G Model

JPOR 569 No. of Pages 6

journal of prosthodontic research xxx (2019) xxx–xxx

Contents lists available at ScienceDirect

Journal of Prosthodontic Research

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

Technical procedure

Novel fully digital workflow for removable partial denture fabrication

Hirotaka Nishiyama, Asuka Taniguchi, Shinpei Tanaka, Kazuyoshi Baba*
Department of Prosthodontics, Showa University School of Dentistry, Tokyo, Japan

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

Article history: Purpose: This technical procedure report introduces a newly developed method for removable partial
Received 11 January 2019 denture (RPD) fabrication using computer-aided design and computer-aided manufacturing (CAD/CAM)
Received in revised form 8 May 2019 and rapid prototyping (RP) technologies.
Accepted 13 May 2019
Methods: Full-arch digital impressions of the partially edentulous jaw were made by an IOS or the
Available online xxx
conventional method. The denture framework, artificial teeth, and denture base were designed by
commercially available CAD software. Each of the denture components including connectors, clasps, and
Keywords:
artificial teeth and the denture bases were fabricated separately by the CAM machine or the three-
CAD/CAM
Digital impression
dimensional (3D) printer, and then assembled using an adhesive material.
Removable partial denture Conclusions: RPDs were successfully fabricated using fully digital workflow and delivered to the patient,
Fully digital workflow and no clinical complications were reported. Within the limitations of this report, the newly developed
Rapid prototyping RPD fabrication techniques have the potential to change clinical and laboratory workflow from analog to
digital.
© 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction artificial teeth [8–10]. However, the conventional analogue

Demands for prosthodontic treatment are expected to increase
in developed countries due to rapid aging of the society [1].
Because of the higher costs and necessity of surgical procedures
for dental implants, removable partial dentures (RPDs) continue
to be widely provided as a treatment option for replacing missing
teeth [2].
For conventional RPDs, cobalt–chromium (Co–Cr) alloy has
been used traditionally as the standard framework material due
to its desirable mechanical properties and biological stability. One
of the problems with this alloy, however, is the associated
complicated framework fabrication procedure due to a high
casting temperature. Over the last decade, digital dentistry based
on computer-aided design and computer-aided manufacturing
(CAD/CAM) has become increasingly popular [3], and the
workflow for the fabrication of crowns and fixed partial dentures
has changed dramatically. Recently, CAD/CAM-based removable
denture fabrication methods have also been introduced in several
studies [4–6]. These studies reported successful applications of a
variety of digital techniques for impression making, jaw
registration, arrangement of artificial teeth and designing of
denture bases [4–7], and manufacturing of the denture base and
workflows are still utilized with these digital techniques and
the digital workflow has not completely replaced the analog
workflow.
This technical procedure report introduces a newly developed
fully digital workflow for RPD fabrication using CAD/CAM and
rapid prototyping (RP) technologies.
2. Materials and methods
2.1. Subjects
Two patients seeking new RPDs, participated in the study after
giving informed consent.
2.1.1. Case #1
A 68-year-old woman with a maxillary Kennedy class III
conventional RPD sought a new RPD because of esthetic problems
with the clasps of her denture (Fig. 1). A full-arch digital impression
of the maxillary dentition with the alveolar ridge was made by an
intraoral scanner (TRIOS2, 3Shape, Copenhagen, Denmark; IOS).
An IOS was also used for the impression of the opposing dentition
and the bite registration (Fig. 2a and b).

* Corresponding author at: Department of Prosthodontics, Showa University
School of Dentistry, 2-1-1 Kitasenzoku, Ota-ku, Tokyo 145-8515, Japan.
E-mail address: kazuyoshi@dent.showa-u.ac.jp (K. Baba).
2.1.2. Case #2
A 67-year-old woman with a mandibular Kennedy class I
conventional RPD sought a new RPD because of chewing problems
with her denture (Fig.3). The clinical and laboratory procedures,

https://doi.org/10.1016/j.jpor.2019.05.002
1883-1958/ © 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002
G Model
JPOR 569 No. of Pages 6
2 H. Nishiyama et al. / journal of prosthodontic research xxx (2019) xxx–xxx
Fig. 1. Frontal view of the patient (Case #1).
Fig. 2. 3D images captured by the IOS. (a) A full-arch digital impression of the
maxillary arch. (b) The bite registration (Case #1).
Fig. 3. Occlusal view of the patient (Case #2).
Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002
Fig. 4. 3D image of the working cast (Case #2).
Fig. 5. Flow chart of the study set-up.
which included impression making, the working cast fabrication,
and bite registration were conducted according to the conventional
method, and the working cast was scanned by a laboratory digital
scanner (Dental System D-810, 3Shape) (Fig. 4).
2.2. Denture fabrication
Denture fabrication workflow was shown in Fig. 5. As described
above, stereolithography (STL) data were acquired by IOS or the
conventional method. three-dimensional (3D) images formatted
by STL were imported into two different CAD software systems
(Dental System D-810, 3Shape and Freeform, 3D SYSTEMS, Santa
Clara, CA, USA). The framework of the major and minor connectors,
clasps, and artificial teeth were designed using Dental System D-
810, while that of the denture base was designed by Freeform. The
major and minor connectors, the clasps, and the artificial teeth
were milled from ceria stabilized zirconia and alumina composite
blanks (Ce/TZP-A, Yamakin, Osaka, Japan) (Fig. 6a and b),
polyetheretherketone blanks (PEEK, EVONIK, Essen, Germany)
(Fig. 7), and composite resin blanks (VITA ENAMIC, VITA, Muttenz,
Switzerland) (Fig. 8a and b), respectively, by the milling machine
(CORiTEC 250i, imes-icore, Eiterfeld, Germany). The polished
surface of the denture base had depressed areas, to which the
artificial teeth were connected. The denture base was molded by
the 3D printer (D30, Rapidshape, Unna, Germany) using poly-
methyl methacrylate (PMMA) (Base, NextDent, Soesterberg,
Netherlands) (Fig. 9a–c). Finally, using the 3D printed working
G Model
JPOR 569 No. of Pages 6

H. Nishiyama et al. / journal of prosthodontic research xxx (2019) xxx–xxx 3

Fig. 7. Clasps milled from a PEEK disk. Clasps were designed with 1.5 mm thickness
at the tip and engaged in a 0.5 mm undercut area (Case #1).

cast, all of these components were assembled into the RPD by

bonding with the adhesive material (Super-Bond, SUN MEDICAL,
Siga, Japan) after surface conditioning (Table 1,Fig.10a and b).

2.3. Evaluation of patient satisfaction

The patients evaluated the RPD using the McGill Denture

Fig. 6. (a) Screen captures of the framework designed using the CAD software. (b)
The framework milled from a Ce-TZP/A disk (Case #1).
Satisfaction Instrument [11], which was administered 3 and 12
months after delivery of the prosthesis. The McGill Denture
Satisfaction Instrument included 7 questions, which asked
patients to assess general satisfaction, comfort, stability,
chewing ability, ability to speak, esthetics, and ease of cleaning.
The patient’s answers were recorded on a 100 mm visual analog
scale (VAS) anchored by the words “not at all satisfied’’ and
“extremely satisfied’’, where higher scores indicated greater
satisfaction.

Fig. 8. (a) Occlusal adjustment was performed on the virtual articulator (Case #2). (b) Artificial teeth milled from composite resin blank (Case #1).

Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002
G Model
JPOR 569 No. of Pages 6

4 H. Nishiyama et al. / journal of prosthodontic research xxx (2019) xxx–xxx

Fig. 9. (a) 3D image of the denture base with artificial teeth. (b) After removal of the artificial teeth. (c) 3D printed denture base (Case #1).

Table 1. Surface treatment for each denture component.

Components of RPD Surface materials Surface treatment Bonding materials

Denture bases PMMA Primer treatment RESIN PRIMER, GC, Tokyo, Japan
Frameworks Ce/TZP-A Rocatec treatment Rocatec Pre, 3M ESPE, St. Paul, MN, USA
Rocatec Soft, 3M ESPE, USA
ESPE Sil, 3M ESPE, USA
Epricord OPAQUE PRIMER, kuraray NORITAKE Dental, Tokyo, Japan
Clasps PEEK Silane treatment CLEARFIL MEGABOND2 PRIMER, kuraray NORITAKE Dental, Japan
CLEARFIL PORCELAIN BOND ACTIVATOR, kuraray NORITAKE Dental, Japan
Artifcial teeth Composite resin Silane treatment CLEARFIL MEGABOND2 PRIMER, kuraray NORITAKE Dental, Japan
CLEARFIL PORCELAIN BOND ACTIVATOR, kuraray NORITAKE Dental, Japan

Ce/TZP-A: ceria stabilized zirconia and alumina composite; PEEK: polyetheretherketone; PMMA: polymethyl methacrylate.

Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002
G Model
JPOR 569 No. of Pages 6
H. Nishiyama et al. / journal of prosthodontic research xxx (2019) xxx–xxx
Fig. 10. Finished RPD. (a) Case #1. (b) Case #2.
3. Difference from conventional methods
First, this technical report introduced the fully digital workflow
for RPD fabrication in the dental laboratory, where all of the
denture components were designed and fabricated digitally, and
therefore traditional analog laboratory workflows, such as waxing-
up, investing, or casting were not utilized at all.
Second, none of the RPD components was made of metallic
materials. The major and minor connectors were made of Ce-
TZP/A and the retention clasp was made of PEEK instead of Co–
Co alloy, which is generally used for the conventional RPD
frameworks.
Third, in Case #1, the fully digital workflow was utilized not
only for the laboratory procedures but also for the clinical
procedures. The IOS was utilized for impression making and jaw
registration instead of elastic impression materials or bite-wax.
4. Effect or performance
Using fully digital workflow, the RPDs were successfully
delivered to the patients, and during a six-month follow-up
period, no clinical complications or denture fractures were
reported (Fig. 11a–c). Furthermore, patients’ satisfaction scores
were generally improved after delivery of the denture (Fig. 12a
and b).
The development of the fully digital workflow for RPD fabrication
procedure changes the laboratory workflow significantly. Conven-
tional laboratory procedures, such as casting of frameworks,
arrangement of artificial teeth, or resin polymerization, were much
Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002
5
Fig. 11. The RPDs delivered to the patients. (a, b) Case #1. (c) Case #2.
more complicated compared to the digital workflow. In our
technique, each denture component was designed using CAD
software and the designed data were sent to the CAM machine
and then fabricated automatically, which simplified the manufactur-
ing process significantly.
Regarding the materials selected for the framework, Ce-TZP/
A was utilized for the connectors requiring higher rigidity, and
PEEK for the clasps requiring higher flexibility. This framework
is unique because it is completely metal-free, and thus, clearly a
benefit to patients with allergies/sensitivities to metal [12]. It
also allows better esthetics because it does not use metallic
clasps, which was illustrated by the esthetic denture satisfaction
score.
We also utilized the IOS instead of conventional elastic
impression material, which requires less materials and makes the
impression procedure more patient friendly [13]. However, this
method cannot be applicable to the patient with multiple teeth,
as in Case #2, since these patients require border modeling to
determine the denture border and wax rim for the jaw
registration. In the near future, these procedures might be done
digitally; in fact, several studies have already reported the
application of digital technology for the process of impressions in
edentulous patients [14,15].
G Model
JPOR 569 No. of Pages 6

6 H. Nishiyama et al. / journal of prosthodontic research xxx (2019) xxx–xxx

5. Conclusion

Within the limitations of this report, the newly developed RPD

fabrication techniques have the potential to change clinical and
laboratory workflow from analog to digital.

References

[1] Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the
United States in 2020? J Prosthet Dent 2002;87:5–8.
[2] Petropoulos VC, Rashedi B. Removable partial denture education in U.S. dental
schools. J Prosthodont 2006;15:62–8.
[3] Miyazaki T, Hotta Y, Kunii J, Kuriyama S, Tamaki Y. A review of dental CAD/
CAM: current status and future perspectives from 20 years of experience. Dent
Mater J 2009;28:44–56.
[4] Kanazawa M, Inokoshi M, Minakuchi S, Ohbayashi N. Trial of a CAD/CAM
system for fabricating complete dentures. Dent Mater J 2011;30:93–6.
[5] Inokoshi M, Kanazawa M, Minakuchi S. Evaluation of a complete denture trial
method applying rapid prototyping. Dent Mater J 2012;31:40–6.
[6] Bilgin MS, Erdem A, Aglarci OS, Dilber E. Fabricating complete dentures with
CAD/CAM and RP technologies. J Prosthodont 2015;24:576–9.
[7] Katase H, Kanazawa M, Inokoshi M, Minakuchi S. Face simulation system for
complete dentures by applying rapid prototyping. J Prosthet Dent
2013;109:353–60.
[8] Sun Y, Lü P, Wang Y. Study on CAD&RP for removable complete denture.
Comput Methods Programs Biomed 2009;93:266–72.
[9] Kattadiyil MT, Goodacre CJ, Baba NZ. CAD/CAM complete dentures: a review of
two commercial fabrication systems. J Calif Dent Assoc 2013;41:407–16.
[10] Mansour M, Sanchez E, Machado C. The use of digital impressions to fabricate
tooth-supported partial removable dental prostheses: a clinical report. J
Prosthodont 2016;25:495–7.
[11] Awad MA, Feine JS. Measuring patient satisfaction with mandibular
prostheses. Community Dent Oral Epidemiol 1998;26:400–5.
[12] Granchi D, Ciapetti G, Stea S, Savarino L, Filippini F, Sudanese A, et al. Cytokine
release in mononuclear cells of patients with Co–Cr hip prosthesis.
Biomaterials 1999;20:1079–86.
[13] Schepke U, Meijer HJ, Kerdijk W, Cune MS. Digital versus analog complete-arch
impressions for single-unit premolar implant crowns: operating time and
patient preference. J Prosthet Dent 2015;114:403–6.
Fig. 12. Patients’ satisfaction scores. (a) Case #1. (b) Case #2.
[14] Mansour M, Sanchez E, Machado C. The use of digital impressions to fabricate
tooth-supported partial removable dental prostheses: a clinical report. J
Overall, the method suggested in this report might allow efficient Prosthodont 2016;25:495–7.
[15] Fang JH, An X, Jeong SM, Choi BH. Digital intraoral scanning technique for
denture fabrication procedure, in both clinical and laboratory
edentulous jaws. J Prosthet Dent 2018;119:733–5.
workflow; however, more systematic evaluation of the procedure
using a larger sample and long-term follow-up are necessary to prove
such claims.

Please cite this article in press as: H. Nishiyama, et al., Novel fully digital workflow for removable partial denture fabrication, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.05.002