|Year : 2021 | Volume
| Issue : 4 | Page : 120-124
Removable sectional complete denture for managing oral sub-mucous fibrosis patient with restricted mouth opening: A clinical report
Ravi Maheshchandra Joshi1, Dipti S Shah1, Kalpesh Vaishnav1, Komal Shah2, Radhika Agnihotri1
1 Department of Prosthodontics, Karnavati School of Dentistry, Karnavati University, Gandhinagar, Gujarat, India
2 Department of Women's Health Physiotherapy, Ahmedabad Institute of Medical Science, Gujarat University, Ahmedabad, Gujarat, India
|Date of Submission||20-May-2021|
|Date of Decision||15-Jun-2021|
|Date of Acceptance||15-Jul-2021|
|Date of Web Publication||16-Oct-2021|
Ravi Maheshchandra Joshi
C-402, Vishwas City-11, Besides Silver Harmony, Off S.G. Highway, New Gota, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Restricted mouth opening (microstomia) can be defined as a reduction in the circumference of the oral cavity, although the intraoral structures may be of normal size. It is observed that the size of the oral opening decreases, the difficulty increases in required dental treatment. Prosthetic rehabilitation of microstomia patients due to oral sub-mucous fibrosis (OSMF) presents difficulties at all stages, right from preliminary impressions to insertion of prostheses, as the maximal oral opening is smaller than the size of a removal intra-oral prosthesis. To rehabilitate this type of patient successfully, the methods and designs incorporated in the fabrication of prosthesis have to be modified to achieve favourable mastication, retention and aesthetics. This article describes modified primary impression procedure without using tray and other techniques used to fabricate maxillary and mandibular custom sectional trays, sectional denture bases and removable sectional complete dentures for completely edentulous patient with limited oral opening caused by OSMF. Fabricating the sectional denture allows the patient to insert and remove the denture with ease.
Keywords: Dentures, microstomia, mouth, oral sub-mucous fibrosis
|How to cite this article:|
Joshi RM, Shah DS, Vaishnav K, Shah K, Agnihotri R. Removable sectional complete denture for managing oral sub-mucous fibrosis patient with restricted mouth opening: A clinical report. Adv Hum Biol 2021;11:120-4
|How to cite this URL:|
Joshi RM, Shah DS, Vaishnav K, Shah K, Agnihotri R. Removable sectional complete denture for managing oral sub-mucous fibrosis patient with restricted mouth opening: A clinical report. Adv Hum Biol [serial online] 2021 [cited 2021 Dec 4];11:120-4. Available from: https://www.aihbonline.com/text.asp?2021/11/4/120/328406
| Introduction|| |
An abnormally small oral orifice is termed as microstomia. A limited mouth opening can be caused by (1) oral sub-mucous fibrosis (OSMF), (2) surgical treatment of orofacial cancers, (3) cleft lip and palate, (4) micrognathia, (5) post-radiation therapy for head and neck cancer, (6) cranio-carpo-tarsal dystrophy also known as Freeman-Sheldon syndrome, (7) epidermolysis bullosa – a genetic skin condition that results in fragility of the skin and mucous membranes with the subsequent formation of blisters after minor trauma or spontaneously, (8) scleroderma – a connective tissue disease of the skin, joints and sometimes internal organs in which facial skin and oral mucosa become thin, taut and wrinkles disappear, resulting in a mask-like appearance with reduced mouth opening, (9) reconstructive surgery of lip, (10) facial burns, (11) facial tumour, (12) facial trauma, (13) surgically induced after treatment for cleft lip and palate, (14) trismus that affects mandibular movements, (15) Plummer-Vinson syndrome – a rare condition characterised by a triad of iron deficiency dysphagia, oesophageal webs and anaemia, (16) Hallermann-Streiff syndrome – a rare disorder characterised by malformation of the head and face with dental abnormalities, (17) Treacher-Collins syndrome – a congenital disorder of craniofacial development that most often affects facial bones, jaw, chin and ears, (18) micro-invasion of muscles of mastication, (19) temporomandibular joint dysfunction syndrome and (20) genetic disorders.,,,,,,, Some other conditions also cause transient microstomia for a limited time such as tooth pain, mumps and oral space infections.
OSMF is an oral precancerous condition characterised by inflammation and progressive fibrosis of the sub-mucosal tissue, resulting in marked rigidity and trismus. It is a chronic progressive and irreversible disease that affects the oral, oropharangeal and sometimes the oesophageal mucous. It is a disease that causes changes similar to those of systemic sclerosis (scleroderma) but limited to oral tissues. OSMF primarily affects people of South-East Asian origin.,
Various treatment modalities include surgery, with the help of dynamic opening devices called microstomia orthoses, and by modifying denture design.,,,, It is mandatory for patients to keep their mouth widely open for proper tray insertion and alignment in prosthetic treatment during impression procedures, which is not possible in patients with restricted mouth opening. Such patients pose a challenge at each step of denture fabrication. Difficulty in making preliminary and final impressions for patient with constricted oral openings can be minimised using flexible modified stock trays and sectional trays.]
Sectional and collapsible dentures have been described for these types of patients. A reviewed literature shows that there are different mechanisms for connecting sectional dentures which include customised Co-Cr hinges,, pins, rods, stud attachments, orthodontic expansion screws, swing-lock attachments, bolts, telescope system, clasps, cast locking recesses, magnets, stainless steel (SS) gingival approaching wire clasp, orthodontic mandibular molar tube with stainless steel wire and prefabricated stainless steel hinge.
The aims of the clinical report presented here is to describe the clinical management of an edentulous patient with microstomia induced by OSMF using modified preliminary impression technique without using trays, sectional custom trays and sectional temporary denture bases to fabricate sectional dentures. The patient's low socioeconomic status demanded least expensive dental treatment.
| Clinical Report|| |
A 63-year-old male edentulous patient with restricted mouth opening induced by OSMF reported to the Department of Prosthodontics, Karnavati School of Dentistry. An informed consent was obtained from the patient regarding the study. The chief complaint of the patient was difficulty in chewing due to missing teeth for the last 12 years. He had visited few dental clinics to replace his missing teeth by fabricating removable complete denture, but all dentists denied due to limited mouth opening. Finally, the patient came to the Department of Prosthodontics and explained the facts. Patient's medical and dental history was taken. He had not relevant past medical history. He gave a history of partially edentulism for 5 years and completely edentulism for the last 7 years. The patient had habit of betel nut (areca nut) chewing for the last 34 years. Intra-oral examination revealed completely edentulous maxillary and mandibular resorbed ridges. The buccal and labial mucous membrane were firm and thick on palpation; there was a dense fibrous band extending from the buccal aspect of the molar area up to the angle of mouth. Extra-oral examination revealed small oral aperture of 18 mm [Figure 1]. He was provisionally diagnosed with OSMF. The patient was referred to the Department of Oral Surgery to take opinion and treatment in respect of OSMF. Oral surgeon had explained him for surgical procedure, but he denied for any surgical procedure. Hence, it was planned to make sectional denture using modified primary impression technique, sectional custom trays and sectional temporary denture base.
Preliminary impression was taken using elastomeric impression material of putty consistency reinforced with heavy gauge SS wire. First, the wire was adapted according to the shape of residual alveolar ridge [Figure 2]a and [Figure 2]b, and the primary impression was taken, while incorporating it in silicone putty [Figure 3]a and [Figure 3]b. This provided rigidity to flexible impression preventing its distortion. Preliminary impression was poured to get primary cast. This primary cast was used to fabricate special tray.
Maxillary and mandibular sectional impression trays were fabricated using auto-polymerising acrylic resin on the primary cast. Maxillary custom impression tray was fabricated in two parts with anterior and posterior sections [Figure 4]a. Three dowel pins (cross-pins) with plastic sleeves were used as aid to stabilise and realign the two parts of the tray in proper position. These cross-pins (without sleeves) were placed 1 cm posterior to the anterior border of posterior section at three wide spread points: one on the top of right alveolar crest of the ridge, another on the left top of crest of alveolar ridge whereas third in the mid palatal part. They were positioned in such a way that they are parallel to each other using auto-polymerising acrylic resin. The petroleum jelly was applied onto the anterior border of posterior section and three dowel pins were than covered with the plastic sleeves. The anterior section of the tray was fabricated using the same acrylic resin, with the tinch of blue colour added to it, to achieve distinguishable margin of two sections. The anterior section was made in such a way that it overlapped the anterior border of posterior section as well as slided over the dowel pins giving a continuity to tray without any discrepancy or step formation.
|Figure 4: (a) Anterior and posterior section of the maxillary custom tray, (b) Mandibular custom tray.|
Click here to view
Low fusing compound (green stick) was used for border moulding. Posterior section of the tray was first inserted intraorally, and the buccal vestibule and post-palatal seal areas were recorded using functional method. After that, anterior section was inserted intra-orally and the functional labial vestibule and frenum areas were registered. Border moulding was carried out separately for each half followed by sectional final impression with polyvinyl siloxane light body elastomeric impression material. The two parts of the tray were retrieved separately and were assembled extra orally to form a single unit [Figure 5]a and was then poured to get the master cast.
|Figure 5: (a) Maxillary final impression and (b) mandibular final impression.|
Click here to view
Mandibular sectional impression tray having two halves was fabricated in such a way that they exactly realigned with the help of dowel pins incorporated in handle [Figure 4]b. After the border moulding and final impression was made, the sectional trays were removed separately from the mouth and were reassembled outside [Figure 5]b to form a single unit and were then poured to get master cast. The temporary sectional maxillary record bases retained with press buttons and foldable mandibular denture base with hinge attachment were fabricated on the master cast using auto-polymerising acrylic resin. Wax occlusion rims were fabricated over these sectional records [Figure 6]a and [Figure 6]b. Maxillomandibular jaw relation was recorded by nick and notch method [Figure 7]a. Denture bases were removed separately from the mouth and were reassembled using centric records. This assembly was than mounted to articulator; teeth arrangement using nonanatomic teeth and final try-in [Figure 7]b were carried out in a conventional manner.
|Figure 6: (a) Maxillary sectional denture base with occlusal rim and (b) mandibular foldable denture base with occlusal rim.|
Click here to view
|Figure 7: (a) Maxillomandibular jaw relation was recorded by nick and notch method, (b) final try-in.|
Click here to view
Denture was acrylised in sections using heat cure acrylic resin, where first the section bearing matrix part of press button was acrylised and polished [Figure 8]a. Then, the master cast was duplicated along with polished section. The section-bearing patrix part of press button was than acrylised after proper wax up carving on duplicated master cast [Figure 8]b. The same process was repeated for mandibular arch. The dentures were finished and polished [Figure 9]a. Maxillary sectional denture was retained with three press buttons placed on mid of the palate, and mandibular denture was retained with one lingually placed press button [Figure 9]b and [Figure 9]c. The patient was instructed to place matrix half of dentures first into mouth followed by insertion of the patrix half of the dentures. The patient was thoroughly educated and instructed regarding the use of the prosthesis to ensure proper assembly. Post-operative views of the patient are shown in [Figure 10]. Post-insertion follow-ups were taken till 6 months followed by physiotherapy intervention for improving mouth opening.
|Figure 8: (a) Acrylised matrix part, (b) wax up carving of patrix part on duplicated master cast.|
Click here to view
|Figure 9: (a) Finished and polished dentures, (b) maxillary sectional denture with three press buttons, (c) mandibular sectional denture with one press buttons.|
Click here to view
| Discussion|| |
Limited mouth opening is common in patients with OSMF. OSMF is defined as a chronic disease of the oral mucosa characterised by inflammation and progressive fibrosis of the lamina propria and deeper connective tissue layers. A number of factors trigger the disease process by causing juxta epithelial inflammatory reaction in the oral mucosa. Suggested contributory factors include areca nut chewing, ingestion of chillies, nutritional deficiencies, genetic and immunologic processes, and other factors. OSMF is a potential premalignant condition with an incidence of oral cancer in 3%–7.6% of cases., The presenting symptoms of OSMF are burning pain, progressive inability to open the mouth, difficulty in mastication and swallowing. It is most common between 20 and 40 years of age with a female: male ratio of 3:1., When it affects geriatric patients with partial or complete edentulism, the task of restoring function becomes a challenge to a prosthodontist due to the patient's clinical condition.
This condition poses trouble during each prosthetic step starting from primary impression till insertion of the dentures. Several methods of constructing sectional special trays have been discussed in the literature, few of them being Robert J Luebke's sectional stock tray system, flexible tray made with silicone putty, flexible tray used for fluoride application, etc. Usually, a semi-rigid silicone putty impression material can be used as impression tray for preliminary impression. However, in this case, SS heavy gauge wire was reinforced because it served as handle to carry the impression material as well as prevented distortion by providing additional support and rigidity to the flexible silicone putty impression material.
A customised sectional impression tray with two halves, which allowed the functional impression to be made despite difficulties associated with limited mouth opening. The advantage of custom tray with two halves is that it can be removed as two separate segments and reassembled externally after recording a functional impression. Nick and notch method employed for recording jaw relation assured the accuracy in reassembling the unit by providing key and keyway.
The fabrication of sectional prosthesis as presented in this case is practical, economical and simple in design. This technique was accomplished without using complicated machinery or attachments for sectioning or assembling the trays or prosthesis together. The attachments used are readily available at nominal cost.
To determine the long-term success of this technique, periodic recalls were also made, which proved to be satisfactory.
| Summary and Conclusion|| |
This clinical report describes an economical, quick and easy method for fabrication of a sectional custom tray and removable sectional complete denture. Patients with OSMF seeking prosthetic rehabilitation pose a challenge to the clinician; they can be conservatively managed by modifying clinical skills and laboratory procedures; however, in these modifications, the basic principles of providing optimum function and aesthetics to the patient shall not be compromised. The upper and lower sectional dentures delivered were convenient for the patient in terms of insertion, removal and function as reported on follow-ups.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The glossary of prosthodontic terms: Ninth edition. J Prosthet Dent 2017;117:e1-105.
Weinstein S, Gorlin RJ. Cranio-carop-tarsal dysplasia or the whistling face syndrome. I. Clinical considerations. Am J Dis Child 1969;117:427-33.
Colin GM, Zepeda CH, McKinster CD, Romero MT. Inherited epidermolysis bullosa: A multisystem disease of skin and mucosae fragility. IJPD 2017; 18:267-73.
Gulses A. Advances in the Study of Genetic Disorder. Microstomia: A Rarer but Serious Oral Manifestation of Inherited Disorders. Ch. 22. United Kingdom: InTech; 2011. p. 450-72.
Lo KB, Albano J, Sandhu N, Candelario N. Plummer-Vinson syndrome: Improving outcomes with a multidisciplinary approach. J Multidiscip Healthc 2019;12:471-7.
Thomas J, Ragavi BS, Raneesha P, Ahmed NA, Cynthia S, Manoharan D, et al.
Hallermann-Streiff syndrome. Indian J Dermatol 2013;58:383-4.
] [Full text]
Kumar T, Puri G, Konidena A, Arora N. Treacher Collins Syndrome: A case report and review of literature. J Indian Acad Oral Med Radiol 2015; 27:488-91. [Full text]
Naylor WP, Manor RC. Fabrication of a flexible prosthesis for the edentulous scleroderma patient with microstomia. J Prosthet Dent 1983;50:536-8.
Kumar B, Fernandes A, Sandhu PK. Restricted mouth opening and its definitive management: A literature review. Indian J Dent Res 2018;29:217-24.
] [Full text]
Dado DV, Angelats J. Upper and lower lip reconstruction using the step technique. Ann Plast Surg 1985;15:204-11.
Engelmeier RL, King GE. Complications of head and neck radiation therapy and their management. J Prosthet Dent 1983;49:514-22.
Brunello DL, Mandikos MN. The use of a dynamic opening device in the treatment of radiation induced trismus. Aust Prosthodont J 1995;9:45-8.
Maragakis GM, Garcia-Tempone M. Microstomia following facial burns. J Clin Pediatr Dent 1998;23:69-74.
Cohen SG, Quinn PD. Facial trismus and myofacial pain associated with infections and malignant disease. Report of five cases. Oral Surg Oral Med Oral Path 1998; 65:538-44.
Shafer GW, Hine MK, Levy BM. Benign and malignant tumors of the oral cavity. Shafer's Textbook of Oral Pathology. 6th
ed. US, Philadelphia: WB Saunders: Elsevier Publications; 2009.p. 96.
Ghom AG. Textbook of Oral Medicine. 2nd
ed. India Jaypee Publications; 2010.p. 217-8.
Conine TA, Carlow DL, Stevenson-Moore P. The Vancouver microstomia orthosis. J Prosthet Dent 1989;61:476-83.
Conroy B, Reitzik M. Prosthetic restoration in microstomia. J Prosthet Dent 1971;26:324-7.
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.
Cheng AC, Wee AG, Morrison D, Maxymiw WG. Hinged mandibular removable complete denture for post-mandibulectomy patients. J Prosthet Dent 1999;82:103-6.
Geckili O, Cilingir A, Bilgin T. Impression procedures and construction of a sectional denture for a patient with microstomia: A clinical report. J Prosthet Dent 2006;96:387-90.
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.
Whitsitt JA, Battle LW. Technique for making flexible impression trays for the microstomic patient. J Prosthet Dent 1984;52:608-9.
Luebke RJ. Sectional impression tray for patients with constricted oral opening. J Prosthet Dent 1984;52:135-7.
Mirfazaelian A. Use of orthodontic expansion screw in fabricating section custom trays. J Prosthet Dent 2000;83:474-5.
Dosumu OO, Arigbede AO, Ogunrinde TJ. Sectional removable partial denture design for the treatment of partial mandibulectomy patient: A case report. Afr J Biomed Res 2007;10:197-201.
Sharma A, Arora P, Wazir SS. Hinged and sectional complete dentures for restricted mouth opening: A case report and review. Contemp Clin Dent 2013;4:74-7.
] [Full text]
Kumar S, Arora A, Yadav R. Foldable denture: for microstomia patient. Case Rep Dent 2012;2012:757025.
Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.
Kajave M, Shingote S, Mankude R, Chodankar K. An innovative prosthodontic approach in managing oral submucous fibrosis patient. SRM J Res Dent Sci 2015;6:139-43. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]