Evaluation of Currently Available CAD/CAM Denture Systems

Patricia-Anca Steinmassl, MD, DMD1/Florian Klaunzer, DMD1/Otto Steinmassl, MD, DMD2/

Herbert Dumfahrt, MD, DMD1/Ingrid Grunert, MD, DMD1

Purpose: The introduction of computer-aided design/computer-assisted manufacture (CAD/

CAM) technology into removable denture prosthodontics enables denture adaptation in
fewer patient visits, an advantage that appeals to dentists and patients. Since manufacturers
follow very different approaches, an evaluation of the different clinical CAD/CAM complete
denture fabrication protocols is desirable. The aim of this article is to assess and evaluate the
different clinical fabrication protocols of currently available CAD/CAM denture systems to
provide decision support for dental practitioners. Materials and Methods: The information
for the present article was gathered by questionnaires from (in alphabetical order) Global
Dental Science, Merz Dental, Wieland Dental + Technik, Ivoclar Vivadent, VITA Zahnfabrik,
and Whole You, and complemented with results from the authors’ clinical experience.
Results: Wieland Digital Denture involves four patient visits. Both AvaDent digital dentures
and Whole You Nexteeth enable denture fabrication in three (including a try-in session) or
two (without try-in) visits. Baltic Denture System stipulates complete denture fabrication
in two visits, and VITA VIONIC material system is an open system enabling choice between
different treatment protocols. It can be combined with several open scanners, CAD software
options, and milling machines. Conclusion: The available CAD/CAM denture fabrication
systems provide a variety of advantages, and the decision on a system should depend on
the dentist’s prosthodontic expertise, patient throughput rate, and requirements regarding
denture individualization. Int J Prosthodont 2017;30:116–122. doi: 10.11607/ijp.5031

I n computer-aided design/computer-assisted manu-

facture (CAD/CAM), a three-dimensional (3D) object
is designed using computer software and fabricated
preformed acrylic resin blocks1 that were previously
polymerized under great heat and pressure,8 resulting
in a highly condensed resin that is assumed to release
via a fully automated process.1 CAD/CAM has been less monomer8 and to have fewer microporosities.8
used in dentistry since the early 1980s,1,2 especially Porosities are among the factors for the microbial
for fixed prosthodontic restorations such as crowns colonization of the denture base,9 which is often high,
and bridges. particularly among older or dependent patients.10
For removable dentures, CAD/CAM fabrication rep- Since polymerization shrinkage is not an issue
resents a novelty.3–7 The denture base is milled from among milled denture bases,11,12 the congruence
between denture base and denture-bearing tissues
is higher.8 This results in better denture fit11,12 and
1Senior Scientist, Dentist, Department of Dental Prosthetics and Restorative
thereby a lower frequency of traumatic ulcers,13 com-
Dentistry, Medical University of Innsbruck, Innsbruck, Austria.
2Researcher, Dentist, Department of Dental Prosthetics and Restorative mon issues with removable dentures.14 The digitally
Dentistry, Medical University of Innsbruck, Innsbruck, Austria. designed occlusion is not subject to polymerization
3Researcher, Dentist, Maxillofacial Surgeon, Department of Cranio- shrinkage either, thus it might be better balanced and
Maxillofacial and Oral Surgery, Medical University of Innsbruck, show higher chewing effectiveness, perhaps making
Innsbruck, Austria.
4Professor, Executive Senior Physician (Dentist), Department of Dental
remounting unnecessary.
Prosthetics and Restorative Dentistry, Medical University of Innsbruck,
The most appealing advantage for dentists and pa-
Innsbruck, Austria. tients is probably the reduced number of patient vis-
4Professor, Head of Department, Department of Dental Prosthetics and its9,11–13 required for most CAD/CAM denture systems.
Restorative Dentistry, Medical University of Innsbruck, Innsbruck, Austria. The different manufacturers have developed different
approaches, and choosing the right denture system is
Correspondence to: Dr Patricia-Anca Steinmassl, Department of Dental difficult without support. Few reports on CAD/CAM-
Prosthetics and Restorative Dentistry, Medical University of Innsbruck, fabricated dentures have been published, and those
MZA, Anichstr. 35, A – 6020 Innsbruck, Austria.Fax: +43 512 504 27184.
few studies refer mainly to two systems (AvaDent Digital
Email: patricia-anca.steinmassl@i-med.ac.at
Dentures, Dentca).1,8,11–13 A comparison of and guide to
©2017 by Quintessence Publishing Co Inc. the currently available systems is lacking.

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 Steinmassl et al

Conventional Complete Wieland Digital Denture AvaDent Digital Dentures WholeYou Nexteeth Baltic Denture System
Denture Concept

Anatomical Anatomical Functional Functional Functional

impression impression impression (silicone) impression (silicone) impression (silicone)
(alginate) (alginate) Determination of Determination of Adjustment of
Registration of vertical jaw relation vertical jaw relation BD Keys to occlusal
vertical jaw relation plane, lip support
Determination of Determination of and centric
Provisional occlusal plane incisor length jaw relation
determination of Determination of lip Gothic arch Try-in
occlusal plane support registration (adjusted key)
Gothic arch
registration

Functional Functional Try–in Try–in Final dentures

impression impression (wax/PMMA) (acrylic polymer)
(silicone/polysulfide) (silicone) (optional) (optional)
Definitive
determination of
occlusal plane
Gothic arch
registration

Try–in Final dentures Final dentures

Adjustment of (PMMA)
wax rim: (optional)
Determination of
vertical jaw relation,
occlusal plane,
and lip support
Gothic arch
registration

Try–in (wax) Final dentures

Final dentures

Fig 1   Comparison of conventional and digital workflow.

Purpose Wieland Digital Dentures (Wieland Dental + Technik

Ivocar Vivadent), and Whole You Nexteeth (Whole
It is the aim of this paper to evaluate and compare You). Amann Girrbach was repeatedly contacted,
the clinical protocols of the different currently avail- but the requests for information or support were not
able CAD/CAM denture systems. The results will give answered. To ensure that the presentation of the
an overview of the different clinical denture adapta- different concepts is correct and that there are no
tion protocols and provide decision support for dental misinterpretations, each manufacturer confirmed the
practitioners. correctness and approved the presentation of the sys-
tem prior to submission of the article. The complete
Materials and Methods denture concept taught at the Medical University of
Innsbruck, Austria served as an example for the con-
The information for the present study was gath- ventional denture adaptation protocol.
ered by standardized questionnaires directly from
the following manufacturers (in alphabetical order): Results
Global Dental Science, Merz Dental, VITA Zahnfabrik,
Wieland Dental + Technik Ivoclar Vivadent, and The CAD/CAM denture fabrication protocols are
Whole You, and from the authors’ own clinical ex- listed by the number of required patient visits (Fig 1,
perience with Baltic Denture System (Merz Dental), Table 1). The two companies with equal patient visit

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Evaluation of CAD/CAM Denture Systems

Table 1   Overview of CAD/CAM Denture Systems

Wieland AvaDent Whole You Baltic
Digital Denture Digital Dentures Nexteeth Denture System
Manufacturer Wieland Dental + Technik Global Whole You Merz Dental
Ivoclar Vivadent Dental Science
No. of patient visits 4 (3) 3 (2) 3 (2) 2
(without try-in)
Definition of denture Dental technician Dentist (marker) or Automated Dental technician
border extension (digitally) automated (according to (digitally) (digitally)
impression)
Assessment of vertical Dentist Dentist Dentist Dentist
dimension (measurement of esthetic (measurement of esthetic (measurement of esthetic (measurement of
height of height of lower face) height of lower face) esthetic height of
lower face) lower face)
Registration of vertical Individual trays Anatomical Extrusion of bite Individually
dimension milled in correct vertical measuring device registration pin relined BD Keys
relation
Determination of Dentist: UTS Dentist: Adjustment of AMD Automated Dentist:
occlusal plane CAD-transferring arch or wax rim (digitally) Individually
relined BD Keys
Determination of Dentist: Marking individual Dentist Automated Dentist:
dental midline tray (marker) (digitally) Individually
relined BD Keys
Registration of Gothic arch Gothic arch Gothic arch Relining
maxillomandibular jaw registration registration registration BD Keys into
relation centric relation
Try-in option Milled white Wax or milled PMMA- 3D-printed white acrylic Adjusted BD Keys
PMMA-monobloc monobloc polymer
Systems listed by number of patient visits required.

Fig 2  Individual impression trays on cast

(conventional denture fabrication).

protocols are listed in alphabetical order. VITA VIONIC with thermoplastic impression compound prior to the
is an open system and can be used with any adapta- polysulfide impression. During the third patient visit,
tion protocol. the vertical relation, occlusal plane, and position of
the dental arches are determined by adjusting wax
Conventional Protocol rims, and the centric maxillomandibular jaw rela-
tion is assessed by gothic arch recording. In a fourth
The Innsbruck complete denture concept requires dental visit, the patient tries a wax set-up of the final
five patient visits. In the first visit, alginate impres- dentures. This allows visualization of the future den-
sions (anatomical impressions) are made with ture esthetics, occlusion, and speaking ability. If nec-
Schreinemakers impression trays for edentulous pa- essary, adjustments can still easily be made. In the
tients. In a second session, functional impressions are fifth and final session, the patient receives the final
taken using individual impression trays (Fig 2) and dentures. Following denture placement, a remount-
light body polysulfide impression material. If neces- ing of the dentures after 3 to 7 days is recommended
sary, the individual impression trays can be adapted to refine occlusion.

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 Steinmassl et al

Fig 3   UTS CAD transfer arch (left) and milled 3D bite plate with gnathometer CAD (right), Wieland Digital Den-
ture (Wieland Dental + Technik Ivoclar Vivadent). Photos courtesy of Ivoclar Vivadent, copyright Ivoclar Vivadent
AG, Liechtenstein.

Wieland Digital Denture relation is determined by gothic arch recording.11 In an

(Wieland Dental + Technik Ivoclar Vivadent) optional second session, the final result can be visual-
ized through PMMA try-in dentures. In case a try-in
The protocol for the Wieland Digital Denture concept session is not desired, AvaDent Digital Dentures sys-
is reduced to four patient visits, three if the try-in ses- tem offers the option of visualizing the final result by
sion is omitted. During the first patient visit, anatomical fixing cellophane resembling teeth to the AMD.11 In the
alginate impressions are generated using conventional last session, the final dentures are placed.
impression trays. In addition, the vertical dimension and
provisional jaw relation are registered using the so- Whole You Nexteeth
called centric tray and the occlusal plane is determined (Whole You; Formerly DENTCA)
provisionally using a special instrument, the UTS CAD
transfer arch (Fig 3). During the second visit, functional During the first session, the vertical height is determined
silicone impressions are taken with milled individual by placing two reference marks on the upper and lower
impression trays that already contain the information lip and recording the distance between them. Functional
about the vertical jaw relation and the occlusal plane. impressions are then generated using DENTCA trays,
If necessary, both can be adjusted by noting the com- which are available in three standard sizes, and silicone
pensation values registered by the UTS CAD transfer impression material. The previously measured vertical
arch. The gothic arch is then registered using the func- occlusal dimension is reproduced by positioning the in-
tional impressions and a click-in set called gnathometer tegrable stylus in the lower impression tray and adjust-
CAD (Fig 3). In the third patient session, try-in dentures ing it to the required height when placed in the patient’s
milled from a polymethyl methacrylate (PMMA) mono- mouth. With the adapted stylus, the centric maxilloman-
bloc are inserted. Necessary corrections can be made dibular relation can be registered by gothic arch record-
at this stage. In the fourth and final session, the patient ing on a plane integrated in the upper impression tray.
is handed the final, milled dentures. The Whole You Nexteeth system generates the infor-
Global Dental Science and Whole You enable digi- mation about lip support and occlusal plane automati-
tal complete denture fabrication in three visits. If the cally from the anatomical structures in the impression.
optional try-in session is omitted, the final dentures Additional information (eg, incisor length) can be com-
can be placed in the second visit. municated through correction values measured by the
dentist. The system also offers optional try-in dentures
AvaDent Digital Dentures made from 3D-printed white acrylic polymer, which is
(Global Dental Science) recommended for visualizing the final result and evaluat-
ing the necessity of further adjustments. In the following
At the beginning of the adjustment session, the vertical and last session, the final dentures can be handed over
dimension is assessed and marked with two reference to the patient. Besides the Whole You Nexteeth system,
points on the nose and chin.11 The distance between which produces a milled denture base with bonded resin
the points is measured and recorded.11 Next, functional teeth, Whole You offers a product in which the dentures
silicone impressions are generated using individually are conventionally processed, Denture CP.
adjustable thermoplastic impression trays. The vertical
occlusal dimension is reproduced using the so-called Baltic Denture System (Merz Dental)
anatomical measuring device (AMD).11 After the lip
support and occlusal plane are determined by adjusting The principle of Baltic Denture System is to adjust bite
the AMD or a wax rim, the centric maxillomandibular rims containing preformed occlusal arches (BD Keys,

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Evaluation of CAD/CAM Denture Systems

a b c
Fig 4  (a) Lower BD Key, (b) Upper BD Key, and (c) both keys click-fixed together, Baltic Denture System (Merz Dental).

Fig 5   High congruence between milled CAD/CAM denture base and master
cast. Green = maximal concordance; turquoise and yellow = less concordance.
Image courtesy of Merz Dental, copyright Merz Dental GmbH, Germany.

Fig 4) by relining, until the dental arches are placed in whatever adjustment protocol to which the user is ac-
the anatomically correct 3D position. The occlusal arch- customed. Therefore, the conventional denture fabri-
es have a fixed tooth set-up, which is available in eight cation protocol with five steps can be applied, as can
different dimensional configurations (S, M, and L, with a reduced-session protocol with only three sessions
different palatal widths). The teeth therefore cannot be (anatomical impression, functional impression plus
adjusted relative to one another. The Baltic Denture determination of vertical and maxillomandibular jaw
System protocol includes one adjustment session and relation, denture placement). The impressions, casts,
the denture placement session. Initially, the vertical or registrations are generated conventionally and dig-
occlusal dimension is measured and demarcated and italized, thereby entering the CAD/CAM manufactur-
functional impressions are taken. By supporting the ing pathway. If a try-in session is desired, the try-in
BD Upper Key (a bite rim resembling the final maxillary dentures can be milled from wax discs provided by
dental arch) with silicone impression material or ther- VITA. VITA VIONIC is not yet available. It is expected
moplastic impression compound, the occlusal plane, to launch in 2017.
incisor length, and lip support are determined. When
the maxillary dental arch has been adjusted to the ideal Discussion
position, the BD Lower Key (a bite rim resembling the
final mandibular dental arch) is interlocked with the BD Material Specifics
Upper Key by click mechanism and, again, supported
with silicone impression material to reach the previously Most systems include the dental technician in the
determined vertical dimension and the centric maxillo- fabrication process by offering labside denture mill-
mandibular relation. Since the BD Keys resemble the fi- ing. Except for AvaDent Digital Dentures and Whole
nal dental arches, the adjusted keys also serve as try-in You Nexteeth dentures, all dentures require manual
dentures so that the final dentures can be placed at the refinement of the nonmucosa-side denture surfac-
next appointment. es, another task involving the dental technician. The
mucosa-side denture surfaces, on the other hand, are
VITA VIONIC (VITA Zahnfabrik) finished by milling in most CAD/CAM denture sys-
tems, and appear to be smoother than conventional
The VITA VIONIC system provides materials for open dentures and might therefore be easier to clean. Whole
CAD/CAM systems. The digital design and fabrication You Nexteeth dentures are additionally dip coated, a
can be facilitated by nonsystem-inherent scanners, strategy that supposedly further enhances the surface
software, and milling machines. The system supports properties.

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 Steinmassl et al

While all dentures are fabricated from PMMA-based Whole You Nexteeth. The Whole You Nexteeth
resin, the polymerization protocols differ between the system allows complete denture adaptation in three
systems. The hypothesis that fit and retention are en- (two without try-in session) visits. Since many features
hanced in CAD/CAM-fabricated dentures because are generated automatically by software, the adap-
of the avoided polymerization shrinkage of the den- tation procedures are limited and can be performed
ture base has been supported by recent literature12 quickly. The options for individualization, however, are
and clinical evidence (Fig 5). Regarding other mate- also limited. The Whole You Nexteeth system compo-
rial- and production-specific properties, scientific evi- nents are similar to conventional trays and bite regis-
dence is scarce so far. tration equipment. Therefore, they are easy to handle,
It is very likely, however, that the industrially pro- even for dentists with less prosthodontic experience.
cessed resin loads show a constant product quality A try-in session is recommended to ensure a favorable
and fewer microporosities,8 which might also lead to result.
better stress resistance and long-term durability. It Baltic Denture System. The Baltic Denture System
also seems that the industrially processed resin en- differs completely from the conventional denture ad-
ables a thinner minimum denture base. Whole You aptation protocol. The great advantage is the single-
Nexteeth dentures, for instance, have a palatal plate visit denture adaptation including visualization of the
thickness of only 1.0 mm, which most likely increases final result. Adapting the BD Keys, however, can be
patients’ denture-wearing comfort. Due to the auto- tricky for beginners and bears some failure potential,
mated denture base processing, the minimum thick- particularly during bite registration. Due to the prepo-
ness can also be applied to a greater extent compared lymerized tooth-arch bearing loads, it is only possible
with manual processing, where repetitive caliper to produce dentures pairwise; single-arch dentures
measurements would be required to ensure constant cannot be fabricated with Baltic Denture System.
material thickness. In case of denture fractures or Dysgnathia also represents a limitation. Practical train-
loss, the digital manufacturing process enables the ing is recommended prior to use in patients.
fabrication of duplicate dentures without a need for VITA VIONIC. The VITA VIONIC system can ac-
new adjustment sessions. quire the digital information from either a master cast
or wax rim scans or directly from impression scans,
System-Inherent Advantages and Disadvantages depending on the scanning device used. Therefore,
the conventional denture adaptation protocol can be
Wieland Digital Denture. Wieland Digital Denture followed. The main advantage is that the dentist can
protocol maintains and simplifies the key features of profit from the material-specific advantages provided
conventional denture adaptation. Therefore, the sys- by CAD/CAM-milled denture bases without changing
tem is simple to learn for an experienced prosthodon- his or her routine. There is also the option to reduce
tist. Another great advantage is that the functional the treatment sessions to three, provided the den-
impressions are performed with milled individual tist has the necessary experience. Although the open
impression trays, which do usually not require much system allows the integration of pre-existing scan-
adaptation. The detailed adjustment procedure allows ners, software, or milling machines, the digitalization
the fabrication of individualized dentures. Currently process is not system inherent and customized. The
(as of February 2016), the system only allows com- greatest challenge might therefore be establishing
bined maxillary and mandibular denture fabrication. a practical and functional workflow with a dental
Avadent Digital Dentures. AvaDent Digital laboratory.
Dentures enables complete denture adaptation in
three sessions, or two if the try-in appointment is Selecting a CAD/CAM System
omitted. All adjustment procedures are performed in
one session, which may become stressful for CAD/ The potential material-specific advantages apply to
CAM-denture novices. Although the system was all digitally fabricated dentures, which is why reduced
rated as “easier to perform” than conventional den- adaptation protocols also produce well-retained den-
ture adaption on a clinical trial among students,12 the tures.12 Due to its adherence to conventional proce-
students were not “more confident in performing” dures, VITA VIONIC is recommended for dentists who
CAD/CAM denture adaption “without faculty super- wish to follow their usual workflow while benefitting
vision.”12 Any failure during denture adjustment can from the material-specific advantages, provided the
be corrected in the try-in session. Since the denture dentist has access to a dental laboratory with a well-
adaptation is performed with system-specific trays established digital workflow. Wieland Digital Denture
and instruments that differ from the conventional requires some change of habits, but the basic ad-
equipment, practical training is recommended. aptation steps are the same as in the conventional

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Evaluation of CAD/CAM Denture Systems

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12. Kattadiyil MT, Jekki R, Goodacre CJ, Baba NZ. Comparison of
The authors thank (in alphabetical order) Ivoclar Vivadent, Merz treatment outcomes in digital and conventional complete re-
Dental, Vita Zahnfabrik, and Whole You for their support with movable dental prosthesis fabrications in a predoctoral setting.
information, materials, and patient treatment. The authors thank J Prosthet Dent 2015;114:818–825.
Global Dental Science for their support with information. The data 13. Bidra AS, Farrell K, Burnham D, Dhingra A, Taylor TD, Kuo
used were collected from the companies included in the study. CL. Prospective cohort pilot study of 2-visit CAD/CAM mono-
The authors are not liable for completeness and correctness of lithic complete dentures and implant-retained overdentures:
this information. Prof Grunert is an advisor for Mitsui Chemicals. Clinical and patient-centered outcomes. J Prosthet Dent 2016;
The other authors declare that they have no conflicts of interest. 115:578–586.e1.
14. Steinmassl PA, Steinmassl O, Kraus G, Dumfahrt H, Grunert I.
Shortcomings of prosthodontic rehabilitation of patients living
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