Prosthetic Rehabilitation of an Edentulous Patient

with Microstomia Using Both Digital and

Conventional Techniques: A Clinical Report
Sina Saygılı, DDS, Onur Geckili, DDS, PhD , & Tonguc Sulun, DDS, PhD
Department of Prosthodontics, Istanbul University, Faculty of Dentistry, Istanbul, Turkey

Keywords
Collapsible complete denture; intraoral
scanning; microstomia.
Correspondence
Dr. Onur Geckili, Istanbul University, Faculty
of Dentistry, Department of Prosthodontics,
2nd floor, C¸ apa-Istanbul, Turkey. E-mail:
geckili@istanbul.edu.tr
Abstract
This clinical report describes prosthetic rehabilitation applied to an edentulous
patient with microstomia. Intraoral scanning was used for preliminary impressions,
edentu- lous models were printed using a 3D printer, custom 2-piece impression
trays for definitive impressions were made, and a 2-piece collapsible maxillary and
a conven- tional mandibular denture were fabricated. Intraoral scanning is a useful
alternative to conventional impression techniques and can be used safely in patients
with microsto- mia for preliminary impressions.

The authors deny any conflicts of interest

regarding this study.

Accepted March 25, 2019

doi: 10.1111/jopr.13061

Prosthetic rehabilitation of patients with an abnormally small In recent years, there has been a shift from the use of ana- log
oral orifice or microstomia1 presents many difficulties for the applications to digital technologies in the field of dentistry.
clinician from examination to final delivery of the
prosthesis.2 Patients with microstomia present with limited
mouth open- ing and jaw mobility that makes impression
procedures challenging.2-5 Impression methods need to be
modified start- ing from preliminary impressions since it may
not be possible to use stock impression trays. Making high-
quality preliminary impressions that record all anatomic
landmarks is mandatory for successful complete denture
treatment.5 Moreover, numer- ous clinical trials have shown
that the one-step impression pro- cedure for complete denture
fabrication produces similar suc- cess rates compared to
dentures fabricated using conventional two-step impression
techniques if the preliminary impressions are of high
quality.5-9
Preliminary impressions from patients with microstomia
have been made using various tray modifications such as
antero- posteriorly or mediolaterally sectioned or flexible
trays.10-13 Im- pressions without conventional trays have also
been described using an initial vinyl polylsiloxane (VPS)
impression as a cus- tom tray.3 Even though these techniques
have been used suc- cessfully, the proper method for making
a preliminary impres- sion for an edentulous patient with
microstomia has not been determined. Instead, selection of an
applicable technique is left to clinician skills and
preferences.4
488 Journal of Prosthodontics 28 (2019) 488–492 §C 2019 by the American College of
Prosthodontists
Today, it is possible to make impressions and
design and fab- ricate dental restorations using
computer-aided technologies.14 These
technologies not only reduce time spent
chairside and at the laboratory, but also provide
greater accuracy of defini- tive restorations.15,16
With the use of intraoral scanners for
impressions, tray selection and adaptation,
infection transmis- sion from patients, and
shipping of the impressions to the lab- oratory
are eliminated.17,18 The efficacious use of
computer- aided design and computer aided
manufacturing (CAD/CAM) in tooth- or
implant-supported fixed prosthodontics has been
well documented.14-17 However, the application
of CAD/CAM in complete denture impressions
has been limited. Since the dy- namic
movements of soft tissues cannot be precisely
captured digitally, and errors are encountered
because of the dispersed reflection of saliva on
soft tissues, it is difficult to use intraoral
scanners to capture edentulous arches.17
Conventional methods are used to make the
preliminary and final impressions and to
fabricate dental casts, and the casts are
digitalized using table- top scanners
afterwards.17 The subsequent steps are acquired
with CAD/CAM after scanning the dental
casts.14-17 However, microstomia patients
usually have a history of surgical treat- ment of
head or neck tumors or some other systemic
diseases that result in less displaceable soft
tissues and reduced salivary flow due to
formerly received radiotherapy.15 In these
patients, because of the above-mentioned
factors, it might be easier to capture edentulous
arches and gather more precise digital im- ages,
at least for obtaining the preliminary models.

Journal of Prosthodontics 28 (2019) 488–492 §C 2019 by the American College of 489

Prosthodontists
Digital Approach to
Microstomia
Figure 1 Application of intraoral scanner using a plastic dental
retractor.
Figure 2 STL file format of edentulous maxilla.
Figure 3 Mandibular edentulous cast printed using PLA.
The aim of this clinical report is to present the prosthetic
treatment applied to an edentulous patient with microstomia
using an intraoral scanner for preliminary impressions.
Saygılı et al
Figure 4 Maxillary sectional tray with a locking mechanism using dowel
pins.
Figure 5 Mandibular sectional tray with a locking mechanism using
dowel pins.
Figure 6 Maxillary impression after the tray segments were joined.
Clinical report
A 63-year-old edentulous man with microstomia with a his-
tory of surgical excision of a lower lip squamous cell carci-
noma with subsequent surgical reconstruction, was referred to
Department of Prosthodontics, Faculty of Dentistry at Istan-
bul University. Before undergoing oral cancer treatment, his

Figure 7 Two-piece maxillary framework.
Figure 8 Hinge mechanism of the maxillary denture.
Figure 9 Definitive maxillary denture.
remaining teeth were extracted with no immediate prosthetic
rehabilitation. His oral opening measured 20 to 25 mm
because of the extremely taut reconstructed lower lip.
Therefore, it was decided to fabricate a sectional maxillary
and a conventional mandibular complete denture.
Journal of Prosthodontics 28 (2019) 488–492 §C 2019 by the American College of
Prosthodontists
Figure 10 Definitive prosthesis in place.
Since it was not possible to insert the smallest tray for pre-
liminary impressions, an intraoral scanner (Carestream 3600;
Rochester, NY) was used to obtain 3D intraoral scans and
gener- ate digital models of the edentulous maxillary and
mandibular arches. The tightness of the lip and the limited
oral aperture made it difficult to use a dental mirror for
retraction. A plas- tic dental retractor was used for broadening
the lips to achieve visibility of the vestibular sulcus (Fig 1)
and allow intraoral scanning to be performed successfully.
The same procedure was completed for both arches. For the
mandibular arch, a den- tal mirror was used to hold the
tongue while scanning. When the scanning procedure was
finished, digital data was exported as standardized
stereolithography (STL) file format (Fig 2) to import to the
supporting software of the fused + deposition mod- eling
(FDM) 3D printer (Ultimaker 2 ; Ultimaker B.V., Gel-
dermalsen, The Netherlands). The maxillary and mandibular
edentulous
± casts were printed using polylactic acid (PLA)
with a 100 µm accuracy (Fig 3).
Custom impression trays were fabricated using autopoly-
merizing acrylic resin (Vertex; Vertex-Dental BV, Zeist, The
Netherlands) on the printed PLA models following
procedures described in previous reports. 11 Both trays were
divided diag- onally into 2 unequal sections, and the 2
sections were joined using medium-sized dowel pins (dowel
pin # 5420074; MTD Dental Products, Tel Aviv, Israel) with
the aid of a surveyor (Rotaxdent, Istanbul, Turkey) to position
them parallel to each other (Figs 4 and 5). 2 Separate tray
handles were prepared on both sections of the trays. Tray
borders were trimmed 2 mm short of the vestibular depth to
gain space for border molding and evaluated intraorally for
adaptation.
Modeling plastic impression compound (Kerr Green
Sticks: 00444; Kerr Corp, Orange, CA) was used on both
segments of the tray borders to register the functional labial
and buc- cal vestibule, frena, and postpalatal seal areas. A
zinc-oxide eugenol (ZOE) impression paste (S.S. White Mfg,
Gloucester, UK) was used for the final impressions. The
impression paste was placed in the tray segment with the pins
initially and after setting the other tray segment with the
impression paste placed over the pins to secure locking of the
2 tray segments. After the impression material set, the tray
491
segments were removed from the mouth one by
one, and fixed together outside (Fig 6). The

490 Journal of Prosthodontics 28 (2019) 488–492 §C 2019 by the American College of

Prosthodontists
final impressions were boxed and poured using ADA type III an implant present in the edentulous maxilla that could be used
dental stone (Anadolu Dental Products, Istanbul, Turkey).
Maxillary and mandibular denture bases were fabricated
with Cr-Co-Mo reinforcement (Wironit LA; BEGO, Bremen,
Ger- many). The maxillary base consisted of 2 segments (Fig
7). The posterior segment was fabricated with a custom-made
hinge mechanism to create a foldable appliance and 2-stud
attachment (Vario-Stud-Snap vks; Bredent) patrices in the
canine regions. The anterior segment on which the maxillary
anterior teeth would be arranged was fabricated with
embedded correspond- ing matrices in the canine region. The
hinge mechanism of the posterior segment that enabled the
denture to collapse was de- signed in the laboratory as
described previously (Fig 8).2 Since it was possible to place
the mandibular denture in the mouth by changing the
direction while inserting, the mandibular frame- work was
produced in one piece.
After the frameworks were tried intraorally, the maxillo-
mandibular relationship was recorded with wax and
transferred to a simple hinge articulator. The artificial teeth
(Ivoclar Vi- vadent AG, Schaan, Liechtenstein) were
arranged, and the try- in dentures were evaluated intraorally.
Two-piece maxillary and one-piece mandibular dentures were
processed using heat- polymerized polymethylmethacrylate
(Meliodent; Bayer UK Ltd, Newbury, UK) and delivered to
the patient (Fig 9). The patient was instructed to fold the
posterior segment of the max- illary denture and lock it with
the anterior detachable segment in the mouth. Written
instructions with figures for prostheses insertion, removal,
and cleaning were provided to the patient. The patient had no
difficulties using the dentures, and satis- factory results were
obtained during a 1-year follow-up period (Fig 10).

Discussion
For the patient presented, preliminary impressions were made
using an intraoral scanner, which is often not recommended
in edentulous arches because of the inability of these devices
to capture displaceable soft tissues.17 A high-resolution
intraoral scanner working without powder was selected to
protect the patient from the possible adverse health effects
that may oc- cur from inhalation of large amounts of powder
that should be applied to capture the entire edentulous areas. 17
During the scanning of soft tissues, some difficulties were
encountered (i.e., capturing the frenula and the vestibular
sulcus). The op- erating system occasionally revealed errors,
but deleting and rescanning made it possible to create an
acceptable STL file to produce a 3D-printed model. Because
the patient had relatively immobile soft tissues and reduced
salivary flow, the printed models were adequate to fabricate
custom trays. This method is superior to the methods
described using VPS without trays for preliminary
impressions.3,11 Impressions without trays may be corrupted
with the weight of the gypsum when pouring, since they are
not supported, and the casts on which the custom trays are to
be fabricated may not reflect the soft tissues, which in turn
could negatively affect the retention and stability of the
definitive prosthesis.
A similar method applied in a patient with an excessively
tight reconstructed lip has been described by Kim et al, 15 with
as a reference point; intraoral scanning was used
as a definitive impression. In our report, intraoral
scanning was used only for preliminary Summary
impressions, while definitive impressions were
Preliminary impressions can be made using intraoral scanners
made with sectional trays. This allowed
for edentulous patients with microstomia who have immobile
lengthening the tray borders to vestibular depth
soft tissues and reduced salivary flow.
and functionally register peripheral tissues by
border molding. Satisfactory final impressions
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