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A Review of Selected Microstomia Prevention Appliances

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A Review of Selected Microstomia Prevention Appliances Scientific Article A review of selected microstomia prevention appliances Lincoln B. Taylor, BSc, DDS, MS Jerry Walker, BS, DDS, MA Abstract sues, and the live wire makea complete circuit, gener- 8 Perioral burns mayoccur due to electrical, thermal, or ating heat from 2500-3000°C. In a contact burn, the chemicalagents. The resultant contracture of the facial electrical current passes through the body along the tissue during healing causes limited oral access, compro- path of least resistance from the point of contact to the groundor exit site. mised esthetics, and other related problems. This article presents various microstomiaprevention appliances used The initial appearance of the electrical burn of the commissureis a grayish-white, coagulated lesion out- by dentists and hospital burn centers. These appliances 9 reflect different treatmentconcerns, ease of fabrication, age line with a rim of erythematous tissue. Twoto 4 weeks appropriateness, and cost effectiveness. An understand- later the eschar sloughs, leaving an ulceration. Thetis- ing of these factors and availabile applianceswill aid the sue is replaced by collagenous fibrous connective tis- clinician in selecting or developingthe best appliancefor sue. It takes up to 1 year for the postburn scar to be- burn patients. (Pediatr Dent 19:413-18, 1997) come stable due to the sphincteral action of the orbicularis oris muscle. acial burnscan occur as a result of electrical, ther- The burn is usually painless, and drooling of food al, or chemical injury. 1 Burns of the face may and saliva occurs because of destruction of the sensory F~nnvolve the oral cavity, and if left untreated, re- innervation of the lip. Bleeding mayoccur at the time sult in microstomia. Perioral facial burns maybe ei- of injury or secondary to vacuolation of the vascular endothelium due to rupture of the labial artery and ther partial or full thickness, which upon healing can y, cause tissue scarring and contraction 2 due to sphinc- vessel walls during the necrosis stage of healing, s teral action of the orbicularis oris muscle.3 Contrac- Dental dysplasia and malocclusion may occur de- tion can interfere with vocalization, facial expression, pendingon the severity, timing, and site of injury. The eating, oral hygiene, dental care, and in children may lip contracture in young children may cause lingual inclination and crowding of the teeth resulting in an- affect the developmentof facial structures if proper ~, treatment is not instituted immediately.2 The litera- terior crossbite or overbite. 10 ture has demonstrated that burn contractures and Management scar formation can be modified with pressure and General splinting. 4,s If early splint therapy is not provided, the resultant contracture, will require later surgical Although systemic complications occur infre- reconstruction. The reconstruction involves linear quently, the patient should be evaluated for such prob- release of the scar band with lateral advancementof lems as dehydration, hypothermia, shock, and cardiac the orbicularis oris muscle, recreation of modiolus arrhythmia, s Tetanus prevention is recommended,as labii,6 and reestablishment of vermilion continuity. is prophylactic antibiotic therapy for the severely A conservative appliance-therapy approach with no burnedpatient, s, 10-12 Topical antibiotic maybe used in 8 surgical consideration for approximately 1 year is the presence of secondary wound infection. It is considered to be the best approach. This literature re- thought that oral woundsdo not benefit from prophy- view presents various treatment appliances and the lactic systemic antibiotic therapy and when applied conditions required for their success. topically, these agents have soothing effect rather than any13 antibacterial action. Etiologyand characteristic Daily homecare with saline or hydrogen peroxide rinses and swabsmay be used to debride the necrotic tis- The commonscenario leading to oral electrical burns 8 involves preschool-age children chewing or sucking on sue and promoteformation of healthy granulation tissue. live electrical wires/There are two types of electrical Placementof a splint should be within 10-14 days of the burns, arc and contact. In an arc burn, the saliva, tis- initial injury to allow for proper approximationof the lip dimension before substantial healing has begun. PediatricDentistry- 19:6, 1997 AmericanAcademy of PediatricDentistry 413 Type Appliance Description, Impression Measurement (A;P;AP) Fabrication, and Placement Necessary for Cast Needed Advantages Disadvantages Intraoral Maxillary Full acrylic coverage with Yes N/A None Poor compliance Full8 vestibular extension and with pre-choolers (PI acrylic covered wire post Monitor erupting for commisure support teeth Mandibular Full acrylic coverage with Yes N/A None Poor compliance ~~1119 vestibular extension and with preschoolers (PI acrylic covered wire post Monitor erupting for commisure support teeth Metal crown adapted on Yes Yes Reduces compliance None upper central incisor and 1st problems in or 2nd primary molars. Avoid pre-schoolers tooth preparation. Labial archwire soldered to crowns and acrylic post for the commissures. Over- Same as above (Crown) but with Yes Yes Reduces compliance None denture acrylic overdenture with problems in (PI projecting post for commisures pre-schoolers Modified Upper Hawley retainer: Adam Yes Yes Minimalacrylic Limited to older Hawley clasps on the primary 2nd thus speaking and children retainer15 molars and a labial bow from eating not affected Monitor erupting (PI cuspid to cuspid. Two 0.036 Good retention teeth extends labially to form acrylic-covered post. Occlusal anterior bite plane. Reverse A reverse headgear fitted to No Yes Parental and infant None Head- the face. Left and right cooperation gearI5 outer bows of the headgear Easy insertion and (MP) were reshaped to the removal commissures and covered with acrylic. This is positioned and shaped to maintain the lips at equidistance. Poly- Polyvinyl stents made from Yes Yes Easy insertion and None vinyl mouthguards blanks. Each is removal intral 3 mm thick at mucogingival No intraoral/ (AD) junction, and enlarging towards commissural incisal/occlusal table (8 mm). ulceration Extraoral Prefabricated consists of 2 Supported acrylic sections (fits into MPA2 mouth commissures) joined by No Yes Easy insertion and Potentiate tissue (NP) an adjustable stainless-steel removal breakdown with bar with thumbscrew closure Prefabricated thus excessive force (2-mm increments). immediate delivery Poor salivary Available: S, M, L, and XL Range of sizes retention 3.8-9.0 cm for accommodation Slow expansile force 414 American Academy ofpediatric Dentistry Pediatric Dentistry - 19:6, 1997 Acrylic The commissure is adapted with No Yes Easy insertion and None holder21 wax; the wax is invested in removal with finger (A) flask for boil-out. The wax is pressure, no lubrication replaced with heat curing resin. required Angle of bent wire is adjusted so that forces are applied distally and parallel to facial contour. The 2 acrylic commissures are adapted to an £2-steel wire self-curing resin Vancouver U-shaped Kirschner wire is No Yes Inexpensive material Limited to orthosis14 covered with thermoplastic, Slow expansile force older children (A/P) The flat ends of the thermo- Easy insertion/ plastic are heated for attach- removal ment of the commissural ends, angled at 140° upwards and 160° backwards with respect to the wire spring. By the varing length of static wire bar, placed inside the U-wire, the desired pressure may be applied to the commissure. Hyrax Consists of 2 acrylic No No Easy insertion/ None Screw22 phalanges (fits into mouth removal (A/P) commissures) between which Slow expansile force is a Hyrax screw. Allows incremental expansion: 0.25 mm A—Active P—Passive A/P—Utilized active or passive as needed Commisure appliances aged 2 years or younger.16'17 At this age, the child has Numerous appliances have been used to manage an incomplete primary dentition and is in the active oral burns. Selection of an appropriate microstomia- stage of tooth eruption. Retention of an appliance can prevention device for a patient should be based on age, be a significant problem. Fig 1 is an example of a max- the presence or absence of teeth, condition of the den- illary full-coverage acrylic denture base with posterior tition, type and extent of injury, patient's ability to com- palatal seal and two .032-in wires extending from the ply with the regimen of use, comfort, cosmetics, dura- bility, expense, complexity of fabrication, and need for repair and readjustment.14 There are two basic appliance types, tooth supported and tissue supported.15 Often, the tissue-supported appli- ances are indicated for infants who have few teeth, low tolerance for pain or discomfort, and lack the ability to understand the need for the appliance. Tooth-supported appliances may be designed for similar concerns but can either be further designated as removable or fixed. An- other method for categorizing these labial commissure devices are passive stents and dynamic widening devices. The passive stent is applied for immediate (early) burn treatment while the dynamic device is for a delayed treat- ment situation where contracture of the commissure had Figure 1. The maxillary full coverage denture base with posterior palatal seal. already begun. This report will be presented according to support location: intraoral- and extraoral-supported 8 appliances. The clinical characteristics of the appliances
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