Case JM 31 with Blue Sky Plan

Lower 2nd molar surgical site

Surgical plan using Blue Sky Plan, with cross-sectional, axial, panoramic, and 3D views of the bone, gingiva, and teeth. Articulated models shown in 3D view and outline of opposing teeth visible in cross sectional view.

In the panoramic view, the implant is placed, with the abutment diameter sized (~10 mm diameter for molars) to use as a “virtual tooth”. The mesial-diatal position of the implant is approximated by placing the abutment against the distal of the 1st molar.

In the cross-sectional view, the abutment is resized to 1 mm diameter for use as center line of implant. The implant is oriented in the bone so that the platform is at the crest and the center line is aligned with the lingual cusp of the opposing tooth. The outline of the gingiva is evident, allowing determination of tissue thickness at the implant site.

In the 3D view, the “centered” model shown is a scanned image of a stone model in which a reference point was made, indicating the ideal entry point for the osteotomy. For a molar implant the entry point would be approximately 6 mm from the distal of the adjacent tooth.

Center line of the implant is viewed relative to the reference mark. It may not always be possible to achieve the ideal entry point, but this view will indicate the planned position relative to the ideal position.

“Virtual tooth” abutment shows the relationship between the future tooth and the adjacent tooth.

Viewing the scanned articulated model in the 3D view is another way to check the relationship between the implant center line and the opposing tooth.

Final quality control test: look at all views to ensure everything is ok. Plan is then submitted for fabrication of a drill guide.

Missing lower 2nd molar

Placed tube guide, which was manufactured from the 3D plan. Drill stops were placed on each drill in the sequence.

Radiograph of spear drill and drill sleeve in the tube guide to illustrate drill trajectory.

Created a bleeding point with the spear drill, through the guide tube. The tube guide was replaced with a ThinLayer™ guide, which was also manufactured from the 3D plan. The spear drill was placed through the guide hole, the tip placed into the bleeding point and drilled to a depth of 4-5 mm.

With the initial pilot hole established, a flap was reflected. The 2 mm drill is inserted at an angle, requiring no more space than freehand drilling. As shown, the ThinLayer™ guide allows visual and physical access to the surgical site.

The drill is rotated upright until the tip engages the pilot hole and the dill stop engages the guide hole.

The drill is placed to depth, the depth stop engaging the top of the guide to control depth. Each drill in the sequence has its own drill stop.

Surgical analog in place illustrating the position within the guide hole.

Countersink centered in the guide hole used to countersink the osteotomy.

Implant driver centered in the guide hole to place the implant, which can be helpful in Type 3 or Type 4 bone.

View of the implant position

Implant position is identical to planned position of implant as shown in the 3D model.

Radiographic view of the implant position – identical to planned position of implant as shown in the 3D model.

Planned position of implant in the 3D model.

Lower 2nd molar, with flap exposure, including treatment planning with Blue Sky Plan and the ThinLayer^® Guide

The surgical plan for this case was developed in Blue Sky Plan, with cross-sectional, axial, panoramic, and 3D views of the bone, gingiva, and teeth. Articulated models are shown in 3D view and outline of opposing teeth visible in cross-sectional view. Whereas traditional “tube” guides often cannot be used with molars due to vertical space constraints, this case features a ThinLayer^® Guides from Guided Surgery Solutions, which requires no more vertical space than freehand drilling.

In the panoramic view, the implant is placed with the abutment diameter sized to use as a “virtual tooth” (~10 mm diameter for molars). The mesial-distal position of the implant is approximated by placing the abutment against the distal of the 1st molar.

In the cross-sectional view, the abutment is resized to 1 mm diameter for use as the center line of the implant. The implant is oriented in the bone so that the platform is at the crest and the center line is aligned with the lingual cusp of the opposing tooth. The outline of the gingiva is evident from a scanned stone model, allowing determination of tissue thickness at the implant site.

In the 3D view, the “centered” model is a scanned image of a stone model in which a reference point was made, indicating the ideal entry point for the osteotomy. For a molar implant the entry point would be approximately 6 mm from the distal of the adjacent tooth. It may not always be possible to achieve the ideal entry point, but this view will indicate the planned position relative to the ideal position. The resized “virtual tooth” abutment also shows the relationship between the future tooth and the adjacent tooth. Viewing the scanned articulated model in the 3D view is another way to check the relationship between the implant center line and the opposing tooth.

The surgery was performed with the tube and ThinLayer^® Guides from Guided Surgery Solutions, who manufactured the guides from the 3D Blue Sky Plan and provided custom, disposable drill stops for each drill in the sequence. The inner diameter of each drill stop holds it flush to the drill shaft and fluted area. The outer diameter of each stop is flush with the inner diameter of the tube (in the tube guide) and the diameter of the hole in the ThinLayer^® Guide.

First the tube guide was placed and a spear or lance drill placed through the insert (drill stop) in the tube to create bleeding points in the implant positions. An endo file through the insert could also be used, if preferred. Next, a spear drill was used through the insert/tube to create pilot hole by placing the tip into the bleeding point and drilling through gingiva to 4-5 mm bone depth.

The tube guide was removed and a flap was reflected before the ThinLayer^® Guide was placed. Its guide hole replicates the top of a guide tube. The open buccal “window” allows an unobstructed view of the surgical site and ease of flap reflection. The 2 mm drill is placed through the guide hole at an angle, which requires no more vertical space than freehand drilling. The drill is then uprighted until the tip of the drill is in the pilot hole before being inserted to depth.

This is repeated with drills of increasing diameter, until the final drill is placed through guide hole and used. The countersink and implant driver were centered in the guide hole. This can be especially helpful in Type 3 or Type 4 bone.

Radiographs of the planned and final implant positions are included.

Please visit our Advantages page for more information for about the ThinLayer^® Guide system.

Related Downloads

ThinLayer^® Guide case 31, flap exposure, with Blue Sky Plan	Download
Treatment Planning Software (partially and fully edentulous)	Download