Virard et al.

BMC Oral Health (2018) 18:120

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CASE REPORT Open Access

Manufacturing of an immediate removable

partial denture with an intraoral scanner
and CAD-CAM technology: a case report
Francois Virard1,2,3, Laurent Venet2, Raphaël Richert2,3, Daniel Pfeffer4, Gilbert Viguié2,3, Alexandre Bienfait5,
Jean-Christophe Farges2,3,6 and Maxime Ducret2,3,6*

Abstract
Background: Incisor loss constitutes a strong aesthetic and psychologic traumatism for the patient and it remains a
challenging situation for the dental practitioner because of the necessity to rapidly replace the lacking tooth.
Various therapeutic procedures have been proposed to replace the incisor concerned, for example by using a
removable partial denture. However, the manufacturing of such a denture with classical procedures is often subject
to processing errors and inaccuracies. The computer-aided design and computer-aided manufacturing (CAD-CAM)
technology could represent a good alternative, but it is currently difficult because of the lack of dental softwares
able to design easily immediate removable partial dentures.
Case presentation: A 30-year- patient complained about pain caused by a horizontally and vertically mobile
maxillary right central incisor. After all options were presented, extraction of the traumatized incisor was decided
due to its very poor prognosis, and the patient selected the realization of a removable denture for economic
reasons. The present paper proposes an innovative procedure for immediate removable denture, based on the use
of an intraoral scanner, CAD with two different softwares used sequentially, and CAM with a 5-axis machine.
Conclusions: We show in this report that associating an intraoral scanner and CAD-CAM technology can be
extended to immediate dentures manufacturing, which could be a valuable procedure for dental practitioners and
laboratories, and also for patients.
Keywords: Computer-aided manufacturing, Computer-aided design, Intraoral scanner, Removable immediate partial denture

Background context or economic difficulties. Integration to the re-

In the case of anterior tooth loss, for example after movable dentures of the extracted natural tooth crown
trauma and/or infection, the rapid replacement of the or previous fixed prostheses have been proposed to over-
lacking tooth is a major challenge for dental practi- come those limitations [2, 3]. However, these approaches
tioners. Indeed, in addition to masticatory dysfunction, are subject to human processing errors and inaccuracies,
the absence of an anterior tooth is psychologically highly and additional time and cost.
traumatic for aesthetic reasons and greatly impairs the To avoid such drawbacks, digital workflow using
patient’s quality of life. In this clinical situation, immedi- computer-aided design and computer-aided manufactur-
ate placement of a dental implant or a cantilever bridge ing (CAD-CAM) technology may represent a suitable al-
can provide early aesthetic solutions [1]. However, the ternative. Indeed, the use of this technology has been
indications of these strategies can be limited by the gin- shown to improve the fitting and aesthetics of the pros-
gival biotype and its inflammation degree, the occlusal thesis while reducing costs and manufacturing difficul-
ties for the dental laboratory [4]. Numerous strategies
have been already described for manufacturing complete,
* Correspondence: [email protected]
2
Faculté d’Odontologie, Université de Lyon, Université Lyon 1, Lyon, France
metal or nonmetal clasp partial dentures with an
3
Service d’Odontologie, Hospices Civils de Lyon, Lyon, France intraoral scanner and a digital workflow [5, 6]. However,
Full list of author information is available at the end of the article

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Virard et al. BMC Oral Health (2018) 18:120 Page 2 of 6

issues still remain regarding use of these technologies of active infection. The dental radiograph of the incisor
for immediate partial dentures, due to the complexity to revealed periradicular bone loss (Fig. 1b).
match the size, shape and color of the artificial tooth to An early treatment was proposed to the patient to
those of the neighboring teeth in a patient smile. In manage the loose incisor. It involved the extraction of
addition, the lack of dental softwares able to design im- the traumatized incisor due to its very poor prognosis,
mediate removable partial dentures requires the devel- and then the immediate replacement of the lacking
opment of original procedures to extend the indications tooth with an artificial one. Several options were pro-
of digital dentistry [7, 8]. posed to the patient, including the placement of a dental
The purpose of the present paper is to describe the implant with a provisional crown, of a cantilever bridge,
clinical and technical steps of an original and rapid pro- or of a removable partial denture. All options were dis-
cedure for manufacturing an immediate removable par- cussed, and after a one week period of reflection the pa-
tial denture with an intraoral scanner, CAD with two tient finally selected the realization of a temporary
different softwares used sequentially, and CAM with a removable denture for economic reasons. The patient
5-axis machine. was informed that final prosthetic rehabilitation will be
initiated only after treatment of the periodontal disease
Case presentation and disappearance of tissue inflammation. Clinical and
A 30-year-old male patient presented for a consultation technical steps were summarized in a timeline
in the Prosthodontics department of the Lyon University (Additional file 1).
Hospital (France). The patient complained of a pain
caused by the mobility of his maxillary right central inci- Digital impression, color registration and tooth virtual
sor (11) (Fig. 1a). Patient history revealed a trauma with removal
luxation and periradicular infection of the tooth, as well To avoid the risk of extraction of the loose incisor that
as daily use of tobacco and cannabis. Clinical examin- could occur when taking an impression with alginate,
ation of the oral cavity indicated poor hygiene, dental we decided to make a digital impression of the patient’s
discolorations, moderate periodontal disease, and eden- maxillary and mandibular dental arches with an
tulous zones due to upper first premolar extractions. intraoral scanner (TRIOS 2; 3Shape Copenhagen,
The painful tooth was horizontally and vertically mobile Danemark) (Fig. 1c and d). Vestibular areas were
(more than 2 mm), partially extruded with vestibular scanned using lip and cheek retractors (Optragate, Ivo-
position and gingival inflammation, without local signs clar, France). Arches were then virtually aligned using

a b

c d e

Fig. 1 Initial situation. The patient consulted for a pain caused by the mobility of the maxillary right central incisor (a). An intraoral radiography
confirmed the partial extrusion of the tooth (b). A digital impression of the patient’s maxillary arches was made with an intraoral scanner (c and
d) and color registration was performed (e)

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Virard et al. BMC Oral Health (2018) 18:120 Page 3 of 6

two vestibular records, as recommended by the manu- Clasps were integrated into the denture base with autop-
facturer. Color registration was performed with the olymerisable resin (Probase, Ivoclar, France) (Fig. 3e).
Vivodent PE shade guide (Ivoclar, France) (Fig. 1e). Upon reception to the clinics (three weeks after digital
Arch digital impressions were converted into STL files impressions), the removable denture was cleaned, and
and imported in dental CAD software (DentalCad, Exo- finishing and polishing were checked.
cad, Germany) (Fig. 2a). The traumatized incisor was
then removed virtually (Fig. 2b, c and d).
Tooth extraction and denture try-in
Conception and manufacturing of the removable partial After oral disinfection with 0,5% chlorhexidine (Eludril
denture Pro, Pierre Fabre Oral Care, France), a local anesthesia
A virtual central incisor was generated from the was realized in the buccal and palatal oral mucosa next to
contralateral central incisor (21) by using the mirror tool the loose incisor. The latter was then extracted atraumati-
(Fig. 2e) and saved in an independent file. The latter was cally and hemostasis was realized by compress application
then imported into a second CAD software (Freeform, (Fig. 4a). After having controlled the formation of the ini-
3D Systems, US) and two small cylindrical volumes were tial clot, the immediate removable partial denture was po-
created into the palatal side of the virtual incisor to cre- sitioned into the mouth (Fig. 4b and c). No correction was
ate a retention area (Fig. 3a and b). In the same software, needed. The initial retention of the denture base was ex-
limits of the denture base were virtually designed by cellent. The patient reported no difficulty with mastication
using the point and click tool. The denture was gener- and expressed his great satisfaction for aesthetical appear-
ated with a volume (average thickness of 2.5 mm) ance of the prosthesis. Occlusal integration was checked
corresponding to a replica of the patient palatal surface to prevent any static or dynamic dysfunctional contacts.
(Fig. 3c and d). Data generated were then exported to a The form, volume and texture of the milled central incisor
5-axis milling machine (DWX 52 DC, Roland, Japan) was adequate. The tooth color was fine, although translu-
and the resin artificial incisor was made by milling a cency matching was difficult to obtain with a resin
stratified ivory disk of PolyMethylMethAcrylate stratified ivory disk. He was recalled after one week to as-
(PMMA) (Trilux, Vipi, Italy). The denture base was pro- sess wound healing and the patient tolerance to the imme-
duced from a disk of pink PMMA (Ivobase CAD, Ivoclar, diate prosthesis. Patient reported an excellent
France). The incisor was bonded onto the denture base aesthetic and occlusal integration (Fig. 4d). Healing
using an adhesive agent (Probase, Ivoclar, France). Two of the oral mucosa was confirmed by the closure of
metal clasps were manually designed and manufactured extraction socket and the non-inflammatory aspect of
on a model printed in parallel (ProJet 3500 HD, 3D Sys- the oral mucosa (Fig. 4e). There were no adverse and
tems, US) by using clap wires (Wironit, Bego, France). unanticipated events to report.

a b c

d e

Fig. 2 Virtual removal of the tooth. A digital impression of the maxillary arch was made and imported in the dental CAD software (a). The central
incisor to be extracted was then removed virtually from the working model with the cutting tool (b and c). After having closed the file hole (d), a
new virtual incisor was generated from the contralateral incisor (21) with the mirror tool (e). The new virtual working model and central incisor
were saved in independent files

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Virard et al. BMC Oral Health (2018) 18:120 Page 4 of 6

a b c

d e

Fig. 3 Conception and manufacturing of the immediate removable partial denture. Both files were imported into a second CAD software and two
cylindrical shapes were then subtracted from the palatal side of the artificial incisor to create a retention zone (a and b). The volume corresponding to
the denture base was generated as a replica of the patient palatal surfaces (c and d). The incisor and the denture base were independently milled, and
then were bonded together. Two metal clasps were manually integrated in the denture base with autopolymerisable resin (e)

Discussion and conclusions The realization of immediate removable partial den-

The objective of this article was to describe a digital tures is nowadays indicated in many clinical situations
workflow for manufacturing an immediate removable that need the placement of transitional prostheses or to
partial denture. After the digital impression was realized overcome financial limitations [4]. However, like all re-
with an intraoral scanner, the removable denture was de- movable dentures, immediate dentures present limita-
signed by using sequentially two CAD-CAM softwares, tions, such as human processing errors and inaccuracies
milled in the dental laboratory and immediately posi- during manufacturing, that require improving technolo-
tioned into the mouth after tooth extraction. To our best gies and/or procedures [4]. For example, during the first
knowledge, this report is the first one describing a strat- step of the treatment (i.e. the impression), tooth mobility
egy of immediate removable partial denture manufactur- is a source of anxiety for patients and dental practi-
ing associating an intraoral scanner and CAD-CAM tioners because of the risk of tooth extraction that exists
technology. during conventional impression taking. This risk has led

a b c

d e

Fig. 4 Tooth extraction and denture try-in. The loose central incisor was extracted atraumatically (a) and the immediate denture was placed
without any correction (b and c). The patient was recalled after one week to confirm the good functional and aesthetic integration of the
prosthesis (d) and to check oral mucosa wound healing (e)

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Virard et al. BMC Oral Health (2018) 18:120 Page 5 of 6

to the development of various alternative clinical proto- second for the conception of the denture. The use of the
cols/procedures. In the present paper, we used an intraoral intraoral scanner makes easier data acquisition in the
scanner to prevent tooth extraction during making the presence of a loose tooth compared to classical impres-
impression. Intraoral scanners have been reported to be sion taking. The present protocol is currently making
highly precise devices to register a full dental arch, more progress to propose applications for manufacturing lar-
precise than the alginate impression paste. Accordingly, ger immediate dentures.
digital impression has been associated with facial scans or
integrated in smile design protocols in several cases of Additional file
large aesthetic rehabilitations [9–12].
Laboratory steps for classical immediate denture con- Additional file 1: Timeline of events. Clinical and technical steps of the
ception are numerous and include cast pouring, articula- case report. (PPTX 39 kb)

tor mounting, teeth removing from the cast, and wax

conception. All of these steps are error-prone, and a Abbreviations
CAD: Computer-Aided Design; CAM: Computer-Aided Manufacturing;
diminution of their number is clearly warranted. In our PMMA: PolyMethylMethAcrylate
study, we increased the precision of the rehabilitation by
setting up an alternative protocol using milled resin. In- Availability of data and materials
deed, the latter offers a higher accuracy and reproduci- Data (pictures, radiographs and STL files) are available from the
corresponding author on request.
bility than the auto- and chemo-polymerisable resins
that are used for traditional manufacturing of removable Authors’ contributions
prostheses [13]. Indeed, during the traditional manufac- All authors made substantial contributions to the present study. FV, MD, DP
and AB contributed to the conception and design of the procedure. FV, MD,
turing process, dentures undergo, during polymerization, RR and JCF wrote and edited the manuscript. LV realized pictures. AB
a distortion ranging from 0.45 to 0.9% that decreases the performed denture milling. DP made available the intraoral scanner. GV
fitting of the denture base to the oral mucosa [14]. Such supervised the study and revised the manuscript before submission. All
authors read and approved the final manuscript.
distortion does not exist with the milling strategy.
Likewise, the porosity of the CAM milled denture is de- Ethics approval and consent to participate
creased, which reduces the risks of growth of microor- The patient was verbally informed and provided written consent for the digital
ganisms such as Candida albicans [14]. manufacturing of the immediate removable partial denture. Since the article is
a clinical case report, the ethics committee of the Hospices Civils de Lyon (Lyon
Removable dentures have to be designed as retentive Universitary Hospital) ruled that no formal ethics approval was required.
and stable as possible [15, 16]. We confirm in the
present paper that the milling process offers an excellent Consent for publication
Written informed institutional consent was obtained from the patient for the
fitting after the insertion of the immediate denture and, publication of personal details and accompanying images in this manuscript.
accordingly, a real satisfaction to the practitioner and
the patient [8, 17]. We decided nevertheless to add two Competing interests
clasps to the denture because the patient might conserve The authors declare that they have no competing interests in relation to the
present work.
this temporary denture for a long, unknown period, and
also to eliminate the risk that the patient swallows this
small-sized denture. Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
Interestingly, the digital workflow allows for keeping a published maps and institutional affiliations.
virtual backup of the situation that can be easily reached
Author details
in the case of future repair or reproduction that would 1
INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de recherche en
be needed if the prosthesis is fractured or lost [4, 8]. cancérologie de Lyon, Université Lyon 1, Lyon F-69373, France. 2Faculté
Joda et al. have demonstrated that CAD-CAM technol- d’Odontologie, Université de Lyon, Université Lyon 1, Lyon, France. 3Service
d’Odontologie, Hospices Civils de Lyon, Lyon, France. 4Laboratoire
ogy could be, in the dental implantology field, a time- Pfeffer-Corus, Dardilly, Lyon, France. 5Laboratoire Bienfait, Francheville, Lyon,
and cost-saving procedure for dental practitioners and France. 6Laboratoire de Biologie Tissulaire et Ingénierie thérapeutique,
laboratories, and also for patients [18]. Further investiga- UMR5305 CNRS/Université Lyon 1, UMS3444 BioSciences Gerland-Lyon Sud,
Lyon, France.
tions are warranted to determine if it could also be the
case for immediate partial dentures. Received: 28 January 2018 Accepted: 14 June 2018
Despite being a relatively nascent approach compared
to implantology, the use of digital workflow for immedi-
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