CHROME GuidedSMILE – Single Arch with C2F Case Review

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Speaker 1
Hi, thank you for watching this video of a single CHROME GuidedSMILE case. This case was completed with Dr. Gregory Young in Michigan. He is a seasoned implant doctor, a few decades placing implants, knows his stuff. I’ve worked with him cheer side many times now, and I always learn he is just very, very impressive. Couple years ago, he began doing full arch with CHROME and he excelled and it excelled so quickly that I thought I’d make a video out of his case and talk about some tips and things along the way. But just go through a CHROME case and just kind of talk our way through it. This particular case that we did just a couple weeks ago was a challenging one. It was a young patient with no other way to say it with meth teeth, and his grandparents decided to take care of his mouth for him and give him a new smile and give him another chance.

So this kind of case, the records were very pretty straightforward, except he’s missing his molars and I think it really affected his bite. You’ll see in the end we have a little bit of a challenge with a bite at the end for some adjustment. But otherwise, regular crown bridge records, upper lower scans including the vestibule bite, photos left, right center in occlusion retracted, and then we made CHROME and went to work. The first step on this case was to extract five and 12 so that doctor could seat the pins because the patient has a lot of teeth and a lot of roots. So in order to make room for the pins, five and 12 had to come out first. 18 and 30 are noticed are noted because this is going to be extractions on the lower and some implants placed after the chrome surgery. So that’s just for that note. So doctor extracted the two teeth on the upper to seat the pin guide. Pretty a traumatic extractions. Doctor has a lot of experience with extractions and adjusting bone to make the teeth looser in order to extract them. He does a really nice job of adjusting the bone. I believe I have a video in here showing this.

This is just a nice photo showing the surgimat on the wall and then the tools here on the tray. And what we’ve done together is we’ve, we’ve been working on completing these surgeries quicker, and so the doctor and I and Carol work on processes, repeat processes and protocols to make these surgeries go quicker. The first case we did was five hours and then four hours. We completed a case in just a couple hours a few weeks ago, and one of them the keys is just proximity to componentry, keep things on the tray that you’re going to use now, keep ’em close to the mouth and don’t have things scattered around the office. Be very organized. So just a couple of pictures. This is Bill, Bill’s an anesthesiologist. We always do anesthesiology with Dr. Young and it certainly helps patient management. One of the things that doctor does, and I’ve seen this before, not too often is putting the pins in Neosporin for a number of reasons.

They slide in a little bit easier, but it’s very aesthetic. I mean very, very by biologically friendly. The first step is to either out and then full labial reflection, a little bit of lingual reflection, and so that the pin guide can go in. Now something we work on quite a bit is the pin guide process. Okay, so I’m going to talk through this process with a pin guide. You can see that the first drill just came out, but it is of utmost importance that the pin guide goes in properly. And that means that in the window here and the window is in the posterior, that the teeth and the plastic is in contact, that there are no gaps. The pin guide must seat firm and solid and be fully seated, otherwise, the fixation base does not go in the right place. So we kind of pound and pound on this in all of our training videos that the fixation base is in the wrong place.

Everything is in the wrong place, literally everything. So the technique for pinning push play here, we put the doctor, put the drill in, drilled one site, and then push to pin in thumb tighten. Do not use a mallet at this point. Drill the next site and the next site and the next site. So you go through the process habitually, routinely, drill, pin, drill, pin, drill, pin. Normally there are four pin sites, and the reason we do this is because if you put a pin in and then you hit it with a surgical mallet, you can and will probably put some tension on the pin guide, right? Because you’ll tap a little too far with the pin guide. So don’t tap at all and drill all the sites. And when they’re all in, then you have four pins, sometimes five pins, all at different trajectories. And then that will hold the pin guide solid, and then you tap in. Now this is the maxilla, so you can see that all the sites, the pins, the drill is all, they’re all stopping short, three millimeters, millimeters short. I want to show something else here too. We kind of chuckle about this being the young technique, Dr. Young, where you, he’s pressing with his finger, so you’re not forcing the handpiece in. You’re forcing the trajectory down the long axis of the drill that keeps things from binding, breaking. You just push directly down. There you go. And put the pin in.

Now all four pins are in. All right, there we go. The next step is to take in an instrument. In almost every case, it’s the mirror with the mirror head, the mirror handle with the head removed and tap. Now you can see Carol is still holding that pin guide in place. You never release a pin guide until the pins are in. So tap, tap and you’ll hear an audible tap when you’re tapping these in. And what we’ll do is we’re going to play some of the audio here through the rest of it, and you’ll hear how the tapping changes. Because when you’re tapping on metal, it’s one sound. And then when you reach the metal to metal, the pin hitting the metal fixation base, you’ll hear the noise change. Right? So it thud, thud, thud, and then tick, tick, tick. You’ll know when you’re done and don’t keep hitting because you could push the metal or the whole pin guide and torque and actually move it.

Let’s listen to it again. This one took little extra tapping than the other one did. Listen for the different noise. So that’s the proper pinning technique. And let’s going to turn the volume back down a bit, but let’s watch to the rest. So now the CHROME locs are loosened and the pin guide will be removed. This patient’s kind of biting down a little tricky to remove it. Alright? Sometimes forceps are needed to open up the chrome locs. And out it comes. A pin guide, all right, that is proper pinning and you’ll know it’s proper pinning. There’s, it’s a little bit of blood buildup here, which you’ll notice once it’s removed that the gap here is the same as the gap on the surgimat and the pin guide has been successfully installed. The fixation base is successfully installed. All right, that’s pinning.

So the next step will be to complete the bone reduction. And bone reduction is, it’s a whole topic in itself, but there are some very particular burs and techniques that most of our clients follow. Normally it’s a very aggressive burr. We call these Mr. Hungry, ROE Dental Lab sells these and these, this is a Meisinger burr. This one works really well. I’m not sure the brand of this one, but they really all do the same thing. And if you’re working with a straight handpiece, which most of the time you are, then you can reach the bone at an angle from here. But see, there’s no football shape, so you don’t have that concavity on the bone. You have a flat bone surface. These burs really do collect bone, especially this Meisinger bone. It’ll collect bone, you have to clean it off during the process of reducing, but those are for the gross reduction. And then sometimes the BB or even these other burs here, there’s either burs that use to go interdental to break up the bone between the teeth and then these bb birds to grind bone around the necks of the teeth because in one of the goals is to extract teeth aromatically. So reduce the bur around the C, the bone around the CEJ around each one of the teeth go inter proximal. And the teeth really come out much easier when that is accomplished first. So you can see the little BB bur here.

Doctor is very, very good at extracting teeth. There was a little bit of extra bone removed here that he ended up grafting at the end, but otherwise, these are young vital teeth. So really a good job with removing them. And then choice of instruments. Doctor likes to use Rozeurs, and often that’s for some gross reduction because using a bur for a lot of bone makes a lot of snowflakes in the mouth and it can clog up suction and it can have some other issues. It fills up the CHROME locs with bone. So pick and choose and then gross reduction, and then maybe move to a bur after that. There’s so many different instruments out there. So choose your weapon. And usually speed is one of the most important things here. I say that a little hesitantly because of course, accuracy and you don’t want to reduce too much lingual or too much, too much of anywhere, not too little. So it does take some skill to get this bone down just like this. Exactly. Flat means the carrier guide fits flat means tissue can be sutured, nice and flat over the surface, and we can make a hygienic prosthetic. That’s one of the magical things about CHROME. Once the, I don’t have an image of it here, unfortunately. Lemme see if I do.

At this point. The normal protocol would be to try in the carrier guide. The carrier guide will help determine if the bone has been reduced because the carrier guide sits above this, just a millimeter or two. And if you haven’t reduced enough bone, it will not seat passively. And that’s your test. So try the carrier guide in and the carrier guide, just so we’re on the same page is, I’m flashing forward here a little bit, but that’s the carrier guide. And you would passively seat that onto the reduced bone in order to make sure that you’ve accomplished the bone reduction. So next step is to drill the osteotomies. And in this case we have angled, angled, angled. There’s four angled, you can tell by the nubs. We put indexing on these nubs so you can make sure you have the implants rotated properly so that the multi unit buttons are facing in the proper direction rotation and the temp cylinders will all fit into the prosthetic as planned. These do not have nubs. And so those are straight.

So the doctor is going to drill all the sites he uses Megagen kit. All right. And here’s the young technique. Again, pushing on the drill to drill all the sites we go and one, once they’re alt drilled, then with this particular system, you can see here the nubs, right for indexing, I believe I took a nice picture that showed, oh, that’s on a straight. And then just kind of showing where the depth line would be on this particular implant. All right, so it’s just showing some pictures of some mounts. In this case, the doctor ended up freehanding one of the implants because we had to upsize. And this particular kit would not allow upsizing of an implant through the guide. Through the guide. So we had to go to a , doctor freehanded, an osteotomy that had already been drilled. And then we attach, we put the osteotomy guide back on with the mount and then finished the, get the case finished, placing the implant guided doctor uses a megatorque for placing the abutments to the proper torque and the temp copings. This is a mechanical rechargeable device that works really well. It keeps the fingers out of the mouth right? Instead of using thumb, thumb drives and screwdrivers and some torque wrenches. This is a contra angle. And so you can keep your fingers out of the mouth at, recommend anybody purchase this or some other contra angle torque wrench, because that way when you’re in the back of the mouth, you don’t have to fuss around with parts and screwdrivers with multiple fingers where there’s limited space.

So the next step is to seat all the multi-unit abutments. And these are straights. So those are easy enough to put in. The angled, have a specific rotation that they go in. So if as long as you follow the indexing on the osteotomy guide, then you would make sure that this gray mark and this little notch are in the same position as the the abutment screw. All right? So that your driver, whatever driver you have, screwdriver, goes this way right into this follows the same as the black line here, and then that your abutment is facing up or in the exact trajectory is planned. Okay? So that’s what this notch is for, and that’s what that black line is for. So you can see here there’s a screw and a black line here, it’s a distal, and here it’s distal. You can see the little notch.

And then right here, two, and then those are straights. So these are the trajectory of the temp cylinders, these handles, because they go directly into the top of the, the multi-unit abutment. Next step is put the temp cylinders on. Now this doctor uses long screws, and if you’re in a little facial, or if you’re splayed out a little bit like this, it’s supposed to be like this. It’s actually by design that they’re splayed out just because we don’t have control over every aspect of bone and implant position. But these long screws can get in the way of trying to unseat the prosthetic. It could not be might passive here, and you might have to open up the prosthetic. So blue plugs are better, but long screws work. So the doctor will put the temp cylinders on and then put the gaskets on and then seat the prosthetic and then hold it firmly down.

And then just simply backfill. Backfill to attach to prosthetic to the copings. Now this is a rapid appliance. So the beautiful thing about a rapid appliance with this C2F technology is that you only have to pick up the rapid. You don’t have to pick up the take home prosthetic. And what you’ll do is remove this from the mouth and you’ll hand it to your assistant or somebody in the office, or maybe a lab tech, and they’ll go through the C2F process, which we’ll go through real quickly here. These are special C2F analogs. They are alluded to the pro I, I’m sorry, they’re screwed into the prosthetic. They are placed inside of our pre-manufactured model. So we flip over to the back and we, sorry, flip over to the back. And we lute the analogs to the model, and we create a model.

These are the heads. So the prosthetic is removed, but you can see how we instantly fabricated a model back in the lab. Just takes a few minutes and while this is going on, the doctor is going to suture. Alright, going back to the back to the room. And then we go back to the lab. And what we do is the C2F heads, these heads unscrew from the analogs and they leave hollow analogs. In the model, you can see their hollow. And so what we do is we take a drill and we drill through the analog and then through the prosthetic, and we make holes. You see the take home prosthetic does not have holes like the rapid appliance. Rapid has holes take home doesn’t. And what we do is we put the prosthetic on the model and we drill holes through it. And when the holes are all drilled through, then we go back and we take copings.

We put copings on the C2F analogs, C2F heads, and there are videos that show this in detail. I didn’t want to go through that in this whole process. But bottom line is we make small holes so that the prosthetic looks and functions and feels like a final preserved occlusion. There’s no giant blobs of pickup material you’d see in the rapid appliance. It’s a very clean, very nice prosthetic. And then we just simply do an injection through the lingual right there to connect the copings to the prosthetic. So it’s an extra oral conversion. And then we use this little tip here, a little endo tip or a composite tip to fill in all the little voids and then it’s ready to deliver. All right, so you have small holes, beautiful little holes, very clean intaglio, and a beautiful prosthetic.

Here we go, prosthetic next to the rapid appliance. You can see the improvement, the quality of doing a C2F conversion. Doctor has sutured with healing collars, and then the prosthetic is seated quickly, and then the patient is equilibrated. Now, this is when I said there was a, now he, he’s biting a little funny, but there was a little bit of an issue with the bite. Not a hundred percent sure. Little bit. Maybe it could be some conjular. I hope it wasn’t some articulation in the lab. I think it was just not a very good, very good bite there, but just some minor equilibration that posterior and the case really ended up nicely. All right, thank you Dr. Young for allowing us to work with you and document this case and share it with everyone.

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