Successful CHROME Surgery in Under 2 Hours: Pin Guide & Fixation Base

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Transcript

Alan Banks
In this second section James and I are going to talk about the pin guide and the fixation base. Maybe we’ll drift a little bit over to the carrier guide too, but the main thing is the pin guide and the fixation base. The key component is getting these seated properly. I noticed that one thing you did when we were seating the pin guide, you used the word “always”, and that related to how deep you drill and how you always tap in a pin. And I don’t always hear ‘always’, I hear sometimes “I feel the bone first”, or “I know it’s a lower, so I don’t need to that kind of thing.” But I like the policy of ‘always’ with the pins. They are designed with a step-down function on the drill that’s coordinated with the pin for ‘always’.

James Hamill
You taught me that. When I started doing these surgeries you stressed to me the importance of this step. I’ve brought that on with anybody I’ve taught because if you get this bit wrong, you’re going to carry your error all the way through. So I call it the deep breath moment. I say to the surgeon this is the bit we’re not going to rush. This is the bit that we’re going to take our time and we must get it right. So I suppose in doing the surgeries initially myself, before I ever went to teach anybody how to do it, I consistently followed that protocol of drill one mil. short and tap the pin home. And it has never failed me. I’ve never had a loose fixation base.

I’ve never had a problem with a fixation base. So why change something that’s not broken? It just works right. It’s almost impossible to assess what that bone is like because you’ve got this metal channel you have to put your drill through. Your tactile feel there is minimal, really minimal, so why risk it. I suppose I just don’t see the reason to risk it in the mandible. Sometimes I think you can get away with it, but I will maybe drill to even, even if it’s just half a mil. short, but I always want to tap that pin.

Alan Banks
When you placed a pin guide, you seat one, but you wait to tap, right? Drill one, seat. Drill the next one, seat. I’ve seen different variations, many variations. I even was at a recent one where the doctor would want to drill all of them and then start putting pins. And I can tell you that will cause an error. If that fixation base can move or drift at all, or it’s not held secure, then the holes can vary just a little bit and you’ll have a tough time getting them in. So drill, seat. Drill, seat. I’ll usually do four, then go back. You still hold firm on the pin guide.

James Hamill
The nurse that I work with in most situations holds the pin guide. And the reason that I do that is it gives me two hands free. I trust her implicitly. I can check that the windows and see the teeth are lined up. Obviously I have checked that before but I will say to the nurse, once we start, you cannot let go. Your fingers will go white and your knuckles will go white because you’re holding so tight because you have to hold this. This is your job. And it comes back to that communication and permission. I will say to all the nurses this is your role in this bit, therefore step up to the mark. It’s a really important part. And actually, they like doing it. I’m sure you’ve seen a lot of people struggling to manage the pin guide, manage the drilling, lifting up the soft tissue to make sure you don’t pin this off tissue. It’s almost too much to do. So we utilize your team.

Alan Banks
So the pin guide sets the stage and interestingly that’s the one thing where you might slow down on because if that’s off then the whole surgery is off. Pin guide seating can be very quick. Yours was quick and efficient because you had a system and the two people working on the patient knew the process, repeat, repeat, repeat, don’t question it or guess based on bone density or bone depth.

James Hamill
So there are a couple of things in terms of efficiencies with it. When the nurse goes to hold the pin guide in place, all my pins are sitting right beside me. They’re sitting on the patient’s chest. And so therefore it’s just drill, lift pin in, drill, pin in, rather than drilling and then going to look for your pin, which often happens. “Where did I put the pin?” I go get the pin and the pin could be other side of the surgery. And in doing that, things can move because the nurse that’s potentially holding gets distracted. She looks up to help to look for the pin and things move away. I would say that the other thing then is that I take a mirror handle and place it on top of the pin and then tap the top of the handle with the mallet.

Alan Banks
And I would totally agree with where the components are because very often they’re sitting in a Dixie cup over on a shelf being soaked and they should be as close as possible to what you’re working on. Organization of parts, even down to the pin guide. And of course, before the pin guide is laying the flap. I noticed during the surgery you used the word ‘always’ again, and that is, you always elevate it beyond where you think the fixation is going to be. Because if you leave it where the fixation base is going to be, you’re still going have to elevate it more. So do it the first time. And you also used two instruments instead of one, which I don’t see that very often.

James Hamill
A normal sharp elevator, which is really important, if you’re going to lift the tissue. Let’s just get it done in one sweep because you see people doing a bit and then they try the pin guide, and then they do another bit then you lose 20 minutes messing about. Get the tissue up, but get it up nice and cleanly. I was taught by brilliant consultants in the hospital how to lift flaps pretty quickly. And the word that they always used to use was tension. Let’s get a little bit of tension on the perio and this thing will fly up. So I used the Minnesota and I started in the corner. So say I was going right to left, I’d start on the ridge. And the way I think about it is if you’ve ever peeled wallpaper off a wall, the way when you were a child, you went to the corner that just started.

You get it lifted up first. You don’t run halfway across the wall and try to lift up another bit cuz that’s what so many people do. You’ve seen it. They try to lift it in three or four different places, start at the corner and get that elevator down onto boom. Then put your Minnesota in, get tension on it. And then all you’re doing is pushing against your Minnesota with a very sharp, really sharp, nice clean elevator. Too many blunt instruments on too many tables. And you just see these people chopping and pushing and cutting and you want one incision, one with your blade and then lift from the corner and all the way across.

Alan Banks
And your pressure on the sharp instrument is against the bone.

James Hamill
The Minnesota is reflecting the soft tissue and keeping it under tension. Right. And then the sharp instrument is basically on the bone, pushing against the Minnesota basically lifting the tissue.

Alan Banks
I really like that two-instrument technique and I don’t see it very often. I thought it was really efficient. It also keeps the tissue out of the way while you’re working, already elevated, and just keep working around. It was very quick. So the fixation base pinning went well, pin guide comes off. My favorite instruments for extracting teeth, that’s easy enough, but my favorite instruments for bone reduction. You used a very aggressive bur and a lot of our customers are. I’ve been to surgeries recently where they use a little BB bur for the finish and a big round bur for the gross reduction. But the goal is flat, so why not get a bur that mirrors the flat? Was that a Mr. Hungry or a Meisinger or barrel bur? I noticed a trick that you had the nurse doing and that was using a fairly wide spatula. And it was just to the lingual of the bur. And whenever you would grind bone into that spatula and it would not go into the mouth, it would go to the spatula and it would run right off into suction.

James Hamill
There are a couple of reasons. One is to try to reduce soft tissue trauma. So that’s why it’s there as well protection. And secondly, as it does reduce that spray of white everywhere, it’s a bit of an art, I think. Sharp burs so on a decent handpiece that’s important, a lot of people use fairly rubbishy burs. You need a good sharpener and absolutely I’ve gone away from the torpedo shape ones probably to a more flat-sided one and that has helped. When I say there are teeth to take out, I will reduce bone around the teeth. So I’ll generally fissure bur between each of the teeth, which helps the extraction. And I often fissure bur across the buckle so that if there’s going to be a buckle fracture of the bone, it’s more controlled when you’re taking the tooth out. So if you do that, I think that helps speed it up a little bit. I haven’t used it personally, but one of our customers used peso recently and it was wonderful.

Alan Banks
For that function, for releasing the tension or around the bone.

James Hamill
Well, he did everything. He removed his teeth and he did his full bone reduction using Peso.

Alan Banks
Did you find that it was a smooth surface?

James Hamill
It was incredibly good. Incredibly good. And then he finished it with a ceramic bur. He’s very used to using Peso. I don’t think I could do it as well as he did without some practice.

Alan Banks
I don’t see many anymore. A couple of years ago I saw a few, but now I don’t. I mostly see bur, rongeurs. Sometimes I see a little bur scarring scoring then rongeurs to take the bulk off, usually oral surgeons.

James Hamill
My concern with rongeurs is the lack of control. So yeah, you need to have your fissure bur cuts because I’ve seen people do rongeurs without doing that particularly well. And bone breaking shelfing up into the pallet. And obviously your implants are going to be more ply placed. Therefore you’re dealing with a lack of bone then.

Alan Banks
Jimmy had a lot of bone reduction. I mean, it was seven millimeters and six millimeters in some areas, maybe I, I forget the measurement, right?

James Hamill
There was one, there was one particular area, it was probably about six. The rest of it was about three, four, but his bone was rock solid.

Alan Banks
It was fine. In some situations, I would see doctors probably grabbing a rongeur for that, for that bulk of bone. But because you had that spatula, you knew you could control the volume of bone flakes going into the mouth. Sometimes it looks like a snowstorm in there. The bur worked great, but then you have other problems suction getting clogged and bone going into the throat.

James Hamill
We generally don’t have that issue. I have to say using that technique any bone chips are really well irrigated. There’s so much water there as they hit the spatula or hit the retractor. So we don’t generally have a problem.

Alan Banks
Adjusting to loosen teeth, teeth come out, mostly aggressive bur. But the other is confirming and I’ve been to surgeries where the carrier guide might have been used four or five, or six times to either figure out if it’s tissue or bone and it’s 10, 15 minutes or more trying to get that bone level. I think the combination of the nurse and the doctor looking down the plane, feeling it with your fingers, visualizing it, and then using that flat barrel bur between those three, you really should be able to do just about everything before you even try the carrier. You should be able to see it.

James Hamill
I see that probably as one of the most critical points where doctors get frustrated is managing that checkpoint, which is your carrier guide going to fit after you’ve adjusted the bone.  And if you think about it, if you have good pallet reflection that’s going to help that first situation.

Alan Banks
Because the hang-up is usually on the lingual posterior.

James Hamill
So really you’ve taken that problem away by doing it right in the first place. And the second one then is problem-solving. It’s about problem-solving. So if that carrier guide doesn’t fit in, deep breath time number two, let’s have a look. Okay. Rather than getting frustrated and annoyed because you want to get to the next step, you take a deep breath and you use your nurse because sometimes your nurse can see things that you can’t see. Have a little look. Look where the blanche is. Get your nurse to use suction, get a probe, fill it into the hole. What I often do is I’ll put the carrier guide on and I’ll generally pin the anterior pin first because usually it’s pretty easy to get in. So I’ll pin the anterior. Then that gives us hands-free and you can then push on it. Well, where’s it flexing? Where’s the blanking? But it is about problem-solving. So you have to put your problem-solving hat on at that point.

Alan Banks
I like the pero probe part because you can go in the hole. You can usually visualize it, but you can spin it around and see where the space is See where the rock is. You’ll feel the fulcrum, it’s kind of like trying in a partial framework. I agree a second set of eyes on the other side of the patient with the assistance of the nurse is key and that’s where you get them involved. Allow them to speak and allow them to communicate and help. And a lot of that is bone reduction. Most of it is visual. Yes you can visualize. The fixation base is going this way. The bone is going this way. Visualize where it has to be flat from a couple of different angles and you’ll succeed.

James Hamill
That’s the old classic isn’t it, people leave it high on the pal or high in the linguals almost.

Alan Banks
In the anterior there’s concern about nerve bundles, that kind of thing. Sometimes there’s a little bit there.

James Hamill
My last point on this one is I do my surgery standing up. Some people do it sitting down, moving around the patient. So get yourself up, move around and look at it from different angles. And you’ll see different things. If you just sit in the one place you’re only going to see the thing in one direction or one dimension. So get up.

Alan Banks
You perform your surgery standing up. Is that an “always”?

James Hamill
Always.

Alan Banks
Always standing up. Because you’re thinking I want to get this done in two hours because I’m gonna be darn tired if I have to stand up for any longer.

James Hamill
Yeah.

Alan Banks
Or your back, your neck, your back. I mean just stand up and lift the patient high, right?

James Hamill
I suppose that’s the way I’ve always done it.

Alan Banks
Last thing on this since the carrier guide is on. It’s passive. It’s clipped in this time but that’s the time to put in either the rapid appliance or the prosthetic and check bite before the muscles are sore, while the patient can hopefully still be pushed in, and then you can see where you are. How close is the bite? Is it right on, do I need to do anything?

James Hamill
Totally, that’s another “always.”

Alan Banks
Always.

James Hamill
So I check it at that point because it gives me a heads up. Am I close or am I going to have to do work later on? It just prepares me and it also prepares the team. I might put that in and we go, you know what I think we’re gonna have a bit of work to do on the bite. So everybody knows it’s not a surprise. The patient also knows. And I’ll say “the bite is okay, but it’s not fantastic. We’re going to have to do some work at the end. Therefore it’s maybe going to take us an extra 10 minutes to adjust this.” But you’re right. If you only do that at the very end muscles are tired, everybody’s laying back. Just a nicer time to do it. I think it’s a more accurate time to check.

Alan Banks
It’s not something you folks are doing so much in Ireland, but over here we do a lot of the C2F and we want to capture bite for some of these cases. Actually we end up not using them because CHROME, it’s not an advertisement or anything, but CHROME bites are very accurate. It’s really rare that something is off. But if it is a little bit off and you’re going to articulate and do something extra orally, like an extra conversion, take the bite before the muscles are sore. I hope our audience is picking up some tips with efficiencies. With that we’ll conclude section number two.

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