INTRODUCTION:

Oral submucous fibrosis is a precancerous lesion commonly seen in the Indian subcontinent. The condition has a multifactorial origin but is commonly associated with habit of chewing of areca nut (the fruit of the Areca catechu palm), which is commonly known as betel nut or supari. This condition was first described by Schwartz in 1952.¹ Areca nut contains arecoline which stimulates fibroblastic proliferation and collagen synthesis. It also contains tannins which stabilizes the collagen fibrils rendering them resistant to degradation by collagenase. All these leads to juxtaepithelial hyalinisation and muscle fibrosis resulting in to trismus.² The onset of the condition is insidious, and the most common initial symptom is a burning sensation experienced on eating spicy, hot food or on intake of hot beverages. Early symptoms are blisters, ulcerations, or recurrent stomatitis.

Excessive salivation, defective gustatory sensation, regurgitation, and nasal resonance are rarely encountered. Restricted tongue movements are seen in advanced cases. Malignant transformation has been noticed in 3-7.6% of cases.³

In this report, we describe a case of OSMF which presented to us with reduced mouth opening (6 millimeter) which was treated with bilateral fibrectomy and reconstructed using bilateral nasolabial flap under general anesthesia.

Case Report:

A 27 years old male reported to oral & maxillofacial department with a complaint of reduced mouth opening since past 6 months. Patient noticed gradual reduction in mouth opening which has further reduced since past 6 months. Pt was completely asymptomatic before 6 months then pt felt burning sensation in both buccal mucosa and also gives history of repeated ulceration in both buccal mucosa. Then he gives history of gradual decrease in mouth opening up to present 6 mm.

Extraoral examination revealed bilateral facial symmetry. Nasolabial groove was present on both the sides The mouth opening is reduced to 6 millimeters (mm) [figure 1]. Temporomandibular movements are within normal limits and there was no clicking, no deviation on movement. Bilateral submandibular lymphnodes were not palpable. Intraoral examination revealed fractured crown in relation with 21, Angle’s Class I malocclusion and generalized stains and calculus were present [figure 2]. Blanching of both buccal mucosa was present. Circular fibrous band were palpable in relation to the upper and lower lip. Vertical fibrous band were also palpable in relation to the right and left buccal mucosa. Stiffness was present at both buccal mucosa. Generalized gingival recession with bleeding on probing was present. A diagnosis of oral submucous fibrosis was done. Surgical treatment with bilateral fibrectomy and reconstruction with bilateral naso labial flap under general anaesthesia was selected.

Treatment: The patients was operated on under general anaesthesia given through a nasoendotracheal tube using a fibreoptic bronchoscope. Incisions were placed bilaterally on the buccal mucosa using a number 15 Bard Parker blade and number 3 Bard Parker handle; they extended from the corner of mouth to the retromolar area at the level of the linea alba, and avoided injury to Stenson’s duct. After fibrous bands had been released the interincisal opening was recorded. Bilateral nasolabial flaps were marked and raised in the plane of the superficial musculoaponeurotic system. The flap was transposed intraorally through a small transbuccal tunnel near the commissure of the mouth, with no tension. The transposed flaps were used to cover the intraoral defects. The extraoral defect was closed primarily in layers after liberal undermining of the skin in the subcutaneous plane to prevent any tension across the suture line.

Postoperative course: The post-operative (PO) course was uneventful. Only PO pain medication was prescribed. There was no motor deficit on either side of the face. After a latent period of 10 days, physiotherapy was started with the help of Heister’s jaw exerciser to prevent contractures and relapse. The patients were instructed and motivated to continue the physiotherapy themselves. The patient was followed at one month, 6 months intervals, with a maximum mouth opening of 26 mm .

Figure 1. Clinical extraoral photograph showing facial symmetry.

Figure 2. Showing preoperative mouth opening of 6mm

Figure 3a, b. Bilateral fiberectomy extending from the corner of the mouth till the retromolar area.

Figure 4: Right upper and lower third molars and left upper third molar were extracted.

Figure 5: Intra op mouth opening of 40mm was achieved.

Figure 6. Extraoral Nasolabial flap was marked bilaterally.

Figure 7. Bilaterally Nasolabial flaps were raised and tunneled intraorally and sutured to the margin of intraoral wound .

Figure 8. Primary closure was done for the extraoral wound.

Figure 9. Follw up after one month

Figure 10 Mouth opening after one month.

DISCUSSION:

Long standing oral sub mucous fibrosis is a debilitating disease. It presents with difficulty in mouth opening with poor oral hygiene and its complications. The aim of treatment for this condition is to provide good release of fibrosis and provide long term results in terms of mouth opening. Conservative treatment with local steroids, hyaluronidase injections and physiotherapy are not beneficial in advanced cases.⁴ Surgery is required in all advanced cases. Release of fibrosis and split skin grafting have a high recurrence rate due to graft shrinkage.⁵ Use of island palatal flap has limitations such as its involvement with fibrosis and second molar tooth extraction is required for flap cover without tension. Bilateral palatal flaps leave a large raw area on palatal bone. Some times the defect created may be large and local flaps may not be able to cover the entire defect.

The bilateral tongue flaps cause severe dysphasia, disarticulation, and carry the risk of postoperative aspiration. They also provide a limited amount of donor tissue as their reach is inadequate. The stability of a tongue flap and dehiscence are the common postoperative complications of uncontrolled tongue movements.⁶

The use of nasolabial flaps is an aesthetically pleasing procedure as the postoperative extraoral scars were hidden in the nasolabial fold. The scars were more acceptable in older patients who had prominent nasolabial folds and laxity of the skin as compared to the younger patients. Also the change of appearance is minimal and very acceptable for the patients.⁷

CONCLUSION:

In conclusion, the use of nasolabial flaps in patients with oral submucous fibrosis provides simple and viable option which do not require the microvasculature expertise.

REFERENCES:

1. Schwartz J. Atrophia idiopathica mucosa oris. Presented at the 11th International Dental Congress, London; 1952.

2. Caniff JP, Harvey W. The aetiology of oral submucous fibrosis. The stimulation of collagen synthesis by extracts of areca nut. Int J Oral Surg 1981:I0 (Suppl. i): 163-7.

3. Pindborg J J, Zacharia J. Frequency of oral submucous fibrosis among 100 south Indians with oral cancer. Bull World Health Organ 1965; 32: 750-3.

4. Gupta D, Sharma SC. Oral submucous fibrosis: a new treatment regimen. J Oral Maxillofac Surg 1988;46(10):830–3.

5. Borle RM, Borle SR. Management of oral submucous fibrosis: a conservative approach. J Oral Maxillofac Surg 1991;49(8):788–91.

6. Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995; 24:433–9.

7. E. I. Hofstra Et Al. Oral functional outcome after intraoral reconstruction with nasolabial flaps. The British Association of Plastic Surgeons (2004) 57, 150–155.

Received on 28.02.2019 Modified on 15.03.2019

Res. J. Pharmacology and Pharmacodynamics.2019; 11(3):106-108.

DOI: 10.5958/2321-5836.2019.00019.3