The vancouver microstomia orthosis

The vancouver microstomia orthosis

The Vancouver microstomia Tali A. Conine, Dr.H.Sc.,+ Peter Stevenson-Moore, University of British Columbia, Eighteen microstomia use, and limit...

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The Vancouver

microstomia

Tali A. Conine, Dr.H.Sc.,+ Peter Stevenson-Moore, University

of British

Columbia,

Eighteen

microstomia

use, and limitations. designed

to incorporate

drawbacks. la-month gain

flame period.

with

burns

were

fitted

In 9 weeks

increase

in both

before

respect

(paired

to their

with

secondary

to second-

the prosthesis

treatment t-test,

p < .Ol).

orthosis,

was

and eliminate

some

or third-degree

and observed

was were

characteristics,

microstomia

and 13 mm in the vertical this

and

of many of the orthoses

or less, microstomia

and after

dimensions

with

the Vancouver

microstomia

of 7 mm in the horizontal

The measures

are compared

prosthesis,

the advantages

Ten adults

circumoral

Deborah L. Carlow, B.S.R.,** B.D.S., M.S.D., M.R.C.D.(C)*** Vancouver, R.(:.

orthoses A new

orthosis

over

a

corrected

with

an average

active

range

of motion.

statistically

significant

for

(J PROSTHET DENT 1989:61:476-

83.)

A

variety of microstomia orthoses have been described for prevention or stretching of scar contractures that occur as a complication of facial or mouth burns, trauma, diffuse scleroderma, or reconstructive surgery involving the orbicularis oris muscle.1v 2 However, only a few authors have identified the limitations of the devices that they have proposed. This article presents a comparative overview of the major microstomia orthoses presently in use, and reports the preliminary results of the application of a new prosthesis, the Vancouver microstomia orthosis (VMO), which was designed to eliminate many of the drawbacks of other prostheses.

RELATED

LITERATURE

The selection of an appropriate microstomia device for a patient should be based on the patient’s age, the presence or absence of teeth, the condition of the dentition, the type and extent of injury, the patient’s ability to comply with the regimen of use, comfort, cosmesis, durability, expense, complexity of fabrication, and need for frequent repair and readjustment. The structural and clinical characteristics of 18 microstomia prostheses are classified in Table I.“-15 Most of these devices, once in place, are static (fixed) with no movable parts. Controlled progressive pressure can be provided only through serial splinting, basic structural alterations, or other time-consuming modifications. A few require the presence of teeth. Several designs may be inappropriate for use in the presence of open wounds in the contacting regions of face, cheeks, neck, or head; in patients where force in both horizontal and vertical directions is required; and when simplicity of fabrication and costs are important considerations.‘, 2

*Registered Physical Therapist; Professor of Rehabilitation Meditine. **Staff Occupational Therapist, Vancouver General Hospital; thirdyear student in Medicine, University of British Columbia. ***Head, Division of Dentistry, Cancer Control Agency of British Columbia, Vancouver, B.C. 476

7.5 cm

f-1

4.5 cm E 0 (3

B G!

Fig. 1. Thermoplastic material pattern: section A for Ushaped spring (cut one) and section B for commissural portions (cut two). A new thermoplastic orthosis was designed at the Vancouver General Hospital to correct most limitations encountered with existing prostheses. With careful testing of the VMO, modifications and improvements were implemented.16 The VMO is easily removable by the patient to allow for oral hygiene. Its fabrication does not require the making of a moulage and the administration of anesthesia to the patient. The VMO is inexpensive in material, time saving (made in 30 minutes), and is uncomplicated if adjustments are needed to accommodate changes in the patient’s range of motion of the oral aperture.

VMO FABRICATION Materials

PROCEDURES

Materials consist of a 12 cm x 12 cm piece of unperforated low temperature thermoplastic material (San-Splint x H, Smith and Nephew Inc., Lachine, Que.) heated at 65” to ‘iO”C); Kirschner wire, 10 cm length, 1.1 mm diameter; outrigger wire, 3 to 5 cm length, 2 mm in diameter; a wire cutter. and a drill.

Fabrication 1. The splint pattern is traced onto the thermoplastic material in dimensions shown in Fig. 1. One U-shaped porAPRIL

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Table

I.

PROSTHESIS

The structural and clinical characteristics of major microstomia orthoses Area

Type

Major materials

of orthosis

Static Microstomia prevention appliance (R)* (Dallas, Tex.) McGowan’s sliding bars3 Expansile4 Vertical stretch appliance3 Buccal paddles5

Alginate mold required

Teeth required

Circumoral

Commissure

Approximate age

applied Oral vestibule

Horizontal

Vertical

Adults

Older child

Young child (2 yr.)

Acrylic,

metal bars

No

No

X

X

X

X

Acrylic,

metal bars

No

No

X

X

X

X

Acrylic, Acrylic,

Myrax metal bars

No No

No No

X

X x

X x

X X

Lip retractors, metal bars, universal joints Acrylic and thermoplastic

No

No

x

x

X

Yes

No

-

X

X

Acrylic tusks4 Facemasks

Acrylic Acrylic, orthodontic headgear

No Yes

No No

X X

X X

X

X

Acrylic posts6 Fixed maxillary3

Acrylic Acrylic, chrome, crowns, wire

Yes Yes

Yes Yes

X X

X X

Acrylic Thermoplastic

Yes No

Yes Yes

X X

X X

X X

X X

Thermoplastic Kirschner wires, orthodontic elastics

No

No

X

X

X

X

Lip-expander”

Acrylic, wires, rubber bands

Yes

Yes

X

X

X

X

Microstomia Prevention Appliance (R) (Dallas, Tex.) Circumoral retractor12

Acrylic, metal bars, orthodontic elastics

No

No

X

X

X

X

Two lip and cheek retractors, acrylic resin frame, rubber bands

No

No

X

x

x

Dynamic microstomia prevention splint13

Acrylic, elastic neck strap

No

No

X

X

X

X

X

Occipitally supported appliance14

Wire, IV tubing, orthodontic head-gear

No

No

X

X

X

X

X

Mouth

Thermoplastic, straps

No

No

X

X

X

X

X

Mouthguard

Removable maxillary4 Molded bite plater0 Dynamic Sansplint X-R splint Wg

conformer15

elastic

X

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X

Xand Cheeks

x

X

*Microstomic Prevention Appliance(R) can be adapted and used as a static or a dynamic Adapted by the permission of the Journal of Rehabilitation Research and Development.‘-2 THE

pressure

X

device.

477

CONINE,

(‘ARLOW.

r( OUTSIDE * Fig.

AND

STEVENSON-MOORE

MOUTH

PORTION MOULDED INSIDE THE MOUTH

4. Superior (top) view of shaped commissural portion.

Fig. 2. Shaping Kirschner wire. A indicates distance between commissures.

KIRSCHNER

WIRE Fig. 5. Surface coating is removed from shaded regions that are to be heated and molded together.

3. Anterior view of U-shaped Kirschner wire wrapped in heated thermoplastic material.

Fig.

tion in form A and two commissural portions in form I3 are cut. 2. The Kirschner wire is shaped into a U-shape based on the commissural distance (Fig. 2). 3. Form A (Fig. 1) is heated and shaped around the Kirschner wire except for the ends, which are left flat (Fig. 3). 4. One form B (Fig. 1) is heated and molded against the patient’s commissure (Fig. 4) with at least 2.5 cm of the material molded inside the mouth to aid in the retention of the device. The procedure is repeated for the other form B. The top and bottom edges of the commissural pieces are flared to prevent the edges from cutting into the upper or lower lip. 5. The surface coating of the thermoplastic material is removed from the ends of the U-shaped spring and commissural portions in areas shaded in Fig. 5. These areas are heated and stuck together as shown in Fig. 6 with the commissural portion angled at 140 degrees upward and 160 degrees backward with respect to the wire spring. 6. A hole 2 mm in diameter and 2 to 3 mm deep is drilled into both sides of the spring (Fig. 7).

478

7. The prosthesis is fitted into the patient’s mouth. A piece of outrigger wire is cut and fitted into the holes to act as a static bar and maintain the desired pressure to the commissures (Fig. 8). Omission of the static bar will produce a dynamic device (Fig. 9). 8. Fig. 10 shows the device in place. To remove it, the static bar is removed first and then the device. To increase the vertical opening of the mouth, the size of the commissural portions may be increased. To change the horizontai pressure, the spring can be pulled further apart. The length of the static bar may also be increased or decreased to alter the pressure across the commissures of the lip.

PILOT TRIAL Subjects

OF THE VMO

During 1985 to 1987, consenting microstomia patients at the Burn Unit of the Vancouver General Hospital who were between I9 to 55 years of age and had suffered second- or third-degree circumoral flame burns were selected to use the VMO and undergo observation for a 12-month period. Other patients, not meeting these criteria, were given an appropriate microstomia prosthesis.

Procedures The study subjects began wearing the VMO as soon as the open regions on the lips had healed sufficiently to allow tolerance of the prosthesis. The patient wore the prosthesis to tolerance, beginning with 10 minutes every 2 hours and progressing to 30 minutes every hour when awake. If the patient was intubated, the VMO was applied around the oral airway 3 days after burn trauma or as soon as microstomia appeared to be a risk. APRIL

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140

angl

0

Fig. 8. Anterior with static bar.

view of Vancouver

microstomia

orthosis

160°

angle

@

Fig. 6. A, Side view of Vancouver microstomia Superior (top) view of Vancouver microstomia

orthosis. B, orthosis.

Fig. 9. Anterior view of dynamic model of Vancouver crostomia orthosis with static bar removed.

mi-

Fig. 7. Anterior view of U-shaped spring with holes drilled for static bar to transverse horizontally just below lower lip.

Subjects who were alert and could cooperate performed a set of facial exercises instructed by the Burn Unit’s physical therapist. Subsequent to the stabilization of the range of motion, the splint was discontinued and the range of motion was maintained through the performance of daily facial exercises. If the range of motion could not be maintained through exercise alone, the patient was advised to wear the device for 2 to 3 hours daily until scarring had matured with maximum tissue elasticity. THE

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Fig. bar.

10. Vancouver microstomia

orthosis in use with static

Measurements For the purposes of the study, measurements of the opening of the mouth in horizontal and vertical directions were made from the patients at the initial application of the VMO and thereafter on a weekly basis until measurements re479

Table

II.

Characteristics of burn patients using Vancouver microstomia orthosis

- “---^

.--_-.--

I

Burn Patient

Age (yrs)

.%3X

Etiology

Location

and extent

Days in ICU

Areas requiring skin grafting

C’ompiieationb

1

20

F

Flame burn House fire

78% TBSA, 54% PT: H&N, trunk, U/E, LIE

38

2

51

F

Flame burn

0

(R) U/E, chest, neck

3

24

M

Flame burn or vehicle accident

25% TBSA 24% FT: H&N, trunk, U/E 17% TBSA, 17% FT: H&N, trunk, U/E

1

U/E, face, neck, chesi

4

24

F

Flame House fire

14% TBSA, 3% FT: H&N, trunk, U/E

26

5

46

F

L/E, U/E, face, back

29

M

4

7

22

F

27% TBSA, 25% FT: H&N, trunk, U/E 9% TBSA, 5% FT: H&N, trunk, U/E 39% TBSA 6% FT: H&N, trunk, U/E,

0

6

Flame burn Self-inflicted Flame burn gasoline explosion Flame burn propane explosion

12

Hands, chest, neck, ears Hands and feet

8

32

M

Flame burn House fire

45% TBSA, 40% FT: H&N, trunk, U/E

81

U/E

9

19

M

H&N, trunk, LIE

21

F

74% TBSA, 63% FT: H&N, trunk, U/V L/E 47% TBSA 10% FT: H&N, trunk, U/E, L/E

21

10

Flame burn Motor vehicle accident Flame burn Motor vehicle accident

38

Grafts to U/E

U/E, flank, back. buttocks

f’neumonia Speticerni:i Heterotopic bone \Yound irlfection Heterotopic bone Wound infection Graft. failure Hlnn wjound iIlfWtil)ll

U/E, chest

L/E

Key: TBSA, total body surface area; FT, full thickness; PT, partial thickness;

mained stable. The horizontal measurement was made with the patient smiling as much as possible to create the greatest distance between the lip commissures. The measurement was made from the inside of the commissure on one side to the inside of the commissure on the other side. The vertical measurement was made with the patient opening his mouth in the vertical direction as wide as possible. The measurement was made at the widest point (usually the midsection of the upper and lower lips) from the inside of the upper lip to the inside of the lower lip. A period of practice was allowed to ensure that the patient understood the procedures. The device used for the measurements was an inside caliper with a scale that read to the nearest millimeter. When reading, minimal pressure was applied to the lips with the caliper to prevent inaccuracies of measurement caused by the displacement of soft tissues. At each session, three measurements were made in each direction by the same occupational therapist. Because of the difficulties in measuring soft tissue distance points, the value of each measure was rounded off to the nearest millimeter. The average of each set of measures was recorded. 480

H&N,

head and neck; U/E, upper extremity;

U/E,

Pneumonia Septicemm Wound infection Graft failure Severe contracture Nil Pneumonia Septicemia Heterotopic bone Pneumonia Wound infection Renal failure Severe contracture IIVT, pneumonia, severe scarring Pneumonia Septicemia Acute renal failure Graft failure

L/F,, lower extremity.

RESULTS Ten patients met the selection criteria; all consented and all completed the study, including a 12-month follow-up. Table II describes the subjects’ characteristics. Six women and four men, 19 to 51 years of age (x = 28.8 years), required grafting (two to face) and all except one suffered complications in addition to microstomia that were unrelated to the use of the VMO. Table III shows the initial and final measurements of the active range of motion in horizontal and vertical opening of the mouth. The subjects gained an average of 5 mm in the horizontal and 13 mm in the vertical active range of motion. The changes were achieved in 9 weeks, or less, of VMO use and in as little as 2 to 3 weeks by four subjects. Two-tailed paired t-test comparisons of the before and after measurements were significant @ <.Ol) for the increase of active motion in both dimensions. Figs. 11 to 14 show photographs of the anterior and side view of one of the 10 patients who used the VMO. Patients were compliant in the use of the VMO and considered it to be reasonably comfortable. No pressure sores or APRIL

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Fig.

11.

Table

III.

PROSTHESIS

Anterior

view of static VMO in patient’s

Changes in active vertical

and horizontal

mouth.

Fig.

12. Anterior view of dynamic VMO in patient’s mouth.

opening of mouth of 10 patients

using the Vancouver

microstomia

orthosis Days postburn splint applied

Patient 1

2 3 4 5 6 I 8 9 10

Mean

Median SD Paired t-test Two-tailed

Horizontal Splint us6 (Weeks)

40 8 60 28 24 20 20 3 30 45 27.8 26 13.32

7 8 8 3 9 3 3 9 5 2 5.7 6 2.65

opening

(mm)

Vertical

Initial

Final

50 46 61 51 52 44 41 51* 62 49 51.3 50.5 5.62

52 60 62 60 58 54 58 62 62 55 58.3 59 3.41 t = 4.63 p < .Ol

opening

Initial

(mm) Final

27 21 27 29 25 34 38 25* 45 24 29.5 27 6.99

36 38 35 47 35 41 43 63 52 35 42.5 39.5 8.74 t = 4.31 p < .Ol

*Passive mouth openingbecausepatient was unable to cooperate with active movement.

changes in dental alignment were observed, even with rigorous use of the device. At l-year after burn trauma, none of the subjects was found to have required corrective contracture release. Their range of motion of the opening of the mouth was stable and oral functions (speech, ability to feed with normal-size spoon) were within acceptable limits.

DISCUSSION The conservative and early management of microstomia by the application of an orthosis has received wide acceptance. However, experience with various devices and search THE

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DENTISTRY

of literature reveals several deficiencies. The VMO incorporates the design advantages of the existing orthoses without the drawbacks. The VMO may be applied as a static or a dynamic device. It does not require the presence of teeth, the making of a mold, expensive material, or a great deal of professional labor for fabrication. It applies graduated pressure in the horizontal and vertical directions even when the patient is intubated. Although the VMO was applied to adult subjects, it can be prescribed for older children (>2 years) if compliance is not a problem. The limitations of these preliminary results are recog481

CONINE,

(‘ARLOW,

AND

STEVENSON-MOORE

Most published data on the etficacy 01’ the caxisting orthoses are commonly restricted to singIt%subject clinical reporta. Where larger numbers of subjects were involved. the prosthesis was given to a heterogeneous group with respect to important variables such as age, etiology, location and extent of burn, and presence or absence of’ complications.“-‘” An equally serious impediment in interpreting the results of the application of any microstomia orthosis is the lack of established anthropometric norms pertaining to the oral opening and range of motion. 2ovY There are no reported reliable and replicable methods of measurement for investigators to make appropriate comparisons or convey their results in meaningful terms. The results reported in this article were preliminary to the initiation of a controlled randomized clinical trial for investigating the comparative efficacy of three microstomia ortheses, including the VMO. There is a need to identify through research the most practical device presently available. It would be useful to investigate the most effective force direction, amount of force, and the timing of microstomia prosthesis application. Fig.

13. Side view of VMO in patient’s mouth. We thank Dr. Charles F. ‘1‘. Snelling, Director ot the Hurn llnlt at Vancouver General Hospital, for his encouragement and support.

REFERENCES 1. Carlow DL. &nine TA. Stevenson-Moore P. Static orthoses I’w the maw agement of microstomia. J Rehabil Res Dev 1987;24:95-42 2. &nine TA, Carlow DL. Stevenson-Moore P. Dynamic orthoses for the, management of microstomia. J Rehabil Res Dev 1987;24:4%R. 3. McGowan RH. Prevention of mirrostomia following facial hums. Rr I lent J 1980;149:83-4. 4. Silverglade D, Ruberg RL. Nonsurgical management of INJ~S to the lips and commissures. Clin Plast Surg 1986;13:87-94 5. Clark WR, McDade GO. Microstomia in burn victims: a new appliance for prevention and treatment and literature review. .I Burn Care Rehabil 1980;1:33-6. 6. Xaylor WP. Manor RC. Fabrication of a flexible prosthesis for the edmLU~OUS scleroderma patient with mirrostomia. .I PROSTHFI‘ DEW 1983: 50:536-A. 7. Richardson DS, Kittle PE. Extraoral management of a lip commissure burn. J Dent Child 1981;48:352-6. 8. Colcleugh RG, Ryan JE. Splinting electrical burns 01 the mouth in rhildren. Plast Reconstr Surg 1976;58:239-41. 9. Holt GR, Pare1S, Richardson DS, Kittle PE. The prosthetic management of oral commissure burns. Laryngoscope 1982:92:407-l 1. 10. Gorham JA. A mouth splint for hum microstomia. Am J Occup Ther 1977;31:10.?-6. 11. Jackson MJ. The use of a dynamic lip-expander in the rehabditution CII a severely burned face: report of case. J Dent Child 1979;66:230-3. 12. Gay, WI). Prostheses for oral burn patients. .I PROS’THEl’ DENT 1984:

Fig.

14. Resolved microstomia after 8 weeks of VMO use.

nized. Without a control group, the observed before to after changes in measurement could be attributed to healing. However, the progressive and devastating changes associated with scar tissue are clinically anticipated. The subjects were limited to younger adults (19 to 55 years of age) so that any possible increase in the range of motion or lack of suc-

cess could not be attributed to age-related factors.

482

52564-G.

Reisb-ergDJ, Fine L, Fattore L, Edmonds DC. Electrical burns of the oral commissure. J I%STHET DENT 1983;49:71-6. 14. Josell SD, Owen D, Kreutzer LW, Goldberg, NH. Extraoral management for electrical burns of the mouth. d Dent Child 1984;51:47-52. 15. Denton BG. Shaw SE. Mouth conformer for prevention and correction of burn scar contracture. Phys Ther 1976$6&U-G. 16. Carlow DL, Conine TA, Stevenson-Moore P. Fabrication of a removable microstomia orthosis. Can J Occup Ther 1988;55:206-10. 17. Blakley
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of a custom maxillary night splint with lateral projections in the treatment of microstomia. Phoenix, Ariz: The Proceedings of the Seventeenth Annual Meeting of the American Burn Association, March 1985;127. 19. Sadone AM, Jones JE, Palin W, Lynch TR, Bennett JE. Appliance therapy for perioral burns: a conservative approach. Phoenix, Aris: The Proceedings of the Seventeenth Annual Meeting of the American Burn Association, March 1985;124. 20. Cervenka J, Figalova P, Gorlin RJ. Cranio-carpo-tarsal dysplasia or the whistling face syndrome: II. Oral intercommissural distance in children. Am J Dis Child 1969;117:434-5.

ANNOUNCING

21. Farkas LG. Munro IR. Anthropometric facial proportions in medicine. Springfield, Ilh Charles C Thomas, 1987. Reprint requests to: T&r CONINJ!? THE UNIVERSITY OF BRITISH COLUMBU SCHOOL OF REHABILITATION MEDICINE VANCOUVER, BC V6T lW5 CANADA

A NEW SECTION-CLINICAL

REPORTS

The JOURNAL OF PROSTHETIC DENTISTRY is pleased to announce a new section-Clinical reports. This section will contain reports of the clinical treatment procedures of a patient that will be of special interest to our readers. A CLINICAL REPORT should be no longer than three to four double-spaced, typewritten pages supplemented by no more than eight good-quality, descriptive coEor illustrations. CLINICAL REPORTS will be evaluated in the same manner as all other manuscripts that are submitted to the JOURNAL OF PROSTHETIC DENTISTRY for possible publication.

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