By Dr. Yasir Almadani — dental implantologist and digital surgical guide designer.
RealGUIDE is one of the most widely used implant planning programs, and it is the software my surgical guide design course is built on. This article walks through the complete workflow, from raw files to a print-ready guide. The aim here is to understand the logic and the order; the hands-on, step-by-step practice on real cases is what the course covers.
Before you start: data quality
Every error in the data ends up in the guide. Make sure you have:
- A CBCT in DICOM format that covers the whole implant area, with no patient movement, and with lips and tongue held away from the teeth where possible.
- An intraoral scan in STL of the treated arch and the opposing arch, including the full neighbouring teeth the guide will rest on.
Step 1: Import and orient the CBCT
Import the DICOM files, align the volume to the occlusal plane, and draw the panoramic curve along the dental arch. That curve is the basis for every cross-section you will work in.
Step 2: Mark the nerve and anatomical landmarks
In the mandible, trace the inferior alveolar canal from the mandibular foramen to the mental foramen, watching for an anterior loop. In the maxilla, identify the sinus floor and the incisive canal. The software shows the nerve as a coloured tube, which makes the distance to the implant easy to see.
Step 3: Import the scan and register it
Import the STL and register it to the CBCT by picking clear matching points on the teeth in both files, then let the software refine the fit across the surface. Afterwards, check in several cross-sections that the tooth outlines from the scan sit exactly on the tooth outlines in the CBCT. This is the most important step in the whole design: an inaccurate registration means an inaccurate guide, however good the rest of the work is.
Step 4: Set up the virtual tooth (restoration-driven planning)
Before placing any implant, place the missing tooth virtually from the software’s tooth library — or import a designed restoration — in the right functional and aesthetic position. The implant goes under this tooth, so its position serves the final restoration.
Step 5: Choose and position the implant
Select the implant system, diameter and length from the library, then adjust position and angle in the different views. Commonly reviewed guidelines (always defer to the surgeon’s protocol and the implant system):
- Usually at least 1.5 mm between implant and adjacent tooth.
- Usually at least 3 mm between two adjacent implants.
- A safety margin to the inferior alveolar nerve, often at least 2 mm.
- Enough bone around the implant buccally and lingually.
- An axis that emerges where the crown needs it — through the occlusal surface posteriorly, and through the cingulum anteriorly for screw-retained restorations.
Step 6: Choose sleeves and the drilling kit
Choose the sleeve type, diameter and height to match the guided kit the surgeon will use — or a sleeve-in-sleeve system, or a pilot drill guide. This is also where the distance from sleeve to bone crest is set, which determines the drill length needed to reach the planned depth.
Step 7: Design the guide
Outline the guide on the teeth or mucosa, then set its parameters:
- Extension: enough teeth covered for good stability, without making insertion difficult.
- Thickness: enough for rigidity without adding unnecessary height — typically a few millimetres.
- Offset: a small gap between guide and teeth so it seats without binding, set according to your printer and material.
- Inspection windows: small openings over the tooth edges so the surgeon can confirm full seating before drilling.
- Irrigation openings where needed, to help coolant reach the drilling site.
Step 8: Final review and export
Review every implant in all three views, check the guide’s path of insertion and that nothing blocks seating, then export the guide as STL for printing, along with a surgical report listing for each implant: type and size, sleeve, and the drill and drill length required.
After design: printing and preparation
Print the guide in a resin approved for surgical guides, then wash and post-cure it according to the manufacturer’s instructions and fit any metal sleeves. Try the guide on the model or in the mouth before surgery day.
Common beginner mistakes
- Accepting an inaccurate registration because it “looks close”.
- Placing the implant where the most bone is, without considering the crown position.
- Forgetting to check available drill lengths against the required depth.
- A guide that is too short and rocks during drilling.
Learn it hands-on with Dr. Yasir Almadani
- Learn this complete workflow on real cases in Dr. Yasir Almadani’s surgical guide design course: browse the courses.
- Prefer us to design the guide for you? Send your CBCT and scan: request a design.
- A clinic or lab? Collaborate with Dr. Yasir Almadani.
This article is educational. Planning and the final surgical decision remain the responsibility of the treating dentist after examining the patient.