DENTAL TECHNIQUE

Complete denture digital workflow: Combining basic principles

with a CAD-CAM approach
George Kouveliotis, DDS, MSc,a Theodoros Tasopoulos, DDS, MSc,b Ioannis Karoussis, DDS, MSc, Dr med dent,c
Nelson Rfa Silva, DDS, MSc, PhD,d and Panagiotis Zoidis, DDS, MS, PhDe

Complete dentures have been ABSTRACT

the predominant treatment This report describes a digital workflow for the fabrication of a complete maxillary denture
option for restoring complete opposing an implant-retained overdenture. This procedure provides a predictable and accurate
edentulism, with different 3-visit technique to digitally scan and articulate edentulous ridges, avoiding the discomfort
clinical approaches being pro- associated with analog impression making. Wax rims were applied to intraorally relined plastic
posed to restore function and edentulous stock trays. The occlusal relationship was registered at the appropriate vertical
provide natural esthetics. In- dimension of occlusion by using these tray and rim assemblies. The digital laboratory scanning
of the relined tray and rim assemblies resulted in accurate virtual articulation of the digital
formation on detailed impres-
edentulous intraoral scans. The removable restorations were digitally designed, milled, and
sion techniques or appropriate delivered, and the clinical and laboratory steps are described. (J Prosthet Dent 2021;-:---)
tooth positioning has been
well established.1,2 should be followed during digital scanning, as it has been
Computer-aided design and computer-aided found to be more effective than the conventional one for
manufacturing (CAD-CAM) systems provide advantages thin or sharp mucosa biotype and flabby, movable tissue,
for complete denture fabrication,3 including avoiding the resulting in fewer posttreatment adjustments and
discomfort of conventional impression making, improving increased patient satisfaction.11-17
processing accuracy, and reducing laboratory and chair-
side time.4-8 The use of intraoral scanners (IOSs) and TECHNIQUE
laboratory scanners for fixed or implant-supported resto-
A completely digital protocol is described for the resto-
rations has also been well documented.9
ration of an edentulous maxilla opposing a mandibular
Intraoral digital scanning for edentulous patients has
overdenture retained by 2 implants (Fig. 1).
been problematic because of the lack of accuracy and
difficulty in capturing viscoelastic soft tissues, although 1. Use an IOS (TRIOS 3; 3Shape A/S) to make digital
different approaches have been developed for complete scans of the edentulous arches. Send the standard
denture digital scanning and manufacturing.10 Initial tessellation language (STL) files to the laboratory
comparison of conventional impression making with through the appropriate server (3 Shape Commu-
digital scanning revealed differences related to mucosa nity; 3Shape A/S) (Fig. 2).
resilience.10 These results indicated that digital complete 2. Choose the appropriate size of handle-free eden-
denture fabrication should follow a different workflow tulous stock plastic trays (DENTALINE; Falcon) for
from the conventional one. The mucostatic concept both ridges. Attach occlusion wax rims and

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Private practice, Athens, Greece.
b
Private practice, Athens, Greece.
c
Associate Professor, Department of Periodontics, National and Kapodistrian University of Athens, Dental School, Athens, Greece.
d
Professor, Department of Restorative Dentistry, Federal University of Minas Gerais (FUMG), Belo Horizonte, Brazil.
e
Associate Professor and Director, Division of Prosthodontics, Department of Restorative Dental Sciences, University of Florida - College of Dentistry, Gainesville, Fla.

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Figure 1. Edentulous ridges. A, Maxilla. B, Mandible.

Figure 2. Intraoral digital scans. A, Maxillary. B, Mandibular.

Figure 3. Intraoral registration assemblies. A, Occlusion rims on edentulous stock trays. B, Tray and rim assemblies intraorally relined with polyvinyl
siloxane impression material.

perform an intraoral reline by using medium vis- 3. Make modifications to the wax rims according to
cosity polyvinyl siloxane material (Regidur i; Bie- the patient’ s facial esthetics and lip support, facial
lefelder Dentalsilicone GmbH & Co KG) to midline, canine position, smile line, and occlusal
conform to arch form and provide retention and plane (Fig. 4).
stability (Fig. 3).

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Figure 4. Determining esthetic and functional parameters. Figure 5. Registering centric relation at appropriate vertical dimension
of occlusion.

Figure 6. Scanned tray and rim digitized assemblies. A, Maxillary. B, Mandibular.

Figure 7. Three-point anatomic registering allowing superimposition and articulation. A, Maxillary intraoral scan. B, Mandibular laboratory scan.

4. Adjust the wax rim height to an acceptable vertical A/S) and digitize the registration to an STL file
dimension of occlusion. Make a centric relation record (Fig. 6).
in the selected vertical dimension of occlusion (Fig. 5). 6. Superimpose the IOS STL files and the laboratory
5. Transfer the articulated relined tray and rim STL files (3 reference points on each STL file are
assemblies to a laboratory scanner (E3; 3Shape needed) (Fig. 7) and allow for the simultaneous

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Figure 8. Articulated digital scans.

articulation of digital casts, digital base plates, and

wax rims and digital records (Fig. 8).
7. Digitally design denture bases for complete eden-
tulous coverage with maximized retention and lip
support. Digitally design tooth position and select
artificial teeth from the available digital library
(Dental System; 3Shape A/S) (Fig. 9).
8. Send the resulting file to a 3D printer (Asiga MAX;
Asiga) to produce a trial denture (FREEPRINT;
DETAX GmbH & Co, KG) to imitate the conven-
tional wax tooth clinical evaluation. Assess clinical
parameters such as denture retention, flange
extension, esthetics, phonetics, vertical dimension,
maxillomandibular relation, and occlusion. Make
necessary adjustments at this stage (Fig. 10).
9. Scan the adjusted prototypes with the same labo-
ratory scanner. Send the new STL files to a milling
machine (Ceramill Motion 2; Amann Girrbach AG)
to fabricate the definitive dentures.
10. Bond milled teeth (SR Vivodent CAD Multi; Ivoclar
Vivadent AG) to the denture base with an auto-
polymerizing polymethyl methacrylate-based 2-
component bonding system, according to the
manufacturer’s instructions (IvoBase CAD Bond;
Ivoclar Vivadent AG).
Figure 9. Designing prostheses. A, Digitally designed sockets in denture
11. Polish and glaze the definite prostheses (Fig. 11). base to receive milled teeth. B, Digital library tooth selection and
12. Incorporate the LOCATOR attachments (Xive customization. C, Complete dentures digitally articulated and designed
Locator Abutment; Dentsply Sirona) intraorally for milling process.
with an autopolymerizing polymethyl methacrylate
resin (LuxaPick-up; DMG Chemisch-
Pharmazeutische Fabrik GmbH) (Fig. 12). clinical time.6,7 Saponaro et al reported that the mean
number of clinical appointments needed for CAD-CAM
complete denture fabrication was 2.39, whereas with
conventional workflow, at least 5 appointments are
DISCUSSION
needed.8
The use of CAD-CAM technology in complete denture In the clinical technique presented, 3 clinical ap-
fabrication has helped dentists reduce the use of different pointments were scheduled (digital scanning and re-
materials, standardize clinical procedures, and save cords, printed clinical evaluation, and definitive

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Figure 10. Trial dentures of clinical evaluation to verify esthetics, Figure 11. Definitive prostheses. Reverse articulation recorded in
phonetics, and function. occlusion rims transferred to prostheses.

prosthesis delivery). Retention was satisfactory, and no

postinsertion appointment was needed. Even though
studies report that approximately 85% to 87% of patients
require a postinsertion adjustment within 24 hours when
conventional protocols are used, minor or no adjust-
ments were needed when the digital protocol was used.5
The intraoral digital scanning of fully edentulous areas
is based on the mucostatic impression concept, with no
pressure being applied to the recorded areas and no
border molding. The limitation of not recording the
vestibular depth and width is compensated for by this
mucostatic digital scanning that results in maximizing the
surface tension between the intaglio surface of the den-
ture base and the underlying tissue.10,11
Digital mucostatic scans result in slightly under- Figure 12. Delivered prostheses.
extended denture flanges, resulting in no trauma for
overextension. Denture retention is not achieved by the the trial denture and can be transferred to the definitive
peripheral seal, but mainly by the intimate contact of the prosthesis. Bidra et al16 evaluated edentulous patients
surface of the denture base with the underlying tissues treated with a digital workflow and reported favorable
under the principle of surface tension.12 Slight under- patient-centered outcomes at the 1-year evaluation for
extension of the flange does not affect denture retention, phonetics (93%), lip support (94.3%), mastication effi-
although excessive underextension is not desirable ciency (91.5%), esthetics (94.8%), and overall denture
because it may reduce secondary retention and denture satisfaction (92.8%) according to a visual analog scale.
stability and impair lip and cheek support.13,14 Border A 2-visit technique has been proposed by Bidra17 for
molding and palatal seal have been reported not to be the fabrication of a CAD-CAM implant overlay denture,
required, and shorter denture flanges do not impact involving border molding, definitive impression making,
denture retention because of the intimate tissue intraoral registration, and occlusal plane recording with
contact.15 proprietary materials provided by the manufacturer
Esthetics and occlusion were assessed in the first visit (AvaDent Digital dentures; Global Dental Science LLC).
(determined in the record base stage and followed An anatomic measuring device with a plastic pin on the
through the intraoral registration stages). The reverse palate and a central plate on the mandibular base (central
articulation design resulted from the configuration and bearingetracing device) was used to record the max-
shape of the mandibular arch resulting from the ridge ilomandibular relationship, and an occlusal plane reader
resorption pattern and was used to enhance mandibular was used to record the horizontal angulation of the
denture stability and retention and avoid cheek tissue occlusal plane. A laboratory scanner was used to digitize
injury during function. Esthetics and occlusion were and articulate the definitive casts. The present digital
confirmed in the second visit by using the denture pro- technique does not require the use of proprietary mate-
totype. Alterations and changes can still be performed on rials or special devices and allows the clinician to follow

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conventional reline impression and registering methods. 8. Saponaro PC, Yilmaz B, Heshmati RH, McGlumphy EA. Clinical performance
of CAD-CAM fabricated complete dentures: A cross-sectional study.
Limitations of the described technique include the J Prosthet Dent 2016;116:431-5.
extended clinical time of the first visit that included 9. Chochlidakis KM, Papaspyridakos P, Geminiani A, Chen CJ, Feng IJ,
Ercoli C. Digital versus conventional impressions for fixed prosthodon-
digital scanning, the intraoral reline procedure, the tics: A systematic review and meta-analysis. J Prosthet Dent 2016;116:
transformation of the stock trays into occlusion rims, and 184-90.
10. Lo Russo L, Caradonna G, Troiano G, Salamini A, Guida L, Ciavarella D.
the interocclusal registration procedure. In addition to a Three-dimensional differences between intraoral scans and conventional
laboratory scanner, an IOS is required. Moreover, any impressions of edentulous jaws: A clinical study. J Prosthet Dent 2020;123:
264-8.
design software program and milling machine can be 11. Lo Russo L, Salamini A. Removable complete digital dentures: A
used with this digital technique. workflow that integrates open technologies. J Prosthet Dent 2018;119:
727-32.
12. Rao S, Chowdhary R, Mahoorkar S. A systematic review of impression
SUMMARY technique for conventional complete denture. J Indian Prosthodont Soc
2010;10:105-11.
13. Lo Russo L, Salamini A. Single-arch digital removable complete denture:
A 3-clinical appointment digital dental technique was a workflow that starts from the intraoral scan. J Prosthet Dent 2018;120:
described to fabricate complete dentures. This digital 20-4.
14. Lo Russo L, Ciavarella D, Salamini A, Guida L. Alignment of intraoral scans
technique eliminated the need for expensive proprietary and registration of maxillo-mandibular relationships for the edentulous
materials and devices and the uncomfortable conven- maxillary arch. J Prosthet Dent 2019;121:737-40.
15. Carlsson GE, Ortorp A, Omar R. What is the evidence base for the efficacies
tional impression technique, facilitating and shortening of different complete denture impression procedures? A critical review. J Dent
dental treatment for completely edentulous patients. 2013;41:17-23.
16. Bidra AS, Farrell K, Burnham D, Dhingra A, Taylor TD, Kuo CL. Prospective
cohort pilot study of 2-visit CAD/CAM monolithic complete dentures and
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