PEDIATRIC DENTISTRY/Copyright~ 1982 byThe American Academy of Pedodontics/Vol. 4, No. 4

Oral electrical burns in children-early treatment and appliancefabrication

E. Joseph LeCompte, DDS, MSBarry M. Goldman, DDS, MS

AbstractA case report of an electrical burn oF the lips in a

22-month-old child is presented. The principles oFearly medical and dental treatment and the sequence ofappliance Fabrication are detailed. The applianceFabrication utilized in this case is unique because it isan intraoral treatment approach to a commissural burnin a child that had not yet erupted primary secondmo[aFS.

Electrical burns of the commissures of the mouth

often result in severe facial scarring and deformation.This scarring and deformation is caused by adhesion ofthe lips, constriction of the commissure of the mouthand a generalized contracture of the wound during heal-ing. The vast majority of these burns are due to the childsucking on the female end of a live extension cord or atthe junction of an extension cord and a partially pluggedin appliance. 1-3 Saliva acts as the contact mediumthrough which the electric current flows, resulting in theoral electrical burn. Most electrical burr~ will occur inchildren under three years of age and they rarely areseen after the age of four years.3-~

The incidence rate of oral electrical burns has seldombeen documented in the literature. Based on a report bythe U.S. Consumer Product Safety Commission, Crike-lair and Dhaliwal have reported a yearly incident rate ofmore than 4,000 extension and appliance cord injuriesserious enough for emergency treatment. 2 In comparisonwith flame and scald burns, electrical bums are infre-quent. 5 Muir ~ reported that Mount Vernon Center,which receives all of the severe burns from a populationof five million, receives only two or three electrical burnsper year. Thomson et al. 7 reported oral electrical burnsto 43 children admitted to the Hospital for Sick Childrenin Toronto between the years 1945 and 1963. A total of2,491 patients were admitted to the hospital for thermalburns during the same period. Oral electrical burnsrepresented less than 2% of the total burn admissions.

The purpose of this paper is to present a detailedintraoral approach for treatment of a lip commissure

burn to a 22-month-old child whose primary secondmolars had not yet erupted. Previous reports 8-1° havedescribed the use of intraoral appliances utilizing stain-less steel bands, Adam’s clasps, ball clasps, or a Hawleyretainer@ for retention of the intraoral appliance. Mostreports have been documented on patients with a fullcomplement of primary teeth. Larson~° reported thesuccessful use of an intraoral acrylic splint appliance ina one-year-old patient. The appliance utilized was simi-lar to that described in this paper, but few details onappliance fabrication are given in Larson’s report. Rich-ardson and Kittle 1~ recently have reported on the prob-lems associated with retaining intraoral appliances in theyoung burn patient with incomplete primary dentition.They reported the use of an extraoral facemask type ofappliance in managing a lip commissure burn in a 28-month-old patient who did not have primary secondmolars. The technic they describe requires a generalanesthetic with nasoendotracheal intubation to obtain afull facial alginate moulage prior to construction of theextraoral appliance.

The technic described in this paper does not requirethat a general anesthetic be administered, only thatmaxillary and mandibular alginate impressions be ob-tained in the dental office prior to appliance construc-tion.

Facial photographs made over a one-year period todemonstrate the progression of the burned commissureare provided. This paper reviews briefly the medicaltreatment and wound healing sequence associated withoral electrical burns.

Immediate TreatmentMost commissural electrical burns involve mucosa,

submucosa, muscle, nerve, and vascular tissue. The childshould be examined for other points of electrical currententrance or exit. If the offending wire or appliance wasin the oral cavity, burns of the tongue, palate, andalveolar ridges may be found.12 A thorough and completeexamination is absolutely necessary to determine theextent of the damage.

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Bleeding is not a common finding because of cauteri-zation of the blood vessels. Occasionally damage to thelabial or lingual artery will cause massive bleeding.3’ 7.12This usually occurs three to four days after the burnwhen spontaneous loosening and sloughing of nonvitaltissue begins. Pre:ssure should be applied to the hemor-rhage site to stop the bleeding and the patient should be

taken to the nearest hospital emergency room for defin-itive care. This complication has prompted Gifford et al.to recommend hospitalization until the eschar sloughs.4

Antibiotic ointments have been recommended bysome authors for application to the burn area.1 Bacitracinis an acceptable topical agent because it is effectiveagainst many strains of streptococci and staphylococciand it has a low sensitizing tendency. Unlike bacitracin,topical application of penicillin in the mouth has pro-duced a variety of unfavorable local reactions and its usefor the local treatment of electric burns is contraindi-cated, la Systemic antibiotics are recommended by mostclinicians to prevent wound infection. ~’ s, 7, 14

The duration of antibiotic coverage depends on theseverity of the wound. Pitts et al. s recommend antibioticcoverage until necrotic tissues slough and edema sub-sides. This is typically between 14 and 28 days.~ Becausepostburn infectior.s often are caused by penicillin-resist-ant organisms such as staphylococci and nonhemolyticstreptococci, a perdcillinase resistant semisynthetic pen-icillin is the antibiotic of choice. Methicillin, oxacillin,nafcillin, cloxacilEn, dicloxacillin are examples. If sub-sequent wound infection occurs, culture and sensitivitytests should be performed and the appropriate antibioticadministered.la. 1~

Tetanus immunization should be performed for chil-dren not previously immunized, or who have not had abooster within the last five years.~2’ 14

Pain is not a serious complication. Most individualsexperience little or no pain after the initial burn.a’ v, 1~, ~4Acetaminophen may be used to ease discomfort if nec-

essary.Parents are usually upset and tend to blame them-

selves for the accident. Before and after treatment pho-tographs of other similar cases and reassurance by the

doctor help to ease tension and promote cooperation.

Wound Healing SequenceThe healing process of most oral electrical burns

involves three phases.1. The wound will appear charred and coagulated for

the initial 10 days with prominent swelling for seven to10 days.a’s Drooling often is present due to a lack ofmuscle and nerve l~unction.

2. Sloughing us~aally begins with initial loosening ofnonvital tissue at three to four days and becomes notice-able in 10-14 day.,;. It generally is complete by two tothree weeks,a’ ~

3. The process of wound healing usually is completed

four to six weeks after the electrical burn. In the absenceof an oral splint appliance, lip adhesions, scarring, andsevere contraction of the commissure usually can beexpected. Healing without a splint often will result infacial disfigurement. The resulting microstomia will limitthe extent of oral opening, hinder oral hygiene efforts,and compromise the ability to eat and speak normally.Many of these children have required multiple plasticsurgical revisions to correct microstomia.

Appliance TreatmentBoth removable and fixed appliances have been de-

scribed,a. ~o. 1~ and have the advantages and disadvan-tages of any fixed or removable appliance. Both typesare similar in that they have posts which pass throughand maintain the commissure of the lips during and afterthe healing process. Post position is critical to the successof these appliances. 8 The removable appliance has anadditional advantage in that a wax-up and fitting of theposts is accomplished easily prior to final insertion ofthe appliance. The objective of appliance therapy is toprevent or minimize lip adhesions and contracture dur-

ing healing and to minimize contracture following heal-ing.

Lip contracture may occur for many months after thewound healing process is complete and often is evi-denced soon after the appliance is left out of the mouth.For this reason, when possible, the appliance should beworn 24 hours a day for the first six months and theneight to 12 hours per day, usually at night, for the nextsix months,a’~’~°’ 11 Child and parent cooperation are

critical factors in the success,a

Case ReportA 22-month-old white male was referred to the De-

partment of Pedodontics, Medical College of Georgiaone day after an electrical burn to the oral cavity. Thechild had been seen initially in the emergency room atUniversity Hospital. The child was well nourished, welldeveloped and in no acute distress when he came to thedental clinic. Both parents were present at the initial visitand a history of the accident revealed the child had beensucking on an electrical junction at the time of the injury.The child’s past medical and dental history was noncon-tributory.

The clinical examination revealed edema and swellingof the right commissure area of the face (Figure 1). Otherareas of electrical current entrance or exit were notfound. The teeth were not damaged and were in normalocclusion. The primary second molars had not yeterupted.

Pain and bleeding at the injury site were not elicitedor observed, probably due to cauterization of the bloodvessels and nerves. The child had been given an IMinjection of a semisynthetic penicillinase-resistant peni-cillin (nafcillin 25 mg/kg) at the emergency room, and

334 ORAL ELECTiRICAL BURNS-TREATMENT: LeCompte and Goldman

Figure 1. Facial photographs one day after an oral electricalburn to a 22-month-old child.

Figure 2. Facial photographs two weeks after electrical burn.

Figure 3. Facial photographs one month after electrical burn.

was placed on nafcillin elixir, 5 ml (one teaspoon) everysix hours for 14 days (250 mg/5 ml). Tetanus immuni-zations were up-to-date.

The parents were reassured that a satisfactory resultcould be achieved with their help and cooperation. Thewound-healing process was explained to both parentsand the importance of closely monitoring their child forthe next few days for bleeding complications of thelingual or labial artery was stressed. Before and afterphotographs of similar cases were shown to the parentsto help promote reassurance and cooperation.

Alginate impressions were made at the initial visit.Vertical and lateral measurements of the unaffectedcommissure relative to the teeth and midline were made.8

The patient returned to the clinic the next day to try theappliance. The acrylic resin base was adjusted for uni-form occlusal contacts and the wax posts were adjustedfor the desired position and tension at the commissures.The appliance was delivered the next day after conver-sion of the wax posts to acrylic. The importance ofwearing the appliance 24 hours a day was stressed to theparents. Maintenance of the child's teeth and soft tissuesand care of the appliance were reviewed. Fluoride drops3

were prescribed with daily use of two to three drops todecrease caries susceptability. The appliance had posi-tive retention and at the one-week recall visit the parentsreported that the child wore the appliance constantlyand had no discomfort. However, drooling from theright commissure area was reported to have occurredwith regularity. They reported no other complications.

The child was then seen two weeks postburn (Figure2) and subsequently at one month postburn (Figure 3) atwhich time the parents reported no problem with thechild's acceptance of the appliance. He had been wearingthe appliance constantly except during meals and tooth-

* Thera-Flur, .5% F, Hoyt Laboratories, Norwood, MA.

Figure 4. Facial photographs one year after electrical burn.

brushing. From this point on, the child was seen andevaluated monthly. The only problem reported by theparents was occasional chapping of the right commissurearea, which was treated with petroleum jelly. At the six-month recall the parents reported that the child was tiredof the appliance and that occasionally during the sixthmonth, a day or two would pass when the child refusedto keep the appliance in his mouth. At this time it wasdecided to have the child wear the appliance only atnight. The eruption of the second primary molars re-quired relief of the acrylic which was performed at thistime and at each subsequent monthly recall. At the 12-month recall (Figure 4), appliance therapy was discontin-ued and no further treatment was deemed necessary.The child was referred for plastic surgery consultationand yearly follow-up. No corrective surgery is planned.

Appliance Fabrication and MaintenanceThe following is a step-by-step description of the

appliance fabrication and maintenance used and rec-ommended for similar cases.

1. Maxillary and mandibular alginate impressionsshould be made as soon as possible after the burn (twoto four days). Anesthesia is usually unnecessary due tothe relative absence of pain during this period. Anaccurate impression with full vestibular extension shouldbe obtained for the maxillary arch.

2. After pouring the maxillary and mandibularmodels an acrylic base is made on the maxillary modelusing an autopolymerizing acrylic resin. No blockout orrelief of tooth or tissue undercuts is done unless theyare severe. Acrylic resin should extend into the vestibularareas to aid in appliance retention and stability. Thepalate and maxillary tubercle areas also are covered.Clear orthodontic acrylic resin is desirable in order tosee erupted and newly erupting teeth.

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3. A small amount of sticky wax is applied to thelabial flange of the base adjacent to the labial surface ofthe primary canines. Red utility or pink baseplate waxthen is added to the acrylic base to form the posts orwings. Prior clinical measurements of the unaffectedcommissure relative to the midline will aid in properlocation of the posts.

4. The appliance is tried in the mouth. Relief of theinternal surface of the acrylic base is performed onlywhere necessary in order to obtain a snap-type retention.The occlusal portion of the splint should be adjusted toassure uniform bilateral occlusal contacts. The wax postsnow are adjusted to obtain the desired position, curva-ture, and tension at the lip commissures. Since electricalburns usually involve only one commissure, the nonburnside can be used to establish the ideal position of theposts. Once this position is established, the wax post onthe burned side is adjusted posteriorly 1-2 mm to com-pensate for the expected contracture during the laterhealing phase.

5. The maxillary model is placed on a flat surface.The wax-up and the exposed gypsum surfaces of thecasts are lubricated with separating medium. A labialstoneb matrix is formed after carefully brushing somestone around the wax posts. When the stone of thematrix is fully set, all the wax is removed and the moldis flushed with boiling or very hot water. The acrylicresin surface is roughened in the area of the posts toincrease the bond strength. A tinfoil substitute is appliedto all exposed gypsum surfaces of the mold and cast. Aheavy elastic band is applied around the cast and thematrix. A clear acrylic resin is sprinkled and flowed toassure a well rounded post contour. The assemblage isplaced into a pressure pot with warm water under 30 psifor 20 minutes to complete the cure.

6. Ideally, the completed appliance should be insertedinto the mouth as soon as possible or within one weekafter the initial burn (Figure 5). Recheck for uniformocclusal contact of all teeth. The appliance should behighly polished and retentive. If retention appears in-adequate, the use of a small amount of denture adhesivein the palate can aid retention, but will compromise oralhygiene. The commissure posts should be shaped witha gentle, rounded curvature passing around the commis-sures. The posts also should be smooth and highlypolished. Observe the shape of the lip commissure ashealing progresses (Figure 3). If the corner of the mouthis too large after some epithelization has occurred, thinthe post superiorly-inferiorly to allow a more normalshape to occur during healing.

Since the appliance will be used over a period of aboutone year, proper cleaning of the teeth and applianceshould be demonstrated to the child and parents. Fluo-ride gel placed in the appliance daily should decreasecaries susceptability. Plan for the future eruption ofh Mounting Stone, Whip-Mix Corporation, Louisville, KY.

primary teeth by making the acrylic resin coveragethicker over the areas of expected eruption. As eruptionoccurs, reduce the internal surface of the appliance overthe teeth to extend the useful life of the prosthesis.

DiscussionThe 12-month photographs (Figure 4), reveal that the

right commissure appears somewhat constricted whencompared to the left. However, when comparing Figure4 to Figure 1, treatment looks successful. Indeed, thiscase was successful and a great deal of credit for thesuccess must be given to patient and parent for theircooperation. If patient cooperation had been minimal, afixed appliance, removable appliance ligated to severalof the erupted teeth, or an extraoral appliance as de-scribed by Richardson and Kittle11 might be used. Ifparental cooperation had been minimal, one could likelypredict an unfavorable result. Although the esthetic re-sult of the case was not perfect, it was successful sincethe child may avoid extensive reconstructive surgery.With no appliance therapy this child would be disfiguredand be subject to multiple extensive surgical proceduresto improve the disfigurement.

The appliance therapy used in this case was acceptableto the child in spite of his young age and the fact that hehad no primary second molars. The dentist also shouldanticipate a decline in patient and parental interest overtime. Motivation was aided by placing the patient on aregular monthly recall schedule. Photographs or slidesmade at the time of the burn and at follow-up visits werehelpful in motivating and reinforcing continued parentalcooperation. The parents were unaware of the extent ofthe initial burn and the marked gains made in maintain-ing the commissure until they viewed photographs a fewmonths later. The emphasis on prevention of caries withhygiene and fluoride therapy aids followup. This em-phasis serves to educate the parent and to prepare thevery young patient for future dental treatment.

Figure 5. Completed appliance and delivery.

There are several advantages of the removal appliancedescribed in this report.1. The ease of fabrication and conventional laboratory

technic enables the dentist to insert the splint withina minimal time period following the burn (one tothree days). The technic does not require adaptationof bands or the cementation of the appliance.

2. The use of the wax posts at the try-in appointmentpermits accurate location and adjustment of the ten-

336 ORAL ELECTRICAL BURNS-TREATMENT: LeCompte and Goldman

sion necessary to optimally splint the lip commis-sures.

3. The removable prosthesis allows adjustments andevaluations to be made easily, without having toremove and recement bands.

4. The removable prosthesis can serve as a carrier forfluoride gel, thus minimizing the risks of developingcarious lesions.

Dr. LeCompte is assistant professor, Department of Pediatric Den-tistry, School of Dentistry, Medical College of Virginia, Richmond,VA 23298. Dr. Goldman is associate professor, Department ofProsthodontics, Medical College of Georgia. Requests for reprintsshould be sent to Dr. LeCompte.

1. Horton, C. E., Crawford, H. H., Adamson, J. E., and Brown, L. H.Electrical burns of the mouth. Va Med Monthly 95:213-217, 1968.

2. Crikelair, G. F. and Dhalowal, A. S. The cause and prevention ofelectrical burns of the mouth of children. Plast Reconstr Surg58:206-209, 1976.

3. Wood, R. E., Quinn, R. M., and Forgey, J. E. Treating electricalburns of the mouth of children. JADA 97:206-208, 1978.

4. Gifford, G. H., Marty, A. T., and MacCollum, D. W. The manage-ment of electrical mouth burns in children. Pediatrics 47:113-119,1971.

5. Pitts, W., Pickrell, K., Quinn, G., and Massengill, R. Electricalburns of the lips and mouths in infants and children. Plast ReconstrSurg 44:471-479, 1969.

6. Muir, 1. F. K. The treatment of electrical burns. Br J Plast Surg10:292, 1958.

7. Thomson, H. G., Juckes, A. W., and Farmer, A. W. Electrical burnsto the mouth in children. Plast Reconstr Surg 35:466-467, 1965.

Florence, Italy, 1974 Dr. Theodore P. Croll

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