oncol2012%3athe%2befficacy%2bof%2bmouth%2bopening%2bexercises%2bon%2btreating%2btrismus%2bafter%2bmaxillectomy...

8/10/2019 ONCOL2012%3aThe%2befficacy%2bof%2bmouth%2bopening%2bexercises%2bon%2btreating%2btrismus%2baft

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The efficacy of mouth opening exercises on treating trismus after

maxillectomy

REN Wei-hong1, AO Hong-wei1, LIN Qing1, XU Zhen-gang2, and ZHANG Bin2

1. Dea!"#en" o$ %!o&"hodo"i'&, (ai"a) *edi'a) Uni+e!&i" 'hoo) o$ "o#a"o)og,

Beiing 1///0/, (hina.

2. Dea!"#en" o$ Head and Ne' !ge!, (an'e! Ho&i"a), %eing Union *edi'a)

(o))ege, (hine&e A'ade# o$ *edi'a) 'ien'e&, Beiing 1///21, (hina.

This study was supported by: the Capital Development of Medical Scientific Research

Funds (2!"2#$%

Correspondence to: D!. REN Wei-hong, e-#ai)3 !enweihong4+i.&ina.'o#, hone3

/1/-05/66216

Abstract:

Backgroud &atients with ma'illary tumor often suffer from trismus after ma'illectomy

which could turn out to be a permanent se)uela without proper interventions* +n this

study the efficacy of mouth openin, e'ercises on preventin, and treatin, trismus was

observed in patients with ma'illary tumor early after their operations* -t the same time

the radiotherapy was evaluated as the influential factor to the mouth openin, e'ercises*

Methods +n this study twenty"two patients with ma'illary oncolo,y be,an their mouth

openin, e'ercises at an early sta,e (. to 2 wee/s% after ma'illectomy* They were divided

into two ,roups in principle of voluntariness: .. patients in 0roup . chose Thera1ites as

their instruments of mouth openin, e'ercises and the others in 0roup 2 used stac/ed

ton,ue depressors to help their e'ercises* -ll participants were trained to e'ercise $"

times a day $"3 oscillations at one time with a 2"second pause at their ma'imum

mouth openin, available* The ma'imal interincisor distances (M+D% of patients were

measured and recorded by a sin,le investi,ator every wee/ after the be,innin, of mouth

openin, e'ercises* Medical information and the responses of patients were also

recorded* +nitial and final M+Ds were calculated by Statistical &ac/a,e for the Social

Scienes (S&SS version .$%*
mailto:[email protected]:[email protected]



Results The chan,es of mouth aperture every wee/ durin, e'ercises in both ,roups

were described in fi,ures and there were statistical increases in the final M+Ds

comparin, with the initial ones* 4owever no si,nificant differences were achieved

between 0roup . and 0roup 2 (%5*#67*%* The radiotherapy seemed to have no

ne,ative impact on the mouth openin, results durin, the e'ercises*

Conclusion &hysical mouth openin, e'ercises should be e'ecuted early after

ma'illectomy for the prevention and treatment of trismus especially for those who had

radiotherapy as part of antitumor treatments*

Key words:ma'illary tumor trismus Thera1ite system ma'imal interincisor distance

(M+D%

Trismus is a widely"reco,nised complication of head and nec/ cancer especially the

ma'illary oncolo,y and one of the se)uelae after treatment* +t may occur at the first time

of dia,nosis post sur,ery or postirradiation* There are different literatures about the

prevalence of trismus after head and nec/ oncolo,y treatment ran,in, from 8 to $#8* 9.

Trismus was observed at the first consultation in about 38 patients with a head and nec/

cancer as a result of tumor e'tension*92 For patients who received curative doses of

radiation therapy in the re,ion of head and nec/ the morbidity of trismus increased to

38*9$4owever there are no e'act reports about the rate of trismus in lar,e population

of patients with ma'illary tumor because of the low morbidity*

;arious factors contribute to the development of trismus in ma'illary tumors*

Mali,nant diseases ad



antitumor treatments it is hard to predict the prevalence and pro,nosis of trismus in the

population*

Trismus has a detrimental effect on the )uality of life because of the impairment of

basic oral functions such as chewin, and swallowin,* 9 +n addition it may adverse to

daily maintenance of oral hy,iene as well as surveillance of cancer recurrence* Some

studies also point out that a reduced mouth openin, capacity could further a,,ravate the

respiratory condition of persons with pulmonary impairment* 96 ?

&lenty of modalities such as physiotherapy pharmacotherapy hyperbaric o'y,en

botulinum to'in and so on have been tried in the treatment of trismus*9#".1ut for the

trismus followed by the ma'illectomy and irradiation therapy only the physiotherapy

,enerally referred to as the muscle e'ercise has been considered the mainstay of

trismus treatment*9..".$ Mouth openin, e'ercises with special desi,ned mechanical

devices can be easily learned and have been widely used in clinic alone or in

combination with other modalities* More than si' appliances have been described in the

literature 9.3which are used in con



Picture 1* The Thera1ite =aw Motion Rehabilitation System Thera1ite

This study aimed to observe the efficacy of mouth openin, e'ercises in con



3?*$2 (standard deviation SD .$*!3% ran,in, from .6 to #$* Fifteen patients (6#*28%

were male* .3 patients (6$*68% have received radiotherapy includin, 2 preoperative .

postoperative and 2 both* Most of them (!*!8% had ma'illary defects after the operation

re)uirin, for rehabilitation with obturators and only two of them underwent sur,ical

reconstruction with free flaps ri,ht after the resection*

The patients were divided into two ,roups by principle of voluntariness: .. patients

chose Thera1ite as their instruments of mouth openin, e'ercise mar/ed as 0roup .*

(The Thera1ite was provided by the 1ei



-,e (year% 2*.#.2*?26 32*3.$*!6 3?*$2.$*!3

Se'

Male ! 6 .

Female 2 ?

Radiotherapy &reoperative radiotherapy . . 2

&ostoperative radiotherapy 6 3 .

both 2 2

no radiotherapy 2 6 #

Rehabilitation methods

Sur,ical reconstructed with free flaps . . 2

@bturator rehabilitated . . 2

RE"$%T"

-ll the participants had normal mouth openin, capacity before the operation* -t the

early sta,e (.G2 wee/s% after ma'illectomy the ma'imal mouth openin, distances

decreased to .6*!mm by avera,e ( to $$mmH standard deviation SD !*%*

&igure 1and 'igure (described the chan,es of M+D ,ains (present M+D #in&initial

M+D% respectively in each patient every wee/ durin, mouth openin, e'ercises in 0roup .

and 2* Different colors represented the curve of different patients* Four patients (one in

0roup . and three in 0roup 2% discontinued their e'ercises for ? to . days durin, the

period of radiotherapy* 2 persons were interrupted by the pains in the re,ion of TM= one

by the infection of e'ternal auditory canal and the other one by the oral pains induced by

mucosa ulcers and edema* The curves were suspensive at the correspondin, places*

-ll the participants started their mouth openin, e'ercises early after ma'illectomy

(.G2 wee/s% and continued for 2 to 6 wee/s* +t could be seen that the mouth aperture

increases numerically in most of the patients in both ,roups* The curves were more

re,ular and consecutive in 0roup .* M+Ds fell at several time points maybe because of

the sufferin, durin, radiotherapy the numbers usually turned to increases at the final

points* 4owever the curves were messier in 0roup 2*



&igure 1#Ileven curves of M+D ,ains in 0roup . at different measurement points* (M+D

,ain5 present M+D-initial M+D%

&igure (# Ileven curves of M+D ,ains in 0roup 2 at different measurement points* (M+D

,ain5 present M+D-initial M+D%

The initial and final M+Ds of patients are shown +n Table (* The final M+Ds reach to

$.*2mm (SD 3*!6% with a statistical ,ain comparin, with the initial M+Ds* There were no

si,nificant differences between 0roup . and 2 (%5*$27*% indicatin, no efficacy

difference between Thera1ite and stac/ed ton,ue depressors* There are no si,nificant



differences between radiotherapy and non"radiotherapy (%5*.7*%*

Table (#Comparison of initial and final M+Ds (mm%

Mechanism devices %value +rradiation treatment %value Total

0roup . 0roup 2 radiotherapy Eon"radiotherapy

+nitial M+D .6*6!*#$ .?*2#*6# *#27* .!*!*3 .$*#?*# *.!?7* .6*!!*

Final M+D $*3*?6 $.*!*2# *$27* 2!*!*6# $$*2*.3 *.7* $.*23*!6

% value *.J* *2J* *2J* *J* *J*

&igure )* Comparison of final M+D ,ains in 0roup . and 2* (0roup .: mean .$*!mmH SD

.*!* 0roup 2: mean .3*?mmH SD .*##*%5*#67*%

&igure ** Comparison of final M+D ,ains in ,roup of radiotherapy and non"radiotherapy*



(Radiotherapy: mean ..*2mmH SD .*?6* Eon"radiotherapy: .!*#mmH SD ?*#*

%5*67*%

&igure ) and 'igure *show the comparisons of final increased M+Ds in different

,roups* The avera,e M+D ,ain in 0roup . is .$*!mm (SD .*!%* -nd in 0roup 2 it is

.3*?mm (SD .*##%* +n the ,roup of radiotherapy the avera,e increase of M+D is

..*2mm (SD .*?6% and it is .!*#mm (SD ?*#% in the ,roup of non"radiotherapy* There

are no si,nificant differences between 0roup . and 0roup 2 and between radiotherapy

and non" radiotherapy*

!+"C$""+,

The mouth openin, e'ercises have been proved of ,reat value in the treatment of

reduced mouth openin, caused by sur,ery and irradiation in patients with head and nec/

cancer* Durin, the process the e'ercises are carried out by repeated attempts to open

the mouth a,ainst applied resistance* The muscles of mastication are pushed to motion

passively and the tonic spasm is bro/en which would discoura,e the formation of

fibrosis in and around the TM=* +t is on the basis of the physiolo,ical phenomenon that

the activation of one muscle ,roup refle'ly causes rela'ation of the muscular anta,onist

affectin, the same


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between 0roup . and 0roup 2 the Thera1ite has advanta,es in comparison with

traditional mouth openin, e'ercises* 1ecause it was desi,ned with the principles of

human physiolo,ical en,ineerin, mattresses which ,uarantee mandible move alon, with

the physiolo,ical movement of condyle*

The application of this device is considered safer than other mouth openin, devices

for the stretchin, force is dispersed alon, the len,th of the bite trays and is symmetrical

on both sides of the Mandible* 9.? +n this study no complications related to the use of the

Therabite were noted in any patient neither was there any adverse effect on the

ma'illary healin, sur,ical site or free flap reconstruction* The Thera1ite system was

reflected more normalied and easily handled* Meanwhile patients are more li/ely to

follow the ,iven trainin, plan and e'ercise more initiatively and insistently*

+t is important for patients with ma'illary tumor to start mouth openin, e'ercises early

after ma'illectomy and durin, the radiotherapy* The ma'illecttomy contribute ,reatly to

the occurrence of trismus* The spasm edema and destructed in



patients with head and nec/ cancer*

4owever trismus is easily ne,lected by patients and medical practitioners durin, the

entire process of antitumor treatments because the patients mi,ht focus more on facial

disfi,urement or difficulties in phonation and swallowin, after operation while the doctors

traditionally focus on the success of the operations or the rate of recurrence and mi,ht

not notice the occurrence and development of trismus and the nurses even the close

careta/ers mi,ht not realie the slow pro,ressive onset of trismus because of most of

patients ta/in, in nutrition usin, nasal feedin, tubes or bein, limited to li)uids after

operations and durin, radiotherapy* 1ut without ade)uate interventions trismus would

turn to be permanent in the whole life of patients so post operation patient must start

mouth openin, e'ercises as early as possible* -ll the patients achieved si,nificant

improvement of mouth openin, in this study* They were advised to start mouth openin,

e'ercises early after the ma'illectomy* 3 patients discontinued but restarted after ?G.

days* The final M+Ds are related to self"mana,ement and forbearance of individuals

durin, the mouth openin, e'ercises* +n the observation of patients after radiotherapy it is

found that the mouth openin, aperture decreases as early as the irradiation is applied*

4owever all of them ,et M+D ,ains after muscle e'ercises* There are no si,nificant

differences in the final M+Ds between ,roups of radiotherapy and non"radiotherapy* Thus

patients should be su,,ested proper mouth openin, e'ercises durin, the radiotherapy*

The mouth openin, e'ercises with Thera1ite is supposed to be protective to muscles

of mastication and the TM= which needs more evidences of medical ima,in,* Further

study with more samples is necessary to assess lon,"term results*

C,C%$"+,

&hysical mouth openin, e'ercise is an effective and feasible way to prevent and

treat trismus after ma'illectomy especially for those who have radiotherapy as part of

antitumor treatments* -lthou,h the advanta,es of Thera1ite are not prominent in this

study it is proved effective and user"friendly that can be applied in clinic*

ACK,-%E!.EME,T

Than/s to 1ei



Re'erence :

.* Di



.#* Steelman K So/ol =* Puantification of trismus followin, irradiation of the

temporomandibular

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