Ministry of Higher Education

And Scientific Research

Al-Manara University

College of Dentistry

COMPLETE DENTURE DIGITAL FABRICATION

A graduation project submitted the college of dentistry , Al-

Manara medical college , department of Prosthodontics in
partial fulfillment of the requirement for B.D.S

By:
Ali hazim lafta

Supervised by:
[Link] waleed manaa
BDS , MSc
1
 Acknowledgment

First of all, I want to thank God Almighty, for the guidance, strength, power of
mind, protection and skills and for giving us a healthy life.

I would like to thank and appreciate my supervisor Assist. Dr. Bayan waleed
manaa who helped me to complete my graduation project in its best form and
best knowledge and for her encouragement, meaningful and valuable
instructions.

Finally, I would like to thank my family for all support they have provided
throughout the years of studying.

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 List of contents
No. Subject Page No.
Declaration of the supervisor
Dedication
Acknowledgment
List of contents
List of figures
List of tables
List of abbreviations
Introduction
Aim of study
Chapter one: review of literature
Epidemiology of Edentulism and
Longevity of Complete Dentures
Challenges of Treatment with
Complete Dentures
Digital Complete Denture
Definition and History
CAD/CAM systems parts
Stages in fabrication of
prosthesis with CAD/CAM
technology
Computer surface digitization
Computer- aided designing
Computer-aided manufacturing
(CAM)
Classification of CAD-CAM
systems
Subtractive method (milling

3
 method)
Review of subtractive method

4
INTRODUCTION

Although dentists may offer to an edentulous patient in the first place an

implant therapy, there are reasons to refuse this type of treatment by the patient:
anxiety about surgery, fear of pain, costs, and treatment time. Furthermore, from
a general health point of view, patients may not be candidates per se for
implants: uncontrolled diabetes, immune deficiency issues, heavy smoking
habits, alcohol abuse, psychology, and dementia (Kullar and Miller, 2019). In
such cases, professionally fabricated and well-maintained removable complete
dentures still represent a treatment of choice. Fabrication of conventional
complete dentures involves a complex restoration method, requiring significant
time and typically involving primary impressions, definitive impressions, jaw
relation records, clinical try-in, and complete denture placement (Basker et al.,
2011), which has been used for nearly a century without change. However,
inexperienced dentists or students often face difficulty with achieving
satisfactory retention, stabilization, and balanced occlusion of complete
dentures, especially in some elderly patients and those with severe alveolar
ridge absorption. In recent years, digital complete denture systems has been
developed that can improve the accuracy and efficiency of denture fabrication
and reduce the required number of clinic visits. These systems involve different
protocols for clinical and laboratory processes, requiring two to five clinical
visits (Bidra et al., 2013; Schweiger et al., 2018). The CAD/CAM process in
Dentistry describes an indirect restoration designed by a computer (Computer
Aided Design) and milled by a computer-assisted machine (Computer Aided
Machined) (Correia et al., 2006). Despite the exceedingly growing use of dental
implants, dentures still represent an indispensable treatment option for some
edentulous individuals who cannot afford or are contraindicated for implant
therapy. Over the past 100 years, complete denture fabrication has not changed

5
considerably and was mainly based on conventional techniques which consists
of multiple steps requiring traditionally 4 to 5 clinical appointments, from the
preliminary impressions to denture placement, and lengthy laboratory
[Link] usually requires substantial human intervention and extensive
material manipulation, which may lead to inaccuracies, processing errors, and
increased time and expenses (Bidra et al., 2013). For several years now,
computer-aided design and computer-aided manufacturing (CAD/CAM)
technology has been available and continues to develop in the field of fixed
prosthodontics showing significant impact on the design and fabrication of fixed
dental prostheses (Miyazaki et al., 2009). Recently however, it has expanded to
embrace implant, maxillofacial and removable prosthodontics including the
fabrication of complete dentures (Busch and Kordass, 2006).

6
AIM OF STUDY

The aim of the review is to present the historical, clinical, and

technological developments in the field of digital removable complete dentures.

7
 CHAPTER ONE

REVIEW OF LITERATURE

8
1. Epidemiology of Edentulism and Longevity of Complete Dentures.

Edentulism is the state of being edentulous, or without natural

teeth(Adam, 2006). Complete edentulism is an oral cavity without any teeth.
Adequate dentition is quite essential for well-being and life quality. Edentulism
is one of the public health burdens for elderly people and effects clearly the
practice of primary care. Edentulism is a devastating and irreversible condition
and is described as the “final marker of disease burden for oral health. Patients
who are suffering from edentulism exhibit a wide range of physical variations
and health conditions. Teeth loss affects mastication, speech, and may result in
poor esthetics which in turn affect the quality of life (Cunha-Cruz et al., 2007).
Evidence regarding the longevity of complete dentures is limited. A recent
systematic review found a denture replacement period of about 10 years, in
which the longevity of maxillary dentures was greater than that of mandibular
[Link] authors claim to educate patients to seek regular maintenance for
their dentures as well as for their oral mucosal health (Taylor et al., 2021).

2. Challenges of Treatment with Complete Dentures.

The conventional workflow for fabrication of complete dentures is elaborate

and
requires considerable time and experience in the clinic and especially in the
dental laboratory. It normally takes 4–5 sessions: (i) a primary impression with
a prefabricated impression tray or with the existing denture, (ii) a final
impression with a customized impression tray, (iii)a determination of the
vertical and horizontal dimension, (iv)a functional and esthetic try-in of the
denture teeth, and
(v)a delivery and incorporation of the complete dentures. Furthermore, the post-
insertion workload for maintenance and repair of the dentures must be
considered (Felton et al., 2011). These sessions are accompanied by a subtle and

9
laborious handicraft in the laboratory. A simplification of the treatment is
desirable by combining some clinical and laboratory steps and by saving time
and possibly costs for dentist, technologist, and patient. Systematic reviews
confirm that a conventional step-by-step complete denture fabrication procedure
does not produce perse better clinical results than the use of a simplified method
in terms of general satisfaction, denture quality, and mastication ability. The
often reduced neuroplasticity and stereognostic abilities of elderly edentulous
patients may provoke adaptation problems to new complete dentures. In such
cases, digitally fabricated duplicate new dentures may be an adequate and
efficient
solution (Takeda et al., 2020). They allow the processing of a high-quality
biomaterial and a better adaptation of the intaglio fit, while copying the
functional areas of the cameo surface of the existing dentures. Furthermore, the
digital data of the denture in case of loss, fracture, or reworking remain
available to replicate the affected dentures. This may be particularly important
for the frail elderly in longterm care facilities. In such cases, additionally the
potential microbiological burden (e.g., risk for aspiration pneumonia, adherence
of candida) from the removable dentures must be considered. From a biological
point of view, easy cleansable complete dentures with a high-quality surface (no
porosities, easy polishable) facilitating denture hygiene -could potentially have
a relevant preventive effect on mortality from pneumonia in hospitalized elderly
people and elderly nursing home residents (Al-Fouzan et al., 2017).

3. Digital Complete Denture.

3.1. Definition and History

According to the Glossary of Digital Terms, a digital denture is a complete

10
denture created by or through automation using CAD (computer-aided
designing), CAM (computer-aided manufacturing), and CAE (computer-aided
engineering) in lieu of traditional processes. A digital denture is achieved when
the final shape of the denture is manufactured through automation to ensure
there are no conventional errors from pouring, investment casting, or injecting
the material as done in traditional denture fabrication (Grant et al., 2016). CAD-
CAM has become an indispensable part of dentistry in general and of
prosthodontics in particular. The idea of successfully digitizing the workflow for
fabrication of complete dentures was considered for a long time as rather
improbable. It was felt that the necessary comprehensive application of
individual clinical and technical rules, as well as of the essential clinical
experiences of dentist and dental technologist, may be obstacles. Although the
conventional workflow to fabricate complete dentures is well established and
successful, factors such as standardization and simplification accelerated the
interest in CAD-CAM technology for removable prosthodontics (Bidra et al.,
2013). Digital design and manufacturing was introduced to dentistry by
Andersson, who developed the Procera system in 1983, and Mörmann, who
introduced the CEREC system in 1985 (Goodacre et al., 2012). Earlier CAD/
CAM innovations were mostly geared toward indirect, tooth-borne restorations.
The first report of CAD/CAM use for dentures is attributed to (Maeda et
al.,1994), who, in 1994, employed additive manufacturing technology. In The
1990S, Fabricated A Complete Denture for The First Time By Using Computer-
Aided Design/Computer-Aided Manufacturing (Cad/Cam) Technology (Maeda
et al., 1994).

11
3.2. CAD/CAM systems parts

(1) A data acquisition unit, which gathers the information or data from the
mouth and then converted into visual or optical impressions which are created
directly or indirectly at the same time (Deng et al., 2020). (2) Prosthesis design,
Denture-designing software offers a powerful tool that lets clinicians select
molds from a library of teeth to generate the tooth arrangement automatically
although it is still possible to customize the tooth setup. It is the authors’ opinion
that use of CAD technology for complete dentures can be a great teaching tool
for students, as it can show them the proper positioning of the denture teeth in
terms of esthetics, relationship to the residual ridge, location of the occlusal
plane, and occlusal relationship (Deng et al., 2020). (3) Manufacturing
Technologies, Since the introduction of polymethyl methacrylate by Wright in
1936, many issues of conventional complete denture materials have been
associated with polymerization shrinkage, leading to issues of fit, strength, and
also release of monomer. With CAD/CAM technology, two types of fabrication
methods can be used to overcome these shortcomings (Deng et al.,2020).

4. Stages in fabrication of prosthesis with CAD/CAM technology

1. Computer surface digitization

2. Computer-aided designing
3. Computer-aided manufacturing
4. Computer-aided esthetics
5. Computer-aided finishing
The last two stages are more complex and are still being developed for inclusion
in commercial system (Patil et al., 2018).

4.1. Computer surface digitization

12
Scanning of prepared tooth is done either digital (with Light emitting diode
LED based or Laser based) or mechanical scanners ( Patil et al., 2018).

4.1.A. Digital (either LED or laser based)

I. LED based scanner:
A small hand-held video camera with a 1cm wide lens (scanner) when placed
over
the occlusal surface of the prepared tooth, emits infrared light which passes
through an internal grid containing a series of parallel lines. The pattern of light
and dark stripes which falls on the prepared tooth surface is reflected back to the
scanning head and onto a photoreceptor, where its intensity is recorded as a
measure of voltage and transmitted as digital data to the CAD unit (Patil et al.,
2018).

II. Laser based scanner:

A high-speed laser takes digital scans of the preparation and proximal teeth to
create an interactive 3D image. Rapid scan allows automatic capture of digital
images at the operator's preferred speed to scan in the mouth or extra-orally on
conventional impressions or models, all without powder. Newer laser-based
scanners can scan at subgingival level based on optical coherence (OCT). At
least 9 scans are required to produce the image. There are stabilizers present
with the scanning device (Patil et al., 2018).

4.1.B. Mechanical scanner

In this scanner variant, the master cast is read mechanically line-by-line by
means of a ruby ball and the three-dimensional structure measured. The Procera
Scanner from Nobel Biocare (Göteborg) is the only example for mechanical
scanners in dentistry. This type of scanner is distinguished by a high scanning
accuracy, whereby the diameter of the ruby ball is set to the smallest grinder in

13
the milling system, with the result that all data collected by the system can also
be milled. The drawbacks of this data measurement technique are to be seen in
the inordinately complicated mechanics, which make the apparatus very
expensive with long processing times compared to optical (Webber et al., 2003).

4.2. Computer- aided designing

It is a computer unit with a software package for visualization of the
scanned data, planning and designing dental restorations on a computer screen.
Software’s collect data in the "Standard Transformation Language (STL)" or so
called "Standard Tessellation Language" format. It is possible to design a
variety
of dental restorations such as veneers, inlays, onlays, individual crowns, bridge
copings, partial denture frameworks and complete dentures. When the design of
the restoration is complete, the CAD software transforms the virtual model into
a
specific set of commands, which in turn drive the CAM unit to fabricate the
designed restoration (Beuer et al., 2008; Bilkhair, 2013). The software of the
CAD-CAM systems can be divided into two types based on the digital data
sharing capacity: closed and open systems. In the closed system, all the steps of
digitizing, designing and manufacturing are integrated in the unique system
with no interchangeability with any components manufactured by another
company. e.g., CEREC® AC-Bluecam, Apollo DI and CEREC® AC-Omnicam
(Sirona Dental System). However, the new trends are directed towards the open
systems, which allow the adoption of the original digital data by CAD software
and CAM devices from different companies (Ting-Shu and Jian,
2015;Alghazzawi, 2016).

14
4.3. Computer-aided manufacturing (CAM)

Third and the final stage is computer-aided manufacturing (CAM). The CAM
technologies can be divided in three groups according to the technique used
(Parasher, 2014):
A. Subtractive technique from a solid block:
In this stage the milling is done with computerized electrically driven diamond
disks or burs which cut the restoration from ingots or blocks. The CAM
technique in recent years can milled any material in any sizes even a complete
denture (Parasher, 2014).
B. Additive technique (Solid free form fabrication):
This category new technologies originating from the area of rapid prototyping
(RP), The term 3-D printing is generally used to describe a manufacturing
approach that builds objects one layer at a time, adding multiple layers to form
an object. This process is more correctly described as additive manufacturing,
and is also referred to as rapid prototyping which have been adapted to the
needs of dental technology (Prajapati et al., 2014).
C. Additive technique (by applying material on die):
Here in this technique Alumina or Zirconia is dry pressed on the die and the
temperature is raised to a temperature similar to the pre sintering state. At this
stage, enlarged and porous coping is stable. Its outer surface is milled to the
desired shape and coping, removed from die, and sintered into the furnace for
firing to full sintering (Tamrakar et al., 2014).

15
5. Classification of CAD-CAM systems
The CAD-CAM system classified according to production method into:

5.1. Subtractive method (milling method)

The prepolymerized acrylic resin used to fabricate milled CAD-CAM complete
dentures is dimensionally stable and provides a superior fit of the denture bases
whereas the resin of conventional processed bases undergoes polymerization
shrinkage (AlHelal et al., 2017; Goodacre et al., 2018). The prepolymerized
acrylic resin has improved physical properties allowing for designing a thinner
base overlying the palate. This property is particularly advantageous when an
immediate denture will overlay a prominent anterior maxilla. A thinner facial
flange is associated with less prominence of the upper lip and a more esthetic
result. There is evidence of improved physical properties of the milled base
material. For instance, the resin is more hydrophilic (wettable) (Sipahi et al.,
2001), contains less residual monomer (Ayman, 2017; Steinmassl et al., 2017),
has a smoother surface (Arslan et al., 2018; Srinivasan et al., 2018), provides
better resistance to surface staining (Al-Qarni et al., 2020), and exhibits a higher
modulus of elasticity (Steinmassl et al., 2017), flexural strength (Arslan et al.,
2018; Al‐ Dwairi et al., 2020), and fracture toughness (Steinmassl et al., 2017).
In addition to containing less residual monomer, the milled prepolymerized
acrylic resin is denser than heat-activated conventional denture base resins (Ali
et al., 2008; Ayman, 2017).

5.1.A. Review of subtractive method

Subtractive manufacturing was used by (Kanazawa et al., 2011). in an effort to
improve and speed up the CAD-CAM denture fabrication process. They
scanned a set of artificial teeth and the patient’s existing complete denture and
used a cone beam computed tomography scan (CBCT) to obtain information

16
about the patient’s mucosa and centric relation. The virtual denture was
designed with the use of a 3D-CAD software program. Then a subtractive
milling machine computer numerical control (CNC) was employed to mill the
transparent denture bases with recesses into which denture teeth were
subsequently bonded manually. CAD-CAM systems offer numerous clinical
benefits since the PMMA pucks used for the milling of denture are polymerized
by injection under high temperature and pressure, a process that promotes the
formation of longer polymer chains leading to a higher degree of monomer
conversion and lower values of residual monomer as well as minimal porosity.
It is probably a result of the processing method under high temperature –
pressure leading to a low residual MMA concentration (Murakami et al., 2013;
Kattadiyil et al., 2015).

17
It has been reported that these processing conditions decrease the intermolecular
distances and reduce the free volume (Ali et al., 2008). Surface hardness
indicates the density of the material and its resistance to wear and-or scratching
which reflects on the dental prosthesis during its function and cleaning
(Murakami et al., 2013). The results of the present study showed a significant
attributed to the polymerization process of each resin as the heat cure is
polymerized by additional (free radical) polymerization and leads to the
formation of a partial cross-linked polymer chain which results in the superior
hardness. On the other hand, the high temperature and high-pressure conditions
for the polymerization of CAD-CAM resins and the addition of inorganic fillers
restrict dimensional polymerization shrinkage and enhance the CAD-CAM
resins mechanical properties including hardness and wear resistance (Ali et al.,
2008; Consani et al., 2014). With the subtractive method, the denture base is
milled from a pre polymerized resin blank. Depending on the system,
prefabricated or milled denture teeth are subsequently bonded on the base. Such
contemporary systems include Zirkonzahn Denture System (Zirkonzahn, Italy),
Ivoclar Digital Denture (Ivoclar Vivadent, Liechtenstein), Vita Vionic (Vita
Zahnfabrik, Germany) and AvaDent Digital Dentures Bonded Teeth (AvaDent,
USA). Recently, few systems developed a method to mill the denture and the
teeth out of a single blank AvaDent Digital Dentures XCL1 and XCL-2, Baltic
Denture System (Merz Dental, Germany) and Ivoclar Vivadent Ivotion
( Anadioti et al., 2020) The main disadvantage of the subtractive technique is
the waste, as a large portion of the blank remains unused and is discarded during
this process. Another limitation is the monochromatic and unaesthetic teeth,
which AvaDent has overcome in their XCL-2 denture by using a unique
layering system resulting in polychromatic teeth that simulate the dentin and
enamel of natural teeth, providing premium esthetics (Lamb et al., 1983).

18
19
5.2. Additive method (rapid prototype)
The additive method (also called rapid prototyping) was invented in 1981 and
can be encountered as 3D printing. The additive manufacturing method includes
a group of techniques that fabricate a 3D object in a layer-by-layer fashion
based on the relevant CAD file. Rapid prototyping has many applications in the
field of engineering and the greater area of medicine. In short, the 3D-printed
denture production concept comprises printing of the denture base in pink
material, printing of the teeth individually or in complete arches in tooth shade
material and processing of the printed products for removal of excess
unpolymerized material, mostly utilizing ultrasonic baths in alcohol. Printed
teeth are next bonded to the denture bases with liquid material from the printer
tank and, finally, are light-cured for complete polymerization. The output is one
of high detail and smooth surface. Cutting of the supports and final polishing of
the denture is the last step. As an alternative, commercially available denture
teeth selected from the digital library of CAD software may be used and bonded
to the printed base. There are numerous additive manufacturing systems,
however not all of them are suitable for CD production; either due to the lack of
appropriate compatible materials or due to the lack of available building
volume. A scan of the relevant market revealed a list of systems that can be
utilized for the production of CDs, both in a laboratory setting as well as
chairside. The 3D printers usually require specialized cartridges containing
resins intended for denture bases and acrylic resins are mostly used for the base
of dentures. The offered variety of the material hue and color stability are
important factors to be considered while purchasing the product, since esthetics
is an important aspect for the acceptance of the final restoration by the patient.
Particular attention should also be placed on the mechanical properties of the
material after it has been fully polymerized, as they contribute both to longevity
of the prosthesis and patient comfort. Therefore, utilization of certified materials

20
according to manufacturer’s instructions is strongly recommended. Since the
technology is evolving and incompatibilities might arise, one should carefully
plan the transition to the new era. The dedicated 3D printers utilize light sources
or lasers that polymerize a liquid to produce the required objects. The
production procedure requires some moving parts, which are computer-guided
with high precision; specifically, a traveling printing platform that submerges in
the printing material and a processing system that hardens the material layer-
by-layer, forming the required shape. The most commonly used 3D printer
technologies in dentistry for CD production are briefly described in Table 1

5.3. comparing the additive vs the subtractive method

Both cam technologies offer clinically acceptable results faster than the
traditional process . The additive manufacturing technique is more recent and
has the advantage that a 3D printer is more affordable than a milling machine.
Furthermore, the 3D printing technology is advancing rapidly, with applications
in many fields, including dental laboratories. A range of materials are available
for the manufacturing of a plethora of products, such as models, parts and
complete restorations. Additive manufacturing methods are more efficient than
the subtractive ones and are available for a range of tasks, output volumes and
laboratory sizes. Selection of the appropriate 3D printer is a complicated task
that includes considerations about software compatibilities, printable materials
and services provided by the manufacturer. The milling machines, on the other
hand, have been on the market for a longer period and the customers are more
likely to be familiar with the available options. Accuracy for both techniques
seem to be acceptable, however 3D printing might present a higher variance.

21
The additive manufacturing technique is evolving and several parameters that
seem to affect accuracy need to be addressed. The orientation of the printed
denture base, for instance, seems to affect the accuracy of the resulting product
with some additive techniques. Although in laboratory studies the wear
resistance of the 3D-printed artificial teeth seem to be at least adequate for
denture use, long duration randomized clinical trials are necessary for in depth
evaluation of this aspect as well. Regarding other mechanical properties, CDs
produced with the subtractive
method have been found to be superior in toughness and surface roughness than
the 3D-printed ones. Additionally, the CDs produced with the subtractive
method have been found to have better color stability than the ones produced
with the additive technique. Digitally produced dentures seem to maintain the
selected occlusal schemes better than conventionally produced ones. However,
the bond strength of denture teeth might be a concern with both CAM
techniques.

22
1. Advantages for the Dentist, Dental Technologist, and Patient

[Link] data are recorded in fewer appointments, reducing clinical chair time
and—in selected cases—the costs, leading to a higher patient satisfaction. As a
side effect, there may be a greater likelihood of the patient to return to the same
dentist who has the documentation of all the past data (Clark et al.,2021).
[Link] to the clinical digital data and the software in the dental laboratory,
technological steps are accomplished in a shorter time, leading to a more
standardized high-quality end product. For the dental technologist, the design of
a complete denture is shifted from a manual wax-up and denture teeth set-up to
a digital design on a screen, and the fabrication of a complete denture from a
manual to a digitally guided fabrication. Both are in a more standardized,
controlled, easy, fast, and predictable way (Srinivasan et al., 2019).
[Link] repository of digital data allows any time the fabrication of a spare or
replacement denture, the fabrication of a new denture as a copy (duplicate) of
the old denture, and an easy rebasing by producing a “new old” denture (Takeda
et al., 2020).
[Link] edentulous patients who are in need of implants, the data may be used for a
complete digital workfow by designing and fabricating a diagnostic denture
teeth
set-up, a provisional denture, a radiographic or surgical template that supports
the
planning and the placing of implants, and, not least, the fabrication of a fnal
restoration (Swamidass and Goodacre, 2021).

2. Disadvantages of CAD-CAM complete dentures

CAD-CAM complete dentures present several disadvantages when compared to

conventional processed complete dentures. When manufacturer’s denture teeth
are bonded manually to milled denture bases and not adjusted on an articulator,

23
the development of a balanced occlusion will often require a clinical remount
procedure to balance the denture teeth. One other disadvantage of CAD-
CAM complete dentures to the clinician is that communication with the dental
laboratory can be more challenging and may be required multiple efforts to
resolve design-related issues. The impact of CAD-CAM on the environment
should not be neglected, the milling procedures produce resin particles, which
contribute to the plastic pollution of the environment. Similarly, silicone
impression materials are not biodegradable. Finally, the logistics require
packaging and shipping of dentures that may include international customs
procedures (Baba et al., 2021).

24
 CHAPTER TWO

CASE REPORT

25
CASE REPORT
A 90-year-old ambulative female patient was presented in SY’s private practice
for the replacement of the existing upper complete denture, projecting the lack
of its retention as her main complaint. During her interview, she was wearing
the denture and she elaborated that the problems were lack of retention during
speech and chewing. She also revealed that she could use her denture only after
the application of denture [Link] medical record revealed excellent
mental clarity, good general health in the absence of general diseases and taking
medication only for hypercholesterolemia. The clinical examination showed that
the upper complete denture was a repair of an old removable partial denture,
which was lacking coverage of the palate and unilateral contacts with the
antagonists (Figure 1). The Kennedy class I edentulism of the lower jaw had
been rehabilitated with a removable partial denture (RPD), supported by a
single metal-ceramic bridge from the lower left canine to the lower right one
(33 to 43), with all the abutments present. The intraoral examination also
revealed extensive absorption of the anterior upper and posterior lower alveolar
ridge, displacement of the occlusal plane in the posterior region well below the
middle of the retromolar pads, as well as a flabby ridge in the upper anterior
area, between the canine regions, advocating the presence of combination
syndrome.

Figure 1. Patient’s existing upper denture.

26
The patient was informed that both the upper CD and the lower RPD should be
replaced. Nevertheless, she agreed to proceed with the replacement of the lower
partial removable denture after the upper CD was inserted.
In order to counteract the expressions of the combination syndrome, the
following
steps were taken: Firstly, emphasis was given to the accuracy of the
impressions.
Secondly, an accurate functional impression was taken, which captured the
flabby
ridge in a rest state. The lower RPD was relined chairside with a tissue
conditioner material to facilitate the fit with the absorbed posterior mandibular
alveolar ridge. The patient was also informed and agreed upon necessary
occlusal adjustments. Furthermore, precautions were taken in order to avoid
application of occlusal forces on the flabby ridge and an occlusion scheme was
selected that would distribute forces evenly on the underlying alveolar ridge.

Considering the main complaint of the geriatric patient, execution of the

treatment plan initiated with fabrication of a new upper complete denture, which
was accepted by the patient. For the fabrication of the upper CD, a digital
workflow was implemented utilizing CAD/CAM technology, the clinical and
laboratory steps of which are presented next. The initial CD in this case was
designed, for educational purposes, with two different CAD programs, namely;
the Dental System 2019 program (3Shape A/S,Copenhagen, Denmark) and the
DentalCAD 2.4 Plovdiv program (exocad GmbH,Darmstadt, Germany). During
the first clinical session, an initial impression was taken with putty silicone
(Silagum.™-Putty, DMG®, Hamburg, Germany) and a market tray for
edentulous
patients. In the following step, dental stone casts were fabricated from the
impressions in the laboratory and a baseplate with wax rim was produced for

27
the upper jaw (Figure 2). In the second clinical appointment, the upper baseplate
was checked intraorally for under or overextended flanges and appropriate
corrections were made. The vertical and horizontal jaw relationships were
recorded, appropriate lip support was formed and the required elements'
guidelines for anterior tooth selection were carved on the wax. The existing
RPD in the lower
jaw was relined chairside with a tissue conditioner material (GC® tissue
conditioner, GC® Corporation, Tokyo,Japan), to compensate the alveolar ridge
absorption. For this step, the upper baseplate and the wax rim was in place
and the newly defined vertical jaw relationship was maintained. After this step,
an aliginate impression of the lower jaw with the RPD was taken. Finally, with
the patient being in occlusion and utilizing the upper baseplate a wash
impression with lighte body silicone was taken (Figure 3).

Figure 2. Baseplate-wax rim.

Figure 3. Maxillomandibular records

and wash impression.

28
In the following step, three scans were performed in a laboratory scanner
(E3,
3ShapeT™ A/S, Copenhagen, Denmark), which were the tissue surface of the
baseplate-wash impression, the lower jaw cast and the baseplate wax rim in
relation with the mandible cast (Figure 4). The "impression scanning" option
was selected in the CAD software, in order to digitally shift the maxillary tissue
surface from the negative representation (impression) to a positive
representation (digital cast). Finally, the digital files were imported into the
CAD software for further processing (Figures 5 and 6). Next, the alignment of
the casts took place by selecting reference points. The occlusal plane was
determined by the digitized wax rim in the Dental System 2019 program
(3ShapeT™ A/S, Copenhagen, Denmark) (Figure 7). The functional borders of
the denture were next designed (Figure 8). The marking of the appropriate
reference points on the alveolar ridge (canines, incisive papilla and maxillary
tuberosity) followed for tooth set-up (Figure 9). The ideal path of insertion and
the degree of undercut blocking was also determined in the software (Figure
10). In the following step, parameters for the appropriate tooth selection and set-
up were determined. In the present case, the option for milling teeth was
preferred. Therefore, after the initial selection of size and shape, teeth were
further individualized for the needs of the occlusion in this case (Figures 11 and
12). Upon the completion of the tooth set-up, the design of the denture base and
the "configuration of cameo surface"followed. A key parameter was the
thickness of the palate for the upper denture. In this case, a thickness of 1.5 mm
was chosen. Finally, a monolithic trial denture was manufactured utilizing a 3D
printer (Asiga Max UVT™, Sydney, Australia) designated for rapid prototypes.

29
Figure 4. Maxillomandibular records and wash impression scanning in a lab
scanner.

Figure 5. Digital cast of the upper edentulous jaw.

30
Figure 6. Digital Maxillomandibular records

Figure 7. Determination of the occlusal plane in Dental System 2019

(3ShapeTM A/S, Copenhagen, DDenemnmarka)rsko)ftswoafrtew.

31
Figure 8. Designing the functional border of the denture.

Figure 9. Reference points ( canines , incisive papilla and maxillary tuberosity )

are marked digitally and serve as guidelines for tooth set-up.

Figure 10. Ideal denture’s path of insertion.

32
Figure 11. Tooth selection and draft arrangement.

Figure 12. Customized tooth set-up with individual corrections in size, shape
and
position. The intensity of the occlusal contacts and the relationship of the cusps
with the occlusal plane were noted in color Blue contacts indicated teeth that
needed to be moved upward in relation to the occlusal plane or a required
virtual selective grinding.

At the third clinical session, evaluation of the trial denture took place. The
required
changes were made chairside, which included tooth arrangement by grinding or
wax addition and correcting the extension and the thickness of the base. A mild
33
overjet was created in order to avoid application of occlusal forces on the flabby
ridge. Additionally, a bilaterally balanced occlusal scheme was created and
carefully regulated chairside on the try-in denture.
A corrective impression with tissue conditioner material (GC® tissue
conditioner, GC® Corporation, Tokyo, Japan) was taken in the same
appointment. The absorbed residual ridge and the flabby mucosa in the anterior
region advocated for this decision. The monolithic denture in combination with
the selected material facilitated the taking of an accurate functional impression
(Figure 13). The final outcome was approved by the clinician and the patient
and was photographically documented (Figurcs 14-16). Finally, the adapted trial
denture and the photos were shipped to the laboratory for final adjustments and
completion of the manufacturing.

Figure 13. Corrective functional impression.

with the trial denture.

Figure 14. 3D-printed trial monolithic

denture at the session of clinical evaluation ,
unilateral occlusal contact and wax
correction were detected.

34
Figure 15. Patient’s photo in rest position with a light smile.

Figure 16. The midline has to move slightly to the right, regardless of the
midline
below. Moreover a cervical movement of 21 to the distal and a slight movement
of 22 and 23 downwards were recommended.

35
Figure 17. Defining a new tissue surface and correcting the position of the teeth. The color contrast indicates the
old and the new digital outline overlapping each other (DentalCAD 2.4 Plovdiv, exocad® GmbH, Darmstadt,

Germany).

Figure 18. Milled denture base with shaped teeth socket.

36
Figure 19. Milled denture teeth.

Figure 20. Digital denture teeth bonding kit.

Figure 21. Denture after teeth bonding.

37
Figure 22. The digitally manufactured CD after the finishing and polishing procedures.

Delivery to the patient was the final clinical step. No selective grinding was
required at this point. The final clinical session included insertion of the CD,
evaluation of the occlusion, training of the patient regarding use and
maintenance of the CD and scheduling of recall appointments [68] (Figure 23).

Figure 23. The patient wearing her new CD

The patient returned a week later for her first post-insertion recall appointment.
Two minor sore spots were recognized. One was located in the labial sulcus to
the right and the other at the buccal sulcus to the left, probably caused during
insertion of the CD. After the necessary minor adjustments, the patient did not
return for a second post-insertion visit, nor reported any problems on the phone,
which is in accordance with the reported post-insertion management from other
authors [69].

38
39
 CHAPTER THREE

DISCUSSION

40
DISCUSSION

The available systems for digital dentures present a variety of clinical

advantages. It is obvious that the influence on the well-established clinical
practices is slow as the new digital techniques need to be mastered by the
dentists, the auxiliaries and the dental technicians. Once the learning curve
starts to flatten and the indications for the application of a digital workflow
become clearer, then the community might adapt faster to the new technology.
Additionally, the CAD files can be easily stored for future use. However, digital
dental archives are considered sensitive personal data, therefore, dedicated
personnel should be adequately trained and data security policies should be
implemented. File type compatibilities should also be taken into consideration
whenever software is updated or hardware, such as 3D printers, is being
replaced. Among the advantages of the digital techniques are the superior
mechanical properties of denture bases milled from pre-polymerized PMMA
pucks, although the clinical impact of these improvements is yet to be
established through future research. Furthermore, the CDs produced from a
digital workflow seem to have improved fit with the underlying tissues in
comparison to the conventional ones. The principal idea behind digital
technology in removable prosthodontics is sparing chair time in the dental
practice, time which could be used for other, possibly more urgent or more
profitable, treatments. The goal is to shorten the denture-making technique and
to improve the final product. However, if this is actually achieved remains to be
verified with randomized long-term clinical trials. It is not clear or self-evident
that incorporation of digital technology is immediately leading to faster
production per case, unless otherwise stated by the

41
system’s protocol. As with so many scientific breakthroughs in the past, the rise
of the digital era is also associated with enthusiasm. Nonetheless, the wide
range of possible applications of the new technology and its potential value in
everyday dentistry are slowly being revealed over time. There are additional
reasons to proceed with the digital transformation. Conventional removable
prosthodontics require professionals with skills that develop over time, along
with experience, and the outcome is technique-sensitive, since error might
accumulate through the numerous manufacturing steps. It is challenging to find
experienced dental technicians for high-quality removable dentures.
Furthermore, the conventional technique is harder to track and record for post
hoc quality control and optimization of the procedure, which can significantly
benefit both the patient and the dentist. Regarding the patient benefits from the
digital CD technology, traditional dentures take a long time to be produced and
usually require multiple
appointments, which might be problematic for geriatric patients or patients with
special needs. The digital transition offers the option for faster treatment,
enhancing the convenience for the patients. Furthermore, the easily stored CAD
files from a previous treatment can be used for the production of a new
prosthesis in case of loss of the old one. In such a case, the patient is only
required for the insertion appointment. The transition to the digital era requires a
careful financial planning from the side of the dentist, who also gets the role of
the entrepreneur. In busy practices, chair time is treated as an asset that should
be optimally exploited in order to increase the business revenue. However, one
has to think as a business manager in order to comprehend and value the new
technology. Admittedly, diving into the digital world requires a totally different
mindset than earlier, a large initial investment followed by high maintenance
costs, development of new skills and recognition of previously non-existent
threats. Additionally, a large number of combinations between the classic
treatment procedure and the digital approach can be applied. Besides, the

42
selection of a CAD/CAM denture fabrication system and the pathway
combining conventional and digital workflows depends on the dentist’s
prosthodontic experience and patient-specific requirements. Moreover,
compatibilities between CAD software and CAM systems, as well as between
materials and CAM systems, are still under discussion. The technology is
evolving rapidly, which is an additional point of concern. Although the digital
transformation is accompanied by many advantages, it is not, by definition,
lucrative in all business models. It requires busy practices or dental technician
laboratories with demand for a large number of prostheses, mature markets with
developed logistic chains and an educated workforce. A quick and
wide digital transformation that is not thoroughly planned and adequately
supported both by the entrepreneur and the market might lead to unwanted
results. Therefore, the digital transformation, despite its numerous practical
advantages, requires knowledge of the market and has the characteristics of an
investment that should be analyzed not only from its technical aspects, but also
financially, before proceeding with a purchase. Nowadays, educational
institutions are in a state of incorporating the new technology in their curricula.
However, dental schools and dental technology schools might need to equally
emphasize subjects of business administration, including business planning,
development, finance, data analysis, quality assurance, sales and marketing. A
plethora of advantages derive from the digital transition and the implementation
of the digital workflow in the educational field. Apart from the positive effect
on the reputa- tion of the institution, the researchers and the students could
benefit from the transition as well, since tracking in CAD/CAM procedures is
easily performed. With the appropriate software, students can even follow up
the production steps remotely or in asynchronous distance learning set-ups, the
value of which is easily recognizable, especially nowadays, during the COVID-
19 pandemic.

43
 CHAPTER FOUR

CONCLUSION

44
CONCLUSION

In conclusion, complete denture fabrication through digital

technology seems to be versatile, enabling the combination of
the well-documented traditional technique in clinical practice
with the latest CAD/CAM breakthroughs in the laboratory
setting. The new digital technology provides new and
promising
opportunities and a way to bring the dental profession in the
next level. Nevertheless, this path should not be taken without
consideration and careful planning.

45
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