Indian Journal of Dental Research

CASE REPORT
Year
: 2010  |  Volume : 21  |  Issue : 2  |  Page : 299--301

Prosthodontist contribution in treating post-burn hypertrophic facial scars


TV Padmanabhan, Kasim Mohmad, Rajiv Kumar Gupta 
 Department of Maxillofacial Prosthodontics, Sri Ramachandra Dental college, Chennai, India

Correspondence Address:
T V Padmanabhan
Department of Maxillofacial Prosthodontics, Sri Ramachandra Dental college, Chennai
India

Abstract

The formation of hypertrophic scars is common following healing of the burn wound, particularly in children. The face is one of the areas of the body most frequently affected by burns. Scar formation as a result of burn wounds leads to contraction of the formed granulation tissue, which causes both aesthetic and functional impairment for the patient. Scarring has major psychological and physical repercussions. Scarring on the face and visible regions of the body can be very distressing for the patient. Prevention of scars involves early and continuous use of a compressive orthesis. However, their efficacy is often limited to the facial region because of the contours of this area of body. This paper describes a clinical case of post-burn hypertrophic scars treated with silicone gel sheeting applied with pressure under custom made auto-polymerizing resin stent.



How to cite this article:
Padmanabhan T V, Mohmad K, Gupta RK. Prosthodontist contribution in treating post-burn hypertrophic facial scars.Indian J Dent Res 2010;21:299-301


How to cite this URL:
Padmanabhan T V, Mohmad K, Gupta RK. Prosthodontist contribution in treating post-burn hypertrophic facial scars. Indian J Dent Res [serial online] 2010 [cited 2021 May 15 ];21:299-301
Available from: https://www.ijdr.in/text.asp?2010/21/2/299/66641


Full Text

Hypertrophic scar is defined as a scar which has not overgrown the original wound boundaries but is instead raised. [1] It is widespread, red, raised, sometimes itchy scar, confined to the border of the burn injury. [2] It represents an abnormal exaggerated healing response after skin injury such as trauma, surgical intervention or burn and usually causes major physical, psychological and cosmetic problems.

 Case Report



An 11-year-old female patient referred to the Department of Maxillofacial Prosthodontics of Sri Ramachandra Dental College and Hospital, Chennai from the Department of Plastic Surgery of Sri Ramachandra Medical College and Hospital, Chennai for the management of post-burn hypertrophic scars on face. The patient's history revealed that she met with a fire accident one month back. On examination immature hypertrophic scars were found, on mid-facial region, involving naso-labial, labio-cheeks and naso-cheeks folds. Scars were more extensive on patient's left side of the face extending up to the cheek [Figure 1].

Treatment procedure

As per the international clinical recommendations on scar management, for this patient, there was no alternative to silicone gel sheeting along with pressure therapy. As lesion was present on the cheeks and naso-labial folds, it was decided to fabricate custom made hard acrylic stent using auto-polymerizing resin to act as a carrier for silicone gel sheeting and to provide adequate pressure even in concave areas. A positive plaster mold was obtained from a negative alginate mold of the patient's face. An acrylic stent was fabricated using auto-polymerizing resin [Figure 2] after application of separating media on plaster model. Once fabricated, stent was finished and polished. Adhesive silicone gel sheeting was applied to the tissue side of the stent [Figure 3]. A siliconized facial stent worn with the help of elastics [Figure 4] improved esthetics and functional results by equalizing distribution of pressure forces [Figure 5].

The patient was instructed to wear the stent continuously for at least 23 hours a day, except when bathing and eating, for a minimum period of three months. The fit of the stent was re-assessed regularly and adjustments were made and new elastics were replaced to ensure that adequate pressure is maintained over the course of the treatment.

 Discussion



No ideal and all-purpose method of scar control exists. Successful management of hypertrophic scars depends upon early and aggressive treatment. The creative use of available products facilitates the production of a cosmetic and functional scar. [3]

Pressure therapy has been the preferred conservative management of scars since the 1970s, especially in treating hypertrophic scarring after burn injury. Although the exact mechanism of action is unknown, pressure appears clinically to enhance the scar maturation process. [4] Various proposed actions of pressure therapy are:

Hypoxia, which causes hypertrophic scarring is increased by pressure and causes the resolution of scar by induction of fibroblast death.Pressure causes an increase in collagenase activity and a consequent increase in extra-cellular matrix degradation.Pressure therapy restores in part the extra-cellular matrix organization observed in normal scar and induces the disappearance of alpha smooth muscles actin-expressing myofibroblasts, probably by apoptosis.Pressure causes thinning of the dermis, decrease in edema and reduction of blood flow and oxygen. The hypoxic environment is hypothesized to decrease collagen formation and increase collagen lysis.

Silicone gel sheeting is widely used for hypertrophic scar and keloid treatment. Silicone gel sheeting has a 20-plus year history with several randomized and controlled trials that support its safe and effective use. [2],[5] The exact mechanism of action responsible for the effectiveness of silicone gel dressings is unknown. Various proposed actions are:



Static electricity generated by friction could be the reason for the anti-scarring effect.Silicone gel sheeting improves hydration and occlusion.Increased temperature elevation of 1΀C (or less) that can affect the collagenase kinetics and change in the adhesion molecule expression of the lymphocytic infiltrate.Silicone sheets decrease hyperemia and minimize fibroblast production of collagen and promote wound flattening.

Sawada concluded that occlusion may be synergistic in wound healing. They found that the use of silicone cream alone compared with silicone cream with occlusive dressing showed 22℅ and 82℅ scar improvement respectively, with respect to erythema, tenderness, pruritis and hardness. [6]

 Conclusion



It is the God-given right of a human being to appear human and the face is a person's visiting card. We can hide everything but not our face. Scars, especially facial scars, can be very distressing for the patient. The first step towards treatment of excessive scarring is early recognition and institution of therapy after surgery or trauma. This case report shows another successfully treated post-burn hypertrophic scar patient with combination of silicone gel sheeting with pressure therapy.

References

1General principles Vol. 1 - Mathews; p. 209-34.
2Mustoe TA, Cooter RD, Gold MH, Richard Hobbs FD, Ramelet AA, Shakespeare PG, et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002;110:560-71.
3Carr-Collins JA. Pressure techniques for the prevention of hypertrophic scars. Clin Plast Surg 1992;19:733-43.
4Garcia-velasco M, Ley R, Mutch D, Surkes N, Williams HB. Compression treatment of hypertrophic scars in burned children. Can J Surg 1978;21:450-2.
5Gold M. Topical silicone gel sheeting in the treatment of hypertrophic scars and keloids: A dermatologic experience. J Dermatol Surg Oncol 1993;19:926.
6Sawada Y, Sone K. Treatment of scars and keloids with a cream containing silicone oil. Br J Plast Surg 1990;43:683-8.