Category: My Post

This is probably my favorite upgrade to Blue Sky Plan in the last 5 years!  If you’ve ever done bone segmentation the old school, manual way in BSB, then you know how tedious a process it is.  It was not uncommon for a difficult maxilla to take well over an hour and that does not include individually segmenting the roots of the teeth.  So why is bone segmentation important?….  Because if you want to build a surgical guide directly on bone you must have an stl of the bone to build the guide on.
Here’s a case I’m working on where I’ve just opened the CT and pulled in the intraoral scans.  To do the segmentation, you need to be in the Model Builder Module and then you’ll open the Segmentation panel.  Just choose Automatic Jaw Segmentation and tell it if you want to do 1 or both jaws and whether you want it to separate the teeth from the bone.

There’s several AI segmentation options out there currently and I’ve used them all.  Here’s the things I love about BSB’s and why I prefer it

–  It’s fast:  in my experience, times will range from 2 minutes to 8 minutes depending on whether you’re doing 1 or both arches, whether you want to segment teeth too, and just the overall processing power of your computer.  Even with some of the other great AI services, I found that I usually spent at least  10 minutes uploading and downloading the files and another 5 to pull them back into BSB.  With this, you run the segmentation and you’re DONE……..everything is there and ready to begin work

–  No file transfers-  Since I’m already making my guides in BSB, it’s so nice to be able to do this within a single program which I’m already working with.  I don’t have to save files, upload them to a service, wait for processing, download the files, and re-import them.  With this, you eliminate all those extra steps……just run the segmentation and within a few minutes, everything is in place and you’re ready to start planning/making guides

–  Files are already stitched in place with the ct data- sometimes with other programs I’ve used, the files would be out of orientation with the ct and I’d have to go back and re-stitch them

–  You get a chance to preview and edit the segmentation-  This is probably my favorite.  As good as these AI segmentations are, there’s often a small area that they may miss.  When I’d get the files back and evaluate them, if there was a missed area, I’d have to go back and manually segment those areas.  With BSB, it actually stops once it performs the segmentation and gives you the opportunity to evaluate it before finalizing.  This way if there’s a missed area, I can use the tools to edit (in red box)  the data very quickly and get it perfect before finalizing.  I rarely have to do any editing unless it’s a case with lots of scatter and even then it’s usually minimal.  This pic shows a slice of the preview before any editing……..it was dead on with the bone in red and the roots in purple.  Since there was nothing to edit, I just pushed finalize.

–  Accurate tooth segmentation-  BSB now segments every individual tooth root and builds the true socket walls into the bone segmentations.   It has also drastically improved it’s scatter reduction.  I’ve found it to be so accurate that I’ve made surgical guides directly on the tooth segmentation from the CT only (no intraoral scans) and the guides fit great.  I’m not necessarily advocating that but I have done it and it worked great.  The thing you won’t have if you try this is the soft tissue so you have to leave the guide edges above any soft tissue like the papilla.  I’m not a big ortho guy but the tooth segmentation has a lot of great applications for ortho too……to my knowledge, BSB is the only ortho aligner software that segments the teeth/roots and reflects the root movements in each step.  This can remove the risk of pushing roots out of the bone in your ortho cases.
Look at the accuracy of the segmented root outlines compared to the IOS outline

Here’s a video I made on the process but it’s pretty self explanatory

This build is available to anyone who wants it right now but it’s not a public release yet.  That means you can’t just download it off the BSB website.  You’ll have to go to the Blue Sky Bio Users Group on Facebook and just search for Michael Saltzmann’s post that shares the download link.  This should be a fully public release within the next few weeks.  If you ever make bone supported guides, I’d highly recommend you download this and try it!

I’ll share some more cases soon of how I’m using this.

One of the most underused tools for selling big cases in my opinion is smile simulations. These can be done quickly on any new patient or patient interested in cosmetic treatment and, if done well, they can be incredibly motivating for patients. Imagine being this patient: you’re ashamed of your teeth and can’t imagine spending the money to fix them because you cant even imagine what it would look like to have nice teeth.

Simply get a smiling pic at approximately the right VDO and you can do this in five minutes. This particular simulation was done in a monthly subscription software called DTS Pro which I really like.

You can’t tell me you wouldn’t do a ton more elective cases by implementing this. However, many get turned off by monthly fees and even photoshop these days is a monthly subscription fee.

Enter GIMP. I’m not sure where I heard about it but it’s basically a free/open source program like photoshop that anyone can download. It’s incredibly robust and there are tons of tutorials on youtube including one I made which I’ll link in next post.

Basically what you do is have your base layer of the patient smiling. You can pull in individual teeth or an entire smile and position it properly. This simulated smile would then get sandwiched on top by the same full face photo with the mouth cutout. That’s the basics. The downside is you’d need to create your own library of nice smiles. I did this by just going through some cosmetic dentist’s websites and snipping their after smile pics and just saving them in a folder.

Here you can see some of them in my powerpoint template.

Ok now in the software, I’ve just opened the picture of my own smile……..worn teeth and short anteriors from my sleep apnea when I was a fatty.

You can pull in all kinds of visualization aids to help you align the perfect teeth.

Again, you can pull in an entire smile which is awesome for FMR, implant rehabs, and dentures or you can pull in individual tooth images and superimpose them like I’ve done here. This option takes a bit longer but gives you incredible control and ability to customize things exactly to your patient.

Now I’ve just duplicated my base layer of my face and cut out everything between the lips on the top copy. I’ll just bring that layer to the top where it’s over my simulated teeth and you get this photorealistic smile simulation.

I also love that you can turn the transparency of your simulated teeth up and down which really lets you (or more important, your lab) visualize how much tooth structure needs to be altered. I can’t overemphasize the importance of this not only for lab communication, but also because you need to see if your simulation is even possible……..for example, if you’re doing a crown and bridge rehab, you have pretty strict limits to how much you can alter teeth with crown and bridge. You might create some amazing simulation that looks great but can’t really be done without ortho or orthognathic surgery.

This was an example of a case where none of the smile simulation softwares were giving me good results. She has such a wide lip display and a narrow arch that everything I tried looked goofy. I was able to do this in gimp in about 8 min with individual teeth