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French Journal of Dental Medicine | November 2020 | 1
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
INTRODUCTION
e removable complete denture (RCD) is the most com-
mon rehabilitation of edentulous patients worldwide.1-4 Proto-
cols for the fabrication of RCDs following the traditional
workow consist of registering the geometry of supporting tis-
sues and peripheral musculature (through one or two impres-
sions), recording the maxillo-mandibular relationship,
designing the denture (with tooth arrangement), try-in, fabri-
cation and insertion. is prosthetic chain is a succession of
clinical and laboratory steps involving multiple operators, and
consequently, prone to errors.5-7
e development of computer-aided design (CAD) and
computer-aided manufacturing (CAM) technologies is pro-
foundly changing complete denture treatment. Edentulous
ridges and maxillo-mandibular relationships can nowadays be
recorded with intra-oral scanners (IOS), RCDs can be digitally
designed through multiple commercially available soware, and
traditional asks can be replaced by milling and printing ma-
chines.8-17 More importantly, these technologies can guarantee
for the rst time a reproducible manufacturing quality. How-
ever, the diversity of tools and protocols complicates their inte-
gration into daily practice, especially since they have not all
reached the same level of maturity. Nevertheless, the digital
transformation is gradually revolutionising complete dentures.18
e objective of this narrative review was to summarise the
current knowledge about digital RCDs through a presentation
of currently available devices and technologies to produce re-
movable dentures and implant-supported dentures for edentu-
lous patients.
Digital removable complete dentures: a narrative review
Abstract:
Removable complete dentures have recently entered the digital area, through various workflows constantly evolving
with the maturity of digital technologies. Indeed, practitioners and laboratories are particularly challenged with the
integration of digital tools and techniques in the daily treatment of complete edentulism. The aim of this narrative
review was to summarise the current knowledge about digital removable complete dentures, to enable practitioners
and laboratories to decide either to move to a fully digital workflow or to integrate some of these new tools into
their current practice. The first part of this article reviews different techniques for recording edentulous ridges and
the maxillo-mandibular relationship. Then, the second part describes the digital steps involved in designing pros-
theses, while the last part describes the materials and manufacturing technologies. As a conclusion, digital tech-
nologies provide several options for the treatment of edentulous patients, but there is a need for remaining vigilant
on the quality of the delivered prostheses and treatment.
Key words: CAD/CAM, additive manufacturing, milling complete dentures, intraoral scanner, digital denture,
digital impression, 3D printing, digital workflow
Manuscript submitted: 10 June 2020. Manuscript accepted: 9 September 2020.
Doi: https://doi.org/10.36161/FJDM.0005
Corresponding author: Dr. Maxime Ducret, Prosthodontics, Université de Lyon, Faculty of Dentistry, France.
Email: ducret.maxime@gmail.com
Claudine Wulfman,1,2 Guillaume Bonnet,3,4 Delphine Carayon,5,6,7 Cindy Batisse,3,4 Michel Fages,5,6,8
Virard François,9,10 Marwan Daas,1,11 Christophe Rignon-Bret,1,12 Adrien Naveau,13,14 Catherine Millet9,10 and
Maxime Ducret9,10
1. Université de Paris, UR 4462, F-92049, Montrouge, Sorbonne Université Paris Nord, F-93000, Bobigny, France
2. Département d’Odontologie, AP-HP, Hôpital Henri Mondor, F-94010 Créteil, France
3. Université Clermont Auvergne, CROC EA4847, Faculté d’Odontologie, Clermont-Ferrand, France.
4. CHU Clermont-Ferrand, Service d’Odontologie, Clermont-Ferrand, France.
5. Faculté d’Odontologie, Université de Montpellier, Montpellier, France.
6. CHU de Montpellier, Service d’Odontologie, Montpellier, France.
7. Laboratoire AMIS, UMR 5288 CNRS, Université Toulouse III-Paul Sabatier, Toulouse, France.
8. Laboratoire Bioingénierie et Nanosciences, EA4203, Université de Montpellier, Montpellier, France.
9. Faculté d’Odontologie, Université Claude Bernard Lyon 1, Lyon, France.
10. PAM d’Odontologie, Hospices Civils de Lyon, Lyon, France.
11. Département d’Odontologie, AP-HP, Hôpital Louis Mourier, F-92700 Colombes, France
12. Département d’Odontologie, AP-HP, Hôpital Charles Foix, F-94200 Ivry sur Seine, France
13. Unité de parodontologie et prothèse dentaire, Hôpital Saint André, CHU de Bordeaux, Bordeaux, France
14. Département de prothèses, UFR des sciences Odontologiques, Université de Bordeaux, Bordeaux, France.
Digital impression for RCD
A digital scanner is a non-contact measuring device that
records and reconstructs three-dimensional (3D) surfaces or
volumes.16,19 It consists of an optical acquisition system in as-
sociation with a 3D reconstruction soware (Figure 1). IOS are
mobile and record directly in the mouth, while extra-oral scan-
ners (EOS) are used to digitise impressions/models in labora-
tories. Facial scanners can be used for recording aesthetic lines
or extra-oral defects in maxillofacial prosthetics.
Digital scanning of edentulous ridges
Scanning of edentulous arches presents three recording chal-
lenges: the lack of anatomical landmarks, the functional
borders,20 and the posterior palatal seal. Intraoral scans allow
preliminary non-compressive digital scanning of the ridges.8-12
However, it is necessary to follow specic scanning protocols
to record areas without anatomical landmarks such as the
palate or edentulous ridges.20-23 Placement of composite mark-
ers or use of a dermal marker on the mucosa facilitates the im-
pression.21,24,25 A custom impression tray can then be fabricated
from this preliminary impression to make a conventional nal
impression. e accuracy of digital scanning is similar to that of
conventional materials in the maxilla, with 0.70 ±0.18 mm for
IOS, 0.75 ±0.17 mm for polyvinylsiloxane and 0.75 ±0.19 mm
for eugenol zinc oxide-modied polyvinylsiloxane.26 However,
these results remain to be conrmed for the mandible as well.
Borders stretching is the most dicult area to record with dig-
ital scanning.21,25 Jung et al. proposed to match conventionally
registered functional borders with the original digital
scanning.27 Other authors proposed mobilising so tissues with
a nger or a mirror to record their position.22,24,25 Concerning
the posterior palatal seal, the anterior and posterior vibrating
line on the so palate could be delineated by using an indelible
pencil or small spots of light-polymerised gingival barrier ma-
terial before scanning.21 e accuracy of digital scanners is sen-
sitive to other factors such as learning curve, brightness during
scanning, presence of saliva or scanning strategy.28-33 Each IOS
requires specic settings and training.
Digital impression of implants
Scan bodies used in digital scanning for implant-supported
prosthetic rehabilitation are landmarks on edentulous ridges.
However, the similarities between the landmarks create a risk
of confusion for the reconstruction algorithm when individu-
alising each implant.34,35 Two technologies were proposed for
digital scanning of implants: confocal microscopy (IOS) and
stereo photogrammetry.36 Both systems were documented in
short-term clinical studies and the conclusions were similar:
satisfactory survival rate aer 1 to 2 years and clinical and ra-
diological passivity of the prosthetic frameworks.37-39
Several in vitro studies measured the accuracy of digital
scanning for distance and angulation, and recent IOS oered
superior or equal results when compared to conventional im-
pressions.40-47 However, caution is needed when interpreting
these measurements because deviations measured in vivo could
be doubled compared to in vitro measurements.48
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
French Journal of Dental Medicine | November 2020 | 2
Figure 1: Strategies to obtain digital scans of edentulous patients, using an
intraoral scanner (A), or by digitisation of the prothesis (B) or the cast (C)
A
B
C
e accuracy of digital scanning is improved when the inter-
implant distance is short,49 the scan bodies are high and simple
in design, the operator is experienced50 and complies to the
manufacturer’s recommended scanning strategy.37,45,50,51 How-
ever, implant angulation, depth, and type of connection do not
inuence the accuracy.45,52,53 Similarly, implant transfers splint-
ing does not increase accuracy.49,54 Finally, a digital scan is twice
as fast as a conventional impression, with the possibility of par-
tial retake.39 ese recommendations were validated for digital
scanning of 4 to 6 implants in both the maxilla and the
mandible. On the other hand, the optical impression is not yet
validated for overdentures on two implants.55
Extraoral scanners
Many laboratories already use EOS in their daily practice to
scan impressions and models. Regardless of the measurement
acquisition technology (laser, structured light or contact), a
soware program generates a 3D reconstruction of the object
and an STL le that can be used in most CAD soware pro-
grams. Although the performance of IOS and EOS are close,56
EOS is generally considered more accurate than IOS because
of the conditions controlled during acquisition (temperature,
light and humidity).19,57,58 Optical scanners are faster than con-
tact scanners due to the controlled conditions, but they could
be aected by the optical properties of the scanned object.
Facial scanners
e digitalisation of the face was proposed by some authors
to improve denture design and facilitate communication.26,59,60
e facial 3D le could, in theory, be matched with the edentu-
lous ridge le, but this combination has not been described yet.
Maxillomandibular
relationship record
None of the currently available workows is entirely digital
for recording the maxillo-mandibular relationship; all ap-
proaches rely on conventional or 3D-printed baseplates sup-
porting wax occlusion rims.61-65 In the Ivoclar-Vivadent®
workow, the maxillo-mandibular relationship is recorded in
two steps. First, the practitioner records the preliminary im-
pressions conventionally and a preliminary jaw relation with a
specic device. Aer connection, the whole set is then scanned
in the laboratory with an EOS,13 and positioned on a virtual ar-
ticulator (Figure 2). e occlusion rims are then digitally de-
signed in a position close to the clinical situation, facilitating
the nal recording.
For the realisation of occlusion rims, the CAD soware is
able to detect the anatomical landmarks on the ridges to visu-
alise the situation of the future prosthetic teeth (centre of the
incisal papilla, maxillary tuberosity, labial frenulum, retro-
molar trigone). e occlusal rims may be designed for a max-
illo-mandibular co-adaptation procedure or to receive devices
such as central bearing tracing.13,14,22 In this case, the height of
the occlusal rim will be underestimated to facilitate device
French Journal of Dental Medicine | November 2020 | 3
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
Figure 2: Maxillomandibular relationship record. Digital transfer of the
preliminary jaw relation (A) and design of the occlusion rims (B)
A
B
Figure 3: Computer assisted design of complete denture. The software offers an automatic proposition of maxillar and mandibular tooth alignment (A),
that could be modified following anatomic landmarks (B). The digital set-up could also be matched with a picture of the patient to improve
communication and esthetic outcomes (C).
ABC
placement and registration. Other authors prefer silicone bite
registration and a secondary scan in the laboratory (EOS) or
directly with an IOS.17,24,26,65
Computer-assisted
design of complete denture
Numerous soware programs were developed specically
for RCD: 3Shape Dental System®, Ceramic D-Flow®, Exocad®,
Lucy®, Dental Wings®, 3Shape Digital Denture®, Modier®.
ese digital tools are increasingly used in dental laboratories
independently from the dentist’s clinical workows, as they
save time, increase accuracy and reproducibility of RCD.65,66
CAD of complete denture:
prosthetic bases and teeth
e soware includes teeth libraries of dierent brands and
shapes, yet it is also possible to personalise the shape of teeth
according to the needs of the set-up (morphological tooth
adaptation).
e occlusal plane and the insertion axis of the denture are
dened according to anatomical landmarks (Figure 3). e so-
ware then automatically proposes a bilaterally balanced set-up,
which signicantly saves time when compared to conventional
techniques.67 e operator can then customise the set-up by
modifying the position of one or more teeth, or even remove
them. e virtual articulator allows static and dynamic occlusal
analysis. Finally, the volumes, the dimensions of the papilla and
the canine eminences, the marginal curve, and the nish can
be adjusted. e les are then prepared for the production of
the denture and/or templates for try-in and functional valida-
tion of the set-up.67 ese templates can serve as transitional
dentures in the treatment of patients with temporomandibular
disorders or can be used as radiological and/or surgical tem-
plates for a subsequent implantation project.67
CAD of the single-arch RCD
In these rehabilitations, occlusal balance is essential. Several
soware programs oer an ideal teeth assembly and indicate
the corrections to be made in the antagonist arch. is allows
the operator to easily switch from the ideal set up to a set up
without modifying the antagonist arch. As with the anterior
teeth, the size and shape of the teeth can be customized to fa-
cilitate occlusal balance.
CAD of immediate RCD
With new tools such as digital extraction, the practitioner
also handles the transition to complete edentulism.68-70 e
working model is prepared by superimposing the model with
the patient’s CBCT for post-extraction crest modelling.60 A du-
plicate of the future immediate RCD can also serve as a surgical
guide. e patient’s face can be integrated into the model using
photographs or facial scans to optimise the determination of
the interincisor point.
It is also possible to superimpose the patient’s RCD and their
residual teeth during the design. e objective is to position
the interincisal point according to its optimal situation and to
facilitate the choice of tooth shape and size (Figure 4).
Design of implant-supported framework
e use of CAD/CAM processes for the fabrication of im-
plant infrastructures has been used for decades. New materials,
not available for traditional casting techniques, have appeared
with increased biocompatible and aesthetic properties.71 In-
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
French Journal of Dental Medicine | November 2020 | 4
Figure 4: Illustration of the virtual protocol of immediate denture design, before (A) and after digital extraction and ridge modelling (B)
AB
Figure 5: Computer assisted manufacturing of complete denture, using a
milling machine
deed, zirconia is easily machined into pre-sintered blocks and
the design soware eectively compensates for sintering
shrinkage.72 However, the mechanical properties of the metal
are superior when the framework is milled from industrial
blocks with fewer micro-defects, porosities and impurities.73
Deformations and stresses stored in the material disappear as
there is no longer any need of the cooling phase.72 e tting
accuracy is less than 150 μm, which guarantees the passivity of
the implant framework.74 In addition, these techniques are less
operator-dependent, more reproducible, and at a lower cost
than the casting of precious alloy frameworks.72 It should be
noted that these CAD/CAM frameworks do not tolerate braz-
ing and cannot be modied.
Computer-assisted
manufacturing (CAM)
New manufacturing processes have also inuenced the ma-
terials used in the manufacture of RCDs. e main and univer-
sally used component is polymethyl methacrylate (PMMA). Its
exothermic polymerisation causes material shrinkage. In the
conventional process, strict control of temperature, pressure and
polymerisation time improve the material homogeneity and in-
tegrity of the denture surface, and also reduce the shrinkage and
porosities. However, these traditional protocols were operator
dependent. Fabrication of RCDs, whether by milling or 3D
printing, reduces these sources of error (Figure 5).
Computer-assisted milling
of complete denture
Milling from polymerised resin discs is the most developed
CAM process. e inversion of the shaping and polymerisation
steps removed shrinkage diculty and shied the quality con-
trol of the polymerisation process to the manufacturer. e
main clinical consequence is the excellent t of the denture on
the supporting tissues, with increased comfort and better re-
tention.15,75-77 It also became possible to optimise the composi-
tion of the materials in order to improve their mechanical
properties (exural strength, fracture resistance, hardness) and
biocompatibility.78-80 However, the properties of resin materials
commercially available vary considerably and do not currently
represent a uniform class of materials.76,79,81
Although milling processes are currently the most widely
used, they nevertheless have economic and environmental
costs, since a large part of the disc is not used.
Computer-assisted printing
of complete denture
Additive processes thus seem very promising.82 3D printing
consists of shaping the dental prosthesis by successive addition
of material.16 Stereolithography (SLA) or digital light processing
(DLP) achieve satisfying precision with resin layers from 20 to
150 μm thick, which are compatible for the manufacture of the
base and/or the teeth.83 Several commercial systems, such as
Dentca CAD-CAM (DENTCA Inc) or Pala (Kulzer) digital
denture, already propose medical devices and clinical proto-
cols.84-85 It is also possible to print dentures directly with CE
marked Class IIa resins (Next-Dent B.V. and Envisiontec Inc).
First, the base is printed with compartments to glue the printed
dental arch or commercially available teeth.84-85 Repositioning
of the teeth is then facilitated by a printed transfer key.26 3D
printing must still be used with caution when making a nal
RCD, due to the lack of clinical evidence regarding mechanical
properties, wear resistance, ageing and biocompatibility.86 In-
deed, it appears that the accuracy of the printed RCD is lower
than that of milling, but remains clinically acceptable, satises
patients, requires less equipment and less sophisticated ma-
chinery than milling.86-87 Finally, milling or 3D printing gives
monochrome shades to the bases and prosthetic teeth, which
may require the laboratory team to stain with dierent shades
of pink composite (Figure 6).
French Journal of Dental Medicine | November 2020 | 5
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
Figure 6: Examples of denture characterisation using pink composite
■ Wulfman et al.:Digital removable complete dentures: a narrative review ■
French Journal of Dental Medicine | November 2020 | 6
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