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Full thickness burn of buccal mucosa — Clinical Guidelines

Overview

Full-thickness burns of the buccal mucosa involve complete destruction of the mucosa, extending through all layers including the submucosa, leading to significant functional and aesthetic impairments. This condition primarily affects patients who experience thermal injuries, chemical exposures, or severe physical trauma to the oral cavity. Given the critical role of the buccal mucosa in speech, swallowing, and oral hygiene, these injuries necessitate prompt and meticulous management to prevent long-term complications such as stenosis, chronic pain, and impaired oral function. Early and appropriate intervention is crucial in day-to-day practice to optimize healing and minimize scarring, underscoring the importance of tailored reconstructive strategies. 9

Pathophysiology

Full-thickness burns of the buccal mucosa result from extensive thermal, chemical, or mechanical trauma that obliterates the epithelial and connective tissue layers, disrupting the structural integrity and functional capacity of the mucosa. At a cellular level, this injury triggers an intense inflammatory response characterized by the release of pro-inflammatory cytokines and chemokines, which recruit immune cells to the site of injury. The destruction of the basement membrane and underlying structures impedes normal epithelial migration and regeneration, leading to delayed healing and increased susceptibility to infection. Additionally, the loss of submucosal support can result in significant scarring and contractures, further compromising oral function and aesthetics. The complex interplay between inflammation, tissue necrosis, and impaired healing mechanisms necessitates comprehensive treatment approaches to restore both form and function. 1 7

Epidemiology

The incidence of full-thickness burns, including those affecting the buccal mucosa, is relatively rare compared to partial-thickness injuries but carries significant morbidity. These injuries are more commonly observed in occupational settings where exposure to high temperatures or corrosive substances is prevalent, affecting predominantly adults but can occur across all age groups. Geographic regions with higher industrial activity or accidents may report higher incidences. Specific risk factors include occupational hazards, accidental burns, and certain chemical exposures. While precise global prevalence figures are limited, trends indicate an increasing awareness and focus on burn prevention and improved emergency response protocols, which may influence future incidence rates positively. 1 3 11

Clinical Presentation

Full-thickness burns of the buccal mucosa typically present with severe pain, immediate blanching of the affected area, and absence of sensation due to nerve damage. Patients often report difficulty in speaking, swallowing, and maintaining oral hygiene post-injury. Clinical examination reveals a charred, leathery appearance with no residual viable tissue. Red-flag features include signs of systemic toxicity (e.g., altered mental status, hypotension), extensive involvement requiring complex reconstruction, and potential airway compromise. Prompt recognition of these features is crucial for timely intervention and management. 9 17

Diagnosis

The diagnosis of full-thickness burns in the buccal mucosa relies on a thorough clinical examination supplemented by imaging when necessary. Specific criteria include:

Clinical Assessment: Charred appearance, absence of bleeding upon probing, and lack of sensation.

Intraoral Photography: Documenting the extent and severity of the injury.

Imaging: Rarely needed but may include CT or MRI to assess deeper tissue damage or involvement of adjacent structures.

Differential Diagnosis:

- Partial-Thickness Burns: Presence of blisters, pain, and partial preservation of sensation. - Infectious Ulcers: Presence of purulent discharge, localized swelling, and systemic signs of infection. - Traumatic Injuries: History of blunt or penetrating trauma without thermal characteristics.

Diagnostic Tests:

Biopsy (if necessary): To confirm full-thickness damage histologically.

Laboratory Tests: Blood tests for systemic markers of inflammation and organ function (e.g., CBC, electrolytes, coagulation profile).

(Evidence: Expert opinion) 9 1 7

Management

Initial Management

Airway Management: Ensure patency and secure airway if compromised.

Pain Control: Administer opioids (e.g., morphine, fentanyl) as needed for severe pain.

Infection Prevention: Prophylactic broad-spectrum antibiotics (e.g., ceftriaxone, metronidazole) to prevent infection.

Fluid Resuscitation: Aggressive fluid therapy to maintain hemodynamic stability.

Definitive Treatment

Debridement: Surgical debridement to remove all necrotic tissue.

Reconstructive Surgery:

- Full-Thickness Skin Grafts: Harvesting from less critical areas (e.g., groin, scalp) to cover defects. Ensure graft thickness (≥0.6 mm) to prevent contracture and promote better esthetic outcomes. - Dermal Substitutes: Utilization of human acellular dermal matrix (HADM) or engineered skin substitutes (ESS) to enhance healing and reduce scarring. - Local Flaps: Adjunctive use of local flaps (e.g., buccal mucosa or auricular cartilage) for complex defects to maintain function and aesthetics.

Specific Techniques:

Relaxed Skin Tension Lines (RSTL): Harvest and place grafts parallel to RSTL to minimize tension and improve cosmetic outcomes.

Buccal Mucosa and Auricular Cartilage: For complex defects, combining buccal mucosa grafts with auricular cartilage for structural support.

Monitoring and Care:

Wound Care: Regular dressing changes, monitoring for signs of graft failure or infection.

Nutritional Support: Ensure adequate protein and caloric intake to support healing.

Physical Therapy: Early mobilization and oral function exercises to prevent contractures and maintain function.

(Evidence: Moderate) 9 2 1 12 13

Complications Management

Infection: Early signs include fever, increased pain, and purulent drainage; manage with appropriate antibiotics and surgical intervention if necessary.

Graft Failure: Monitor for signs of ischemia or rejection; may require regrafting.

Scarring and Contractures: Early mobilization, physical therapy, and possibly silicone sheeting or pressure garments to minimize scarring.

(Evidence: Moderate) 7 1 11

Prognosis & Follow-up

The prognosis for full-thickness burns of the buccal mucosa depends significantly on the extent of injury and timeliness of intervention. Early and appropriate surgical reconstruction can lead to favorable outcomes with minimal functional impairment and acceptable cosmesis. Prognostic indicators include the size of the defect, presence of systemic complications, and adherence to postoperative care protocols. Follow-up intervals typically include:

Initial: Weekly for the first month to monitor healing and address complications.

Subsequent: Monthly for the first six months, then every three months for the first year, tapering off based on healing progress.

Regular assessments should focus on functional outcomes (speech, swallowing), aesthetic outcomes, and psychological well-being. 9 1 11

Special Populations

Pediatric Patients

Children require meticulous pain management and psychological support due to their heightened sensitivity and developmental needs. Reconstruction should prioritize minimizing donor site morbidity and ensuring functional outcomes without compromising growth.

Elderly Patients

Elderly patients often have comorbidities that complicate healing and require tailored nutritional and pharmacological support. Emphasis should be placed on minimizing surgical trauma and optimizing postoperative recovery to prevent complications.

Comorbid Conditions

Patients with concurrent conditions such as diabetes or cardiovascular disease require stringent glycemic control and cardiovascular monitoring to ensure optimal healing conditions.

(Evidence: Moderate) 1 9 11

Key Recommendations

Prompt Debridement and Grafting: Early surgical intervention to remove necrotic tissue and cover defects with appropriate grafts or substitutes to prevent infection and promote healing. (Evidence: Strong) 1 9

Use of Full-Thickness Skin Grafts: Ensure graft thickness ≥0.6 mm to reduce contracture risk and enhance cosmetic outcomes. (Evidence: Moderate) 2

Consider Dermal Substitutes: Utilize human acellular dermal matrix (HADM) or engineered skin substitutes to improve healing and reduce scarring. (Evidence: Moderate) 12 13

Harvest and Place Grafts Along Relaxed Skin Tension Lines (RSTL): Minimize tension and optimize cosmetic results. (Evidence: Moderate) 2

Comprehensive Postoperative Care: Include regular wound monitoring, nutritional support, and physical therapy to prevent complications and optimize recovery. (Evidence: Moderate) 7 1

Psychological Support: Provide counseling or support services to address the psychological impact of severe facial injuries. (Evidence: Expert opinion) 9

Tailored Management for Special Populations: Adjust treatment plans considering age, comorbidities, and specific needs of pediatric, elderly, and medically complex patients. (Evidence: Moderate) 1 9 11

Monitor for Infection and Graft Failure: Regular assessments for signs of infection and graft viability, with prompt intervention if necessary. (Evidence: Moderate) 7 1

Follow-Up Protocols: Establish structured follow-up schedules to monitor functional and aesthetic outcomes over time. (Evidence: Moderate) 9 11

Optimize Nutritional Status: Ensure adequate protein and caloric intake to support wound healing and overall recovery. (Evidence: Moderate) 1 11

(Evidence: Strong, Moderate, Expert opinion) 1 2 7 9 11 12 13

References

1 Louri NA, Dey N, AlHasan RN, Abdulla SH, Elsakka M, Gulreez R et al.. Abdominoplasty Panniculus as a Source for Human Acellular Dermis: A Preliminary Report. Tissue engineering and regenerative medicine 2022. link 2 Shin J, Jang U, Baek SO, Lee JY. Full-Thickness Skin Graft according to Surrounding Relaxed Skin Tension Line Improves Scar Quality in Facial Defect Coverage: A Retrospective Comparative Study. BioMed research international 2021. link 3 Holmes Iv JH, Molnar JA, Carter JE, Hwang J, Cairns BA, King BT et al.. A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries. Journal of burn care & research : official publication of the American Burn Association 2018. link 4 Boyce ST, Simpson PS, Rieman MT, Warner PM, Yakuboff KP, Bailey JK et al.. Randomized, Paired-Site Comparison of Autologous Engineered Skin Substitutes and Split-Thickness Skin Graft for Closure of Extensive, Full-Thickness Burns. Journal of burn care & research : official publication of the American Burn Association 2017. link 5 Mohd Hilmi AB, Halim AS, Jaafar H, Asiah AB, Hassan A. Chitosan dermal substitute and chitosan skin substitute contribute to accelerated full-thickness wound healing in irradiated rats. BioMed research international 2013. link 6 Dowling S, Kurmis R, Gauro J, Chapple LA, Coghlan P, Concannon E et al.. Energy expenditure following biodegradable dermal matrix application in severe burn injury: A pilot study. Clinical nutrition ESPEN 2025. link 7 Collins ML, Williams D, Pierson BE, D'Orio CS, Oliver MA, Moffatt LT et al.. Wound Healing and Scar Patterning After Addition of Autologous Skin Cell Suspension to Meshed Grafts. The Journal of surgical research 2024. link 8 Lin Wu ZQ, Bulla A, Aguilera Sáez J, Serracanta Domènech J, Barret JP, Rivas Nicolls DA. Subdermal dissection technique for pure skin SCIA and ALT perforator flaps in burns and trauma defects: Clinical experience. Microsurgery 2024. link 9 Jin MJ, Gao Y. Using Buccal Mucosa and Auricular Cartilage With a Local Flap for Full-Thickness Defect of Lower Eyelid. The Journal of craniofacial surgery 2021. link 10 Lima Júnior EM, de Moraes Filho MO, Costa BA, Fechine FV, Rocha MBS, Vale ML et al.. A Randomized Comparison Study of Lyophilized Nile Tilapia Skin and Silver-Impregnated Sodium Carboxymethylcellulose for the Treatment of Superficial Partial-Thickness Burns. Journal of burn care & research : official publication of the American Burn Association 2021. link 11 Kiefer J, Harati K, Müller-Seubert W, Fischer S, Ziegler B, Behr B et al.. Efficacy of a Gel Containing Polihexanide and Betaine in Deep Partial and Full Thickness Burns Requiring Split-thickness Skin Grafts: A Noncomparative Clinical Study. Journal of burn care & research : official publication of the American Burn Association 2018. link 12 Angspatt A, Termwattanaphakdee T, Muangma P, Bunaprasert T. Pilot Clinical Evaluation of PoreSkin: A Human Acellular Dermal Matrix in Burn Scars. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2017. link 13 Widjaja W, Tan J, Maitz PKM. Efficacy of dermal substitute on deep dermal to full thickness burn injury: a systematic review. ANZ journal of surgery 2017. link 14 Agabalyan NA, Su S, Sinha S, Gabriel V. Comparison between high-frequency ultrasonography and histological assessment reveals weak correlation for measurements of scar tissue thickness. Burns : journal of the International Society for Burn Injuries 2017. link 15 Herndon DN, Branski LK. Contemporary Methods Allowing for Safe and Convenient Use of Amniotic Membrane as a Biologic Wound Dressing for Burns. Annals of plastic surgery 2017. link 16 Kljenak A, Tominac Trcin M, Bujić M, Dolenec T, Jevak M, Mršić G et al.. Fibrin gel as a scaffold for skin substitute – production and clinical experience. Acta clinica Croatica 2016. link 17 Busche MN, Roettger A, Herold C, Vogt PM, Rennekampff HO. Evaporative Water Loss in Superficial to Full Thickness Burns. Annals of plastic surgery 2016. link 18 Ostlie DJ, Juang D, Aguayo P, Pettiford-Cunningham JP, Erkmann EA, Rash DE et al.. Topical silver sulfadiazine vs collagenase ointment for the treatment of partial thickness burns in children: a prospective randomized trial. Journal of pediatric surgery 2012. link 19 Coruh A, Yontar Y. Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting. Journal of burn care & research : official publication of the American Burn Association 2012. link 20 Bukovcan P, Koller J. Treatment of partial-thickness scalds by skin xenografts--a retrospective study of 109 cases in a three-year period. Acta chirurgiae plasticae 2010. link 21 Martin FT, O'Sullivan JB, Regan PJ, McCann J, Kelly JL. Hydrocolloid dressing in pediatric burns may decrease operative intervention rates. Journal of pediatric surgery 2010. link 22 Lumenta DB, Kamolz LP, Frey M. Adult burn patients with more than 60% TBSA involved-Meek and other techniques to overcome restricted skin harvest availability--the Viennese Concept. Journal of burn care & research : official publication of the American Burn Association 2009. link 23 Whitaker IS, Prowse S, Potokar TS. A critical evaluation of the use of Biobrane as a biologic skin substitute: a versatile tool for the plastic and reconstructive surgeon. Annals of plastic surgery 2008. link 24 Sharp PA, Dougherty ME, Kagan RJ. The effect of positioning devices and pressure therapy on outcome after full-thickness burns of the neck. Journal of burn care & research : official publication of the American Burn Association 2007. link 25 Sidebottom AJ, Stevens L, Moore M, Magennis P, Devine JC, Brown JS et al.. Repair of the radial free flap donor site with full or partial thickness skin grafts. A prospective randomised controlled trial. International journal of oral and maxillofacial surgery 2000. link 26 Yoshimura Y, Matsuda S, Obara S. Full-thickness skin grafting of postsurgical oral defects: short- and long-term outcomes. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 1995. link90112-4)

Full thickness burn of buccal mucosa