Effects of Active Mandibular Exercise for Mouth Opening Limitation Patients after Maxillomandibular Fixation Release: A Non-Randomized Controlled Trial

Hyo Jin Jang; Myung Hee Kim

doi:10.4040/jkan.2018.48.1.26

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Jang and Kim: Effects of Active Mandibular Exercise for Mouth Opening Limitation Patients after Maxillomandibular Fixation Release: A Non-Randomized Controlled Trial

Original Article

J Korean Acad Nurs 2018;48(1):26-37.

Published online: 15 January 2018

DOI: https://doi.org/10.4040/jkan.2018.48.1.26

Effects of Active Mandibular Exercise for Mouth Opening Limitation Patients after Maxillomandibular Fixation Release: A Non-Randomized Controlled Trial

Hyo Jin Jang^1,², Myung Hee Kim^1,

¹Department of Nursing, Pusan National University, Yangsan

²(Bio)Medical Research Institute, Pusan National University Hospital, Busan, Korea

Address reprint requests to : Kim, Myung Hee Department of Nursing, Pusan National University, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea Tel: +82-51-510-8334 Fax: +82-51-510-8308 E-mail: myung@pusan.ac.kr

Received 7 June 2017 Revised 9 January 2018 Accepted 9 January 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

Abstract

Purpose

The aim of this study was to evaluate the effects of active mandibular exercise (AME) in patients with limited mouth opening after maxillomandibular fixation (MMF) release.

Methods

The study used a quasi-experimental, nonequivalent control group and a pre test-post test design. Sixty-two patients with Maxillomandibular Fixation Release were assigned to the experimental (n=31) or control group (n=31). The AME was performed in the experimental group for 4 weeks. The exercise AME consisted of maximal mouth opening, lateral excursion and protrusive movement. These movements were repeated ten times a day. After the final exercise of the day, the number of tongue blades used for mouth opening was noted. The effect of AME was evaluated after MMF release at different time intervals: a) immediately, b) after 1 week, c) after 2 weeks, d) after 4 weeks, and e) after 12 weeks. The exercise was assessed using the following criteria: a) mandibular movements, b) pain scores associated with maximal mouth opening, c) discomfort scores associated with range of movement, and d) daily life activities that involve opening the mouth.

Results

The experimental group showed significant improvement regarding the range of mandibular movements (maximal mouth opening (F=23.60, p<.001), lateral excursion to the right side (F=5.25, p=.002), lateral excursion to the left side (F=5.97, p=.001), protrusive movement (F=5.51, p=.001)), pain score (F=39.59, p<.001), discomfort score (F=9.38, p<.001). Daily life activities that involve opening the mouth were more favorable compared to those in the control group.

Conclusion

The AME in patients after MMF release is helpful for increasing mandibular movement range, decreasing pain and discomfort, and improving day life activities that involve opening the mouth. Therefore, AME is highly recommended as an effective nursing intervention.

Keywords: Mouth rehabilitations, Trismus, Exercise movement techniques, Muscle stretching exercises, Quality of life

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Figure 1.

Flow of the study.

Table 1.

Homogeneity Tests for Subject’s Characteristics and Study Variables (N=62)

Characteristics	Categories	Exp. (n=31)	Cont. (n=31)	χ² or z	p
		M±SD or n (%)	M±SD or n (%)
Gender	Male	20 (64.5)	22 (71.0)	0.29	.786
	Female	11 (35.5)	9 (29.0)
Age (yr)	10~19	3 (9.6)	7 (22.6)	0.14	.890^†
	20~29	18 (58.2)	14 (45.2)
	30~39	3 (9.6)	3 (9.6)
	40~49	3 (9.6)	2 (6.4)
	50~59	3 (9.6)	2 (6.4)
	≥60	1 (3.2)	3 (9.6)
	Median (IQR)	23 (19.00)	25 (11.00)
Education	Elementary	−	1 (3.2)	2.57	.767^††
	Middle	3 (9.7)	4 (12.9)
	High	21 (67.7)	17 (54.8)
	College	7 (22.6)	9 (29.0)
Fx. side	Right	6 (19.4)	6 (19.4)	0.80	.705
	Left	10 (32.3)	7 (22.6)
	Both	15 (48.3)	18 (58.0)
Operation type	Mn. Fx. Reduction (ORIF)	18 (58)	20 (64.5)	0.70	.902^††
	Orthognathic Surgery (1jaw)	11 (35.5)	9 (29.0)
	Orthognathic Surgery (2jaw)	2 (6.5)	2 (6.5)
MMF period (day)	≤7	14 (45.2)	14 (45.2)	0.42	.673^†
	8~14	16 (51.6)	16 (51.6)
	≥15	1 (3.2)	1 (3.2)
	Median (IQR)	8 (4.00)	8 (4.00)
Range of mandibular movements (mm)
Maximal mouth opening		12.85±5.92	13.14±6.42	0.18	.852
Lateral excursive movement to right side		1.00 (2.18)	1.12 (2.04)	−0.50	.613^†
Lateral excursive movement to left side		0.96 (2.05)	0.81 (2.13)	−0.08	.932^†
Protrusive movement		−0.83 (2.31)	−0.23 (2.20)	−0.76	.444^†
Pain when maximal mouth opening		5.00±1.06	5.29±0.58	1.32	.189
Discomfort when measuring movements range		8.70±2.23	9.45±1.92	1.40	.166

Exp.=Experimental group; Cont.=Control group; M±SD=Mean±standard deviation; IQR=Interquartile range; Fx.=Fracture; Mn.=Mandible; ORIF=Open reduction internal fixation; MMF=Maxillomandibular fixation.

^†Mann-Whitney U test; ^††Fisher’s exact test.

Table 2.

Range of Mandibular Movements after MMF Release (N=62)

Variable	Period	Exp. (n=31)	Cont. (n=31)	Source	F	p	Period	Exp. (n=31)	Cont. (n=31)	t	p
		M±SD	M±SD					Differences
Maximal	Immediate	12.85±5.92	13.14±6.42	Group	15.06	<.001	1w-Im.	16.29±4.62	7.97±4.52	7.15	<.001^†
mouth	1 week	29.14±5.90	21.12±7.72	Time	772.63	<.001	2w-Im.	22.67±4.71	14.25±5.03	6.80	<.001^†
opening	2 weeks	35.53±5.60	27.40±8.34	G*T	23.60	<.001	4w-Im.	30.89±5.79	20.79±4.71	7.51	<.001^†
	4 weeks	43.74±4.73	33.94±7.61				12w-Im.	33.32±6.23	30.69±5.21	1.80	.077
	12 weeks	46.18±5.28	43.84±6.38
Lateral	Immediate	1.97±2.02	2.02±2.12	Group	0.93	.339	1w-Im.	3.54±1.97	1.57±1.94	3.96	<.001^†
excursive	1 week	5.52±3.27	3.59±2.79	Time	130.34	<.001	2w-Im.	4.38±2.55	3.29±2.64	1.64	.105
movement	2 weeks	6.36±3.48	5.32±3.33	G*T	5.25	.002	4w-Im.	4.98±2.04	4.48±2.65	0.82	.411
to right	4 weeks	6.96±2.99	6.51±2.77				12w-Im.	5.60±2.07	5.84±2.53	0.40	.689
side	12 weeks	7.58±2.82	7.87±2.60
Lateral	Immediate	1.47±1.63	1.85±2.71	Group	2.69	.106	1w-Im.	3.03±1.76	1.19±1.58	4.31	<.001^†
excursive	1 week	4.51±2.56	3.04±3.13	Time	137.32	<.001	2w-Im.	4.63±2.04	2.56±3.23	3.00	.004^†
movement	2 weeks	6.11±2.76	4.41±3.00	G*T	5.97	.001	4w-Im.	5.42±1.80	3.59±2.56	3.24	.002^†
to left side	4 weeks	6.90±2.59	5.44±2.34				12w-Im.	5.79±1.48	5.06±2.90	1.25	.216
	12 weeks	7.27±2.17	6.91±2.27
Protrusive	Immediate	1.97±1.88	1.58±1.53	Group	5.51	.022	1w-Im.	2.61±1.60	1.19±1.76	3.29	.002^†
movement	1 week	4.37±2.52	2.67±1.99	Time	147.13	<.001	2w-Im.	3.77±1.47	2.21±1.71	3.85	<.001^†
	2 weeks	5.48±2.74	3.70±2.06	G*T	5.51	.001	4w-Im.	4.23±1.49	2.97±1.88	2.88	.005^†
	4 weeks	5.88±2.84	4.47±2.14				12w-Im.	4.70±1.38	4.15±1.75	1.37	.173
	12 weeks	6.05±2.11	5.24±1.88
Pain scores	Immediate	5.00±1.06	5.29±0.58	Group	97.91	<.001	1w-Im.	3.32±1.16	1.45±1.12	6.44	<.001^†
	1 week	1.38±0.91	3.83±1.12	Time	566.50	<.001	2w-Im.	4.32±1.22	2.83±1.00	5.22	<.001^†
	2 weeks	0.38±0.55	2.45±0.96	G*T	39.59	<.001	4w-Im.	4.61±1.28	4.38±1.02	0.76	.446
	4 weeks	0.10±0.30	0.90±0.87				12w-Im.	4.70±1.18	5.29±0.58	2.43	.019
	12 weeks	0.00±0.00	0.00±0.00
Discomfort	Immediate	8.70±2.23	9.45±1.92	Group	27.87	<.001	1w-Im.	4.12±1.55	2.54±2.11	3.35	.001^†
scores	1 week	4.58±1.63	6.90±2.10	Time	239.77	<.001	2w-Im.	5.35±1.92	3.90±2.02	2.89	.005^†
	2 weeks	3.35±0.75	5.54±1.87	G*T	9.38	<.001	4w-Im.	5.70±2.23	5.33±2.07	0.67	.501
	4 weeks	3.00±0.00	4.11±1.13				12w-Im.	5.70±2.23	6.35±1.93	1.21	.229
	12 weeks	3.00±0.00	3.09±0.39

MMF=Maxillomandibular fixation; Exp.=Experimental group; Cont.=Control group; Im.=Immediate; w=week; M±SD=Mean±standard deviation.

^†Independent t-test: significant differences with one another by Bonferroni correction p<.01.

Table 3.

Correlations between Range of Maximum Mouth Opening and Tongue Blade Counts in the Experimental Group (N=31)

Period	Maximal mouth opening	Tongue blade counts	r	p
	M±SD	M±SD
Immediate	12.85±5.92	6.97±3.81	.97	<.001
1 week	29.14±5.90	17.77±3.85	.97	<.001
2 weeks	35.53±5.60	22.65±3.88	.97	<.001
4 weeks	43.74±4.73	28.55±3.20	.96	<.001

M±SD=Mean±standard deviation.

Table 4.

Daily Life Activities That Involve Opening the Mouth after MMF Release (N=62)

Categories	Exp. (n=31)				Cont. (n=31)
	n (%)				n (%)
	1 week	2 weeks	4 weeks	12 weeks	1 week	2 weeks	4 weeks	12 weeks
Meals type
Liquid diet	28 (90.3)	13 (41.9)	−	−	28 (90.3)	14 (45.2)	3 (9.7)	−
Solid diet	3 (9.7)	18 (58.1)	31 (100.0)	31 (100.0)	3 (9.7)	17 (54.8)	28 (90.3)	31 (100.0)
Eating tools
Syringe	−	−	−	−	9 (29.0)	7 (22.6)	2 (6.5)	−
Spoon	31 (100.0)	31 (100.0)	31 (100.0)	31 (100.0)	22 (71.0)	24 (77.4)	29 (93.5)	31 (100.0)
Diet limitation
Yes	18 (58.1)	12 (38.7)	−	−	28 (90.3)	25 (80.6)	16 (51.6)	−
No	13 (41.9)	19 (61.3)	31 (100.0)	31 (100.0)	3 (9.7)	6 (19.4)	15 (48.4)	31 (100.0)
Toothbrush type
Child brush	3 (9.7)	−	−	−	5 (16.1)	4 (12.9)	3 (9.7)	−
Adult brush	28 (90.3)	31 (100.0)	31 (100.0)	31 (100.0)	26 (83.9)	27 (87.1)	28 (90.3)	31 (100.0)
Pain
Mastication	18 (58.1)	14 (45.2)	−	−	30 (96.8)	27 (87.1)	17 (54.8)	−
Toothbrushing	18 (58.1)	4 (12.9)	−	−	30 (96.8)	24 (77.4)	16 (51.6)	−
Conversation	12 (38.7)	5 (16.1)	−	−	19 (61.3)	15 (48.4)	5 (16.1)	−
Awkward facial expression
Yes	7 (22.6)	2 (6.5)	−	−	13 (41.9)	7 (22.6)	1 (3.2)	−
No	24 (77.4)	29 (93.5)	31 (100.0)	31 (100.0)	18 (58.1)	24 (77.4)	30 (96.8)	31 (100.0)

MMF=Maxillomandibular fixation; Exp.=Experimental group; Cont.=Control group.

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