Abstract
OBJECTIVES:
The purpose of this study was to analyze the characteristics of oral-motor movements and facial mimic in patients with head and neck burns.
METHODS:
An observational descriptive cross-sectional study was conducted with patients who suffered burns to the head and neck and who were referred to the Division of Orofacial Myology of a public hospital for assessment and rehabilitation. Only patients presenting deep partial-thickness and full-thickness burns to areas of the face and neck were included in the study. Patients underwent clinical assessment that involved an oral-motor evaluation, mandibular range of movement assessment, and facial mimic assessment. Patients were divided into two groups: G1 - patients with deep partial-thickness burns; G2 - patients with full-thickness burns.
RESULTS:
Our final study sample comprised 40 patients: G1 with 19 individuals and G2 with 21 individuals. The overall scores obtained in the clinical assessment of oral-motor organs indicated that patients with both second- and third-degree burns presented deficits related to posture, position and mobility of the oral-motor organs. Considering facial mimic, groups significantly differed when performing voluntary facial movements. Patients also presented limited maximal incisor opening. Deficits were greater for individuals in G2 in all assessments.
CONCLUSION:
Patients with head and neck burns present significant deficits related to posture, position and mobility of the oral myofunctional structures, including facial movements.
Burn; Head; Face; Post-burn contracture; Speech-language and hearing sciences
INTRODUCTION
According to the literature, worldwide, burns and fires account for more than 300,000
deaths, and almost 11 million people per year require burn-related medical attention
11. Peck MD. Epidemiology of burns throughout the world. Part I:
Distribution and risk factors. Burns. 2011;37(7):1087-100,
http://dx.doi.org/10.1016/j.burns.2011.06.005</doi>.
http://dx.doi.org/10.1016/j.burns.2011.0...
. In Brazil, burns remain a
significant problem for the public health system 22. Cruz BF, Cordovil PBL, Batista KNM. Epidemiological profile of
patients who suffered burns in Brazil: literature review. Rev Bras Queimaduras.
2012;11(4):246-50.. Brazil is the fifth largest country in the world,
both by geographical area and by population. For this reason, the prevalence rate of
burns tends to vary considerably across the literature, and reports are often
limited to one healthcare setting. A review of the literature published in 2012
indicated that over 4% of the total number of hospitalizations in public hospitals
in the country are caused by burns 22. Cruz BF, Cordovil PBL, Batista KNM. Epidemiological profile of
patients who suffered burns in Brazil: literature review. Rev Bras Queimaduras.
2012;11(4):246-50.. The Brazilian National Health Surveillance Agency
(ANVISA) notes that there are approximately 300,000 new cases
of burns in children per year in Brazil 33. Brasil. Anvisa - Agência Nacional de Vigilância
Sanitária. O álcool na forma de gel é ou não um
saneamento? [access: 2014 jan 10]. Available at :
http://www.anvisa.gov.br/divulga/noticias/2002/130302.htm.
http://www.anvisa.gov.br/divulga/noticia...
. Studies tend to agree that adult males are often more affected than
females 4. Montes SF, Barbosa MH, Neto ALS. Aspectos clínicos e
epidemiológicos de pacientes queimados internados em um Hospital de Ensino.
Rev Esc Enferm USP. 2011;45(2):369-73,
http://dx.doi.org/10.1590/S0080-62342011000200010</doi>.
http://dx.doi.org/10.1590/S0080-62342011...
5. Coutinho BBA, Balbuena MB, Anbar RA, Almeida KG, Almeida PYNG.
Perfil epidemiológico de pacientes internados na enfermaria de queimados da
Associação Beneficente de Campo Grande Santa Casa/MS. Rev Bras
Queimaduras. 2010;9(2):50-3.4-66. Gawryszewski VP, Bernal RTI, Silva NN, Morais Neto OL, Silva MMA,
Mascarenhas MDM, et al. Atendimentos decorrentes de queimaduras em serviços
públicos de emergência no Brasil, 2009. Cad Saúde Pública,
Rio de Janeiro. 2012;28(4):629-40..
The prevalence rates of burns of the head and neck also vary considerably across the
literature, with estimates ranging from 6 to 60% of all burns 77. Kara IG, Gok S, Horsanli O, Zencir M. A population-based
questionnaire study on the prevalence and epidemiology of burn patients in
Denizli, Turkey. J Burn Care Res. 2008;29(3):446-50,
http://dx.doi.org/10.1097/BCR.0b013e3181710807</doi>.
http://dx.doi.org/10.1097/BCR.0b013e3181...
. The neck and face regions are exposed to diverse
injuries, such as scalds, electrical shocks and splashes. The traction forces caused
by contracture may pull and cause insufficient neck extension, incomplete oral
occlusion, oromaxillofacial skeletal deformities and tracheal position alterations,
resulting in difficult intubation, which can be life-threatening and can result in
other severe complications 88. Makboul M, El-Oteify M. Classification of post-burn contracture
neck. Indian Journal of Burns. 2013;21(1):50-4,
http://dx.doi.org/10.4103/0971-653X.121883</doi>.
http://dx.doi.org/10.4103/0971-653X.1218...
. The
extrinsic contractile forces from the neck can also cause facial deformities and can
adversely affect the maturation of facial scars 99. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6..
There have been numerous articles pertaining to burns of the head and neck, mostly
devoted to surgical and physiotherapeutic treatments and their results 1. Peck MD. Epidemiology of burns throughout the world. Part I:
Distribution and risk factors. Burns. 2011;37(7):1087-100,
http://dx.doi.org/10.1016/j.burns.2011.06.005</doi>.
http://dx.doi.org/10.1016/j.burns.2011.0...
9. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.1,9,1010. Pallua N, Demir E. Postburn head and neck reconstruction in
children with fasciocutaneous supraclavicular artery island flap. Ann Plast
Surgery. 2008;60(3):276-82,
http://dx.doi.org/10.1097/SAP.0b013e3180db2775</doi>.
http://dx.doi.org/10.1097/SAP.0b013e3180...
. However, only a very
small number of articles describe the disastrous influence of burn sequelae on
oral-motor structural morphology, mobility and functions, such as mastication,
swallowing and speech. Severe burn injury to the face may result in complications
such as facial and labial sensation deficits, poor oral access for oral/dental
hygiene, and inadequate oral competence, causing chronic drooling and poor
articulation 1111. Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK.
Rehabilitation of speech and swallowing after burns reconstructive surgery of
the lips and nose. J Burn Care Res 2009;30(6):1039-45.. The literature
suggests that oral contracture resulting in microstomia may have serious adverse
effects on the patient’s ability to perform activities of daily living,
including swallowing 12. Wust KJ. A modified dynamic mouth splint for burns patients. J
Burn Care Res. 2006;27(1):86-92,
http://dx.doi.org/10.1097/01.bcr.0000192267.55348.dd</doi>.
http://dx.doi.org/10.1097/01.bcr.0000192...
13. Bahnof R. Intra-oral burns: rehabilitation of severe restriction
of mouth opening. Physiotherapy. 2000;86:263-6,
http://dx.doi.org/10.1016/S0031-9406(05)60913-3</doi>.
http://dx.doi.org/10.1016/S0031-9406(05)...
14. Dougherty ME, Warden GD. A 30-year review of oral appliances
used to manage microstomia, 1972-2002. J Bur Care Rehabil 2003;24(6):418-31,
http://dx.doi.org/10.1097/01.BCR.0000095517.97355.98</doi>.
http://dx.doi.org/10.1097/01.BCR.0000095...
12-1515. Johnson J, Candia J, La Trenta G, Madden MR, Goodwin CW,
Finkelstein J. A nasal trumpet orthosis to maintain nares opening and
respiratory function for patients with facial burns: a case report. J Burn Care
Rehabil 1992;13(6):677-9,
http://dx.doi.org/10.1097/00004630-199211000-00012</doi>.
http://dx.doi.org/10.1097/00004630-19921...
. Moreover, facial
skeletal deformities are likely to occur at any age if burn contractures are
neglected or are not properly and promptly treated 99. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.. There have been reports of the effects of
electrical injuries to the lip, cheeks, tongue and hard and soft palates. The
sequelae described include severely limited mandibular movement, limited tongue
movement due to adhesions to the floor of the mouth, speech problems and difficulty
with oral hygiene 1616. Hilbert L, Peters WJ, Tepperman PS. Temporomandibular joint
destruction after a burn. Burns. 1984;10(3):214-6,
http://dx.doi.org/10.1016/0305-4179(84)90032-9</doi>.
http://dx.doi.org/10.1016/0305-4179(84)9...
.
Given the complexity of burn care rehabilitation, adequate assessment and monitoring should be undertaken in burn-injured patients. Rehabilitation following severe burn injuries requires an individualized approach to achieve the optimum functional outcome possible for every patient 1717. Al-Mousawi AM, Mecott-Rivera GA, Jeschke MG, Herdon DN. Burn teams and burn centers: The importance of a comprehensive team approach to burn care. Clin Plast Surg. 2009;36(4)547-54.. Effective rehabilitative technical skills can only be developed if sequelae, i.e., physical and functional, have been well described.
The state of São Paulo, Brazil, has a population of 11.32 million people, comprising approximately 5.7% of the total Brazilian population. There are 13 burn centers registered by the Brazilian Ministry of Health in São Paulo. One of the most important centers is located at Hospital das Clínicas, the largest public school hospital in all of South America. Hospital das Clínicas admits approximately 192 patients with acute burns each year. The purpose of this study was to analyze the characteristics of the oral-motor movements and facial mimic of patients who suffered burns to the head and neck and who were seen at the Division of Orofacial Myology of a Brazilian public hospital.
MATERIALS AND METHODS
Ethics
The study design was approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq HCFMUSP no. 178.972). Prior to their enrollment, all participants were informed of the purpose and procedures, after which all patients provided written informed consent.
Study design and inclusion criteria
An observational, descriptive, cross-sectional study was conducted with patients who suffered burns to the head and neck and who were referred by the medical team to the Division of Orofacial Myology for assessment and rehabilitation. Patients meeting the following criteria were eligible for participation: aged ≥4 years, referred to the Division of Orofacial Myology between January 2013 and December 2013, had a mean total burn surface area (TBSA) >4%, presented deep partial-thickness and full-thickness burns to areas of the face and neck, had received or not received skin grafting resulting in potential functional impairment within a minimum of two months after epithelialization or medical intervention, presented stable medical conditions according to medical records and were fed exclusively by mouth. For characterization purposes, individuals were divided into two groups: G1 - patients with deep partial-thickness burns; G2 - patients with full-thickness burns (i.e., all participants presented third-degree burns). Importantly, patients who met the inclusion criteria had not yet undergone any form of rehabilitation.
A number of patients were excluded, including those who had cognitive, neurological, hearing and/or communication impairment, a documented diagnosis of facial trauma, previous surgical procedures to the head and neck (i.e., not related to burn wounds), and readmission due to pre-existing burns, as registered in the patient’s medical record.
Oral-motor clinical assessment
Participants underwent clinical oral-motor assessment. Individuals were examined
while sitting in a chair in a room with appropriate lighting. The Expanded
Protocol of Orofacial Myofunctional Evaluation with Scores (OMES-E) was used for
this assessment 1818. Felício CM, Folha GA, Ferreira CLP, Medeiros APM. Expanded
protocol of orofacial myofunctional evaluation with scores: Validity and
reliability. Int J Pediatr Otorhinolaryngol. 2010;74(11):1230-9,
http://dx.doi.org/10.1016/j.ijporl.2010.07.021</doi>.
http://dx.doi.org/10.1016/j.ijporl.2010....
. This
protocol was constructed based on previous models of evaluation, with the
addition of numerical scales that reflect the physical characteristics and
orofacial behaviors of the subjects (individuals can reach a total of 230
points). Although the protocol was initially developed for 6-12-year-olds, its
validity has now been reported for young and adult subjects 1919. Felício CM, Medeiros APM, Melchior MO. Validity of the
‘protocol of oro-facial myofunctional evaluation with scores’ for
young and adult subjects. J Oral Rehabil. 2012;39(10):744-53,
http://dx.doi.org/10.1111/joor.2012.39.issue-10</doi>.
http://dx.doi.org/10.1111/joor.2012.39.i...
.
The clinical protocol used in this study is one of the three validated protocols
for orofacial myofunctional evaluation that have been published in the specific
literature 1919. Felício CM, Medeiros APM, Melchior MO. Validity of the
‘protocol of oro-facial myofunctional evaluation with scores’ for
young and adult subjects. J Oral Rehabil. 2012;39(10):744-53,
http://dx.doi.org/10.1111/joor.2012.39.issue-10</doi>.
http://dx.doi.org/10.1111/joor.2012.39.i...
. Because it is
based on a scale and requires no special equipment, it can be useful both in
clinical practice and in research.
The evaluation was performed according to the OMES-E, and the stomatognathic system components, i.e., lips, tongue, jaw and cheeks, were evaluated in terms of posture and position, mobility and performance during deglutition and mastication functions. The participants were individually evaluated by visual inspection, and the evaluation was later complemented by analyzing images recorded on a digital camera (Sony DSC-W120).
All participants were evaluated by two experienced speech-language pathologists. Inter-rater agreement was verified using Cohen’s Kappa Coefficient. The speech-language pathologists who assigned the scores of the OMES-E presented a high level of agreement (0.87).
Mandibular range of movement
The technique used to measure the mandibular range of movement was based on a
methodology already published in the literature 20. Celic R, Jerolimov V, Knezovic-Zlataric D, Klaic B. Measurement
of mandibular movements in patients with temporomandibular disorders and
asymptomatic subjects. Coll Antropol. 2003;27Suppl 2:43-9.20,2121. Celic R, Jerolimov V, Knezovic-Zlataric D. Relationship of
slightly limited mandibular movements to temporomandibular disorders. Braz Dent
J. 2004;15(2):151-4,
http://dx.doi.org/10.1590/S0103-64402004000200012</doi>.
http://dx.doi.org/10.1590/S0103-64402004...
. Using a digital caliper (Digimess Pró-Fono Digital
Caliper), the following measurements (in millimeters) were performed:
-
maximal incisor opening - We measured the distance between the incisive faces of the mandibular and maxillary central incisors.
-
mandibular lateralization to the right - We measured the horizontal distance from the mandibular central incisor to the maxillary central incisor after asking the individual to glide his/her mandible to the right. When there was a midline deviation (i.e., between the mandibular and maxillary central incisors), we used the appropriate adjustment.
-
mandibular lateralization to the left - The same procedure described above was performed to measure mandibular lateralization to the left.
-
mandibular protrusion - For this measurement, the patient was asked to glide the mandible forward. We then measured the horizontal overlap value between the mandibular central incisors and the maxillary central incisors.
-
horizontal dental occlusion overlap - We measured the distance between the occlusal face of the maxillary central incisors and the distal face of the mandibular central incisors.
Facial mimic
Facial symmetry and mobility were evaluated using the Clinical Score for Facial
Mimic Protocol 2222. Salles AG, Toledo PN, Ferreira MC. Botulinum toxin injection in
longstanding facial paralysis patients: improvement of facial symmetry observed
up to 6 months. Aesthetic Plast Surg. 2009;33(4):582-90,
http://dx.doi.org/10.1007/s00266-009-9337-9</doi>.
http://dx.doi.org/10.1007/s00266-009-933...
. This
protocol was originally developed to perceptually investigate the impact of
peripheral facial paralysis on the ability of individuals to produce symmetrical
facial movements. To date, there are no specific functional scales available to
explore the influence of burn sequelae on facial mimic. This protocol assesses
facial functional/cosmetic symmetry.
The muscle groups from each facial side were analyzed under different voluntary facial expressions and scored as follows: zero (0) if there were no movements; one (1) for partial or moderate movement; and two (2) for complete or marked movement. The frontal region was assessed for eyebrow-raising movement, eyelid movement during eye closure, upper lip elevation through the movement of “frowning the nose”, oblique traction of the upper lip required for smiling, horizontal traction of the upper lip based on the clinical smile, lip closure by means of lower lip protrusion and depression with the movement for exposing the lower teeth. After this stage, involuntary emotion-related movements were assessed on each side of the face by observing the participants during blinking, talking and spontaneously smiling, using the same scoring criteria mentioned above: zero (0) when absent, one (1) when reduced, and two (2) when normal. Lip and eyelid deformities at rest and the presence of synkinesia or hypertonia were also scored, with negative values: (0) if absent; (-1) if partially or mildly deformed; and (-2) if totally or severely deformed. Finally, the partial sum of the values obtained amounted to the final score, which could range from -6 to 20 points for each evaluated hemiface.
All participants were evaluated by two experienced speech-language pathologists. Inter-rater agreement was verified using Cohen’s Kappa Coefficient. The rates of agreement indicated that the reliability was high: OMES-E 0.87; mandibular range of movement 0.85; Facial Mimic Protocol 0.79.
Statistical analysis
Qualitative variables were presented in contingency tables comprising absolute (n) and relative (%) frequencies. All quantitative data were entered into an SPSS 21.0 database. Descriptive analyses of the quantitative data with a normal distribution were performed and presented as the mean values followed by the respective standard deviations (±SD). Data without a normal distribution were presented as the medians and interquartile ranges (IQR25-75%). Normal and homogenous distribution was assessed by the Shapiro-Wilk test.
Student’s t test for independent samples was used to analyze data with a normal distribution, and the non-parametric Mann-Whitney U test was used for data without a normal and homogenous distribution. Categorical data were analyzed using the Chi-squared test and Fisher’s exact test. The adopted significance level was 5% for all analyses.
RESULTS
During the study period, 50 of the 52 patients who were eligible for the oral-motor and facial mimic characterization consented to participate in the study. The OMES-E was not completed in 6 patients, and 4 did not complete the mandibular range of motion measurement, leaving 40 patients for the final analysis. Student’s t test did not indicate significant differences between the groups for age (G1 - 28.7±17.6 years-old; G2 - 35.9±19.3 years-old; p=0.23).
G1 comprised 19 individuals, including 2 females and 17 males; 8 individuals presented burns restricted to the face, 1 individual presented burns restricted to the neck, and 10 individuals presented burns in both the facial and neck regions. The majority of participants had suffered a thermal burn (n=17), and only 2 patients had burns caused by chemical agents. The mean total body surface area (TBSA) affected was 13.27% (SD=7.06, range=4-28). G2 comprised 21 individuals, including 12 females and 9 males; 8 individuals presented burns restricted to the face, 2 individuals presented burns restricted to the neck, and 11 individuals presented burns in both the facial and neck regions. In this group, 2 individuals had burns caused by chemical agents. All of the other participants had suffered thermal burns. All of the patients included in G2 had suffered surgical procedures due to the presence of sequelae (i.e., skin graft, commissuroplasty, Z-plasty). The mean total body surface area (TBSA) affected was 17.72% (SD=9.18, range=4-35).
Table 1 presents the results of the Mann-Whitney U test for between-group comparisons, considering the scores obtained on the OMES-E. The results indicate that the groups significantly differed only when considering the static posture and the position of oral-motor organs. Individuals with deep partial-thickness burns presented higher scores in the clinical protocol compared with individuals with full-thickness burns. The presence of scar contractures and hypertrophic scars were responsible for the lower scores received by patients in G2 (i.e., the presence of facial asymmetry, difficulty maintaining sealed lips, tongue inadequately positioned inside of the oral cavity). When analyzing the overall OMES-E scores, Student’s t test indicated that the groups also significantly differed (p=0.021); G1 presented higher overall scores (179.68±18.06) compared with G2 (162.1±26.50).
The results for the mandibular range of movement are presented in Table 2. Differences between groups were significant for the measurement of maximal incisor opening. G1 presented a better range of movement for this parameter. Overall, the results indicate that burns to the head and neck had the same impact on mandibular lateralization and protrusion for both groups of patients.
The analyses of the results obtained for facial mimic are summarized in Tables 3 to 5. Because the data obtained for these analyses are categorical (i.e., a distribution of the individuals among the possible scores), the results were analyzed using the Chi-squared test (number of individuals >5) and Fisher’s exact test (number of individuals <5). According to the protocol for facial mimic assessment, individuals could score a maximum of 14 points for each hemiface, considering voluntary facial movements (Table 3). The groups significantly differed when producing voluntary facial movements. Individuals in G1 presented better scores, with approximately half of the patients obtaining full scores on the analyzed parameters (i.e., symmetrical and preserved movements). Individuals in G2, however, due to their more severe burns, presented 11 points or less in this item and less symmetrical movements when comparing the scores obtained for the different hemifaces. The differences were not significant when comparing the groups for involuntary facial movements (Table 4). Individuals could receive a maximum of 6 points for each hemiface when assessed for involuntary facial movements. The results indicate that the majority of the participants (i.e., G1 and G2) received a full score for this parameter. Negative findings were indicated by negative scores on the Facial Mimic Protocol (Table 5). Overall, individuals in G1 did not present negative findings (score of 0), whereas individuals in G2 presented moderate or pronounced symptoms.
Given the results obtained for the overall scores on the Facial Mimic Protocol, we decided to assess the scores obtained on the sub-items of the protocol in detail. This analysis is presented in Table 6 (i.e., Chi-squared test when the number of individuals was >5 and Fisher’s exact test when the number of individuals was <5). Looking closely at the sub-items for voluntary facial movements, we can observe that individuals with more severe burns presented significantly lower scores for movements corresponding to the muscles involved in smiling (i.e., upper lip elevation, upper-lateral traction of the lips and horizontal traction of the lips) and for lip closure. Moreover, individuals in G2 presented poorer scores on the parameter involving negative findings due to the presence of hypertonia.
DISCUSSION
To the best of our knowledge, the present study is the first extensive clinical characterization study that has investigated the impact of deep partial-thickness and full-thickness head and neck burns on oral-motor movements and facial mimic. Our results indicated that patients with burns present significant deficits related to oral myofunctional structural posture, position and mobility, including facial movements (i.e., mimic). Moreover, the results indicated that patients with full-thickness burns present poorer performance compared with patients with deep partial-thickness burns.
Our results confirm what has already been described in the literature, indicating
that contractures and hypertrophic scars have a negative impact on the oral
myofunctional system 11. Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK.
Rehabilitation of speech and swallowing after burns reconstructive surgery of
the lips and nose. J Burn Care Res 2009;30(6):1039-45.12. Wust KJ. A modified dynamic mouth splint for burns patients. J
Burn Care Res. 2006;27(1):86-92,
http://dx.doi.org/10.1097/01.bcr.0000192267.55348.dd</doi>.
http://dx.doi.org/10.1097/01.bcr.0000192...
13. Bahnof R. Intra-oral burns: rehabilitation of severe restriction
of mouth opening. Physiotherapy. 2000;86:263-6,
http://dx.doi.org/10.1016/S0031-9406(05)60913-3</doi>.
http://dx.doi.org/10.1016/S0031-9406(05)...
14. Dougherty ME, Warden GD. A 30-year review of oral appliances
used to manage microstomia, 1972-2002. J Bur Care Rehabil 2003;24(6):418-31,
http://dx.doi.org/10.1097/01.BCR.0000095517.97355.98</doi>.
http://dx.doi.org/10.1097/01.BCR.0000095...
15. Johnson J, Candia J, La Trenta G, Madden MR, Goodwin CW,
Finkelstein J. A nasal trumpet orthosis to maintain nares opening and
respiratory function for patients with facial burns: a case report. J Burn Care
Rehabil 1992;13(6):677-9,
http://dx.doi.org/10.1097/00004630-199211000-00012</doi>.
http://dx.doi.org/10.1097/00004630-19921...
16. Hilbert L, Peters WJ, Tepperman PS. Temporomandibular joint
destruction after a burn. Burns. 1984;10(3):214-6,
http://dx.doi.org/10.1016/0305-4179(84)90032-9</doi>.
http://dx.doi.org/10.1016/0305-4179(84)9...
11-15,16,2323. Rumbach AF, Ward EC, Cornwell PL, Bassett LV, Muller MJ. The
challenges of dysphagia management and rehabilitation after extensive thermal
burn injury: a complex case. J Burn Care Res. 2009;30(5):901-5,
http://dx.doi.org/10.1097/BCR.0b013e3181b487e0</doi>.
http://dx.doi.org/10.1097/BCR.0b013e3181...
. Nevertheless, the
overall scores obtained on the OMES-E indicated that patients with deep
partial-thickness and full-thickness burns present deficits related to oral-motor
organs and movements (i.e., full scores were not observed in either group of
patients). According to the literature, differences in wound healing and medical
interventions can explain the differences found in our patient groups. Deep
partial-thickness burns usually heal with some scarring. After the initial healing
with wound closure and complete epithelialization, these patients require careful
management and monitoring as they have the potential to develop severe late
hypertrophic scars and contractures 8. Makboul M, El-Oteify M. Classification of post-burn contracture
neck. Indian Journal of Burns. 2013;21(1):50-4,
http://dx.doi.org/10.4103/0971-653X.121883</doi>.
http://dx.doi.org/10.4103/0971-653X.1218...
8,99. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.. Full-thickness burns
are usually excised and skin grafted. Any tension on the neck region may promote
early hypertrophic scarring 8. Makboul M, El-Oteify M. Classification of post-burn contracture
neck. Indian Journal of Burns. 2013;21(1):50-4,
http://dx.doi.org/10.4103/0971-653X.121883</doi>.
http://dx.doi.org/10.4103/0971-653X.1218...
8,99. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.. In addition to purely physical
problems, studies clearly indicate that extensive head and neck scarring from burns
may cause permanent alterations to the oral-motor organs 8. Makboul M, El-Oteify M. Classification of post-burn contracture
neck. Indian Journal of Burns. 2013;21(1):50-4,
http://dx.doi.org/10.4103/0971-653X.121883</doi>.
http://dx.doi.org/10.4103/0971-653X.1218...
9. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.10. Pallua N, Demir E. Postburn head and neck reconstruction in
children with fasciocutaneous supraclavicular artery island flap. Ann Plast
Surgery. 2008;60(3):276-82,
http://dx.doi.org/10.1097/SAP.0b013e3180db2775</doi>.
http://dx.doi.org/10.1097/SAP.0b013e3180...
8-1111. Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK.
Rehabilitation of speech and swallowing after burns reconstructive surgery of
the lips and nose. J Burn Care Res 2009;30(6):1039-45..
Our study also found deficits in the mandibular range of movement in patients with
burns. The groups significantly differed only when considering the measurement of
the maximal incisor opening, with deep second- and third-degree burns presenting
more mandibular movement restriction. This result can be explained by the fact that
although some of the participants in G2 had undergone commissuroplasty, the patients
still presented restrictions to opening their mouths. According to previous studies
20. Celic R, Jerolimov V, Knezovic-Zlataric D, Klaic B. Measurement
of mandibular movements in patients with temporomandibular disorders and
asymptomatic subjects. Coll Antropol. 2003;27Suppl 2:43-9.20,2121. Celic R, Jerolimov V, Knezovic-Zlataric D. Relationship of
slightly limited mandibular movements to temporomandibular disorders. Braz Dent
J. 2004;15(2):151-4,
http://dx.doi.org/10.1590/S0103-64402004000200012</doi>.
http://dx.doi.org/10.1590/S0103-64402004...
, the expected values for mandibular movements
in healthy individuals are as follows, with no distinction between genders and age
groups: maximal incisor opening - between 40 mm and 60 mm; mandibular lateralization
- between 7 mm and 11 mm (i.e., to each side); and mandibular protrusion - between 7
mm and 11 mm. When more closely analyzing our results, patients with deep
partial-thickness and full-thickness burns presented a greater limitation of all
mandibular movements compared with the measurements expected for healthy
individuals.
Mandibular function requires adaptation to a wide variety of factors related to the
stomatognathic system 2424. Yamada R, Ogawa T, Koyano K. The effect of head posture on
direction and stability of mandibular closing movement. J Oral Rehabil.
1999;26(6):511-20,
http://dx.doi.org/10.1046/j.1365-2842.1999.00386.x</doi>.
http://dx.doi.org/10.1046/j.1365-2842.19...
.
Mandibular movements are responsible for intraoral space modifications. These
movements have a strong impact on mastication, swallowing and speech patterns
because they are responsible for enabling adequate movements of the tongue and other
soft tissues (i.e., amplitude) inside of the oral cavity 2525. Bianchini EMG, Paiva G, Andrade CRF. Mandibular movements
patterns during speech in subjects with temporomandibular disorders and in
asymptomatic individuals. Cranio. 2008;26(1):50-66.. Maximal incisor opening movement has
traditionally been used to evaluate temporomandibular joint (TMJ) functioning 2626. Szentpetery A. Clinical utility of mandibular movement ranges. J
Orofac Pain. 1993 Spring;7(2):163-8.. Adequate TMJ functioning is
therefore reflected by mandibular movements. The literature indicates that
functional limitation secondary to burn injury usually results from an anatomical
alteration of a major joint 8. Makboul M, El-Oteify M. Classification of post-burn contracture
neck. Indian Journal of Burns. 2013;21(1):50-4,
http://dx.doi.org/10.4103/0971-653X.121883</doi>.
http://dx.doi.org/10.4103/0971-653X.1218...
8,99. Güven E, Ugurlu AM, Hocaoglu E, Kuvat SV, Elbey H. Treatment
of post-burn upper extremity, neck and facial contractures: report of 77 cases.
Ulus Travma Acil Cerrahi Derg. 2010;16(5):401-6.. The degree to which the
function of a joint is affected is greatly influenced by the amount of soft tissue
loss and the degree of pain associated with the movement 16. Hilbert L, Peters WJ, Tepperman PS. Temporomandibular joint
destruction after a burn. Burns. 1984;10(3):214-6,
http://dx.doi.org/10.1016/0305-4179(84)90032-9</doi>.
http://dx.doi.org/10.1016/0305-4179(84)9...
16,2727. Fricke N, Omnell M, Dutchere K, Hollender L, Engrav L. Skeletal
and dental disturbances in children after facial burns and pressure garment use:
a 4 year follow-up. J Burn Care Rehabil. 1999;20(3):239-49,
http://dx.doi.org/10.1097/00004630-199905000-00016</doi>.
http://dx.doi.org/10.1097/00004630-19990...
.
Full-thickness burns may also result in secondary damage to muscles, bones, tendons
and ligaments.
Studies have indicated that even when functional and/or structural limitations are
present, the orofacial functions are made feasible by means of adaptations that are
frequently not perceived by the individual 2828. Johnson DL, Brand JW, Young SK, Duncanson MG. Adaptation of the
temporomandibular joint to altered mandibular function. Int J Prosthodont.
1995;8(5):446-55.. Muscle and structural adaptations arising from
numerous conditions with different etiologies may be responsible for restricting
muscle function, which can in turn impact mandibular movements 2929. Greene CS. Managing the care of patients with temporomandibular
disorders: a new guideline for care. J Am Dent Assoc. 2010;141(9):1086-8,
http://dx.doi.org/10.14219/jada.archive.2010.0337</doi>.
http://dx.doi.org/10.14219/jada.archive....
. This reduction in muscle activity may cause
future structural problems such as atrophy (lack of use), thereby reducing muscle
strength, restricting mandibular movements even more and causing structural
modifications to the TMJ 3030. Roda RP, Fernandez JMD, Bazan SH, Soriano YJ, Margaix M,
Sarrión G. A review of temporomandibular joint disease (TMJD). Part II:
Clinical and radiological semiology. Morbidity processes. Med Oral Patol Oral
Cir Bucal. 2008;13(2):102-9..
Likewise, facial muscle pain is a condition that can be associated with
physiological alterations such as vascular changes and co-contraction of adjacent
muscles if functional muscle imbalances are present 3131. Graff-Radford SB, Bassiur JP. Temporomandibular disorders and
headaches. Neurol Clin. 2014;32(2):525-37,
http://dx.doi.org/10.1016/j.ncl.2013.11.009</doi>.
http://dx.doi.org/10.1016/j.ncl.2013.11....
. The reduction of mandibular movements, either
because of muscle atrophy or secondary to pain, may cause changes or compensations
in the execution of the stomatognathic functions. Our results strongly suggest that
patients with head and neck burns, especially when presenting scar contractures in
the perioral region, should be considered at risk for developing future
temporomandibular disorders.
As expected, patients also presented deficits in the facial mimic assessment. The
effects of severe burns are debilitating and often cause depressive emotional
conditions with a variety of possible functional and aesthetic problems 3232. Ye E. Psychological morbidity in patients with facial and neck
burns. Burns. 1998;24(7):646-8,
http://dx.doi.org/10.1016/S0305-4179(98)00081-3</doi>.
http://dx.doi.org/10.1016/S0305-4179(98)...
. Participants with more severe
burns (G2) presented greater limitations when performing voluntary facial movements
due to hypertrophic scars. Patients, however, did not differ significantly when
considering involuntary facial movements. We believe that this result can be
explained by differences in performing voluntary and involuntary movements. Natural
facial expressions tend to have a more subtle range of movements. When being
assessed for voluntary facial movements, patients were asked to perform the goal
movement with the highest range possible. Although the main goal in facial burns is
the restoration of normal facial subunits with acceptable or good anatomical balance
and symmetry and dynamic facial expressions, the outcomes of treatment are not
always successful 1212. Wust KJ. A modified dynamic mouth splint for burns patients. J
Burn Care Res. 2006;27(1):86-92,
http://dx.doi.org/10.1097/01.bcr.0000192267.55348.dd</doi>.
http://dx.doi.org/10.1097/01.bcr.0000192...
. The
management of facial burns remains one of the most argued burn-related topics. The
timing, strategy and options for treatment tend to vary considerably across the
literature.
Until 2000, the treatment of patients with burns in Brazil was not regulated by the Ministry of Health 3333. Almeida PCC, Gomez DS. Organização de um centro de tratamento de queimaduras. In: Ferreira MC, Gomez DS (Eds). Tratado de Cirurgia Plástica volume 2: Queimaduras. 1a ed, São Paulo: Atheneu, 2013. p.1-14.. In 1994, the city of São Paulo was the first to publish a series of technical procedures for the treatment of burns 3333. Almeida PCC, Gomez DS. Organização de um centro de tratamento de queimaduras. In: Ferreira MC, Gomez DS (Eds). Tratado de Cirurgia Plástica volume 2: Queimaduras. 1a ed, São Paulo: Atheneu, 2013. p.1-14.. Since 2000, 42 burn centers have been regulated by the Ministry of Health, with new physical and functional structures and specialized multiprofessional teams 3333. Almeida PCC, Gomez DS. Organização de um centro de tratamento de queimaduras. In: Ferreira MC, Gomez DS (Eds). Tratado de Cirurgia Plástica volume 2: Queimaduras. 1a ed, São Paulo: Atheneu, 2013. p.1-14.. Although rehabilitation is a major emphasis, quality work remains to be performed. It is imperative that burn centers evaluate the functional outcome of thermally injured patients and include the role of all professionals involved the rehabilitation process. This is important not only for assessing disability but also for evaluating multiprofessional teams. Speech-language pathologists, as determined by the Brazilian Ministry of Health, are not part of the multiprofessional team designated to treat patients with burns.
Finally, our study had some limitations. First, the population of patients with burns
was heterogeneous. Patients presented different TBSAs and different burned areas
(although all had face and/or neck burns), were assessed at different times after
receiving the burn and underwent different medical procedures. These differences
should be included in future research. Second, the OMES-E 1818. Felício CM, Folha GA, Ferreira CLP, Medeiros APM. Expanded
protocol of orofacial myofunctional evaluation with scores: Validity and
reliability. Int J Pediatr Otorhinolaryngol. 2010;74(11):1230-9,
http://dx.doi.org/10.1016/j.ijporl.2010.07.021</doi>.
http://dx.doi.org/10.1016/j.ijporl.2010....
and the Clinical Score for Facial Mimic Protocol
2222. Salles AG, Toledo PN, Ferreira MC. Botulinum toxin injection in
longstanding facial paralysis patients: improvement of facial symmetry observed
up to 6 months. Aesthetic Plast Surg. 2009;33(4):582-90,
http://dx.doi.org/10.1007/s00266-009-9337-9</doi>.
http://dx.doi.org/10.1007/s00266-009-933...
were not specifically
designed to assess patients with burns but rather to investigate primary oral-motor
deficits/disorders and facial mimic deficits/alterations as a consequence of facial
palsy. For this reason, these tests do not include specific assessment parameters to
investigate the impact of different amounts of soft-tissue loss on oral-motor
functions. The evaluation of the orofacial myofunctional system is a fundamental
step for the diagnosis of oral myofunctional disorders, which are present in several
different health problems, including burns 11. Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK.
Rehabilitation of speech and swallowing after burns reconstructive surgery of
the lips and nose. J Burn Care Res 2009;30(6):1039-45.11,1616. Hilbert L, Peters WJ, Tepperman PS. Temporomandibular joint
destruction after a burn. Burns. 1984;10(3):214-6,
http://dx.doi.org/10.1016/0305-4179(84)90032-9</doi>.
http://dx.doi.org/10.1016/0305-4179(84)9...
.
In our study, we aimed to verify how head and neck burns can affect the oral-motor
organs and functions, including facial movements. In this sense, the adopted
protocols were demonstrated to be effective instruments to perform this
characterization/diagnosis. Nevertheless, specific protocols to evaluate the impact
of head and neck burns on the oral myofunctional system should also be considered in
future studies.
Patients with head and neck burns present significant deficits related to oral myofunctional structural posture, position and mobility, including facial movements. The results indicated that patients with full-thickness burns present poorer performance compared with patients with deep partial-thickness burns. Perioral burns that result in microstomia or mouth contracture reduce mandibular movements.
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» http://dx.doi.org/10.1590/S0103-64402004000200012 -
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» http://dx.doi.org/10.1007/s00266-009-9337-9 -
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24Yamada R, Ogawa T, Koyano K. The effect of head posture on direction and stability of mandibular closing movement. J Oral Rehabil. 1999;26(6):511-20, http://dx.doi.org/10.1046/j.1365-2842.1999.00386.x</doi>.
» http://dx.doi.org/10.1046/j.1365-2842.1999.00386.x -
25Bianchini EMG, Paiva G, Andrade CRF. Mandibular movements patterns during speech in subjects with temporomandibular disorders and in asymptomatic individuals. Cranio. 2008;26(1):50-66.
-
26Szentpetery A. Clinical utility of mandibular movement ranges. J Orofac Pain. 1993 Spring;7(2):163-8.
-
27Fricke N, Omnell M, Dutchere K, Hollender L, Engrav L. Skeletal and dental disturbances in children after facial burns and pressure garment use: a 4 year follow-up. J Burn Care Rehabil. 1999;20(3):239-49, http://dx.doi.org/10.1097/00004630-199905000-00016</doi>.
» http://dx.doi.org/10.1097/00004630-199905000-00016 -
28Johnson DL, Brand JW, Young SK, Duncanson MG. Adaptation of the temporomandibular joint to altered mandibular function. Int J Prosthodont. 1995;8(5):446-55.
-
29Greene CS. Managing the care of patients with temporomandibular disorders: a new guideline for care. J Am Dent Assoc. 2010;141(9):1086-8, http://dx.doi.org/10.14219/jada.archive.2010.0337</doi>.
» http://dx.doi.org/10.14219/jada.archive.2010.0337 -
30Roda RP, Fernandez JMD, Bazan SH, Soriano YJ, Margaix M, Sarrión G. A review of temporomandibular joint disease (TMJD). Part II: Clinical and radiological semiology. Morbidity processes. Med Oral Patol Oral Cir Bucal. 2008;13(2):102-9.
-
31Graff-Radford SB, Bassiur JP. Temporomandibular disorders and headaches. Neurol Clin. 2014;32(2):525-37, http://dx.doi.org/10.1016/j.ncl.2013.11.009</doi>.
» http://dx.doi.org/10.1016/j.ncl.2013.11.009 -
32Ye E. Psychological morbidity in patients with facial and neck burns. Burns. 1998;24(7):646-8, http://dx.doi.org/10.1016/S0305-4179(98)00081-3</doi>.
» http://dx.doi.org/10.1016/S0305-4179(98)00081-3 -
33Almeida PCC, Gomez DS. Organização de um centro de tratamento de queimaduras. In: Ferreira MC, Gomez DS (Eds). Tratado de Cirurgia Plástica volume 2: Queimaduras. 1a ed, São Paulo: Atheneu, 2013. p.1-14.
Publication Dates
-
Publication in this collection
May 2015
History
-
Received
15 Dec 2014 -
Reviewed
16 Jan 2015 -
Accepted
13 Feb 2015