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.

Effect of botulinum toxin-A on pain and mouth opening following surgical intervention in oral submucous fibrosis - A controlled clinical trial

The purpose of this trial was to study the effect on pain and mouth opening of intramuscular injection of botulinum toxin-A into masticatory muscles following surgical intervention in oral submucous fibrosis (OSMF) cases. Injections of either botulinum toxin A (BTX-A) (study group) or normal saline (control group) were given 2 weeks prior to surgical intervention in OSMF patients, into the bilateral masseter and temporalis muscles. All patients were evaluated for pain and ease of active physiotherapy at 1 week and 1, 3, and 6 months after surgery using a numerical rating scale and appropriate questionnaires, with comparisons made between the study and control group patients. Electromyographic studies of the masticator muscles were also carried out in all patients before injection, and at 1 month and 6 months after injection. 20 OSMF patients were equally divided into study and control groups (n = 10 each). At 1, 3, and 6 months after surgery, the study group patients showed significantly greater decreases in pain (p-values of 0.007, 0.001, and 0.005, respectively) and greater ease in physiotherapy compared with the control group. EMG recordings of masticator muscles showed a transient drop in microvolt value in the study group 1 month after injection, unlike the control group recordings. It was concluded that preoperative BTX-A injection was a good addition to surgical therapy in the patient group.

Surgical management of oral submucous fibrosis using buccal fat pad: a retrospective study of 30 cases

The aim of our study was to evaluate the effectiveness of buccal fat pad (BFP) in the management of oral submucous fibrosis (OSMF). Retrospective records of 30 patients of OSMF treated with BFP with atleast a year of follow-up were analyzed. Patients were divided into groups based on the stages of OSMF. Surgical management consisted of resection of fibrous bands, bilateral temporalis myotomy, and coronoidectomy followed by grafting with BFP. There were 17 patients of stage III (mouth opening 16-25 mm) and 13 patients of stage IV OSMF (mouth opening less than 16 mm). The mean mouth opening of stage III group pre-operatively was 19.94 ± 2.19 mm which increased to a mean of 35.12 ± 5.69 mm (p < 0.0001). For patients with stage IV OSMF, the mouth opening increased from a pre-operative of 10.23 ± 4.07 mm to a post-operative of 31.46 ± 6.78 mm (p < 0.0001). No intra-operative complications were noted in any patient. Relapse was seen in 1 patient (5.8%) of stage III while 3 patients (23.07%) had relapse in stage IV group. Our results indicate that BFP is a good flap owing to its benefits which are easy to harvest and entails minimal morbidity for management of OSMF.

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis-a prospective study in Central India

PURPOSE

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

PATIENTS AND METHOD

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

RESULTS

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

CONCLUSION

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study

PURPOSE

Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis.

PATIENTS AND METHOD

In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years.

RESULTS

Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient's ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5-7 weeks.

CONCLUSION

Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

Temporoparietal fascia flap in intra-oral reconstruction without split thickness skin graft cover: a case report

The temporoparietal fascia flap with its long rotational axis and extensive mobilisation properties, can provide vascularised tissue to repair the most distant areas in the orofacial region. The donor site morbidity is minimal with a well-concealed scar hidden in the hair-bearing scalp. However, the temporoparietal fascia flap is usually used together with a split thickness skin graft. This leads to one more donor site causing increased morbidity. In this case temporoparietal fascia flap was used for an intra-oral reconstruction in a case of oral submucous fibrosis, without a split thickness skin graft cover. The healing was excellent and the flap provided a good surface for remucosalisation.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0-5mm (mean 2.3mm). The intraoperative mouth opening was 12-20mm (mean 16 mm) after submucous release, and 32-42 mm (mean 35.5mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8-9 cm in length and 2-2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18-38 mm (mean 28.2mm) after a mean of 21 months' follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.

[Oral submucous fibrosis in a 31-year-old Indian women: first case report from Germany]

BACKGROUND

Oral submucous fibrosis (OSF) is a chronic disease characterized by subepithelial collagen deposition with formation of bands involving the oral cavity and adjacent structures. Oral submucous fibrosis is a precancerous condition. It is caused by chewing of betel quid (Areca catechu L., Piper betle, lime and tobacco) and ready-made products like pan masala and gutka which also contain areca nut. These products are available all over South Asia. The hallmark of OSF is extremely restricted mouth opening.

CASE REPORT

A 31-year-old Indian woman who has lived in Germany since 1997 presented herself because of limitation of mouth opening. She reported that she has chewed pan masala and gutka since she was 17 years of age. History, clinical and histological findings clearly pointed to the diagnosis of OSF.

DISCUSSION

Conservative as well as surgical interventions for OSF have not resulted in adequate long-term results. Since OSF may occur in children and young adults, the primary aim should be to avoid progression of the disease, initially by physiotherapy. Surgical interventions should not be applied at an early stage of the disease because recurrences and further surgical interventions are often necessary. Due to the increasing numbers of migrants from South Asia more cases of OSF will probably also be observed in Germany, where areca nut-containing products are also available.

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft--a new technique

Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally. A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function.

Importance of Coronoidotomy and Masticatory Muscle Myotomy in Surgical Release of Trismus Caused by Submucous Fibrosis

Thirty patients with trismus resulting from betel nut chewing-induced oral submucous fibrosis were treated with either fibrotic tissue release only (group I) or fibrotic tissue release in combination with masticatory muscle myotomy and coronoidotomy (group II). The latter procedures were only performed in patients whose intraoperative interincisal distance remained less than 35 mm immediately after submucous fibrous tissue release. There were eight and 22 patients in groups I and II, respectively. In group I patients, the average intraoperative interincisal distance improved from 19.5 mm to 42 mm. In group II patients, the average intraoperative interincisal distance improved from 13.5 mm to 27 mm after fibrotic tissue release and further improved to 40 mm after masticatory muscle myotomy and coronoidotomy. At an average follow-up of 22.1 months (range, 7 to 70 months), the group I and II patients had an average interincisal distance of 41.5 mm (range, 35 to 50 mm) and 32.9 mm (range, 20 to 42 mm), respectively. These results demonstrate the efficacy of submucous fibrotic tissue release in treating trismus resulting from betel nut chewing-induced submucous fibrosis and confirm the role of additional masticatory muscle and coronoidotomy in treating its severe forms.

Histologic examination of pedicled buccal fat pad graft in oral submucous fibrosis

PURPOSE

This report evaluates the wound healing process of buccal fat pad (BFP) grafted on a defect of the buccal mucosa for oral submucous fibrosis (OSF).

PATIENTS AND METHODS

Sixteen patients with limitation of mouth opening under the diagnosis of OSF were surgically treated by cutting the fibrotic bands on the buccal mucosa (10 bilateral and 6 unilateral). The defects created were then covered by a BFP graft. The bulging BFP was trimmed postoperatively on a weekly basis until it was fully epithelialized. The specimens were stained and examined microscopically.

RESULTS

Inflammatory cell infiltrate, blood vessel congestion, and fibrinous exudates covering the BFP were obvious by week 2. At week 3, blood vessel congestion and fat cell number decreased markedly. Evidence of stratified squamous epithelium with parakeratosis was seen in the margin of the BFP graft. At week 4, the number of fat cells decreased significantly and the original BFP was almost completely replaced by granulation tissue. The original BFP was fully covered by stratified squamous epithelium by week 5.

CONCLUSIONS

The BFP graft has been widely used for covering exposed defects created by fibrotic band excision for the improvement of mouth opening limitation. The healing process was documented microscopically by weekly observation.

Squamous cell carcinoma of the oral mucosa after release of submucous fibrosis and bilateral small radial forearm flap reconstruction

Oral submucous fibrosis is a collagen disorder that affects the submucosal layer of the upper digestive tract. The major cause is the habit of betel quid chewing, which is common in central, southern, and southeast Asia. The progressive and irreversible course of disease results with trismus, dysphagia, xerostomia, and rhinolalia. The most serious complication of this disorder is the development of oral carcinoma, and the incidence in different series varies from 1.9 to 10 percent. A sufficient mouth opening can be achieved by complete release of fibrotic tissue, and coronoidectomy and temporal muscle myotomy when needed, and reconstruction of the resultant defect can be best achieved by microsurgical free-tissue transfer because of the discouraging results with skin grafting or local flaps. From April of 1997 to May of 2001, a total of 26 patients received reconstructive surgery with small radial forearm flaps after release of submucous fibrosis with or without temporalis muscle myotomy and coronoidectomy. All patients were men, with a mean age of 40.1 years (range, 18 to 62 years) and all had a history of betel nut chewing ranging from 8 to 40 years. The interincisal distance ranged from 5 to 29 mm, with a mean of 15 mm, before operation. After the release procedure, the interincisal distance increased to 40 mm (range, 35 to 50 mm). At a follow-up period of 3 to 48 months, the interincisal distance was a mean of 35 mm (range, 18 to 57 mm), with an average increase of 20 mm compared with the preoperative distance. During follow-up, three patients developed squamous cell carcinoma of the oral cavity 24 to 36 months after submucous fibrosis release. Two of them occurred in the release site and the other one occurred at the soft palate. Oral cancer occurred in three of 13 patients who had received release of submucous fibrosis and who were followed for longer than 2 years (range, 24 to 48 months), which means that 23 percent of these patients developed squamous cell carcinoma of the intraoral mucosa. High risk of cancer occurrence strongly indicates the importance of an earlier and more aggressive surgical approach toward submucous fibrosis, and long-term follow-up on a regular basis. The purpose of an early and aggressive approach to submucous fibrosis is to provide a good quality of life to the patient by improving oral hygiene and oral intake quality and at the same time to obtain a sufficient mouth opening, which is mandatory for the inspection of the excision site and the remaining oral mucosa during follow-up.

Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new, reliable approach

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and often severely limiting mouth opening. Previous surgical treatments have been disappointing. This article introduces a new surgical approach: reconstructing the bilateral buccal mucosa with two small radial forearm flaps. The surgical method includes the complete surgical release of fibrotic buccal mucosa and, if necessary, a bilateral coronoidectomy and temporalis muscle myotomy. From 1997 to 1999, 15 patients with moderate-to-severe trismus received reconstructive surgery, for a total of 30 small radial forearm flaps after surgical release. The flap size was between 1.5 x 5 and 2.5 x 7 cm. All donor sites were directly closed, and all flaps survived completely, except for one with partial necrosis. Six flaps required minor revisions because of size redundancy. Two patients developed buccal cancer in the area of reconstruction. At an average of 12 months' follow-up, the inter-incisal distance averaged 33 mm, an increase of 17 mm compared with the preoperative value. The donor-site morbidity was minimal, except in one heavy smoker who developed dry gangrene of his fingertips. The use of two small free forearm flaps for buccal mucosa reconstruction allows more radical release of fibrotic tissue. Coronoidectomy and temporal muscle myotomy further contribute to the effect of trismus release. The combined effects of this approach have consistently given good results. An aggressive approach toward surgical treatment of this precancerous lesion also facilitates the detection of cancer at an early stage.

Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis

The pedicled buccal fat pad has been widely used for the repair of oral defects. A new application of this flap in the treatment of patients suffering from trismus caused by oral submucous fibrosis is reported. The patients underwent incision of the fibrotic bands and coverage of the buccal defect with a pedicled buccal fat pad flap. The surgical technique is described, and the results suggest that this is a logical, convenient, and reliable technique for the treatment of oral submucous fibrosis.

Oral stent as treatment adjunct for oral submucous fibrosis

Oral submucous fibrosis is a chronic inflammatory disease that results in progressive juxtaepithelial fibrosis of the oral soft tissues that can cause increasing difficulty in chewing, swallowing, speaking, and mouth opening. Many treatment regimens for oral submucous fibrosis have been proposed to alleviate the signs and symptoms of the disorder. In severe cases, surgical intervention is the only treatment modality, but relapse is a major problem. This article describes the use of an oral stent as an adjunct to surgery to prevent relapse.

Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases

Oral submucous fibrosis (OSF) is a collagen disorder commonly seen in the Indian subcontinent. A series of 100 patients is presented. All lesions were biopsied. The condition was staged into four categories. Very early and early cases were treated by local injection of triamicinolone acetonide, while advanced cases were treated by surgical intervention. A new surgical technique of a palatal island flap based on the greater palatine artery in combination with temporalis myotomoy and bilateral coronoidectomy was used in 35 cases. A follow-up ranging from 6 months to 31/2 year showed good results.

Clinical evaluation of different treatment methods for oral submucous fibrosis. A 10-year experience with 150 cases

Over a 10-year period (1982-1991); a total of 150 patients divided into two groups with varying degrees of oral submucous fibrosis (OSF) were treated by either medical or surgical therapies. Medical treatment involved (a) conservative oral administration of vitamin B-complex, buflomedial hydrochloride and topical triamcinolone acetonide 0.1%, or (b) conventional submucosal injections of a combination of dexamethasone and hyaluronidase, or (c) a combination of both (a) and (b). The surgical group was treated by the excision of fibrotic tissues and covering the defect with split-thickness skin, fresh human amnion, or buccal fat pad (BFP) grafts. Treatment was chosen according to the stage of clinical progression to gain maximal interincisal distance (ID). The cases were followed up by monthly examinations for at least two years, or when possible even longer. A combination of (a) and (b) medical treatment was satisfactory in cases of mild impairment (ID > 20 mm) but in the long term it led to symptomatic relief only. Surgical therapy, on the other hand, when accepted by the patients, led to a significant improvement of trismus in cases of severe limitation (ID < 20 mm). Following this strategy, an additional ID increase was observed in all patients. BFP grafting was particularly successful in diminishing scarring after two years as compared with the other two grafts. Together with a cessation of the betel quid chewing habit before and after therapy, these treatment regimens combined with daily mouth opening exercises were found to be necessary to manage OSF cases in early and advanced stages of progression.

Oral submucous fibrosis

2 cases of oral submucous fibrosis have been reported. In each case, the diagnosis was confirmed histologically, and the treatment instituted was identical. Excision of buccal fibrotic bands was carried out, with subsequent placement of skin grafts. The patients were followed postoperatively to monitor results and particularly, to screen for malignant changes. The literature concerning oral submucous fibrosis is reviewed.

Surgery for severe trismus in submucous fibrosis

Bilateral full thickness naso-labial flaps have been used successfully in three patients to give long-term relief of the severe trismus caused by oral submucous fibrosis. The flaps are set into defects created by incision of the oral mucosa. The postoperative rehabilitation compared favourably with other methods and we now advocate the technique for all cases of submucous fibrosis requiring correction of severe trismus.