CAD/CAM fabricated complete dentures:

concepts and clinical methods of

obtaining required morphological data
Charles J. Goodacre, DDS, MSD,a Antoanela Garbacea, DDS,b
W. Patrick Naylor, DDS, MPH, MS,c Tony Daher, DDS, MSEd,d
Christopher B. Marchack, DDS,e and Jean Lowry, PhDf
Loma Linda University School of Dentistry, Loma Linda, Calif;
Loma Linda University School of Allied Health Professions, Loma
Linda, Calif; University of Southern California School of
Dentistry, Los Angeles, Calif
The clinical impression procedures described in this article provide a method of recording the morphology of the
intaglio and cameo surfaces of complete denture bases and also identify muscular and phonetic locations for the
prosthetic teeth. When the CAD/CAM technology for fabricating complete dentures becomes commercially available,
it will be possible to scan the denture base morphology and tooth positions recorded with this technique and import
those data into a virtual tooth arrangement program where teeth can be articulated and then export the data to a
milling device for the fabrication of the complete dentures. A prototype 3-D tooth arrangement program is described
in this article that serves as an example of the type of program than can be used to arrange prosthetic teeth virtually
as part of the overall CAD/CAM fabrication of complete dentures. (J Prosthet Dent 2012;107:34-46)

The acronym CAD/CAM repre-
sents Computer-Aided Design (CAD)
and Computer-Aided Manufactur-
ing (CAM). In some industries, an
equivalent term, CAD/NC (Numerical
Control) is used. With this design and
manufacturing technology, CAD soft-
ware defines the geometry of an ob-
ject while CAM programming directs
the fabrication process.
The CAM manufacturing compo-
nent was actually developed in ad-
vance of the CAD technology.In the
1950’s, manufacturers first adopted
tools controlled by a system of num-
bers and letters to produce objects
with complex shapes in both an accu-
rate and repeatable manner (Numeri-
cally Controlled or NC). Paper tapes
fed numerical data into machines
that then positioned and directed
tools to create the shape of the item
in production.1 The world’s first CAM
software program using a numeri-
cal control programming tool named
PRONTO, was developed in 1957 by
Dr Patrick J. Hanratty, who is often re-
ferred to as the father of CAD/CAM
technology.2
It was not until the late 1960s
that numerically controlled machines
became commercially available. How-
ever, the development began in 1962
as an outcome of a universal and en-
hanced NC programming language
known as Automatically Programmed
Tools (APT) created at the Massachu-
setts Institute of Technology. Surpris-
ingly, the introduction of Computer-
Aided Design (CAD) had little impact
on Computer Numerical Control
(CNC) processes until the actual de-
velopment of enhanced CAD applica-
tions occurred. This resulted in a last-
ing linkage between CAD and CAM1
software and machinery, and the
technology expanded from that point
forward.
Initial dental applications
In the early 1980s, CAD/CAM tech-
nology was used to produce clinical
dental restorations when Andersson3
envisioned the use of titanium for
the fabrication of crowns. Anders-
son selected titanium because of the

Presented at the Academy of Prosthodontics meeting, Hilton Head, NC, May 6, 2011.

a
Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry.
b
Advanced Education Student, Implant Dentistry and Prosthodontics, Loma Linda University School of Dentistry.
c
Associate Dean for Advanced Dental Education; Professor, Department of Restorative Dentistry, Loma Linda University School of
Dentistry.
d
Associate Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry.
e
Associate Clinical Professor, Advanced Prosthodontics, University of Southern California School of Dentistry.
f
Emeritus Professor, Speech-Language Pathology, Loma Linda University School of Allied Health Professions.
The Journal of Prosthetic Dentistry Goodacre et al
January 2012
established biocompatibility he had
learned about from the pioneering
work of Brånemark, who is recognized
for the development and introduction
of contemporary dental implants.
Since casting titanium was not pos-
sible at that time, dental restorations
were fabricated by using another pro-
cess. In 1982, Andersson developed
the CAM portion of the fabrication
process by using a combination of
spark erosion and copy milling.3 In
that same year, he cemented the first
CAM fabricated titanium complete
crown.3
Andersson quickly recognized that
the potential commercialization of
the process would be costly and the
resulting fabrication processes would
involve digitization, a realization which
then led to the development of the
CAD fabrication process. His pioneer-
ing activities became commercially
available as the Procera method of
fabricating crowns in 1983. The Proc-
era system was subsequently acquired
by Nobelpharma (now Nobel Bio-
care) in 1988. The patent that served
as the basis for the 1982 production
process did not limit fabrication to
the use of a physical definitive die of
the prepared tooth but included the
potential use of a virtual tooth prepa-
ration and definitive die derived from
a computer. Andersson indicated that
the first CAD/CAM Procera crown,
derived from a computer file rather
than a conventional gypsum die, was
fabricated around 1990 (Personal
communication, Matts Andersson
PhD, e-mail November 2010).
Another important dental appli-
cation of CAD/CAM technology also
occurred in the 1980s. Mörmann4 de-
veloped an interest in tooth-colored
restorations. He wanted dentists to
be able to produce durable inlay res-
torations chairside by scanning cav-
ity preparations intraorally and using
the resulting CAD data to form a ce-
ramic restoration that would fit the
prepared tooth by using CAM tech-
nology. Mörmann developed a proto-
type CAD/CAM device in 1983, and
a system became fully functional in
Goodacre et al
1985. In September of that same year,
Mörmann placed the first chairside
fabricated ceramic restoration with
equipment introduced and marketed
as the CEREC 1 system (Sirona Dental
Systems LLC, Charlotte, NC).5 That
first clinical restoration was an MOD
feldspathic porcelain inlay fabricated
for a maxillary left second molar.4
The design and milling of single
crowns, partial fixed dental prostheses,
and a variety of implant components
and prostheses have since become
relatively common clinical and labora-
tory procedures. Despite these many
advances, CAD/CAM technology has
yet to be used for the fabrication of
conventional complete dentures.
Transition to complete denture
fabrication
Since 1995, the principal author
has used a series of clinical procedures
intended to facilitate the fabrication
of conventional complete dentures
and implant prostheses. These same
procedures can also be adapted for
the fabrication of complete dentures
with CAD/CAM technology when it
becomes commercially available.
The clinical technique is different
from conventional complete denture
methods in that it requires impres-
sions that record the shape of both
the intaglio and cameo surfaces of
complete denture bases while also
identifying muscular and phonetic lo-
cations suitable for the placement of
prosthetic teeth. In the future, it will
be possible to scan the morphology
recorded by using this technique and
to transfer that digital data to a CAD
software program where denture teeth
can be virtually placed into appropri-
ate positions. Then a dental labora-
tory technician can export the denture
base form and tooth arrangement
morphology to a milling machine for
the fabrication of the maxillary and
mandibular complete dentures.
As an additional step beyond this
clinical technique, a prototype CAD
program, known as the 3D Tooth
Arrangement Program, was devel-
35
oped by the principal author aided
by computer programmers in 2009.
This prototype software was created
for the following 4 purposes: 1) to
pilot test the software programming
and obtain student and faculty input
on its design and use; 2) to help stu-
dents visualize the different types of
occlusal schemes that can be created
for complete dentures by being able
to produce mandibular movements
between different types of opposing
3-dimensional (3-D) denture teeth;
3) to teach students how to arrange
teeth virtually before performing the
actual laboratory procedure; and 4)
to permit faculty to develop a library
of acceptable and inappropriate
tooth arrangements to assess student
competency. This program was used
for the first time by second year dental
students at the Loma Linda University
School of Dentistry in the fall of 2010
during the complete denture preclinical
course. The educational applications
and benefits of this program will be de-
scribed in a subsequent publication.
The purpose of this article is to de-
scribe the clinical procedures required
to record the morphology of the inta-
glio and cameo surfaces of complete
denture bases as well as the muscular
and phonetic locations suitable for the
placement of prosthetic denture teeth.
CLINICAL TECHNIQUE
The following technique includes
all the requisite steps required to pro-
duce maxillary and mandibular de-
finitive impressions of the edentulous
arches in a manner that will permit the
application of CAD/CAM technology.
The overall goal is to make de-
finitive edentulous impressions that
capture the edentulous ridges and
borders (vestibules) while record-
ing as much as possible of the func-
tional soft tissue that will be in con-
tact with the facial surfaces of the
denture bases located occlusal to the
denture borders. Additionally, the
impressions should record muscu-
lar and phonetic positions suitable
for placing prosthetic denture teeth.
36 Volume 107 Issue 1

A B C
1 A, Custom acrylic resin mandibular impression tray. Tray handle is fabricated so it extends vertically from anterior
ridge crest and then turns anteriorly to pass through lips with minimal interference with oral musculature. B, Maxil-
lary and mandibular moldable stock trays. C, Maxillary tray was softened in hot water and intraorally molded to fit
edentulous maxilla form. It was then border molded and coated with vinyl polysiloxane adhesive in preparation for
definitive maxillary impression.

A B C

D E F
2 A, Mandibular vinyl polysiloxane impression made with moldable tray shown in Figure 1B. B, Scalpel used to
remove impression material that flowed over ridge crest of tray. Exposed occlusal surface of tray coated with adhesive.
C, Medium-body vinyl polysiloxane expressed onto occlusal surface of tray and extended occlusally to level of center
of retromolar pads. D, Patient instructed to swallow 3 times while pressing lips together, thereby extruding impression
material occlusally as result of muscular contraction. E, Dashed line shows depth of tongue depression used to trim
impression material. F, Impression material trimmed at depth of lingual tongue depression, thereby locating neutral
zone identified by flat area.

Impression trays
The edentulous impressions can
be made by using either a custom tray
(Fig. 1A) or a stock tray that can be
molded to conform to the shape of
each patient’s arch and provide the
required border extensions.
Newly designed thermoplastic
stock trays (Vident, Brea, Calif ) (Fig.
1B), specifically designed for edentu-
lous patients, have been developed
by Dr Stephen Wagner. They are ad-
vantageous for this technique as the
The Journal of Prosthetic Dentistry
trays can be adapted to the shape of
the edentulous arch by softening each
tray in an 80°C (180°F) water bath
for 1 minute (no tempering needed)
and then adapting it intraorally to fit
the specific contours of each patient’s
edentulous arch. In the softened
state, the tray borders can be trimmed
with scissors if the extensions need to
be shortened. Likewise, the softened
material can be stretched or added to
when the tray needs to be extended
to reach desired landmarks. After the
tray has been customized to fit the
arch, only the borders are softened,
and the patient’s musculature is ac-
tivated to mold the softened borders
(Fig. 1C).
Mandibular impression making
After the impression tray has been
selected (custom or stock tray), and
conformed to the patient’s mouth,
border molding is then performed.
A medium-body vinyl polysiloxane
impression material (Aquasil Mono-
phase Smart Wetting Impression
Goodacre et al
January 2012
Material; Dentsply Intl Inc, Milford,
Del) is recommended for this proce-
dure because the completed impres-
sion can be removed from the mouth
and repositioned intraorally multiple
times without adversely altering the
polymerized material and the border
extensions. A light-body impression
material (Aquasil LV Smart Wetting
Impression Material; Dentsply Intl
Inc) is then used to complete the
mandibular impression (Fig. 2A).
The mandibular posterior neutral
zone impression technique
Once the border molding and de-
finitive impression is completed, an
accompanying neutral zone impres-
sion6,7 is made on the occlusal surface
of the tray by removing impression
material that may have extended onto
the tray’s occlusal surface and by coat-
ing the tray with adhesive (Fig. 2B). It
is critical to preserve the impression
material closest to the impression tray
borders because it has recorded the
form of the corresponding contacting
buccal mucosa.
Medium-body vinyl polysiloxane
impression material (Aquasil Mono-
phase Smart Wetting Impression
Material, Dentsply Intl Inc) is then
dispensed along the entire occlusal
surface of the tray, from each ret-
romolar pad area of the tray to the
handle, at a vertical height sufficient
to reach the level of the center of the
retromolar pads bilaterally (Fig. 2C).
The impression is promptly placed
intraorally, and the patient asked to
swallow 3 times in succession while
pressing their lips together and press-
A B
3 A, Tray handle and lingual impression material removed. Adhesive applied. B, Impression material applied. C, Im-
pression material molded by pronouncing letters “Q” and “U”.
Goodacre et al
ing their tongue laterally against their
lips and cheeks. These mouth and
tongue movements activate the oral
musculature, so the impression mate-
rial is compressed between the lower
lip, cheeks, and tongue muscles,
thereby recording the location of the
posterior neutral zone.
After completing these move-
ments, the patient is instructed to re-
lax the mandible and tongue. The im-
pression can be removed in as short a
time as 2 minutes, if needed, for pa-
tient comfort. If the material has not
completely polymerized, sufficient
viscosity will have developed to es-
tablish the desired form of the neutral
zone. The repeated swallowing and
resulting compression of the impres-
sion material between the tongue and
cheeks extrudes the impression mate-
rial occlusally (Fig. 2D).
The lateral borders of the tongue
usually create a depression in the lin-
gual surface of the impression mate-
rial. Differences in the form of the de-
pressions are to be expected given the
variations in pressure recorded by the
tongue against the mandibular mo-
lars. According to Fröhlich et al,8 the
force ranges from 11.3 kPa to 49.6
kPa with a median pressure of 27.7
kPa. In another study by these same
authors, a maximum pressure range of
2.8 kPa to 39.1 kPa was recorded by
the tongue against the lingual aspect
of the mandibular second premolar
and first molar during swallowing.9
A scalpel is used to cut through the
material in a faciolingual direction at
the depth of the depression (Fig. 2E).
Experience has shown that the deep-
est aspect of the lingual depression
37
is typically located vertically around
the center of the retromolar pads, a
level that is useful in approximating
the height of the mandibular occlusal
plane.
After sectioning through the neu-
tral zone impression, a flat occlusal
platform is formed that represents the
faciolingual location of the posterior
neutral zone and provides a physi-
ological guide for posterior tooth po-
sitioning (Fig. 2F).
Mandibular anterior tooth positioning
impressions
Sometimes the mandibular tray
handle interferes with the lingual mor-
phology of the anterior aspect of the
neutral zone impression. When this
occurs, the tray handle should be re-
moved along with any impression ma-
terial that may be covering the occlu-
sal aspect of the tray in the area where
the mandibular anterior teeth will be
located (Fig. 3A). Impression material
adhesive is applied and medium-body
impression material is dispensed over
this exposed anterior region (Fig. 3B),
the tray is placed intraorally, and the
patient is instructed to swallow once
and then pronounce the letters “Q”
and “U” 3 times consecutively to
mold the lingual area (Fig. 3C). After
the patient completes these sounds,
the lower lip is grasped and pulled
facially so the impression can be re-
moved without having the lip displace
the impression material. Although the
pressure of the resting lip against this
area is light (mean of 0.9 kPa),10 it is
still capable of displacing unpolymer-
ized impression material.
C
38
A B
4 A, Facial impression material removed. B, Facial impression material ap-
pearance after molding by pronouncing letters “Q” and “U” and saying word
“Christmas”.
It is also possible to form the an-
terior-facial aspect of the impression
tray by trimming away the facial im-
pression material without disturbing
the lingual form and applying adhe-
sive (Fig. 4A). After dispensing medi-
um-body impression material and re-
seating the tray, the patient is asked to
pronounce the letters, “Q” and “U”, 3
times in succession and then say the
word, “Christmas,” 3 times. As soon
as the patient finishes pronouncing
the word “Christmas,” the lower lip
is pulled anteriorly away from the
impression material and the tray re-
moved so the anterior material can
polymerize without being displaced
by the lower lip. Once polymerization
is complete, the material is trimmed
so that it is level with the posterior
neutral zone areas (Fig. 4B).
Production of the sounds required
to form the letters, “Q” and “U”, and
saying the word, “Christmas,” acti-
vates the muscles of the chin as well
as those muscles associated with the
mentolabial angle. These facial move-
ments, in turn, create the form of the
mandibular anterior denture base.
Maxillary impression making
As with the mandible, maxillary
edentulous impressions can be made
with either a custom or stock impres-
sion tray. The posterior extension of
the tray is determined by the location
of the vibrating line that delineates
the transition between the immov-
able hard palate tissue and the mov-
able tissue of the soft palate. This
line is located by having the patient
The Journal of Prosthetic Dentistry
5 Maxillary impression made with
border molded tray shown in Figure 1C.
say “Ahh”11 and marking the junc-
tion between movable and station-
ary soft tissue with an indelible pencil
or marker (Dr. Thompson’s Sanitary
Color Transfer Applicators; Great
Plains Dental Products Co Inc, King-
man, Kans). Trim or stretch the tray
so its posterior border coincides with
the location and form of this vibrating
line. The depth to which the soft tis-
sue anterior to the vibrating line can
be displaced determines the depth of
the posterior palatal seal. been recommended for evaluating the
The palatal thickness of the max-
illary impression tray should be suffi-
cient to provide tray rigidity but not
be excessive. A thickness of 2 mm is
preferable. This dimension is critical
so the tray’s thickness does not inter-
fere with the development of palatal
contours since the patient’s speech
will be used to produce tongue move-
ments which then shape medium-
body vinyl polysiloxane impression
material that will be applied on the
cameo surface of the palatal portion
of the tray.
Next, the maxillary impression is
made so as to accurately record the
edentulous ridge morphology and
the border extensions. On the facial
surface of the tray, the light-body im-
pression material should be extended
as far as possible occlusally beyond
the borders (flanges) by muscular and
manipulative movements made dur-
ing the border molding. It is through
this process that the tissue contact-
ing facial surfaces of the denture are
formed (Fig. 5). If there are areas on
the facial surface of the tray where the
cameo surface morphology has not
Volume 107 Issue 1
been completely recorded, more tray
adhesive should be applied to the af-
fected area(s), followed by a thin lay-
er of additional light-body impression
material.
Speech analysis in prosthodontics
The clinical assessment of speech
has been used effectively in prosth-
odontics for many decades. In fact,
a number of articulation tests have
quality of a patient’s speech and pho-
netics. In 1959, Morrison12 published
a 1 stanza test he recommended as a
means to establish the occlusal verti-
cal dimension as well as the retruded
contact position. Guichet13 proposed
reading prose familiar to the dentist
as a means of evaluating anterior
tooth positions. In 1973, Chierici and
Lawson,14 published several test sen-
tences designed for evaluating articu-
latory factors involved in consonant
sound production. A speech articu-
lation test consisting of 12 sentences
was proposed by Kestenberg15 in 1983
and Howell16 published the results of
a 1986 study in which subjects read
aloud a passage of text known as
“The Rainbow Passage.”
Silverman17-19 is credited with de-
vising a method to evaluate phonet-
ics that he referred to as the “closest
speaking space,” and his technique
continues to be used today. The let-
ter “S” produces the most frequently
used sibilant (hissing) sound that oc-
curs during speaking and reading.19
In fact, asking patients to make the
“S” sound has been used clinically to
Goodacre et al
January 2012 39

Sue is missing one piece. (s sound) She is washing the dish. (sh sound)
Zelma is busy. (z sound) Measure the garage. (zh sound) Lee will allow it. (l sound)

“s” & “z” “sh” & “zh”

Tongue contacts the Tongue contacts the
palatal mucosa and palate and posterior “l”
teeth except for a nar- teeth but does not con- Tongue tip contacts
row central area of the tact the central area of anterior palate
anterior palate the anterior palate

A B C
Tom wanted a bite. (t sound) Chuck is watching Butch. (ch sound)
Did Eddy lead. (d sound) Jane enjoyed the fudge. (j sound) Ned won many prizes. (n sound)

Contact folled Contact folled

by release by release

“t” & “d” “ch” & “j”

Tongue contacts Tongue contacts “n”
n

n
Stabil

Stabil
the palate and the palate and Tongue main-
Stabilizatio

Stabilizatio

teeth all around tains continuous

izatio

izatio

teeth all around

the arch followed the arch followed contact with the
n

by anterior by anterior release palate and teeth all

release with sus- with sustained around the arch
tained posterior posterior contact
contact D E F
Ralph arrived after everyone else. Young men like yellow kayaks. King Gregory was gagging.
(r sound) (y as in yellow) (k, g, and ng sounds)

“r” “y” “y”, “g”, “ng”

Tongue contacts Tongue contacts the Tongue contacts the poste-
the posterior palatal palate and posterior rior hard palate, soft palate,
mucosa and teeth but teeth but does not and most posterior teeth fol-
does not contact the contact the central lowed by release in the center
anterior palate area of the anterior of the soft palate
palate Stabilization
Stabilization
Contact folled
G H by release
I
6 A, Clinical image showing contact area between tongue, teeth, and palate when /s/ and /z/ sounds are pro-
nounced in stimulus sentences found at top of picture. B, Image showing contact area when /sh/ and zh/ sounds are
pronounced. C, Image showing contact area when /l/ sound is pronounced. D, Image showing contact area when /t
and d sounds are pronounced. E, Image showing contact area when /ch/ and /j/ sounds are pronounced. F, Image
showing contact area when /n sound is pronounced. G, Image showing contact area when r sound is pronounced.
H, Image showing contact area when the y as in “yellow” sound is pronounced. I, Image showing posterior area of
contact between tongue, teeth, and hard/soft palate when /k/, /g/, and /ng/ sounds are pronounced.

Goodacre et al
40
identify the closest approximation of
the maxillary and mandibular central
incisors, thereby providing clinical in-
formation regarding the intercuspal
position.20,21 Additionally, there have
been several studies that record the
average distance between the closest
speaking space and the intercuspal
position.16,17, 22-26
Use of the tongue during speech to
record palatal morphology
The tongue has the capacity to
change its position more than any
other organ, varying its shape and size
interminably.22 In speech, the tongue
is the principal articulator of conso-
nants by contacting specific regions
of the hard palate, alveolar ridge, and
teeth during speech. The tongue also
changes position and shape to pro-
nounce each vowel.27 As such, the
tongue is an important component of
the speech system because it must el-
evate, narrow, thin, protrude, retract,
produce a groove, and lie flat in the
mouth to create different sounds.28
Thus when recording the contours
of the palate, it is vital to capture
the movements of the tongue during
speech because the resulting tongue
pressure exerted on the palate can be
used advantageously to produce pala-
tograms. A palatogram is defined as a
graphic representation of the area of
contact between the tongue and pal-
ate during speech.29 It has also been
described as a “map of the palate in-
dicating all areas of tongue contact
while producing different sounds
used in normal speech.”30
As a result, palatograms are used
to evaluate the nature of the tongue-
palate contact that occurs during
speech.31-43 Oakley-Coles is credited
with developing the technique31 by
painting his tongue with a mixture of
gum and flour and then examining
his tongue after speech to determine
where it had contacted the palate.32
Maxillary complete denture pala-
tograms have been made with several
different materials: 1) applying talcum
powder to the dry palatal surface of a
The Journal of Prosthetic Dentistry
Volume 107 Issue 1
maxillary complete denture and observ- cally are custom acrylic resin palates
ing where it was removed by the tongue with sensors located in the thin pala-
as a result of speech33-36; 2) applying tal acrylic resin.43
cornstarch to the palate of a denture When making palatograms, it is
and then observing where it was re- important to note that the degree
moved by the tongue30, 37; 3) spraying of tongue pressure44 and the area of
green aerosol marking medium onto contact between the tongue and pal-
the denture palate and observing the ate vary considerably depending on
areas that became moistened and the sounds being produced. There-
thereby darkened by tongue con- fore, it is important to use a wide
tact39; 4) applying utility wax to the range of sounds known to produce
palate and having the patient speak tongue-palate contact. The lingual-
and thereby mold the soft wax37; 5) alveolar consonants are examples of
applying impression wax to the palate key sounds that can be used to record
of the denture and observing areas palatal morphology. Additionally, be-
that became shiny and smooth when cause it has been proposed that single
contacted by the tongue as opposed word tests are not reliable24 when as-
to other areas where the wax was dull sessing phonetics, sentences should
from lack of tongue contact38; and 6) be read aloud by the patient covering
applying a thin mix of irreversible hy- the range of sibilants (/s/, /z/, /sh/, /
drocolloid to the palate of a denture zh/, /ch/, and /j/) and other sounds
and using speech to create a custom- that produce contact between the
ized palatal form.39 While individual tongue and palate.
variations exist in the precise areas
of tongue-palate contact, maps have The use of stimulus sentences
been created that are representative
of typical patterns of contact be- In 1973, Tanaka45 published 10
tween the tongue, palate, and maxil- stimulus sentences recommended for
lary teeth.33,35,36,39-41 Palatograms have use in evaluating the morphology of
also been recorded with electronic de- the palate in complete denture wear-
vices42 and electropalatography (EPG) ers. The sentences placed the conso-
has been used for 30 years in phonetic nants /s/, /z/, /sh/, /zh, /l/, /t/, /d/,
and clinical research associated with /ch/, /j/, and /n/ in 3 different loca-
speech therapy.43 EPG devices typi- tions: at the beginning, in the middle,
Table I. Thirteen sentences that stimulate tongue-palatal contact
1. Sue is missing one piece (s sound)
2. Zelma is busy (z sound)
3. She is washing the dish (sh sound)
4. Measure the garage (zh sound)
5. Lee will allow it (l sound)
6. Tom wanted a bite (t sound)
7. Did Eddie lead (d sound)
8. Chuck is watching Butch (ch sound)
9. Jane enjoyed the fudge (j sound)
10. Ned won many prizes (n sound)
11. Ralph arrived after everyone else (r sound)
12. Young men like yellow kayaks (y sound)
13. King Gregory is gagging (k, g, and ng sounds)
Goodacre et al
January 2012
used to establish the proper palatal
morphology and tooth positioning
for a complete denture.
There are 3 additional sounds pro-
duced from tongue-palate contact
that the authors recommend adding
to the original 10 used by Tanaka,
thereby resulting in a list of 13 sen-
tences (Table I). The 3 new stimulus
A
sentences added to Tanaka’s original
list require production of the fol-
lowing sounds: /r/; /y/, and the /k/,
/g/, and /ng/sounds (Figs. 6 G to I).
The /k/, /g/, and /ng/sounds are key
sounds for the most posterior area
of the palate46 since the posterior as-
pect of the tongue elevates to create a
B seal across the soft palate, posterior
alveolar ridges, and the second/third
molars.
Clinical technique for establishing
palatal morphology
The morphology of the palate is
recorded by placing medium-body vi-
C nyl polysiloxane impression material
onto the cameo surface of the pal-
ate, replacing the impression intra-
orally, and instructing the patient to
read the 13 stimulus sentences aloud
(Table I). It is advisable to rehearse
this step with the impression in the
patient’s mouth but before inject-
ing the impression material onto the
D tray. Rather than attempt to capture
7 A, Medium-body polyvinyl si- the entire palate in 1 seating, a 2-step
loxane impression material applied process is recommended.
posteriorly so tongue can mold mate- First, the posterior aspect of the
rial during speech. B, Impression tray is thinned, and then a 3 mm
material molded by patient reading
thickness of medium-body vinyl poly-
stimulus sentence “King Gregory
siloxane impression material is placed
is gagging.” C, Impression material
applied to anterior aspect of tray. in the area of the second molars bilat-
D, Impression material molded by erally and across the posterior border
patient reading first 12 stimulus of the tray (Fig. 7A). The posterior as-
sentences. pect of the palate is developed first in
the area of the second molars at the
same time as the posterior extension
and at the end of sentences. These to the soft palate is formed by plac-
sounds are formed as the result of ing medium body impression material
contact between the tongue and vari- onto that area of the tray. The patient
ous parts of the teeth, alveolar ridge, is instructed to read the following
posterior aspect of the hard palate, sentence 3 times: “King Gregory is
and anterior portion of the soft pal- gagging.” Pronunciation of the words
ate (Figs. 6A-F). They also can be in this sentence causes the tongue to
Goodacre et al
41
phonetically shape the impression
material (Fig. 7B), thereby defining
the second molar region along with
the posterior palatal extension.
Secondly, to capture the remain-
ing form of the palatal slope, a 3-mm
thick layer of medium-body impres-
sion material is dispensed onto the
remainder of the palate (Fig. 7C). The
patient is immediately instructed to
read the first 12 stimulus sentences in
order (Table I). The first 12 sentences
are read aloud and then repeated in
that same order to complete the form
of the lingual palatal slope (Fig. 7D).
There are no speech sounds that
establish the contours of the central
portion of the palate. This portion
of the denture base is formed by pro-
ducing a smooth transition between
the previously developed palatal mor-
phology on 1 side of the arch with the
corresponding palatal contour on the
opposite side of the arch and devel-
oping the appropriate thickness in the
central area of the palate on the digi-
tized impressions.
As an alternative to the reading of
13 stimulus sentences, 2 sentences
have been developed by the authors
that include all of the consonants
capable of producing tongue-palate
contact. Use of these alternative sen-
tences involves expressing the appro-
priate 3 mm thickness of heavy-body
vinyl polysiloxane impression material
over the entire palatal aspect of the
impression tray and then reseating
the impression and asking the patient
to read the following 2 sentences:
“What is your slow toe doing in the
yellow liquid on the shelf? Is it trying
to judge or measure the temperature,
change its color, or just reach out and
touch something grand and glorious.”
The reading should be repeated twice.
Clinical technique for determining
maxillary anterior tooth positions
The faciolingual and incisocervi-
cal locations of the maxillary anterior
prosthetic teeth have traditionally
been determined by using tooth vis-
ibility and lip support. Phonetics and
42 Volume 107 Issue 1

A B C
8 A, Maxillary tray handle removed along with polymerized impression material. Medium-body vinyl polysiloxane
impression material placed into anterior-lingual area. B, Patient pronounced word “thank” and letter “V” to mold ma-
terial. C, Polymerized impression material removed anteriorly, medium-body material deposited into area, and patient
pronounced letters “Q” and “U” to mold anterior-facial aspect of impression.

A B C

D E F

G H
9 A, Maxillary and mandibular impressions trimmed so posterior areas do not interfere with each other when patient
closes at selected occlusal vertical dimension. B, Midline marked on maxillary impression and buccal corridor evalu-
ated. C, Putty indices made over lubricated anterior aspect of maxillary impression. D, Anterior impression material
trimmed away and hot wax spatula used to remove tray material, making room for anterior teeth. E, Maxillary anterior
teeth arranged. F, Clinical evaluation of maxillary anterior teeth. G, Interocclusal record material placed over lubri-
cated impressions with patient occluding at appropriate occlusal vertical dimension. H, Impressions and interocclusal
record removed from mouth and record trimmed so intercuspation can be verified.

the lip position at rest also can be
used to help identify the area where
denture teeth can be appropriately
located. To determine anterior tooth
positions with these guides, the tray
handle is removed along with the
The Journal of Prosthetic Dentistry
impression material located over the
occlusal aspect of the tray where the
anterior teeth will be positioned. Af-
ter applying tray adhesive, medium-
body vinyl polysiloxane impression
material is placed over the anterior
ridge crest area (Fig. 8A), and the pa-
tient is instructed to pronounce the
word “thank” followed by pronuncia-
tion of the letter “V”. This combina-
tion is pronounced 3 times and then
the word “thank” is repeated an ad-
Goodacre et al
January 2012
ditional 3 times. When pronouncing
the word “thank”, the tongue molds
the lingual aspect of the impression
material and helps to locate the ap-
proximate faciolingual position of the
lingual surfaces of the anterior teeth
(Fig. 8B). Pronouncing the letter, “V”,
helps to identify the incisal length of
the impression material and thereby
establishes the approximate location
of the incisal edge of the maxillary
central incisors. After the pronuncia-
tion exercise is completed, the patient
is instructed to relax their tongue and
lips for several seconds. Then the up-
per lip is grasped gently and pulled
facially so the entire maxillary impres-
sion can be removed without disturb-
ing any unpolymerized impression
material.
Following polymerization of the
impression material, the facial half
of the anterior impression material is
removed to expose the tray, the area
coated with adhesive, and the impres-
sion material deposited into the recess.
The patient is instructed to pronounce
the letters “Q” and “U” 3 times and
then relax their tongue and lips for sev-
eral seconds so the upper lip can rest
against the impression material and
establish an approximate anteroposte-
rior position for the maxillary anterior
teeth. The upper lip is then grasped
and pulled facially so the impression
can be removed without disturbing
the incompletely polymerized impres-
sion material (Fig 8C).
Resting the upper lip against the
unpolymerized impression material
is permissible since measurements of
the resting pressure of the lip against
the maxillary incisors are low. Conse-
A B
10 A, Scan of maxillary impression. B, Scan of mandibular impression. C, Teeth arranged in scanned impressions on
virtual casts mounted at occlusal vertical dimension.
Goodacre et al
quently, this level of pressure is unlikely
to produce any substantive displace-
ment of the impression material. In
fact, in 1 study a slightly negative pres-
sure was recorded at rest.47 A second
study reported there was no labial
pressure against the maxillary incisors
in 11 out of 30 subjects and the mean
pressure was low.48 When the same
author compared adults with differ-
ent occlusal relationships, the pres-
sure was slightly more positive (mean
of 0.08 kPa) for the normal horizon-
tal overlap group; 0.14 kPa for the in-
creased horizontal overlap group and
0.14 kPa for the reduced horizontal
overlap group.49 Another study found
the upper lip pressure at rest to be 0.2
kPa with a range from -0.7 to 1.4 kPa;
the upper lip pressure was negative in
21 of the 84 children studied.50
A technique has been used where-
by patients bring their lips together
into light contact and air is blown
between the teeth so the upper lip is
pushed anteriorly by the air. The up-
per lip is allowed to relax and assume
its normal resting pressure.47 With
this particular technique, a slightly
negative pressure was found to be ex-
erted on the maxillary incisors.47
Occlusal vertical dimension, tooth
positioning, and interocclusal records
The occlusal vertical dimension is
established by using any one of sev-
eral appropriate methods and marks
placed on the skin for future refer-
ence. The maxillary and mandibu-
lar impressions are used as record
bases to establish the occlusal verti-
cal dimension and make interocclu-
43
sal records. The impressions are both
seated simultaneously to evaluate the
amount of impression material and
tray material that typically has to be
removed posteriorly because it inter-
feres with proper mandibular closure
at the established occlusal vertical di-
mension. Following complete closure
without interference between the 2
impressions, a scalpel is used to cre-
ate notches in the impression materi-
al and exposed tray material if present
(Fig. 9A). The maxillary impression is
placed intraorally so the midline can
be marked on the impression with a
permanent marker and the buccal
corridor space can be assessed (Fig.
9B). The maxillary impression is then
ready to have the 6 maxillary anterior
prosthetic teeth selected at the initial
diagnostic appointment arranged into
the area now occupied by impression
material. By using the impressions as
record bases-wax rims, the previously
selected maxillary anterior teeth are ar-
ranged in the impression and the tooth
size, form, and color verified. As with
traditional complete denture tech-
niques, different teeth can be selected,
should a change need to be made.
Facial and lingual putty indices
of the form of the maxillary anterior
phonetic impression can be made for
use as guides in arranging the anterior
teeth (Fig. 9C). To arrange the maxil-
lary anterior teeth, impression materi-
al is removed along with the required
amount of tray material (Fig. 9D) to
create space for the addition of wax
where the prosthetic anterior teeth
are located (Fig. 9E). Once arranged,
the positions of the anterior teeth are
verified intraorally for proper phonet-
C
44 Volume 107 Issue 1

A B C

D
11 A, Maxillary proof of concept denture milled from clear acrylic resin that incorporated recesses into
which denture teeth have been bonded. B, Mandibular milled denture base with teeth bonded in place.
Note that clear resin block used with this first CAD/CAM fabricated denture was not sufficiently thick
to reproduce retromolar pad area of clinical impression. C, Lateral view of mandibular denture showing
teeth bonded in position. Note milling marks due to use of 3-axis milling machine and large tools during
fabrication of this proof of concept denture. D, Maxillary denture placed intraorally.

A B
12 A, Virtual maxillary cast with posterior palatal seal “carved” into cast based
on clinical measurements. B, Seal applied to scan of maxillary impression.

ics and modified as necessary to meet
the patient’s esthetic requirements
(Fig. 9F). The anterior teeth identify
the mediolateral orientation of the
occlusal plane and along with the
posterior impression material, they
guide the anteroposterior angulation
of the occlusal plane.
The occluding surfaces of the
notched impressions are coated with
a thin layer of petroleum jelly. Then
the 2 impressions are reseated clini-
cally and a small amount of soft wax
(Periphery Wax, Heraeus Kulzer LLC,
South Bend, Ind) is placed onto se-
lected areas of the notched impression
material as needed so that mandibu-
lar closure at the established occlu-
The Journal of Prosthetic Dentistry
sal vertical dimension will result in
stabilized positioning of the impres-
sions against the edentulous arches.
A vinyl polysiloxane interocclusal re-
cord material (EXABITE II NDS Bite
Registration Crème; GC America Inc,
Alsip, Ill) is injected intraorally so it
can flow into the notched occlusal
surfaces and around the teeth. The
patient’s mandible is then immedi-
ately guided to its retruded contact
position, and the mandible is closed to
the appropriate occlusal vertical dimen-
sion where it is maintained motionless
until the interocclusal record material
is completely polymerized (Fig. 9G). A
protrusive interocclusal record can also
be made by using the notched impres-
sions. The impressions and interocclusal
record are removed from the mouth so
the record can be trimmed and accurate
intercuspation of the 2 impressions can
be further verified extraorally (Fig. 9H).
At this stage, the impressions and
interocclusal record are scanned,
the teeth arranged virtually in the
scanned impressions (Fig. 10A-C),
and the surfaces of the bases refined
in the computer. The resulting data is
then exported to a milling machine
for fabrication of the dentures. The
first set of complete dentures made
with the described clinical proce-
dures and milling process are shown
in Figure 11A-D. The scanning, virtual
arrangement of the teeth, base form
Goodacre et al
January 2012 45

A B C

D E F
13 A, Scans of most recent patient treatment where maxillary and mandibular impressions were made and 4 maxil-
lary incisors arranged. Scans have been articulated by using interocclusal record. B, Virtual mounted casts. C, Virtual
arrangement of maxillary teeth and base formed from impression scan. D, Denture base being milled from block of
pink denture base resin. E, Recesses in denture base being refined to accept cervical morphology of prosthetic teeth. F,
Milled maxillary denture base with prosthetic teeth bonded in place. Milling was performed with 5-axis milling ma-
chine and fine tools. Denture base is not polished. Small ridge on facial surface was produced as milling tool changed
direction of approach to denture base.

development, and the milling proce-
dures were performed by using these
procedures (Courtesy of Dr. Stephen
Schmitt, Voxelogix Corporation, San
Antonio, Texas). The 3-axis milling
machine and large milling tool used
in this first proof-of-concept denture
resulted in a denture base with sub-
stantial milling lines, but the clinical
procedures were validated.
Subsequently, the process focused
on the refinement of the base mill-
ing by using a 5-axis milling machine
and fine milling tools. Additionally, a
posterior palatal seal technique was
developed whereby a seal was cre-
ated by “carving” it into the virtual
cast based on clinical measurements
that identified the appropriate loca-
tion, form, and depth of the seal (Fig.
12A). The form created in the virtual
cast was then applied to the scanned
image of the impression so a seal
would be present in the milled den-
ture (Fig. 12B).
Recently, the previously described
procedures have been used to scan
clinical records (Fig. 13A), create and
articulate virtual casts (Fig. 13B), ar-
Goodacre et al
range the teeth, and virtually form the
bases (Fig. 13C). The resulting data
were used to mill a denture base from
a block of pink denture base resin with
recesses into which conventional den-
ture teeth were bonded (Fig. 13D-F).
Another future possibility would
be to import the clinical base mor-
phology and tooth position data into
an enhanced version of the 3-D Tooth
Arrangement Program, arrange the
teeth and form the bases virtually,
and then export the resulting data to
a milling machine for fabrication of
the prostheses.
SUMMARY
It is anticipated that the fabrica-
tion of complete dentures will be
commercially available with CAD/
CAM technology. The clinical impres-
sion procedures described in this ar-
ticle record the morphology of the
intaglio and cameo surfaces of com-
plete denture bases and also identify
muscular and phonetic locations for
the placement of prosthetic denture
teeth. This information can then be
scanned, the teeth and base forms
virtually established, and the resulting
data exported to a milling machine
for fabrication of the denture bases.
In addition to the development
of clinical procedures that record the
required morphology, the prototype
3D Tooth Arrangement Program de-
scribed in this article indicates that
CAD programs can be developed
whereby prosthetic teeth are arranged
virtually as part of the CAD/CAM fab-
rication of complete dentures.
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Corresponding author:
Dr Charles J. Goodacre
Loma Linda University School of Dentistry
11092 Anderson Street
Loma Linda, CA 92350
Fax: 909-558-0483
E-mail: cgoodacre@llu.edu
Copyright © 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Goodacre et al