Grammetry Workflow Options: Screws or Registration Tads

Let’s get into the modalities of Grammetry. The modalities are the different ways to integrate Grammetry into the full arch surgical workflow and we will talk about a few. The first one, which is screws and tads. That’s the same type of process that you would use for photogrammetry and I think you’re going to like the twist. So, using screws or OptiSplint arch tracers. This modality is very familiar in the marketplace if you’ve been involved in photogrammetry or used a digital protocol to make restorations. For this protocol, you place screws somewhere in the mouth, or place the Grammetry arch tracers; you can see an example here, and we have another image of it coming up in a minute, but the key here is that this occurs at the beginning of surgery. In this case, it’s flapped on the right image. When using the arch tracers, you have to flap first to set them, and with screws you place them in the retromolar pads, place them back in the pallet, or just beyond where the suturing and the flap is going to be, or even down in the pallet. Those screws remain in the mouth during the entire surgery. That is key to saving the bite. And these are placed prior to digital impressions being captured with the bite. These screws can be purchased from a couple different companies; Salvin sells a nice screw with a big head, Osteogenics… both of these companies sell really good kits with all kinds of lengths.

If you’re going to purchase our Grammetry arch tracers, then you’re going to want to purchase a 10 to 12-millimeter-long screw, which are available through either one of these companies. The screw head needs to be wider than two millimeters. We will be inventorying a screw soon that we can include along with the arch tracer, but for now 10 to 12 millimeters. On the day of surgery, at a minimum, if we’re printing you’ll need the OptiSplint kit, you’ll need Stellar acrylic material, the white, not the pink variety. You want to be sure and purchase the white because scanners pick up white better than pink. You’ll need some other things as well, but for the OptiSplint portion of the case, you’ll need some forceps, a curing light… and really, everything you see here on the screen is what you need. And then of course, if you’re going to print, you need a 3D printer. But this is just to do the intraoral capture. So that’s all the simple tools.

This is where we turn what everybody in the marketplace has learned on its head; this is where the car can fly. What you’re going to do for a surgical case is to place the three screws; you decide the upper, lower, pallet, distal… you’ll place the screws, and you’re going to scan the upper, lower, and the bite in centric is what normally comes over, and we can open the bite in software a couple millimeters if you need to do a leaf gauge or a centric relation bite, and you can capture that, that’s fine. Otherwise we will open the bite. So screws are in, the patient is scanned, and now you go through the entire surgery until you have the multi-unit abutments in the mouth. Then you perform the OptiSplint luting intraorally. We’ll discuss that a bit later on, but what I really want to convey here is that these are the three simple records. You’re going to scan the full arch, you’re going to capture the healing collars and sutured tissue with the screws, and those are the two intraoral scans and your patient is done.

The extraoral scan will be of the OptiSplint on a benchtop under a controlled environment with your iOS scanner. You don’t have the patient breathing on the mirror, don’t have blood oozing, you don’t have sutures… you don’t have anything going on behind or under the OptiSplint that’s going to throw off the scanner. You’re getting a clean scan on the benchtop. And that is where the precision comes in that nobody else offers; you cannot do this with photogrammetry, you cannot do this just by luting a bunch of scan bodies together or a bunch of healing collars together, it’s just not feasible. So the OptiSplint comes out of the mouth and you scan it, and this is what you upload. So now, let’s go through a patient case. The patient is ready for surgery, so take your full face full smile picture. Now, maybe they’re a little nervous on the day of surgery, so maybe you took this picture last week. A full face full smile is what we want, showing the soft tissue with the lips, the eyes… the whole patient anatomy. So get us a nice photograph, and we are going to design this case behind the lips. Place the screws, and scan.

I’m going to give you a bit of a different option here that is being taught in a lot of these courses: the week before or two weeks before, have the patient come in. Scan the upper and lower, and we will design the smile, we can give you some idea of bone reduction levels, and if you’d like we can give you the tooth position. We can really help set the case up for success. This patient came for esthetics, and they only have five teeth remaining, so let’s do a setup, let’s make things ideal. Then on the day of surgery, when the patient comes in, you’re going to scan with the screws placed, scanning the upper, lower, and bite, and then it’s go time. Proceed through the surgery; teeth come out, bone is adjusted, implants go in, multi-unit abutments go in, and at that point, you are going to complete the OptiSplint intraoral process.You’re going to put an OptiSplint scan body on each of the multi-unit abutments, then you seat the metal honeycomb frame on the horizontal OptiSplint arms. Lute them all together, remove it from the MUAs, and place the OptiSplint on the benchtop. That is the simple process of capturing the implant position. Now that we have the implant positions, we do not need to relate this back to the bite or the tissue or anything in an intraoral scan. The next step will be to scan the patient and pick up the healing collars and screws, just like the image there on the left.

When you are scanning, you need to make sure you always pick up the screws, or we lose the bite. The screws are there to bring us back to the original scan. If your scanner is struggling or if you’re struggling that particular day with capturing this, be prepared with a stock tray and a lot of impression material, and pick it up. Notice back here there are four screws; this case comes to us courtesy of Dr. Germaine Charles, a friend of ROE who completes these cases. He placed four screws back here, and he does four screws because in his long experience of doing full arch cases, he found the tripoding was better with four instead of two. So you take this out of the mouth and take an iOS scan of the impression. Now we have the implant positions, we have the screws, and we can bring this back into the original scan of the patient. And then we can bring in the OptiSplint scans. So this is just a matter of stacking files, and we are very good at it. We are we have a very precise method for stacking these files together, but just think of the simplicity you have here: you do a simple IVJ, take it out of the mouth, place the healing collars in, and suture around. The patient is almost done at this point. Take a PVS or take an ios scan, and the patient’s done. The patient goes home, or they can go off and relax while we get the case ready. When it comes to the available healing collars in our system, there are many options.

And we’ll add more in as we move along, but as long as you have one of these, then you’ll let us know which one they are in the RX. Then we are integrated with OptiSplint. Tell us which one you’re using and you’re good to go. If you don’t have the healing collars, maybe for some reason you don’t have healing collars on the day of surgery, or there’s some other reason that you want to scan the OptiSplint in the mouth, that’s fine. That’s how the product has been used for the past year.

I’m going to quickly go through this next bit: once the OptiSplint is in and it’s been luted together, clean off the palatable screws to make sure there’s no dried blood or anything obscuring them, and once it’s all ready to go, you can scan. When you scan with an OptiSplint intraorally or extra-orally, you always start in the middle and scan the full area. You’ll see this is pink in the case, but we have since changed to white acrylic material. Both materials work, but white’s a little bit easier to scan. Scan this area, scan the palate, and scan the main area of the OptiSplint. In this case, the doctor used a really nice scanner, specifically the Primescan. The doctor actually grabbed the screws there as well. Once you scan the main area, then you start to come out across the scan bodies, so let me show you. You come out to a scan body, and then you go back to the original area. With this case you’ll see the doctor is going to come back and then they’re going to go out to another one like this and then they’ll go back to the center. And just keep picking them all up.

You’ll see this in the rest of this video, but the protocol was not perfectly followed; you see they went around to the labial and they captured a little bit of tissue and a little bit of bone area there. That’s where you can get some inaccuracy your intraoral scans, and we don’t want any of those scans. We only want the OptiSplint. So I’m showing you a little bit here of what not to do. Scan this, go out to each arm, and come back, back and forth, back and forth, until you have it fully captured. Don’t forget to pick up the screws. And that is the intraoral process for scanning the OptiSplint. When you do that method, you have the option of scanning the OptiSplint outside the mouth again. You can scan it twice, but when you scan the OptiSplint in the mouth, then you also want to perform this scan here with the healing collars. Let’s do a real quick recap: take photographs on the day of or the day before if you wish, scan the patient pre-surgery with the screws, scan the patient after surgery with the healing collars and the screws again to match, and scan the OptiSplint outside the mouth. That is how this case is completed. If you scan the OptiSplint in the mouth, that’s perfectly fine. Just be sure to also scan extraorally because we like the accuracy of the scan. What you see on the screen is what you send to the lab. Zip these files together in a folder and upload them on our website.

Please call us to discuss any of this. Once we have the records, we will design your case. So there’s the screws, we have the case articulated with the screws, and now with the OptiSplint, based on the screws (you can see them down here that was our that was our alignment) then we quickly work with the geometries, design the prosthesis, and then we ship it to you all ready to go; a fantastic coping-free direct to multi-unit abutment, extreme precision…boom, go to print. Now because this is OptiSplint, you have the ability to make a model. With the model, if you want to have copings, simply put copings on the multi-unit abutment analogs, seat the prosthesis down onto them, and lute them together. If you don’t want to have copings, that’s perfectly fine, that’s how most of our cases are done. If you do want to have copings, let us know as we’re going to need to design these interfaces a bit differently, but at this point all you have to do is nest the design, print, clean, beautify, and seat. It’s a very smooth, very accurate workflow.