$2800!!!!!!! That’s how much a doctor at one of my courses recently told me he paid the lab for a single arch bone reduction guide and surgical guide. It stunned me because I’ve been teaming up with clinicians to do these routinely in the Blue Sky Bio Guided Surgery Software for well under $100. I understand that some doctors don’t want to learn to use software but that is an insane amount of money to spend if you could do it yourself in under an hour. The only explanation I can come up with is that people just don’t know it’s an option. They think this can only be done with some super top secret lab software and that it takes a week to plan. However, nothing could be further from the truth.
This is a case I teamed up with an oral surgeon friend on and we were able to pull off a bone reduction guide, implant placement guide, and transitional prosthesis. My all in costs were an $18 export fee, 4 guide tubes for $28, and maybe $5-10 worth of printing resin. THAT’S IT. The time to plan was under 1 hour.
Now it’s worth mentioning that there are 2 necessary pieces to the puzzle that allow me to do all this. First, you can’t do any of it without a CBCT scan so that’s the price of admission. Secondly, I did a lot of 3d printing on this case so being able to do it in house myself was huge. I use a Moonray S 3d printer. I have several but currently, it’s my favorite for cases like this. Finally, you have to learn how to use the software. There is a ton of free content out there that myself and others have put out to teach the software but there are also live courses. I give them pretty regularly and others do as well. See my home page for course dates. Let me show you how we did it.
Patient presented with a lower partial and a few remaining lower teeth. A dual scan was done meaning a scan was taken of the patient with radiographic markers on the partial and then the partial was scanned by itself. The BSB software allows these to be merged as seen below. Secondly, when doing bone level guides, you have to segment the bone- in other words, you have to turn the CBCT rendering of the jaw into an STL model. This can be done in the BSB software too but it can be tedious. I often delegate this task out to Image3DConversion and they do an excellent job with 24 hour turnaround.
The implants should be planned from the prosthetic endpoint backwards. I try to have the anterior implants emerging lingual to incisal edges and the posterior implants emerging through the occlusal of the teeth
Bone reduction guides can be made in BSP by creating a “guide” direct on the segmented jaw STL but with no holes in it. You want to create a simultaneous cut through this guide and the jaw and the same time but BSP will only cut one stl surface at a time, not two. Solution: Export both together and then bring them right back into BSP and now they are 1 surface and you can use the cut tool to make the bone reduction cut between the guide tubes and the platforms of the implants.
I 3D printed a practice model of the jaw to be able to do mock surgery. Always nice to be able to do a “dry run”
Bone reduction completed on the practice model. It should be taken down to where it’s even with the guide.
Once that is complete, the surgical guide can go on. This guide is just made it the normal way in the BSB software by turning the guide tubes on and building it directly on the reduced jaw.
For this case, the BSB Fully Guided Keyless Kit was used. I’m going to dedicate an entire future post to why a keyless guide is the way to go but for now, take my word for it……..keys suck.
Fully guided implies that the implant is placed through the guide as well on a guided carrier as shown here.
Here you can see all the practice jaws and surgical guides on the build plate for 3d printing on the Moonray printer.
I was also able to 3d print a temporary that was fabricated in the BSB Denture Software. Because I know where the multi unit abutments are going to emerge, I can export them from Blue Sky Plan into Meshmixer and do a Boolean subtraction. This will leave premade holes exactly where the implants should emerge.
Here is the 3d printed temporary prosthesis. Currently, our materials are a bit lacking for being able to 3d print a definitive prosthesis so this could be milled out of something like PMMA or another easy solution is just print it and then duplicate in acrylic.
I use the Anaxdent large flask for this purpose and it works really well.
The prosthesis gets invested inside and out using PVS putty.
I created an injection hole and a vent hole and then injected acrylic to create the temporary.Here is the temp ready for surgery
Time for surgery
The downside to doing guided surgery on these cases is that it requires a large flap. You need to fully dissect the mental nerve as you can see here.
Once the teeth are removed, the bone reduction guide goes on.
Here you can see the bone being reduced to the level of the guide.
Completed bone reduction
Once bone reduction is complete, the surgical guide can go on.
The fully guided drills are used to create the osteotomies.
4 Blue Sky Bio Max implants were inserted with very good initial stability
Angled multi unit abutments were placed on the back implants to provide angle correction.
Temporary copings were placed on the multis and then picked up directly in the mouth with acrylic. Once set, it’s removed from the mouth and any voids are filled and the prosthesis is trimmed and polished.
Very important that the underside be flat or convex so that the patient can cleanse the area.
While this looks complex, it is well within the reach of any dentist or technician that is halfway computer literate. Furthermore, I think that by doing your own planning, you have so much more control and knowledge of the case and can give your patient a better end result.