| Abstract|| |
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.
Keywords: Collapsible denture, flexible denture, reduced mouth opening, sectional denture
|How to cite this article:|
Kumar B, Fernandes A, Sandhu PK. Restricted mouth opening and its definitive management: A literature review. Indian J Dent Res 2018;29:217-24
|How to cite this URL:|
Kumar B, Fernandes A, Sandhu PK. Restricted mouth opening and its definitive management: A literature review. Indian J Dent Res [serial online] 2018 [cited 2019 Jul 20];29:217-24. Available from: http://www.ijdr.in/text.asp?2018/29/2/217/229618
| Introduction|| |
Microstomia is a term used to describe a small oral aperture. Limited mouth opening could be because of cleft lip and palate, micrognathia, craniocarpotarsal dysplasia, epidermolysis bullosa, scleroderma, oral submucous fibrosis, Plummer–Vinson syndrome, Hallermann–Streiff syndrome, Treacher-Collin syndrome, burns, trauma, postradiation therapy for facial cancer, surgically induced after treatment for cleft lip and palate, facial tumor or facial trauma, and trismus. Some other conditions such as tooth decay/dental pain, mumps, oral space infections, and trismus/temporomandibular dysfunction syndrome also cause transient microstomia for a limited time.
Such patients are unable to perform normal functions such as mastication, deglutition, and speech. Other difficulties encountered by patients with limited mouth opening are caries and periodontal diseases. Furthermore, dental treatment for such patients is difficult due to limited access. Along with limited mouth opening, tongue rigidity, constantly changing peripheries/vestibule in the oral cavity and patient's loss of tactile sensation coupled with hand deformities make prosthetic treatment difficult. Patients who are not responding to exercise or expansion prosthesis and who are candidate for removable prosthesis need special attention and modifications in prosthetic steps such as modified stock trays, sectional custom trays, and collapsible/sectional or flexible final dentures. To provide fixed tooth-supported prosthesis, special emphasis is required during crown preparation and impression making, whereas in implant-supported prosthesis, placement procedure is difficult as instrumentation needs good access for proper positioning and parallelism of implants, especially in posterior regions.
| Materials and Methods|| |
Electronic databases were searched using Medline, PubMed, and Google for the keywords: microstomia and treatment options for restricted mouth opening. However, all published articles on desired topic were not accessible online due to need of subscription, and it was a big limitation in search process. Hard copies of journals in the library were then hand searched for such articles.
Selection criteria included case reports and review articles focusing mainly on the management of patients with microstomia. The majority of the selected articles were case reports for individual condition, concentrating on that particular aspect. For ease of understanding, management part is divided into prosthodontic management and surgical correction. However, the prosthodontic management part is further divided into subheadings based on type of final prosthesis planned for the patient.
It includes removable prosthesis, fixed tooth-supported prosthesis, implant-supported prosthesis, and maxillofacial prosthesis [Table 1].
In a patient with restricted mouth opening, it is difficult to obtain the “perfect” impression that captures all possible details. Hence, priorities must be established according to the restorative and reconstructive needs of an individual patient. To make an impression, various modifications have been suggested.
Modifications for making primary impression
Stock tray modifications
While making primary impression, generally, a stock tray is used [Table 2]. However, a loaded stock tray is the largest item, requiring wide mouth opening during intraoral placement. Various stock tray modifications have been suggested while making impression for limited mouth opening.
The rigid stock tray possibly gives accurate impression, but they cannot be used as a single unit. The tray needs to be made in sections so as to permit insertion and removal from the patient's mouth. To orient the sectional tray during impression, making a reliable orientation and connecting mechanism is needed which will help in holding sections during impression making and re-orientating the same relationship while pouring cast. Various mechanisms for orienting the segments suggested in literature are use of modeling compound at the junction of two segments. For very severe microstomia, impression can also be taken in three sections (one from canine to canine region and two from canine to retromolar area on both sides), for which also plaster indices can be made over junctions on nontissue surface. Moghadam  took two stock trays and sectioned them as much as possibly away from midline to cover maximum areas. One section can be poured first and the common/overlapping part between two trays help in orientation while pouring remaining part of impression. This is easy as well as accurate method too, but it requires sufficient teeth present and is difficult in mandibular arch when multiple teeth are missing. Luebke  sectioned stock tray just side to midline so that one part contains handle and attached three LEGO plastic building blocks around junction to orient and stabilize parts while pouring. Two small LEGO blocks were fixed at junction on each segment, and one large was attached only over small segment with extending part to engage on LEGO of other section. It is an easy, accurate technique and even can be carried out for mandibular impression.
Impressions recorded without using stock tray
For patients who were wearing well-fitting denture preoperatively, casts were poured into the bases of previous dentures, either in plaster or in elastomers depending on the presence of undercuts. The obtained casts can be used to make custom-made sectional tray. Whitsitt and Battle  adapted putty directly in mouth with finger without any tray and used same as a tray for taking light body wash impression, whereas Cheng et al. used occlusal registration material adapted intraorally again with finger without tray, in which a wash impression was taken later with light body silicon material. In these procedures, plaster index was made before pouring to prevent distortion; however while removing from mouth, some distortion is normal and unavoidable, as there is no rigid support. A rigid support by use of tongue blade was recommended by few authors., Supoj and Kiattisorn  suggested the use of horseshoe-shaped perforated flexible fluoride application tray to take diagnostic impression. To record the palate, it was suggested to place the putty material on the palate before the placement of the flexible tray. All these techniques are easy and less time-consuming for operator, comfortable for patients but are not giving an accurate impression.
Custom tray modifications
These can be sectional custom trays, sectional-collapsible custom trays, only collapsible custom trays. A more horizontal motion is used for the placement of tray in patients with limited mouth opening as compared to both vertical and horizontal motion in normal mouth opening patients. Hence, flange height as well as amount of loaded impression material should be less, to enable easy manipulation while making impression. It is more difficult to insert the tray than to remove it from the mouth. While placing tray intraorally, the operator usually stretches one corner, making the oral opening still smaller. During removal, the orbicularis oris can be stretched beyond the limit of the patient's normal function, thus providing the additional maneuverability. Dhanasomboon and Kiatsiriroj  described a technique where two custom trays were made and later sectioned as much as away from the midline to cover maximum overlapping in impression portions which will help in orientation of first poured cast while pouring remaining part of impression. Equally sectioned custom tray can also be joined together with butt joint, latch-locking system, fins,, key and keyway,, dowel plug holes, and a screw joint for rigid connector, at midline junctional area to get proper orientation. These guiding assemblies can also be incorporated in handle of tray such as Mirfazaelian  puts orthodontic expansion screw without screw axis. Similarly, Fernandes et al. have put anterior lock (similar to precision attachment containing male and female part) in sectioned handle. They advocated a posterior lock (press-button) additional for maxillary, whereas for mandibular, only anterior lock is sufficient. For severe microstomia patients, tray can also be fabricated in three sections which can be reassembled, fixed together with the modeling compound index made at junctions. In flexible custom tray, the two segments of tray are connected by hinge at center and are also attached with elastics to stretch and dental floss to fold which makes its use easy. Suzuki et al. designed sectional tray using LEGO blocks (plastic building blocks - first used by Luebke ) to the sectional custom tray so that the tray could be exactly reassembled. In another design, tray is divided into two sections (posterior and anterior) and two parts are oriented by three vertically placed metal bars/rods. Similarly, pins were placed vertically on nontissue surface of both sectional trays, and an acrylic block was made to engage in these pins for keeping tray segments in proper orientation, while taking impression and while pouring too.
During recording jaw relation, record bases along with occlusal rims should be easy to place and should remain stable during the procedure. Hence, it is recommended to make permanent sectional denture bases with flexible joint which allows easy reorientation.
Various denture designs have been described in the literature for patients with limited intraoral access [Table 3]. Sectional prosthesis that could be introduced separately and assembled intraorally and/or collapsible prosthesis that could be folded during insertion and reopened intraorally are sometimes the only options for final prosthesis. Flexible, noncollapsing monoblock (valplast) can be used for mandibular dentures and maxillary palateless/roofless dentures. The long-term follow-up revealed that the choice of a flexible denture is an appropriate solution for restricted mouth opening for restoring esthetic and function without damaging surrounding structures, provided mouth opening allows it to move in and out. Root-retained overdentures  are based on the principle of reconstructive prosthodontics to preserve natural teeth or their roots as long as possible. Retention can be achieved from ball and socket attachment which enables to have prosthesis well retained with minimal flange extensions, thus allowing easy placement in the oral cavity. Lee evolved the system of two-part partial denture design, in which each component had an individual path of insertion. Both parts were held together inside the mouth by miniature bolts. L'Estrange and Pullen-Warner , introduced a split-pin and sleeve device to unite the denture components. This system had two advantages. The pin was manufactured from Wiptam wire and thus readily attached to cobalt-chrome castings. The pin could also be replaced to accommodate for wear resulting from friction locking. Compared to this method, anchor attachments are smaller and more compact than split pins. The Dalla Bona  nonresilient stud was the first anchor attachment. This is indicated when the path of insertion of the second component of the denture is at a right angle to that of the first component. Segal described a technique in which a nonresilient standard existing attachment-like Rotherman or an Ackerman bar clip attachment was soldered to a cast framework to fabricate a simplified maxillary split denture. However, in magnet-retained sectional denture, the two parts are held in position in mouth by the use of magnets. It is mainly indicated for a maxilla having partial edentulous conditions with either severe undercuts or limited mouth opening. Benetti described a collapsible prosthesis technique  for making a complete denture consisting of two pieces joined by a stainless steel rod fitted palatal to the central incisors. The rod acts as a hinge for this collapsible prosthesis. In similar design, complete denture was fabricated in two halves; both halves were joined rigidly by a stainless steel post that is inserted into three tubes within the palatal region of complete denture. The post which is removable was attached to the right maxillary incisor, which served both as a tooth and as a handle for the post. Use of simple custom-made hinge in between using a stainless steel orthodontic bracket with a buccal tube and 1 mm stainless steel wire is also advocated for mandibular collapsible denture. Swing-lock collapsible denture design is also described for mandibular complete denture. On the lingual side, two segments are joined by a hinge which makes it collapsible while labial side is provided with swing lock to make it stable after seating. Prosthesis can also be made in three segments, in which two posterior segments are hinged for making them collapsible during insertion and after placement and a third anterior segment is attached to make it a rigid single framework. Various attachments have been described for attachment of third segment with the other two. The third triangular anterior segment can be attached to the first two hinged segments using two stud attachments to complete the base and hold it rigid. The patrix of each stud attachment was placed in the canine region of each of the two main hinged segments. The matrices of the stud attachments were located at the appropriate point on the third detachable section.,, Similarly, two posterior sections hinged with clip hinge in center can be attached to third anterior part with dental magnets. In another design, telescopic copings were prepared over two posterior hinged segments, whereas telescopic crowns were a part of the third segment which fits over copings to make the prosthesis a single-rigid unit. In a similar design, Conroy and Reitzik  placed a wrought wire clasp assembly to engage tooth undercuts in inferior segment instead of telescopic crowns in the third part for attachment over first two parts (inferior segments). Author has also mentioned the use of a surveyor to prepare the recessed channels palatally between second premolar and first molar, third part was fabricated to fit in this recess for locking. Gay and Kent  designed a tripartite prosthesis, in which maxillary denture was initially fabricated and divided into two equal parts. Each part had two Zest semi-precision attachments placed in the palatal sections. An acrylic resin bridge or palate with four corresponding Zest attachments was then fabricated. The two denture halves were joined intraorally for a stable denture by the acrylic resin plate. However, this design may restrict tongue space. In another design, the two halves of denture can be given with vertical and horizontal dovetails individually or together to keep two parts as a single unit. A third segment with pins can be given over two halves to maintain locking more snugly.
Tooth-supported fixed partial denture
Difficulties are faced during tooth preparations and impression making for recording finish line and other details. Hence, small head pedodontic hand-piece can be used along with small head mouth mirror. All above-mentioned modifications can be employed in tray design for a good impression.
McGill  considered the mandibular overdenture retained by two implants as the standard of care for edentulous patients. Implant-supported fixed or implant-supported screw-retained prosthesis are the options for completely edentulous patients. However, it requires the placement of sufficient number of implants to withstand the occlusal load. In microstomia patients, access does not allow to place more number of implants. Shortened dental arch concept is the best suited protocol for such conditions. Langer and Langer  advocated the placement of two endosseous implants in the maxilla and fabrication of a maxillary complete overdenture retained by bar and clip attachment. Cheng et al. and Marianna Pasciuta et al. also advocated two implant-supported overdentures. Low-profile resilient attachments were selected. These approaches have solved the retention problem but not solved the insertion problem. In certain cases such as epidermolysis bullosa, blister formation results from mechanical friction of the denture on the mucosa. In this situation, a fixed prosthesis is likely to be more comfortable to the patient as it is completely implant supported and has limited nonload bearing contact with the mucosa, thereby limiting the possibility of the soft tissue ulcerations. Patel et al. have proposed four implants in the mandible which support fixed partial denture up to a short dental span. However, here, masticatory efficiency is very less due to limited coverage by prosthesis. Haas  had placed seven implant-supported maxillary fixed complete dentures in scleroderma patients. Hence, shortened dental arch concept is best suited for such condition. Overdenture prosthesis requires a certain amount of space for adequate denture base thickness and to house the prosthetic components. Limited interarch space may also limit the choice of prosthetic components. Modifications mentioned in impression techniques and denture designs can be applied for implant-supported prosthesis also.
Almost all perioral maxillofacial surgeries with or without radiotherapy lead to fibrosis and finally result in reduction of mouth opening. In 1983, Lauciello et al. suggested fabrication of flexible obturator for patients with severely limited mouth opening using either silicone or even a flexible vinyl resin mouth guard material. However, they cautioned that these materials are far from ideal, and in an average maxillectomy case, it would be inadequate. In 1990, Boris Schwartzman et al. conducted a photoelastic study of various retainer designs for definitive obturators and their effect on natural teeth during gravitational forces on the prosthesis. They concluded that since the force of gravity is always active on a maxillary prosthesis, the design of an obturator should minimize its weight; or else, it would induce detrimental effects on the remaining teeth, which are engaged by retentive parts of the obturator., To reduce weight of prosthesis, various techniques of making hollow denture have been mentioned in the literature.,,,, In partial maxillary resection, retention can be gained from nasal extension/retainer. It not only gives retention but also improves facial symmetry. Cheng et al. have suggested following points in maxillectomy patients. Vinyl polysiloxane can be used as a tray to take impression as patient's oral opening is limited for tray placement. This material can be hand dispensed intraorally without using a stock tray, and thus, the problem to insert tray in microstomia is eliminated. If programming of the condylar elements of the articulator is not possible due to lack or limited protrusive and lateral movements, use of zero degree teeth has been suggested. Vertical dimension can be kept less to facilitate food entry in anterior region and also to manipulate food bolus during chewing. Patients should be instructed to limit mastication from defect side.
Instructions after prosthetic treatment in limited mouth opening
With the complicated design of the prosthesis along with the poor access to the most posterior region of the oral cavity, it is important that the patient should be given proper instructions so as to achieve optimum function.
- To maintain the mouth opening, an exercise program should be performed as scheduled by dentist 
- The use of an electric toothbrush  and 0.2% chlorhexidine solution should be recommended. Collis Curve Toothbrush is designed especially for patients with limited mouth opening 
- To prevent caries, daily application of a 0.4% stannous fluoride gel was recommended on the root surfaces which were used for over-dentures
- Routine follow-up appointments should be scheduled
- If dentures are relined with soft liners (as in cases of oral submucous fibrosis), that should be changed after every 10–12 months 
- They should be educated and instructed regarding the removal and insertion of the prosthesis
- Dental floss should be tied to the framework segments during insertion to prevent accidental swallowing 
- Postinsertion and oral hygiene instructions should be given.
Corrective microstomia involves plastic and reconstructive surgery, including microsurgery. These surgical procedures require an ample supply of tissue for reconstructive procedures, so most of time these are preceded by the use of stretching appliances or splints to increase tissue mass, followed by splints to maintain results at least during healing phase.,, Different surgical procedures have been presented to reconstruct microstomia. In 1831, Diffenbach  demonstrated a technique with using mucosal flaps after scar tissue excision. The same technique was modified by Converse  and later by Friedlander et al. Kazanjian and Roopenian  presented two methods of reconstruction which were functionally satisfactory and esthetically acceptable. Karapandzic  used local arterial flaps to reconstruct lip defects. Finally, Berlet et al. described a new technique which inhibits occurrence of postoperative scar tissues. Treatment sequences include removal of fibrotic bands with commissuroplasties/commissurotomy first followed by retention of gained vermilion length with semidynamic mouth splints. Revision surgery can be performed 1 month later if required to remove granulation tissue and additional scar. Controversy exists as to the time for surgery in burn patients. Hyslop advocated early debridement and repair as he believes that the line of demarcation between healthy and devitalized tissue is present no longer than 12 h. This early intervention decreases the chance of infection and provides sufficient blood supply, promotes faster healing, and thus reduces secondary healing and contraction. Fleury and Frank advocated a wait of 4–7 days before treatment for better delineate the area of necrotic tissue. Others suggest that the true extent of necrosis only becomes evident after sloughing of the eschar. By delaying surgery until eschar has sloughed, it is possible to find area of viable tissue with adequate blood supply for restructuring. Pittset al. recommended deferring repair from 6 months to several years in children, as they believe that early repair may result in a tight lower lip that may alter jaw growth and relationships. Thompson showed no difference between results of surgery performed within the first 4 weeks and later. Splints are recommended postoperatively to prevent further collapse in oral opening.
| Conclusion|| |
Restricted mouth opening is a big psychological trauma for the patients as their oral functions are restricted and facial esthetics is also compromised. The fabrication of prosthetic restoration is difficult using conventional procedures because these cannot be applied directly to patients with limited mouth opening. Hence, clinician should have a sound knowledge of all possible modifications and approaches to carry out innovative design of prosthesis along with retaining their basic mechanical principles to achieve satisfactory esthetics and function. This article is aimed to provide collective information for successful management of such patients.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Bhushan Kumar
7-A Manikshaw Colony, Pathankot - 145 001, Punjab
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]