CHROME Webinar Series: The CHROME Records

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Rewritten Transcript

Well, good afternoon, everyone.Uh, thank you very much for joining us for this Chrome guided smile program. This is one of five that we’re going to have starting today. Uh, through next Tuesday, we’ll take Monday off, but then we’ll have one for next Tuesday and we’re going to go through Chrome from really from a to Z, uh, a being today, which is the records. Uh, my name is Alan Banks. I work for road dental laboratory, and we are the main, uh, facilitator of Chrome for the main partner with our production facility. Um, we handle all the IP in the background, uh, the fabrication and the design, and, um, work with some folks on all the R and D. And it is, uh, really a very exciting product, uh, to be involved in, uh, we’re nearing 6,000 cases. In the past two years, we built an entire team around this, nearly 30, uh, 30 dental technicians, including dentists full-time for us.

Um, and it’s, it’s quite an adventure. So, uh, RO dental laboratory, we’re a full service lab. We’ve been in business since the mid 1920s. One of the oldest laboratories in the country, uh, with this, uh, with this product we developed, uh, um, uh, brands around it, uh, that support Chrome, uh, from dentures, uh, to the IGETC to the final restorative protocols, uh, some, some brand names that have become kind of popular around the world. Uh, we’re in Cleveland, Ohio, actually, we’re a little suburbs South of Cleveland called independence. Uh, we fabricated Chrome in all 50 States. Uh, we have, uh, we have a partner, uh, in Ireland who is very successful with this who have partnered in Australia and, um, planning to expand even more than that. Uh, the, the webinars up coming up Wednesday, Thursday, Friday, next Tuesday are listed on our website. We hope you join all of them. Uh, today’s goal is to go through, as I mentioned, the records, uh, and there are some challenges with records, you know, although they’re, they’re, they’re relatively straightforward. They’re general dentistry really, um, for the most part today. Um, but uh, many of these cases are compromised patients, and so the records are very important and, uh, we take great care in, um, assessing them and working through them with you. So Chrome guided smile. I’m going to just play a little video here. It’s really quick.

It’s a culmination of years

Guided surgery technology wrapped up

Into one industry leading full-arch product developed in both the clinical and laboratory environment. Chrome delivers a doctor and patient preplanned service for bone reduction, osteotomy creation, implant in multiunit, above indexing and an integrated nano prosthetic. There are no comparable services, new world it’s available for nearly all implant systems offers full visualization during surgery, minimally invasive exposure, fully pre-planned surgery with implant indexing, a beautifully crafted and integrated prosthetic. Any level of precision planning that is unique in the industry for implants components and prosthetics Chrome delivers what is expected by the patient and the doctor every time for every patient after patient, after patient, after happy patient, each time you try Chrome and its family of products and services for your next full arch surgery.

[inaudible]

All right. Thank you. That kind of summarizes, um, you know, the, the, the message of Chrome, um, but what is Chrome? Chrome is a pre-planned surgery that starts with a smile simulation and ends with an ideally designed full arch prosthetic. It’s a sequential Chrome is sequentially delivers, bone reduction, guidance, osteotomy, guidance, implant, and abutment control, a simplified prostetic conversion, and a very simplified method of converting to the final restoration. In fact, that’s one of the, uh, that’s most, one of the most wonderful components of Chrome is a simplified restorative protocol for today. Uh, hopefully in about the next, um, 35, 45 minutes. And we’ll go through the whole, um, all the records, if you’re just tuning in, if you wouldn’t mind, please muting. That’d be great. Thank you. Uh, we’ll go through dental. Uh, we’ll go through a single edentulous arch doubly dental arch, and then, uh, some, a little more tricky ones with the partially dentureless with existing partials.

That’s a common, a common, um, situation. So one of the nice things about, uh, the development of it, and we have a team of people that work on these types of things we’ve developed checklists for our customers to use, and the checklists can be found on our website. And here you would just simply go to our website, go to Chrome, guided smile, and drop down to getting started with Chrome and Chrome patient records. And on that page, are the checklists all by the different types of situations that patients present with a double Dan Tate, single denti to opposing denture, uh, double dentures, partial dentures, and it will go through categorically every record that you need, uh, in, in clear, well thought out, um, uh, format, uh, for your team to collect the records. So I highly advise, uh, we recommend that, uh, when you start a case print off the checklist and, uh, and just follow it’s a follow simple protocol for collecting the records.

Another nice, um, feature that we have is the Chrome FAQ. And again, it’s on Chrome guided smile on our page, go down to the frequently asked questions and we have been collecting compiling questions and answers for the last couple of years. And I mean, just as an example, I mean, we have the Chrome records, which we’ll go through today, but tomorrow we’re going to go through the pin guide and just the pin guide alone, um, to relatively simple device to use, but there are many Q and a, uh, items around it. And this entire section is just about the pin guide. You can learn everything you ever want to know about the pin guide on our FAQ. It’s a very helpful tool, um, for, for both doctors and staff.

So let’s start with, uh, let’s start in the records. Um, the most common type of case that we see is a den date, single large den date, uh, and often double our dent date. The records are very similar for both. And as mentioned, uh, the records are also very straightforward for Chrome guided smile. In fact, uh, one, two, three, um, a series of photos, very standard photographs, uh, upper and lower caste and a bite and a CT scan. That’s all that is needed for, um, to start a dented case. So let’s, we’ll go, we’ll go through the dentist first. So as you can see, this is a collection of records for a single arch, or even for a double arch, uh, Chrome case on the left are the models, uh, upper and lower castes, uh, bite registration. Is this from a digital, actually, this is not a digital, this is a conventional impression has been digitized, uh, poured up and digitized a CT scan that captured both upper and lower, uh, arches with space between with a den Tate.

You always have the patient open and then the photographs full phase, full smile. Uh, we’d like to see a little bit more of an exaggerated smile then than this. Um, but often that’s kind of tricky with these cases. A lot of these patients have, um, uh, you know, have, have had years of stress with their dentition. And so sometimes it’s tough to smile, but we’d like to have a full face smile, and I’ll explain why in just a minute. Uh, and then the photographs, uh, retracted, uh, center left and right. Uh, so we can see how the teeth come together and we’ll go through a little bit more of that, um, in the coming slides. And we could just say those that are records, um, you know, have a nice afternoon, um, you know, all done records for identity case, but the fact is, uh, over, over the past couple of years, even a few years, uh, at least we’re we’re things are getting a little better now, but for a time it was seven cases.

Now it’s maybe five or six cases out of 10. Uh, the records come in and the red light goes, which means we, um, we either have to make a phone call or have some kind of discussion about the particular records, either something is, um, something is missing or, uh, or additional records need to be captured. Um, most of the records, again, they’re straightforward, um, but there are questions that need to be answered and just some missing items. So that’s why today’s program will be so helpful for, uh, for the doctor and the staff. So the photographs, um, very simple, straightforward photographs, uh, you know, we do recommend an SLR camera, but frankly, a cell phone, a cell phone pics are very high quality these days. I would recommend that even if it’s a cell phone, uh, put the camera right in the center of the nose and take the picture at that level, we really like to see the plane of occlusion as, as we are looking at the, at the center of the face, uh, full face, full smile, try to get your patient to have an exaggerated smile and then left right and retracted photos.

We always want these in the occlusion, uh, because we want to see how the teeth come together when we are analyzing the models on the articulator. So it’s kind of a, it’s a verification that we had the case articulated correctly. Uh, we also, um, on, on a lot of cases would also like this photograph with lips at rest, uh, that may be seen with how much tooth display there is and how much, um, you know, aesthetic changes we’re going to have. Uh, but then also on the right, if a patient is severe class three severe class to take, um, take profile photographs, uh, those can help consider considerably with, um, with the two set up

The full face, full smile photograph. We use this for a smile simulation. In fact, uh, uh, every case that comes through our laboratory, we perform a smile simulation. We do it with this software called preview. We have been using smile simulation softwares for years, many years. Um, this is by far the best software we have ever used. Uh, it’s a very simple process. In fact, they boast, uh, after they train you, uh, that you could do a smile simulation and in about a minute and a half, two minutes, a really nice quality, um, photo, um, and the patients just love I’ll show you some examples of it. Uh, they love doing demos, a column it’s this, there we are. We’re not associated or we’re associated with them, but this isn’t a, um, uh, this is basically a promotion for them. They’re, they’re actually a wonderful company with an easy to use software.

So preview. So we take the preview software and we, um, essentially take the patient’s STL files, the, the, the, the files from the digital impressions or the digitized models. And we superimpose the patient’s face over the models over the 3d models. So a 2d face over the model, and then we use a smile simulation to perform the setup. So we, we, um, they’re normally, there’s about four more images here, but one of them will be the, the simulation that we did with preview. So we set the teeth, uh, we sent them in, in an ideal position behind the lips, according to the STL models, uh, and, and really do a nice job of, of, uh, putting teeth in the right place, uh, physiologically and aesthetically. And from that, that is the, this is what we use to do the setup, and then eventually make the Chrome prosthetics. So you can see this case has come full circle, uh, from the beginning here to the end. And the setup I would see is very similar to the, you know, to the restoration at surgery.

So we really try to make a one-to-one, uh, smile simulation through, to the prosthetic. And we do that through this preview system, uh, preview. Um, we, we, we partnered with them a couple of years ago, and they were nice enough to take, uh, STL files of denture teeth that we use to set, you know, real denture teeth that we use, that we export as STLs to fabricate, um, prosthetics. And they took their beautiful natural smiles, and they morphed them in the shape of our denture teeth. So when we set a tooth, for instance, when we set a triangular mold, uh, in the software, it’s the same as the smile. So it’s, is it, is it a one-to-one? No, it’s not an it, but it’s pretty close. It’s definitely an a, uh, especially in the patient’s eyes, it’s an a, um, you know, eight to eight plus.

So we use those smiles. We make these smiles every day, uh, for patients all around the country. Patients love them. Uh, we have a lot of doctors who actually have the software and use the software on patients throughout the day. So these are just some examples you can imagine these, you know, these patients have been through, um, basically dental trauma for many, many years. They see a preview smile. That’s part of our records system, uh, and, and they are more empowered to make a decision. They know what they’re going to look like, and these smiles are brilliant. If you have a, a 60 inch monitor in your, in your, uh, patient consultation room, these smiles still look magnificent. You really will be shocked. So you can imagine all these patients we’ve shown you, um, what their, what their reaction must be when they see them.

Uh, one thing about photographs is we want very good photos to do a smile simulation. So obviously the, um, we want to see a smile. I want to see teeth. I want to see the eyes open. Um, try not to like the one on the right, um, try to bring the camera a little bit closer, because by the time you zoom in on this gentlemen, uh, it’ll be, it’ll be fuzzy. Uh, it’ll be a little bit out of focus. Um, the patient on the left, you know, I have him stand up, you know, he’s kind of leaning back in the, in the chair. Uh, actually, he’s actually, I think he’s leaning back in a chair against a wall, a patient on the right, little too much flash, a little too much wash out. I mean, our, one of our goals is to, um, to really wow, the patient with, uh, with this record, you know, with this smile.

So, you know, here’s, um, here’s gentlemen, they’ve went through several different photographs and we’ll take them all, you know, we can, we can pick which ones, um, which ones that are best, but, you know, you can pick them too. And so it went through a whole smile of this guy, just being happier and happier and happier. And then finally the happiest he can be right there, uh, take both of those pictures and upload them with the case. Um, this gentleman is not happy. Um, uh, but I know that you can make them happier for the photograph and certainly through the surgery. So, um, work hard to take a, please work hard to take a nice photograph. And then, and then the other set of series, as already mentioned, um, uh, teeth in occlusion, and we take these images, we put them on a big screen here, uh, at our stations, uh, with your models in hand in the articulator. And we confirm that the case is articulated properly. Um, articulation occlusion is just one of the most important things that we do here, so that you have a successful surgery. So did you have a good bite experience? And part of that is just really these simple photographs, um, sending them in with the case. So we magnified them and we literally look back and forth from the screen to the models and make sure that we were articulated, right.

Uh, one thing important about the cast, uh, either the cast or the digital impressions or the impressions that you send in is that they, uh, that they involve all of the land areas. Uh, you want to capture, imagine you’re taking an impression for a denture, right? Immediate denture, because essentially you, you, you are, uh, most of these cases, uh, the doctors order a backup denture, just in case things, don’t go perfectly, um, during the surgery. So you want the vibrating line, the full roll. Uh, if it’s an analog impression, if it’s a digital impression, sometimes you cannot capture all the land areas, uh, down into the vestibule, but you can at least capture all of the labial lingual tissue capture the pallet, et cetera. Um, in fact, most, uh, today, most of the cases that come in for Chrome are from digital impressions, uh, doctors, um, have just found the value in, in, uh, in digital for, for speed, for accuracy, uh, an excellent way of capturing a bite with digital impressions. We work with all the systems, uh, there’s more out there on the market. We work with all of them.

And the reason, again, the reason want to capture it the full, uh, I think these are videos. The reason you want to capture the entire scope, the entire, all the land areas is because the first step of every surgery is the pin guide. The pin guide is what rests on the teeth or tissue, but it also on many cases goes deep into the vestibule. If there is significant bone reduction, as you can see on the, on the left, uh, that case is going to require a lot of bone reduction. The pin guide is going to seat deeply. Uh, and therefore we don’t want to guess where the tissue is, where the support for that pin guide is. Um, so please try to capture a full, uh, full land area impression and make sure that the impressions are very accurate. Uh, um, you know, some, some polls, some drags, some bubbles, some voids, uh, you know, those, some of those things is going to be overcome.

Uh, but if it’s, if there is distortion or if, you know, a case like this, um, please retake, um, good, good, good to catch at the office before it comes into the laboratory, because we’ll definitely give you a call. You know, if it’s, if it’s not perfect, we want to be, we want your success to be part of, um, good, good record digging. All right. So those are photos and models. And then, uh, and then the bites, vertical measurement, this type of thing. Um, so we get all kinds of, uh, we got all kinds of, we get a lot of the standard bites. Most of the cases come in, have a centric occlusion bite, which is perfect. It’s fine. Um, you know, most of these cases, a patient is over closed and we have to open, um, on the articulator and either go forward with production, or if the vertical opening is more than three, maybe four millimeters, uh, then we have a little device that we send you to confirm the opening, you know, simply just because the arc of closure of an articulator cannot be transferred always to the mouth.

So centric is the most common. Uh, we do get some centric, um, relation, I’m sorry, centric occlusion is most common centric relation we do receive. Um, and then we do receive occasionally some neuromuscular bites, um, might make the argument that a neuromuscular bite is, um, is the best bite for these cases. Uh, putting a patient in the most comfortable, relaxed position, um, might, might be the most, uh, the most advantageous, uh, the most accurate, but we accept different bites. Of course. And we, um, we do our analysis accordingly based on the bite that you send in. Uh, so for dented photos, cast bite registration, and then finally the CT scan. So a CT scan for a dental patient is always open out of occlusion. Uh, I know that there are other companies out there that, that make surgical guides full arts or guides, and they want the bite in occlusion.

Never really understood that because we always use the stone casts, um, or, or optical scans to, um, to articulate, to open, to do the, the, the concrete records or bite registration, not the cone beam. The comb beam is just for bone tooth, uh, to make the surgical guide and to design the guide. That’s all. So when you capture for, um, whether a single arch or double arch, we want the full scope of, of the arch of interest or both arches. So the green line is the maxilla. We would like to see a CT scan of, of the patient from the sinus middle of the sinus down to the opposing teeth, and then on the mandibular, down from the chin at least, or at least, uh, you know, below the metal for Raymond, um, but down to the chin. And then, uh, and then also including the upper teeth. And we know we have the full range of, of bone that we need to, to plan the case.

And every cone beam out there has a mechanism for exporting raw DICOM. Normally what you’ll see, well, what we want you to see is a folder full of DCM files. Sometimes it’s 200, sometimes a date hundred. Um, our, our upload page, uh, limits at 400 megabytes. Now, normally when, uh, when a folder is, uh, zipped, it’s under 400, if you find that it’s over 400 megabytes, uh, the best thing I suggest doing is contacting the Colombian company and asking them to export a smaller, not fob, but a smaller Boxell. So that you’re at maybe 0.4, um, probably point for thickness between the slices and that will minimize down to, um, at least 200 to 300 numb, uh, file numbers. And you zip those into a folder, and you submit those along with your records. That’s the DICOM. So let’s say, uh, the records have been collected, they’ve been sent into us, and now we analyze them.

We have, um, we have, uh, veterans CDTs who work on these casts. We have a couple of dentists whose full-time job is analyzing cast, doing these case workups. Uh, and I think we do a very good job with this. Uh, these are all very challenging cases, just about every single one of them. Uh, we go through a rigorous analysis of the, of the records, um, things, uh, um, an analyzing the smile, uh, the bites, the models, the vertical needed, uh, for prosthetics, uh, reverse smile lines, a gummy smiles, um, just the whole range of things that we need to analyze for full arch. We go through that with every single case. And if, if everything is, um, uh, accepted the models are good. Um, the records are all perfect that night. You would get an email. And in that email, there would be a link to set up your online meeting, uh, online.

If we find that, um, the records are not, um, perfect and good to go, then we contact you and we have a discussion and just see which direction we’re going to go with. Um, either attaining more records or moving forward, depends on what the discussion needs to be. So when we are analyzing, uh, the models, I’m going to go through a few different scenarios here of how patients present and what we do with them. Now, this is from a laboratory’s perspective. So we’re looking at, you know, cast mounted, printed, uh, articulated, uh, but you can also do some of this analysis in the mouth. Uh, you know, for instance, I mean, this, this patient is, uh, just has anterior contact only. This is probably a hidden slide situation. The patient probably doesn’t, they may have a repeated bite, uh, but their, but their position might change based on manipulation.

So what we recommend in a case like this is a couple of things, one is, and you can perform this into orally. Uh, this is a simple measurement that we, that is called the shimbashi measurement, and that is simply taking a measurement from the Zenith of say 25 and eight, and measuring this distance in the mouth. And we’re looking for 17 to 18 millimeters. Um, shimbashi the, the, the person who invented this, found that through studies, the average person is somewhere between 17 and 19. And if you find that’s the case in the mouth, then there’s a pretty good chance. We don’t have to open the bite. So you can see how helpful that is, uh, because you may want to, you may want to open the bite clinically before the records come in, and this can confirm, uh, if you need to, or not

Now a case like this,

You know, there’s a couple of options for, uh, confirming a bite. One is a bite block set up, try and, um, uh, making sure that the, that the bite is ideal, the teeth position or our ideal, it’s exactly what you would do for a partial denture process that an acrylic perhaps make a scan appliance for a dual scan and then send all the records in that’s one option, another option that we offer. And I’m going to show that in a few slides is called the, um, the JC tryin, uh, which is a fantastic prosthetic that we developed. Um, really just for Chrome. We use it for other situations too, but we use it for Chrome to confirm bites, to confirm opening a bites on articulator. I’ll show you some examples of that.

Uh, this is a,

This is a case where the patient has a pretty stable occlusion, um, but in the shimbashi measurement, uh, we agreed with the doctor that the, that the patient only has 13 millimeters. So the patient is going to be opened up to three, maybe four millimeters, uh, you know, through a discussion. We will open it up on the articulator. We’ll send out this, uh, this tryin, uh, that’s a calibrated the mouth, and I’ll show that in just a minute, but a case like this, this is kind of straightforward, uh, crown and bridge, I’m sorry. Uh, then Tate over dental records, right? Mounted casts, photographs that we discussed, CT scan with the teeth apart, and then a bite, uh, probably in a case like this, it would just be a centric, uh, repeatable, a habitual bite. Uh, and then, and then we make a JC Trion. Many, many cases are in this situation.

Patient is over closed, collapsed, and needs to be opened. Um, patient has, um, some, some mobile teeth, uh, which we want to know about, you can, you can, uh, notate them when uploading the case. Uh, but this patient has 10 millimeters of, uh, of shimbashi and his shimbashi isn’t, um, you know, a black or white rule that we follow. It’s just simply a tool. It’s a guide, uh, in, in this patient, doesn’t have number eight or nine. So we kind of estimate where number eight and nine should be and take the measurement. And then we have a discussion. This patient needs to be opened, um, six millimeters, maybe even a little bit more to make room for prosthetics. Uh, so there’s two ways to accomplish that, right? Either open them on the articulator or reduce bone that this patient probably needs a combination of both.

And so what we will do is, um, articulate in with the bite that you send us, open it up on the articulator, and then we fabricate this. This is the device, uh, that we use to either confirm existing bites as it is on the articulator or open the, uh, the articulator, um, more than three millimeters fabricated JC tryin in that position, and then send it out for, uh, for tryin, for fitting in equilibration. So you can see the images here on the left, um, upper and lower JC trends, try them in, make sure they don’t rock, make sure they have a perfect fit, perfect seat. And then, uh, either equilibrate down into the proper bite, or if it’s the patient’s still not open enough, you could add composite to it. You could take another bite over it. If you want to do a, some kind of centric, um, uh, centered relation bite. Uh, but this is a great way to confirm that the arc of closure has been preserved and that the bite is accurate on the articulator. And so you would equilibrate take a bite either way. You’d take a bite, send the JC trends back to us. We will re articulate the cast, and then we move forward with the case. Um, just show a little,

This video will just quickly demonstrate a JC trial, double large JC trial. So this is a case where we want to open up the patient’s bite and the case was submitted as overcast and occlusion, poke height, and a little bit eccentric registration. You articulated the case. And on the articulator, we opened it up a few millimeters. Then we digitally designed to JC triathlons, maxillary, and mandibular. Some of them, we send them out and we send them out. I believe that the case was a little bit opened and the doctor just adjusted it down. You can see there’s adjustment marks here, and there’s adjustment marks on the, on the, on the maxillary. So once the bite is a calibrated down to just where the doctor wants it, just where it’s ideal in the mouth. Um, and they like registration is captured between the two. A suggestion would be not to do a full arch bite, but just do sections where there’s gaps, maybe one year, one year and one year a tripod, a full arch is acceptable, but it’s just sometimes better to just put strategically placed bites. And you can see visually throughout the arch where the teeth are coming together, JC drive.

Okay.

Um, JC triune may also have some scan appliances. This is case by case basis, depending on how many teeth the patient has remaining. If, if the patient just has a few teeth, a couple of teeth, one tooth, and we’re still making a JC tryin, uh, cause sometimes if the patient has almost no teeth or we probably want to go a different Avenue by blocks and setups, but if we’ve made a JC trine in this situation that we will probably put markers on it, and then you would do a dual scan when the patient is in the dual scan technique, just like the denture dual scan, which we’ll discuss at the end with essentialist cases. So just again, showing a shimbashi, this is, um, you know, 11 millimeters. And then with the appliance that you saw in the video, uh, 17 millimeters opens a bite great tool, um, other common, uh, situations, uh, class two, class three, severe class three and two, especially class three.

We see this often and, uh, you know, for these patients, um, you know, we don’t diagnose where the laboratory, but what we have seen over the years is, uh, sometimes these cases, uh, the, the patient wants normal occlusion, maybe the dentist watched normal occlusion and, and it might be possible. Um, but we run into issues situations as in, we ended up having to open the patient up maybe too much to get, um, to get to room for prosthetics. But we also end up with an anterior shelving of the prosthetic because when the bone is reduced, it’s going to be some bone reduction on this case. Now the bone is even further distal. And then the prosthetic has to essentially come out as a ledge to come out labially to meet the lower, and that causes problems. Uh, the lips get caught above the prosthetic. It’s a, it’s a food trap.

It’s a speech issue. Uh, normally in these situations, if it’s going to go the route of full arch restoration on implants, um, generally you preserve the class, uh, the class and, uh, and just really trying to work out, um, or maybe even a flat plain occlusion, a severe class two, sometimes the same thing. Um, so just these are, these are considerations, you know, th these are the normal records you’d send in this patient probably has a repeatable bite, uh, perhaps should the patient’s missing an awful lot of teeth, maybe not. Um, but anyway, often these patients should go a different route. This is probably a denture patient. This is probably an orthognathic patient, et cetera.

Uh, also another case that’s very common, no centric stops at all. Um, uh, patient may not even have prosthetics and in these cases, uh, best thing to do is to send the casts in. Uh, we will just, uh, we would probably not even a bite registration. We will make bite blocks, perform setups, uh, go through just general dentistry to put teeth in the right place and the right vertical until you and the patient are happy. And then we use those appliances in a dual scan situation, uh, and, and, and send them in, and then we can move forward with Chrome, but really need to establish a bite in tooth position on a patient like this. There is, um, there is one, uh, um, note here, um, besides the shimbashi measurement, we also have what we call an inter vestibular measurement. So if for some reason, the patient is exhibiting some kind of repeatable, um, uh, capture a bite you can capture, then you can always measure from one best to be able to the other.

And, uh, a good number, kind of like the shimbashi number, good numbers about 35 millimeters. And that would be, I really have this in the posterior now, but it would be more in the anterior, right? So, you know, somewhere here, vestibule the vestibule 35 millimeters, again, just another, a tool, uh, within a range and other, um, dented CRA uh, you know, dentine situation is a mobile teeth. Um, this is, this, this happens often, you know, quite often the patient doesn’t have a 100%, um, uh, mobile teeth that there’s, that there’s some mobility and a lot of the teeth, but some of them are stable. This is kind of a case by case basis. We’ve seen cases where the patient, every tooth in the, in the mouth is mobile. And then the pin guide, um, the pin guide is inserted. The pin guide actually moves the teeth into a different position than the implants in a different position. Uh, it’s not a good day of surgery, so there’s a couple of options with these cases. Uh, but the best option is if the patient has some stable teeth and you can capture a bite, let us know what teeth are stable. The teeth that are mobile can be extracted on the day of surgery and the pin guide can rest on those existing stable teeth. Otherwise these cases go through full extraction, uh, go to immediate dentures, uh, stabilize the bite, and then come back later, uh, with some type of surgical guide.

So

That was dented, dented over den date. Um, um, um, w w will be available at the end of this, um, at the end of this whole program for questions. And I hope everyone has questions. Uh, if you’re, you’re more than welcome to call in email, uh, have a private discussion about any of these topics fix any time. But if you’d like to raise a question at the end, please do. So the next is an evangelist single arch, uh, and we have specific records for these, uh, the checklist, single arch, um, uh, evangelist surgery with an opposing, um, teeth or an opposing denture. So I definitely recommend, uh, printing these off often. These are the most confusing, uh, cases that the [inaudible], but let’s just quickly go through the normal records. So, um, the important notes for an essentialist case is that it’s always going to be a dual scan situation and a dual scan means you’re going to scan the denture in the mouth, uh, in occlusion.

And then you’re going to scan the denture by itself. Those are the two scans. We do not need a scan of the patient with no appliance, unless it’s going to be a totally different type of surgical guide. If it’s going to be Chrome or a tissue supported guy, then it has to have a dual scan. So, um, here’s the, the rules the denture has to fit well, no movement. Um, you can perform a hard Relynn, uh, that would be ideal if the denture has, um, any movement recommend, not doing a soft liner, because if you do a soft line or then we have to go a little different route with the scans, uh, the tooth position I put here must be ideal, but really it should be ideal because we can deviate, uh, in our planning from teeth are not in a great position of it.

Patient has a denture with some flare teeth or teeth that are just not, not, not ideal. At least we know where they are. We can plan for future teeth, um, given the current two situation. So, uh, two positions should be ideal, um, but not mandatory. And then I’ll show a slide in a minute about how you can use green moves or blue moose. Uh, if it does, if the denture does have a soft free line already in it, um, occlusion is important. The, the pin guide is going to fit the tissue, but it’s also going to fit the opposing teeth. So we want occlusion to be good and fit to be good. Uh, and then always do a dual scan with the bite, uh, with the patient biting closed in occlusion. We don’t want anything separating the denture from the opposing teeth. This is a recent development, uh, kind of discovered this. Um, um, I think at the end of the, is that a doctor was testing these materials. So if you have a soft liner, you know, historically had to take the soft liner out and do a hard realign. Uh, that’s not the case. Now either use either one of these products, um, load the denture up with this material and just basically perform a relined impression. And that is a radio, um, radiolucent material that shows up in the CT scan,

Um,

Single arch essential. So these, these will be essentially the records that you send in this will be the patient’s scan, dual scan, bite registration, and opposing model. You can send them in digitally. Um, but we really recommend, um, for [inaudible] just take a, an opposing model, take a nice bite registration between the two. And, um, and those are the only records we need, dual scan opposing, and a bite, and the photographs, we always need the photographs, but the records are very simple with the denture case, and this is what they, this is what they should look like on the CT scanner. So this above is the denture seated. These are markers. Um, we recommend using sure, Mark, you can order them, uh, from, from us. You can order Mike from the company sharmarke.com and there’s six markers in here and here you see only three, but there’s also three on the labial buckle of the denture. So you scan the patient in occlusion with the denture seated, then you place the denture say on a piece of foam or on those little scan table that comes with most, um, most CT scanners set the denture on it. And then, uh, at the, uh, on our end, what we see is the denture, um, seated in the patient. We use the dots, uh, to merge the denture with the denture scan and the patient. That’s how we bring the denture in. So we can see the teeth, uh, when we’re planning

A case. So that’s

A single arch. Now double arch is a little bit different. It’s actually a little bit simpler because you only scan the dentures and take photos, but you, you would, um, place the markers on the upper denture, placed them on the lower denture place, the dentures, both dentures in the mouth and, uh, scan the patient and then scan the dentures by themselves. So essentially this is what we’ll see when we, when we print the dentures. Um, now, if you do not have a, um, a CT scanner that will scan from the chin to the middle of the sinus, then you would just scan the upper first and the lower first silver to a den Tate, but always in occlusion, we want to have a little bit of compression on the tissue, so you have the patient biting into it. Um, but we want it, it’s really the only way for us to verify occlusion on the Dublin Angeles is to do a dual scan, a what not to send, uh, for an evangelist case, uh, especially WDN, but he then eventually his case, we don’t need a scan of the denture of the arch of interest because we cannot articulate it.

We can’t really use it at all, and we can’t use impressions of it. It just, it won’t, it won’t help us, um, just a dual scan opposing in bite for single, and then dual scan dual scan for, uh, for a double.

Um, again, don’t also don’t need these models. We do not need, um, impressions of the essentialist arch because when we print the denture, if we’re going to print it as a pin guide, we’re not going to print it, um, to do any kind of articulating. And even if we could, we could not make the denture fit onto a tissue model, just doesn’t work. So, uh, save your stone, save your impression material. Uh, and then the last, um, the last, at least in this program, the last type of case is partially edentulous, uh, also a very common situation. And we developed a system where you don’t have to go through the process of bite blocks and setups and dual scans and scan appliances, et cetera. Instead, what you’ll do is you will take study models of, uh, of the partial seated, and then you’ll take a Mastercam X of the, part of the patient without the partial seated.

Those are the two models that we can cross Mount back and forth. Um, and you’ll take a CT scan of the patient with no partial in the mouth. And this, this is all on that checklist. So I would highly recommend using the checklist for a partially dentureless case every time. Um, we can cross Mount with this. So again, take a CT scan without the partial seated, you know, unless they’re flippers, which is kind of a nice thing. If, if you can take, um, take you, take a flipper or the page, you can see that you can put them in inclusion. Um, and that is fine. Uh, even if they have a metal clasps, um, forgiving CT scan out of occlusion, you can have the patient biting on cotton rolls or on, um, on the bite fork. Forgive me, cotton rolls are better because often if a patient has anterior teeth in a flipper is going to flip up in the posterior, right? I have them bite on cotton rolls, uh, master cans with the study model, with a partial seated and then a master cast without the partial seated. And then of course the photographs, these are this case particular, this type of case is critical with, um, uh, having the retracted photographs.

Uh, you can also take, uh, digital impressions of, uh, um, partially edentulous. So you see left to right, same patient, right? So this is a, um, a digital impression with a partial out digital impression with the partial end, et cetera, um, that will help maintain the patient’s bite when you’re taking the bite scan while you have the partial end.

Okay.

Uh, as mentioned a couple of times earlier, if the patient exhibits, uh, this, uh, one tooth, two teeth, no stops, um, difficult to, to, um, you know, to take a bite, to establish occlusion, go through conventional workup by blocks, set ups, try and make an ideal, convert that to a scan appliance and not like an all acrylic scan appliance, do a dual scan technique, uh, send it over. And, uh, and off we go, Well, these were supposed to start automatically that’s okay.

So all types of situations, uh, come through our door and come through our, our internet provider. Um, just about everything you can imagine, uh, it comes through for full arch cases and we can work with, uh, really just about any situation that you send us. I think sometimes the only thing we can’t do is create bone. If the patient has bone and any kind of occlusal scheme, uh, any kind of clues, all disease, uh parafunction, whatever it is, uh, we can work with it. Um, many thousands of cases so far, uh, just the last couple of slides. Um, we have this private, uh, uh, Facebook page it’s, uh, closed only to members. This is where we post all of our updates, all of our innovations, uh, many, many surgeries around here with voiceover, uh, tips. Uh, we have, uh, many of our customers posting cases.

Uh, this, this, um, site does not have vendors does not have implant companies. Um, it has some staff we get, we do we’re happiest staff join, uh, and doctors. So we hope you’ll all join this site and follow Chrome. Uh, we post on here just about every day, uh, tomorrow’s course will be on the pin guide and the fixation base. And those are the two first parts of, uh, of a surgery. The pin guide goes in, delivers a fixation base for the bone reduction, and we’ll go through that whole process tomorrow. So hope you’ll join us, uh, and, uh, be happy to take some questions if anybody wants to, um, wants to stay on. Thank you very much for joining us today.

Yeah.

If, if you, if you have a question you could either just type it, um, or you could turn your mute off and ask, but I think there’s an awful lot of participants. So I think probably a typing would be typing would be better.

[inaudible]

There’s a, there’s a question here on, um, denture alone with foam. What is this? Okay. When, whenever you do a dual skin technique, if you take the denture out of the patient’s mouth and you just put it in the CT scanner, many CT scanners have a plastic chin rest or plastic plate. And if you scan the denture on that plate, the denture and the plate merge. And so essentially you, we ended up with a denture with a plate attached to it, and we have to virtually kind of remove the two. They, they, they morphed together. So instead put a piece of foam, it could be pretty thin, you know, half an inch, quarter of an inch on the chin rest or on the plate, then put the denture on top of that. And on our end, it appears that the denture is floating in space and it could be right side up or upside down. It doesn’t matter. We can, we can, uh, we can reverse it. Any other questions Got some thumbs up. Thank you very much.

Uh, there was a question, uh, we are recording this and on our website, uh, we do on, on the Chrome guided smile website, there’s a dropdown for education, and there are many videos on there already, um, uh, surgeries with voiceovers. Uh, there’s even, I believe there’s even a course already on records. Um, but you’ll find a lot of educational videos on that site already. Um, do you need bite registration or cotton during a [inaudible] scan? You always want to have the patient biting in occlusion. That’s very important for [inaudible] scans. In fact, um, some, a lot of cases, they just stop at that point. Um, so put the denture in the mouth, make sure it seats perfectly, make sure the occlusion is good, have the patient bite together, put them on the chin rest as opposed to the bite fork and take the scan. There’s two issues with that.

One is, is if the denture is seated, then we can work with occlusion because we can turn the denture on and off. Unlike denti, we can turn it on and off within the CT scan. It’s very easy for us to plan trajectory of implants and where they’re going to come out in the inclusion. The other is often, um, staff of anyone put you put the patient in the CT scan. You have them bite on the bite fork, the back of the denture tips up every time. And that’s, that’s a, that’s a red light. Uh, we have to give it another scan. Uh, so just have the patient biting on cotton roll. I mean, bite in occlusion every single time.

Uh, what are those settings for the plan Mecca scan for the denture alone? Okay. That’s a great question. Uh, we, we used to have, um, we used to have rules for planned scan and a few other systems they’re on our website. Now we have a, there’s a, there’s a page on there for the decision tree of what type of scan you take for all the different types of guides that you make. And if you have to scan with a, with a plan Mecca, I believe today, you do not have to change those, uh, the, uh, the, the ma and the KV. I believe you scan it just like a, um, just like a patient. Um, you, you could pick, I think sometimes you pick large patient, um, on a, on a scan appliance, but you should not have to change the KV and the ma anymore. The only ones I see where you have to change the settings are, um, the old Galileo’s because you have to have their, uh, aluminum cylinder to scan a denture, this special device they made and change the settings and the old Carestream’s for sure. The old, um, uh, before the 9,100, I don’t really remember the number. Maybe it was a 9,000, it was a 9,000 with the, um, stitching. You have to change the KB in the MAs.

Yeah.

The JC Trion. Is there an extra charge for it or is it part of the package? It’s an extra charge because we want to Allah it, cause it’s not always needed. So a JC trine is $125 that, that sends your, send your records in, um, you know, part of Chrome is we include printing models, pouring models, that type of thing. So JC trials, $125 flat, flat fee, um, small VJC, try it around. Oh, doctor was answering it for us. Uh, but yeah, one 25. And that, thank you, dr. Schall. If we have to put radiopaque markers, which is not often, but if the patient is mostly evangelists, we may have to put markers on it and we’d charge, um, I think $50 to put the markers on it. Um, my suggestion is that you have a, um, is that you have markers in your office to be sure markers order them.

They’re easy to use. You can actually clean them and reuse them if you want, if you really want to put holes in the denture and, um, acrylic them in there, but, uh, keep, keep some on hand and then you can put them on yourself. Uh, otherwise ordering from us, uh, green moose or blue moose can be used instead. Yes, that tray it’s either green or blue. If you have a soft liner and you don’t want to remove it and do a hard realign, um, just like in whatever slide number that was, uh, green or blue moose. Yes.

Um,

I was not totally avoiding the question of CE credit. Um, but if, if we, if, if you, if anybody watching today would like CE credit, um, I’m going to read off my email address and I’d be happy to send you an evaluation and we can do one hour of CE. No problem. We actually just got to about an hour right now. It’s, uh, my name a L a n@roedentallab.com allen@roaddentallab.com. And we will take care of CE it’ll be, uh, Ohio state dental board, CE, which is good for most, um, licensing out there. Can we just go to purchase points as radiopaque markers? Absolutely. That’s, uh, an age old tried and true way to make markers, uh, works very well. Use the number five, number eight round Berg buried about a millimeter deep with the gutta-percha in, um, just, you know, you do it at the very beginning and do the dual scan with it.

Uh, I think, you know, a lot of times you just leave it in the denture. Um, the denture is, um, really has, uh, a life span at that point, but, uh, got approach it, yes, six points randomly around the arch in the pink. You don’t need to put it into the teeth, but randomly like three on the pallet or tongue area. Uh, and the rest out on the buccal labial, uh, if a patient is partially denture and has an all acrylic partial that is fitting well, where you saying you can or cannot use that to do a dual scan radiographic markers like you did with the patient. Okay. That depends on the, um, that depends on the size of the flipper. If the flipper is three teeth or 14, you don’t need to, um, take the flipper out and just do the whole take conventional records as if you’re doing den Tate.

Uh, if, if the flipper, if the flipper is not holding the bite up, if it’s holding the bite up, then use it as a study model. Uh, um, but if it is extensive, as in the flipper is half the teeth and the mouth and the, and the bite depends on it. And it, and it has some substance, right. It’s pretty thick. Um, I kind of give you, um, not a very good answer on the thickness of it. Um, two, three, three millimeter thick has some substance, then yes, you can use that as a dual scan, um, prosthetic. Um, but again, if it’s not holding the bite open, then you just use regular, um, uh, dental records, any recommendation for a scanning soft tissue with [inaudible] palette is easy, but the vestibule on mandibular post to your Ridge has been difficult. Now I know that the trick and, and sorry to be a little dodgy on this, but I know the trick with trios is you use a, a surgical marker, like an indelible surgical marker, and you paint a grid of dots on the palette. And I think you can do that in the vestibule too. And then the scanner will pick up the dots. I don’t know about that with I taro, uh, my experience with [inaudible] is one of the best scanners out there. Uh, it, it, it may be the patient is, um, uh, has too much saliva a particular patient, but I taro it takes a tremendous scan. Um, so I’m sorry to see I’m having issues with that. It really should be able to scan the vestibule.

Uh, so the moose is impressed over the soft relined material, do not remove the software line. Exactly. Yeah, yeah, yeah. That’s actually, that’s the point of it that the stock free line can stay in and just do a wash. Um, um, maybe, um, you know, you want the, the, the green or blue moves to be kind of everywhere. Not, not to be, um, you know, not to be washed out, uh, so use, uh, use, uh, a fair amount of it. So you can see green, green, or blue pretty much everywhere. And that is your, that is now your scan appliance. Yes.

Uh, should we a cool, a great the bite at the time of the JC Trion? Absolutely. Thank you, Raj, for that question. Uh, often the, uh, the, um, JC train goes out and it comes back and says, good, start, start making Chrome. Well, um, without any burn marks or anything, or a new bike registration, now we can trust you, you know, smiley face. We can trust you for sure. Um, but mice, our suggestion is finally equilibrated until it’s just right. You have blue marks, red marks, um, all around the arch, then capture a strategic bite registration, um, um, where the, where there’s gaps or three, you know, tripod the bite registration and send in the physical JC and with the bite registration we’ll have better success. The better the bite, the better surgical experience, no doubt every time, uh, the blue most is radiopaque. Yes, we can see it. And it is the brand name. You want to use green moose or blue moose. You can buy them from park

Hill.

What’s the difference in indications for green moose over blue moose? I have no idea. In fact, uh, when we first learned about this, uh, that we learned that it was green most, and then we learned from, I believe the same person who was doing their studies on it, that, that it doesn’t matter blue or green doesn’t seem to make any difference unless somebody knows anything different out there. And I’d be happy if you typed it in right now. But my understanding is both work

With the shimbashi measurement. Are we using the CEJ as our points of reference since there, uh, this can, it can be issues with tissue overgrowth and or recession, right. Um, good one. Um, and, and super eruption, right. Are the teeth even in the right place right now? Um, so it’s, it’s a, it’s a range, it’s a guide, it’s a tool. Uh, I would use it at the highest part of the, the, the, the apex, um, the highest point of the CEJ upper and lower. And again, just use it as a tool. I mean, a lot of times with these patients, you have inflammation as well, or you have, um, severe super reduction of the lower teeth, and it can give you a false number. Um, we’ve had great success with it though, and definitely use it clinically.

Yep.

Any other questions?

Thank you all for staying on, uh, after for this Q and a, I hope you hope to see you all tomorrow. Uh, uh, same, same Chrome time, same Chrome place.

Okay.

All right. Thank you, everybody. And everybody be safe. Uh, actually we’ll have a little update on our, um, coronavirus printing. We have a whole task force here. That’s, uh, that’s scouring the government and the hospitals, and anywhere out there trying to, um, to give us a good direction of printing masks, uh, printing, uh, shield, face shield holders, uh, these, these, uh, nasal, um, uh, applicators for testing. Uh, we have, uh, we have an entire room full of printers. If anybody has something that is concrete from FEMA or somebody that says, this is what you print, this is where you ship it on. This is what you make. We’d love to hear from you. I know many, many dentists out there are in the know, um, uh, you know, like a direct contact with CVC. So if you hear anything at all, please let us know. Um, uh, we anticipate within, within the week, we’ll be printing hopefully on a, kind of a small mid-sized laboratory mass scale of, of, uh, items for the coronavirus.

So,

Okay. Everybody have a nice day. See you tomorrow. Thank you again.

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