Computer-aided technology for

fabricating complete dentures:

Systematic review of historical
background, current status, and
future perspectives
Avinash S. Bidra, BDS, MS,a Thomas D. Taylor DDS, MSD,b and
John R. Agar, DDS, MAc
University of Connecticut Health Center, Farmington, Conn
Statement of problem. Computer-aided technology is an emerging method for fabricating complete dentures. Con-
solidated information about historical background, current status, and scope for the future is lacking.

Purpose. The purpose of this systematic review was to analyze the existing literature on computer-aided technology
for fabricating complete dentures and provide the reader with a historical background, current status, and future per-
spectives on this emerging technology.

Material and methods. An electronic search of the English language literature between the periods of January 1957
and June 2012 was performed by using PubMed/MEDLINE with the following specific search terms: CAD-CAM com-
plete dentures, digital complete dentures, computer dentures, designed dentures, machined dentures, manufactured
dentures, milled dentures, and rapid prototyping dentures. Additionally, the search terms were used on the Google
search engine to identify current commercial manufacturers and their protocols.

Results. A total of 1584 English language titles were obtained from the electronic database, and the systematic ap-
plication of exclusion criteria resulted in the identification of 8 articles pertaining to computer-aided technology for
complete dentures. Since the first published report in 1994, multiple authors have described different theoretical
models and protocols for fabricating complete dentures with computer-aided technology. Although no clinical trials
or clinical reports were identified in the scientific literature, the Google search engine identified 2 commercial manu-
facturers in the United States currently fabricating complete dentures with computer-aided design and computer-
aided manufacturing (CAD/CAM) technology for clinicians world-wide. These manufacturers have definitive proto-
cols in place and offer exclusive dental materials, techniques, and laboratory support. Their protocols contrast with
conventional paradigms for fabricating complete dentures and allow the fabrication of complete dentures in 2 clinical
appointments.

Conclusions. A body of scientific literature related to computer-aided technology for complete dentures is emerg-
ing. Significant advancements in this technology have now resulted in their commercial availability with shorter clinical
protocols. However, prospective clinical trials with true clinical endpoints are necessary to validate this technology. This
could affect dental education, patient care, research, and public health worldwide. (J Prosthet Dent 2013;109:361-366)

Clinical Implications
The application of computer-aided technology for complete
dentures has considerable potential for patient care, public health,
education, and research.

Computer-aided technology is a or subtractive manufacturing (such successive layers of a chosen material.

broad term that implies the use of com-
puter skills to aid in the design, analy-
sis, and manufacture of products.1 It
can either involve additive manufac-
turing (such as rapid prototyping)
as computerized numerical control
[CNC] machining). Additive manu-
facturing, or 3-dimensional (3D)
printing, uses images from a digital
file to create an object by laying down
Subtractive manufacturing uses im-
ages from a digital file to create an ob-
ject by machining (cutting/milling) to
physically remove material and achieve
the desired geometry. In prosthodon-

a
Assistant Professor, Department of Reconstructive Sciences.
b
Professor, Department of Reconstructive Sciences.
c
Professor, Department of Reconstructive Sciences.
Bidra et al
362
tics, the subtractive procedure, com-
puter-aided design and computer-
aided manufacturing (CAD/CAM), is
widely used.2 It represents a modern
method for designing, developing, and
producing a dental restoration/pros-
thesis, partially or completely. Sev-
eral reports have described the use of
CAD/CAM technology to fabricate in-
lays, onlays, crowns, fixed and remov-
able partial dental prostheses, implant
abutments, maxillofacial prostheses,
and substructures for removable and
fixed implant-supported prostheses.3
However, few reports have described
the use of computer-aided technology
for complete dentures.4-11 This is prob-
ably because of the inherent nature of
fabricating complete dentures, which
includes the multiple steps of record-
ing, transferring, evaluating, and then
creating artificial substitutes for teeth
and gingiva, which are required to be
in harmony with the patient’s mouth
and face. All of these elements require
the clinician’s artistic and technical
acumen, which is less easily adapted to
CAD/CAM technology than intracoro-
nal or tooth-supported restorations.
The ability to customize tooth ar-
rangements and to confirm all preced-
ing steps before the trial placement
stage is a significant advantage of
the conventional method of fabricat-
ing complete dentures. Additionally,
the conventional method has been
shown to be clinically predictable for
almost a century.12 However, some of
the disadvantages of the conventional
method of fabricating complete den-
tures are 1) the need for a minimum
of 4 to 5 patient visits and additional
postinsertion visits; 2) high treat-
ment costs due to increased patient
visits; 3) varying laboratory expenses
and time; 4) lack of intimate fit of the
denture bases with underlying tissues
due to polymerization shrinkage; and
5) inability to easily create an opti-
mal duplicate denture. The first 2
disadvantages are significant enough
to cause many dentists in the United
States to decline treating patients re-
quiring complete dentures.13
Use of CAD/CAM technology for
The Journal of Prosthetic Dentistry
fabricating complete dentures may
ameliorate these disadvantages. In-
dications for CAD/CAM dentures en-
compass individual patient care, edu-
cation, research, and public health
because of 1) increased aging popu-
lation in the United States;14 2) con-
tinued growth of edentulous patients
and increased demand for complete
dentures in the US14; 3) access to
dental care issues around the world;
4) easier implementation in pub-
lic health programs; 5) shortage of
dental laboratory technicians in the
US15; and 6) shortage of dentists and
dental faculty in the US.16 Some of
the anticipated advantages of CAD/
CAM dentures are 1) reduced num-
ber of patient visits, which is espe-
cially beneficial to elderly patients; 2)
superior strength and fit of dentures
due to use of prepolymerized acrylic
resin blocks for milling; 3) reduced po-
tential for dentures to harbor microor-
ganisms and minimize resultant infec-
tions; 4) reduced cost for the patient
and the clinician; 5) easily reproduc-
ible (creation of duplicate dentures)
due to stored digital data; 6) improved
potential for standardization in clinical
research on complete dentures as well
as implant-retained overdentures; and
7) ability for better quality control.
With the recently increased inter-
est in complete dentures fabricated
by using computer-aided technol-
ogy, it is important to consolidate
the existing scientific information to
promote accuracy and consistency in
future scientific reporting. Therefore,
the purpose of this article was to sys-
tematically review the existing litera-
ture on computer-aided technology
for complete dentures and provide
the reader with historical background,
current status, and future perspec-
tives about this emerging technology.
MATERIAL AND METHODS
An electronic search of the English
language literature was conducted
by using PubMed/MEDLINE and the
search terms CAD-CAM complete
dentures, digital complete dentures,
Volume 109 Issue 6
computer dentures, designed den-
tures, machined dentures, manufac-
tured dentures, milled dentures, and
rapid prototyping dentures. The peri-
od searched was from January 1957 to
June 2012. The inclusion criteria were
set to permit inclusion of as many ar-
ticles as possible. The only 2 criteria
were that the article be in English and
that it included the specified search
terms in the title or the abstract. Any
article that did not involve items de-
scribed in the inclusion criteria or any
article that described repetitive data
from another included article was ex-
cluded. Additionally, articles that did
not clarify descriptions of CAD/CAM
as defined by the Glossary of Prosth-
odontic Terms2 were also excluded.
All 3 authors predetermined the inclu-
sion and exclusion criteria.
The search was conducted in a
systematic manner in 3 stages: titles,
abstracts, and full text articles. Dur-
ing stage 1, a record of titles was ac-
quired from PubMed/MEDLINE, and
the search terms and relevant titles of
articles were analyzed according to
the predetermined inclusion criteria.
At this stage and before excluding an
article, any discrepancy was resolved
by discussion. In cases of uncertain-
ty, the disputed article was included
in the abstract stage for consider-
ation. At stage 2, the abstracts of
all selected titles were screened, and
again, in uncertain cases, the ab-
stract of interest was included for the
subsequent stage of full-text analysis.
At stage 3, all full-text articles were
studied in detail. Thereafter, final ex-
clusion criteria were applied, and the
final list of articles was reviewed in
depth to satisfy the objectives of the
systematic review.
Additionally, the Google search
engine was used, and web pages on
the Internet were searched until the
tenth page to identify current com-
mercial manufacturers of CAD/CAM
dentures and their protocols. The web
pages were used to draw any addi-
tional articles from scientific journals
that were not identified through the
PubMed search. The collected data
Bidra et al
June 2013
were scrutinized, organized, and con-
solidated into 2 sections: historical
background and current status.
RESULTS
The electronic search from
PubMed resulted in 1584 titles in the
English language literature, of which
30 titles were relevant to this review.
Further application of predetermined
exclusion criteria resulted in the elimi-
nation of 22 articles. The remaining
8 articles4-11 were reviewed in depth
to study the use of computer-aided
technology to fabricate complete
dentures (Table I). Of the 8 articles,
3 reported on the use of subtractive
manufacturing (CNC milling) to pro-
duce complete dentures5,9,10 and 3
articles reported on the use of addi-
tive manufacturing (rapid prototyp-
ing technology).4,7,11 The remaining
2 articles did not describe the manu-
facturing of complete dentures but
only addressed the use of computer-
aided technology for denture teeth ar-
rangement.6,8 One article6 described
the use of a specialized computer
program to arrange teeth digitally
by using anatomic and average mea-
surements, and the other article8 de-
scribed the use of a multimanipulator
prototype robotic system for tooth
arrangement. Most articles described
unique theoretical constructs for the
production of a prototype denture
and it was not clear whether the den-
ture was used for treatment purposes.
As a result, this systematic review did
not identify any case reports or clini-
cal trials on dentures fabricated with
computer-aided technology.
The Internet search on Google
resulted in 299 000 items, and a de-
tailed search of the first 10 web pages
identified 2 commercial manufactur-
ers of complete dentures (Dentca;
Denta Inc, Los Angeles, Calif )17 and
(Avadent; Global Dental Science,
Scottsdale, Ariz)18 with CAD/CAM
technology. Dentca claims to be the
world’s first CAD/CAM denture man-
ufacturer.17 Both manufacturers have
listed definitive clinical and labora-
Bidra et al
tory protocols using exclusive dental
materials, techniques, and laboratory
support. These protocols contrast
with conventional protocols for fab-
ricating complete dentures, and both
manufacturers allow fabrication of
complete dentures in 2 clinical ap-
pointments.17,18
DISCUSSION
Historical background
Maeda et al,4 a group of Japa-
nese investigators, are credited with
the first published scientific report in
English on the concept of using com-
puter-aided technology to fabricate
complete dentures.5,7,9,11 Their report
in 1994 described the fabrication of
complete dentures from photopo-
lymerized composite resin material
with rapid prototyping technology.
This was followed by a report in 1997
from another Japanese group, Kawa-
hata et al,5 who explored the con-
cept of digitally duplicating existing
dentures and milling them by using
a CNC milling machine. Since then,
several investigators have contributed
to improvements in this field, rang-
ing from digital tooth arrangement to
incorporating cone beam computed
tomography (CBCT) to scanning
and fabricating complete dentures
through either rapid prototyping
technology or CNC milling.6-11 A brief
summary of the 8 articles identified in
this systematic review is presented in
chronological order in Table I.
Current status
This systematic literature review
did not identify any clinical reports
or trials on complete dentures fabri-
cated with computer-aided technol-
ogy. Additionally, complete dentures
fabricated by CAD/CAM technol-
ogy appear to be more amenable to
clinical use than complete dentures
fabricated with rapid prototyping
technology. An internet search identi-
fied 2 current commercial manufac-
turers of complete dentures, both of
363
which use CAD/CAM technology.17,18
The clinical and laboratory protocols
for both systems (Dentca17 and Ava-
dent18) incorporate many principles
previously described in the literature
on digital dentures. Both commercial
manufacturing systems allow fabrica-
tion of complete dentures in 2 clinical
appointments. The first clinical ap-
pointment is for systematic data gath-
ering (impressions, occlusal vertical
dimension (OVD), maxillomandibular
relationships (MMR) and tooth selec-
tion), and the second appointment is
for denture insertion and adjustments.
The limitations and disadvantages
of the current commercial systems are
that optimally assessing OVD, MMR,
lip support, and maxillary incisal edge
position is challenging; establishing the
mandibular occlusal plane is impossible;
the opportunity for patient input is min-
imal; and current material and labora-
tory costs are higher than for traditional
methods. Some of these disadvantages
may necessitate remaking the complete
denture at a cost of additional time and
expense. Another important disadvan-
tage is the lack of opportunity for clini-
cians and patients to evaluate a trial
denture intraorally. This disadvantage
has been partially addressed by one of
the manufacturers (Avadent18) but addi-
tional treatment costs are involved.
The expected advantages of cur-
rent CAD/CAM denture commercial
protocols over conventional methods
of denture fabrication are several: the
denture can be fabricated in as few as
2 clinical visits, which benefits both
patients and clinicians; the fit is bet-
ter as the denture base is milled from a
prepolymerized block of acrylic resin;
minimal porosity means fewer chanc-
es of microorganisms such as Candida
albicans; an optimal occlusal scheme
can be developed with only minimal
adjustments; a denture can be easily
duplicated as the CAD files are digi-
tally stored; and research on edentu-
lism can be standardized. Moreover,
with progress and broader acceptance
of technology, the cost of materials
and laboratory support can be signifi-
cantly lower than traditional methods.
364 Volume 109 Issue 6

Table I. Summary of historical background (8 articles identified through this systematic review) on
computer-aided technology for fabricating complete dentures
Article Summary

Maeda et al4 (1994) Data acquisition: 3D laser scanner and charge coupled-device (CCD) cameras of double-arch
impressions made with silicone impression material and a specialized custom tray.
Denture fabrication: Rapid Prototyping (3D laser lithography) technology as 2 outer shells
(cameo/occlusal surface and intaglio/tissue surface), which was then connected by using
predetermined reference points.
Kawahata et al5 (1997) Data acquisition: CCD cameras assisted by lasers to record digital images of cameo and intaglio
surfaces of set of complete dentures of patient.
Denture fabrication: computerized numerical control (CNC) milling by using block of wax to
create duplicate denture.
Busch and Kordass6 (2006) Data acquisition: Scanning of edentulous casts with laser and other types of scanners.
Digital tooth arrangement performed with a specialized computer program using anatomic
measurements and averages.
Sun et al (2008)
7
Data acquisition: 3D laser scanning of edentulous casts and occlusal rims, followed by digital
tooth arrangement and creation of virtual flasks for denture processing.
Denture fabrication: Rapid Prototyping technology to create physical flasks, followed by
insertion of teeth and conventional laboratory procedures to fabricate complete dentures
Zhang et al (2011)
8
Tooth arrangement performed by using prototype multimanipulator tooth arrangement robot
system. Multimanipulator tooth-arrangement robot system consisted of 14 independent
manipulators (1 for each denture tooth), dental arch generator, and slipway mechanism
Kanazawa et al (2011)
9
Data acquisition: Separate extraoral cone beam computed tomography (CBCT) scans of
patient’s dentures and artificial teeth, followed by virtual tooth arrangement.
Denture fabrication: CNC milling of denture base by using a clear block of acrylic resin,
followed by manual bonding of denture teeth into the recesses of base.
Goodacre et al (2012)
10
Data acquisition: Scan of silicone impressions made by neutral zone technique and scan of
interocclusal records, followed by virtual tooth arrangement.
Denture fabrication: CNC milling of denture base by using pink block of acrylic resin, followed
by manual bonding of denture teeth into recesses of base.
Inokoshi et al (2012)
11
Data acquisition: CBCT scans of wax trial dentures of 10 patients, followed by various
modifications performed on computer.
Denture fabrication: Rapid Prototyping technology to create 7 prototype dentures for each
patient with various alterations in tooth positions to study feasibility of using prototype
dentures for trial placement purposes.

An additional implicit advantage is the
fact that complete denture therapy
is a noninvasive and reversible form
of intervention. Should a CAD/CAM
denture fail to satisfy a patient or cli-
nician’s requirements, the clinician can
revert to the conventional method of
denture fabrication or remove the ar-
tificial teeth from the CAD/CAM den-
ture. The milled denture base can then
be used to proceed with subsequent
The Journal of Prosthetic Dentistry
steps of MMR, trial placement, and
denture processing using conventional
methods. The clinician and patient
should be prepared for the additional
time and expenses incurred if any of
these outcomes ensue.
Future perspectives
Historically, dentistry has wit-
nessed controversy whenever there
has been an acute change in treatment
protocols. Some of the controversial
topics include: immediate complete
dentures, single-visit endodontic ther-
apy, metal ceramic crowns without a
bisque bake/esthetic evaluation, sin-
gle-visit CAD/CAM crowns, immedi-
ate implant placement, sinus grafting
and simultaneous implant placement,
immediate loading of implants, and
several other such treatments. How-
Bidra et al
June 2013
ever, with sufficient evidence, many
of these topics have ceased to be con-
troversial. The adoption of new treat-
ment protocols to fabricate dentures
with computer-aided technology will
be no exception to controversy. How-
ever, current commercial protocols
should be improved and validated
through sound clinical and laboratory
research to overcome many of the dis-
advantages listed. Thus, current and
future clinicians should aid manufac-
turers in improving the current treat-
ment protocols. Additionally, with
the potential for digital technology to
expand significantly, properly trained
dental professionals have a responsi-
bility to guard against quackery and
the abuse of computer-aided denture
technology.
All reports from published litera-
ture and current commercial manu-
facturing systems use a combination
of manual and digital procedures for
the clinical and laboratory stages of
computer-aided denture fabrication.
This is because the impressions of
edentulous arches are still made using
conventional techniques and materi-
als. A complete digital impression of
the edentulous arches as performed
for tooth preparations/implant abut-
ments has not yet been researched.
This is challenging because digital
impressions for edentulous arches
require registration with a dynamic
movement of the muscles and jaws,
which may be difficult to execute with
an intraoral 3D scanning type of de-
vice. However this gap could be ad-
dressed by future research. Another
manual step in the laboratory stage
is bonding the artificial teeth into the
recesses of the denture base. Under-
standing the strength of this bond or
even eliminating this procedure by
milling the denture in 1 piece with the
artificial teeth should be the focus of
future research.
Though not validated by the re-
sults of this systematic review, the au-
thors believe that with the advent of
commercial manufacturing of CAD/
CAM dentures, a remarkable oppor-
tunity exists for clinicians to improve
Bidra et al
not only individual patient care but
also dental education, public health
programs, and clinical research. It is
important that future clinical research
on this topic focuses not only on sur-
rogate treatment outcomes but also
addresses true treatment outcomes.
Examples of surrogate outcomes in-
clude elements such as denture exten-
sions, denture retention, lip support,
and OVD. Examples of true outcomes
include elements that provide un-
equivocal tangible benefits to the
patient, such as oral health-related
quality of life, prosthesis satisfac-
tion, esthetic and functional satisfac-
tion, and comfort. Classic literature
on complete denture prosthodontics
preceded modern concepts of evi-
dence-based dentistry, resulting in a
paucity of evidence-based discussion
of many of the principles and tech-
niques used in the fabrication of com-
plete dentures. Therefore, future clini-
cal research on CAD/CAM dentures
should adhere to modern concepts of
evidence-based dentistry at this incep-
tion stage. This can provide the oppor-
tunity to examine many of the funda-
mental principles of complete denture
therapy and create new knowledge us-
ing standardized methods.
CONCLUSION
The use of computer-aided tech-
nology to fabricate complete dentures
has been studied since 1994 by mul-
tiple investigators using CAD/CAM
as well as rapid prototyping methods.
Significant advancements in this tech-
nology have been made since its in-
ception, but currently no clinical trials
or clinical reports are available in the
scientific literature. However, 2 com-
mercial manufacturers in the United
States offer complete dentures fab-
ricated with CAD/CAM technology
to clinicians across the world. These
manufacturers have in place defini-
tive protocols using exclusive dental
materials, techniques, and laboratory
support, which sharply contrast with
conventional protocols for fabricat-
ing complete dentures, allowing the
365
fabrication of complete dentures in
2 clinical appointments. There is an
impending need for clinical trials on
computer-aided dentures that can
affect individual patient care, den-
tal education, research and public
health around the world. The ability
to manufacture complete dentures
using computer-aided technology has
untold educational, investigational,
and clinical possibilities for the future.
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Volume 109 Issue 6
17.Dentca- CAD/CAM Denture; Dentca Inc. Corresponding author:
Available at: http://www.dentca.com Dr Avinash S. Bidra
18.AvaDent Digital Dentures; Global Dental University of Connecticut Health Center
Science LLC. Available at: http://www. 263 Farmington Avenue, L6078
avadent.com Farmington, CT 06030
Fax: 860-679-1370
E-mail: avinashbidra@yahoo.com

Copyright © 2013 by the Editorial Council for

The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature

Fracture resistance of crowns cemented on titanium and zirconia implant abutments: a
comparison of monolithic versus manually veneered all-ceramic systems

Martínez-Rus F, Ferreiroa A, Özcan M, Bartolomé JF, Pradíes G.

Int J Oral Maxillofac Implants 2012;27:1448-55.

Purpose: To evaluate the fracture resistance of all ceramic crowns cemented on titanium and zirconia implant abut-
ments.

Material and Methods: Customized implant abutments for maxillary right central incisors made of titanium (Ti) and
zirconia (Zr) (n=60, n=30 per group) were fabricated for an internal connection implant system. All-ceramic crowns
were fabricated for their corresponding implant abutments using the following systems (n=10 per group): (1) mono-
lithic computer-aided design/computer-assisted manufacture (CAD/CAM) lithium disilicate (MLD); (2) pressed
lithium disilicate (PLD); (3) yttrium stabilized tetragonal zirconia polycrystal (Y TZP). The frameworks of both PLD
and Y TZP systems were manually veneered with a fluorapatite-based ceramic. The crowns were adhesively cemented
to their implant abutments and loaded to fracture in a universal testing machine (0.5 mm/minute). Data were ana-
lyzed using two-way analysis of variance (ANOVA) and Tukey’s test (α=0.05).

Results: Both the abutment material (P=.0001) and the ceramic crown system (P=.028) significantly affected the
results. Interaction terms were not significant (P=.598). Ti-MLD (558.5±35 N) showed the highest mean fracture re-
sistance among all abutment-crown combinations (340.3±62-495.9±53 N) (P<.05). Both MLD and veneered ceramic
systems in combination with Ti abutments (558.5±35-495.9±53 N) presented significantly higher values than with Zr
abutments (392.9±55-340.3±62 N) (P<.05). MLD crown system showed significantly higher mean fracture resistance
compared to manually veneered ones on both Ti and Zr abutments (P<.05). While Ti-MLD and Ti-PLD abutment-
crown combinations failed only in the crowns without abutment fractures, Zr-Y TZP combination failed exclusively in
the abutment without crown fracture. Zr-MLD and Zr-PLD failed predominantly in both the abutment and the crown.
Ti-Y TZP showed only implant neck distortion.

Conclusions: The highest fracture resistance was obtained with titanium abutments restored with MLD crowns, but
the failure type was more favorable with Ti-Y TZP combination.

Reprinted with permission of the International Journal of Oral and Maxillofacial Implants.

The Journal of Prosthetic Dentistry Bidra et al