Orofacial rehabilitation in head and neck burns: a systematic review of the literature

Magnani, Dicarla Motta; Sassi, Fernanda Chiarion; Andrade, Claudia Regina Furquim de

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Audiology - Communication Research

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Literature Review • Audiol., Commun. Res. 24 • 2019 • https://doi.org/10.1590/2317-6431-2018-2077 copy

Orofacial rehabilitation in head and neck burns: a systematic review of the literature

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

Analyze studies addressing the treatment of head and neck burns in different fields of health care, especially treatments that involve the functional rehabilitation of the head and neck muscles.

Research strategy

This qualitative review of the literature analyzed international scientific publications in the PubMed database that used the following keywords: “burn and face and speech-language pathology”, “burn and face and speech language”, “burn and face and rehabilitation”, “burn and face and myofunctional rehabilitation”, “burn and face and myofunctional therapy”, “nonsurgical and scar and management”, “burn and face and nonsurgical”, and “burn and face and scar and management”.

Selection criteria

Scientific publications on treatment strategies for head and neck burns associated to functional rehabilitation of the head and neck muscles using muscle exercises and/or manual therapy were included in this study.

Results

Overall, most of the treatments described in the investigated studies presented positive outcomes for patients with head and neck burns. The studies showed wide variability in terms of treatment proposals and methodologies used to verify treatment efficacy.

Conclusion

Although a growing number of publications on the rehabilitation of head and neck burns were observed, the best therapeutic technique and its real benefits remain unclear. There is a wide range of treatment protocols, and very few focus on the functional treatment of the orofacial myofunctional system. Most of the studies propose isolated motor activities to improve the mandibular range of movements.

Keywords:
Burns; Head; Neck; Speech, Language and hearing sciences; Rehabilitation; Review

Reference	Article title	Area of professional action	Study sample	Age	Gender	BBSA	Study objectives	Techniques used	Results/Conclusion
Fischer et al.⁽²³23 Fischer S, Kueckelhaus M, Pauzenberger R, Bueno EM, Pomahac B. Functional outcomes of face transplantation. Am J Transplant. 2015;15(1):220-33. http://dx.doi.org/10.1111/ajt.12956. PMid:25359281. http://dx.doi.org/10.1111/ajt.12956... ⁾	Functional Outcomes of face transplantation	Medicine	Face transplantation recipients of the institution n=5 Face transplantation recipients of other institutions n=29	19-59 years	Both	Not mentioned	Provide a compilation of functional impairments before and improvements after face transplantation.	Treatment for patients of the institution: data collection, physical examination, computed tomography and laryngoscopy; auditory-perceptual assessment of speech intelligibility; facial sensibility assessed by the Semmes-Weisntein test. Treatment for patients from other institutions: literature review.	Patients showed improvement in smell, breath, eat, speak, grimace and facial sensation. Standardized outcome evaluation is inevitable to enlarge the field of application.
Philp et al.⁽²⁴24 Philp L, Umraw N, Cartotto R. Late outcomes after grafting of the severely burned face: a quality improvement initiative. J Burn Care Res. 2012;33(1):46-56. http://dx.doi.org/10.1097/BCR.0b013e318234d89f. PMid:22002207. http://dx.doi.org/10.1097/BCR.0b013e3182... ⁾	Late outcomes after grafting of the severely burned face: A quality improvement initiative	Medicine	Patients with facial grafts n=35 Post-graft patients for late follow-up n=14	43 (±16) years	Not mentioned	Total BBSA 23% (± 21%)	Perform a detailed evaluation of the late outcomes in adult patients who have undergone grafting using a standardized surgical and rehabilitation approach for facial burns.	Evaluations used for treatment: Vancouver scar scale, pressure sensibility sensation, Semmes-Weinstein monofilaments, and esthetic and functional measures. Treatments performed: surgical (tangential burn wound debridement and grafting), massage, and compression mask.	Outcomes showed the scalp as a preferred donor site, pressure preference at the graft edges around the mouth and chin, scalp use for hairlines such as eyebrows, use of grafts of varying thicknesses, and orientation to the patient regarding the probability of changes in sensitivity.
Isaac et al.⁽²⁵25 Isaac C, Carvalho VF, Paggiaro AO, Maio M, Ferreira MC. Intralesional pentoxifyline as an adjuvant treatment for perioral post-burn hypertrophic scars. Burns. 2010;36(6):831-5. http://dx.doi.org/10.1016/j.burns.2009.11.002. PMid:20064692. http://dx.doi.org/10.1016/j.burns.2009.1... ⁾	Intralesional pentoxifylline as an adjuvant treatment for perioral post-burn hypertrophic scars	Medicine	Case group treated with pentoxifylline n= 10 Control group n= 8	12-45 years	Both	Not mentioned	Determine whether the use of pentoxifylline intradermally would improve the elasticity of hypertrophic scars in the peribuccal area in burned patients.	Case group: Measurements of mouth opening (lip-to-lip and tooth-to-tooth distances in mm) were taken using a digital caliper, before and after five therapeutic sessions with pentoxifylline with weekly intervals; application of patient satisfaction scale and a quantitative analogue pain rating scale. Control group: No treatment performed.	Significant improvement in the opening of the mouth, in vermilion distance as much as the dental distance in the case group compared with the control group.
Clayton et al.⁽¹⁶16 Clayton NA, Ward EC, Maitz PKM. Full thickness facial burns: outcomes following orofacial rehabilitation. Burns. 2015;41(7):1599-606. http://dx.doi.org/10.1016/j.burns.2015.04.003. PMid:25979798. http://dx.doi.org/10.1016/j.burns.2015.0... ⁾	Orofacial contracture management outcomes following partial thickness facial burns	Speech-language Pathology	Patients with partial-thickness orofacial burn n=229 Control group n=120	Patients with burn: aged 16-79 (±15.7) years Control patients: aged 16-80 years	Both Patients with burn: Males=183 Females=46 Control patients: Males=60 Females=60	11.7% (1-71%) (±12.1%)	Analyze clinical outcomes following non-surgical exercise for contracture management post partial-thickness orofacial burn in a cohort of patients.	Pre- and post-treatment assessments were performed through vertical and horizontal mouth opening/lip-to-lip measurements in patients with orofacial burn. The treatment combined exercise and stretching performed 10 times each, 5 times a day. For patients (n=4) who had prolonged healing over 21 days, a mouth splint was used 1 hour per day (Free Access II Cheek Reatractor®). Treatment completion was defined with closure of the wounds and functional objectives achieved. Stabilization of treatment was monitored for additional 4 weeks and referred to the medical staff of origin; if regression was observed, the patient returned to the previous level of treatment. For the control group, the same measures were performed only once and no treatment was offered.	For the group of patients, significant differences (p˂0.001) were observed regarding vertical and horizontal mouth opening compared with the control group. Treatment duration was, 30.7 days on average. After treatment significant improvement (p<0.001) was found for vertical and horizontal opening. At treatment conclusion, a significant (p<0.01) difference remained between the burns cohort and control group for vertical mouth opening. Study results support positive outcomes following orofacial contracture management for patients with partial-thickness orofacial burn; however, some functional loss remained with patients demonstrating persistent reduced vertical mouth opening at conclusion of treatment compared with the control group.
Clayton et al.⁽¹⁷17 Clayton NA, Ellul G, Ward EC, Scott A, Maitz PK. Orofacial contracture management: currente patterns of clinical practice in Australian and New Zealand adult burn units. J Burn Care Res. 2016;38(1):204-11. http://dx.doi.org/10.1097/BCR.0000000000000351. http://dx.doi.org/10.1097/BCR.0000000000... ⁾	Full-thickness facial burns: Outcomes following orofacial rehabilitation	Speech-language Pathology	Patients with orofacial burn n=12 Control group n=120	Patients with orofacial burn aged 17-61 years Control group aged 16-80 years	Both Patients with orofacial burn Males=4 Females=8 Control group Males=60 Females=60	8-80%	Measure length extension after full-thickness facial burn and describe results associated with orofacial rehabilitation in a cohort of prospectively studied patients with full-thickness facial burn.	Pre- and post-treatment assessments were performed through vertical and horizontal mouth opening/lip-to-lip measurements in patients with orofacial burn. The treatment combined exercise and stretching performed 10 times each, 5 times a day and the use of Cheek Retrator® for 1 hour, twice a day. For some patients (n=9) additional stretching was required and the TheraBite® or OraStretch® were used with 5 sustained stretches of 30 s for 3 times. After reaching mouth opening greater ≥35 mm, patients were followed-up every 3 months and, if regression of results was observed, they returned to the previous level of treatment. For the control patients, the same measures were performed only once and no treatment was offered. .	Participants had significantly (p<0.001) reduced vertical and horizontal mouth opening range compared with controls. Average duration of orofacial contracture management was 550.25 days, with 33% of patients demanding 1 year of treatment, half requiring >2 years rehabilitation, and 175 needing more than 2 years rehabilitation. After treatment, significant (p<0.01) positive improvement in vertical and horizontal mouth opening had been achieved, however measures had returned to lower limits of normal function and remained significantly (p<0.05) reduced compared to the control group. This study demonstrates that although positive gains can be achieved through non-surgical exercise after full thickness burn, some degree of long term loss in functional mouth opening remains. Methods to optimize results, especially for vertical mouth measures, need to be examined.
Parry et al.⁽²⁶26 Parry I, Sen S, Palmieri T, Greenhalgh D. Nonsurgical scar management of the face: does early versus late intervention affect outcomes? J Burn Care Res. 2013;34(5):569-75. http://dx.doi.org/10.1097/BCR.0b013e318278906d. PMid:23816994. http://dx.doi.org/10.1097/BCR.0b013e3182... ⁾	Nonsurgical scar management of the face: does early versus late intervention affect outcomes?	Physical therapy	n=82	Mean age of 5.4 (± 4.5) years	Both Males=62% Females=38%	Mean of 35.2% (± 22.5%)	Assess the timing of common noninvasive scar management interventions after facial skin grafting in children with facial burns.	General data from the medical records were analyzed and the modified Vancouver scar scale was used to monitor the evolution of patients after the use of non-invasive treatment techniques for facial burns, such as massage, exercise, pressure therapy and earlier application of silicone.	Earlier use of silicone for the face is associated with a better score in the modified Vancouver scar scale, specifically in the subscales of vascularity and pigmentation. It was also possible to observe an improvement in vascularity after pressure therapy and facial exercise.
Parlak Gürol et al.⁽²⁷27 Parlak Gürol A, Polat S, Nuran Akçay M. Itching, pain, and anxiety level are reduce with massage therapy in burned adolescents. J Burn Care Res. 2010;31(3):429-32. http://dx.doi.org/10.1097/BCR.0b013e3181db522c. PMid:20453734. http://dx.doi.org/10.1097/BCR.0b013e3181... ⁾	Itching, pain, and anxiety levels are reduced with massage therapy in burned adolescents	Nursing	Massage group n=32 Control group n=31	Aged 12-18 years Mean of 14.07 (±1.78) years	Both	Between 11 and 20%	Examine whether the effects of massage therapy reduced burned adolescents’ pain, itching, and anxiety levels.	Assessments of itching and pain were performed through visual analogue scales and a Likert scale composed of 20 questions was applied for the evaluation of anxiety. Pre- and post-massage therapy assessments were performed. Patients in the massage treatment group received 15-min massages twice weekly for 5 weeks.	Massage therapy was effective because it reduced the itching, pain, and anxiety levels of the treated patients compared with those in the control group.

Reference	Article title	Area of professional action	Study sample	Age	Gender	BBSA	Study objectives	Techniques used	Results/Conclusion
Wei et al.⁽²⁹29 Wei Y, Li-Tsang CWP, Liu J, Xie L, Yue S. 3D-printed transparent facemask in the treatment of facial hypertrophic scars of young children with burns. Burns. 2017;43(3):e19-26. http://dx.doi.org/10.1016/j.burns.2016.08.034. PMid:28040366. http://dx.doi.org/10.1016/j.burns.2016.0... ⁾	3D-printed transparent facemasks in the treatment of facial hypertrophic scars of young children with burns	Not mentioned	n=2	Aged 1-6 years	Male	Not mentioned	Test the efficacy of 3D-printed transparent facemasks on two children with facial burns resulting hypertrophic scars.	Facial features were scanned using a portable 3D scanner to produce the customized printable facemasks printed out on the transparent biocompatible material followed by adding the medical grade silicone gel to provide extra pressure on the scar site. The facemasks were fitted to the patients with elastic straps. The scar thickness was measured through ultrasound and a second layer of silicone was added to the sites where the scar thickness was in relief to increase pressure. Both children and family were instructed to wear the facemask for at least 20 h per day and they were assessed before treatment, one month and three months after treatment on the facial scar conditions.	The 3D-printed transparent facemask is convenient and efficient to fabricate, and is suitable for treating pediatric facial hypertrophic scars after burn.
Pontini et al.⁽³⁰30 Pontini A, Reho F, Giatsidis G, Bacci C, Azzena B, Tiengo C. Multidisciplinary care in severe pediatric electrical oral burn. Burns. 2015;41(3):e41-6. http://dx.doi.org/10.1016/j.burns.2014.12.006. PMid:25716757. http://dx.doi.org/10.1016/j.burns.2014.1... ⁾	Multidisciplinary care in severe pediatric electrical oral burn	Medicine, Odontology, and Speech-language Pathology	n=1	Aged 16 months	Female	Not mentioned	Describe a multispecialist team approach that ensures satisfactory outcome by reconstructive surgery, careful progressive evaluation of dental and soft tissue healing, and speech recovery.	Reconstructive surgeries, long-term x-ray evaluation, and SLP rehabilitation.	The multidisciplinary care involving the treatment of soft tissues, teeth, and rehabilitation of speech articulation results in satisfactory long-term recovery.
Sadiq et al.⁽³¹31 Sadiq Z, Farook SA, Ayliffe P. The role of free flap reconstruction in paediatric caustic burns. Br J Oral Maxillofac Surg. 2013;51(6):563-4. http://dx.doi.org/10.1016/j.bjoms.2013.01.003. PMid:23369780. http://dx.doi.org/10.1016/j.bjoms.2013.0... ⁾	The role of free flap reconstruction in pediatric caustic burns	Odontology and Physical Therapy	n=2	Aged 21-36 months	Both	Not mentioned	Describe cases of caustic soda scarring with free flap reconstruction in children.	Free flap reconstruction surgery and physical therapy rehabilitation with exercises and use of TheraBite® in 1 of the 2 reported cases.	Free flap surgery is complex and demanding, but if done at an early age may reduce the need for repeated operations and the growth and development of the facial skeleton.
Clayton et al.⁽³²32 Clayton NA, Ward EC, Maitz PK. Intensive swallowing and orofacial contracture rehabilitation after severe burn: a pilot study and literature review. Burns. 2017;43(1):e7-17. http://dx.doi.org/10.1016/j.burns.2016.07.006. PMid:27575671. http://dx.doi.org/10.1016/j.burns.2016.0... ⁾	Intensive swallowing and orofacial contracture rehabilitation after severe burn: A pilot study and literature review	Speech-language Pathology	n=2	Aged 18-54 years	Male	53% and 76%	Outline the development of principles/basic elements that should be adopted for the rehabilitation of dysphagia and orofacial contracture in this specific population.	Pre- and post-treatment assessments were conducted using horizontal and vertical range of movement and the Vancouver, POSAS, FOIS, AusTOMS, FEES protocols, and the laryngeal penetration/pharyngeal aspiration, pharyngeal residue severity rating, Marianjoy secretion, and Patterson edema scales. Treatment for orofacial contracture was performed through stretching (10 times each, 5 times a day) and with the use of OraStretch® (5 times, for 30 s, 3 times a day) and Free Access II Cheek Retractor® (for 1 h, twice a day). Dysphagia rehabilitation included base of tongue (Masako Manoeuver) and pharyngeal strengthening (Effortful Swallow) exercises performed 10 times each, 5 times a day.	Active rehabilitation achieved full functional outcomes for swallowing and orofacial range of movement. A long-lasting therapy can be anticipated in this complex population.
Clayton et al.⁽³³33 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. PMid:19826257.⁾	Rehabilitation of speech and swallowing after burns reconstructive surgery of the lips and nose	Speech-language Pathology	n=1	Aged 62 years	Male	Not mentioned	Describe the physical rehabilitation of a patient with full-thickness burns to the nose, lips, mouth, and chin following electrical burn injury.	Surgical reconstructive procedures, rehabilitation of swallowing, articulation and speech intelligibility, and exercises were performed aiming to minimize the development of contractures, such as reduction of the vertical opening of the mouth. Exercises included puffing up the lips and cheeks (each exercise was performed for 3s and repeated 10 times, 5 times a day) and a passive range of stretching techniques, such as horizontal and vertical stretching (each stretching was performed for 30 s and repeated 5 times per session). Splinting was conducted using the Free Access II Cheek Retractor® (for 1 h, twice daily) and the Therabite® (5 repetitions held for 15-20 s per session, twice daily).	In the multidisciplinary work involving surgical planning and post-surgical rehabilitation, the patient presented an ideal result, both esthetic and functional, with good speech quality and swallowing, and with ability to maintain functional oral movement. Rehabilitation of speech and swallowing is an essential factor to consider when planning postburn reconstructive procedures.

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[1] Conflict of interests: No.