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Drilling an osteotomy poses two challenges for the surgeon:

  1. Surgical: the hole must be positioned in sufficient bone to hold the implant
  2. Prosthetic: the hole must be correctly aligned with the position of the future tooth to restore it correctly

To meet these challenges, doctors can obtain 3D data of a patient’s jawbone (typically through a CT scan), import the data into implant planning software, and virtually place the implant in the correct position. The CT scan-based surgical plan is then used to make a surgical guide for that specific patient/case.

Literature has shown that CBCT-based implant planning and surgical guides offer advantages to the surgeon, restorative dentist, and patient. Implants are placed where planned, in the ideal location, leading to improved surgical confidence, outcomes, and esthetic results. And many doctors have adopted guided surgery for all of their cases.

Benefits of CT-based guided surgery include, but are not limited to:

  • Restorative-driven surgery: Implant placement is pre-operatively agreed to by the surgeon and restorative dentist
  • Accurate placement: Implants are placed where planned, in the ideal location, leading to improved surgical outcomes and esthetic results
  • Lower liability: costly surgical mistakes (i.e., perforating the side of the jawbone or sinus, or damaging the mandibular nerve) are minimized because patient anatomy is known
  • Sub-gingival knowledge and planned placement provide a better, more predictable, surgical experience
    • Enter surgery with less stress and more confidence, knowing fewer anatomical “surprises” await
    • More trust in a flapless protocol, which provides a more painless patient experience and recovery
    • Spend less time in surgery
    • Minimize intraoperative radiography (“check films”)

However, guided surgery still requires experience and good judgment. No matter how confident a doctor is in their treatment plan, they must still assess the placement of the surgical guide and implant in vivo.

Research has shown that 3-D treatment planning provides the clinician with a greater depth of information than traditional models, and that CT-based surgical guides are more accurate than free hand drilling as well as more accurate than conventional surgical guides.

Implant dentistry is increasingly restorative-driven. This is due in part to virtual planning and guided surgery, powerful collaboration tools that benefit – and allow for seamless communication between – the surgeon and restorative dentist. By working from the same digital plan, surgeons can work closer with restorative dentists to optimize restorative and surgical outcomes.

Correct virtual planning delivers a restorative-driven placement that also meets surgical parameters. Everything once done on the bench – wax-ups, stents, barium sulfate (BaSO4) teeth – is now done virtually in the software, saving significant time. With a precise model of the patient’s jaw and the surgical guide, an accurate prosthesis can often be manufactured by a dental technician prior to implant surgery.

Surgical surprises, if present, can be reduced or eliminated. The amount and location of available bone can be determined in advance of surgery. Three-dimensional CT scans can provide accurate information on treatment area proximity to the aveolar nerve channel and sinus walls that 2-D x-rays may not always reveal.

We have heard many dentists complain of getting patients back with an implant that is “surgically well placed,” but nearly impossible to restore. We can’t tell you how to have the tough conversation with your surgeon, but we can suggest you contact us with the name of your surgeon – and we will be happy to reach out and introduce our solution. We won’t let them know it was your idea…
Overall, guided surgery provides greater accuracy with equal or less than time than non-guided techniques. Collecting the necessary data upfront (scans and models) requires a few minutes of staff time. And as with any technique, there is a learning curve to online treatment planning. After a few cases, though, dentists find that planning goes quickly, certainly much more quickly than creating a restorative-based surgical guide by hand. With trust in the planning and guide, surgeries go more quickly. And with our disposable drill stops, there is no need for cleaning keys after the surgery.
Where other systems require proprietary software and surgical kits costing $5,000-10,000, the ThinLayer® Drill Guide System has no upfront cost: the implant planning software is free, and the custom disposable drill stops work with most standard drills. The ThinLayer® Guided Surgery System including a custom tube guide, disposable drills stops custom to your handpiece and drills and an endofile with stop costs $250 for a single-implant case, plus $50 for each additional implant site, self-planned using free treatment planning software.
The factors which trigger the need for guided surgery for multiple implant cases are the same for single implant placement. These include cross-sectional width and shape, position of the inferior alveolar nerve, mental foramen or maxillary sinus, cant of the mandible or maxilla, angulation and position of the roots of adjacent teeth, and poor physical and/or visual access to the surgical site.

For these reasons, there are many single tooth implant cases for which a surgical guide can assure a predictable result. For example, lower 2nd molar sites are often difficult to access both physically and visually, and can be further challenging if located posterior and deep in the patient’s mouth.

We have found that patients appreciate the use of guided surgery, as well as a thoughtful explanation of what it is. Below is a script that resonates well:

We place implants by computer-guided surgery.

To accurately place an implant, a precisely positioned hole has to be drilled into the jaw. Jaws come in different sizes, shapes, and angulations, and there are nerves, blood vessels and sinuses that limit where one can drill. Therefore, we use a 3D scan of your jaw to visualize your anatomy on the computer. Using special implant planning software, an implant can be placed virtually in the image of your jaw, while viewing the dimensions and shape of your jaw – and the locations of vital structures. These enhanced diagnostic tools help to reveal any potential problems and eliminate unexpected complications.

On the basis of this virtual plan, a drilling jig called a surgical guide is fabricated. The guide fits on your teeth and includes a guide hole, which guides the implant drill in surgery. In this way, the surgical guide transfers the virtual position of the implant to your mouth, and provides a method to precisely position the hole for the implant.

ThinLayer® Guides require the same vertical clearance as freehand drilling, which is especially helpful in posterior sites (~30% of all implants). Tube guides require you to insert your drill straight down the trajectory of a tube, whose rigid sides prevent you from going off track. To line up with the tube, the drill must be stacked on top of the tube. ThinLayer® guides create the same trajectory, defining the bottom of the “tube” with a guided bleeding point or pilot hole, and the top with the guide hole. Once the surface point is established and the ThinLayer® guide placed, the drill can be inserted at an angle before turning it upright to insert the tip in the bleeding point, engage the disposable drill stop, and begin drilling. For more information, click here.
The ThinLayer® Guided Surgery System is compatible with all implant companies and most standard drills. We also work with any guided surgery kit drills you may have already purchased. We also offer a 5-piece set of stepped drills, providing notable benefits for guided surgery, at a very affordable price; for more information, click here.
Most tube guide manufacturers mill or “print” their surgical guides on 3D printers. Their surgical guides are bulkier because they may warp over time if made any thinner. They admit that the material “is sensitive to moisture and UV light” and should be stored “together with a moisture absorbent in the UV protective plastic bag in which it was delivered… in a dry and dark location” and out of direct sunlight. Furthermore, they “may deform if exposed to liquids (even water) for more than 30 minutes.”

Our patented manufacturing process is designed to alleviate the warping and fit issues. ThinLayer® Guides are thin, which makes them much easier to use and conform well to teeth and gingiva, but also strong for handling and intended use. They fit snugly and you can see and access the drill site, approach the posterior with no additional vertical space, and modify the plan in surgery, if needed.

There are specific indications and contraindication for flapless surgery. Guided surgery does not have to be flapless surgery, yet most tube guides are bulky and impair visibility of the surgical site, and have a flange that prevents access to the site and impedes flap reflection. A device should not dictate surgical technique, so we designed ThinLayer® Guides to be open laterally and to allow visibility of the surgical site and easy access for flap exposure, when desired.
Guided surgery has in many places become synonymous with flapless surgery. Although well-planned cases and guides do offer more confidence in performing flapless surgery, in many cases flap reflection is still indicated. Below are some indications for flap reflection in guided surgery:

  1. Flared healing abutments: these abutments hang up on adjacent bone if any portion of the implant perimeter is below the osseous crest. Flap exposure is needed for  access to remove interfering bone
  2. Preservation of attached gingiva:  if the width of the  attached gingiva is minimal relative to the implant diameter, an incision along the midpoint of the band of attached gingiva with flap reflection allows the attached gingiva to be mobilized along the buccal and lingual of aspects of the healing abutment. In contrast, the buccal and/or lingual attached gingiva would have been completely removed with a tissue punch
  3. Buried implant: if the implant must be buried for any reason, a flap must be reflected
  4. Ridge reduction
  5. Thin or knife edge ridge: although properly used surgical stents guide the drill to within 0.5 mm of the planned position, a thin or knife edge ridge should be exposed and visualized before an osteotomy is initiated
ThinLayer® Guides are designed to fit the teeth tightly, with excellent retention and stability, even when drilling. Our confidence in the fit is reinforced with a money back guarantee.

We have heard from many dentists that fit is an issue with many printed or milled guides currently on the market. And in the March/April issue of the International Journal of Oral and Maxillofacial Implants there is a study that compares the accuracy of computer-generated and conventional surgical guides. The authors concluded that “CAD/CAM more accurately reproduced planned implant positions”, however, they also mentioned that at least 20% of the “CAD/CAM guides need to be relined with clear acrylic resin prior to surgery to ensure stability.” They were “adjusted intraorally to achieve a stable fit prior to surgery.”

Farley et al, Split-Mouth Comparison of the Accuracy of Computer-Generated and Conventional Surgical Guides. Int J Oral Maxillofac Implants 2013;28:563-572.

Yes, ThinLayer® Guides are engineered to be thin and strong, due to the strong dual-layer laminate and their corrugated shape, which maintains rigidity when locked onto the teeth. In edentulous cases, bone screws are used to provide further rigidity. Doctors have described “forcing” drills into other tube guides – especially in areas with restricted clearance. Essentially, they must stack the drills over the tube and keys before inserting the drills through the tubes. The design of our surgical guides and disposable drill stops do not require stacking of longer drills, so avoid the need for lateral pressure.
Yes. If you don’t already know a CBCT provider in your area, check out our list of CBCT scan centers or contact us and we’ll be happy to help find you a high-quality site with reasonable prices.
Your choice will depend upon your individual needs. For guided surgery, we recommend a scanner that can adjust to capture our recommended FOV and exposure.

Patient scan:

  1. FOV: 8.5 cm (W) x 4-5 cm (H) for single arch
  2. Voxel: 0.4 mm
  3. Scan time: 4.8 sec

Stone model scan:

  1. FOV: 8.5 cm (W) x 4-5 cm (H) for single arch
  2. Voxel: 0.2 mm
  3. Scan time: 12.8 sec

Helpful guides can be found at ConeBeam.com and The 3D Orthodontist.

Unfortunately, that plan can only be used to make a Sirona/SICAT guide. We plan in Blue Sky Bio software using the raw DICOM files, which can be exported from the CBCT.
Please consult your attorney for advice on this subject. Our protocol limits the scan field – and the files we look at together – only to the anatomy pertinent to implant planning.
CBCT scanners produce much less radiation than do medical CTs. Additionally, the AAOMR recommends that “cross-sectional imaging be used for implant site assessment” and “recommends CBCT imaging as the current method of choice for cross-sectional imaging.”With our recommended protocol, the patient will receive the equivalent of approximately two panoramic x-rays. We found this radiation exposure comparison to be helpful information from Marvin M. Rosenberg, D.D.S., F.A.C.D., F.I.C.D, Diplomate, American Board of Periodontology.

Further guiding principles can be found in the EADMFR Basic Principles on the use of Cone Beam CT.

Please follow our CBCT protocol.
No. As with anything, there is a learning curve, but doctors we work with have found it to be quite short. To get started, download free Blue Sky Plan software (for Mac or PC), look at our treatment planning protocol, and take advantage of Blue Sky’s training site. We are also happy to walk through it with you. Let us know, and we will find time!
Click here to find out the latest requirements.
No. This is true of any surgical guide provider, and we will let you know if we recognize any limitation.
We work with any planning software that exports a non-proprietary STL file. Blue Sky Plan is the only software we currently know of that has this capability. It also has the added benefit of being free to customers. Please let us know if you find other software that exports a non-proprietary STL file.
The fit of the drill guide on the patient’s teeth is dependent on the quality of the stone model and, thereby, the accuracy of the impression. We cannot manufacture a guide unless we receive a good model.

Please ensure that each model meets the following requirements:

  • No voids
  • Captures all anatomy
  • Can’t have been fractured and glued back together
  • Name of patient and doctor written on the back
  • Alignment marks on models which are to be hand articulated

Steps to an accurate impression and model:

  1. Place alginate onto a finger and smear the impression material onto the occlusal surfaces of the teeth and into undercuts before the impression tray is placed to capture all anatomy
  2. Avoid bubbles when pouring the model:
    • Pour alginate impressions immediately
    • Apply a debubblizer (soapy water) to the alginate before the model is poured. Blow the debubblizer out with a gentle air stream before pouring
    • When pouring the model, fill each concavity in the alginate individually, allowing the stone to flow sequentially from one concavity to the next

Be sure to create an adequate base on the models to prevent breakage in shipping. Thin models tend to break, even when padded.

For more detailed instructions, click here.

We use appliances with fiducial markers to avoid inaccuracies caused by radiographic scatter. The first step is to make an impression tray or stent with fiducial markers, then scan both the patient and stone model wearing the appliance – in a CBCT. We then merge the two data sets based on the fiducial markers, which set above or below the vertical plane of any scatter. The advantage to using CBCT over optical scans is that you are not dependent on anatomical features of the patient’s bone, teeth, or gingiva. The technique is immune to the effects of scatter and delivers clean, accurate merges.

Please visit our protocols page for more details on how it works.

We recommend using Suremark’s VF-10 2.0mm non-metallic and self-adhesive markers which can be purchased here. You may also use 2-4 mm pieces of a #50 gutta percha point.
Yes, our surgical guide is a registered FDA Class I medical device.


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