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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 2  |  Page : 165-168
Dynamic commissural splint


1 Department of Prosthodontics, AECS Maaruti College of Dental Sciences and Research Centre, Bangalore, India
2 Department of Prosthodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India

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Date of Submission27-Apr-2007
Date of Decision10-Nov-2007
Date of Acceptance21-Nov-2007
 

   Abstract 

Microstomia, an abnormally small oral orifice, can manifest as a sequela of burns involoving the oral and perioral tissues due to contraction of the tissues and hypotonia of the circumoral musculature. Regardless of the etiology, scar contracture results in deformities that produce esthetic and functional impairment. Changes in the circumoral anatomy prevent optimal dental care and maintenance of good oral hygeine. The anatomic changes may detrimentally alter eating, speech, and mandibular motion. Prosthetic treatment involves providing physical resistance to scar contracture by maintaining the oral commisssures in their normal relationship by means of a splint. This article describes a method to fabricate a dynamic commissural splint and decribes its use in two cases.

Keywords: Commissural splint, microstomia

How to cite this article:
Nair CK, Sivagami G, Kunnekel AT, Naidu ME. Dynamic commissural splint. Indian J Dent Res 2008;19:165-8

How to cite this URL:
Nair CK, Sivagami G, Kunnekel AT, Naidu ME. Dynamic commissural splint. Indian J Dent Res [serial online] 2008 [cited 2019 Sep 20];19:165-8. Available from: http://www.ijdr.in/text.asp?2008/19/2/165/40475
Burns to the oral and perioral region result in crippling scarring, with contraction of the tissues and hypotonicity of the circumoral musculature eventually leading to microstomia. [1],[2],[3] This may cause oral asymmetry, abnormalities in speech, disfigurement, psychological problems, functional difficulty in feeding, limitations in dental care, increased incidence of dental decay, abnormal development of the dentition and dental arches, restriction to mandibular motion, and problems with intubation during general anesthesia. [1],[2],[3],[4],[6],[7],[8],[9]

Microstomia can be prevented with the timely use of an appliance such as a commissural splint, which maintains the commissures in their normal relationship during the healing process and offers physical resistance to scar contracture. The first commissural splint was introduced in 1975 and radically altered the management of burns to the lips. [1] Numerous reviews and clinical reports are available describing different techniques and treatments using commissural splints. [1],[2],[3],[4],[5],[6],[7],[8] Perioral splinting devices have been proven to be effective. [1] Previously published devices were associated with limitations due to design, complexity, and poor patient compliance. Several authors have advocated intraoral anchorage devices. These were limited in their application due to problems with impression making, difficulty in fabrication and insertion, interference with speech and eating, and esthetic compromise. [1],[5] Extraoral commissural splints obtained anchorage by means of head and neck straps. However, these methods necessitated contact of the straps with the skin of the cheek or neck, and this limited their application in cases where cervical and facial skin grafts were necessary. [1] Commercial splints are not widely available and the designs are technically challenging as well as time consuming and expensive to fabricate. [1]

The splint presented in this article was designed to meet certain criteria: simple to design, efficient in preventing contracture, and user friendly

The method of fabrication of the dynamic commissural splint and its use in two cases are reported.


   Materials and Methods Top


For construction of the splint the following materials are required:

  1. Disposable plastic syringe (2 ml)
  2. Autopolymerizing acrylic resin
  3. Stainless steel spring with a minimum force application capability of 0.3N
  4. Digital vernier calipers


Design of the dynamic commissural splint

A disposable plastic syringe (2 ml) is the principal component. The nozzle of the barrel and the rubber stop of the plunger is removed. The stainless steel spring is placed inside the barrel and the plunger placed over it so that the spring can be compressed. On both the ends of this unit acrylic rods with retaining hooks are attached; the spring keeps the hooks apart [Figure - 1]. The hooks hold the oral commissure in a stretched position when the splint is positioned [Figure - 2].

Customization of the splint:

  1. The intercommissural distance (ICD) of the patient at rest is measured using digital vernier calipers [Figure - 3].
  2. The length of the retractors is adjusted according to this dimension to allow atraumatic insertion.
  3. The maximum tolerable ICD of the patient is measured by engaging and gradually stretching the commissures, using the beaks of the digital vernier callipers, till the point where the patient expresses discomfort [Figure - 4].
  4. The spring is activated by opening its coils such that the splint, when placed, maintains the commissures at the maximum tolerable ICD [Figure - 5].
  5. The force exerted by the spring can be decreased by reducing its length if the patient has any discomfort.


In our cases, initial evaluation was done weekly, and later the patient was evaluated on a monthly or bimonthly basis. [5],[8] Clinical progress was monitored by measuring mouth opening and the ICD. The distance between the vermilion borders of the upper and lower lip or the maximum opening, as recommended by Wood et al . and Bedard et al ., [1],[10] was also recorded.

Clinical trials

Clinical trials were conducted on patients with burns at Kilpauk Medical College and Hospital, Chennai.

Case 1

A male patient aged 11 years, who suffered burns on his face from a cracker blast, reported to the burns department, Kilpauk Government Medical College Hospital. The patient was examined on the fifth day post injury and the splint was customized according to the ICD at rest and at the maximum tolerable ICD. Mouth opening ability was monitored using the ICD and the maximum oral opening. The patient was reviewed 10 days post placement and measurements were recorded.

Case 2

A 9-year-old male patient who suffered burns to his face due to a cracker blast reported to the burns department at Kilpauk Government Medical College Hospital. The patient was examined on the fifth day post injury and the splint was customized according to the ICD at rest and the maximum tolerable ICD and placed. Mouth opening ability was monitored. The patient was reviewed 10 days post placement and measurements were recorded.


   Results Top


All parameters evaluated showed an increase in values 10 days post placement [Table - 1],[Figure - 6],[Figure - 7].

  1. ICD at rest showed an increase of 11 mm and 8 mm for case 1 and case 2, respectively.
  2. Maximum tolerable ICD demonstrated an increase of 8 mm in both the cases.
  3. Vertical distance between the vermillion borders of the upper and lower lips showed an increase of 4 mm and 5 mm for case 1 and case 2, respectively.



   Discussion Top


The results of the two clinical trials indicate the potential of the dynamic commissural splint in preventing contraction of the oral commissures in patients suffering from burns. The recommended time of placement of the splint is as early as 3 days and not beyond 6 days of injury, which corresponds to the fibroplasias phase of wound healing. [5],[6],[8] Due to the sphincter-like nature of the orbicularis oris muscle, the splint must provide resistance in the horizontal direction. [1],[7],[8] The major component of scar contracture occurs in a direction nearly parallel to the occlusal plane, and the splint must exert a force accordingly. [8],[9] By virtue of being dynamic, the splint allows movements of the perioral musculature. As the horizontal component is incorporated below the chin of the patient, it does not interfere with normal activities such as speech and mastication. Insertion of the splint is easily and painlessly accomplished by the patient as the lengths of the retractors can be adjusted to prevent undue stretching. The splint should be worn continuously, except while taking food. [1],[3],[7],[8] Depending on the extent of the burn, the splint is worn for up to 12 months. [7],[8] Clinical progress is evaluated by comparing ICD and maximum mouth opening measurements with the values before appliance delivery and between each follow-up visit. [1]

As the appliance is removable, patient compliance has to be ensured; however, there is the advantage that maintenance of adequate hygiene of the appliance is possible. In our experience, the patients found the splint comfortable to insert and wear and good compliance was observed. Furthermore, in cases of electrical burns to the oral commissure, splinting may obviate the need for commissuroplasty.

The process of scar contraction in burns continues for up to 12 months post injury. Early results with the dynamic commissural splint, though promising, will have to be substantiated with long-term clinical trials to fully ascertain the potential of this appliance.


   Acknowledgment Top


We acknowledge the wholehearted support and cooperation extended by Dr. A. Dhanikachalam, Professor and Head of Department, Dr. R. Gopinath, Assistant Professor, Dr. T. Mathivanan, Reader, and all staff members at the Department of Burns, Plastic, and Reconstructive Surgery, Government Medical College and Hospital, Kilpauk, Chennai.

 
   References Top

1.Bedard JF, Thongthammachat S, Toljanic JA. Adjunctive commissure splint therapy: A revised approach. J Prosthet Dent 2003;89:408-11.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Khan Z, Banis JC. Oral commissure expansion prosthesis. J Prosthet Dent 1992;67:383-5.  Back to cited text no. 2    
3.Wolfaardt JF, Levesque R. A technique for construction of dynamic oral commissure retractors. J Prosthet Dent 1990;64:195-7.  Back to cited text no. 3  [PUBMED]  
4.Sela M, Tubiana I. A mouth splint for severe burns of the head and neck. J Prosthet Dent 1989;62:679-81.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Conine TA, Carlow DL, Stevenson-Moore P. The Vancouver microstomia orthosis. J Prosthet Dent 1989;61:476-83.  Back to cited text no. 5  [PUBMED]  
6.Carlow DL, Conine TA, Stevenson-Moore P. Static orthoses for the management of microstomia. J Rehabil Res Dev 1987;24:35-42.  Back to cited text no. 6  [PUBMED]  
7.Cheuk SL, Kirkland JL. Splint for burns to lip commissures. J Prosthet Dent 1984;52:563.  Back to cited text no. 7  [PUBMED]  
8.Gay WD. Prostheses for oral burn patients. J Prosthet Dent 1984;52:564-6.  Back to cited text no. 8  [PUBMED]  
9.Reisberg DJ, Fine L, Fattore L, Edmonds DC. Electrical burns of the oral commissure. J Prosthet Dent 1983;49:71-6.  Back to cited text no. 9  [PUBMED]  
10.Wood R, Lee P. Analysis of the oral manifestations of systemic sclerosis. Oral Surg Oral Med Oral Pathol 1988;65:172-7.  Back to cited text no. 10    

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Correspondence Address:
Ashish T Kunnekel
Department of Prosthodontics, Meenakshi Ammal Dental College and Hospital, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.40475

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
 
 
    Tables

  [Table - 1]

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