Dental Management of Patients with Microstomia. a Review of the Literature and Update on the Treatment

Dental management of patients with microstomia. REVIEW A review of the literature and update on the treatment.

Javier Silvestre-Rangil. Abstract: Difficulty in dental management is one of the factors that cha- Mayte Martinez-Herrera. racterize the patient that requires special care in dentistry. One of the clinical Francisco-Javier Silvestre. conditions that make dental treatment particularly complex is microstomia. Microstomia is defined as a small and insufficient oral aperture that will 1. Unidad de pacientes especiales, De- hinder diagnosis and dental treatment. Although there have been reports of partamento de Estomatología, Univer- patients with diseases and syndromes that cause microstomia, the available sidad de Valencia, España. 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, diag- Corresponding author: Mayte Martí- nosis and treatment of microstomia. In addition, to describe the therapeutic nez-Herrera. Unidad de pacientes espe- adaptations to be applied in dental procedures in patients with microstomia, ciales, Departamento de Estomatología, emphasizing the importance of a preventive approach in this group of pa- Clínica Odontológica Universitaria C/ Gascó i Oliag, 1. 46010. Valencia, Es- tients. paña. Phone: 96 3864175. Ext 55047. Keywords: Microstomia, Trismus, Dental practice management, Dental care. E-mail: [email protected] DOI: 10.17126/joralres.2015.065. Cite as: Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management Receipt: 09/23/2015 Revised: 10/07/2015 of patients with microstomia. A review of the literature and update on the treatment. J Acceptance: 10/12/2015 Online: 10/12/2015 Oral Res 2015; 4(5): 340-350.

INTRODUCTION. Trauma and chemical or physical burns resulting in re- Microstomia is an insufficient or small oral aperture tractable scars can alter perioral soft tissues or face tissues that, if permanent, can affect diagnosis or proper dental and lead to microstomia. It also may appear with some treatment. Adequate oral aperture is essential for facial diseases such as epidermolysis bullosa or scleroderma and expression, oral feeding and speech. Furthermore, it can in some rare syndromes that affect connective tissue4. be an obstacle for proper oral hygiene1. Because there is great clinical variability in the range Decreased oral aperture can occur acutely caused by of oral aperture it is difficult to determine when there an infectious or odontogenic inflammatory process, but is a real limitation of the aperture. This would requi- the real problem arises when it is structural or perma- re establishing the mean value of the population by age, nent. This is usually common in the group of patients sex or race. Diagnosis is usually performed by measuring with special needs2. the interincisal distance during maximum opening of the In most cases the presence of microstomia is associated mouth. It was established that the opening in an adult with a poor healing process of perioral soft tissues or a should be of at least 3-4 fingers wide5. tissue alteration related to the temporomandibular joint2. Good oral aperture is essential for a good intraoral There are causes directly related to disorders of the examination, and to perform a good dental treatment. neuromuscular masticatory system, such as spasms, or Similarly, decreased oral aperture can be an obstacle to direct damage of muscle tissue or temporomandibular intraoral intubation for general anesthesia, which is often joint. It also can occur following oral surgery on these necessary to perform dental treatment in patients with structures or radiotherapy of head and neck3. special needs.

340 ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065

Treating microstomia is complex and depends prima- accompanied by pain. rily on the causes that produce it. A variety of surgical Likewise, microstomia also appears as a clinical mani- procedures have been described especially when it comes festation in certain systemic diseases and rare syndromes. to changes in soft tissues6; although it is also possible to Scleroderma is a chronic connective tissue disease charac- use some non-surgical procedures such as oral physiothe- terized by changes in skin, blood vessels, skeletal muscles rapy exercises7. and internal organs15. Its causes are unknown but there The aim of this study is to review some of the dental seems to be an autoimmune mechanism causing an over- problems caused by microstomia, adopting a preventive production of collagen matrix, resulting in growing and approach where possible and adapting techniques for the hardening of connective tissue. It usually affects women dental treatment of these patients. between 30 and 50 years. Among its clinical manifestations we find the appearance of Raynaud’s phenomenon ETIOLOGY OF MICROSTOMIA. (deformities in the fingers and toes), fibrotic skin compli- Microstomia is defined as an abnormally small oral cations, in skeletal muscles, in the gastrointestinal tract, aperture associated with several etiological factors8. This lungs, kidneys and cardiovascular system. Involvement is a congenital or acquired condition involving a seve- of the orofacial tissues is characteristic in these patients, re reduction of oral opening enough to compromise the leading to a tense and mask-like facial skin and reduced patient’s aesthetics, nutrition and quality of life9. oral aperture7,14,16,17. Reduced oral aperture may be caused by multiple and Microstomia also occurs in patients with epidermolysis varied situations and may be both horizontal and ver- bullosa. Bullous epidermolysis or epidermolysis bullosa tical10. Microstomia can result from congenital defects, is an inherited condition characterized by blistering of trauma (mechanical, chemical or thermal) or after surgi- the skin and mucous membranes as a result of trauma. It cal resections10. is due to the failure of anchoring elements between the Microstomia can be produced by a physical or chemical layers of the epithelium and chorion. There are several trauma such as electrical or chemical burns in perilabial types such as simple, junctional and dystrophic forms, areas that after healing leave retractable scars on these being the latter and especially those with a recessive in- tissues, deforming and closing the corners of the lips1,4,11. heritance pattern the most severe manifestations. During During the 1990s, microstomia was common in children clinical examination a reduction in oral aperture and as a result of domestic accidents, caused by electrical dis- numerous blisters on the oral mucosa can be observed, charge or ingestion of caustic substances contained in tongue can also appear limited in mobility and attached cleaning products. Nowadays, due to the introduction of to the floor of the mouth. All this conditions may arise safety measures such accidents are rare12. during the healing of lesions, forming scars that limit the Microstomia can also be secondary to some type of mobility of soft tissues at various levels18-21. traumas or injuries after lip reconstructive surgery or af- Similarly, severe cases of microstomia can occur in ter cancer surgery for head and neck tumors. In the latter rare syndromes such as Freeman-Sheldon with craniofa- microstomia may be associated with radiotherapy as an cial involvement, giving the patient the appearance of a additional factor that can damage the masticatory mus- “whistling face”22-25. It is a form of multiple congenital cles limiting their mobility13,14. In some cases when the contracture whose characteristics are small mouth, flat masticatory muscles or the temporomandibular joint be- face with a small nose, long philtrum, deep-set eyes and come damaged a protective reflex contracture may occur microglossia. reducing oral aperture and, sometimes, mobility can be There are joint contractures, abnormal hands and sco-

ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com 341 Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065 liosis. Its main form is autosomal dominant inheritance developmental delay is the Fine-Lubinsky syndrome in although there is a recessive X-linked form. Patients have which craniosynostosis, prominence of the frontal bone, a normal life expectancy and normal mental development flat facial profile, small nose, hearing loss and micros- although some cases of mental retardation have been re- tomia are observed. Microstomia is the most prominent ported. From their first year of life patients have a small manifestation making feeding difficult and entailing a oral aperture that makes feeding and oral hygiene diffi- risk of suffocation27. Other syndromes with microstomia cult, and causes a speech delay; some patients may even are Hallerman-Streiff, Schwartz-Jampel, Burton skeletal suffer from respiratory system anomalies10,22-26. dysplasia, Leopard syndrome and Moebius syndrome22,28. Another syndrome with craniofacial abnormalities and Table 1 summarizes the causes of chronic microstomia.

Table 1. Causes of chronic microstomia.

CAUSES OF CHRONIC MICROSTOMIA Trauma Physical: direct on masticatory muscles or TMJ Chemical: acid or alkali burn Electric: electrical burn Post cancer treatment for head and neck tumors After cancer surgery After radiotherapy Diseases or syndromes Scleroderma Recessive dystrophic epidermolysis bullosa Freeman-Sheldon syndrome Fine-Lubinsky syndrome Hallerman-Streiff syndrome Schwartz-Jampel syndrome Burton skeletal dysplasia Leopard syndrome Moebius syndrome

DIAGNOSIS AND CLINICAL CHARACTE- aperture in children is smaller2,5. RISTICS OF MICROSTOMIA. One of the first methods to assess microstomia was Microstomia is characterized by a reduction in the size proposed by Naylor et al.30, measuring the distance from of the oral aperture that is not defined by specific size the incisal edge of the right central incisor to the incisal criteria. Diagnosis is determined by its effect on function edge of the right lower central incisor, or its equivalent and appearance29. root fragments, in maximum oral aperture. Mild micros- In general, microstomia shows a great variability and tomia is determined when the maximum oral aperture is it is difficult to establish exactly when the reduction in between 41-50mm, moderate microstomia, between 31 oral aperture has clinical significance. Normal values in and 40mm, and severe if the aperture does not exceed the population may vary according to parameters such as 30mm. Normal maximum oral aperture should be from age, sex or race. It is usually more frequent in men than 51 to 60mm18. However, it also necessary to assess soft in women and tends to decrease with age, although oral tissue aperture, measuring the largest vertical diameter

342 ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065 between the upper and lower lip and the diameter bet- (commissuroplasty) by means of upper, lateral and lower ween the two commissures of the mouth. The magnitude oral mucosal advancement flaps, following wedge resec- of oral aperture is a determining factor for dental diagno- tion of the scar tissue12 have been described. sis and may have implications for the treatment of these After surgical correction of microstomia, the tissue is patients. replaced by fibrous connective collagen tissue. This scar Clinically, microstomia may affect social relations- tissue is subject to constant contraction for months, and hips, mastication and proper oral hygiene31. Difficulty in together with the action of the orbicularis muscle of the oral hygiene results in a higher incidence of oral diseases lips results in the recurrence of microstomia34. For the such as caries, periodontal diseases or other type of oral prevention and management of recurrent microstomia a infections that are difficult to treat due to the limited compression therapy should be applied, involving a com- access11,12,16. Likewise, it may be associated with halitosis missural splint that provides resistance to shrinkage of and in certain syndromes with dysphagia, it may also be the scar, massaging the scar and educating the patient on accompanied by drooling. exercises on horizontal, vertical and perilabial exercises10. Sofos et al.35 developed a new device called Whiston PREVENTION AND TREATMENT OF MI- device used during surgery and in the early postopera- CROSTOMIA. tive period. It acts as a surgical aid to prevent or reduce The treatment of microstomia goes from physiothera- microstomia and to deal with other problems associated py to complex surgical and prosthetic treatments10. with facial burns. This device has a total of 4 uses; 1) acts It has been documented that tissue contractures by as a circumoral and comissure retractor, 2) as a means of burn and retractable scars can be modified with pressu- counter-pressure during excision of the burn, 3) counter- re and splinting. An apparatus for preventing microsto- pressure to the graft after placement, and 4) gives access mia has been described (MPA: Microstomia Prevention to the patient’s mouth to keep oral hygiene. The Whiston Appliance), this has been shown effective in reducing the device is used for 1 or 3 months. Although there is only need for reconstructive procedures and preventing the limited objective evidence for such device, it has been occurrence of microstomia. It is a commissural retractor, effective in preventing microstomia, in maintaining oral 35 a horizontal stretching device which opposes the contrac- hygiene and in the maintenance of grafts . tion of scar tissue32. The MPA must be placed immedia- On the other hand, surgical techniques to treat de- tely after the facial edema has decreased and the patient fects caused by microstomia due to the alteration of soft must wear it throughout the day, removing it only for ea- tissues have been undergoing several modifications over ting and brushing his/her teeth10,32. The use of this device time. Triangular flaps with pedicles have been used for must be discontinued at the discretion of the physician, commissuroplasty, in the form of Z-plasty at the level of 12,36 whose decision is based on the degree of maduration of the internal mucosa or rhomboid flaps . Transposition the facial burn wound.32. of the orbicularis muscle along with an advance of the Surgical treatment of microstomia. oral mucosa or free grafts from thigh or forearm have 37 For the treatment of microstomia, particularly soft tis- been used to rebuild the edge of the lip flaps . Flaps with sues, a variety of surgical procedures has been described. oblique incision of vermilion to transpose them or bring 37 Surgical reconstruction of the oral commissures is a com- them closer to the new oral commissure have also been plex procedure because of the functional and aesthetic used. In recent years, a technique that uses pericomisural aspects involved in the oral cavity33. flaps with mucomuscular advancement, “a simple fishtail Procedures for the reconstruction of the commissures flap” to correct deformed oral commissures with the goal

ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com 343 Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065 of extending the oral aperture to make it functional and vertical, and perioral) and they are grouped according to aesthetically acceptable without recurrence. This techni- whether the device is intraoral or extraoral, unilateral or que is simpler and cheaper when compared to traditional bilateral41. Intraoral devices can be of two types: fixed or surgical methods that are generally more expensive, com- removable and both are customizable31. Removable de- plex, and less practical38. vices are used because they are less expensive than fixed Non-surgical treatment of microstomia. ones, the latter are more costly to make and require gene- Non-surgical procedures for treating microstomia are ral anesthesia for placement in most cases31. based on oral physiotherapy and the use of both static Patients who have suffered burns and systemic sclerosis and dynamic devices to provide resistance to scar con- will be good candidates for the use of stretching devi- traction or for promoting stretching and mobility respec- ces of the soft oral tissue. They are physical therapies to tively3,10. These devices are designed to reduce scarring maintain the range of motion and minimize or prevent and keep normal functions10. contractures or synechiae39,40. Static devices as commissural splints that keep perioral Other types of devices used to improve the range tissues in good condition during the healing period must of oral aperture are cone-shaped corks or resins with a be easy to design, relatively comfortable for the patient progressive diameter. These devices allow the patient to and effective for preventing the contraction of tissues. slowly increase the diameter of the opening7. They can be They are usually placed 3-6 days after the injury compri- used at home and especially before visiting the dentist to sing the healing phase where fibrosis occurs31,39,40. reach maximum oral aperture42. Dynamic devices are classified into three categories In recent years, a new alternative of non-surgical according to the type of stretching provided (horizontal, treatment for microstomia, IPL (intensed pulsed light),

Table 2. Therapeutic measures in microstomia.

THERAPEUTIC MEASURES IN MICROSTOMIA Scar excision Commissurotomy: - Triangular flaps with pedicles (Z-plasty) - Rhomboid flaps SURGICAL Procedures - Oblique flap of vermillion - Transposition of the orbicularis muscle - Free grafts from thigh or forearm Static intraoral devices (splints) Dynamic devices: - For stretching / mobility - Intraoral / extraoral NON-SURGICAL Procedures - Horizontal / vertical / perilabial - Fixed / removable - Unilateral / bilateral Progressive diameter cones for progressive opening IPL- Intense pulsed light

344 ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065 most commonly known as photorejuvenation has been Other materials such as cotton rolls and aspirators should used. The longer wavelengths penetrate deeper into the also be smaller; and frequent pauses are moreover requi- dermis and lead to damaged collagen stimulating the for- red to correctly aspirate water and saliva.29,44. To carry mation of new collagen, which in turn results in a softer out restorative treatment in these patients it would be and elastic skin43. Table 2 summarizes therapeutic mea- also useful to use the atraumatic restoration technique sures used in microstomia. (ART), which involves making the carious cavity prepa- ration by hand instrumentation without anesthesia or ro- THERAPEUTIC ADAPTATIONS IN PATIENTS tary instruments or aspiration, especially in back teeth28. WITH MICROSTOMIA. Current methods of caries prevention, such as using car- A small oral aperture, large tongue or rigidity of the bon dioxide lasers, genetically modified foods and vacci- masticatory muscles poses a major challenge for both ne against cavities are options with which the dentist can 46 diagnosis and dental treatment. It has been found that treat this group of patients . performing stretching exercises and mouth opening be- Regarding filling materials in restorative dentistry, fore dental treatment increases oral aperture of a patient some authors have proposed the use of dental compomers with microstomia in 3-5mm15. However, it is convenient for faster and easier insertion into the cavities under very to install a small rubber wedge to keep mouth space open. complex conditions. However, the sealing material will Dental treatments can be uncomfortable for the patient depend on the achieved isolation and caries risk of the 42 with microstomia, and difficult or impossible to carry out patient . by the dentist. Therefore, in these cases it is of utmost Despite the use of small instruments, procedures such importance to establish prior prevention regimens29. Avoi- as endodontic treatment in molars is quite complicated, ding cariogenic food and keeping a proper maintenance so the treatment should be done only in strategic teeth of oral hygiene is important in chronic and permanent and sometimes it will be only viable in anterior teeth, microstomia for preventing oral disease. being extraction the treatment of choice in the case of For daily oral hygiene toothbrushes with small heads, posterior teeth. To access the pulp chamber, sometimes short and medium-soft bristles or electric toothbrushes dentists must use a vestibular access, and to determine with small heads are recommended. Fluoride toothpaste the working length of the root canals the dentists will and mouthwash rinses with 0.12% chlorhexidine and a have to use the electronic apex locator due to the difficul- 29,42 daily application of fluoride gel with a cotton swab are ty of taking a periapical x-ray . also recommended in order to prevent the onset of condi- For diagnosis, if it is not possible to take intraoral x- tions such as caries and periodontal disease42. rays, dentists can use orthopantomography. As alternative Similarly, in patients who have to undergo tumor re- options, it is also advisable to use small bitewing radiogra- 42 section surgery, followed by radiotherapy, an oral exami- phs, occlusal radiograph or oblique lateral techniques . nation and all the necessary dental treatments such as the For extractions, if the extraction of all the teeth is in- restoration of viable teeth, the extraction of teeth with dicated, the dentist should extract anterior teeth first to 42 active infection or poor prognosis, should be performed facilitate access to the back teeth . before the surgery29. In prosthodontic treatment, making the impression 17,47 To treat patients with microstomia, the dentist will represents the initial difficulty . It is important to need small rotary instruments such as dental burs with adapt the different tray designs and techniques to obtain small heads and short axis21,42,44,45. The use of magni- adequate impressions, since a good registry is required fying loupes to work with more precision is often helpful. with minimum patient discomfort. In many cases it is

ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com 345 Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065 preferable to obtain preliminary impressions, followed by by the patient55. A folding denture in a single piece is a bet- the use of individualized trays, modified to obtain de- ter choice for the functional rehabilitation of these patients. finitive impressions17,40,47. Many authors propose the use Foldable dentures may be easily introduced and easily re- of sectioned trays to facilitate improved intraoral inser- moved from the mouth by the patient and at the same time tion and subsequent relocation of the sections outside the provide adequate functionality56. mouth14,17,48,49. Procedures with general anesthesia may be indicated Prosthesis likewise will be sectioned with hinge sys- for extensive treatments in patients with special needs. tems for easy placement and removal50. There are sectioned Treatment under general anesthesia allows the provision of a prosthesis with various systems for relocation such as pins, comprehensive dental reconstructive treatment and multiple orthodontic expansion screws, plastic blocks with dovetail extractions even in the presence of microstomia42. However, joints, locking levers or magnets14.51-53. These prosthesis are microstomia poses problems for intubation, consequently not only difficult to manufacture, they are also expensive the support of an expert team becomes necessary42. People and difficult to manage by the patient in situations where with microstomia may have difficulty with nasotracheal -in manual dexterity is compromised9,17. The advantage of this tubation33. Patients with the Freeman-Sheldon syndrome design is structural durability, being more resistant to de- may have problems to ventilate their airways and be at a flection and break50. However, they have some disadvanta- high risk of developing pulmonary complications26. Patients ges such as increased laboratory time, limited space for the with the Schwartz-Jampel syndrome are at risk of develo- tongue and the level of patient’s engagement49,54. There are ping malignant hyperthermia45. Similarly, in Moebius syn- other types of removable prostheses that instead of being drome there is a risk of palatine tracheomalacia and uvula sectioned are folding, i.e., they can be folded to facilitate weakness leading to the loss of airway function and respira- their placement in the mouth, making them easier to handle tory insufficiency28.

Table 3. Dental strategies for treating microstomia.

DENTAL STRATEGIES FOR TREATING MICROSTOMIA Rotary instruments with small heads or burs Burs with short axis Dental instruments and materials Magnifying loupes Rubber wedges Aspirator and small cotton rolls Restorative material: compomers Endodontics: - Strategic or anterior teeth only - Opening by vestibular - Apex locator Specific techniques - Previous Orthopantomography Prosthesis: - Preliminary impressions → individualized trays. - Flexible memory materials - Sectioned prosthesis with hinges

346 ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065

The frequency of visits to the dentist should be based on proper oral hygiene and dental appearance. Dental problems the caries risk of the patient, every 3 or 6 months, to carry are prevalent in patients with microstomia. Dental mana- out a professional oral hygiene and the application of fluo- gement of patients with microstomia is a challenge for the ride varnish. Dental treatment strategies for patients with dentist and it is difficult for the dentist to perform a correct microstomia are summarized in Table 3. diagnosis in some dental pathologies due to the limited oral aperture. However, the problem of obtaining a proper diag- DISCUSSION. nosis can be solved by the use of panoramic radiographs. Microstomia is defined as an abnormally small oral aper- In these cases it is important to prevent oral diseases ture that affects appropriate diagnosis and dental treatment. through diet, avoiding cariogenic food and keeping a proper Microstomia is a condition that may be caused by multiple oral hygiene, using toothbrushes with small heads and short and varied situations; from birth defects, such as scleroder- bristles, and oral hygiene aids such as the daily use of fluori- ma, epidermolysis bullosa or in some rare syndromes that de gel and mouthwash rinses with chlorhexidine 0.12%. In affect connective tissue4, or even as a consequence of the cases when the dentist needs to treat a specific dental con- healing of the perioral soft tissues after surgical resection or dition, the procedure should be carried out as atraumatica- trauma such as burns in perilabial areas, that while healing lly as possible using instruments and techniques adapted to leave retractile scars of these tissues, deforming and closing the task. Performing mouth opening exercises before dental mouth commissures1,4,11. treatment, as well as placing a small rubber wedge for kee- Clinical diagnosis of this condition has not yet been ping the mouth space open during surgery is recommended. clearly defined by precise size criteria29, although some It would also be interesting to evaluate the prescription of a authors as Serrano-Martínez et al.18, based on the values of muscle relaxant to be taken by the patient one hour before normal opening in adults (51 to 60mm), suggest that if the the treatment. maximum oral aperture is less than 50mm we are in the In this review various strategies that can be taken into ac- presence of microstomia. However, there should be a more count for the dental treatment of patients with microstomia consolidated diagnostic method that takes into account the are described. However, information available in the lite- time of evolution of such limitation (oral aperture), to es- rature on the topic is quite scarce, since most of the papers tablish whether it really is a permanent condition or just a dealing with dental management of patients with clinical temporary trismus. microstomia are isolated clinical cases or series of cases, with With respect to the treatment of microstomia, surgical few original papers and systematic reviews of the topic. procedures that involve the surgical reconstruction of oral commissures and non-invasive procedures such as oral phy- CONCLUSIONS. siotherapy, together with the use of static and dynamic de- A reduced oral aperture complicates and compromises vices have been proposed. These devices provide resistance the dental treatment of patients, so dentists should have a to the retraction of the scar promoting stretching and mo- preventive approach from an early age with proper oral hy- bility3,10. However, to date, most surgical techniques to treat giene techniques. This review can be useful to clarify the microstomia are complex and have a high rate of recurrence, most important clinical aspects and familiarize oral health affecting aesthetics and functionality. Consequently, deve- professionals with this condition, offering adaptive techni- loping new and innovative surgical procedures with aesthe- ques for the dental treatment of patients with microstomia. tically acceptable results together with devices that effecti- Still, dental treatment in patients with microstomia is diffi- vely prevent recurrence of microstomia is a priority. cult, being the preventive approach the most suitable dental Insufficient oral aperture can be an obstacle to maintain treatment for this group of patients.

ISSN Online 0719-2479 - ©2014 - Official publication of the Facultad de Odontología, Universidad de Concepción - www.joralres.com 347 Silvestre-Rangil J, Martinez-Herrera M & Silvestre FJ. Dental management of patients with microstomia. A review of the literature and update on the treatment. J Oral Res 2015; 4(5):340-350. DOI:10.17126/joralres.2015.065

Manejo clínico odontológico del paciente con tes con enfermedades y síndromes que cursan con micros- microstomia. Una revisión de la literatura y pues- tomia, no hay muchas revisiones del tema en la literatura. ta al día. El objetivo de este artículo es presentar una revisión sobre Resumen: La dificultad en el manejo odontológico es uno la etiología, la clínica, el diagnóstico y el tratamiento de la de los factores que definen al paciente que requiere cuida- microstomia. Así como, describir las adaptaciones terapéuti- dos especiales en odontología. Una de las situaciones clínicas cas que se deben aplicar en los procedimientos dentales en el que más dificulta el tratamiento dental es la microstomia. La paciente con microstomia, recalcando la importancia de un microstomia se define como una apertura bucal pequeña e enfoque preventivo en este grupo de pacientes. insuficiente que va a dificultar el diagnóstico y el tratamiento Palabras clave: Microstomia, Trismus, Gestión de la prácti- bucodental. Aunque se han descrito casos clínicos de pacien- ca odontológica,Cuidado dental.

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