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Contents lists available at ScienceDirect

Journal of Prosthodontic Research

j o u r n a l h o m ep a g e: w w w . e l s e v i e r . c o m / l o c at e / j p o r

Case Report

Development of complete dentures based on digital intraoral impressions

—Case report
Jing-Huan Fang, Xueyin An, Seung-Mi Jeong, Byung-Ho Choi*
Department of Dentistry, Yonsei University Wonju College of Medicine, Wonju, South Korea

ARTICLE INFO ABSTRACT

Article history: Patient: A 60-year-old man presented for refabrication of his maxillary complete denture. In this case, a digital process was
Received 23 January 2017 chosen to replace the ill-fitted complete maxillary denture. A specialized scan retractor was used to retract the mobile tissues
Received in revised form 19 April 2017 of the lips, cheeks and vestibule while taking a digital impression. The interocclusal record obtained in the patient’s mouth
Accepted 24 May 2017 Available online xxx
was scanned in order to digitally register the occlusal vertical dimension. The denture base and teeth were designed on virtual
models that were mounted at the occlusal vertical dimension, and were made using CAD/CAM technology.

Keywords:
Discussion: Unlike conventional impression techniques, intraoral scanning is not able to be performed while the tissue is
Digital denture
moving. This case report used a scan retractor that facilitated stretching and fixation of the vestibular area. It also helped to
Complete denture
Digital impression retract the lips and cheeks. This report also demonstrates that virtual models at OVD can be obtained without the use of
Dental CAD/CAM conventional stone models, flasking or processing techniques. One of the main shortcomings in the existing CAD/CAM
denture fabrication technology is that it is not able to produce customized denture teeth. The present article demonstrates that
the digital denture fabrication workflow can provide customized denture teeth to optimize occlusion.

Conclusion: This case demonstrated how digital complete dentures can be made without requiring conventional stone models
or mounting the models in an articulator.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction requires considerable time and material. Therefore, the whole process is
subject to human processing errors, inaccuracies, and further increased time
According to the American Dental Association in 2014, more than one and cost [4].
third of Americans did not visit a dentist at all in the past year [1]. Infrequent Recently, computer-aided design and computer-aided manufacturing
or inconsistent dental health care puts patients at risk of tooth loss due to (CAD/CAM) technology has been applied to complete dentures [5,6]. Until
advanced caries or periodontal disease. Unfortunately, despite improvements recently, laboratory scanners were used for the digitalization process in
in dental technology and science, the total number of patients who are edentulous jaws. The information needed for a CAD/CAM restoration in
becoming edentulous has not decreased in recent years [2]. According to edentulous jaws was previously acquired extraorally based on an impression
prospective studies in the United States, the number of patients who are fully or a model cast. This technique has the same deficiencies that conventional
edentulous in one or both jaws will continue to increase, from 33.6 million in impressions and model casting have. There is also concern given the
1991 to almost 38 million by 2020 [3]. This phenomenon is partially possibility of scanning inaccuracies when using the laboratory scanner [7,8].
explained by a longer life expectancy. With an aging population, treating In order to avoid errors of the conventional CAD/CAM-production workflow,
large numbers of edentulous patients is a challenge. One of the treatment it would be more practical to perform digitalization directly in the patient's
options for these patients is complete dentures. However, the conventional mouth using intraoral scanners. Therefore, this clinical report describes the
methods of manufacturing dentures have not changed in the past 50 years. CAD/CAM fabrication of complete dentures based on direct digital
The process typically involves multiple clinical appointments and lengthy impressions of edentulous jaws taken using intraoral scanners.
laboratory schedules, and each of the involved steps

2. Outline of the case

* Corresponding author at. Dept. of Oral and Maxillofacial Surgery, Yonsei University
Wonju College of Medicine, 162 Ilsandong, Wonju, South Korea. A 60-year-old man with no significant past medical history presented with
E-mail address: [email protected] (B.-H. Choi). an unstable complete maxillary denture. On

http://dx.doi.org/10.1016/j.jpor.2017.05.005
1883-1958/© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: J.-H. Fang, et al., Development of complete dentures based on digital intraoral impressions—Case report, J Prosthodont Res (2017),
http://dx.doi.org/10.1016/j.jpor.2017.05.005
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Fig. 1. Preoperative clinical view. Fig. 3. Scan retractor positioned on the maxillary edentulous jaw.

Fig. 2. Specialized scan retractor for digital impressions of the maxillary edentulous jaws.

examination, the patient had multiple missing teeth in the mandibular jaw.
The canine, first and second premolars, and first molar were still present in the Fig. 4. Scanned image of the edentulous maxilla taken with an intraoral scanner (TRIOS) and
right mandible (Fig. 1). The patient was not interested in any treatment of the scan retractor.
mandible given financial difficulties. He was only interested in a new
maxillary denture. A digital process was chosen to replace the ill-fitted completely dried of saliva. The scan retractor was then positioned on the
complete maxillary denture. edentulous jaw so that the frame would push the vestibule down further. This
movement exposed the edentulous ridge in order to capture the greatest
In order to make digital intraoral impressions of the maxillary edentulous amount of surface area of the vestibule (Fig. 3). Scanning was performed by
jaw, a specialized scan retractor was fabricated by a company (DIO Implant retracting the lip and cheek with the scanner head itself while stretching and
Co., Korea), having a universal size (Fig. 2). It is used to retract the mobile fixing the vestibular area with the metal frame of the retractor. The scanner
tissues of the lips, cheeks and vestibule. The retractor has an aluminum frame head was moved in a zigzag manner, starting at the distobuccal areas,
and connected handle. The frame is flexible, allowing it to fit into the following the crest to the opposite side and finally scanning the palate (Fig. 4).
vestibular area. The frame thickness should be sufficient to provide retractor The scanner head was also moved in a zigzag manner to scan the mandibular
rigidity while not being excessive. The handle extends vertically from the arch, starting at the distal area of one side and following the jaw crest to the
frame in the canine region and then turns anteriorly to pass over the lip with opposite side (Fig. 5). Any areas that were not captured fully were rescanned.
minimal interference with the oral musculature. The handle located in the
canine region allows the scan head to move from the anterior to posterior
alveolar ridge segment without interference. In order to record the occlusal vertical dimension (OVD), the OVD was
established using bimanual manipulation of the mandible. Marks were placed
on the tip of the patient’s nose and on the anterior prominence of the chin.
Prior to intraoral scanning, the scan retractor was bent and adapted Putty(polyvinyl siloxane impression material) was used to make interocclusal
intraorally to fit the contours of the patient’s edentulous arch. The frame records at the OVD. First, heavy-body putty was used to make a record base
should be extended bucally as far as possible to scan the labial or buccal for the maxillary arch. The material was seated and adapted intraorally to fit
surface of the edentulous ridge. After the scan retractor was contoured, the contours of the patient’s maxillary edentulous arch. After placing the
intraoral digital impressions were acquired using an intraoral scanner light-body putty over the heavy-body putty base, the record base was reseated
(TRIOS, 3Shape A/S, Copenha-gen, Denmark). First, the edentulous ridge on the maxillary
was cleaned and

Please cite this article in press as: J.-H. Fang, et al., Development of complete dentures based on digital intraoral impressions—Case report, J Prosthodont Res (2017),
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Fig. 8. Interocclusal record image taken using an intraoral scanner.

Fig. 5. Scanned image of the mandible taken using an intraoral scanner (TRIOS).

Fig. 9. Virtual models that were mounted according to the scanned interocclusal record.

Fig. 6. Record base made using heavy and light-body putties.

Fig. 7. Interocclusal record made by injecting interocclusal record material into the area
between the record base and the occlusal surfaces of the mandibular teeth.

edentulous arch (Fig. 6). A vinyl polysiloxane interocclusal record material Fig. 10. Virtual models mounted at OVD.
(EXABITE II NDS Bite Registration Creme; GC America Inc., Alsip, Il,
USA) was injected into the area between the record base and the occlusal interocclusal record (Fig. 9). In order to do so, the two scanned images were
surfaces of the mandibular teeth. The patient’s mandible was then aligned using the interocclusal record image by means of best-fit matching.
immediately guided to the OVD, where it was stabilized until the After mounting the two scanned images, the interocclusal record image was
interocclusal record material was completely polymerized (Fig. 7). The deleted. Next, the virtual models mounted at the OVD were obtained (Fig.
interocclusal record was then removed from the mouth and scanned using the 10). The obtained data were imported into the software to design the complete
intraoral scanner (Fig. 8). The scanned maxillary edentulous jaw and the dentures. The denture base and maxillary teeth were virtually designed by
scanned mandibu-lar teeth were virtually mounted according to the scanned using denture planning software (Dental

Please cite this article in press as: J.-H. Fang, et al., Development of complete dentures based on digital intraoral impressions—Case report, J Prosthodont Res (2017),
http://dx.doi.org/10.1016/j.jpor.2017.05.005
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Fig. 14. Milled denture base and teeth.

Fig. 11. Virtual design of the denture base and teeth.

Fig. 15. Complete denture.

Fig. 12. Virtual articulator settings.

Fig. 16. Patient with complete denture.

Fig. 13. Milling data for the denture base and teeth.
securely bonded onto the milled denture base (Fig. 15). Finally, the denture
System, 3Shape A/S, Copenhagen, Denmark) (Fig. 11). The program allowed was placed in the patient’s mouth (Fig. 16). There were minimal chairside
occlusal adjustment via the virtual articulator (Fig. 12). More accurate denture adjustments needed. The retention of the denture base was excellent. The
teeth could be prepared through simulation of the mastication function using patient did not have difficulty with mastication and was pleased with the
the virtual articulator. The resulting data were then exported to a milling esthetic outcome of his denture.
machine (Trione Z; Dio Implants, Pusan, Korea) for dentures manufacturing
(Fig. 13). The denture base was milled from a pink block of prepolymerized
cross-linked polymethyl methacrylate (PMMA) disks. The teeth were also 3. Discussion
milled from the PMMA disk using the 5-axis milling machine and fine milling
tools (Fig. 14). The milled teeth were There are several key steps in the digital denture fabrication workflow.
The first step is to take direct digital impressions of a

Please cite this article in press as: J.-H. Fang, et al., Development of complete dentures based on digital intraoral impressions—Case report, J Prosthodont Res (2017),
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patient’s edentulous jaw. The second step is to digitally register the OVD. The well on the patient’s arch without relining it. One of the main shortcomings in
last step is to mill the denture bases and teeth using CAD/ CAM technology. the existing CAD/CAM denture fabrication technology is that it is not able to
The first step was the most difficult in this case; this was because the mobile produce customized denture teeth. The present case demonstrates that the
tissue of the lips, cheeks, and vestibule constantly changed while taking the digital denture fabrication workflow can provide customized denture teeth to
digital impression. Unlike conventional impression techniques, intraoral optimize occlusion. A further controlled clinical study will be necessary to
scanning could not be performed while this tissue was moving [9]. It was determine whether the digital workflow for dentures is an improvement over
more difficult to scan mobile soft tissues, such as the vestibule, than it was to the conventional technique in terms of denture-base fitness and occlusion.
scan immobile soft tissues, such as the palate or alveolar ridge. The main
advantage of the scan retractor used in this case is that it facilitated stretching
and fixation of the vestibular area. It also helped to retract the lips and cheeks.
The time needed for the full-arch scans was approximately 2 min for the 4. Conclusion
maxillary arch and 1.5 min for the mandibular arch. During the intraoral
scanning procedure in the edentulous patient’s mouth, the patient felt This report presents a digital workflow for CAD/CAM fabricated
comfortable and pleasant in the dentist’s chair. During the intraoral scanning complete dentures. Digital impressions of edentulous jaws are taken directly
procedure in the edentulous patient’s mouth, there were no specific stitching in patients’ mouths using a specialized scan retractor and intraoral scanner.
problems. However, many pictures were taken, and considerable time was The digital registration of the maxillomandibular relationship is made using
required to stitch the separated pictures. Approximately 2000 3D pictures scanned images of the interocclusal record. Both the denture base and teeth
were used to capture the maxillary arch and about 4 min were needed to stitch are milled using CAD/CAM technology. This digital workflow allows dentists
the pictures, whereas approximately 1000 3D pictures were used to capture to make complete dentures without using conventional stone models or
the mandibular arch and about 2 min were needed to stitch the pictures. mounting stone models in an articulator.

Acknowledgments

With regard to the second step in the digital denture fabrication workflow, The author would like to express appreciation for the support provided by
scanned images of the interocclusal record were used to record the the Ministry of Trade, Industry & Energy (MOTIE, Korea) under Industrial
maxillomandibular relationship. Virtual models were mounted according to Technology Innovation Program (grant # 10060000).
the scanned interocclusal record. Prior to this case, it has not been possible to
use intraoral scanners to directly take the maxillomandibular relationship
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Please cite this article in press as: J.-H. Fang, et al., Development of complete dentures based on digital intraoral impressions—Case report, J Prosthodont Res (2017),
http://dx.doi.org/10.1016/j.jpor.2017.05.005