The Saudi Journal for Dental Research (2014) 5, 93–97

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sawww.sciencedirect.com

CASE REPORT

Prosthetic management of microstomia

with sectional denture

* Corresponding author. Address: Type 2, House No. 4, Faculty

Residence, VCSGGMSRI Campus, Srinagar, Pauri Garhwal, Uttrak-

hand, India. Tel.: +91 8755902525.

E-mail address: laxmansingh6@gmail.com (L.S. Kaira).

Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

2352-0035 ª 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University.

http://dx.doi.org/10.1016/j.sjdr.2014.01.003

Laxman Singh Kaira *, Esha Dabral

Department of Dentistry, Veer Chandra Sing Garhwali Government Medical Sciences and Research Institute,Srinagar, Pauri Garhwal, Uttrakhand, India

Private Practionner, Srinagar, Garhwal, Uttrakhand, India

Received 25 November 2013; revised 3 January 2014; accepted 29 January 2014Available online 22 February 2014

KEYWORDS

Oral submucous fibrosis;

Restricted mouth opening;

Sectional denture

Abstract Prosthetic rehabilitation of microstomia patients presents difficulties at all stages as the

maximal oral opening is smaller than the size of a complete denture. Such a condition may often

result from the surgical treatment of orofacial cancer, cleft lip, trauma, burns, Plummer–Vinson

syndrome or scleroderma. Microstomia frequently leads to several incapacitating sequelae such

as the inability to masticate, speech problems, impaired delivery of oral hygiene or dental care,

and psychological problems secondary to facial disfigurement. This article focuses on fabrication

of sectional trays and sectional dentures that could enable easier and competent in a patient with

limited oral opening.ª 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University.

1. Introduction

Restoration and preservation of the dentition in patients withlimited oral opening has been a challenging task for dentists.Microstomic patients may experience a significant limitation

of mandibular opening, eccentric mandibular movements andan overall mandibular immobility. It has been reported thatthe limited oral opening may result from the surgical treatment

of orofacial cancers, cleft lips, trauma, burns, Plummer–Vin-

son syndrome, or scleroderma.The maximum oral opening that is smaller than the size of

complete denture can make the prosthetic treatment challeng-ing. Several techniques have been described for use when either

standard impression trays or the denture itself becomes toodifficult to place and remove from the mouth. Sectional den-tures have been recommended, with the denture pieces con-

nected by the clasps. Nair et al.1 describe a maxillarycomplete denture consisting of 2 pieces joined by a stainlesssteel rod with a diameter of 1 mm fitted behind the central inci-

sors. Bedard et al.2 and McCord et al.3 describe a sectionalimpression procedure for edentulous patient by using 2 plasticsectional impression trays assembled with Lego building

blocks and autopolymerizing resin. In this paper, a differentdesign for the fabrication of maxillary and mandibular sec-tional trays and a foldable maxillary and mandibular completedenture is described. Different management techniques to aid

Figure 1 Sectional trays and sectional primary impression.

94 L.S. Kaira, E. Dabral

prosthetic rehabilitation in such cases include surgical modal-ities, but unwanted scar formation may further reduce oralopening.4 The prosthetic rehabilitation of microstomia pa-

tients presents difficulties at all stages, from preliminaryimpressions to prosthesis fabrication. Making the ideal impres-sions is often encountered as the initial difficulty in treating

these patients. However, recommended techniques for obtain-ing preliminary impressions for microstomia patients have in-cluded the use of modeling plastic impression compound, the

use of stock impression trays with heavy and light body sili-cone impression materials and flexible impression trays withsilicone putty material.5 In prosthetic treatment, the loadedimpression tray is often the largest item requiring the intra-oral

placement. During the impression procedures, wide verticaland horizontal oral opening is required for proper tray inser-tion and alignment, but is not possible in patients with re-

stricted opening.6,7 The overall bulk and the height of typicalimpression trays make the recording of impressions exception-ally difficult if not impossible because the paths of insertion

and removal of impressions are compromised by lack of clear-ance. A modification of the standard impression procedure isoften necessary to accomplish this fundamental step in the fab-

rication of a successful prosthesis. This clinical report pre-sented describes a simple, cost-effective and time-savingmethod for fabrication of custom sectional trays and prosthe-sis for a patient with limited oral opening.

2. Case report

A 55 years old female patient suffering from microstomia and

poor manual ability resulting from systemic sclerosis was re-ferred to the Department of Prosthodontics, Institute of Den-tal Sciences, Rohailkhand University, Bareilly for prosthetic

rehabilitation.

2.1. Intra oral examination

The important orofacial manifestations include fibrosis of thesalivary and lacrimal glands, and symptoms consistent withdry mouth or xerostomia. The diameter and circumference

of her mouth were 36 and 27 mm, respectively. Mucosa ap-peared blanched with palpable fibrotic bands extending toright buccal frenum vestibule involving buccal frenum withshallow sulcus on right side of maxilla.

2.2. Extraoral examination

Patients develop dry eyes with keratoconjunctivitis sicca.

2.3. Procedure

2.3.1. Sectional primary impressions

Two similar stock trays are selected and sectioned antero- pos-

teriorly in such a way that excess tray after the handle is re-moved from right side of tray 1 and left on tray 2.Impressions are made separately of left and right side of the

oral cavity using irreversible hydrocolloid material (Alginate,Zelgan 2002, Dentsply, India; batch no. Z090218) (Fig. 1)and the cast obtained from impression 1. This cast orientedto impression 2 and remaining portion is poured in Model

plaster (type II) to obtain the final primary cast.

2.3.2. Sectional custom tray fabrication and final impression

A special tray with wax spacer was fabricated in acrylic (M.P.

Sai Enterprise) on primary cast. This special tray was then sec-tioned through the midline, after which cross-pin slots wereplaced on the handle of each tray using the Pindex machine.The trays were then stabilized on the cast using sticky wax

(M.P. Sai Enterprise). The cross pins, along with sleeves, wereplaced in position, petroleum jelly was applied on the outersurface of tray that would come in contact with the other half,

and the remaining portion of the tray was fabricated. To en-sure tray stability, as well as uniformity of pressure andimpression material, 4 tissue stops were placed on the intaglio

surface of the trays (Fig 2a and b). Border moulding of themaxillary and mandibular sectional trays was then completedin sections using low fusing compound (DPI Pinnacle), fol-lowed by the making of sectional final impressions using euge-

nolfree zinc oxide impression paste (Cavex, Holland) (Fig. 2cand d). The impressions were refined and the trays were assem-bled extraorally for pouring of the master casts after beading

and boxing of the same.

2.3.3. Sectional record base fabrication

Temporary record bases were fabricated on the obtained mas-

ter casts using autopolymerizing acrylic resin. The record basewere recovered and sectioned through the midline. The sec-tioned halves were then connected using size ‘0’ stainless steel

press buttons (snap fasteners, Needle Ind.) and acrylic tabs.

2.3.4. Fabrication of wax rims and sectional jaw relations

On these sectional record bases, wax rims were fabricated and

jaw relation were recorded, after placing the individual sec-tions intra-orally (Fig. 3).

2.3.5. Try-in of waxed up sectional prosthesis

The transfer of jaw relation record to the articulator, arrange-ment of teeth, and the try-in were carried out in the conven-tional manner.

2.3.6. Acrylisation of the sectional prosthesis

Before fabrications of dentures by conventional technique, thepress buttons were smoothened using acrylic stones and burs.

The master cast was duplicated using reversible hydrocolloid

Figure 2 Sectional custom tray and final impression. (a) Depicts maxillary sectional special tray. (b) Depicts mandibular sectional special

tray. (c) Depicts maxillary sectional final impression. (d) Depicts mandibular sectional final impression.

Sectional denture for osmf patient 95

(agar) and kept aside for later use. The fabrication of denture

was carried out in the following manner:

(a) The right half of the waxed up sectional prosthesis was

placed on the original master cast and sealed withwax. Three (1 in case of mandibular sectional denture)new size ‘0’ press buttons (male portion) were waxed

in position, 4–5 mm from midline (Fig. 4a).(b) The above mentioned assembly was acrylized conven-

tionally, after which the right half of the sectional pros-thesis was recovered, polished, and finished. The right

half of the sectional prosthesis was placed on the dupli-cated master cast and sealed with wax (Fig. 4b).

(c) The right half of the sectional prosthesis, along with the

duplicated master cast was duplicated again usingreversible hydrocolloid (agar) (Fig. 4d).

(d) The left half of the sectional prosthesis was placed on the

duplicated cast, and the female portions of the press

Figure 3 Jaw relation recorded.

buttons were fixed in their corresponding positions usingcyanoacylate cement (Fig. 4c).

(e) Waxing and sealing of the left half of the sectional pros-thesis was carried out, ensuring complete coverage of thepress buttons.

(f) Acrylisation of the above was carried out convention-

ally, followed by finishing, polishing the left half sec-tional prosthesis (Fig. 5a–d).

2.3.7. Sectional prosthesis delivery to the patient

After ensuring the fit and stability of the sectional prosthesis, itwas placed in the patient’s mouth (Figs. 6 and 7). The patient

was thoroughly educated and instructed regarding the use ofthe prosthesis, to ensure proper assembly of the same. Post-insertion and oral hygiene instructions were imparted, and

routine follow-up appointments were scheduled. There wasstill decrease in burning sensation and mouth opening was in-creased by 5 mm.

3. Discussion

Patients with microstomia who need to wear a removable den-

tal prosthesis often face difficulty of being unable to insert orremove the prosthesis because of restricted opening of the oralcavity. Scleroderma is an autoimmune multisystem diseaseassociated with vascular abnormalities, connective tissue scle-

rosis and autoimmune changes. Almost all patients have vas-cular symptoms that usually predate the development of thefibrotic connective tissue change. Oral manifestations of

scleroderma include: Microstomia, xerostomia, periodontaldisease, widened periodontal space, and bone resorption atthe angle of mandible.8 Limited oral opening can pose a major

dental problem and the general difficulties of reduced access

Figure 4 Acrylization of the sectional prosthesis in following steps. (a) Sectional teeth arrangement on left side. (b) Duplication of

maxillary sectional teeth arrangement. (c) Sectional teeth arrangement on the right side over the duplicated cast. (d) Duplication of

mandibular left side teeth arrangement.

Figure 5 Maxillary and mandibular sectional dentures. (a)

Depicts mandibular sectional denture dorsal view. (B) Depicts

maxillary sectional denture dorsal view.

Figure 6 Depicts preoperative photograph.

Figure 7 Depicts post operative view.

96 L.S. Kaira, E. Dabral

Sectional denture for osmf patient 97

become even more apparent when providing prostheses. Theoverall bulk and height of an impression tray makes recordingimpression exceptionally difficult, if not impossible because the

paths of insertion and removal of impressions are compro-mised by the lack of clearance. Many authors have advised sec-tional custom trays and collapsible denture systems with

complicated attachment devices. A variety of pins, bolts andLego pieces have been used for the locking mechanism of sec-tional impression trays fabricated for patients with limited oral

openings.9,10 A sectional stock tray system for making preli-minary impressions was described by Luebke.11 Impressionsusing sectional trays may be easier for patients with restrictedoral openings because the two halves can be inserted indepen-

dently, removed separately and reassembled extra-orally. Im-proved fit of the tray was possible because the two halveswere separately fitted to each side of the arch to achieve better

anatomical adaptation to the soft-tissues. Several stock traymodifications and custom tray designs have been describedin the literature.12,13 Sectional impression trays have been fab-

ricated using recesses, orthodontic screws, Lego blocks (LegoSystems Inc., Enfield, CT), dowel plug holes and a screw jointfor rigid connection, locking levers, interlocking tray segments

and flexible impression trays with silicone putty.The most important requirement when sectional trays are

used is the mechanism to accurately adapt and stabilize the twosegments of the tray to each other both intra-orally and extra-or-

ally. Also, the technique should not be complicated and alloweasymanipulation to decrease patient trauma.Uses of both ante-rior and posterior locks are important for better stability. The

technique for sectional tray described in this report fulfills allthese criteria.14,15 A maximal opening smaller than the size of acomplete denture can make prosthetic treatment challenging.

4. Conclusion

It is often difficult to apply clinical procedures to construct

dentures for patients who demonstrate limited mouth opening.However, with careful treatment planning and prudent design-ing, the use of either sectional impression techniques and/or

sectional dentures many of apparent clinical difficulties canbe overcome.

Conflict of interest

None declared.

References

1. Nair CK, Sivagami G, Kunnekel AT, Naidu ME. Dynamic

commissural splint. Indian J Dent Res 2008;19:165–8.

2. Bedard JF, Thongthammachat S, Toljanic JA. Adjunctive com-

missure splint therapy: a revised approach. J Prosthet Dent

2003;89:408–11.

3. Mccord JF, Tyson KW, Blair IS. A sectional complete denture for

a patient with microstomia. J Prosthet Dent 1989;61:645–7.

4. AI-Hadi LA, Abbas H. Treatment of an edentulous patient with

surgically induced microstomia: a clinical report. J Prosthet Dent

2002;87:423–6.

5. Bachhav VC, Aras MA. A simple method for fabricating custom

sectional impression trays for making definitive impressions in

patients with microstomia. Eur J Dent 2012;6:244–7.

6. 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;89:540–3.

7. Baker PS, Brandt RL, Boyajian G. Impression procedure for

patients with severely limited mouth opening. J Prosthet Dent

2000;84:241–4.

8. Langer Y, Cardash HS, Tal H. Use of dental implants in the

treatment of patients with scleroderma. J Prosthet Dent 1992;68:

873–5.

9. 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;84:256–9.

10. Fernandes AS, Mascarenhas K, Aras MA. Custom sectional

impression trays with interlocking type handle for microstomia

patients. Indian J Dent Res 2009;20:370–3.

11. Luebke RJ. Sectional impression tray for patients with constricted

oral opening. J Prosthet Dent 1984;52:135–7.

12. Prithviraj DR, Ramaswamy S, Romesh S. Prosthetic rehabilita-

tion of patients with microstomia. Indian J Dent Res 2009;20:

483–6.

13. Ohkubo C, Ohkubo C, Hosoi T, Kurtz KS. A sectional stock tray

system for making impressions. J Prosthet Dent 2003;90:201–4.

14. Ravindran S, Shetty V, Saraf V, Naran S. An improvised sectional

custom tray technique for patients with microstomia. J Oral

Health Res 2012;3:22–5.

15. Gauri M, Ramandeep D. Prosthodontic management of a

completely edentulous patient with microstomia: a case report. J

Indian Prosthodont Soc 2013;13:263–9.