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, Çapa-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
oral orifice or microstomia1 presents many difficulties for the
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
In recent years, there has been a shift from the use of ana-
log applications to digital technologies in the field of dentistry.
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.

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Saygılı et al
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.
Journal of Prosthodontics 28 (2019) 488–492 
C 2019 by the American College of Prosthodontists
Digital Approach to Microstomia
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
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Digital Approach to Microstomia
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.
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Saygılı et al
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 segments were removed from
the mouth one by one, and fixed together outside (Fig 6). The
C 2019 by the American College of Prosthodontists
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final impressions were boxed and poured using ADA type III
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
an implant present in the edentulous maxilla that could be used
Journal of Prosthodontics 28 (2019) 488–492 
C 2019 by the American College of Prosthodontists
Digital Approach to Microstomia
as a reference point; intraoral scanning was used as a definitive
impression. In our report, intraoral scanning was used only
for preliminary impressions, while definitive impressions were
made with sectional trays. This allowed lengthening the tray
borders to vestibular depth and functionally register peripheral
tissues by border molding. Satisfactory final impressions were
made that compensated for deficiencies encountered during
intraoral scanning.
Custom trays were fabricated in 2 unequal sections with 2
separate handles in order to record the functions of the labial
frenula as recommended in a previous report.12 ZOE impres-
sion paste, a rigid nonelastomeric impression material, is the
preferred material for the final impression to facilitate securing
the tray sections after removal from the mouth.11
A collapsible denture base for the posterior and a rounded
triangular base for the anterior region with a locking mech-
anism via the stud attachment was fabricated for the max-
illa. A less expensive custom-made hinge mechanism instead
of a prefabricated one as shown previously2 was used to al-
low the denture to collapse. The present design was a slight
modification of the design described in previous reports.2,13
Instead of sharp margins and tip of the detachable triangular
segment that were described in these reports,2,13 these parts
were fabricated more rounded in order not to injure the lips
and cheek of the patient while inserting the prosthesis. The
mandibular denture was fabricated in a conventional manner,
since the patient could insert it into his mouth by rotating it
90°, reducing the complexity associated with use of sectional
prostheses.
CAD/CAM technology in prosthodontics offers patient com-
fort and reduction in the number of clinical appointments.18
However, use of digital technologies in edentulous arches does
not reasonably simplify the procedures for complete denture
fabrication.17 Conventional impressions are still needed, and
therefore clinical appointments and patient comfort are not
considerably improved. In patients with relatively less mobile
soft tissues and reduced salivary flow, such as presented in
this report, intraoral scanners may have better utility. Although
use of an intraoral scanner for complete denture final impres-
sions is not possible with current technology, it was able to
assist with obtaining a preliminary impression that was rela-
tively comfortable for the patient, which allowed fabrication of
sectional trays for making definitive impressions in a conven-
tional manner. When CAD/CAM technology finally allows ac-
curate recording of mobile soft tissues for final impressions of
edentulous arches, we will be a step closer to a fully digital
complete denture fabrication workflow.
Summary
Preliminary impressions can be made using intraoral scanners
for edentulous patients with microstomia who have immobile
soft tissues and reduced salivary flow.
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