In simple words: Microstomia means having an unusually small mouth. This can be present from birth (congenital) or develop later in life (acquired) due to injury, illness, or surgery.A small mouth opening can make it difficult to eat, talk, and brush your teeth.

Microstomia,a condition defined by an abnormally small oral aperture, can be congenital or acquired.Congenital microstomia is often associated with various craniofacial syndromes. Acquired microstomia may result from scarring due to burns, trauma, surgery (e.g., following resection of lip masses or head and neck cancer treatment), or conditions like scleroderma. The severity of microstomia varies, impacting functions such as eating, speaking, and oral hygiene.Diagnosis considers the functional and cosmetic implications of the reduced oral aperture.

Example 1: A newborn presents with microstomia as part of a craniofacial syndrome, requiring assessment and management by a multidisciplinary team to address feeding difficulties, potential speech delays, and associated medical issues., A patient sustains a severe facial burn resulting in acquired microstomia.Surgical reconstruction with skin grafts and possibly commissurotomy is planned to restore oral aperture and function., An adult patient develops progressive microstomia secondary to scleroderma.Treatment may focus on managing the underlying disease, stretching exercises, and possibly surgical intervention if functional impairment is significant.

Thorough documentation should include a detailed history (including prenatal history if congenital), physical examination focusing on the oral aperture size and associated facial features, documentation of any associated medical conditions, treatment plan, surgical notes (if applicable), and follow-up assessments documenting functional improvement.

** Consider using additional codes to capture associated conditions or complications (e.g., feeding difficulties, speech impairment) as needed to ensure comprehensive billing.