INTRODUCTION
The aftermath of the devastating fire on August 8, 2023, in Lahaina, Maui, Hawaii, left many locals with unmet basic needs. In addition to becoming homeless overnight, we recognized that some victims had an unexpected dental need. In the chaos of evacuation, many had left behind or lost their dentures. We all know the logistics of the various appointments involved in traditional denture fabrication. For this group of patients struggling with the basics of food, shelter, and transportation, we knew we would have to enact a unique strategy. By utilizing digital technology and the advancements in 3D printed dental resins, we could deliver high-quality replacement dentures with fewer appointments, a drastically shorter waiting period for the patients, and no lab bills. A generous donation of 3D printer resins by Pac-Dent allowed us to offer the service pro bono.
Before the wildfire.
After.
Before.
After.
CASE REPORT
Word spread quickly that we were offering free replacement dentures to any victims who had lost dentures in the fire, and within 3 months, we fabricated 58 replacement arches (Figure 1). We were fortunately prepared for the moment; in an unrelated project, we had set up a dental CAD design center in Nepal in partnership with a dental school faculty in the country the previous year. This allowed us to push the design portion in exocad to them, creating a unique international partnership. Additionally, our relationship with dental 3D printed resin suppliers meant we were able to efficiently scan, design, and print dentures, bringing smiles and oral function back to the victims of the Lahaina fires.
Figure 1. Within 3 months, we fabricated 58 replacement arches.
Figure 2. Intraoral (IO) scans obtained with 3Shape Trios.
With the loss of dental prosthetics, we were starting from the beginning in these cases. First, we obtained an initial digital intraoral scan using either a 3Shape or Medit scanner (Figure 2). After scanning the edentulous arches, we grossly approximated the vertical dimension of occlusion (VDO) in centric relation using cotton rolls or baseplate wax between the edentulous anterior ridges. The VDO was approximated by taking a measurement between the patient’s commissure of his or her lips and his or her interpupillary line and recording it on a tongue depressor or gauge. The VDO was opened or closed until the recorded distance matched the distance from the top of the patient’s filtrum below his or her nose to the bottom of his or her chin. This VDO was stabilized as described with wax, and then bite scans were taken with the IO scanner to relate the upper and lower arch scans.
Due to the time difference between Maui and Nepal, we were sleeping as the digital design team in Nepal designed an initial denture in exocad with a flat occlusal plane. The .STL files of the dentures were sent back to us presliced and nested, ready for 3D printing. After printing the files, the prints were post-processed by removing supports, cleaned, and cured using an Otoflash curing unit. While we find printing the most exciting part of the process, we know that using an approved cure unit matched to the printer and resins being used is the most critical part of the process for patient safety. Undercured 3D printer resins could potentially leach toxic compounds into the patient’s mouth.
We used these initial printed arches in a novel way to replace a wax bite rim, custom trays, and set up wax try-ins to reduce appointments and capture multiple visits worth of information from a traditional workflow in a single appointment.
The second appointment included border molding and final wash impressions with heavy- and light-body PVS, respectively. Chairside adjustments were made with a slow-speed round bur to adjust and finalize the VDO in CR (Figure 3). Using an IO scanner, the intaglio of the denture was recorded first and rolled around the borders to then record the dentition, creating a 360° scan of the prosthetic (Figure 4). The VDO was then recorded using the IO scanner with the prosthetics in the patient’s mouth. Photos were taken of the patient to take advantage of the digital smile creator features within exocad.
Figure 3. Printed monolithic dentures adjusted to correct VDO in CR with final wash impressions.
Figure 4. A 360° IO scan of dentures after adjustment and wash impression.
The resulting files and IO scans were then digitally sent back to Nepal for the final design. The photos were directly imported into the exocad projects by the designers to correct any aesthetic deficiencies in the first design by repositioning teeth. After performing the correct aesthetic positioning of the maxillary anteriors, the remaining teeth were “set” digitally in ideal position using a lingualized occlusal scheme. The final design files were again returned for printing in the office.
We would like to note that, initially, we printed the dentures as a monolithic print and stained and glazed them, but we noticed the glaze did not last. After trying multiple materials and methods, we settled on Rodin (Pac-Dent), printing the teeth and base separately using Rodin Sculpture and Rodin Base materials (Figure 5). By printing the denture teeth and base in their respective materials and then attaching the 2 parts together before the final cure, we avoided using an adhesive to join the 2 parts (Figure 6). We noted improved aesthetics and strength of the final prosthetic using this method (Figure 7). Additionally, the processing time was faster and less technique-sensitive. We noted that it was much easier to train an assistant to quickly gain a predictable outcome using this method instead of gingival characterization of a monolithic print.
Figure 5. Rodin Denture Base and Rodin Sculpture (Pac-Dent).
Figure 6. Denture base and tooth .STL files 3D printed separately.
Figure 7. Assembled final 3D printed denture.
In general, we were very pleased with the resulting digital prosthetics when compared to the result of traditionally processed acrylic dentures. Not only were the dentures aesthetically pleasing to the patients, but the intaglio fit and suction were found to be superior to a processed denture in most cases. We postulate this to be due to the dimensional stability of the 3D printing process compared to the effects of shrinkage as the acrylic cures when processing a traditional denture. We noted our final delivery times to be faster in most cases, with less adjustment of occlusion, flanges, and intaglio pressure spots.
DISCUSSION
The utilization of 3D printing technology in denture fabrication represents a paradigm shift in dental care, offering numerous advantages over traditional methods.
We feel that additive manufacturing in the dental office (3D printing) is a disruptive technology that will forever change the way we practice dentistry.
In our careers, we haven’t seen another technology that combines increased clinical efficiency, reduced turnaround times, a better patient experience, drastically lower cost, and a better final product. Furthermore, the customizable nature of digital sculpting allows for unparalleled personalization, ensuring optimal fit and comfort for each patient.
CONCLUSION
In conclusion, the successful implementation of 3D printed dentures for Maui fire victims underscores the transformative potential of technology in dentistry. By integrating artistic inspiration with cutting-edge innovation, we have not only restored smiles but also instilled hope and confidence in those affected by adversity.
ABOUT THE AUTHORS
Dr. Brinton graduated from the Oregon Health & Science University (OHSU) School of Dentistry as 2013 class valedictorian and served 4 years in the National Health Service Corps. In 2017, he co-founded Arvory Dental Group, which has grown to 9 locations in Northwest Oregon. In 2018, he founded Hero Dental Education, a PACE-accredited CE provider offering online, hands-on, and live patient courses related to dental implants and digital dentistry. He has lectured nationally and internationally on the topics of digital dentistry and dental implant workflows. He is faculty with Dental Success Network and the OHSU School of Dentistry and a clinical site director for the Oral Implantology residency at Jacksonville University. He can be reached at clark@arvory.com.
Dr. Hollander graduated from OHSU in 2012. He completed a general practice residency at Queen’s Medical Center in Honolulu, followed by 3 years of service with the National Health Service Corps in Medford, Ore. Growing up in Kathmandu, Nepal, he developed a passion for increasing access to dental care. This passion led him to co-found Donate Relief, a nonprofit organization dedicated to advancing digital dentistry. Currently, Jesse operates a private dental clinic in Maui, Hawaii. He also recently joined OHSU as associate faculty, with a focus on expanding the university’s 3D printing capabilities. He can be reached at jessehollander@gmail.com.
Disclosure: The authors report no disclosures.
