CLINICAL REPORT

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THE JOURNA

Correction of microstomia in an edentulous patient

Aditi Nanda, MDS,a Sriram Krishnan, MDS,b Harsimran Kaur, MDS,c Dheeraj Koli, MDS,d Karan Manak, MDS,e

Mahesh Verma, PhD,f and Shubhra Gill, MDSg

ABSTRACTThe problem of small oral aperture is big. Irrespective of the etiology, this problem may be over-come by adjunctive therapies in the form of prosthesis, surgery, or exercise. A patient is describedwith this problem, which was overcome by revisiting the 3 adjunctive therapies including acommissural stent designed with the patient’s edentulous state in mind. (J Prosthet Dent2016;115:137-140)

Microstomia has been des-cribed as a diminished oralaperture.1 It may result fromvarious causes that lead tocicatricial scar formation,2 re-sulting in esthetic compromise,hypotonicity of the circumoral

musculatures, and decrease in vertical and horizontalopening of the mouth.3,4 The main problem that can arisedue to microstomia can be functional (speech, nutrition,hygiene) or esthetic (due to asymmetric lip placement).4-6

There are many treatment options available: surgical,6-8

nonsurgical,1,9-13 and a combination.14,15 In any of thetreatment options, the aim is not just providing well-functioning lips with increased mouth opening andimproved esthetics, but also providing a stable and long-lasting result.14 Three adjunctive therapies (surgery,stent, and exercise) were planned for an edentulous pa-tient with microstomia.

CLINICAL REPORT

A 55-year-old man reported with reduced mouth open-ing after surgical intervention (Figs. 1, 2). His historyrevealed that surgical intervention had been undertakento resect a growth (diagnosed as squamous cell carci-noma) in the left lower vestibule and corner of mouthabout 6 months before, which resulted in cicatricial scarformation and the current chief complaint of reducedmouth opening. The patient reported being a chronicchain smoker over the past 10 years. Examination

arch Associate, Maulana Azad Institute of Dental Sciences, New Delhi, Indarch Associate, Maulana Azad Institute of Dental Sciences, New Delhi, Indent, Maulana Azad Institute of Dental Sceinces, New Delhi, India.arch Associate, Maulana Azad Institute of Dental Sciences, New Delhi, Indtice, New Delhi, India.d Head, Maulana Azad Institute of Dental sciences, New Delhi, India.ofessor, Maulana Azad Institute of Dental Sciences, New Delhi, India.

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revealed asymmetry in the location of left and right lipcommissures. The left commissure was closer to the facialmidline (1.5 cm from the facial midline) compared to theright commissure (2.5 cm) at rest. Reduced mouthopening was also noted (approximately 3.5 cm whenmeasuring between the upper and lower lip at thevermillion border of the lips in the region of the facialmidline). Intraoral examination revealed that the patientwas completely edentulous.

Treatment goals were to improve the mouth opening(to improve function); to attain symmetrical positioningof commissure; and to perform long-term maintenanceof the aforementioned goals.

Combined nonsurgical and surgical intervention wasplanned to achieve the treatment goals. The surgicalintervention was to perform commissuroplasty of the leftcommissure. The extent of commissuroplasty was plan-ned to maintain a distance of the left commissureequivalent to distance of the right commissure from thefacial midline. The nonsurgical intervention was tofabricate a passive commissural stent before surgery andput it to effective use immediately after surgery. Thesame stent was to be continued in a dynamic mannerafter initial healing of the wound by a slight modification

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137

Figure 1. Reduced vertical mouth opening. Figure 2. Reduced horizontal mouth opening and asymmetrical place-ment of commissures.

Figure 3. Impression of cheek (extraoral and intraoral).Figure 4. Adapted soft splint sheets to form commissure conformers;J-shaped hooks attached to commissure conformers; attachment ofJ-shaped hooks to cervical headband for adjustable force application.

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of the stent. Additionally, mouth stretching exerciseswere advised to augment the mouth opening.

The presurgically fabricated commissural stent wasdesigned in 2 separate commissure conformers, made outof clear thermoplastic bioplast sheet (Bioplast sheets;Scheu Dental GmbH). The 2 conformers were connectedto each other by removable means using a cervicalheadgear. Impression of both left and right cheeks wasmade with mouth maximally opened. Before making theimpression, the extent of incision for commissuroplastywas marked (with indelible pencil) in relation to the leftcommissure, which was decided by equating it with thedistance from the facial midline and the location of theright commissure at rest. The impression was made withpolyvinyl siloxane (Aquasil Ultra, Putty; Dentsply Caulk)in putty consistency. The material was mixed andadapted over the outer and inner (mucosal) surfaces ofthe cheeks on both the left and right sides (Fig. 3). Whileadapting the impression material intraorally, care wastaken to extend the material to the full depth of themaxillary and mandibular buccal vestibule. The impres-sion was extended extraorally, keeping in mind the arearequired to be covered by the stent for retention yet notinterfering with function. Digital support was provided tothe impression material throughout the setting of theimpression material. Once the material had set, the

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impression was removed, and the cast was poured inType III dental stone (Kaldent; Kalabhai).

The cast of the left side was modified by trimminguntil the extent of the area that was planned to be sur-gically removed (as marked before making the impres-sion). Separating material was applied (Bioplast insulator;Scheu Dental GmbH) on the casts, and 3.0 mm thickthermoplastic material (Bioplast sheets; Scheu DentalGmbH) was adapted using a Biostar V machine (BioplastScheu Dental GmbH) at 6 MPa pressure for 30 secondsto fabricate commissure conformers. The 2 conformerswere attached through the cervical headgear to completethe commissural stent (Fig. 4). Double J-shaped hookswere fabricated using 19-gauge orthodontic stainlesssteel wire (K.C. Smith). One end of the hook wasattached to the conformer through a pierced hole. Thefree end of the J-shaped hook was attached to the cer-vical headgear (Leone Neck Pad for Safety Release;Libraltraders, Leone Safety Release modules; Libral-traders) on both the left and right sides to complete thecommissural stent. The region of attachment to the cer-vical headgear determined the amount of tension createdby the stent using a Dontrix gauge (Leone Dontrix

Nanda et al

Figure 5. Commissural splint in use. Figure 6. Force using same splint with minor adjustment.

Figure 7. Improvement in vertical mouth opening. Figure 8. Improvement in horizontal mouth opening and more sym-metrically placed commissures.

February 2016 139

Gauge; Libraltraders), and it was hence determinedwhether the stent was to be used in passive state(immediately after surgery) or in a dynamic state (afterhealing of surgical wound).

The purpose of the surgical procedure was to removethe scar tissue, enhance primary healing, and minimizetissue contraction.16 The contracture was released by acontinuous incision through the skin (extraorally) andmucosa (intraorally), thereby creating a triangular defect.The extent of the incision was as previously decided.

The patient was shown and instructed how toassemble the 2 separate stent components with theheadgear (Fig. 5). The stent was maintained to be passivefor the initial 14 days, with the main aim to preventrelapse in initial stages. The J-shaped hook was sym-metrically inserted at the third hole of the cervicalheadgear. After 14 days, the position of the hook wasmoved more posteriorly (according to maximum patienttolerance) to make the stent more active and dynamic inorder to consistently apply force and prevent recurrencedue to scar formation (Fig. 6). The patient was instructedto wear the stent for duration of not fewer than 14 hours,including nighttime wearing.

As suggested previously,11 manual mouth-stretchingand jaw-stretching exercises were advised to berepeated alternately 10 times per instance and twice a

Nanda et al

day. A substantial improvement in mouth opening (4.0cm measuring between upper and lower lip at thevermillion border of the lips in the region of the facialmidline) was observed, and placement of the leftcommissure (Figs. 7, 8) was attained at the end of 5weeks. After improvement of mouth opening, a con-ventional complete denture was fabricated. The patientreported with consistent findings in his 9-month recall.

DISCUSSION

A surgical intervention was required because the scarcontracture was already present and needed to beexcised. Addition of exercise augmented the results bypromoting stretch. A commissural stent was fabricatedusing complete extraoral anchorage with the cervicalheadgear. The design of the appliance was made keepingin mind the edentulous state of the patient. The com-missural stent was prescribed in a passive state duringthe early healing phase to prevent any relapse and con-nective tissue growth. The same commissural stent wasmade dynamic to increase the amount of stretch, if anyrelapse should occur, and maintain the achieved open-ing. The other advantages of the commissural stent wereas follows: it provided physical resistance to scarcontracture, together with a horizontal and vertical lip

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stretch3; it permitted movement and function of thesurgical region with traction without applying a constantforce that could cause pressure necrosis; it was easy tofabricate; and no general anesthesia was required for theprocedure. The drawbacks included an esthetic compro-mise (while in use); mechanical interference duringmastication; and dependence on patient compliance(removable appliance) for results.

CONCLUSIONS

Adjunct therapies can be implemented before the fabri-cation of complete dentures in patients with microstomiaas an alternative to a conventional protocol of sectionalcomplete dentures.

REFERENCES

1. Wust KJ. A modified dynamic mouth splint for burn patients. J Burn Care Res2006;27:86-92.

2. Smith PG, Muntz HR, Thawley SE. Local myocutaneous advancement flaps.Alternatives to cross-lip and distant flaps in the reconstruction of ablative lipdefects. Arch Otolaryngol 1982;108:714-8.

3. Bedard JF, Thongthammachat S, Toljanic JA. Adjunctive commissure splinttherapy: a revised approach. J Prosthet Dent 2003;89:408-11.

4. Egan JG, Swindells SA. A novel prosthodontic alternative for patients whoare edentulous and have microstomia: a case report. Spec Care Dentist2012;32:160-4.

5. Mordjikian E. Severe microstomia due to burn by caustic soda. Burns 2002;28:802-5.

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6. Jaminet P, Werdin F, Kraus A, Pfau M, Schaller HE, Becker S, Sinis N.Extreme microstomia in an 8-month old infant: bilateral commissuroplastyusing rhomboid mucosa flaps. Eplasty 2009;10:e5.

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8. Mehra P, Caiazzo A, Bestgen S. Bilateral oral commissurotomy using buccalmucosa flaps for management of microstomia: report of a case. J OralMaxillofac Surg 1998;56:1200-3.

9. Reisberg DJ, Fine L, Fattore L, Edmonds DC. Electrical burns of the oralcommissure. J Prosthet Dent 1983;49:71-6.

10. Silverglade D, Ruberg RL. Nonsurgical management of burns to the lips andcommissures. Clin Plast Surg 1986;13:87-94.

11. NaylorWP, Douglass CW,Mix E. The nonsurgical treatment of microstomia inscleroderma: a pilot study. Oral Surg Oral Med Oral Pathol 1984;57:508-11.

12. Khan Z, Banis JC Jr. Oral commissure expansion prosthesis. J Prosthet Dent1992;67:383-5.

13. Koumjian JH, Firtell DN. A prosthesis to control microstomia. J Prosthet Dent1990;64:502-3.

14. Sadrimanesh R, Hassani A, Vahdati SA, Chaghari H, Sadr-Eshkevari P,Rashad A. Freeman-Sheldon syndrome: combined surgical and non-surgicalapproach. J Craniomaxillofac Surg 2013;41:397-402.

15. Koymen R, Gulses A, Karacayli U, Aydintug YS. Treatment of microstomiawith commissuroplasties and semidynamic acrylic splints. Oral Surg OralMed Oral Pathol Oral Radiol Endod 2009;107:503-7.

16. Richardson DS, Kittle PE. Extraoral management of a lip commissure burn.ASDC J Dent Child 1981;48:352-6.

Corresponding author:Dr Aditi NandaDepartment of Prosthodontics, Rm 116Maulana Azad Institute of Dental SciencesBhadur Shah Zafar RoadNew Delhi, 110002INDIAEmail: aditinanda@yahoo.com

Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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