CombiGuide and Photogrammetry – Patient Case Study

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This video will discuss photogrammetry combined with guided surgery. The guided surgery that we’re discussing is just bone reduction and implant drilling and placement. And this case is performed by Dr. Sully Sullivan through 3D dentist through their training workshops. And we encourage anyone interested in this combination or any kind of photogrammetry training to go through this program, they really do a wonderful job. You can see the link here at the bottom of the screen. So let’s go through the case. This type of case is part analog and part digital. And what I mean by analog is that we’re going to have a physical guide system that manages the bone reduction and manages the implant site drilling and implant placement. Why is that important? Because freehand dentistry, although is most prevalent and very popular, it often in full arch, it misses a few things. And one of those is adequate amount of bone reduction, planned bone reduction, and with our combiguide and with other types of guided bone reduction services we have at the laboratory, we can predictably give the proper amount of vertical space for long-term prosthetics, which is really the key for space.

So what we’re going to do is go through a whole case where we’re going from start to finish, a little bit of the ideas, a little bit of the concept, and then what actually transpired during the surgery. So what you see on this screen is what we call a pin guide. Step one, this is a tooth born or tissue born guide, but these are windows for teeth. And this delivers the fixation base, which is the bone reduction guide. And the bone reduction guide and the fixation base are what the osteotomy guide and carrier guide clip into. So it’s a stackable system that is fixated to the bone after the tissue is reflected. So this is the assembly and these are all the components. Now, when you start a photogrammetry case, there are two directions to go. One direction is to use a pin or a tab or a screw in the patient prior to extraction, either in the palate, usually in the pal, the maxilla, or in the labial or buccal areas, or sometimes even the posterior.

But the idea is you have it before surgery and after surgery, and that’s how you register the patient’s bite before and after. Otherwise, when the teeth are gone, you lose the bite. The other way to do it is to fabricate an immediate denture prior to surgery and then use this as a reline to capture the ICAM or the PIC skin references, not the flags, but the references, the scanned bodies. So in this case, Dr. Sullivan went through both processes to demonstrate. So the first step with this combination is to seat, is to well make a reflection and then seat the pin guide and fixation base together. And then drill and seat. We have lots of videos on our website and on the internet that show the process of seating and pinning. It’s not complicated, but it does help to have the tips and tools to be able to do this.

So once this is seated, the delivery device, the pin guide is removed, and then the fixation base remains in the mouth full-time. Now this is plastic most of the time our combiguide is metal, metal osteotomy guide metal fixation bases. But for this process for Dr. Sullivan, he orders both types for this particular teaching case to use plastic, which is perfectly fine. We make it a little bit more thick, make it a little bit thicker, about four and a half, five millimeters thick so that we have a nice robust plastic in the mouth. And what the doctor will do is reduce the bone down to the level of this fixation base. This is the guide for reducing. And once you think you’ve reduced enough, then you try on this carrier guide. And if it seats passively, then you’ve reduced the bone enough underneath it.

If not, go back and reduce more and then come back and try this again. And once it’s passive, the bone is reduced. And really this is a feel a visual process to make sure that there’s an adequate bone reduction. Once the bone is reduced, then the osteotomy guide is seated. This is a BioHorizon guided kit. As you can see by the master tube sleeves that are inserted. The rotation indexing is controlled by, well by two things. One is the little slot here in the sleeve and the other is, you can kind of see ’em here. We put nubs on the plastic guide to indicate rotation, and then there will be a notch here in the sleeve that matches up with one of these nubs. So yeah, obviously implant rotation is critical and it’s nice to have that guided as opposed to freehand. I know that there’s different processes of rotating implants and confirming that your temp cylinder is going to be straight up and down.

Well, this one pretty much guarantees are going to be straight up and down. So go through the whole process of creating osteotomies. Put the implants in. Implants do go through the guide in bio horizon. So the implants are in, you can see the tabs still down here. The reference tab for before and after, implants are in, MUAs are on. Then the next step is to go through the photogrammetry scanning. So put this particular system, this is I a M. So the scan flags go in and the doctor will scan for almost a hundred percent accuracy. It’s microns within perfection. All right, so it’s scanned and the first scan, the second scan will be of the scan bodies after the patient is sutured. And then, so once the patient is sutured, these little scan bodies go in and there are different ones, not even sure the brand of these, but there are several on the market.

I recommend just using the ones from ICAM or from PIC, whichever comes with the system. But some are taller, some are easier for suturing. So the they’re seated patient is sutured. And then at this point, the doctor will scan the mouth, capturing scan bodies and capturing the palatal tab. Obviously this is important, just as important as the rest of the scan because this will reference back to the pre-surgical tab. The doctor will, this is what the scans will look like, right pre, post surgery. And that pin is used for registering. You can see here points are taken matched, and then this is a registration process, just like any kind of digital registration setting points. And then these two will merge together. So once these are merged together, then we take, then the files are exported, they’re sent up to ROE. We have a special portal for these files because sometimes these are quick urgent, as in we want a 30 to 30 minute to one hour turnaround time on the setup.

We guarantee two hours just depending on how busy we are. But this will be exported along with all the other files. And when you’re on our portal, you’ll see the stack of files, which is photos, working arch, opposing arch, scan flags, scan bodies, and then these before and after images and opposing and bites. So please make sure you have all the files uploaded that otherwise it’s either go or no go, depending on the files being uploaded. So that’s one process. That’s the tab process. The other process is to have a denture and we can design it, print it, ship it along with the guide, or we can design it. This doctor printed it. Dr. Sully printed this in office. No problem, because it doesn’t have to be fancy, it just has to be accurate. So what the doctor will do now is load up the impression material around scans bodies, right? Not the flags but the scan bodies. Screwed in and sutured. And then the denture will be delivered loaded with impression material. Open wide seat to denture, normal denture protocols. Lemme just pause that right there. Now remember, the inside of this denture was tried in, right? Because you don’t want the denture touching any of those scan bodies and holding it up and manipulating the bite. So the palate needs to fully seat and the inside of this would need to be adjusted until that denture seats. Alright, then it’s loaded with impression material.

Okay, Patient bite, pretty fast set material if the, make sure the mid line’s on, rotate the denture if needed and then boom, wait. And then when that comes back out of the mouth, it is scanned. Oops, let me show. Oh yeah, that’s right. So we want to show outside adjusting it, right? Because we want to see the teeth, not when you take an impression. There’s flash, you’re getting tired material everywhere. So trim it away so that you only have material on the intaglio and that way we can see the teeth. And then use your iOS scanner. This will work with just about any scanner. Digitize that denture, scan it 360, intaglio teeth, everything you want that floating on the screen, every bit of that denture so that we can register it to the mouth and register it to the opposing for the bite. So actually, so the doctor can register. Because what what’s going to happen now is this, you can see it being scanned here. All right, so now it’s just showing how the doctor is scanning the denture in his hand, what it looks like on the screen, digitizing it. That is a Cerec scanner and it’s does just a terrific job of scanning one. Really one of the best for full art scanning. Alright, scan the opposing Normal stuff here and then seat the denture. Seat, the denture and scan the bite.

So what do we have here? Now we have the scan flags. Now we have the scan flags that have been exported. We have the ICAM export scan flags. We have the scan bodies that are picked up inside the denture. That’s our reference rather than the palatal pin. In this method, we have the opposing, we have the bite, we have the teeth, we have tooth position, we have everything we need to design this upper prosthetic and this, a doctor does not do these in a rush. All right, so the seating is the next day, that’s how he trains. But we can do same day. It’s kind of a long process. Couple of hours maybe to get the files back. Then you have to print clean cure, then make it pretty with pink, then deliver. So how many hours is that? It might be a lot. So it’s probably better to send the patient home, have ’em come back the next day and seat. But that’s up to the doctor. We make the files as quickly as we can. These were printed in office and seated. Probably need to be a little more cautious with the cantilevers. However, I believe this patient had no posterior teeth, so that’s an option. Looks really nice work. And then seated. Don’t recall if this was same day or next. I believe this was actually a same day seating for the live program.

And that is the process. These are DESS screws. We work with a couple different DESS screws. We work with the Dan Rosen and we can work with a couple of others. But our preference really today is the DESS screws is the 1901s I believe. And that is how you perform a photogrammetry and combiguide combination type case. So thank you very much to Dr. Sullivan for teaching this in his course and for sharing this very nice documentation and work with us, work with ROE Dental Lab. We offer these services and the records are very straightforward, just like any full arch guided surgery case records. Thank you.

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