What can you tell me about CHROME Patient Records (1/12)?

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Transcript

So let’s start with in the records. The most common type of case that we see is dentate, single, large dentate and often double large. The records are very similar for both, and as mentioned, the records are also very straightforward for Chrome guided smile. In fact, 1, 2, 3, a series of photos, very standard photographs, upper and lower cast, and a bite and a CT scan. That’s all that is needed for to start a dentate case. So let’s go through the dentate first. So as you can see, this is a collection of records for single arch or even for a double arch Chrome case. On the left are the models upper and lower casts bite registration. This is from a digital, actually this is not a digital, this is a conventional impression that’s been digitized, poured up and digitized CT scan that captured both upper and lower arches with space between the dentate, you always have the patient open and then the photographs full face, full smile.

We’d like to see a little bit more of an exaggerated smile than this Thomas, but often that’s kind of tricky with these cases. A lot of these patients have years of stress with their dentition and so sometimes it’s tough to smile. But we’d like to have a full face smile and I’ll explain why in just a minute. And then the photographs retracted, center left so we can see how the teeth come together and we’ll go through a little bit more of that in the coming slides. And we could just say those are the records. Have a nice afternoon, all done records for a dentate case. But the fact is over the past couple of years, even the few years at least, things are getting a little better now, but for a time it was seven cases, now it’s maybe five or six cases out of 10 the records come in and the red light goes, which means we either have to make a phone call or have some kind of discussion about the particular records.

Either something is missing or additional records need to be captured. Most of the records, again, they’re straightforward, but there are questions that need to be answered and just some missing items. So that’s why today’s program will be so helpful for the doctor and the staff. So the photographs, very simple, straightforward photographs. We do recommend an S SLR camera, but frankly cell phone. Cell phone picks are very high quality these days. I would recommend that even if it’s a cell phone, put the camera right in the center of the nose and take the picture At that level. We’d really like to see the P plain of occlusion as we are looking at the center of the face, full face, full smile, try to get your patient to have an exaggerated smile and then left and retracted photos. We always want these in occlusion because we want to see how the teeth come together when we are analyzing the models on the articulator.

So it’s kind of a verification that we have the case articulated correctly. We also, on a lot of cases would also like this photograph with lips at rest that may be patient by patient with how much tooth display there is and how much aesthetic changes we’re going to have. But then also on the right, if a patient is severe, class three, severe class two take profile photographs, those can help consider considerably with the two set up the full phase full smile photograph. We use this for a smile simulation. In fact, every case that comes through our laboratory, we perform a smile simulation. We do it with this software called preview.

We have been using smile simulation softwares for years, many years. This is by far the best software we have ever used. It’s a very simple process. In fact, they boast after they train you that you could do a smile simulation in about a minute and a half, two minutes, A really nice quality photo and that patients just love. I’ll show you some examples of it. They love doing demos. Call this. They’re we are, we’re not associated, we’re associated with them, but this is basically a promotion for them. They’re actually a wonderful company with an easy to use software. So preview. So we take the preview software and we essentially take the patient’s s t L files, the files from the digital impressions or the digitized models and we superimpose the patient’s face over the models over the 3D models. So a 2D face over the model.

And then we use a smile simulation to perform the setup. So there normally, there’s about four more images here, but one of them will be the simulation that we did with preview. So we set the teeth, we set them in an ideal position behind the lips according to the STL models and really do a nice job of putting teeth in the right place physiologically and aesthetically. And from that, this is what we use to do the setup and then this eventually make the chrome prosthetics. So you can see this case has come full circle from the beginning here to the end. And the setup obviously is very similar to the restoration at surgery.

So we really try to make a one-to-one smile simulation through to the prosthetic and we do that through this preview system preview. We partnered with them a couple years ago and they were nice enough to take STL files of denture teeth that we use to set real denture teeth that we use, that we export as STLs to fabricate prosthetics. And they took their beautiful natural smiles and they morphed them in the shape of our denture teeth. So when we set a tooth, for instance, when we set a triangular mold in the software, it’s the same as the smile. So is it a one-to-one? No it’s not, but it’s pretty close. It’s definitely, especially in the patient’s eyes, it’s to a plus. So we use those smiles, we make these smiles every day for patients all around the country. Patients love them. We have a lot of doctors who actually have the software and use the software on patients throughout the day.

So these are just some examples you can imagine. These patients have been through basically dental trauma for many, many years. They see a preview smile that’s part of our records system and they are more empowered to make a decision. They know what they’re going to look like and these smiles are brilliant. If you have a 60 inch monitor in your patient consultation room, these smiles still look magnificent. You really will be shocked. So you can imagine you all these patients, we’ve shown you what their reaction must be when they see ’em. One thing about photographs is we want very good photos to do a smile simulation. So obviously we want to see a smile, want to see teeth, I want to see the eyes open. Try not to the one on the right, try to bring the camera a little bit closer because by the time you zoom in on this gentleman, it’ll be fuzzy, it’ll be a little bit out of focus.

The patient on the left, I have him stand up. He is kind of leaning back in the chair actually. He’s actually, I think he’s leaning back in a chair against a wall, a patient on the right, a little too much flash, a little too much washout. I mean one of our goals is to really wow the patient with this record, this smile. So here’s gentlemen, they went through several different photographs and we’ll take ’em all. We can pick which ones are the best, but you know can pick ’em too. And so he went through a whole smile of this guy’s just being happier and happier and happier. And then finally the happiest he can be right there. Take both of those pictures and upload ’em with the case. This gentleman’s not happy, but I know that you can make him happier for the photograph and certainly through the surgery.

So work hard to take. Please work hard to take a nice photograph. And then the other set of series has already mentioned teeth in occlusion and we take these images, we put ’em on a big screen here at our stations with your models in hand in the articulator and we confirm that the case is articulated properly. Articulation occlusion is just one of the most important things that we do here, so that you have a successful surgery so that you have a good bite experience. And part of that is just really these simple photographs sending them in with a case. So we magnified them and we literally look back and forth from the screen to the models and make sure that we are articulated.

One thing important about the casts, either the casts or the digital impressions or the impressions that you send in, is that they involve all of the land areas you want to capture. Imagine you’re taking an impression for a denture, right? Immediate denture because essentially you are, most of these cases the doctor’s order a backup denture just in case things don’t go perfectly during the surgery. So you want the vibrating line, the full roll if it’s an analog impression, if it’s a digital impression, sometimes you cannot capture all the land areas down into the vestibule, but you can at least capture all of the labial lingual tissue, capture the palate, et cetera. In fact, most today, most of the cases that come in for Chrome are from digital impressions. Doctors have just found the value in digital for speed, for accuracy, an excellent way of capturing a bite with digital impressions. We work with all the systems. There’s more out there on the market. We work with all of ’em.

And the reason, again, the reason you want to capture the full, I think these are videos. The reason you want to capture the entire scope, the entire, all the land areas is because the first step of every surgery is the pin guide. The pin guide is what rests on the teeth or tissue, but it also on many cases goes deep into the vestibule. If there is significant bone reduction, as you can see on the left, that case is going to require a lot of bone reduction. The pin guide is going to seat deeply and therefore we don’t want to guess where the tissue is, where the support for that pin guide is. So please try to capture a full land area impression and make sure that the impressions are very accurate. Some pulls, some drags, some bubbles, some voids, some of those things can be overcome, but if there is distortion or if a ca case like this, please retake.

Good, good. It’s good to catch at the office before it comes into the laboratory because we’ll definitely give you a call if it’s not perfect. We want to success to be part of good record taking. Alright, so those are photos and models and then the bites, vertical measurement, this type of thing. So we get all kinds of we, not all kinds, we get a lot of the standard bites. Most of the cases come in, have a send to occlusion bite, which is perfect. It’s fine. Most of these cases a patient is overc closed and we have to open on the articulator and either go forward with production or if the vertical opening is more than three, maybe four millimeters, then we have a little device that we send you to confirm the opening simply just because the arc of closure of an articulator cannot be transferred always to the mouth. So acentric is the most common. We do get some centric relation, I’m sorry, centric occlusion is most common centric relation we do receive and then we do receive occasionally some neuromuscular bites might make the argument that a neuromuscular bite is a best bite for these cases. Putting a patient in the most comfortable relaxed position might be the most advantageous, the most accurate, but we accept different bites of course, and we do our analysis accordingly based on the bite that you send in.

So for dentate photos, cast bite registration, and then finally the CT scan. So a CT scan for a dentate patient is always open out of occlusion. I know that there are other companies out there that make surgical guides full art surgical guides and they want the bite in occlusion. Never really understood that because we always use the stone casts or optical scans to articulate to open to do the concrete records for bite registration, not the cone beam. The cone beam is just for bone tooth to make the surgical guide and to design the guide, that’s all. So when you capture for whether it’s single arch or double arch, we want the full scope of the arch of interest or both arches. So the green line is the maxilla. We would like to see a CT scan of the patient from the sinus, middle of the sinus down to the opposing teeth and then on the mandibular down from the chin at least or at least below the metal ramen but down on the chin.

And then also including the upper teeth and we know we have the full range of bone that we need to plan the case and every cone beam out there has a mechanism for exporting raw dotcom. Normally what you’ll see, well what we want you to see is a folder full of DCM files. Sometimes it’s 200, sometimes it’s 800. Our upload page limits at 400 megabytes. Now normally when a folder is zipped it’s under 400. If you find that it’s over 400 megabytes, the best thing suggest doing is contacting the cone bean company and asking them to export a smaller, not F O v but a smaller box so that you’re at maybe 0.4, probably 0.4 thickness between the slices and that will minimize down to at least 200 to 300 num file numbers and you zip those into a folder and you submit those along with your records.

That’s the dicom. So let’s say the records have been collected, they’ve been sent into us and now we analyze them. We have veteran CDTs who work on these casts. We have a couple of dentists whose full-time job is analyzing cast, doing these case workups and I think we do a very good job with this. These are all very challenging cases, just about every single one of ’em. We go through a rigorous analysis of the records things an analyzing the smile, the bites, the models, the vertical needed for prosthetics, reverse smile lines, gummy smiles, just the whole range of things that we need to analyze for full arch. We go through that with every single case and if everything is accepted, the models are good, the records are all perfect. That night you would get an email and in that email there would be a link to set up your online meeting online.

If we find that the records are not perfect and good to go, then we contact you and we have a discussion and just see which direction we’re going to go with either attaining more records or moving forward. Depends on what the discussion needs to be. So when we are analyzing the models, I’m going to go through a few different scenarios here of how patients present and what we do with them. Now this is from a laboratories perspective, so we’re looking at cast mounted, printed articulated, but you can also do some of this analysis in the mouth. For instance mean this patient just has anterior contact only. This is probably a hit and slide situation. The patient probably doesn’t, may have a repeated bite but their position might change based on manipulation. So what we recommend in a case like this is couple of things. One is, and you can perform this into orally, this is a simple measurement that is called the shimbashi measurement and that is simply taking a measurement from the zenith of say 25 and eight and measuring this distance in the mouth and we’re looking for 17 to 18 millimeters.

Shimbashi, the person who invented this found that through studies, the average person is somewhere between 17 and 19 and if you find that’s the case in the mouth, then there’s a pretty good chance we don’t have to open the bite. So you can see how helpful that is because you may want to open the bite clinically before the records come in and this can confirm if you need to or not. Now a case like this, there’s a couple of options for confirming a bite. One is by block setup tryin making sure that the bite is ideal, the teeth position are ideal. It’s exactly what you would do for a partial denture process that in acrylic perhaps make a scan appliance for a dual scan and then send all the records in. That’s one option. Another option that we offer, and I’m going to show that in a few slides, is called the JC Trien, which is a fantastic prosthetic that we developed really just for chrome.

We use it for those situations too, but we use it for Chrome to confirm bites to confirm opening of bites on an articulator. I’ll show you some examples of that. This is a case where the patient has pretty stable occlusion but in a shimbashi measurement we agreed with the doctor that the patient only has 13 millimeters, so the patient is going to be opened up two, three, maybe four millimeters through a discussion. We will open up on the articulator, we’ll send out this tryin that’s aqui in the mouth and I’ll show that in just a minute. But a case like this is kind of straightforward. Crown and bridge, I’m sorry, dentate over dentate records, right? Mounted casts photographs that we discussed. CT scan with the teeth apart and then a bite probably in a case like this it would just be a centric, repeatable, habitual bite.

And then we make a JC tryin. Many, many cases are in this situation, patient is overc, closed, collapsed and needs to be opened. Patient has some mobile teeth which we want to know about. You can notate them when uploading the case, but this patient has 10 millimeters of shimbashi and is ishibashi a black or white rule that we follow? It’s just simply a tool, it’s a guide in and this patient doesn’t have number eight or nine. So we kind of estimate where number eight, nine should be and take the measurement and then we have a discussion. This patient needs to be opened six millimeters, maybe even a little bit more to make room for prosthetics. So there’s two ways to accomplish that, right? Either open ’em on the articulator or reduce bone that this patient probably needs a combination of both. And so what we will do is articulate in with the bite that you send us, open it up on the articulator and then we fabricate this.

This is the device that we use to either confirm existing bites as it is on the articulator or open the articulator more than three millimeters, fabricated JC trien in that position and then send it out for tryin for fitting and equilibration. So you can see the images here on the left upper and lower JC trens. Try them in, make sure they don’t rock, make sure they have a perfect fit, perfect seat and then either equilibrate down into the proper bite or if it’s the patient’s still not open enough, you could add composite to it. You could take another bite over it if you want to do some kind of centric centric relation bite. But this is a great way to confirm that the arc of closure has been preserved and that the bite is accurate on the articulator. And so you would equilibrate take a bite either way you’d take a bite, send the JC tris back to us, we will re-articulate the cast and then we move forward with the case. Just show them, boom.

This video will just quickly demonstrate a JC tri, a doubler JC tri. This is a case where we want to open up the patient’s and the case was submitted as registration. We articulated the case and on the articulator we opened it up a few millimeters and then we digitally designed two JC Tris. Max Mandibular assembled them and we send them out and when we send them out, I believe that the case was a little bit opened and the doctor just adjusted it down. You can see there’s adjustment marks here and there’s adjustment marks on the maxillary. So once the bite is acqui down to just where the doctor wants it just for its ideal in the mouth, then a pipe registration is captured between the two. Suggest chin would be not to do a full arch bite but just do sections where there’s gaps. Maybe one here, one here, one here. Tripod it. A full arch is acceptable but it’s just sometimes better to just put strategically placed bites that you can see visually throughout the arch where the teeth are coming together. JC Trium.

Okay, JC Trium may also have some scan appliances. This is case by case basis depending on how many teeth the patient has remaining. If the patient just has a few teeth, couple teeth, one tooth and we’re still making a JC tryin because sometimes if the patient has almost no teeth or we probably want to go a different avenue by blocks and setups, but if we’ve made a JC TRI in this situation, we will probably put markers on it and then you would do a dual scan when the patient is in the dual scan technique, just like the denture dual scan, which we’ll discuss at the end with E cases. So just again showing abasi, this is 11 millimeters and then with the appliance that you saw in the video, 17 millimeters opens a bite, great tool.

Other common situations, class two, class three, severe class three and two, especially class three. We see this often and for these patients we don’t diagnose we’re the laboratory, but what we have seen over the years is sometimes these cases the patient wants normal occlusion, maybe the dentist watch normal occlusion and it might be possible but we run into issues situations as in we end up having to open the patient up maybe too much to get, get pros room for prosthetics, but we also end up with an anterior shelving of the prosthetic because when the bone is reduced, there’s going to be some bone reduction on this case. Now the bone is even further distal and then the prosthetic has to essentially come out as a ledge to come out to meet the lower and that causes problems. The lips get caught above the prosthetic. It’s a food trap, it’s a speech issue. Normally in these situations, if it’s going to go the route of full arch restoration on implants, generally you preserve the clasp, the cla and just really trying to work out maybe a flat plain occlusion, severe class two, sometimes the same thing.

So just these are considerations, these are the normal records you’d send in. This patient probably has a repeatable bite. Perhaps actually the patient’s missing an awful lot of teeth, maybe not. But anyway, the often these patients should go a different route. This is probably a denture patient, this is probably an orthotic patient et cetera. Also another case that’s very common, no centric stops at all. A patient may not even have prosthetics and in these cases best thing to do is to send the casts in. We will probably not even a bite registration, we will make bite blocks, perform setups, go through just general dentistry to put teeth in the right place, in the right vertical until you and the patient are happy. And then we use those appliances in a dual scan situation and send them in and then we can move forward with chrome.

But really need to establish a bite and tooth position on a patient like this. There is one note here besides the shimbashi measurement, we also have what we call an vestibular measurement. So if for some reason the patient is exhibiting some kind of repeatable capture, a bite you can capture, then you can always measure from one vest to bele to the other. And a good number like the number, a good number is about 35 millimeters. And that would be, I really have this in the posterior now, but it would be more in the anterior, right? So somewhere here, vestibule, the vestibule, 35 millimeters. Again, just another tool within a range.

Another dentate crown dentate situation is mobile teeth. This happens often, quite often the patient doesn’t have 100% mobile teeth that there’s some mobility in a lot of the teeth, but some of them are stable. This is kind of a case by case basis. We’ve seen cases where the patient, every tooth in the mouth is mobile and then the pin guide, the pin guide is inserted, the pin guide actually moves the teeth into a different position than the implants in a different position. It’s not a good day of surgery. So there’s a couple of options with these cases, but the best option is if the patient has some stable teeth and you can capture a bite. Let us know what teeth are stable. The teeth that are mobile can be extracted on the day of surgery and the pin guide can rest on those existing stable teeth. Otherwise these cases normally go through full extraction, go to immediate dentures, stabilized a bite, and then come back later with some type of surgical guide.

So that was dentate over be available at the end of this, at the end of this whole program for questions and I hope everyone has questions if you’re more than welcome to call in email, have a private discussion about any of these topics anytime, but if you’d like to raise a question at the end, please do so. The next is an edentulous single arch and we have specific records for these, the checklist, single arch EULA surgery with an opposing teeth or an opposing denture. So I’d definitely recommend printing these off often these are the most confusing cases that the eula, but let’s just quickly go through the normal records. So the important notes for an edentulous case is that it’s always going to be a dual scan situation and a dual scan means you’re going to scan the denture in the mouth in occlusion and then you’re going to scan the denture by itself.

Those are the two scans. We do not need a scan of the patient with no appliance unless it’s going to be a totally different type of surgical guide. If it’s going to be chrome or a tissue supported guide, then it has to have a dual scan. So here’s the rules, the denture has to fit well, no movement, you can perform a hard reline. That would be ideal. If the denture has any movement, recommend not doing a soft liner because if you do a soft liner then we have to go a little different route with the scans. The tooth position I put here must be ideal but really it should be ideal because we can deviate in our planning from teeth. They’re not in a great position of patient has a denture with some flare teeth or teeth that are just not ideal. At least we know where they are.

We can plan for future teeth given the current tooth situation. So tooth positions should be ideal but not mandatory. And then I’ll show a slide in a minute about how you can use green moose or blue moose if it does, if the denture does have a soft free line already in it, occlusion is important. The pin guide is going to fit the tissue but it’s also going to fit the opposing teeth. So we want occlusion to be good and fit to be good and then always do a dual scan with the bite with patient biting closed in occlusion, we don’t want anything separating the denture from the opposing teeth.

This is a recent development kind of discovered this I think at the end of the summer is that a doctor was testing these materials. So if you have a soft liner historically you had to take the soft liner out and do a hard reline. That’s not the case now either use either one of these products, load the denture up with this material and just basically perform a reline impression. And that is a radio radiolucent material that shows up in the CT scan. So nice trick. So single arch. So these will be essentially the records that you send in. This will be the patient scan, dual scan, bite registration and opposing model. You can send them in digitally but we really recommend for edentulous just take an opposing model, take a nice bite registration between the two and those are the only records we need dual scan opposing and a bite and the photographs, we always need the photographs but the records are very simple with the denture case and this is what they should look like on the CT scanner.

So this above is the denture seated. These are markers we recommend using she mark, you can order them from us. You can order ’em right from the company she mark.com and there’s six markers in here and here you see only three but there’s also three on the labo buckle of the denture. So you scan the patient in occlusion with the denture seated, then you place the denture say on a piece of foam or on there’s little scan table that comes with most CT scanners. Set the denture on it and then on our end what we see is the denture seated in the patient. We use the dots to merge the denture with the denture scan and the patient. That’s how we bring the denture in so we can see the teeth when we’re planning a case. So that’s a single large. Now double large is a little bit different.

It’s actually a little bit simpler be because you only scan the dentures intake photos but you would place the markers on the upper denture, place ’em on the lower denture, place the dentures, both dentures in the mouth and scan the patient and then scan the dentures by themselves. So essentially this is what we’ll see when we print the dentures. Now if you do not have a CT scanner that will scan from the chin to the middle of the sinus, then you would just scan the upper first and the lower first. Similar to a dentate but always in occlusion we want to have a little bit of compression on the tissue so you have the patient biting into it but we want, it’s really the only way for us to verify occlusion on the double edentulous is to do a dual scan what not to send for an edentulous case, especially double edentulous. But Eden edentulous case, we don’t need a scan of the denture of the arch of interest because we cannot articulate it. We can’t really use it at all. We can’t use impressions of it, it won’t help us just a dual scan opposing and bite for single and then dual scan, dual scan for a double.

Again, don’t also don’t need these models. We do not need impressions of the edentulous arch because when we print the denture we’re going to print it as a pin guide. We’re not going to print it to do any kind of articulating and even if we could, we could not make the denture fit onto a tissue model. Just doesn’t work. So save your stone save and impression material and then the last, at least in this program, the last type of case is partially ous. Also a very common situation and we developed a system where you don’t have to go through the process of bite blocks and setups and dual scans and scan appliances, et cetera. Instead what you’ll do is you will take study models of the partial seated and then you’ll take a master cast of the patient without the partial seated. Those are the two models that we can cross mount back and forth and you’ll take a CT scan of the patient with no partial in the mouth and this is all on that checklist.

So I would highly recommend using the checklist for a partially credentialist case every time, but we can cross mount with this. So again, take a CT scan without the partial seated unless they’re flippers, which is kind of a nice thing. If you can take a flipper the page, you can seat it, you can put them in occlusion and that is fine. Even if they have metal clasps, forgive me, CT scan out of occlusion. You can have the patient biting on cotton rolls or on the bite fork. Forgive me, cotton rolls are better because often if a patient has anterior teeth in a flipper, it’s going to flip up in the posterior so I have them bite on cotton rolls. Master cast with the study model with a partial seated and then a master cast without the partial seated. And then of course the photographs. These are this case particular, this type of case is critical with having the retracted photographs. You can also take digital impressions of partially so you see left to right, same patient. So this is a digital impression with a partial out digital impression with a partial in et cetera that will help maintain the patient’s bite when you’re taking the bite scan, while you have the partial N

As mentioned a couple times earlier, if the patient exhibits this one tooth, two teeth no stops, difficult to take a bite to establish occlusion, go through conventional workup, bite blocks, setups, try ins, make it ideal, convert that to a scan appliance in like an all acrylic scan appliance. Do a dual scan technique, send it over and off we go. Well these were supposed to start automatically, okay, so all types of situations come through our door and come through our internet provider. Just about everything you can imagine comes through for full large cases and we can work with really just about any situation that you send us. I think sometimes the only thing we can’t do is create bone if the patient has bone and any kind of occlusal scheme, any kind of AL disease, parafunction, whatever it is, we can work with it. Many thousands of cases so far are just the last couple slides. We have this private Facebook page, it’s closed only to members. This is where we post all of our updates, all of our innovations, many, many surgeries around here with voiceover tips. We have many of our customers posting cases. This site does not have vendors, does not have implant companies, it has some staff. We get do. We’re happiest staff join and doctors. So we hope you’ll all join this site and follow Chrome. We post on here just about every day.

Tomorrow’s course will be on the pin guide and the fixation base and those are the two first parts of a surgery. The pin guide goes in, delivers a fixation base for the bone reduction and we’ll go through that whole process tomorrow. So hope you’ll join us and I’ll be happy to take some questions if anybody wants to stay on. Thank you very much for joining us today. If you have a question, you could either just type it or you could turn your mute off and ask, but I think there’s an awful lot of participants so I think probably a typing would be typing would be better.

There’s a question here on denture alone with foam. What is this? Okay, whenever you do a dual scan technique, if you take the denture out of the patient’s mouth and you just put it in the CT scanner, many CT scanners have a plastic chin, rast or plastic plate and if you scan the denture on that plate, the denture and the plate merge. And so essentially we end up with a denture with a plate attached to it and we have to virtually kind of remove the two. They morph together. So instead put a piece of foam, it could be pretty thin, a half an inch, quarter of an inch on the chin rests or on the plate. Then put the denture on top of that and on our end it appears that the denture is floating in space and it could be right side up or upside down, doesn’t matter. We can reverse it later. Any other questions? Got some thumbs up. Thank you very much.

Are there’s a question? We are recording this and on our website we do on the chrome guided smile website, there’s a dropdown for education and there are many videos on there already. Surgeries with voiceovers, there’s, I believe there’s even a course already on records, but you’ll find a lot of education in videos on that site already. Do you need bite registration or cotton during E scan? You always want to have the patient biting in occlusion. That’s very important for EUS scans. In fact some, a lot of cases they just stop at that point. So put the denture in the mouth, make sure it seats perfectly, make sure the occlusion is good, have the patient bite together, put them on the chin rests as opposed to the bite fork and take the scan. There’s two issues with that. One is if the denture is seated then we can work with occlusion because we can turn the denture on and off. Unlike dentate, we can turn it on and off within the CT scan. It’s very easy for us to plan trajectory of implants and where they’re going to come out in the occlusion. The other is often staff, anyone put, you put the patient in the CT scan, you have them bite on the bite fork, the back of the denture tips up every time and that’s a red light we have to get another scan. So just have the patient biting on cotton roll, I mean, I’m sorry, bite in occlusion every single time.

What are those settings for the plan mecca scan for the denture alone? Okay, that’s a great question. We used to have rules for plan scan and a few other systems. They’re on our website now There’s a page on there for the decision tree of what type of scan you take for all the different types of guides that you make and if you have to scan with a plan mecca, I believe today you do not have to change those. The MA and the kv, I believe you scan it just like a patient you could pick. I think sometimes you pick large patient on a scan appliance but you should not have to change the KV in the MA anymore. The only ones I see where you have to change the settings are the old galileos because you have to have their aluminum cylinder to scan a denture, this special device they made and changed the settings and the old care streams for sure.

The old before the 9,100, I don’t really remember the number. Maybe it was a 9,000. It was the 9,000. With the stitching you have to change the KV and the JC tryin. Is there an extra charge for it or is it part of the package? It’s an extra charge because we want to alo card it because it’s not always needed. So a JC tri is $125. So that send your records in part of Chrome is we include printing models, pouring models, that type of thing. So JC TRI is $125 flat, flat fee small JC trying around, oh doctor was answering it for us. But yeah, 1 25 and that. Thank you Dr. S sha. If we have to put radiopaque markers, which is not often, but if the patient is mostly edentulous we may have to put markers on it and we charge I think $50 to put the markers on it.

My suggestion is that you have markers in your office, they’re sure markers order ’em easy to use you. You can actually clean ’em and reuse if you really want to put holes in the denture and acrylic ’em in there but keep some on hand and then you can put ’em on yourself. Otherwise order ’em from us. Green moose or blue moose can be used instead. Yes, that’s right. Either green or blue. If you have a soft liner and you don’t want to remove it and do a hard reline just like in whatever slide number that was greener blue moose, yes, I was not totally avoiding the question of CE credit, but if anybody watching today would like CE credit, I’m going to read off my email address and I’d be happy to send you an evaluation and we can do one hour of ce, no problem.

We actually just got to about an hour right now. It’s my name, a l a n at r o e dental lab.com. alan@roaddentallab.com and we will take care of ce, it’ll be Ohio State Dental Board ce, which is good for most licensing out there. Can we use go to purchase points says radio pick markers? Absolutely. That’s an age old tried and true way to make markers works very well. Use the number five, number eight round burb buried about a millimeter deep with a gutter che in just you know, do it at the very beginning and do the dual scan with it. I think a lot of times you just leave it in the denture. The denture is really has a lifespan at that point. But gutter che, yes, six points randomly around the arch in the pink. You don’t need to put ’em in the teeth but randomly like three in the pal or tongue area and the rest out on the buckle labial.

If a patient is partially D and has an all acrylic partial that is fitting well were you saying you can or cannot use that to do a dual scan radiographic markers like you did with edentulous patient? Okay, that depends on the size of the flipper. If the flipper is three teeth or four teeth, you don’t need to take the flipper out and just do the whole, take conventional records as if you’re doing dentate. If the flipper flipper is not holding the bite up, if it’s holding the bite up, then use it as a study model.

But if it is extensive, as in the flipper is half the teeth in the mouth and the bite depends on it and it has some substance, right, it’s pretty thick, I kind of give you not a very good answer on the thickness of it. Two, three millimeter thick has some substance, then yes, you can use that as a dual scan prosthetic. But again, if it’s not holding the bite open, then just use regular dentate records. Any recommendation for scanning soft tissue with arteri palate is easy. But the vestibule and mandator posterior ridge has been difficult. Now I know that the trick, and I sorry to be a little dodgy on this, but I know the trick with trios is you use a surgical marker, like an indelible surgical marker and you paint a grid of dots on the pallet and I think you can do that in the vestibule too and then the scanner will pick up the dots. I don’t know about that with iro. My experience with IRO is one of the best scanners out there. It may be the patient has too much saliva, a particular patient, but IRO takes a tremendous scan. So I’m sorry to see I’m having issues with that. It really should be able to scan the vestibule.

So the moose is impressed over the soft reline material. Do not remove the soft freeline. Exactly. Yeah, yeah, yeah, that’s actually, that’s the point of it that the soft reline can stay in and just do a wash. Maybe you know, want the greener blue moose to be kind of everywhere, not to be washed out. So use a fair amount of it. So you can see green, greener blue pretty much everywhere and that is now your scan appliance. Yes. Should we equilibrate the bite at the time of the JC tryin? Absolutely. Thank you Raj for that question. Often the JC Trian goes out and it comes back and it says, good start making chrome. Well without any marks or anything or a new bite registration. Now we can trust you smiley face, we can trust you for sure, but mice, our suggestion is finally equilibrate it until it’s just right. You have blue marks, red marks all around the arch. Then capture a strategic bite registration where there’s gaps or three tripod the bite registration and send in the physical JC Trien with the bite registration will have better success, the better the bite, the better surgical experience. No doubt. Every time the blue moose is radiopaque, yes, we can see it. And it is the brand name you want to use green moose or blue moose, you can buy them from Parl.

What’s the difference in indications for green moose over blue moose? I have no idea. In fact, when we first learned about this that we learned that it was green moose and then we learned from, I believe the same person who was doing their studies on it that it doesn’t matter, blue or green doesn’t seem to make any difference unless somebody knows anything different out there. And I’d be happy if you typed it in right now, but my understanding is both work

With the shavai measurement. Are we using the C E J as our points of reference since there? This can be issues with tissue overgrowth and or recession, right? Good one and super eruption right? Are the teeth even in the right place right now? So it’s a range, it’s a guide, it’s a tool. I would use it at the highest part of the apex, the highest point of the C E J, upper and lower. And again, just use it as a tool. I mean a lot of times with these patients you have inflammation as well or you have severe super eruption of the lower teeth and it couldn’t give you a false number. We’ve had great success with it though, and definitely use it clinically. Any other questions? Thank you all for staying on after for this q and a. I hope you hope to see you all tomorrow. Same chrome time, same chrome place.

All right, thank you everybody. Hey and everybody be safe. Actually, we’ll have a little update on our coronavirus printing. We have a whole task force here that’s scouring the government and the hospitals and anywhere out there trying to give us a good direction of printing masks, printing a shield, face shield holders, these nasal applicators for testing. We have an entire room full of printers. If anybody has something that is concrete from FEMA or somebody that says this is what you print, this is where you ship it, this is what you make. We’d love to hear from you. I know many, many dentists out there are in the know, like a direct contact with C V C. So if you hear anything at all, please let us know. We anticipate within the week we’ll be printing hopefully on a kind of small mid-size laboratory mass scale of items for the coronavirus. Okay, everybody, have a nice day. See you tomorrow. Thank you again.

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