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Show Your Work: Bytes Create Bites by Dr. Steven Glassman and Ryan Wagner

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With a completely digital workflow, patients can receive custom dentures in only three office visits instead of the traditional seven

by Dr. Steven Glassman and Ryan Wagner

A 65-year-old male patient (Fig. 1) presented needing his 10-year-old denture repaired because of a fractured #6 and #7. A thorough soft-tissue examination was performed and two treatment options were presented to the patient:
  • Repairing the existing denture with two new teeth in place of the fractured ones, which had been temporarily glued back onto the existing denture.
  • A newly fabricated set of complete dentures.
Digital Custom dentures
Fig. 1: Full-face photo with original denture. Fractured #6 and #7 were being temporarily retained by glue.


After the patient expressed concern about the number of appointments required to obtain a new set of dentures, the clinician clarified the steps in the era of digital dentures. Once the patient was informed about the efficient process requiring fewer appointments—three, on average, compared with the seven required for traditional nondigital treatment—he decided to opt for new dentures.


Treatment plan
The foundation of the treatment began with a holistic, facially driven treatment plan that emphasized how a custom digitally fabricated denture would fit the patient’s intraoral anatomy and simultaneously complement his overall personality.

As explained to the patient, the appointments would run as such: At the initial appointment, clinical photographs and measurements would be recorded, along with an intraoral scan using an iTero scanner. At the second, the patient could try a 3D-printed denture and comment on fit, aesthetics and preferences so the clinician could make adjustments. The third and final appointment would include the final denture delivery.


Appointment #1
During the first appointment, the aesthetics and tooth position of the existing denture were evaluated, and modifications to existing tooth placement were noted based on the shade of the teeth and gingiva and the location of the facial midline. Vertical dimension of occlusion was measured between the patient’s nose and chin using a Conmetior gauge. The rest position was evaluated, and the patient was guided into centric relation, where a standard 2–4 mm difference was observed between the two positions (Fig. 2). Speech and freeway space were evaluated by requesting the patient to pronounce words that contain fricative (“F”/“V”) sounds, such as “fifty-five” and “violin,” and sibilant (“S”) sounds, such as “sixty-six,” to assess maxillary incisor position in relation to the wet-dry line of the lower lip to dictate initial tooth placement.
Digital Custom dentures
Fig. 2: Anatomic landmark analysis of the patient’s facial midline, vertical dimension of occlusion, interpupillary distance, buccal corridor, facial thirds, fox plane, lip support, incisal length, overjet and overbite.

The first appointment also consisted of an iTero scan, which captured the intraoral anatomy of both the edentulous maxillary and mandibular ridges, as well as a 360-degree scan of the existing dentures in occlusion (Fig. 3).
Digital Custom dentures
Digital Custom dentures
Digital Custom dentures

Digital Custom dentures

Digital Custom dentures

Figs. 3a-e: Intraoral scans of denture reline (top), patient maxillary and mandibular ridges, and existing denture in occlusion.

Creating the 3D-printed try-in denture
The golden proportion was used when digitally designing the denture (Fig. 4) by first ensuring the midline was properly located. It was then followed up with dimensions of teeth within the aesthetic zone having a length-to-width ratio of approximately 1.2:1. Once tooth size was verified, the zenith locations of the anteriors were assessed, in addition to the incisal overjet and overbite in relation to the mandibular denture. Lip support and buccal corridor would be assessed at the denture try-in appointment to modify flare of the teeth as needed.
Digital Custom dentures
Fig. 4: Exocad design of new denture, using full-face digital metrics such as pupillary and midface lines to identify ideal aesthetics.


Appointments #2 and #3
At the second appointment, the patient was able to evaluate the 3D-printed try-in dentures firsthand (Figs. 5 and 6); the fit, aesthetic and any other requested modifications were noted and adjusted as needed. The patient said he felt like he was “showing too much teeth” with the try-in denture, indicating the anterior teeth were slightly longer than he preferred. This request was accounted for and corrected in Exocad Smile Creator software before final dentures were fabricated and delivered at the third appointment (Fig. 7).
Digital Custom dentures
Fig. 5a-b: 3D-printed dentures for try-in at second appointment.
Digital Custom dentures
 
Digital Custom dentures
Fig. 6: Try-in of 3D-printed dentures.
Digital Custom dentures
 
Digital Custom dentures
 
Digital Custom dentures
 
Fig. 7: Final denture delivered at third appointment.


Conclusion
The denture process is no longer constrained to the same time-consuming process patients once had to endure, involving a plethora of appointments and lengthy time commitments. Intraoral scanning, digital smile analysis and 3D printing offer tremendous patient convenience and clinical accuracy.

In this patient’s case, the treatment plan was accepted based on the convenience the digital process offered as it related to the number of appointments required. Additionally, the accuracy and precision of the denture meets patient expectations and is stored in the cloud so it can be accessed at any time for adjustments or general reference.

Author Bios
Dr. Steven Glassman A pioneer in digital scanning, Dr. Steven Glassman was one of the first users of the iTero digital scanner in the world and he continues to publish and lecture on comprehensive digital workflow. Glassman practices with his wife in the Lincoln Center area in New York City and focuses on cosmetic, implant and aligner therapy. He has been a member of the Align faculty since 2004.
Ryan Wagner Ryan Wagner is a fourth-year dental student at Indiana University School of Dentistry, where he is pursuing a career in cosmetic dentistry. Wagner has copublished dental case reports, conducted behavioral research and volunteered at local and international health clinics. He has honed his technical and interpersonal skills working at Dr. Glassman’s New York dental practice and is eager to join the wonderful profession of dentistry.
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