Using Intraoral Scanning to Capture Complete Denture

Impressions, Tooth Positions, and Centric Relation Records

Brian J. Goodacre, DDS, MSD1/Charles J. Goodacre, DDS, MSD2/Nadim Z. Baba, DMD, MSD3

Intraoral scanning was used to capture the soft tissue surfaces of both maxillary and
mandibular edentulous ridges and the denture borders. Additionally, an intraoral scanner
was used to digitize existing dentures with their tooth positions and base forms and a
centric relation record obtained with a Gothic arch-tracing device. These scans provided
all the required records for fabrication of computer-aided design/computer-assisted
manufacturing of complete dentures. Int J Prosthodont 2018 (5 pages). doi: 10.11607/ijp.5741

C omplete denture (CD) fabrication has traditionally

involved five appointments, which results in a sig-
nificant amount of chair time and associated costs.
Some clinicians have been able to condense the num-
ber of appointments by combining clinical procedures.
With computer-aided design and computer-assisted
manufacturing (CAD/CAM) of CDs, techniques have
been described that further reduce the number of
appointments to as little as two.1 While this has de-
creased clinical chair time, the procedures involved
with CD impressions have remained unchanged.
Intraoral scanning has been used with dentate pa-
tients for decades2 and was recently successfully used
to fabricate a removable partial denture framework
that demonstrated retention and stability.3 However,
challenges have been reported with the scanning of
edentulous arches. For instance, one study evaluated
the use of an intraoral scanner to capture a completely
edentulous model and found inaccuracies in the ability
of the scanner and software to create an accurate digi-
tal scan.4 As a result, other studies have tested the use
of tissue additives, such as pressure-indicating paste
(PIP) and composite resin markers, to improve the abil-
ity of intraoral scanners to capture the palatal area of
edentulous maxillary arches.5,6 These studies conclud-
ed that the addition of surface additives did improve
the ability to capture maxillary edentulous arches.
One patient treatment report has been published
that described how intraoral scanning can be used to
fabricate a maxillary CD.7 However, additional reports
1Assistant Professor, Loma Linda University School of Dentistry,
Loma Linda, California, USA.
2Distinguished Professor, Loma Linda University School of Dentistry,
are needed that evaluate the ability of intraoral scan-
ners to accurately capture the mucosal morphology
and denture borders of both maxillary and mandibu-
lar edentulous arches. Therefore, the purpose of this
technique article is to describe how intraoral scanning
was used to capture all the anatomical and occlusal
records required to make a maxillary CD and mandib-
ular implant overdenture using CAD/CAM fabrication
technology.
Clinical Report
A 78-year-old male presented with a chief complaint
that he wanted a new set of dentures that exactly re-
produced his existing dentures, allowing him to use
his existing dentures as a spare without him notic-
ing a difference between the two sets. The patient
received maxillary and mandibular CDs 15 years ago
made by the second author, with the mandibular CD
subsequently converted to an implant overdenture
(IOD). Over the years, the junction between the por-
celain denture teeth and the denture bases had be-
come stained, and one maxillary lateral incisor was
dislodged and repaired (Fig 1).
As mentioned, the patient specifically requested
reproduction of the teeth irregularities—especially
the mandibular anterior teeth—that helped make the
dentures appear more natural (Fig 2). The patient’s
occlusal vertical dimension (OVD) was evaluated, and
it was decided that no modifications were required.
Following a thorough discussion of the treatment op-
tions, the patient elected to have a new maxillary CD
and mandibular IOD fabricated.

Loma Linda, California, USA. Technical Description

3Professor, Loma Linda University School of Dentistry, Loma Linda,

California, USA.
Correspondence to: Dr Brian J Goodacre, Loma Linda University
School of Dentistry, Graduate Prosthodontic Clinic, 11092 Anderson Street,
Loma Linda, CA, 92350, USA. Email: bgoodacre@llu.edu
©2018 by Quintessence Publishing Co Inc.
During the first appointment, an intraoral evaluation
of the patient’s edentulous arches was completed
along with marking of the posterior extension of the
maxillary denture using Dr Thompson’s Color Transfer
Applicators (Fig 3). Using an intraoral scanner (Trios 3,

doi: 10.11607/ijp.5741 1
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Using Intraoral Scanning to Capture Complete Denture Impressions

scanned using the same in-

traoral scanner (Fig 8). In ad-
dition, the patient’s existing
denture was scanned using
the intraoral scanner so the
existing tooth positions and
base forms could be recorded
for use in designing the new
CAD/CAM–fabricated den-
Fig 1   Patient’s existing denture, fabricated 15 Fig 2   Pretreatment smile. tures. The intraorally scanned
years ago. maxillary and mandibular im-
pressions, CR record, and ex-
isting dentures were saved in a
standard tessellation language
(STL) file format and digitally
sent to Global Dental Science
for the fabrication of maxillary
and mandibular trial dentures.
Using the digitally scanned
CR record from the Gothic
arch tracing, the maxillary and
mandibular impressions were
digitally articulated in CR at
Fig 3   Occlusal view of the maxilla. Fig 4  Finger retraction of cheeks to deter- the desired OVD (Fig 9). The
mine vestibular depth.
scan of the patient’s existing
dentures was used to create
a digital tooth arrangement
that ensured the tooth posi-
tions matched those present in
the existing dentures (Fig 10).
A CAD/CAM esthetic try-in
was requested (BTI AvaDent,
Global Dental Science) to
evaluate the denture’s reten-
tion, occlusion, and esthetics
a b (Fig 11).
Fig 5  (a) Suggested scanning pathway for maxillary arch. (b) Suggested scanning pathway for At the second appointment,
mandibular arch. the retention, occlusion, and
esthetics of the trial dentures
3Shape A/G), maxillary and mandibular arches were scanned to obtain digital were evaluated, and only a mi-
impressions while approximating the denture borders and frenum attachments nor adjustment was made to
by gently grasping the lip/cheek between the index finger and thumb (Fig 4). the cusp length of both maxil-
Special care was taken to retract the soft tissues to positions that simulated lary canines (Fig 12). The max-
the border extensions of a CD while avoiding excessive stretching. The path- illary esthetic try-in was then
way used to scan the edentulous maxilla started with the crest of the ridge, scanned and digitally sent
then extended to cover the palatal area, and finally captured the buccal and back to Global Dental Science
labial vestibules (Fig 5a). Scanning the mandible started with the crest of the for the fabrication of the de-
ridge, then extended to the vestibules, and finally covered the lingual border finitive fully milled monolithic
extensions (Fig 5b). When scanning the vestibules it is important to capture the maxillary CD and mandibular
entire buccal and labial vestibules in one pass, as returning later to recapture a IOD (Fig 13).
missed area will result in a different position of the reflected soft tissue, lead- During the third appoint-
ing to an error in the digital impression. The intraorally scanned maxillary and ment, the definitive dentures
mandibular impressions are shown with and without color (Figs 6a to 6d). were placed and minor ad-
Using a Gothic arch-tracing device (AMD AvaDent, Global Dental Science), justments made to the intaglio
a centric relation (CR) record was made (Fig 7). The CR record was then surface of the maxillary and

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 Goodacre et al

mandibular prostheses using

PIP. A clinical remount was per-
formed, minor occlusal adjust-
ments made, and two Locator
attachments (Zest Anchors
LLC) picked up in the mandib-
ular denture. The patient was
pleased with the retention, sta-
bility, and esthetics of his new
dentures (Fig 14).

Discussion a b

Intraoral scanning can be

used to capture both the mu-
cosal morphology and border
extensions of an edentulous
patient, and the resulting
digital data used to fabricate
CAD/CAM CDs. This tech-
nique offers multiple benefits,
allowing the patient appoint-
ments to be condensed, elimi-
nating the need for custom c d
trays and conventional im- Fig 6  (a) Intraoral scan of maxillary arch in color. (b) Maxillary scan without color. (c) Scan of
pression materials, and pre- mandibular arch in color. (d) Mandibular scan without color.
venting the need to physically
ship records to a dental labo-
ratory, thereby reducing the
overall time required to re-
ceive the final prostheses. In
the example shown above,
the treatment involved three
short appointments that in-
cluded an esthetic try-in at
Fig 7   Gothic arch-tracing device. Fig 8  Intraoral scan of gothic arch-tracing
the second appointment. The device.
minimal adjustments needed
at the second appointment
demonstrated that when ex-
isting dentures are estheti-
cally appropriate, they can be
scanned and used as a guide
in the desired tooth posi-
tions, and the definitive den-
tures could be fabricated and
placed in as few as two ap-
pointments. Otherwise, three Fig 9  Digital mounting of intraoral impres- Fig 10   Intraoral scan of the patient’s existing
appointments are used, as sions using interocclusal record. denture.
in this patient treatment with
the use of an esthetic try-in to
validate the retention, occlu- of interest, as it can result in less time while eliminating the inconvenience
sion, and esthetics prior to the to the patient when they have to sit for several minutes while the impression
definitive denture fabrication. material hardens. In this patient treatment, 2 minutes were required to scan
The amount of time required the maxilla and 5 minutes to scan the mandible. With experience and future
to scan edentulous arches is improvements in scanners, the time involved with scanning could decrease.

doi: 10.11607/ijp.5741 3
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Using Intraoral Scanning to Capture Complete Denture Impressions

While this technique demon-

strated the ability to intraorally
scan both the maxillary and
mandibular mucosal morpholo-
gy, the process does have tech-
nique sensitivity. For instance,
the presence of a minimal
amount of attached mucosa
can negatively affect the ability
Fig 11   CAD/CAM esthetic try-in denture. Fig 12   Esthetic try-in. of the scanner to stitch the sur-
faces together, as movement of
the soft tissue will occur during
scanning, making it more diffi-
cult to obtain a complete scan in
one pass of the scanner tip over
the mucosa. To optimize the po-
tential of obtaining a complete
scan of edentulous arches, it is
important that the scanner be
Fig 13   CAD/CAM–milled mono­lithic de- Fig 14   Patient’s smile with new prostheses in able to stitch together a series
finitive denture. situ. of multiple images; therefore,
specific scanning pathways
However, the mandible is more difficult to intraorally scan than the maxilla have been suggested to allow
and may not be scannable in all patients. In a previous patient treated by the software to accurately stitch
the authors, it was only possible to scan the labial and buccal borders along the captured surfaces together
with the ridge crest and a portion of the lingual extension. The resulting scan to create a full maxillary and
with deficient lingual borders was then used to order a milled trial denture mandibular impression. These
(AvaDent WTI, Global Dental Science) that was used to make a conventional pathways are only suggestions,
reline impression that established the desired lingual borders. The authors as there is no consensus on the
judged the process of making a reline impression inside the milled trial den- most accurate pathway.
ture to be easier than making a conventional mandibular impression. It is important to remember
Additional benefits with this technique include the ability of the intraoral that this is a new application for
scanner to capture the tissue in a true mucostatic state.3 This can be ben- intraoral scanning that needs
eficial for patients with mobile tissue, where a mucostatic impression is sug- further evaluation to validate its
gested.8 Previous techniques have been suggested to reduce the amount of accuracy and reproducibility,
force placed on the soft tissue,9–11 but these techniques still place some force since no clinical studies to date
on the mobile tissue. Therefore, the ability of the soft tissue to be recorded have evaluated the accuracy of
in a true mucostatic state should not be overlooked, as this could provide edentulous intraorally scanned
many additional benefits. Another benefit is the use of intraoral scanners on impressions. However, any in-
patients with increased gag reflex3 or limited mouth opening.12 A previous accuracies that may be incor-
article discussed a limitation with the large size of the intraoral scanner tip porated in the scanning of this
with patients with deep palatal vaults.13 This also was found to be a concern; patient were not found to affect
however, the larger intraoral scanner tip was advantageous when scanning the retention or stability of the
the denture borders through retraction of the soft tissue. dentures fabricated.
The ability of many intraoral scanners to not only capture the mucosal A concern that will be ex-
morphology but also provide color images allows the posterior extensions of pressed by some clinicians is
the maxillary denture to be marked and transferred to the final prosthesis. the perceiving inability to accu-
While the color information is lost when the scan is exported as an STL file rately record denture borders.
and sent to the lab, a screenshot of the intaglio surface is taken and used to However, using fingers to gen-
transfer the position to the digital denture. The position can then be verified tly stretch the soft tissue bor-
or modified as needed at the trial denture appointment. Additionally, using ders and create the roll of soft
the intraoral scanner to capture other records, such as the CR record and the tissue and frenum attachments
patient’s existing dentures, allows more information to be digitized and sent proved to be successful and al-
to the laboratory. This information can greatly benefit the ability of laboratory lowed an acceptable approxi-
technicians to fabricate a denture that will require minimal adjustments. mation of the denture borders

4 The International Journal of Prosthodontics

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with a good peripheral seal. In fact, if multiple clinicians
were to make conventional impressions of the same
edentulous patient using their preferred border mold-
ing and impression procedures, there would be varia-
tions in the border extensions. Therefore, it is proposed
that using fingers to stretch the mucosa and then scan
the reflected tissue is yet another means of establish-
ing a peripheral seal. It is important to note that not
all patients can be successfully treated with intraoral
scanning, and careful patient selection is required to
ensure patients have adequate ridge height and at-
tached mucosa to allow the required manipulation.
When determining the lingual border extensions of
mandibular impressions, the most difficult area is the
mylohyoid and retromylohyoid areas. This extension
can be determined clinically by using a mouth mir-
ror to displace the tongue and scan the lingual area.
A measurement can even be made and transferred
to the desired depth of the lingual extension, similar
to the procedure used to determine the lateral throat
form as described by Neil in 1932.14
Another area of concern with CAD/CAM–fabri-
cated CDs is the ability to digitally create a bilaterally
balanced occlusion. Multiple articles have discussed
the use of virtual articulators and the required data
that must be uploaded into software, as well as ad-
ditional ways to track mandibular movements.15–17
When these processes are not possible, measure-
ments are made clinically and manually uploaded into
the software.16,17 However, the technique of transfer-
ring edentulous jaw movements to virtual articulators
has not been established. In addition, the positioning
of edentulous digital casts in relation to the condyles
has not been refined for virtual articulators. Therefore,
it is important to note that the use of virtual articula-
tors to fabricate CAD/CAM CDs has not been actual-
ized; therefore, a clinical remount will be required to
develop a fully balanced occlusion.
Intraoral scanning of edentulous patients is in its
infancy and needs further studies to compare the ac-
curacy of intraorally scanned denture impressions to
conventional border-molded impressions to deter-
mine their differences. Also, other intraoral scanners
need to be evaluated, since only one intraoral scanner
was used in this report. Additionally, manufacturers
need to focus more research on the development of
scanning that can improve the capturing of soft tis-
sues when no teeth are present.
Conclusions
A technique that used intraoral scanning to capture
CD impressions has been described. It was deter-
mined that a maxillary CD and mandibular IOD can be
successfully fabricated from digital impressions made
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
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Goodacre et al
using an intraoral scanner. A benefit of intraoral scan-
ning is the ability to capture a true mucostatic impres-
sion, which resulted in good mucosal adaptation and
stability of the CAD/CAM–milled prostheses. In ad-
dition, it was possible to use the intraoral scanner to
digitally record a traditional CR record as well as scan
the existing dentures, thereby providing completely
digitized records for the fabrication of prostheses that
replicated the tooth positions and base morphology of
the existing dentures as desired by the patient. This
process streamlined the clinical procedures and elimi-
nated the need to transport conventional records to
the dental laboratory.
Acknowledgments
The authors report no conflicts of interest.
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doi: 10.11607/ijp.5741 5