Intraoral Scanning in Children with Congenital Zika Virus Syndrome: Using a Technological Resource to Diagnose Oral, Dental, and Occlusion AlterationsABSTRACT
Objective: To describe digital intraoral scanning in five children with microcephaly caused by the Zika virus, detailing occlusal and dental characteristics using digital models.
Material and Methods: An observational study assessed the dental occlusal profile of five 4-year-old children with Congenital Zika Virus Syndrome (CZS) using digital oral scanning. The children were treated at the Unichristus School of Dentistry Clinic. The Panda 2 intraoral scanner was utilized. A mouth opener made from wooden sticks, adhesive tape, and gauze was used individually for each patient, thereby minimizing the risk of trauma. The upper arches were scanned first, followed by the lower arches, and finally the arches in occlusion.
Results: The 3D digital models revealed the relationship between the distal faces of the deciduous second molars, Baume's arch type, tooth eruption chronology, anterior open bite, posterior crossbite, overbite, overjet, and deviated midline.
Conclusion: Intraoral scanning in children with congenital Zika virus microcephaly proved to be a viable alternative for producing reliable digital study models, offering more comfort and safety to these patients and replacing conventional molding techniques.
Keywords:
Microcephaly; Zika Virus; Craniofacial Abnormalities; Congenital Abnormalities
Introduction
The Zika virus (ZIKV), an emerging mosquito-borne flavivirus, was first isolated from a rhesus monkey in the Zika Forest in Uganda in 1947. Several species of Aedes mosquitoes are responsible for transmitting the virus. In 2015, a dramatic increase in reports of ZIKV infection was observed in the Americas, with Brazil being the most affected country. Preliminary estimates indicated between 440,000 and 1.3 million cases of autochthonous ZIKV infection reported by December 2015 [1].
In October 2015, the state of Pernambuco, Brazil, experienced an unexplained surge in cases of microcephaly in newborns, coinciding with a significant outbreak of Zika virus infection. That same month, Brazil reported 140 suspected cases of congenital microcephaly and declared a national public health emergency on November 11, 2015. By mid-November, the number of suspected microcephaly cases potentially linked to ZIKV exceeded 700, and the virus was detected in the amniotic fluid of two pregnant women [2].
According to the Ministry of Health's epidemiological bulletin from March 2019, a national total of 17,041 cases of microcephaly were recorded between epidemiological weeks 45/2015 and 52/2018. Of these, 3,332 cases were confirmed as ZIKV infections, while the remaining cases were either under investigation or ruled out as non-ZIKV infections. In the state of Ceará, the April 2018 bulletin from the State Health Department reported 163 confirmed cases of microcephaly suggestive of congenital ZIKV infection, with 57 of these cases confirmed in Fortaleza [3].
Children with Congenital Zika Virus Syndrome (CZS) exhibit a marked tendency toward delayed eruption of the primary dentition. Preliminary findings have identified alterations in tooth number and shape, changes in eruption sequence, and an increased prevalence of ogival palates [1,4].
The significant challenges in providing dental care for patients with congenital microcephaly have driven the search for new alternatives – particularly those involving technological resources — to facilitate patient management and optimize treatment outcomes [1,5].
Digital scanning has been proposed in dental practice since the 1970s as a method to simplify and enhance the impression technique for obtaining study models, when compared to conventional approaches [6]. Dedicated digital impression systems eliminate several clinical steps, resulting in reduced chair time and improved accuracy [7]. Digital scanning offers a viable solution for addressing the clinical needs of children and patients with behavioral or physical management challenges [8].
This study aims to describe the use of digital intraoral scanning in children with microcephaly due to CZS; to assess the characteristics of dental occlusal relationships; to collect data on the specific challenges related to oral manipulation in these children; to generate digital models of the dental arches; to support diagnostic efforts; and to gather information relevant to the prevention and planning of dental treatment for this population.
Material and Methods
Sample, Design, and Place of Study
The methodology used was an observational, descriptive study with both qualitative and quantitative approaches, in which five children aged 4 years, diagnosed with Congenital Zika Virus Syndrome (CZS), underwent evaluation of their dental occlusal profile using a digital intraoral scanning technique. The children were treated at the Unichristus School of Dentistry Clinic, through the NEAMi (Center for the Study and Care of Microcephaly) extension group, established in 2016.
The age range of the children included in the study was determined based on the actual age profile of the population affected by Congenital Zika Syndrome (CZS). Considering that CZS is a rare condition, with cases primarily concentrated between 2015 and 2016 in Brazil, the available sample consisted of individuals within a specific age range. Therefore, the age criteria adopted reflect the reality of the studied population and were defined to ensure the representativeness of the target group.
Inclusion and Exclusion Criteria
The following inclusion criteria were established: children aged 4 years with Congenital Zika Virus Syndrome, whose parents agreed to participate in the study by signing an informed consent form. Children with other syndromes or congenital anomalies not associated with Zika virus infection, children with microcephaly unrelated to Zika virus, and children with Zika-related microcephaly who were under three or over four years of age were excluded.
Ethical Aspects
This research was conducted in accordance with the Helsinki Declaration guidelines, approved by the Research Ethics Committee of the Christus University Center (CAAE: 60740616.4.0000.5049), and adheres to the ethical principles for research involving human subjects established in Resolution 466/12 of the National Health Council [9].
Scanning Technique
The Panda 2 scanner (Pengtum Technologies, Shanghai, China) was used to perform the intraoral scan. Before the procedure, caregivers were informed about the scanning process and encouraged to ask questions regarding the technique. Mouth openers made from wooden sticks, adhesive tape, and gauze were used to individualize the procedures and prevent patient friction or potential trauma.
The children were positioned on a caregiver’s lap, with stabilization of the hands, trunk, and legs, while another caregiver or professional stabilized the head. Two professionals, positioned on either side of the patient, performed the scan. The scanning sequence began with the upper right arch, followed by the upper left, and then the lower arch. After scanning both arches, the occlusal relationship was recorded in maximum intercuspation (MIH). Due to the difficulty in managing the patients, the duration of the scans ranged from 60 to 90 minutes.
Dentition and Occlusion Analysis
Occlusion was assessed through the analysis of scanned images from frontal, left, and right lateral views, as well as digital models segmented by occlusal views of the maxilla and mandible (Figure 1). The following aspects of deciduous occlusion were investigated: the relationship between the second deciduous molars, the presence or absence of anterior open bite and posterior crossbite, Baume arch type, the presence or absence of primate diastemas, eruption chronology, palatal shape, midline alignment, overjet, and overbite.
3D digital model produced by scanning. (A) Frontal view. (B) Lateral view. (C) Occlusal view.
Results
A descriptive analysis of the occlusal characteristics is presented in Table 1. Among the five patients scanned, three were male and two were female. All children presented microcephaly, ocular and auditory alterations, were mouth breathers, and did not exhibit non-nutritive sucking habits.
In the 3D digital models generated from the scans, the relationship of the distal surfaces of the second deciduous molars was assessed from the buccal view in right and left occlusion. Three children exhibited the mesial step type, one presented the flush terminal plane, and in one case, the second deciduous molars had not yet erupted, preventing evaluation of this occlusal relationship.
Concerning the presence of malocclusion, analysis of the frontal intraoral scan in occlusion revealed that three patients presented an anterior open bite. Posterior crossbite was also observed in three patients, two of whom simultaneously exhibited anterior open bite. Regarding arch type classification according to Baume, four patients exhibited Baume type I arches, while one patient presented a mixed Baume arch type – that is, type I in one arch and type II in the other. Regarding primate spaces, all patients exhibited this type of diastema in both the maxilla and mandible. With respect to the chronology of tooth eruption, two children had completed the eruption of all 20 deciduous teeth, whereas the remaining three presented with delayed eruption: one had 15 teeth, one had 16, and one had 19, indicating an altered eruption chronology.
Palatal morphology was also assessed in terms of depth/height: three children had an ogival palate (narrow and high-arched), and two had a typical palatal shape. In the evaluation of dental midlines, only two children had maxillary and mandibular midlines aligned with the glabella and philtrum. At the same time, the other three showed deviations and a lack of coincidence. Another relevant feature analyzed was overjet and overbite. Overbite was considered abnormal and accentuated in two patients, while three exhibited normal vertical overlap. In contrast, overjet was abnormal and accentuated in all children evaluated.
Discussion
This study employed digital scanning to generate 3D images of dental arches, yielding findings comparable to those of Aragón et al. [10], who used conventional plaster models. Both studies identified common characteristics in children with ZIKV-related microcephaly, such as mouth breathing, anterior open bite, posterior crossbite, and altered overbite. The use of 3D digital models avoids the discomfort and potential risks associated with conventional impression techniques, which may be unsuitable for patients with motor and cognitive impairments, as emphasized by Alencar et al. [3], Gomes et al. [11], and Carvalho et al. [12].
The analysis of the results obtained through intraoral scanning revealed patterns consistent with those of previous studies, but also presented particularities that warrant interpretation in light of the pathophysiology of Congenital Zika Syndrome. Factors such as the high prevalence of anterior open bite and posterior crossbite may be associated with muscular hypotonia and the mouth breathing pattern observed in these patients. Chronic mouth breathing, often related to upper airway obstruction and orofacial hypotonia, interferes with facial development and tooth eruption, thus justifying the identified malocclusion pattern [13-15].
The presence of primate spaces in all the evaluated patients differs from studies involving typically developing populations, in which there is greater variation in the occurrence of these diastemas. This difference may be explained by the influence of genetic and environmental factors on bone growth and tooth eruption, which, in the case of CZS, are compromised by early neurological disorders and altered swallowing and chewing patterns [14]. According to Amaral et al. [13] and Ming et al. [16], neurodevelopmental disorders have a direct impact on the chronology and morphology of teeth, reinforcing the findings of delayed tooth eruption observed in three of the children in this study.
The identification of a high-arched palate in three patients is consistent with the literature on neurological syndromes that report altered muscle tone and deleterious oral habits. The formation of a narrow and deep palate is often associated with inadequate stimulation of the tongue against the palate during rest and swallowing. This condition is further exacerbated by mouth breathing, leading to excessive vertical development of the maxilla and narrowing of the palatal arch [17].
As for discrepancies in dental midline coincidence, these may reflect asymmetric craniofacial growth patterns, often associated with compensatory postures and asymmetrical use of the orofacial musculature, which are common in individuals with neurological alterations. Midline deviations may be linked to the absence of symmetrical bilateral stimulation during oral functions, which is also applicable to the functional profile of children with CZS [18].
The comparison with Aragón et al. [10] is relevant but limited by the small sample size and the methodology's reliance on plaster models. The use of 3D digital models in this study allowed for greater accuracy in the measurement and visualization of dental structures, in addition to providing a more comfortable and safer alternative for this vulnerable population, as also highlighted by Asquith and McIntyre [19], who validated the use of digital scanning in pediatric populations with special needs.
Despite the challenges related to patient recruitment, the study demonstrated that digital scanning is a valuable and safe tool for diagnosis and treatment planning in patients with special needs. The sample consisted exclusively of syndromic patients, resulting in a reduced sample size and justifying the absence of a control group, given the practical limitations and contraindications of using traditional techniques in this population.
Conclusion
This study demonstrated that intraoral scanning in children with microcephaly due to Congenital Zika Virus Syndrome is a viable and safe alternative for producing digital study models. This technique enables detailed visualization of dental anatomy and occlusal relationships without the risks associated with conventional impression techniques, such as aspiration of molding materials. Furthermore, scanning provides increased comfort for patients, facilitating early diagnosis and orthodontic planning. The results confirm that the quality of digital models surpasses that of plaster models, and the scanning process offers significant time efficiency. These findings represent an important initial contribution to the understanding of oral structure reproduction in this population and support the development of preventive and therapeutic dental approaches. Children with CZS require multidisciplinary care, and early dental intervention is a critical component of this support.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alessandro Leite Cavalcanti
