Review of the Current Medical and Surgical Treatment Options for Microstomia in Patients With Scleroderma.

BACKGROUND: Most patients with scleroderma suffer from microstomia, which can have debilitating consequences on their quality of life. Unfortunately, treatment options remain limited. No specific guidelines exist; hence, microstomia remains a challenge to treat in this patient population. OBJECTIVE: This review aims to evaluate the different medical and surgical treatment modalities currently available for microstomia in patients with scleroderma and make recommendations for future research. MATERIALS AND METHODS: A search of PubMed, Ovid MEDLINE, and Ovid Embase was conducted to identify articles discussing the treatment of microstomia in scleroderma. Twenty articles discussing surgical therapy and one article discussing medical therapy were reviewed. RESULTS: Mostly because of a scarcity of high-level evidence, no individual therapy has documented long-term efficacy. Some treatments demonstrate positive results and warrant further research. CONCLUSION: Given the variability of results, specific recommendations for the treatment of microstomia in patients with scleroderma are difficult to establish. A multifaceted approach that includes surgical and medical therapy is likely the best option to improve oral aperture in this patient population. Surgical treatments such as neurotoxins, autologous fat grafting, and ultraviolet A1 phototherapy may hold the most potential for improvement.

Microstomia: Aplicação da fotogrametria para mensurar a eficiência da órtese oral associada à terapia fonoaudiológica / Microstomy: Application of photogrammetry to measure the efficiency of oral orthosis associated with speech therapy

OBJETIVO: Esse estudo teve como propósito verificar, por meio da fotogrametria computadorizada, a eficácia do uso da órtese oral como auxiliar na terapia fonoaudiológica. MÉTODO: Após a documentação fotográfica, cada paciente foi submetido a terapia fonoaudiológica, por meio da terapia miofuncional orofacial, associada ao uso da órtese oral, confeccionada segundo Borges et al. (2011). Ao término do tratamento, foi realizado novo registro fotográfico, em seguida, a mensuração da dimensão vertical (distância entre lábio superior/inferior) e horizontal (distância entre comissuras direita/esquerda), com o uso do programa Corel Draw X3. RESULTADOS: As médias da abertura bucal aumentaram da avaliação inicial para a avaliação final, tendo aumentado 5,1 mm no sentido horizontal (67,3 mm para 72,4 mm) e 13,9 mm no sentido vertical (de 32,7 mm para 46,6 mm). Essas diferenças se revelam significativas para as avaliações (p <0,05). CONCLUSÃO: O uso da órtese oral associado a terapia fonoaudiológica demonstrou ser eficaz como mais um instrumento na prevenção da microstomia.

OBJECTIVES: The aim of this study was to through computerized photogrammetry, the efficacy of oral orthosis as an aid in speech therapy. METHODS: After the photographic documentation, each patient underwent speech therapy, through orofacial myofunctional therapy, associated with the use of an oral orthosis, made according to Borges et al. (2011). At the end of the treatment, a new photographic record was taken, then the vertical dimension measurement (distance between upper lip) and horizontal (distance between corners right/left), using the program Corel Draw X3. RESULTS: The mean mouth opening increased from the initial evaluation to the final evaluation, increasing 5.1 mm in the horizontal direction (67.3 mm to 72.4 mm) and 13.9 mm in the vertical direction (from 32.7 mm to 46.6 mm). These differences are significant for the evaluations (p<0.05). CONCLUSION: The use of oral orthosis associated with speech therapy proved to be effective as another tool in the prevention of microstomia.

Restricted mouth opening and its definitive management: A literature review.

PURPOSE: This review was intended to discuss the various possible modifications suggested in the literature for prosthetic steps and surgical corrective procedures in nonresponding or complicated cases during rehabilitation of patients with restricted mouth opening. MATERIAL AND METHODS:: Medline, PubMed, and Google were searched electronically for articles using keywords: microstomia and treatment options for restricted mouth opening. The various articles on prosthodontic rehabilitation in microstomia were segregated. From these, various modifications in the prosthetic steps were reviewed. RESULTS:: Oral hygiene maintenance is difficult for patient either due to limited access or due to associated lack of manual dexterity, so dental decay and periodontal problems are more extensive in such patients; hence, tooth loss is a common finding. All prosthetic procedures require wide mouth opening to carry out various steps, starting from tray placement during impression making to the final prosthesis insertion, especially removable prosthesis. Various prosthetic modifications given by authors are included in this review for each step in prosthodontic management. A total of eight stock tray designs, 12 custom tray designs, and 17 removable prosthesis designs are discussed along with fixed (either tooth-supported or implant-supported) and maxillofacial prosthesis. However, some patients require surgical intervention also for the correction of microstomia either for function or for esthetic purpose before prosthetic rehabilitation and are also enumerated here. CONCLUSION: Among all prosthetic restorative options, removable prosthesis is most difficult for dentist to fabricate as conventional methods are either very difficult or impossible to apply. To get a more accurate final prosthesis, we need to modify these steps according to the existing case. Several modifications available are discussed here which can help while managing these patients.

Integrating hinge axis approximation and the virtual facial simulation of prosthetic outcomes for treatment with CAD-CAM immediate dentures: A clinical report of a patient with microstomia.

This clinical report describes a digital workflow using extraoral digital photographs and volumetric datasets from cone beam computed tomography (CBCT) imaging to create a 3-dimensional (3D), virtual patient with photorealistic appearance. In a patient with microstomia, hinge axis approximation, diagnostic casts simulating postextraction alveolar ridge profile, and facial simulation of prosthetic treatment outcome were completed in a 3D, virtual environment. The approach facilitated the diagnosis, communication, and patient acceptance of the treatment of maxillary and mandibular computer-aided design and computer-aided manufacturing (CAD-CAM) of immediate dentures at increased occlusal vertical dimension.

Restoring masticatory function in a patient with severe microstomia using rapid prototyped mesh and a custom-made hinge and swing-lock prosthesis.

This clinical report describes the use of rapid prototyped mesh in a complete swing-lock prosthesis to restore masticatory function in an edentulous patient with severe microstomia and perioral scar tissue after an industrial hot tar accident.

Management of postburn perioral contracture using a customized static commissural splint and intralesional injections of triamcinolone.

A perioral facial burn is usually accompanied by a reduction in size of the oral orifice because of the contraction of the healing wound. Perioral contracture leads to microstomia, restricting nutrition, speech, and jaw movements and impairing the esthetic appearance of the face. It is imperative to introduce splints as early as possible to prevent the postburn sequelae. A delay in splinting allows postburn contractures. Overcoming these contractures to regain the size of the stoma requires restructuring of the hypertrophic scar using mechanical force and the biomodification of the tissues. This article describes the treatment of microstomia and the hypertrophic scarring of the perioral tissue using a novel static commissural splint with customizable components in conjunction with intralesional injections of triamcinolone. Within 6 months, the splint together with the steroid injections had helped increase the vertical opening of the mouth by 15 mm and the intercommissural distance by 16 mm.

Postburn Microstomia Prevention Using an Appliance Providing Simultaneous Horizontal and Vertical Adjustable Forces.

Microstomia, an abnormally small oral orifice, is a complication of perioral facial burns. In this case, contraction of the circumoral tissues and hypotonia of the musculature is responsible for this microstomia, which can produce aesthetic and functional impairment with eating, swallowing, communication (speech and facial expressions), compromised dental care and maintenance due to limited oral access, social interactions, and psychological well-being. Conservative management involves providing physical resistance to scar contracture, with opposing horizontal and vertical circumoral forces by means of appliances that aim to stretch the commissures and fibrotic muscles. Numerous appliances, either intraoral or extraoral, have been described to prevent or treat microstomia by delivering a static or dynamic stretch horizontally or vertically, with most designed to stretch the mouth horizontally. Finding a comfortable effective way to stretch the mouth vertically has proved to be a challenge. This article describes the fabrication of a dynamic commissural appliance, constructed using acrylic resin and expansion screws, which provide simultaneous horizontal and vertical circumoral forces. This appliance is constructed easily and inexpensively without the need for taking impressions, can be adjusted so that it is almost painlessly inserted, and is progressively activated. It is convenient for use because the patient controls the pressure that is applied by the appliance. Its use in a case is described where the appliance has improved mouth opening and consequently functional outcomes.

Effects of intense pulsed light in microstomia in patients with systemic sclerosis: A pilot study.

INTRODUCTION: The effects of intense pulsed light (IPL) on collagen structures are well known in the treatment of photodamaged skin. OBJECTIVE: The objective of this study was to investigate the effect of IPL on sclerotic skin by treating patients with microstomia due to systemic sclerosis. METHODS AND MATERIALS: 13 patients all with microstomia and systemic sclerosis were treated with IPL, PR (530-750 nm filter) and/or VL (555-950 nm filter) applicator. They were treated in the perioral area 8 times with 3-4 weeks of interval and follow-up for 6 months. The outcomes were the inter-incisal distance and the inter-ridge distance. RESULTS: A significant increase in mouth opening of 4.1 mm (95% confidence interval, 1726-6638, p < 0.005) was found in the inter-ridge distance when comparing the distance before treatment with the distance at six-month follow-up. No significant difference was found in the inter-incisal distance. The patients experienced improved mobility and better control of lip movements after the treatments. CONCLUSION: IPL can improve the inter-ridge distance between the lips in patients with microstomia due to systemic sclerosis but does not affect the inter-incisal distance, which is also dependent on the mobility of the mandibular joints. This treatment can be considered an adjunctive therapy in patients with microstomia due to systemic sclerosis.

Correction of microstomia in an edentulous patient.

The problem of small oral aperture is big. Irrespective of the etiology, this problem may be overcome by adjunctive therapies in the form of prosthesis, surgery, or exercise. A patient is described with this problem, which was overcome by revisiting the 3 adjunctive therapies including a commissural stent designed with the patient's edentulous state in mind.

Dental management of patients with microstomia: a review of the literature and update on the treatment / Manejo clínico odontológico del paciente con microstomia: una revisión de la literatura y puesta al día

Difficulty in dental management is one of the factors that characterize the patient that requires special care in dentistry. One of the clinical conditions that make dental treatment particularly complex is microstomia. Microstomia is defined as a small and insufficient oral aperture that will hinder diagnosis and dental treatment. Although there have been reports of patients with diseases and syndromes that cause microstomia, the available literature offers only a limited number of reviews on this topic. The aim of this paper is to present a review of the etiology, clinical characteristics, diagnosis and treatment of microstomia. In addition, to describe the therapeutic adaptations to be applied in dental procedures in patients with microstomia, emphasizing the importance of a preventive approach in this group of patients...

La dificultad en el manejo odontológico es uno de los factores que definen al paciente que requiere cuidados especiales en odontología. Una de las situaciones clínicas que más dificulta el tratamiento dental es la microstomia. La microstomia se define como una apertura bucal pequeña e insuficiente que va a dificultar el diagnóstico y el tratamiento bucodental. Aunque se han descrito casos clínicos de pacientes con enfermedades y síndromes que cursan con microstomia, no hay muchas revisiones del tema en la literatura. El objetivo de este artículo es presentar una revisión sobre la etiología, la clínica, el diagnóstico y el tratamiento de la microstomia. Así como, describir las adaptaciones terapéuticas que se deben aplicar en los procedimientos dentales en el paciente con microstomia, recalcando la importancia de un enfoque preventivo en este grupo de pacientes...

Sectional collapsible complete removable dental prosthesis for a patient with microstomia.

Patients who have unusually small mouths may have difficulty in obtaining dental care and maintaining good oral hygiene. The fabrication of conventional complete removable dental prostheses for an edentulous patient with microstomia is challenging because of the limited access to the oral cavity. Sectional collapsible complete removable dental prostheses were designed as hinged maxillary and mandibular complete dentures that can be folded for denture delivery. This design also prevented denture deflection during function by using the upper part of the prosthesis, minimizing the possibility of breakage.

Fabrication of a unilateral oral commissure retractor.

The fabrication of a unilateral device to treat microstomia after trauma is presented. Maximum opening was recorded before treatment. A dual arch impression that captured the dentition and commissure on the affected side was made with vinyl polysiloxane (VPS) impression material. A 1 mm vacuum formed template (VFT) was fabricated over the maxillary dentition, and a 2 mm VFT was fabricated around the commissure. A 0.9 mm (0.036") stainless steel wire was attached with acrylic resin to both templates in order to apply a constant force to the commissure. The use of a helix in the wire allowed for flexibility and adjustment of the retractor. The patient was instructed to wear the retractor for 6 hours per day, and, during a 10-week period, the maximum opening increased from 30 mm to 45 mm.

Improvement of microstomia in scleroderma after intense pulsed light: A case series of four patients.

INTRODUCTION: Intense pulsed light (IPL) treatment is well known for, for example, photo rejuvenation, where higher cut-off filters are used. The longer wavelengths penetrate deeper in the dermis leading to damage of the collagen and stimulation of new collagen formation, which lead to more soft and elastic skin. Microstomia in systemic sclerosis is the end result of excessive collagen deposition, which makes the perioral skin firm and tight. The patients have difficulties performing oral self-care, and even professional dental care can be complicated. METHODS: Four patients with systemic sclerosis and microstomia were treated with IPL (Ellipse A/S Flex System, Denmark ) in the perioral region. The patients received 3-5 treatments with 4-week interval. Oral opening was measured before and after treatments. results: The oral opening increased approximately 1 mm per treatment in three patients. One patient had temporomandibular joint symptoms of locking and did not have any increase in mouth opening. All four patients felt softening of the perioral skin, and all four patients described that articulation, eating and tooth brushing had become easier. CONCLUSION: IPL can be a new adjunctive alternative in the non-surgical treatment of microstomia in patients with systemic sclerosis.

Treatment of microstomia with commissuroplasties and semidynamic acrylic splints.

Microstomia is defined as an abnormal small oral orifice. Burns and injuries of perioral tissues, perioral surgeries, and genetic disorders can lead to perioral scar formations and restrict mouth opening. Treatment of microstomia requires surgical or conservative approaches. The aim of this report is to assess the effects of surgical commissuroplasty techniques combined with the application of semidynamic mouth splints on 4 microstomia patients with different etiologies. The combination of surgical and conservative techniques proves to be the best method of treating compromised perioral tissues in microstomia patients.

Tratamento de microstomia grave: relato de caso / Treatment of severe microstomia: case report

O tratamento da microstomia é frequentemente um desafio no dia-a-dia do tratamento das sequelas de queimaduras. De maneira geral, as técnicas utilizadas são complexas, com resultados muitas vezes insatisfatórios e com alta taxa de recidiva. O presente trabalho teve como objetivo apresentar um caso grave de microstomia em uma criança de 2 anos, que teve sua resolução alcançada de forma simples, prática e econômica em contrapartida aos métodos tradicionais que muitas vezes são caros, complexos e pouco práticos.

The microstomia treatment is still a challenge in the day by day of the burn sequelae treatment. Usually, the techniques are complex, with poor results and high incidence of recurrence. This study presents a severe case of microstomia in a 2 years old child. The solution was simple, and cheap, in comparison to the traditional surgical methods, usually expensive, complex and low acessibility in a small Center.

Management of patients with reduced oral aperture and mandibular hypomobility (trismus) and implications for operative dentistry.

Reduced oral aperture and mandibular mobility/trismus are relatively common conditions that can be encountered in patients attending general dental practice, community dental practice and district general or dental teaching hospitals. All dental specialties may see patients with these conditions, and regardless of which environment or specialty, both patient and clinician may experience significant problems. The purpose of this opinion-based paper is to identify and review the causes of such conditions, to review the development of problems encountered for patients and clinicians, and to identify options to treat or manage the conditions.

[Application of stud structure to sectional upper complete denture for a patient with microstomia].

PURPOSE: Prosthetic rehabilitation with stud structure to sectional complete denture for a patient with microstomia was done and the treatment result was evaluated. METHODS: A sectional impression tray technique was used. And a custom-made palatal hinge mechanism with stud structure on the left and right side of the upper complete denture along the middle line were also designed and fabricated. Half metal abutment was fabricated on the left and right side of the denture on the position of the upper central incisor, and a PFM was made according to the metal abutment. After the sectional upper complete denture was inserted, the PFM was set to connect the sectional denture as a whole and provide stability. RESULTS: The sectional upper complete denture was successfully and easily inserted and provided adequate function in the patient's mouth. CONCLUSIONS: Application of stud structure to sectional upper complete denture for patient with microstomia is feasible.

Scleroderma and dentistry: every dentist is a scleroderma specialist.

Scleroderma is an autoimmune, rheumatoid factor-positive disease that may be localized or systemic, affecting the skin, lungs, kidneys, and cardiovascular system. Dental effects include xerostomia, microstomia, idiopathic resorption of tooth and bone, oral effects of medications, erosion and decay caused by gastroesophageal reflux disease (GERD), and poor oral hygiene due to physical and emotional effects of the disease. All dentists have the knowledge and ability to treat those suffering with scleroderma.

[Sectional acrylic dentures for a partially edentulous patient with microstomia: a clinical report].

PATIENT: The patient was a 48-year-old partially edentulous male with microstomia. His chief complaints were masticatory disturbance and aesthetic problems caused by missing teeth. After trayless impressions for diagnostic casts were made, sectional trays and a sectional record block were used for the definitive impression and maxillomandibular registration. Maxillary and mandibular acrylic sectional dentures were simultaneously delivered. DISCUSSION: Low caries activity, minimal occlusal force, appropriate plaque control, and simple designs for connecting portions of the two halves of the sectional dentures might lead to satisfactory results in this case. CONCLUSION: No problems have been observed for approximately 6 years after delivery of the acrylic sectional dentures for this microstomic patient.