Nobel Biocare, and Greg was later promoted to product manager in charge of the Steri-Oss family of products. In 2002, he was promoted to Director of Marketing for the Americas. Contact him at [email protected].


■ PARISh P. SEDGhIzADEh, DDS, MS

Dr. Parish P. Sedghizadeh is Direc-tor of the University of Southern California Center for Biofilms and assistant professor of Clinical Den-tistry. He received his undergradu-ate degree in biology from UCLA, and went on to receive his dental degree from USC. After his doctor-ate, he pursued specialty training in Oral and Maxillofacial Pathology at

Ohio State University, where he also attained a Master of Science degree in oral biology and Fellowship sta-tus in the American Academy of Oral and Maxillofa-cial Pathology. He was also awarded Fellowship in the American Cancer Society for conducting research at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, investigating the early molecular events involved in the progression of head and neck cancer. Dr. Sedghizadeh is a Diplomate of the American Board of Oral and Maxillofacial Pathology, and he con-ducts research, publishes, consults and teaches in this capacity. Contact Dr. Sedghizadeh at 213-740-2704 or [email protected].

■ SAMUEL M. STRONG, DDS, DICOI

Dr. Sam Strong received his den-tal degree from Baylor College of Dentistry. He has been involved in implant prosthetics and teach-ing since 1985. He is a member of the American Academy of Fixed Prosthodontics and International Congress of Oral Implantologists with Fellowship and Diplomate sta-tus. He is also a Diplomate of the

American Board of Dental Sleep Medicine. Dr. Strong’s patient education DVD, “Dental Implant and Alterna-tive Options Featuring Informed Consent,” has been ac-claimed as one of the most effective case presentation tools available. Presently, Dr. Strong maintains a private practice in Little Rock, Ark., and is an adjunct professor at the University of Oklahoma College of Dentistry. He is co-designer and co-developer of the Massad Edentu-lous Impression Tray and the Strong-Massad DenPlant Impression Tray. Contact him at 501-224-2333 or [email protected].

■ VICTOR RODRIGUEz, CDT

Victor Rodriguez, Manager of Remov-able Implants at Glidewell Labora-tories, studied Dental Technology at Orange Coast College and Southern California College of Medical and Dental Careers. In 1994, he achieved certification in the Swissedent Tech-nique and passed the national CDT exam in the area of Full Dentures. Victor spent most of his 25 years in

the industry as part of a restorative team focused on re-construction, as the in-house technician for a group of prosthodontists in Newport Beach, Calif. In 1995, Victor received his Credential of Mastership in the Technology section of the American Academy of Implant Prostho-dontics. Victor served as component president for the California Dental Laboratory Association (South Coun-ties) from 1996-1998. Today, Victor is a member of the Osseointegration Study Club of Southern California, as well as the American Prosthodontic Society, lectures ex-tensively on removable and fixed-removable prosthetics from the laboratory perspective. Contact him at 800-521-0576 or [email protected].

■ RIChARD L. SEBERG, DDS

Dr. Richard L. Seberg is a graduate of the Nebraska School of Dentistry. He entered the U.S. Navy Rotating Internship in 1964 and served on the USS Sperry from 1965-1967. Dr. Seberg is a member of several pro-fessional organizations, including the American Dental Association, the Orange County Dental Society, the California Dental Association

and the American Academy of Osseointegration. He is a Diplomate of the American Board of Implant Dentistry and a Fellow in the American Academy of Implant Den-tistry and the Academy of General Dentistry.

– Contributors – 5

Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique

We now have access to technologies that greatly enhance our abilities to restore our

patients with high precision in a shortened treatment time utilizing a minimally invasive surgical procedure. This case report will demonstrate several of these technolo-gies. Utilizing Glidewell Laboratories’ Digital Treatment Planning Services allowed me to easily integrate these technologies into my practice.

There are several treatment planning software programs on the market. These programs allow you to virtually plan your cases utilizing CT scans. Scanning the patient with an appliance that has the teeth to be replaced in the ideal positions allows you to digitally plan the case from both the surgical and prosthetic perspectives, making it a truly restoratively-driven process. Because Nobel Biocare im-plants were to be placed, the NobelGuide™ System (Nobel Biocare; Yorba Linda, CA) was utilized for this case. The case was planned following the All-on-4 technique.1-5 This design involves tilting the distal implant on each side of the arch distally in order to improve the anterior-posterior spread and provide posterior support for the prosthesis. Using stereolithography, a Surgical Template was pro-duced to transfer the digital plan to the clinical setting. An immediate screw-retained provisional restoration was delivered at the time of surgery through a flapless proce-dure.

This technology can be used to completely rehabilitate a fully edentulous patient by placing the implants and delivering maxillary and mandibular provisional restora-tions in one appointment. These cases require meticulous attention to detail and must be staged correctly. I had re-stored more than 20 individual arches using the All-on-4 protocol prior to restoring both arches in one appoint-ment. Working with Glidewell Laboratories and utilizing the Digital Treatment Planning software allowed me to make the major planning decisions pre-surgically.

by Irfan Atcha, DDS, DICOL, DADIA


Pre-surgical work-uP and digital treatment Planning

The patient was a young male that had been edentulous for some time. His chief desire was to have a fixed restoration. Due to the amount of ridge resorption, screw-retained dentures were the restoration of choice.

Standard procedure was used to determine the ideal positions of the teeth. Impressions and bite blocks were used to fabricate and ar-ticulate the study models. A wax try-in was done to finalize the set-up.

Radiographic Guides were fabricated and the patient was sent for a CT scan. The DICOM files of the three scans (patient with Radiographic Guides, then maxillary and mandiubular Ra-diographic Guides alone) were uploaded and sent along with my Digital Rx to Glidewell’s Digital Treatment Planning Department.

Following a Web-based teleconference, the plan was finalized. Due to the size of the im-plants that could be placed and the patient profile, six implants were planned in the max-illa: four in the anterior and two angled dis-tally paralleling the anterior walls of the max-illary sinuses (Fig. 1-3).

The mandibular plan included four implants: two in the lateral incisor regions and two an-gled distally to improve the anterior-posterior spread (Fig. 4,5).

Figure 3: The implant parallels the anterior wall of the sinus.

Figure 5: This is a view of the mandibular digital plan.Figure 4: The implant is angled distally to improve the A-P spread.

Figure 2: A digital plan of the implants and Anchor Pins is cre-ated.

Figure 1: A panoramic view of the planned implants is shown in the scan.

– Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique – 7

Pre-surgical laboratory Procedures

Once the plans were approved, the Surgical Templates were ordered from Nobel Biocare. Master casts were fabricated from the Surgi-cal Templates (Fig. 6) and articulated utilizing duplicate dentures.

Provisional restorations were fabricated based on the approved set-up (Fig. 7).

Jigs were fabricated to correctly reposition each of the 30-degree Angled Multi-Unit Abut-ments in the mouth. A Surgical Index was fab-ricated to ensure accurate seating of the Surgi-cal Templates (Fig. 8).

surgical Procedure

After obtaining adeqaute anesthesia, the Sur-gical Templates were seated in the patient’s mouth with the Surgical Index (Fig. 9). The 1.5 mm Twist Drill was used through the sleeves for the Anchor Pins in both arches.

The Surgical Index and mandibular Surgical Template were then carefully removed (Fig. 10).

Figure 6: Master casts are fabricated from the Surgical Tem-plates.

Figure 7: Reinforced provisional restorations are fabricated.

Figure 8: A Surgical Index is fabricated.

Figure 10: The anchor pins are placed and the index removed.Figure 9: The Surgical Templates and Index are seated intraoral-ly.


Figure 13: Healing Abutments maintain the soft tissue opening.

Figure 12: The remainder of the implant sites is pre-pared.

Figure 11: The first site is prepared and the implant placed. A Template Abutment further secures the Surgical Template.

Figure 15: The osteotomies are prepared and the implants placed.

Figure 14: The mandibular Surgical Template is reseated and the Anchor Pins pressed into place.

The first maxillary implant was placed and a Template Abutment used to lock it to the Sur-gical Template (Fig. 11).

The second implant was placed in the #10 area with a Template Abutment. Between the three Anchor Pins and the two Template Abutments, the Surgical Template is held securely in place and the remaining oseotomies prepared (Fig. 12) and the implants threaded into place using the Guided Implant Mounts.

Healing Abutments were threaded into the im-plants to maintain the soft tissue opening dur-ing the mandibular surgery (Fig. 13).

The mandibular Surgical Template was seated and the Anchor Pins pressed into place (Fig. 14).

Standard NobelGuide procedure was followed to create the osteotomies and place the im-plants (Fig. 15).


Prosthetic delivery

The jigs were used to deliver the 30-degree Angled Multi-Unit Abutments (Fig. 16,17).

The anterior implants were restored at the im-plant level (no abutments).

The remaining Healing Abutments were re-moved. The prostheses were delivered and the prosthetic screws tightened (Fig. 18).

A post-operative radiograph was taken to ver-ify complete seating (Fig. 19).

Adjustments were made and a bilateral bal-anced occlusion was verified. The screw ac-cess openings were then sealed (Fig. 20) and post-operative instructions given.

Impressions for the final prosthesis will be made in approximately six months (Fig. 21).

Figure 16: Jigs are used to correctly align the angled Multi-Unit Abutments.

Figure 17: This is what the Multi-Unit Abutments look like in place.

Figure 18: Prostheses are seated and the prosthetic screws tightened.

Figure 20a: The screw access openings are sealed.Figure 19: A post-op radiograph verifies complete seating.


conclusion

The All-on-4 technique in combination with digital treatment planning and guided surgery has allowed us to take a patient with a severely atrophic ridge from a poorly fitting denture to a fixed prosthesis in a precise manner with a shortened treatment time.

To earn Continuing Education credits on this topic, visit www.inclusivemagazine.com.

references

1. Malo P, MechEng MN, Rangert B. All-on-Four Immediate-Function Concept with Branemark System Implants for Completely Edentulous Mandibles: A Retrospective Clinical Study. Clinical Implant Dentistry and Related Research, Vol. 5, Supplement 1; 2003.

2. Malo P, MechEng MN, Rangert B. All-on-Four Immediate-Function Concept with Branemark System Implants for Completely Edentulous Maxillae: A 1-Year Retrospective Clinical Study. Clinical Implant Dentistry and Related Research, Vol. 7, Supplement 1; 2005.

3. Bellini CM, Romeo D, Galbusera F, Taschieri S, Raimondi MT, Zampelis A, Francetti L. Comparison of Tilted Versus Nontilted Implant-Supported Prosthetic Designs for the Restoration of the Edentulous Mandible: A Biomechanical Study. The Interna-tional Journal of Oral & Maxillofacial Implants, Vol. 24, Number 3; 2009.

4. Cruz M, Wassall T, Toledo EM, Paulo de Silva Ba L. Finite Element Stress Analysis of Dental Prostheses Supported by Straight and Angled Implants. The International Journal of Oral & Maxillofacial Implants, Vol. 24, Number 3; 2009.

5. Bedrossian E, Sullivan RM, Malo P. Fixed Prosthetic Implant Restoration of the Edentulous Maxilla: A systematic Pretreatment Evaluation Method. Journal of Oral and Maxillofacial Surgeons; 2008.

Figure 20b: Mandibular Access openings are sealed. Figure 21: The provisional restorations in place.


Screw-Retained Denture with CAD/CAM Framework

The screw-retained denture, also known as the hybrid denture, has been the standard fixed-removable res-toration for edentulous mandibles for more than 40 years. I used this prosthesis extensively 25 years ago. However, after experiencing problems obtaining a passive fit accompanied by routine screw loosening and fracture, I stopped providing it to my patients as a routine solution. It simply became too high-maintenance and repair-intensive, creating frustration for both the patient and myself and hurting profitability. The intro-duction of new technologies such as CAD/CAM fabrication of frameworks and bars has allowed me to re-introduce the screw-retained denture back into my practice with confidence as a solution for the edentulous patient.

by Ken Hebel, DDS, MSLabwork by Victor Rodriguez, CDT

The patient, a 56-year-old female, presented with recurrent decay around the crown margins of her mandibular teeth and a chronic in-ability to successfully wear a partial lower denture, which compro-mised her ability to function. She sought a long-term solution for her mandibular dentition. The recommended treatment plan was to remove her mandibular teeth and access the mandibular symphysis for place-ment of implants to support a fixed, detachable prosthesis. All other options were discussed with the patient as part of the informed consent process.

The severe atrophy of the posterior areas precluded the placement of posterior implants. The teeth were extracted. Implants were placed be-tween the mental foramina and spaced according to the available bone. Two of the implants were placed closer together due to bone anatomy. An immediate denture was delivered. The intaglio surface of the den-ture was relieved and soft tissue relined in the area over the implants.

Implant Placement

Preoperative Appointment

Screw-Retained Denture with CAD/CAM Framework 13

First Prosthetic AppointmentFigure 3: The decision was made to place and restore the case at the abutment level for ease of access and

to avoid disturbing the soft tissues during the restoration process. Multi-Unit Abutments were seated on the implants. The Abutment Screw was tightened to a torque of 35 Ncm with a manual wrench.

Figure 4: The abutment collar heights were selected so the shoulder is supragingival. Once the abutments are placed they will not be removed. All procedures are performed at the abutment level.

Figure 5: Multi-Unit Abutment Transfer Copings are threaded on top of the abutments in preparation for preliminary impression. The cast made from this impression will be used to fabricate a verification jig. This will allow a final impression to be made with verification occurring within the impression. This step will be clarified as we move forward with the technique.

Figure 6: Impression material is injected around the copings, taking care to capture the copings accurately.

Figure 7: A stock tray is filled and seated.

Figure 8: Once set, the impression is removed from the patient’s mouth. The impression is inspected for voids and proper border extensions. An impression of the opposing dentition should be made. If the patient is happy with the mould of the existing denture, an impression of the patient’s mandibular denture is taken to help the lab select the proper denture tooth mould.

Figure 3

Figure 6

Figure 4

Figure 7

Figure 5

Figure 8


Figure 9: The Transfer Copings are removed and replaced with Healing Caps. These caps will protect the tops of the abutments between appointments. The patient’s existing denture is relieved so that it does not ride on the Healing Caps. The denture is relined with tissue conditioner.

LaboratoryFigure 10: A soft tissue model is poured from the preliminary impression utilizing Abutment Analogs.

Figure 11: A bite block is fabricated. This consists of a base plate and a wax rim. Two Temporary Cylinders are incorporated to provide stability while obtaining occlusal records.

Figure 12: Because all overdenture bars and screw-retained denture frameworks are fabricated utilizing CAD/CAM technology, it is critical to obtain accurate impressions. The procedure Glidewell Laborato-ries recommends involves “picking-up” an Implant Verification Jig (IVJ) in the final impression. The lab fabricates the IVJ by tying Titanium Cylinders together with Triad material. A thin slice is made between each cylinder. Each section is numbered on the model.

Figure 13: A custom tray is fabricated with openings to allow access to the tops of the Guide Pins.

Second Prosthetic AppointmentFigure 14: The Healing Caps are removed, exposing the tops of the Multi-Unit Abutments.

Figure 9 Figure 10 Figure 11



Figure 15: The IVJ sections are seated in the mouth in the same positions as they were on the model. The Guide Pins are hand-tightened. Ensure there is a thin space, about the thickness of a credit card, between each section of the IVJ. If necessary, the sections can be trimmed with a disk.

Figure 16: The sections of the IVJ are luted together with a self-cured or light-cured resin material. The space should be completely filled in order to ensure a solid connection.

Figure 17: The custom tray should tried in, making sure there is clearance around the IVJ. Border molding can be done to ensure accurate border extensions. Impression material should be injected around and under the IVJ. The custom tray is filled and seated. Instruct the patient to lift their tongue and go through all border molding procedures as you would for a denture impression. Uncover the heads of the Guide Pins. Once the material has set, loosen the Guide Pins and pull the impression. The IVJ will be picked up in the impression. Inspect the impression for accuracy.

Figure 18: The bite block is seated and the two prosthetic screws tightened, providing excellent stability. The wax rim should be adjusted to the correct vertical dimension of occlusion and the midline marked.

Figure 19: Bite registration material is injected onto the top of the bite block and the patient closed into centric relation.

Figure 20: The bite block is removed and the Healing Caps replaced.

Figure 15

Figure 18

Figure 16

Figure 19

Figure 17

Figure 20


LaboratoryFigure 21: The master cast is fabricated from the final impression.

Figure 22: The models are articulated using the bite block and bite registration.

Figure 23: Denture teeth are set on the bite block with a bilateral balanced occlusal scheme.

Third Prosthetic AppointmentFigure 24: The trial set-up is seated and the two prosthetic screws hand-tightened.

Figure 25: VDO, CR, midline and esthetics are evaluated, and any necessary changes are made or noted on the Rx. Final tooth position is always established before the fabrication of the substructure. The substructure needs to be designed under the teeth for esthetics and support.

Figure 26: In this case a discrepancy was found in CR, so a new bite registration was made.




LaboratoryFigure 27: A functional remount was done using the new bite registration.

Figure 28: The teeth were adjusted to the new CR.

Figure 29: The lingualized bilateral balanced occlusion was checked and adjusted as needed.

Figure 30: A silicone putty index was made of the final set-up.

Figure 31: The soft tissue model and the set-up were optically scanned and the framework was virtually designed.

Figure 32a: Once the CAD is completed, the framework is milled from a solid block of titanium.

Figure 32b: The framework is seated back on the model. Here you can see the precision fit of the framework utilizing CAD/CAM technology.

Figure 33: The putty index is used to transfer the tooth set-up to the framework.

Figure 34a: The denture tooth set-up, on the framework in wax.

Figure 34b: An occlusal view shows the locations of the prosthetic screws.


Figure 30 Figure 31 Figure 32a


Fourth Prosthetic AppointmentFigure 35: The Healing Caps are removed. The trial set-up is seated on the abutments.

Figure 36: The fit of the framework is evaluated. This can be done by tightening one screw and making sure no lifting occurs on the opposite side. Remove the screw and repeat the process for each abut-ment. Periapical radiographs should be taken if the interface is subgingival or cannot be easily seen clinically.

Figure 37: In this case, the patient was very concerned about support for the lower lip. The anterior section of the prosthesis was built up to “plump out” the lip. Here you can see the patient profile during the try-in appointment.

LaboratoryFigure 38: The model with the prosthesis is placed in a hydrocolloid flask.

Figure 39: A hydrocolloid mold is fabricated.

Figure 40: The teeth are removed and the wax boiled off the model. Pink opaque is applied to the framework to mask the gray color.

Figure 32b Figure 33 Figure 34a

Figure 34b Figure 35 Figure 36


Figure 41: The denture teeth are seated back into the hydrocolloid mold. Note diatoric holes have been added to the base of the teeth for added retention.

Figure 42: The prosthesis is processed.

Figure 43a: The prosthesis is finished and polished.

Figure 43b: The occlusion is verified.

Figure 44: The screw access openings are checked to ensure there are no interferences for the prosthetic screws.

Figure 45: In this case, the underside of the prosthesis is an ovate, high-water design to facilitate ease of hygiene.

Fifth Prosthetic Appointment: Final DeliveryFigure 46: Delivery of the definitive prosthesis. The Healing Caps are removed, the abutment screws of the

Multi-Unit Abutments are retightened to 35 Ncm, the prosthesis is seated on the abutments and the prosthetic screws tightened to 15 Ncm.

Figure 47: The occlusion is checked and adjusted as needed.

Figure 48: The heads of the prosthetic screws are covered with a cotton pellet and access opening sealed with composite or acrylic.

Figure 37

Figure 40

Figure 38

Figure 41

Figure 39

Figure 42


Figure 43a

Figure 45

Figure 48

Figure 43b

Figure 46

Figure 49

Figure 44

Figure 47

Figure 50

Figure 49: Panoramic radiograph is taken to verify complete seating of the prosthesis.

Figure 50: The patient is given oral hygiene instructions and put on a recall schedule.

ConclusionThe use of CAD/CAM technology has allowed me to re-introduce the hybrid, or screw-retained, denture into my practice. This case report illustrates how, working with an experienced lab, a severely resorbed edentu-lous mandible can be restored in a very systematic, predictable manner with a fixed prosthesis.


Glidewell Laboratories offers three options for custom implant abutments under the Inclusive® brand: Titanium, Zirconia with Titanium Insert and All-Zirconia. We use your implant level impression and pro-

vide a tailor-made CAD/CAM solution that is fabricated to fit your patients’ individual needs. The margin and gingival contours are designed to ensure ideal soft and hard tissue esthetics. The abutment height and the emergence profile are precisely milled to facilitate gingival health and prosthetic support, resulting in a superior restoration.

■ The Inclusive Titanium Abutment provides strength and biocompatibility. It is primarily indicated to support posterior restorations.

■ The Inclusive All-Zirconia Abutment provides superior esthetics without sacrificing durability and is ideal for anterior restorations.

■ The Inclusive Zirconia with Titanium Insert Abutment is another esthetic option that maximizes strength and is suited for anterior restorations.

♦ The All-Zirconia Abutment is available for the following implant systems:

• NobelReplace • Biomet3iCertain • ZimmerScrew-Vent

♦ The Titanium and the Zirconia with Titanium Insert Abutments are available for:

• Noess • NobelReplace • NobelActive • BranemarkSystemRP • Biomet3iCertain • ZimmerScrew-Vent • StraumannBoneLevel

R&D Corner

Mechanical Testing of Inclusive® Custom Abutments

by Grant Bullis, R&D Manager, Glidewell Laboratories


Zirconia with Titanium Insert Abutments include a metal insert and provide a titanium-to-titanium abutment-implant interface. The insert is permanently cemented to the zirconia section in the lab.

Inclusive Abutments are designed utilizing CAD/CAM technology and milled from precision-machined blanks. Extensive testing is performed, and high-strength materials are utilized to provide a consistent, high-quality product.

superior materials

The high strength of Inclusive Titanium Abutments begins with material se-lection. The titanium abutments are precisely machined from ASTM grade 23 alloy titanium. Grade 23 titanium has a minimum yield strength of 760 MPa before plastic deformation occurs compared to the 480 MPa minimum yield strength of grade 4 commercially pure titanium used for many abutments. For ceramic materials such as zirconia, flexural strength is used to measure the strength of the material in bending. Inclusive All Zirconia Abutments are ma-chined from high strength zirconia with a flexural strength of 1500 MPa.

Glidewell Laboratories uses titanium abutment blanks that are manufactured on Swiss-style CNC automatic lathes utilized throughout the implant industry. The zirconia abutment blanks are manufactured on five-axis CNC mills. The entire manufacturing process is tightly controlled, from material issue to final inspection, to ensure quality and consistency.

rigorous testing

Abutment-to-implant compatibility requires manufactur-ing the prosthetic components to very close tolerances. Further, the mechanical function and performance of the abutment/implant assembly should be determined by fatigue testing that approximates actual-use conditions. Fatigue-strength testing based on the ISO 14801 protocol was conducted on the implant/abutment assemblies to determine fatigue strength. Fatigue-strength testing was performed at an independent laboratory on both Titanium and All Zirconia Inclusive Custom Abutments for every implant system offered.

The fatigue strength is the maximum force that the as-sembly can withstand after cyclical loading at a frequency of 14Hz. Testing is typically done on the smallest, and therefore the weakest, diameter implant. In this test, 3.5 mm (Narrow Platform) Inclusive Zirconia Abutments had a fatigue strength of 289 – 333 N after 5 million cycles. To put it in perspective, the bite forces in the anterior region where zirconia would be primarily indicated have been reported in the range of 109 to 299N.1,2

the clear choice

Inclusive Custom Abutments provide an array of benefits that ultimately lead to superior final restorations. A variety of options including All Zirconia, Titanium and Zirconia with Titanium Insert allow you to work with a material that best meets the needs of you and your patients. Mechanical testing results show that you can count on a dependable abut-ment that maintains long-term prosthetic function.

1. Helkimo E, Carlsson GE, Helkimo M. Bite forces used during chewing of food. J Dent Res 1959;29:133–136. 2. Waltimo A, Könönen A. A novel bite force recorder and maximal isometric bite force values for healthy young adults. Scand J Dent Res 1993;1001:171–175.

Inclusive is a registered trademark of Glidewell Laboratories.

Mechanical Testing of Inclusive Custom Abutments 23

Screw-Retained BruxZir® Crown

The Screw-Retained BruxZir Crown pro-vides a one-piece alternative to cement-ed implant restorations. This restoration combines the abutment and crown into one solid restoration. The benefits in-clude: no crown margin, and therefore no concerns about excess cement; easy retrievability; and because it is all zirco-nia, there is no possibility of porcelain fracturing off. Inclusive Custom Abut-ments, as well as the Screw-Retained BruxZir Crown, are compatible with the following implant systems:

•Neoss•NobelReplace•NobelActive

•Biomet3iCertain•BranemarkSystemRP

•StraumannBoneLevel•ZimmerScrew-Vent

by Richard L. Seberg, DDS, and Bradley C. Bockhorst, DMD

BruxZir® Solid Zirconia Crown and Inclusive® Custom Titanium Abutment

Why should you be interested in the monolithic concept of a solid zirconia crown? As you know, when you fuse porcelain to a metal or zirconia sub-structure, there is always the possibil-ity that the two layers could separate. The best-case scenario is a small chip of the porcelain that you might be able to polish off. The worst-case scenario is that the porcelain completely fractures,

exposing the substructure and requiring replacement.

A key benefit of monolithic restorations is that nothing can chip off, as we don’t have two materials fused together. The restoration is made of one homogeneous material. BruxZir is a full-contour zirconia restora-tion with no porcelain veneer.

More brawn than beauty, the BruxZir Solid Zirconia crown has rap-idly gained popularity for posterior restorations thanks to the preci-sion milling of CAD/CAM technology. With the increasing price of gold for porcelain-fused-to-metal restorations, the proven strength of zirco-nia gives you a viable option for your posterior implant crowns and bridges.

Inclusive® Custom Titanium Abutments provide ideal support for the restoration and the soft tissue. This CAD/CAM-designed abutment ex-hibits a natural-looking emergence and provides strength and durabil-ity. The laboratory virtually designs your abutment and mills a tailor-made solution of the highest quality. Also available in the Inclusive line of products is the Inclusive All-Zirconia Abutment and the Inclusive Zirconia Abutment with Titanium Insert.

BruxZir and Inclusive are registered trademarks of Glidewell Laboratories.

Inclusive® Titanium Abutment BruxZir® Solid Zirconia Crown Screw-Retained BruxZir® Crown Sealed screw access opening

Product Spotlight


My First Implant

As featured in the last issue of Chairside® magazine, “My First

Implant” showcases the selection, work-up including digital treatment planning, and placement of a single-tooth implant utiliz-ing guided surgery. The restoration consisted of an Inclusive® Custom Titanium Abutment (Glidewell Laboratories; Newport Beach, CA)and a PFM crown.

Below is an excerpt from the article detail-ing the experience of seating my first implant case. You’ll find the complete article, a photo essay, video of the procedure and more at www.inclusivemagazine.com.

I’vealwaysknownthatpatientswouldratherstay in my office than be referred to another office, but I was afraid to surgically place an implant. Up to this point I had been restoring implantsforsometimeandhadtakennumer-ous implant courses. However, when our im-plant department convinced me that Digital Treatment Planning technology would elimi-nate theguesswork, Idecided Iwasready togive it a try.

I can honestly say it was the most fun I have had in a long time, and it was easier than al-most any crown prep I’ve recently done. I wish there was this much technology available to walkme throughmolar endo, wisdom toothextractions or multiple-unit bridge preps.

With the patient anes-thetized, we begin the procedure by inserting the Surgical Guide and using the start drill. The tip of the start drill creates a countersink in the bone, while the upper part of the start drill acts as a tissue punch. Since no grafting was necessary, no flap was utilized as part of the pro-cedure. Note how the large diameter of this drill fills the sleeve in the Surgical Guide.

A close-up view of the Surgical Guide on the model. It should seat into place, much like an occlusal splint. The guide will have some inspection windows from which cusp tips will stick out so that you can verify that the guide is completely seated. The metal sleeve in the Surgical Guide controls the angle and the depth of the implant drills.

by Michael DiTolla, DDS, FAGD


Guided SurGerywith Grafting and Ridge Expansion

Guided Surgery and Grafting

FiGUrE 1: After fabrication of a Radiographic Guide, the patient has a CT scan taken and the case is virtually planned. Note: The patient’s buccal defect can be seen in the cross-sectional slice. A Surgical Template is fabricated based on the digital plan.

FiGUrE 3: Next, the Surgical Template is seated.

FiGUrE 2: At the time of surgery, a full thickness flap is re-flected.

FiGUrE 4: The drills are guided through the Surgical Template to create the osteotomy.

ne of the most exciting recent advancements in implant dentistry is digital treatment planning and guided sur-gery. In some cases ancillary procedures may be required. This photo essay showcases grafting and the use of

osteotomes in conjunction with guided surgery.

Here, you will see the step-by-step process, from planning the case to the final restoration.

O

by Richard L. Seberg, DDS

Guided Surgery with Grafting and Ridge Expansion 27

FiGUrE 5: The implant is threaded into place. FiGUrE 6: The buccal graft is placed and the flap closed.

FiGUrE 7: Once the implant has had time to osseointegrate, an implant level impression is made.

FiGUrE 8: The model is scanned and an Inclusive® Titanium Custom Abutment is virtually designed.

FiGUrE 9: An Inclusive® Titanium Custom Abutment is deliv-ered.

FiGUrE 10: After adjustments are made, the PFM crown is cemented into place.

Guided Surgery and Ridge Expansion

FiGUrE 11: The patient’s old bridge is removed and the preps are cleaned up. Note the typical saddle defect in the edentulous area.

FiGUrE 12: The patient had a CT scan, and the implant was virtually planned. The SurgiGuide® is fabricated based on the digi-tal plan.


FiGUrE 13: The SurgiGuide is seated and used to direct the pilot drill.

FiGUrE 14: Osteotomes are used to expand the ridge and create the osteotomy.

FiGUrE 15: The implant is threaded into place. FiGUrE 16: An implant level impression is made.

FiGUrE 17: Note the improved labial contour due to the ridge expansion.

FiGUrE 18: A BioTemps® bridge is modified to seat over the Healing Abutment during the osseointegration period.

FiGUrE 19: An Inclusive All-Zirconia Custom Abutment is seat-ed.

FiGUrE 20: Individual Prismatik Clinical Zirconia™ crowns are delivered.

BEFORE

AFTER

Prismatik Clinical Zirconia is a trademark of Glidewell Laboratories. Inclusive and BioTemps are a registered trademark of Glidewell Laboratories. SurgiGuide is a registered trademark of Materialise.

To see two videos related to this article, go to www.inclusivemagazine.com.

Guided Surgery with Grafting and Ridge Expansion 29

A key to the success of any implant case, from the simplest to the most advanced, involves the team concept in which the surgeon, restorative dentist and laboratory are all in sync. Here, we will outline a

practice concept in which the surgeon, working closely with the laboratory, can support his or her referral base through a restoratively-driven approach. That support can be offered at various levels, from the traditional approach-to a hybrid that includes immediate loading-to digital dentistry.

Utilizing technologies such as cone beam scanners with digital treatment planning and guided surgery allows the case to be focused on the prosthetic side from the start, providing a more predictable end result. The surgeon can differenti-ate himself or herself and provide superior treatment to the patient by incorporating this concept into daily practice. The restorative dentist, no matter his or her level of experience, can benefit from working closely with the surgeon who has incorporated this practice approach to achieve simple, esthetic solutions.

The first thing I think we need to discuss is: “What is the restorative-driven surgical practice?” Is there a definition, or how is it applied. For me, the definition that I like is: It is a dentist, a specialist, a laboratory that uses a menu of services to provide patients and referrals with their implant procedures. This menu will vary depending on your philosophy, your understanding of the literature and your clinical experience.

With any menu, we need to think about our basic philosophy of implant dentistry. My menu has been shaped much by my colleagues and mentors. The present philosophy I have on implant dentistry is that it is a laboratory procedure with a surgical and a prosthetic component. It’s my belief that because in implant dentistry, for the most part we’re working with prefabricated machine parts or CAD/CAM parts, that everything should fit, and we should not dedicate a lot of chairtime to making things fit, when in fact the laboratory can get things to fit for us.

My experience in traveling across the United States is that depending on what group you’re talking to, they will tell you that their part of implant dentistry is the most important. So if I’m talking to restorative dentists, they’ll tell you their part is most important; if I’m talking to surgeons, they’ll tell you why what they have to do in placing implants is so critcal; and finally, somebody has to make the teeth – dentists don’t make their own teeth, so to speak — so the laboratories will be owning implant dentistry. We’ll discuss this further in the section on digital dentistry.

To see Dr. Duello’s complete lecture on the Restorative-Driven Practice, go to www.inclusivemagazine.com. You’ll also find a photo essay on this piece online.

The Restorative-Driven Surgical Practice■

by George V. Duello, DDS, MS


Recent advancements in Cone Beam (CBCT) scanners have resulted in much greater utilization of this technology as a diagnostic and treatment planning tool. Three-dimensional imaging is rapidly becoming a

standard of care in dentistry. The online presentation by Dr. Parish Sedghizadeh includes:

❖ A brief introduction to conventional CT and CBCT scanning technology.

❖ An overview of the use of CBCT scans in various fields of dentistry including diagnosis and treatment planning for implants.

❖ A brief refresher on common pathology, including osteonecrosis of the jaw secondary to bisphosphonate use.

❖ A discussion on medical-legal liability and CT scans.

Conventional CT works in slices. Cone Beam CT, as the name implies, is a cone through the tissue. This volume is then reconstructed into various slices such as axial, coronal and sagittal views. The software can also create a 3D rendering of the anatomy. While both types of CTs are similar, the applications and uses for Cone Beam CT are better in dental use, as you’ll see.

The applications of CBCT are increasing right now in dentistry, and pretty soon it’s going to become a standard of care for radiology and for radiographic diagnosis – not just digital planning for implants, but for many disciplines.

The standard of care is shifting to Cone Beam CT, and it’s happening now. It’s not going to be a very long time before in dentistry and dental-related procedures and treatment planning, it is the standard of care over any other imaging studies. The reasons for that: The radiation from CBCT, in one volume, is very low. So if you just do one Cone Beam CT, that’s your baseline imaging for anything you need for that patient. Right now we don’t do it because it’s not as sensi-tive and specific for caries detection and periodontal disease detection. But that’s changing because oral radiologists are on the cutting edge of research and fine-tuning this technology and the software associated with it to allow us to start looking at things like caries and periodontal disease and pocketing, two dimensionally and three dimensionally with these different slices. So it will become the standard of care in the very near future for probably any dental imaging procedure that needs to be done.

To see Dr. Parish Sedghizadeh’s complete presentation, including specific examples of Cone Beam CT applications and detailed images, along with a discussion on pathology and medical-legal liability, visit www.inclusivemagazine.com.

by Parish P. Sedghizadeh, DDS, MS

Cone Beam Computed Tomography:Applications in Diagnostic Oral and Maxillofacial Radiology and Pathology

Cone Beam Computed Tomography: Applications in Diagnostic Oral and Maxillofacial Radiology and Pathology 31

Implant Removable Instructions for Use

Digital Treatment Planning Instructions for Use

Step-by-step guides for procedures used during the implant reconstruction are available from Glidewell Laboratories. These informational pieces will guide you through the entire process, from the initial appointment to delivery of the final prosthesis. In addition, these guides will help you schedule appointments with your patients thanks to a list of laboratory turnaround times. Go to www.glidewelldental.com to obtain copies, or call 800-839-9755.

Digital Treatment Planning and guided surgery are rapidly becoming a standard of care in implantology. This technology allows you to plan implant cases from both surgical and prosthetic perspectives in a 3-D environment. Glidewell Labo-ratories can help you easily integrate this technology into your practice without having to spend extensive time training on, or investing in, expensive software.

■ locator® overdenture

Get information on restoring an edentulous arch with an overdenture and free-standing attachments.

■ locator bar overdenture

Instructions on restoring an edentulous arch with a CAD/CAM bar overdenture.

■ screw-retained denture (imPlant level)

Find technical information on restoring an edentulous arch with a fixed prosthesis, di-rectly to the implants. This piece features a CAD/CAM titanium framework with denture teeth and pink acrylic.

■ screw-retained denture (abutment level)

See step-by-step instructions on restoring an edentulous arch with a fixed prosthesis, on abutments. Device features a CAD/CAM titanium framework with denture teeth and pink acrylic.

■ screw-retained denture (glidewell selects abutments)

Get information on restoring an edentulous arch with a fixed prosthesis that features a CAD/CAM titanium framework with denture teeth and pink acrylic. Impressions are taken at the implant level. The laboratory determines the abut-ments, if necessary, based on the positions of the implant analogs in the model and the trial denture tooth set-up.

■ Premium bar hybrid

Restore an edentulous arch with a fixed prosthesis that features a CAD/CAM titanium framework with individual all-ceramic crowns and pink composite to simulate the soft tissues.

■ nobelguide™ fully and Partially edentulous

These guides offer specific instructions on how to plan cases for fully and partially edentulous patients. Get detailed information on Digital Treatment Planning and Guided Surgery using the Nobel Biocare system.

■ simPlant® fully and Partially edentulous

These convenient guides offer all you need to know about utilizing SimPlant on your fully and partially edentulous patients. This system has an open architecture. Most implant systems available today can be planned with the Sim-Plant software.

For a complete step-by-step guide detailing how to utilize Glidewell Laboratories’ Digital Treatment Planning Services, visit www.inclusivemagazine.com. Here, you can download the full IFU for future reference on how to take advantage of this cutting-edge technology.


Implant Removable Instructions for Use

Digital Treatment Planning Instructions for Use

Beyond learning the techniques and procedures for successful completion of im-

plant prosthetics lays the problem of fee determination. This can be a thorny issue with many

clinicians unless a rational method for analysis of the case can be identified. In order to deter-

mine a fair fee for any implant case, we must first know our total costs involved to produce the

prosthesis. I suggest breaking down the total case cost figure into three components:

■ Lab costs ■ Implant component costs ■ Overhead costs

Learn how to calculate your costs and determine the fee you should be charging for these types of cases in a comprehensive article available exclusively at inclusivemagazine.com.

by Samuel M. Strong, DDS

Fee Determination...

Fee Determination for Implant Cases 33

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Documents

Restorative driven implant solution