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Rehabilitación de Un Paciente Con Esclerodermia
Rehabilitación de Un Paciente Con Esclerodermia
Clinical Dentistry
Rehabilitation for a scleroderma patient with
severe microstomia using digital and
conventional methods
Yan Zhang, MD; Jun Luo, PhD, DDS; Yumei Zhang, PhD, DDS; Jiang Wu, PhD, DDS
ABSTRACT
cleroderma, a disease that causes fibrosis affecting connective tissues and blood vessels, is
S believed to stem from a disorder of the immune system.1 In most patients, scleroderma is
characterized by thickening and hardening of the skin and loss of elasticity, giving the face a
masklike expression. Hardening of the skin around the mouth causes severe reduction in the oral
opening, and microstomia is observed in 80% of patients with systemic scleroderma.2 In these
patients, the limited mouth opening causes difficulty in accessing the teeth for oral health care
maintenance and obtaining impressions for dentures.3,4 Altered and innovative impression tech-
niques have been proposed based on modified standard and sectioned trays.5-9 Although they can be
applied successfully, these new techniques still may not be suitable for patients with severe
microstomia. Disadvantages of these modifications include the additional time required and the
difficulty in correcting the fit of the existing components.
With improvements in digital technology, intraoral scanning is becoming increasingly popular in
obtaining impressions for removable complete dentures.10,11 Compared with traditional impression
procedures, construction of a virtual cast using intraoral scanning can improve the comfort of the
patient, avoid errors related to the distortion of impression materials, and improve the efficiency and
accuracy of the procedure.12,13 Furthermore, the intraoral scanner is much easier to manipulate in the
mouth than the impression tray. Based on these advantages, intraoral scanning could be an alternative
method for obtaining impressions for patients with microstomia. In 2017, a digital impression was
Copyright ª 2020 successfully made for a patient with a limited mouth opening using the intraoral scanning method.14
American Dental
Association. All rights In addition to digital impressions, 3-dimensional printing (3DP) technology has been applied
reserved. successfully in fabricating removable partial denture (RPD),14-17 indicating the promising potential
METHODS
A 56-year-old woman with severe microstomia due to scleroderma sought treatment at the
Department of Prosthodontics at Stomatological Hospital, Fourth Military Medical University,
Xi’an, China, requesting a maxillary complete denture and mandibular RPD to restore masticatory
function. Her oral opening was measured and found to be 25 through 27 millimeters (Figure 1).
Clinical examination revealed a maxillary edentulous arch, loss of multiple mandibular anterior
teeth, and a mesially inclined no. 19 tooth. Before restoration, the periodontal treatment was
completed and home oral hygiene maintenance resulted in good condition of the residual teeth and
edentulous ridges. Owing to her severe microstomia, the traditional or customized sectional
impression tray was not an option for this patient. Therefore, we developed a novel digital treat-
ment procedure. Before the clinical treatment, informed consent was obtained from the patient, and
the clinical procedures were approved by the institutional review board of Stomatological Hospital.
Initially, embrasure clasp grooves were prepared on teeth nos. 27-30, and we used an intraoral
scanning system (Panda 2, Freqty Technology) to obtain initial digital impressions of the maxillary
and mandibular arches (Figures 2A and 2B), which were saved as standard tessellation language
(STL) data. Owing to the severely limited mouth opening and the inclination of the teeth, some
data relating to the mandibular arch were missed.
Next, the occlusal vertical dimension was measured and silicone impression material (light and
medium body Impregnum, 3M) was used to record the primary jaw relation using the 2-step method.
After both the jaw relation and partial impression were obtained (Figure 2C), we scanned the
silicone record and saved it as an STL file. By matching the data of the remaining teeth and mucosa
as references in the software (Geomagic Wrap, 3D Systems) (Figure 2D), the missing portion of the
primary mandibular impression was filled and the initial digital jaw relation was confirmed
(Figures 2E and 2F). Next, the STL data were uploaded into the denture design software (SViva FD
Designer, Shandong Hoteamsoft) to design the virtual diagnostic dentures (Figure 3A). Finally, the
polylactic acid (PLA) diagnostic dentures were fabricated using a 3D printer (Lingtong II, Beijing
Sinotech) (Figure 3B).
At the second visit, the diagnostic dentures were placed in the patient’s mouth to verify the
extension, jaw relation, and intercuspal stability. The proposed teeth setup could be modified with wax
to adjust the vertical dimension, if needed. Modeling plastic impression compound (Peri Compound,
GC Australia) was used for maxillary functional border molding. Then the closed-mouth technique
was applied to form the definitive maxillary and partial mandibular impressions with soft polyether
impression material (light body Impregum). The final jaw relation record was reconfirmed using a
polyvinyl siloxane occlusal registration material (O-Bite, DMG) (Figure 3C), and a marking pen was
used to record the esthetic information if any adjustment was required. The final maxillary and
mandibular impressions were scanned with the relation record, and, using the overlapping method, the
final digital casts were reconstructed in STL files, which were then used to design and fabricate the
definitive PLA maxillary diagnostic denture for the third visit (Figures 4A and 4B). ABBREVIATION KEY
Digital frameworks for maxillary and mandibular dentures were also designed (Figures 4C and CAD: Computer-aided
4D), and the polymerized casts were fabricated with methacrylate using digital light processing design.
3DP: 3-dimensional
(Haloþ, Realmaker Electronics Technology). The titanium alloy frameworks with adequate sup- printing.
ports were manufactured using a selective laser melting machine (Concept Laser M2, GE). Before PLA: Polylactic acid.
removing the supports, the titanium alloy frameworks were annealed by means of heating and PMMA: Polymethyl
holding them at 800 C for 4 hours and then slowly cooling them in an argon environment. The methacrylate.
RPD: Removable partial
annealing process decreases the strength, hardness, internal strains, and likelihood of fracture, and
denture.
increases the ductility and plastic strain capacity of the framework.14 After the supports were STL: Standard tessellation
removed and polished, the frameworks were fitted to the casts (Figures 4E and 4F). language.
Figure 2. Obtaining the impression and primary jaw relation record. Digital maxillary (A) and mandibular (B) impressions obtained by intraoral scanning
method. Recording primary jaw relation with silicone material (C). Alignment of maxillary and mandibular data with silicone record (D). Filling in the
missing data of the mandibular arch using the overlapping method (E). Digital jaw relation of the maxillary and mandibular impression (F).
At the third visit, the maxillary diagnostic denture was fitted to the patient for evaluation of
retention, esthetics, and jaw relation (Figure 5A). The teeth setup and occlusion were adjusted
slightly and reconfirmed. Based on the maxillary setup, the mandibular teeth were set up on the
RPD framework by an experienced technician (Figure 5B). After adjustment, the definitive
maxillary diagnostic denture was scanned (D900, 3Shape), and the dentition, including the gingival
margin, was digitally built as 3 separate parts (Figure 5C). Through a milling process, the 3 parts of
the dentition were directly fabricated from the cross-linked polymethyl methacrylate (PMMA) disk
(PMMA Disk, Yamahachi Dental) (Figure 5D). Next, we wrapped the maxillary dentition part of
the PLA diagnostic denture with silicone impression material (Zetalabor, Zhermack) and heated it
with water. The softened maxillary pattern was removed, and the milled dentition parts were
Figure 4. Computer-aided design (CAD) and 3-dimensional printing of diagnostic denture and removable partial denture (RPD) frameworks. CAD of
secondary maxillary diagnostic denture (A). Polylactic acid maxillary diagnostic denture fabricated using 3-dimensional printing (B). CAD of RPD
frameworks (C, D). Titanium alloy RPD frameworks fabricated by selective laser melting fit on the casts (E, F).
inserted into the tooth sockets (Figure 5E). Next, we filled the 3DP framework with acrylic resin,
and the final RPDs were made using the injection molding process (Figure 5F).
A prosthodontic consultant assessed the quality of fit of the RPD in the patient’s mouth ac-
cording to recommended standard practice,18 and we successfully fitted the dentures for the patient
with scleroderma and severe microstomia (Figure 6). Home care and hygiene instructions were
provided to the patient. After 2 weeks of wear, the patient returned because of tenderness, and the
dentures were adjusted slightly. At the 10-month follow-up examination, we found that the den-
tures fit well without discomfort.
DISCUSSION
Obtaining impressions is the key step in prosthetic rehabilitation. During impression procedures, a
wide vertical and horizontal oral opening is required for proper tray insertion and alignment, which
is not possible in patients with severe microstomia.19 Although the sectional impression tray
method has been proposed and used successfully in some patients, the additional time, materials,
and labor make it more complicated. Wide application of an intraoral scanning system in dentistry
could be an alternative method of obtaining impressions for patients with restricted mouth
Figure 6. Insertion of removable partial dentures (RPD). Right lateral view after placement of RPD (A), front view after placement of RPD (B), left lateral
view after placement of RPD (C).
openings.14 The advantages of this method include avoiding patient discomfort, potential allergies
to impression materials, and errors related to the distortion of impressions.20
In this case, however, it was still difficult to make integral and accurate impressions using only the
intraoral scanning method. Although the primary digital impressions were acquired by means of
intraoral scanning, some data from the mandibular arch were still missing owing to restricted mouth
opening and tooth inclination. In addition, we were not able to record definitive impressions of the
maxillary edentulous arch and the jaw relation record. Therefore, we developed a combined
impression process including the digital method. After the primary intraoral scanning impression,
we placed silicone impression material in the patient’s mouth using the 2-step method. In this way,
the primary jaw relation was confirmed, and the contours of the residual ridge and teeth were
CONCLUSIONS
We developed a digital option for treating a patient with microstomia requiring a removable
prosthesis. Through the use of intraoral scanning, CAD and computer-aided manufacturing, and
3DP methods, we successfully fabricated a maxillary complete denture and a mandibular RPD. With
future digital developments, we believe this process will become both more convenient and more
efficient. n
Dr. Yan Zhang is an attending doctor, State Key Laboratory of Military Dr. Yumei Zhang is a professor, State Key Laboratory of Military
Stomatology and National Clinical Research Center for Oral Diseases and Stomatology and National Clinical Research Center for Oral Diseases
Shaanxi Key Laboratory of Stomatology, Department of Prosthodontics, and Shaanxi Key Laboratory of Stomatology, Department of Prostho-
School of Stomatology, Fourth Military Medical University, Xi’an, China. dontics, School of Stomatology, Fourth Military Medical University,
Dr. Luo is an associate professor, Stomatological Hospital of Chongqing Xi’an, China.
Medical University, Chongqing, China.
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