100% In House Computer Guided Surgical Templates with Blue Sky PlanMichael A. Ravens D.M.D.

Why Model Based Guide?

I. CostII. Multiple materials available for guide

fabrication. III. Potential to fabricate guide completely in-

officeIV. Less software to learn

Can I Really Make A Guide for $50?

Yes, you absolutely can.I. .stl export license from BlueSkyBio $10-20

II. Metal guide tube $5III. 3-D Printed model $10-25IV. Guide material $2-15V. Scan of model $0-20

VI. BlueSky Plan Software $0VII. Additional surgical kit $0

VIII. Keyless $0

Requirements

I. CBCT Scan (dicom)II. .stl model

A. Intraoral ScannerB. Lab Scanner of ModelC. CBCT Scan of Model

III. Blue Sky Plan

Beginning a Case

I. Start a New Project and load your dicom data

II. Select area of concern to speed up the process

Aligning .stl Model

I. Import .stl modelII. Under Model Alignment tab

choose points and then click align.

Aligning .stl ModelSelect points on the buccal, lingual and occlusal. Typically 7-10 points works well.Check ICP, this will have the software perform an automatic alignment as well.

Verification of Model Alignment

Important to verify model alignment in multiple views. Make sure model outline is selected in the model alignment tab.

Restorative Driven DesignInsert tooth into the model. Line the tooth up so that it is in the proper position to help plan the implant placement. Once done, lock the tooth so that you don’t move it by accident.

Insertion of Second Model

For more complex cases, you can import a second model with a wax-up completed. You can use this model for implant alignment and the first model to fabricate the guide.

Implant Placement

I. Click on the virtual tooth.

II. Choose Align New Implant.

III. Choose your implant and the software will insert it aligned to the tooth.

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Implant Alignment

Implant will be centered under the tooth. Adjust alignment as necessary.

Creation of Guide PostGoal is to create a guide post to support the metal guide tube.

This is done by modifying the abutment and guide tube settings in the software.

Guide Tube SelectionSelect appropriate guide tube from the BSB website. Guides are available for every direct cut drill. If you place other implants, they have a Universal BIO Cut Solution where you use the widest BIO | Cut drill that is equal or less than the apical diameter of the manufacturer's final drill for the implant that is being placed. Use the final manufacturer's drill without the surgical guide to complete the osteotomy.Write down the inner and outer diameter of the guide tube as well as the height. In this example we are placing a 4.3x8mm Biomaxx implant with the direct cut drill.

Abutment

Add in a custom abutment with a length of 10mm and set the diameter equal to 0.1mm less than that of your guide tube.

Guide TubeSet the height and offset of the guide tube in the software to 5. Set the inner diameter of the guide tube to the inner diameter of the abutment. Click on Prepare guide tubes, this will automatically adjust the outer diameter to 2mm larger than the inner diameter.

Verify Guide Post In some instances, the guide post will be below the gingival level. Verify this by looking at the model. If this happens, you will need to increase the height and offset of the guide tube as well as the height of the abutment. You will need to compensate for your drilling depth.

Drilling DepthI. Your drilling depth will equal the implant

length plus the height of the abutment. II. Most abutment heights are 10mm

because we are using guide tubes with 5mm lengths. So for our example, our drilling length will be 18mm.

III. You can print out the corresponding drill stop file. These files are available on BSB website. Many labs will print these out.

Export .stl Model for PrintingI. Surfaces tab turn off the

the density surface or you will export the CT data as well. Also hide or delete the nerve.

II. Check Very High for export quality

III. Check A and DG, uncheck I.

IV. You can export multiple times from the same file.

Exported .stl Model

Your exported model will look like this model with a post sticking up. You can view the file in netfabb basic or any .stl viewer. This software can be used to make sure your file is ready for printing.

3D PrintingI. Currently, we recommend

uploading your file to a dental lab or 3D printing company for fabrication.

II. www.3daddfab.com Average model $15-25 with a 3 day turnaround time. Printed at 25 micron resolution with feature size of 100 microns on an Objet printer.

Fabrication of Surgical GuideI. Need a material that can be

formed around the teeth and pick up the metal guide tube.

II. The material must be strong but easy to work with.

III. It is necessary to block out undercuts with a material such as rope wax or PVS block out.

Fabrication of Surgical Guide

Primosplint (www.primotecusa.com)● Sterilizable● Transparent● Strong● Must blockout!

Fabrication of Surgical Guide

Thermoplastic● Good, snap fit● Quickest fabrication● Limited visibility● Difficult to adjust

Fabrication of Surgical Guide

Vacuform● Nice fit● Transparent● Tube not stable until

reinforced on underside

● Must add acrylic to part of it

Direct Cut Drills

I. Recommend viewing Dr. Daryn O’Bryan’s webinar from December 2013 on the Direct Cut Drill

II. Visit BSB website to view a study supporting the one drill protocol

III. Specially designed tip, must be used with a restricted guide if used as only drill

In Office Printing

Pegasus SLA Printer by Full Spectrum Laser● 3000mm/sec laser draw speed● 7”x7”x9” build area● 25 micron layer resolution● Easy calibration● Low cost to printForm1 by Formlabs is the other printer in this class with many more coming out this year.

Biocompatible MaterialsI. BSP is capable of designing the actual surgical guide.

We lack a biocompatible material that cures at the 405nm wavelength that todays home printers output.

II. Current biocompatible materials are tied to their printers. An example is the Objet30 Orthodesk and the MED 610 material. The printer cost is $45,000 with the material cost of $700/2kg.

III. High interest in a biocompatible material for these printers.

CEREC .stl ConversionI. After creating the model, export as .cdt

II. Using Open Dental Blender, https://sites.google.com/site/blenderdental/cerec-file-importer convert the .cdt to .stl.

III. Necessary to run through netfabb basic to add a “base” to the model for printing.

Clinical Case #1

4.3x10mm Biomaxx implant to replace tooth #4

Clinical Case #1

Primosplint fabricated with guide tube for 4.3mm final direct cut drill.

Clinical Case #1

Final radiograph

Clinical Case #2

3.5x8mm implant to replace tooth #29 (retained primary molar). Close proximity to mental nerve.

Clinical Case #2

Essix guide reinforced with primosplint. Direct cut drill used.

Essix retainer with drill and drill guide in place. Taken before primosplint added to reinforce guide.

Guide in place, note that it is not fully seated in this picture.

Implant seen through guide after placement.

Clinical Case #2Post op CBCT scan taken. The .stl model used to create model based guide was imported and aligned against the post op scan. Direct cut drill system used.

Clinical Case #3

3.5x8mm Biomaxx implant to replace tooth #13.During design, the height of the abutment and guide tube had to be increased by 1mm so the drilling depth was changed to 19mm. Plan is for semi-guided with 2.8mm conus drill then free hand to 3.4 mm drill due to width limitations of guide tube for 3.4mm drill.

Clinical Case #3

Pre-op plan and post-op CT scan.

Clinical Case #4

Placement of a 4.3x8mm BSB Trilobe implant with direct cut drill.