ORIGINAL CONTRIBUTIONS
Use of intraoral scanning and
3-dimensional printing in the
fabrication of a removable partial
denture for a patient with limited
mouth opening
Jiang Wu, PhD, DDS; Yan Li, PhD, DDS; Yumei Zhang,
PhD, DDS
P
atients with extensive head and neck injuries due
to trauma or extensive surgical procedures can
have severely limited mouth openings.1 During
prosthodontic treatment, restricted maximal
mouth opening commonly leads to compromised im-
pressions and prostheses.2 When using the traditional
method, the loaded impression tray is placed intraorally,
and wide mouth opening is necessary for proper tray
insertion and alignment. However, for the patient with
limited mouth opening, a modification of the standard
impression procedure is often necessary to accomplish
this fundamental step in the fabrication of a successful
prosthesis. Baker and colleagues3 improved the custom-
ized separated impression tray for taking impressions.
However, in some cases, this improved method is still
not suitable for those with severely limited mouth
openings. In addition, disadvantages include the addi-
tional time and difficulty in correction of fitting com-
ponents required by this method.
Clinicians have used 3-dimensional (3D) digitization
technology, also known as the intraoral scanning method,
successfully in dentition impression making. In this way,
clinicians can construct a highly accurate virtual denti-
tion cast in a short time, eliminating the number of
procedures for making a dental prosthesis, such as inlay,
crown, and bridge.4,5
In addition, 3D printing technology has become more
important in medicine. Equipped with the advantages of
precise reproduction from virtual to physical objects, 3D
Copyright ª 2017 American Dental Association. All rights reserved.
ABSTRACT
Background and Overview. When treating patients
with severely limited mouth openings, it is difficult for
the dentist to obtain an impression and fabricate a
removable partial denture (RPD) by using traditional
methods. Intraoral scanning, computer-aided design, and
3-dimensional (3D) printing have provided alternative
methods for fabricating dental prostheses.
Case Description. The authors present a case in which
they aimed to improve the efficiency and quality of fabri-
cating an RPD framework by integrating the technologies
of intraoral scanning, computer-aided design, and 3D
printing. Initially, the authors reconstructed the digital cast
with multiple intraoral scans. Subsequently, the authors
designed the virtual RPD framework. On the basis of the
virtual framework, the titanium alloy framework was
fabricated by means of a 3D printing process, and the
authors fitted the final RPD to the patient.
Conclusions and Practical Implications. Unlike the
traditional method, this integrated system has the potential
to design a custom-made dental prosthesis and directly
make an RPD framework with complicated patterns.
Key Words. Intraoral scanning; computer-aided design;
3-dimensional printing; limited mouth opening;
removable partial denture.
JADA 2017:-(-):---
http://dx.doi.org/10.1016/j.adaj.2017.01.022
printing technology has shown promising potential in
dentistry and has been used in maxillofacial surgery,6
orthodontics,7 restorations,8,9 and frameworks.8,10-12 In
this clinical report, we describe an integrated treatment
procedure, combining intraoral scanning and 3D print-
ing technologies, for impression making and the
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 ORIGINAL CONTRIBUTIONS

format. Although the

final digital maxillary
cast was not complete,
the region of the
reconstructed part was
still enough to use
computer-aided design
(CAD) and fabricate
the RPD framework.
We selected the
software (3Shape
Dental System, 3Shape)
Figure 1. Photographs of the patient’s unrestored dentition. A. Central occlusion. B. Maximum open position.
for the CAD of the
RPD framework
because of its capability
in the design of com-
plex, well-defined RPD
frameworks. In addi-
tion to this capability,
several precise func-
tions within the soft-
ware allowed us to
perform electronic
surveying. We tilted
the cast anteriorly, ac-
cording to the angle of
the path of insertion,
Figure 2. Reconstruction of dentition defect cast with overlapping intraoral computer-aided design scans. A. automatically elimi-
Reconstruction with overlapping scanning method. B. Final digitized maxillary dentition defect cast.
nating the unwanted
undercuts. After that,
fabrication of a titanium alloy removable partial denture we designed the digital RPD framework and built it on
(RPD) framework for a patient with a severely limited the digital cast (Figure 3A).
mouth opening. On the basis of the scanning data, we successfully
fabricated the polymerized cast by using a 3D printing
CASE REPORT stereolithography apparatus, also known as rapid proto-
A 46-year-old woman sought care at the Department of typing. We used the stereolithography apparatus for
Prosthodontics at the Qindu Dental Hospital of the creating models, prototypes, patterns, and production
Fourth Military Medical University, China. The patient’s parts layer by layer by using photopolymerization.
chief symptom was tooth loosening, and she requested a Therefore, by means of 3D printing, we made the poly-
new RPD to replace the worn old one. Clinical exami- merized cast more precisely and quickly than we could
nation results revealed multiple missing anterior and have by making a plaster cast the traditional way.
posterior maxillary teeth. Moreover, the patient also In some studies, the investigators used 3D printing
had a severely limited mouth opening that had been methods to produce sacrificial patterns of the RPD
caused by an accident several years previously (Figure 1). framework.10,12 In our study, we directly manufactured
Because of her severely limited mouth opening, using the the titanium alloy RPD framework with the aim of
traditional or customized separated impression was not eliminating the time- and material-consuming invest-
possible. ment casting process. The 3D printing development of
Initially, we prepared the mesial occlusal rests on selective laser melting (SLM) technology showed poten-
teeth nos. 16 and 25, and we recorded the vertical dis- tial use in dentistry because of its ability to produce
tance. After that, we used an intraoral video scanning complex-shaped objects in hard-wearing and corrosion-
system (CEREC Omnicam, Dentsply Sirona) to perform resistant metals and alloys directly from CAD data.11
intraoral scanning. We used multiple overlapping
scans to collect enough data. Then we united the data by
using software (Mimics 17.0, Materialise) and recon- ABBREVIATION KEY. 3D: 3-dimensional. CAD: Computer-
structed the digitized maxillary dentition defect cast aided design. RPD: Removable partial denture. SLM: Selective
(Figure 2) in the standard triangulation language file laser melting.

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Figure 3. Computer-aided design and 3-dimensional (3D) printing of the removable partial denture (RPD) framework. A. Digital design of the RPD
framework. B. RPD framework as it emerged from the 3D printing machine. C. Framework fitted on the 3D printing cast.

Figure 4. The final removable partial denture (RPD) fabricated by means of 3-dimensional (3D) printing. A. Finished framework fitted to the patient.
B. Fabricated RPD with 3D printing framework. C. Final RPD fitted to the patient.

With 3D printing technology, we fabricated the tita-
nium alloy RPD framework with adequate supports by
using an SLM machine (BLT-S200, Bright Laser Tech-
nologies). Figure 3B shows the RPD framework in the
built stage as it emerged from the SLM machine. Before
removing the supports, we annealed the titanium alloy
framework by heating it and holding it at 800 C for
4 hours; we then slowly cooled it in argon. With
annealing, the strength and hardness of the framework
decrease, and the ductility and plastic strain capacity
increase at room temperature, providing material that is
less likely to crack. After we removed the supports, the
RPD framework fit the 3D printing polymer cast well
(Figure 3C). We then polished the 3D printing frame-
work and made the RPD by means of the injection
molding process. Finally, we successfully fitted the RPD
to the patient who had a severely limited mouth opening
(Figure 4).
DISCUSSION
During impression procedures, a wide mouth opening
is required for proper tray insertion and alignment,
but this is not possible for patients with restricted
mouth openings. Baker and colleagues3 outlined and
illustrated a method of using sectional, locking custom
impression trays for such patients. Although it can
simplify the manipulation and decrease the patient’s
trauma, the additional time, materials, and labor made
this method more complicated. For some patients with
severely limited mouth openings, this method is still
not applicable. With the development of the intraoral
scanning system, clinicians can reconstruct highly
accurate 3D surfaces of teeth or mucosa and record
them in a short time, which allows them to make ac-
curate impressions for patients with limited mouth
openings.
However, even with the intraoral scanning system in
this case, we still could not obtain the digital impression
in 1 scanning process because of the narrow opening.
Therefore, we used overlapping scans and aligned the 2
sets of scanning data to reconstruct the final digital cast.
Although the reconstructed digital impression was not
complete (we did not scan some areas because of the
patient’s limited mouth opening), the region of the final
reconstructed digital cast was still sufficient for the
design and fabrication of the framework and RPD. With
this digital impression, we precisely built the polymer-
ized cast by using 3D printing technology.
For the RPD framework design, the CAD software
package can seal the unwanted undercuts automatically,
select suitable components from the library, and drag
and drop them on the dental cast. This process not only
saves much labor-intensive work but also eliminates
interoperator variability.
Although there were a few powder adhesions, the
surface of the SLM framework was still smooth. After the
framework was suitably treated, an experienced techni-
cian evaluated the adaptability of the titanium alloy RPD

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 ORIGINAL CONTRIBUTIONS
framework on the cast and judged it to be well fitted to
the cast. The fit of traditionally made dental prostheses
often is influenced by impression flaws, design discrep-
ancies, and casting defects. For the process we used, the
excellent quality of fit can be attributed to the highly
precise intraoral scanning, accurate CAD, and unique
SLM processing technique. Moreover, the dental frame-
work fabricated in this way has good mechanical
strength for end use and has dense cross-sections
without any cavities. In short, 3D printing technology has
the potential to directly make a metal alloy framework
with complicated patterns.
CONCLUSIONS
In this case report about a patient with a severely limited
mouth opening, we successfully used intraoral scanning,
CAD, and 3D printing technologies for the reconstruc-
tion of a digital impression and the fabrication of an
RPD alloy framework. Unlike the traditional method,
the method we used has the potential to design and
fabricate an RPD framework. With improvements in the
intraoral scanning system and use of the batch method
by networks in the future, this new method also may
reduce interoperator variability and increase speed and
precision over those of the traditional handcrafting and
investment casting techniques. n
Dr. Wu is an associate professor, State Key Laboratory of Military
Stomatology and National Clinical Research Center for Oral Diseases and
Shaanxi Key Laboratory of Stomatology, Department of Prosthodontics,
School of Stomatology, Fourth Military Medical University, No. 145,
Changlexi St., Xi’an 710032, Shaanxi, China, e-mail wujiang@fmmu.edu.cn.
Address correspondence to Dr. Wu.
Dr. Li is an attending doctor, Department of Oral and Maxillofacial
Surgery, Chengdu Military General Hospital, Chengdu, China.
Dr. Zhang is a professor, State Key Laboratory of Military Stomatology
and National Clinical Research Center for Oral Diseases and Shaanxi Key
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Laboratory of Stomatology, Department of Prosthodontics, School of
Stomatology, Fourth Military Medical University, Xi’an, China.
Disclosure. None of the authors reported any disclosures.
J.W. and Y.L. equally contributed as co-first authors.
The authors thank Junjie Pan, BDS, for his help with the computer-aided
design of the framework and Xueya Wang, BDS, for her assistance in the
intraoral scanning process.
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