CLINICAL REPORT
Fabrication of a definitive obturator from a 3D cast with a chairside digital scanner for a patient with severe gag reflex: A clinical report Jimmy Londono, DDS,a Amara Abreu, DDS, MSD,b Philip S. Baker, DDS,c and Alan R. Furness, DMDd Gagging is a common problem ABSTRACT in dental procedures such as Patient gagging is a common problem during dental procedures such as maxillary impression maxillary impression making. making. This clinical report describes the use of a chairside intraoral scanner for a patient with a It is a natural reflex reaction hypersensitive gag reflex. The technique proved to be a more comfortable alternative for the paresulting from the stimulation tient and an accurate method for the clinician to capture both hard and soft tissue detail for the of certain intraoral structures.1 fabrication of a definitive obturator. (J Prosthet Dent 2015;-:---) Multiple conditions are assothat both intraoral scanning and cone-beam computed ciated with gagging, which is thought to have a multitomography scanning of alginate impressions are reliable factorial origin.2 The management of gagging depends on and valid in obtaining measurements for diagnostic its severity and causes, and multiple strategies have been purposes.10,11 Others have reported that the current gold reported to help dental patients deal with the problem, 3-5 standard for impression making, the physical impression, including the use of dental prostheses. Digital imcannot yet be fully replaced by the digital impression for pressions could be better tolerated by patients who gag restorative procedures.12 during impression making. Recently, a clinical report Digital technology has been difficult to integrate into described the use of an intraoral scanner (Cadent iTero; the fabrication of RPDPs. In a previous study,7 a definiAlign Technology) to capture hard and soft tissues in a tive cast was digitized and a 3-dimensional cast propassive state for the fabrication of a removable partial duced. A prototype RPDP was designed and created by dental prosthesis (RPDP). The information obtained was using digital software, and the resulting plastic pattern used to design and fabricate a trial resin framework, was invested, cast, and finished in the conventional which was later cast in a cobalt-chromium alloy. Good manner. Casting imperfections were observed and the soft tissue adaptation was reported.6 system proved costly. Computer-aided design and computer-aided manAnother study13 reported the digital fabrication of a ufacturing technology has been introduced over the last RPDP framework based on the scan of a definitive cast 10 years for the fabrication of removable partial dental made from a conventional impression. Design software prostheses6-8 and complete dentures.9 If applied as (FreeForm Software; SensAble Technologies) was used to intended, this technology facilitates the clinical dental survey the digital cast, identify the path of placement, procedures and reduces the length of appointments, provide adequate relief, and plan the design. The which benefits both the patient and the clinician. The framework was then printed from a cobalt-chromium accuracy of digitized impressions for alternative uses has alloy. However, because the framework alloy had not been widely investigated. Some authors have reported
a
Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. c Associate Professor and Program Director, Advanced Education Program in Prosthodontics, College of Dental Medicine, Georgia Regents University, Augusta, Ga. d Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. b
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
-
Issue
-
Figure 1. Pretreatment occlusal view of maxillary arch.
Figure 2. Articulated computer-aided design and computer-aided manufacturing casts produced from digital impression data.
been tested for toxicity, the framework was only used to evaluate the accuracy of the technology and was not used clinically. The purpose of this patient treatment report was to describe the use of a chairside intraoral digital scanner to record hard and soft tissues for the fabrication of a definitive obturator.
the patient. After completing tooth preparations and modifications for the metal framework, hard and soft tissue anatomy was captured with a chairside oral scanner (Lava Chairside Oral Scanner COS; 3M ESPE). During the scanning procedure, a high-resolution video camera captured hard and soft tissues within the focused area, which is a 3-dimensional box located a few millimeters from the surface of the camera lens. The total time for scanning was approximately 15 minutes. The scanned files were used to create a 3-dimensional polyurethane dental cast (In’Tech Dental; In’Tech Industries Inc) (Fig. 2). The digital impression of the maxillary arch did not include the defect area. The interim appliance was placed on the milled definitive cast and luted to it. Hard laboratory putty (Lab Putty Hard; Coltène/Whaledent) was adapted around the obturator bulb, including the bottom and sides of the definitive cast. Subsequently the interim appliance was carefully removed from the definitive cast. The putty material was coated with a separating medium, and the cast/putty combination was duplicated with a silicone duplicating material. A secondary stone cast was poured in the duplicating mold, obtaining a definitive cast adequate for 2 purposes: to fabricate a metal framework and to process a bulb which exactly duplicated the patient’s existing obturator, because it had been carefully adjusted for patient comfort and maximum function (Fig. 3). The defect area on the milled cast allowed precise placement of the internal finishing line for the interface of the metal framework and the acrylic bulb and the design of the retentive lattice in the most favorable position. The cast was blocked out and relieved, and a refractory cast was made to wax the framework. The completed framework was evaluated and fitted intraorally. Because of the large defect area and the patient’s objection to anterior retentive clasps for esthetic concerns, the obturator was designed as a hollow bulb
CLINICAL REPORT A 41-year-old African American man was referred from private practice for prosthodontic treatment at the Faculty Practice Clinic of the College of Dental Medicine, Georgia Regents University. The patient presented with a history of adenoid cystic carcinoma of the soft palate, surgically resected 5 months before consultation (Fig. 1). The patient was completely dentate except for a missing maxillary left second molar. His chief complaint included difficulty swallowing liquids and hypernasal speech. After clinical and radiographic evaluation to assess the patient’s chief complaint, an obturator was suggested as a treatment option. The patient exhibited an exaggerated gag reflex, as shown by multiple unsuccessful attempts to make a preliminary impression. In order to control the gagging, the systematic desensitization technique was used.14,15 The patient was instructed to gradually introduce a lollipop into the mouth and hold it until the gag reflex started. He was trained to do it several times a day, progressively increasing the amount of time holding it in the mouth. After 4 weeks of therapy, he was able to manage impression making without the gag reflex. An alginate impression with a stock tray was made for a preliminary cast, allowing for the fabrication of an interim acrylic resin obturator, in which the obturator bulb portion was built incrementally and adjusted. However, a digital impression was suggested as a more tolerable approach to making a definitive prosthesis for
THE JOURNAL OF PROSTHETIC DENTISTRY
Londono et al
-
2015
3
Figure 3. Lateral view of secondary stone cast showing demarcation between digitally generated cast and functionally generated bulb portion.
Figure 4. Anterior view of completed obturator on maxillary cast.
Figure 5. Close-up of right obturator framework on cast.
Figure 6. View of inserted prosthesis.
type.16 The framework was luted to the definitive cast, and wax was flowed around and over the retentive lattice area to ensure that the thickness of acrylic was adequate. A layer of liquid wax was also added into the remainder of the defect area, followed by a single thickness of baseplate wax. A 3 mm ledge was placed around the periphery of the palatal extent of the bulb. This would later allow the palatal lid to be reliably aligned and fixed into place. Laboratory putty (Coltène/Whaledent) was placed below the ledge and into the waxed defect to create the desired contour of the palatal side of the bulb. A single thickness of baseplate wax was then adapted over the putty. The 3-mm ledge was completely covered by the lid. This contoured piece of baseplate wax was then removed and set aside. The laboratory putty was carefully removed from the cast side of the waxed defect. The framework with the waxed bulb was then placed in an oversized flask (Atlas Giant Flask Model 44G; Handler Intl). The palatal lid portion was invested in a standard denture flask (Atlas Flask Model 44U; Handler Intl), and the 2 molds were boiled out, packed, and heat polymerized for 9 hours using conventional techniques. The framework with hollow bulb and the lid were deflasked
and finished. The fit of the lid onto the ledge in the bulb side was evaluated. Bonding agent (Triad Bonding Agent; Dentsply Intl, Inc) was applied to the internal edge of the lid and the ledge of the palatal bulb and light polymerized for 1 minute. A bead of light-polymerized gel (Clear Colorless Triad Gel Light Cure Material; Dentsply Intl) was placed around the entire periphery of the ledge. The lid was gently placed on the gel and pressed into position, ensuring the presence of a slight excess of gel around the entire periphery. The lid was then light polymerized into place. Final finishing and polishing of palatal side of hollow bulb obturator was completed. Figures 4 and 5 show the fit of the framework on the digital cast and the configuration of the obturator bulb. When the maxillary prosthesis was inserted (Fig. 6), pressure areas during head movements, speech, and swallowing were located with pressure indicator paste (Mizzy Inc) and relieved. The patient was instructed in oral hygiene measures, emphasizing specific care procedures for his new maxillary prosthesis. Postinsertion appointments were scheduled at intervals of 1 day, 1 week, 1 month, and 6 months after placement of the prosthesis. During this time, no problems were noted
Londono et al
THE JOURNAL OF PROSTHETIC DENTISTRY
4
regarding the patient’s oral and prosthetic hygiene. The patient was then placed on a 6-month recall. DISCUSSION The use of digital impressions to capture soft tissues has only been reported once and was used for the fabrication of a maxillary RPDP.6 The present treatment combined the advantages of this digital technology to overcome the problem of making a definitive impression in a patient with a hyperactive gag reflex with traditional methods for RPDP framework design and fabrication. The limitations of digital impressions include the cost of the intraoral scanner and the fact that they cannot capture the tissues in function but only in a passive state.17 In this treatment, it worked well because the edentulous area was limited to 1 tooth, and the defect area was captured from the existing interim obturator and adjusted intraorally. However, this might not be feasible in the presence of unilateral or bilateral distal extensions, in which allowance for tissue movement during function is critical. Movable tissue is adequately addressed with the traditional methods of a custom tray, border molding, and an elastomeric impression material, in conjunction with the altered cast procedure.18 Although this technique demonstrated that it was a suitable alternative for those patients who have problems tolerating certain dental procedures such as dental impressions, clinical studies should be carried out to fully explore the potential benefits offered by the use of digital technology in removable prosthodontics. SUMMARY Patient gagging is a common reaction during dental procedures such as maxillary impression making. In this clinical report, the use of a chairside intraoral scanner for a patient with a hypersensitive gag reflex proved to be a more comfortable alternative for the patient and allowed the clinician to accurately capture hard and soft tissue detail for the fabrication of a definitive obturator.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
-
REFERENCES 1. Meeker HG, Magalee R. The conservative management of the gag reflex in full denture patients. N Y State Dent J 1986;52:11-4. 2. Hoad-Reddick G. Gagging: a chairside approach to control. Br Dent J 1986;161:174-6. 3. Leslie SW. A new operation to overcome gagging as an aid to denture construction. J Can Dent Assoc 1940;6:291-4. 4. Kovatts JJ. Clinical evaluation of the gagging denture patient. J Prosthet Dent 1971;25:613-9. 5. Conny DJ, Tedesco LA. The gagging problem in prodthodontic treatment. Part II: patient management. J Prosthet Dent 1983;49:757-61. 6. Kattadiyil MT, Mursic Z, AlRumaih H, Goodacre CJ. Intraoral scanning of hard and soft tissues for partial removable dental prosthesis fabrication. J Prosthet Dent 2014;112:444-8. 7. Williams RJ, Rafik T. A technique for fabricating patterns for removable partial denture frameworks using digitized casts and electronic surveying. J Prosthet Dent 2004;91:85-8. 8. Williams RJ, Bibb R, Eggbeer D, Collis J. Use of CAD/CAM technology to fabricate a removable partial denture framework. J Prosthet Dent 2006;96: 96-9. 9. Goodacre CJ, Garbacea A, Naylor WP, Daher T, Marchack CB, Lowry J. CAD/ CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological data. J Prosthet Dent 2012;107:34-46. 10. Cuperus AM, Harms M, Rangel F, Bronkhorst EM, Schols J, Breuning KH. Dental models made with an intraoral scanner: a validation study. Am J Orthod Dentofacial Orthop 2012;142:308-13. 11. Wiranto MG, Engelbrecht WP, Tutein Nolthenius HE, van der Meer WJ, Ren Y. Validity, reliability, and reproducibility of linear measurements on digital models obtained from intraoral and cone-beam computed tomography scans of alginate impressions. Am J Orthod Dentofacial Orthop 2013;143:140-7. 12. Ender A, Mehl A. Accuracy of complete-arch dental impressions: a new method of measuring trueness and precision. J Prosthet Dent 2013;109:121-8. 13. Williams RJ, Eggbeer D, Bibb R. CAD/CAM rapid manufacturing techniques in the fabrication of removable partial denture frameworks. Quintessence J Dent Technol 2008;6:42-50. 14. Wilks CG, Marks IM. Reducing hypersensitive gagging. Br Dent J 1983;155: 263-5. 15. Ramsay DS, Weinstein P, Milgrom P, Getz T. Problematic gagging: principles of treatment. J Am Dent Assoc 1987;114:178-83. 16. Wu YL, Schaaf NG. Comparison of weight reduction in different designs of solid and hollow obturator prostheses. J Prosthet Dent 1989;62:214-7. 17. Page HL. Mucostatics. Ticonium Contacts 1946;4:7. 18. Leupold RJ, Kratochvil FJ. An altered-cast procedure to improve tissue support for removable partial dentures. J Prosthet Dent 1965;15:672-8. Corresponding author: Dr Jimmy Londono Georgia Regents University 1120 15th St Augusta, GA 30912-1260 Email: [email protected] Acknowledgment The authors thank Shawn Gwaltney, Denture Kraft Dental Laboratory, Augusta, Ga, for his assistance in fabricating the prosthesis for this patient. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Londono et al
Fabrication of a definitive obturator from a 3D cast with a chairside digital scanner for a patient with severe gag reflex: A clinical report Jimmy Londono, DDS,a Amara Abreu, DDS, MSD,b Philip S. Baker, DDS,c and Alan R. Furness, DMDd Gagging is a common problem ABSTRACT in dental procedures such as Patient gagging is a common problem during dental procedures such as maxillary impression maxillary impression making. making. This clinical report describes the use of a chairside intraoral scanner for a patient with a It is a natural reflex reaction hypersensitive gag reflex. The technique proved to be a more comfortable alternative for the paresulting from the stimulation tient and an accurate method for the clinician to capture both hard and soft tissue detail for the of certain intraoral structures.1 fabrication of a definitive obturator. (J Prosthet Dent 2015;-:---) Multiple conditions are assothat both intraoral scanning and cone-beam computed ciated with gagging, which is thought to have a multitomography scanning of alginate impressions are reliable factorial origin.2 The management of gagging depends on and valid in obtaining measurements for diagnostic its severity and causes, and multiple strategies have been purposes.10,11 Others have reported that the current gold reported to help dental patients deal with the problem, 3-5 standard for impression making, the physical impression, including the use of dental prostheses. Digital imcannot yet be fully replaced by the digital impression for pressions could be better tolerated by patients who gag restorative procedures.12 during impression making. Recently, a clinical report Digital technology has been difficult to integrate into described the use of an intraoral scanner (Cadent iTero; the fabrication of RPDPs. In a previous study,7 a definiAlign Technology) to capture hard and soft tissues in a tive cast was digitized and a 3-dimensional cast propassive state for the fabrication of a removable partial duced. A prototype RPDP was designed and created by dental prosthesis (RPDP). The information obtained was using digital software, and the resulting plastic pattern used to design and fabricate a trial resin framework, was invested, cast, and finished in the conventional which was later cast in a cobalt-chromium alloy. Good manner. Casting imperfections were observed and the soft tissue adaptation was reported.6 system proved costly. Computer-aided design and computer-aided manAnother study13 reported the digital fabrication of a ufacturing technology has been introduced over the last RPDP framework based on the scan of a definitive cast 10 years for the fabrication of removable partial dental made from a conventional impression. Design software prostheses6-8 and complete dentures.9 If applied as (FreeForm Software; SensAble Technologies) was used to intended, this technology facilitates the clinical dental survey the digital cast, identify the path of placement, procedures and reduces the length of appointments, provide adequate relief, and plan the design. The which benefits both the patient and the clinician. The framework was then printed from a cobalt-chromium accuracy of digitized impressions for alternative uses has alloy. However, because the framework alloy had not been widely investigated. Some authors have reported
a
Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. c Associate Professor and Program Director, Advanced Education Program in Prosthodontics, College of Dental Medicine, Georgia Regents University, Augusta, Ga. d Assistant Professor, Oral Rehabilitation Department, College of Dental Medicine, Georgia Regents University, Augusta, Ga. b
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
-
Issue
-
Figure 1. Pretreatment occlusal view of maxillary arch.
Figure 2. Articulated computer-aided design and computer-aided manufacturing casts produced from digital impression data.
been tested for toxicity, the framework was only used to evaluate the accuracy of the technology and was not used clinically. The purpose of this patient treatment report was to describe the use of a chairside intraoral digital scanner to record hard and soft tissues for the fabrication of a definitive obturator.
the patient. After completing tooth preparations and modifications for the metal framework, hard and soft tissue anatomy was captured with a chairside oral scanner (Lava Chairside Oral Scanner COS; 3M ESPE). During the scanning procedure, a high-resolution video camera captured hard and soft tissues within the focused area, which is a 3-dimensional box located a few millimeters from the surface of the camera lens. The total time for scanning was approximately 15 minutes. The scanned files were used to create a 3-dimensional polyurethane dental cast (In’Tech Dental; In’Tech Industries Inc) (Fig. 2). The digital impression of the maxillary arch did not include the defect area. The interim appliance was placed on the milled definitive cast and luted to it. Hard laboratory putty (Lab Putty Hard; Coltène/Whaledent) was adapted around the obturator bulb, including the bottom and sides of the definitive cast. Subsequently the interim appliance was carefully removed from the definitive cast. The putty material was coated with a separating medium, and the cast/putty combination was duplicated with a silicone duplicating material. A secondary stone cast was poured in the duplicating mold, obtaining a definitive cast adequate for 2 purposes: to fabricate a metal framework and to process a bulb which exactly duplicated the patient’s existing obturator, because it had been carefully adjusted for patient comfort and maximum function (Fig. 3). The defect area on the milled cast allowed precise placement of the internal finishing line for the interface of the metal framework and the acrylic bulb and the design of the retentive lattice in the most favorable position. The cast was blocked out and relieved, and a refractory cast was made to wax the framework. The completed framework was evaluated and fitted intraorally. Because of the large defect area and the patient’s objection to anterior retentive clasps for esthetic concerns, the obturator was designed as a hollow bulb
CLINICAL REPORT A 41-year-old African American man was referred from private practice for prosthodontic treatment at the Faculty Practice Clinic of the College of Dental Medicine, Georgia Regents University. The patient presented with a history of adenoid cystic carcinoma of the soft palate, surgically resected 5 months before consultation (Fig. 1). The patient was completely dentate except for a missing maxillary left second molar. His chief complaint included difficulty swallowing liquids and hypernasal speech. After clinical and radiographic evaluation to assess the patient’s chief complaint, an obturator was suggested as a treatment option. The patient exhibited an exaggerated gag reflex, as shown by multiple unsuccessful attempts to make a preliminary impression. In order to control the gagging, the systematic desensitization technique was used.14,15 The patient was instructed to gradually introduce a lollipop into the mouth and hold it until the gag reflex started. He was trained to do it several times a day, progressively increasing the amount of time holding it in the mouth. After 4 weeks of therapy, he was able to manage impression making without the gag reflex. An alginate impression with a stock tray was made for a preliminary cast, allowing for the fabrication of an interim acrylic resin obturator, in which the obturator bulb portion was built incrementally and adjusted. However, a digital impression was suggested as a more tolerable approach to making a definitive prosthesis for
THE JOURNAL OF PROSTHETIC DENTISTRY
Londono et al
-
2015
3
Figure 3. Lateral view of secondary stone cast showing demarcation between digitally generated cast and functionally generated bulb portion.
Figure 4. Anterior view of completed obturator on maxillary cast.
Figure 5. Close-up of right obturator framework on cast.
Figure 6. View of inserted prosthesis.
type.16 The framework was luted to the definitive cast, and wax was flowed around and over the retentive lattice area to ensure that the thickness of acrylic was adequate. A layer of liquid wax was also added into the remainder of the defect area, followed by a single thickness of baseplate wax. A 3 mm ledge was placed around the periphery of the palatal extent of the bulb. This would later allow the palatal lid to be reliably aligned and fixed into place. Laboratory putty (Coltène/Whaledent) was placed below the ledge and into the waxed defect to create the desired contour of the palatal side of the bulb. A single thickness of baseplate wax was then adapted over the putty. The 3-mm ledge was completely covered by the lid. This contoured piece of baseplate wax was then removed and set aside. The laboratory putty was carefully removed from the cast side of the waxed defect. The framework with the waxed bulb was then placed in an oversized flask (Atlas Giant Flask Model 44G; Handler Intl). The palatal lid portion was invested in a standard denture flask (Atlas Flask Model 44U; Handler Intl), and the 2 molds were boiled out, packed, and heat polymerized for 9 hours using conventional techniques. The framework with hollow bulb and the lid were deflasked
and finished. The fit of the lid onto the ledge in the bulb side was evaluated. Bonding agent (Triad Bonding Agent; Dentsply Intl, Inc) was applied to the internal edge of the lid and the ledge of the palatal bulb and light polymerized for 1 minute. A bead of light-polymerized gel (Clear Colorless Triad Gel Light Cure Material; Dentsply Intl) was placed around the entire periphery of the ledge. The lid was gently placed on the gel and pressed into position, ensuring the presence of a slight excess of gel around the entire periphery. The lid was then light polymerized into place. Final finishing and polishing of palatal side of hollow bulb obturator was completed. Figures 4 and 5 show the fit of the framework on the digital cast and the configuration of the obturator bulb. When the maxillary prosthesis was inserted (Fig. 6), pressure areas during head movements, speech, and swallowing were located with pressure indicator paste (Mizzy Inc) and relieved. The patient was instructed in oral hygiene measures, emphasizing specific care procedures for his new maxillary prosthesis. Postinsertion appointments were scheduled at intervals of 1 day, 1 week, 1 month, and 6 months after placement of the prosthesis. During this time, no problems were noted
Londono et al
THE JOURNAL OF PROSTHETIC DENTISTRY
4
regarding the patient’s oral and prosthetic hygiene. The patient was then placed on a 6-month recall. DISCUSSION The use of digital impressions to capture soft tissues has only been reported once and was used for the fabrication of a maxillary RPDP.6 The present treatment combined the advantages of this digital technology to overcome the problem of making a definitive impression in a patient with a hyperactive gag reflex with traditional methods for RPDP framework design and fabrication. The limitations of digital impressions include the cost of the intraoral scanner and the fact that they cannot capture the tissues in function but only in a passive state.17 In this treatment, it worked well because the edentulous area was limited to 1 tooth, and the defect area was captured from the existing interim obturator and adjusted intraorally. However, this might not be feasible in the presence of unilateral or bilateral distal extensions, in which allowance for tissue movement during function is critical. Movable tissue is adequately addressed with the traditional methods of a custom tray, border molding, and an elastomeric impression material, in conjunction with the altered cast procedure.18 Although this technique demonstrated that it was a suitable alternative for those patients who have problems tolerating certain dental procedures such as dental impressions, clinical studies should be carried out to fully explore the potential benefits offered by the use of digital technology in removable prosthodontics. SUMMARY Patient gagging is a common reaction during dental procedures such as maxillary impression making. In this clinical report, the use of a chairside intraoral scanner for a patient with a hypersensitive gag reflex proved to be a more comfortable alternative for the patient and allowed the clinician to accurately capture hard and soft tissue detail for the fabrication of a definitive obturator.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
-
REFERENCES 1. Meeker HG, Magalee R. The conservative management of the gag reflex in full denture patients. N Y State Dent J 1986;52:11-4. 2. Hoad-Reddick G. Gagging: a chairside approach to control. Br Dent J 1986;161:174-6. 3. Leslie SW. A new operation to overcome gagging as an aid to denture construction. J Can Dent Assoc 1940;6:291-4. 4. Kovatts JJ. Clinical evaluation of the gagging denture patient. J Prosthet Dent 1971;25:613-9. 5. Conny DJ, Tedesco LA. The gagging problem in prodthodontic treatment. Part II: patient management. J Prosthet Dent 1983;49:757-61. 6. Kattadiyil MT, Mursic Z, AlRumaih H, Goodacre CJ. Intraoral scanning of hard and soft tissues for partial removable dental prosthesis fabrication. J Prosthet Dent 2014;112:444-8. 7. Williams RJ, Rafik T. A technique for fabricating patterns for removable partial denture frameworks using digitized casts and electronic surveying. J Prosthet Dent 2004;91:85-8. 8. Williams RJ, Bibb R, Eggbeer D, Collis J. Use of CAD/CAM technology to fabricate a removable partial denture framework. J Prosthet Dent 2006;96: 96-9. 9. Goodacre CJ, Garbacea A, Naylor WP, Daher T, Marchack CB, Lowry J. CAD/ CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological data. J Prosthet Dent 2012;107:34-46. 10. Cuperus AM, Harms M, Rangel F, Bronkhorst EM, Schols J, Breuning KH. Dental models made with an intraoral scanner: a validation study. Am J Orthod Dentofacial Orthop 2012;142:308-13. 11. Wiranto MG, Engelbrecht WP, Tutein Nolthenius HE, van der Meer WJ, Ren Y. Validity, reliability, and reproducibility of linear measurements on digital models obtained from intraoral and cone-beam computed tomography scans of alginate impressions. Am J Orthod Dentofacial Orthop 2013;143:140-7. 12. Ender A, Mehl A. Accuracy of complete-arch dental impressions: a new method of measuring trueness and precision. J Prosthet Dent 2013;109:121-8. 13. Williams RJ, Eggbeer D, Bibb R. CAD/CAM rapid manufacturing techniques in the fabrication of removable partial denture frameworks. Quintessence J Dent Technol 2008;6:42-50. 14. Wilks CG, Marks IM. Reducing hypersensitive gagging. Br Dent J 1983;155: 263-5. 15. Ramsay DS, Weinstein P, Milgrom P, Getz T. Problematic gagging: principles of treatment. J Am Dent Assoc 1987;114:178-83. 16. Wu YL, Schaaf NG. Comparison of weight reduction in different designs of solid and hollow obturator prostheses. J Prosthet Dent 1989;62:214-7. 17. Page HL. Mucostatics. Ticonium Contacts 1946;4:7. 18. Leupold RJ, Kratochvil FJ. An altered-cast procedure to improve tissue support for removable partial dentures. J Prosthet Dent 1965;15:672-8. Corresponding author: Dr Jimmy Londono Georgia Regents University 1120 15th St Augusta, GA 30912-1260 Email: [email protected] Acknowledgment The authors thank Shawn Gwaltney, Denture Kraft Dental Laboratory, Augusta, Ga, for his assistance in fabricating the prosthesis for this patient. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Londono et al
