RealGUIDE tutorial: CT import, implants, surgical guide, report

This tutorial covers the full path in RealGUIDE from a patient's CT to a surgical guide: importing DICOM and scans, matching, the nerve, implants, the guide, the report and segmentation. Steps and button names come from the official user guide (rev.8, June 2023, version 5.3), ZimVie's SafeCut plugin manual (November 2025) and the version 6.0 release notes (March 2026).

In 6.0 AI takes over part of the work: it suggests implant positions and builds a draft guide with the sleeves in place. The draft still has to be checked and edited by hand.

How to import a CT (DICOM) into RealGUIDE

Create a patient: ADD PATIENT on the toolbar, fields Name, Surname and Date of birth. If you already have the DICOM, you can leave the fields empty and click OK; the data will be read from the files. The user guide advises running received data through an antivirus before import.

Then click IMPORT 3D EXAM/PROJECT and choose one of two buttons:

• IMPORT FILE(S) — DICOM (single or multiframe) or a RealGUIDE project in a ZIP archive;
• IMPORT FOLDER — an unpacked folder or a CD.

The series appears on the patient toolbar under DICOM Images; open it with OPEN. LOCATION shows the folder with the files on disk, and CANCEL removes the series from the patient folder.

If the CT does not open, check the scanner export first. RealGUIDE accepts standard DICOM without post-processing, and the user guide advises importing axial images only, since that is the only orientation the software handles. Your CBCT manufacturer can tell you the right export settings.

A project sent by a colleague is loaded with the same IMPORT 3D EXAM/PROJECT button. If it was shared through the cloud, it appears in cloud storage with a DOWNLOAD icon.

STL import and matching with the CT

Add scans with IMPORT STL, choosing the type: Anatomy, Wax-up, Evobite or other. At this step the file is only linked to the patient. Matching happens later, at the Data import step of the planning window:

• select the STL, click MATCHING, set the object name and click OK;
• the CT opens on the left and the scan on the right: mark at least three pairs of corresponding points;
• FIT POINTS performs the initial point-based alignment, BEST FIT refines it using the surfaces around the points;
• a mean error value appears under BEST FIT, the average distance between the surfaces; check the scan outline on the MPR slices.

Place points on areas that are clearly visible on both the CT and the scan: Evobite markers or stable tooth surfaces without metal. Avoid areas with heavy artifacts (scatter).

Other scans from the same case do not need matching again: in MATCHING choose SAME AS: [ANATOMY], and the software applies the same transformation. For this the lab has to scan and save all STL files in the same coordinate system.

Nerve tracing and implant placement

Before the implants, the step-by-step wizard takes you through preparation. First, at the VOI step, trim excess volume with TRIMMING and SCULPTING. Then, at the CPR step, choose the arch and draw the panoramic curve on an axial slice. The nerve is traced point by point on the panoramic view: FINISH DRAWING completes the right canal and ADD LEFT NERVE starts the left one. In the 2025 SafeCut manual the curve is drawn by the Assisted button (manually with By Points) and the nerve is found by Detect Nerves.

At the Teeth Setup step, mark the teeth you are going to restore. They are highlighted in light blue; clicking one opens the library window, where a standard implant is already placed in the bone. Download the manufacturer library you need from the cloud right there (no more than two during the 3DIEMME trial), choose the abutment and click APPLY.

Implant position and size are changed with buttons: tilting with the apex fixed or with the top fixed, increasing and decreasing size, moving 0.5 mm per click, and moving along the axis with the up and down arrow keys. To make prosthetic axes parallel, right-click an axis, choose SET THE AXIS PARALLEL TO and pick the implant to align with. Bone density around the implant in HU is shown by BONE DENSITY in the RULER drop-down menu.

In 6.0 you only need to say how many implants you want and at which teeth: AI suggests positions based on the patient's anatomy, and you adjust them.

Surgical guide design in RealGUIDE

The guide is built on the Guide Design tab, following the wizard steps:

• undercut blockout — set the thickness, angle, grip grade and smoothness, much like a preliminary wax blockout;
• insertion direction — drag the arrow in the center of the model or set it perpendicular to the screen with SET DIRECTION FROM VIEW, then click GENERATE UNDERCUT;
• guide margin — mark it with points on the model; you do not have to close the loop, placing the last point near the first is enough. Set the fitting tolerance and the occlusal and lateral thickness, then click CREATE GUIDE;
• finishing — tools add and remove material, smooth edges and fill depressions; below them are buttons for inspection windows (cylindrical holes and rectangular slots), including windows for re-administering anesthetic;
• finalization — NEXT STEP builds the sleeve seats, and the REPORTS / EXPORT DATA tab with STL export appears.

In 6.0, once the implants and fixation pins are placed, AI builds a draft guide with all the sleeves in place; you then refine it by hand.

Drill report in RealGUIDE

The user guide does not describe the path to the drill report step by step. Judging by the name of the REPORTS / EXPORT DATA tab, reports are in the same place as guide export, and 3DIEMME's feature list includes exporting a project report as PDF.

ZimVie describes the automatic drill report using its own Z3D kit as the example: the software generates it from a project with TSX, TSV, Trabecular Metal or Eztetic implants and a Z3D sleeve. This suggests the report is built from the implant, sleeve and surgical kit combination. If it is not generated, check which kit and sleeve are selected for each implant.

So pick the library for your system, for example Osstem for RealGUIDE or ZimVie. If you cannot find the report in your version, 3DIEMME has video tutorials (video-tutorial.3diemme) and a help desk knowledge base (helpdesk.3diemme).

Segmentation: exporting teeth, roots and bone to STL

Segmentation turns CT data into separate 3D objects. In the SafeCut manual the segmentation tab has four options: Crown, Tooth, Bone and Tools. 3DIEMME's feature list names segmented anatomy export to STL as a separate item, and the SafeCut manual says plainly that bone segmentation is needed to convert DICOM to STL.

Teeth and roots. Roots require Tooth segmentation on the CT, since an intraoral scan has no roots. Turn on BRUSH mode and trace the tooth while holding the left mouse button. If AUTO SEGMENT is on, the tooth is segmented immediately; otherwise click TOOTH SEGMENT. Refine the shape with seed points: CTRL+click adds a tooth seed, SHIFT+click adds a background seed. Since version 5.4 AI segments all teeth at once, without tracing each one.

Bone. Move the Lower Threshold slider until the green overlay on the slice follows the bone without spilling onto artifacts. Turn on Fill Holes and click Segment Bone. Then smooth the surface with Smooth, close holes with the FREEFORM tools, click Finalize and save the segmentation project.

In the user guide for version 5.1 the last wizard step is called EXPORT DATA, and STL is exported from there. None of the available guide revisions describes exporting segmentation step by step, so in your version look for it at the export step.

How to use RealGUIDE: FAQ