ORAL SUBMUCOUS FIBROSIS simply OSMF.

1. ORAL SUB-MUCOUS FIBROSIS:
SURGICAL MANAGEMENT OF ORAL
SUBMUCOUS FIBROSIS- LAST RESORT CASE
REPORT AND REVIEW OF LITERATURE

2. ORAL SUB-MUCOUS FIBROSIS
INTRODUCTION:
(J.J Pindborg and Sirsat 1966)
It is an insidious chronic disease affecting any part of the oral
cavity and sometimes the pharynx. Although occasionally preceded
by and /or associated with vesicle formation ,it is always associated
with juxta-epithelial inflammatory reaction followed by a fibro-elastic
changes of the lamina propria with epithelial atrophy leading to
stiffness of the oral mucosa and causing trismus and inability to eat.

3. ORAL SUB-MUCOUS FIBROSIS
EPIDEMIOLOGY:
• OSMF is a crippling fibrotic disorder prevalent in South East Asia,
mostly in India .
• Incidence of OSMF in India is 0.2-0.5% of population.
• AGE : 20 and 40 years of age are most commonly affected
• No cast or religious community is especially affected
• sex predilection conflicting, Earlier it was thought to be common in
females. But at present ,study ratio shows 2.3: 1 =M:F

4. ORAL SUB-MUCOUS FIBROSIS
ETIOLOGY:
The strongest risk factor for OSF is
the
• chewing of betel quid or areca nut
• Other factors, such as genetic and
immunologic
• predisposition, probably also play a
role as OSF has been reported in
families (both children and adults)
whose members are not in the habit
of chewing betel quid or areca nut.

5. ORAL SUB-MUCOUS FIBROSIS
MULTIFACTORIAL PATHOGENESIS
ARECANUT TOBACCO LIME VOLATILE LIQUIDS
TANNIN&
AFLOTOXIN ARECOLINE
DEGRADATION
OF COLLAGEN
MECHANICAL
INCREASED SYNTHESIS
OF COLLAGEN
TRAUMA
CHEMICAL BURN HYPERSENSITIVITY
ALTERED IMMUNITY
GENETIC
REDISPOSITION
FIBROBLAST
FORMATION
IRREVERSIBLE FIBROSIS
CONTINOUS EXPOSURE CARCINOMA

6. ORAL SUB-MUCOUS FIBROSIS
CLINICAL FEATURES:
• Onset is insidious.
• burning sensation
• blanching oral mucosa
• fibrous band restricting mouth
opening
• dry mouth
• Inability to whistle, blow
• Difficulty in swallowing

7. ORAL SUB-MUCOUS FIBROSIS
COMMON SITES INVOLVED
• Buccal mucosa,
• faucial pillars ,
• soft palate,
• lips and
• hard palate.
The fibrous bands in the
buccal mucosa run in a
vertical direction ,sometimes
so marked that the cheeks are
almost immovable.

8. ORAL SUB-MUCOUS FIBROSIS
Biopsy report characteristically showing
histopathologically
- Atrophic Oral epithelium
- Loss of rete pegs
- Epithelial atypia may be observed.
- Hyalinization of collagen bundles.
- Fibroblasts decreased and blood
vessels obliterated

9. ORAL SUB-MUCOUS FIBROSIS
To aid treatment planning, Khanna and Andrade developed a
classification system for OSF based on mean interincisal opening (MIO)
• stage I- early OSF without trismus (MIO >35 mm)
• stage II- mild to moderate disease (MIO 26–35 mm)
• stage III-moderate to severe disease (MIO 15–25 mm)
• stage IVa- severe disease (MIO <15 mm)
• stage IVb- extremely severe–malignant/premalignant lesions noted
intraorally.

10. ORAL SUB-MUCOUS FIBROSIS
MANAGEMENT
Various modalities of treatment-
1. Restriction of habits/ Behavioral therapy
2. Medicinal therapy
3. Surgical therapy.
4. Oral Physiotherapy

11. ORAL SUB-MUCOUS FIBROSIS
MEDICINAL THERAPY:

12. ORAL SUB-MUCOUS FIBROSIS
SURGICAL MODALITIES FOR OSMF TO MANAGE TRISMUS
• NASOLABIAL FLAP
• BUCCAL PAD OF FAT
• RADIAL FOREARM FLAP
• SUPERFICIAL TEMPORAL FASCIA FLAP
• PALATAL ISLAND FLAP
• TONGUE FLAP

13. ORAL SUB-MUCOUS FIBROSIS
BUCCAL PAD OF FAT:
• The buccal fat pad (BFP) is a supple and
lobulated mass, easily accessible and
mobilized.
• It is a well accepted graft for defects after
incision of fibrotic bands in the surgical
management of oral submucous fibrosis
(OSMF).
• BFP occupies the buccal space and rests
on the periosteum that covers the
posterior buccal aspect of the maxilla.
• The BFP has a rich blood supply

14. ORAL SUB-MUCOUS FIBROSIS
Defects measuring up to 3 - 5 cm
can be covered with BFP without
compromising the blood supply.
The buccal extension and the
main body of BFP are in close
proximity to the buccal defect
and may be approached through
the same incision.

15. ORAL SUB-MUCOUS FIBROSIS
The surgical procedure -
• Step 1 - resection of the fibrous bands

16. ORAL SUB-MUCOUS FIBROSIS
Step 2-recording of intraoperative forced mouth opening of 35–50 mm

17. ORAL SUB-MUCOUS FIBROSIS
Step 3-NEED OF CORONOIDECTOMY AND MASTICATORY MUSCLE
MYOTOMY ??
• If intraoperative mouth opening < 35 mm

18. ORAL SUB-MUCOUS FIBROSIS
Step 4 -the release, mobilization and securing of the buccal fat pad graft
• The buccal fat pad approached by
bluntly opening the fine haemostat
and gently dissected until the fat
protruded into the mouth.
• The buccal fat pad is teased into the
mouth gently by applying external
pressure over the cheek until a
sufficient amount is obtained to
cover the defect without tension. The buccal fat pad graft is secured
in place with horizontal mattress sutures.

19. ORAL SUB-MUCOUS FIBROSIS
CASE REPORT
Patient named ONORINA NONGKESH was referred to the Department
of Oral and Maxillofacial Surgery ,RDC with the CHIEF COMPLAINT of
long-standing difficulty in mouth opening and a positive history of betel
nut, tobacco chewing with lime.

20. ORAL SUB-MUCOUS FIBROSIS
• Blanching present on B/L buccal mucosa
• Fibrotic bands palpable on B/L buccal mucosa Khanna and Andrade
stage IV As the mouth opening was < 10mm

21. ORAL SUB-MUCOUS FIBROSIS
• Surgical resection of fibrous bands
• Intra operative mouth opening achieved was >35 mm
• No coronoidectomy was performed

22. ORAL SUB-MUCOUS FIBROSIS
Partial stripping of temporalis muscle attachment on coronoid process
was done bilaterally

23. ORAL SUB-MUCOUS FIBROSIS
Reconstruction of buccal mucosal defect by buccal fat pad secured with
interrupted and mattress sutures by 2-0 vicryl
immediate mouth opening after the procedure was =42 mm

24. ORAL SUB-MUCOUS FIBROSIS
• From the third postoperative
day patient began mouth
opening exercises using Heister
jaw opener four times a day for
half an hour.
• One month postoperatively,
the buccal fat pad is completely
epithelised with maximal IO of
35–45 mm.

25. ORAL SUB-MUCOUS FIBROSIS
DISCUSSION:
Khanna and Andrade considering the severity of the
trismus and the histopathological findings of secondary muscle
degeneration and fibrosis in stages III and IV, suggested surgical
treatment was the only solution in patients with stages III or IV,
and that bilateral temporalis myotomy and coronoidectomy were
highly effective surgical procedure.

26. ORAL SUB-MUCOUS FIBROSIS
Chang et al.
• supported the study by Khanna and Andrade and revealed that
these additional procedures further improved IO in their
patients from an average distance of 26.9 mm (range 20–35
mm) to an average of 39.6 mm(range 35–45 mm)
intraoperatively.

27. ORAL SUB-MUCOUS FIBROSIS
Adequate surgical release often results in bilateral buccal
soft tissue defects which tend to contract and shrink if left to heal
by secondary intention. Thus, the resulting soft tissue defect
requires resurfacing with well-vascularized tissue of adequate
dimensions

28. ORAL SUB-MUCOUS FIBROSIS
CONCLUSION:
In surgical management of OSMF bilateral sectioning and
releasing of fibrous bands with or without coronoidectomy
followed by covering of the surgical defect with buccal fat pad
serves as a good substitute with a good outcome.
• It is a simple and easy to use flap,
• It has a rich blood supply,
• Its epithelialisation is complete within 6 weeks,
• The morbidity and the failure rates are low
• It is well accepted by the patient.

29. ORAL SUB-MUCOUS FIBROSIS
References
1. J.J. Pindborg, P.R. Murti, R.B. Bhonsle, P.C. Gupta, D.K. Daftary, F.S. Mehta Oral submucous
fibrosis as a precancerous condition Scand J Dent Res, 92 (1984), pp. 224–229
2. J.N. Khanna, N.N. Andrade Oral submucous fibrosis: a new concept in surgical management.
Report of 100 cases Int J Oral Maxillofac Surg, 24 (1995), pp. 433–439 Article | PDF (3921 K)
3. S.R. Aziz Oral submucous fibrosis: case report and review of diagnosis and treatment J Oral
Maxillofac Surg, 66 (2008), pp. 2386–2389 Article | PDF (733 K)
4. B.K. Kaviraj An English translation of the Susruta Samhita Vol. II Nidhana-sthana to Kalp-sthana
(1911) p. 111–2 [Chapter 16]
5. D. Mehrotra, R. Pradhan, S. Gupta Retrospective comparison of surgical treatment modalities
in 100 patients with oral submucous fibrosis Oral Surg Oral Med Oral Pathol Oral Radiol
Endod, 107 (2009), pp. e1–e10 Article | PDF (2158 K)
6. D. Gupta, S.C. Sharma Oral submucous fibrosis – a new treatment regimen J Oral Maxillofac
Surg, 46 (1988), pp. 830–833 Article | PDF (437 K)
7. C.J. Yeh Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis
Int J Oral Maxillofac Surg, 25 (1996), pp. 130–133 Article | PDF (4737 K)

30. ORAL SUB-MUCOUS FIBROSIS
8. R.M. Borle, P.V. Nimonkar, R. Rajan Extended nasolabial flaps in the management of oral
submucous fibrosis Br J Oral Maxillofac Surg, 47 (2009), pp. 382–385 Article | PDF (782 K)
9. X. Jiang, J. Hu Drug treatment of oral submucous fibrosis: a review of the literature J Oral
Maxillofac Surg, 67 (2009), pp. 1510–1515 Article | PDF (182 K)
10. I.Y. Huang, C.F. Wu, Y.S. Shen, C.F. Yang, T.Y. Shieh, H.J. Hsu, et al. Importance of patient's
cooperation in surgical treatment for oral submucous fibrosis J Oral Maxillofac Surg, 66
(2008), pp. 699–703 Article | PDF (436 K)
11. D.R. Lai, H.R. Chen, L.M. Lin, Y.L. Huang, C.C. Tsai Clinical evaluation of different treatment
methods for oral submucous fibrosis. A 10-year experience with 150 cases J Oral Pathol Med,
24 (1995), pp. 402–406
12. N.J. Mokal, R.S. Raje, S.V. Ranade, J.S. Prasad, R.L. Thatte Release of oral submucous fibrosis
and reconstruction using superficial temporal fascia flap and split skin graft – a new
technique Br J Plast Surg, 58 (2005), pp. 1055–1060 Article | PDF (462 K)
13. E.C. Ko, Y.H. Shen, C.F. Yang, I.Y. Huang, T.Y. Shieh, C.M. Chen Artificial dermis as the substitute
for split-thickness skin graft in the treatment of oral submucous fibrosis J Craniofac Surg, 20
(2009), pp. 443–445

31. ORAL SUB-MUCOUS FIBROSIS
14. J.J. Huang, C. Wallace, J.Y. Lin, C.K. Tsao, H.K. Kao, W.C. Huang, et al. Two small flaps from one
anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of
submucous fibrosis and/or contracture
15. J Plast Reconstr Aesth Surg, 63 (2010), pp. 440–445 Article | PDF (895 K)
16. Y.M. Chang, C.Y. Tsai, M. Kildal, F.C. Wei Importance of coronoidotomy and masticatory
muscle myotomy in surgical release of trismus caused by submucous fibrosis Plast Reconstr
Surg, 113 (2004), pp. 1949–1954
17. R.M. Borle, S.M. Borle Management of oral submucous fibrosis: a conservative approach J
Oral Maxillofac Surg, 49 (1991), pp. 788–791 Article | PDF (431 K)
18. A. Kumar, A. Bagewadi, V. Keluskar, M. Singh Efficacy of lycopene in the management of oral
submucous fibrosis Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 103 (2007), pp. 207–
213 Article | PDF (220 K)
19. H.J. Lin, J.C. Lin Treatment of oral submucous fibrosis by collagenase: effects on oral opening
and eating function Oral Dis, 13 (2007), pp. 407–413
20. S. Shekhar TMJ ankylosis and physiotherapy – a review Indian J Oral Surg, 1 (1981), pp. 1–6
21. C.K. Chao, L.C. Chang, S.Y. Liu, J.J. Wang Histologic examination of pedicled buccal fat pad
graft in oral submucous fibrosis J Oral Maxillofac Surg, 60 (2002), pp. 1131–1134
Article | PDF (189 K)

32. ORAL SUB-MUCOUS FIBROSIS
22. D.R. Nayak, S.G. Mahesh, D. Aggarwal, P. Pavithran, K. Pujary, S. Pillai Role of KTP-532 laser in
management of oral submucous fibrosis J Laryngol Otol, 123 (2009), pp. 418–421
23. J.P. Canniff, W. Harvey, M. Harris Oral submucous fibrosis: its pathogenesis and management
Br Dent J, 160 (1986), pp. 429–434
24. J.T. Lee, L.F. Cheng, P.R. Chen, C.H. Wang, H. Hsu, S.H. Chien, et al. Bipaddled radial forearm
flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis Int J Oral
Maxillofac Surg, 36 (2007), pp. 615–61

33. ORAL SUB-MUCOUS FIBROSIS