DENTAL TECHNIQUE

Digital maxillomandibular relationship registration for an

edentulous maxilla: A dental technique
Neil T. Griseto, BA, BDentSca and German O. Gallucci, DMD, Dr med dent, PhDb

Successful prosthodontic ABSTRACT

treatment planning requires
Recording the maxillomandibular relationship in a patient with an edentulous arch can be
modeling of the restorative challenging in a completely digital workflow. A technique is presented that uses a scan of an
space. To do this, adequate existing removable prosthesis to align intraoral scans of the arches. (J Prosthet Dent 2020;-:---)
diagnostic mounting of the
presenting dentition and existing restorations is a
necessity. With the arrival of digital modeling, various
techniques of acquiring and relating the necessary
data are still being developed, particularly in relation
to the edentulous patient.1 Current digital workflows
typically require the use of traditional methodologies,
including impressions and gypsum casts that are
mounted on an articulator and then scanned and
transferred to the digital format.2 Intraoral scan-
ning provides advantages, including ease of use,
reduced visits, increased patient comfort, the ability
to produce a completely pressureless recording of
the tissues, instant correction of errors, and
reduced influence of disadvantageous material
properties such as expansion, shrinkage, and
distortion.3-5
A significant challenge of the intraoral scan technique
is aligning an edentulous arch in the correct max-
illomandibular relationship to the opposing arch,
essential before treatment planning implant placement
or prosthesis fabrication. Techniques have been proposed
to overcome this difficulty, but they rely on additional
scans and sectioning of the maxillomandibular relation-
3,6-8
ship record. The presented technique uses a scan of
an existing prosthesis at the vertical dimension of oc-
clusion to record a maxillomandibular relationship that
can provide a static point to commence treatment
planning.
TECHNIQUE
1. By using an intraoral scanner (TRIOS 3 Pod; 3Shape
A/S), acquire a digital scan of the cameo and intaglio
surfaces of the maxillary denture and then the
opposing dentition and occlusal registration (Fig. 1).
Before scanning, set up the order to export standard
tessellation language files. Set up a second order,
and scan the maxillary edentulous arch (Fig. 2).
2. Save and export the scans in standard tessellation
language format.
3. Importthescanstoafreecomputer-aideddesignsoftware
program (Meshmixer; Autodesk Inc) (Fig. 3).
4. Open the “Object Browser” window and isolate the
denture scan by switching off the visibility of the
other scans. Create a duplicate of the denture scan,
separate the denture intaglio from the cameo by
highlighting the desired shape, optimizing and
3
smoothing the boundary, inverting the selection,
and deleting the cameo surface (Fig. 4). Similarly,
the maxillary tissue scan can be refined by removing
extraneous peripheral scan data. This permits better
visualization during the alignment process.
5. Identify at least 3 regions with positive and negative fea-
tures that exhibit adequate contact intraorally. These areas
need to be as far apart as possible (Fig. 5).
6. Make the tissue scan the active object by clicking on it
and selecting “Edit.” It is recommended to start the

a
Instructor, Department of Restorative Dentistry and Biomaterials Science, Harvard School of Dental Medicine, Boston, Mass.
b
Associate Professor and Chair, Department of Restorative Dentistry and Biomaterials Science, Harvard School of Dental Medicine, Boston, Mass.

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Figure 1. A, Maxillary denture scan. B, Denture and mandibular scans in
occlusion.
alignment process with the objects positioned close
together. Use the “Transform” function to move the
tissue scan closer to the denture intaglio (Fig. 6).
7. Make the denture the target object by clicking the
magnet icon in the “Object Browser.” The target
object does not translate during the alignment
process. The other object involved in the alignment
moves toward the target.
8. Click on the tissue scan, and then, using the
“Select” tool, highlight the previously identified
common regions on the tissue.
9. Click “Edit>Align to Target.” The software will go
through 1 round of best fit analysis and trans-
formation. Move the iterations slider to 100 and
error tolerance to zero and click “Improve Solu-
tion.” Click “Improve Solution” until no further
movement is observed (Fig. 7).
10. The tissue should now be aligned to both the scan of
the mandible and the scan of the denture (Fig. 8)
DISCUSSION
The ability to approximate scans of objects to each other
in a manner accurately representing their relationship in
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Figure 2. Maxillary tissue scan.
Figure 3. Scans imported to modeling software.
the physical world enables considerable advantages in
cost and time savings. In the technique presented, the
mounting of the existing prosthesis to the tissue enables
modeling of the restorative space.
A common feature of digital dental design software is to
allow the approximation of 2 similar objects with common
positive or negative features (anatomic or nonanatomic
“landmarks”). A typical attribute of this process is to fit a
positive feature to a positive or a negative feature to a
negative. This is not true in the analog world, where positive
features are typically fit to negative replicas to allow posi-
tioning of objects in space; for example, an interocclusal
record (negative likeness of the surfaces of the teeth) might
be used to mount casts (positive likenesses of the surfaces of
the teeth) in a position that replicates what is seen in vivo.
The clinical significance of this technique is the ability to fit
positive features to negative features resulting in an alterna-
tive digital process to the conventional articulation of pros-
thodontic replicas. The technique requires an iterative
algorithm that uses a mathematical method to move the
meshes into their “best fit” and a collision constraint. A
collision constraint is a software feature that prevents the
meshes from overlapping. In the method presented, a
Griseto and Gallucci
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Figure 4. Process of sectioning maxillary denture mesh to remove impediments to visualization of fit. A, Desired shape highlighted with “Select” tool.
B, “Smooth Boundary” function. C, Selected surface with clean visible margins. D, Inverting selection. E, Inverted selection erased.

collision constraint was not available in the software program,
which is why the meshes are visibly overlapped in Figure 7.
Previously presented techniques have described the use
of relating anatomic and nonanatomic landmarks to land-
marks in scans of the same object.1,2,6-8 The technique
presented here allows the relation of scans of 2 different
objects that have a common fitting surface. This technique
requires no additional apparatus such as a scan appliance or
a wax occlusal rim. To improve accuracy, a well-fitting in-
taglio is important and so relining may be necessary. This
technique could be used similarly in the mandible if the
tissue is relatively immobile and the removable prosthesis
has an intimate fit to the supporting tissue. Furthermore, the
data could easily be combined with cone beam computed
tomography and facial scan records to produce a 3-dimen-
sional (3D), multilayered representation of the patient.9
SUMMARY
A technique is described that allows the digital mounting
of a 3D surface scan of a denture to a 3D surface scan of

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Figure 5. A, Maxillary landmarks. B, Intaglio landmarks.
Figure 8. Maxillomandibular relationship.
an edentulous maxillary arch. The principal advantage of
this is to allow diagnostic mounting and modeling of the
restorative space with fewer steps than other digital
methods or traditional analog methods.
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THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 6. Approximation of soft tissue maxillary digital scan to intaglio
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Figure 7. Alignment of surfaces, gray banding represents reverse side of
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Corresponding author:
Dr Neil T. Griseto
Department of Restorative Dentistry and Biomaterials Science, Harvard School of
Dental Medicine
188 Longwood Ave
Boston, MA 02115
Email: neil_griseto@hsdm.harvard.edu
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.04.008
Griseto and Gallucci