An Introduction to Digital Dentures .txt

An Introduction to DIGITAL DENTURES Thomas S. Giugliano, DDS, DICOI Assistant Clinical Professor Assistant Director Post-Graduate Prosthodontics Department of Prosthodontics CAD - CAM Computer Aided Design Computer Aided Manufacturing WHAT’S NEW? DIGITAL DENTURE COMPANIES Torrance, CA Austria German...

An Introduction to DIGITAL DENTURES Thomas S. Giugliano, DDS, DICOI Assistant Clinical Professor Assistant Director Post-Graduate Prosthodontics Department of Prosthodontics CAD - CAM Computer Aided Design Computer Aided Manufacturing WHAT’S NEW? DIGITAL DENTURE COMPANIES Torrance, CA Austria Germany Liechtenstein Scottsdale, AZ South Bend, Indiana Denmark York, PA Los Angeles, CA Scottsdale, AZ HONORABLE MENTION Liechtenstein DENTCA company quick view: • Started in 2007 • Created unique impression trays • Denture bases and teeth are 3D printed DENTCA Avadent company quick view: • Started in 2011 • All denture bases are milled AVADENT “Almost any tooth you want” Denture base is milled to fit the tooth AVADENT ONE-PIECE MILLING TECHNOLOGY Ivoclar / Vivodent company quick view: • Started in Zurich in 1923 (artificial teeth company) • Branches in 24 countries • Denture bases can be milled or 3D printed • Only available since June 2018 DIGITAL DENTURES PAST PRESENT FUTURE THE TRADITIONAL PROCESS TRADITIONAL TECHNIQUES COMPLETE DENTURES • Medical / dental history • Intraoral examination • Radiographic examination TRADITIONAL TECHNIQUES: COMPLETE DENTURES • Preliminary Impressions • Custom Trays • Border Molding • Final impressions TRADITIONAL TECHNIQUES COMPLETE DENTURES • Box impression • Pour impression • Master cast TRADITIONAL TECHNIQUES COMPLETE DENTURES • Baseplate/Wax Occlusion Rims • CRR/VDO/OP/Lip Support • Anterior tooth try-in • Posterior tooth try-in • Send to lab for processing TRADITIONAL TECHNIQUE DENTURE FLASK COMPRESSION MOLDING MECHANICAL FLASK PRESS INJECTION MOLDING THE DIGITAL PROCESS START-UP KIT DENTCA START-UP KIT DENTCA IMPRESSION TRAYS AVADENT STARTUP KIT AVADENT TRAYS THE CLINICAL PROCESS STEP 1: PROPER TRAY SELECTION • No preliminary impression • No custom tray Use existing old denture Compare border to border Use existing old denture PROPER TRAY SELECTION • Try-in the mouth, adjust if necessary • Thermoplastic • 80% of the time: medium tray RESORPTION PATTERN • Max and mand trays may not always be same size Image from: Selection of Artificial Teeth for Completely Edentulous Patients, Dr. Ahlam El-Sharkaway STEP 2: IMPRESSIONING IMPRESSION “MASSAD TECHNIQUE” Heavy-bodied PVS first, adjust, Wash with light-bodied PVS Massad JJ, Cagna DR. (2007) Compend Contin Educ Dent FINAL IMPRESSIONS Light or medium bodied PVS tissue wash FINAL IMPRESSIONS 1 st CHALLENGE: RECORDS INTRA ORAL or EXTRA ORAL TRACING DEVICE Gothic Arch Tracer Coble Balancer Arrow Point Tracing Needle Point Tracing ADJUSTABLE PIN and a PLATE Balkwill FH. (1866) The best form and arrangement of artificial teeth for mastication. Trans Odontol Soc Gt Br 5: 133-158 Gysi A. (1910) The problem of articulation. Dent Cosmos 52: 1-19. Trapozzano VR. (1949) A comparison of the equalization of pressure by means of the central bearing point and wax check bites. J Am Dent Assoc 38:586-591 Sears VH. (1952). Centric jaw relation. Dent Dig 58:302-306. El-Aramany MA, George AW, Scott RH. (1965) Evaluation of the needle point tracing as a method for determining centric relation. J Prosthet Dent 15:1043-1054. Smith HF. (1975) A comparison of empirical centric relation records with location of terminal hinge axis and apex of the gothic arch tracing. J Prosthet Dent 33:511-520. Myers M, Dziejma R, Goldberg J, et al. (1980) Relation of gothic arch apex to dentist-assisted centric relation. J Prosthet Dent 44:78-81. Zarb GA, Bolender CI, HickeyJC, et al. (1990) Boucher’s Prosthodontic Treatment for Edentulous Patients (ed 10). St. Louis, MO, Mosby, 290-295. Rubel B, Hill EE. (2011) Intraoral gothic arch tracing. N Y State Dent J 77(5):40-43. Photo courtesy of Lin KC, Wagner SA. (2015) J Prosthodont PROTRUSIVE RIGHT LATERAL LEFT LATERAL CENTRIC RELATION POSITION EXCURSION EXCURSION centric relation ˘n′tri˘k ri˘-lā′shun 1: the maxillomandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anterior-superior position against the shapes of the articular eminencies. This position is independent of tooth contact. This position is clinically discernible when the mandible is directed superior and anteriorly. It is restricted to a purely rotary movement about the transverse horizontal axis (GPT-5) 2: the most retruded physiologic relation of the mandible to the maxillae from which the individual can make lateral movements. It is a condition that can exist at various degrees of jaw separation. It occurs around the terminal hinge axis (GPT-3) 3: the most retruded relation of the mandible to the maxillae when the condyles are in the most posterior unstrained position in the glenoid fossae from which lateral movement can be made at any given degree of jaw separation (GPT-1) 4:The most posterior relation of the lower to the upper jaw from which lateral movements can be made at a given vertical dimension (Boucher) 5: a maxilla to mandible relationship in which the condyles and disks are thought to be in the midmost, uppermost position. The position has been difficult to define anatomically but is determined clinically by assessing when the jaw can hinge on a fixed terminal axis (up to 25 mm). It is a clinically determined relationship of the mandible to the maxilla when the condyle disk assemblies are positioned in their most superior position in the mandibular fossae and against the distal slope of the articular eminence (Ash) 6: the relation of the mandible to the maxillae when the condyles are in the uppermost and rearmost position in the glenoid fossae. This position may not be able to be recorded in the presence of dysfunction of the masticatory system 7: a clinically determined position of the mandible placing both condyles into their anterior uppermost position. This can be determined in patients without pain or derangement in the TMJ (Ramsfjord) The Glossary of Prosthodontic Terms, (2005) J Prosthet Dent centric relation ΄trĭk rĭ-la΄shun: acronym is CR; a maxillomandibular relationship, independent of tooth contact, in which the condyles articulate in the anterior-superior position against the posterior slopes of the articular eminences; in this position, the mandible is restricted to a purely rotary movement; from this unstrained, physiologic, maxillomandibular relationship, the patient can make vertical, lateral or protrusive movements; it is a clinically useful, repeatable reference position The Glossary of Prosthodontic Terms, (2017) J Prosthet Dent CENTRIC RELATION Condyles are restricted to rotation Unstrained, physiologic position 3. Repeatable Patient can make lateral movements NOT CR position • Not physiologic • No lateral movement from here “GOTHIC ARCH” TRACING 2 nd CHALLENGE: POSTERIOR CLEARANCE DENTCA TRAYS DETACHABLE (SECTIONAL) CLOSE UP VIEW CLOSE UP VIEW THE TRAYS ARE DETACHABLE CENTRAL BEARING PIN: VDO AND CRR USING CENTRAL BEARING PIN TO ADJUST VDO ESTABLISHING CENTRIC RELATION prweb.com Built-in registration plate E-Z tracer CENTRAL BEARING PIN MARKS E-Z TRACER CENTRAL BEARING PIN MARKS E-Z TRACER DENTCA’s GOTHIC ARCH TRACING AVADENT FINAL IMPRESSIONS Photos courtesy of Antoanela Garbacea, DDS AVADENT- ANATOMIC MEASURING DEVICE Photos courtesy of Antoanela Garbacea, DDS AVADENT ADJUST VDO AVADENT’s GOTHIC ARCH TRACING Photos courtesy of Antoanela Garbacea, DDS DENTCA AVADENT CENTRIC RELATION AVADENT DENTCA DR. TAE KIM University of Southern California, Los Angeles, CA anatomical landmarks and parameters TOOTH SELECTION Wright WH. (1936) Selection and arrangement of artificial teeth for complete prosthetic dentures. J Am Dent Assoc 23: 2291-2307. Schiffman P. (1964) Relation of maxillary canines to the incisive papilla. J Prosthet Dent 14: 469-472. Kern BE. (1967) Anthropometric parameters of tooth selection. J Prosthet Dent 17: 431-437. Ehrlich J, Gazit E. (1975) Relationship of the maxillary central incisors and canines to the incisive papilla. J Oral Rehabil 2: 309-312. Mitchener RW. (1990) Selection of the width of the maxillary six anteriors. Ill Dent J 59: 38-39. Sellen PN, Jagger DC, Harrison A. (1999) Methods Used to Select Artificial Anterior Teeth for the Edentulous Patient: A Historical Overview. Intl J of Pros 12: 51-58 Ellakwa A et al. (2011) Quantifying the selection of maxillary anterior teeth using intraoral and extraoral anatomical landmarks. J Contemp Dent Pract 12: 414-421. DENTCA - LIP RULER JAW GAUGE (VD GAUGE) AVADENT- AVAMETER FOUR MEASUREMENTS WIDTH of the NOSE FROM ALA to ALA AVADENT- AVAMETER INTERPUPILLARY DISTANCE AVADENT- AVAMETER LIP AT REST LIP SMILING Baltic/ Merz Dentca 3 Shape Ivoclar DENTCA DENTCA AVADENT TRY-IN ? DENTCA 3-D PRINTER DENTCA 3-D PRINTED DENTURE FOR TRY IN Streamlining and Simplifying Denture Fabrication with Digital Processes, Larry R. Holt, DDS May 2015 Course - Expires May 31st, 2018 Updates in Clinical Dentistry DENTCA 3-D PRINTED DENTURE FOR TRY IN DENTCA “FUNCTIONAL PROTOTYPE” AVADENT TRY-IN AVADENT WAGNER TRY-IN 3 rd CHALLENGE: PROCESSING ERROR Mojon P, Oberholzer JP, Meyer JM, Belser UC. (1990) J Prosthet Dent 6.5 - 7.9% shrinkage AVADENT-ACRYLIC BLOCK PLACED INTO MILLING MACHINE- PRE CURED LUCITONE 199 3-D printing: 20 microns = 0.020 mm Milling : 10 microns = 0.010 mm Conventional : 250 microns = 0.250 mm Clinical Processes TRADITIONAL I/O EXAM + PRELIM IMPRESSIONS BORDER MOLD + FINAL IMP RECORDS + TOOTH SELECTION ANTERIOR TRY-IN POSTERIOR TRY-IN DELIVERY ADJUSTMENT(S) 7-8 VISITS DIGITAL I/O EXAM, FINAL IMP, RECORDS TRY-IN (OPTIONAL) DELIVERY 2-3 VISITS TRADITIONAL • Withstood the test of time • Extensive tooth selection • Better control of esthetics • More visits • Longer treatment time • Harder to duplicate DIGITAL • Fewer visits • Less treatment time • Easier duplication • Limited control of esthetics • Limited tooth selection • Limited patient input DISADVANTAGES ADVANTAGES SKILL AND KNOWLEDGE ARE STILL REQUIRED! CD PRINCIPLES REMAIN THE SAME. • Materials, anatomy, occlusion • Esthetics, function, PO complaints • Make accurate impressions • VDO/CR COSTS AVADENT • Two arches complete……$630 • Single arch…………………$315 • Spare denture……….$215/arch DENTCA • Two arches complete……$600 • Single arch…………..……$300 • Spare denture……….$225/arch IVOCLAR Outsourced to lab COSTS AVADENT DENTCA • Startup kit…………$799 • Starter Kit………….$100 • Try-in……………….$230/arch • 3-D Try-in…………..Free • Functional Try-in…..Free DIGITAL DENTURES Fewer visits Faster treatment Easier duplication [email protected] Thomas S. Giugliano, DDS, DICOI REFERENCES Bidra A, Taylor T, Agar J. (2013) Computer-aided technology for fabricating complete dentures: Systematic review of historical background, current status, and future perspectives. J Prosthet Dent 109 (6): 361-366. “no clinical trials or clinical reports were identified in the scientific literature,…” Chen MS. (1980) Reliability of the fovea palatini for determining the posterior border of the maxillary denture. J Prosthet Dent 43 (2): 133-137. Drago CJ. (2003) A Retrospective Comparison of Two Definitive Impression Techniques and Their Associated Postinsertion Adjustments in Complete Denture Prosthodontics. J Prosthodont 12 (3): 192-197. Goodacre CJ, Garbacea A, Naylor WP, Daher T, Marchack CB, Lowry J. (2012) CAD/CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological data. J Prosthet Dent 107: 34–46. Infante L, Yilmaz B, E. McGlumphy E, Finger I. (2014) Fabricating complete dentures with CAD/CAM technology. J Prosthet Dent 111: 351-355. Kanazawa M, Inokoshi M, Minakuchi S, Obayashi N. (2011) Trial of a CAD/CAM system for fabricating complete dentures. Dental Materials Journal 30 (1): 93-96. Kattadivil MT, Goodacre CJ, Baba NZ . (2013) CAD/CAM complete dentures: a review of two commercial fabrication systems. J Calif Dent Assoc 41 (6): 407-416. Kawai Y, Murakami H, Shariati B, Klemetti E, Blomfield JV, Billette L, Lund JP, Feine JS. (2005) Do traditional techniques produce better conventional complete dentures than simplified techniques? J Dent 33: 659-668. Keng SB, Ow R. (1983) The relation of the vibrating line to the fovea palatini and soft palate contour in edentulous patients. Aust Dent J 28 (3): 166-170. Kyung KY, Kim KD, Jung BY. (2014) The study of anatomic structures in establishing the posterior seal area for maxillary complete dentures. J Prosthet Dent 112 (3): 494-500. Lin KC, Wagner SA. (2015) An Efficient and Cost Effective Technique to Construct an Intraoral Central Bearing Tracing Device. J Prosthodont 24: 511-514. Lye TL. (1975) The significance of the fovea palatini in complete denture prosthodontics. J Prosthet Dent 33 (5): 504-510. Massad J, Davis WJ, Lobel W, June R, Thornton J. (2005) Improving the stability of maxillary dentures: the use of polyvinyl siloxane impression materials for edentulous impressions. Dentistry Today 24 (2):120-123. Massad J, Lobel W, Garcia LT, Monarres A, Hammesfahr PD. (2006) Building the edentulous impression–a layering technique using multiple viscosities of impression material. Compend Contin Educ Dent 27 (8): 446-451. Massad JJ, Cagna DR. (2007) Vinyl polysiloxane impression material in removable prosthodontics. Part 1: Edentulous impressions. Compend Contin Educ Dent 28 (8): 452-459. McLaughlin JB, Ramos V. (2015) Complete denture fabrication with CAD/CAM record bases. J Prosthet Dent 114 (4):493-497. Nicol BR, Somes GW, Ellinger CW, Unger JW, Fuhrmann J. (1979) Patient response to variations in denture technique. Part II: Five-year cephalometric evaluation. J Prosthet Dent 41(4): 368-372. Yarapatineni R, Vilekar A, Kumar JP, Kumar GA, Aravind P, Kumar PA. (2013) Comparative evaluation of border molding, using two different techniques in maxillary edentulous arches An in vivo study. J Int Oral Health 5 (6): 82-87. The Glossary of Prosthodontic Terms. (2005) J Prosthet Dent 94 (1): 10-92. HISTORY Maeda et al (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 al (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 Kordass (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) 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) 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)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) 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) 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.