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Frequently Asked CHROME Questions

Click on the titles below to find the answers to the most commonly asked questions concerning the components and processes around CHROME GuidedSMILE.

Patient Records

The Pin Guide

The Fixation Base

Pins and Drills

Osteotomy Guide

Carrier Guide

Nano-Ceramic Prosthetic

Prosthetic Conversion Kit

RAPID Appliance

Patient Records

1. Single Arch or Double Arch ‐ Dentate against Dentate

  • Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side
  • CBCT patient open biting on cotton rolls. Place cotton rolls between cheeks and teeth.
  • Maxillary & mandibular master casts or impressions. Must capture vestibule of the CHROME arch
  • CO or CR bite registration
  • Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

2. Dentate against Denture: Single Arch ‐ If CHROME is the Dentate Arch

  • Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side
  • Master casts or impression of dentate arch (must capture vestibule), and impression of denture teeth and tissue
  • Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient open biting on cotton rolls. – IN OF OCCLUSION
  • CO or CR bite registration
  • Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

3. Dentate against Denture: Single Arch ‐ If CHROME is the Edentulous Arch

  • Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side
  • Master casts or impression of dentate arch and impression of denture teeth and tissue
  • Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient biting on cotton rolls – IN OCCLUSION
  • CO or CR bite registration
  • Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

4. Dentate against Denture: Double Arch Edentulous

  • Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side
  • Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient open biting on cotton rolls.
  • Bite should be worked out in the denture fabrication. If not, maximum opening of bite is 3mm.
  • Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

5. Existing Metal Partial Denture in CHROME Arch

Metal frames cause scatter and must be removed for the CBCT. If partial is needed for establishing bite, capture in an impression. If not, send master casts, opposing and bite.

6. Free‐end case with unstable bite

The bite must be established through bite blocks and set‐ups. Once the case can be articulated then CHROME can move forward.

7. Opening bite more than 2mm

  • 3mm is the maximum we will open in the laboratory w/o an open bite record being returned for verification. More than 3mm must be established clinically with CR bite, or through splint therapy. We can assist via our special JC Try‐In Repositioning Device.
  • Tip: if distance between #9 & #24 gingival zeniths is less than 17mm (Shimbashi rule) then opening may be needed. Same if intervestibular is less than 35mm.

The Pin Guide

1. What if the pin guide does not fully seat on the teeth, visibly in the Pin Guide windows?

Seat using indicator and adjust until all the windows on the Pin Guide are in contact with the teeth. Caution, due to tooth undercut, not all of the window needs to be seated, just the occlusal/incisal. View how the Pin Guide seats on the model. This should be repeated intraorally.

2. Are teeth mobile?

If so, they may need to be manipulated into the Pin Guide similar to how they were impressed.

3. Has the patient had dental work since initial impressions?

Modify the PG or extract teeth that do not impact the seating of the PG.

4. Are there teeth to be removed?

Refer to the notes! We make notes on extractions. Remove the specific teeth noted on the GSI form, due to mal-occlusion or draw.

5. When is too much adjustment too much?

if aggressive adjusting clearly changes the fit and seating accuracy of the PG, this may be cause enough to stop the surgery and capture new records to start over.

6. Is the appliance contacting the vestibular tissue and will not seat?

Flap the tissue until the Pin Guide seats. In other words, flap earlier on this arch. This is due to the initial impression not capturing the full vestibule, or the bone reduction is beyond the vestibule. Once seated, inspect and adjust if needed.

7. Pin Guide CHROME Loc Loop is broken

Must use manual clamping (fingers) to hold the Pin Guide and Fixation Base together. Pin Guide and Fixation base insertion accuracy is vital to the success of the case. The surgery could also be put on hold for a new Pin Guide to be ordered. The case should be returned to us to ensure accurate assembly.

8. What to look for when inspecting?

Does it fit into the Fixation base passively? Do the CHROME Loc plungers easily and almost passively insert? If not, there could be material inside the CHROME Loc box preventing. This could also mean that someone heat cleaned the guide. Use a narrow bur and open the hold on the Pin Guide CHROME Loc loop until the plunger seats.

9. What if it does not seat after an adjustment?

This probably means the model is not accurate, or perhaps the Pin Guide is fabricated with errors. The case must start with a fully seated Pin Guide. The case may have to be delayed. This is a clinical call based on how far off.

10. What if the CHROME Loc plunger pin pulled out?

The pin can be re-seated. It will not function as the others. It will pull out every time, so please use care when pulling so as not to drop in the mouth. The plunger will still work.

11. What if the Pin Guide loops are broken?

Must use manual clamping (fingers) to hold the Pin Guide and Fixation Base together. Pin Guide and Fixation base insertion accuracy is vital to the success of the case. The surgery could also be put on hold for a new Pin Guide to be ordered. The case should be returned for us to ensure accurate assembly.

12. Edentulous flap first? Seat drill and then Flap? What is our protocol?

The protocol is to not flap first. Seat the Pin Guide, drill all the sites, remove the Pin Guide, flap and re-seat and insert pins. The flap can be made first. If so, carefully follow the instructions that are provided with each case. This is a ridge incision first, top of ridge flapped forward. Must use care with swelling from anesthesia. Must ensure the Pin Guide is very accurately seating even though there is no labial support.

13. Edentulous Pin Guide seating? How to adjust?

Just like a denture, using indicator and finding the perfect seat. Be sure to account for swelling from inflammation from the anesthesia. Hold FIRM using two people or more, solid, consistent pressure. Do not use a surgical mallet until all the pins have been pushed in as far as they will go with finger pressure. Using a surgical mallet too early can put uneven pressure on the assembly of Pin Guide and Fixation Base.

14. All or most of the teeth are mobile?

This is critical. If the Pin Guide moves the teeth, the implants will be in the wrong position. Let us know early in the planning. We will fabricate a Pin Guide with opposing bite integrated. The patient will be closed biting on the Pin Guide while the facial pins are being seated. If there is no bite designed in the Pin Guide, use the palate for stability, or on lowers try to use the tissue.

15. Edentulous Pin Guide used to verify vertical

If the Pin Guide is a replica of the denture, seat the Pin Guide and mark the nose and chin to verify final prosthetic accuracy. If this is a double arch, the Pin Guide will probably have a bite integrated, so the vertical is not centric and this technique cannot be used.

16. Double Edentulous protocol?

Options: 1) Complete upper full surgery and prosthetic conversion and then lower arch. The mandibular Pin Guide has a bite that is designed for the maxillary temporary prosthetic. In other words, when the max is finished, use the max teeth to ensure proper seating of the mandibular Pin Guide. 2) Seat both Pin Guides initially and drill all the max and man sites. Complete the max case, then flap the mandibular and the holes are already there for the pins. Both methods are acceptable. Follow the instructions included with each case for the flapping technique.

The Fixation Base

1. Does the CHROME loc’s engage? What if the plunger does not plunge?

CHROME Loc’s are carefully checked. Guides may be going in crooked. Inspect the CHROME Loc Box for material. Might be clear, broken Pin Guide plastic that is hard to see. Perhaps the case was heat cleaned and warped. Carefully adjust the hold on the insertion part that is going in the box, until the plunger plunges.

Taper the end of the plunger tip, round off the edge.

Rongeurs twist and pull. Be delicate, full removal is not terrible, just inconvenient because it will not work as designed for the rest of the surgery.

NO Autoclave, only 20 minutes cold sterilization

2. What if the plunger pulls out?

The pin can be re-seated. It will not function as the others. It will pull out every time, so please use care when pulling so as not to drop in the mouth. The plunger will still work. Clinical chairside support may have extra plastic sleeves to replace the damaged one. CHROME is on the 3rd generation CHROME Loc design and a new design is being rolled out Q1 2019.

3. What if Fixation Base contacts bone in the posterior? What could that mean?

Exostosis that we missed. Lab may have trimmed the model and missed it. Inspect, a flap and adjust bone, or adjust metal with a disc, if possible – do not cut off a CHROME Loc or pin site.

Pin Guide may have seated crooked. This is BAD. If the teeth are still in, remove the Fixation Base and re-insert with the Pin Guide FULLY seated.

Mobile teeth may exist and the Pin Guide moved the teeth. If the Pin Guide has an integrated bite, re-start the case using the bite for seating the Pin Guide. Next time, inform the CHROME team of mobile teeth, especially of most or all are mobile. We will design a Pin Guide that seats against the opposing teeth.

4. What if it contacts labial bone?

Pin Guide is not seated correctly. Perhaps the bone is very soft and the malleting pushed the fixation base and oblonged the holes. This is bad. Suggest pulling the Fixation Base back out to mimic the GSI report images, pack gauze plugs between the Fixation base and the bone and be gentile during the surgery. Or, just use the Fixation Base for bone reduction and then freehand the implants using the Carrier Guide as just a guide for close implant location. These are just suggestions for a case that is not aligned correctly. This is not a surgical recommendation! These suggestions can lead to very unpredictable surgery and results.

5. If the fixation base wobbles?

Do not drill to depth. Drill ½ into the bone and use a surgical mallet to force the pins in. If it is too late and all the pins are in, this is bad. Suggest pulling the Fixation Base back out to mimic the GSI report images, pack gauze plugs between the Fixation base and the bone and be gentile during the surgery.

6. The fixation drill breaks?

If you cannot back it out or easily remove, and you have an extra 2mm, leave it in place and use the other drill. Length can be measured by setting it next to a pin and using a sharpie. If this is the only drill, it must be removed. Remove the Pin Guide and the other pins and remove the drill. This is a last resort, as the removed pins will not fit the same as the initially did, and can be detrimental to the stability of the Fixation Base.

Pins and Drills

1. Break a drill?

Remove and start over, or leave in if it is in the shaft of the Fixation Base

Be sure to have back-up pins and drills.

2. Pins are all short but the plan says long?

This is ok. Use the short pins and do not drill to full depth. Use a surgical mallet and tap the remaining 3-4 mm’s. If the plan calls for short pins and you only have long, a judgement call must be made. It may be okay to tap through the lingual cortical plate. This solution changes doctor by doctor and where the exit point is, mandibular or maxilla. Long Drills are 25mm and Short Drills are 21mm. Can leave the long drills protruding from the Fixation Base. This is the best option, as the trajectories of the pins should hold the base in place.

3. Drill breaks in the Fixation Base – how do you remove it?

First question, do you remove? If it is not protruding through the Fixation hole then may just leave, especially if there are 3 more. If removal is needed, remove the Pin Guide, remove other pins and then Fixation base, and remove with rongeurs. Now what? Your drill broke. The drill is a 2.0mm that coordinates with the pin length, but, you can simply get another drill from another kit and use a sharpie to measure the length compared to the pin, and drill. You can always under drill and mallet into place.

4. Drill all sites first? Or what is the procedure?

Drill one at a time, push in the pin and move to the next site. Best practice is switch from far right or left, over to far opposite site. It is very important to not move the Fixation Base with the pin, rather, stop the pin at the Fixation Base sleeve.

5. When to mallet the pins?

‘Always mallet’ is a good protocol, even if it is just the last few millimeters. The pins should have resistance so that they do not come lose during the procedure. If the pin(s) is pushed to full depth easily, do not drill the next site to depth. Leave the drill a few mm’s short and mallet the pin until flush with the fixation base sleeve.

6. Pin Breaks, what is a substitute?

Very rare, but can use a drill or bur shank to hold the base in place.

Recommend back-up drills and pins kits

7. Pin is loose

Don’t drill to depth. Stop 3-4mm or more short of the drill stop and mallet the pins in. If the Fixation base is lose after all the pins are seated then the bone is probably of very low density. There is no good solution, but can us a cotton plug and wedge between the bone and the Fixation Base to force the metal out, away from the bone. Try to mimic the image on the GSI report. There are images of how the metal should relate to the alveolar bone. Be very careful with assembling and disassembling the guides.

Osteotomy Guide

1. What to test first?

Check kit early to ensure passive fit. Spoons should fit with little to no resistance. If the spoons are a little lose, ensure the top of the Osteotomy guide sleeves and the spoon are flush seated when drilling all sites. Be sure if there are divergent, very close implants, that the spoons will seatfully w/o touching one of the other sites. This would have been checked in the lab, but a verification is still suggested.

2. Spoons from the guided kit are tight how to adjust?

Adjust as minimally as possible. Use a metal cutting bur and indicator in the guide tube to identify exactly where the contact it. Turn the Guide upside down and look up into the tube and visualization of the hang-up area should be evident. If the spoons are so lose that it appears the wrong design was made, clinical decision to move forward must be made. If the bone is very wide, proceeding may be ok.

3. Spoons are lose, how do you overcome?

Use the top of the spoon, make sure it is flat on the osteotomy guide and drill. If the ridge is very narrow use much more caution. Wrapping the spoon with Teflon tape is an option.

4. Trajectory of site looks off. How do you test to ensure it is correct?

Assemble the spoon and drill and show the trajectory all the way to the bone. Often the sleeves seems lingual, but the sleeve is just the trajectory not the stopping point of the implants. In other words, the guide may look lingual, but it is in the position as designed.

Clinical judgement must be made if the guide clearly shows a wrong trajectory. Free-hand may be needed.

5. At what point do you bail and freehand?

Clinical solution: see the drill touching the bone first.

6. Implants have threads exposed, but spoon is buried in guide, what to do?

Perhaps the bone was reduced too much. Bone level must be and extension of the Fixation Base and not angle up or down from that plane. If this is the case, use training on treating exposed threads. If anatomically and prostheticly allowable, place the implant deeper using a hand driver.

7. What if crooked drill locks into the osteotomy guide?

Do not use forceps. Do not want to dislodge the Fixation Base.

8. Wrong implant sizes and parts are ordered? Can this be overcome?

Call the rep. Call the company to find the rep. Call doctors in area with inventory! Find a compatible implant system and contact their rep. Try not to bail.

Carrier Guide

1. What are the purposes of it?

Bone reduction verification, MUA angle guide, delivery of the prosthetic and RAPID appliance, spacer for reflected soft tissue, verification that the driver is going in the right direction on angled implants (note the black square on angled sites – see instructions for specifics), tissue reflection.

2. What if the implants are not protruding directly under/through the sites?

This could mean any number of things went awry: Pin Guide was not seated correctly; angle implants are too deep or too shallow changing the connection position; implant chose a different path if they were inserted by hand, not guided; decide if they are placed in an area that is not acceptable – take an x-ray to verify that they are in an acceptable position and make a judgement to move or leave. The plan called for the implants to emerge in specific poition, and the fix is to modify the Carrier Guide and the prosthetic for pick-up. Be sure the Temp Cylinders do NOT contact the Carrier Guide or the prosthetic during the pick-up.

3. What if the angle implants, MUA’s and Temp cylinders are not aligning through the holes?

Verify that the implants are in the correct position. This can be observed visually through the carrier guide. If looks good, then the angled implants may be inserted in the wrong rotation. If it is, then the implant must be rotated, as little as just a few degrees. This should ‘right’ the MUA and Temp Cylinder. Also, verify that the abutment screw is in line with the black square on the Carrier Guide. This square is where the driver passes through to deliver the abutment screw, in the same trajectory as the implants. If the implant has been place with the correct indexing to the hex on the Osteotomy Guide, then the MUA may need to be remove and placed in one rotation clockwise or counterclockwise. Best course of action is to follow the implant guided kit to deliver the implant exactly as the Hex indicates.

5. Do you have to use the Green Gaskets?

YES. Must block out the pick-up material so as not to lock in the prosthetic. Can use light body, gloves for rubber damn, wax, other similar easily removed material.

6. What if Carrier Guide is not seating? Do you force it?

NO, do not force or bend. It will break and be detrimental to success. Three main reasons it will not seat: 1) something is in the CHROME Loc box. Carefully inspect and clean 2) bone was not reduced sufficiently and is ‘holding it up’ 3) soft tissue is in the way. Make a stitch, or reflect more if needed.

7. What do you look for that might be holding it up?

1) Something is in the CHROME Loc box. Carefully inspect and clean

2) Bone was not reduced sufficiently and is ‘holding it up’

3) Soft tissue is in the way. Make a stitch, or reflect more if needed.

8. Can the prosthetic or RAPID be used early on to check occlusion?

Yes, checking occlusion early is a good trick to know if there will be adjustment and to judge how surgery is going so far, to see that everything is stacking correctly.

9. What if Carrier Guide breaks?

If the CHROME Loc insert breaks there should be two remaining that work. That is sufficient. If more break, then hold down the Carrier Guide through the remaining procedures. If the guide broke in half, reinforce with acrylic on the INTAGLIO side, not the occlusal side. Do not want it raising the prosthetic. There is a gap under between it and the bone. This part can be reinforced.

10. What if there is not enough torque on the implants?

This is very critical. The prosthetic must not be loaded if the torque does not meet the minimum number. We recommend using and ISQ device to check NCm’s. If you do not plan to load, at least pick up 3 of the Temp Cylinders on the MUA’s for tripoding. This is a good index for the delivery of the prosthetic in two to three months. The remaining implants can be picked up later. There is NOW WAY to do this once CHROME removed. Anything in the future is floating and cannot be picked-up. Pick up the RAPID appliance at this point as well if possible.

Nano-Ceramic Prosthetic

1. What to do if the temp cylinders are touching the sides of the holes?

First check implant rotation on angled implants – best course of action is to rotate the implant until the Temp Cylinder is straight and parallel with the others. This means remove the MUA and use a hand driver to slightly adjust. Implant must be indexed precisely according to the Hex on the Osteotomy Guide for straight temp cylinders. Goal with CHROME is to deliver all parallel Temp Cylinders. This creates simple pick-up at surgery and ideal screw access in the final. If the Temp Cylinders are going to be picked up in the current tipped position, then adjust the prosthetic slightly to remove the contact. Sometimes the Temp Cylinders can be seated from the top down. In other words, seat the prosthetic on the remaining cylinders and deliver the crooked cylinder from the occlusal hole. If not, again, adjust the shaft of the prosthetic to accommodate. DO not over adjust, need 3mm from shaft to outside of prosthetic.

2. How about if they are not aligned, divergent? What steps should be taken?

First check implant rotation on angled implants – best course of action is to rotate the implant until the Temp Cylinder is straight and parallel with the others. This means remove the MUA and use a hand driver to slightly adjust. Implant must be indexed precisely according to the Hex on the Osteotomy Guide for straight temp cylinders. Goal with CHROME is to deliver all parallel Temp Cylinders. This creates simple pick-up at surgery and ideal screw access in the final. If the Temp Cylinders are going to be picked up in the current tipped position, then adjust the prosthetic slightly to remove the contact. Sometimes the Temp Cylinders can be seated from the top down. In other words, seat the prosthetic on the remaining cylinders and deliver the crooked cylinder from the occlusal hole. If not, again, adjust the shaft of the prosthetic to accommodate. DO not over adjust, need 3mm from shaft to outside of prosthetic

3. What if the doctor wanted ports and we did not add them?

Use #4 round bur and drill a hole through to the cylinder

4. The prosthetic is seated but hitting the posterior or anterior first? Steps to correct? Or adjust the teeth?

Verify that the Carrier Guide is fully seated. If so, can shim a few millimeters and backfill. This will open the bite a little. If very high in the posterior, trim ½ of the pegs to remove resistance and shim half way to occlusion then adjust the occlusion.

5. Prosthetic is already thin, and now there has to be a lot adjustment?

Float the anterior and backfill. If double arch then trim the thicker of the two. Do not reduce to less than 8mm’s of vertical prosthetic material remaining. This very thin! MUST make an analog model with a flask as a back-up. MUST complete the RAPID pick-up to have a means of ordering another prosthetic during healing time. This could have been observed at the bone reduction time with the Carrier Guide and RAPID or Prosthetic seated for testing. This means it should not be a surprise.

6. How do you check occlusion if the temp cylinders are too high?

Cut down the cylinders to be flush with the prosthetic.

7. What is the best tool for adjusting the cylinders?

Bite should have been verified at the RAPID and cylinders can be trimmed after the pick-up is completed. If the doctor wants to test the bite on the conversion prosthetic, then trim the cylinders in the mouth, or remove and trim. Mark with sharpie first. Trim with a 557 Carbide.

Prosthetic Conversion Kit

1. How much does it cost?

2019/2 $188

2. What is included?

Quick-Up, adhesive blockout gaskets, syringeable blockout, applicators

3. Do you have to use the adhesive?

YES – will not bond without the bonding agent

4. Is Voco light cure or self-cure… or dual cure?

We only includes the SELF CURE ONLY Voco

5. Does the prosthetic have to be dry to use Voco and adhesive?

Must be completely dry, including clean of blood. Future debonding eminent if the surface of the prosthetic cylinders is dry or contaminated.

6. What alternatives are good when VOCO is gone or missing?

Duralay, acrylic, Holmes Quick Set, GC Pattern Resin, Stellar. If these materials are not available find a doctor in the area and ask. Do not use standard acrylics.

7. Should the inside of the cylinders be adjusted for mechanical retention?

Yes, very helpful, especially if not using VOCO or GC Pattern resin. If using acrylic or ERA pick-up (not advised materials), yes.

8. When to cut off posterior teeth?

5mm distal from the posterior hole. Optional to grind down the posterior tooth down so that there is a flange extending posteriorly for the iJIG to capture the ridge when going to final. This is nice for capturing the posterior ridge in the future. This is up to the doctor if to leave the distal flange. If the doctor is going to make an iJIG then recommended to leave the flange. If picking up the RAPID (advisable), the posterior teeth are not removed and the ridge can be captured under the molars later.

9. What is the minimal torque for immediate loading? Do you add the implant torques together?

Totally up to the doctor. But we’ve heard doctors add them for a total of 140 rule between all of them. We don’t recommend. Can add another implant in the area. Sleep implants and add to the RAPID, or iJIG later.

10. What if the hole is too deep for the doctor’s tools to tighten and loosen the temp cylinders?

Ask the implant rep for a longer driver. Our clinical techs bring long lab drivers to surgeries.

11. What if you have to choose a different site for an implant? How do you adjust the carrier guide and prosthetic?

Index the carrier where the hole is and adjust the prosthetic, making the hole smaller than the others so that not to jeopardize strength. Can also go back to the denture prosthetic and convert, All-on-4 style, as a last resort./p>

12. How many implants is too few to continue?

3, unless one is in the middle. Total clinician judgment call.

13. Can you load a spinner?

NO.

RAPID Appliance

1. What is the purpose of the RAPID appliance?

RAPID Appliance has two unique and very important primary functions. 1) Serves as a back-up indexed prosthetic in case the surgical prosthetic fails. Simply seat the RAPID, equilibrate, capture a bite and opposing and send to us for a new temporary, or final prosthetic. 2) Serves as the simplest method of transitioning to the final. Simply add tray adhesive to the intaglio, seat, equilibrate, capture a reline impression and send to us with bite opposing and photographs. The CHROME team can go to final or return what we call the Printed Try-In, a screw-down final prototype for clinical verification.

2. Can it be picked up in a few months if not during surgery?

NO. If it is not picked up on the Carrier Guide while CHROME surgery is live, then the RAPID is not indexed to the implant, it’s just floating. This is not to be attempted. If the RAPID is not to be picked up at surgery, using lab analogs on the surgical prosthetic, make a stone model and use lab putty to flask over. This will allow the RAPID appliance to be placed in the flask, just like the conversion prosthetic, on temp cylinders on the analogs, and acrylic to be flowed in the flask to make the connection from RAPID to Temp Cylinder.

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