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CDA JOURNAL voL

41, No6

Complete
CAD/CAM
A Review
Dentures:
of TwoCommercial
Fabrication
Systems
M A T H E WT . K A T T A D I Y I L D
, D 5 , M D S , M S ; C H A R L E SJ . G O O D A C R ED, D 5 , M S D , M S ;
A N D N A D I MZ , B A B A ,D M D ,M 5 D

manufac tur i ng
design
andcomputer - aided
A B srR A crT h eu seo f com puter - aided
and
(CAD/CAM)
dentures
throughtheAvaDent
available
for complete
hasbecome
Teethare
technology.
andcomputer
AvaDent
uses[aserscanning
Dentcasystems.
Thebasesaremitledfrom
software.
andbasesformedusingproprietary
arranged
virtual
softwareto produce
prepolymerized
pucksof resin.Dentcausescomputer
r idges,
ar r ange
theteethandfor mbasesT.he
edentulous
ma xi [[a a
ryn dma n d i b u lar
pr ocessing
technique.
d
a conventionaI
d e n tu reasrefa b ri ca teusing

AUTHORS
MathewT.Kattadiyil,oos,
t"ros,t"ts,is a diplornate
Board
of theAmerican
of Prosthodontics
anda fellowofthe
American
College
of
Heis
Prosthodontists.
currently
thedirectorof
Specialty
theAdvanced
Program
in
Education
Prosthodontics
at Loma
Schoolof
LindaUniversity
Dentistry.
Conftictof Interest
Nonereported
Disciosure:
oos,
Charles
J,Goodacre,
MsD,Ms,is a diplomate
Board
ofthe American
of Prosthodontics
andafettowofthe
College
of
American
Prosthodontists.
He

is currentlyprofessor
anddeanat LomaLinda
University
SchooIof
Dentistry.
Conflictoflnterest
Nonereported.
Disclosure;
NadimZ. Baba,ouo,
r"rso,
of
is a diplomate
theAmerican
Board
of Prosthodontics
anda fellowofthe
of
American
College
Heis
Prosthodontists.
currentlyprofessorof
Dentistryat
Restorative
LomaLindaUniversity
Schoolof Dentistry.
Conflictof lnterest
Disclosure;
Nonereported,

completedentures,the CAD/CAM
manufacturing systemsusea two-appointmenttechnique
computer-aided
(CAD/CAM)technologyhas
wherebyimpressions,interocclusal
recordsand tooth selectioncanbe
beenusedfor the fabrication
completedin one appointment,The
of inlays,crowns,fixedpartial
dentures,implant abutments/prostheses denturesare then fabricatedusing CAD/
CAM technologyand placedat the second
CAD
and maxillofacialprostheses.
appointment.
softwarerendersthe geometricalshape
TheCAD/CAMprocessoffers
of an object.CAM softwaredirectsthe
significant advantagesto the dental
fabricationprocess.
it
practitioner
and the patient,Because
Recently,CAD/CAM technology
data
possible
to
record
all
the
clinical
is
has becomecommerciallyavaiiablefor
in one appointment(oneto two hours),
fabricationof completedenturesthrough
chair time is reducedconsiderably,thereby
the lntroductionof AvaDentdigital
(Global
providing
the opportunity for a more
dentures
DentalScienceLLC,
set of appropriatelyaccurate
cost-effective
Ariz.) and the DentcaCAD/
Scottsdale,
(Dentca
A repositoryof
complete
dentures.
Inc.,
Los
Angeles).
CAM system
remains
availablethat allows
process
digital
data
Insteadof a five-appointment
for more rapidfabricationof a spare
usedwith conventionallvfabricated
n m n r r i c r - e i re lr qpersl

ru cl ^J 1"5i 1- 1-

a"r-r ru l

- , u r . rzro r s 4 0 7

( D A

J O I ] R N A I ,

V O I

4 I ,

N O 6

F l G UR E 1 . A v a D e n t s t a f t e r k i t
F I c U R E 2. Puttycast cfeatedby adaptationto the old
m a x i l l a rcyl e n t u r e .

dr:nture, a replacement denture or even a


radiograplric or surgical template that aids
in the plar:rningand placement of den[a]
implants in the future. Additionally,
becausethe digital data is associatedwitl-r
a specific practitioner, it is more 1ike1y
that patients will return to the dentist
who Fabricatedtheir first digitaJdentur:e
when future treatment is needed.
A review of recent literature reveals
m u l t i p J er c p o r [ s w h e r e c o m p u t er - a i d e d
technology was used in the f.abrlcationof
c o m p l e fe < l c n[ u r c s .T h e a c t u a lp r o c e s so l
c o m p u i c r - a i d c dd e s i g n i n gh a s i n c l u d c d
laser scanning' of delinitive impressions
or previous dentures,' as wel.las the use
of cone beam compu[erized tomography
( C B C T )o f m o d i f ic d e x i s li i r g c l e nf u r e s . ,
The compLlter-aidedmanufacturing
processhas utiljzcd lascr lithography,
computer numerical control (CNC)
milling techniques,' refined versions of
the rapid prototyping technique'r'ri
and
state-of-the-art CNC techniques that
used five-axis milling.3
Currently, two techniques are
being used for the actual fabrication
of CAD/CAI\4 dentures. One process
(the AvaDent system) uses the
subtractive technique of milling a
d e n t u r e b a s ef r o m a p r e p o l y m e r i z e d
"puck" of denture base resin and the
otJrerprocess (the Dentca system) uses
an additive technique whereby rapid
p r o i o t y p i n g ( s i e r e o l i t h o g r : a p h yi s) u s e d
L o f o r m a t r i a l d e n l u r - e i, f r e q u e s i e db y
the dentist. The definitive denture is
processedconventlonally.
4 0 8 r L r r , : . : r:,r

Reporting the "first proof-ofconcept" for the clinical fabrication


and placement of CAD/CAM complete
dentures in a patient and describing
clinical methods used to acquire the
necessarymorphoJogicaldata, Goodacre
et a1."pr:edicted,"[W]hen the CAD/CAM

F I GU RE g. Selected
AvaDent
stockhayandmaxillary
puttycast.

t ' 1 . 1 ' : '

: ,

i , ' l ' ;

Theprocedurestartswith fabrication
of a putt.ycastformed by pressingmixed
poly(viny1siloxane)putty into the
i n t a g l i os r - r r f a o
ce
f t h e p a r i e n t 'esx i s L i n g
dentures(rrcunez). If thesedentures
areunacceptable
or unavailable,
then
Lechrrologyfor fabricating complefe
diagnosfic
castscanbc generated
from a
dentures becomes commercially available,
prelimirraryimpression.
jt will be possibleto scan the denture base
F r c u R3Es h o w st h e t h e r m o p l a s t i c
morphology and tooth positions recorded tray selcct.ion
for the maxillaryarch.
with this technique and impor:t those data
T h et r a yi s s o f r e n e db y i m n r e r s i n igt i n
into a virtual tooth arrangement program
a waterbath set at Bo' C (r7o' F) for
where teeth can be articulated and then
approximatelyone minute and adapting
c x p o r i t h e d a t a [ o a m i l l i n g d e v i c ef o r t h e
the tray to the putty castby pressingthe
fabrlcation of the complete dentures."
materiaIinto contactwith the castor
W i t h t h e j n t r o d u c t i o no f c o m m c r c i a l l y
stretchingthe materialto coverrequired
a v a j l a b l eC A D / C A M d e n t u r es y s f e m s
areas.Theaclaptedtrayscan then be
such as AvaDent and Dentca, the era of
adjustecl
r-rsing
acrylicresinburs to
digital complete dentures has arrived. The
removeoverextended
areas.
purpose of this article is to describethe
After:the trayshavebeenadapted
procedures associatedwith the AvaDent
on the putty cast,theyareplacedin the
and Dentca systems.
patient'smouth to determineif thereare
areasof overextensionor underextension
and adjustmentsaremadeas needed.It is
The AvaDent digital denLureprocess
lmpor:tantthat the maxillarytray extends
involves the following two appolnrments:
posteriorlyto coverthe areaof the
r. Impressions, jaw relation records,
vibratingline and the pterygomaxillary
occlusalplane orientatlon, tooth mold
fissures(hamularnotches).It is als<;
and shade selectlon and maxillary anterior
importar:rtthat the mandibulartray cover
tooth positioning record; and
the retromolarpads,the buccalshelves
z. Placement of the dentures.
and availableareasof the lateralthroat
form (retromylohyoidarea).Coverage
of
: '
the appropriate
maxillaryareasrequires
TheAvaDentsystemincludes
a kit of
determiningthe locationof the vibrating
all the required materials and devices to
line by havingthe patientpronounce
complete the two-appointment clinical
the word"aah"or by coughingand by
p r o c e s s( r r c u n er ) .
palpationof the distalaspectof the

C D A . ] O U R N A L ,V O L 4 ] , N O 6

F I c U RE 6. MandibularA[y'D
plateand
withtracing
maxitlarv
AMDwithstvlus,
F I GU RE S, Maxillary
AMDshowing
wrench
usedto move
theadjustable
lipsupport
flange,
F I GU RE 4. Maxillaryand
mandibulardefinitive
impressions,

tuberositiesto locatethe pterygomaxillary aredefectsin the bordermolding,adhesive


fissures.Determiningthe extensionof the is appliedto theseareasand additional
mandibular tray requiresvisuallylocating
bordermoldingmaterialappliedso the
the retromolarpadsand reflectingthe
bordermolding canbe refinedin those
cheeksto locatethe extentof the buccal
areas.
shelves.Evaluationof the retromylohyoid
Definitive impressionsof the maxillary
areasrequiresplacingthe head of a
and mandibulararchesaremadeusing the
dentalmirror into theseareasand asking AvaDentlight-bodypoly(vinyl siloxane)
the patient to wet his,/herlips with his/
impressionmaterial(rrcune +).Because
her tongueto determinethe degreeof
there is no pol;rmerizationshrinkageof
displacementof the mirror by the tongue
the denturebase,because
it is milledfrom
musculature.
prepolymerizedresin,posteriorpalatal
sealsarenot alwaysneeded,unlessthere
M aki np,Maxi Il a r y ttn d Ma n dibuLar
is considerable
moveabletissuepresent
I) efini tiv e lrn p r ession s
in the posteriorpalateand overthe
After customizingthe impression
edentulousridges.
trays and confirming appropriatecoverage
When a posteriorpalatalseal
and adaptationin the patient'smouth,
is needed,the areaof coverage
is
tissuestopsshouldbe addedto the trays.
identifiedby markingthe vibrating
After applying the appropriateadhesive,
Iine and the areaslocatedanteriorly
AvaDentregistrationis appliedasfour
wherethe sealcanbe positionedbased
dabsto distributed areason the maxillary
on the areasof compressibility
and
tray and three areason the mandibular
the depth to which the tissue can be
tray.The trays are then seatedin the
compressed
in theseareas.Theseareas
patient'smouth and orientedso the
are marked and then transferredto the
traysarenot pressedinto contactwith
impression.The traditionalmethod of
the soft tissue,therebyleavingspace
scoringthe definitive maxillary cast to
for the subsequentbordermoldingand
establishthe posterior palatal sealarea
light-bodywashimpressionmaterial.
is not usedwith CAD/CAM maxillary
TheAvaDentbordermoldingimpression
denturesbecausethereis no physical
materialis usedto bordermold the
cast.Wax can be appliedto the areas
maxillary and mandibular trays employing of the impressionwherea posterior
the method usedwith conventional
palatalsealis neededand the wax
cusromrrays.
built to a height that correspondsto
Theborder-moldedtraysareinspected. the desireddepth of the compressible
If thereareareaswherethe tray has
tissue.It is proposedthat the height of
contactedthe mucosa,theseareasare
the wax be one-halfor lessof the tissue
removedusingan acrylicresinbur. If there
compressibility
depth.

Jaw Relq.tionRecords
TheAvaDentdenturetechniqueuses
an anatomicalmeasuringdevice(AMD)
that canbe adjustedto the desired
occlusalverticaldimension(OVD)and
then usedto maintain that dimension
while centricrelationis recordedusingthe
incorporatedgothicarchtracingplateand
stylus.TheAMD is alsousedto determine
the correctamount of upperlip support,
the position of the maxillarysix anterior
teeth and the desiredmediolateral
orientationof the occlusalplane.The
AMD consistsof a maxillarytray with a
centrallylocatedadjustablestylusand an
adjustablelip supportflange(rrcunr s)
and a mandibular tray with a flat occlusai
tracingplate(rrcunee). In addition,there
is an occlusalplaneorientationruler that
canbe insertedinto the maxillaryAMD
and usedto recordthe alignmentof the
maxillary AMD with the interpupillary
Iine so that the computerprogramwill be
ableto align the maxillary teeth with the
inl-prnr rnill errr linp

The maxillary AMD is coatedwith


adhesivethen coveredwith AvaDent
registration
material(rrcunez). It is then
seatedto recordthe ridgemorphologyof
the maxillaryarchaswell asthe portion
of the palatecoveredby the AMD. There
shouldbe suffrcientmaterialto stabilize
the tray or the processshouldbe repeated.
The mandibular ftay with the
recordingplate is then coatedwith
adhesiveand filled with the recording
material so it can be seatedin the
patient'smouth. Careshould be taken
r u N ez o r a 4 0 9

{ I)i

Fl c URE 7. N4axillafyAf4
hD
lleclwith
recofdingmalerial.

F I G U R E 8 . M a x i l l a rayn dn a n d i b u l aAr M Dp l a c e cf a
l i rl y
p a ra l l e {t o e a c ho t h e L
FIGURE

F T G U R El o . O c c l u s a l v e r t i c a l c l i n e n s i o n b e i n q a d i u s t e d .

tl-ratthe maxillary and mandibular


A M D s a r c l t o s i t i o n c ds o t h a f t h e y a r e
fairly parallel to each other and the
maxillary stylus is located over the
anterior aspect of the manclibularAMD
t r a c i r r gp l a t e( r r c u n e e ) , o r t h e p r o c e s s
should be r:epeated.
The occlusalvertical dimension is
d e l c r m i n c d . I f t h e c x i s t i n gd e n t u r e s
provide an appropriate occlusalvertical
dirnension, they can be used to record
thr: distance between marks on the
face when the dentures are in occlusal
contact. ]f not, use conventlonal
methods to determine the desired
dimension, The rest vertical dimension,
speech,tonicity of the musculature,
facralproportions and biofeedback
can be useclto confirm appropriate
o c c l u s a vl e r : t i c adl i m e n s i o n ( r r c u n e e ) .
The adjustable screw in the maxillary
tray is turned clockwise to extenclthe
stylus, or counterclockwise to retract
the stylus so it contacts the mandibular
4 1 0 r r i rr . r ,rr ,

10trltilil

1 l . Gothicarchrecorcling

9 . E v a l u a l i nogc c l u s avle r t i c acl l i n e n s i o n .

F I c U R E l 2 . S t y l u s s e a t e c lt ihne r e c e s s c r e a t e d
t haet a p e x
o f t h e g o t h i ca r c hr e c o r c l i n g .

ir:acingplate at the appropriate vertical


d i m e n s i o n ( r r cu n e r o ) . O n c e t h e v e r t i c a l

maxil lary stylus and the mandibu]ar


AMD tracingplate.The patient is

dirnension has been established,the


adjustable screw ln the maxillary AMD
i s u s c d t o e x t e n d o r r e t r a c Lt h c u p p e r l i p
support flange so it provldes appropriate
lip support.Thepatjent is given an
o p p o r t u n i t y l o a s s e s st h e a d j u s L r n e n L s
by viewing his or her lips in a mirror.
Recording centric relatior-ris
accomplished by making an intraoral
gothic arch recording. While the
stylus on the maxillary AMD can
produce markings on the mandibular
plate when jaw movements are

then instructed to move his/her jaw


to one side, making a lateral excursive
movement from the centric relation
positlon, and then to the contralateral

made, it is helpful to place a marking


medium on the tracing plate by either
rubbing artlculatlng paper over the
plate or spraying the plate with an
aerosol marking medium. The gothic
arch tracingis made by instructing
the patient to move his,/her lower
jaw forward and backward while
maintaining contact between the

slde. The stylus on the rnaxillary


tray scribes lines on the mandlbular
r:ecordingplate, and if the process is
done correctly, an arrow point or gothic
arch recording should be clearly seen
( r r c u n e r r ) . T h e a p e xo f t h e r e c o r d i n g
denotes the centric relation positiorr.A
r e c e s si s t h e n m a d e i n L h et r a c i n gp l a i e
t h a t r p p r o x i n r a r e sf h e t j p d i a m e f e ro F
the stylus at the apex of the gothic arch
arrowpoint using an approprlately sized
round bur or acrylic resin bur, and the
mandibular tray is reinserted in the
patient's mouth. The patient can then
move his/her mandible or be guided to
t h e p o s i t i o n w h e r e L h em a x i J l a r ys t y l u s
engagesthe recessso as to maintain the
c e n t r i cr e l a t i o np o s i t i o n ( r r c u n e r z ) .

To record the occlusalplane


orienl,ation,the AvaDent ruler rs insert.ed
il-rtl-rernaxillaryAMD (rrcune ra) anrl
the anterior acljustableportion movec[
u r t l i li t i s , r l i p , n cl )d, 1 r ' l ] lLt 'ol ( l r t 'i r t r , r g r l . r r y
i r tI ( ' r l ) r l ) i l l . r ' yIi r t t 'c t , r n , ' tI rn g t l r t ,c u rrI c r s
of thep
r u p i l so 1 ' t h ee y e s( r r c u n r r + ) .
'lhe
angJeis noted anclrccordedon the
laboratorywork authorization form. Ihis
will assistthe rnanufacturerin orientlng
tl'remedlolatcral occlr-rsal
planc so it
para11e1s
the interpr,rpillary1lnc.
TtLenext pr:ocedurein t1-risfirst
appointment is to mark the lridline or-t
fhc 1ip support flange as well as tlre smile
lir-refor the naxillary antel.ior teeth based
o r r t l r e c u r v l t r r c o l tI l t c l c r w c rl i p r l u r i n g
smiling. lhe :;izeof the maxillary anterior
l c c f h i s d c L e l l n i n c db y o v c r l a y i n gt l r c
l l r r c ca v ; r i l e b ll tt :, r , t l sr i z cL t ' r n | l a t ctsr n t l t t '
teetlr in thc existing denture, asisr-Lming
the existing ilcnture tooth size is desjrable
t o t 1 - rpea t i e n t( r r c u n e sr s n N o r o ) . I f
not, the tootJrten'rplateis selectedthat
t n , r t c f t c lsl r c r r r t i c r r l ' cd o s i r c dL o o l l ts j z e .
ln addition, by overlaying the maxiJlar:y

F I c U R E 1 4 . D e t e r n r i n i nt hgea p p ro p r i a l eo c c l u s apll a n e
w il h A v a D c nol r i { l n t a t i ornu l e r .
F I G U R E 1 3 . A v a l J e nrtu l e rl l e i n ga t t a c h e dt o t h e
n r a x i l l a rAy M D .

F I c U R E 1 6 . D e t e r n r i n i ni ngc i s a l - c e r v i lcearlr g t h
of clenlure
t o c t hu s i n go l dc l e n t u r e . a
r sg u i c l e .

0.ffi0
F l c U R E 1 5 . T c e t hs e l e c t i o n r o k lt a b s

f o o l l t l e m r l l , r t ' c sn n l l r l n x i s f i n o d p r r l r r r o

the position of tio pink clenturebase


resin around tl-renecks o1 t1-reteeth car-r
be selectedfrom the tl-rreenr-rmbereil
l o c a fi o n s p r r ' s i { I' no r r I h c t o o fh t . e m p l l.tt' .
fb serve as a guicledur:ing der-rture
fabrication,fl owable contpositeresin
is applied to the inside of the selecteil
'll're
tooth mold ternplate.
tooth mold
femnl.lle is llrln

rrnsilinned rrr,.f, ,llrr,rrrot

t h c m i d l j n er n d s r r r i l cl i n c m a r k i r r g as n d
placeclin the exact location where ther
denture teeth should be arranged. The
l e s i n i s f- -h' " e
. , 'n
b , 'l-r p l r tn o l v m c r i z e d
to afltx
L h ct e m p l a t ei n p o s i t i o n( r r c u n er z ) .
T h eo l i e n f a t i t - r o
n f f h e t e m p l a t ei s t h c n
assessedduring talking and smiling.

F I c U R E 1 7 . L u l i n g s e l e c t e r l t a b w iftl ho w a l l l e
light-cured
c D m p o s i tree s i n .
F l G U R E l S . l n j e c t i n g r e c o r i l i n g n a tteorci a p
l ture
c e n l r i cf e l a t i o n .

With the mandible stabillzed in


j I s c en l r i c r e l . r t i o p
n o s i t i o nb y t h e
styJusengagrngthe recessin the
r r a c i n gp l a t e ,A v aD e n t r e g i s t r a L i o n
n r a t e r j r li s i n j c c L c di n t o t h c s p a c e
h t r l \ ^ / p et nh e m . r ' i l l e r va n d m . f n d r b U l a r
a r c l r e (sr r c u n Er a ) . l f i s i m p o r L a n t h a f
n e r o u s. l n r o r r n ot f m a t e r i a lb e u s ed
*I bs' p
"'_"*"

s o i l f l o w s ; t r o u n d r h e L r , r c i n gl r l . r f e
, . , r - r . . r , , .-r.r .r u. r rrr;1 -1 *r r 1r /, . c.r L. l . r c l t eLsh e
rnrrillrr',

. ' . , . 1- " - . l i l . " l e r

f \ N / lD rt |r\ ,Lr/ r' ,<

l l l v l u

l n p e fh e r . T l r e r n r p r o r r l r r s l lr e c o r d
_.-b.

''r'_'

r"sc'rrhlv

is then remnrgd

1nd

i' n
' ' s" nr _c ._l _p _d ' ' l , r e o n F i r m t h a t r h e s t r i l r r ci c

in the centric relation recess and that


fhc AVID rr:\/q)rp firmlv interlnrl<pd
L,

4ll

F I c U R E 1 9 . J a w i e l a t i o n r c ( : o r c l w i t htranl or l c l

l' /l

l)L

it f l: r

\ / ri

it r, r

F I G U R E 2 1 . V i fl ! . r l t e e t ha rI a n g e n r e nl ttyA v a D e nst y s l e n r
F I G U R E 2 O . D o t e r m i n i n g v i r t L rlahlel y
b o r c l e rosl ' l h en r a x i l l a rcyo n t p l e l ce l e n l uer

'r

F T G U R E 2 3 . D c n l l r f too o t h p l a c e c tl hi ne m i l l e c l r e c e s s .
Flt!URE 22. lvlilleclAvaDentclenturoltase
F I G U R E 2 4 . A v a D e nwt a xt r - i adl c n t u0r

F I c U R E 2 6 . C o m p o s i t e r e s i n a d d et fcilat o
l c l e n t L r r e t e e t h F I G U R E 2 7 , D e l i n i t i v e A v a D e n t c l i g i t a l c l e fnat bu r iec a t e c l
c r e a t r n ng a t u r aal p p e aar n c e. r n da p p r o p r i a tvei s i b i l i t oy f
reseillllingtlte nrodifiedtrial denture.
F I c U R E 2 5 . A v a D e n t f e s i n t r i a l c l e n t i r r e ( c l i f f e r e n t p a t i eannt jt e r i o tre e t ho n n o d i f i e csl i d e .

(rrcune rs). After following normal


disrnfection protocol, the final
r m p r e s s i o n sa u d c o n n e c t e dA \ 4 D t r a y s
(along with the completed laboratory
authorizatiorr for:m) are mailed to
U I ( ) b a lI J L ' n I aSl c i c n c eL L C , p r o d u c c n
ofAvaDent digital dentures, along
with any special instructions.
412. ',tr:

rrirr

The con-rpanyprocessesthe
impressior-rand the AN4D so they can
be more easily recorded during the
l a s e r s c a n n i n gp r o c e s s .L a s e rs c a n so f
the complete arch impressions and the
connected AMD trays are made and
the morpl-rologicdata merged so as to
establish the occlusalrelationship of

the arch morphology obtained fr:om the


complete arch impressions. The denture
border:sare iclentified and marked using
t h e c o m p u t e r s o f t w a r e( r r c u n e z o ) ,
teeth are set virtually so they occlltde
properly and have the desired occlusal
planeorientation(rrcune zr) and the
morphology of the denture base is

C D A J O U R N A L ,V O L 4 ] , N O 6

FtcuRE zs. Maxillary


andmandibular
Dentca
detachable
stocktrays.

FIGURE 3o. l\4axillary


andmandibular
definitive
impressions.

F I G U R E 2 8. Smileviewof a patientwith AvaDentdigital


completedentures.

established.Oncethe denturehas been


designedvirtually, the denturebaseis
milled with recesses
that accuratelyfit
e a c hd e n t u r et o o t h ( r r c u n e sz z a N oz a )
and the teeth arebondedin position
uslnga proprietarybondingmechanism.
Thedenturebasecan be fabricatedfrom
different choicesof basematerial and
different options are availablefor the
denture teeth.

A p p o i n t m e n1t w o

Plar.ement
Theplacementand postplacement
adjustmentsof CAD/CAMcomplete
denLures
aresimilarto the placement
of conventionaldentures.Because
the
denturebaseis madefrom a traditional
resinmaterial,implant attachments,if any,
asin the patient situation illustrated,can
be pickedup intraorallyusing conventional
'
I'r i uL PIutentent Oytt.io
rts
techniques.
FrcuRE
28 showsthe frontal
Cl.inicianscan requesta wax trial
smileview of a patient wearinga maxillary
denturethat hasa CAD/CAM milled base completedentureand a mandibular
with the dentureteeth set in wax so they
implant overdenturefabricatedby the
canbe repositionedasneeded(r rc u ne
AvaDentdigitaldenturesystem.The
za).Another trial dentureoption is to
patientis seenasneededfor routine
requesta tooth-coloredstereolithographic follow-up and maintenanceappointments.
trial denture that canbe modified by
reshapingthe teeth or addingcomposite
DentcaTechniqueAppointment0ne
resinto guidein fabricationof the
TheDentcasystemprovidesa starter
(rrcunes2s, 26 AND kit aswell that includesa small,medium,
definitiveprosthesis
zz). Thisstereoiithographic
trial denture
largeand extralargeset of stocktraysin
canalsobe usedfor diagnosticpurposes
additionto a lip ruler.
to determineif a fixedimplant prosthesis
(fixedcompleiedenture)will provide
Customiziny,
St ock' I r ctys
adequatelip support or the denture flange
Both maxillaryand mandibular
supportprovidedby an overdentureis
Dentcastocktraysaretwo-piecetrayswith
needed.It canalsobe convertedto a
posteriorsegments(rrcunezs).
detachable
surgicaltemplate for implant placement.
Theappropriatelysizedmaxillaryand

mandibularstocktraysareselectedbased
on the patient'sarchsize.TheDentcatrays
areusedfor both the definitiveimpression
and alsofor the jaw relationrecordsby
sectioningthe completearchimpression,
removingthe posteriorsegmentsand then
attachinga gothicarchdevice.
Thechosentraysareplacedin the
patient's mouth to evaluatethem for areas
of overextension
or underextensionand
adjustmentsaremadeasneeded.
NIaking Mtrxi llar y anri M andibulttr
I) efini t ive I rnpressions
The trays are painted with an adhesive
and a heavy-bodypoly(vinyl siloxane)
impressionmaterialusedfor the border
molding.Definitiveimpressionsof the
maxillary and mandibular archesare made
using a light-body poly(vinyl siloxane)
impressionmaterial(rrcuneao).Thearea
of the posteriorpalatalsealis identified,
marked and then transferredto the
impressionin the conventionalmanner.
,law RelationRecords
In preparationfor the jaw relation
records,a No. r5 surgicalbladeis used
to slicethrough the poly(vinyl siloxane)
impressionmaterialon both the maxlllary
; u N ez o r a 4 1 3

CDA JOURNAL

vt)L

.Il. No6

FrcuRE32. Separated
m a x i l l aar n
y dm a n d i b u l a r
impressions.

FIcURE 3r. No.t5scalpelbladeusedtoslicethrough


the inrpression.

FIcURE 33, Adjustablestylusbeingsloftedintothe


mandibular
tray.

F I c U R E 3 4. Dentcaimpressions
with the recording
assemblyat the appropriateOVD,
Ft c U RE 3s. Dentcajawrelationrecord.

and mandibularimpressionso as to
producea singleincisionline to detach
the poster:iorpart(s)from the anterior
part(s)(rrcunear).Careshouldbe taken
duringthe separarion
of the partsto
avoidbreakageor distortion of the trays.
Carefuland intermittent wigglingand
pulling motions arerecommendedto
achieve
appropriate
(rrcuneaz).
separation
Excess
impression
materialcovering
the occlusalsurfaceof the maxillarytray is
carefullyremovedto revealthe flat occlusal
tracingplatethat is incorporatedinto
the maxillarytray.An adjustablestylusis
carefullyinsertedinto slotslocatedin the
lingualsurfaceof the mandibulartray (rrcune
as).A clearclickingsoundis heardwhen the
srylusassembly
is correctlypositioned.
Theanteriorparts of the maxillaryand
mandibularimpressionsarethen inserted
in the patient'smouth and confirmation
madethat the traysarestableprior to
any recordmaking.Theocclusalvertical
dimensionis determinedin the usual
mannerand adjustmentsaremadeto
the mandibularstylusasneeded.If the
414 ruNr::or:

existingdenturesprovidean appropriate
occlusalverticaldimension,they can
be usedto recordthe distancebetween
selectedmarks(points)on the facewhen
the denturesarein occlusalcontact.When
finalizingthe occlusalverticaldimension,
the mandibularstylusshouldcontactthe
maxillarytracingplate(rrcuneaa).
Recordingcentricrelationis
accomplished
by makingan intraoralgothic
archtracingby havingthe mandibularstylus
scribelineson themaxillarytracingplate.
Because
the maxillaryplateis very smooth
andhighlypolished,the mandibularstylus
mightnot produceclearmarkingson the
rnaxillaryplatewhenjaw movementsare
rnade.Therefore,
it maybe necessary
to place
a markingmediumon the tracingplateby
sprayingthe piatewith an aerosolmarking
mediumor rubbingarticulatingpaperover
Lhesurfaceandtransferringthepigment
from the paperto the plate.Thegothicarch
tracingis madein the usualmanner.
A recess
is then madein the maxillary
tracingplaieat the apexof the gothicarch
arrowpointthat approximatesthe tip

diameterof the stylus.An appropriately


sizedround bur or acrylicresinbur is used
to createthe recess
and thenboth trays
arereseatedin the patient'smouth.
An interocclusal
registrationrecord
materialis injectedin the spacebetween
the maxillaryand mandibulartrayswhile
ensuringthat the jawsarestabilizedin
the centricrelationpreviousJy
registered
(rrcunrss).After the materialhasset,the
interocclusalrecordassemblyis removed
from the mouth and evaluatedto confirm
that the stylusis positionedin the centric
relationrecessand that the traysare
adequatelylockedtogether.
A lip ruler is providedin the kit to
measurethelengthof the maxillarylip.
A measurementis madebetweenthe
incisivepapiliaand the inferior borderof
the upperlip(rrcuneso).Thetraysare
then disinfectedand mailedalongwith
a laboratorywork authorizationform to
the manufacturer.Dentcaofferstwo types
of dentures:standardandpremium.The
premium dentureis meant asan upgrade
with characterized
denturebase,gingival

C D N J O U R N A L ,

V O L

4 I ,

N O 6

F I G U R E3 7 . V I U A I
maxillary
andmandibular
edentulous
ridges
and
teetharrangement
by

3040=

F I c U RE 3 6. Ruler
usedto measure
length
of upperlip.

protocolto conventionalwaxtrial dentures


and reportedfavorableor higherratings
regardingestheticsand stabilityfor the wax
trial dentures.Because
thereis a lackof data,
it is cautionedthat, for objectivecomparison
of CAD/CAMcompletedentureswith
conventionallyfabricateddentures,research
is neededto obtainevidence-based/scientific
assessment
of this new concept.
F I G U R Ea a . M a x i l l a r y a n d m a n d i b u l a r D e n t c a
Because
CAD/CAM techniquesrely
F I c U R E 9 9 . S m i l e v i e waopfa t i e n t w i t h D e n t c a
stereolithographic
trialdentures.
CAD/CAM
complete
dentures.
on the useof gothicarchtracingsto
recordjaw relationships,
thereis concern
that it might be beyondthescopeof an
toning, anatomicalpalatalcameosurface AppointmentTwo
inexperienceddentist,asthis technique
and CandulorPhysioStarNFC anterior
is not routinelytaught in dentalschools.
teeth and Condyloformposteriorteeth
PluL.ernerrt.
Futureresearchwill be neededto validate
(CandulorUSAInc.,LosAngeles).
Theplacementandpost-placement
or rejectthis hypothesis.A1so,a gothicarch
lhe definitiveimpressionsand the
adjustmentsof CAD/CAMcomplete
tracingis not readilyachievedin certain
centricrelationrecordarescannedto
denturesaresimilarto the placemeniof
clinicalsituationssuchasthosewith
producemaxillaryand mandibularvirtual
conventionaldentures.rrcu ne sg shows
severeskeletaldiscrepancies,
resorption
edentulousridgesusingspecialcomputer
the frontal smileview of a patientwearing
and patientswith ataxiaof the mandible.
software(r rcu ne rz). Theprovidedlip
maxillaryand mandibularcompletedentures Hence,utilization of a classificationsystem
Iengthis alsointroducedinto the software. fabricatedby the DentcaCAD/CAMsystem. suchasthe prosthodonticdiagnostic
Dentureteeth arethen setvirtuallyso
index developedby the AmericanCollege
they occludeproperlyand havethe desired D i s c u s s i o n
of ProsthodontistsT
might be beneficialin
planeorientation(rrcuneaz).
occlusal
Basedon clinicalexperience
with
earlyand appropriatedeterminationof
Oncethe dentureshavebeendesigned the CAD/CAM fabricationof complete
techniquefor differentclinicalsituations,
virtually,the datais transferredto a 3-D
dentures,the authorsbelievethe advantages
Thepurposeof this artlcleis not
Iaserlithographymachinethat fabricates
gainedthroughuseof this technology
to endorseanyproductbut to provide
trial denturesusing a rapid prototyping
will causethe processto continuallygain
information on the technologyavailable
process(rrcune aa).Thestereolithographic tractionasan alternativeto conventionally regardinga potentialparadigmshift in the
trial denturesareprovidedaspart of the
processed
completedentures.
methodof fabricationof completedentures.
fabricationfee,if requested
by the clinician.
PreviouspublicationsdescribingCAD/
However,this processaddsan additional
CAM fabricationof completedentureswere
Conclusion
appointment.Thestereolithographi
c
initial reportsofferingproof of concept
Theuseof CAD/CAMtechnology
trial denturescanalsoserveas surgical
anddid not includeclinicalassessment.
to fabricatecompletedentureshas
templatesfor implant placement,A
However,onepublicationby Inokoshiet
positivebenefi.tsfor both the patientand
conventional
processing
techniqueis used
al.5compareda completedenturetrial
practitioner,Because
the requiredclinical
to fabricatethe definitive dentures.
placementmethodusinga rapidprototyping recordscanbe obtainedin oneaDDointment
r u r ' r zeo r s 4 1 5

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and the clenturescompleted for a second


appointn-rent,there is less clinical tin're
involved in the treatrnent. Therefore,it
should be possibleto reducethe cost of care
for patientswhile still providing quality
clentr:res using state,of-tl re-ar:tclental
rraLerials.Jllirninationof the polymerjza[ion
shrinl<ageinherent in conventionally
processecl
completedenti-rresenhancesthe
fit oi't:hedr:nturebase.Adclitbna11y,
having
a rcpository of dlgital data a11ows
for rapid
l.abric;,rtior-r
of spareor replacernentdentures.
lhere are two commerclally available
CAD/CAM systems,AvaDent and Dentca,
witl'r tl.reAvaDenl sys[em bemg tl're
only one tlrat does not use conventional
processingof the cler:rturebase resin.
As wc transition to the wodcl of CAD/
CAM dentures,cornpetencyin, mal<ir-rg
acccptableimpressions,delennining the
appropriatcOVD, capturingaccLrrate
rccorcls,
applying esthcticpr:ir:rcipJ
esand intervention
for behavioralrnoclificationwhen requircd
will continuc to play a preclominantrrrle,
evenas thc applicatlonsfor this new
teclrnologycontinue [o expanrl. r I r lr
REFERENCES
'[su
'1.
t. MaeclaI lzlinoura
M,
tsurri5, OkaclaM, Nokubi A CAD/
C A Ms y s [ e nfro r re n r o v a b ldee n t u r e . P al r:F
. ta b irc a t i o no I
conrpIete clerrfures.lntJ Prostltoclont
teg4:l17-21.
2. K.rwahala
N,Onol-1,
NishiY l-lamano
T,NagaokaE.Tiialof
clrplicationprocedLtfe
for contpletederrtlres by CAD/CAM.J
0 0l Rehibiltg97;24t54o-8.
M, InokoshiM, MinakuchiS,Ohbayashi
3. Kanazaw.r
N.Tri.rlof
a CAD/CAMsystemfof l'abricating
contpletedentures.Dent
Motef J 20ll;:tO:93-6.
zf.SunI Lii f WangY Stuclyon CAD&RPfor removable
contplete
denture.Conlruf Me tlnds ProgtontsBionje(l2009:93:266.1
2.
5. InokoshiN4,Kanazawa
M, Minakuchi5. Evaluation
ol a
conrpletedefture tr ial rrethodapplyingrapidprototyping.
DentMoter J 2oi2:3tt4a-6.
6. Goodar:re
[..J,
Garbacea
A, NaylorWf DaherT,MarchackCB,
Lowry1.CAD/CAMfabricatedcompletedentures:concepts
a n dc l i n i c aml e t h o d so f o b t a i n i nIge q r i r e cnl t o r p h o l o g i ccal al t a .
J PtosthetDent2o12:1a134-46.
, i n m oA ,S k i b aJ EA h l s i r o mR H ,S m i t hC R ,
7 .M c G a ryr T J N
Kounr.iian
JHClassiflcation
systemfor conplete edentulism.
TheAmericanCollegeof Prosthodontics.
I Prosthodont1999
Mar;8(l)r2l-lg.
rHEcoRREspoNDrNG
aurpon, MathewT.Kattadiyil,DDS,MDS,
M5, canbe reachedat mkattadiyil@llu.edu.

41t;