Fabricating complete dentures with

CAD/CAM technology
Luis Infante, DDS,a Burak Yilmaz, DDS, PhD,b
Edwin McGlumphy, DDS, MS,c and Israel Finger, DDS, MSd
School of Dentistry, Louisiana State University Health Sciences Center,
New Orleans, La; Division of Restorative and Prosthetic Dentistry, The
Ohio State University, College of Dentistry, Columbus, Ohio
Conventional complete denture prosthetics require several appointments to register the maxillomandibular relationship and
evaluate the esthetics. The fabrication of milled complete dental prostheses with digital scanning technology may decrease the
number of appointments. The step-by-step method necessary to obtain impressions, maxillomandibular relation records, and
anterior tooth position with an anatomic measuring device is described. The technique allows the generation of a virtual
denture, which is milled to exact specifications without the use of conventional stone casts, flasking, or processing techniques.
(J Prosthet Dent 2014;111:351-355)

Present-day advances have led to
the incorporation of computer-aided
design/computer-aided manufacturing
(CAD/CAM) technology into the
design and fabrication of dental res-
torations, including complete den-
tures. Different systems for making
impressions and fabricating casts of a
patient’s dental structures have been
introduced,1,2 some of which also
allow for the production of specific
restorations in the laboratory, in the
dental office, or at a centralized pro-
duction center.3-5
The information for the develop-
ment of a CAD/CAM cast or restora-
tion can be acquired extraorally from
an impression or from a cast of
the object or intraorally by directly
recording the structures intraorally.
Different systems use different tools to
collect this information. Mechanical
digitizing systems rely on touch probes
(tactile),6,7 whereas optical digitizing
systems use cone beam computed to-
mography,8,9 laser,5 or light-emitting
diode scanners.5,6 These data are pro-
cessed by software and then used
to fabricate the desired object or
restoration with the CAM portion of
the system.
In 2007, Quaas et al6 studied the
measurement uncertainty and the 3-
dimensional accuracy of a mechanical
digitizing system and concluded that
the measurement uncertainty for the
system was low and the precision was
high. However, they discouraged the
application of this method for the
digitization of flexible impression ma-
terials because the physical contact of
the probe with the soft material might
lead to deformation and increased in-
accuracy. In 2012, Goodacre et al2
proposed a technique to obtain maxil-
lary and mandibular definitive impres-
sions of the edentulous arches so these
could be scanned and data acquired to
mill denture bases with CAD/CAM
technology. They also described the
process for recording the neutral zone,
the maxillary and mandibular anterior
teeth position, the palatal morphology,
the occlusal vertical dimension, and the
interocclusal relation so these could be
included as part of the process of
fabricating the bases. Furthermore, they
used a prototype of 3-dimensional
software that allowed the milling of
the tooth sockets in the denture base
according to the desired arrangement.
The use of computer-generated
dentures is changing the procedures
for denture fabrication. CAD/CAM
technology differs from the conven-
tional method in that the laboratory
work is simplified and fewer appoint-
ments are needed.10 Recently, Bidra11
reported the use of CAD/CAM tech-
nology for the fabrication of mandib-
ular implant-retained overdentures in
only 2 clinical appointments. This
report describes a technique to fabri-
cate a complete dental prosthesis with
CAD/CAM technology. The technique
presented uses a standard clinical pro-
cedure to fabricate dentures for a pa-
tient with existing dentures in only 2
appointments. The measurements were
recorded at the first appointment and
inserted at the second appointment.
TECHNIQUE
1. Make a definitive impression
with the impression materials and ther-
moplastic moldable trays which are

a
Assistant Professor, Louisiana State University Health Sciences Center.
b
Assistant Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University.
c
Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University.
d
Adjunct Clinical Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University.

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352
available in different sizes (AvaDent).
Initially, mix the 2 part heavy-consistency
polyvinyl siloxane (PVS) and press it
into the existing denture to create a
PVS cast.
2. Measure the residual ridge and
select the appropriate thermoplastic
tray. Place the tray in a hot water bath
(77 C) and mold to the cast.
3. Evaluate the tray intraorally to
ensure it covers all the appropriate
anatomic areas and adjust the borders
as needed. As with any conventional
edentulous impression technique, dry
the tissue with gauze. First, border the
mold with heavy-body material and
make the definitive impression with a
regular-set light-body PVS material
(Figs. 1, 2).
4. Choose the correct size anatomic
measuring device (AMD) (1 of 3 avail-
able sizes) (AvaDent) by using the
caliper to measure the widest part of
the residual ridge (Fig. 3). If the residual
ridge is between sizes, use the smaller
AMD size. With the existing dentures in
the mouth, assess the occlusal vertical
dimension (OVD) and rest position
with a preferred assessment method.12
Establish whether these dimensions are
correct or whether they need to be
altered. Once established, place dots
on the patient’s facial features and re-
cord the OVD with a caliper.
5. Coat the AMD maxillary tray
with the specified adhesive (Express fast
set polyvinyl siloxane PVS max-
illomandibular registration record; Xer-
tec) material onto the tray and place
intraorally to stabilize the AMD on the
residual ridge before making the re-
cords. Coat the AMD mandibular tray
with adhesive, express the PVS max-
illomandibular relationship record ma-
terial onto the tray, and place the tray
in the mouth. Extend the mandibular
Volume 111 Issue 5
AMD as far posteriorly as possible and
place it horizontally (Fig. 4).
6. Place both AMDs into the
mouth and attach the AvaDent ruler
(Fig. 5). Align the ruler parallel to the
interpupillary line and record the angle
that will be used to correlate the
completed AMD to the virtual
mounting with software algorithms.
With the central bearing tracing device
resting on the mandibular tray, adjust
the OVD by turning the fitting on the
side of the AMD to raise and lower the
central bearing pin (Fig. 6). Then
confirm the OVD. To confirm the
centric relation with a gothic arch
tracing, coat the tip of the bearing pin
with a marking agent, coat the
mandibular tray with occlusal spray, or
rub it with occlusal paper. Guide the
patient’s mandible back and trace
lateral, anterior, and posterior excur-
sions on the mandibular tray with the

1 Maxillary definitive impression. 2 Mandibular definitive impression.

3 Maxillary and mandibular anatomic measuring devices 4 Maxillomandibular relationship record material being
(AMDs). expressed into AMD maxillary tray.
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May 2014 353

5 Registration of interpupillary line. 6 OVD adjustment by turning screw on side of AMD.

7 Stabilization of AMD by injecting maxillomandibular 8 Use of composite resin to stabilize transparent guide.
relationship record material into area between maxillary and
mandibular trays.

bearing pin. Direct the patient to “keep
jaws together,” “slide lower jaw as far
forward as possible,” “as far back as
possible,” and “as far left and right as
possible.” Create the gothic arch
tracing accordingly.
7. Remove the mandibular tray and
drill a divot into the tray at the tip of
the arrow. Replace the tray intraorally,
place the tip of the pin into the divot,
and stabilize the AMD by liberally
injecting maxillomandibular relation-
ship record material into the area be-
tween the maxillary and mandibular
AMD trays (Fig. 7). Remove any record
material from the maxillary AMD that
might interfere with the drape of the lip.
Adjust the lip support to the desired lip
fullness by turning the fitting on the
anterior of the lip support.
8. As a guide for selecting the
appropriate denture tooth mold, overlay
the esthetic transparent guide onto the
existing denture. Use 1 of 3 overlay
esthetic transparent guides, which repre-
sent different tooth sizes. Once the
proper transparent guide is chosen,
establish the desired gingival height and
mark it on the prescription. Mark the
midline and incisal edge for the anterior
teeth on the lip support. Place composite
resin (Tetric EvoFlow; Ivoclar Vivadent)
onto the transparent guide and adhere
this to the lip support. With the AMD in
the mouth, verify the esthetics and OVD
(Fig. 8).
9. Send both the completed im-
pressions and the final AMD to the
laboratory for fabrication of the
dentures.
10. Examine the digital preview vir-
tual setup sent by the laboratory, and
modify the design of the denture if
needed (Fig. 9).
11. Once processed, the dentures are
returned to the dentist for delivery to
the patient (Fig. 10).
DISCUSSION
Many materials have been used in
the fabrication of denture bases. From
wood to porcelain, no material has
received the same attention or gained
the same popularity as PMMA [poly(-
methyl methacrylate)].13-15 Although
it is the most common material
used today, PMMA is not without
problems. These problems are related to
processing, porosity, fracture strength,
dimensional stability, color stability,
and biocompatibility (allergenic re-
actions).16,17 Challenges with the use of
PMMA bases are being met by either
improving the qualities and properties

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354
9 Virtual arrangement.
10 Maxillary and mandibular complete dental prosthesis.
of the material or the use of alternative
materials.18-22 The AvaDent dentures
are produced by machining a pre-
formed cylinder of acrylic resin mate-
rial. This cylinder is produced under
high pressure and heat, which prevents
shrinkage of the definitive milled pros-
thesis. As a result of the highly con-
densed resin, there is a decrease in free
monomer, a decrease in the porosity
when compared to a conventionally
processed denture, and a decrease in
the retention of Candida albicans by the
denture base.10 Manufactured acrylic
resin teeth, which are not CAD/CAM
produced, are used.
The fabrication in the laboratory
starts with relating the scanned maxil-
lary and mandibular impressions to the
scanned AMD. The 2 files are digitally
overlaid and merged by best-fit trian-
gulation. Millions of digital triangles
overlap each other to form a vertical
representation of jaw position and
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vertical height. A virtual record base is
created, and functional controls are
then applied. The algorithms for the
occlusal arrangement are written using
traditional rules.12 The occlusal plane
is set from the incisal edges of the
mandibular teeth to halfway up the
retromolar pad, and the curves of
Spee and Wilson are incorporated into
the software to create the optimum
occlusal arrangement on the basis of
the operator’s preference. Lingualized
or monoplane occlusal schemes may be
chosen.23 The designed software ar-
ranges the teeth according to the spe-
cific guidelines of the desired occlusion,
with the transparency being the guide
for the maxillary anterior teeth. A digital
preview is sent to the dentist, who can
examine the virtual setup and modify
the design of the denture.
Once the design of the teeth is
accepted by the clinician, the intaglio
surfaces of the denture and tooth
Volume 111 Issue 5
sockets are milled with a 5-axis milling
machine. The sockets for the selected
teeth are milled according to the posi-
tion of the selected teeth. The selected
teeth are chemically bonded to the
AvaDent base material by means of a
proprietary PMMA bonding technique
that uses heat and pressure, or if
requested, a clinical evaluation of the
denture can be selected. The teeth are
set into the milled sockets in wax and
returned to the dentist for evaluation,
allowing for movement of the anterior
and posterior teeth, adjustment of
the occlusion, and adjustment of the
denture base. In the wax evaluation
method, the teeth are attached to the
base with conventional techniques.
Should the patient not have existing
dentures, irreversible hydrocolloid im-
pressions are made and casts are
poured. The thermoplastic trays are
adapted to these casts. The vertical
dimension of rest is obtained by the use
of phonetics, specifically the bilabial
sounds. Once obtained, the OVD is
calculated. The same technique is then
followed as with a patient who has
existing dentures.
The stability of a denture, that is the
ability to “resist displacement by func-
tional horizontal or rotational stresses,”
depends to a great degree on the oc-
clusion and base adaptation.24 The
transfer of concentrated stresses from
the denture base to the underlying
supporting structures has been associ-
ated with trauma to the tissues and
accelerated bone resorption.25-27 In the
currently described technique, there
should be reduced dimensional sta-
bility problems because the denture is
milled from preformed acrylic resin.
This quality should compare favorably
to bases fabricated with conventional
processing techniques. This may con-
tribute to the improved stability and
retention of the denture base with less
trauma and fewer postinsertion ad-
justment visits.
The digital system facilitates the
completion of dentures in 2 visits. Im-
pressions, occlusal relation records, and
an orientation record are made at the
first visit and the dentures inserted at the
Infante et al
May 2014
second. This significantly reduces the
time the patient spends in the dental
office. Unlike in the fabrication of con-
ventional dentures, there is no facebow
record. If the maxillomandibular record
is made at the correct OVD, the lack of
facebow should not cause any error. A
repository of the digital record is stored,
and an exact duplicate denture can be
reproduced at any time. The denture can
be designed according to the dentist’s
specifications. Bases can be fabricated
with various anatomic features, in-
cluding stippling, rugae, thickness of
the actual base, and borders of the
dentures. A wax evaluation can also be
requested. Various shades of acrylic
resins are available for the fabrication of
the bases, and manufactured acrylic
resin teeth are used. The denture teeth
are placed virtually and the bases with
tooth sockets milled. The exact positions
of the teeth are recorded. These tooth
positions are compared to a scan made
of the denture and tooth positions after
the dentures have been fabricated. A
virtual remount is possible, and where
discrepancies are noted, the equilibra-
tion of the teeth is completed in the
milling center and clinical remount
procedures are avoided. A denture kit is
provided with all the materials required
to make the initial records and impres-
sions. The actual scanning of records is
made off-site, eliminating the need for
the dentist to purchase expensive ma-
chines. Commercial laboratories can
now scan impressions and design the
dentures; however, all denture base
milling is done at the central laboratory.
Complete dentures, immediate den-
tures, and implant dentures can be
fabricated with this system.
Although initial results are prom-
ising, the technique has some disad-
vantages. The central bearing tracing
device can be a challenging method of
recording jaw relationships. Although
the recording of the gothic arch tracing
in some patients may be difficult,
Infante et al
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alternative techniques are being intro-
duced. Further, the system does not
provide for all schemes of occlusion,
and no long-term results have been
published. Long-term clinical trials
should be performed to evaluate the
success of the technique presented.
SUMMARY
A technique for the fabrication of a
CAD/CAM denture is described. By using
an AMD, the dentist can make clinical
records in 1-step appointments. The
AMD allows the clinician to gather all the
clinical information needed with a single
intraoral device. The virtual denture is
milled to exact specifications without the
use of conventional stone models or
flasking and processing techniques.
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Corresponding author:
Dr Burak Yilmaz
The Ohio State University, College of Dentistry
Division of Restorative and Prosthetic Dentistry
Columbus, Ohio 43210
E-mail: yilmaz.16@osu.edu
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.