Escolar Documentos
Profissional Documentos
Cultura Documentos
41, No6
Complete
CAD/CAM
A Review
Dentures:
of TwoCommercial
Fabrication
Systems
M A T H E WT . K A T T A D I Y I L D
, D 5 , M D S , M S ; C H A R L E SJ . G O O D A C R ED, D 5 , M S D , M S ;
A N D N A D I MZ , B A B A ,D M D ,M 5 D
manufac tur i ng
design
andcomputer - aided
A B srR A crT h eu seo f com puter - aided
and
(CAD/CAM)
dentures
throughtheAvaDent
available
for complete
hasbecome
Teethare
technology.
andcomputer
AvaDent
uses[aserscanning
Dentcasystems.
Thebasesaremitledfrom
software.
andbasesformedusingproprietary
arranged
virtual
softwareto produce
prepolymerized
pucksof resin.Dentcausescomputer
r idges,
ar r ange
theteethandfor mbasesT.he
edentulous
ma xi [[a a
ryn dma n d i b u lar
pr ocessing
technique.
d
a conventionaI
d e n tu reasrefa b ri ca teusing
AUTHORS
MathewT.Kattadiyil,oos,
t"ros,t"ts,is a diplornate
Board
of theAmerican
of Prosthodontics
anda fellowofthe
American
College
of
Heis
Prosthodontists.
currently
thedirectorof
Specialty
theAdvanced
Program
in
Education
Prosthodontics
at Loma
Schoolof
LindaUniversity
Dentistry.
Conftictof Interest
Nonereported
Disciosure:
oos,
Charles
J,Goodacre,
MsD,Ms,is a diplomate
Board
ofthe American
of Prosthodontics
andafettowofthe
College
of
American
Prosthodontists.
He
is currentlyprofessor
anddeanat LomaLinda
University
SchooIof
Dentistry.
Conflictoflnterest
Nonereported.
Disclosure;
NadimZ. Baba,ouo,
r"rso,
of
is a diplomate
theAmerican
Board
of Prosthodontics
anda fellowofthe
of
American
College
Heis
Prosthodontists.
currentlyprofessorof
Dentistryat
Restorative
LomaLindaUniversity
Schoolof Dentistry.
Conflictof lnterest
Disclosure;
Nonereported,
completedentures,the CAD/CAM
manufacturing systemsusea two-appointmenttechnique
computer-aided
(CAD/CAM)technologyhas
wherebyimpressions,interocclusal
recordsand tooth selectioncanbe
beenusedfor the fabrication
completedin one appointment,The
of inlays,crowns,fixedpartial
dentures,implant abutments/prostheses denturesare then fabricatedusing CAD/
CAM technologyand placedat the second
CAD
and maxillofacialprostheses.
appointment.
softwarerendersthe geometricalshape
TheCAD/CAMprocessoffers
of an object.CAM softwaredirectsthe
significant advantagesto the dental
fabricationprocess.
it
practitioner
and the patient,Because
Recently,CAD/CAM technology
data
possible
to
record
all
the
clinical
is
has becomecommerciallyavaiiablefor
in one appointment(oneto two hours),
fabricationof completedenturesthrough
chair time is reducedconsiderably,thereby
the lntroductionof AvaDentdigital
(Global
providing
the opportunity for a more
dentures
DentalScienceLLC,
set of appropriatelyaccurate
cost-effective
Ariz.) and the DentcaCAD/
Scottsdale,
(Dentca
A repositoryof
complete
dentures.
Inc.,
Los
Angeles).
CAM system
remains
availablethat allows
process
digital
data
Insteadof a five-appointment
for more rapidfabricationof a spare
usedwith conventionallvfabricated
n m n r r i c r - e i re lr qpersl
ru cl ^J 1"5i 1- 1-
a"r-r ru l
- , u r . rzro r s 4 0 7
( D A
J O I ] R N A I ,
V O I
4 I ,
N O 6
F l G UR E 1 . A v a D e n t s t a f t e r k i t
F I c U R E 2. Puttycast cfeatedby adaptationto the old
m a x i l l a rcyl e n t u r e .
F I GU RE g. Selected
AvaDent
stockhayandmaxillary
puttycast.
: ,
i , ' l ' ;
Theprocedurestartswith fabrication
of a putt.ycastformed by pressingmixed
poly(viny1siloxane)putty into the
i n t a g l i os r - r r f a o
ce
f t h e p a r i e n t 'esx i s L i n g
dentures(rrcunez). If thesedentures
areunacceptable
or unavailable,
then
Lechrrologyfor fabricating complefe
diagnosfic
castscanbc generated
from a
dentures becomes commercially available,
prelimirraryimpression.
jt will be possibleto scan the denture base
F r c u R3Es h o w st h e t h e r m o p l a s t i c
morphology and tooth positions recorded tray selcct.ion
for the maxillaryarch.
with this technique and impor:t those data
T h et r a yi s s o f r e n e db y i m n r e r s i n igt i n
into a virtual tooth arrangement program
a waterbath set at Bo' C (r7o' F) for
where teeth can be articulated and then
approximatelyone minute and adapting
c x p o r i t h e d a t a [ o a m i l l i n g d e v i c ef o r t h e
the tray to the putty castby pressingthe
fabrlcation of the complete dentures."
materiaIinto contactwith the castor
W i t h t h e j n t r o d u c t i o no f c o m m c r c i a l l y
stretchingthe materialto coverrequired
a v a j l a b l eC A D / C A M d e n t u r es y s f e m s
areas.Theaclaptedtrayscan then be
such as AvaDent and Dentca, the era of
adjustecl
r-rsing
acrylicresinburs to
digital complete dentures has arrived. The
removeoverextended
areas.
purpose of this article is to describethe
After:the trayshavebeenadapted
procedures associatedwith the AvaDent
on the putty cast,theyareplacedin the
and Dentca systems.
patient'smouth to determineif thereare
areasof overextensionor underextension
and adjustmentsaremadeas needed.It is
The AvaDent digital denLureprocess
lmpor:tantthat the maxillarytray extends
involves the following two appolnrments:
posteriorlyto coverthe areaof the
r. Impressions, jaw relation records,
vibratingline and the pterygomaxillary
occlusalplane orientatlon, tooth mold
fissures(hamularnotches).It is als<;
and shade selectlon and maxillary anterior
importar:rtthat the mandibulartray cover
tooth positioning record; and
the retromolarpads,the buccalshelves
z. Placement of the dentures.
and availableareasof the lateralthroat
form (retromylohyoidarea).Coverage
of
: '
the appropriate
maxillaryareasrequires
TheAvaDentsystemincludes
a kit of
determiningthe locationof the vibrating
all the required materials and devices to
line by havingthe patientpronounce
complete the two-appointment clinical
the word"aah"or by coughingand by
p r o c e s s( r r c u n er ) .
palpationof the distalaspectof the
C D A . ] O U R N A L ,V O L 4 ] , N O 6
F I c U RE 6. MandibularA[y'D
plateand
withtracing
maxitlarv
AMDwithstvlus,
F I GU RE S, Maxillary
AMDshowing
wrench
usedto move
theadjustable
lipsupport
flange,
F I GU RE 4. Maxillaryand
mandibulardefinitive
impressions,
Jaw Relq.tionRecords
TheAvaDentdenturetechniqueuses
an anatomicalmeasuringdevice(AMD)
that canbe adjustedto the desired
occlusalverticaldimension(OVD)and
then usedto maintain that dimension
while centricrelationis recordedusingthe
incorporatedgothicarchtracingplateand
stylus.TheAMD is alsousedto determine
the correctamount of upperlip support,
the position of the maxillarysix anterior
teeth and the desiredmediolateral
orientationof the occlusalplane.The
AMD consistsof a maxillarytray with a
centrallylocatedadjustablestylusand an
adjustablelip supportflange(rrcunr s)
and a mandibular tray with a flat occlusai
tracingplate(rrcunee). In addition,there
is an occlusalplaneorientationruler that
canbe insertedinto the maxillaryAMD
and usedto recordthe alignmentof the
maxillary AMD with the interpupillary
Iine so that the computerprogramwill be
ableto align the maxillary teeth with the
inl-prnr rnill errr linp
{ I)i
Fl c URE 7. N4axillafyAf4
hD
lleclwith
recofdingmalerial.
F I G U R E 8 . M a x i l l a rayn dn a n d i b u l aAr M Dp l a c e cf a
l i rl y
p a ra l l e {t o e a c ho t h e L
FIGURE
F T G U R El o . O c c l u s a l v e r t i c a l c l i n e n s i o n b e i n q a d i u s t e d .
10trltilil
1 l . Gothicarchrecorcling
F I c U R E l 2 . S t y l u s s e a t e c lt ihne r e c e s s c r e a t e d
t haet a p e x
o f t h e g o t h i ca r c hr e c o r c l i n g .
F I c U R E 1 4 . D e t e r n r i n i nt hgea p p ro p r i a l eo c c l u s apll a n e
w il h A v a D c nol r i { l n t a t i ornu l e r .
F I G U R E 1 3 . A v a l J e nrtu l e rl l e i n ga t t a c h e dt o t h e
n r a x i l l a rAy M D .
F I c U R E 1 6 . D e t e r n r i n i ni ngc i s a l - c e r v i lcearlr g t h
of clenlure
t o c t hu s i n go l dc l e n t u r e . a
r sg u i c l e .
0.ffi0
F l c U R E 1 5 . T c e t hs e l e c t i o n r o k lt a b s
f o o l l t l e m r l l , r t ' c sn n l l r l n x i s f i n o d p r r l r r r o
t h c m i d l j n er n d s r r r i l cl i n c m a r k i r r g as n d
placeclin the exact location where ther
denture teeth should be arranged. The
l e s i n i s f- -h' " e
. , 'n
b , 'l-r p l r tn o l v m c r i z e d
to afltx
L h ct e m p l a t ei n p o s i t i o n( r r c u n er z ) .
T h eo l i e n f a t i t - r o
n f f h e t e m p l a t ei s t h c n
assessedduring talking and smiling.
F I c U R E 1 7 . L u l i n g s e l e c t e r l t a b w iftl ho w a l l l e
light-cured
c D m p o s i tree s i n .
F l G U R E l S . l n j e c t i n g r e c o r i l i n g n a tteorci a p
l ture
c e n l r i cf e l a t i o n .
s o i l f l o w s ; t r o u n d r h e L r , r c i n gl r l . r f e
, . , r - r . . r , , .-r.r .r u. r rrr;1 -1 *r r 1r /, . c.r L. l . r c l t eLsh e
rnrrillrr',
l l l v l u
l n p e fh e r . T l r e r n r p r o r r l r r s l lr e c o r d
_.-b.
''r'_'
r"sc'rrhlv
is then remnrgd
1nd
i' n
' ' s" nr _c ._l _p _d ' ' l , r e o n F i r m t h a t r h e s t r i l r r ci c
4ll
F I c U R E 1 9 . J a w i e l a t i o n r c ( : o r c l w i t htranl or l c l
l' /l
l)L
it f l: r
\ / ri
it r, r
F I G U R E 2 1 . V i fl ! . r l t e e t ha rI a n g e n r e nl ttyA v a D e nst y s l e n r
F I G U R E 2 O . D o t e r m i n i n g v i r t L rlahlel y
b o r c l e rosl ' l h en r a x i l l a rcyo n t p l e l ce l e n l uer
'r
F T G U R E 2 3 . D c n l l r f too o t h p l a c e c tl hi ne m i l l e c l r e c e s s .
Flt!URE 22. lvlilleclAvaDentclenturoltase
F I G U R E 2 4 . A v a D e nwt a xt r - i adl c n t u0r
F I c U R E 2 6 . C o m p o s i t e r e s i n a d d et fcilat o
l c l e n t L r r e t e e t h F I G U R E 2 7 , D e l i n i t i v e A v a D e n t c l i g i t a l c l e fnat bu r iec a t e c l
c r e a t r n ng a t u r aal p p e aar n c e. r n da p p r o p r i a tvei s i b i l i t oy f
reseillllingtlte nrodifiedtrial denture.
F I c U R E 2 5 . A v a D e n t f e s i n t r i a l c l e n t i r r e ( c l i f f e r e n t p a t i eannt jt e r i o tre e t ho n n o d i f i e csl i d e .
rrirr
The con-rpanyprocessesthe
impressior-rand the AN4D so they can
be more easily recorded during the
l a s e r s c a n n i n gp r o c e s s .L a s e rs c a n so f
the complete arch impressions and the
connected AMD trays are made and
the morpl-rologicdata merged so as to
establish the occlusalrelationship of
C D A J O U R N A L ,V O L 4 ] , N O 6
A p p o i n t m e n1t w o
Plar.ement
Theplacementand postplacement
adjustmentsof CAD/CAMcomplete
denLures
aresimilarto the placement
of conventionaldentures.Because
the
denturebaseis madefrom a traditional
resinmaterial,implant attachments,if any,
asin the patient situation illustrated,can
be pickedup intraorallyusing conventional
'
I'r i uL PIutentent Oytt.io
rts
techniques.
FrcuRE
28 showsthe frontal
Cl.inicianscan requesta wax trial
smileview of a patient wearinga maxillary
denturethat hasa CAD/CAM milled base completedentureand a mandibular
with the dentureteeth set in wax so they
implant overdenturefabricatedby the
canbe repositionedasneeded(r rc u ne
AvaDentdigitaldenturesystem.The
za).Another trial dentureoption is to
patientis seenasneededfor routine
requesta tooth-coloredstereolithographic follow-up and maintenanceappointments.
trial denture that canbe modified by
reshapingthe teeth or addingcomposite
DentcaTechniqueAppointment0ne
resinto guidein fabricationof the
TheDentcasystemprovidesa starter
(rrcunes2s, 26 AND kit aswell that includesa small,medium,
definitiveprosthesis
zz). Thisstereoiithographic
trial denture
largeand extralargeset of stocktraysin
canalsobe usedfor diagnosticpurposes
additionto a lip ruler.
to determineif a fixedimplant prosthesis
(fixedcompleiedenture)will provide
Customiziny,
St ock' I r ctys
adequatelip support or the denture flange
Both maxillaryand mandibular
supportprovidedby an overdentureis
Dentcastocktraysaretwo-piecetrayswith
needed.It canalsobe convertedto a
posteriorsegments(rrcunezs).
detachable
surgicaltemplate for implant placement.
Theappropriatelysizedmaxillaryand
mandibularstocktraysareselectedbased
on the patient'sarchsize.TheDentcatrays
areusedfor both the definitiveimpression
and alsofor the jaw relationrecordsby
sectioningthe completearchimpression,
removingthe posteriorsegmentsand then
attachinga gothicarchdevice.
Thechosentraysareplacedin the
patient's mouth to evaluatethem for areas
of overextension
or underextensionand
adjustmentsaremadeasneeded.
NIaking Mtrxi llar y anri M andibulttr
I) efini t ive I rnpressions
The trays are painted with an adhesive
and a heavy-bodypoly(vinyl siloxane)
impressionmaterialusedfor the border
molding.Definitiveimpressionsof the
maxillary and mandibular archesare made
using a light-body poly(vinyl siloxane)
impressionmaterial(rrcuneao).Thearea
of the posteriorpalatalsealis identified,
marked and then transferredto the
impressionin the conventionalmanner.
,law RelationRecords
In preparationfor the jaw relation
records,a No. r5 surgicalbladeis used
to slicethrough the poly(vinyl siloxane)
impressionmaterialon both the maxlllary
; u N ez o r a 4 1 3
CDA JOURNAL
vt)L
.Il. No6
FrcuRE32. Separated
m a x i l l aar n
y dm a n d i b u l a r
impressions.
F I c U R E 3 4. Dentcaimpressions
with the recording
assemblyat the appropriateOVD,
Ft c U RE 3s. Dentcajawrelationrecord.
and mandibularimpressionso as to
producea singleincisionline to detach
the poster:iorpart(s)from the anterior
part(s)(rrcunear).Careshouldbe taken
duringthe separarion
of the partsto
avoidbreakageor distortion of the trays.
Carefuland intermittent wigglingand
pulling motions arerecommendedto
achieve
appropriate
(rrcuneaz).
separation
Excess
impression
materialcovering
the occlusalsurfaceof the maxillarytray is
carefullyremovedto revealthe flat occlusal
tracingplatethat is incorporatedinto
the maxillarytray.An adjustablestylusis
carefullyinsertedinto slotslocatedin the
lingualsurfaceof the mandibulartray (rrcune
as).A clearclickingsoundis heardwhen the
srylusassembly
is correctlypositioned.
Theanteriorparts of the maxillaryand
mandibularimpressionsarethen inserted
in the patient'smouth and confirmation
madethat the traysarestableprior to
any recordmaking.Theocclusalvertical
dimensionis determinedin the usual
mannerand adjustmentsaremadeto
the mandibularstylusasneeded.If the
414 ruNr::or:
existingdenturesprovidean appropriate
occlusalverticaldimension,they can
be usedto recordthe distancebetween
selectedmarks(points)on the facewhen
the denturesarein occlusalcontact.When
finalizingthe occlusalverticaldimension,
the mandibularstylusshouldcontactthe
maxillarytracingplate(rrcuneaa).
Recordingcentricrelationis
accomplished
by makingan intraoralgothic
archtracingby havingthe mandibularstylus
scribelineson themaxillarytracingplate.
Because
the maxillaryplateis very smooth
andhighlypolished,the mandibularstylus
mightnot produceclearmarkingson the
rnaxillaryplatewhenjaw movementsare
rnade.Therefore,
it maybe necessary
to place
a markingmediumon the tracingplateby
sprayingthe piatewith an aerosolmarking
mediumor rubbingarticulatingpaperover
Lhesurfaceandtransferringthepigment
from the paperto the plate.Thegothicarch
tracingis madein the usualmanner.
A recess
is then madein the maxillary
tracingplaieat the apexof the gothicarch
arrowpointthat approximatesthe tip
C D N J O U R N A L ,
V O L
4 I ,
N O 6
F I G U R E3 7 . V I U A I
maxillary
andmandibular
edentulous
ridges
and
teetharrangement
by
3040=
F I c U RE 3 6. Ruler
usedto measure
length
of upperlip.
A s d e n t i s t so n d b u s i n e s sp r o f e s s i o n o l sw,e u n d e r s t o n dt h e
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