CLINICAL REPORT

CAD-CAM approach to designing and fabricating a low-

maintenance metal-acrylic resin implant-supported fixed
complete dental prosthesis: A clinical report
Stephanie Yeung, DDS,a Raffi Aghvinian, BA,b Alexandre-Amir Aalam, DDS,c and Sajid Jivraj, DDSd

Implant-supported fixed com- ABSTRACT

plete dental prostheses
The metal-acrylic resin implant-supported fixed complete dental prosthesis (IFCDP) is a reliable
(IFCDPs) have been reported restorative option. However, clinical complications and laboratory fabrication concerns are
to have high survival rates associated with these restorations. Maintenance and repair lead to increased chair time, but
with moderate complication recently introduced computer-aided design and computer-aided manufacturing (CAD-CAM)
rates1 and have been fabri- materials and technology can improve efficiency and mitigate complications. In this clinical
cated with different materials report, the existing design principles and CAD-CAM materials were combined to fabricate a
for the restorative superstruc- metal-acrylic resin IFCDP that minimized individual tooth fracture and facilitated efficient
2
ture. Advancements in the resurfacing of worn surfaces. (J Prosthet Dent 2020;-:---)
design and fabrication methods of these restorations
tooth fracture and allows efficient resurfacing of worn
have sought to mitigate esthetic, functional, mechanical,
surfaces.
and maintenance concerns.3,4
Metal-acrylic resin IFCDPs have been fabricated
CLINICAL REPORT
with computer-aided design and computer-aided
manufacturing (CAD-CAM) with improved accuracy A healthy 67-year-old man presented with a severely
and passivity of fit as compared with laser-welded or resorbed maxilla restored with a complete denture (CD)
cast frameworks.5 However, maintenance complications and periodontally involved mandibular dentition (Fig. 1).
persist, especially the fracture or wear of teeth and The patient reported a 50-year history of smoking, which
veneering acrylic resin.3,6-10 Thus, framework design he had recently ceased to address his need to restore the
currently focuses on providing a rigid metal framework function of his mandibular teeth. Extraoral and tempo-
with sufficient surface area to support the acrylic romandibular joint evaluation was within normal limits.
resin.11 Intraoral examination revealed generalized severe loss of
Improvement of the CAD-CAM removable prosthesis periodontal support around the remaining teeth. The
workflows has enabled design modifications that may patient’s diagnoses were Prosthodontic Diagnosis Index
help mitigate maintenance concerns related to metal- class IV for partial edentulism and stage IV, grade B
acrylic resin IFCDPs, including the introduction of periodontitis.
machinable acrylic resin that reacts with acrylic mono- The definitive treatment plan was for a new maxillary
mer. This clinical report presents a combination of CDP and metal-acrylic resin IFCDP on 4 or 5 endosseous
existing design principles and CAD-CAM materials to implants. The mandibular interim prosthesis was an
fabricate a metal-acrylic resin IFCDP that minimizes immediate denture to be converted to an implant-

a
Private practice, Los Angeles, Calif.
b
Private practice, Los Angeles, Calif.
c
Private practice, Los Angeles, Calif.
d
Private practice, Oxnard, Calif.

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Figure 1. Panoramic radiograph of initial patient presentation.
Figure 3. Digital denture design superimposed on cobalt-chromium
framework and scan of interim prosthesis.
supported prosthesis at the time of surgery. Informed
consent was obtained from the patient, with emphasis on
regular maintenance and smoking cessation.
Phonetics, centric relation, and the vertical dimension
of occlusion were assessed based on facial soft-tissue
landmarks. A new maxillary CD and mandibular imme-
diate denture were fabricated through conventional
procedures and prefabricated denture teeth (Vitapan
Excell; VITA Zahnfabrik). During the surgery, 5 endo-
sseous implants (NobelReplace Tapered CC; Nobel Bio-
care) were placed, and 4 were adapted to the immediate
denture by using multiunit abutments and autopolyme-
rizing resin (GC Unifast; GC) around titanium interim
cylinders. Denture surfaces were modified for hygiene
and occlusion (Fig. 2). A postoperative panoramic image
was made to visualize implant positioning and verify
seating of the components.
After 4 months of healing, the interim complete fixed
prosthesis was removed for an open-tray impression.
Impression copings were splinted with incremental ad-
ditions of light-activated polymerizing resin (Triad Gel;
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Figure 2. Patient presentation 4 months after implant surgery with
maxillary removable dental prosthesis and mandibular interim complete
fixed prosthesis.
Figure 4. Intaglio view of milled denture design displaying stabilization
features.
Dentsply Sirona). A polyvinyl siloxane 1-step definitive
impression (Honigum Fast; DMG) was made to capture
the splinted copings and soft-tissue surfaces. The
impression was poured in Type IV stone (Fujirock; GC),
and analogs were verified by seating the mandibular
interim prosthesis for passivity. Subsequently, a new
facebow transfer was made with the new maxillary CD in
place and mounted onto a semi-adjustable articulator
(Panadent PCH; Panadent) after making an intaglio sil-
icone matrix (Sil-Tech; Coltène). With the CD and
interim complete fixed prosthesis in place, a centric
relation record was made and used for mounting the
mandibular prosthesis and cast.
The completed articulator mounting with prostheses
was then scanned by using a laboratory scanner (inEos X5;
Dentsply Sirona) in the following situations: articulated
prostheses on articulator, individual casts with prostheses
attached, and definitive cast with individual scan bodies,
no implant prosthesis. The images were then imported to a
design software program (exocad; exocad GmbH) and
Yeung et al
- 2020
Figure 5. Frontal intraoral view of evaluation of milled denture tooth
arrangement on framework.
Figure 7. Frontal intraoral view with definitive prostheses.
superimposed by using soft-tissue and prosthetic land-
marks on the casts and restorations. Care was taken during
the design process to ensure that sufficient space was
available to subsequently accommodate teeth and denture
base acrylic resin. By using the superimposed scans, a 3.0-
mm-wide by 6.0-mm-high rectangular bar framework was
designed for passivity and rigidity; the design was then
milled (CORiTEC 350i; imes-icore) in cobalt-chromium
alloy (Argen Cobalt Chrome 275; Argen).
The framework was then minimally finished to
remove milling struts and seated intraorally by using the
1-screw Sheffield test.12 Periapical images were made of
each implant abutment to ensure seating of the frame-
work to verify fit and passivity before subsequent design
procedures. Upon verification, the framework was seated
on the definitive cast and scanned. The scan containing
the interim mandibular prosthesis was then super-
imposed onto the framework scan to finalize the space
available for acrylic resin and to design the tooth
arrangement (Fig. 3). The tooth form was a clone of the
preexisting interim prosthesis, with freeform digital
Yeung et al
3
Figure 6. Frontal view of laboratory wax pattern for heat-polymerized
denture base resin veneer.
Figure 8. Panoramic radiograph with definitive prostheses in place.
modifications to improve occlusion and anatomy. The
tooth arrangement was then adapted to passively overlay
buccal and lingual aspects of the bar and screw access
holes to improve rigidity and stability of the milled tooth
acrylic resin (SR Vivodent CAD Multi; Ivoclar Vivadent
AG). This design also allowed visual seating intraorally
when the vertical dimension of occlusion, centric relation,
phonetics, and esthetics was verified (Figs. 4, 5).
After the trial tooth arrangement and making necessary
occlusal adjustments, the acrylic resin tooth arrangement
was manually modified to accommodate pink baseplate wax
for esthetics and retention. Pink baseplate wax was adapted
to the buccal, lingual, and intaglio aspects for flasking and
heat-processing procedures for adaptation of denture base
resin (Lucitone 199; Dentsply Sirona) (Fig. 6). Finishing
procedures of the prosthesis involved removing all concav-
ities on the intaglio surfaces and polishing on a lathe. The
definitive restoration was inserted, and occlusion adjusted as
needed (Fig. 7). Multiunit abutment screws were tightened
to 15 Ncm on initial insertion and then retightened after 2
weeks. Screw access holes were filled with
THE JOURNAL OF PROSTHETIC DENTISTRY
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polytetrafluoroethylene tape and light-polymerized com-
posite resin (Clearfil Majesty ES-2; Kuraray). A post-
operative panoramic radiograph was made (Fig. 8). Recall
was established at every 3 months for hygiene and periodic
evaluation.
DISCUSSION
Metal-acrylic resin IFCDPs are indicated in patients for
whom control of wear is needed.13 The advantages of the
metal-acrylic resin restoration include its reparability, es-
thetics, and documented history. Disadvantages include
long-term maintenance involving acrylic resin wear and
fracture of denture teeth or the veneering layer.14
The process described in this clinical report provided a
rigid framework, minimized tooth fracture, and provided
support for the acrylic resin. To prevent delamination of the
veneering denture base resin, the resin used for the teeth
must be reactive with monomer. In this report, the acrylic
resin disk used for the tooth arrangement was made of
acrylic resin identical to that of standard denture teeth. The
milled teeth remained unpolished until after denture base
processing, which allowed for improved bonding between
the denture base and tooth acrylic resins. Additionally,
replacement of worn acrylic resin can be completed effi-
ciently by remilling a digitally saved tooth arrangement that
readily adapts to a straightforward, retrievable framework
design. These processes can prevent appointments related
to complications while shortening the repair time.
Modifications to the presented treatment might involve
intraoral scanning and making the interim complete fixed
prosthesis by using a digital workflow rather than
conventionally. Such a change would reduce the number
of visits required from the time of the initial consultation.
Another design modification might be the replacement of
cobalt-chromium with other CAM framework materials.
SUMMARY
This clinical report presented a combination of existing
design principles and CAD-CAM materials to fabricate a
metal-acrylic resin IFCDP that minimized individual tooth
fracture and allowed efficient resurfacing of worn surfaces.
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REFERENCES
1. Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A systematic review
of the survival and complication rates of implant-supported fixed dental
prostheses (FDPs) after a mean observation period of at least 5 years. Clin
Oral Implants Res 2012;23:22-38.
2. Rawal S, Balshi TJ, Jivraj S, Birdi B. Evolution of full-arch implant prostho-
dontics: from analog protocols to digital workflows. Compend Contin Educ
Dent 2019;40:578-85.
3. Hogsett Box VL, Sukotjo C, Knoernschild KL, Campbell SD, Afshari FS.
Patient-reported and clinical outcomes of implant-supported fixed complete
dental prostheses: a comparison of metal-acrylic, milled zirconia, and
retrievable crown prostheses. J Oral Implantol 2017;44:51-61.
4. Wee A, Aquilino SA. Strategies to achieve fit in implant prosthodontics: a
review of the literature. Int J Prosthodont 1999;12:167-78.
5. Abduo J. Fit of CAD/CAM implant frameworks: a comprehensive review.
J Oral Implantol 2014;40:758-66.
6. Johansson G, Palmqvist S. Complications, supplementary treatment, and
maintenance in edentulous arches with implant-supported fixed prostheses.
Int J Prosthodont 1990;3:89-92.
7. Bozini T, Petridis H, Garefis K, Garefis P. A meta-analysis of prosthodontic
complication rates of implant-supported fixed dental prostheses in edentu-
lous patients after an observation period of at least 5 years. Int J Oral Max-
illofac Implants 2011;26:304-18.
8. Priest G, Smith J, Wilson M. Implant survival and prosthetic complications of
mandibular metal-acrylic resin implant complete fixed dental prostheses.
J Prosthet Dent 2014;111:466-75.
9. Jemt T, Johansson J. Implant treatment in the edentulous maxillae: a 15-year
follow-up study on 76 consecutive patients provided with fixed prostheses.
Clin Implant Dent Relat Res 2006;8:61-9.
10. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP, Gallucci GO.
A systematic review of biologic and technical complications with fixed
implant rehabilitations for edentulous patients. Int J Oral Maxillofac Implants
2012;27:102-10.
11. Drago C, Howell K. Concepts for designing and fabricating metal frameworks
for hybrid implant prostheses. J Prosthodont 2012;21:413-24.
12. Burguete RL, Johns RB, King T, Patterson EA. Tightening characteristics for
screwed joints in osseointegrated dental implants. J Prosthet Dent 1994;71:
592-9.
13. Ghazal M, Yang B, Ludwig K, Kern M. Two-body wear of resin and
ceramic denture teeth in comparison to human enamel. Dent Mater
2008;24:502-7.
14. Papaspyridakos P, Bordin TB, Kim YJ, El-Rafie K, Natto ZS, Teixeira ER, et al.
Technical complications and prosthesis survival rates with implant-supported
fixed complete dental prostheses: a retrospective study with 1- to 12-year
follow-up. J Prosthodont 2020;29:3-11.
Corresponding author:
Dr Stephanie Yeung
11645 Wilshire Boulevard
Suite 704
Los Angeles, CA 90025
Email: stephwyeung@gmail.com
Acknowledgments
The primary author thanks Natura-Like Dental Ceramics for providing laboratory
support.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.04.006
Yeung et al