CHROME FAQ

1. Single Arch or Double Arch ‐ Dentate against Dentate

Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side

CBCT patient open biting on cotton rolls. Place cotton rolls between cheeks and teeth.

Maxillary & mandibular master casts or impressions. Must capture vestibule of the CHROME arch

CO or CR bite registration

Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

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

Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side

Master casts or impression of dentate arch (must capture vestibule), and impression of denture teeth and tissue

Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient open biting on cotton rolls. – IN OF OCCLUSION

CO or CR bite registration

Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

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

Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side

Master casts or impression of dentate arch and impression of denture teeth and tissue

Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient biting on cotton rolls – IN OCCLUSION

CO or CR bite registration

Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

4. Dentate against Denture: Double Arch Edentulous

Photographs: full face full smile photo, profile photo if Class II or III, and retracted photographs – front, left side, right side

Place 6 radiopaque markers on the denture (SureMark.com, or gutta percha 2mm round) – CBCT patient open biting on cotton rolls.

Bite should be worked out in the denture fabrication. If not, maximum opening of bite is 3mm.

Full GuidedSMILE CHROME Rx completed when uploading DICOM and photos

5. Existing Metal Partial Denture in CHROME Arch

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

 

6. Free‐end case with unstable bite

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

 

7. Opening bite more than 2mm

3mm is the maximum ROE will open in the laboratory w/o an open bite record being returned for verification. More than 3mm must be established clinically with CR bite, or through splint therapy. ROE can assist via our special JC Try‐In Repositioning Device.

Tip: if distance between #9 & #24 gingival zeniths is less than 17mm (Shimbashi rule) then opening may be needed. Same if intervestibular is less than 35mm.

 

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

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

2. Are teeth mobile?

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

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

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

4. Are there teeth to be removed?

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

5. When is too much adjustment too much?

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

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

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

7. Pin Guide Swiss Lock 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 for ROE to ensure accurate assembly.

8. What to look for when inspecting?

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

9. What if it does not seat after adjustment?

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

10. What if the Swiss Lock plunger pin pulled out?

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

11. What if the Pin Guide loops are broken?

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

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

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

13. Edentulous Pin Guide seating? How to adjust?

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

14. All or most of teeth are mobile?

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

15. Edentulous Pin Guide used to verify vertical

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

16. Double Edentulous protocol?

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

 

1. Break a drill?

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

Be sure to have back-up pins and drills. 

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

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

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

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

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

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

5. When to mallet the pins?

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

6. Pin Breaks, what is a substitute?

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

Recommend back-up drills and pins kits 

7. Pin is loose

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