and overreaction of the patient and the peo ple around him are eliminated. The mother or father, acting as coach, also feels more confi dent about the situation because a mild at tack, when recognized early, can be stopped from becoming severe. Once the individual learns to breathe through his asthmatic at tack independently, he has no further need to look for secondary gains.
Mouth Conformer for Prevention and Correction of Burn Scar Contracture
BETTY G. DENTON, MA, and SHARON E. SHAW, MA
The decrease in diameter of the opening of the oral cavity is a problem commonly seen in patients with burns involving the face. With the passage of time, the oral opening dimin ishes in vertical as well as horizontal dimen sion. This decrease in size appears directly related to hypertrophic scarring around the exterior of the mouth and possibly to con tracture formation of the mucosal lining of the mouth and lips. 1 , 2 A review of the litera ture did not reveal an effective nonsurgical method of prevention or correction of hyper trophic scarring of the perioral region. Cur rent nonsurgical approaches to control facial scarring include the use of constant pressure garments* and facial conformers.t 3 - 7 When used together, these two items have been helpful in controlling hypertrophic scar for mation and in restoring and maintaining the contour of the nasolabial fold as well as the lower labial depression. The diameter of the Mrs. Denton is supervisor of clinical education, Depart ment of Physical Therapy, University Hospital, Birming ham, AL 35294. Miss Shaw is assistant director, Physical Therapy Clinical Services, University Hospital, Birmingham, AL 35294. * Jobst Burn Supports, Jobst Institute, Toledo, OH 43694. f Thermoplastic material molded to conform to facial contours for additional pressure over hypertrophic scars.
Volume 56 / Number 6, June 1976
opening of the oral cavity will continue to de crease, however, because of lack of pressure at the corners of the mouth. Figure 1 illustrates the typical thick scar ring which occurred in a patient following burns of the perioral region. Figure 2 shows the normal appearance of the perioral region following spontaneous healing of burns; however, five months later, the patient pic tured in Figure 2 had developed tight bands of scar tissue at the corners of his mouth (Fig. 3). Because of this problem, we sought a method of preventing and correcting this de formity. An attempt was made to fashion a conformer to the entire interior lip area; however, the difficulty in obtaining good contact with the tissue and in making adjustments to in crease pressure caused this design to be dis continued. A conformer which applied pres sure only to the corners of the mouth was tried with more satisfactory results. The fol lowing case will demonstrate the use of a conformer. A four-year-old white child sustained sec ond and third degree flame burns to 55 per cent of his body. His entire face required grafting for wound closure. Three weeks after grafting, a mouth conformer was made and applied by the method described below.
683
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
For the procedure to be successful, the child must have confidence in the person assisting him. After several successful attempts, the patient will learn to use this procedure inde pendently. This breathing procedure promotes posi tive productive behavior of the patient at the time of an asthmatic attack. The typical panic
Fig. 2. Spontaneous healing of burns of the per ioral region.
1. Take measurements for the length and the width of the conformer. The length of the conformer is determined by meas uring the distance from the corner of the mouth to the temporomandibular joint bilaterally. The width should be narrow enough so that the conformer will not impinge on the gingivae. (For our pa tient, the width measurement was 1.3 cm.) 2. Using the length and width measure ments, draw an oblong pattern slightly reduced in the center for better contour to the corner of the mouth (Fig. 4). 3. Trace the pattern onto thermoplastic splint material.Heat material slightly to facilitate cutting. 4. After the conformer is cut out, heat it in hot water until it is pliable. Check the temperature to be sure it is tolerable to the skin. 5. Place one end of the softened material directly against the buccal mucosa. Curve the remaining material so it lies against the exterior surface of the £ 3M Brand Thermoplastic Splint Material, Medical Products Laboratory, 230-3, 3M Center, St. Paul, MN 55501.
684
Fig. 3. Same patient as in Figure 2, five months postburn.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 1. Scarring from burns of the perioral region.
Fig. 5. Mouth conformer with elastic strap riveted to it.
cheek. Ask the patient to bring his teeth together. Apply pressure to the interior portion of the conformer with the index finger while applying opposing pressure with the thumb to the exterior portion of the conformer. Shape the contour of the conformer at the corner of the mouth for more comfortable fit. 6. Remove the conformer when it is firm and rivet a 1-cm elastic strap to the end of the exterior portion of the mouth piece (Fig. 5). The elastic strap should be long enough to reach from one mouthpiece across the back of the head to the other mouthpiece. A second strap, of sufficient length to reach across the back of the neck, is attached by rivets to the first strap just anterior to the ears (Fig. 6). The elastic straps allow the conformer to be applied easily, and the tension can be increased as indi cated. A closely supervised wearing schedule was initiated beginning with one hour twice daily and with wearing time gradually increased. Within 24 hours, notable improvement was evident in the patient's ability to speak and eat. Because the conformer was being worn
TABLE 1
Increase in the Horizontal Dimension of the Mouth Resulting From Use of a Mouth Conformer
Fig. 6. Mouth conformer with supporting straps in place.
Volume 56 / Number 6, June 1976
r-. Day
Horizontal Di.. mension (in cm)
... T. Wearing Time mim * '
1 2 3 4 5 6
3.62 4.00 4.25 4.44 4.44 4.44
1 hour 1 1 /2 hours 2 hours 2V2 hours 3 hours 3 hours
685
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 4. Pattern for mouth conformer.
Fig. 8. Same child with increased horizontal measurement after wearing conformer.
by a young child, nap time was a good time to wear it. Before using the mouth conformer, this child could not open his mouth wide enough to insert a feeding utensil (Fig. 7). After four days, maximum stretching seemed to have occurred; however, continued wearing of the conformer was necessary to maintain the en larged opening. The Table demonstrates the progression of stretching. Because the child had a face conformer also, he wore the mouth conformer and the face conformer on alternate nights. A constant pressure gar ment was worn 24 hours a day. The increase in diameter of the oral cavity, as seen in Figure 8, demonstrates the improvement achieved by using the mouth conformer. The
child has continued to wear the mouth con former and has tolerated it well. Precautions should be taken to watch the mouth and lip region for skin breakdown. Attention to gum irritation and good oral hy giene should be encouraged. The design of the mouth conformer can be readily duplicated, and construction is eco nomical and relatively fast. The device can be applied easily by the patient or family mem ber. While these results are not optimal, we believe that use of a mouth conformer is a beginning toward preventing contracture of the mouth when a burn involves the lip and adjacent structures, as well as correcting contracture which may restrict mouth open ing.
REFERENCES 1. Converse JM: Orbicularis advancement flap for resto ration of angle of the mouth. Plast Reconstr Surg 49:99-100, 1972 2. Fairbanks GR, Dingman RD: Restoration of the oral commissure. Plast Reconstr Surg 49:411-413, 1972 3. Jaeger D: Maintenance of function of the burn patient. Phys Ther 52:627-633, 1972 4. Kischer CW: Predictability of resolution of hyper trophic scars by scanning electron microscopy. J Trauma 15:205-208, 1975
686
5. Larson DL: The Prevention and Correction of Burn Scar Contracture and Hypertrophy. Galveston, TX, Shriners Burn Institute, University of Texas Medical Branch,1973 6. Lavore JS, Marshall JH: Expedient splinting of the burned patient. Phys Ther 52:1036-1042, 1972 7. Willis B: The use of orthoplast isoprene splints in the treatment of the acutely burned child. Am J Occup Ther 24:187-191, 1970
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 7. Child with limited mouth opening as a re sult of scar tissue.
Mouth Conformer for Prevention and Correction of Burn Scar Contracture
BETTY G. DENTON, MA, and SHARON E. SHAW, MA
The decrease in diameter of the opening of the oral cavity is a problem commonly seen in patients with burns involving the face. With the passage of time, the oral opening dimin ishes in vertical as well as horizontal dimen sion. This decrease in size appears directly related to hypertrophic scarring around the exterior of the mouth and possibly to con tracture formation of the mucosal lining of the mouth and lips. 1 , 2 A review of the litera ture did not reveal an effective nonsurgical method of prevention or correction of hyper trophic scarring of the perioral region. Cur rent nonsurgical approaches to control facial scarring include the use of constant pressure garments* and facial conformers.t 3 - 7 When used together, these two items have been helpful in controlling hypertrophic scar for mation and in restoring and maintaining the contour of the nasolabial fold as well as the lower labial depression. The diameter of the Mrs. Denton is supervisor of clinical education, Depart ment of Physical Therapy, University Hospital, Birming ham, AL 35294. Miss Shaw is assistant director, Physical Therapy Clinical Services, University Hospital, Birmingham, AL 35294. * Jobst Burn Supports, Jobst Institute, Toledo, OH 43694. f Thermoplastic material molded to conform to facial contours for additional pressure over hypertrophic scars.
Volume 56 / Number 6, June 1976
opening of the oral cavity will continue to de crease, however, because of lack of pressure at the corners of the mouth. Figure 1 illustrates the typical thick scar ring which occurred in a patient following burns of the perioral region. Figure 2 shows the normal appearance of the perioral region following spontaneous healing of burns; however, five months later, the patient pic tured in Figure 2 had developed tight bands of scar tissue at the corners of his mouth (Fig. 3). Because of this problem, we sought a method of preventing and correcting this de formity. An attempt was made to fashion a conformer to the entire interior lip area; however, the difficulty in obtaining good contact with the tissue and in making adjustments to in crease pressure caused this design to be dis continued. A conformer which applied pres sure only to the corners of the mouth was tried with more satisfactory results. The fol lowing case will demonstrate the use of a conformer. A four-year-old white child sustained sec ond and third degree flame burns to 55 per cent of his body. His entire face required grafting for wound closure. Three weeks after grafting, a mouth conformer was made and applied by the method described below.
683
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
For the procedure to be successful, the child must have confidence in the person assisting him. After several successful attempts, the patient will learn to use this procedure inde pendently. This breathing procedure promotes posi tive productive behavior of the patient at the time of an asthmatic attack. The typical panic
Fig. 2. Spontaneous healing of burns of the per ioral region.
1. Take measurements for the length and the width of the conformer. The length of the conformer is determined by meas uring the distance from the corner of the mouth to the temporomandibular joint bilaterally. The width should be narrow enough so that the conformer will not impinge on the gingivae. (For our pa tient, the width measurement was 1.3 cm.) 2. Using the length and width measure ments, draw an oblong pattern slightly reduced in the center for better contour to the corner of the mouth (Fig. 4). 3. Trace the pattern onto thermoplastic splint material.Heat material slightly to facilitate cutting. 4. After the conformer is cut out, heat it in hot water until it is pliable. Check the temperature to be sure it is tolerable to the skin. 5. Place one end of the softened material directly against the buccal mucosa. Curve the remaining material so it lies against the exterior surface of the £ 3M Brand Thermoplastic Splint Material, Medical Products Laboratory, 230-3, 3M Center, St. Paul, MN 55501.
684
Fig. 3. Same patient as in Figure 2, five months postburn.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 1. Scarring from burns of the perioral region.
Fig. 5. Mouth conformer with elastic strap riveted to it.
cheek. Ask the patient to bring his teeth together. Apply pressure to the interior portion of the conformer with the index finger while applying opposing pressure with the thumb to the exterior portion of the conformer. Shape the contour of the conformer at the corner of the mouth for more comfortable fit. 6. Remove the conformer when it is firm and rivet a 1-cm elastic strap to the end of the exterior portion of the mouth piece (Fig. 5). The elastic strap should be long enough to reach from one mouthpiece across the back of the head to the other mouthpiece. A second strap, of sufficient length to reach across the back of the neck, is attached by rivets to the first strap just anterior to the ears (Fig. 6). The elastic straps allow the conformer to be applied easily, and the tension can be increased as indi cated. A closely supervised wearing schedule was initiated beginning with one hour twice daily and with wearing time gradually increased. Within 24 hours, notable improvement was evident in the patient's ability to speak and eat. Because the conformer was being worn
TABLE 1
Increase in the Horizontal Dimension of the Mouth Resulting From Use of a Mouth Conformer
Fig. 6. Mouth conformer with supporting straps in place.
Volume 56 / Number 6, June 1976
r-. Day
Horizontal Di.. mension (in cm)
... T. Wearing Time mim * '
1 2 3 4 5 6
3.62 4.00 4.25 4.44 4.44 4.44
1 hour 1 1 /2 hours 2 hours 2V2 hours 3 hours 3 hours
685
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 4. Pattern for mouth conformer.
Fig. 8. Same child with increased horizontal measurement after wearing conformer.
by a young child, nap time was a good time to wear it. Before using the mouth conformer, this child could not open his mouth wide enough to insert a feeding utensil (Fig. 7). After four days, maximum stretching seemed to have occurred; however, continued wearing of the conformer was necessary to maintain the en larged opening. The Table demonstrates the progression of stretching. Because the child had a face conformer also, he wore the mouth conformer and the face conformer on alternate nights. A constant pressure gar ment was worn 24 hours a day. The increase in diameter of the oral cavity, as seen in Figure 8, demonstrates the improvement achieved by using the mouth conformer. The
child has continued to wear the mouth con former and has tolerated it well. Precautions should be taken to watch the mouth and lip region for skin breakdown. Attention to gum irritation and good oral hy giene should be encouraged. The design of the mouth conformer can be readily duplicated, and construction is eco nomical and relatively fast. The device can be applied easily by the patient or family mem ber. While these results are not optimal, we believe that use of a mouth conformer is a beginning toward preventing contracture of the mouth when a burn involves the lip and adjacent structures, as well as correcting contracture which may restrict mouth open ing.
REFERENCES 1. Converse JM: Orbicularis advancement flap for resto ration of angle of the mouth. Plast Reconstr Surg 49:99-100, 1972 2. Fairbanks GR, Dingman RD: Restoration of the oral commissure. Plast Reconstr Surg 49:411-413, 1972 3. Jaeger D: Maintenance of function of the burn patient. Phys Ther 52:627-633, 1972 4. Kischer CW: Predictability of resolution of hyper trophic scars by scanning electron microscopy. J Trauma 15:205-208, 1975
686
5. Larson DL: The Prevention and Correction of Burn Scar Contracture and Hypertrophy. Galveston, TX, Shriners Burn Institute, University of Texas Medical Branch,1973 6. Lavore JS, Marshall JH: Expedient splinting of the burned patient. Phys Ther 52:1036-1042, 1972 7. Willis B: The use of orthoplast isoprene splints in the treatment of the acutely burned child. Am J Occup Ther 24:187-191, 1970
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/6/683/4568233 by Washington University in St. Louis user on 11 February 2019
Fig. 7. Child with limited mouth opening as a re sult of scar tissue.
