Journal of Oral Rehabilitation 2005 32; 696–700
A prosthodontic management alternative for scleroderma
patients
M . Y E N I S E Y , T . K Ü L Ü N K , Ş. K U R T & Ç . U R A L
of Ondokuz Mayıs, Samsun, Turkey
SUMMARY Hardening of the skin around the mouth
causes the oral opening to become limited in
scleroderma patients. A maximal oral opening that
is smaller than the size of a complete denture can
make prosthetic treatment challenging. This clin-
ical report presents the prosthodontic management
of a total edentulous patient with microstomia
induced by scleroderma. Sectional mandibular and
maxillary trays and a collapsed mandibular den-
ture were fabricated for the total edentulous
Introduction
Scleroderma is a disease that involves connective
tissues and blood vessels and leads to fibrosis. This
causes a clinical picture characterized by hardening and
tightening of the skin and mucosa (1–4). The aetiology
of scleroderma is unknown but it is characterized by
both vascular injury and overproduction of normal
collagen (1).
The first symptom with scleroderma is deformity
in the fingers and the toes, caused by a circulation
disorder, called the Raynaud phenomenon. The early
skin effects begin with the oedema of the face and
extremities. It is followed by the loss of elasticity. The
rigidity of the perioral skin causes restriction of the oral
orifice. Oral hygiene and routine dental care become
difficult. Fibrosis of salivary glands gives rise to xero-
stomia and potentially to cervical caries. Accentuation
of periodontal disease also occurs, believed to be due
not only to poor oral hygiene but also to the vascular
changes associated with the disease itself. With disease
progression may come a uniform widening of the
periodontal ligaments of all teeth (3–9).
ª 2005 Blackwell Publishing Ltd
Department of Prosthodontics, Faculty of Dentistry, University
patient. With the use of lingual midline hinge,
the collapsed denture was successfully and easily
inserted and provided adequate function in the
patient’s mouth. The cast hinge design reduced the
overall costs and simplified the laboratory tech-
nique.
KEYWORDS: complete denture, microstomia, sclero-
derma
Accepted for publication 18 October 2004
This change seen in a minority of patients occurs at
the expense of alveolar bone (lamina dura) rather than
root surface. In addition, in a minority of patients there
is mandibular bone resorption in non-tooth bearing
areas. The inferior border, the posterior border of the
ramus, the mandibular angle, and the coronoid and
condylar processes may exhibit radiographic evidence
of resorption. This is believed to be related to an
associated muscle atrophy, pressure of tightening of
skin overlying the bone and vascular changes (2).
The most common problem with dental treatment of
scleroderma patients is the physical one caused by the
narrowing of the oral aperture and rigidity of the
tongue. The oral opening may be increased an average
of 5 mm by use of stretching exercises. One particularly
effective technique is the use of an increasing number
of tongue blades between the posterior teeth to stretch
the facial tissues. If this is insufficient a bilateral
commissurotomy may be necessary (1).
Without surgical operation it is very difficult to
perform prosthetic treatment for patients with micro-
stomia, especially when the mouth circumference
length is <160 mm. Because the smallest diameter of
696
 PROSTHODONTIC TREATMENT OF SCLERODERMA
a fully retentive denture and a impression tray may be
larger than the greatest diameter of the mouth opening,
a sectional impression tray and a sectional denture may
be indicated (3, 9).
This clinical report describes a technique for the
fabrication of mandibular and maxillary sectional trays
and a sectional mandibular complete denture fabrication
for a patient with microstomia induced by scleroderma.
Clinical report
A 37-year-old (B.A.) total edentulous female sought
treatment at the prosthodontic department of the
faculty of dentistry of OMU University (Samsun,
Turkey). She had a limited oral opening of about
40 mm, caused by scleroderma, and other symptoms
of scleroderma. The patient had the symptoms of
scleroderma in her hands (Fig. 1).
B.A. had complained of scleroderma symptoms since
she was 19 years old. Scleroderma was not diagnosed in
her family. She ended the drug therapy because of
adverse effects and used only an anti-inflammatory
drug (275–550 mg naproxen sodium) every day. Her
alveolar crest was sufficiently high, but her mucosa
was thin. She had a limited oral opening and her lips
were stretched. Saliva quantity and flowability were
adequate. Various treatment options were discussed,
and the patient accepted the treatment described
below.
Impression procedure
Preliminary impressions for both dental arches were
obtained with a putty silicon impression material
Fig. 1. Malformed hands of the patient.
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 696–700
697
Fig. 2. Sectional individual trays for the maxillary and mandib-
ulars arches with metal snaps.
(Zetaplus*) by finger pressure. The diagnostic casts
were poured with dental stone (Moldano†).
An autopolymerizing acrylic resin (Meliodent‡) tray
was prepared on each stone cast. For each tray a total of
four metal snaps were attached (Fig. 2). Two female
parts were attached on the canine regions and two were
attached on molar regions. And another block that was
carrying the male parts of the snaps were constructed.
In the mandibular tray only one block was adequate for
the stability of the right and left parts. In the maxillary
tray two blocks were constructed and they were joined
together to provide stability.
Border moulding was alternately made for the first
and second halves of the sectional trays. Impression
trays were inserted into the patient’s mouth in two
separate pieces: left and right. After placement, these
pieces were stabilized by means of the acrylic resin
block. A zinc-oxide eugenol impression paste§ was
placed on the impression tray. After the impression
paste set, the acrylic resin blocks were detached in the
mouth, and the right and left pieces were removed
separately by fracturing the impression material. The
acrylic resin blocks were carefully joined out of the
mouth, and after it was determined that the fracture line
joined smoothly, dental stone (Moldano†) was poured.
In the maxillary impression procedure we realised
that the oral opening was sufficient for the maxillary
tray when it was removed from the mouth with the
*Zhermack, Rovigo, Italy.
†
Bayer Dental, Leverkusen, Germany.
‡
Bayer UK Ltd, Newbury, UK.
§
S.S. White Manufacturing, Gloucester, UK.
698 M . Y E N I S E Y et al.

right and left pieces together. Because of this, a sectional

maxillary complete denture was not necessary. Jaw
relation records were obtained with the use of occlusion
rims oriented to the established vertical dimension of
occlusion, the anatomic occlusal plane, and the
patient’s centric relation. The try-in sectional denture
was evaluated to verify jaw relations and tooth
arrangement.

Fabrication process

The wax patterns for the left and right halves of the
Co–Cr frameworks of the mandibular denture were
Fig. 3. Completed mandibular prosthesis with the hinge in the
fabricated on a phosphate-bonded refractory cast lingual midline.
(Wirowest¶). A plastic pattern of the concave hinge
cylinder was constructed, invested and cast with Co–Cr
alloy (Wironit¶) separately. It was desprued, polished
and returned to the master cast. This hinge part was
connected at the lingual midline of the framework by
soldering.
This hinge design allowed for the rigid connection of
the left and right segments (Fig. 3). A labial swing-lock
attachment was not necessary for the mandibular
denture because the dimensions of the hinge design,
and the frictional stability of the parts, were sufficient
for both left and right segment’s stability in delivery.
To prevent resin flowing into the connecting area,
silicone impression material was placed into the gap
in the hinge design. Heat-polymerized acrylic resin
Fig. 4. Insertion of collapsed mandibular prosthesis.
(Meliodent‡) was then polymerized, and the dentures
were completed with conventional techniques.
Home care instruction was given to the patient on narrowing of the oral opening and rigidity of the
the operation of the lock and hinge assembly. The tongue. In some cases successful prosthetic treatment
patient expressed her satisfaction with this method of for a patient with microstomia is very difficult without a
placement (Fig. 4). Recalls have been performed every surgical operation (3–9).
3 months. In the second recall it was realized that The construction of complete or partial prosthesis
the hinge design alone could not maintain uniform without surgical operation has been studied by various
retention and stability. For this reason a micro-anchor authors. Some of these prosthesis are sectional (4–6),
was added as a secondary labial lock, to prevent magnetic (7, 10, 11) or collapsed (3, 9).
denture deflection during chewing (Figs 5 and 6). Patients with scleroderma often present with caries
Follow-up was continued with satisfactory results and moderate-to-advanced periodontal disease due to
(Fig. 7). poor oral hygiene and patient susceptibility. Limited
access to the oral cavity makes definitive treatment
difficult, and extraction often becomes the treatment of
Discussion
choice. Denture fabrication is complicated by limited
The most common problem with dental treatment of access and the constriction of the alveolar ridges and
scleroderma patients is the physical one caused by the border extensions. The denture borders are usually far
short of what is considered normal, and in some
¶
Bego, Bremen, Germany. situations, sectional dentures must be fabricated (12).

ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 696–700

 PROSTHODONTIC TREATMENT OF SCLERODERMA 699

Prior to the introduction of endosseous implants,

saving teeth for use with an overdenture was viewed as
advantageous. For example, copings could be placed
and a magnetic retention system could assist in guiding
the denture into place. In scleroderma patients, this
seemed to help compensate for the patient’s decreased
manual dexterity, but these teeth were often lost due to
caries or periodontal disease. The use of implants solved
the caries problem but did not solve the insertion
problem associated with removable overdentures
(12, 13). However in these cases the patient must be
scheduled for routine monthly recall appointments to
have the implant abutments professionally cleaned.
Fig. 5. Figure of the micro-anchor.
The fabrication of complete dentures depends on
making accurate final impressions that capture the
movable tissues in their functional state. A few methods
have been advocated to obtain optimal final impres-
sions. Border moulding and a custom tray with mod-
elling plastic impression compound before making final
impressions is an established technique for recording
these tissues (8).
In our totally edentulous patient maxillar and man-
dibular impressions were obtained by conventional
techniques. The only difference was the individual tray
with two pieces.
When the oral opening is limited, joining the pieces
of a sectional denture base intraorally may be prob-
lematic (4). For this reason we preferred to fabricate the
Fig. 6. Buccal view of the prosthesis with micro-anchor.
collapsible design mandibular complete denture.
Although our patient had difficulty using her hand,
she was able to use this design very easily.

Conclusions
For the patient described, a sectional mandibular
denture was a suitable treatment to resolve the problem
of microstomia caused by scleroderma. The cast hinge
design reduced the overall costs and simplified the
laboratory technique. This technique has proven to be
simple, inexpensive and applicable to selected micros-
tomic patients.

Fig. 7. Frontal view of patient after insertion of maxillary and References

mandibular prosthesis.
1. Lynch MA, Brightman VJ, Greenberg MS. Oral medicine
In our totally edentulous patient we fabricated a diagnosis and treatment. 9th ed. Philadelphia: JB Lippincott;
1994:578.
complete denture which had a hinge on the middle of
2. Regezi JA, Sciubba J. Oral pathology clinical-pathologic
the lingual surface of the prosthesis and patient used correlations. 2nd ed. Philadelphia: WB Saunders, 1993:582.
this design without any problem.

ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 696–700

700 M . Y E N I S E Y et al.
3. Suzuki Y, Abe M, Hosoi T, Kurtz KS. Sectional collapsed
denture for a partially edentulous patient with microstomia: a
clinical report. J Prosthet Dent. 2000;84:256–259.
4. Cura C, Cotert HS, User A. Fabrication of a sectional
impression tray and sectional complete denture for a patient
with microstomia and trismus: a clinical report. J Prosthet
Dent. 2003;89:540–543.
5. Al-Hadi LA. A simplified technique for prosthetic treatment of
microstomia in a patient with scleroderma: a case report.
Quintessence Int. 1994;25:531–533.
6. Al-Hadi LA, Abbas H. Treatment of an edentulous patient with
surgically induced microstomia: a clinical report. J Prosthet
Dent. 2002;87:423–426.
7. Watanabe I, Tanaka Y, Okhubo C, Miller AW. Application of
cast magnetic attachments to sectional complete dentures for
a patient with scleroderma: a clinical report. J Prosthet Dent.
2002;88:573–577.
8. Cheng AC, Wee AG, Shiu-yin C, Tat-Keung L. Prosthodontic
management of limited oral access after ablative tumor
surgery: a clinical report. J Prosthet Dent. 2000;84:269–273.
9. Okhubo C, Watanabe I, Tanaka Y, Hosoi T. Application of cast
iron-platinum keeper to a collapsible denture for a patient
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 696–700
with constricted oral opening: a clinical report. J Prosthet
Dent. 2003;90:6–9.
10. Watanabe I, Tanaka Y, Fukunaga H, Hisatsune K, Atsuta M.
Attractive force of castable iron-platinum magnetic alloys.
Dent Mater. 2001;17:197–200.
11. Watanabe I, Hai K, Tanaka Y, Hisatsune K, Atsuta M. In vitro
corrosion behavior of cast iron-platinum magnetic alloys.
Dent Mater. 2001;17:217–220.
12. Haas SE. Implant-supported, long-span fixed partial denture
for a scleroderma patient: a clinical report. J Prosthet Dent.
2002;87:136–139.
13. Patel K, Welfare R, Coonar HS. The provision of dental
implants and a fixed prosthesis in the treatment of a patient
with scleroderma: a clinical report. J Prosthet Dent.
1998;79:611–612.
Correspondence: Dr Murat Yenisey, Ondokuz Mayıs Üniversitesi Dis¸
Hekimliği Fakültesi, Protetik Dis¸ Tedavisi Anabilim Dalı, 55139
Kurupelit-Samsun, Turkey.
E-mail: muratyen@omu.edu.tr