Digitally Fabricated Dentures 2023 PDF

10/11/2023 • Digitally Fabricated Complete Dentures, pt 1 Inception, Workflow, Digital Preview, BTI Fabrication Ronni A. Schnell, DMD, MAGD, FICD, FACD RS 522 ~ 10/11/23 10/11/2023 Show me the Evidence… 2012 – 2017 – “The first 5 years” Fit, Occlusion, Superior Material Properties Traditional v...

10/11/2023 • Digitally Fabricated Complete Dentures, pt 1 Inception, Workflow, Digital Preview, BTI Fabrication Ronni A. Schnell, DMD, MAGD, FICD, FACD RS 522 ~ 10/11/23 10/11/2023 Show me the Evidence… 2012 – 2017 – “The first 5 years” Fit, Occlusion, Superior Material Properties Traditional vs. Milling vs. Early printing Maeda Y, Minours, Tsutsumi S, Okada M, Nokubi T, A CAD_CAM System for Removable Denture. Part 1 Fabrication of Complete Dentures. Int J Pros 1994;7:17-21 Kawahata N et.al Trial of Duplication Procedure for Complete Dentures by CAD-CAM. J Oral Rehab 1997;24:540-8 10/11/2023 Clinical reports and technique papers… >37 10/11/2023 Material Studies - 6 University of Buffalo (4) 10/11/2023 Original Research >14 6 clinical + 4 lab on fit and satisfaction 1 dentures adhesives which were shown to actually reduce the fit due to the bases’ excellent adaption to the tissues 10/11/2023 Systematic Reviews - >4+ Because there are so many studies 10/11/2023 Material Studies – Milled vs. Early Printed • No fracture toughness • If you drop it in a bathroom sink it will break into many pieces • Many labs were printing the trial denture in a single color and “coloring’ the denture base: • Porous • Habitat for fungus 10/11/2023 Digital Technology: Milled & Printed in 2017 Subtractive Manufacturing Additive Manufacturing 10/11/2023 Digital Technology: Milled & Printed in 2017 Subtractive Manufacturing Additive Manufacturing 10/11/2023 Monolithic vs Individual Teeth AvaDent Monolithic Teeth contribute to its strength Conventional- pack and press Only the denture base contributes to its strength 10/11/2023 Surface Customization – post production Acrylic powder stains with an Optiglaze surface 10/11/2023 Minimal Shrinkage / Greater Accuracy Comparison of denture tooth movement between CAD-CAM and conventional fabrication techniques Brian J. Goodacre, DDS,a Charles J. Goodacre, DDS, MSD,b Nadim Z. Baba, DMD, MSD,c and Mathew T. Kattadiyil, DDS, MDS, MSd 10/11/2023 SUNY Buffalo Department of Restorative Dentistry Tests Summary:  Acrylic Porosity Results: • Shows no micro-porosity resulting in negligible C. Albicans adherence Also found to be more hydrophobic Conventionally processed Diamond D acrylic vs. AvaDent processed/milled Diamond D acrylic 10/11/2023 SUNY Buffalo Department of Restorative Dentistry Tests Summary:  Teeth Bonding Procedure Results: • The bond exceeds ADA requirements  Color Stability Results: • Is more color stable than traditionally processed dentures  Residual Monomer Results: • Has 20% less residual monomer than conventionally fabricated dentures Denture Base Materials Denture Teeth Avadent Blue Line Diamond D Portrait Lucitone 199 Ivostar Classic 10/11/2023 Wear Testing of Custom Milled Teeth in A Monolithic Denture  Denture teeth will be milled with the same denture base material  There were no significant differences between the wear parameters of Dentsply IPN teeth and AvaDent teeth (There was a trend toward lower wear with the AvaDent teeth but it was not statistically significant) Testing performed by Minnesota Dental Research Center for Biomaterials and Biomechanics University of Minnesota School of Dentistry 10/11/2023 Multi-layered Teeth and Sharp Gingival Margins 10/11/2023 Denture Base Options  Rugae or no rugae 10/11/2023 Denture Shade Tabs Avadent shades XCL1, XCL2 vs Portrait Shades (must be converted to Avadent shades) A1, A2, A3, A3.5, B1, B2, C1, C2, D2 10/11/2023 Current Research Focus… 2018 – Present:     Introduction of: Intraoral scanning Digital records capture New printed materials – Lucitone Digital Print 10/11/2023 Material Studies – Milled vs. Printed Ivoclar Vivadent vs Dentsply Sirona Lucitone® w IPN 3D Teeth Conrad J. Rensburg, Absolute Dental Services 10/11/2023 Milled & Printed Baltic Avadent 10/11/2023 Can Your Analog Denture Do This? 10/11/2023 Sept 2019… Lucitone Digital Print + Carbon 3D 10/11/2023 Fracture Toughness of Denture Base ISO 20795 1. Lucitone Digital Denture Base Resin 2. "First Generation" Digital Denture Base Resin Carbon 3d M1 Printer 3. Conventional Acrylic Powder/Liquid packed and cured 4. Milled Digital Denture Disc Sectioned from the disc Courtesy of Dr. Russell Giordano - Boston University Goldman School of Dental Medicine 10/11/2023 Fracture Toughness  Fracture Toughness According to ISO 20795 RT 4 3.5 3 2.5 MPa.m20.5 1.5 1 0.5 0 resistance to crack propagation 37°C D D C A C D C B First Lucitone Digital Lucitone Disc Generation Print Lucitone Conventional Bars with different letters are significantly different at p ≤ 0.05, Tukey. 10/11/2023 Work of Fracture Energy needed to break the denture 1800 1600 1400 1200 J/m2 1000 800 600 400 200 0 RT 37°C “Body Activated Material - BAM” ISO Minimum A B A C A C D Lucitone Digital Print Lucitone Disc Lucitone Conventional D First Generation Printed Bars with different letters are significantly different at p ≤ 0.05, Tukey. 10/11/2023 10/11/2023 10/11/2023 Shear Bond Strength of Denture Teeth to Base  Static and Fatigue(60% static load for 200 cycles1 Hz) Static Fatigue 35 30 25 MPa 20 A AB A AB C C 15 10 5 0 Lucitone Digital Print Lucitone Conv First Generation Printed Bars with different letters are significantly different at p ≤ 0.05, Tukey. 10/11/2023 Comparison of Overall Fit to Master Model M1 M2 M3 1st Generation Printable Resin 2GPR1 2GPR2 Lucitone Digital Print Resin 2GPR3 M4 M5 2GPR4 2GPR5 within 100uM 10/11/2023 Digital Options - Comparisons Lucitone Print – D/S Monolithic Milled • • Teeth are virtual There are 4 different libraries of anterior teeth to choose from: – Dentsply Portrait IPN: • 39 moulds • 14 shades: A, B, C, D + bleach • • Teeth are “carded” Dentsply Portrait Inspired 3-D Anteriors: – 7 moulds – 6 shades – Ivoclar Blue Line – 55 moulds – Candulor (Swissdent) – 27 moulds – Signature teeth (custom morphed) Mould Charts are on BB RS532 & RS642 Analog Chart and Guide is still in dispensary Digital chart only online (no guide avail) 10/11/2023 Digital Options - Comparisons Monolithic Milled • Utilizes an infinitely small amount of inter-ridge space >12mm, if necessary… Lucitone Print – D/S • • Minimum inter-ridge requirement 15mm Algorithm will not allow you to proceed to the next step, if < 15 mm A perforation of the denture is not possible due to the teeth being bonded 13mm 12mm The ridge lap will be milled off during denture milling 10/11/2023 Digital Digital processes give us a more effective way to interact with our patients Transitioning from analog to digital to analog presents certain difficulties  Fundamentals are still requisite for fabrication 10/11/2023 Key to Successful Dentures  Knowledge of the musculature is the key to successful denture borders and optimal impressions  Knowledge of edentulous anatomy and their predicted effects on the outcome of the denture  Knowledge of optimal esthetics and how to achieve desirable results  Knowledge and skill to manage denture occlusion: as compared to natural occlusion 10/11/2023 The Digital Process:  The digital process can accomplish all of these steps too, but in a different way:  Impressions are scanned with machines  Machines directly scan the patient’s anatomy intraorally  Physical records transfer the data as reference scans  We ultimately end with a virtual patient  So why digital? 10/11/2023 The Digital Process: Machines are very accurate and predictable The digital record is a permanent record We can add layers of information, such as… UTS CAD  A CT scan  A digital gothic arch tracing  A digital facebow registration  Custom mandibular movements  Virtual articulation  Reproducible occlusal schemes & esthetics  And facial scans Dr. Valerie McMillan 10/11/2023 Benefits of Digitally Fabricated Dentures  Greater accuracy, minimal shrinkage or expansion  Teeth may be customized or morphed to opposing natural dentition  Strength  Bio-hygienic  Permanent record  Precise duplication 10/11/2023 Mutiple Techniques for Clinical Records Intra-oral scans Wagner Try-in Various Devices Duplicate Denture Reference Denture Patient’s own denture Wax Rim Technique Wagner Try-in 10/11/2023 Workflow – Analog v Digital Impressions Records Set-up Try-in Processing & Insertion Conventional: Pack & Press Injection Pour OR 10/11/2023 Workflow – Analog v Digital Impressions Records Set-up Try-in Processing & Insertion Conventional: Pack & Press Injection Pour Digital: Monolithic milled Milled & bonded Milled & milled Milled & printed Printed & bonded Printed & printed Others… 10/11/2023 Workflow – Reference Denture Impressions Records Set-up Try-in Processing & Insertion Digital: Monolithic milled Milled & bonded Milled & milled Milled & printed Printed & bonded Printed & printed Others… Current denture Requiring alterable changes in: • VDO / Occlusion • Esthetics, • Tooth position Scanned after impressions & bite 10/11/2023 Wax Rim or Reference Denture? Wax Rim Technique  No existing denture  If current denture… completely unserviceable Reference Denture Technique  KEY for simplifying digital denture workflow  capturing key records in patient’s own denture is more accurate  Must have existing denture  PREFERRED TECHNIQUE if… VDO and CR acceptable or “correctable” prior to impressions and CR record 10/11/2023 Critical records needed: (regardless of the technique)*  Intaglio - Final Impression or wash impression  VDO  CR  Midline and horizontal plane  Lip Support  Tooth mould, shade, denture base shade  PPS (if maxillary)  Photos * Analog or Digital Occlusion Rim or Reference Denture 10/11/2023 Boston University Goldman School of Dental Medicine Viewer Link: https://dashboard‐ us.avadent.com/AvaDentViewer/Approval?PublicInvitationKey= 16ac8c2c‐020d‐4da4‐9fd8‐d6aca779f75e (WITH A STUDENT) Assessing a case 10/11/2023 Clinical photos Current denture, if available 10/11/2023 10/11/2023 Digital Denture Checklist… The Power of the Checklist 10/11/2023 Checklist:             Complete Denture Workflow Pages Clinical Techniques Clinical Records Required Set-up & Appt Tasks Checklist for QC meeting Req’d Photos – Wax rim technique Req’d Photos – Reference Denture Lab Rx template – for BTI Lab Rx template – for final milled dentures Digital Preview Evaluation BTI Try-in Denture Shade Tabs 2-3 4-5 6 7-10 11 12-13 13-14 15 16 17-30 31-36 37 10/11/2023 For Occlusion Rim Technique, After completing interocclusal records students will:  Prepare PPT  Prepare Work Authorization  Email via DataMotion to me & GSF Occlusion Rim Technique 10/11/2023 The first three steps are the same, because the fundamentals are the same… Preliminary Final Intermaxillary Records 10/11/2023 Clinical photos  Take full face photo, profile and close ups as follows:  all photos should show – Front and Profile images:  Repose  Smile  and BIG smile  with current denture and with adjusted occlusion rims or  with duplicated dentures or reference dentures  Retracted edentulous/ridges parallel  Retracted CR Record  Mounted occlusion Rims 10/11/2023 Current Denture Repose Smile 10/11/2023 Occlusal Rims Repose Smile 10/11/2023 Retracted Occlusal Rims in CR – WITH Midline, Canine & High Smile Line Drawn 10/11/2023 Retracted Edentulous – with ridges PARALLEL Maxillary and mandibular ridge parallelism has been reported to indicate appropriate VDO This will also be compared to your mounting and the scanned ridges 10/11/2023 And Mounting… 10/11/2023 Posterior Palatal Seal and… Verify that post dam is prepped into final cast, so that it can be captured and incorporated when scanned 10/11/2023 LAB Rx Initial PPT & RX Sent to me and the GSF Page 15 10/11/2023 Meet with digital denture QC faculty for review Case is first Initiated with AvaDent - then sent for scan 10/11/2023 5 Scans Files are submitted… www.avadent.com 10/11/2023 Reference Denture Technique Case must be scanned during clinical appt. Student must:  Schedule patient for a double session (1&2)  Schedule a lab appointment to ensure that tech will scan  Send PPT & Lab Rx to Dr. Schnell & GSF initiate case 10/11/2023 2 most important things to know and capture during Reference Denture Technique Impressio n Bite 10/11/2023 Use the thinnest amount of final impression material and bite reg material Do Not Increase VDO…! 10/11/2023 10/11/2023 Required Clinical Records  Intaglio  VDO & CR  CR  Midline and horizontal plane  Lip Support  Tooth mould, shade, denture base shade  PPS (if maxillary)  Photos 10/11/2023 Digitize Records Chairside (or with your lab tech/scanner) 10/11/2023 Clean up denture and return to patient at same visit 10/11/2023 Meet with digital denture QC faculty for review Case is first scanned – then Sent to AvaDent 10/11/2023 Reference Denture Wax Rims Digital Preview Evaluation 10/11/2023 Digital Preview Evaluation 10/11/2023 Digital Preview Evaluation 10/11/2023 Digital Preview Evaluation Checklist – pgs 16-27 AlHelal A, Goodacre B, Kattadiyil M, Swamidass R. Errors associated with digital preview of computer engineered complete dentures and guidelines for reducing them: A technique article. J Prosthet Dent 2018;119(1):17-25. 10/11/2023 Digital Preview, Editing and Approval 10/11/2023 BTI - Biofunctional Try-In / Bouma Try-in Courtesy of Dr. Lars Bouma  All-resin PMMA Trial Denture  Milled or printed entirely in the actual tooth shade  Fully functional denture  Accuracy – can assess retention with 100% certainty  Pt can take home for prototype or spare  Used for radiographic and surgical guides 10/11/2023 BCTI – Bio-Functional Try-In – Printed two-color monolithic • Printed monolithic try‐ins • Stratasys inkjet technology • More dimensionally accurate than DLP printing • Strong enough for a try‐in and short‐term temporary denture • Tooth esthetics not fully developed / more opaque denture base than PMMA • Vita & Lucitone Classical shades 10/11/2023 BTI Try-in 10/11/2023 BTI Try-in 10/11/2023 BTI Try-in – Prototype / Provisional Because this patient does not have a very high smile line, you cannot see that the denture base is the same shade as the teeth. This patient will now wear these BTI’s while he has mandibular implants planned and placed. We will adjust, reline, alter this prototype until the patient is ready for his final dentures and then a wash impression and CR record will be made and scanned (digital reline). Digital relines will be discussed next semester… 10/11/2023 How to evaluate the Try-in pgs 32-36  Flanges – extensions and width (may need to adjust to seat)  Intaglio and Post Dam – check with PIP  Occlusion, Occlusal Plane and CR  Phonetics   Incisal Edges and VDO Esthetics  Tooth display, High Smile, Midline, Lip Support Think of it as a denture insertion… 10/11/2023 Try each arch in individually Checking the fit – PPS 1. If the Maxillary denture does not seat initially, a. evaluate the length and thickness of the borders b. Use PIP on the intaglio c. Evaluate the PPS 2. If the Maxillary denture seats, has good retention, but then drops when the pt starts to speak, a. Adjust the length of the denture 10/11/2023 Try each arch in individually Checking the fit – Intaglio Pressure Indicating Paste Fit Checker • Support, stability, and extension • Show through / tissue impingement 10/11/2023 Try each arch in individually Checking the fit – Borders Length and width of your flanges A function of your final impression IO scan Cast 10/11/2023 Next- Evaluate the Occlusion & VDO 10/11/2023 Repose (incisal edges) & Lip Support Evaluate Esthetics MidlineDraw & score Full Smile Get esthetics consent 10/11/2023 Retention and stability… If after adjusting each arch separately, you are not satisfied with the fit or retention, make a new wash in the intaglio of the trial denture (evaluate VDO first) 10/11/2023 Occlusal or VDO Adjustments… Esthetic Modification…  If adjust VDO  If adjust occlusion and eliminate anatomy  If some teeth are not in contact  If no cusp / fossae contacts not aligned  If midline is deviated after occl adj  Always take new CR record @ VDO  Always take new photos of BTI 10/11/2023 Ensure Bite Record is Taken @ VDO …and doesn’t hide CEJ’s of teeth 10/11/2023 No teeth in contact on CR? VDO will be increased in the software 10/11/2023 A BTI try-in from an unsuccessful interocclusal record IN OTHER WORDS – WHAT EVER COULD GO WRONG… DID!! 10/11/2023 BTI Try-in • Excessive VDO • Occlusal plane to low • High smile line • Incisal edges in repose 10/11/2023 CR incorrect 10/11/2023 BTI Try-in • • Make al of your changes in the BTI as though they were occlusion rims Take a new CR record – this time @ VDO 10/11/2023 The new scan and digital design preview will show the new set up and the previous tooth set (your BTI) up as your reference for comparison 10/11/2023 Final Dentures 10/11/2023 Reference Denture  Impressions  Records DO NOT POUR Reference Denture Impressions – Scan it! 10/11/2023 BTI Provisional  Pt will now wear his BTI provisionals until after implant placement and healing  After abutments are placed a new impression will be made in lower to proceed with final denture 10/11/2023 BTI take home messages: When to take a new CR record and Scan  If any occlusal adjustments  If some teeth are not in contact @ correct VDO  If no cusp / fossae contacts  If a wash impression is made (always in function!)  If midline is deviated after occlusal adjustment*  Always take photos: repose, full smile (full face and close up) and retracted in occlusion  Use Aluwax, not Blu-mousse – tooth to tooth contact - @ VDO  Check the CR Record before dismissing the patient 10/11/2023 Things I have learned in my digital journey… When working with an established VDO as with a BTI, Reference denture or Duplicate Denture…  Make the final wash impression with as thin a wash as possible – DO NOT CHANGE VDO  Take the bite with Aluwax, not Blu-mouse – it will leave a film thickness – DO NOT CHANGE VDO 10/11/2023 And Finally… Today’s Take Home Message…  A Digital Denture Workflow does not make the CLINICAL RECORDS better….    It highlights the errors (if any) And wow, it does make communication easier and the final product extremely accurate  Know your REFERENCE  Pay attention to every detail 10/11/2023 Questions?