iJIG™

What are the purposes of it?

• Bone reduction verification
• MUA angle guide
• Delivery of the Provisional 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)
• Tissue reflection

Click here to learn more

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
• Implants are too deep or too shallow, changing the connection position
• Implant was placed by hand or not inserted properly

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 judgment to remove or leave in place.

The plan called for the implants to emerge in a specific position, 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.

What if the 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 placed with the correct indexing to the hex on the Osteotomy Guide, then the MUA may need to be removed and placed in one rotation clockwise or counterclockwise. The best course of action is to follow the implant guided kit to deliver the implant exactly as the Hex indicates.

Do you have to use the gaskets?

YES. You 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.

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.

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

• Something is in the CHROME Loc box. Carefully inspect and clean
• Bone was not reduced sufficiently and is ‘holding it up’
• Soft tissue is in the way. Make a stitch, or reflect more if needed.

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 the surgery is going so far, to see that everything is stacking correctly.

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.

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 NO 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.

What is the purpose of the Fixation Base?

• Bone reduction. The occlusal edge of the Fixation Base is designed to indicate the level to which the bone needs to be reduced. The passive placement of the Carrier Guide onto the Fixation Base indicates sufficient bone reduction.
• The Fixation Base is the foundation for all subsequent components in the CHROME GuidedSMILE surgery.

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

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.

What if the 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.

What if the Fixation Base 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 gentle 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.

What 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 gentle during the surgery.

What if 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.

Do I have to buy two Fixation Kit for a double edentulous arches surgery?

Now the only time that you would need more pins is if you were going to do a double edentulous arch. In this situation, we often ask the doctor to do both Fixation Bases at the same time because the Pin Guides are duplicates of the denture, but are not the same teeth as the long term temps. In other words, the Pin Guides put the fixation base in the exact position using the teeth of BOTH dentures. You’ll need ALL the pins on these cases.

Further, the Pin Guide is a duplicate of the patient’s denture. So if there are dual pin guides, we want both of those in the mouth at the same time and at the right occlusion, everything fits perfectly, just like their old denture did, then you drill everything.

If you just do the maxillary, for example, and you go through the whole procedure and three hours later the patient’s wearing their future maxillary teeth, it doesn’t match up with the old denture lower Pin Guide. In this situation, we would have to make a pin guide that’s designed for the lower for the second surgery of the day. We would have to design it so that it meets the patient’s new prosthetic.

So instead of this, we encourage you to put both pin guides in, drill all the facial sites, put the pins in, load both metals, and you could take the lower metal out and put it back in in a few hours. It doesn’t have to be in there for three hours, but at least the sites are drilled in the right position.

What is the difference between CHROME and the many plastic guides I’ve seen?

There are significant differences between CHROME and every other guide. Unlike other surgical guides, which are made of plastic, CHROME guides are made of an extremely durable Cobalt CHROME alloy. This material is over 20 times stronger than surgical plastic and will not flex or break during surgery.

Because of their low strength and high flexibility, plastic guides must rest directly on the bone for stability. This means a doctor must create a large lingual flap to expose the bone, and then adjust the bone for the guide to seat. The teeth usually have to be removed, leaving very few good references for the guide. The guide must now fit the sockets of extracted sites, which is not very accurate.

Unlike plastic guides, metal CHROME guides float over the bone. This floating guide technology means zero bone contact and minimal lingual flapping, improving accuracy, patient comfort and healing times.

If you’d like to learn in depth about the benefits and functionality of a metal surgical guide system, download our free CHROME ebook.

What is the difference between CHROME and nSequence?

• CHROME is much less invasive- no lingual bow, much smaller lingual flap
• Full visualization during drilling and placing implants
• Includes 5 parts rather than many, many parts that require training and extended manual
• Tooth-supported, not bone-supported
• No metal substructure to restrict implant position changes in surgery
• Compatible with all implant systems with guided kits and MUA’s
• Much simpler prosthetic conversion with the Carrier Guide, rather than the gasket floating system

Who works on CHROME cases?

Team of 26+, including 4 dentists, several CDT’s and many people with years of dental, surgical, CAD technology. The team is very impressive.

How long does a CHROME case take to make?

The CHROME timeline starts after you have collected all of the patient records and submitted your CHROME Patient Rx. We don’t start these cases until we have ALL of the CORRECT records – that is when the timeline begins.

This complete process can be completed in a min. of 20 business days. This is unachievable if the patient records are incomplete or of poor quality – this is the reason we place so much importance on accurate, complete patient records.

Do not schedule your patient’s surgery until AFTER the online planning meeting. If changes are needed in the plan then this will delay manufacturing.

How much should I expect to spend on my first case?

Very good question. There a few things to consider, the Full Package, The Fixation Kit, Prosthetic Conversion Kit, spare denture(s), JC Try-In (optional), Chairside support and any work-up items. Email ROE your particular patient scenario and we can do the math together.

What if I want to split the fees with my surgeon (or referral)?

• This is very important because you hate to have to figure out who owes what later. And quite often with these, the surgeon bears very limited lab costs.
• It is best to agree on who pays for what upfront. ROE can provide a spreadsheet that breaks down our suggestion for surgical and restorative fees. We can email you this upon request.

What is the most challenging part of getting a case in my hands?

Generally, it’s the records that’s usually hold a case. CHROME GuidedSMILE records are simple but specific.
This section is designed to help you in all aspects of record capture.

Avoid surgical delays by going through our patient record checklists, watching our patient record videos, and educating your team on what is needed. We even help with the exporting of IOS files from your IOS, or DICOM files from your CBCT.

What diagnostic steps are not included in CHROME?

• If we need to open the bite with our JC Try-In, or other lab fabricated methods.
• If we need to duplicate or create a new denture, create a scan appliance, perform wax-ups… these items are outside the cost of CHROME.

What is included in a CHROME Complete Package?

• The package includes almost everything to complete a CHROME case, from the PreVu smile simulation through day-of-surgery guides and long term temp, the final restoration, and the miniComfort guard.
• The package includes one iJIG, one Printed Try-In, and one final restoration. It includes planning, live online meeting, digital set-ups, and much more. Cases do require our Fixation Kit, which has the pins and drill(s) needed to support the guide.
• We offer a Prosthetic Conversion Kit for blocking out and luting during the conversion.
• The package does not include implants, abutments, temp cylinders or other implant components, chairside support.

The complete CHROME package includes everything for the day of surgery?

The full package includes:

• Pin Guide
• Fixation Base
• Osteotomy Guide
• Carrier Guide
• RAPID Appliance
• Provisional Prosthetic
• Implant Report
• miniComfort Guard

What is a miniComfort guard?

• The miniComfort is a patented guard that covers the lower teeth only, except for the molars
• It has two ‘elements’ that rest under the maxillary canines to keep the teeth separated
• The idea is that the patient’s biting force is limited due to limited occlusal contact
• It is a very popular guard for all patients

Click here to learn more about the miniComfort.

What is the Bite Proof product?

• It is a long-term temporary.
• If you really need to verify more than just our chairside JC Try-In, the bite-proof is more like an overlay temporary, more like a snap-on smile.
• You’d actually bond it in place and send a patient home and have them back and equilibrate, workout the bite, workout the occlusion, et cetera. It might even be a week or two or more. And then once satisfied, they are the patient’s new teeth essentially.
• That’s what the Pin Guide will fit when we move forward.
• You would treat those like the patient’s new teeth. We don’t use it very often, but if you have a patient who you’re really concerned about producing a good bite, as they’ve had issues, then this is a possible solution.

How much can you open the bite in the lab?

We limit the bite to opening 3mm’s, sometimes 4 if the original bite is very accurate.

What is the cost of iJIG and Printed Try-In outside of the CHROME package?

Price may vary due to parts. Part prices will vary greatly depending on the implant system. Call ROE to get an accurate price.

What articulators does the lab use?

Our standard is a Stratos. We’re all calibrated. A lot of our doctors bought them from us so that they’re all calibrated. So if I wanted to buy a Stratus from you that’s calibrated what would the fee for that be? About a thousand dollars. We order it. We would buy it with the magnetic mounts and we would calibrate it for you and ship it to you.

What if a patient is edentulous and has not denture?

Well that patient walks in and they’ve got an awful denture, doesn’t fit, teeth are in the wrong place, etc, or they don’t have a denture. Let’s make them a new economy denture to be used as a back-up and a scan appliance. This is a cost outside the full CHROME package.

Do you make back-up dentures for the day of surgery?

• Most doctors order a backup spare denture.
• If this is a single arch case then you would order our 3D printed economy denture.
• If it is a double arch case, then we like to mill both arches from the same PMMA material that is used in the long term temp so that the materials match if one arch does not get completed. The cost of this is double.
• Rationale – you have a double arch surgery with beautiful nano-ceramic temporaries that are going to be loaded. But let’s say the maxilla doesn’t go and you have to load it with a denture. Well, the 3D printed economy denture does not have the same aesthetics as that nano-ceramic. So we can mill those backup dentures so that they are the same material as that nano product.

Does ROE have Ivoclar universal mounting jigs so that if I take a face bow with a Denar, Whip Mix or Hanau facebows?

Yes, we can mount your facebow with our universal Facebow Mount

What is iJIG?

• The iJIG is a fit verification jig with teeth.
• It is a scanned version of the provisional prosthetic, with our special iJIG scan analogs. It is the simplest method of transitioning from an existing full-arch prosthetic to a new final.
• In CHROME, the RAPID appliance is an even simpler method.

What final restorations are available with CHROME?

CHROME GuidedSMILE is compatible with FP1 to FP3 prosthetic options and is available in a range of restorative materials.
Click here for a detailed comparison of all prosthetic options.

Choose from material options including, but not limited to:

• Acrylic/titanium
• UltraNano Trilor ceramics
• TLZ-IB monolithic implant bridge (most popular)

TLZ-IB zirconia is layered with cutting-edge translucent liquid ceramics to capture natural gingival esthetics, and is polished smooth for ease of cleaning.

All options include a functional prototype, which is tried-in and worn to verify function and esthetics prior to fabricating the final restoration. This facilitates a predictable final appointment and provides the patient with an excellent spare, “just in case”, appliance.

What is Ultra-Nano?

• One solid block of composite is milled for the teeth and is bonded to either an opaqued titanium bar or on a Trilor bar.
• Trilor is a metal-free material, kind of like Kevlar composite.
• They are used by most of our clients, especially in double arch when clanking is a concern between zirconia arches.

Click here to learn more about Ultra-Nano ceramics.

What is a JC Try-In?

• The JC Try-In is an appliance that we fabricate when a bite needs to be verified. We also use it when we open a bite on the articulator more than 3mm’s.
• It is a printed flipper essentially, that the patient does not usually wear home. It is made for clinical equilibration.
• If the patient is to wear it home, we need to know, because we will design it a little bulkier.
• It should be returned equilibrated with a new bite registration, and always analog, never digitally. Capture photographs if the bite is changing much with the JC seated.

What are the normal steps to a final after CHROME surgery?

RAPID appliance or iJIG appointment and then a Printed Try-In and then a final.

Are we allowed to give out a list of doctors who do CHROME with our lab to patients?

ROE Dental Laboratory works only with doctors, dental practices and other dental laboratories. We cannot do any dental work for patients. We do not want to leave you needing help with no recourse though.

The CHROME GuidedSMILE patient booklet is to aid CHROME doctors in persuading patients to accept the proposed treatment plan. This booklet goes all aspects of the patient decision-making journey. Click here to download a sample file, or click here to purchase on our online store.

What is the purpose of the Provisional Prosthetic?

The Provisional Prosthetic is a strong and esthetic prototype for the final restoration. It is designed for immediate load and extended use. The Provisional is delivered the day of surgery and remains in use until the final prosthetic delivery.

Is the Provisional Prosthetic milled or printed?

It is milled. We may have a printed option later, but for best esthetics and tooth strength, we mill from a solid puck.

Is the long term temp reinforced with metal?

We’ve made thousands of these cases and have had very little breakage. We offer metal for a nominal additional cost, in case you forsee a problem with a particular patient, or if the prosthetic is less than 12mm thick. The metal can cause issues during surgery if an implant needs to be moved.

Instead, we recommend an alternative modalities for improved strength in provisional prosthetics: C2F

• C2F provisionals have small 2.5mm holes, similar to final restorations, and are compatible with all implant systems

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

First, check implant rotation on angled implants – the 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. The implant must be indexed precisely according to the Hex on the Osteotomy Guide for straight temp cylinders. The goal with CHROME is to deliver all parallel Temp Cylinders. This creates simple pick-up at the 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.

For a small-hole, or no-hole protocol, ROE is proud to offer an alternative modalities: C2F. This system does NOT require the large occlusal holes in the provisional and the adjustments that come with such.

What if the doctor wanted ports and we did not include them?

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

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 halfway to occlusion then adjust the occlusion.

Prosthetic is already thin, and now there has to be a lot of 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 the healing time. This could have been observed at the bone reduction time with the Carrier Guide and RAPID Appliance or Prosthetic seated for testing. This means it should not be a surprise.

For a small-hole, or no-hole protocol, ROE is proud to offer an alternative modalities: C2F. This systems does NOT require the large occlusal holes in the provisional and the adjustments that come with such.

How do you check occlusion if the Temp Cylinders are too high?

Cut down the cylinders to be flush with the prosthetic.

What is the best tool for adjusting the cylinders?

Bite should have been verified at the RAPID Appliance 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.

How do you modify or add-to your Provisional Prosthetic?

You can use powder and liquid monomer materials, other resins, composites.

How does one start a CHROME case?

First, click the orange Submit CHROME Case button on any CHROME page. Fill out the digital Rx and click “Submit Rx and Go to Records Upload” button.

You will be prompted to upload patient records. CHROME records are simple, but specific.
For more information on records, we highly recommend visiting our easy-to-follow checklists & patient records page.

Summary:

1.  Patient Photographs:

1. Full face full smile
2. Full face exaggerated smile
3. Full face profile
4. Center retracted in occlusion
5. Left retracted in occlusion
6. Right retracted in occlusion

2. Master Casts / Impressions

• Capture full palate
• Capture most/all of the surrounding labial & lingual tissues, the vibrating line, and the full roll
• If digital, export impression from intraoral scanner
• Models are free of noticeable holes, skips, voids, or bubbles

3. Bite Registration

• Capture full occlusion or CR bite
• Taken with the patient in a closed bite, in natural occlusion
• Taken with the patient’s prosthesis in mouth, if applicable

4. CBCT Scans – Protocol is specific to dentate vs. edentulous patients

Dentate:

• Capture both arches
• Taken with the patient in the open position
• Taken with the patient’s denture(s) out of the mouth, if applicable
• Export DICOM files from your CBCT scanner

Edentulous:

• Follow a dual scan protocol
• Use the patient’s well-fitting denture or scan appliance in the mouth during the scan
• Capture a scan of the patient with their denture(s) in the mouth, in occlusion, not separated
• Capture a scan of the denture(s) alone resting on the foam
• Export DICOM files from your CBCT scanner

What if I am not digital? I don’t have digital impressions

• Send your PVS impressions or models with a bite. Feel free to mount your case on a semi-adjustable articulator and we’ll scan the models and begin working on the case.
• Whether digital or not, every case gets articulated on semi adjustable articulator. Every case goes through a multiple step evaluation. Actually we have dentists here who analyze the cases, make measurements of space, measurements of gingival zeniths for standard openings; we do all kinds of things to make sure that we’re ready to move forward, and that that’s a two or three day process.

How do I know what records to send for each type of case?

Click here for our easy-to-follow checklists

What CBCT cone beam scanners do you work with?

• We work with all cone beam scanners.
• We just need the ‘raw DICOM’ from the scanner. We need multi-file DICOM, which should be a set of files that end in .dcm.
• Simply export them into a folder, and then zip the folder.
• Submit CHROME Case and upload this zipped folder along with the rest of your records.
• If you are having trouble, check out our page on how to export DICOM files.

Walk through beginning a CHROME case

• Optional: Before taking the patient records, you may wish to submit a full face, smiling photo of your patient for a Smile Simulation to photos@roedentallab.com. Smile Simulations use advanced software to give a preview of a final smile and are a great case-acceptance tool.
• Click the orange Submit CHROME Case button on any CHROME page. Fill out the digital Rx and click “Submit Rx and Go to Records Upload” button.
• Upload your records as listed in our easy-to-follow checklists or patient records page
• ROE will perform a set-up that you can see if requested.
• Within 3 days of receiving the records, we will contact you for additional records, or send an email asking for the online meeting schedule.
• We host a live online meeting where a pre-planned case is ready for your review.
• After the online meeting, schedule surgery.
• We fabricate the case and ship to you after 10 lab days of production.
• Optional: You may request a chairside technician to be present on day-of-surgery. We recommend this option especially for your first CHROME GuidedSMILE case.

What if the patient is wearing a temporary prosthesis?

• Ensure the patient is wearing any existing prostheses in the patient photographs.
• If the patient has a temporary on the surgical arch, capture impressions with and without the temporary seated.
• When taking the bite registration, if the patient has an opposing prosthesis, the patient should wear it to stabilize the bite.
• If the patient is dentate, take the CBCT scan in an open position with the prosthesis OUT of the mouth.
• If the patient is edentulous, take the CBCT scan in a closed position with the prosthesis IN the mouth. Follow a dual scan protocol

What photographs do you want for CHROME?

We require six patient photographs to start a case:

1. 1. Full face full smile
   2. Full face exaggerated smile
   3. Full face profile
   4. Center retracted in occlusion
   5. Left retracted in occlusion
   6. Right retracted in occlusion

For examples and helpful tips, check out our easy-to-follow checklists & patient records page.

Optional: Before taking the patient records, you may wish to submit a full face, smiling photo of your patient for a Smile Simulation to photos@roedentallab.com. Smile Simulations use advanced software to give a preview of a final smile and are a great case-acceptance tool.

What is the purpose of the RAPID Appliance?

The RAPID Appliance (ROE Advanced Prosthetic Implant Device) is a duplicate of an existing prosthetic. It has two functions:

1. Serves as the simplest method of transitioning to the final. Simply add tray adhesive to the intaglio, seat, capture a reline impression, equilibrate, and send to ROE with bite opposing and photographs.
2. 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 printed try-in. We can go to final, or return what we call the Printed Try-In, a screw-down final prototype for clinical verification.

What is the purpose of the Pin Guide?

The Pin Guide ensures that the surgery starts accurately. Its only purpose is to accurately deliver the Fixation Base.

Dentate Pin Guides seat securely on the teeth and are verified via occlusal windows. The Pin Guide is held down firmly to maintain its position while the fixation pins are set. Due to tooth undercut, not all the windows need to be seated, just the occlusal/incisal

What if the Pin Guide does not seat fully on the teeth?

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.

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

What if the patient had dental work since initial impressions?

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

Are there teeth to be removed?

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

When is too much adjustment too much?

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

What if the Pin Guide is 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.

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.

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 such. 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.

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.

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.

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.

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.

Alternatively, 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.

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.

What if 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.

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.

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 maxillary and mandibular sites. Complete the maxillary first, 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.