DENTAL TECHNIQUE

Removable complete digital dentures: A workflow that

integrates open technologies
Lucio Lo Russo, DDS, PhDa and Angelo Salamini, Engb

Digital technologies for the ABSTRACT

design and fabrication of
Digitalization of the design and manufacture of removable complete dentures has numerous ad-
removable complete dentures vantages. The workflow as presented integrates current open digital technologies into a functional
have made rapid progress. protocol, enabling complete dentures to be designed and fabricated without system-specific
Current innovations and tech- trays or instruments. This is done by using a conventional technique to acquire anatomic
nological developments in information. (J Prosthet Dent 2017;-:---)
computer-aided design and
computer-aided manufacture (CAD-CAM), such as mill- digital technologies may sometimes be limited to denture
ing and rapid prototyping, allow the design and manu- design, whereas production may still be based on a con-
facture of removable dentures to be fully digitized.1 Full ventional technique (CFD).7
2
digitalization leads to favorable clinical outcomes, better Thus, to exploit the benefits derived from incorpo-
retention,3 fewer patient visits,4 potentially enhanced rating digital technologies and materials into complete
material properties and biocompatibility,5,6 advances in denture prosthodontics, a workflow was developed to
standardization of both clinical results and research,1 transfer as much of the conventional technique as
simplified identification of anatomical landmarks on possible into the digital approach. The aim was to avoid
digitized casts, reproducible and less time-consuming the use of system-specific trays or instruments, exclusive
7
tooth arrangements, easy data storage, and production dental materials, or system-inherent techniques. In
of duplicate dentures. addition, the idea was to integrate open technological
To date, 5 different systems for digital complete den- systems, thus facilitating the combined and efficient use
ture fabrication have been described: Wieland Digital of any open scanner, CAD-CAM software, or milling
8
Denture (WDD), AvaDent Digital Dentures (ADD), 5 machine.
Whole You Next Teeth (WYNT),9 Baltic Denture System These aspects may be beneficial for an easier transi-
9 7
(BDS), and Ceramill Full Denture (CFD), and another tion to the digital concept, as clinicians can still work with
9
recently announced system, Vita Vionic. Many aspects of familiar techniques and devices. Clinicians can thus
these systems do not favor the routine application of gradually change the way they work by incorporating
digital concepts and workflows to complete denture new aspects without abandoning acquired expertise or
fabrication. In fact, some systems require system-inherent discarding their equipment, all of which makes sense
equipment, trays, or materials (WDD, ADD, WYNT, from a practical, financial, and psychological point of
9 10
BDS), have proprietary features that limit integration view.
with other systems (WDD, ADD, WYNT, BDS, CFD), or
cannot manage patients with a single edentulous arch TECHNIQUE
9
(WDD, DBS). In addition, as their clinical application
may be quite different from that of conventional proced- 1. Make anatomic impressions (Alginoplast; Heraeus
ures, specific training and expertise are needed. Moreover, Kulzer GmbH) of the edentulous arches (Fig. 1A, B).

a
Associate Professor, Oral Diseases, Department of Clinical and Experimental Medicine, School of Dentistry, University of Foggia, Foggia, Italy.
b
Co-founder, Sintesi Sud Srl, Ariano Irpino, Italy.

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Figure 1. Preoperative conditions. A, Maxilla. B, Mandible.

Figure 2. Occlusal records. A, Occlusion rims with hard wax mounted on 3D-printed baseplates. B, Adapted occlusion rims register occlusal plane and
other information needed for tooth arrangement.

2. Make casts and scan them with 3Shape Trios 3

color, enabling the function for gypsum scanning,
and then process and export scans with the Trios
software. Use Trios 3 also for all the other scans.
3. Design custom trays for definitive impressions. Use
the specific workflow available in 3Shape Dental
System 2016 (release 3). Use this software also for
all the other steps in the design process.
4. Fabricate rapid prototype custom trays. Transfer
the standard tessellation language (STL) files of the
designed custom trays to the software application
of the 3-dimensional (3D) printer (M200; Zortrax)
to obtain the printable file. Use a 0.09-mm thick-
ness of the material (Z-Ultrat; Zortrax).
5. Make definitive impressions (Impregum Penta; 3M Figure 3. Frontal view of scanned casts and occlusion rim alignment.
ESPE).
6. Pour definitive casts (Vel-Mix Stone; Kerr Corp) completely adapted to the mucosa. Add some
and scan them. mechanical retention for the wax rim to the
7. Using the digitized definitive casts, design base- baseplates.
plates for occlusion rims. Use the workflow for 8. Make rapid prototype baseplates for occlusion
individual impression trays, setting the space for rims. Transfer the STL files of the designed base-
the material to zero so that the baseplates are plates to the software application of the 3D printer

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Figure 4. Digital workflow for denture design. A, Setting occlusal plane: lateral view of aligned casts and occlusion rims. B, Tooth selection and proposal
for tooth arrangement. C, Tooth position can be modified according to information integrated in occlusion rims. D, Software proposal for denture
base design.
(M200; Zortrax) and then print with a 0.09-mm
thickness of the material (Z-Ultrat; Zortrax).
9. Add hard wax to the baseplates for the definitive
occlusion rims (Fig. 2A).
10. Record the vertical dimension, occlusal plane, and
lip support. Adapt the occlusion rims to the patient
in order to register all the relevant information for
the tooth arrangement in terms of adequate lip
support, maxillary incisor length, midline, vertical
dimension, and occlusal plane.
11. Make the facebow and jaw relationship records.
Use Arcus Digma II (KaVo Dental GmbH) to re-
cord settings for the virtual articulator and centric
relation according to the following procedure:
a. Adapt the para-occlusal spoon (KaVo Dental
GmbH) to the mandibular occlusion rim and
stabilize with hard wax. Create notches on the
occlusal aspect of both rims.
b. Obtain centric relation according to the guided
method and workflow recommended by the
manufacturer.
c. Place recording material (Registrado X-tra;
Voco) on the occlusal aspect of the rims. Gently
Lo Russo and Salamini
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guide the mandible into the registered jaw
relation and hold in place until the material has
completely polymerized (Fig. 2B).
12. Put the definitive casts on the occlusion rims and
scan the buccal aspect of the rims and cast bases as
a single object. The aim is to align the casts as
detailed in the subsequent step and to transfer all
the information registered and incorporated in the
occlusion rims to the design process. Make small
scratches on the rims to optimize the scanning,
and create small notches on the cast bases to
optimize the alignment (Figs. 3, 4A).
13. Create the order (“order” is how the design pro-
cess is referred to in 3Shape Dental System soft-
ware) for the maxillary and mandibular complete
denture.
14. Import, in the order created in point 13, the digi-
tized definitive casts (as obtained in point 6) and
the scan of the occlusion rims (as obtained in point
12) and align them (Figs. 3, 4A). Carry this out
using the 3-point method available in the specific
workflow in the ScanItDental application, which is
part of the 3Shape Dental System.
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Figure 5. A, Definitive denture design. B, Clinical evaluation of trial
dentures. C, Definitive dentures delivered to patient.
15. Design complete dentures according to the
straightforward 3Shape Dental System workflow.
Briefly, the main steps of the workflow are setting
the occlusal plane (as integrated in the occlusion
rims) (Fig. 4A), identifying anatomic landmarks,
blocking out undercuts, selecting teeth from
available libraries (Fig. 4B), moving and arranging
teeth according to the desired occlusal concept,
considering information included in the occlusion
rims (Fig. 4C), designing denture bases (Fig. 4D),
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and finalizing the design (Fig. 5A). At the end of
the design process, an STL file of the denture bases
is created. While creating this file, the CAD soft-
ware automatically creates sockets for teeth in the
denture base.
16. Make a rapid prototype of the trial dentures. After
printing with a 3D printer (M200; Zortrax), cover
the trial dentures with a thin layer of pink wax
(Fig. 5B).
17. Clinically assess trial dentures to evaluate fit, es-
thetics, maxillomandibular relation, and occlusion
(Fig. 5B). At this stage, changes are still possible
and, if required, can be incorporated into the
definitive dentures.
18. Mill the denture bases from the STL files of the
denture bases in Hyperdent CAM software
(Fig. 6A) to create the corresponding project in a
25-mm-high poly(methyl methacrylate) blank
(Smile Cam Total Prosthesis; Pressing Dental srl)
and the corresponding output for the specific
milling machine (Roland DWX-51D) (Fig. 6B-D).
19. Bond commercial teeth (as selected during the
design process) to the milled bases with a
methacrylate-based bonding agent (IvoBase CAD
Bond; Wieland Dental) (Figs. 5C, 7).
DISCUSSION
In the technique as presented, open digital technologies
(3Shape Trios 3 [scanner]; 3Shape Dental System 2016
[CAD software]; Hyperdent [CAM software]; Roland
DWX-51D [milling machine]; and Zortrax M200 [3D
printer]) were integrated into a functional workflow to
fabricate complete dentures (Figs. 5C, 7) from anatomic
information acquired with a conventional technique
procedure that does not require any system-specific trays
or instruments.
Milling the definitive denture base, which is still not
feasible with other proposed systems (CFD),8 can be
performed in a single step. This can be carried out in any
equipped laboratory, with no need for a central milling
laboratory. Just 1 blank is milled for each denture arch,
whereas, for example, the WDD system requires 3 blanks
to be milled. This is possible because 3D printing is used
to produce the custom trays, baseplates for occlusion
rims, and trial dentures to reduce the costs and time
involved. With a workaround in the current release of
3Shape Dental System 2016, single arch dentures can
also be created.
This workflow can also be tailored to individual needs
without affecting its functionality. For example, it is
possible to scan impressions and avoid cast preparation,
or prepare custom trays and occlusion rims according to
the conventional procedure. Gothic arch registration of
centric relation is possible by adding the necessary
Lo Russo and Salamini
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Figure 6. Details of production phase. A, Computer-aided manufacture project of maxillary denture base with tooth sockets. B, Milled maxillary base.
Note outline of holes in thin septa dividing tooth sockets. C, Intaglio of maxillary denture. D, Mandibular denture with teeth inserted to evaluate fit.

impression is made in the first visit by using existing

dentures as trays or if the patient can wait approximately
2 hours for the custom trays to be built.
The provision of maxillary and mandibular prostheses
took an average of 90 minutes of chairside time, 150
minutes of laboratory time, and 270 minutes to mill 2
denture bases before manual polishing.
The presented workflow is completely functional.
However, the entire process can still be fine tuned,
especially in terms of reducing production time and
digitizing anatomic information. In addition, clinical trials
addressing long-term results are needed.

REFERENCES
Figure 7. Patient with definitive dentures.
equipment to the occlusion rims. The casts, rims, and
their alignment can also be scanned with a laboratory
scanner and a transfer stand.
Dentures can normally be delivered within 5 clinical
sessions: in 2 of 7 patients, minor adjustments were
required in a further clinical session after denture de-
livery. Treatment may also be reduced to 4 visits by
omitting the trial evaluation, or even to 3, if the definitive
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