DENTAL TECHNIQUE

Virtual evaluation for CAD-CAM-fabricated complete dentures

Josef Schweiger, CDT,a Jan-Frederik Güth, PhD,b Daniel Edelhoff, PhD,c and Juliane Stumbaum, DMDd

Complete dentures will ABSTRACT

continue to be an important
New treatment concepts for complete denture fabrication, including digital components, may in-
part of prosthetic dentistry. crease the predictability of the treatment outcome. The reduced number of appointments,
Recently, the fabrication of improved biocompatibility of the materials, opportunity to copy the outline of existing dentures,
complete dentures has been possibility of a virtual evaluation, and reduction of costs have changed the treatment workflow
developed with computer-aided considerably. This becomes even more important against the background of an aging population.
design and computer-aided The innovative approach presented describes the combination of an impression-occlusal rim with a
manufacturing (CAD-CAM) 3-dimesional face scan that allows a virtual evaluation, which might complement or even replace
1,2 the traditional evaluation of a conventional tooth arrangement. (J Prosthet Dent 2017;117:28-33)
technology. Parallel with the
manufacturing process, the
design process has been improved with the development of arrangements that were then printed in 3-dimensions (3D)
virtual tooth arrangement on edentulous jaw sections.3,4 in wax.
Another approach described the use of data from extrao- The goals of digital fabrication of complete dentures
ral computed tomography scans of dentures and prosthetic are to reduce the number of patient appointments and to
teeth to create virtual tooth arrangements, which were then improve the predictability of treatment outcome. Some
forwarded for milling.5 Inokoshi et al6 modified the data authors have described the combination of impression
from computed tomography scans of patients for tooth making and occlusal recording in a single step7; others

Figure 1. A, Impression occlusal rim intraoral (IOR). B, IOR after registration.

a
Laboratory Head, Department of Prosthetic Dentistry, Ludwig-Maximilians-University, Munich, Germany.
b
Associate Professor, Department of Prosthetic Dentistry, Ludwig-Maximilians-University, Munich, Germany.
c
Director, Department of Prosthetic Dentistry, Ludwig-Maximilians-University, Munich, Germany.
d
Associate Professor, Department of Prosthetic Dentistry, Ludwig-Maximilians-University, Munich, Germany.

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January 2017
Figure 2. 3D face scan for virtual evaluation.
have described impression making and occlusal
recording in 2 separate steps but in 1 appointment.8-10
However, no standardized procedure has been
Figure 3. A, Three scans to digitize extraoral clinical situation (neutral face, smiling face, face with cheek retractor, and placed IOR. B, Virtual alignment
of 3 face scan datasets. IOR, impression occlusal rim.
Schweiger et al
29
established for the digitally assisted fabrication of com-
plete dentures, and current analog work steps and digital
denture fabrication approaches have yet to be integrated
and linked to 1 complete digital workflow.11 Neverthe-
less, the requirements are clear: facilitation of the work-
flow, minimization of treatment steps and appointments,
and an increase in the quality of complete dentures.
One key element in the fabrication workflow and an
interface between clinical work and laboratory fabrication
is the traditional clinical evaluation of the trial tooth
arrangement. This holds true also for CAD-CAM com-
plete dentures. However, not all workflows offer the
possibility for a traditional clinical evaluation, using wax
bases. Generally, waiving the traditional clinical evalua-
tion risks subsequent problems in the complete refabri-
cation of the CAD-CAM denture. The connection
between the current workflows and existing face scan
technologies that allows a virtually simulated evaluation
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30 Volume 117 Issue 1

Figure 4. A, Stereolithography (STL) record of impression occlusal rim. B, STL record of maxilla. C, STL record of mandible.

may minimize the risk of a remake. The example given in

this article shows the clinical and technical integration of
an impression occlusal rim (IOR) and a face scan for
virtual evaluation in the fabrication workflow of a CAD-
CAM complete denture.

TECHNIQUE

1. Examine the patient in the dental operatory and

make preliminary impressions (Alginoplast, regular
set; Heraeus Kulzer GmbH).
2. Fabricate custom trays (Palatray XL; Heraeus
Kulzer GmbH) from the anatomic impression.
3. Border mold with impression compound modeling
plastic (GC Compound; Kerr Corp) and make
functional impressions of the maxilla and mandible
(Impregum Penta; 3M ESPE). Use the same
impression trays as record bases for the occlusal
registration record. For this, reseat the maxillary
impression tray in the mouth and align the
maxillary record base parallel to the Camper plane
and bipupillary line. Mark the midline, upper lip
line, and canine position and make a facebow re-
cord using the maxillary impression tray.
4. Reseat the mandibular impression tray and deter-
mine the vertical dimension of speech, extraoral
appearance, and interocclusal rest space. The
maxillary and mandibular impression trays in the Figure 5. A, Reference markers on face scan and model. B, Model data
correct maxillomandibular relationship form the aligned with 3D face scan using reference markers on impression
IOR (Fig. 1). occlusal rim.
5. Make a 3D face scan (Pritimirror Face Scanner;
Pritidenta) during the same appointment (Fig. 2) to
allow later virtual evaluation in the absence of the 7. Mount the conventional stone casts in an articu-
patient. Scan the patient in 3 different positions lator (SAM 2 PX, SAM Präzisionstechnik GmbH)
(Fig. 3A): neutral face with closed lips, smiling face using the facebow and the IOR.
with lips slightly open, and face with cheek 8. Align the stereolithography (STL) data of the IOR
retractor and IOR in place. Align these 3 face scan with the face scan using a best-fit algorithm and
datasets virtually by using a best-fit alignment with reference markings on the IOR (Fig. 5).
software (Priti Imaging; Pritidenta) (Fig. 3B). 9. Send the STL records of the scanned maxillary
6. Scan the IOR with a laboratory scanner (S600 and mandibular impressions and the IOR
optical strip-light scanner; Zirkonzahn) (Fig. 4A). electronically to a fabrication center (Merz-
Subsequently, pour stone casts and digitize them Dental), where the virtual tooth arrangement is
(Fig. 4B, C). conducted.

THE JOURNAL OF PROSTHETIC DENTISTRY Schweiger et al

January 2017 31

Figure 6. Virtual evaluation using 3D face scan. A, Left lateral view. B, Frontal view. C, Right lateral view.

Schweiger et al THE JOURNAL OF PROSTHETIC DENTISTRY

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Figure 7. Prostheses after definitive polishing.
Figure 8. Comparison of virtual evaluation and delivered prostheses shows predictability of described workflow.
10. Receive the virtual tooth arrangement data after
CAD modeling and import them into the face
scanner software.
11. Conduct a virtual evaluation of the digital tooth
arrangement and carry out necessary modifications
step-by-step: optimize the midline and the posi-
tion of the occlusal plane versus the bipupillar line
and the Ala Tragus-Camper plane. Additionally,
modify, if necessary, the anterior maxillary teeth in
length and their position (Fig. 6).
12. Order the computer numerical control fabrication of
the prostheses from the central fabrication center.
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Volume 117 Issue 1
12. Receive the milled prostheses and finish and polish
them (Fig. 7).
13. Deliver both prostheses and carry out regular
recall-appointments. (Fig. 8).
DISCUSSION
In the reported technique, the clinical workflow mostly
followed known methods, facilitating the approach in a
practice setting. The functional impression and max-
illomandibular relationship record were combined into a
single step, resulting in the IOR and complemented with
Schweiger et al
January 2017
a 3D face scan. This enabled a virtual evaluation without
an additional patient appointment. Depending on the
clinical situation, the demands of the patient, and the
financial limitations, this virtual evaluation could replace
the traditional clinical evaluation or at least serve as an
additional tool to evaluate the digital tooth arrangement.
Combining the maxillary and mandibular impressions
and the maxillomandibular relationship record into one
IOR reduces the errors caused by inaccurate matching of
the occlusal relationship scan with the impression scan.
The virtual evaluation presented allows the dentist to
conduct an assessment of a suggested digital tooth
arrangement from an esthetic and functional aspect and
allows corrections. So far, it has not been possible to
reevaluate the mandibular relationship record and the
vertical dimension of speech in the face scan. Therefore,
the correct maxillomandibular relationship record has to
be determined accurately during the clinical appointment
using the IOR.
In the described technique, conventional stone casts
were poured to enable mounting in a conventional
articulator with a facebow in order to evaluate the dy-
namic occlusion. As an alternative, working without any
dental casts would be possible by scanning only the IOR.
However, this limits the conventional control opportu-
nities and prevents the evaluation of the static and,
especially, the dynamic occlusion before placement. In
the future, a face scan for virtual transmission of the
facebow recorded position of the maxillary casts in the
face scan and the virtual articulator may be possible.
To what extent face scanners can be integrated into
clinical practice remains to be seen. Katase et al12 recom-
mended further studies to assess various parameters in the
face scan in order to use them in complete digital denture
fabrication. The virtual evaluation on the basis of a face scan
could be integrated into various CAD systems of digital
denture manufacturers and could also serve to correct the
shortcomings of existing dentures. In the presented
approach, the IOR represents a key element in the combi-
nation of analog clinical techniques and the digital world.
Schweiger et al
33
SUMMARY
This report presents an approach for the virtual evalua-
tion of digital tooth arrangement for CAD-CAM com-
plete dentures. The impressions and maxillomandibular
record are made in a similar manner to the conventional
process and can be combined into a single step. The IOR
is combined with a 3D face scan to enable a virtual
evaluation in the absence of the patient.
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Corresponding author:
Josef Schweiger
Department of Prosthetic Dentistry
Ludwig-Maximilians-University Munich
Goethestr. 70
80636 Munich
GERMANY
Email: Josef.Schweiger@med.uni-muenchen.de
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY