journal of prosthodontic research 62 (2018) 116–120

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Case Report

Development of complete dentures based on digital intraoral

impressions—Case report
Jing-Huan Fang, Xueyin An, Seung-Mi Jeong, Byung-Ho Choi*
Department of Dentistry, Yonsei University Wonju College of Medicine, Wonju, South Korea

A R T I C L E I N F O A B S T R A C T

Article history: Patient: A 60-year-old man presented for refabrication of his maxillary complete denture. In this case, a
Received 23 January 2017 digital process was chosen to replace the ill-fitted complete maxillary denture. A specialized scan
Received in revised form 19 April 2017 retractor was used to retract the mobile tissues of the lips, cheeks and vestibule while taking a digital
Accepted 24 May 2017
impression. The interocclusal record obtained in the patient’s mouth was scanned in order to digitally
Available online 16 June 2017
register the occlusal vertical dimension. The denture base and teeth were designed on virtual models that
were mounted at the occlusal vertical dimension, and were made using CAD/CAM technology.
Keywords:
Discussion: Unlike conventional impression techniques, intraoral scanning is not able to be performed
Digital denture
Complete denture
while the tissue is moving. This case report used a scan retractor that facilitated stretching and fixation of
Digital impression the vestibular area. It also helped to retract the lips and cheeks. This report also demonstrates that virtual
Dental CAD/CAM models at OVD can be obtained without the use of conventional stone models, flasking or processing
techniques. One of the main shortcomings in the existing CAD/CAM denture fabrication technology is
that it is not able to produce customized denture teeth. The present article demonstrates that the digital
denture fabrication workflow can provide customized denture teeth to optimize occlusion.
Conclusion: This case demonstrated how digital complete dentures can be made without requiring
conventional stone models or mounting the models in an articulator.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction requires considerable time and material. Therefore, the whole

According to the American Dental Association in 2014, more
than one third of Americans did not visit a dentist at all in the past
year [1]. Infrequent or inconsistent dental health care puts patients
at risk of tooth loss due to advanced caries or periodontal disease.
Unfortunately, despite improvements in dental technology and
science, the total number of patients who are becoming edentulous
has not decreased in recent years [2]. According to prospective
studies in the United States, the number of patients who are fully
edentulous in one or both jaws will continue to increase, from
33.6 million in 1991 to almost 38 million by 2020 [3]. This
phenomenon is partially explained by a longer life expectancy.
With an aging population, treating large numbers of edentulous
patients is a challenge. One of the treatment options for these
patients is complete dentures. However, the conventional methods
of manufacturing dentures have not changed in the past 50 years.
The process typically involves multiple clinical appointments and
lengthy laboratory schedules, and each of the involved steps
process is subject to human processing errors, inaccuracies, and
further increased time and cost [4].
Recently, computer-aided design and computer-aided
manufacturing (CAD/CAM) technology has been applied to complete
dentures [5,6]. Until recently, laboratory scanners were used for the
digitalization process in edentulous jaws. The information needed
for a CAD/CAM restoration in edentulous jaws was previously
acquired extraorally based on an impression or a model cast. This
technique has the same deficiencies that conventional impressions
and model casting have. There is also concern given the possibility of
scanning inaccuracies when using the laboratory scanner [7,8]. In
order to avoid errors of the conventional CAD/CAM-production
workflow, it would be more practical to perform digitalization
directly in the patient's mouth using intraoral scanners. Therefore,
this clinical report describes the CAD/CAM fabrication of complete
dentures based on direct digital impressions of edentulous jaws
taken using intraoral scanners.

2. Outline of the case

* Corresponding author at. Dept. of Oral and Maxillofacial Surgery, Yonsei
University Wonju College of Medicine, 162 Ilsandong, Wonju, South Korea. A 60-year-old man with no significant past medical history
E-mail address: choibh@yonsei.ac.kr (B.-H. Choi). presented with an unstable complete maxillary denture. On

http://dx.doi.org/10.1016/j.jpor.2017.05.005
1883-1958/© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
 J.-H. Fang et al. / journal of prosthodontic research 62 (2018) 116–120
Fig. 1. Preoperative clinical view.
Fig. 2. Specialized scan retractor for digital impressions of the maxillary edentulous
jaws.
examination, the patient had multiple missing teeth in the
mandibular jaw. The canine, first and second premolars, and first
molar were still present in the right mandible (Fig. 1). The patient
was not interested in any treatment of the mandible given financial
difficulties. He was only interested in a new maxillary denture. A
digital process was chosen to replace the ill-fitted complete
maxillary denture.
In order to make digital intraoral impressions of the maxillary
edentulous jaw, a specialized scan retractor was fabricated by a
company (DIO Implant Co., Korea), having a universal size (Fig. 2).
It is used to retract the mobile tissues of the lips, cheeks and
vestibule. The retractor has an aluminum frame and connected
handle. The frame is flexible, allowing it to fit into the vestibular
area. The frame thickness should be sufficient to provide retractor
rigidity while not being excessive. The handle extends vertically
from the frame in the canine region and then turns anteriorly to
pass over the lip with minimal interference with the oral
musculature. The handle located in the canine region allows the
scan head to move from the anterior to posterior alveolar ridge
segment without interference.
Prior to intraoral scanning, the scan retractor was bent and
adapted intraorally to fit the contours of the patient’s edentulous
arch. The frame should be extended bucally as far as possible to
scan the labial or buccal surface of the edentulous ridge. After the
scan retractor was contoured, intraoral digital impressions were
acquired using an intraoral scanner (TRIOS, 3Shape A/S, Copenha-
gen, Denmark). First, the edentulous ridge was cleaned and
117
Fig. 3. Scan retractor positioned on the maxillary edentulous jaw.
Fig. 4. Scanned image of the edentulous maxilla taken with an intraoral scanner
(TRIOS) and scan retractor.
completely dried of saliva. The scan retractor was then positioned
on the edentulous jaw so that the frame would push the vestibule
down further. This movement exposed the edentulous ridge in
order to capture the greatest amount of surface area of the
vestibule (Fig. 3). Scanning was performed by retracting the lip and
cheek with the scanner head itself while stretching and fixing the
vestibular area with the metal frame of the retractor. The scanner
head was moved in a zigzag manner, starting at the distobuccal
areas, following the crest to the opposite side and finally scanning
the palate (Fig. 4). The scanner head was also moved in a zigzag
manner to scan the mandibular arch, starting at the distal area of
one side and following the jaw crest to the opposite side (Fig. 5).
Any areas that were not captured fully were rescanned.
In order to record the occlusal vertical dimension (OVD), the
OVD was established using bimanual manipulation of the
mandible. Marks were placed on the tip of the patient’s nose
and on the anterior prominence of the chin. Putty(polyvinyl
siloxane impression material) was used to make interocclusal
records at the OVD. First, heavy-body putty was used to make a
record base for the maxillary arch. The material was seated and
adapted intraorally to fit the contours of the patient’s maxillary
edentulous arch. After placing the light-body putty over the heavy-
body putty base, the record base was reseated on the maxillary
118 J.-H. Fang et al. / journal of prosthodontic research 62 (2018) 116–120
Fig. 5. Scanned image of the mandible taken using an intraoral scanner (TRIOS).
Fig. 6. Record base made using heavy and light-body putties.
Fig. 7. Interocclusal record made by injecting interocclusal record material into the
area between the record base and the occlusal surfaces of the mandibular teeth.
edentulous arch (Fig. 6). A vinyl polysiloxane interocclusal record
material (EXABITE II NDS Bite Registration Creme; GC America Inc.,
Alsip, Il, USA) was injected into the area between the record base
and the occlusal surfaces of the mandibular teeth. The patient’s
mandible was then immediately guided to the OVD, where it was
stabilized until the interocclusal record material was completely
polymerized (Fig. 7). The interocclusal record was then removed
from the mouth and scanned using the intraoral scanner (Fig. 8).
The scanned maxillary edentulous jaw and the scanned mandibu-
lar teeth were virtually mounted according to the scanned
Fig. 8. Interocclusal record image taken using an intraoral scanner.
Fig. 9. Virtual models that were mounted according to the scanned interocclusal
record.
Fig. 10. Virtual models mounted at OVD.
interocclusal record (Fig. 9). In order to do so, the two scanned
images were aligned using the interocclusal record image by
means of best-fit matching. After mounting the two scanned
images, the interocclusal record image was deleted. Next, the
virtual models mounted at the OVD were obtained (Fig. 10). The
obtained data were imported into the software to design the
complete dentures. The denture base and maxillary teeth were
virtually designed by using denture planning software (Dental
 J.-H. Fang et al. / journal of prosthodontic research 62 (2018) 116–120
Fig. 11. Virtual design of the denture base and teeth.
Fig. 12. Virtual articulator settings.
Fig. 13. Milling data for the denture base and teeth.
System, 3Shape A/S, Copenhagen, Denmark) (Fig. 11). The program
allowed occlusal adjustment via the virtual articulator (Fig. 12).
More accurate denture teeth could be prepared through simulation
of the mastication function using the virtual articulator. The
resulting data were then exported to a milling machine (Trione Z;
Dio Implants, Pusan, Korea) for dentures manufacturing (Fig. 13).
The denture base was milled from a pink block of prepolymerized
cross-linked polymethyl methacrylate (PMMA) disks. The teeth
were also milled from the PMMA disk using the 5-axis milling
machine and fine milling tools (Fig. 14). The milled teeth were
119
Fig. 14. Milled denture base and teeth.
Fig. 15. Complete denture.
Fig. 16. Patient with complete denture.
securely bonded onto the milled denture base (Fig. 15). Finally, the
denture was placed in the patient’s mouth (Fig. 16). There were
minimal chairside adjustments needed. The retention of the
denture base was excellent. The patient did not have difficulty with
mastication and was pleased with the esthetic outcome of his
denture.
3. Discussion
There are several key steps in the digital denture fabrication
workflow. The first step is to take direct digital impressions of a
120 J.-H. Fang et al. / journal of prosthodontic research 62 (2018) 116–120
patient’s edentulous jaw. The second step is to digitally register the
OVD. The last step is to mill the denture bases and teeth using CAD/
CAM technology. The first step was the most difficult in this case;
this was because the mobile tissue of the lips, cheeks, and vestibule
constantly changed while taking the digital impression. Unlike
conventional impression techniques, intraoral scanning could not
be performed while this tissue was moving [9]. It was more
difficult to scan mobile soft tissues, such as the vestibule, than it
was to scan immobile soft tissues, such as the palate or alveolar
ridge. The main advantage of the scan retractor used in this case is
that it facilitated stretching and fixation of the vestibular area. It
also helped to retract the lips and cheeks. The time needed for the
full-arch scans was approximately 2 min for the maxillary arch and
1.5 min for the mandibular arch. During the intraoral scanning
procedure in the edentulous patient’s mouth, the patient felt
comfortable and pleasant in the dentist’s chair. During the
intraoral scanning procedure in the edentulous patient’s mouth,
there were no specific stitching problems. However, many pictures
were taken, and considerable time was required to stitch the
separated pictures. Approximately 2000 3D pictures were used to
capture the maxillary arch and about 4 min were needed to stitch
the pictures, whereas approximately 1000 3D pictures were used
to capture the mandibular arch and about 2 min were needed to
stitch the pictures.
With regard to the second step in the digital denture fabrication
workflow, scanned images of the interocclusal record were used to
record the maxillomandibular relationship. Virtual models were
mounted according to the scanned interocclusal record. Prior to
this case, it has not been possible to use intraoral scanners to
directly take the maxillomandibular relationship record in
patients’ mouths. Therefore, the correct maxillomandibular
relationship record was determined by pouring stone to enable
mounting in a conventional articulator with a facebow [4,10,11].
This article demonstrates that virtual models at OVD can be
obtained without the use of conventional stone models, flasking or
processing techniques. This technique allows dentists to make
dentures without mounting the stone models in an articulator.
When we consider the intraoral working time for conventional
impressions and the time for preparation and stone pouring, the
conventional technique would be a more time-consuming proce-
dure.
In the last step of digital denture fabrication, the digital files
were not only used to mill the denture bases, but also the denture
teeth using CAD/CAM technology. Previously, the denture base was
milled from a block of pink denture base resin and conventional
denture teeth, which are not CAD/CAM produced, were then
bonded into the sockets of the milled denture base [4,6,11]. In this
case, digital scan images of the edentulous maxillary jaw and
opposing teeth at OVD were used for production of the denture
bases and teeth. The virtual articulator in the software enabled a
more sophisticated virtual teeth design. The teeth were then made
using the CAD/CAM milling process. Occlusal adjustments for the
denture teeth at chair-side were minimal. The denture base fitted
well on the patient’s arch without relining it. One of the main
shortcomings in the existing CAD/CAM denture fabrication
technology is that it is not able to produce customized denture
teeth. The present case demonstrates that the digital denture
fabrication workflow can provide customized denture teeth to
optimize occlusion. A further controlled clinical study will be
necessary to determine whether the digital workflow for dentures
is an improvement over the conventional technique in terms of
denture-base fitness and occlusion.
4. Conclusion
This report presents a digital workflow for CAD/CAM fabricated
complete dentures. Digital impressions of edentulous jaws are
taken directly in patients’ mouths using a specialized scan
retractor and intraoral scanner. The digital registration of the
maxillomandibular relationship is made using scanned images of
the interocclusal record. Both the denture base and teeth are milled
using CAD/CAM technology. This digital workflow allows dentists
to make complete dentures without using conventional stone
models or mounting stone models in an articulator.
Acknowledgments
The author would like to express appreciation for the support
provided by the Ministry of Trade, Industry & Energy (MOTIE,
Korea) under Industrial Technology Innovation Program (grant #
10060000).
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