Вы находитесь на странице: 1из 13

concepts and clinical methods of obtaining required morphological data

CAD/CAM fabricated complete dentures:

Charles J. Goodacre, DDS, MSD,a Antoanela Garbacea, DDS,b W. Patrick Naylor, DDS, MPH, MS,c Tony Daher, DDS, MSEd,d Christopher B. Marchack, DDS,e and Jean Lowry, PhDf Loma Linda University School of Dentistry, Loma Linda, Calif; Loma Linda University School of Allied Health Professions, Loma Linda, Calif; University of Southern California School of Dentistry, Los Angeles, Calif
The clinical impression procedures described in this article provide a method of recording the morphology of the intaglio and cameo surfaces of complete denture bases and also identify muscular and phonetic locations for the prosthetic teeth. When the CAD/CAM technology for fabricating complete dentures becomes commercially available, it will be possible to scan the denture base morphology and tooth positions recorded with this technique and import those data into a virtual tooth arrangement program where teeth can be articulated and then export the data to a milling device for the fabrication of the complete dentures. A prototype 3-D tooth arrangement program is described in this article that serves as an example of the type of program than can be used to arrange prosthetic teeth virtually as part of the overall CAD/CAM fabrication of complete dentures. (J Prosthet Dent 2012;107:34-46) The acronym CAD/CAM represents Computer-Aided Design (CAD) and Computer-Aided Manufacturing (CAM). In some industries, an equivalent term, CAD/NC (Numerical Control) is used. With this design and manufacturing technology, CAD software defines the geometry of an object while CAM programming directs the fabrication process. The CAM manufacturing component was actually developed in advance of the CAD technology.In the 1950s, manufacturers first adopted tools controlled by a system of numbers and letters to produce objects with complex shapes in both an accurate and repeatable manner (Numerically Controlled or NC). Paper tapes fed numerical data into machines that then positioned and directed tools to create the shape of the item in production.1 The worlds first CAM software program using a numerical control programming tool named PRONTO, was developed in 1957 by Dr Patrick J. Hanratty, who is often referred to as the father of CAD/CAM technology.2 It was not until the late 1960s that numerically controlled machines became commercially available. However, the development began in 1962 as an outcome of a universal and enhanced NC programming language known as Automatically Programmed Tools (APT) created at the Massachusetts Institute of Technology. Surprisingly, the introduction of ComputerAided Design (CAD) had little impact on Computer Numerical Control (CNC) processes until the actual development of enhanced CAD applications occurred. This resulted in a lasting linkage between CAD and CAM1 software and machinery, and the technology expanded from that point forward. Initial dental applications In the early 1980s, CAD/CAM technology was used to produce clinical dental restorations when Andersson3 envisioned the use of titanium for the fabrication of crowns. Andersson selected titanium because of the

Presented at the Academy of Prosthodontics meeting, Hilton Head, NC, May 6, 2011. Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry. Advanced Education Student, Implant Dentistry and Prosthodontics, Loma Linda University School of Dentistry. c Associate Dean for Advanced Dental Education; Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry. d Associate Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry. e Associate Clinical Professor, Advanced Prosthodontics, University of Southern California School of Dentistry. f Emeritus Professor, Speech-Language Pathology, Loma Linda University School of Allied Health Professions.
a b

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012
established biocompatibility he had learned about from the pioneering work of Brnemark, who is recognized for the development and introduction of contemporary dental implants. Since casting titanium was not possible at that time, dental restorations were fabricated by using another process. In 1982, Andersson developed the CAM portion of the fabrication process by using a combination of spark erosion and copy milling.3 In that same year, he cemented the first CAM fabricated titanium complete crown.3 Andersson quickly recognized that the potential commercialization of the process would be costly and the resulting fabrication processes would involve digitization, a realization which then led to the development of the CAD fabrication process. His pioneering activities became commercially available as the Procera method of fabricating crowns in 1983. The Procera system was subsequently acquired by Nobelpharma (now Nobel Biocare) in 1988. The patent that served as the basis for the 1982 production process did not limit fabrication to the use of a physical definitive die of the prepared tooth but included the potential use of a virtual tooth preparation and definitive die derived from a computer. Andersson indicated that the first CAD/CAM Procera crown, derived from a computer file rather than a conventional gypsum die, was fabricated around 1990 (Personal communication, Matts Andersson PhD, e-mail November 2010). Another important dental application of CAD/CAM technology also occurred in the 1980s. Mrmann4 developed an interest in tooth-colored restorations. He wanted dentists to be able to produce durable inlay restorations chairside by scanning cavity preparations intraorally and using the resulting CAD data to form a ceramic restoration that would fit the prepared tooth by using CAM technology. Mrmann developed a prototype CAD/CAM device in 1983, and a system became fully functional in 1985. In September of that same year, Mrmann placed the first chairside fabricated ceramic restoration with equipment introduced and marketed as the CEREC 1 system (Sirona Dental Systems LLC, Charlotte, NC).5 That first clinical restoration was an MOD feldspathic porcelain inlay fabricated for a maxillary left second molar.4 The design and milling of single crowns, partial fixed dental prostheses, and a variety of implant components and prostheses have since become relatively common clinical and laboratory procedures. Despite these many advances, CAD/CAM technology has yet to be used for the fabrication of conventional complete dentures. Transition to complete denture fabrication Since 1995, the principal author has used a series of clinical procedures intended to facilitate the fabrication of conventional complete dentures and implant prostheses. These same procedures can also be adapted for the fabrication of complete dentures with CAD/CAM technology when it becomes commercially available. The clinical technique is different from conventional complete denture methods in that it requires impressions that record the shape of both the intaglio and cameo surfaces of complete denture bases while also identifying muscular and phonetic locations suitable for the placement of prosthetic teeth. In the future, it will be possible to scan the morphology recorded by using this technique and to transfer that digital data to a CAD software program where denture teeth can be virtually placed into appropriate positions. Then a dental laboratory technician can export the denture base form and tooth arrangement morphology to a milling machine for the fabrication of the maxillary and mandibular complete dentures. As an additional step beyond this clinical technique, a prototype CAD program, known as the 3D Tooth Arrangement Program, was developed by the principal author aided by computer programmers in 2009. This prototype software was created for the following 4 purposes: 1) to pilot test the software programming and obtain student and faculty input on its design and use; 2) to help students visualize the different types of occlusal schemes that can be created for complete dentures by being able to produce mandibular movements between different types of opposing 3-dimensional (3-D) denture teeth; 3) to teach students how to arrange teeth virtually before performing the actual laboratory procedure; and 4) to permit faculty to develop a library of acceptable and inappropriate tooth arrangements to assess student competency. This program was used for the first time by second year dental students at the Loma Linda University School of Dentistry in the fall of 2010 during the complete denture preclinical course. The educational applications and benefits of this program will be described in a subsequent publication. The purpose of this article is to describe the clinical procedures required to record the morphology of the intaglio and cameo surfaces of complete denture bases as well as the muscular and phonetic locations suitable for the placement of prosthetic denture teeth.

35

CLINICAL TECHNIQUE
The following technique includes all the requisite steps required to produce maxillary and mandibular definitive impressions of the edentulous arches in a manner that will permit the application of CAD/CAM technology. The overall goal is to make definitive edentulous impressions that capture the edentulous ridges and borders (vestibules) while recording as much as possible of the functional soft tissue that will be in contact with the facial surfaces of the denture bases located occlusal to the denture borders. Additionally, the impressions should record muscular and phonetic positions suitable for placing prosthetic denture teeth.

Goodacre et al

36

Volume 107 Issue 1

1 A, Custom acrylic resin mandibular impression tray. Tray handle is fabricated so it extends vertically from anterior ridge crest and then turns anteriorly to pass through lips with minimal interference with oral musculature. B, Maxillary and mandibular moldable stock trays. C, Maxillary tray was softened in hot water and intraorally molded to fit edentulous maxilla form. It was then border molded and coated with vinyl polysiloxane adhesive in preparation for definitive maxillary impression.

2 A, Mandibular vinyl polysiloxane impression made with moldable tray shown in Figure 1B. B, Scalpel used to remove impression material that flowed over ridge crest of tray. Exposed occlusal surface of tray coated with adhesive. C, Medium-body vinyl polysiloxane expressed onto occlusal surface of tray and extended occlusally to level of center of retromolar pads. D, Patient instructed to swallow 3 times while pressing lips together, thereby extruding impression material occlusally as result of muscular contraction. E, Dashed line shows depth of tongue depression used to trim impression material. F, Impression material trimmed at depth of lingual tongue depression, thereby locating neutral zone identified by flat area. Impression trays The edentulous impressions can be made by using either a custom tray (Fig. 1A) or a stock tray that can be molded to conform to the shape of each patients arch and provide the required border extensions. Newly designed thermoplastic stock trays (Vident, Brea, Calif ) (Fig. 1B), specifically designed for edentulous patients, have been developed by Dr Stephen Wagner. They are advantageous for this technique as the trays can be adapted to the shape of the edentulous arch by softening each tray in an 80C (180F) water bath for 1 minute (no tempering needed) and then adapting it intraorally to fit the specific contours of each patients edentulous arch. In the softened state, the tray borders can be trimmed with scissors if the extensions need to be shortened. Likewise, the softened material can be stretched or added to when the tray needs to be extended to reach desired landmarks. After the tray has been customized to fit the arch, only the borders are softened, and the patients musculature is activated to mold the softened borders (Fig. 1C). Mandibular impression making After the impression tray has been selected (custom or stock tray), and conformed to the patients mouth, border molding is then performed. A medium-body vinyl polysiloxane impression material (Aquasil Monophase Smart Wetting Impression

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012
Material; Dentsply Intl Inc, Milford, Del) is recommended for this procedure because the completed impression can be removed from the mouth and repositioned intraorally multiple times without adversely altering the polymerized material and the border extensions. A light-body impression material (Aquasil LV Smart Wetting Impression Material; Dentsply Intl Inc) is then used to complete the mandibular impression (Fig. 2A). The mandibular posterior neutral zone impression technique Once the border molding and definitive impression is completed, an accompanying neutral zone impression6,7 is made on the occlusal surface of the tray by removing impression material that may have extended onto the trays occlusal surface and by coating the tray with adhesive (Fig. 2B). It is critical to preserve the impression material closest to the impression tray borders because it has recorded the form of the corresponding contacting buccal mucosa. Medium-body vinyl polysiloxane impression material (Aquasil Monophase Smart Wetting Impression Material, Dentsply Intl Inc) is then dispensed along the entire occlusal surface of the tray, from each retromolar pad area of the tray to the handle, at a vertical height sufficient to reach the level of the center of the retromolar pads bilaterally (Fig. 2C). The impression is promptly placed intraorally, and the patient asked to swallow 3 times in succession while pressing their lips together and pressing their tongue laterally against their lips and cheeks. These mouth and tongue movements activate the oral musculature, so the impression material is compressed between the lower lip, cheeks, and tongue muscles, thereby recording the location of the posterior neutral zone. After completing these movements, the patient is instructed to relax the mandible and tongue. The impression can be removed in as short a time as 2 minutes, if needed, for patient comfort. If the material has not completely polymerized, sufficient viscosity will have developed to establish the desired form of the neutral zone. The repeated swallowing and resulting compression of the impression material between the tongue and cheeks extrudes the impression material occlusally (Fig. 2D). The lateral borders of the tongue usually create a depression in the lingual surface of the impression material. Differences in the form of the depressions are to be expected given the variations in pressure recorded by the tongue against the mandibular molars. According to Frhlich et al,8 the force ranges from 11.3 kPa to 49.6 kPa with a median pressure of 27.7 kPa. In another study by these same authors, a maximum pressure range of 2.8 kPa to 39.1 kPa was recorded by the tongue against the lingual aspect of the mandibular second premolar and first molar during swallowing.9 A scalpel is used to cut through the material in a faciolingual direction at the depth of the depression (Fig. 2E). Experience has shown that the deepest aspect of the lingual depression is typically located vertically around the center of the retromolar pads, a level that is useful in approximating the height of the mandibular occlusal plane. After sectioning through the neutral zone impression, a flat occlusal platform is formed that represents the faciolingual location of the posterior neutral zone and provides a physiological guide for posterior tooth positioning (Fig. 2F). Mandibular anterior tooth positioning impressions Sometimes the mandibular tray handle interferes with the lingual morphology of the anterior aspect of the neutral zone impression. When this occurs, the tray handle should be removed along with any impression material that may be covering the occlusal aspect of the tray in the area where the mandibular anterior teeth will be located (Fig. 3A). Impression material adhesive is applied and medium-body impression material is dispensed over this exposed anterior region (Fig. 3B), the tray is placed intraorally, and the patient is instructed to swallow once and then pronounce the letters Q and U 3 times consecutively to mold the lingual area (Fig. 3C). After the patient completes these sounds, the lower lip is grasped and pulled facially so the impression can be removed without having the lip displace the impression material. Although the pressure of the resting lip against this area is light (mean of 0.9 kPa),10 it is still capable of displacing unpolymerized impression material.

37

3 A, Tray handle and lingual impression material removed. Adhesive applied. B, Impression material applied. C, Impression material molded by pronouncing letters Q and U.

Goodacre et al

38

Volume 107 Issue 1

B
5 Maxillary impression made with border molded tray shown in Figure 1C. been completely recorded, more tray adhesive should be applied to the affected area(s), followed by a thin layer of additional light-body impression material. Speech analysis in prosthodontics The clinical assessment of speech has been used effectively in prosthodontics for many decades. In fact, a number of articulation tests have been recommended for evaluating the quality of a patients speech and phonetics. In 1959, Morrison12 published a 1 stanza test he recommended as a means to establish the occlusal vertical dimension as well as the retruded contact position. Guichet13 proposed reading prose familiar to the dentist as a means of evaluating anterior tooth positions. In 1973, Chierici and Lawson,14 published several test sentences designed for evaluating articulatory factors involved in consonant sound production. A speech articulation test consisting of 12 sentences was proposed by Kestenberg15 in 1983 and Howell16 published the results of a 1986 study in which subjects read aloud a passage of text known as The Rainbow Passage. Silverman17-19 is credited with devising a method to evaluate phonetics that he referred to as the closest speaking space, and his technique continues to be used today. The letter S produces the most frequently used sibilant (hissing) sound that occurs during speaking and reading.19 In fact, asking patients to make the S sound has been used clinically to

4 A, Facial impression material removed. B, Facial impression material appearance after molding by pronouncing letters Q and U and saying word Christmas. It is also possible to form the anterior-facial aspect of the impression tray by trimming away the facial impression material without disturbing the lingual form and applying adhesive (Fig. 4A). After dispensing medium-body impression material and reseating the tray, the patient is asked to pronounce the letters, Q and U, 3 times in succession and then say the word, Christmas, 3 times. As soon as the patient finishes pronouncing the word Christmas, the lower lip is pulled anteriorly away from the impression material and the tray removed so the anterior material can polymerize without being displaced by the lower lip. Once polymerization is complete, the material is trimmed so that it is level with the posterior neutral zone areas (Fig. 4B). Production of the sounds required to form the letters, Q and U, and saying the word, Christmas, activates the muscles of the chin as well as those muscles associated with the mentolabial angle. These facial movements, in turn, create the form of the mandibular anterior denture base. Maxillary impression making As with the mandible, maxillary edentulous impressions can be made with either a custom or stock impression tray. The posterior extension of the tray is determined by the location of the vibrating line that delineates the transition between the immovable hard palate tissue and the movable tissue of the soft palate. This line is located by having the patient say Ahh11 and marking the junction between movable and stationary soft tissue with an indelible pencil or marker (Dr. Thompsons Sanitary Color Transfer Applicators; Great Plains Dental Products Co Inc, Kingman, Kans). Trim or stretch the tray so its posterior border coincides with the location and form of this vibrating line. The depth to which the soft tissue anterior to the vibrating line can be displaced determines the depth of the posterior palatal seal. The palatal thickness of the maxillary impression tray should be sufficient to provide tray rigidity but not be excessive. A thickness of 2 mm is preferable. This dimension is critical so the trays thickness does not interfere with the development of palatal contours since the patients speech will be used to produce tongue movements which then shape mediumbody vinyl polysiloxane impression material that will be applied on the cameo surface of the palatal portion of the tray. Next, the maxillary impression is made so as to accurately record the edentulous ridge morphology and the border extensions. On the facial surface of the tray, the light-body impression material should be extended as far as possible occlusally beyond the borders (flanges) by muscular and manipulative movements made during the border molding. It is through this process that the tissue contacting facial surfaces of the denture are formed (Fig. 5). If there are areas on the facial surface of the tray where the cameo surface morphology has not

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012
Sue is missing one piece. (s sound) Zelma is busy. (z sound) She is washing the dish. (sh sound) Measure the garage. (zh sound)

39

Lee will allow it. (l sound)

Tongue contacts the palatal mucosa and teeth except for a narrow central area of the anterior palate

s & z

Tongue contacts the palate and posterior teeth but does not contact the central area of the anterior palate

sh & zh

Tongue tip contacts anterior palate

A
Tom wanted a bite. (t sound) Did Eddy lead. (d sound)

B
Chuck is watching Butch. (ch sound) Jane enjoyed the fudge. (j sound) Ned won many prizes. (n sound)

Contact folled by release

Contact folled by release

Tongue contacts the palate and teeth all around the arch followed by anterior release with sustained posterior contact

t & d

Tongue contacts the palate and teeth all around the arch followed by anterior release with sustained posterior contact

ch & j

Tongue maintains continuous contact with the palate and teeth all around the arch

Stabilizatio

Stabilizatio

Ralph arrived after everyone else. (r sound)

Stabil izatio n

Young men like yellow kayaks. (y as in yellow)

Stabil izatio n

E
King Gregory was gagging. (k, g, and ng sounds)

Tongue contacts the posterior palatal mucosa and teeth but does not contact the anterior palate

Tongue contacts the palate and posterior teeth but does not contact the central area of the anterior palate

Tongue contacts the posterior hard palate, soft palate, and most posterior teeth followed by release in the center of the soft palate
Stabilization Stabilization Contact folled by release

y , g , ng

6 A, Clinical image showing contact area between tongue, teeth, and palate when /s/ and /z/ sounds are pronounced in stimulus sentences found at top of picture. B, Image showing contact area when /sh/ and zh/ sounds are pronounced. C, Image showing contact area when /l/ sound is pronounced. D, Image showing contact area when /t and d sounds are pronounced. E, Image showing contact area when /ch/ and /j/ sounds are pronounced. F, Image showing contact area when /n sound is pronounced. G, Image showing contact area when r sound is pronounced. H, Image showing contact area when the y as in yellow sound is pronounced. I, Image showing posterior area of contact between tongue, teeth, and hard/soft palate when /k/, /g/, and /ng/ sounds are pronounced.

Goodacre et al

40
identify the closest approximation of the maxillary and mandibular central incisors, thereby providing clinical information regarding the intercuspal position.20,21 Additionally, there have been several studies that record the average distance between the closest speaking space and the intercuspal position.16,17, 22-26 Use of the tongue during speech to record palatal morphology The tongue has the capacity to change its position more than any other organ, varying its shape and size interminably.22 In speech, the tongue is the principal articulator of consonants by contacting specific regions of the hard palate, alveolar ridge, and teeth during speech. The tongue also changes position and shape to pronounce each vowel.27 As such, the tongue is an important component of the speech system because it must elevate, narrow, thin, protrude, retract, produce a groove, and lie flat in the mouth to create different sounds.28 Thus when recording the contours of the palate, it is vital to capture the movements of the tongue during speech because the resulting tongue pressure exerted on the palate can be used advantageously to produce palatograms. A palatogram is defined as a graphic representation of the area of contact between the tongue and palate during speech.29 It has also been described as a map of the palate indicating all areas of tongue contact while producing different sounds used in normal speech.30 As a result, palatograms are used to evaluate the nature of the tonguepalate contact that occurs during speech.31-43 Oakley-Coles is credited with developing the technique31 by painting his tongue with a mixture of gum and flour and then examining his tongue after speech to determine where it had contacted the palate.32 Maxillary complete denture palatograms have been made with several different materials: 1) applying talcum powder to the dry palatal surface of a maxillary complete denture and observing where it was removed by the tongue as a result of speech33-36; 2) applying cornstarch to the palate of a denture and then observing where it was removed by the tongue30, 37; 3) spraying green aerosol marking medium onto the denture palate and observing the areas that became moistened and thereby darkened by tongue contact39; 4) applying utility wax to the palate and having the patient speak and thereby mold the soft wax37; 5) applying impression wax to the palate of the denture and observing areas that became shiny and smooth when contacted by the tongue as opposed to other areas where the wax was dull from lack of tongue contact38; and 6) applying a thin mix of irreversible hydrocolloid to the palate of a denture and using speech to create a customized palatal form.39 While individual variations exist in the precise areas of tongue-palate contact, maps have been created that are representative of typical patterns of contact between the tongue, palate, and maxillary teeth.33,35,36,39-41 Palatograms have also been recorded with electronic devices42 and electropalatography (EPG) has been used for 30 years in phonetic and clinical research associated with speech therapy.43 EPG devices typi-

Volume 107 Issue 1


cally are custom acrylic resin palates with sensors located in the thin palatal acrylic resin.43 When making palatograms, it is important to note that the degree of tongue pressure44 and the area of contact between the tongue and palate vary considerably depending on the sounds being produced. Therefore, it is important to use a wide range of sounds known to produce tongue-palate contact. The lingualalveolar consonants are examples of key sounds that can be used to record palatal morphology. Additionally, because it has been proposed that single word tests are not reliable24 when assessing phonetics, sentences should be read aloud by the patient covering the range of sibilants (/s/, /z/, /sh/, / zh/, /ch/, and /j/) and other sounds that produce contact between the tongue and palate. The use of stimulus sentences In 1973, Tanaka45 published 10 stimulus sentences recommended for use in evaluating the morphology of the palate in complete denture wearers. The sentences placed the consonants /s/, /z/, /sh/, /zh, /l/, /t/, /d/, /ch/, /j/, and /n/ in 3 different locations: at the beginning, in the middle,

Table I. Thirteen sentences that stimulate tongue-palatal contact


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Sue is missing one piece (s sound) Zelma is busy (z sound) She is washing the dish (sh sound) Measure the garage (zh sound) Lee will allow it (l sound) Tom wanted a bite (t sound) Did Eddie lead (d sound) Chuck is watching Butch (ch sound) Jane enjoyed the fudge (j sound) Ned won many prizes (n sound) Ralph arrived after everyone else (r sound) Young men like yellow kayaks (y sound) King Gregory is gagging (k, g, and ng sounds)

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012
used to establish the proper palatal morphology and tooth positioning for a complete denture. There are 3 additional sounds produced from tongue-palate contact that the authors recommend adding to the original 10 used by Tanaka, thereby resulting in a list of 13 sentences (Table I). The 3 new stimulus sentences added to Tanakas original list require production of the following sounds: /r/; /y/, and the /k/, /g/, and /ng/sounds (Figs. 6 G to I). The /k/, /g/, and /ng/sounds are key sounds for the most posterior area of the palate46 since the posterior aspect of the tongue elevates to create a seal across the soft palate, posterior alveolar ridges, and the second/third molars. Clinical technique for establishing palatal morphology The morphology of the palate is recorded by placing medium-body vinyl polysiloxane impression material onto the cameo surface of the palate, replacing the impression intraorally, and instructing the patient to read the 13 stimulus sentences aloud (Table I). It is advisable to rehearse this step with the impression in the patients mouth but before injecting the impression material onto the tray. Rather than attempt to capture the entire palate in 1 seating, a 2-step process is recommended. First, the posterior aspect of the tray is thinned, and then a 3 mm thickness of medium-body vinyl polysiloxane impression material is placed in the area of the second molars bilaterally and across the posterior border of the tray (Fig. 7A). The posterior aspect of the palate is developed first in the area of the second molars at the same time as the posterior extension to the soft palate is formed by placing medium body impression material onto that area of the tray. The patient is instructed to read the following sentence 3 times: King Gregory is gagging. Pronunciation of the words in this sentence causes the tongue to phonetically shape the impression material (Fig. 7B), thereby defining the second molar region along with the posterior palatal extension. Secondly, to capture the remaining form of the palatal slope, a 3-mm thick layer of medium-body impression material is dispensed onto the remainder of the palate (Fig. 7C). The patient is immediately instructed to read the first 12 stimulus sentences in order (Table I). The first 12 sentences are read aloud and then repeated in that same order to complete the form of the lingual palatal slope (Fig. 7D). There are no speech sounds that establish the contours of the central portion of the palate. This portion of the denture base is formed by producing a smooth transition between the previously developed palatal morphology on 1 side of the arch with the corresponding palatal contour on the opposite side of the arch and developing the appropriate thickness in the central area of the palate on the digitized impressions. As an alternative to the reading of 13 stimulus sentences, 2 sentences have been developed by the authors that include all of the consonants capable of producing tongue-palate contact. Use of these alternative sentences involves expressing the appropriate 3 mm thickness of heavy-body vinyl polysiloxane impression material over the entire palatal aspect of the impression tray and then reseating the impression and asking the patient to read the following 2 sentences: What is your slow toe doing in the yellow liquid on the shelf? Is it trying to judge or measure the temperature, change its color, or just reach out and touch something grand and glorious. The reading should be repeated twice. Clinical technique for determining maxillary anterior tooth positions The faciolingual and incisocervical locations of the maxillary anterior prosthetic teeth have traditionally been determined by using tooth visibility and lip support. Phonetics and

41

D
7 A, Medium-body polyvinyl siloxane impression material applied posteriorly so tongue can mold material during speech. B, Impression material molded by patient reading stimulus sentence King Gregory is gagging. C, Impression material applied to anterior aspect of tray. D, Impression material molded by patient reading first 12 stimulus sentences.

and at the end of sentences. These sounds are formed as the result of contact between the tongue and various parts of the teeth, alveolar ridge, posterior aspect of the hard palate, and anterior portion of the soft palate (Figs. 6A-F). They also can be

Goodacre et al

42

Volume 107 Issue 1

8 A, Maxillary tray handle removed along with polymerized impression material. Medium-body vinyl polysiloxane impression material placed into anterior-lingual area. B, Patient pronounced word thank and letter V to mold material. C, Polymerized impression material removed anteriorly, medium-body material deposited into area, and patient pronounced letters Q and U to mold anterior-facial aspect of impression.

9 A, Maxillary and mandibular impressions trimmed so posterior areas do not interfere with each other when patient closes at selected occlusal vertical dimension. B, Midline marked on maxillary impression and buccal corridor evaluated. C, Putty indices made over lubricated anterior aspect of maxillary impression. D, Anterior impression material trimmed away and hot wax spatula used to remove tray material, making room for anterior teeth. E, Maxillary anterior teeth arranged. F, Clinical evaluation of maxillary anterior teeth. G, Interocclusal record material placed over lubricated impressions with patient occluding at appropriate occlusal vertical dimension. H, Impressions and interocclusal record removed from mouth and record trimmed so intercuspation can be verified.

the lip position at rest also can be used to help identify the area where denture teeth can be appropriately located. To determine anterior tooth positions with these guides, the tray handle is removed along with the

impression material located over the occlusal aspect of the tray where the anterior teeth will be positioned. After applying tray adhesive, mediumbody vinyl polysiloxane impression material is placed over the anterior

ridge crest area (Fig. 8A), and the patient is instructed to pronounce the word thank followed by pronunciation of the letter V. This combination is pronounced 3 times and then the word thank is repeated an ad-

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012
ditional 3 times. When pronouncing the word thank, the tongue molds the lingual aspect of the impression material and helps to locate the approximate faciolingual position of the lingual surfaces of the anterior teeth (Fig. 8B). Pronouncing the letter, V, helps to identify the incisal length of the impression material and thereby establishes the approximate location of the incisal edge of the maxillary central incisors. After the pronunciation exercise is completed, the patient is instructed to relax their tongue and lips for several seconds. Then the upper lip is grasped gently and pulled facially so the entire maxillary impression can be removed without disturbing any unpolymerized impression material. Following polymerization of the impression material, the facial half of the anterior impression material is removed to expose the tray, the area coated with adhesive, and the impression material deposited into the recess. The patient is instructed to pronounce the letters Q and U 3 times and then relax their tongue and lips for several seconds so the upper lip can rest against the impression material and establish an approximate anteroposterior position for the maxillary anterior teeth. The upper lip is then grasped and pulled facially so the impression can be removed without disturbing the incompletely polymerized impression material (Fig 8C). Resting the upper lip against the unpolymerized impression material is permissible since measurements of the resting pressure of the lip against the maxillary incisors are low. Consequently, this level of pressure is unlikely to produce any substantive displacement of the impression material. In fact, in 1 study a slightly negative pressure was recorded at rest.47 A second study reported there was no labial pressure against the maxillary incisors in 11 out of 30 subjects and the mean pressure was low.48 When the same author compared adults with different occlusal relationships, the pressure was slightly more positive (mean of 0.08 kPa) for the normal horizontal overlap group; 0.14 kPa for the increased horizontal overlap group and 0.14 kPa for the reduced horizontal overlap group.49 Another study found the upper lip pressure at rest to be 0.2 kPa with a range from -0.7 to 1.4 kPa; the upper lip pressure was negative in 21 of the 84 children studied.50 A technique has been used whereby patients bring their lips together into light contact and air is blown between the teeth so the upper lip is pushed anteriorly by the air. The upper lip is allowed to relax and assume its normal resting pressure.47 With this particular technique, a slightly negative pressure was found to be exerted on the maxillary incisors.47 Occlusal vertical dimension, tooth positioning, and interocclusal records The occlusal vertical dimension is established by using any one of several appropriate methods and marks placed on the skin for future reference. The maxillary and mandibular impressions are used as record bases to establish the occlusal vertical dimension and make interocclusal records. The impressions are both seated simultaneously to evaluate the amount of impression material and tray material that typically has to be removed posteriorly because it interferes with proper mandibular closure at the established occlusal vertical dimension. Following complete closure without interference between the 2 impressions, a scalpel is used to create notches in the impression material and exposed tray material if present (Fig. 9A). The maxillary impression is placed intraorally so the midline can be marked on the impression with a permanent marker and the buccal corridor space can be assessed (Fig. 9B). The maxillary impression is then ready to have the 6 maxillary anterior prosthetic teeth selected at the initial diagnostic appointment arranged into the area now occupied by impression material. By using the impressions as record bases-wax rims, the previously selected maxillary anterior teeth are arranged in the impression and the tooth size, form, and color verified. As with traditional complete denture techniques, different teeth can be selected, should a change need to be made. Facial and lingual putty indices of the form of the maxillary anterior phonetic impression can be made for use as guides in arranging the anterior teeth (Fig. 9C). To arrange the maxillary anterior teeth, impression material is removed along with the required amount of tray material (Fig. 9D) to create space for the addition of wax where the prosthetic anterior teeth are located (Fig. 9E). Once arranged, the positions of the anterior teeth are verified intraorally for proper phonet-

43

10 A, Scan of maxillary impression. B, Scan of mandibular impression. C, Teeth arranged in scanned impressions on virtual casts mounted at occlusal vertical dimension.

Goodacre et al

44

Volume 107 Issue 1

D
11 A, Maxillary proof of concept denture milled from clear acrylic resin that incorporated recesses into which denture teeth have been bonded. B, Mandibular milled denture base with teeth bonded in place. Note that clear resin block used with this first CAD/CAM fabricated denture was not sufficiently thick to reproduce retromolar pad area of clinical impression. C, Lateral view of mandibular denture showing teeth bonded in position. Note milling marks due to use of 3-axis milling machine and large tools during fabrication of this proof of concept denture. D, Maxillary denture placed intraorally.

12 A, Virtual maxillary cast with posterior palatal seal carved into cast based on clinical measurements. B, Seal applied to scan of maxillary impression. ics and modified as necessary to meet the patients esthetic requirements (Fig. 9F). The anterior teeth identify the mediolateral orientation of the occlusal plane and along with the posterior impression material, they guide the anteroposterior angulation of the occlusal plane. The occluding surfaces of the notched impressions are coated with a thin layer of petroleum jelly. Then the 2 impressions are reseated clinically and a small amount of soft wax (Periphery Wax, Heraeus Kulzer LLC, South Bend, Ind) is placed onto selected areas of the notched impression material as needed so that mandibular closure at the established occlusal vertical dimension will result in stabilized positioning of the impressions against the edentulous arches. A vinyl polysiloxane interocclusal record material (EXABITE II NDS Bite Registration Crme; GC America Inc, Alsip, Ill) is injected intraorally so it can flow into the notched occlusal surfaces and around the teeth. The patients mandible is then immediately guided to its retruded contact position, and the mandible is closed to the appropriate occlusal vertical dimension where it is maintained motionless until the interocclusal record material is completely polymerized (Fig. 9G). A protrusive interocclusal record can also be made by using the notched impressions. The impressions and interocclusal record are removed from the mouth so the record can be trimmed and accurate intercuspation of the 2 impressions can be further verified extraorally (Fig. 9H). At this stage, the impressions and interocclusal record are scanned, the teeth arranged virtually in the scanned impressions (Fig. 10A-C), and the surfaces of the bases refined in the computer. The resulting data is then exported to a milling machine for fabrication of the dentures. The first set of complete dentures made with the described clinical procedures and milling process are shown in Figure 11A-D. The scanning, virtual arrangement of the teeth, base form

The Journal of Prosthetic Dentistry

Goodacre et al

January 2012

45

13 A, Scans of most recent patient treatment where maxillary and mandibular impressions were made and 4 maxillary incisors arranged. Scans have been articulated by using interocclusal record. B, Virtual mounted casts. C, Virtual arrangement of maxillary teeth and base formed from impression scan. D, Denture base being milled from block of pink denture base resin. E, Recesses in denture base being refined to accept cervical morphology of prosthetic teeth. F, Milled maxillary denture base with prosthetic teeth bonded in place. Milling was performed with 5-axis milling machine and fine tools. Denture base is not polished. Small ridge on facial surface was produced as milling tool changed direction of approach to denture base. development, and the milling procedures were performed by using these procedures (Courtesy of Dr. Stephen Schmitt, Voxelogix Corporation, San Antonio, Texas). The 3-axis milling machine and large milling tool used in this first proof-of-concept denture resulted in a denture base with substantial milling lines, but the clinical procedures were validated. Subsequently, the process focused on the refinement of the base milling by using a 5-axis milling machine and fine milling tools. Additionally, a posterior palatal seal technique was developed whereby a seal was created by carving it into the virtual cast based on clinical measurements that identified the appropriate location, form, and depth of the seal (Fig. 12A). The form created in the virtual cast was then applied to the scanned image of the impression so a seal would be present in the milled denture (Fig. 12B). Recently, the previously described procedures have been used to scan clinical records (Fig. 13A), create and articulate virtual casts (Fig. 13B), arrange the teeth, and virtually form the bases (Fig. 13C). The resulting data were used to mill a denture base from a block of pink denture base resin with recesses into which conventional denture teeth were bonded (Fig. 13D-F). Another future possibility would be to import the clinical base morphology and tooth position data into an enhanced version of the 3-D Tooth Arrangement Program, arrange the teeth and form the bases virtually, and then export the resulting data to a milling machine for fabrication of the prostheses. scanned, the teeth and base forms virtually established, and the resulting data exported to a milling machine for fabrication of the denture bases. In addition to the development of clinical procedures that record the required morphology, the prototype 3D Tooth Arrangement Program described in this article indicates that CAD programs can be developed whereby prosthetic teeth are arranged virtually as part of the CAD/CAM fabrication of complete dentures.

REFERENCES
1. What is CAD/CAM? Internet. Harvard University Graduate School of Design. Available from http://internal.gsd.harvard. edu/inside/cadcam/whatis.html 2. CAD software history. Internet. CADAZZ. com. 2004. Available from http://www. cadazz.com/cad-software-history.htm 3. Marchack CB. The use of CAD CAM fabrication technology. chapter in Implant dentistry DVD-ROM v.1.0.07.378, Loma Linda University School of Dentistry, 2007. 4. Mrmann WH. The origin of the Cerec method: a personal review of the first 5 years. Int J Comput Dent 2004;7:11-24. 5. Mrmann WH. The evolution of the CEREC system. J Am Dent Assoc 2006;137suppl:7S-13S.

SUMMARY
It is anticipated that the fabrication of complete dentures will be commercially available with CAD/ CAM technology. The clinical impression procedures described in this article record the morphology of the intaglio and cameo surfaces of complete denture bases and also identify muscular and phonetic locations for the placement of prosthetic denture teeth. This information can then be

Goodacre et al

46
6. Fish EW. Using the muscles to stabilize the full lower denture. J Am Dent Assoc 1933;20:2163-9. 7. Beresin VE, Schiesser FJ. The neutral zone in complete dentures. J Prosthet Dent 1976;36:356-67. 8. Frhlich K, Ther U, Ingervall B. Pressure from the tongue on the teeth in young adults. Angle Orthod 1991:61:17-24. 9. Frhlich K, Ingervall B, Ther U. Further studies of the pressure from the tongue on the teeth in young adults. Eur J Orthod 1992;14:229-39. 10.Ther U, Janson T, Ingervall B. Application in children of a new method for the measurement of forces from the lips on the teeth. Eur J Orthod 1985;7:63-78. 11.Laney WR, Gonzalez JB. The maxillary denture: its palatal relief and posterior palatal seal. J Am Dent Assoc 1967;75:1182-7. 12.Morrison ML. Phonetics as a method of determining vertical dimension and centric relations. J Am Dent Assoc 1959;59:690-5. 13.Guichet NF. Occlusion. Edition 2, Anaheim, Niles F. Guichet, DDS, 1997. p 77. 14.Chierici G, Lawson L. Clinical speech considerations in prosthodontics: perspectives of the prosthodontist and speech pathologist. J Prosthet Dent 1973;29:29-39. 15.Kestenberg JM. Speech assessment in dentistry. Aust Dent J 1983;28:98-101. 16.Howell PGT. Incisal relationships during speech. J Prosthet Dent 1986;56:93-99. 17.Silverman MM. Accurate measurement of vertical dimension by phonetics and the speaking centric space. Dent Dig 1951;57:308-11. 18.Silverman MM. The speaking method in measuring vertical dimension. 1952. J Prosthet Dent 2001;85:427-31. 19.Silverman MM. Determination of vertical dimension by phonetics. J Prosthet Dent 1956;6:465-71. 20.Pound E. Let /S/ be your guide. J Prosthet Dent 1977;38:482-9. 21.Pound E. The vertical dimension of speech: the pilot of occlusion. J Calif Dent Assoc 1978;2:42-7. 22.Benediktsson E. Variations in tongue and jaw positions in S sound production in relation to front teeth occlusion. Acta Ondontol Scand 1957;15:275-303. 23.Gillings BR. Jaw movements in young adult men during speech. J Prosthet Dent 1973;29:567-76. 24.Burnett CA, Clifford TJ. Closest speaking space during the production of sibilant sounds and its value in establishing the vertical dimension of occlusion. J Dent Res 1993;72:964-967. 25.Burnett CA. Mandibular incisor position for English consonant sounds. Int J Prosthodont 1999;12:263-271. 26.Lu GH, Chow TW, So LK, Clark RK. A computer-aided study of speaking spaces. J Dent 1993;21:289-96. 27.Rothman R. Phonetic considerations in denture prosthesis. J Prosthet Dent 1961;11:214-23. 28.Palmer JM. Analysis of speech in prosthodontic practice. J Prosthet Dent 1974;31:605-14. 29.Glossary of Prosthodontic Terms. 8th Ed. J Prosthet Dent 2005; 94:1-92. 30.Whitmyer CC, Esposito SJ. Principles of speech and their application to dental reconstruction. Compend Contin Educ Dent 1998;19:378-82, 384-5. 31.Moses ER. A brief history of palatography. Q J Speech 1940;26:615-625. 32.Coles O. On the production of articulate sound. Trans Odontol Soc Great Britain 1872;4:110-23. 33.Moses ER. Palatography and speech movement. J Speech Disord 1939;4:103-14. 34.Sears VH. Principles and techniques for complete denture construction. St. Louis, CV Mosby Co, 1949, p. 312-321. 35.Allen LR. Improved phonetics in denture construction. J Prosthet Dent 1958;8:753-763. 36.Rothman R. Phonetic considerations in denture prosthesis. J Prosthet Dent 1961;11:214-223. 37.Hansen CA, Singer MT. Correction of defective sibilant phonation created by a complete maxillary artificial denture. Gen Dent 1987;35:357-60. 38.Goyal BK, Greenstein P. Functional contouring of the palatal vault for improving speech with complete dentures. J Prosthet Dent 1982;48:640-46. 39.Farley DW, Jones JD, Cronin RJ. Palatogram assessment of maxillary complete dentures. J Prosthodont 1998;7:84-90.

Volume 107 Issue 1


40.Slaughter MD. Speech correction in full denture prosthesis. Dent Dig 1945;51:242-246. 41.Harley WT. Dynamic palatography--a study of linguopalatal contacts during the production of selected consonant sounds. J Prosthet Dent 1972;27:364-76. 42.Hamlet SL, Stone M. Speech adaptation to dental prostheses: the former lisper. J Prosthet Dent 1982;47:564-9. 43. Wrench AA, Advances in EPG palate design. Adv Speech Lang Pathol 2007;9:3-12. 44.Proffit WR, McGlone RE. Tongue-lip pressures during speech of Australian Aborigines. Phonetica 1975;32:200-20. 45.Tanaka H. Speech patterns of edentulous patients and morphology of the palate in relation to phonetics. J Prosthet Dent 1973;29:16-28. 46.Goodacre CJ, Lowry J. Speech. Chapter in Electronic atlas of human occlusion and the TMJ, DVD-ROM v.1.0, eHuman.com, 2008. p 141. 47.Gould MS, Picton DC. A study of pressures exerted on the lips and cheeks on the teeth of subjects with normal occlusion. Arch Oral Biol 1964;9:469-78. 48.Luffingham JK. Pressure exerted on teeth by the lips and cheeks. Dent Practit 1968;19:61-64. 49.Luffingham JK. Lip and cheek pressure exerted upon teeth in three adult groups with different occlusion. Arch Oral Biol 1969;14:337-50. 50.Ther U, Ingervall B. Pressure from the lips on the teeth and malocclusion. Am J Orthod Dentofac Orthop 1986;90:234-42. Corresponding author: Dr Charles J. Goodacre Loma Linda University School of Dentistry 11092 Anderson Street Loma Linda, CA 92350 Fax: 909-558-0483 E-mail: cgoodacre@llu.edu Copyright 2012 by the Editorial Council for The Journal of Prosthetic Dentistry.

Erratum Dr. Faysal Succaria is a new Diplomate of the American Board of Prosthodontics (ABP) effective February 2011, and should have been listed in the ABP Annual Report published in the December 2011 journal.

The Journal of Prosthetic Dentistry

Goodacre et al