- Understand the basic componentry of stackable full arch workflows
- Understand the records needed for stackable guided systems
- Understand the advantages of a guided workflow
- Learn the basic surgical and restorative processes using CHROME GuidedSMILE
Transcript
Hello. And I want to welcome everyone to this lecture on an intro to guided full-arch stackable workflows. we’re gonna go through a specific guided workflow, which is with CHROME GuidedSMILE but this could be applied to most other stackable workflows as well. Of course, since we’re specifically going over CHROME GuidedSMILE, I will point out some good features and benefits and some differences with with CHROME compared to other options out there on the market. So, before we go into that, let me introduce myself and why I’m talking to you. my name is Chris Moore, and I work at a National Dental laboratory. Been here for about six years, and I mainly focus on, you know, these full-arch workflows, whether it’s guided or non non guided. And then really have honed in my skills and knowledge on the stackable workflows at my time here in the lab, whether it’s surgical or restorative workflows, and have been chairside for man, a couple hundred at least full-arch surgeries. So, really had some time with these and, and have seen a lot of the different options out there. And as I mentioned, again, we’re gonna cover CHROME GuidedSMILE today.
So some learning objectives. So what’s, what are some takeaways from this? first of course, we wanna understand the basic componentry of a stackable full-arch workflow, and again, specifically with CHROME GuidedSMILE. we’re gonna understand the records needed for stackable guided systems. the records are very basic, but also of course, important. And what we’ve seen out there with these cases, you know, they’re, they’re very important to, obviously you and the patient, and of course, to the lab. we don’t want these to be delayed, but we find that about 80% of cases that do come in for a full arc stackable workflow, the records are incomplete or just incorrect. So we really want to focus on that the records needed. Also, we’re gonna learn some advantages of a guided workflow versus, of course, freehand. And then we’re gonna cover the basics of the surgical and restorative processes using CHROME GuidedSMILE.
So, just some quick background on CHROME GuidedSMILE. it is the, the market leading surgical guide. And of course, it brings a lot of benefits of a metal guide versus plastic. The, the, the main components, the fixation base or the bone the Bone Foundation guide, as it’s called on with other systems, is all metal. And then the osteotomy guide is all metal, which we’re gonna kind of see the advantages of that here shortly. CHROME GuidedSMILE is patent protected. I believe they were issued the first patent in November of 2021, and they’ve expanded that patent back in February of 2023 as well. So it’s, it’s, you know, very proud. I know CHROME GuidedSMILE is very proud of that patent, of course, and it just shows that there’s been a lot of research and development put into this, and there’s a lot of options out there.
But this one is the only patented stackable guided system on the market. they’ve, they’ve restored at least 16,000 arches and counting throughout CHROME GuidedSMILE with in 2016. And there is a unique small hole restorative option. it’s called C two F with CHROME GuidedSMILE. there are, there’s different options for, for your different restorative outcomes. As I mentioned, you have a small hole, there’s a standard hole and CHROME GuidedSMILE has a, a natural, that’s called her FP one delivery. We’re not going to dive too deep into those today. but just wanted to mention that there are options out there with this stackable system. All right, so let’s go into patient records. You know, as I mentioned, they’re very basic. There’s photographs a small series of photographs that are needed, of course, impressions and bite.
And those can be either digital or analog. And then CBCT scans, you know, we with the stackable workflow, gotta have good, clear CBCT scans, and I’ll talk a little bit more about that on the next slide. So, with the photographs, it’s a very simple series of six photographs. A lot of times, you know, there’s, there’ll be 20, 30, 40 photographs submitted. Don’t necessarily need all that. We really just need these six that you see here. We want a full face, full smile photo, actually, I should have mentioned prior to that. Have the patient standing up, don’t have them laying back in the chair. So stand up, nice, full face, full smile photo, an exaggerated smile. And then a profile is always helpful with these pro, with these full-arch cases. And then on the bottom there, four, five, and six, we want retracted in occlusion photos.
So center left, right retracted in occlusion photos, and that’s all we really need. and that’s for CHROME GuidedSMILE and, and really any kind of full-arch workflow, even if it’s freehand, I mean the, these photographs are what you’re looking for on a full-arch workflow if you’re gonna freehand the case. Stackable workflow, of course. same thing. So what we don’t need are, if it’s just a picture of the patient’s face with the half smile like you see there, not gonna cut it. don’t need that. And then any occlusal photos don’t really need to see anything there unless there’s something really, really specific that is kind of an outlier that you’re trying to show the lab. but really the occlusive photos don’t do much for us as far as a case workup and the plan and design of the guide.
So it’s more of a waste of your time to take those just to submit to the lab, because we do get those a lot. So we just don’t want you wasting your time. We want to make sure that this is, you know, a, a nice easy process for you, your team, and of course the patient. And as far as cameras and all that, all we need is a nice nice smartphone camera. We don’t need one of those fancy cameras. Great if you have one. but just a nice smartphone. Again, reminder, have the patient standing up and full face, full smiles is what we’re looking for.
So next, the impressions. digital records are great. Just please make sure that there are no holes and it’s a complete clear scan, especially with dentate patients. Now, denist, that’s a whole different workflow, which we’ll, I’ll talk about shortly here, but if you’re physical impressions, just make sure you’re capturing, you know, all the land areas full. Again, digital or analog. the full palette can be a little tricky with your intraoral scanner, depending on the scanner that you have. Now, there’s, I mean, most all of ’em are great out there now, so, just make sure you’re capturing the full pal for us, because a lot of these cases, doctors will request a backup denture. Well, it’s tough to make a denture without a full, you know, a nice paddle scan, all the, all the tissue and all the important landmarks marks. So please make sure that you have that.
I can’t stress that enough because a lot of times we don’t get that. And then you have to have the patient back, or we’re kind of fudging in a pallet, which everyone knows that just doesn’t work. And then a nice bite, you know, full occlusion. and the bite you know, we wanna make sure that, ideally if it’s you’re taking a physical bite, I know it shows a full, a full bite here, but if you can take it and you know, have a, have three different, you know, anterior and two posterior, maybe three different, like a kind of a section bite sent in if you wanna hold it up to the light to make sure you can kind of see through it. That way we know the patient’s biting correctly in their natural bite.
And then, of course, CBCT scans. Now, I mean, honestly, I could probably do a whole lecture on CBCT scans, good versus bad, and what we’re looking for and what we see out there. But to keep this more of just about an intro on the basics for a dentate case, we want to please make sure that the patient is out of occlusion. So that just means biting on a bite stick or like the bite fork of your CBCT or cotton rolls, something like that. We just wanna make sure that the teeth are apart and this makes planning much easier and much more accurate. That way the designer and the planner don’t have to separate that jaw in the scan, which can be, can be pretty tricky and cause some inaccuracies. So dentate, have the, have the teeth apart. And then if it’s any ous patient, that’s where we have to get into a dual CBCT scan.
I won’t go into that. just, again, we wanna keep this kind of basic, but the denist workflows have to have a dual, a dual CBCT scan. So one of the patient wearing, wearing a scan appliance or a good fitting denture, and then one without the scan appliance and make sure there’s fiducial markers on that. And there’s a couple options there for fiducials. But, again, not gonna spend too much time on that. I could talk, talk for a while on, on dual scans. This is one of the trickier, trickier records we get that are incorrect. So I would recommend, you know following A-C-B-C-T scan protocol, there’s a bunch of information out there on the, on the internet to figure out what that is or call your lab and just ask them what a proper protocol, what they’re looking for is.
and then I would say have the patient wait there and submit it to the lab, and then have them verify that it’s a good, good record, that they can use that to start planning the case. I’m sure your labs will be open to it. It only helps everyone else, everyone out in the long run and keeps these cases from getting held up. And you, you know, you hate to have the patient come back because of a, a, a bad or inaccurate CBCT scan. Also, make sure they’re not moving. That can cause some issues. I mean, that can be pretty, pretty obvious on the CT if they’ve moved. So just take a look at that before you submit it as well.
So once all the records are submitted, and you’ll want to verify with the lab, but the average rule here is the lab typically takes about five business days to prepare for the online meeting. So once they receive the records and the records are verified that they’re good, that they can, the lab can use them, then it starts, it takes five business days to get this ready for an online meeting. And then within those five days, you should receive an email or a phone call. Just depends on the lab email or phone call to schedule that online meeting. Now, once that email is sent out, that case, of course, is on pause. So you want to kind of keep that in mind as far as the overall workflow and timing with these cases. So the case is on pause, you’ll jump online with the doctor and go over, you know, the, the case plan implant positions, set up bone reduction, all the, all the pertinent information, and then you’ll approve, you’ll approve it.
Once that case is approved, then it takes 10 business days or 10 lab days to fabricate the guide to fabricate CHROME for surgery. And then you wanna figure in a two day ship to your office. So there’s, there’s a longer timeline for these cases because there’s a lot that goes into them, of course. And we wanna make sure that everything’s perfectly accurate and everything is up to, up to what you’re looking for and, and have a great result for that patient. So, and you want to kind of, have that conversation with the patient. ’cause they’re anxious. They probably just handed over 30 to $60,000 or, or even more depending on where you’re, where you’re located. and they want to get this thing scheduled. Well, what, what we ask for is to please don’t schedule that meeting. I’m sorry. Please don’t schedule the surgery until after the online meeting is complete. So it’s very important because the labs know that there is 10 business days to fabricate CHROME, then it gets shipped. So that timing we have down, the timing that’s up in the air, are the records, are they good? You have to have the patient back in. so there’s a lot of things that can happen prior to that meeting that would extend this overall length of time to get the case shipped and get surgery done. So again, please, please don’t schedule the surgery till after that online meeting is complete. very important.
All right, so now we’re gonna go into the components of CHROME GuidedSMILE. And again, there are many stackable workflows out there. Some have a, a little more components than what you’re gonna see here. So you’ll wanna familiarize yourself, of course, with those prior to surgery. And we always ask that, since I mentioned that once you receive CHROME back, please, please, please open that up. Check everything, make sure you have all your pieces, parts, make sure that the implant parts, the implants, the temp cylinders, the multi-units are ordered, and you have backups of everything. And I would say, you know, if you have a, you have a good implant rep, they should want to be chairside that day of surgery. so I would have the implant rep there as well, just in case something’s going on and you need their assistance or you need some additional parts or something like that. But you know, we’ll go over the components, just make sure everything is there prior to surgery. Don’t open that thing up day of surgery, and then there’ll be a surprise.
So here’s a quick overview of just the, the a stackable metal guide and the benefits of getting a stackable metal guide versus, you know, a plastic guide. the obvious one, of course, is the strength. These guides are unbreakable. I could, I can’t imagine you’ll be able to break one of these guides in surgery. We haven’t seen it yet, and I’d be very surprised if it ever happened. I couldn’t imagine the situation where that would happen. but very strong. it’s a, it’s with chrome GuidedSMILE. You’ll notice there’s a gap between the bone here and the fixation base. It’s about two millimeters, and that is done on purpose. And that gap should be pretty uniform across the arch. It does not, this is not a bone borne stackable guide. They’re all the other guides out there from what I’ve, what I’ve research, researched and seen.
they are all bone borne. Well, chrome is not bone born. And the reason for that is the fact that there could be some deficiency or something on A-C-B-C-T that doesn’t show up on the CT when you’re guide designing the guide. And then you may have to make some adjustments to the guide or to the bone itself when seeding a bone born guide. And that can cause obviously, inaccuracies down the road when placing implants and the restorative process. So that gap is supposed to be there. It’s very important that you understand that. And if you have done other stackable workflows, we’ve seen it before where doctors have done other stackables and they see that there is a gap and they take a mallet or something and they’ll mallet that fixation base right to the bone. That’s of course gonna set the whole surgery is gonna be com, you know, completely inaccurate, implants in the wrong position, and then everyone’s having a bad day.
So that gap’s on purpose, and it’s, it’s it, like I said, it’s planned like that. And it’s an advantage to have that floating guide like that visibility, irrigation, as you can see here, you, you’re drilling protocol, you have full visualization of that and very nice irrigation built into a stackable metal guide because it’s metal stronger. You don’t need, you don’t need the inherent strength and build above an acrylic guide, the bulkiness of acrylic guide due to the fact that it, you know, it could break. So with metal, you’re good to go. And that’s how you have so much visibility. There’s also a smaller footprint in the mouth with the, with the, with CHROME GuidedSMILE being a metal guide, and not to have to have a bulky, a acrylic guide compatibility. It’s compatible with any implant system out there. I’m sure I’ll mention that a few more times in this.
But all the, all the lab needs to know is what implant system you’re using and what guided kit you’re using, because sometimes you’ll place X implant, but use a universal guided kit. So as long as we know the lab knows all that we can plan CHROME to any implant system out there. some of the, some questions we get are on what sleeves do we use. If it is a implant system that requires sleeves for their guided protocol, then we’ll use the original manufacturer sleeve recommended from the implant company. So we make everything nice and easy for you, and it arrives before you’re ready to go for surgery. One last thing here. well, a couple things. The in indexing of the implants I’ll mention this a couple more times as well, I’m sure in this lecture. But on the angled implant sites, there’s a timing consideration that is all planned out during this, during the online planning and in the design of a guide.
So, you know, an implant typically has a hex and there’s six different ways that can fit that can, that you can stop that rotation in six different ways. A multi-unit abutment, the angled MUA will insert into that implant, and that affects the screw access hole. And, you know, prosthetically, you want to have ideal screw access hole. So chrome GuidedSMILE will tell you exactly where to stop your your guided implant driver at the ideal position for the ideal angulation and angulation correction. With that multi-unit abutment, there’s a little indicator on your implant driver, the guided driver. Now, a lot of doctors don’t even know they see these. There’s little nubs or some dimples or, or marks. A lot of doctors don’t even know what that is for until they get into a guided workflows, you know, this kind of guided workflow where then they’re really paying attention to that. So we, we, we figure in all that and plan for that.
So here’s your components. we’ll start at the top left here. So all of the components, of course, stack into that metal fixation base. Now, once that fixation base is pinned in the mouth, it does not come out, it stays in the mouth the entire surgery. There are other stackable guides out there. They’re kind of sequential. So you pin one thing in, one component in, and then on pin, and then you pin the next component in. That can be time consuming, it can be frustrating. Right here with CHROME gutted smile, the fixation base is pinned in and it stays in the entire surgery until the prosthesis is delivered. So how does that fixation base get in the right position? Well, that’s with that top left image, that’s the pin guide. So it’s an acrylic piece that locks into the fixation base. And for a dentate patient, it’s gonna use the existing dentition to line up the ideal position for that fixation base.
And you remember we talked about the two millimeter gap roughly two millimeter, three millimeter gap between the fixation base and the bone. Well, that’s all figured into the delivery of the fixation base. With that pin guide, that gap’s gonna be automatically built in. That’s not something you have to think about or worry about. If the patient’s edentulous, then the pin guide is going to index into the opposing arch. So you’re gonna close the patient into the pin guide. Or if it’s a double edentulous case, those pin guides are gonna index into each other. and again, I won’t go too much into that workflow, but that’s kind of how it works. So these, these can be done with dentate or dentalist patients. The next slide, the, or the next image, the top middle, that’s your fixation base. So once the pin guides in, then you’re done with that part of it.
You, you remove that using the three. There’s three chrome locks you see here, the little blue locks. Those are what engage and disengage all the stackable components with chrome gutted smile. So they just push in to engage, pull it out to disengage. Nice thing is those are Swiss locks. They do not come out fully out. So you’re not worrying about, you know, patient laying back in the chair mouth wide open. You’re not worried about small pins flying around and potentially them swallowing it or losing it on the ground. They stay in the, the fixation base and just engage and disengage, which is very nice. But once that’s in, it stays in. And this also acts as your bone reduction guide. So you do extractions and you’ll reduce bone down to a nice flat surface of the, with this fixation base, nice even surface. And we’re gonna see a couple videos here shortly on these, these different processes.
Next is your osteotomy guide. As I mentioned, any implant system out there, we can it works with, we just need to know the implant system and the guided kit you’re using. And there you have another visualization of the, of, of how you can really see everything, your drilling protocol and your implant placement. There’s no surprises once your implants are in, like with your standard acrylic guides. The bottom left is your carrier guide. This is another acrylic piece that locks into the fixation base and that serves a few different functions. the first function is you can verify your bone reduction by seating that carrier guide. So once you have the fixation base, seated teeth are extracted, bones reduced, you can seat your carrier guide to verify the bone reduction. If something gets held up, then you just gotta reduce a little more bone in that area.
So it’s helpful with knowing how much bone you, you have to reduce and verifying all that. post implants being in that carrier guide goes back on and that stays in out until the provisional is delivered. So that gives you, it acts as a tissue gap. It’s three millimeters thick. So that carrier guide acts as your tissue gap, ’cause of course the patient’s flapped. And then it also will give you your timing or your indexing of your multi-unit abutments on the angled sites. And we’re gonna see some images of that and a video of that shortly. But that tells you where to push position that screw access hole on the angled multi-unit abutment sites. And then you’ll see there’s, there’s a couple little pegs on that carrier guide. Those pegs, interact with two holes that are, that are pre-designed into the provisional. You line those holes up with those pegs and the provisional locks into that carrier guide.
So it’s not moving around when you’re trying to do your pickup. And it stays in place as long as it’s flush against that carrier guide on those pegs. So it’s a very easy pickup with the provisional. And then the rapid appliance, the bottom right, that’s a duplicate appliance. There’s other stackable systems out there that will have your duplicate appliance. this is a very big time saver for the restorative doctor or on the restorative side. So if you’re a, if you’re a oral surgeon or, or even a, you know, or a general dentist that’s doing these and someone referred you to the case, this is a referral’s best friend. And this is how you keep your referrals coming back to you for these workflows. If you’re, if you’re working on referrals, this rapid appliance, you pick up temp cylinders, you index them in the, in the rapid appliance, the day of surgery, this is your verification jig. This is your bite from a screw down bite rim all in one. So you have your vertical, you have your passive implant positions already for the restorative doctor, so they don’t have to reestablish those on the restorative end. Again, I won’t go too much into that ’cause that’s another, you know, restorative how to, how to restore these cases. That’s another lecture in itself. So again, we’re just trying to do some intro here.
So now we’re gonna focus briefly on the pin guide. Again, it delivers a fixation base, on the denate case, it uses the existing dentition and you want to verify it’s seated. And that’s what there, there’s typically three windows cut outta here, so you can see that it is fully seated and verify that it’s seated. And then from there, you move on to your drilling protocol. You wanna make sure that someone, you or your assistant is holding that pin guide in place. So pushing apically the entire time you’re, you’re drilling the pin sites for that guide. ’cause this is the most important step of CHROME right here is delivering well any, any, any stackable system uh, out there. But especially with CHROME, you wanna make sure this thing is perfectly seated. So then you have everything will go as planned.
So here’s your pin guide and there’s of course dentate case, doctor’s trying it in, make sure it’s, it’s seats perfectly, no rock. So obviously everything there is good to go. So then the doctor removes it and inserts the pin guide into the fixation base, and gets everything ready for surgery. Now, of course, here, patient’s flapped, and now he just making sure the, the tissue’s out of the way and make sure, again, fully seated, pushing apically. I’ll fast forward a little bit here and then start drilling your pin sites. Now as far as the drilling sequence is, is concerned, you wanna make sure that you drill one site and then you place the pin, and again, all while someone’s pushing aply, then drill the neck site and push the fixation pin in. You don’t want to drill, drill, drill, drill. Then then pin, pin, pin. you wanna drill pin. That’s, that’s the most accurate and the best way to seat that fixation base to, to move on to the next step for your surgery. So now the fixation base is in, and this is then you extract your teeth, reduce bone to a nice flat plane. with the fixation base, you’ll eye it up, feel it with your finger, you want a nice transition. And then of course you’ll check the bone reduction. You can verify you reduced enough bone with that clear carrier guide, that clear plastic waiver that comes with the case.
So here’s a quick video fixation base is seated, and then you’re just gonna reduce bone. Some doctors start with wrong years and finish with a burr. Some doctors use a surgical saw, which is awesome to watch actually. but whatever your method is of bone reduction, just wanna make sure you reduce down to a nice flat plane. And here doctor’s checking and it wobbles a little bit, so there’s a little, there’s a little bone in the way still. So he kind of sees where that is and then reduces more in that area. And then doctor’s gonna reet that carrier guide and see that it’s flush and then move on to the next step. So there we go. So now next step is your osteotomy guide. And again, it works with any implant system out there. You just need to need to tell the lab what system you’re using as far as implants.
And then what guided kit. And just a quick little side note, a lot of the implant systems out there have many different lines of implants, so make sure that’s clear as well with your lab. Otherwise they’re, it, it can hold up the case. So all these little things you wanna make sure you include. And typically with the RXs, as you upload these cases, it asks those specific questions. And there’s a section for notes too. So too much information is never a bad thing. So if you have any additional notes, go ahead and pop those in the, in that section. but yeah, guides obviously the trajectory and depth of the drills and the implants. And you have nice full irrigation and visualization very strong chrome cobalt guide. And you see on this bottom picture, there’s an example of the OEM sleeves that are inserted into the guide. Again, the lab does that, it comes to you with those sleeves in it, so you don’t have to worry about anything the day of surgery other than, well, of course surgery. the protocol with your gut, with your stackable guided system, and then ordering your implant parts. But the guide comes ready to go for you
And mentioning the timing. So this is showing with CHROME GuidedSMILE. There are six nubs that are on the osteotomy guide. Now those nubs are only gonna be on the angled implant site. And those will coincide with some timing or, or your positioning of your multi-unit abutment your angled, your 1730 degree multi-unit abutment. as you’re at depth, that’s when you start watching for the timing and where to stop the implant, where to stop rotating the implant. It’s gonna line up directly with one of the six indicators on your guided implant driver. So you wanna pay close attention to that. Again, the better attention you pace, place to that, make sure it’s dead on. That’s gonna give you a much better restorative outcome.
All right, so here’s a quick little video. This is the osteotomy guy being locked in place with those three chrome locks, those blue locks there. So now it’s locked in. And doctor’s just gonna go through the guided drilling protocol. I won’t bore you with going through this whole protocol, but this is where it really highlights that visualization. You can watch your implants going in, see your drilling protocol. this particular system, it starts with a non guided on the adapter on the handpiece, but then doctor switches over to the guided adapter with the ratchet. And that’s where the indicators are. This is an angled site, so he’ll watch the indicators, there’s little dimples on this one, and then it’ll stop it right at one of the nubs when it’s at the proper depth. And again, watching the implant go in. There’s no surprise, like you have with a plastic guide, even a single implant guide, you don’t know where that implant is or what, what you drilled until you pull that guide off. So same thing with the stackables acrylic means you can’t see. It’s gotta be bulked up. So here you can see everything.
So next step, once your implants are in and they’ve been timed out on the angled sites, we’re gonna reseat this carrier guide. And again the carrier guide is about three millimeters thick. And so that, that takes care of your tissue, that that preserves that tissue gap for a nice restorative outcome. And then it’s also going to give you your timing of your angled multiunit abutments. And that’s what this black hash mark here is in the bottom picture. That’s put, that’s put, that’s put on there by the lab. And there’s actually a little, a little square rectangular, I guess notch cut out on the angled sites too, to where it lines up perfectly with your screw access hole of the, of the multiunit abutment on the angled sites. Remember, on the straits the zero degrees timing doesn’t matter. Depth is important, but the timing of the implant doesn’t matter that it just, you seat those and move on to the next site.
So that’s why there’s no indicator on the straits. And here’s a good image of those two pegs on the carrier guide that line up with the two holes on your prosthesis, your pre prefabricated prosthesis to aid you in the pickup. So again, everything’s pre-planned, so it’s gonna line up perfectly with the midline is gonna line up, it’s gonna be at the right vertical and the tissue gap, the tissue is preserved. So everything’s all pre-thought out for you. So just, you know, as long as you follow the protocol, you’re gonna have a nice, happy outcome for you and the patient. All right, so here again, we’re gonna talk a little bit about the provisional. This a prefabricated provisional that you receive, and then of course that rapid appliance, the duplicate of that provisional. But it’s very strong, very aesthetic prototype in that, you know, patient wears that four to six months, deliver the day of surgery, and that stays in until you’re ready to get ready to transition onto the final prosthesis.
So here we have the carrier guide in the mouth, we’re gonna seat an angled multi-unit abutment, and that’s where that screw access, you see it line up right with the black hash mark. And then your screw, there’s a little, that little cutout is also to kind of help give you access to that screw. So as long as it’s lined up and you’ve timed your implant out, you’re gonna have a nice restorative outcome where the, the holes are gonna be in the proper place in the, the screw access hole gonna be in the proper place in the provisional.
Let me fast forward this just a little bit. Doctors going through and checking, you know, making sure they’re, it’s all proper torque. And then the temp cylinders are placed. Now I wanna mention, you want to order two sets of temp cylinders with this protocol. ’cause you’re gonna pick up one set in the provisional that’s provided, and then you’re gonna pick up a second set of temporary cylinders in the provisional or I’m sorry, in the rapid appliance. And that’s where you just hold onto that and we’ll briefly touch on that workflow. Dr. Tritin. Now we have blue plug or blue gaskets. These are your rubber gaskets that kind of block out the acrylic from locking your prosthesis to the carrier guide. Everything’s seated, nice and flush, locked into the pegs. And now you have your acrylic going in. Then this particular example that’s stellar, but you can use whatever acrylic you, there’s voco, there’s, some chair side material chair side as well.
So whatever your material of choice is, great, get that pickup done. And once everything’s picked up, then of course unscrew it and get that cleaned up and ready for delivery. And as I mentioned, then you do your duplicate appliance. So you wanna make sure you order two sets of temp cylinders, and then you’d go through that same protocol again, seat the temp cylinders express your acrylic, and then pick up the duplicate rapid appliance. here you notice there’s blue plugs. So those blue plugs can be sent with the chrome case as well. Those go into the end of the temp cylinders, so you don’t have to worry about expressing your acrylic down into the temporary cylinder and blocking that screw access hole. Not a fun time when that happens. And of course, an even worse time if you don’t have those blue gaskets down those blockout gaskets, if you, you know, again, cure that to the carrier guide it, it makes for a long, long morning or a long afternoon trying to remove that properly.
So just be aware, it’s a methodical process. It’s the same process over and over with the stackable guides. You just want to take a step back, think about the next step, and then, and then proceed. And then you wanna make sure that your team understands this too. That’s also very important for these cases that your team is on board. They know the ins and outs of the system because you want this to be a fun and exciting time for them too. If you do your first surgery with a stackable guide and it takes forever and there’s a bunch of mistakes, team’s gonna hate this stuff. They’re never gonna wanna talk about it, and you’re not gonna be successful with these cases. So again, just making sure everything’s on board, it’s a little, just a little side note for you. but again, with this rapid appliance, this duplicate appliance, it is your best friend on the restorative side. So with a protocol, I won’t go into it too much, but you have your rapid appliance appointment. So that’s appointment one, post healing. The next appointment you’ll receive a printed tryon or a prototype of the final from the lab. And then appointment three is going to be your final zirconia. So you can get to a final with this stackable workflow in just three appointments.
So let’s go through, I know we had some videos here. Let’s just rehash CHROME start to finish with a nice case here. I do wanna mention, you see on here it says smile simulation. One thing you can do, you can order from the lab is a smile simulation just from a a 2D photo, a full face, full smile photo, had the patient standing up, they’ll take a, take a nice picture, send that to the lab, and they can work up a smile stimulation. There is an extra charge for that, just depends on, on the lab fees there. But it’s a, it’s a great tool to help present these cases to patients and maybe help, help them you know, accept treatment. So wanna mention that. And then we’re gonna go see the surgical protocol extraction to wrap it here. And then the prostate delivery.
So here we are, patient is flapped, Pingu gets seated, and you’re gonna verify that seating with those occlusal windows there. So make sure it’s seated all the way. Check the windows, make sure there’s nothing in the way, no tissue in the way, and then you’ll move forward with your drilling protocol. As a reminder, you want to have someone on your team pushing aply you or someone on your team or you and someone on your team push aply while you’re drilling your pin sites. Again, this is one of the most important steps of your stackable guided workflow, is making sure this pin guide and fixation base or foundation guide, depending on what system you’re using is delivered properly. If it’s not delivered properly, the whole surgery is gonna be off and everyone’s having a bad day and you’re calling the lab not so happy.
So please pay attention to this and all the steps, but this is also very, very, very important. But you wanna drill one site at a time and then place the pin like I mentioned. So drill a site, place a pin, and then move forward. It does mention here, it was worth mentioning, of course, if, if you drill the first site and that thing drops right in, you got very, very soft bone. The next site, just drill about three quarters of the way down, leave it about a millimeter or two short uh, from on the drilling protocol, don’t, don’t bury it all the way to the fixation base. And then you can place your pin and either push it in with your finger or you could always tap the pin in with a mallet that will get ideal fixation uh, with the soft bone. So there’s a nice soft bone protocol with chrome GuidedSMILE as well.
So now the fixation base is delivered and you’ll remove the pin guide. You’re done with that on for, for day of surgery. So you’re done with that. next is you’re gonna extract teeth and reduce bone. Now I like to show this, this is a, a fun slide to show because it shows the accuracy of the plan versus the real life ex, the fabrication and the real life execution. Now this little purple wafer, that’s your, you don’t see that in the mouth yet, but that is your fix. I’m sorry, that’s your carrier guide and that’s your tissue gap and then the setup there. So, but this just shows the accuracy of real life versus the plan.
So now the teeth are extracted. I’d like to kind of point this out, let me go back here. this looks like a lot of bone reduction, but once the teeth are extracted, it’s really not that much bone reduction. You know, the labs try to plan the least amount of bone reduction needed for the ideal prosthetic space. So, or to get to some good bone, it all, you know, there’s a lot of factors that go into that. But, you know, our goal is not to just hack off a bunch of bone. We wanna preserve the bone like everyone else out there and make sure that we preserve the bone, but while having enough restorative space because we don’t want things breaking down the road and unhappy patients and they’re wanting their money back. So we, we take all that in consideration when planning the bone reduction. So here, bones reduced, again, you do reduce to a nice flat plane with that fixation base, and then you’re gonna verify that bone reduction with the the plastic carrier guide as well. here again, just kind of comparing the plan to real life and the reminder of that gap between the bone that’s supposed to be there. And you see here, there’s a nice even gap. This isn’t a mirror, so it’s a little fogged up here, but a nice even gap between the fixation base and the bone.
And here’s your verification reminder. Verify that bone reduction. Take your carrier guide seat that make sure it doesn’t wobble like you saw in that video earlier. make sure it doesn’t wobble and it seats perfectly. And, and you wanna lock, lock in those chrome blocks. Make sure it seats perfectly and passively. And then once you, once you verify that, remove that carrier guide, set it aside ’cause you’re gonna need it down the road to pick up your temp cylinders and deliver your prosthesis. Don’t just toss it on the floor but seat that remove that carry guide set aside. And next you’ll move on to your osteotomy guide stacks into the fixation base. this image, this is a little older image. There’s only two nubs with CHROME guided model. What they’ve done, gosh, over the past, well, however, 6, 7, 8 years, however long, however long it’s been around, they’re always changing and always making things better.
It’s constant innovation with this. And that’s another reason why, you know, we love CHROME GuidedSMILE is the innovation that changes. And you know, they listen to doctor feedback out there. So if there’s ever something you see, maybe you have a different idea for it, let the lab know and they can, we can make some changes and potentially make some changes and, and incorporate that in the workflow. But here there’s two nubs but you’ll get six with your, with your guide and just make sure you’re paying attention to the timing of that. in this bottom picture, you, this, this little, little pro tip if you will. depending on your implant system or how many pieces of parts you have, you may have multiple guided uh, guided drivers. So this doctor leaves a guided driver in and he goes on to the next implant site. Just adds a little more stability to the whole, to the whole guide. You don’t need to do this, but doctor likes to do this protocol just ’cause he feels like it’s a little bit more, even even more stable doing that.
So again, real life compared to the plan. And you can kind of see just comparing positions of the nubs and, seeing the position of, of where the guide is seated on the plan versus real life. So again, very accurate. This is all methodically thought out and well-planned by all the planners to make sure you have a great outcome. So now the implants are in and the next step is going to be receipt that plastic wafer, the the carrier guide. So here we have the, the carrier guide and, and uh, you’ll see that this times out your or or uh, it times out the implant the multiunit abutments with the implant. So it gives you your indexing and that’s what these arrows are showing. It shows a screw access hole with the little cutout on the carrier guide. And then there is a black marker here.
It’s a little bit hard to see in this image but there’s a black, black line there that shows also where that screw access hole’s gonna be. So make sure you time out your angled multi-unit abutment sites. And then on, as I mentioned earlier on the straits, the zero degrees. There’s no timing to worry about. You just seat those, torque them down to the implant specs and you’re good to go with those straits. And of course, the nubs, these two little pegs I guess we can call ’em that are on the carrier guide to help deliver your prosthesis so you’re not having that thing move around. there are other stackable systems out there that have to have the patient in occlusion when delivering the prosthesis and picking up the temp cylinders. That can be kind of cumbersome because, you know, maybe the patient’s not biting correctly. so that’s all avoided with chrome GuidedSMILE. it locks directly into the carrier guide as long as it’s nice and flush. You have access from the occlusal to pick up those temp cylinders. one little note here. Bone profile. Yes, angled sites especially you wanna profile the bone ’cause you wanna make sure that the multi-unit is seated all the way and you wanna make sure you know, that nothing gets held up because that can obviously cause ill-fitting prosthetics and then issues down the road.
So here we look at, again, real life versus the plan. you know, it’s all the temp cylinders. They’re in the, in the miller. We’re darn close to the center of these these access holes. And this is a angled, all these implants are angled, which, you know, a lot of doctors, they, they, they hate hearing, you know, angle multiunit abutment because of having to figure out that timing. Well, again, that’s all figured out here with, with the chrome GuidedSMILE. So the timing is down as long as you pay attention to your implant indicators. The timing indicators on the O osteotomy guide, you’ll be all set and everything is is planned out and line up with the angulation of your multi-unit and that screw access hole.
So now we have the blue blockout gaskets are seated and the prosthetic is delivered. Slides over these temp cylinders, locks into the pegs and then nice easy access to express material, your pickup material from the occlusal. And then here you have, you notice your blue, your blue plugs. Those go into the temp cylinders, they’re tapered. So they do work with any temp cylinder out there. And move forward your, with your pickup process. And a reminder, make sure you do that second pickup order, a second set of temp cylinders. You notice I say that multiple times in this lecture because it’s very important and it’s huge on the restorative end and you know, sure you can restore it. And there’s, we have, we have ways to do that and there’s easy workflows, but nothing as easy as the rapid appliance or that duplicate appliance workflow on the restorative end.
So here we look just looking from the occlusal, there’s different these are purple block lock gaskets, but typically they’re blue anyway. yep, occlusal, again, nice access. And then comparing real life to the plan. Everything is planned out and executed perfectly by this doctor. Again, pick up, this is just reminding of that duplicate appliance doctor got kind of fancy here with the acrylic. No need to do that. I think he did it once and then that was the only time the doctor ever did it. But yeah, just express your acrylic again, stellar voco and the chair side, there’s, there’s a lot of stuff out there. So a lot of different options on the acrylic when you’re picking up your temp cylinders. Whatever you are comfortable with we wanna make sure, again, you and your team are fully comfortable when day of surgery. So don’t change up anything too new. ’cause you’re already starting over, starting, starting something different with this stackable workflow. So wanna make sure everyone’s comfortable.
And then once you have both of your prosthesis deliver picked up, so your provisional and your rapid appliance that gets handed over to a chairside, to a technician, whether it’s someone internally or a lot of the labs will offer chairside service. And that chairside technician will get there the day of surgery and, you know, be there with you for the case. And then they clean up the prosthetic, cut down the temp cylinders, get it ready for delivery, and they’ll even teach your team how to do that. So we, we wanna make, make sure that everything is nice and smooth. And if, if that entails having a chairside person, they’re great. We do highly recommend a chairside technician to chairside expert there the first time you’re doing this workflow. ’cause again, things can be pretty hectic just because it’s a surgery and a full-arch surgery.
So having that person chairside is, is a, a huge advantage to you and your team and the patient to have ’em there. So there is a fee to that, just depends on what you know, the lab. So contact your lab and figure out what that fee might be. But it’s something that is offered, but beautiful prosthesis delivered. And then four to six months later, that’s when you go through that rapid or duplicate appliance used to transition to the final zirconia. So three appointments, rapid appliance printed tryin or your, your prototype of the final and then the final zirconia. So very, very easy restorative workflow with your guided stackable system with CHROME GuidedSMILE. All right, I appreciate everyone taking time out their busy schedules to view this webinar and I hope I was able to shed some light on some of the ins and outs of the, the different protocols for all of the stackable guided workflows out there. Thank you.
