Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature

A Retrospective Study Comparing the Surgical Results of Platysma Myocutaneous Flap, Buccal Pad of Fat, and Nasolabial Flap for Reconstruction After Fibrotomy in Cases of Oral Submucous Fibrosis

PURPOSE

To evaluate the effectiveness of nasolabial flap (NLF), a buccal pad of fat flap (BFP), and platysma myocutaneous flap (PMF) for reconstruction following fibrotomy for individuals with oral submucous fibrosis (OSMF).

MATERIAL AND METHOD

A retrospective study was conducted among patients diagnosed with grade III and IV OSMF in the Department of Oral and Maxillofacial Surgery at Sharad Pawar Dental College between January 2016 and August 2018. The essential patient information was obtained from the Medical Record Department (MRD) at Acharya Vinoba Bhave Rural Hospital (AVBRH), Datta Meghe Institute of Medical Sciences (DMIMS) Sawangi (Meghe) Wardha. The patients were categorized into three groups: the NLF, the BFP, and the PMF groups. Each group had 16 patients, and factors such as interincisal width, diminished burning sensation in the mouth, inter-commissure distance, and flap necrosis were compared pre- and post-operatively. Student's unpaired t-test and chi-square test were employed for statistical analysis.

RESULT

Mean interincisal mouth-opening increased from pre-operative 4.79 to 41.42 mm post-operatively in the NLF group, BFP group from 6 to 39.42 mm and in the PMF group from 9.26 to 39.34 mm with p value=0.0001. NLF group showed complete and partial resolution of the burning sensation of the mouth at 93.75% and 6.25%, BFP at 62.25% and 32.75% while in PMF it was 68.5% and 31.25% respectively. One year postoperatively 3.28 mm increase in inter-commissure width was observed in the NLF group with a marginal increase in the PMF group and a negligible increase in the BFP group. 18.75% partial flap necrosis was seen in BFP, 18.75% in the PMF group, and 6.25% in the NFL group.

CONCLUSION

All the flaps are efficacious in treating OSMF, however, NLF stands ahead with its higher reliability owing to its excellent blood supply.

Plant leads for mitigation of oral submucous fibrosis: Current scenario and future prospect

The aim of this review is to enumerate medicinal plants and their bioactive compounds that may become potential leads in the mitigation of oral submucous fibrosis (OSMF) in the forthcoming future. It is focused on pathophysiology, risk factors, current treatment regimen, potential plant leads, and future therapies for OSMF. Data were extracted from a vast literature survey by using SciFinder, Web of Science, Google Scholar, and PubMed search engines with relevant keywords. Upon literature survey, we found that the phytochemical 'arecoline' present in the areca nut is the main causative agent of OSMF condition. Currently, OSMF is treated by immunomodulatory and anti-inflammatory agents such as corticosteroids, enzymes (hyaluronidase, chymotrypsin, and collagenase), anti-inflammatory mediators (isoxsuprine and pentoxifylline), dietary supplements (vitamins, antioxidants, and micronutrients), and anti-fibrotic cytokines like interferon-gamma that provides short-term symptomatic relief to OSMF patients. However, some plant leads have been proven effective in alleviating symptoms and mitigating OSMF, which ultimately improves the quality of OSMF patients' life. We concluded that plant drugs like lycopene, curcumin, Aloe vera, colchicine, and Glycyrrhiza glabra are effective against OSMF in various in vitro and/or clinical studies and are being used by modern and traditional practitioners.

Comparative evaluation of nasolabial flap and buccal fat pad flap in the surgical management of oral submucous fibrosis: a systematic review and meta-analysis

PURPOSE

Oral submucous fibrosis (OSMF) is a chronic, potentially malignant condition affecting any part of the oral cavity and is prevalent in Southeast Asia and the Indian subcontinent. The aim of this study is to compare the efficacy of buccal fat pad flap with the nasolabial flap in the management of OSMF.

METHODS

We systematically compared two commonly used constructive techniques in the management of OSMF: the buccal pad of fat flap and the nasolabial flap. We performed a comprehensive search in four databases for all articles published between 1982 and November 2021. We assessed the risk of bias using the Cochrane Handbook and Newcastle-Ottawa Scale. We used the mean difference (MD) for pooling the data with 95% confidence intervals (CIs) and evaluated the heterogeneity between pooled studies using χ2 and I2 tests.

RESULTS

Out of 917 studies, six were included in this review. The meta-analysis significantly favored conventional nasolabial flap over buccal fat pad flap in improving the maximal mouth opening (MD, - 2.52; 95% CI, - 4.44 to - 0.60; P = 0.01; I2 = 0%) after OSMF reconstructive surgery. Conversely, when it comes to esthetic outcomes, these studies favored buccal fat pad flap.

CONCLUSION

Our meta-analysis found that nasolabial flap was better than buccal fat pad flap in terms of mouth opening restoration after OSMF reconstructive surgery. Also, the included studies found better results, favoring nasolabial flap over buccal fat pad flap in terms of oral commissural width restoration. Also, these studies reported better outcomes in terms of esthetics, favoring buccal fat pad flap. Further studies with larger sample sizes and different populations/races are needed to confirm our findings.

Interventions for managing oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a chronic disease of the oral cavity that causes progressive constriction of the cheeks and mouth accompanied by severe pain and reduced mouth opening. OSF has a significant impact on eating and swallowing, affecting quality of life. There is an increased risk of oral malignancy in people with OSF. The main risk factor for OSF is areca nut chewing, and the mainstay of treatment has been behavioural interventions to support habit cessation. This review is an update of a version last published in 2008.

OBJECTIVES

To evaluate the benefits and harms of interventions for the management of oral submucous fibrosis.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 5 September 2022.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) of adults with a biopsy-confirmed diagnosis of OSF treated with systemic, locally delivered or topical drugs at any dosage, duration or delivery method compared against placebo or each other. We considered surgical procedures compared against other treatments or no active intervention. We also considered other interventions such as physiotherapy, ultrasound or alternative therapies.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. participant-reported resumption of normal eating, chewing and speech; 2. change or improvement in maximal mouth opening (interincisal distance); 3. improvement in range of jaw movement; 4. change in severity of oral/mucosal burning pain/sensation; 5.

ADVERSE EFFECTS

Our secondary outcomes were 6. quality of life; 7. postoperative discomfort or pain as a result of the intervention; 8. participant satisfaction; 9. hospital admission; 10. direct costs of medication, hospital bed days and any associated inpatient costs for the surgical interventions. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included 30 RCTs (2176 participants) in this updated review. We assessed one study at low risk of bias, five studies at unclear risk of bias and 24 studies at high risk of bias. We found diverse interventions, which we categorised according to putative mechanism of action. We present below our main findings for the comparison 'any intervention compared with placebo or no active treatment' (though most trials included habit cessation for all participants). Results for head-to-head comparisons of active interventions are presented in full in the main review. Any intervention versus placebo or no active treatment Participant-reported resumption of normal eating, chewing and speech No studies reported this outcome. Interincisal distance Antioxidants may increase mouth opening (indicated by interincisal distance (mm)) when measured at less than three months (mean difference (MD) 3.11 mm, 95% confidence interval (CI) 0.46 to 5.77; 2 studies, 520 participants; low-certainty evidence), and probably increase mouth opening slightly at three to six months (MD 8.83 mm, 95% CI 8.22 to 9.45; 3 studies, 620 participants; moderate-certainty evidence). Antioxidants may make no difference to interincisal distance at six-month follow-up or greater (MD -1.41 mm, 95% CI -5.74 to 2.92; 1 study, 90 participants; low-certainty evidence). Pentoxifylline may increase mouth opening slightly (MD 1.80 mm, 95% CI 1.02 to 2.58; 1 study, 106 participants; low-certainty evidence). However, it should be noted that these results are all less than 10 mm, which could be considered the minimal change that is meaningful to someone with oral submucous fibrosis. The evidence was very uncertain for all other interventions compared to placebo or no active treatment (intralesional dexamethasone injections, pentoxifylline, hydrocortisone plus hyaluronidase, physiotherapy). Burning sensation Antioxidants probably reduce burning sensation visual analogue scale (VAS) scores at less than three months (MD -30.92 mm, 95% CI -31.57 to -30.27; 1 study, 400 participants; moderate-certainty evidence), at three to six months (MD -70.82 mm, 95% CI -94.39 to -47.25; 2 studies, 500 participants; moderate-certainty evidence) and at more than six months (MD -27.60 mm, 95% CI -36.21 to -18.99; 1 study, 90 participants; moderate-certainty evidence). The evidence was very uncertain for the other interventions that were compared to placebo and measured burning sensation (intralesional dexamethasone, vasodilators). Adverse effects Fifteen studies reported adverse effects as an outcome. Six of these studies found no adverse effects. One study evaluating abdominal dermal fat graft reported serious adverse effects resulting in prolonged hospital stay for 3/30 participants. There were mild and transient general adverse effects to systemic drugs, such as dyspepsia, abdominal pain and bloating, gastritis and nausea, in studies evaluating vasodilators and antioxidants in particular.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that antioxidants administered systemically probably improve mouth opening slightly at three to six months and improve burning sensation VAS scores up to and beyond six months. We found only low/very low-certainty evidence for all other comparisons and outcomes. There was insufficient evidence to make an informed judgement about potential adverse effects associated with any of these treatments. There was insufficient evidence to support or refute the effectiveness of the other interventions tested. High-quality, adequately powered intervention trials with a low risk of bias that compare biologically plausible treatments for OSF are needed. It is important that relevant participant-reported outcomes are evaluated.

Antifibrotic effect of silymarin on arecoline-induced fibrosis in primary human buccal fibroblasts: an in silico and in vitro analysis

BACKGROUND

This study aimed to assess silymarin's anticancer and antifibrotic potential through in silico analysis and investigate its impact on in vitro arecoline-induced fibrosis in primary human buccal fibroblasts (HBF).

METHODS & RESULTS

The study utilized iGEMDOCK for molecular docking, evaluating nine bioflavonoids, and identified silymarin and baicalein as the top two compounds with the highest target affinity, followed by subsequent validation through a 100ns Molecular Dynamic Simulation demonstrating silymarin's stable behavior with Transforming Growth Factor Beta. HBF cell lines were developed from tissue samples obtained from patients undergoing third molar extraction. Arecoline, a known etiological factor in oral submucous fibrosis (OSMF), was employed to induce fibrogenesis in these HBFs. The inhibitory concentration (IC50) of arecoline was determined using the MTT assay, revealing dose-dependent cytotoxicity of HBFs to arecoline, with notable cytotoxicity observed at concentrations exceeding 50µM. Subsequently, the cytotoxicity of silymarin was assessed at 24 and 72 h, spanning concentrations from 5µM to 200µM, and an IC50 value of 143µM was determined. Real-time polymerase chain reaction (qPCR) was used to analyze the significant downregulation of key markers including collagen, epithelial-mesenchymal transition (EMT), stem cell, hypoxia, angiogenesis and stress markers in silymarin-treated arecoline-induced primary buccal fibroblast cells.

CONCLUSION

Silymarin effectively inhibited fibroblast proliferation and downregulated genes associated with cancer progression and EMT pathway, both of which are implicated in malignant transformation. To our knowledge, this study represents the first exploration of silymarin's potential as a novel therapeutic agent in an in vitro model of OSMF.

Comparison of Intralesional Placentrex Versus Hyaluronidase and Dexamethasone Injection in the Symptomatic Management of Stage II Oral Submucous Fibrosis - a Prospective Study

AIM

The present study aimed to compare the effectiveness of intralesional placentrex versus hyaluronidase + dexamethasone injection in the symptomatic management of stage II OSMF.

MATERIALS AND METHODS

This was a non-randomized prospective study conducted over a period of 14 months at a tertiary referral center. Patients with clinical stage II OSMF were randomly grouped into A(n = 18) and B(n = 17). These patients were treated with weekly intralesional injection of placentrex and hyaluronidase + dexamethasone respectively, over a period of six weeks. Variables such as mouth opening, burning sensation and colour of mucosa were evaluated at baseline(T0), second week(T1), fourth week(T3), sixth week(T4) of follow up. A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 15 patients completed the study in each group with regular follow up. The mean improvement in mouth opening was 4.3 ± 0.57 mms in group A(p-value < 0.001) and 7.2 ± 0.76 mms in group B(p-value < 0.001) which were significant at the end of six weeks. Mean change in burning sensation at the end of six weeks in group A was 1.2 ± 0.73(p-value < 0.001), and 3.6 ± 0.63(p-value < 0.001) in group B. Mean change in colour of mucosa at the end of six weeks was 1.4 in group A(p-value > 0.05) and 2 in group B(p-value > 0.05). On comparison between both groups, patients in group B exhibited better mouth opening and reduction of burning sensation than patients in group A(p-value < 0.001).

CONCLUSION

Both intralesional placentrex and hyaluronidase + dexamethasone injection are effective in alleviating the symptoms of stage II OSMF. However, hyaluronidase + dexamethasone injection showed slightly better improvement in mouth opening and burning sensation after six weeks.

Nasolabial Flap in the Management of Oral Sub Mucous Fibrosis: A Series of Cases

The objective of this study was to evaluate the outcomes of the nasolabial flap in the management of oral submucous fibrosis (OSMF). The descriptive case series included 75 patients diagnosed with OSMF who underwent surgical intervention under general anesthesia. Preoperative mouth opening measurements were compared with postoperative measurements taken after 2 months. Regarding mouth opening, out of the 75 patients, 4 (5.3%) had unsatisfactory results after treatment, while 22 (29.3%) experienced satisfactory outcomes. The majority of patients, 49 (65.3%), achieved normal mouth opening (more than 30 mm) following the Nasolabial flap procedure. This indicates that the Nasolabial flap yielded favorable results in terms of restoring normal mouth opening and benefiting the patients. Based on the findings of this study, the Nasolabial flap was determined to be a viable surgical option for managing oral submucous fibrosis due to its ease of operation, reliable flap vascularity, and low post-operative complication rate. The only drawback identified was the presence of a surgical scar, which can be addressed through secondary correction procedures.

Comparative Effectiveness of Medicinal Interventions for Oral Submucous Fibrosis: A Network Meta-Analysis

OBJECTIVES

This network meta-analysis presents an exhaustive description and comparison of the available medical interventions for the management of oral submucous fibrosis (OSMF).

MATERIALS AND METHODS

A systematic review and network meta-analysis was conducted after registration with PROSPERO. (PROSPERO ID CRD42022303441). Databases (PubMed, Cochrane, EMBASE, Web of Science, and others) were searched for randomized clinical trials (RCT) trials from inception till September 2022 for the medical interventions in OSMF. The primary outcome was the improvement in mouth opening. The secondary outcomes were improvement in burning sensation, tongue protrusion, and cheek flexibility. The interventions were ranked according to their efficacy based on the surface under the cumulative ranking.

RESULTS

47 studies including 2393 patients were assessed for quantitative analysis. For mouth opening, the combined treatment with steroid, hyaluronidase, and antioxidant was most effective [MD, 7.05 (95%CI 1.76,12.34)], followed by the combination of oral antioxidants with injectable steroids, [MD, 3.80 (95%CI -0.44,8.03)]. Additionally, the combined treatment with steroid, hyaluronidase, and antioxidant was most effective in reducing the burning sensation [MD, -8.62(-10.95,-6.30)], followed by aloe vera [MD, -8.45(-10.40,-6.49)] and pentoxifylline [MD -7.57(-9.46,-5.68)]. For tongue protrusion, curcumin was most effective followed by antioxidants. Most of the drugs used were reported to cause negligible or mild adverse effects.

CONCLUSION

This network meta-analysis reported the efficacy of medicinal interventions in OSMF patients compared to the placebo in the improvement of mouth opening and burning sensation, and cheek flexibility. The methodological quality of included RCTs was low. Well-designed studies are recommended to obtain strong evidence.

Oral Submucous Fibrosis: a Premalignant Condition in a 22-Year-Old Iranian Man

Oral submucous fibrosis (OSF) is a chronic, irreversible disease. The etiology of OSF has been linked to several risk factors, including local factors, systemic factors, and immunological disorders. We report a 22-year-young male patient case of Oral submucous fibrosis, referred to the Maxillofacial Surgery Department of Zahedan University of Medical Sciences, Zahedan, Iran. Treatment for oral submucous fibrosis is based on the disease's clinical involvement and rate of advancement. Even though there are numerous innovative therapeutic techniques for this illness, none of them can cure it. Early diagnosis and treatment can improve the quality of life of a person. Some of the findings of this study are different from reference texts and other studies.

Oral Potentially Malignant Disorders: Etiology, Pathogenesis, and Transformation Into Oral Cancer

Among oral diseases, oral cancer is a critical health issue due to its life-threatening potential. Globocan, in its 2020 report, estimated ∼0.37 million new cases of oral cancer, with the majority of them coming from the Asian continent. The WHO has anticipated a rise in the incidences of oral cancer in the coming decades. Various factors, such as genetic, epigenetic, microbial, habitual, and lifestyle factors, are closely associated with oral cancer occurrence and progression. Oral lesions, inherited genetic mutations (dyskeratosis congenital syndrome), and viral infections (HPV) are early signs of oral cancer. Lesions with dysplastic features have been categorized under oral potentially malignant disorders (OPMDs), such as oral leukoplakia, erythroplakia, oral submucous fibrosis (OSMF), and proliferative verrucous leukoplakia, are assumed to have a high risk of malignancy. The incidence and prevalence of OPMDs are recorded as being high in South-Asian countries. Early detection, prevention, and treatment of OPMDs are needed to prevent its malignant transformation into oral cancer. Many advanced diagnostic techniques are used to predict their progression and to assess the risk of malignant transformation. This communication provides insight into the importance of early detection and prevention of OPMDs.

Comparative Evaluation of Reconstructive Methods in Oral Submucous Fibrosis

Background

Oral submucous fibrosis is a chronic, progressive, scarring, precancerous condition of oral mucosa which on progression causes severe trismus.

Aim and Objectives

To compare and evaluate the efficiency of buccal fat pad, platysmal mucocutaneous flap, nasolabial flap, collagen membrane graft, split thickness skin graft and temporoparietal fascia in reconstruction of surgical defect created by excision of fibrous bands in oral submucous fibrosis.

Results

After 6 months of follow-up, the interincisal mouth opening was 40.0 mm in case of buccal pad fat, 24.5 mm in temporoparietal fascia flap group, 33.8 in collagen membrane graft group, 34.5 mm in platysma flap group, 34.7 mm in nasolabial flap group, 29.3 mm in split thickness skin graft. ANOVA statistical analysis for postoperative interincisal distance at various time intervals and between pre-, intra- and postoperative interincisal distances were carried out which showed the results were significant at p value < 0.05 in all groups. No postoperative complications were noted in buccal fat pad group, split thickness skin graft group and collagen membrane group. However, platysmal group had flap necrosis and temporoparietal flap group patients had to undergo a second debulking procedure after one month.

Conclusion

From our study, we concluded buccal fat pad yields superior results with respect to postoperative mouth opening and related complications.

Functional outcome of two different grafting techniques in the surgical management of oral submucous fibrosis: a comparative evaluation

OBJECTIVE

To evaluate the functional efficacy of two different grafting techniques following the fibrotomy among subjects with oral submucous fibrosis (OSMF).

DESIGN

Forty consecutively treated OSMF subjects between 20 and 40 years who had grades 3 and 4a OSMF and mouth opening < 15 mm were included in the present study. All the subjects were randomly divided into two groups. In Group I, all the subjects received a buccal pad of fat sandwiched with a nasolabial flap following fibrotomy. In contrast, Group II subjects received a buccal pad of fat combined with a collagen graft. The effect of two different surgical protocols on mouth opening was evaluated clinically before the surgery (T₀) and 1 month (T₁), 6 months (T₂), and 12 months (T₃) after the surgery.

RESULTS

In Group I subjects, the mouth opening increased significantly (P < 0.001) from 10.90 ± 1.971 mm at T₀ to 34.25 ± 3.127 mm at T₁, but reduced marginally to 32.15 ± 3.422 mm at T₂, and 31.30 ± 3.358 mm at T₃. In Group II, the mouth opening increased significantly (P < 0.001) from 10.85 ± 1.725 mm at T₀ to 28.90 ± 3.059 mm, 29.10 ± 2.808 mm, and 28.20 ± 2.285 mm at T₁, T₂, and T_3, respectively. At the end of 12 months of follow-up, the mean value improvement in the mouth opening (T₀-T₃) was 20.4 ± 3.5 mm and 17.3 ± 2.9 mm in Groups I and II, respectively, and the difference was statistically significant (P = 0.006).

CONCLUSION

The buccal pad of fat sandwiched with a nasolabial flap for the reconstruction following fibrotomy had a slightly better beneficial effect on the postoperative mouth opening among OSMF subjects.

Efficacy of Collagen Membrane Graft in Intraoral Surgery - An Evaluative Study

Introduction

Bovine-derived collagen membrane is usually and regularly used as a temporary cover or dressing for extraoral wounds and burns. It has wide applications because of its usefulness and biocompatibility. This has provoked us to do a study with the use of collagen membrane even for minor intraoral surgical defects. The aim of this evaluative study was to evaluate the clinical efficacy of collagen membrane in intraoral wounds created by removal of various soft tissue lesions.

Materials and Methods

A total of 25 healthy patients (16 males and 9 females) were taken for this study. This study was confined to secondary defects of the oral mucosa, which occur after excision of premalignant lesions and other conditions, such as benign lesions, reactive proliferations, and incisional biopsy wounds. Only those lesions that were sufficiently large and could not be closed primarily were included in the study.

Results

The results were evaluated on the day of surgery and in the postoperative period. The usefulness of collagen membrane as an intraoral temporary wound dressing material to promote haemostasis, relieve pain, induce granulation, and assist in rapid epithelialization at the wound site and prevent infection, contracture, scarring, and donor-site morbidity was evaluated, and finally, the efficacy of collagen membrane was tested by the use of Chi-square test and P < 0.001, which is a statistically and clinically significant value.

Discussion

Collagen membrane was observed as both biological dressing material and drug carrier. It was found to be a suitable alternative to other graft materials mentioned for the repair of defects in the mucous membrane created by surgical excision of lesions. Therefore, when used judiciously in a controlled clinical situation, collagen membrane is biologically acceptable in nature. It is an alternative to autologous grafts rather than a replacement of other grafts used in the oral cavity.

Effect of trans retinoic acid on patients with oral submucous fibrosis-randomized single-blind monocentric study

Various treatment modalities have been practiced for the suppression of premalignant conditions such as oral submucous fibrosis (OSMF) to prevent their differentiation into malignant lesions. Conventional treatment includes steroids, enzymes like hyaluronidase, trypsin, chymotrypsin and placental extracts which are advocated intralesionally and oral drugs like carotenoids, alpha lipoic acid, lycopene, vitamins, microelements and tea pigments have also been advocated.In this study, a total number of 30 patients with OSMF were taken and randomly divided into two groups with 15 patients each according to Khanna and Andrade group of classification 1995. Group 1 (test group) received the test drug Tretiome 20 mg, whereas Group 2 (control group) received an antioxidant lycopene 20 mg/day for a period of 1 month and the effect of the therapy with the changes in the symptoms was recorded every 1 week, 15 days and 30 days of follow-up. The result of this study showed an improvement in the mouth opening of the patients of test Group with a significant decrease in the burning sensation as compared to the control group (P < 0.05). Xerostomia and headache were the two most commonly seen side effects which were reported in the patients of the test group, of which headache was associated with the withdrawal symptom of habit cessation and xerostomia was taken care by increase in hydration.

A Comparative Evaluation between the Use of Buccal Pad of Fat and Bovine Collagen Membrane in the Management of Oral Submucous Fibrosis

Purpose

This study is intended to assess and compare the effectiveness of BFP and BCM as reconstruction materials in treating oral submucous fibrosis (OSMF).

Materials and Methods

This study comprised twenty patients of 20 and 60 years who were clinically diagnosed with OSMF. All patients were subjected to fibrotomy with reconstruction under general anesthesia. In all the patients, following fibrotomy reconstruction was done using the buccal pad of fat on the left and with the collagen membrane on the right. The temporal muscle insertions were released, and coronoidectomy was performed as and when required. Any third molars if present were removed. All patients were feeded for 7 days by Ryle's tube and were on intravenous antibiotics for 5 days. Clinical evaluation was done at periodic intervals of 7, 30, 90, and 180 days postoperatively for mouth opening, burning, pain on mouth opening, and recurrence.

Results

The mean age of patients was 27.3 years. A 12 mm was mean preoperative mouth opening. Intraoperative mouth opening was 37 mm in all the patients and maintained at 36 mm at the 6^th-month postoperative period. No significant difference was observed between both sides pertaining to pain on maximal mouth opening, burning sensation, or postoperative infection. However, there was a significant difference in the time taken for epithelization on both sides.

Conclusion

The results of this study reveal that both Buccal Pad of Fat (BPF) and BCM are viable reconstruction options, but BFP as a reconstruction material exhibited prompt epithelization with the lowest wound contracture.

Use of the greater palatine pedicled flap for the surgical management of trismus in oral submucous fibrosis

The aim of this paper was to clinically evaluate the efficacy of the greater palatine pedicled flap (GPPF) for the correction of trismus in oral submucous fibrosis (OSMF). This retrospective study was designed from the patients diagnosed with OSMF who underwent transection of fibrous bands and coverage of the defect in the retromolar trigone (RMT) region using GPPF from 2008-2019. Cases were analysed for preoperative (MO_pre-op), and postoperative mouth opening (MO_post-op), secondary healing of the palate, and complications of the procedure. A total of 29 diagnosed cases of OSMF were divided into two groups: group I/stage III (n=13) and group II/stage IV (n=16). The mean (SD) follow up was 29.6 (2.92) months for Group I and 32.4 (3.54) months for Group II. Increase in MO_post-op in group I from 20.0 to 32.92 mm (p=0.0001) and in group II from 6.81 to 26.31 (p=0.0001) was statistically significant. The mean difference of 6.57 mm in MO_pre-op and MO_post-op among the groups was also statistically significant (p=0.0001). The mean (SD) duration for secondary healing of the palate was 5 (1) week(s) and flap necrosis was encountered in two cases of group II/stage IV OSMF. We conclude that GPPF is reliable for the treatment of trismus in advanced stages of OSMF.

Role of coronoidectomy and temporalis myotomy in surgical management of oral submucous fibrosis

PURPOSE

The involvement of temporalis muscle fibers by oral submucous fibrosis (OSMF) and the procedure of coronoidectomy and temporalis myotomy in the surgical treatment protocol for the disease is a controversy. The primary objective of this study is to evaluate the histopathological changes in temporalis muscle fibers in patients undergoing surgical treatment for OSMF and to authenticate the importance of temporalis myotomy and coronoidectomy in surgical treatment protocol.

METHOD

A 3-year prospective study was conducted to assess the histopathological changes in temporalis muscle in surgically treated OSMF cases. The predictor variables were drawn from demographic characteristics (age and gender) etiology, and mouth opening. The outcome variables were histopathological assessment of temporalis muscle fibers for parameters suggestive of degenerative changes and fibrosis changes at cellular level.

RESULTS

Out of 56 patients, 30 patients were had surgical intervention. Twenty-eight (93.3%) were male and 2 (6.6%) were female with a ratio of 14:1. Histopathological examination of temporalis muscle fibers revealed hyalinization of muscle fibers in 80% of the patients followed by loss of striation (73.33%), fragmentation (60%), nucleus internalization (33.33%), infiltration of macrophages and other inflammatory cells (20.67%), multiple nuclei (20%), and swollen muscle fibers (6.67%). Mean preoperative mouth opening was 12.4 and post-operatively 41.3 mm on 1-year follow-up and this was stable on further follow-up.

CONCLUSION

The results of this study suggest involvement of temporalis muscle with disease itself and the justification for coronoidectomy and temporalis myotomy in the surgical protocol was established.

What is the Optimal Reconstructive Option for Oral Submucous Fibrosis? A Systematic Review and Meta-analysis of Buccal Pad of Fat Versus Conventional Nasolabial and Extended Nasolabial Flap Versus Platysma Myocutaneous Flap

Background

To systematically review the reconstructive options for oral submucous fibrosis utilizing buccal pad of fat versus conventional nasolabial and extended nasolabial flap versus platysma myocutaneous flap.

Objective

The succeeding systematic review and meta-analysis addresses the following question, what is the optimal reconstructive option for oral submucous fibrosis?

Study Design

A systematic electronic and manual database search revealed five relevant articles comparing buccal fat pad, nasolabial flap and platysma myocutaneous flap as reconstructive options in oral submucous fibrosis.

Methods

A total of 1538 articles were found across PubMed, Cochrane and clinical trials.gov. Only five relevant articles were selected for the study. Quality assessment of the selected studies was executed by Newcastle-Ottawa scale. Statistical software RevMan (Review Manager [Computer program], version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) was used for meta-analysis. Differences in means and risk ratios were used as principal summary measures. The overall estimated effect was categorized as significant where p < 0.05.

Results

Three of the five studies selected favoured buccal fat pad over nasolabial flap owing to its ease of harvest and lesser number of post-operative complications. One study favoured nasolabial flap because of the progressive increase in mouth opening and bulk of the tissue obtained for reconstruction. A single study favoured platysma flap over nasolabial flap although no difference was obtained in mouth opening, owing its excellent tissue bulk, fewer complications compared to the nasolabial flap.

Conclusion

Definitive conclusions cannot be drawn as there are number of limitations in the studies included. However, a general consensus has been towards favouring buccal fat pad over nasolabial flap. The platysma flap owing to its excellent tissue bulk and fewer complications can be considered as an alternative when dealing with defects which are challenging to reconstruct with the buccal fat pad.

Oral submucous fibrosis: a contemporary narrative review with a proposed inter-professional approach for an early diagnosis and clinical management

Oral Submucous fibrosis (OSMF) has traditionally been described as "a chronic, insidious, scarring disease of the oral cavity, often with involvement of the pharynx and the upper esophagus". Millions of individuals are affected, especially in South and South East Asian countries. The main risk factor is areca nut chewing. Due to its high morbidity and high malignant transformation rate, constant efforts have been made to develop effective management. Despite this, there have been no significant improvements in prognosis for decades. This expert opinion paper updates the literature and provides a critique of diagnostic and therapeutic pitfalls common in developing countries and of deficiencies in management. An inter-professional model is proposed to avoid these pitfalls and to reduce these deficiencies.

Extended nasolabial flap in oral submucous fibrosis - our modification

Nasolabial Flaps are the most popular and commonly used flap in reconstructing mucosal defect left by fibrous band excision in developing countries like India where free flap expertise is not easily available and affordable by poor patients. Extended nasolabial flaps have been used in oral sub mucous fibrosis to cover mucosal defect. Normally these flaps are not wide enough to cover the mucosal defect left by fibrous band excision. Our modification utilises the extended nasolabilal flap to cover the wide mucosal defect in young patients by modified insetting of these flaps. I hope this technical modification will be useful to surgeons managing oral sub mucous fibrosis in developing countries or when free flap is not possible.

Fibrotomy with diode laser (980 nm) and habit correlation in oral submucous fibrosis: a report of 30 cases

To evaluate the efficacy of laser fibrotomy in patients with oral submucous fibrosis (OSMF) and also to correlate the habit variables causing OSMF. Thirty patients diagnosed clinically and histopathologically with OSMF were included in the study. Laser fibrotomy was done under local anesthesia using Zolar diode laser (980 nm frequency) at 2-W power in contact mode with fibro-optic cutting tip. The patients were advised to practice mouth-opening exercises rigorously, and topical corticosteroid was given for burning sensation and pain for 6 months. Pre- and post-treatment comparison of mouth opening, burning sensation, tongue protrusion, and cheek flexibility was analyzed after a follow-up period of 9 months. After a follow-up period of 9 months from the surgical intervention, the mean value of difference in pre- and post-treatment of VAS score, mouth opening, and tongue protrusion was found to be 3.3 ± 2.1, 7.7 ± 5.1, 1.6 ± 2.7, and 0.38 ± 0.61 respectively. Using the Wilcoxon signed rank test, all the above difference in mean was found to be significant with p value < 0.05. With above suggested significant results, lasers can provide an alternative and better means for surgical fibrotomy, relieving trismus in moderate OSMF as they are minimally invasive, cause less hemorrhage, and have faster healing and minimal surgical site scaring and relapse.