Original Contributions

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

Background. Microstomia is a principal clinical symptom in patients with scleroderma. It is

characterized by an abnormally small mouth opening, which makes traditional prosthetic rehabil-
itation difficult.
Methods. First, the primary impression and jaw relation record were acquired using an intraoral
scanning technique and the primary diagnostic dentures were fabricated using 3-dimensional
printing (3DP). The definitive impression and jaw relation were obtained and digitally scanned.
The second diagnostic denture was also made to confirm the esthetic and occlusal effects. Next, the
adjusted dentition parts were scanned and milled from a cross-linked polymethyl methacrylate
disk. In addition, the titanium alloy frameworks were also fabricated using 3DP. With flasking, the
milled dentition parts were inserted and the definitive dentures were finally fabricated and
delivered to the patient.
Results. The authors constructed the definitive removable partial dentures successfully using the
digital methods of intraoral scanning, computer-aided design, and 3DP.
Conclusions and Practical Implications. These digital methods provide an alternative option
for prosthetic rehabilitation in scleroderma patients with severe microstomia.
Key Words. Digital; scleroderma; severe microstomia; 3-dimensional printing.
JADA 2020:151(9):684-690
https://doi.org/10.1016/j.adaj.2020.05.016

S
cleroderma, a disease that causes fibrosis affecting connective tissues and blood vessels, is
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
Copyright ª 2020 mouth than the impression tray. Based on these advantages, intraoral scanning could be an alternative
American Dental
method for obtaining impressions for patients with microstomia. In 2017, a digital impression was
Association. All rights
reserved. successfully made for a patient with a limited mouth opening using the intraoral scanning method.14
In addition to digital impressions, 3-dimensional printing (3DP) technology has been applied

JADA 151(9) n http://jada.ada.org n September 2020 1

 successfully in
fabricating
removable
partial denture
(RPD),14-17
indicating the
promising
potential

2 JADA 151(9) n http://jada.ada.org n September 2020

of producing physical results from precise virtual reproductions. Compared with traditional
methods, the use of intraoral scanning and 3DP technologies could improve the efficiency and
convenience of both obtaining impressions and fabricating RPDs.
In this article, we describe the integrated digital rehabilitation procedure combining intraoral
scanning, computer-aided design (CAD), and 3DP technologies that we used for a scleroderma
patient with severe microstomia, including impression making, diagnostic denture design, and
fabrication of a maxillary complete denture and mandibular RPD.

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 ABBREVIATION KEY
and 4B). CAD: Computer-aided
Digital frameworks for maxillary and mandibular dentures were also designed (Figures 4C and design.
4D), and the polymerized casts were fabricated with methacrylate using digital light processing 3DP: 3-dimensional
printing.
(Halo þ, Realmaker Electronics Technology). The titanium alloy frameworks with adequate sup- PLA: Polylactic acid.
ports were manufactured using a selective laser melting machine (Concept Laser M2, GE). Before PMMA: Polymethyl
removing the supports, the titanium alloy frameworks were annealed by means of heating and methacrylate.
RPD: Removable partial
holding them at 800○C for 4 hours and then slowly cooling them in an argon environment. The denture.
annealing process decreases the strength, hardness, internal strains, and likelihood of fracture, and STL: Standard tessellation
increases the ductility and plastic strain capacity of the framework. 14 After the supports were language.
removed and polished, the frameworks were fitted to the casts (Figures 4E and 4F).
Figure 1. Front view (A), patient with vertically (B) and horizontally (C) restricted openings.

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 3. Closed-mouth impression with diagnostic dentures. Digital diagnostic dentures (A). Diagnostic dentures fabricated with 3-dimensional printing
(B). Definitive impression and jaw relation record (C).

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 5. Try in and fabrication of removable partial denture. Esthetic and jaw relation evaluation of maxillary diagnostic denture (A). Maxillary
diagnostic denture after slight adjustment (B). Computer-aided design of dentition parts (C). Milled dentition parts (D). Dentition parts inserted into
sockets (E). Fabricated removable partial denture with titanium alloy frameworks (F).

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
recorded. The partial silicone impression was then scanned as a digital one. Using this overlapping
method, the primary jaw relation record for the intraoral scanning impressions was confirmed, and
the missing gaps were filled.
Based on the primary digital casts, a pair of primary diagnostic dentures, which can also be
recognized as custom trays, were digitally designed and fabricated and then used for the maxillary
definitive impression and the jaw relation record. Before obtaining the impression, closed-mouth
functional border molding was performed on the maxillary edentulous arch to record the true
position of the labial and buccal flanges.21 Under moderate occlusal force, the closed-mouth
impression is similar to the surface of the mucosa when food is masticated using a definitive den-
ture,17 and, therefore, the denture fabricated based on this impression should have improved fit and
cause minimal tenderness.22 In addition, with suitable adjustments, the diagnostic dentures were
used to confirm and record the definitive jaw relation by means of repeated occlusion, which has
been proven in previous research.17
In the CAD process of creating diagnostic dentures, virtual tooth arrangement is important. The
tooth arrangement software used in our case can quickly and automatically finish the process based
on the occlusal plane of the edentulous arches. However, for our patient who had an irregular
mandibular condition and owing to the lack of customizable options in the software, virtual tooth
arrangement created using the software may have led to esthetic and occlusal dissatisfaction. The
secondary pair of diagnostic dentures for the third visit were therefore necessary to allow the
esthetic and occlusal effects to be evaluated and adjusted.
In addition, as indicated by the adjustment necessary to the second maxillary diagnostic denture,
fabrication of definitive dentures with proper contours and occlusion remains important. The
software used in the care of our patient was not capable of customized tooth arrangement.
Therefore, the occlusion and dentition contours of the PLA maxillary diagnostic denture were
manually adjusted according to the mandibular condition and the patient’s request. We developed
this innovative method to ensure that the definitive maxillary denture had contours and occlusion
similar to those of the adjusted pattern. First, the adjusted diagnostic pattern was scanned and
digital dentition parts were formed. The PMMA dentition parts were fabricated using milling
methods and inserted into the silicone impression sockets instead of artificial teeth. In this way, the
contour and occlusion of the definitive maxillary denture would be similar to those of the adjusted
diagnostic denture. Using this method could save considerable time in the adjustment of the
definitive den- ture. However, the long-term effects of PMMA dentition require additional study,
and customized tooth arrangement functions should be updated to meet the clinical requirements of
different patients.
In some patients with microstomia, foldable dentures connected by means of a hinge system
have been used for prosthetic rehabilitation.8,23,24 With the use of a custom-made device, the
collapsible prosthesis can be easily removed from the mouth. However, fabricating dentures with a
hinge system is a time-consuming and labor-intensive process, and repair of a broken hinge or a
missing part is complicated. In our study, we created a traditional complete denture with a
selective laser melting fabricated framework.

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 and
Shaanxi Key Laboratory of Stomatology, Department of Prosthodontics,
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.
 Dr. Wu is an associate professor, State Key Laboratory of Military Sto-
matology and National Clinical Research Center for Oral Diseases and
Shaanxi Key Laboratory of Stomatology, Department of Prosthodontics,
School of Stomatology, Fourth Military Medical University, Xi’an, China.
Address correspondence to Dr. Wu, School of Stomatology, Fourth
Military Medical University, No. 145, Changlexi St., Xi’an, 710032,
Shaanxi, China, e-mail wujiang@fmmu.edu.cn.
Disclosure. None of the authors reported any disclosures.
Drs. Yan Zhang and Luo contributed to this article equally and should be
considered co-first authors.
This work was supported by grant 2020ZDLSF04-06 from the Key Research
and Development plan of Shaanxi Province and grant 2018YFB1106902
from National Key Research and Development Program of China.
The authors also would like to thank Ms. Jing Kang and Ms. Jing Sun for
their help with the computer-aided design of the diagnostic patterns.

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