oral submucous fibrosis (osmf)
TRANSCRIPT
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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