SYSTEMATIC REVIEW

Digitally versus conventionally fabricated complete dentures:

A systematic review on cost-efficiency analysis and
patient-reported outcome measures (PROMs)
In Meei Tew, DDS, MDS,a Suet Yeo Soo, DDS, MSc,a and Edmond Ho Nang Pow, BDS, MDS, PhDb

Before the introduction of dental ABSTRACT

implants, complete dentures
Statement of problem. Reports on digitally fabricated complete dentures are increasing. However,
(CDs) were the sole treatment comprehensive evidence-based research on their cost-efficiency and patient-reported outcome
option for rehabilitating com­ measures (PROMs) is lacking.
pletely edentulous patients.
Purpose. The purpose of this systematic review was to compare the cost-effectiveness and
Their conventional fabrication
PROMs between digitally and conventionally fabricated complete dentures.
involves multiple clinical visits
and lengthy laboratory proce­ Material and methods. An electronic search of publications from 2011 to mid-2023 was
dures, 1–4
resulting in a pro­ established using PubMed/Medline, EBSCOhost, and Google Scholar. Retrospective, prospective,
randomized controlled, and randomized crossover clinical studies on at least 10 participants were
longed treatment with high total
included. A total of 540 articles were identified and assessed at the title, abstract, and full article
labor and laboratory costs.5,6 In level, resulting in the inclusion of 14 articles. Data on cost, number of visits, patient satisfaction,
recent years, digital workflows and oral health-related quality of life were examined and reported.
in dentistry have emerged as an
Results. The systematic review included 572 digitally fabricated complete dentures and 939
alternative to conventional CD
conventionally fabricated complete dentures inserted in 1300 patients. Digitally fabricated
fabrication.7 Most commercially complete dentures require less clinical time with a lower total cost, despite higher material
available digital CD fabrication costs compared with the conventional fabrication technique. Digitally and conventionally
systems involve intraoral scan­ fabricated complete dentures were found to have significant effects on mastication efficiency,
ning or scanning an impression comfort, retention, stability, ease of cleaning, phonetics, and overall patient satisfaction, as well as
or cast of the edentulous jaws social disability, functional limitation, psychological discomfort, physical pain, and handicap.
for a virtual CD design, which is Conclusions. Digitally fabricated complete dentures are more cost-effective than conventionally
then fabricated using computer- fabricated dentures. There are various impacts of conventionally and digitally fabricated complete
aided design and computer- dentures on PROMs, and they are not better than one another. (J Prosthet Dent xxxx;xxx:xxx-xxx)
aided manufacture (CAD-CAM)
technology with either a subtractive or an additive tech­ (3D) printing with its layer-by-layer additive method re­
nique.8 Although both techniques could produce similar duces the material used10 and excels in fabricating CDs with
CDs from a digital file of denture design, there are distinct intricate geometries, thereby accelerating the production
differences in terms of cost and time. The subtractive process.11
technique, which mills the CDs from a prepolymerized Systematic reviews on digitally fabricated CDs are
resin block often incurs higher costs and is associated with sparse, focusing primarily on accuracy,12 clinical out­
considerable material wastage.9 Conversely, 3-dimensional comes13,14 and physical properties.15–17 Notably, digitally

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors report no known competing financial interests or personal relationships that could influence the work reported in this paper.
a
Lecturer, Department of Restorative Dentistry, Faculty of Dentistry, The National University of Malaysia, Kuala Lumpur, Malaysia.
b
Clinical Associate Professor, Division of Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong, PR China.

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this systematic review aimed to compare the cost-ef­

Clinical Implications fectiveness, the frequency of clinical and postdenture
The integration of digital technology in complete delivery visits, patient satisfaction, and OHRQoL be­
denture fabrication diminishes clinical time and tween conventionally and digitally fabricated complete
dentures. The null hypothesis was that the CD fabrica­
costs while yielding patient-reported outcome
measures (PROMs) comparable with those of tion method would have no significant influence on the
conventionally fabricated dentures. time-cost analysis and PROMs.

MATERIAL AND METHODS

fabricated CDs have shown several advantages, including
enhancements in hydrophilicity,15 fracture strength,16 This systematic review followed the Preferred Reporting
toughness,17 as well as improved retention,13 occlusal Items for Systematic Reviews and Meta-Analyses
trueness, and surface adaptation.12 Despite 2 systematic (PRISMA) guidelines24 and used the population, inter­
reviews reporting the decreased laboratory costs17 and vention, comparison, and outcome (PICO) approach.
clinical time14 involved in the digital fabrication of CDs, a The review was registered with the International Pro­
few studies10,18–20 have been published recently, and the spective Register of Systematic Reviews (PROSPERO)
techniques used for the digital fabrication of CDs have (CRD 42023423072) and aimed to answer the PICO
also improved, primarily because of the advancement in question: How do milled and 3D-printed complete
3D printing technology. Moreover, the cost-effectiveness dentures affect fabrication and postinsertion adjustment
of using digital technology in CD fabrication has not been time, cost-effectiveness, patient satisfaction, and oral
explored systematically. health-related quality of life compared with con­
Three systematic reviews13,14,17 have evaluated pa­ ventionally fabricated complete dentures for patients
tient-reported outcomes (PROMs), but with limited who have received complete dentures. Only compara­
patient satisfaction parameters such as retention, es­ tive, retrospective, prospective, randomized controlled,
thetics, and overall patient satisfaction. PROMs, in­ and randomized crossover clinical studies were eval­
cluding patient satisfaction and oral health-related uated. The eligibility criteria encompassed studies
quality of life (OHRQoL), have been commonly used to written in English with a minimum of 10 participants
assess treatment efficacy from the patient’s perspective. and focused on contrasting the key parameters of milled,
Previous studies have reported inconclusive results 3D-printed, and conventionally fabricated complete
when comparing the PROMs of conventionally and dentures: cost analysis, frequency of denture fabrication
digitally fabricated CDs, likely because of variations visits and postinsertion reviews, patient satisfaction, and
in study design, sample sizes, and patient demo­ OHRQoL. Articles on implant-supported complete
graphics.21,22 However, there is some evidence to sug­ dentures were excluded.
gest that the CD fabrication technique may not An electronic search of publications in English from
significantly impact patient satisfaction and QoL.23 In­ 2011 to July 2023 was performed in the PubMed/
stead, other factors such as CD quality and the experi­ Medline, EBSCOhost, and Google Scholars databases
ence of clinicians and dental laboratory technicians in using the keywords listed in Table 1. The search was
CD fabrication may play a more significant role in de­ supplemented by a hand search and citation mining.
termining patient outcomes. To address these concerns, The titles and abstracts were independently screened by

Table 1. Search strategy

Database Search Strategy
PubMed/Medline ((((“jaw edentulous” OR “mouth edentulous” OR (“mouth” AND “toothless”)) AND (“denture” AND “complete” AND (“denture” AND “full”))
AND ((“CAD-CAM” OR “computer-aided” OR “computer-assisted”) AND (“conventionally manufactured” OR “conventionally fabricated”)))
OR (“patient satisfaction” OR “patient-centered outcome” OR “patient-reported outcome”)) AND “quality of life” AND ((“cost-
effectiveness analysis” AND (“cost” AND “time”)) OR (“time” AND “fabrication”)))
EBSCOhost (“edentulous, jaw” OR “mouth, edentulous” OR “mouth, toothless”) OR (“denture, complete” OR “prosthesis, complete” OR “denture,
full”) OR (“CAD/CAM fabricated” OR “computer-aided” OR “computer-assisted” OR “three-dimensional printed” OR “digitally
manufactured” OR “digital scanning”) OR (“conventionally manufacture” OR “conventionally fabricated” OR “compression molding” OR
“injection molding”) AND (“patient satisfaction” OR “patient experience” OR “patient-centered outcome” OR “patient-reported outcome”
OR “quality of life”) OR (“time, cost” OR “time, fabrication” OR “time, adjustment” OR “time analysis” OR “cost-effectiveness” OR “cost
analysis”)
Google Scholars (“edentulous, jaw” OR “mouth, edentulous” OR “mouth, toothless”) OR (“denture, complete” OR “prosthesis, complete” OR “denture,
full”) OR (“CAD/CAM fabricated” OR “computer-aided” OR “computer-assisted” OR “three-dimensional printed” OR “digitally
manufactured” OR “digital scanning”) AND (“conventionally manufacture” OR “conventionally fabricated” OR “compression molding” OR
“injection molding”) OR (“patient satisfaction” OR “patient experience” OR “patient-centered outcome” OR “patient-reported outcome”
OR “quality of life”) OR (“time, cost” OR “time, fabrication” OR “time, adjustment” OR “time analysis” OR “cost-effectiveness” OR “cost
analysis”)

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Table 2. Quality assessment of included randomized controlled trials using Cochrane risk of bias tool
Study Random Allocation Blinding of Blinding of Incomplete Selective Other Bias
Sequence Concealment Participants Outcome Outcome Data Reporting
Generation and Personnel Assessment Addressed
Srinivasan et al9 Low Low Low Low Low Low No
Ohara et al18 Low Unclear High High Low Low No
Peroz et al31 Low Low Low Low Low Low No
Heikal et al20 Low Low Low Low Low Low No
Cepic et al35 Low Low Low unclear Low Low No

Table 3. Quality assessment of included nonrandomized clinical studies using Newcastle-Ottawa scale (NOS)
Study Selection Comparability Outcome Total Score
(Max Score:****) (Max Score:**) (Max Score:***)
Kattadiyil et al23 *** * ** 6
Drago et al33 *** * * 5
Srinivasan et al2 *** * * 5
Smith et al10 *** * * 5
Kim et al19 *** * * 5
Clark et al34 *** * * 5
Gabry et al36 *** * * 5
Otake et al5 *** * ** 6
Arakawa et al6 *** * * 5
Studies that met five or more of NOS score criteria considered as good quality.

2 reviewers (T.I.M., S.S.Y.). Any discrepancies were re­ manufacturing costs (4 articles),2,5,6,10 number of clinical
solved by discussion. The full text of selected abstracts visits (9 articles),2,6,10,18,19,23,31,33,34 patient satisfaction (5
was further analyzed. Items including authors’ names, articles),9,18,20,23,35 and OHRQoL (5 articles).9,18,31,35,36
year of publication, sample size, fabrication technique, Because of the marked heterogeneity of the populations
manufacturing and laboratory cost, number of visits, and data collection methods among the studies, statis­
patient satisfaction, OHRQoL, and instruments used to tical analysis was not feasible.
assess patient satisfaction and OHRQoL were recorded. Table 4 shows 9 studies comparing clinical times for
The quality of the included studies was evaluated digital and conventional CD fabrication and adjust­
independently by 2 reviewers (T.I.M., S.S.Y.). The ran­ ments. Five of 6 studies favored milling methods, re­
domized controlled trials (RCTs) were assessed by using porting shorter clinical times, while 1 favored 3D
The Cochrane Risk of Bias tool25 (Table 2), with each printing for its efficiency. One study reported no sig­
study categorized as having a low risk, unclear risk, or nificant time difference between milling and conven­
high risk of bias. The quality of other included clinical tional techniques. Regarding follow-up visits, 4 of 6
studies was evaluated by using the Newcastle-Ottawa studies found no notable variation between the groups,
scale (NOS)26 (Table 3). Studies that met 5 or more of with 2 of these using the milling technique and the other
the NOS score criteria were considered to be of good 2 using the 3D printing technique. Two studies reported
quality and were included in the study. fewer postdelivery visits for milled CDs. Table 5 com­
pares the clinical, laboratory, and total costs of the 2
fabrication techniques from 4 selected studies. Among 3
studies assessing clinical costs, 2 studies reported higher
RESULTS
material costs for milled CDs. However, 1 study using
Following the search strategy, a total of 560 titles were the milling technique showed no cost difference when
found. After applying the inclusion and exclusion cri­ considering dentists’ hourly earnings. Regarding la­
teria, 20 relevant articles were identified. Further boratory costs, 2 studies favored the milling technique,
screening excluded 11 articles because of the lack of a and 1 study favored a combination of 3D printing and
comparison group,22,27,28 inadequate sample size,21,29,30 milling for cost-efficiency. One identified higher costs
article repetition,2,10,23,31 or being in a language other with the custom disk milling method. Three of 4 studies
than English.32 An additional 5 articles were included reported lower total costs with milling techniques.
after reference and hand searching, resulting in a final Table 6 compares patient satisfaction between digitally
selection of 14 articles that met the criteria for evaluating and conventionally fabricated CDs across various para­
cost-effectiveness or patient-reported outcomes of meters in 5 studies. Three studies reported no significant
conventionally and digitally fabricated CDs (Fig. 1). The difference in overall patient satisfaction between milling
data for the conventionally and digitally fabricated or 3D printing and conventional fabrication techniques.
CDs from the 14 included articles were compared for One study favored milled CDs, noting significantly higher

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Identification
Search results (n=560)
20 duplicates removed
(PubMed=17, EBSCOhost=346
and Google Scholar Search=197)
Screening

Titles and abstract screening

520 studies irrelevent
(n=540)

11 studies excluded based on:

Full text analysis (a) Repeated articles (n=4)

(n=20) (b) No comparison group (n=3)

Eligibility

(c) Sample size less than 10 patients (n=3)

(d) Not in English language (n=1)

Hand search

(n=5)

Final list for data extraction and analysis (n=14)

(a) Studies on number of visits (n=9)

Inclusion

(b) Studies on cost (n=4)

(b) Studies on patient satisfaction (n=5)

(d) Studies on OHRQoL (n=5)

Figure 1. Flow diagram showing identification, screening, eligibility, and inclusion process of studies.

patient satisfaction in mastication efficiency, comfort, DISCUSSION

maxillary CD retention, and overall satisfaction. In con­
trast, another study favored conventionally fabricated CDs This review showed that milled and 3D printed CDs
for their comfort, ease of cleaning, better stability, and reduced clinical times and costs compared with con­
phonetics. Table 7 presents 5 studies comparing the impact ventional methods, with significant differences in many
of digitally and conventionally fabricated CDs on items related to PROMs, leading to the rejection of the
OHRQoL in completely edentulous patients. Two studies null hypothesis that the CD fabrication method would
reported no significant difference in oral health impact have no significant influence on the time-cost analysis
profile (OHIP) domains between milling or 3D printing and PROMs. This review also compared data on sub­
and conventional fabrication techniques. However, the tractive milling methods (AvaDent, Baltic, Ivoclar/
other 3 studies reported different findings. One study re­ Wieland) or the additive 3D-printing technique (Dentca)
ported higher social disability in patients with 3D printed with either conventional compression or injection
CDs. Another noted more physical pain in patients with molding techniques. The majority of the studies had
milled CDs after 2 weeks, while those with conventionally been done by predoctoral or postdoctoral dental stu­
fabricated CDs experienced less functional limitation and dents. In a few studies involving experienced prostho­
handicap after 2 weeks and 3 months, respectively. The dontists,5,6,18,35 a preference was specified for a partially
remaining study found that conventionally fabricated CDs digital approach, possibly because of the challenges of
were significantly associated with higher functional lim­ achieving correct functional border impressions when
itation, psychological discomfort, and social disability edentulous arches are directly digitized with an intraoral
compared with 3D printed CDs. scanner.37

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Table 4. Studies comparing number of visits between digitally and conventionally fabricated complete denture protocols
Authors/ Study Sample Fabrication Fabrication Clinical Time of Post-insertion
Year Design Size Technique Protocol Denture Fabrication Visits
Kattadiyil Prospecti­ 15 patients Milling Milled CDs: 2 steps Conventional N/A
et al23 ve study (AvaDent) (partial digital technique required
versus workflow) clinical time 3.5 h
compression CCDs: 5 steps more than milling
molding technique
Srinivasan Retrospe­ 18 patients Milling Milled CDs: 2 steps CCDs (10.73 h) N/A
et al2 ctive (AvaDent) (partial digital required higher
study versus workflow) clinical time than
compression CCDs: 5 steps milled CDs (6.85 h)
molding
Drago Retrospe­ 106 Milling Milled CDs: 4 steps N/A No differences in
et al33 ctive patients (AvaDent) (partial digital the number of
study with versus injection workflow) post-insertion
33CCDs molding (Ivocap CCDs: 5 steps visit for milled
and 73 injection CDs and CCDs
milled CDs system) group
Clark et al34 Retrospe­ 314 Milling Milled CDs: 4 steps A significant higher Milled CDs (1–2
ctive patients (Avadent) versus (partial digital percentage of visits) required a
study with 242 compression workflow) patients with CCDs significant fewer
CCDs, 39 molding CCDs: 5 steps (50%) required 6 or post-insertion
milled CDs more visits than visits than CCDs
patients with milled (2–3 visits)
CDs (5%)
Kim et al19 Retrospe­ 636 3D printing 3D printed CDs: 3 N/A No significant
ctive patients (Dentca) versus steps (partial difference was
study with 420 compression digital workflow) reported in 3D
CCDs and molding CCDs: 5 steps printed CDs and
216 3D CCDs; both
printed groups required 6
CDs visits and above
Smith Retrospe­ 30 patients A combination CDs using a CDs using a Number of post-
et al10 ctive of 3D printing combination of 3D combination of 3D insertion visits
study and milling printing and printing and milling were decreased in
(Ivoclar) versus milling approach: 4 approach (7 h) CDs group using
compression steps (partial required significantly a combination of
molding digital workflow) lower chair side time 3D printing and
CCDs: 5 steps compared to milling approach
CCDs (8 h) as compared to
CCDs group
Ohara Randomi­ 15 patients 3D printing 3D printed CDs: 3 Number of visits No significant
et al18 zed (Dentca) versus steps required for difference was
crossover compression (partial digital fabricating 3D printed reported between
trial molding workflow) CDs (3–4 visits) was 3D printed CDs (4
CCDs: 5 steps significantly lower visits) and CCDs
than CCDs (5–6 visits) (3 visits)
Arakawa Retrospe­ 16 patients Milling Milled CDs No significant No significant
et al6 ctive (AvaDent/ (AvaDent): 2 steps differences were differences were
study Wieland) versus (partial digital reported between reported between
compression workflow) milled CDs milled CDs
molding Milled CDs (median=31.25 days) (median=18 days)
(Ivoclar): 4 steps and CCDs (median=32 and CCDs
(partial digital days) (median=27.5
workflow) days)
CCDs: 5–6 steps
Peroz Randomi­ 16 patients Milling (Baltic Milled CDs: 2 steps Milled CDs (252 mins) N/A
et al31 zed Denture system) (partial digital had lower working
controlled versus workflow) time than CCDs
trial compression CCDs: 5 steps (630 mins)
molding
CCDs, conventionally fabricated complete dentures; CDs, complete dentures; N/A, not applicable.

This review found that the digital fabrication of CDs spending 3 hours less than with conventional CDs. Peroz
was either equally or significantly less time-consuming et al31 reported that experienced dentists were able to
than the conventional method, irrespective of specific reduce the clinical time required for digital CD fabrication
CAD-CAM system or the extent of the digital workflow. by 6 hours using a 2-step Baltic Denture system. In
The time-saving benefits of using subtractive milling contrast, the 4-step Ivoclar system only reduced the
techniques for the fabrication of CDs were cited in several clinical time by 1 hour compared with a 5-step conven­
studies, particularly in the context of 2-appointment tional workflow.10 Despite the potential time-saving
visits. For example, Srinivasan et al2 and Kattadiyil et al23 benefits of digital fabricating CDs, Arakawa et al6 re­
reported that predoctoral students were able to fabricate ported that the treatment duration of certain commer­
milled CDs using a 2-step Avadent Denture system, cially available digital systems, such as 2-appointment

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Table 5. Studies reporting clinical and laboratory cost of digitally and conventionally fabricated complete dentures
Author (s)/ Sample Size Fabrication Technique Clinical Cost Laboratory Cost Total Clinical and
Year Laboratory Cost
Srinivasan 18 patients Milling (AvaDent) (partial Materials cost was higher Laboratory cost was Total cost was
et al2 digital workflow) versus for milled CDs (202.79 CHF) significantly lower in milled CDs significantly lower
compression-molding than CCDs (18.46 CHF) (819.91 CHF) than CCDs for milled CDs
(1980.8 CHF) (1022.70 CHF) than
CCDs (1999.26 CHF)
Smith et al10 30 patients A combination of 3D N/A 3D printed CDs (229.03 USD) N/A
printing and milling and milled CDs (379.67 USD)
(Ivoclar) (partial digital were significantly more cost-
workflow) versus effective, yielding as much as
compression-molding 65% savings over CCDs
(678 USD)
Arakawa et al6 16 patients Milling (AvaDent or Clinical cost (dentist’s fees Laboratory cost of milled CDs Total cost of milled
Wieland) (partial digital and materials cost) was (926–1591 USD) was CDs
workflow) versus similar between groups significantly lower than CCDs (2791–4106 USD)
compression-molding (1821–2190 USD) was significantly
lower than CCDs
(3864–4824 USD)
Otake et al5 44 patients Milling (custom disks) Material cost was Median of Laboratory cost of Median of total cost
(partial digital workflow) significantly higher for milled CDs (12297 JPY) was of milled CDs
versus compression milled CDs (14206 JPY) significantly higher than CCDs (41104 JPY) was
molding than CCDs (8641 JPY) (4764 JPY) significantly lower
than CCDs
(45276 JPY)
CCDs, conventionally fabricated complete dentures; CDs, complete dentures; CHF, Swiss Franc; JPY, Japanese yen; N/A, not applicable; USD, United
States dollar.

visits of Avadent and 4-appointment visits of Wieland Only 4 relevant studies on the cost of CD fabrication
Digital solution, may not be significantly different from were identified. The costs varied across the studies because
the conventional workflow, even when all clinical pro­ of differences in clinical protocols and calculations.
cedures are performed by experienced prosthodontists Srinivasan et al2 reported a marked increase in material
and dental laboratory technicians. Ohara et al18 similarly costs when implementing a 2-step subtractive milling
reported no significant difference in treatment duration protocol that required specialized stock trays, polyvinyl
between 3D printed and conventionally fabricated CDs siloxane impression material, and specific jaw record de­
and identified occlusion registration errors as a potential vices during the first visit. In contrast, Otake et al5 reported
cause of prolonging treatment duration when providing on a more cost-effective approach by first using an in­
digital CDs. To address this issue, AlHelal et al38 re­ traoral scanner for preliminary digital recording and
commended a digital preview of the CDs in a grid view maxillomandibular relation records, followed by the con­
mode before milling or printing, particularly when sche­ ventional procedure for definitive impressions. However,
duling a denture trial appointment is not possible. This when the hourly earnings of the dentists were included in
approach can help reduce occlusal complications.38 the clinical costs analysis, Arakawa et al6 reported that the
The postdelivery follow-up is an essential part of clinical expense of subtractive milling and conventional
denture care. The CD fabrication method has been re­ fabrication techniques were comparable because they used
ported to have little correlation with the number of similar conventional methods and materials within the
scheduled6,18,19 and nonscheduled33 adjustment visits. digital workflow. Furthermore, Smith et al10 identified a
However, digitally fabricated CDs have been reported in notable increase in profitability per hour associated with
some studies to require fewer adjustment visits because of reduced chairside time during denture fabrication and
the improved fit of the denture base. Clark et al34 reported postdelivery visits with the milling technique. The in­
that patients receiving digitally milled CDs required only 1 creased profitability suggests that fewer clinical hours were
to 2 postoperative adjustment visits compared with 2 to 3 needed for the digital protocol, which helped minimize the
visits for those with conventional CDs. This highlights the initial clinical cost, even though clinical materials costs
advantage of digitally milled CDs in ensuring better den­ were greater than those of the conventional technique.29
ture fit and retention, attributed to the enhanced proper­ The cost of milling the CDs has been significantly reduced
ties of milled polymethylmethacrylate.34 Similarly, Smith by automating most of the laboratory procedures, resulting
et al10 reported a significant reduction in patient adapta­ in lower overall fabrication cost compared with the con­
tion time when using a 4-step subtractive milling protocol ventional method.2,5,6,10 In contrast, the conventional
in a university setting. The fewer postinsertion visits could method is less cost-effective because of its high labor
be associated with the use of an occlusal pre-equilibration costs.30 Smith et al10 reported that the total laboratory costs
software program. of conventionally fabricated CDs were 3 times higher than

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Table 6. Studies comparing satisfaction level in patients with digitally and conventionally fabricated complete dentures
Kattadiyil et al23 Srinivasan et al9 Heikal et al20 Ohara et al18 Cepic et al35
Study type Prospective study Randomized, Randomized Randomized crossover trial Randomized, crossover
crossover trial controlled trial trial
Sample size 15 15 48 15 10
Fabrication Milling (partial 3D printing or Milling (partial 3D printing (partial digital Milling (partial digital
technique digital workflow) milling (partial digital workflow) versus compression workflow) versus
[Link] digital /workflow) workflow) molding compression molding
molding versus compression versus. 3D
molding printing (partial
digital
workflow)
versus
compression
molding
Data collection 1 week 1 and 6 weeks 2 weeks, 3, and Day of denture delivery, after Before denture insertion, 2
timeline postinsertion postinsertion 6 months denture adjustment weeks postinsertion
postinsertion
Rating scale 5-point Likert scale 5-point Likert scale VAS VAS VAS
Functional N/A N/A No significant N/A n/a
complaint difference
among 3
groups
Chewing Significant higher N/A No significant No significant difference No significant difference
efficiency preference with difference between 2 groups between 2 groups
milled CDs among 3
than CCDs groups
Comfort Significant higher N/A N/A CCDs (78.24 ± 5.04) scored No significant difference
satisfaction with significantly higher than 3D between 2 groups
milled CDs printed CDs (62.88 ± 4.79)
than CCDs
Phonetics N/A No significant N/A CCDs (83.80 ± 5.64) scored No significant difference
difference between significantly higher than 3D between 2 groups
2 groups printed CDs (69.08 ± 5.05)
Occlusion N/A No significant N/A N/A N/A
difference between
2 groups
Pain N/A N/A N/A No significant difference N/A
between 2 groups
Ease of cleaning N/A N/A N/A CCDs (92.93 ± 3.44) scored No significant difference
significantly higher than 3D between 2 groups
printed CDs (86.20 ± 3.16)
Retention Significant higher No significant N/A No significant difference N/A
scores were difference between between 2 groups
reported for 2 groups
maxillary milled CDs
than mandibular
miled CDs and CCDs
Stability N/A No significant N/A CCDs (75.87 ± 5.11) scored No significant difference
difference between significantly higher than 3D between 2 groups
2 groups printed CDs (68.46 ± 4.92)
Aesthetic No significant N/A N/A No significant difference No significant difference
difference between between 2 groups between 2 groups
2 groups
Psychological N/A N/A No significant N/A N/A
difference
among 3
groups
Overall Significant higher No significant No significant CCDs (78.83 ± 6.41) scored No significant difference
satisfaction satisfaction with difference between difference significantly higher than 3D between 2 groups
milled CDs 2 groups among 3 printed CDs (61.10 ± 5.75)
than CCDs groups
CCDs, conventionally fabricated complete dentures; CDs, complete dentures; N/A, not applicable; VAS, visual analog scale.

of CDs that were digitally milled in an in-house dental which enhanced mastication efficacy. Improved retention
laboratory. has been reported to be because milled CDs can over­
PROMs are essential for assessing the success of CD come the polymerization shrinkage associated with con­
treatment. However, the correlation between CD fabri­ ventionally fabricated CDs,39 providing improved denture
cation techniques and patient satisfaction is conflicting as adaptation and patient comfort.40,41 Furthermore, despite
shown in this review. Cepic et al35 reported that replacing using digital preview images instead of a clinical evalua­
old CDs improved patients’ mastication efficacy, irre­ tion appointment, the esthetics of milled CDs provided
spective of the type of fabrication technique used. Ac­ with a 2-appointment digital protocol was reported to
cording to Kattadiyil et al,23 many patients preferred be comparable with that of conventional CDs.23 How­
digitally milled CDs because of their improved retention, ever, to minimize the risk of patient dissatisfaction with

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Table 7. Studies comparing oral health-related quality of life in patients with digitally and conventionally fabricated complete dentures
Authors/ Study Design Number of Fabrication Questionnaire Follow up Main Results
Year Patients Technique
Srinivasan Randomized 15 3D printing or OHIP-EDENT: 1 and 6 weeks No significantly difference was
et al9 crossover trial milling (partial postinsertion reported in OHIP scores for all
digital workflow) domains among conventional,
versus milled and printed CDs at 1 and 6
compression weeks postinsertion.
molding
Gabry et al36 Randomized 17 3D printing (partial OHIP-EDENT 1 week post- CCDs had significantly higher score
controlled trial digital workflow) insertion in functional limitation,
versus psychological discomfort and social
compression disability than 3D printed CDs. No
molding significantly differences in other
domains and overall OHIP score
Ohara Randomized 15 3D printing (partial OHIP-EDENT-J: Baseline and 3D printed CDs (Mean=0.690,
et al18 crossover trial digital workflow) after denture SD=0.161) group had significantly
versus adjustment higher OHIP score in social
compression disability than CCDs (Mean=0.150,
molding SD=0.179). No significant
differences between groups in
other variables.
Peroz et al31 Randomized 16 Milling (partial OHIP-G49 At baseline, 14 Participants with milled CDs had
controlled trial digital workflow) days and 3 more physical pain after 14 days;
versus months post- participants with CCDs had less
compression insertion functional limitation after 14 days
molding and felt less handicapped after 3
months
Cepic et al35 Randomized 10 Milling (partial OHIP-20 Before insertion OHIP scores of CCDs (Mean=101.7,
controlled trial digital workflow) of new CDs, 2 SD=12.0) and milled CDs
versus weeks post- (Mean=95.6, SD=24.2) were higher
compression insertion as compared with old denture
molding (Mean=83.1, SD=27.1). No
significantly differences in all
domains between CCDs and
milled CDs.
CCDs, conventionally fabricated complete dentures; CDs, complete dentures; OHIP-EDENT, Oral Health Impact Profile for edentulous; OHIP-EDENT-
J, Japanese version of Oral Health Impact Profile for edentulous patients; OHIP-G49, German version of Oral Health Impact Profile; SD, standard
deviation.

the esthetics of the CDs, Srinivasan et al9 recommended step of scanning the waxed trial dentures. This approach
bonding prefabricated denture teeth to the milled or ensures control over essential clinical factors in digital
printed denture bases, as the single-shade milled or parameters such as vertical dimension, occlusion, lip
printed artificial teeth may be less esthetically pleasing.18 support, and smile line.9 This finding was consistent with
In contrast, Ohara et al18 reported that conventionally that of Cepic et al,35 who also reported similar results 2
fabricated CDs were associated with higher satisfaction weeks after denture delivery. However, Peroz et al31 re­
levels in terms of denture stability and comfort compared ported significant time-dependent differences in OHIP
with 3D printed CDs. The higher satisfaction with con­ scores for both conventionally and digitally milled CDs at
ventionally fabricated CDs could be attributed to experi­ baseline, 2 weeks, and 3 months after denture insertion.
enced prosthodontists achieving better border capturing Patients showed better adaptation over time with con­
and balanced occlusal contacts in conventional CDs, ventionally fabricated CDs compared with digitally milled
whereas over-extension is a common issue with digitally CDs, which caused more physical pain associated with
fabricated CDs.42 Additionally, the thick palatal base of sore spots. Predoctoral dental students with little experi­
3D printed CDs may limit tongue space, leading to dis­ ence in handling digital technology were claimed to be a
turbances in phonetic adaptation.18 This finding was possible cause of CDs with inferior quality.31 This finding
consistent with that of Mahross et al,43 who identified the was further supported by Saponaro et al,22 who reported
importance of using a thin palatal base with rugae re­ that patient denture expectations might be influenced by
production to enhance consonant pronunciations in CDs. the dentists’ experience in the fabrication process.
With regard to the OHRQoL, this review found in­ Two contrasting studies assessed the impact of 3D
consistent results across studies. Srinivasan et al9 reported printing technology on OHRQoL in denture wearers.
no significant difference in OHIP scores across all do­ Ohara et al18 reported that procedural errors, including
mains among conventionally fabricated, digitally milled, nonconformity with the mucosal surfaces, occlusal in­
and 3D printed CDs at 1 and 6 weeks after denture de­ stability, and dimensional changes after processing, were
livery. An explanation could be that digital workflow more likely to occur when using additive manufacturing
predominantly integrates conventional protocol up to the systems. These errors subsequently led to increased social

THE JOURNAL OF PROSTHETIC DENTISTRY Tew et al

Month xxxx 9

disability.18 The accuracy of dentures fabricated using 3D 7. Kouveliotis G, Tasopoulos T, Karoussis I, Silva NR, Zoidis P. Complete
denture digital workflow: Combining basic principles with a CAD-CAM
printing technology was also reported to be highly vari­ approach. J Prosthet Dent. 2022;127:550–555.
able44 and affected by parameters such as 3D printing 8. Janeva NM, Kovacevska G, Elencevski S, Panchevska S, Mijoska A,
Lazarevska B. Advantages of CAD/CAM versus conventional complete
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and social disability. This finding was consistent with that 11. Alhallak K, Hagi-Pavli E, Nankali A. A review on clinical use of CAD/CAM
of Cristache et al,45 where the patient’s high level of sa­ and 3D printed dentures. Br Dent J 2023.
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