ORAL SUB-MUCOUS FIBROSIS:SURGICAL MANAGEMENT OF ORAL

SUBMUCOUS FIBROSIS- LAST RESORT CASE REPORT AND REVIEW OF LITERATURE

ORAL SUB-MUCOUS FIBROSIS

INTRODUCTION:

(J.J Pindborg and Sirsat 1966)

It is an insidious chronic disease affecting any part of the oral

cavity and sometimes the pharynx. Although occasionally preceded

by and /or associated with vesicle formation ,it is always associated

with juxta-epithelial inflammatory reaction followed by a fibro-elastic

changes of the lamina propria with epithelial atrophy leading to

stiffness of the oral mucosa and causing trismus and inability to eat.

EPIDEMIOLOGY:• OSMF is a crippling fibrotic disorder prevalent in South East Asia,

mostly in India .• Incidence of OSMF in India is 0.2-0.5% of population.• AGE : 20 and 40 years of age are most commonly affected• No cast or religious community is especially affected

• sex predilection conflicting, Earlier it was thought to be common infemales. But at present ,study ratio shows 2.3: 1 =M:F

ORAL SUB-MUCOUS FIBROSIS

ORAL SUB-MUCOUS FIBROSIS

ETIOLOGY:

The strongest risk factor for OSF is

the

• chewing of betel quid or areca nut

• Other factors, such as genetic and

immunologic

• predisposition, probably also play a

role as OSF has been reported in

families (both children and adults)

whose members are not in the habitof chewing betel quid or areca nut.

ORAL SUB-MUCOUS FIBROSIS

MULTIFACTORIAL PATHOGENESISARECANUT TOBACCO LIME VOLATILE LIQUIDS

TANNIN&AFLOTOXIN ARECOLINE

DEGRADATIONOF COLLAGEN

INCREASED SYNTHESISOF COLLAGEN

MECHANICAL TRAUMA

CHEMICAL BURN HYPERSENSITIVITY

ALTERED IMMUNITYGENETIC

REDISPOSITION

FIBROBLASTFORMATION

IRREVERSIBLE FIBROSIS

CARCINOMACONTINOUS EXPOSURE

ORAL SUB-MUCOUS FIBROSIS

CLINICAL FEATURES:

• Onset is insidious.

• burning sensation

• blanching oral mucosa

• fibrous band restricting mouth

opening

• dry mouth

• Inability to whistle, blow

• Difficulty in swallowing

ORAL SUB-MUCOUS FIBROSIS

COMMON SITES INVOLVED• Buccal mucosa, • faucial pillars ,• soft palate, • lips and • hard palate.

The fibrous bands in thebuccal mucosa run in avertical direction ,sometimesso marked that the cheeks arealmost immovable.

ORAL SUB-MUCOUS FIBROSIS

Biopsy report characteristically showing histopathologically

- Atrophic Oral epithelium- Loss of rete pegs - Epithelial atypia may be observed.- Hyalinization of collagen bundles.- Fibroblasts decreased and blood

vessels obliterated

ORAL SUB-MUCOUS FIBROSIS

To aid treatment planning, Khanna and Andrade developed a classification system for OSF based on mean interincisal opening (MIO)

• stage I- early OSF without trismus (MIO >35 mm)• stage II- mild to moderate disease (MIO 26–35 mm)• stage III-moderate to severe disease (MIO 15–25 mm)• stage IVa- severe disease (MIO <15 mm)• stage IVb- extremely severe–malignant/premalignant lesions noted

intraorally.

ORAL SUB-MUCOUS FIBROSIS

MANAGEMENT

Various modalities of treatment-

1. Restriction of habits/ Behavioral therapy

2. Medicinal therapy

3. Surgical therapy.

4. Oral Physiotherapy

ORAL SUB-MUCOUS FIBROSIS

MEDICINAL THERAPY:

ORAL SUB-MUCOUS FIBROSIS

SURGICAL MODALITIES FOR OSMF TO MANAGE TRISMUS• NASOLABIAL FLAP• BUCCAL PAD OF FAT• RADIAL FOREARM FLAP• SUPERFICIAL TEMPORAL FASCIA FLAP• PALATAL ISLAND FLAP• TONGUE FLAP

ORAL SUB-MUCOUS FIBROSIS

BUCCAL PAD OF FAT:• The buccal fat pad (BFP) is a supple and

lobulated mass, easily accessible andmobilized.

• It is a well accepted graft for defects afterincision of fibrotic bands in the surgicalmanagement of oral submucous fibrosis(OSMF).

• BFP occupies the buccal space and restson the periosteum that covers theposterior buccal aspect of the maxilla.

• The BFP has a rich blood supply

ORAL SUB-MUCOUS FIBROSIS

Defects measuring up to 3 - 5 cmcan be covered with BFP withoutcompromising the blood supply.The buccal extension and themain body of BFP are in closeproximity to the buccal defectand may be approached throughthe same incision.

ORAL SUB-MUCOUS FIBROSIS

The surgical procedure -• Step 1 - resection of the fibrous bands

ORAL SUB-MUCOUS FIBROSIS

Step 2-recording of intraoperative forced mouth opening of 35–50 mm

ORAL SUB-MUCOUS FIBROSIS

Step 3-NEED OF CORONOIDECTOMY AND MASTICATORY MUSCLE MYOTOMY ??• If intraoperative mouth opening < 35 mm

ORAL SUB-MUCOUS FIBROSIS

Step 4 -the release, mobilization and securing of the buccal fat pad graft• The buccal fat pad approached by

bluntly opening the fine haemostat and gently dissected until the fat protruded into the mouth.

• The buccal fat pad is teased into the mouth gently by applying externalpressure over the cheek until a sufficient amount is obtained to cover the defect without tension. The buccal fat pad graft is secured in place with horizontal mattress sutures.

ORAL SUB-MUCOUS FIBROSIS

CASE REPORTPatient named ONORINA NONGKESH was referred to the Departmentof Oral and Maxillofacial Surgery ,RDC with the CHIEF COMPLAINT oflong-standing difficulty in mouth opening and a positive history of betelnut, tobacco chewing with lime.

ORAL SUB-MUCOUS FIBROSIS

• Blanching present on B/L buccal mucosa• Fibrotic bands palpable on B/L buccal mucosa Khanna and Andrade

stage IV As the mouth opening was < 10mm

ORAL SUB-MUCOUS FIBROSIS

• Surgical resection of fibrous bands• Intra operative mouth opening achieved was >35 mm• No coronoidectomy was performed

ORAL SUB-MUCOUS FIBROSIS

Partial stripping of temporalis muscle attachment on coronoid process was done bilaterally

ORAL SUB-MUCOUS FIBROSIS

Reconstruction of buccal mucosal defect by buccal fat pad secured with interrupted and mattress sutures by 2-0 vicryl

immediate mouth opening after the procedure was =42 mm

ORAL SUB-MUCOUS FIBROSIS

• From the third postoperativeday patient began mouthopening exercises using Heisterjaw opener four times a day forhalf an hour.

• One month postoperatively,the buccal fat pad is completelyepithelised with maximal IO of35–45 mm.

ORAL SUB-MUCOUS FIBROSIS

DISCUSSION:

Khanna and Andrade considering the severity of the

trismus and the histopathological findings of secondary muscle

degeneration and fibrosis in stages III and IV, suggested surgical

treatment was the only solution in patients with stages III or IV,

and that bilateral temporalis myotomy and coronoidectomy were

highly effective surgical procedure.

ORAL SUB-MUCOUS FIBROSIS

Chang et al.

• supported the study by Khanna and Andrade and revealed that

these additional procedures further improved IO in their

patients from an average distance of 26.9 mm (range 20–35

mm) to an average of 39.6 mm(range 35–45 mm)

intraoperatively.

ORAL SUB-MUCOUS FIBROSIS

Adequate surgical release often results in bilateral buccal

soft tissue defects which tend to contract and shrink if left to heal

by secondary intention. Thus, the resulting soft tissue defect

requires resurfacing with well-vascularized tissue of adequate

dimensions

ORAL SUB-MUCOUS FIBROSIS

CONCLUSION:In surgical management of OSMF bilateral sectioning and

releasing of fibrous bands with or without coronoidectomyfollowed by covering of the surgical defect with buccal fat padserves as a good substitute with a good outcome.

• It is a simple and easy to use flap,

• It has a rich blood supply,

• Its epithelialisation is complete within 6 weeks,

• The morbidity and the failure rates are low

• It is well accepted by the patient.

ORAL SUB-MUCOUS FIBROSIS

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ORAL SUB-MUCOUS FIBROSIS

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