DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

RUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCHKOHKA, BHILAI

PRESENTED BY –

DR. SHEETAL KAPSE

2nd YEAR, P.G. STUDENT

MODERATORS -DR. SUNIL VYASDR. M. SATISHDR. MANISH PANDITDR. DEEPAK THAKUR

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Retrospective comparison of surgical treatment

modalities in100 patients with oral submucous fibrosis

D Mehrotra, R Pradhan, S Gupta. Retrospective comparison of surgical treatment modalities in 100 patients with oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e1-e10

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Authors

D Mehrotra : Associate Prof., Department of Oral & Maxillofacial Surgery, Chhatrapati Shahuji Maharaj Medical University (formerly King George Medical University).

R Pradhan : Principal, U P Dental College and Research Center, Professor and Head, Department of Oral and Maxillofacial Surgery, Uttar Pradesh Dental College and Research Center.

S Gupta : Lecturer, Department of Oral Pathology, Chhatrapati Shahuji Maharaj Medical University (formerly King George Medical University).

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- 1. Abstract

2. Introduction

3. Aims & objectives

4. Review of literature

5. Source of data

6. Materials & methods

7. Approach for the treatment

8. Procedure

9. Post op workout

10. Different graft harvesting technique

11. Results

12. Discussion

13. References

Inclusions

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Abstract Oral submucous fibrosis has been a scourge of southeastern Asia and

its residents since time immemorial. Scores of medicinal agents, singly and in combination, have been tried with not very encouraging results.

In this study, therefore, the authors have compared different surgical modalities in the management of this condition and have tried to lay down indications of each surgical procedure.

A total of 100 patients of oral submucous fibrosis were included in this study and randomly allocated to different surgical groups, 25 patients per group.

After excision of fibrous bands, group I had buccal fat pad graft, group II had tongue flap, group III had nasolabial fold flap, and group IV had split skin graft for correction of mucosal defect created after incising the fibrous bands.

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Abstract

On the basis of immediate postoperative & 1 month post operative mouth opening the authors Concluded that buccal fat pad rotation is superior to other procedures, because –

1. It offers ease of surgery,

2. Can be performed under local anesthesia as a day care procedure,

3. Shows little postoperative morbidity,

4. Has good patient acceptance, and there appear to be no contraindications to its use.

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Oral submucous fibrosis is a chronic progressive debilitating disease of the oral mucosa involving the oropharynx and rarely the larynx.

The disease is characterized by blanching and stiffness of the oral mucosa, trismus, burning sensation in the mouth, and hypomobility of the soft palate and tongue with loss of gustatory sensation.

It is associated with a juxtaepithelial inflammatory reaction followed by fibroelastic change of the lamina propria and epithelial atrophy leading to stiffness of the oral mucosa, causing trismus and inability to eat.

Borle RM, Borle SM. Management of oral submucous fibrosis: aconservative approach. J Oral Maxollofac Surg 1991;49:788-91.

INTRODUCTION

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It is generally noted in individuals who have emigrated from southeastern Asia or India. Other ethnic clustering may be noted in Pakistani and Burmese, with sporadic cases observed in southern Vietnamese, Thais, Chinese, and Nepalese, and it carries high risk of malignant transformation (2.3%-7.6%).

Gupta PC, Mehta FS, Daftary D. Incidence rates of oral cancerand natural history of oral precancereous lesions in a 10 yearfollow up study of Indian villages: Community Dent Oral Epidemiol 1980;8:287-333.

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The etiology of the disease is still obscure, although data have been postulated on various aspects of the disease.

It is strongly - habit of areca nut, which is used as a mouth freshener and is deeply rooted in Indian culture and history.

persons of all ages and both genders across the Indian subcontinent.

The mainstay in the treatment of submucous fibrosis is concentrated on attempts to improve the mouth opening and relieve the symptoms by medicinal or surgical means.

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The present study was undertaken to compare the

postoperative results of various surgical techniques

described in the literature in terms of achieving a stable

mouth opening with minimum morbidity, and to lay down

specific indications for each procedure.

Aim & objective of the study

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Oral submucous fibrosis is a well known entity described since the time of Sushruta as “vidari.”

Since then, this condition has also been described as

• Idiopathic scleroderma of the mouth,

• Idiopathic palatal fibrosis,

• Atrophic idiopathic mucosa oris,

• Sclerosing stomatitis.

REVIEW OF LITERATURE

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Epidemiologically

The prevalence rates of oral submucous fibrosis in South Africa, Burma, and India range from 0.04% to 24.4% .

The incidence –

In Earnakulam (southern India) = 8 per 100,000 men per year

19 per 100,000 women per year.

In Bhavnagar (northwestern India) = 2.6 per 100,000 men per year

8.5 per 100,000 women per year.

Gupta PC, Mehta FS, Daftary D. Incidence rates of oral cancer and natural history of oral precancereous lesions in a 10 year follow up study of Indian villages: Community Dent Oral

Epidemiol 1980;8:287-333.

Pindborg JJ, Mehra FS, Daftary DK. Incidence of oral cancer among 30,000 villages in India in a 7 year follow up study of oral precancerous lesions: Community Dent Oral Epidemiol 1975;3:86-8.

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Etiologic aspect - Sirsat and Khanolkar :

1. Capsaicin found in green chilis (Capsicum annum)

2. Alkaloid arecoline in betel nut

3. Alcohol consumption along with sharp teeth

4. Vitamin and iron deficiency states

5. Autoimmune basis

Oral submucous fibrosis has been restricted almost to the Indian subcontinent, owing to a possible allergen present in Indian food.

Sirsat SM, Khanolkar VR. Submucous fibrosis of the palate andpillars of the fauces. J Med Science 1962;16:189-97.

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The precancerous nature of oral submucous fibrosis has been observed

with development of slowly growing squamous cell carcinoma in one-third

of oral submucous fibrosis patients.

In southern India, 40% of oral cancer patients had oral submucous fibrosis.

Paymaster JC. Cancer of the buccal mucosa; a clinical study of 650 cases in Indian patient. Cancer 1956;9:731-5.

Pindborg JJ, Zachariah J. Frequency of oral submucous fibrosis among 100 south Indians with oral cancer. Bull WHO 1965;30:750-3.

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The present study comprised 100 patients with oral submucous fibrosis who attended as outpatients the Department of Oral Pathology and Department of Oral Maxillofacial Surgery, Chhatrapati Shahuji Maharaj Medical University, Lucknow, in the period 2002-2005.

Source of data

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These patients were subjected to surgical management

using various surgical procedures after thorough general

and local examination in a standardized format.

MATERIALS AND METHODS

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Patients for surgery were selected irrespective of age, gender, religion, or socioeconomic status, on the basis of following criteria:

1. Decreased mouth opening (20 mm interincisal distance).

2. Palpable fibrous bands in buccal mucosa, blanched oral mucosa (soft palate, buccal, labial, retromolar).

3. Reduced elasticity of mucosa.

4. Burning sensation of the oral mucosa.

5. Restricted tongue movements.

Diagnostic criteria

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based on the severity of the disease

Grade I: stomatitis, burning sensation in the buccal mucosa, and no detection of fibers.

Grade II: stomatitis, burning sensation, fibrous bands, involvement of soft palate, and mouth opening 26-35 mm.

Grade III: symptoms of grade II, blanched oral mucosa, involvement of tongue, and mouth opening 6-25 mm.

Grade IV: symptoms of grade III, fibrosis of lips, and mouth opening 5 mm.

Classification by the author

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Patients were thoroughly counseled to quit all deleterious habits of tobacco, pan, or betel nut chewing.

Grade I and II patients were prescribed medical management

With 50,000 IU vitamin A for 1 month followed by

25,000 IU as a maintenance dose for 6 months and

Vitamin E 200 mg, vitamin C 500 mg, vitamin B complex daily orally for 6 weeks,

Along with topical application of 0.1% triamcinolone acetonide 3-4 times daily.

Approach for the treatment

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Grades III and IV were managed surgically.

These patients were then randomly allocated to different surgical groups where proposed surgical procedures were carried out.

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Under local or general anesthesia

the fibrous bands in buccal mucosa were palpated and incised along the occlusal line starting from the angle of mouth

extending posteriorly up to the retromolar region, bilaterally, deep to the connective tissue.

Furgusson mouth gag - to achieve maximum interincisal opening.

Hemostasis

Suitable graft or dressing material was then placed over the mucosal defect

Procedure

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Physiotherapy with wooden tongue depressors from the fifth postoperative day at least 5 times a day for a minimum of 6 months.

Mouth opening was measured on the first postoperative day and at 1 week, 1 month, 6 months, 1 year, and 2 years.

Follow-up period ranged from 2 to 5 years, median 2.6 years.

Outcome measurement tools were mouth opening in mm and pain, esthetics, and function, the scores evaluated on a 5-point Likert scale, where higher scores represented better results.

Post operative work out

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Different graft harvesting techniques

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Blunt dissection was carried out

through the buccinator muscle to reach

the body or the buccal extension of the

buccal fat pad.

The buccal fat pad was then gently

teased into the defect, taking care not

to rupture its delicate capsule .

Adequate volume of the graft was

harvested to ensure tension-free

closure.

Vicryl was used to suture the graft to

the periphery of the defect, taking care

to prevent damage to the parotid

papilla while harvesting the flap.

Group I: Buccal fat pad graft

Buccal fat pad graft sutured in position to cover the mucosal defect.

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Group I: Buccal fat pad graft

Result 1 month after buccal fat pad grafting.

Result 1 month after buccal fat pad grafting.

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A tongue flap was designed on the dorsal surface of tongue about 4 x1.5 cm in size, based anteriorly on the lateral border.

The flap was dissected and sutured to the cheek defect created after sectioning of fibrous bands.

The tongue flap was sectioned from its base after 21 days, once the graft was cross-vascularized.

Group II : Tongue flap

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A flap about 4 x 1.5 cm in size was designed on the nasolabial fold area with sufficient length and width to fill the defect without tension.

Incision was carried out up to the subdermal tissues, leaving the base of the flap intact.

The flap was raised by blunt dissection, taking care not to disturb the facial muscles.

After raising the flap, a liberal tunnel was made near the base of the flap, to facilitate uncompressed entry of flap into the oral cavity.

Group III: Nasolabial fold flap

Healed nasolabial scar 1 month after surgery, withhair growth intraorally.

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The flap was then de-epithelialized at its base; along the portion that would rest in the myomucosal tunnel followed by its rotation in the oral cavity, and sutured using 3-0 black silk.

The lateral skin flaps were then undermined just beneath the dermis to facilitate subcuticular closure using 4-0 prolene.

Pressure dressing of sterile gauze wrapped in Framycetin gauze was then placed intraorally over the graft to maintain intimate relationship of the graft to the mucosal defect, and sutures were removed on the 10th day after surgery.

Group III: Nasolabial fold flap

Healed nasolabial scar 1 month after surgery, with hair growth intraorally.

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Approximately 0.014–0.018-inch-thick split skin graft was harvested from the lateral aspect of the thigh using Humby knife , and the donor site was covered with antibiotic-impregnated gauze and a pressure dressing.

The harvested graft was placed on a wet wooden slab and cut into the desired size and shape to conform with the intraoral mucosal defect.

Group IV : Split thickness skin

graft

Surgical site 1 month after split skin grafting.

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Puncture holes were created in the graft before it was sutured to the mucosal margins using Vicryl.

Transbuccal quilt suture was placed in the central portion of the graft to minimize dead space, thereby maintaining intimate contact of the graft with the wound bed.

An adequate size of pressure dressing of sterile gauze wrapped in antibiotic gauze was placed intraorally to cover the graft, which was removed after 4-5 days followed by removal of sutures on the 10th postoperative day.

Group IV : Split thickness skin

graft

Surgical site 1 month after split skin grafting.

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Outcome assessment Subjective assessment - based on a 5-point Likert scale questionnaire

• for pain, esthetics, and function.

Objective outcome assessment

• Done by measuring postoperative mouth opening at 1 week, 1 month, 6 months, 1 year, and 2 years. Complications in each group were assessed and analyzed at follow-up visits ranging from 2 to 5 years.

• Chi-squared test, analysis of variance, and paired t test were used for statistical analysis of the results.

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Result Regarding age and gender, there was no significant difference

among the 4 surgical groups.

The severity of submucous fibrosis was grade III in 74% of the patients, grade I and IV each in 13% patients.

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Mean mouth opening at 1 week after surgery was

highest in group I = (36.36 ± 2.75 mm)

lowest in group II (35.36 ± 3.65 mm).

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Outcome score at 1 month after surgery for pain, esthetics, and function

was highest in group I and lowest in group II , suggesting that buccal fat

pad graft was the most feasible graft compared with tongue flap, which

caused the most inconvenience to the patient.

• Mean mouth opening at 1 week after surgery was 35.79 ± 3.53 mm, ranging between 24.00 and 42.00 mm.

• Mean values were highest in group I = (36.36 ± 2.75 mm)

lowest in group II (35.36 ± 3.65 mm).

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There was difficulty in tongue movement, causing discomfort

to the patients, in the tongue flap group .

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Discussion

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Oral submucous fibrosis (OSF) is a collagen disorder commonly seen in the Indian subcontinent.

J. N. Khanna, N. N. Andrade: Oral submucous fibrosis." a new concept in surgical management. Report of 100 cases. Int. J. Oral Maxillofac. Surg. 1995; 24." 433- 439.

ETIOLOGY

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A predominance of women suffering from oral submucous fibrosis has been observed in several studies.

Most of the patients in the present study were in the 20–40-year age group.

The most frequently affected locations in oral submucous fibrosis are the buccal mucosa and the retromolar areas.

It also commonly involves the soft palate, palatal fauces, uvula, tongue, and labial mucosa.

Gupta PC, Mehta FS, Daftary D. Incidence rates of oral cancer and natural history of oral precancereous lesions in a 10 year follow up study of Indian villages: Community Dent Oral Epidemiol 1980;8:287-333.

Clinical features…….

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The most common initial symptoms are burning sensation of the

oral mucosa, aggravated by spicy food.

Vesiculation, excessive salivation, ulcération, pigmentation change,

recurrent stomatitis, defective gustatory sensation, and dryness of

the mouth have also been indicated in earlier stages.

Gradually, stiffening leads to inability in mouth opening and the

patient may experience difficulty in swallowing food.

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Joshi reported some relief with internal doses of iodine. Injection of collagenase for treatment of the disease has been tried with some success.

Discussion….

Treatment aspect

Joshi SG. Submucous fibrosis of palate and pillars. Indian J Otolaryngol 1953;4:1.

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Rao and Raju reported the use of cortisone for the treatment

of 5 cases suffering from this condition.

Reported the use of vitamins A and E for a patient suffering

from oral submucous fibrosis along with surgical release of

fibrotic bands and injection of fibrinolysins and gold.

Injections of hyaluronidase have been made at the affected

site with favorable results.

Rao V, Raju PR. A preliminary report to the treatment of oral submucous fibrosis of oral cavity with cortisone. Indian J Otolaryngol 1954;2:81-4.

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Desa suggested treatment with nonspecific protein therapy

and arsenotyphoid injection (fibrin-dissolving agent), which

yielded poor results, and later with parenteral cortisone 200

mg/day for 2 days followed by 100 mg the next 6 days along

with local hydrocortisone 6.25 mg and 1% procaine

hydrochloride, which provided relief in oral burning

sensation, return of normal color of mucous membrane, and

relief of trismus with improved mobility of palate.

Desa JV. Submucous fibrosis of the palate and the cheek. Ann Otorhinolaryngol 1957;66:1143.

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Hammer reported the use of triamcinolone acetonide in the dose of 50-120 mg/visit, but observed little objective improvement.

Hammer JV. Submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1974;37:412-21.

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Borle and Borle divided 326 patients with oral submucous

fibrosis into 2 groups and treated them with either

conventional submucosal injection of steroid and

hyaluronidase or topical vitamin A, steroid application ,and

oral iron preparation. Although both of the treatments were

purely palliative, they found that topical application of

vitamin, steroid, and oral iron preparation was the better

option.Borle RM, Borle SM. Management of oral submucous fibrosis: a conservative approach. J Oral Maxollofac Surg 1991;49:788-91.

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Gupta et al. studied various treatment modalities and tried a variety of drugs: triamcinalone acetonide 0.1% with neomycin applied topically,

papain and urea mixture for local application intraorally 2-3 times/day for 15 days and repeated after 1 month,

hyaluronidase (1,500 IU) 0.5 mL injected intralesion twice a week for 10 days,

dexamethasonse 1.5 mL with 0.5 mg of lignocaine hydrochloride intra-esion biweekly for 5 weeks, and placental extract (Placentrex) 2 mL intralesion once a week along with ranodine (iodine and vitamin B complex) injected intramuscularly depending upon the severity of the disease.

Vitamin E along with dexamethasone and hyalase has been used with significant improvement in subjective symptoms along with encouraging histopathologic changes at the diseased sites.

Gupta DS, Dolas R, Iqbal A. Treatment modalities in submucousfibrosis- How they stand today? Study of 600 cases. Indian J OralMaxillofac Surg 1992;7:43.

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Khanna and Andrade tried submucosal injection of triamcinolone acetonide (40 mg) in the faucial pillars, retromolar area, and buccal mucosa.

Dose of 150-200 mg in 10-day intervals for a period of 2-3 months gave favorable results, revealed improvement in the clinical picture, and caused an increase in mouth opening along with regression of recurrent stomatitis, ulceration, and burning sensation.

Khanna JN, Andrade NN. Oral submucous fibrosis—a new concept in surgical management. Int J Oral Maxillofac Surg1995;24:433-9.

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Rajendran and Joshy coupled the conventional mode of

management with a new treatment option using 4% acetic

acid, applied topically to the oral mucosa, and recommended

the use of 4% acetic acid together with hot water exercise

as a routine and sustained mode of management for patients

with advanced fibrosis of oral cavity. They stressed that the

choice of therapy is beneficial, affordable, and above all

noninvasive.Rajendran R, Joshy VR. Oral sub-mucous fibrosis: a new treatmentapproach. J Indian Dent Assoc 1998;69:6-10.

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Kumar et al observed a positive clinical response with use of lycopene, the carotenoid that gives tomato a red color and is a potent anticarcinogenic and antioxidant.

Yeh carried out a surgical procedure of incising the mucosa down to the muscles from the angle of mouth to the anterior tonsillar pillar, taking care to prevent damage to the stoma of the parotid duct, followed by split skin grafting into the defect, with acceptable results.

Canniff et al described the procedure of split thickness skin grafting after bilateral temporalis myotomy or coronoidectomy along with daily opening exercise and nocturnal props for a further 4 weeks.

Kumar A, Bagewadi A, Keluskar V, Singh M. Efficacy of lycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:207-13.

Yeh CJ. Application of the buccal fat pad to the surgical treatmentof oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130-3.

Caniff JP, Harry W, Harris M. Oral submucous fibrosis: itspathogenesis and management. Br Dent J 1986;160;429-34.

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Kavarana and Bhatena filled the defect after sectioning of fibrous bands with 2 inferiorly based nasolabial flaps. with division of the pedicle after 3 weeks, and observed average mouth opening of 2.5 cm, with acceptable external scars.

Borle and Borle reported disappointing results with skin grafting to cover the raw area and used tongue flap to cover the defect.

Khanna and Andrade reported the incidence of shrinkage, contraction, and rejection of split skin graft as very high, owing to poor oral condition, with recurrence in 12 cases.

In the present series, esthetics and function achieved with split skin graft was good but showed some degree of relapse due to contracture of the graft.

Kavarana HM, Bhatena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987;40:407-9.

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Tongue flaps were found to be bulky and required additional

surgery for detachment.

Bilateral tongue flaps caused severe dysphagia and

disarticulation along with the risk of postoperative aspiration.

The authors observed restricted mobility of tongue in the

immediate postoperative phase, causing discomfort to the

patient and difficulty in speech, which made it a less ideal

choice.

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Nasolabial flaps can not be extended adequately to cover the

raw area, and they also cause facial scars and at times are hair

bearing, as was seen in our patients.

Palatal island flap based on the greater palatine artery has also

been used to close defect in soft palate after ablative surgery.

This technique, accompanied with bilateral temporalis

myotomy and coronoidectomy, is a highly effective surgical

procedure.

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Mokal et al advocated use of vascularized temporal myofascial pedicled flap to bring in good blood supply to the area of affected muscle and mucosa to improve its function.

Yeh described the application of pedicled buccal fat pad after incision of fibrous bands and suggested that this was a very logical, convenient, and reliable technique for treatment of oral submucous fibrosis. In our hands, buccal fat pad served as a good substitute, because it provided excellent function without deteriorating the esthetics and the results obtained were sustained long term.

Mokal NJ, Raje RS, Ranade SV, Prasad JS, Thatte RL. Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft- a new technique. Br J Plast Surg 2005;58:1055-60.

Yeh CJ. Application of the buccal fat pad to the surgical treatmentof oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130-3.

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Omura and Mizoki used a newly developed collagen /

silicone bilayer membrane as a mucosal substitute and

reported that postoperative course was unremarkable and that

repair was effective.

The membrane comprised an outer layer of silicone and inner

layer of hydrothermal cross-linked composites of fibrillar and

denatured collagen sponge.

The membrane was placed on oral mucosal defects after

removal of the outer silicone layer after 10-14 days.

Omura S, Mizoki. A newly developed ollagen/silicon bilayer membrane as a mucosal substitute—a preliminary report. Br J Oral Maxillofac Surg 1997;35:85-91.

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Authors here suggest a clinical grading of the disease and

treatment methods based on classification

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Grade I:

stomatitis and burning

sensation in the buccal

mucosa with no detection of

fibres.

abstinence from habit and

medicinal management.

Grading symptoms Suggested treatment

Grade III:

symptoms of grade II,

blanched oral mucosa,

involvement of tongue, and

maximal mouth

opening 6-25 mm.

abstinence from habit and

surgical management.

Grade II:

symptoms of grade I, palpable

fibrous bands, involvement of

soft palate, and maximum mouth opening

26-35 mm.

abstinence from habit and

medicinal management.

Grade IV: symptoms of grade III, fibrosis of lips, and mouth opening 5 mm.

abstinence from habit and medicinal

management.

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Medical management

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•50,000 IU vitamin A for 1 month followed by

•25,000 IU as a maintenance dose for 6 months

vitamin A •200 mg,

•500 mg,

•daily for 6 weeks as supportive therapy to promote wound healing, allow the body to repair itself faster, and limit scarring as well as for their antioxidant properties.

vitamin E

vitamin C

vitamin B complex

Local application of triamcinolone acetonide 0.1%

for at least 6 months

physiotherapy in the immediate postoperative phase and later using wooden spatulas.

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CONCLUSION

Buccal fat pad

• served as the best substitute, because it provided excellent function without deteriorating the esthetics.

• ease of surgery• could be very easily

performed under local anesthesia as a day care procedure

• had little postoperative morbidity and good patient acceptance.

Tongue flap

• restricted the mobility of tongue in the immediate postoperative phase, causing discomfort to the patient and difficulty in speech, which made it a less ideal choice.

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Nasolabial flap

• provided both function and esthetics and was extremely good in older patients,

• because author could perform wrinkle lift owing to the resultant stretching of the skin, giving better esthetics in the older age group.

• Mouth opening and function achieved with Nasolabial flap was long term.

• The most unwanted thing associated with such a flap was hair growth intraorally, which was irritating to the patient.

Split skin graft

• Esthetics and function

achieved with was good

but showed some degree

of relapse owing to

contracture of the graft.

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Other Techniques

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Huang et al Bilateral forearm flaps sacrifices one of the two major arteries in the

forearm. And bilateral anterolateral thigh (ALT) flaps, which were traditionally used for reconstruction.

Both options are time consuming and required two donor sites. To eliminate these disadvantages,

Authors have developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery.

Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis.

Jung-Ju Huang, Chris Wallace, Jeng-Yee Lin, Chung-Kan Tsao, Huang-Kai Kao, Wei-Chao Huang, MingeHuei Cheng, Fu-Chan Wei. Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction afterrelease of submucous fibrosis and/or contracture. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010; 63: 440- 445

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All donor sites were closed primarily, with one exception.

One flap failed and was replaced with a contralateral ALT flap.

One patient developed a wound infection and another developed a seroma at the recipient site.

Four flaps required secondary de-bulking in three patients.

The improvement in mouth opening

mean preoperative IID was 9.6 mm (range: 0-20 mm),

mean follow-up time was 16.2 months (range: 10-33 months);

mean postoperative IID was 23.8 mm and

mean improvement in IID was 15.3 mm (range: 10-27 mm).

Jung-Ju Huang, Chris Wallace, Jeng-Yee Lin, Chung-Kan Tsao, Huang-Kai Kao, Wei-Chao Huang, MingeHuei Cheng, Fu-Chan Wei. Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction afterrelease of submucous fibrosis and/or contracture. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010; 63: 440- 445

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J. N. Khanna, N. N. Andrade:

Presented A series of 100 patients.

Only 35 cases were treated by surgical intervention.

A new surgical technique of a palatal island flap based on the greater palatine artery in combination with temporalis myotomy and bilateral coronoidectomy was used in 35 cases.

A follow-up ranging from 6 months to 31/2 years showed good results.

J. N. Khanna, N. N. Andrade: Oral submucous fibrosis." a new concept in surgical management. Report of 100 cases. Int. J. Oral Maxillofac. Surg. 1995; 24." 433- 439.

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Diagram of island flap based on

greater palatine artery to be

transposed to cheek

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References 1. Borle RM, Borle SM. Management of oral submucous fibrosis: a

conservative approach. J Oral Maxollofac Surg 1991;49:788-91.

2. Gupta PC, Mehta FS, Daftary D. Incidence rates of oral cancer and natural history of oral precancereous lesions in a 10 year follow up study of Indian villages: Community Dent Oral Epidemiol 1980;8:287-333.

3. Pindborg JJ, Mehra FS, Daftary DK. Incidence of oral cancer among 30,000 villages in India in a 7 year follow up study of oral precancerous lesions: Community Dent Oral Epidemiol 1975;3:86-8.

4. Sirsat SM, Khanolkar VR. Submucous fibrosis of the palate and pillars of the fauces. J Med Science 1962;16:189-97.

5. Caniff JP, Harry W, Harris M. Oral submucous fibrosis: its pathogenesis and management. Br Dent J 1986;160;429-34.

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References 6. Gupta DS, Dolas R, Iqbal A. Treatment modalities in submucous fibrosis-

How they stand today? Study of 600 cases. Indian J Oral Maxillofac Surg 1992;7:43.

7. Bhonsle RB, Murthi PR, Gupta PC, Mehta FS. Reverse dhumti smoking in Goa—an epidemiological study of 5449 villages for oral precancerous lesions. Indian J Cancer 1976; 13, 301-5.

8. Paymaster JC. Cancer of the buccal mucosa; a clinical study of 650 cases in Indian patient. Cancer 1956;9:731-5.

9. Pindborg JJ, Zachariah J. Frequency of oral submucous fibrosis among 100 south Indians with oral cancer. Bull WHO1965;30:750-3.

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References 9. Haque MF, Harris M, Speight PM. An immunohistochemical study of oral

submucous fibrosis. J Oral Pathol Med1997;25:75-82.

10. Cox SC, Walker DM. Oral submucous fibrosis—a review. Aust Dent J 1996;41:294-99.

11. Mathur RM, Nigam PS, Kumar D. Management of oral submucous fibrosis—a clinicohistologic assessment. MDS thesis, 1978. Lucknow University.

12. Khanna JN, Andrade NN. Oral submucous fibrosis—a new concept in surgical management. Int J Oral Maxillofac Surg 1995;24:433-9.

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