i

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled "A MODIFIED SINGLE STAGE NASO-LABIAL FLAP (WINGED) IN THE SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS" is a bonafide and genuine research work carried out by me under the guidance of Dr. NISHANTH N. SHETTY M.D.S., Reader, Department of Oral, Maxillofacial and Reconstructive Surgery, Bapuji Dental College & Hospital, Davangere.

PLACE : DAVANGERE DATE : / / 2005. Dr. CHHEDA SONAL NEMCHAND

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CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled "A MODIFIED SINGLE STAGE NASO-LABIAL FLAP (WINGED) IN THE SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS" is a bonafide work done by Dr. CHHEDA SONAL NEMCHAND in partial fulfillment of the requirement for the degree of

M.D.S. (Oral and Maxillofacial Surgery).

PLACE : DAVANGERE DATE : / /2005

Dr. NISHANTH N. SHETTY Reader, Dept. of Oral, Maxillofacial & Reconstructive Surgery Bapuji Dental College & Hospital Davangere 577 004.

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ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that this dissertation entitled "A MODIFIED SINGLE STAGE NASO-LABIAL FLAP (WINGED) IN THE SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS" is a bonafide research work done by Dr.CHHEDA SONAL NEMCHAND under the guidance of Dr. NISHANTH N. SHETTY M.D.S, Reader, Department of Oral, Maxillofacial and Reconstructive Surgery, Bapuji Dental College & Hospital, Davangere.

Dr. KIRTHI KUMAR RAI M.D.S., Professor and Head, Dept. of Oral, Maxillofacial & Reconstructive Surgery Bapuji Dental College & Hospital Davangere 577 004. DATE : / /2005

Dr. K. SADASHIVA SHETTY M.D.S., Principal, Bapuji Dental College & Hospital Davangere 577 004.

DATE :

/2005

PLACE : DAVANGERE

PLACE : DAVANGERE

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COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.

PLACE : DAVANGERE DATE : / / 2005. (Dr. CHHEDA SONAL NEMCHAND)

ACKNOWLEDGEMENT
My grateful acknowledgement and gratitude to Late Mr. I.P.Vishwaradhya, Chairman, BEA Dental Colleges, Davangere and Dr. K. Sadashiva Shetty, Principal, Bapuji Dental College and Hospital, Davangere, for providing me an opportunity to undertake this study in this prestigious institution and utilize the necessary facilities. I express my humble, deep sense of gratitude and thanks to my beloved teacher Dr. Kirthi Kumar Rai, Professor and Head, Department of Oral, Maxillofacial and Reconstructive Surgery, Bapuji Dental College and Hospital, Davangere, for his constant encouragement and expert guidance throughout the period of this study and post-graduate course. An enterprise such as this can only be accomplished with expert guidance, assistance and encouragement which I received in good measure from my guide. My special thanks to my Guide Dr. Nishanth N. Shetty, Reader for his excellent suggestions, encouragement and guidance throughout my study period. It is with utmost sincerity and deep sense of appreciation that I thank our beloved Professors Dr. Bhagavan Das, Dr.Bhushan Jayade, Dr.David P. Tauro and Dr.Deepika Kenkere who have enlightened me about the expanding scope of maxillofacial surgery and always held me in check and prevented me from going astray. I am indebted to my beloved Reader Dr.Arun Kumar K.V., and Assistant Professors Dr. H.R. Shiva Kumar and Dr. Dayanand S. for their efficacious guidance, altruistic co-operation and support throughout my curriculum.

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A word of thanks to Dr. Prabhu B.G., anaesthetist, Department of Oral, Maxillofacial and Reconstructive Surgery, Bapuji Dental College and Hospital, for helping me in odds and ends. I would also like to thank Mr.Sanjeev, M/s Gundal Compu-Center, for the neat and flawless typing of this manuscript. Personally, I am grateful to my PARENTS, for their innumerable sacrifices, patience, love and understanding. A special word of thanks to my colleagues and friends for their valuable support which has made this experience a memorable one. I also thank everyone concerned including the Patients for their co-operation, without whom this dissertation would have never materialized. Above all, I thank ALMIGHTY for showering me with blessings and love that have provided me with inspiration throughout my life.

PLACE : DAVANGERE DATE : / / 2005. Dr. CHHEDA SONAL NEMCHAND

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ABSTRACT

BACKGROUND AND OBJECTIVES : The use of nasolabial flap in reconstruction of head and neck defects has proved to be efficacious and reliable. The versatility of this flap has been attributed to the fact that there is often abundant non-hair bearing skin in this well vascularised region. Flap elevation is quick and simple, with minimal donor site deformity and rapid post-

operative rehabilitation. Also the proximity to the defect and achievement of good cosmetic result with preservation of function and least distortion of anatomy makes it the flap of choice. The purpose of this study is to evaluate the role of modified single-stage winged nasolabial island flaps for reconstruction of buccal mucosal defects after surgical

excision of fibrous bands in patients with oral submucous fibrosis.

METHODS : This retrospective prospective study was conducted on 14 patients who presented with oral submucous fibrosis and underwent surgical excision of fibrous bands and reconstruction of the defect with bilateral single-stage winged nasolabial island flaps.

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RESULTS : In our series of nasolabial flaps, flap loss either complete or partial were not encountered. Other complications like infection, flap necrosis, obstructive sialadenitis and damage to facial nerve branches were not observed. However, intra-oral hair growth and extra-oral scar at the donor site were encountered in all our patients. 3 of these patients underwent scar revision at a later date. Mean mouth opening of 43.7mm was achieved at 6 months post-operative, with a mean increase of 24.2mm. No relapse was encountered, even at the last follow-up.

INTERPRETATION AND CONCLUSION : Although our series comprised of a limited number of cases and a short follow-up period, initial results were more than satisfactory, permitting us to logically conclude that modified single-stage winged nasolabial island flaps are a viable and reliable option, that has withstood the test of time for reconstruction of submucous fibrosis. intra-oral defects in oral

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TABLE OF CONTENTS

PAGE NO

1. 2. 3. 4. 5. 6. 7. 8. 9.

INTRODUCTION HISTORY OBJECTIVES REVIEW OF LITERATURE METHODOLOGY OBSERVATION AND RESULTS DISCUSSION SUMMARY AND CONCLUSION BIBLIOGRAPHY

01 03 04 05 23 32 47 56 58

LIST OF TABLES

SL.NO. 1. 2. 3.

TABLES PRE-OPERATIVE EVALUATION POST-OPERATIVE EVALUATION MOUTH-OPENING EVALUATION

PAGE 35 36 37

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LIST OF FIGURES

SL.NO. 1. 2. 3.

FIGURES MOUTH OPENING EVALUATION INCREASE IN MOUTH - OPENING CASE PHOTOS

PAGE 38 39 40

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Introduction

INTRODUCTION
Oral submucous fibrosis (OSMF) has been well established in Indian Medical Literature since the time of Sushruta. In modern literature this condition was first

described by Schwartz in 1952.1 Joshi (1952) is credited to be the first person who described this condition and gave it the present term.2 This condition is predominantly seen in the Indian subcontinent as well as people of this origin settled elsewhere in the world.3 Submucous fibrosis which presents with a severe degree of trismus remains a difficult surgical problem.4 The various surgical procedures include excision of fibrous bands with or without grafts. Materials for attempted grafting included skin or placental grafts, tongue flaps, lingual pedicle flaps, buccal fat pad grafts and nasolabial flaps. Additional procedures like splitting of temporalis tendon and coronoidectomy and

masseter muscle stripping have also been described to enhance mouth opening.5 The use of the nasolabial flap in reconstruction of head and neck defects has proved to be efficacious and reliable. This flap has been employed as a single - staged as well as a two - staged procedure for repair of defects of the upper lip, nasal ala, septum and columella as well as for intra-oral defects of the floor of mouth, tongue and gingival sulcus. The versatility of this flap has been attributed to the fact that there is often abundant non - hair bearing skin in this well vascularized region.6 Flap elevation is quick and simple, with minimal donor site deformity and rapid post operative rehabilitation. All these factors are of importance for many patients because of their advanced age

Introduction

and/or poor medical risk.7 Also the proximity to the defect and achievement of good cosmetic result with preservation of function and least distortion of anatomy makes it the flap of choice. Hence a study has been undertaken to establish the application of modified winged nasolabial island flaps for surgical management of oral submucous fibrosis.

History

HISTORY
The nasolabial flap was first described in the works of Sushruta in 600 BC. Variations since then have included a full thickness cheek flap tunneled through a buccal incision as described by Thiersch in 1868. Esser (1918) was the first to describe a flap consisting of skin only, which subsequently required a second procedure to divide the pedicle and inset the flap. The first single stage, de-epithelized nasolabial flap was described by Wallace (1966) for the closure of a palatal defect. In order to avoid the

bulk of the deep epithelized pedicle in the tunnel and to provide more mobility, a onestep arterialized island flap was designed by Rose (1981). Although many variations have been described, there are a few large clinical series reported. Cohen and Edgerton (1971), in their 14 cases reported minimal complications and a general satisfaction with use of the transbuccal flaps for reconstruction of floor of mouth.7

Objectives

OBJECTIVES
The purpose of this study is to evaluate the role of modified single-stage winged nasolabial island flaps for reconstruction of buccal mucosal defects after excision of fibrous bands in patients with oral submucous fibrosis. The surgical technique, the morbidity associated with the procedure, the behaviour of the flap post operatively and the improvement in mouth opening will be evaluated.

Review of Literature

REVIEW OF LITERATURE
Gewirtz H.S., Eilber F.R., Zarem H.A. (1978)8 : employed nasolabial flaps in eight patients who had undergone resection of floor of the mouth, gingiva, alveolar ridge and mandible followed by primary reconstruction. Three patients had presented with primary carcinoma, three with osteoradionecrosis, one with failure of prior reconstruction and one with both recurrent disease and osteoradionecrosis. All the flaps provided excellent coverage, which survived subsequent irradiation and reoperation in three

patients. They stated that the advantages of nasolabial flap include an excellent dual blood supply from facial and ophthalmic arteries, minimal cosmetic deformity and appropriate consistency for reconstructive purposes and minimal cosmetic deformity. Toomey J.M., Spector G.J. (1979)9 : reconstructed alar defects following

tumour excision using a carefully designed superiorly based nasolabial flap with a permanently buried deepithelized segment underlying the upper portion of the ala thereby providing acceptable ala reconstruction. The technique fulfilled the principles of

reconstruction such as to reconstruct the defect with a lined flap which recreates the contour and length of the original alar rim. The authors also mention that it is not

necessary to attempt specifically to include any major axial vessels in the flap. Gupta D.S., Gupta M.K., Golhar B.L., et al., (1980)10 : reviewed the literature on OSMF and classified oral submucous fibrosis clinically into 4 stages with increasing intensity of trismus.

Review of Literature

i. Very early stage : the patients complain of burning sensation of mouth or ulceration without difficulty in opening the mouth. ii. Early stage : Along with symptoms of burning sensation patient complains of slight difficulty in opening the mouth. iii. Moderately advanced stage : The trismus was marked to such an extent that patient cannot open his mouth more than 2 fingers width, therefore experiences difficulty in mastication. iv. Advanced stage : Patient was undernourished, anemic and had a marked degree of trismus and/or other symptoms as mentioned above. They treated 15 patients by either microwave diathermy (MWD) alone or Vit.A and Vit.B complex tablets and Inj. Hydrocortisone or combination of both for

comparative improvement and they found MWD to be of much value in early as well as moderately advanced stages of oral submucous fibrosis. In very advanced cases the use of microwave diathermy was very poor and without any satisfactory result. The author concluded that this therapy may be attempted in all the early stages and moderately advanced stages of oral submucous fibrosis. Rananjaneyulu P. and Prabhakara Rao. (1980)2 : studied the effect of

intralesional injections of placentrex in 10 patients. The criteria for evaluation of results include symptomatic relief of burning sensation in the mouth, interincisal mouth opening and change of colour of mucosa. Dramatic improvement in symptoms were noted as the relief of stiffness of oral cavity and burning sensation in the mouth. An initial

Review of Literature

improvement of 5mm with the first injection and subsequent improvement of 2mm per injection on an average was noted. Disability like inability to protrude the tongue was relieved and improvement in the vascularity of the oral mucosa was evident by the change in its colour. 2 cases in this series, which failed to respond to cortisone therapy also responded well with placentrex. The author opined that the mode of action seemed to be essentially biogenic stimulation and also suggested that it stimulates the pituitary, adrenal cortex and regulates the metabolism of tissues. They concluded that local injections of placentrex were safe, cheap and effective and could be used with impunity without any side effects. It had no contraindications and the effect was long lasting. Morgan R.F., et al., (1981)11 : reported their experience with fifty five patients with a total of sixty eight nasolabial flaps treated for intraoral reconstruction, which were followed for 1 to 10 years. Three flaps had partial tissue loss while two flaps had total failure. Successful reconstruction without complication was obtained with 93 percent of flaps. They concluded that nasolabial flap proved very useful in immediate single-stage reconstruction of anterior intraoral defects after ablation for cancer with local tissue. Paissat D.K. (1981)12 : evaluated the importance of OSMF with respect to debilitation and precancerous potential and discussed the current theories of its etiology, pathogenesis, clinical presentation, histological features and management of the disease. They concluded that modern surgical techniques currently offer the best prognosis as local and systemic hydrocortisone therapy gave only temporary improvement. The

author suggests that regular follow-up is mandatory because even though patients with
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Review of Literature

advanced disease give up eating chillies, the disease still progressed and therefore the possibility of developing squamous cell carcinoma always exist, especially if the patient was a smoker or tobacco chewer. Hayes P.S. (1985)13 : presented a case of oral submucous fibrosis in a 4 year old Indian girl. This patient reported with a chief complaint of microstomia, pain in the right ear region and mouth. She gave history of chewing 3-4 pansupari per week since the age of 2 years. Clinical features, histopathological features and laboratory findings were all suggestive of OSMF. The patient showed some improvement after 8 months of

conservative treatment that involved abstinence from pansupari, the use of vitamin supplements, a balanced diet and stretching exercises. The maximum inter-incisal distance increased by 3mm and the blanching of oral mucosa decreased considerably. The buccal mucosa was more resilient with no evidence of vertical fibrous bands. The author stated that the drastic immediate improvement could be attributed to the greater healing potential in pediatric patients. Canniff J.P., Harvey W., Harris M. (1986)14 : analysed 44 patients with OSMF and demonstrated genetic predisposition of the disease involving the HLA antigens A10, DR3, DR7 and probably B7 and the haplotypic pairs A10/DR3,B8/DR3 and A10/B8. All the cases were surgically treated by excising the fibrous bands and split -thickness skin grafting following bilateral temporalis myotomy or coronoidectomy. An inter-incisal opening of 35-40 mm was achieved in all the cases and the patients were subjected to daily opening exercises and nocturnal props for further period of 4 weeks with good results. Based on immunological studies, they postulated that OSMF was an autoimmune

Review of Literature

disease due to the female bias, age of onset (mean 30.1yrs), alteration in serum immunoglobulins. The incidence of autoantibodies and the involvement of DR locus in the genetic predisposition. They also stated that betelnut extracts such as arecoline, stimulated fibroblast proliferation and collagen synthesis in vitro. Further more the flavanoid catechin and tannins from betelnut stabilized collagen fibres and render them resistant to degradation. Based on these findings, they concluded that the study provided the valuable model for studying the role of genetic control of the immune response in the regulation of connective tissue turnover. Hagan W.E. (1986)15 : incorporating the modified the cutaneous nasolabial flap by

underlying mimetic

musculature, thus converting

it into a

musculocutaneous flap. The modified banner shaped flap was used in 8 patients for reconstruction of oral defects following burn or resection of carcinomas of the labial and oral areas. The flap was centered over the nasolabial groove after identifying the underlying facial artery with assistance of a Doppler as well as its anatomic landmarks. The width of this flap ranged between 1.5 to 2.5cms and the length ranged from 5.5 to 7 cms, with the distal tips tapering at an acute angle of 35 or less. The flap incorporated nasalis as well as levator labii superioris alaeque nasi which are nourished by the facial artery. He concluded that this musculocutaneous flap provides adequate bulk with

minimal contracture and an extremely reliable vascularity for reconstruction of the floor of mouth and oral sphincter in a one stage procedure with minimal cosmetic and functional impairment of the donor site.

Review of Literature

Kavarana N.M., and Bhathena H.M. (1987)4 : performed bilateral full thickness nasolabial tunnel flap successfully in 3 patients to relieve severe trismus caused by oral submucous fibrosis each having <1cm interincisal distance. Two of these patients had already received treatment with intralesional injections of kenacort with little

improvement. They incised the buccal mucosa from the angle of the mouth to anterior tonsillar pillars on both sides, down to the muscle to release the trismus. The resultant defect was filled with two inferiorly based nasolabial flaps each approximately 4 x 1.5 to 2 cm. The pedicle of the flaps were divided after 3 weeks and the insetting was so done as to ensure that the divided base of the flaps come upto the vermilion border at the angle of the mouth. They attained an average mouth opening of 2.5 cm and more with a 2 year follow-up. The post-operative rehabilitation compared favourably with other methods. Morawetz G., et al (1987)16 : reviewed the literature and reported two cases of oral submucous fibrosis. The diagnosis was confirmed histologically and both patients were treated with excision of fibrotic bands and subsequent placement of split thickness skin graft. Immediate relief of trismus was observed in both cases which gradually increased with physiotherapy. However, loss of maximal mouth opening secondary to cessation of physiotherapy was seen in one patient. Since surgical therapy probably did not address the etiology of oral submucosal fibrosis and assuming that the process continues, the authors have stressed on direct efforts towards maintaining maximal mouth opening and regular monitoring for development of cancer, since there is higher incidence of malignancy in such patients.

10

Review of Literature

Multimer K.L., and Poole M.D. (1987)7 : conducted a retrospective study on the use of nasolabial flaps in 23 patients for reconstruction of moderate size intraoral defects following ablative tumour resection. For defects situated in the palate and upper alveolus a superiorly based flap was utilised while, defects of the lower alveolus, floor of the mouth, buccal mucosa, retromolar and tonsillar areas were reconstructed using an inferiorly based flap. The flap vascularity was reliable, there being no cases of total loss, although three cases (12%) of partial necrosis were noted. Recurrence of tumor occurred in 8.7% of cases and in those operated in the first instance for recurrence, there was no further local disease. There were minor problems of intraoral hair growth, donor site distortion and obstructive sialadenopathy. Despite disadvantages such as limited size of the flap and reduced length in males to avoid hair bearing area, the authors concluded that the nasolabial skin flap is a useful procedure for closure of selected intraoral defects due to its quick & simple elevation, proximity to the defect and reliable versatility. Gupta D., and Sharma S.C. (1988)1 : reported the treatment of oral submucous fibrosis in 200 patients in whom biweekly submucosal injections of a combination of chymotrypsin, hyaluronidase and dexamethasone administration for 10 weeks proved successful, except in 14 patients who presented with advanced form of the disease. They observed that maximum improvement using submucosal injections was obtained by 10 weeks, and no further improvement was seen even when the therapy was continued on a monthly basis for a year. In 14 patients who were unresponsive to this conservative therapy were subjected to surgical excision of fibrotic bands and submucosal placement of bits of fresh human placenta in the affected areas. After two weeks, biweekly

11

Review of Literature

submucosal injections of dexamethasone administered for 4 weeks, giving definite relief from symptoms. All 14 patients treated with placental grafts had early and significant relief of symptoms. Hynes B., Boyd J.B. (1988)6 : performed anatomic dissection on 12 cadaveric specimens and microangiography on 6 others and confirmed that the facial artery passes deep to the facial mimetic muscles and is not normally included within the flap. Although the vasculature of the flap is technically random the small vessels of the subdermal plexus are generally oriented along its long axis giving it a 'degree of axiality'. They quote two possible reasons for reliability of the flap. 1) Abundant dermo-subdermal plexus supplying the whole area, 2) This vascularity is not haphazard but, exist as axiality of random flap ensuring good perfusion to the most distal parts of the flap. The major contributing vessels to the subcutaneous arterial network include facial artery, transverse facial artery and likely anastomotic contribution from contralateral superior and inferior labial vessels. Seedat H.A., and Van Wyk C.W. (1988)17 : described six patients with typical features of oral submucous fibrosis but without a history of betel nut chewing or an abnormal intake of chillies. All had clinical features and histopathological features suggestive of the disease proper with 3 cases in whom the fibrosis extended into the submucosa. Of the 6 cases, 4 were women and 2 were men, age ranged between 29-52 years. None of the subjects confessed to having practiced the betel nut chewing habit in any form even after in depth investigation. Four used chillies in their food, one smoked, one took alcohol and one had practiced snuff dipping in the buccal sulci, for 12 years but
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Review of Literature

stopped since 4 years. Except for the smoker, the teeth of all others were devoid of extrinsic staining. As no reason for the disease could be demonstrated, the authors suggest genetic predisposition for the development of submucous fibrosis spontaneously. Van Wyx C.W., et al., (1990)18 : carried out an electron - microscopic study of the collagen fibrils for comparison of 11 specimens of moderately advanced and advanced stages of OSMF with 15 control specimes. They noted that the collagen in case of OSMF patients were densely packed bundles in the lamina propria, reaching close to the epithelial - connective tissue junction, to blood vessel walls, salivary glands and muscle fibres, were identified to be the thinner type III collagen fibrils. Immuno-

fluorescent microscopy and special staining with sirius red and polarisation microscopy demonstrate both types, confirming that type I collagen forms the bulk of the collagen and that type III is localised at the sites mentioned above. The author concludes that although there is excessive increase of collagen, especially type I, in submucous fibrosis, the fibrils are still morphologically normal. Borle R.M., and Borle S.R. (1991)5 : Divided 326 patients into two groups Group I had 160 patients with ages ranging from 15-58 years. The group I further divided into A,B,C,D according to age as the disease is more rapid in younger patients. Group-I patients were given biweekly submucosal injections of triamcinolone in lidocaine 2% and hyaluronidase 1500 IU on a biweekly basis, for 4 weeks and followed on monthly basis. Group-II had 166 patients were given vitamin A chewable tablets 50,000 IU/O.D., oral ferrous fumarate 200mg/O.D. and topical beta-methasone drops (0.5mg/ml) / 6 hourly / 3 weeks.

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Review of Literature

A follow-up for 1 year showed that Group-I patients had symptomatic relief within 1 week of treatment, but no improvment in trismus. The disease invariably reactivated in 3-4 months. During the treatment 14 patients developed infection. In Group-II In 2 weeks symptomatic relief was observed. Patients felt

relaxation in the stiffness of buccal mucosa, however there was no improvement in trismus. Relapse was seen in 4-6 months but the number of cases were less when compared to group-I. Thus it was concluded that conventional treatment with injections proved hazardous whereas conservative treatment was found to be safe and both treatment modalities were purely palliative. Garatea J., Buenechea R., et al., (1991)19 : In their technical modification state that the nasolabial island flap provides greater availability of hairless skin for the

intraoral reconstruction. Being an island flap it has a longer pedicle, one stage procedure and is therefore, of greater versatility. The donor site was closed by cheek rotation The

technique, designed by Mustarde (1982) extended to the cervical region.

modification of this technique was based on the principles of the musculocutaneous island flap introduced by Rose(1981) and Hagan (1986), and the hairless skin island was 3.5cms in diameter. Due to the longer pedicle, this flap permits greater versatility. Oral defects of moderate size can be repaired this way, which is particularly advantageous in males.

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Review of Literature

Ioannides C., Fossion E. (1991)20 : reported the use of 59 inferiorly based nasolabial flaps in 43 patients over a period of 10 years, of which 26 flaps in 16 patients were reviewed. They utilized a 2 stage procedure and noted a few complications such as dehiscence, loss of flap, unesthetic extraoral scar and bulky flap which were duly managed.Based on their experience, they concluded that the nasolabial flap is a good alternative for reconstruction of moderate defects of the floor of the mouth, especially in older patients in whom more tissue could be harvested owing to laxity of skin. They also stated that this flap could be used in irradiated patients or in patients who have undergone neck dissection with least donor site morbidity. Pillai R., Balaram P., and Reddiar K.S. (1992)21 : stated that OSMF is multifactorial and appears in people having a genetic predisposition which could render the oral mucosa more susceptible to chronic inflammatory changes on exposure to carcinogens, which include betel quid components including tobacco. The authors also relate the role of viruses and their oncogenic potential to OSMF. Immune dysfunction is a common factor and could be related to any of the factors mentioned above and based on these factors, the author has suggested a possible model for studing genetic environmental - immunologic - nutritional interactions in pathogenesis of OSMF. Khanna J.N., Andrade N.N. (1995)22 : reported their experience with 100 cases of OSMF and found that arecanut was the primary cause of this entity. All lesions were biopsied and a clinico-histopathological staging was proposed. Very early and early stages were treated with conservative approach whereas advanced cases could be successfully treated with only surgical intervention. They described a new surgical

15

Review of Literature

technique of a palatal island flap based on greater palatine artery in combination with temporalis myotomy and bilateral coronoidectomy in 35 cases. They achieved a mean opening of 35mm intra-operatively and on a follow-up of 4 years the mean maximal opening was found to range from 34-35mm. All the donor areas healed well and none of the flaps underwent rejection or necrosis. The authors conclude that surgical treatment was the only solution in advanced cases and the technique of utilising palatal island flap was simple with promising results. Lai D.R. et al., (1995)23 : conducted a retrospective study on a total of 150 patients with varying degrees of oral submucous fibrosis by either medical or surgical therapies. Medical treatment involved a) conservative oral administration of vitamin B complex, bluflomedial hydrochloride and topical triamcinolone 0.1% or b) conventional submucosal injections of a combination of dexamethasone and hyaluronidase, or c) combination of a) and b). The surgical group was treated by the excision of fibrotic tissue and covering the defect with split thickness skin, fresh human amnion or buccal fat pad grafts. Apart from these modalities the authors mention the use of bilateral full thickness nasolabial flaps in such cases but negate its use due to external facial scars, which was not acceptable to the patients. Surgical therapy lead to a significant

improvement of trismus in severe limitation of mouth opening and was the treatment of choice for moderately advanced and advanced cases of OSMF. The authors conclude that apart from surgical treatment, cessation of betel quid chewing before and after therapy combined with daily mouth opening exercises was mandatory for successful management.

16

Review of Literature

Murthi P.R., et al., (1995)24 : reviewed the etiology of OSMF with special reference to the role of arecanut chewing. They summarised and critically analysed the considerable body of evidence which implicated arecanut in the etiology of this condition and commented on the genetic susceptibility and autoimmunity related to the disease. Cox S.C., and Walker D.M. (1996)3 : reviewed the prevelence, incidence, &

etiology of OSMF and also discussed the factors responsible, immunological process, signs & symptoms, histological features and malignant potential of this entity. On reviewing the management for OSMF, they noted that medical line of treatment had unsatisfactory results while surgically dividing the fibrous bands and filling the defect with split- thickness skin graft or nasolabial flaps had gained increasing popularity. They concluded that as the condition was irreversible, early diagnosis and cessation of betel nut chewing would be the best way of controlling the disease. Yeh C.Y. (1996)25 : presented the application of the pedicled buccal fat pad flap in the surgical treatment of oral submucous fibrosis. In his study, 9 patients underwent surgical release of fibrotic bands with or without coronoidectomy to achieve a minimal inter-incisal mouth opening of 35mm following which the defects were covered with pedicled buccal fat pads. The authors noted satisfactory results in all but two patients who failed to follow post operative physiotherapy. They achieved an average increase in the mouth opening by 19.1 mm over a mean follow up of 21.3 months. They noted that the technique was easy to perform and could be approached through the same incision. In addition BFP provided adequate bulk to cover the entire defect and epithelized by 2 to

17

Review of Literature

3weeks with no incidence of breakdown or infection. They concluded that the technique was a logical, convenient and reliable option for the treatment of OSMF. Pogrel et al. (1998)26 : performed a cadaver dissection study to investigate the anatomy of the nasolabial fold with a view to explaining the problems of surgical softening or elimination of the fold. The nasolabial fold is absent in the newborn and deepens and becomes more prominent as age advances. The nasolabial fold is defined by structures that support the buccal fat pad and hold it above the fold. This appeared to be a combination of muscle bundles that run both across and parallel to the fold and also by fibrous septae supporting the fat pad. This had implications for the development of surgical procedures to soften or eliminate the fold, which must separate the muscles from the dermis of the fold and allow the fat to descend and soften the fold. They also noted that in any procedure around the nasolabial area the facial nerve was not at risk, as it was deep to the muscle layer. They suggested that development of surgical techniques taking into account the anatomical structure of the nasolabial fold wound be a logical development. Hosaka Y. et al., (1999)27 : recommended the use of redundant nasolabial flap skin for lining in reconstruction of full thickness alar defects. The technique was successfully used to reconstruct full thickness alar defects in 4 patients and the authors noted that this flap provided the advantage of well vascularized tissue of appropriate colour, texture, thickness for external skin and nasal lining in one stage reconstruction. Ducic Y., Burye M. (2000)28 : described the successful use of pedicled

nasolabial flaps in the reconstruction of various oral cavity defects with or without
18

Review of Literature

adjunctive microvascular free tissue transfer. Twenty eight flaps were preformed in 18 patients, for reconstruction of defects in the anterior tongue, floor of mouth, palate and retromolar trigone. All flaps healed without evidence of necrosis, infection or

dehiscence. Patient satisfaction with this procedure was high. The use of the nasolabial flap appeared to provide an improvement in overall functional outcome. They concluded that the inferiorly based nasolabial flap provided reliable coverage of intermediate size oral cavity defects when used alone. It could improve mastication and speech when used in conjunction with microvascular free tissue transfer for the reconstruction of large combined defects of the tongue and floor of mouth. Feinendegn D.L., Langer M. and Gault D. (2000)29 : described a modification to the standard nasolabial flaps for the simultaneous reconstruction of confluent perialar and full thickness alar defects. The main body of the flap was advanced to cover the external surface of the perialar and alar defects and a side extension to the flap, based only on a dermal blood supply, was turned over to line the reconstructed alar rim. The technique achieved excellent skin match and did not leave the patient with a distinct donor site scar. They noted that nasolabial flap could be safely dissected over long distances in a subdermal layer and their pedicles reduced to areas of subcutaneous vascular supply smaller than 1cm in width. They noted that this was possible, because of the excellent vascular supply of the nasolabial and cheek skin with dense subdermal plexus from the perforators of the facial artery, the infra orbital artery and the transverse facial artery.

19

Review of Literature

Haider S.M., et al., (2000)30 : performed a study on 325 patients suffering from oral submucous fibrosis. The purpose of this study was to investigate the association of location of bands in oral submucous fibrosis and extent of mouth opening. They staged the disease clinically and functionally. Clinical staging : I II III : : : Faucial bands only Faucial and buccal bands Faucial and labial bands

Functional staging : Stage A Stage B Stage C : : : Mouth opening Mouth opening Mouth opening 13 20 mm 10 12 mm < 10 mm

They found that all those who had labial band also had buccal bands, all those who had buccal bands also had faucial bands but 111 (42%) of those with buccal bands did not have labial bands. They concluded that bands are common at the posterior region in mild cases of OSMF and as the disease increases in severity, are more likely to be found anteirorly as well. Haque M.F., Meghji S., et al (2001)31 : in their study investigated -

20

Review of Literature

a)

The effect of interferon gamma on collagen synthesis by arecoline stimulated oral submucous fibrosis fibroblasts in vitro (n=5).

b)

The effect of intra-lesional interferon gamma on the fibrosis of oral submucous fibrosis patients (n=29).

c)

The immunohistochemical analysis of pre and post treatment inflammatory cell infiltrates and cytokine levels in the lesional tissue (n=29). The results showed that the increased collagen synthesis in vitro in response to

arecoline was inhibited in the presence of interferon gamma (0.01 10.0 u/ml) in a dose related way. In an open uncontrolled study intralesional interferon gamma treatment showed improvement in the patients mouth opening from an inter incisal distance before treatment of 217mm to 307mm immediately after treatment and 308mm 6 months later, giving a net gain of 84mm (42%). Patients also reported reduced burning,

dysesthesia and increased suppleness of the buccal mucosa. The effect of interferon gamma on collagen synthesis appears to be a key to the treatment of these patients and intra-lesional injections of the cytokine may have a significant therapeutic effect on oral submucous fibrosis. Lazaridis N. (2003)32 : described the use of a single-stage unilateral subcutaneous pedicled nasolabial island flap, for reconstruction of defects of the anterior floor of mouth by raising the flaps as skin island relying on the pedicle of subcutaneous tissues. 9 flap procedures were performed on 9 patients for reconstruction of defects of anterior floor of mouth. All flaps healed without evidence of infection, dehiscence or

21

Review of Literature

necrosis and the flap provided improved functional integrity of the reconstructed area. The author concludes that this flap provides reliable coverage of small and intermediate sized defects of the anterior floor of mouth when used alone, improving the tongue mobility, articulation and deglutition.

22

Methodology

METHODOLOGY
MATERIALS: This study was carried out in the Department of Oral, Maxillofacial and Reconstructive Surgery, Bapuji Dental College and Hospital, Davangere. This study is concerned with usage of modified single-stage winged nasolabial island flaps for reconstructive procedures in case of oral submucous fibrosis. Patients reporting to our department with the complaint of restricted mouth opening or burning sensation of the buccal mucosa or combination of both, were confirmed for oral submucous fibrosis on the basis of thorough clinical examination with a positive history of habits such as chewing of tobacco/betelnut, etc, and

histopathological examination. Routine haematological investigations and radiographs were done for all patients. METHOD: A total of 14 cases with OSMF were undertaken for the study. All the

procedures were carried out under general anesthesia wherein the patients were intubated using the awake blind nasal technique. All patients received Inj. Amoxycilline 1 gm and Inj. Dexamethasone 8 mg half an hour prior to the surgical procedure. The intraoral incisions to release the fibrous bands were made using

electrosurgical knife along the buccal mucosa at the level of occlusal plane away from Stenson's duct orifice. Incision began from the corner of mouth, where it was forked

23

Methodology

and extended posteriorly upto the anterior faucial pillars and soft palate. The wounds created were further freed by finger dissection and undermining was done by blunt dissection until no resistance was felt. Using Fergusson's mouth gag forcible mouth opening in the range of 35-50 mm was achieved and a bite block was placed. For the reconstruction of the defect in the buccal mucosa, the winged nasolabial skin island flap was used in our study. First the facial artery was palpated as it entered its facial course at the anterior border of masseter muscle near the inferior border of the mandible. The marking for the flap design was done using methylene blue ink. An elliptical shaped nasolabial flap was designed to be centered over the nasolabial groove. The underlying facial artery was identified beneath the facial skin with assistance of its anatomical landmarks. The lateral dimension of the flap was

outlined for maximum cosmetic results. The width was kept as 1.5 cm to 2.5 cm and was largely limited to the laxity of the cheek, so as to avoid distortion of the angle of the mouth. The medial incision line precisely followed the nasofacial folds on it's inferior third, thus causing less distortion after flap transfer and allowed for improved arc of rotation. The medial and lateral limbs of incision tapered together, superiorly approximately 0.5 to 0.65 cms antero-inferiorly to medial canthus. In single stage procedure medial limb of incision was made longer than lateral limb of incision. The distal tips of the flaps tapered at an acute angle of 35 or less. The elliptical design of the flap avoids skin puckering or dog ear formation in the closure of the donor nasolabial area. A width of 2-3 cms can be elevated without causing any donor site problem.

24

Methodology

With the planning completed the flap was raised from superior to inferior in a supramuscular plane by using dissecting scissors. The pedicle was positioned at the region of the modiolus wherein the facial artery enters the skin. The transbuccal tunnel was made in the region of the modiolus just medial to the pedicle. The tunnel was large

enough to easily accommodate 1 or 2 fingers. The flap was then transferred into the oral cavity in a tension free manner and inset onto the defect with a series of simple interrupted sutures using 3 0 absorbable vicryl (910 polyglactin). Generous undermining of the donor site was performed in the subcutaneous plane, as for a skinlift rhytidectomy and layered closure of the donor defect was then performed using 3 - 0 vicryl suture for deeper layer and 5 - 0 prolene for final skin closure. An attempt was made to minimally evert the margins along the nasofacial portion of the incision so as to achieve a slightly depressed scar once healing is

completed, which results in a more natural appearance. All patients received Inj. Amoxycilline 500 mg and Inj. Metronidazole 500 mg 8th hourly by the intravenous route for the first 4 days and then Cap. Amoxycilline 500 mg and Tab.Metronidazole 400 mg by the oral route for the next 3 days, along with 9 doses of intravenous Dexamethasone 8 mg given 8th hourly for the first 72 hours. Patients received analgesics, Injection Voveran 75 mg 12th hourly for the first three days and Tab. Diclofenac Sodium 8th hourly for another four days. Patients were put on nasogastric tube feeding for a duration of 15 days. Extraoral sutures were removed by the end of seventh day and by the end of the fifteenth day all the intraoral sutures were removed. Patients were started on mouth
25

Methodology

opening exercises (using wooden sticks) from

the 10th postoperative day, with a

frequency of four times a day with a duration of half an hour, and later the frequency and duration was increased to facilitate improvement in the mouth opening until values that were achieved intraoperatively. Patients were evaluated for various parameters both intraoperatively and post operatively regarding the surgical procedure (as per proforma), postoperative donor site and recipient site changes and mouth opening (table 1).

26

Proforma

A MODIFIED SINGLE STAGE NASO-LABIAL FLAP (WINGED) IN THE SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS

PROFORMA
Personal details of patient Name : Occupation Address : : Age/Sex:

PRE-OPERATIVE EVALUATION
Chief complaint History of present illness Past medical history Personal history a) b)
Type of Habits Panparag chewing

: :

: : Diet Habits
Betel nut Pan+ Betel nut+ Lime Pan + Betelnut + lime + tobacco Snuff Tobacco Panparag + Smoking Pan+ Betelnut + lime+ Smoking Panparag + Alcohol

Duration Quantity Frequency

GENERAL EXAMINATION OF THE PATIENT Pallor Icterus Cyanosis Vitals : : : BP Pulse : : Koilonychia Lymphadenopathy Edema Respiratory rate Temperature : : : : :

27

Proforma REVIEW OF SYSTEMS a) CNS c) RS : : b) CVS d) GIT : :

LOCAL EXAMINATION I) EXTRA ORAL EXAMINATION OF HEAD & NECK Symmetry of the face Shape of the face TMJ examination Lymphnode examination Nasolabial groove : : : : : : Stage I II III IVa IVb Mouth opening > 35 mm 26 35 mm 15 25 mm 2 14 mm Associated with premalignant and malignant changes

Maximum interincisal mouth opening Stage of presentation :

II) EXAMINATION OF ORAL CAVITY a) Hard tissue examination Number of teeth present Number of teeth missing Number of teeth decayed Number of teeth mobile Type of occlusion b) Soft tissue examination Periodontal status : : : : : :

28

Proforma SOFT TISSUES : Soft tissue (Site) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Upper lip Lower lip Buccal mucosa right Buccal mucosa left Upper vestibule Lower vestibule Palatal mucosa Lingual mucosa Soft palte, Uvula Floor of the mouth Retromolar area Rt Retromolar area Lt Colour Consistency Site and Extent of Fibrosis

PROVISIONAL DIAGNOSIS :

INVESTIGATIONS 1) Blood investigations Hb% TC ESR PCV BT CT 2) Radiographs 3) Biopsy Incisional Histopathological Report Finding 4) Others : Chest X-ray : ECG: - Orthopantomogram HIV HBsAg DC N L M B E

29

Proforma FINAL DIAGNOSIS : INTRAOPERATIVE EVALUATION Procedure : Extent of incision Forced mouth opening (Under GA) : _____________ mm Coronoidectomy Done / Not done Reconstruction : Flap design Flap dimension (length and width) Adequacy of flap : Length = Adequate/ Inadequate Bulk Width = Adequate / Inadequate = Adequate / Inadequate Masseter Muscle Stripping - Done/Not Done

Intra Operative : Bleeding from facial vessels Damage to parotid duct Damage to infraorbital nerve Suture material used : Suturing technique : - E/O I/O POSTOPERATIVE : a) b) c) Postoperative Drug Therapy Nasogastric Tube Feeding (Duration) Jaw Physiotherapy : : : : :

30

Proforma
TABLE 1 : POSTOPERATIVE EVALUATION FINDINGS 1st Flap colour Flap failure Blue /White flap Wound dehiscence Infection Intra Sloughing oral Hair growth
Salivary fistula

DAILY REVIEW 2nd 3rd 4th 5th 6th 7th

WEEKLY REVIEW 2nd 3rd 4th

MONTHLY REVIEW 2nd 3rd 4th 5th 6th

Flap margins Co-apted/ Raised Flap loss partial/ complete Wound healing Wound Extra dehiscence oral Wound infection Scarring Mouth opening ____ mm under GA Pre-Operative Mouth Opening = _______ mm

31

Observation & Results

OBSERVATION AND RESULTS

All the patients in our study were diagnosed to have oral submucous fibrosis based on clinical and histopathological examination. The observations inferred from the patient's case records regarding their age, sex, chief complaint, type of habits (with duration) are tabulated in table-2. Preoperative mouth opening was less than 20 mm in 9 cases while 5 cases had an interincisal mouth opening upto 28 mm. All the patients had varying amounts of restriction in tongue and soft palate function. After routine preoperative workup, patients were taken up for surgery under general anesthesia. Blind awake nasal intubation was carried out in all patients. Intraoral incisions extended from corner of mouth to anterior faucial pillars in 6 cases, while in 8 cases, the incision extended upto soft palate posteriorly. After the release of fibrotic bands, a defect of approximately 6 x 2 cms was created into which bilateral subcutaneous pedicled winged nasolabial skin island flaps were transposed through the buccal tunnel in all 14 cases. The intraoral flap was sutured by placing interrupted sutures using 3-0 vicryl. Extraoral wound was closed in layers, subcutaneous layer using 3-0 vicryl and skin closure was done using 5-0 prolene. 2 of our cases required coronoidectomy since the mouth opening achieved was less than 35mm. Other additional procedures like masseter muscle stripping, temporalis myotomy were not required. In 10 of our cases the third molars were extracted to avoid tooth impingement on the flap postoperatively.

32

Observation & Results

Minor bleeding was encountered intraoperatively which was controlled with a pressure pack. No major vessel damage in the operative region was encountered. Post operatively various parameters with regard to the flap, donor site, mouth opening and other complications were evaluated as per table-2. There was no incidence of infection in the transferred flap and the recipient site in all 14 cases which could be attributed to the seven day antibiotic regimen (4 days IV + 3 days oral), regular intraoral irrigation of the flap and thorough cleaning and dressing of donor wound. Complications due to vascularity (blue flap or white flap) were not encountered, except for slight ecchymosis at the flap tips and suture margins, which subsided after 2 - 3 days postoperatively. In our series of nasolabial flaps, flap loss either complete or partial were not encountered. Other complications like flap necrosis, obstructive sialadenitis and damage to facial nerve branches were not observed due to the careful and meticulous handling of tissues. Intraoral hair growth and extraoral scar at the donor site were encountered in all our patients. By the 3rd-4th postoperative day intraoral hair growth was evident. Regular trimming of intraoral hair was carried out upto 1 month duration after which regular epilation was carried out till the hair growth reduced in all 14 patients. In 12 cases the extra oral scars widened and became readily perceptible one month postoperatively and in 3 of them progressed to become hypertrophic scars. These 3 patients underwent scar revision and plastic closure at a later date. Although the scars were perceptible in all cases, they were readily accepted by the patients.

33

Observation & Results

The preoperative mouth opening was in the range of 12-28 mm, with a mean of 18.8 mm. After release of fibrotic bands a mean forced intraoperative mouth opening of 38.4 mm was achieved. On the first postoperative day a mean mouth opening of 19.7 mm was achieved. Regular mouth opening exercises commenced on the tenth postoperative day with a frequency of four times day and a duration of half an hour was carried out. Later both the frequency and duration was increased which aided in further increasing the mouth opening. Mean mouth opening of 43.7 mm was achieved at 6 months, with a mean increase of 24.2 mm. The mouth opening in all the 14 patients were maintained well above the forcible mouth opening achieved intraoperatively. No relapse was encountered, even at the last follow up. The details of the postoperative mouth opening evaluation is tabulated in table-4.

34

Observation & Results

TABLE 2 PRE-OPERATIVE EVALUATION

Case No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Age (yrs) 29 23 33 28 22 35 19 39 22 30 27 17 18 45 Sex M M M M M M M M M M M M M F Chief complaint Burning sensation & limitation of mouth opening since 4 months Inability to open mouth since 2 years Pain & burning sensation since 2 years Inability to open mouth since 1 years Inability to open mouth since 4 years Pain & decreased mouth opening since 3 months Inability to open mouth since 1 years Inability to open mouth + Burning sensation 4 years Inability to open mouth since 2 years Inability to open mouth since 2-3 months Decrease in mouth opening since 1 year Decrease in mouth opening since 6 months Difficulty in mouth opening since 4 years Inability to open mouth since 2-3 months & burning sensation since 1 year Type of habit (with duration) Star, 4-5 pk/day; 2 yrs Jarda, 10-15pk/day; 9 yrs Betelnut, 4-6/day, 7-8 yrs Betelnut, 5-6/day, 7-8 yrs Pan Parag 8pk/day, 4-5 yrs Pan+Betelnut+Lime+Tobacco, 3-4pk/day, 10 yrs Betelnut, 10-14/day, 7 yrs Pan + Betelnut+Lime+Tobacco, 3-4pk/day 10 yrs Betelnut, 10-12/day 4-5 yrs Smoking & Alcohol occasional Manikchand, 6-7 pk/day, 7 yr Pan Parag, 5-6 pk/day, 5 yr, Pan+Betelnut+Lime, 3-4/day, 5 yrs Star, 2 pk/day, 4 yrs PanParag, 5-6 pk/day, 4yrs, tobacco 1 pk/day, 4 yrs. Tobacco+Lime, 1pk/day, 18 yrs Stage of presentation III IVa III III III II III IVa III II III III III IVa

35

Observation & Results

TABLE 3 POST-OPERATIVE EVALUATION

Findings 1
Flap color Flap failures Blue/ White Flap Wound dehiscence Infection Normal X X X X Scanty X Co-apted X Satis. X X Accept

CASE NO. 2
Normal X X X X Scanty X

3
Normal X X X X Mod. X

4
Normal X X X X Mod. X

5
Normal X X X X Scanty X

6
Normal X X X X Absent X

7
Normal X X X X Mod. X

8
Normal X X X X Scanty X

9
Normal X X X X Mod. X

10
Normal X X X X Mod. X

11
Normal X X X X Mod. X

12
Normal X X X X Mod. X

13
Normal X X X X Absent X

14
Normal X X X X Absent X

Intra oral

Sloughing Hair growth Salivary fistula Flap margin Co-apted/ raised Flap loss Partial/complete Wound healing

Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted Co-apted X Satis. X X Accept X Satis. X X Accept X Satis. X X Accept X Satis. X X Accept X Satis. X X Accept X Satis. X X Hyp. X Satis. X X Accept X Satis. X X Accept X Satis. X X Hyp X Satis. X X Hyp. X Satis. X X Accept X Satis. X X Accept X Satis. X X Accept

Extra

Wound dehiscence Wound infection Scarring

oral

Accept : Acceptable,

Hyp : Hypertrophic,

Satis : Satisfactory,

Mod : Moderate,

X : Absent

36

Observation & Results

TABLE 4 MOUTH OPENING EVALUATION

Case No. Pre-operative Forced spontaneous intra-operative mouth mouth opening (mm) opening (mm)

POSTOPERATIVE MOUTH OPENING

1st 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Means

2nd 3rd 25 25 20 27 31 25 23 22 20 24 13 19 10 15 24 25 20 30 28 25 26 25 20 26 13 20 12 18

Days 4th 5th 21 27 22 25 25 29 26 23 20 28 15 20 12 19 22 27 22 25 21 29 27 27 20 30 17 22 12 20

6th 23 27 23 27 24 27 27 25 19 28 17 25 13 20

7th 24 27 25 27 23 27 27 27 18 25 18 25 15 20

Weeks 2nd 3rd 4th 34 31 26 30 24 39 30 32 22 36 18 24 22 25 40 35 24 35 29 39 35 38 22 40 21 29 24 28 42 40 28 43 38 42 34 38 33 43 23 29 24 30

2nd 3rd 43 50 30 35 38 44 34 42 30 47 28 30 33 32 56 50 38 42 36 46 36 43 37 50 30 33 35 34

Months 4th 5th 56 49 40 45 34 42 39 49 32 47 34 36 35 34 58 50 40 43 38 44 41 44 36 47 38 36 35 36

6th 60 49 40 45 39 46 48 46 34 47 38 38 35 38

23 12 18 22 21 28 16 12 18 28 17 19 18 12 18.8

50 35 41 40 40 40 36 30 30 38 40 40 40 38 38.42

23 20 18 25 30 24 16 18 20 24 17 17 10 15

19.7 21.3 22.2 22.2 22.9 23.2 23.4 28.0 31.3 34.7 36.8 40.4 40.8 41.8 43.7

37

Observation & Results

F IG . 1 : M O U T H O P E N IN G E V A L U A T IO N
45
Mean Mouth Opening in mm
3 8 .4 3 4 .7 3 1 .3 2 8 .0 2 3 .4 1 8 .8 3 6 .8 4 0 .4 4 0 .8 4 1 .8

40 35 30 25 20 15 10 5 0

a -o p

on th

ee k

ks

ks

e-O

s on th 4m

-In tr

1w

2w

3w

1m

Pr

on th

on th

2m

Fo rc

ed

T im e In t e r v a l

38

3m

6m

on th

ee

ee

Observation & Results

FIG.2 : INCREASE IN MOUTH OPENING

Preoperative 70 60 60 Mouth Opening in mm 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 23 18 12 22 49.0 45 40 39 34 28 21 16.0 12 18 28 17 19 46 48 46 47 38 38

Postoperative

35

38

18 12

13

14

No.of Patients

RESULT : Mean Increase in Mouth Opening = 24.2mm

39

Case Photos

Case Photos

Case Photos

Case Photos

Case Photos

Case Photos

Case Photos

Discussion

DISCUSSION
Oral submucous fibrosis is a precancerous condition with increased prevalence in the Indian subcontinent..3 It has wide variety of etiological factors, among which the common and most accepted one is the concept of chewing betel nut and tobacco in its various forms. In our series, all patients gave a positive history of chewing some form of betel nut or tobacco or a combination of the common form being roasted betel nuts.

Diagnostic criteria of OSMF are burning sensation of mucosa, mucosal blanching, which may be spotty, resulting in marbled appearance and stiffness of oral mucosa, formation of vesicles/ulcers, stomatitis, sensation of dry mouth, alteration in taste, fibrosis of the oral mucosa followed by stiffness most commonly in the buccal mucosa, soft palate and faucial pillars. Fibrotic bands running vertically in the cheek and circumferentially in the lips are palpable. Limited function of the soft palate, shrunken and bud like uvula, restricted tongue movements are seen in advanced cases.14,16 Majority of these diagnostic features were observed in all our patients with varying severity. According to Khanna and Andrade's grouping of OSMF22 based on clinical and histolopathogic features, 2 of our patients were of group II, 9 were group III while 3 belonged to group IVa. It is a well established fact that in oral submucous fibrosis there is decreased vascularity to the affected region by fibrosis due to contraction and narrowing of blood vessels as a result of increased pressure on them by fibrous tissue bands.22 Medicinal

47

Discussion

modalities of treatment like topical application of gold16, iodides & intralesional injection of hyaluronidase, hydrocortisone, placentral extract & triamcinolone14,16 along with oral administration of vitamins, iron supplement14, antioxidants & peripheral vasodiators like buflomedial hydrochloride23 & nylhydrin hydrochloride are of temporary benefit and are of no use in treating moderately advanced and advanced cases of OSMF. In these patients (group III and IV) surgical therapy is beneficial. Materials used for grafting in OSMF after excision of fibrotic bands include skin grafts, tongue flaps, buccal fat pat, amnion graft, nasolabial flaps and palatal island flaps. Additional procedures like temporalis myotomy and bilateral coronoidectomy can be performed to enhance mouth opening.5 Mere cutting of the fibrotic bands followed by forcible mouth opening and allowing secondary epithelization left an unsatisfactory rigid buccal mucosal surface even when attempts were made to reduce collagen formation by insertion of steroid impregnated packs.14 Results with skin grafting to cover the raw areas have been disappointing as the incidence of shrinkage, contracture and rejection of graft was found to be very high because of the poor oral conditions and subsequent recurrence of symptoms.22 Split thickness skin grafts along with bilateral temporalis muscle myotomy or coronoidectomy were effective, but have the drawbacks of secondary contracture formation in temporalis tendon and muscle and pterygomandibular raphae, which appears to be the principal cause of restricted mouth opening.14

48

Discussion

Tongue flaps have also been used for treating oral submucous fibrosis but have disadvantages such as postoperative dysphagia, disarticulation, the risk of postoperative aspiration and need for additional surgery for detachment of the pedicle.22 The involvement of tongue in oral submucous fibrosis often precludes its use in treating oral submucous fibrosis.5,22 Application of amniotic membrane is of little benefit when used in single layer over deep buccal defects.23 Human placental grafts can also be applied to cover the defects. It has shown little beneficial results when combined with submucosal injection of dexamethasone.1 Buccal fat pad is also used for coverage of defects after fibrotic band excision. The harvesting of buccal fat pad is simple due to easy access, however gradual recurrence of trismus is observed after some time if physiotherapy is not performed.25 Palatal island flaps based on greater palatine artery to cover the defects of oral submucous fibrosis has been employed by Khanna J.N and Andrade N. The technique of utilizing the palatal island flaps was found to be simple. The highlights of this technique, as applied in the surgical management of OSMF were as follows: The hard palate owing to its minimal quantity of connective tissue has a low percentage of fibrosis in OSMF. The donor area is in close proximity and of a similar texture and colour. There is no muscle in the flap to undergo fibrosis. Since this mucoperiosteal flap is pedicled to the greater palatine artery the chances of shrinkage, sloughing and contracture are minimal. Increased vascularity of the involved regions may help to improve the condition.

49

Discussion

No secondary surgery is required for detachment of the pedicle. There is low morbidity, as the donor area heals well. Surgical treatment was considered to be the only solution in group III and group

IV cases, with bilateral temporalis myotomy and coronoidectomy as additional highly effective surgical procedures.22 It is practically impossible to excise all fibrous bands and to graft the site with lingual pedicle flaps or placental or skin grafts . Surgical excision especially with a disease like OSMF causes contractures during healing. If lingual pedicle flap grafting is done after excision of a limited amount of diseased tissue in the retromolar area, it will certainly relieve trismus for a short period. The tongue, which serves as the donor site, is also involved in OSMF. It is therefore hazardous to graft a part surrounded by the disease with a graft equally prone to develop the disease. The donor site is also compromised and the gain from surgery is short lived.5 The use of nasolabial flaps in treatment of OSMF is more suitable for juxtaposed defects, in particular those of buccal mucosa, and is increasingly popular. The nasolabial flap provides a good example of the transposition flap principle in which the unavoidable tension is transferred from the defect to the donor area where there is sufficient tissue elasticity to absorb it (Huffstadt, 1961). Defects of the ala, the tip and the bridge of the nose, and the upper and lower lip resulting from trauma or surgical excisions are particularly suitable for reconstruction with nasolabial flaps provided that the tissue to be

50

Discussion

transposed is unscarred and has not been previously irradiated. The colour and texture match is excellent and in older patients, the donor scar is quite inconspicuous.27 The versatility of the nasolabial flap depends upon several factors. Owing to a dual blood supply from both facial and ophthalmic arteries, (Fig. 1) the flap can be either superiorly or inferiorly based.8

Fig- 1. Dual vascular supply of the nasolabial flap Intraorally placed nasolabial flap provides 15 cm2 of durable lining11, a mobile pedicle with sufficient blood supply to be safely transposed at the time of primary tumor resection even after ligation of the facial artery, optional use of single or bilateral flaps,

51

Discussion

an excellent method to release secondary ankyloglossia, the option of placing the flap tip anteriorly or posteriorly and the ability to close exposed mandibular prostheses.11 The classic nasolabial flap is an oblique cheek flap based either superiorly or inferiorly. Often used for alar and lip reconstruction, this type of flap has been suggested in the past for palatal and floor of the mouth reconstruction. The flap usually extends inferiorly to an area lateral to the nasolabial fold, but it can be carried more inferiorly to the area of the oral commissure to provide a longer more versatile flap.8 As this part of the cheek remains soft and supple even many years after repair, this led to development of the application of bilateral nasolabial flaps to cover the defect created by excision of fibrotic bands, by Kavarana N.M and Bhatena H.M., with promising results in 3 cases.4 The advantages of nasolabial flaps are, the donor site is in the same operating field, reliable and rich vascularity, provides versatality in design, proximity to the defect, ease of flap elevation, supple skin, thus aiding in increasing mouth opening and causing minimal esthetic deformity, while the disadvantages being intraoral hair growth and occasional hypertropic scar at the donor site. Nasolabial flap can be either cutaneous, subcutaneous, musculocutaneous or island nasolabial flaps. In our study we employed bilateral modified single-stage winged nasolabial island flaps in all our 14 patients. The length of the flap was adequate to cover the intraoral defect and layered closure of donor site was achieved to minimize postoperative extraoral scar. Intraoperative complications like damage to facial vessels, parotid duct and branches of facial nerve were not encountered in any of the 14 patients included in the study.
52

Discussion

Post operatively patients were evaluated for various parameters concerned to donor site as well as the recipient site (Table No. 1). None of the flaps showed either bluish or whitish discoloration in the postoperative phase and no infection was encountered in any of our cases. Complications such as flap loss, flap avulsion, obstructive sialadenopathy or wound dehiscence were not encountered in our series. Intraoral hair growth was observed on the 3rd 4th postoperative day, which was managed by regular trimming initially followed by epilation after 1 months. The donor site healed uneventfully in all our cases except in 4, where dehiscence was noted at the modiolar region where maximal tension was observed during closure. This complication usually occurred at the 2nd 3rd month and was managed with systemic antibiotics and local dressings till the defect healed secondarily. The cause for the dehiscence could be attributed to the excessive muscular forces exerted in that region during vigorous physiotherapy and hence proper layered closure, especially at the modiolar region is mandatory. Initially the scars were inconspicuous but later increased in width (upto 2-3mm) which were readily perceptible in 12 of our cases. 3 out of these 12 patients developed hypertrophic scars and were taken up for revision and plastic closure at a later date. Although the scars were perceptible in all cases, they were readily accepted by the patients. Definite increase in mouth opening was observed over the first four post - operative weeks, three months and at six months period as shown in table - 4. A mean increase in mouth opening at the 4th postoperative week was 34.7 mm, at 3 months was 40.4 mm and by the end of 6 months an increase upto 43.7 mm was noted

53

Discussion

Another case, a 40yrs old edentulous male, (not included in our study), presented with an inter-ridge distance of 42mm (Central incisor region). He underwent the same surgical procedure and forced mouth opening (inter-ridge distance) of 55mm was achieved. It was observed that the inter-ridge distance on the first post-operative day was only 25mm which is significantly low as compared with the readings of other patients. All the other patients had higher or same reading as that of the pre-operative value. By the end of one week, the inter-ridge distance increased to 40mm. Like the other patients physiotherapy was initiated on the 10th post-operative day. The mouth opening

improved slowly over a period of 4 weeks to 50mm, at 3 months to 52mm and at the end of 6 months to 55mm. The slow improvement in mouth opening could be attributed to the edentulous ridges due to which accurate physiotherapy with respect to frequency and duration will be altered. Patient compliance will be inadequate, if minimal inflammation or soreness of the ridges occur thus hampering regular exercises. However, the flap uptake was

excellent, with very little scarring at the donor site and over a period of 2 months, intraoral hair growth ceased completely. In our series of patients, the nasolabial flap has been durable and versatile and has provided adequate mouth opening, making it a reliable flap for use in cases of oral submucous fibrosis. Thus, the application of bilateral single-stage winged nasolabial island flap for surgical management of oral submucous fibrosis showed promising results in our series of cases with a six months follow up period.

54

Summary & Conclusion

SUMMARY AND CONCLUSION

The aim of treating oral submucous fibrosis is to provide relief to the patient from the limitations of mouth opening and burning sensation. Numerous treatment modalities (both medical and surgical) have been employed for the treatment of OSMF. The surgical modalities that have been employed through the years include, mere cutting of fibrous bands and interposition with skin grafts, tongue flaps, palatal island flaps, amnion grafts, placental and buccal fat pad grafts. The application of nasolabial flaps in surgical treatment of OSMF was introduced by Kavarana N.M. and Bhatena H.M in 1987, where they have used successfully in treating three patients with OSMF. The purpose of this study was to evaluate the versatility of the bilateral singlestage winged nasolabial island flaps in the surgical treatment of OSMF. Based on our study, the following conclusions can be made: 1. The nasolabial flap is a versatile flap, which can be successfully used in the reconstruction of defects created after the release of fibrotic bands. 2. Nasolabial region has an excellent dual blood supply, which assures the successful take-up of the flap. No partial or complete flap failures were noted in our series of cases. 3. It is cosmetically acceptable as the line of closure of donor site lies along the nasolabial crease. 4. The technique of harvesting the nasolabial flap is simple.

55

Summary & Conclusion

5.

The donor site is in close proximity to the defect. However this flap has the following drawbacks:

Presence of intraoral hair growth may be a problem especially in males but this can be reduced by regular epilation

Occasional formation of hypertrophic scars at the donor site. Although our series comprised of a limited number of cases and a short follow up

period, initial results were more than satisfactory permitting us to logically conclude that bilateral single-stage winged nasolabial island flaps are a viable and a reliable option, that has withstood the test of time for reconstruction of intraoral defects in oral submucous fibrosis.

56

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