burns 41 (2015) e41–e46

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Case report

Multidisciplinary care in severe pediatric electrical oral burn A. Pontini a,*, F. Reho a, G. Giatsidis a, C. Bacci b, B. Azzena a, C. Tiengo a a

Department of Neurosensorial Specialties, Institute of Plastic Reconstructive Surgery and Burn Unit – Padova University Hospital, Italy b Department of Odontostomatology, Oral Surgery Service – Padova University Hospital, Italy

article info

abstract

Article history:

Oral burns in pediatric patient are commonly due to electrical injuries, representing an

Accepted 5 December 2014

important reconstructive issue even for functional than esthetic reason. Different classification, surgical management and even oral device were described to allow the best long-

Keywords:

term result. In most case a multidisciplinary approach is necessary to achieve a satisfactory

Oral burn

outcome. A severe case of pediatric oral burn with germinative teeth damage is presented,

Electric

describing a multispecialist team approach that guarantee a satisfactory outcome by

Teeth

reconstructive surgery, careful progressive evaluation of dental and soft tissue healing

Integra

and speech recovery. The use of acellular dermal substitute template within traditional

Eastlander

reconstructive surgery had provided a good functional and esthetic result joint to valid preservation of germinative dental element as shown at long-term X-ray evaluation.

Speech

Intensive rehabilitation speech program has also avoided phonetic impairment in an important speech develop period. It was so evident that the necessity of a multispecialist care in such difficult injury to achieve the best long-term result. # 2014 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Electrical burns of the mouth represents a surgical reconstructive challenge even because a frequent involvement of multiple different tissue and anatomical structures than because they particularly affected young children in the average age from 6 months to 3 years [1]. Severe case with hospitalization and surgical treatment are rare and fortunately decreasing in developing countries, representing a limited

part of the total injuries due to electrical burn. In Europe electrical injuries account for 3–8% of the total burns [2] and trough them the incidence of oral burns it is quantified by some authors in a range from 2.2 to 3.5% [3,4]. Despite its rare presentation, the management and the necessity of a longterm rehabilitation permits to classify these injuries as a major problem in burn management [3]. Injuries mechanism commonly are due to the children attitude of sucking all objects they are interested in, so they can damage themselves in domestic accident by chewing on not isolated exposed

* Corresponding author at: Plastic Surgery Clinic, Vth Floor, Padova University Hospital, Via Giustiniani 2, 35100 Padova, Italy. Tel.: +39 0498212713; fax: +39 0498218199. E-mail address: [email protected] (A. Pontini). http://dx.doi.org/10.1016/j.burns.2014.12.006 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

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burns 41 (2015) e41–e46

electrical wires or grabbing the end of electrical cord or its junction when partially plugged in [5]. The damage presentation depending of multiple factors as the time contact, the electrical voltage and isolation, the sucking attitude of the child. Particularly important is knowing the amount of the voltage that directly correlate with the extension of the damage even for the joule effect than for the induction of tetanic muscle contraction with consequent prolongation of the exposure time [5]. Most frequently are involved the commissure, totally or partially, the superior and inferior lip and, in severe cases, are described injuries extended to gums area, alveolar chin, oral mucosa and tongue [6]. The lesions can be of 2 types: direct contact and voltaic arch. The second are particularly common around the mouth, and depended from saliva, rich in electrolytes, acting as high electric and thermic conductor. It is not uncommon consider temperatures till 3000 8C [7]. A clinical classification of the electrical burn of the mouth was reported by Ortiz-Monasterio and factor, dividing the damage in minor, moderate and severe, suggesting an early surgical approach [8]. Anyway a useful classification, particularly in pediatric case, is still lacking and it is particularly difficult to achieve for the wide presentation’s variability and unpredictable daily progression of the damage. So its possible to observe injuries ranging from superficial burn to serious multiple tissue involvement and the literature attention in pediatric case reconstructive option must gone within a is focused both on reconstructive option than in the multidisciplinary approach to obtain the best and stable functional outcome [1,3]. A common reported sequelae is the possible occurrence of microstomia, go with evident alveolar deformity, consequence of scar retractions and were widely described all the possible preventing treatment [1,9]. Besides an important role in preventing functional bad outcome is the attention on swallow and speeching rehabilitation, if they are compromised from the damage and all about the possible sequelae depending from involvement of teeth structures [10]. In terms of reconstructive options were described multiple different techniques for any particular case, to get satisfactory results in esthetical and functional outcome. The different approach could easily been divided in two different forms. The first is the early surgery, often characterized of within an aggressive approach to the non viable or doubt tissue, especially for prevent edema and important inflammatory response to the necrosis, the second is waiting the complete definition of the damage and then planning the best reconstructive option, especially whit wide damage [10]. A variety of surgical different approaches were described, going from mucosal flaps, advance and rotation composite flaps to buccal mucosal tissue or rotation flaps from the inferior lip [11]. We report a case of severe oral electrical injuries in a 16 months child with multiple reconstructive stages with particular attention to trying to minimize the damage on germinative teeth structure involved in the trauma. The satisfactory functional and esthetic result was achieved by traditional reconstructive surgery and, moreover, the teeth damage and the bone growth was mostly preserved by using dermal substitute template to the difficult area of the gingival tissue. An important support to optimize the result was represented by the careful The multidisciplinary approach was conducted with oral surgeon and speech therapist.

2.

Case report

A female children of 16 months, was transferred by helicopter to our hospital for burn of the mouth due to accidental sucking of a live electrical wire. The patient presented a third degree burn that affected the left superior upper lip with severe full thickness loss of substance, left superior gingival tissue of superior dental arch, left commissure, left cheek, left upper gum, half anterior left hard cleft, 2/3 anterior tongue with severe drooling and edema (Fig. 1). Emergency care in operating room provided appropriate cleaning and cooling of the lesions, anesthesiologists and endoscopic surgeons evaluation to assess control the pain and the patency of the airways control. Afterwards she was transferred to the Pediatric Intensive care Unit for strictly monitoring. An enteral nutrition was early provided and continued for the first hospitalization period. Health general conditions were established four days later so she was transferred to our Burn Centre. Needing of a multidisciplinary approach was necessary because the severe involvement of superior dental arch and the pre maxilla bone necrosis. At day 8 the patient underwent a general anesthesia, performing a combined surgical approach with oral surgeon. They removed a cortical bone necrotic area in the left premaxilla within gum, mucosal tissues and 6.1, 5.1, 5.2 decidual dental elements. Element 11 was evident and not removed because its insertion in healthy tissue. Alveolar bone with germinative teeth element was left mostly exposed. Reconstructive time consisted in an upper left lip surgical toilette with removal of necrotic tissue, including devitalized labial orbicular muscle followed by tongue toilette. Mouth vestibule, vestibular muscle and alveolar bone were covered with a dermal substitute template (Integra1), performing then an occlusive medication with a silicon sheet (Fig. 2). Following medications were then performed under general anesthesia with presence of oral surgeons to evaluate teeth condition. After three weeks a new surgical time was performed to reconstruct the upper lip on the left side by an Eastlander rotational flap from the lower left lip, in order to cover the loss of substance of the left upper lip and the upper vestibular arch (Fig. 3). The patient was discharged after one

Fig. 1 – Emergency evaluation of the trauma. Note the wide and severe third degree involvement of left superior upper lip, gingival tissue, maxillary bone and tongue.

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Fig. 4 – Flap design for microstomia correction.

Fig. 2 – Mouth vestibule, vestibular muscle and alveolar bone covered with dermal template after debridment and then silicon sheet medication fixed by sutures.

week and followed by periodic medication and oral surgeon evaluation. The scheduled procedure of microstomia correction was then performed 3 months later by advancement of myomucosal-cutaneous flap to reconstruct the superior and inferior mucosal portion of the lips and the modiolus (Fig. 4). After 4 days the patient was discharged and follow with periodic controls, as well as the oral surgeons to check the state of surgical scars, functional and esthetical outcomes and dental growth. Twelve weeks later we performed a left commissuroplasty according to coverse technique to correct the residual microstomia and improve the mouth opening (Fig. 5). After 1 month the children started an intensive rehabilitation speeching program, twice a week for two daily hours, aiming to minimize the impact of the damage on the speech. Stable healing with satisfactory oral range of movement was present after 12 months (Fig. 6). Only few speech impairment were referred and rehabilitation speech program was reduced to one treatment every 2 months. The speech quality demonstrates a good intelligibility. An oral Xray control was also performed for oral surgeons consideration, demonstrating good opacity of the premaxilla left bone, with no necrosis sign. The remaining dental germinative elements on left side were comparable to the controlateral

Fig. 5 – Result of commisuroplasty with converse technique.

ones, confirming dental pulp and parodontal ligament viability like also the 11 element as evident on clinical examination. It was possible to notice the maxilla median line, suggesting a regular maxillary bone growth (Figs. 7–9).

3.

Discussion

Oral burn represent an insidious surgical challenge, and its management is still debated and controversial. The immediate treatment of the life threatening condition as airways and circulatory support, strictly monitoring, antibiotic prophylaxis and nutritional support are well known [2,3]. Function is the

Fig. 3 – Reconstruction of the upper lip by Eastlander flap. Dissection and final result.

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Fig. 6 – Stable healing at 1-year follow-up. Satisfactory lips profile and tongue heal.

first aim of the reconstructive surgery but esthetic aspect must be also considered, for its psychological importance in young patient. Teeth preservation if damaged represents a fundamental tool in the esthetic oral preservation. The techniques and the best timing are discussed in several reports and are strictly linked to numerously variables such trauma extension, its deep and loss of substance and general health condition. Some authors suggest and early approach meanwhile others prefer a conservative one [12,13]. Use of oral splint seems to be useful even in conservative approach than as a support of the surgical treatment. Colcleugh and Ryan [14] beyond the classic techniques of repair with local flaps, introduced a new conservative procedure at those time by a splinting defined as orthodontical fixing bands within the function of prevent the formation of retraction microstomia. They suggest to wait before burn demarcation and then planning the reconstructive surgery. Most recently prostodontic treatment seems to be a useful support to oral burns [15]. Besides, was also described new type of flap especially done for lip reconstruction. A composite mucosal and muscular tongue flap (ventral tongue flap) were purposed by

Fig. 7 – X-ray evaluation at 1 year. Good opacity of the premaxilla left bone, absence of removed dental elements 51, 52, 61. Remaining dental germinative elements on left side was comparable to the controlateral within dental pulp and parodontal ligament viability. Note the maxilla median line, suggesting a regular maxillary bone growth.

Fig. 8 – Static functional result after 1 year. Satisfactory mouth opening and oral symmetry.

Donelan to cover loss of tissue of lateral portion of the lip, besides Canady and Bardach proposed advancement and rotation mucosal flap sculpted from the cheek to repair defects of lateral parts of the lip [16,17]. So the different reconstructive choice or the support of external device depend of the complex anatomical and functional structure of the oral cavity. In our opinion the treatment choice must be related to the entity of the damage, considering for surgery all the severe case with deep burn and multiple tissue involvement because the high infection risk, the impossibility of a correct evaluation of the damage extension and the necessity of an appropriate surgical planning with a multidisciplinary approach if needed. In fact the oral structure are not only constitute by soft tissue but also from the bone in hard cleft and in premaxilla and from teeth, so it could be fundamental oral surgeon evaluation treatment and long-term follow up. Because oral burn could particularly affect children it is mandatory to prevent or treat all possible damage to the in growth structure like bone and teeth. The teeth damage and premature loss, in particular of the anterior teeth, is reported to important affect the children quality of life in terms of esthetic, social, dental hygiene sequelae as the phonetic production with a subsequent speech impairment [18]. In particular the teeth involvement in oral electric children burn are poorly reported in literature as the treatment option,

Fig. 9 – Dynamic functional result after 1 year. Satisfactory function in phonetic expression (whistle movement).

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the long-term outcome and the employ of speech therapist, even the speech rehabilitation is a fundamental aspect in the long term rehabilitation program of whom suffered by oral burn [10]. For that reason we planned an early oral surgeon’s evaluation of the damage was fundamental for the involvement of alveolar bone process with of the damage, because were not only present soft tissue oral involvement but also alveolar bone process damage permanent lesion risk both for teeth and bone growth. So a surgical reconstructive challenge in early growth age could be represented not only from soft tissue functional and esthetic recover, but also particularly from the necessity to provide a protection and a viable environment to the physiological odontogenesys process. In fact, odontogenesys physiologically develop till the age of three years with dental crown maturation, enamel and dentin deposition and then, from 3 to 6 years, radicular development start with dentin apposition followed by cement to the radicular site that will provide insertion for parodontal ligament [19]. Particularly important is that the growth of the alveolar bone process is conditioned from the development of germinal dental element and their physiologic eruption. So happen for maxillary incisors around 6 year’s age [20]. As evident in agenesis and edentulism process, loss of dental element influences the presence of alveolar process [21]. For that reason element 11 was not removed and were fundamental a series of periodical control to asses the physiological maturation and eruption of this element. The clinical approach could be supported from radiological exams. In our case the trauma effect could stop the maturation of crown and radicular site, similarly to a case of maxillary radiotherapy. Periodic controls are so necessary to detect malocclusion due to the absence of dental elements [22]. When the dental loss happens in so early age, oral surgery approach is to follow maxillary growth with use of orthodontic apparatus if necessary and then start a prosthesis rehabilitation. This one is usually performed to support dental implants. Bone implants could be positioned at the end of alveolar process growth, so after the 14 or even 18 years old, after a preprothesic reconstruction procedure of the alveolar process. The bone growth end could be determined with wrist radiography or, more recently, with cervical bone evaluation [23]. Reconstructive surgery with Eastlander flap also played an important rule to prevent and reduced all this sequelae joint to an appropriate follow up and rehabilitation phonetic program. Based on our experience with dermal template Integra1 we decided to use it to guarantee a viable environment to prevent or to reduce the effect of the germinative teeth damage. At the best of our knowledge this is the first description about the use of the dermal substitute Integra in such a kind of oral trauma. Acellular dermal template Integra1 is consisting in an inner layer of collagen and chondritin-6-sulfate. It can be covered by a silicone sheet for at least 3 weeks or it can be covered at the first step with skin graft. It was born as skin substitute for the coverage of burn wounds but it has already been used in other reconstructive applications, as donor sites for flaps, flap resurfacing and in upper and lower limbs reconstructive surgery, even in complex reconstructive procedures [24,25]. In our case it seems provide the reconstitution of viable tissue

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on gums with protection of germinative teeth. The well known properties of Integra to provide a good vascularized bed could explain as it could protect and allow a physiological growth of germinative element, avoiding also damage of the alveolar process and to the maxillary bone growth, with a relatively simple procedure. All severe cases of oral burns in children poses challenging difficulties to plastic surgeons with necessity of numerous surgery stage and often a multiple care approach. The correct timing, sequencing and appropriate therapeutic option are difficult to plan and the functional and esthetic outcomes could not be completely satisfactory. In some cases are also present threatening damage for the correct oral growth of the patient and very few are the possible solutions. Our surgical planning describes an innovative approach for case of wide and severe loss of tissue with germinative teeth damage, improving the functional and the esthetic result. In our opinion, a properly multidisciplinary management of the soft tissue and the teeth, joint to an intensive speech rehabilitation could provide a satisfactory long term recovery, even avoiding or reducing the use of prostodontic device with an important psychological and health benefit for the young patient.

Conflict of interest statement The authors declare they have no conflicts of interest to disclose.

references

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Multidisciplinary care in severe pediatric electrical oral burn.

Oral burns in pediatric patient are commonly due to electrical injuries, representing an important reconstructive issue even for functional than esthe...
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