|Year : 2013 | Volume
| Issue : 4 | Page : 290-293
Prosthodontic rehabilitation of edentulous patient with surgical induced microstomia
Virsen Patil1, Milind Limaye1, Santosh Shingote1, Koyena Mishra2
1 Department of Prosthodontics, Vasantdada Patil Dental College and Hospital, Sangli, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Kalaka Dental College, Meerut, Uttar Pradesh, India
|Date of Web Publication||7-Feb-2014|
Department of Prosthodontics, Vasantdada Patil Dental College and Hospital, Sangli - 416 416, Maharashtra
Source of Support: None, Conflict of Interest: None
A restricted mouth opening which seems smaller than the size of a complete denture can make prosthetic treatment challenging. Several techniques have been described for use when either standard impression trays or the denture itself becomes too difficult to insert and remove from the mouth. This case report describes innovative techniques of primary impression, sectional custom tray, sectional denture base, and fabrication of 'customized hinge' for hinged mandibular denture.
Keywords: Hinge, hinged denture, microstomia, sectional
|How to cite this article:|
Patil V, Limaye M, Shingote S, Mishra K. Prosthodontic rehabilitation of edentulous patient with surgical induced microstomia. Int J Health Allied Sci 2013;2:290-3
|How to cite this URL:|
Patil V, Limaye M, Shingote S, Mishra K. Prosthodontic rehabilitation of edentulous patient with surgical induced microstomia. Int J Health Allied Sci [serial online] 2013 [cited 2021 Jan 16];2:290-3. Available from: https://www.ijhas.in/text.asp?2013/2/4/290/126765
| Introduction|| |
Microstomia is caused by burns, scleroderma, postoperative head and neck trauma, and surgical resection of facial and oral neoplasms. The contracture of the tissue that surrounds the oral cavity may affect the patient's ability to obtain optimal dental care and maintain good oral hygiene. Patients with extensive head and neck injuries due to trauma and/or extensive surgical procedures often exhibit a severely limited ability to open the mouth. Without surgical operation, it is very difficult to perform prosthetic treatment for patients with microstomia, especially when the mouth circumference length is less than 160 mm. 
A restricted mouth opening which seems smaller than the size of a complete denture can make prosthetic treatment challenging. Several techniques have been described for use when either standard impression trays or the denture itself becomes too difficult to insert and remove from the mouth. During impression procedures, wide mouth opening is required for proper tray placement. In restricted opening ability, a modification of the standard impression procedure is often necessary to accomplish this fundamental step in the fabrication of a successful prosthesis. 
Several methods of prosthodontic treatment for patients with microstomia have been presented, and numerous devices to expand oral commissure have been described. ,,,,,,, A sectional denture has been advocated for severe cases of microstomia.  Sectional impression trays for both primary and final impressions of maxillary edentulous arches have been introduced. Luebke  described a sectional impression procedure for dentulous patients by using two plastic sectional impression trays assembled with Lego building blocks (Lego Systems Inc, Enfield, Conn.) and autopolymerizing resin. Whitsitt and Battle  introduced a procedure for primary impressions of dentulous arches using putty silicone as a flexible tray, washed with light body silicone to obtain more detail. Heasman et al.,  modified a procedure for making final impressions of dentulous arches by using two sectional acrylic resin impression trays joined together with two fins. Moghadam  advocated a practical procedure to obtain maxillary primary casts of dentulous patients. Two identical perforated stock trays are cut symmetrically, leaving their own handles attached. The trays are cut minimally in width to allow their insertion into the oral cavity with ease.
This case report describes innovative techniques of primary impression, sectional custom tray, sectional denture base, and fabrication of 'customized hinge' for hinged mandibular denture.
| Clinical Report|| |
A 62-year-old male patient was with complains of inability to chew food. Patient had undergone for surgical resection of carcinoma of right lower lip, which was done 2 years back.
On examination, patient had restricted mouth opening with diameter 32 mm and circumference length of his mouth 110 mm because of perioral postsurgical skin contracture [Figure 1]. Patient was edentulous with fibrous band at lower right labial sulcus. Patient refused for surgical opening of mouth aperture so, fabrication of denture prosthesis with altered impression procedure was planned.
- It was impossible to insert standard impression tray for mandibular preliminary impression so modification of treatment plan was adopted only for mandibular denture.
- As upper lip was able to retract, maxillary preliminary impression was made with stock tray of small size with impression compound (Y-Dent, MDM Corp. India).
- For mandibular impression plastic stock tray was selected and cut in the lingual side at the midline which made it to flex. Molding of lingual sulcus and distobuccal part was done with impression compound and putty impression (Aquasil, Dentsply, India) was made. Elasticity of silicone impression material and cut in midline of tray allowed flexibility to impression while removing it from mouth [Figure 2].
- For fabricating mandibular sectional custom tray, dowel pin with special plastic sleeve was incorporated in handle of the autopolymerized resin tray and then it was sectioned [Figure 3]a. Sectional border molding was performed with low fusing compound (DPI Pinnacle, India) and final impression was made with light body addition silicone. Two sections were rejoined outside the mouth and poured in a dental stone. Maxillary border molding and final impression was performed in usual manner [Figure 3]b.
- While fabricating autopolymerized resin mandibular denture base, two 4 mm orthodontic wire of 21 gauges with retentive bends at one end were prepared and incorporated at midline in such way that retentive end of one wire to the right and one to the left. Denture bases was then sectioned and pulled to get sectional base with one pin and one hole on each side for rejoining [Figure 4]a.
- Occlusal rims were fabricated with modeling wax. It was easy to rejoining mandibular sectional denture base in mouth with pin and hole adjustments [Figure 4]b. Jaw relation records were obtained and transferred to a mean value articulator with the use of occlusion rims oriented to the established vertical dimension of occlusion, the anatomic occlusal plane, and the patient's centric relation [Figure 5]. The artificial teeth were arranged with the use of remaining maxillary teeth and the anatomical landmarks of the mandibular residual ridge. The try-in sectional denture was evaluated to verify jaw relations and tooth arrangement.
- After try in, denture fabrication was done in usual manner.
- Customizing hinge: It was planned to attach hinge on lingual side of mandibular denture at midline. Vertical height available for hinge at midline was less for any prefabricated hinge, so hinge customization was planned. Two plates of pattern resin (GC Dental Corp, Japan) were formed in a shape as like key and keyway locks. They were united together and with the help of surveyor and micromotor a hole was drilled in the center of lock. Space for autopolymerized resin was prepared in plates and retention holes were created away from the attaching part. Two resin parts then were separated and casted separately with Co-Cr alloy. After casting they were finished and polished [Figure 6]a. With help pattern resin the middle rod was fabricated in the plates where hole was drilled. The rod was then casted and finished. Hence, we got three casted parts two plates and one central rod. Rod was then fitted in the central hole and its end was soldered. Thus, customized hinge was ready for attachment.
- After fabrication denture was not removed from the cast. Space for hinge attachment was prepared on lingual side of mandibular denture and methylene chloride was applied to the created space to improve bonding of autopolymerized resin with heat-cured denture. With autopolymerized resin, hinge was attached to denture. Denture was sectioned till the attachment from labial side. Hinge makes denture foldable and easy for insertion [Figure 7]a.
- Denture was then finished and polished. During insertion appointment, maxillary denture can be inserted with retracting upper lip and mandibular denture was folding with the help hinge. Patient was instructed about use and care of denture and hinge attachment. Patient was then recalled for follow-up [Figure 7]b.
- Follow-up was continued over 6 months with satisfactory results. The patient expressed his satisfaction with this method of placement.
|Figure 2: (a) Cut was given to plastic stock tray lingually at midline and lingual flanges were molded with impression compound (b) Primary impression recorded with addition silicone putty|
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|Figure 3: (a) Die pin was inserted in the handle to produce sectional custom tray. (b) Final impression after sectional border molding|
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|Figure 4: (a) 21 gauge orthodontic wire with retentive hooks embedded in sectional denture base with occlusal wax rims. (b) Sectional denture base with occlusal rims joined together in mouth with wire orientation for jaw relation|
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|Figure 6: (a) Pattern made with pattern resin for casting of metal hinge. (b) Completed customized metal hinge|
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|Figure 7: (a) Foldable mandibular denture with attached metal hinge lingually at midline below mandibular anteriors. (b) Maxillary and hinged mandibular denture after insertion|
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| Discussion|| |
In cases where microstomia is not manageable with surgery or dynamic opening devices, modified impression techniques and prosthesis designs facilitates rehabilitation.
Several techniques have been described in the literature for the fabrication of sectional and hinged tray/complete denture utilizing various mechanisms for connecting each component. ,,,,,,,,, In literature use of sectional stock tray or use of putty as a tray was advised but in this case, plastic stock tray was modified to make putty impression, which in all becomes one unit and flexible. So the aim was taking impression with complete tray support was achieved. Multiple pins slot and rods which were used in literature complicates the custom tray design and time required for its preparation. Dowel pin with plastic sleeve which is used with pindex system was cheaper, easily available option. Locking system present between dowel and sleeve act as antirotation, was inserted in handle of custom tray makes it sectional and easy for reattachment. Sectional occlusal rims are not good option unless it is joined together. Attachments for the sectional denture bases will interfere with jaw relation and teeth arrangement. Orthodontic wire of 21 gauge which was as thick as denture base was a better option to prevent it.
Hinge for sectional denture was best option than other complicated devices. A complicated device used for sectional denture will not be that easy for patient to insert and remove the prosthesis. It will be time-consuming and inconvenient for patient. Space present to attach hinge to mandibular denture is less, so customization of hinge provides a better option, gives better results and reduces cost of the prosthesis.
| Conclusion|| |
Limited mouth opening often complicates and compromises the treatment of patients. However, careful treatment planning and prudent designing of sectional prosthesis should be done for overall well-being of patient. Different methods of overcoming impression difficulties should be planned to obtain a better impression. Resultant prosthesis from such techniques should be stable, functional, and easy to use. Efforts and ideas are key to give maximum benefits in compromised cases.
| Summary|| |
This clinical report described an innovative technique of primary impression, sectional custom tray, sectional denture base, and a cast lingual hinge attachment system applied to lower sectional complete denture for an edentulous patient with microstomia. With the use of lingual midline hinge the sectional mandibular complete denture were successfully and easily inserted.
| Acknowledgment|| |
The Author would like to thank the patient for providing consent to use his photograph in this article.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]