Release and Free Flap Reconstruction for Trismus that Develops after Previous Intraoral Reconstruction

Longitudinal outcomes of trismus release with free-flap reconstruction in primary and secondary oral submucous fibrosis-related trismus

BACKGROUND

Oral submucous fibrosis is a global health concern associated with betel quid use and results in trismus, which can be either primary or secondary in origin. Severe cases often require trismus release with free-flap reconstruction. This study examined longitudinal outcome trends following trismus release and compared the outcomes of patients with primary and secondary oral submucous fibrosis-related trismus.

METHODS

We conducted a retrospective cohort study by including patients who underwent trismus release between 2013 and 2022. All procedures were performed by a single surgical team to ensure technique standardisation. We measured the maximum mouth opening, the interincisal distance, perioperatively and 1, 2, 3, 4, 6 and 12 months post-operatively. Data were analysed using generalised estimating equations.

RESULTS

A total of 35 patients were included in the study, 17 with primary and 18 with secondary oral submucous fibrosis-related trismus. Initially, patients with primary oral submucous fibrosis-related trismus had greater interincisal distance gains than those with secondary oral submucous fibrosis-related trismus (p = 0.015 and p = 0.025 at 3 and 4 months post-operatively, respectively). However, after 12 months, this initial advantage faded, with comparable interincisal distance improvements in patients with primary and secondary disease, despite the more complex surgical procedures required in secondary cases.

CONCLUSION

Surgeons should carefully consider the benefits of trismus release procedures for patients with secondary oral submucous fibrosis-related trismus by recognising the changes in post-operative outcomes.

Challenges in Managing Post-Radiation TMJ Pseudoankylosis

This study demonstrates the outcomes of post-radiation temporomandibular joint (TMJ) pseudoankylosis management and its challenges. A rare maxillary squamous cell carcinoma was treated with subtotal maxillary resection. Subsequent radiation therapy, failure of free flap reconstruction, and 1 year of jaw hypomobility instigated TMJ pseudoankylosis with a maximal mouth opening (MMO) of less than 5 mm. Bilateral coronoidectomy was done simultaneously with maxillary reconstruction, followed up with buccal fibrosis release and extensive jaw exercises. At 16 months of follow-up, the patient's MMO was 20 mm. Although bilateral coronoidectomy released the attachment of the atrophic temporalis muscle, it did not correct the other causes of trismus, specifically the progressive fibrosis of masticatory muscles, loss of elasticity of the TMJ ligaments, and other soft tissue abnormalities. Radiotherapy-induced-trismus refractory to physical exercise may require further management to achieve satisfactory MMO.

"Submarine-Shaped" Radial Forearm Flap for Simultaneous Reconstruction of Oral and Lower Lip Defects"

BACKGROUND

Reconstruction of the oral cavity commonly results in trismus and lip incompetence.

AIM AND OBJECTIVES

In this study, we aim to describe an innovative design of a radial forearm free flap for resurfacing bilateral buccal defects and simultaneous functional lower lip reconstruction in a single stage.

MATERIALS AND METHODS

Between January 2010 and December 2019, 6 males underwent simultaneous buccal and lower lip reconstruction with a radial forearm free flap. The mean age of the patients was 57.3 years (range, 50-68 years). The defects were caused by trismus release and due to previous treatments. The mean size of the defects was 17.9 cm in length and 3.25 cm in width. Flaps were harvested, including the proximal perforators of the radial vessels, and the inset began in the buccal area opposite the anastomosis side.

RESULTS

Flap size ranged from 16 to 21 × 2 to 4 cm. The recipient vessels used were the superficial temporal (4) and facial (2). All flaps survived. Lip infection was seen in 2 cases and managed conservatively. The mean follow-up was 19.2 months (range, 12-28 months). The mean increase in the interincisal distance was 10.7 mm. Oral continence was good in all patients. Speech intelligibility was considered total in 4 patients and partial in the remaining 2.

CONCLUSION

The radial forearm flap constitutes an option for simultaneous lower lip reconstruction and resurfacing of bilateral buccal areas after trismus release. The procedure provides a thin and pliable reconstruction using only 1 donor site and 1 set of recipient vessels.

Secondary Reconstruction of Head and Neck Cancer Defects-Principles in its Practice

Objective

Secondary reconstruction is requested by patients who have completed their head and neck cancer treatment. The reason for the request for reconstruction may be to improve the functional deficits, achieve aesthetic refinements or most commonly both. The article looks at various issues related to reconstruction in the secondary setting and suggesting the ways to approaching patients requesting secondary reconstruction.

Discussion

While considering secondary reconstruction, various factors need to be considered. These include issues related to the disease, the treatment received as well as the patient's comorbid conditions. Aggressive disease and multiple recurrences should deter from undertaking complex reconstructions. Lack of tissue pliability resulting in a woody neck due to radiation makes dissection difficult and wound healing poor. The reconstructive requirements include release of contractures inside the mouth, reconstruction of the missing jaws, replacement of the missing volume of the tongue and correction of the incompetent angle of mouth. Goals of reconstruction should be prioritized by the surgical team. Free soft tissue or bone containing flaps would be provided ideal tissue to meet the reconstructive requirements in secondary reconstruction. However, several impediments could exist for their safe use. Release of contractures and provision of adequate soft tissue should be given priority and must be addressed before bony reconstruction is contemplated.

Conclusion

Bony reconstruction of both mandible and maxilla is possible, with the former being more difficult to deliver good results due to the associated soft tissue fibrosis. Virtual surgical planning with the aid of Stereo lithographic models and planning software will improve the quality of bony reconstruction. Detailed counseling sessions involving patient and the family are essential before embarking on secondary reconstruction as the patient expectations and the surgical outcome may not be easy to match. However excellent improvement in function and appearance will be possible in many patients with appropriate reconstructive procedure.

Trismus intra-operative release and expansion (TIRE): A novel operative treatment for trismus

BACKGROUND

Trismus is a common symptom for patients with head and neck cancer. This study aimed to evaluate outcomes using the novel Trismus Intra-operative Release and Expansion (TIRE).

METHODS

All patients from 2012 to 2022 with histories of head and neck cancers and trismus treated with TIRE were included. Data examined included measured interincisal distance (IID) before and after treatment, and improvement or worsening of trismus.

RESULTS

Thirty-eight patients with trismus were identified, and fourteen underwent TIRE. All had undergone surgery, and 13 had completed radiation therapy prior to TIRE. Mean improvement of IID immediately after TIRE was 18.44 ± 6.02 mm (p < 0.0001). At first follow-up (2.51 ± 3.23 months, n = 8), mean improvement from pre-operational measurements was 11.14 ± 9.17 mm (p = 0.018).

CONCLUSION

TIRE was initially successful in increasing IID in some patients, but sustained improvements were not consistently seen past 1 year follow-up. TIRE could help resolve trismus enough to proceed with options for trismus therapy using devices and/or mouth opening exercises.

Trismus surgery and microsurgical reconstruction after oral cancer treatment

INTRODUCTION

Trismus after oral cancer is frequent, with scarce evidence of surgical release treatment in these patients.

OBJECTIVES

The objective of this study is to determine the results of trismus release and free flap reconstruction after oral cancer treatment, establish immediate and long-term results, and detect factors that influence outcome.

MATERIALS AND METHODS

A retrospective study was performed. Preoperative, intraoperative, and follow-up interincisal distances were measured. The intraoperative, long-term gain, and postoperative loss were calculated. Analysis of the long-term results with the preoperative and intraoperative variables was performed.

RESULTS

Surgical release immediately increased the interincisal distance by 29.25 mm. Sixty-six percent of this gain was lost due to trismus recurrence, giving a long-term interincisal gain of 9.90 mm. Worse results were observed in patients with previous high-stage tumors, maxillectomies, skin resections, and previous radiotherapy. The were no significant differences in the results depending on the type of release or reconstruction performed, with the exception of the reconstruction with the sural flap, which presented worse results. Patients with trismus of ≤10 mm could have more range for improvement after this surgery.

CONCLUSIONS

The results of this surgery are moderate in the long term due to high trismus recurrence in spite of aggressive treatment.

The Effectiveness of Surgical Methods for Trismus Release at Least 6 Months After Head and Neck Cancer Treatment: Systematic Review

Background

The objective of this systematic review was to identify the different surgical treatment modalities of severe trismus after head and neck squamous cell cancer treatment.

Methods

An electronic literature database search was conducted in Medline, Embase, Cochrane, Web of Science, and OpenGrey to determine articles published up to September 2021. Two observers independently assessed the identified papers for eligibility according to PRISMA guidelines. The inclusion criteria were trismus after head and neck squamous cell cancer with consecutive treatment, detailed description of the surgical procedure for trismus release, description of the initial treatment, at least 6 months between initial cancer treatment and trismus release surgery, a minimal follow-up (FU) of 6 months, and availability of full text. The quality was evaluated using the Newcastle-Ottawa scale. A subanalysis of the maximal mouth opening (MMO) was performed using a mixed-effect model.

Results

A total of 8,607 unique articles were screened for eligibility, 69 full texts were reviewed, and 3 studies, with a total of 46 cases, were selected based on the predetermined inclusion and exclusion criteria. Three treatment strategies were identified for trismus release (1) free flap reconstruction (FFR), (2) coronoidectomy (CN), and (3) myotomy (MT). There was a clear improvement for all treatment modalities. A quantitative analysis showed a beneficial effect of CN (mean 24.02 ± 15.02 mm) in comparison with FFR (mean 19.88 ± 13.97 mm) and MT (mean 18.38 ± 13.22 mm) (P < 0.01^*). An increased gain in MMO after trismus release was found if no primary resection was performed (P = 0.014^*). Two studies included in the analysis had an intermediate risk of bias and one had a low risk of bias.

Conclusion

Currently available reports suggest a low threshold for performing a CN compared with FFR and MT. There is a need for high-quality randomized controlled trials with carefully selected and standardized outcome measures.

Coronoidectomy, condylectomy, and free vascularized fibula osteomusculocutaneous flap transfer for severe trismus due to contracture of the oral mucosa and temporomandibular joint ankylosis after maxillectomy: A case report

Severe trismus often causes significant compromise in quality of life due to severe impairment of oral functions. Treatment of trismus needs to be tailored to the cause. Here, we report the case of a successful treatment for severe trismus after maxillectomy using coronoidectomy, condylectomy, and vascularized fibula flap transfer. A 65-year-old female suffered from severe trismus due to temporomandibular joint (TMJ) ankylosis and contracture of the oral mucosa 5 years after partial maxillectomy for a squamous cell carcinoma. Surgical release including a masticatory muscle myotomy, a coronoidectomy, and a condylectomy was performed. After the surgical release, the size of the defect of the oral mucosa was 5 × 10 cm. Then a free vascularized fibula osteomusculocutaneous flap with a 5 × 12 cm skin paddle and a 5 cm fibula bone was transferred. The fibula bone was fixed to the hard palate and zygomatic body. The intraoperative final interincisal distance achieved 30 mm. The postoperative course was uneventful and the free fibula osteomusculocuateous flap survived completely. At 32-month follow-up, although the interincisal distance had regressed to 25 mm, the patient maintained an improvement in the patient's quality of life. Combined treatment with coronoidectomy, condylectomy and free tissue transfer may be effective for severe trismus having multiple causes: oral mucosa contracture and TMJ ankylosis.

Temporomandibular Joint Dislocation following Pterygomasseteric Myotomy and Coronoidectomy in the Management of Postradiation Trismus

Supplemental Digital Content is available in the text.

Trismus is a known complication following treatment of oral and oropharyngeal cancers, with radiation therapy reported as a known risk factor for its development. The prevention of trismus after radiation therapy is hard to achieve, with no clear benefit of early prophylactic rehabilitation. Pterygomasseteric myotomy and coronoidectomy are well described procedures in the management of extra-articular trismus. Herein, we present 2 cases of temporomandibular joint dislocation as a cautionary tale of the potential risk for temporomandibular joint dislocation and need for closed reduction and maxillomandibular fixation.

Treatment of late sequelae after radiotherapy for head and neck cancer

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Exercise therapy for trismus secondary to head and neck cancer: A systematic review

BACKGROUND

Effects of exercise therapy for trismus secondary to head and neck cancer have not been reviewed systematically since 2004.

METHODS

Four databases were searched. The quality of observational studies and randomized controlled trials was assessed.

RESULTS

Two hundred eleven articles were found, 20 studies were included. A large variation in research methodology, stretching techniques, duration of stretch, and repetition of exercises was found. The overall quality was moderate. Five of the 8 preventive studies found that exercises during (chemo)radiotherapy could not prevent a reduction in mouth opening. In 4 therapeutic case studies, mouth opening increased between 17 and 24 mm. In 8 other therapeutic studies, mouth opening increased between -1.9 and 13.6 mm. No exercise therapy was clearly superior to the others.

CONCLUSION

Changes in mouth opening ranged considerably and no stretching technique was superior to others regarding either prevention or treatment of trismus. Clinical guidelines cannot be given based on this systematic review. © 2016 Wiley Periodicals, Inc. Head Neck 39: 160-169, 2017.

Trismus in patients with head and neck cancer: etiopathogenesis, diagnosis and management

BACKGROUND

Trismus indicates severely restricted mouth opening of any aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim of this study was to review the etiopathogenesis, incidence, treatment and prevention of trismus in patients with head and neck cancer.

OBJECTIVE OF REVIEW

Trismus is frequently seen in patients suffering from malignant tumours of the head and neck. The reported prevalence of trismus in those patients varies considerably in the literature and ranges from 0 to 100% depending on the tumour site and extension. Trismus may worsen or remain the same over time, or the symptoms may reduce, even in the absence of treatment. When a patient presents with trismus after tumour treatment, it is important to determine whether the trismus is the result of the treatment, or is the first sign of a recurrence. Restricted mouth opening may impede inspection of the oral cavity as needed for dental care, and particularly for oncologic follow-up.

CONCLUSIONS

Mouth opening after radiotherapy (RT) decreases on average by approximately 20% compared to mouth opening prior to RT. The prevalence of trismus increases with increasing doses of RT to mastication structures. The use of intensity-modulated RT seems to lower the percentage and severity of RT-induced trismus. Treatment of trismus can be conservative (with either medical or physical therapy) or surgical. Exercise therapy is the mainstay of treatment and exercise should start as soon as possible after treatment. The prevention of trismus, rather than its treatment, is the most important objective.

Success of dental implants in vascularised fibular osteoseptocutaneous flaps used as onlay grafts after marginal mandibulectomy

We have evaluated the survival of dental implants placed in vascularised fibular flap onlay grafts placed over marginal mandibulectomies and the effects on marginal bone loss of different types of soft tissue around implants under functional loading. From 2001-2009 we studied a total of 11 patients (1 woman and10 men), three of whom had had ameloblastoma and eight who had had squamous cell carcinomas resected. A total of 38 dental implants were placed either at the time of transfer of the vascularised fibular ostoseptocutaneous flaps (nine patients with 30 implants) or secondarily (two patients with eight implants). Four patients were given palatal mucosal grafts to replace intraoral skin flaps around the dental implants (n=13), and the other seven had the skin flaps around the dental implants thinned (n=25) at the second stage of implantation of the osteointegrated teeth. All vascularised fibular osteoseptocutaneous flaps were successfully transferred, and all implants survived a mean (range) of 73 (33-113) months after occlusal functional loading. The mean (SD) marginal bone loss was 0.5 (0.3) mm on both mesial and distal sides in patients who had palatal mucosal grafts, but 1.8 (1.6) mm, and 1.7 (1.5) mm, respectively, on the mesial and distal sides in the patients who had had thinning of their skin flaps. This difference is significant (p=0.008) with less resorption of bone in the group who had palatal mucosal grafts. Palatal mucosa around the implants helps to reduce resorption of bone after functional loading of implants.

Exercise therapy for trismus secondary to head and neck cancer: A systematic review

BACKGROUND

Effects of exercise therapy for trismus secondary to head and neck cancer have not been reviewed systematically since 2004.

METHODS

Four databases were searched. The quality of observational studies and randomized controlled trials was assessed.

RESULTS

Two hundred eleven articles were found, 20 studies were included. A large variation in research methodology, stretching techniques, duration of stretch, and repetition of exercises was found. The overall quality was moderate. Five of the 8 preventive studies found that exercises during (chemo)radiotherapy could not prevent a reduction in mouth opening. In 4 therapeutic case studies, mouth opening increased between 17 and 24 mm. In 8 other therapeutic studies, mouth opening increased between -1.9 and 13.6 mm. No exercise therapy was clearly superior to the others.

CONCLUSION

Changes in mouth opening ranged considerably and no stretching technique was superior to others regarding either prevention or treatment of trismus. Clinical guidelines cannot be given based on this systematic review. © 2016 Wiley Periodicals, Inc. Head Neck 39: 160-169, 2017.

Surgery for extra-articular trismus: a systematic review

The aim of this systematic review was to identify operations that are used to improve mouth opening in patients with extra-articular trismus (caused by cancer and its treatment, oral submucous fibrosis, or noma) and to find out if they work. We searched the electronic databases PubMed, Embase, Cinahl, and the Cochrane collaboration, and then systematically selected papers before we assessed their quality, extracted the data, and did a meta-analysis. We analysed 32 studies that included 651 patients, the median (IQR) size of which was 11 (7-26). The quality of the methods used and of reporting were relatively low. Median (IQR) duration of follow-up was 12 (8-22) months. Operations resulted in a weighted mean (SD) increase in mouth opening of 19.3 (6.3) mm. None of the operations was better than the others for the improvement of mouth opening. We conclude that operations can improve mouth opening in extra-articular trismus, but the evidence is of moderate quality and there is a need for further research.

Using pneumo-computerized tomography as a quantitative assessment of result in submucous fibrosis patients treated with surgical release and free flap reconstruction

OBJECTIVE

This study investigates the efficacy of oral submucous fibrosis release and free flap reconstruction.

STUDY DESIGN

Pneumo-computerized tomography (pneumo-CT) was used to evaluate postoperative changes in the buccal vestibular volume during maximum blowing.

METHODS

From March 2003 to November 2008, 9 patients underwent 18 microvascular flap reconstructions after oral submucous fibrosis release. The preoperative and postoperative buccal vestibular volumes were determined by capturing the air density in the selected region on CT images, which were composed of 0.75-mm-thick slices that were then summated using analysis software (Biomedical Imaging Resource; Mayo Foundation, Rochester, MN).

RESULTS

Postoperative results were measured for a mean follow-up period of 15 months (range, 6-36 mo). There was significant improvement in the interincisal distance from 12.44 (8.35) mm preoperatively to 32.56 (7.322) mm postoperatively (P = 0.000). There was an accompanying significant increase in the buccal vestibular volume from 5.66 (3.92) mL preoperatively to 9.38 (4.96) mL postoperatively on the right side (P = 0.032) and from 6.44 (4.20) mL preoperatively to 9.64 (4.65) mL postoperatively (P = 0.048) on the left side.

CONCLUSIONS

Adequate release of the mucosa and resurfacing with a free flap can increase the interincisal distance and improve the maximal buccal vestibular volume. Air-contrast pneumo-CT studies demonstrate an improvement in buccal mucosal elasticity.

Oral surgery in patients undergoing chemoradiation therapy

Oral health care in patients undergoing chemotherapy and/or radiation therapy can be complex. Care delivered by a multidisciplinary approach is timely and streamlines the allocation of resources to provide prompt care and to attain favorable outcomes. A hospital dentist, oral and maxillofacial surgeon, and a maxillofacial prosthodontist must be involved early to prevent avoidable oral complications. Prevention and thorough preparation are vital before the start of chemotherapy and radiation therapy. Oral complications must be addressed immediately and, even with the best management, can cause delays and interruption in treatment, with serious consequences for the outcome and prognosis.

Lockjaw treatment after noma in the third world

Surgical correction of post-noma-restricted mouth opening in Africa is of special difficulty. Multiple free-flap reconstruction to replace the missing oral mucosa lining is demanding, and postoperative rehabilitation is difficult to control. Physical treatment to open a post-noma lockjaw is of little success and often followed by relapse.Performing surgical reconstruction of facial defect in noma patients in Niamey, Niger, on a regular basis, we examined the possibility of distracting the scar formation between the jaws without surgical release to correct the lockjaw. The distraction was achieved with a bone distractor, originally prepared for distraction osteoneogenesis of the mandible. The questions were if the scar tissue is capable to be distracted 1 mm day by day until an acceptable opening of the mouth is achieved and what the long-standing results are after distraction mouth opening.A distraction therapy of the scar contracture between the upper and lower jaw using a three-dimensional bone distractor is a promising alternative. The mandible distractor applied between the arcus zygomaticus and the middle part of the mandible on both sides and distraction of 1 mm/d were successful in 2 cases in the long run and have been applied to 4 new cases during the last stay in Africa.

Reconstruction of the buccal mucosa following release for submucous fibrosis using two radial forearm flaps from a single donor site

BACKGROUND

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and can severely limit mouth opening. The use of bilateral forearm flaps to fill buccal defects following trismus release has proven to be effective and reliable. However, it requires the sacrifice of radial arteries from both forearms. We have developed a technique that allows for the harvest of two independent flaps from a single forearm donor site.

METHODS

Two separate flaps are designed on the same radial artery and concomitant vein pedicle. The distal flap is marked in the standard fashion and the proximal skin paddle is designed in the middle third of the forearm, based on septocutaneous branches of the radial artery. The two flaps are elevated and subsequently divided into two independent free flaps. Between June 2004 and June 2007, a total of 16 flaps were harvested from eight donor sites for buccal mucosa defects following trismus release. Improvements in mouth opening and buccal pliancy were evaluated by comparing preoperative and postoperative inter-incisal distance (IID) and maximal mouth capacity.

RESULTS

All flaps survived completely, and all donor sites were closed primarily, except for one. The mean flap size was 6.6x2.6cm (range: 6x2.5cm-7x3cm), mean pedicle length was 5.7cm, mean ischaemia time was 46min and mean total operating time was 8h 45min. At an average of 19.8 months follow-up, the inter-incisal distance averaged 29.13mm, an increase of 20.88mm compared with the preoperative measurement. The maximal mouth capacity averaged 55.63cc, an increase of 9.38cc compared with the preoperative measurement.

CONCLUSION

Two independent small flaps can be harvested safely from one radial forearm donor site. This approach is a useful option for reconstruction of bilateral buccal defects, particularly following submucous fibrosis release. The donor-site morbidity is minimal and limited to one forearm.