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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

ii

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled "A MODIFIED SINGLE


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 Dr. NISHANTH N. SHETTY

Reader, DATE : / /2005 Dept. of Oral, Maxillofacial &

Reconstructive Surgery Bapuji Dental College & Hospital

Davangere 577 004.

iii

ENDORSEMENT BY THE HOD,

PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that this dissertation entitled "A MODIFIED SINGLE


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.

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

DATE : / /2005 PLACE : DAVANGERE

DATE : / /2005 PLACE : DAVANGERE

iv

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)

v

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.

vi

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

vii

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 intra-oral defects in oral

submucous fibrosis.

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TABLE OF CONTENTS

PAGE NO

1. INTRODUCTION 01

2. HISTORY 03

3. OBJECTIVES 04

4. REVIEW OF LITERATURE 05

5. METHODOLOGY 23

6. OBSERVATION AND RESULTS 32

7. DISCUSSION 47

8. SUMMARY AND CONCLUSION 56

9. BIBLIOGRAPHY 58

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LIST OF TABLES

SL.NO. TABLES PAGE

1. PRE-OPERATIVE EVALUATION 35

2. POST-OPERATIVE EVALUATION 36

3. MOUTH-OPENING EVALUATION 37

xi

LIST OF FIGURES

SL.NO. FIGURES PAGE

1. MOUTH OPENING EVALUATION 38

2. INCREASE IN MOUTH - OPENING 39

3. CASE PHOTOS 40

xii

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

1

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.

2

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 one-

step 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

3

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.

4

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.

5


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

6


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

7


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

8


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 : modified the cutaneous nasolabial flap by

incorporating the 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.

9


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


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


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

12


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.

13


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

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

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.

14


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


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


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


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


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


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 : Faucial bands only

II : Faucial and buccal bands

III : Faucial and labial bands

Functional staging :

Stage A : Mouth opening - 13 20 mm

Stage B : Mouth opening - 10 12 mm

Stage C : Mouth opening - < 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


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


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

P R O F O R M A

Personal details of patient

Name : Age/Sex:

Occupation :

Address :

PRE-OPERATIVE EVALUATION

Chief complaint :

History of present illness :

Past medical history :

Personal history :

a) Diet

b) Habits

Type of Habits

Panparag chewing

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 : Koilonychia :

Icterus : Lymphadenopathy :

Cyanosis : Edema :

Vitals BP : Respiratory rate :

Pulse : Temperature :

27

Proforma

REVIEW OF SYSTEMS

a) CNS : b) CVS :

c) RS : 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 :

Maximum interincisal mouth opening :

Stage of presentation : Stage Mouth opening I > 35 mm II 26 35 mm III 15 25 mm IVa 2 14 mm IVb Associated with premalignant and malignant changes

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

PROVISIONAL DIAGNOSIS :

INVESTIGATIONS

1) Blood investigations

Hb% HIV

TC HBsAg

ESR DC N M E

PCV L B

BT

CT

2) Radiographs - Orthopantomogram

3) Biopsy

Incisional Histopathological Report Finding

4) Others :

Chest X-ray : ECG:

29

Proforma

30

FINAL DIAGNOSIS :

INTRAOPERATIVE EVALUATION

Procedure :

Extent of incision

Forced mouth opening (Under GA) : _____________ mm

Coronoidectomy Done / Not done Masseter Muscle Stripping - Done/Not Done

Reconstruction :

Flap design

Flap dimension (length and width)

Adequacy of flap :

Length = Adequate/ Inadequate

Bulk = Adequate / Inadequate

Width = Adequate / Inadequate

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) Postoperative Drug Therapy

b) Nasogastric Tube Feeding (Duration)

c) Jaw Physiotherapy

Proforma

31

TABLE 1 : POSTOPERATIVE EVALUATION

FINDINGS DAILY REVIEW WEEKLY REVIEW

MONTHLY REVIEW

1st 2nd 3rd 4th 5th 6th 7th 2nd 3rd 4th 2nd 3rd 4th 5th 6th Flap colour Flap failure Blue /White flap

Wound dehiscence

Infection Sloughing Hair growth Salivary fistula Flap margins Co-apted/ Raised

Intra oral

Flap loss partial/ complete

Wound healing Wound dehiscence

Wound infection

Extra oral

Scarring Mouth opening ____ mm under GA

Pre-Operative Mouth Opening = _______ mm

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


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


34

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.


TABLE 2 PRE-OPERATIVE EVALUATION

Case No.

Age (yrs)

Sex Chief complaint Type of habit (with duration) Stage of presentation

1. 29 M Burning sensation & limitation of mouth opening since 4 months Star, 4-5 pk/day; 2 yrs III 2. 23 M Inability to open mouth since 2 years Jarda, 10-15pk/day; 9 yrs IVa 3. 33 M Pain & burning sensation since 2 years Betelnut, 4-6/day, 7-8 yrs III 4. 28 M Inability to open mouth since 1 years Betelnut, 5-6/day, 7-8 yrs III 5. 22 M Inability to open mouth since 4 years Pan Parag 8pk/day, 4-5 yrs III 6. 35 M Pain & decreased mouth opening since 3 months Pan+Betelnut+Lime+Tobacco, 3-4pk/day, 10 yrs II 7. 19 M Inability to open mouth since 1 years Betelnut, 10-14/day, 7 yrs III 8. 39 M Inability to open mouth + Burning sensation 4 years Pan + Betelnut+Lime+Tobacco, 3-4pk/day 10 yrs IVa 9. 22 M Inability to open mouth since 2 years Betelnut, 10-12/day 4-5 yrs Smoking & Alcohol occasional III 10. 30 M Inability to open mouth since 2-3 months Manikchand, 6-7 pk/day, 7 yr II 11. 27 M Decrease in mouth opening since 1 year Pan Parag, 5-6 pk/day, 5 yr, Pan+Betelnut+Lime, 3-4/day, 5 yrs III 12. 17 M Decrease in mouth opening since 6 months Star, 2 pk/day, 4 yrs III 13. 18 M Difficulty in mouth opening since 4 years PanParag, 5-6 pk/day, 4yrs, tobacco 1 pk/day, 4 yrs. III 14. 45 F Inability to open mouth since 2-3 months & burning sensation since 1 year Tobacco+Lime, 1pk/day, 18 yrs IVa

35


TABLE 3 POST-OPERATIVE EVALUATION

Findings

CASE NO.

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

Flap color Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Flap failures Blue/ White Flap X X X X X X X X X X X X X X

Wound dehiscence X X X X X X X X X X X X X X

Infection X X X X X X X X X X X X X X

Sloughing X X X X X X X X X X X X X X

Hair growth Scanty Scanty Mod. Mod. Scanty Absent Mod. Scanty Mod. Mod. Mod. Mod. Absent Absent

Salivary fistula X X X X X X X X X X X X X X

Flap margin Co-apted/ raised 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 Co-apted

Flap loss Partial/complete X X X X X X X X X X X X X X

Intra

oral

Wound healing Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis. Satis.

Wound dehiscence X X X X X X X X X X X X X X \Extra

oral Wound infection X X X X X X X X X X X X X X

Scarring Accept Accept Accept Accept Accept Accept Hyp. Accept Accept Hyp Hyp. Accept Accept Accept

Accept : Acceptable, Hyp : Hypertrophic, Satis : Satisfactory, Mod : Moderate, X : Absent

36


TABLE 4 MOUTH OPENING EVALUATION

Case No.

Pre-operative spontaneous

mouth opening (mm)

Forced

intra-operative mouth

opening (mm)

POSTOPERATIVE MOUTH OPENING

Days Weeks Months 1st 2nd 3rd 4th 5th 6th 7th 2nd 3rd 4th 2nd 3rd 4th 5th 6th

1 23 50 23 25 24 21 22 23 24 34 40 42 43 56 56 58 60

2 12 35 20 25 25 27 27 27 27 31 35 40 50 50 49 50 49

3 18 41 18 20 20 22 22 23 25 26 24 28 30 38 40 40 40

4 22 40 25 27 30 25 25 27 27 30 35 43 35 42 45 43 45

5 21 40 30 31 28 25 21 24 23 24 29 38 38 36 34 38 39

6 28 40 24 25 25 29 29 27 27 39 39 42 44 46 42 44 46

7 16 36 16 23 26 26 27 27 27 30 35 34 34 36 39 41 48

8 12 30 18 22 25 23 27 25 27 32 38 38 42 43 49 44 46

9 18 30 20 20 20 20 20 19 18 22 22 33 30 37 32 36 34

10 28 38 24 24 26 28 30 28 25 36 40 43 47 50 47 47 47

11 17 40 17 13 13 15 17 17 18 18 21 23 28 30 34 38 38

12 19 40 17 19 20 20 22 25 25 24 29 29 30 33 36 36 38

13 18 40 10 10 12 12 12 13 15 22 24 24 33 35 35 35 35

14 12 38 15 15 18 19 20 20 20 25 28 30 32 34 34 36 38 Means 18.8 38.42 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


38

1 8 .8

3 8 .4

2 3 .4

2 8 .0

3 1 .33 4 .7

3 6 .84 0 .4 4 0 .8 4 1 .8

05

1 01 52 02 53 03 54 04 5

M

e

a

n

M

o

u

t

h

O

p

e

n

i

n

g

i

n

m

m

Pre-O

pFo

rced-I

ntra-o

p

1 wee

k2 w

eeks

3 wee

ks1 m

onth

2 mon

ths3 m

onths

4 mon

ths6 m

onths

T im e In te r v a l

F IG .1 : M O U T H O P E N IN G E V A L U A T IO N


39

FIG.2 : INCREASE IN MOUTH OPENING

23

1218

22 2128

16.012

18

28

17 19 1812

60

49.0

4045

3946 48 46

34

47

38 3835

38

0

10

20

30

40

50

60

70

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

No.of Patients

M

o

u

t

h

O

p

e

n

i

n

g

i

n

m

m

Preoperative Postoperative

RESULT : Mean Increase in Mouth Opening = 24.2mm

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, intra-

oral 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 single-

stage 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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60

Dr. Chheda Sonal Nemchand.rtfDECLARATION 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. CERTIFICATE BY THE GUIDE ACKNOWLEDGEMENT ABSTRACT 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. TABLE OF CONTENTS

OBJECTIVES REVIEW OF LITERATURE 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. A MODIFIED SINGLE STAGE NASO-LABIAL FLAP (WINGED) IN THE SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS P R O F O R M A Personal details of patient GENERAL EXAMINATION OF THE PATIENT I) EXTRA ORAL EXAMINATION OF HEAD & NECK

TABLE 1 : POSTOPERATIVE EVALUATION

OBSERVATION AND RESULTS TABLE 2 PRE-OPERATIVE EVALUATION Chief complaint TABLE 3 Findings

TABLE 4 Forced

DISCUSSION BIBLIOGRAPHY

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