CLINICAL RESEARCH

Evaluation of removable partial denture frameworks fabricated

using 3 different techniques
Irving Tregerman, DDS,a Walter Renne, DMD,b Abigail Kelly, MS,c and Dalton Wilson, DDSd

ABSTRACT
Statement of problem. Rapid advancements in computer-aided design and computer-aided manufacturing (CAD-CAM) have opened new
pathways in the fabrication of removable partial dentures (RPDs) through additive and subtractive processes. Questions remain whether the
digital pathway is an acceptable one compared with conventional analog or combined analog and digital pathways.
Purpose. The purpose of this clinical study was to determine the quality of RPD frameworks fabricated using 3 different fabrication methods:
analog, combined analog-digital, and digital.
Material and methods. Three RPD frameworks were fabricated for each of the 9 participants using each of the 3 techniques. Of the 9
participants enrolled, 4 were of Kennedy class I, 3 were of Kennedy class II, and 2 were of Kennedy class III. The first technique was completely
analog: a physical impression was made using polyvinyl siloxane, stone casts were made, a survey was performed, and a laboratory technician
waxed and cast the RPD framework. The combined analog-digital workflow had the analog steps, but the stone cast was scanned with a
laboratory scanner to generate a digital cast. The 3Shape CAD software was then used to design a digital RPD, which was fabricated from
a cobalt-chroumum alloy by selective laser melting. The third technique was completely digital: an intraoral digital scanner was used to
make a definitive scan, which was sent to the 3Shape software for digitally designing the RPD framework and subsequent selective laser
melting for fabrication. For all frameworks in the same participant, the same design was used for consistency. The evaluation consisted of
a yes/no survey with 7 framework-related parameters and was completed by 5 clinicians. For statistics, an overall P value was calculated
using a chi-squared test to determine any difference among the groups (a=.05).
Results. Seven of the 9 participants received the framework fabricated using the digital pathway as their definitive prosthesis. The completely
digital method was significantly better than the traditional method of analog fabrication (P<.001). Intraoral scanning was also significantly
better than the combined method of fabrication (P<.001). The completely analog method was better than the combined method of
framework fabrication (P=.008).
Conclusions. Within the limitations of this clinical study, it was concluded that the combined analog-digital pathway of RPD fabrication was
the least clinically acceptable one as determined by 5 calibrated clinicians using a yes/no questionnaire, whereas the completely digital
method of fabrication was found to be the best. (J Prosthet Dent 2018;-:---)

Rapid advancements in computer-aided design and Exocad, have recently become available for 3D
computer-aided manufacturing (CAD-CAM) have designing of RPD frameworks.2
opened new pathways in the fabrication of remov- Once digitally designed, different pathways exist for
able partial denture (RPD) frameworks through ad- the fabrication of the RPD framework. The typical digital
ditive and subtractive processes.1 To produce a workflow includes obtaining a digital model of the oral
digital file that can be milled or 3D printed, so- hard and soft tissues. This can be accomplished directly
phisticated 3D dental modeling software programs from an intraoral digital scan or from a laboratory digital
have been used. Several commercial CAD software scan of a stone cast. Second, the path of insertion is
systems, including 3Shape Dental System and defined, and undercuts are color coded based on the

a
Assistant Professor, Department of Oral Rehabilitation, College of Dental Medicine, Medical University of South Carolina, Charleston, SC.
b
Professor, Department of Oral Rehabilitation, College of Dental Medicine, Medical University of South Carolina, Charleston, SC.
c
Instructor, Department of Public Health Sciences, Medical University of South Carolina College of Dental Medicine, Charleston, SC.
d
Assistant Professor, Department of Oral Rehabilitation, College of Dental Medicine, Medical University of South Carolina, Charleston, SC.

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prostheses. Recently, SLM has been shown to produce

Clinical Implications clinically acceptable RPD frameworks.2 Furthermore,
The digital pathway for removable partial denture these SLM Co-Cr alloy frameworks are considered to
have better microstructure and mechanical properties
framework fabrication is a viable alternative to
than cast or milled RPD frameworks.10
analog techniques.
These digital design and manufacturing workflows on
the laboratory side can be combined with digital definitive
scans on the clinical side for an all-digital workflow. The
depth. Subsequently, the virtual block-outs are auto- literature is mixed regarding the accuracy of complete-arch
matically calculated and displayed on the virtual cast. The and edentulous digital scans.11-19 Recently, digital scans
retention grid and major connector are designed, fol- have been shown to have significantly better trueness than
lowed by the rests and clasps.2 physical impressions for edentulous arches.11 Trueness is a
After the design is completed, the software will digi- measure of how close the scan is to reality and is defined as
tally export the designed RPD framework in the form of a the measurement bias or systematic error between the
stereolithography (SLA) file. The SLA file can be used for reference object and the target object.20 In general, the
the additive or subtractive manufacturing of the RPD literature suggests that digital scans have the same accu-
framework.2 Depending on the manufacturing process, a racy as conventional impressions when they are used for
definitive prosthesis can be made directly from the digital hard tissues.12-15
design or from an intermediate product in the form of a In contrast, some studies have concluded that eden-
resin-elimination pattern which will subsequently be tulous tissue scanning is difficult and lacks the accuracy
invested and cast.3-6 These new digital workflows may be of hard-tissue scanning.16,18 However, high accuracy may
beneficial compared with the traditional process of not be as critical in edentulous areas as the soft tissues
waxing and investing, where wax pattern distortion and have been reported to depress up to 300 mm beneath the
refractory cast distortion may lead to poorly fitting distal extension of an RPD.16 A recent study reported that
castings.7,8 the median value of trueness for edentulous areas was 54
Although dentistry has had a long association with to 180 mm and the precision was 109 to 215 mm.11 This
subtractive manufacturing such as milling, 3D printing trueness is consistent with that of other studies reporting
has opened new possibilities of manufacturing which are on complete-arch scan accuracy.19
impossible with subtractive manufacturing.4 Additive The scan pattern affects the accuracy of intraoral
manufacturing 3D printing techniques include SLA, digital scans and can lead to a wide discrepancy in pre-
digital light projection (DLP), jet printing, fused deposi- cision.21 In addition, the scanner type used can also lead
tion modeling (FDM), and selective laser melting (SLM).9 to varying levels of trueness and precision, with some
The SLA technique uses ultraviolet (UV) lasers for scanners performing better than others.17 For this reason,
polymerization of photosensitive resin materials in small many clinicians are more comfortable with analog
layer thicknesses ranging from 10 mm to 100 mm impression techniques. The laboratory may choose to
depending on the accuracy desired. This technique is convert the physical stone cast or analog impression into
used to manufacture a wide variety of objects, including a digital cast using a laboratory scanner. These scanners
dental casts, resin wax patterns, resin RPD frameworks, are remarkably accurate.17,21
interim restorations, removable denture-base material, The purpose of this study was to evaluate the clinical
denture teeth, and surgical guides.4-6 DLP has a similar fit of RPD frameworks produced by 3 manufacturing
accuracy and range of uses but is a much faster tech- pathways: analog, combined analog-digital, and digital.
nology and can polymerize an entire layer in 1 pulse. The null hypothesis was that no difference would be
Postprint polymerization is used for both DLP and SLA found in clinical acceptability as determined by 5 cali-
with a light-emitting diode UV light source to ensure brated clinicians using a yes/no questionnaire.
complete polymerization and biocompatibility.4,5
Jet printing uses a series of resin-jet print heads from
MATERIAL AND METHODS
which thin streams of resin material are jetted onto the
build platform to create each incremental layer. Each The appropriate institutional review board approval was
jetted layer is then polymerized using a UV light source. obtained, and 9 participants were randomly selected to
Finally, SLM is a technique that melts metal powders participate in this clinical study. Simple random sampling
using high-power lasers which results in fusion of the was used to select individuals from a list of potential
powder particles into a solid layer. This technique can be participants using a table of random numbers. Three RPD
used to print titanium and cobalt-chromium alloy (Co- frameworks were fabricated for each of the 9 participants
Cr) for RPD frameworks.4,5 Laboratories can use these using each of the 3 techniques, labeled 1 to 3 (Fig. 1). Of
additive techniques to fabricate removable dental the 9 participants selected, 4 were of Kennedy class I (all

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Figure 1. Experimental design with 3 workflows compared in graphical form. SLM, selective laser melting.

mandibular), 3 were of Kennedy class II (2 mandibular Table 1. Criteria used to clinically evaluate removable dental prosthesis
and 1 maxillary), and 2 were of Kennedy class III (all frameworks
maxillary). The first technique was completely analog: a All rests are fully seated as prepared and designed. No Yes/no
discernable difference between tooth and metal rests.
physical impression was made using polyvinyl siloxane
All guide plates contact proximal tooth surfaces. Yes/no
(Extrude; Kerr Corp), and a stone cast was poured using No detectable rock on major connector except on Kennedy Yes/no
Type IV stone (Silky-Rock; Whip Mix Corp). In an class I and Kennedy class II due to tissue stop.
edentulous area, border molding was first accomplished Circumferential clasp has continuous contact around the Yes/no
abutment tooth.
using a green modeling plastic impression compound
I-Bar has contact from depth of undercut to height of Yes/no
(Green Stick Compound; Kerr Corp). The impression and contour.
stone cast were evaluated critically to ensure quality. The Lingual plating has no discernible space between teeth and Yes/no
stone cast was surveyed (Ney Surveyor; Dentsply framework.
Sirona), and the framework pattern, identical to the No detectable opening from periphery of the major Yes/no
connector to soft tissue.
pattern design for the other pathways, was hand drawn
using a red pencil (#65045 Red/Blue; Charles Leonard,
Inc). A laboratory technician waxed an RPD framework SC, to be selective laser melted in Co-Cr alloy (EOS
using the design, invested it, and cast it in Co-Cr alloy CobaltChrome SP2; EOS GmbH).
(Vitallium 2000; Dentsply Sirona). The third technique was the completely digital
The second technique was a combined analog-digital pathway, in which an intraoral digital scan was used
technique, in which a physical definitive impression was (3Shape TRIOS III; 3Shape) to make a definitive scan,
made and a stone cast was fabricated as before. The which was then uploaded to the CAD software (Dental
stone cast was then scanned using a laboratory scanner System 2016 Premium; 3Shape) for digitally designing
(D800; 3Shape) to generate a digital model. The 3Shape the RPD framework. For all RPD frameworks in the same
CAD software was used to design a digital RPD (Dental participant, the same design was used for consistency.
System 2016 Premium; 3Shape). The digital RPD design Furthermore, the same laboratory technician fabricated
was then sent to the Sherer Dental Laboratory, Rock Hill, all the RPD frameworks. The digital RPD framework was

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Table 2. Results from clinical evaluation forms

Results
Participant No. Arch Treated RPD Class Digital Analog-Digital Analog Delivered
1 Mandibular I Modification 1 35 yes 35 no 35 no Intraoral
2 Mandibular II Modification 1 35 yes 33 no, 2 yes 33 no, 2 yes Intraoral
3 Mandibular I 35 yes 35 no 35 no Intraoral
4 Mandibular II Modification 1 35 yes 33 yes, 32 no 33 yes, 32 no Intraoral
5 Maxillary III 32 yes, 3 no 35 no 33 yes, 2 no Traditional
6 Maxillary III Modification 1 35 yes 28 yes, 7 no 28 yes, 7 no Intraoral
7 Mandibular I 35 yes 33 yes, 2 no 33 yes, 2 no Intraoral
8 Mandibular I 35 yes 35 yes 30 yes, 5 no Intraoral
9 Maxillary II Modificiation 2 35 yes 35 yes 30 yes, 5 no Combined

RPD, removable partial denture.

then exported and sent to be SLM-formed in Co-Cr alloy was better than the analog-digital method of framework
(EOS CobaltChrome SP2; EOS GmbH). Only the arches fabrication (P<.001). No differences existed among the
that were to have RPD frameworks fabricated were Kennedy classifications (P>.05). Seven of the 9 partici-
scanned. pants received the framework fabricated using the digital
Five clinicians, 3 prosthodontists and 2 general den- pathway as their definitive prosthesis.
tists, were calibrated for participation. The examining
clinicians were calibrated in several sessions that DISCUSSION
reviewed ideal RPD framework fit, with several examples
The null hypothesis was rejected as differences existed in
seated on partially edentulous casts that had areas of fit
the survey results regarding the fit of the RPD frame-
and misfit corresponding to the survey.
works fabricated with the 3 different pathways. RPD
The Cohen Kappa was computed to compare all
frameworks can be considered the ultimate test of ac-
raters with each other individually. The Cohen Kappa
curacy for a pathway because they involve both hard and
metric was equal to 1 for almost all rater comparisons, a
soft tissues. A rigid prosthesis is fabricated which con-
near-perfect agreement, showing that the raters were
tacts considerable surface area where small errors can
correctly calibrated to find the same results. During the
lead to significant discrepancies in fit. It is not surprising
RPD framework evaluation appointment, each calibrated
that the completely digital pathway of framework fabri-
clinician evaluated the framework using the criteria
cation using intraoral digital scans was considered to
shown in Table 1. Only the initial fit was evaluated with
produce a better fitting RPD framework, with 7 of the 9
no adjustments. To decrease the selection bias, 3 casts for
patients receiving the framework fabricated by this
each patient were placed in a numbered cup so that the
method. Recent studies have reported that intraoral
evaluators could not determine the method of fabrica-
digital scans have similar or better trueness, precision,
tion. All frameworks were polished, and the examining
and prosthetic quality than conventional techniques.11-15
clinicians were instructed to place the RPD frameworks in
Intraoral scans have better clinical success and accu-
the mouth without looking at the intaglio surfaces to
racy than traditional impressions.21-23 The 3Shape TRIOS
avoid bias from the visible 3D-printed layers. The overall
III scanner was used in this study and has been shown to
best fit was then determined by each evaluator, and that
have a complete-arch scan accuracy of approximately 52
RPD framework was ultimately used for the definitive
mm.24
processing and delivery of the prosthesis to the patient.
Surprisingly, in this study, the analog technique was
For statistical analysis, an overall P value was calcu-
found to be better than the analog-digital pathway of
lated using a statistical software program (IBM SPSS
fabrication. One potential reason is the compounding of
Statistics, v25; IBM Corp) using a chi-square test to
errors in making a physical impression, pouring it into
determine any difference between the groups (a=.05).
the stone, and then scanning that into a digital cast.
These 3 steps have intrinsic errors that can compound
RESULTS
into a clinically detectable error in a rigid RPD frame-
Raw data are shown in Tables 2 and 3. The completely work. The error of the 3Shape D800 laboratory scanner is
digital method produced RPD frameworks with a approximately 50 mm, which compounds with the inac-
significantly better clinical fit than the analog method of curacy of a physical impression and stone cast.17
fabrication (P<.001). The digital method was also signif- As with any recently introduced technique, there is a
icantly better than the analog-digital method of frame- learning curve when transitioning from making physical
work fabrication (P<.001). The completely analog method impressions to digital scanning. Trying to obtain accurate

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Table 3. Results presented with rater information of the RPD frameworks fabricated from the digital
Clinical Evaluation of Metal Framework for RPDs pathway.
Question Rater Digital Analog-Digital Analog The study has limitations. The critical areas of RPD
1 1 8 yes, 1 no 4 yes, 5 no 4 yes, 5 no framework fit were around the hard tissues with limited
1 2 9 yes 3 yes, 6 no 4 yes, 5 no
soft-tissue contacts. Therefore, with only the tissue-
1 3 9 yes 3 yes, 6 no 3 yes, 6 no
stops on the framework to evaluate soft tissue accuracy, it
1 4 9 yes 4 yes, 5 no 4 yes, 5 no
is difficult to tell whether all areas of the tissue are
1 5 9 yes 4 yes, 5 no 5 yes, 4 no
accurately captured from just a framework evaluation.
2 1 9 yes 5 yes, 4 no 6 yes, 3 no
2 2 9 yes 5 yes, 4 no 6 yes, 3 no
The authors used a yes/no questionnaire rather than a
2 3 9 yes 5 yes, 4 no 6 yes, 3 no
Likert scale because of the difficulty in calibrating 5
2 4 9 yes 5 yes, 4 no 6 yes, 3 no different clinicians on a Likert-type scale. However, a
2 5 9 yes 5 yes, 4 no 6 yes, 3 no Likert scale would have provided more information.
3 1 8 yes, 1 no 4 yes, 5 no 4 yes, 5 no
3 2 9 yes 4 yes, 5 no 5 yes, 4 no CONCLUSIONS
3 3 9 yes 4 yes, 5 no 5 yes, 4 no
Within the limitations of this clinical study, the following
3 4 9 yes 5 yes, 4 no 6 yes, 3 no
3 5 9 yes 5 yes, 4 no 6 yes, 3 no
conclusions were drawn:
4 1 9 yes 5 yes, 4 no 6 yes, 3 no 1. The digital method of RPD framework fabrication
4 2 9 yes 5 yes, 4 no 6 yes, 3 no was significantly better than the analog method of
4 3 9 yes 5 yes, 4 no 6 yes, 3 no
fabrication.
4 4 9 yes 5 yes, 4 no 6 yes, 3 no
2. The digital method was also significantly better than
4 5 9 yes 5 yes, 4 no 6 yes, 3 no
the analog-digital method of framework fabrication.
5 1 9 yes 5 yes, 4 no 6 yes, 3 no
3. The analog method was better than the analog-
5 2 9 yes 5 yes, 4 no 6 yes, 3 no
5 3 9 yes 5 yes, 4 no 6 yes, 3 no
digital method of framework fabrication.
5 4 9 yes 5 yes, 4 no 6 yes, 3 no
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THE JOURNAL OF PROSTHETIC DENTISTRY Tregerman et al