DENTAL TECHNIQUE

Complete denture fabrication supported by CAD/CAM

Timea Wimmer, Dr med dent,a Korbinian Gallus, BSc, CDT,b Marlis Eichberger, CDT,c and
Bogna Stawarczyk, PD Dr rer biol hum Dipl Ing (FH), MSc, CDTd

The use of computer-aided ABSTRACT

design/computer-aided manu-
The inclusion of computer-aided design/computer-aided manufacturing (CAD/CAM) technology
facturing (CAD/CAM) tech- into complete denture fabrication facilitates the procedures. The presented workflow for complete
niques for fabricating fixed and denture fabrication combines conventional and digitally supported treatment steps for improving
removable partial dental pros- dental care. With the presented technique, the registration of the occlusal plane, the determination
theses has been widely re- of the ideal lip support, and the verification of the maxillomandibular relationship record are
ported.1 However, less has considered. (J Prosthet Dent 2015;-:---)
been published on its use for
complete dentures.2-11 Initial reports were on the devel- allows for making the dentures in 2 clinical visits.12 At the
3-7
opment and proof of concept. In 1994, the use of 3- first visit, the impressions, the maxillomandibular rela-
dimensional (3D) laser lithography was described for the tionship record, and the tooth selection are completed,
fabrication of complete dentures of photopolymerized and, at the second visit, the complete dentures are deliv-
composite resin.5 The outer shells were fabricated by using ered. With this technique the dentures are fabricated
laser lithography, and the inside was filled with acrylic without the need for casts, flasking, or other processing
composite resin. A few years later, a method of duplicating methods. Additionally, a review was published which
a complete denture using CAD/CAM technology with a focused on the DENTCA system.13 The DENTCA system,
computerized numeric control processor for cutting similar to the AvaDent system, enables denture fabrication
modelling wax was presented.4 It took approximately 10 in 2 visits, although, a conventional processing technique
years until the next study presented their CAD/CAM- is necessary. The use of CAD/CAM record bases, made
aided method for the fabrication of complete dentures. with the AvaDent system, was described for the fabrication
Virtual flasks were constructed according to the CAD of complete dentures.14
denture casts, and individualized physical flasks were The conventional method of fabricating complete
made with a 3D printer.6 A recent study described a clinical dentures has been established for over 80 years.15 It al-
impression procedure for obtaining the morphology of lows for modification of the arrangement of teeth and the
denture bases and the muscular and phonetic positions of evaluation of the treatment steps before delivery.
the denture teeth. Subsequently, the recorded information Nonetheless, the conventional method has disadvan-
was scanned, and the complete denture bases were tages, including the number of patient visits (at least 5 are
virtually designed and milled from resin.7 Nevertheless, needed plus the visits after insertion), the high treatment
clinical reports are scarce. In 2012, a complete denture trial costs associated with these visits and the time- and cost-
placement method using a rapid prototyping protocol was intensive laboratory work. The inclusion of CAD/CAM
presented and compared with a conventional trial.9 A technology for the fabrication of complete dentures may
clinical report in 2014 dealt with the CAD/CAM fabrication reduce cost-intensive laboratory work. The present report
of complete dentures using the AvaDent system, which of a clinical treatment provides a step-by-step description

a
Assistant Professor, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.
b
Student Assistant, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.
c
Dental Technician, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.
d
Senior Materials Scientist, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.

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Figure 1. Preoperative condition. A, Maxilla. B, Mandible.
of a CAD/CAM-supported method for fabricating com-
plete dentures.
TECHNIQUE
1. In the dental operatory, examine the patient (Fig. 1)
and make anatomic impressions (Alginoplast,
Figure 2. Occlusal record. A, Occlusion rims connected with registration paste (Superbite: zinc oxide eugenol bite registration paste; Harry J. Bosworth
Co) and marked reference lines. B, Casts and occlusion rims mounted in articulator.
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regular set; Heraeus Kulzer GmbH) of the edentu-
lous maxillary and mandibular arches and send
them to the dental laboratory for the fabrication of
casts and custom trays.
2. Make definitive impressions (Impregum Penta; 3M
ESPE) of the maxilla and mandible and send them
to the laboratory for the fabrication of definitive
casts, record bases for the maxillomandibular
relationship record, and a maxillary baseplate for
facebow transfer.
3. Make the facebow and jaw relationship records
and determine the smile line, the positions of the
canines and the midline, and the position of the
anterior teeth for appropriate lip support and
optimal esthetics (Fig. 2A). Send the records to the
dental laboratory so that the casts can be mounted
on an articulator (Fig. 2B) and for the virtual design
of the complete dentures with the software
(Ceramill Mind/D-Flow; Amann Girrbach).
4. In the dental laboratory, scan the definitive casts
separately with an optical scanner (Ceramill
Map400; Amann Girrbach) (Fig. 3A,B). Then, scan
the casts and the occlusion rim positioned in the
transfer stand (Ceramill Transferkit; Amann Girr-
bach) (Fig. 3C).
5. Import the data into the software to design com-
plete dentures (Ceramill Mind/D-Flow; Amann
Girrbach). Mount the scanned maxillary and
mandibular casts virtually according to the scanned
occlusion rim. For this, superimpose the files
digitally and combine them by means of best-fit
matching (Fig. 4).
6. Set the occlusal plane with the help of the occlu-
sion rim (Fig. 5A) and analyze the casts with the
help of the step-by-step instruction in the soft-
ware. Mark the anatomic characteristics of the cast
surfaces, the position of the first premolars, and
the center line with the margin lines (Fig. 5B).
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Figure 3. Screenshots of scanned casts. A, Maxillary. B, Mandibular. C,
Occlusion rim between casts.
Determine the boundary line for the anterior teeth
on the basis of the maxillary record base. With the
entered information, the software calculates the
common arrangement lines and suggests an
applicable set of artificial teeth (Fig. 5C). The
deposited artificial teeth are conventionally man-
ufactured teeth made of acrylic resin from different
manufacturers and not produced by CAD/CAM
technology.
7. Select the preferred artificial teeth and let the
software automatically arrange them in their cor-
rect position (Fig. 5D).
8. Design the gingival parts of the dentures on the
basis of the suggestion of the software with the
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Figure 4. Virtual mounting of casts by means of best-fit matching.
help of the different tools provided, for example, a
virtual wax knife or paint brush (Fig. 5E).
9. Send a preview of the virtual arrangement to the
clinician for evaluation.
10. Shorten the basal surfaces of the artificial teeth
virtually according to the contour of the alveolar
ridges and the minimum denture thickness and
provide them with retention for later fixation in the
denture bases. Generate the data sets for the
denture bases and the tooth sockets.
11. Mill the denture bases with a 5-axis milling ma-
chine from a gingiva-colored wax blank (Ceramill
D-Wax, Ceramill Motion 2; Amann Girrbach).
12. Modify the conventional denture teeth according
to the individual clinical situation. For this, mount
them in a special blank/device and mill their basal
surfaces corresponding to the prior computation.
(Ceramill Motion 2; Amann Girrbach).
13. Wax the adapted denture teeth into the sockets of
the wax bases (Fig. 6) and evaluate the completed
trial denture in the conventional articulator (Fig. 7).
Send the trial denture to the clinician.
14. In the dental office, evaluate the trial dentures in
the patient’s mouth. Make adjustments to the
arrangement in the conventional way, if necessary.
15. Send the trial dentures to the dental laboratory for
their completion by flasking.
16. Deliver the completed dentures (Fig. 8, 9).
DISCUSSION
It has been 20 years since the implementation of CAD/
CAM technology in the fabrication of complete dentures
was reported. In the last few years, significant advance-
ments have taken place in this field, and the first case
reports have been published.12,13
The presented concept of Ceramill Full Denture
Workflow incorporates CAD/CAM technology into the
workflow of fabricating complete dentures. However,
incorporation refers only to the tooth arrangement, the
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Figure 5. Digital workflow of designing complete dentures. A, Setting occlusal plane. B, Cast analysis. C, Proposal for tooth arrangement. D, Articulator
settings. E, Proposal for gingival design. F, Milling data for maxillary complete denture including tooth sockets.

milling of the wax trial bases, and the modification of the
denture teeth so that they can be inserted into the tooth
sockets of the bases with wax and without additional
grinding.
Compared with the completely conventional tech-
nique of fabricating dentures, this procedure has several
advantages. Scanning the maxillary and mandibular casts
and importing them into the software allows for better
detection and visualization of the morphology of the
edentulous maxillary and mandibular arches. Virtual
sectional views facilitate the identification of anatomic
characteristics, and, with the help of a software algo-
rithm, the midlines of the alveolar ridges, for example,
can be identified. A further advantage is that the virtual
arrangement of the artificial teeth is a reproducible pro-
cedure enabling predictable results. With the help of the
virtual articulator, static occlusion and the dynamic
relation of the dentures are considered during digital
arrangement. Also, the digitized maxillary record base
can be taken into account, particularly for anterior teeth
arrangement. With the correct incisal edge position of the
maxillary teeth, ideal lip support can be realized. More-
over, the maxillary record base will be used to establish
the plane of occlusion.
Posterior teeth can be arranged according to the occlusal
concept of the manufacturer. Thus, an ideal contact situa-
tion can be achieved. The arrangement can be performed in
significantly less time in comparison with the manual

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Figure 6. Milled wax dentures. A, Maxillary upper surface with teeth inserted. B, Maxillary intaglio. C, Mandibular upper surface with teeth inserted. D,
Mandibular intaglio.
Figure 7. Milled wax dentures in articulator.
arrangement. Additionally, the time-consuming procedure
of manual waxing is eliminated. The polished surfaces of the
denture bases can be easily designed with different
anatomic features, for example, stippling and rugae. A
preview of the virtual arrangement can be sent to the
clinician for approval. If modifications of the tooth
arrangement are required, this is possible. Also, for example,
for adjustments for esthetic reasons, the arrangement can
be superimposed with the digitized record bases.
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Figure 8. Completed dentures.
At the trial placement, minor adjustments of the
arrangement can be made in the conventional way. In
case of extensive modification, the wax denture base can
be milled once more according to the required arrange-
ment, and a second evaluation appointment is possible.
Indeed, in the presented patient case, increasing the
vertical dimension of occlusion was necessary. The dental
technician unscrewed the anterior guide pin and
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Figure 9. A, B, Patient with complete dentures.
remounted the mandibular cast in the articulator with the
occlusion rim. As a facebow record had been made,
increasing the vertical dimension did not entail errors in
the occlusion. The situation was transferred into the
virtual articulator, and a new mandibular tooth
arrangement was designed with the software.
The virtual design of complete dentures allows for
consistent thickness of the bases. The material thickness
can be adjusted to the material and kept minimal,
allowing for the function and durability of the dentures.
Furthermore, a consistent material thickness minimizes
deviations in the contact relationships of the teeth, for
example, due to polymerization shrinkage, and enables
an improved fit to the mucosa, which is important for
denture retention.16-18
The dentures may be easily duplicated with the digital
data and research in this field is facilitated.10 With the
system used here (Ceramill Full Denture Workflow),
complete dentures can be digitally completed by milling
them from prepolymerized acrylic resin blocks. However,
the manufacturer does not currently enable this option
because of the risk of remake. The source of error is the
manual maxillomandibular relationship record, which is
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difficult and fault-prone. Development should focus on
this field. Also, the problem concerning the durability of
the bond between the base and the teeth has not been
solved.
Clinical and laboratory research is necessary to vali-
date the new computer-aided treatment procedures for
the fabrication of complete dentures.10
SUMMARY
Incorporation of CAD/CAM technology into the design
and fabrication of complete dentures helps to simplify
laboratory work and standardize complete denture
fabrication. Ceramill Full Denture Workflow is a CAD/
CAM-based system. With the help of proprietary soft-
ware, the denture teeth can be arranged and bases
designed. Dentures bases are milled from a wax blank,
allowing for adjustments after clinical evaluation.
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Corresponding author:
Dr Timea Wimmer
Goethestraße 70, 80336 Munich
GERMANY
Email: timea.wimmer@med.uni-muenchen.de
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Wimmer et al