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APPLICATION FORM FOR THE RESEARCH PROTOCOL TFM

Date: 20-04-2022

Supporting researcher/Tutor: Dr. Oriol Cantó Navés

Second tutor: Dr. Raúl Medina Galvez

Student post/degree: Alejandra Estrada Rengel

Research title: SYSTEMATIC REVIEW OF THE RESISTANCE TO DETACHMENT

OF RESIN TEETH IN COMPLETE DENTURES USING CONVENTIONAL AND
DIGITAL TECHNIQUES

Master: University Master's Degree in Aesthetic Restorative Dentistry

SYSTEMATIC REVIEW OF THE RESISTANCE TO DETACHMENT OF RESIN TEETH IN COMPLETE

DENTURES WITH CONVENTIONAL TECHNIQUES AND DIGITAL TECHNIQUES.

1. INTRODUCTION

Since the origins of humanity, the loss of teeth has been suffered. (1) The use of dental
prostheses is by no means recent. Since the first civilizations of Humanity, the use of dental
prostheses has already been observed, practically since the Etruscans in the 4th century BC (1).
This people used the dental pieces of animals, placing them in the existing gaps between teeth by
means of gold bands. (two)

The Greeks and the Phoenicians used soft gold or in a roll format, handling welds, shapes and
measurements with the aim of creating pieces that were perfectly adaptable to the gaps between the
teeth. Around the year 65 BC, the first uses of ivory and wood began to be used to create teeth,
crowns and other dental forms. (3) It will be necessary to wait until the fifteenth century to speak of a
complete dental prosthesis. Bone and ivory were the main materials used in the making of
prostheses. These materials were chosen because they mimicked the natural color of teeth in a very
realistic way. It is necessary to clarify that they were functional prostheses, although very unaesthetic.
(3)

Around the 17th century and in different Asian countries, the technique was improving. Crowns
made of spikes began to be used in China and Japan. (1) At the end of the 18th century,
experimentation with other materials began, specifically with mineral pastes until the first
complete prosthesis made of porcelain was created. The next step was single porcelain teeth
held by a nail with bases made of gold or silver. (4)

In 1851 Nelson Goodyear announced a method to produce vulcanite which is used in the
manufacture of dental plates, replacing carved ivory as denture bases. 1855 SS White uses
artificial teeth in 1856 (5)
Due to the high cost of using these materials, other attempts were made with cheaper metals. At the end
of the 19th century, the use of vulcanized and treated rubber appeared as a new material for making
prostheses. This evolution both in technique and in the use of new products generated a revolution within
the sector itself. From rubber they went to resins with an acrylic appearance and to the use of other
materials. (3)

Overdentures date from this year, full dentures supported by implants or roots of natural
teeth, 1866 FH Balkweel presents an articulator that was endowed with downward
movement and lateral displacement of the condyles, 1869 J. Smith Hyatt discovered
celluloid which began to be used as denture base material. 1896 William E. Walker studied
the movements of the lower jaw with respect to dental prostheses. (5)

At the beginning of the 20th century, the field of dental prosthetics was experiencing a golden
age. Machines specialized in casting are born, articulators capable of simulating the
characteristic movements of the jaws appear and, above all, different advances are made in
dental materials until increasingly refined production techniques are generated. (3)

In 1925, the first material printed on elastic bands appeared, hydrocolloid. In 1935, polymerized
acrylic resin began to be used as a base for artificial teeth. And from there, new ways to improve
the appearance with new techniques are studied every day. In 1936 synthetic resins were used
for complete denture bases. (5)

CAD CAM technology was introduced in the 1990s.

EXP: (Computer-Aided Design) computer-aided design and CAM: (Computer-Aided

Manufacturing) computer-aided manufacturing(6) The virtual arrangement of artificial teeth
in CAD software was reported in the 2000s. (7)

The ways of manufacturing complete dentures with CAD CAM technology can be additive
(printed) or subtractive (milled). (6) Digital processes improve visualization of edentulous
arch morphology and decrease PMMA polymerization shrinkage. (7)

For the preparation of printed prostheses we have different types of 3D printers. (8)

SLA: The technology is based on 3D CAD design that converts the polymer into a solid object through
the repeated solidification of liquid resin through a UV laser (8).

DLP: in this method, the silhouette of each layer is projected onto a surface of the resin that is
polymerized by light either in the visible or the UV spectrum.1(8)

LCD: The main difference is the light source and imaging system. While, the control system and
stepper have little difference. The biggest difference between DLP and LCD 3D printing
technology is the Imaging system. (9)

Milled digital complete dentures are made with a 5-axis milling machine.

Both types of digital full dentures consist of milled or printed bases, into which false teeth are
inserted, these can be printed or milled depending on the base. (7) Depending on the type and
form of preparation, it can lead to occlusion errors.

Conventional prostheses require a complex manipulation, the preparation time is long since it
requires an initial preparation in wax, several tests, removal of the wax and not to mention the
contraction of the PMMA in the polymerization process that decreases the precision of the
same. Digital prostheses have better adaptation to surfaces, better properties and high
patient satisfaction. (7)

Applying a digital workflow, custom artificial resin teeth must be integrated into a milled or
printed full denture base using polymethyl methacrylate (PMMA) applied with a powder-
liquid technique. (10)

In studies carried out by Yamamoto, false teeth were bonded in the holes of a milled prosthetic base,
to evaluate the precision of the bonding and it was concluded that a certain displacement of the
tooth was needed for its correct positioning that did not coincide with the basal shape of the milled
hole. , thus creating occlusion and dental position problems (6,7). In the same way he used the
3Shape dental system and milled bases by finding spaces between the tooth and the hole of the
milled base. (7)

The deformation of the occlusion when using prefabricated teeth can lead to adjustments of the dental
anatomy of these, impairing the final result. (7)

The literature suggests that digital complete dentures have better adaptation than
conventional ones. (7)

2.- APPROACH TO THE PROBLEM

One of the main complaints of patients who use dental prostheses, whether conventional or
digital, is the detachment of the teeth. (8) An article published in 2021 by Dominik klaiber
mentions that monomer application can be proposed as the most effective surface
treatment method for bonding personalized artificial teeth on a milled PMMA denture base,
while nitrogen plasma affects the binding force. (10)

However, there is a gap in the literature on detachment of prefabricated teeth in milled prostheses
vs. printed prostheses, and the comparison of these with conventional techniques. Therefore, the
present systematic review seeks to compare which type of technique (digital or conventional)
presents greater resistance to detachment of its prefabricated teeth.

3.- JUSTIFICATION

The purpose of this literature review is to bring together the information to date and serve as a basis
for future research on the subject.

4.- THEORETICAL FOUNDATION

A conventional workflow for fabricating a complete denture involves laborious manual

waxing of the base with prefabricated resin artificial teeth and transferring them to acrylic.
Commonly, the bases of full dentures are made of polymethyl methacrylate (PMMA) based
on a powder-liquid system, while denture teeth are made primarily of microfilled reinforced
polyacrylic or a micro/nanofilled composite material. Recent advances in computer-aided
design and manufacturing (CAD/CAM) offer digitization of the entire production chain for
complete dentures. (10)
Using precast acrylic resin blanks has some clinical advantages over conventional workflow
(8) some industrial polymerized PMMA blanks offer less monomer release over time, but all
offer low initial monomer release. This leads to the same problem of inferior bonding ability
that is known from industrial custom resin teeth (also made of PMMA) (10).

In conventional flow, the bond between the denture base and the denture teeth occurs
during the polymerization of PMMA in the presence of the artificial resin teeth. (10) In digital
prostheses, the union of both polymerized entities (teeth and base) must be performed
separately. This requires surface conditioning, a bonding material or the simple application
of PMMA polymerization (powder and liquid technique) (10).

The detachment of prosthetic teeth from the denture base is the most reported
complication in complete and partial dentures. (10). Detachment is mainly due to
insufficient connection due to impurities or decontaminations of the corresponding
surfaces (10).

A 2021 study by Klaiber concluded that the application of MMA monomer can be proposed
as the most effective and efficient surface treatment method for the integration of custom
artificial resin teeth into a denture base milled from a denture base. PMMA CAM blank. (10)
Sandblasting and oxygen plasma can also be considered as a reliable pretreatment option,
but it appears to be inefficient. Nitrogen plasma application is not recommended as it can
decrease the bond strength between artificial teeth and PMMA even below 5 MPa. (10)

5.- OBJECTIVES

5.1.- GENERAL OBJECTIVE

To group and analyze the evidence from published studies regarding the resistance to detachment of
prefabricated teeth in complete dentures with conventional technique and digital techniques, to obtain
the scientific foundations when choosing the technique for the manufacture of complete dentures.

5.2.- SPECIFIC OBJECTIVES

• To group scientific evidence on the resistance to detachment of PMMA milled

teeth in milled-based digital complete dentures.
• To group scientific evidence on the resistance to detachment of resin-printed teeth
in full digital dentures with a printed base.
• To group scientific evidence on the resistance to detachment of prefabricated teeth in complete
prostheses with the muffle technique.
• Establish a criterion on the choice of material to choose in digital prosthetics.

6.- HYPOTHESIS

The conventional technique with a flask shows better resistance to detachment of prefabricated
teeth than digital techniques because it presents not only adhesion but also retention.
7.- MATERIAL AND METHOD

7.1. Protocol

PEAK

patient or problem Intervention of Intervention of Outcome of interest

of interest interest comparison
detachment of muffle technique Techniques in prosthetics Choice of technique
prefabricated teeth digital with better resistance.
in complete dentures

This systematic review will be conducted and reported according to the PRISMA (preferred reporting
items for systematic reviews and meta-analysis) guidelines. The review protocol will be registered in
PROSPERO.

It was sought what type of database was available to be able to search for scientific articles. An
exhaustive bibliographical review was carried out based on articles taken from different databases
such as: Pubmed, Dialnet, Google Academics, ResearchGate and through the library portal of the
International University of Catalonia.

To carry it out, the key terms were used, combined among them: “complete denture”, “digital
denture”, “tooth detachment”, “dental muffle”, “3Dprint denture”, “Milled denture”, “artificial
dental teeth” “bond strength”Following these parameters, X articles were found, including
some web pages and doctoral theses.

Of these X publications, a first selection was made according to the title, and we were left with X
articles. Next, the abstracts of each article were analyzed and we were left with X. Finally, the
inclusion and exclusion criteria were applied, X articles were eliminated, leaving us with X.

a. INCLUSION CRITERIA

➢ Articles published in the last 15 years (2008 -2022)

➢ doctoral theses

➢ Websites

➢ Clinical trials 4

b. EXCLUSION CRITERIA

➢ Articles older than 15 years

➢ Articles or web pages where scientific language is not used.

7.2 TYPE AND DESIGN OF INVESTIGATION

The condition or domain that is studied is the presence of a greater resistance to tooth
detachment when digital prostheses, such as milled or printed ones, are compared with
conventional techniques. We would also help to establish a criterion on the choice of materials
to choose to make a digital denture that will have less probability of tooth detachment and
greater durability.

Digitization of dental flow reduces errors and minimizes the technical skills of laboratory
technicians. The level of precision achieved is also better and is used to produce a variety
of dental restorations.

After pubmed research we found some articles related to the topic of our interest. In vitro
studies showed that the presence of grooves, or treatment of the ridge area with
ointments such as methyl methacrylate and dichloromethane along with sandblasting is
effective on bond strength. (12,13,14,15).

According to Chung KH, sandblasting also had a significant positive effect due to better
micromechanical retention. (16,17)

8.- REFERENCES

1. Ibáñez Aracly T, Villalba Rojas C. History of the Fixed Prosthesis. Bolivia, dental Bolivia. 2013;

two. Mayra Rosa Guarat Casamayor L, de la Asunción Izquierdo Hernández A, Iraida Mondelo López D,
Toledano Giraudi R. HISTORICAL ARTICLE Dental prosthesis. Notes on his history Dental
prostheses. Notes on its history.

3. What is the origin of dental prostheses? | E&D Prosthetics [Internet]. 2017 [cited 2022 Sep 10].
Available from:https://www.estudiosydesarrollosdeprotesis.es/breve-historia-de-lasprotesis-
dentales/

Four. Robert G. Craig. Restorative dentistry materials [Internet]. Tenth. Marcus L. Ward, editor.
Madrid; 1998 [cited 2022 Sep 10]. 4–10 p.m. Available from:
https://books.google.co.in/books?id=4NqNObCmTCwC&pg=PA4&dq=history+of+the+prosthesis
+ dental&hl=ca&sa=X&ved=2ahUKEwjmvq2y34n6AhXVhuYKHb0zDgQQ6AF6BAgFEAI#v=onep
age&q=historia%20de%20la%20protesis%20dental&f=false

5. Lic. Mayra Rosa Guarat Casamayor, Dr. Alfredo de la Asunción Izquierdo Hernández, Dr.
Iraida Mondelo López. Dental prostheses. Notes on its history.

6. Yamamoto S, Kanazawa M, Iwaki M, Jokanovic A, Minakuchi S. Effects of offset values for artificial
teeth positions in CAD/CAM complete denture. Comput Biol Med. 2014 Sep 1;52:1–7.

7. Wang C, Shi YF, Xie PJ, Wu JH. Accuracy of digital complete dentures: A systematic review of in
vitro studies.

8. Revilla-León M, Gonzalez-Martín Ó, Pérez López J, Sánchez-Rubio JL, Özcan M. Position Accuracy

of Implant Analogs on 3D Printed Polymer versus Conventional Dental Stone Casts Measured
Using a Coordinate Measuring Machine. Journal of Prosthodontics. 2018;27(6).

9. Quan H, Zhang T, Xu H, Luo S, Nie J, Zhu X. Photo-curing 3D printing technique and its
challenges. Vol. 5, Bioactive Materials. KeAi Communications Co.; 2020. p. 110–5.
10. Klaiber D, Spintzyk S, Geis-Gerstorfer J, Klink A, Unkovskiy A, Huettig F. Bonding behavior of
conventional pmma towards industrial cad/cam pmma and artificial resin teeth for complete
denture manufacturing in a digital workflow. Materials. 2021 Jul 2;14(14).

11. Cho, S.-H.; Schaefer, O.; Thompson, GA; Guentsch, A. Comparison of accuracy and reproducibility of
casts made by digital and conventional methods. J. Prosthet. dent. 2015, 113, 310–315. [CrossRef]

12. Marra J, Freitas de Souza R, Barbosa DB. Evaluation of the shear bond strength of denture base resins
to acrylic resin teeth: Effect of thermocycling. J Prosthodont. 2009;18:438-43.

13. Melota CB, Silva-Concillo LR, Rodrigues-Garcia CM. Effect of surface treatments on the bond strength
of different resin teeth to complete denture base material. Latin American Dental Act. 2013;26:37-42

14. Krishna VP, Premalatha A, Babu JP. Effect of various chemicals on the bond strength of acrylic tooth
and denture base-An invitro study. Journal of International Oral Health. 2014;6:100-06

15. Cardash HS, Liberman R, Helft M. The Effect of Retention Grooves In Acrylic Resin Teeth on Tooth
Denture Base Bond. J Prosthet Dent. 1986;55:526-28.

16. Chung KH, Chung CY, Chan DC. Effect of Pre-Processing Surface Treatments of Acrylic Teeth on
Bonding to the Denture Base. J Oral Rehab. 2008;35:268-75.

17. Zuckerman GR. A Reliable Method of Securing Anterior Denture Teeth in Denture Bases. J
Prosthet Dent. 2003;89:603-07.