TOPICS OF INTEREST

Oral Electrical Burns: Etiolo

Histopathology, and Prostho ontic
Treatment

7r

Michael L. Linebaugh, DDS,MS)* and Sreeniuas Koka, ODs,MS?

Oral electrical burns occur predominantly in young children and may lead to permanent
disfigurement. The etiology and histopathology of oral electrical burns are discussed.Prosthodontic
treatment options are presented to provide clinical guidelines for the practitioner.
J Prosthod 2: 136-141. Copyright D 1993 by the American College of Prosthodontists.

INDEX WORDS: oral burns, commissure burns, burn appliances

RAL EIECINCAL BURNS affect predomi-

nantly young children and can cause disfiguring and functionally compromising injury. The following review of the literature focuses on the etiology
arid histopatholoLgy of oral electrical burns, and
further classifies and describes prosthodontic trratment options for the treatment of oral electrical
burns.

Etiology
Electrical burns from low-voltage sources are the
leading cause of burn injury in children and may lead
to injury of the mouth arid lips. Most injuries of this
type occur in the I - to 2-year age group, and the
healing process often results in the formation of an
unsightly
The most frequent site of involvement is controversial. Fogh-Andersen et aI6reported
that the lower lip was most often involved. In contrast, Thomson et a1 suggested that the incidence of
lower lip involvement is similar to the incidence of
upper lip involvement. Most investigators agree that
the comniissure is involved in almost half of all
oral/perioral electrical burn cases. The literature
also offers conflicting opinion of the sex incidence of
oral clectrical burns. Males appear to be affected
more than females by a ratio of 2 to 1 in most

*Associate Chninnizvi, Department

OJ .i4axillofaarial A-osthodonticj>

Sink Hospiial, Detroit, MI.

filrridnnt Prnjesrm, Dejurtment $Ad& Restorative DentzstT, College
$Dentirb, Unioersi[>ofNebraska Medical Center,Lincoln, NE.
Addres.7 reprint requests to Sreeniuas Koka. DDS,MS, Dvpartment of
Adult Rejtorntiiw Dmtisty, Cot& of DentGty, lTni7,wrig of :Vebraska
Medical Center, 40th and Holdredge, Lincoln, XE 68583-0740.
Copyrizht 0144.1/y the American Collqe ofProsihodontzjls

I O59-941XI 931O20?-0011~5.00/0

studies:-* however, some report an equal ratio between

The prevalent causes of oral burn injury in young
children are sucking or chewing the live end of an
extension cord or chewing through insulation of a
live wire.lD-*Sucking on an electrical outlet is a
relatively infrequent cause of electrical burns. It has
been suggested that most accidents occur when
children gnaw at junctions of extension cords. Under
these circumstances, saliva likely reaches the metal
junction and acts as a conductor.13
The nature of oral electrical burns normally falls
into one of two categories. The more common type of
burn, the arc burn, occurs when an arc is formed
betwecn two wires of opposite polarity and passes
external to the body surface. A childs cytoplasm,
with its concentration of electrolytes, provides a
bridge between the opposite-polarity electrodes with
resultant heat in excess of 3000F. The heat causes
gross tissue destruction in an area confined to the
mouth and may include deep muscle destruction.
Factors that have been reported tu cuntrol the
degree of tissue damage include voltage, current
(amperage),type ofcurrent, duration of current, and
resistance ofthe tissue to current
In general,
the higher the vo1tage,l6 the <greaterthe current,the
longer the duration, and the lowcr the resistance,
then the greater will bc the tissue destruction. In
addition, an altcrnating current at low voltage is
potentially niure destructive than direct current.
A contact burn is usually caused by current as it
enters the mouth, passes through the body, and exits
through a ground source. Contact burns occur inrrequently compared with the incidence of arc burns.
However, contact burns have been reported to cause
cardiac anomalies. A 5% incidence of cardiac arrest

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June 1993, Volume 2, i2urnbm 2

and/or respiratory arrest associated with cases o f

electrical burns ofthe oral cavity has been reported
by Oeconomopoulos.s

Histopathology
A typical electrical burn lesion initially appears as a
light grey, centrally-depressed, well-defined core surrounded by a slightly elevated erythematous border.2
Upon histological analysis, the central core shows
areas of coagulated protein, fat liquefaction, and
collagen necrosis. The erythematous border shows
evidence of hyperemia as it gradually blends into
adjacent unaffected tissue. Because of sensory nerve
damage, electrical burn lesions are often painless
upon palpation.
After approximately 6 hours, the lesion loses its
well-demarcated appearance as swelling in the surrounding tissue causes disfigurement and the wound
margins extend and take on an irregular appearance.@Labial incompetence, and consequently drooling, are frequent manifestations of a swollen commissure. Swelling diminishes over the subsequent 2
weeks, at which point nonviable, devital tissue sloughs
OKThis process is sometimes complicated by labial
artery bleeding that delays complete healing.I9N7right
et all3 have recommended ligation of the offending
blood vessel to control hemorrhage. Hcaling by
secondary intention follows. Although some parenchymal regeneration may occur at the margins of the
defect,within the wound itself all architectural framework is lost, and so most of the repair occurs by
connective tissue scarring. The base and margins of
the wound are first layered with granulation tissue.
Fibroblastic proliferation and capillary budding begin while the acute and sometimes chronic inflammatory reaction is still active in the center of the wound.
As leukocytes remove exudate and debris, the wound
granulates in from its margins. Concurrently, the
epithelial margins migrate and proliferate, but only
to the extent permitted by the underlying granulation tissue. In defects as large as those caused by
electrical burns of the oral and perioral regions,
wound contraction yields disfigurement. The mechanism of wound contraction is still uncertain but
appears to involve the contraction of fibroblasts
within the granulation tissue. Such a shortening by
these multipotential cclls leads to a reduction in the
defect size that needs to be filled by granulation
tissue. Wound contraction may cause scarring and
consequently significant disfigurement. In addition,
wound contraction may lead to microstomia, which

apart from the obvious esthetic problems, affects the

patients ability to eat and drink. The prevention of
such disfigurement and microstomia are the two
most important objectives of burn appliance therapy.

Treatment
The literature separates the treatment of oral electrical burns into two phases, immediate and definitive.
The immediate treatment phase focuses on the
initial hospitalization protocol of the oral electrical
burn patient. Hospitalization is recommended in
order to perform an electrocardiogram, hematologic
evaluation, electrolyte determination, urinalyisis, and
coagulation profile. If warranted, an electroencephalographic examination may also be performed.21
Systemic antibiotic therapy does not appear to have
any predictable therapeutic benefit. Continued hospitalization is warranted in order to observe for any
systemic sequelac, particularly shock, late hemorrhage, cardiovascular irregularities, and respiratory
arrest. Specific attention to the burn site itselffollows
the evaluation of systemic considerations. The literature cites different methods of wound cleansing and
treatment. Hirschfeld et a12 propose gentle cleansing with lukewarm water and mild surgical soap,
followed by irrigation with peroxide and saline. Left
open to air, a clot will form and eventually an eschar.
The authors suggest topical antibiotic treatment
during eschar development, as well as after eschar
sloughing. Nichter et aP2 and Edlich et a123recommend that the wound site be first cleansed with a
topical iodine preparation and then treated with a
petroleum-based topical antibiotic four times a day.
Nichter et a1 and Edlich et a1 also suggest the use of
arm splints to prevent a child from playing with the
burn site. Both groups of investigators agree on the
need for adequate nutrition. In order to prevent
injury to the healing wound during feeding, a cathcter syringe, and in some instances a nasogastric tube,
may be necessary.
Definitive treatment of the oral electrical burn
patient continues to be a controversial topic. The
literature offers variations of four different treatment options. (1) Immediate excision, as recommended by H ~ ~ s l owithin
p , ~ ~ 12 hours after injury to
shorten the period of wound repair and necessitate
minimum reconstructive procedures. (2) Delayed
primary reconstruction, approximately 2 to 3 weeks
after injury, in order to better evaluate the extent of
the burn site and the extent of tissue n e c r o s i ~ . ~(3)
~-2~
Delayed reconstruction following complete healing

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Oral Electrical Bum

of the wound. In the past, oral and pcrioral burn

patients ~7ereallowed to heal by secondary intention
for as long as 9 to I2 months, and thus they suffered
from microstomia deformity.]((4) Immediate postinjury splinting by means of a burn appliance to
preserve oral symmetry, followed by surgical reconstructive measures if necessary. The latter of these
options is currently viewed as the most beneficial.
The use of the oral burn appliance is increasingly
touted as the most conservative of the protocols as
well as one that yields excellent long-term results.
The remainder of this review focuses on various
burn appliance designs and highlights advantges and
disadvantages where clinically relevant. For an overview of surgical techniques, readers are referred to
Edlich et aLZ3

Oral Burn Appliances

A burn appliance must meet certain criteria in order
to achieve clinical success.Josell et a128proposed that
the ideal burn appliance would meet the following
requirements: (1) Simple, nontraumatic, and inexpensive to fabricate; (2) Easily inserted and removed
with minimal discomfort to patient; (3) Welltolerated by patient, comfortable to wear, and compatible with appliance-bearing tissue; (4) Retentive
and well-adapted at the site of injury. To this list we
would like to add that the appliance must be: (5)
Simple and inexpensive to modify or adjust; and (6)
As esthetically pleasing as possible.
In addition, we ~7ouldlike to modify statement (2)
to read Easily inserted with minimal discomfort to
patient. Josell et al suggested that ease of removal
be provided for a burn appliance. In our opinion, an
easily removable burn appliance facilitates removal
of the appliance by the noncompliant patient or the
uncooperative parent. Ease of removal should therefore not be considered a requirement of the ideal
burn appliance.
At present, one design that adequately meets all
of these requirement is not available.
There are three major categories of burn appliances: Appliances retained by extraoral means, intraoral removable appliances, and intraoral fixed appliances. The patients in these groups can be further
subdivided into two groups according to age: Under 6
years, and 6 years or older. This organizational
scheme aids in the choice of burn appliance design
based upon the patients expected compliance and
the parents cooperation. The youngest patients,

Linebaugh and Koka

under 6 years, are best treated with a fixed appliance

attached to teeth, which eliminates the problems of
cooperation and compliance. Patients 6 years or
older may be successfully treated with a removable
appliance, because patient compliance may be easier
to obtain.
The literature offers the reader numerous facial
burn appliance designs, with the prevention of scar
contracture and the prevention of microstomia as
their main objectives. This is generally accomplished
through the application of both vertical and horiLontal pressure on the wound site.

Extraoral Burn Appliances

The simplest of extraoral burn appliance designs,
proposed by Cheuk and Kirkland,29 uses plastic
mouth retractors and a 12-inch piece of tubing that
acts as an elastic tourniquet. The tubing is attached
to the ends of the retractors and is worn below the
ears across the back of the neck. Tension can be
adjusted by shortening the tourniquet or by tying
knots in it. A more sophisticated appliance has been
described by Denton and S h a d n and involves the
fabrication of a silicone rubber mold from a wax
pattern cuslorriized at chairside. After wax elimination from the mold, clear acrylic resin is cured under
pressure to form the mouth conformer. A rigid
wire is processed into a channel prepared in the resin,
and the protruding end is bent for attachment of a
headgear strap. The conformers are placed at the
commissure and attached to the headgear strap and
the splint w-orn continuously, sometimes for up to 12
months, depending on the results of monthly evaluation. This form of appliance therapy is intended to
provide active resistance to contractile forces, to
permit movement and function of the injured area
with intermittent traction, and to avoid constant
force that could cause pressure necrosis. The use of
this particular design was further supported in a
study of 20 patients by Reisberg et al,l who combined treatment of this form of extraoral burn
appliance with pressure garments to treat severe
burns of the face.
A fully-adjustable extra-oral appliance . . . to
limit contracture and prevent microstomia was
proposed by Joscll et a1.28The device is supported
occipitally by directional-force headgear attached to
orthodontic wire adapted to each commissure by
means of elastic headgear straps. The orthodontic
wire is normally covered by rubber tubing to prevent

June 1993. Volume 2, Number 2

139

Figure 1. Extraoral removable burn appliance.

Figure 4. Intraoral removable appliance from Figure 3.

Figure 2. Extraoral removable appliance from Figure 1.

Patient is also wearing burn garments.

Figure 5. Intraoral fixed burn appliance.

Figure 3. Intraoral removable burn appliance.

injury to the patient. An example of an extraoral
burn appliance is presented in Figures 1 and 2.

Intraoral Removable Burn

Appliances
Hartford et a P first described an intraoral splinting
device in 1975 intended to encourage stretching of
scar tissue around the mouth. The design was modified by Colcleugh et aP3and Ryan34for conservative

management of oral electrical burns. The typical

intraoral burn appliance is of the double-post variety.
Under general anesthesia, maxillary and mandibular
alginate impressions are secured. On stone models
an appliance is fabricated that covers the palate, the
maxillary dentition, and extends upward to the
vestibule. Adams clasps can be added to increase
retention. Two ovoid acrylic posts extending from
the mouth and flared laterally are added to the
appliance. The posts maintain the commissural region equidistant to the midline in as normal a
relationship as possible until the time for scar contracture has passed, often 8 to 12 months. Many modifications of this original design have been reported in
the literature.'g,35-3G
The use of dynamic lip expanders has also been reported for the treatment of
commissure burnsG3'The advantage of this form of
appliance over the previously described static appliance is the maintenance of progressive controlled
tension on contracting scars. An example of an

140

Ornl Electrical Bum

intraoral removable appliance is presented in Figures 3 and 4.

Intraoral Fixed Burn Appliances

The literature currently offers only two intraoral
fixed burn appliance designs. Wright et all3proposed
the following technique for the fabrication of a fixed
burn appliance. Stainless stcel bands are fitted to the
primary maxillary second molars and central incisors, and an alginate impression secured of the
maxillary arch. Once the impression has been poured
in dental stone, the appliance, consisting or a stainless steel labial arch wire supporting two acrylic
posts, is constructed.
Silverglade38-39
has presented both a direct and an
inchrect technique of fixed appliance fabrication. The
direct technique follows the same protocol as (he
method suggested by Wright et al. The indirect
technique involves the initial placement of stainless
steel crowns on a model poured in die stone, as
opposed to intraoral stainless steel crown placement.
Interproximal and gingival stone often needs to be
removed for the placement of stainless steel c r o w s
If interproximal diastemata are present between the
maxillary incisors, tooth preparation becomes unnecessary. Two measurements are made to locate the
position of the supporting posts. The horizontal
position is best recorded by measuring the distance
froin the midline to the u n a k t e d commissurc. (In
the unlikely instance of both commissures being
burned, Silverglade recoininends the horizontal position be placed at the distal embrasures of the
maxillary canines.) The vertical position is determined by measuring the distance from the incisal
edge of the maxillary central incisors to an imaginary
line drawn from commissure to commissure. The
position of the acrylic posts on both burned and
unburned sides can be established from the horizontal and vertical measurements. An 0.032-inch wire is
formed into helical loops to retain the cold-cure
acrylic posts. Silverglade recommends cylindricalposts
with a diameter of approximately 8 mm to 12 mm,
and a length of 2 cm to 3 cm. The final appliance is
cemented to place with polycarboxylate cement.
Ideally both anterior and posterior teeth are present.
However, if primary molars arc not present, the
appliance can still function successfully if the four
maxillary incisors have erupted with sufficient clinical crown height. An example of a fixed intraoral
appliance is presented in Figurc 5.
Longitudinal data on the effectivenessofintraoral

Linebaugh and Koka

fixed burn appliances has been presented by Silverglade."9 In a study of 48 patients treated with an
intraoral fixed burn appliances, with treatment completed from 1 to 4 years, none required surgery as
determined by the investigator and by plastic surgeons. The minimum time allowed for softening of
the scar was 6 months, with a maximum of 12
months. However, accurate prediction of the length
of treatment based upon the initial extent of injury
was impossible.

Discussion
Oral electrical burns can cause disfiguring injury and
functional compromise for young children. The goals
of burn appliance therapy concentrate on the prevention of scar contracture and the prevention of microstomia. The most difficult aspect to prosthodontic
treatment relates to the expected levels of patient
compliance and parent cooperation. Children under
the age of 6 years present the greatest challenge in
terms or compliance, and for such patients a fixed
intraoral appliance is recommended whenever possible. An absence of teeth precludes the use of such a
device and leaves the practitioner with an extraoral
removable appliance as the only treatment option.
For patients older than 6 years, an intraoral removable appliance may be considered if excellent patient
compliance and parent cooperation is anticipated.

References
1. Thorrison HG,.Juckes W'W, Farmer AIq Electrical burns to
the mouth in children. Plast Reconstr Surg 1965;35:466-477
2. Ackerman AJ3, Goldfaden GL: Electrical burns of the mouth
in children.Arch Dermatol 1971;104:308-311

3. Neeclleman HL, Berkowitz RJ: Electrical trauma to the oral

tissues ofchildren.,J Dent Child 1971;41:19-22
4. Giffbrd GH)ILlarty AT, MacCollum DLV The management of
electrical mouth burns in chiltlren. Pediatrics 1971;47:113-119
5. Gromley MB, Marshall .J, .Jarrett W: Thermal trauma: A
revkvof22 electrical burns ofthr 1ip.J Oral Surg 1972;30:531553
6. Fogh-Anderson P, Sorensrn B: Electric mouth burns in children-treatment and prevention. Acta Chir Scand 1966;131:
211-218
7. Oeconomopoulos CT: Electrical burns in infancy and early
childtrood. A review of the current literature. A m ~ Dis
J Child
I962;103:6i-70
8. Skoog T Thr surgical trratment of burns. Acta Chir Scand
1963;305:I I
9. Leake JE; Curtin Jiq Electrical burns of the mouth in
children. ClinPlast Surg 1981;11:669-653
10. Pitts W, Pickrell K, Quinn G, et al: Electrical burns of lip and
mouth in infants and children. Plast Reconstr Surg 1969;M:
47 1-179

June 199.7, Volume 2,Number 2

I I . Swmin FR,IinkhaniJR: Treatment of lip commissurc burns

with a commissural stabilizing splint. Quintessence Int 1983;8:
789-798
12. Young TI,, Rcisinger KS: Wall socket electrical burns: Relevance to health tducation. Pediatrics 1980$5:825-%27
13. Wright GZ, Colceugh KG, Davidgc LK: Electrical burns to the
commissurc ofthc 1ips.J Dcnt Child 1977;44:377-381
14. Sturim HS: The treatment of clcctrical in,jurics. .J Trauma
197 I; I 1:959-961
1.5. Balclridgc R R Elcctrical burn-rcport of a case. N Engl ,J
Met1 1954;250:46-49
16. Heimbach DM, Engrav I,H, Marvin~j:Minor burns: Guidclincs for successful outpatient management. lostgrad Mctl
1981;69:22-24
17. Esscs SI, Peters WJ: Elcctrical burns: Ionnophysiology and
complications. C2in.J Surg 1981;24:1 1-13
18. Salman RA, Glickman 1 6 , Super S: Splint therapy for clcctrical burns 0 1 thc oral commissurc in children. J Dcnt Child
1987;54 161-164
19. Cain ,J$ Grcaslry JW: Prosthetic managrment of electrical
burns t o the oral commissurc. Quintessence Dent Techno1

20. Robbins SI, Angcll M, Kumar V Basic IatholoLgy (cd 3).

Saundcrs, Philadelphia, PA, 198 1
2 I . Hirschfeld JJ, Assacl LA: Conservative managcmcnt of clcctric burns to the lips of children. ,J Oral Maxillofac Surg
1981;42:197-202
22. Nirhtrr LS, Morgan IU, Bryant CA, ct a):Electric burns of the
oral cavity. Compr Thcr 1985;11:65-7I
23. Edlich RF, Nichter LS, Morgan RF, et al: Burns of the hcad
and ncck. Otolaryngeal Clinics ofNorth America. 1984;17:361388
24. I l y ~ l o pVB: Treatment of electrical burns to the lips. Plast
Rcconstr Surg 1957;20:315-317

25. Ortiz-Monastcrio F, Factor I<: Early dclinitivc treatment of

141

electrical burnsofthe mouth. Plast Reconstr Surg 1980;65:169-

176
26. Flcury AF: Electrical burns of the lips: A modilird plan of
treatment. Am Surg 1959;25:328-331
27. Orgel MG, Brown HC, Woolhouse IM: Electric burns of tht:
mouth in children: A method for assrssing rcsults.,J Trauma
1975;15:285-289
28. Joscll SD, Owen D, Kreutzer LW, ct al: Extraoral managcmcnt for clcctrical burns of the moulh. J Dent Child 1984;51:
47-52
29. Chcuk SI,, Kirkland,JL Splint for burns to lip conimissurcs.,J
Prosthct Dcnt 1984;52:563
30. Denton BG, Shaw SE: Mouth conformer for prevention and
correction of burn scar contracturc. Phys Thcr 1976;56:683686
31. Rcisbcrg DJ, Fine L, l a t t o r e L, ct al: Elcctrical burns of the
oral commissure.,J Prosthct Dcnt 1983;49:71-76
32. Hartford CD, Kcaley GP, Lavelle WE, et al: An appliance to
prevent and treat microstomia from burns. J Tra uma 1975;15:
356-360
3 3 . Colcleugh RG, Ryan ,JE: Splinting dcctrical burn5 of the
mouth in chilclren. Plast Reconstr Surg I976;58:239-241
34. RyanJE: Prosthetic trratmcnt for electrical burns of thc oral
cavity.J Prosthct Dent 1979;42:431-436
35. Gorham J A A mouth splint for burn microstomia. Arn ,J
Occup Ther 1977;31: 105-106
36. Fowlcr D, Pcgg SP: Modified microstoinia prcvcntion splint.
Burns 1986;12:37 1-373
37. Jackson MJ: The use ofdynamic-lip-expander in the rchabilitation of severely burned face: Report of case. ,J Dent Child

1979;46:230-233
38. Silvergladr D, Rubcrg RL: Nonsurgical management of burns
to t he lips and commiswres. Clin Plast Surg 1986;13:87-92
39. Silvcrgladc D: Splinting electrical burns utilizing a fixed splint
technique: A report of 48 cases.J Dcnt Child 1983;50:455-458