Review of complete denture fabrication processes and the application of CAD/CAM systems

Revisão de literatura sobre confecção de próteses totais e utilização do sistema CAD/CAM

ABSTRACT

Edentulism is the loss of permanent dental structures, which impacts aesthetics and essential functions like chewing and speech. Dental prosthetics, specifically complete dentures, offer a solution. This study provides an overview of the production process using CAD/CAM technology. Digital methods yield monolithic denture bases, enhancing aesthetics and eliminating issues like shrinkage. Digital technologies expedite the fabrication process. The conventional method has shortcomings, leading to poor-fitting dentures, multiple dental visits, higher costs, and limitations. CAD/CAM is poised to replace traditional techniques, but improvements are needed for a seamless transition. Current CAD/CAM systems must enhance digital techniques, ensure fully digital production, and reduce costs for broader consumer accessibility. This evolution holds the key to a brighter and more comfortable future for edentulous patients.

Indexing terms
Computer-Aided Design; Complete; Denture; Edentulism

RESUMO

O edentulismo é a perda de estruturas dentárias permanentes, o que afeta a estética e as funções essenciais, como a mastigação e a fala. As próteses dentárias, especificamente as próteses totais, oferecem uma solução. Este estudo fornece uma visão geral do processo de produção usando a tecnologia CAD/CAM. Os métodos digitais produzem bases de próteses monolíticas, melhorando a estética e eliminando problemas como a contração de polimerização. As tecnologias digitais aceleram o processo de fabricação. O método convencional tem limitações, levando a dentaduras mal ajustadas, várias visitas odontológicas, custos mais altos e limitações. O CAD/CAM está pronto para substituir técnicas tradicionais, mas melhorias são necessárias para uma transição sem problemas. Os sistemas atuais de produção de CAD/CAM devem aprimorar as técnicas digitais, garantir a produção totalmente digital e reduzir custos para uma maior acessibilidade aos consumidores. Essa evolução é a chave para um futuro mais brilhante e confortável para pacientes edêntulos.

Termos de indexação
Desenho Assistido por Computador; Completo; Dentadura; Edentulismo

INTRODUCTION

Edentulism is defined as the complete or partial loss of permanent dental structures due to periodontal diseases or cariogenic lesions. Its prevalence is often linked to limited access to preventive programs and healthcare policies throughout the majority of the population’s lifespan [¹].

Tooth loss negatively impacts aesthetics, but its primary consequences are related to masticatory and phonetic functions, which can also lead to nutritional disturbances. Oral rehabilitation for partially or completely edentulous patients can be achieved through either dental implants or dental prostheses. Prostheses are often the preferred choice due to their accessibility and effectiveness, as they can restore aesthetics and improve the patient’s quality of life [²].

Throughout history, various techniques and materials have been employed in the production of dental prostheses. In contemporary times, technological advancements have become increasingly relevant. Digital methods, such as computer-aided design and manufacturing (CAD/CAM) and 3D printing, have revolutionized the fabrication of complete dentures. These techniques allow for the creation of a monolithic prosthesis base and offer the possibility of attaching pre-manufactured teeth [³].

Conventional complete dentures do not achieve an intimate fit with the underlying tissues due to the polymerization contraction of acrylic resin [⁴]. Digitally manufactured dentures, on the other hand, employ the subtractive method in which the prosthesis bases are milled, and pre-formed polymethylmethacrylate (PMMA) disks are polymerized through injection under high temperature and pressure. This process effectively prevents the shrinkage that occurs in conventional complete dentures [⁵].

Prostheses produced using CAD/CAM systems can be manufactured in two distinct ways. One approach is additive manufacturing, which involves rapid prototyping (RP) or 3D printing. This method utilizes digital files to create objects by depositing successive layers of a chosen material [⁶]. The second method is subtractive manufacturing, where 3D objects are produced by milling away excess material from a solid volume in accordance with the digital model [⁴].

The conventional technique for manufacturing complete dentures allows for the customization of tooth arrangement and thorough verification of all preceding steps before the final delivery [⁷]. However, it comes with several disadvantages. These include the need for a minimum of five visits post-insertion, higher costs associated with the number of visits and laboratory work [⁸], limitations in adjusting the prosthesis bases, and difficulties, or in some cases, impossibility in creating easily duplicable prostheses [⁹].

Currently, there are two manufacturers, AvaDent and Dentca, offering the production of complete dentures using CAD/CAM technology [¹⁰,¹¹]. The digital prosthesis can be crafted in just two appointments. In the initial visit, either a conventional impression is taken or digital records are obtained using an intraoral scanner. These records are then transmitted to the digital laboratory, where the prosthesis is virtually designed and a preliminary version is sent to the dentist for approval. During the second appointment, the prostheses are prepared for insertion, with adjustments made if necessary [¹²].

The present study was conducted by reviewing the existing literature on the production of complete dentures and utilizing the CAD/CAM system. The primary aim was to comprehensively outline the novel technique, step by step, while also highlighting the efficiency, benefits, advantages, and disadvantages associated with these systems.

Conventional technique

Complete dentures are classified as mucosupported prostheses, as they rely on natural physical phenomena like fixation, cohesion, surface tension, and atmospheric pressure to remain in place and be retained by the edentulous alveolar ridges. These prostheses play a vital role in the physiological functions of the stomatognathic system by ensuring stable positioning. Therefore, a comprehensive grasp of anatomical and physiological aspects, combined with careful case planning, is crucial for achieving success in oral rehabilitation [¹³].

The prosthesis can be classified into the following categories: single prosthesis, partial fixed prostheses, removable partial prosthesis, total prosthesis (complete denture), orthodontic prosthesis, and oral and maxillofacial prostheses [¹⁴].

To ensure that a complete denture is considered useful and effectively fulfills its functions in the mouth, as stated by Schlosser and Gehl [¹⁵], it must meet the following criteria: masticatory function (related to prosthesis retention and stability), aesthetics (typically the primary reason for patients seeking dental care), phonetics (essential for clear speech and immediate adaptation to prosthesis use) and convenience (convenience requirements are characterized by sensations of snugness, comfort, and the overall utility of the prosthesis) [¹³].

To ensure a successful prosthetic rehabilitation, it is crucial to adhere to a logical sequence of clinical procedures aimed at minimizing errors. This systematic approach is referred to as a treatment plan and can be summarized as follows: medical and dental history assessment, clinical examination, imaging studies and analysis of study models. This plan should also consider the patient’s specific needs and expectations [¹⁶].

Denture prostheses produced using the conventional method typically involve five dental visits, encompassing the following stages: preliminary impressions, final impressions, recording of mandibular relationships, a trial with a wax prosthesis, and ultimately the placement of complete dentures [²,⁸,⁹].

Next, we will outline the step-by-step process for crafting a dental prosthesis using the conventional method.

- 1st Consultation: During this initial appointment, the anatomical impression is obtained. For edentulous patients, suitable trays are used, and the impression is taken using alginate (irreversible hydrocolloid) because of its ease of handling and excellent replication accuracy. Alternatively, materials like godiva or light silicone can also be utilized [¹³,¹⁴,¹⁶].

- Laboratory Phase: This involves the fabrication of study models and custom individual trays [¹³].

- 2nd Consultation: During this session, the individual tray is utilized for peripheral sealing, with godiva applied to the tray’s edges to shape the vestibular area [¹⁶]. Additionally, in this same appointment, zinc oxide eugenol paste is manipulated for the functional impression, during which the dentist is required to guide the patient in executing functional movements to ensure an accurate impression is obtained [¹³,¹⁷].

- Laboratory Phase: This phase involves the creation of the test base and the adaptation of the wax roundel within the individual tray [¹⁶].

- Third consultation: The individualization of the wax roundel in the individual tray (including the demarcation of the midline, upper smile line, intercanine distance, vertical dimension of occlusion, and centric relation) must be performed. Additionally, the colors of the teeth and gums should be chosen using the color chart as a reference [¹⁴,¹⁶].

- Laboratory Phase: Semi-adjustable articulator mounting [¹⁶].

- Fourth consultation: Try on the wax base test with the adapted teeth so that the patient can assess the aesthetics and verify the functional aspects [¹³,¹⁶].

- Laboratory Phase: After approval by both the patient and the dentist, the prosthesis proceeds to the final stage, which is acrylicization.

- Fifth consultation: In this final step, the prosthesis is delivered to the patient. Nevertheless, adjustments should be made if necessary, and the patient should be informed about the proper care for its optimal preservation [¹⁴,¹⁶].

Digital technique

Technological advances and developments in the field of dentistry have enabled the simplification of clinical and laboratory procedures through the utilization of various materials, instruments, and equipment [¹⁷]. Consequently, it has become possible to produce digital dental prostheses, delivering a less traumatic experience and offering better-fitting prostheses [¹⁸].

In addition to removable prostheses, digital dentistry is applied to fixed prostheses, diagnoses, and implant placement surgeries, as well as inlays, onlays, crowns, digital impressions obtained through intraoral scanners (IOSs), and computer-aided design/computer-aided manufacturing using CAD/CAM systems [¹⁹].

The CAD/CAM system, according to its terminology, means CAD (computer-aided design, which involves designing with the assistance of a computer) and CAM (computer-aided manufacturing, which involves manufacturing controlled by a computer [²⁰]. CAD software recognizes the geometry of an object by scanning and analyzing it, while CAM software is used for fabrication through a milling machine [⁶].

The digitally manufactured dental prosthesis can be produced in two ways: using additive manufacturing, where 3D objects are created by successively depositing material in layers to obtain a model [⁴], or by subtractive fabrication that employs computer numerical control (CNC), where the desired geometry is achieved by physically removing excess materials through machining, including cutting and milling based on the digital model [²].

Currently, there are two commercial manufacturers for the fabrication of digital complete dentures: AvaDent and Dentca. Both of these manufacturers utilize a device to transfer the Maxillomandibular Relationship (MMR) to a digital articulator in order to finalize complete dentures using the CAD/CAM system. In the manufacturing process employed by AvaDent, the prostheses’ bases are milled using the subtractive technique with pre-polymerized resin. On the other hand, Dentca utilizes the additive process, where a provisional prosthesis can be manufactured if the dentist deems it necessary. This is done using Rapid Prototyping (RP) before the conventional fabrication of the definitive prosthesis [¹⁰,¹¹].

Only two clinical appointments are required for the manufacture of dental prostheses using the CAD/CAM system [²,⁶,⁸,¹⁰,¹²,²¹,²²,].

During the first consultation, clinical records are obtained. This involves examining the patient and making anatomical impressions of the edentulous jaw and maxilla. Additionally, records of the face-bow and jaw relationship are established, which includes determining the smile line, canine and midline positions, as well as the anterior teeth position to ensure optimal lip support and aesthetics. These records are then sent to the laboratory, where the models can be mounted in an articulator [⁸].

According to the AvaDent method, there are four commonly used techniques to obtain clinical records: the first technique involves creating a technical reference of the prosthesis by duplicating the existing prosthesis, along with making an interocclusal registration in the vertical dimension of occlusion, the second technique is based on the AvaDent-Wagner guide protocol, which utilizes printed bases with maxillary and mandibular anterior teeth on rims made of a material resembling wax with a pink base, the third technique employs intraoral scanning, where an intraoral scanner is used to perform a complete scan of the oral cavity and the fourth technique relies on conventional registrations, which entail using definitive impressions to create registration bases. Wax occlusion rims are fabricated, and teeth are fixed onto these wax rims. Subsequently, a wax test is conducted. Many professionals still find the conventional technique to be the most efficient (⁹,²³].

After the initial stage, the records are forwarded to the digital dental laboratory, where the prosthesis will be virtually designed [¹²]. The process unfolds as follows [⁶]:

1. First, the definitive models are separately scanned using an optical scanner, followed by scanning the models and occlusion ridge positioned on the transfer stand.

2. The scanned data is imported into the software for designing complete dentures. The virtual models are then assembled according to the scanned occlusion edge.

3. The occlusion plane is defined step by step using the occlusion rim and the software. Anatomical features such as the first premolars and the central line, along with marginal lines, are marked. With this information, the software calculates common arrangement lines and provides a suitable set of artificial teeth. It’s worth noting that artificial teeth are not manufactured by the CAD/CAM system; they are conventionally made from acrylic resin by various manufacturers. Tests are selected and organized correctly by the software, and the gingival parts of the prostheses and the alveolar tooth datasets are generated.

4. The next step involves waxing the teeth of the fitted prosthesis into the wax sockets, followed by evaluating the trial prosthesis in the articulator.

5. Finally, the trial denture is sent to the dentist [⁸]. It’s important to mention that, with the Dentca method, a trial prosthesis can be created for approval by both the clinician and the patient before the definitive prosthesis is made.

During the final appointment, the prostheses are prepared for insertion [¹⁰]. The placement of prostheses manufactured by the CAD/CAM system follows the same procedure as that of a conventional complete denture. A pressure indicator paste is applied to adjust the surface of the ridge to the intraoral mucosa [⁹]. Additionally, occlusion should be carefully evaluated, and any necessary intraoral adjustments should be made [²¹].

The implementation of the CAD/CAM system in dentistry has enabled greater agility and precision in dental work, providing enhanced comfort for patients and reducing the likelihood of errors [³,⁶,¹²,²⁴].

Comparison between Techniques

• Number of dental visits

To create dental prostheses using the conventional method, an edentulous patient typically needs to complete five dental visits. These visits encompass preliminary impressions, final impressions, recording mandibular relationships, trying out a wax prosthesis, and finally, the placement of complete dentures [²,⁸,⁹].

Regarding the digital technique, CAD/CAM technology has enabled the fabrication of complete dentures in just two sessions [²,⁶,⁸,¹⁰,¹²,²¹,²²]. In the first session, systematic data collection is carried out, which includes taking impressions, recording the maxillomandibular relationship, determining the vertical dimension of occlusion, and selecting the teeth. In the second session, the prostheses are delivered, and if necessary, occlusal adjustments are made [⁸].

• The Retention

Prosthesis retention is closely linked to its proper adjustment, impacting both masticatory performance and speech ability, which in turn directly affect an individual’s quality of life [²⁵]. Dentures that fit well can reduce the likelihood of traumatic ulcers [²⁶].

Conventionally fabricated complete dentures often lack an intimate fit with the underlying tissues because of polymerization shrinkage in the acrylic [⁴]. In contrast, those digitally manufactured using the subtractive method involve milling the bases of the prostheses, and the preformed PMMA disk is polymerized by injection under high temperature and pressure. This process helps to prevent the shrinkage of complete dentures [⁵].

• Color stability

A color change on the denture base can be indicative of damage to the surface, material, or aging [²⁷]. Studies have assessed the color stability of both conventional PMMA and CAD/CAM materials when exposed to solutions like coffee and red wine, with coffee dye proving to be the most significant factor affecting color stability [²⁸].

• Surface roughness

After manufacturing complete prostheses using the conventional method, the surfaces tend to be rougher [²⁰]. Unpolished acrylic resin has been shown to lead to surface staining, plaque accumulation, and bacterial adhesion due to excessive surface roughness [²⁹,³⁰]. Several studies have compared the inherent surface roughness of CAD/CAM prostheses with conventional prostheses and consistently found that all CAD/CAM prostheses exhibit smoother surfaces than their conventional counterparts [³¹].

• Its hydrophilicity

It has long been recognized that hydrophilicity plays a crucial role in enhancing prosthesis retention [³²,³³). The presence of a saliva film between the prosthesis and the mucous membranes facilitates the fixation and retention of the prosthesis within the oral cavity. Prosthesis retention occurs when there is hysteresis in the prosthesis-saliva contact angle, underscoring the fundamental importance of the hydrophilicity of the materials used in manufacturing ³²]. Numerous studies have demonstrated that CAD/CAM PMMA surfaces are more hydrophilic than conventional PMMA surfaces [²⁵,³⁴, ³⁵].

• Advantages and Disadvantages

Advantages of the CAD/CAM system include: a reduced number of dental visits; prostheses with superior resistance, uniform thickness, and an adequate fit [⁴,³⁶], improved retention, achieved through the polymerization of the pre-formed PMMA disk by injection under high temperature and pressure, preventing digital prostheses from shrinking [⁵]; reduced risk of microbial colonization on prosthesis surfaces, subsequently lowering the risk of infection; progress in standardization for clinical research related to removable prostheses; easy reproduction and fabrication of test prostheses using stored digital data and enhanced quality control by medical technicians [⁶].

Advantages of the conventional technique include the ability to customize the placement of teeth and verify all preceding steps before the final delivery [⁷]. Furthermore, it allows for the precise definition of the vertical dimension of occlusion [⁶].

Disadvantages of the CAD/CAM system include: manufacturing challenges arising from molding procedures; the inability to define the mandibular occlusal plane; the use of expensive materials; high laboratory costs and the absence of test prosthesis manufacturing within the AvaDent system [⁶,⁸,³¹].

Disadvantages of the conventional technique include: the need for at least 4-5 visits following insertion, making it a time-consuming and tiring process; high treatment costs due to the increased number of additional visits; the challenge of adjusting prosthesis bases to the underlying tissues due to polymerization retraction and difficulty or even impossibility in easily creating an optimal duplicate prosthesis [²,⁸,⁹, ³⁷].

DISCUSSION

The CAD/CAM system enabled the production of dental prostheses with efficient functional and aesthetic outcomes [⁶]. Furthermore, it demonstrated improved retention and adaptation [³⁸].

The present study is based on a literature review of complete denture manufacturing techniques, including the conventional approach and the CAD/CAM system. Therefore, the primary topics addressed in the literature were as follows: the advantages and disadvantages of both techniques, strategies to prevent failures in digital prosthesis production, CAD/CAM system classifications, manufacturers of commercial digital systems, a comparison between these techniques, and future prospects for digital systems.

Over the years, significant advancements have revolutionized the production of complete dentures through the incorporation of CAD/CAM technology. The digital workflow offers enhanced control over desired outcomes, leading to a less traumatic oral rehabilitation experience for patients [¹⁸]. Han et al. [²] noted that conventionally manufactured prostheses entail a multitude of clinical and laboratory procedures, making it a time-consuming and fatiguing process for patients.

In the creation of complete dentures using the CAD/CAM system, three key steps are involved: digitalization, design, and milling of the model. According to the literature, conventional molding of edentulous ridges and obtaining plaster models are necessary because intraoral scanning is infeasible due to the malleability of mucosa and potential tissue tension, which could lead to distortions in the digital model [³⁷]. Additionally, Bilgin et al. [⁶] highlighted one of the main drawbacks of the digital technique − the inability to define the vertical dimension of occlusion (DVO) and the records of maxillomandibular relationship (RMM). Therefore, a combination of digital and conventional techniques is recommended.

Research by Bidra et al. [²²] demonstrates that successful execution of available digital systems necessitates strict adherence to software manufacturer guidelines, along with the technical proficiency and theoretical knowledge of both dental professionals and technicians. Under these circumstances, cases of failure and patient dissatisfaction may occur until the necessary skills for using the system are acquired. In a similar vein, Moraes et al. [²⁴] underscored that achieving success in the production of complete dentures with digital systems depends on the knowledge and expertise of the dental professional.

According to Mubaraki et al. [⁴], conventionally produced complete dentures often lack a precise fit with the underlying tissues due to acrylic resin polymerization shrinkage. Conversely, Infante et al. [⁵] discovered that digital prostheses manufactured through the subtractive method are milled, and preformed PMMA discs are polymerized through injection under high temperature and pressure, thereby preventing denture shrinkage.

The CAD/CAM system can be categorized in two ways: additive manufacturing, where 3D objects are created by depositing material successively in layers to form a model, or subtractive manufacturing, which relies on Computer Numerical Control (CNC) machining. In subtractive manufacturing, the desired geometry is achieved by physically removing excess material through machining, such as cutting and milling, based on the digital model [²,⁴].

In Han et al.’s 2017 study, a comparison was drawn between digital and conventional prostheses, considering factors like flexural strength, detail reproduction, bacterial adhesion, and residual monomer concentration. The flexural strength of the milled CAD/CAM prepolymerized acrylic resin group exceeded that of the conventional method groups. The process of creating complete dentures using the CAD/CAM system is the most precise and reproducible technique when compared to methods like molding, compression, pouring, and injection processing [³⁶].

The conventional method of fabricating complete dentures allows for tooth arrangement modifications and treatment step evaluation before the final delivery phase [⁸]. However, the main drawback of this approach is the requirement for a minimum of 5 dental visits, a time-consuming and exhausting process, high treatment costs due to additional visits, an inability to adjust prosthesis bases to underlying tissues due to polymerization shrinkage, and the difficulty or even impossibility of creating a cloned prosthesis [²].

The introduction of CAD/CAM technology for dental prosthesis manufacturing brings several advantages, including fewer clinical visits, improved retention, reduced risk of microorganism colonization on prosthesis surfaces and, consequently, lower infection risk, easy reproduction and manufacturing of test prostheses using stored digital data, and superior quality control by dental technicians [⁴,⁶].

Current CAD/CAM manufacturing systems combine manual and digital procedures for prosthesis fabrication. However, present technology still cannot accurately record peripheral limits and mandibular relationships in a truly functional state. Impressions of edentulous arches may require techniques and materials from conventional prosthesis fabrication, as functional impressions rely on the dynamic movement of muscles and the jaw, which can be challenging to capture with certain intraoral 3D scanning devices [²²,³¹,³⁹].

Considering these aspects, there is a need for the development of software to facilitate predictable prosthetic treatments. Furthermore, it’s crucial to enhance the adhesive strength and precision of the connection between the framework and the prosthetic base. Additionally, efforts should be made to reduce the costs associated with digital systems, and industry professionals should leverage technology and classic literature to advance digital techniques for fully digital manufacturing [²²,³¹,³⁹].

CONCLUSION

The CAD/CAM system represents the future of dental prosthesis manufacturing and is expected to eventually replace conventional techniques. However, for this transition to occur, current CAD/CAM manufacturing systems need to enhance digital techniques, enable fully digital production, and reduce costs to make them more accessible to consumers.

• How to cite this article
  Cubas LS, Batista DS, Batista LH, Baratto Filho F, Matos TP. Review of complete denture fabrication processes and the application of CAD/CAM systems. RGO, Rev Gaúch Odontol. 2024;72:e20240042. http://dx.doi.org/10.1590/1981-86372024004320230097

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Edited by

• Assistant editor:
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  02 Dec 2024
• Date of issue
  2024

History

• Received
  03 Nov 2023
• Accepted
  28 June 2024