Grammetry and the CombiGuide: Protocol for a Full Arch Lower Prosthesis

This video is going to go through the combination of Grammetry and the CombiGuide for a full arch case. We’re going to go through the whole protocol from start to finish, from the initial records all the way through to the final seating of the temporary prosthesis. The two products that we’re going to combine are the CombiGuide and Grammetry OptiSplint. The CombiGuide is a surgical guide that’s used for bone leveling, site drilling, and implant placement. Grammetry is what we will add to it for the digital workflow to design a prosthesis on the same day. The tools involved in this particular
case are the OptiSplint, the CombiGuide, a Trios scanner, Stellar acrylic material in white, Straumann BLX implants, and the VIS prosthetic screws along with some other things, but those are the main tools that we’re going to use. As with all CombiGuide cases, we start off with guided surgery. The records for a case like this are upper and lower STL files, a cone beam CT, some photographs of the patient smiling, and then we can get the case ready to go for the online meeting. This is usually a 15-20 minute meeting for us to plan the implants.

The significance of combining this type of surgical guide is that we have articulated casts, we take measurements of occlusal space, measurements of prosthetic space, and smile analysis. We go through the whole gamut to make sure that the prosthesis has the ideal thickness for longevity, that the implants are placed ideally, and that there’s a plan. You can see here the red line which is the bone reduction line, and then there are other lines here that we can easily use to measure prosthetic thickness along with rules such as top of the implant to the screw access. The case will be fully planned and once it is, which usually takes about eight days, we ship it to the doctor.

Here is what we ship for CombiGuide: three simple apparatuses which are the Pin Guide, the Fixation Base, and the Osteotomy Guide. Let’s flash forward to the data surgery. In this particular case, Dr. Deliberato and Dr. Shapiro ordered the SurgiMat, which normally comes with CHROME cases, but they love the SurgiMat so much that we offer an A La Carte option. Totally worth it. Tape the SurgiMat to the wall; the SurgiMat gives you a pan view, all of the images of the guides and how they relate to bone reduction, the drilling sequence, and it gives you an area down here to keep track of the torque values during surgery and which pins to use. It really gives you nice guidance through the surgery. We even provide cross-sections of the pin. And then the mat part goes on the counter, and you line up your implants, multi-un abutments, and temp cylinders on it. These are the parts you’re going to use for the surgery. In this case, the doctor used Straumann BLX, which is a very nice implant that gives you a lot of confidence that you’re going to deliver because of the initial torque that it provides.

The CombiGuide is cold sterilized in a bowl. Please do not sterilize it in the autoclave; the CombiGuide contains plastic components. Let that go for about 20 minutes before surgery. Additionally, get the scanner warmed up and ready to go. We don’t want to have to wait for it when we’re in the middle of surgery. In this particular case, the doctor used the 3Shape Trios4. Now let’s jump in to the surgery. With the CombiGuide, as with all of our CHROME and CombiGuide products, The Pin Guide, which is the plastic seating guide, is seated. To make sure that it fits, there are windows on the occlusal to make sure that it fits and there’s no rocking. Remove the Pin Guide and lay a labial flap all the way down to the level of the Fixation Base. Next, deliver the Fixation Base pinned to the Pin Guide. This will be held firmly in place and pinned. We’re not going to go through the whole pinning process today, but there’s a total of four pins that hold the Fixation Base very firmly during the entire surgery. You can see there’s a gap between the bone and the Fixation Base. That is the patented floating guide technology, and that’s going to be important to know for the scanning process, especially later with the Carrier Guide.

At this point, you’ll take a scan and the intention of this scan is to capture the Fixation Base which is roughened pre-delivery to the doctor. We roughen it up to make it easy to scan as opposed to shiny CHROME material. Scan the facial, the occlusal, the bone, and the teeth. We do not need the opposing, the bite, and all the land areas that you would normally capture. We have all this back in the laboratory because we made the CombiGuide and we already have the teeth, the bite, and the opening if we open the bite on the articulator. We just need to introduce the teeth back into the original bite so we can articulate, but you must pick up the Fixation Base so that we have a reference for the end of surgery. Scan away on the facial, occlusal, and the facial of the teeth. If I rolled the scanner behind you would notice that the linguals of the teeth were only captured a little bit; this is what we want. This is the bite reference, and in this case, the doctor is going to leave a molar back here, so he scanned it as a nice secondary reference. So for the surgery, the teeth come out, and the bone is leveled down to the Fixation Base. That is going to be a smooth transition from metal to one so that gives you nice guidance for bone reduction, and you can double-check the bone reduction with the Carrier Guide.

The Carrier Guide is then seated; this MUST seat passively. Make sure there’s no rocking in this at all, and then you will know you’ve reduced enough bone and the tissue is out of the way. If the Carrier Guide rocks, go back and adjust the bone or reflect more tissue if needed to make sure it seats perfectly. The next step is to drill the implant sites. This component is the metal Osteotomy Guide. It is very rigid and has little nubs for rotation to make sure the indexing is perfect when you place the implants. This Osteotomy Guide has four metal sleeves: there’s one additional because the space right in the front wasn’t enough space for a sleeve, which you’ll see in just a minute. Go through the drilling sequence, place the implants, and then for this case, there’s an additional Osteotomy Guide because the sleeves are so close together. So drill, place the implant, and then perform some bone profiling if needed, especially back on the angled sites. Profiling the bone is a good habit to have on every case for multi-unit abutment seating. Now that the implants are placed, the next step is to place the multi-unit abutments. We always leave the handles in just to confirm the direction of the angle to make sure that it’s the same as the plan, which you can see on the SurgiMat. Once we confirm that the trajectory of the multi-unit abutments is just as planned, we’re set.

It works perfectly, especially with angled screw channels, this can be corrected very easily in software with the special screws that we use for Grammetry. The next step is to remove the handles, and place the scan bodies. I’m going to call them scan bodies, but they’re really just simple healing collars. We work with many different healing collars on the market; all the popular ones. Seat the healing collars, then seat the Carrier Guide. These particular healing collars are the protective caps for screw-retained abutments from Straumann. We have this library, which directly correlates back to the OptiSplint, and this will be digitized. When you receive a case, The Carrier Guide will not be clear, but tooth-colored, and it’ll be rough on the surface, making it very easy to scan.

We want to digitize all this, so you must capture the facial of the Fixation Base to reference back to the original scan of the day of surgery. You can see the doctor scanned the molar in the back as that extra reference, and then carefully moved around the arch. You’re going to see here this is always an issue: if it comes up, this is a double scan. There’s a little scan extra; this is like a duplicate because the scanner is a little bit lost. I believe the AI was turned on, so it was corrected. You can also see that it was having a stitching issue. If you can’t correct this with AI, then start over and if you can, turn the AI off and then scan. Because things are moving, the software is trying to be more intelligent than the surface, which is moving. Just turn the AI off if possible, and then keep scanning. The goal is to scan the scan bodies, the Carrier Guide, and the Fixation Base. Take your time with this; it’ll be a pattern type of thing. You want to scan across just like you do with a crown and bridge case, but try not to confuse the scanner too much with moving the handle around. Try to do consistent flows, left to right.

This scan looks really good, the Trios scanner did a nice job. We recommend always scanning in black and white or monochromatic as color is fancy, yes, but you really want to see where the holes are, which is easier in monochromatic color. Then the healing collars come out, the Carrier Guide comes off, and the next step is to place the OptiSplints in the mouth. Screw them down, and finger tighten so you can still rotate them because you want to make sure that none of these are touching. If they’re touching, it’s okay, as long as they’re fully seated. Finger tighten them down until they’re all in, then take an occlusal view of them and rotate them until they’re close. Then tighten the OptiSplints down using a contra-angle driver.

At this point, once all the OptiSplints are in, use the OptiSplint delivery handle or forceps to deliver the frame to the OptiSplint, and you’ll see other videos and other images on our website about exactly how to do this. The frame will sit on the horizontal wings of the OptiSplint; there’s a vertical tower wing and there’s a horizontal wing. This frame was put in upside down because it seemed to fit better, and we luted it with the Stellar acrylic and light-cured it. That is all you do with the OptiSplint, and then remove it. We primarily don’t scan it in the mouth, although it is an option if the doctor wants it. So scan the OptiSplint in the mouth. With this scan, you can do everything: you can pick up the bone, the OptiSplint, and everything in the mouth. These are very bloody surgeries
and it’s really nice to be able to scan the OptiSplint outside the mouth in a more controlled environment.

The OptiSplint is set on the counter, but we don’t scan it just yet. First, let’s move on with the surgery; the next step is to remove the pins and Fixation Base and place the healing collars, suturing around them. At this point, you have an optional third scan: In many cases, we simply build the intaglio of the prosthesis up from the bone two and a half millimeters because we don’t always get this scan. It’s an option, but if you choose to scan it then I would definitely recommend scanning it in monochromatic color again, which you’ll see in a minute. It’s a lot easier to see the holes this way. So scan away, and now we have the tissue position for the intaglio of the prosthesis. Again, it’s optional but this scan really turned out nice and we can build this very effectively. At this point, the decision has probably already been made, but are you going to keep the patient in the office and go through the seating process? We will provide the file to print within two hours, so you will just need to nest, print, clean, cure, beautify, and seat. If you have that down to a system, then keep the patient in the office.

If you’re new to this protocol, then dismiss the patient for the day; they can go home and can come back tomorrow. This way, you won’t be rushed and you can make a beautiful prosthesis. The patients always appreciated it more the next day when they’ve recovered. So, patient’s gone and in this case, patient’s gone the the OptiSplint is sitting on um just a surgical napkin and we’re going to scan it and through the primary protocol, so now we scan the OptiSplint. Scan the frame first, and the luting material. Make sure to get a nice scan of that entire area until it’s on the screen. Then you’ll come out to each one of the OptiSplints individually and scan the round head. This is the scan body. Now, these OptiSplints are pretty close together, so you’re going to pick up two at a time and hopefully, the AI is turned off and it’s not getting confused. Continue scanning until you can see it really nicely on the screen. With this case, we scanned the OptiSplint in a little different direction just to make sure we picked up the round heads; we came at it from the left and from the right, and it was a really nice scan that we took. This is what the scan looks like back in the laboratory; very accurate, very nice work. Now that the case is scanned, it’s digitized. You’ll upload specific files to the laboratory. This is the first scan right here with the teeth and the Fixation Base, the second scan is the Fixation Base, Carrier Guide, and healing collars, and then the third optional scan is on the bottom right, which is the healing collars and tissue. I would definitely recommend sending all three scans, and based on that we are going to design the case. So with that, day one is finished.

Let’s go to day two; we’ve already fabricated the restoration and I’ll show a little bit of the records, but I want to show the plan, which does show a denture, but we also did a workup a week prior to surgery and this shows that the implant positions are the same as the plan. Now, remember that one was a little bit rotated in surgery? We used our special Grammetry screws and we made angled screw channels in the middle of the tooth. It a brilliant screw. Back in the laboratory, we received the files. These are the files that we already received. This is the pre-operative files that we scan, just a stonecast with a hybrid on the upper, and we’re doing the lower. Then we performed a digital workup the week before to make sure the doctor and the lab were all on the same page on where the teeth were going to be set, arch form, esthetics, etc. That’s what we sent to the doctor as a preview.

On the day of surgery, we are bringing back in the files that the doctor captured; this is basically the study model and we brought it back into the original lower position, and now if we open this bite, if we made any modification to the bite, then it will be registered and we can plan to fill the gaps. The gaps are here because the bite was changed a little bit, and then we build into the prosthesis and send a preview if the doctor wants. Otherwise, we go right to manufacturing the case. In this particular case we manufactured the case at the laboratory and on the same day made it beautiful, working on it a little bit more in the morning, drove it over to the doctor’s office, and had a really nice seating appointment. This case is coping-free, meaning no copings, just Grammetry screws. You won’t be able to tell but that one’s a little bit of an angled screw channel there on that side. And here’s the finished prosthesis. We’ve got some talented people here at the laboratory that make these beautiful. The next day at noon, I went to the doctor’s office, brought the prosthesis, brought the screws, bought the special driver, and the doctor took off the healing collars, and seated the prosthesis. This was a very quick appointment with only a little bit of adjustment on occlusion, and I think that was because the scanner had a little trouble with the AI and scanning that Carrier Guide, but we got really nice contact right at the very beginning. I think that this was actually the first tap-tap, a little bit of equilibration, and then, beautiful. That is Grammetry and the CombiGuide full arch protocol, start to finish. Please post any questions and share this video with your friends. Thank you.