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Use of Buccal Fat Pad and Collagen in the Surgical Management of Oral Submucous Fibrosis- a Pilot Study

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Use of Buccal Fat Pad and Collagen in the Surgical Management of Oral Submucous Fibrosis- a Pilot Study 40 Indian Journal of Contemporary Dentistry,Type: January-June Original Research 2020, Vol.8, No.1 Use of Buccal Fat Pad and Collagen in the Surgical Management of Oral Submucous Fibrosis- A Pilot Study Nilesh Bhanawat1, Vikash Ranjan2, Soumendu Bikash Maiti3, Priyank Rai4 1Reader, Department of Oral & Maxillofacial Surgery, Pacific Dental College & Research Centre, Udaipur, Raj, 2Associate Professor, 3Senior Lecture, Department of Oral Medicine and Radiology, Divya Jyoti Collge Of Dental Sciences And Research, Modinagar, 4Senior Lecture , Department of Oral & Maxillofacial Surgery, Pacific Dental College & Research Centre, Udaipur, Raj Abstract Background: Various surgical modalities have been tried in surgical management of submucous fibrosis, but each has its own limitations. Aims & Objectives: To assess the efficacy of buccal pad of fat covered with collagen membrane as a grafting material in the management of Oral Submucous fibrosis. Materials & Method: Seven Grade II and Grade III Submucous fibrosis patients were randomly included in the sample population. Surgical release of the fibrous band and closure of the surgical defect with buccal pad of fat covered with collagen membrane as the interposition material was done. The post operative mouth opening and healing and patient comfort was statistically analzed using SPSS v.20. Results: The mean pre operative mouth opening of the patients was 15.29 + 4.751 mm. The mean post operative mouth opening at the end of 6 month is 30.86+2.268mm. Conclusion: With minimal post operative complication and avoidance of a secondary donor site morbidity, this technique can be safely employed in the management of OSMF patients. Keywords: Oral Submucous Fibrosis; Buccal Pad of Fat; collagen Membrane. Introduction entire oral cavity, sometimes the pharynx, and rarely the 3 In 1952, Schwartz coined the term atrophica larynx, characterized by juxta epithelial inflammatory idiopathica mucosa oris to describe an oral fibrosing reaction followed by progressive fibrosis of the lamina disease which he discovered in five Indian women propria and deeper connective tissues with concomitant 4 from Kenya. Joshi, subsequently coined the term oral muscle Degeneration. .1,2 submucous fibrosis (OSF) for the condition in 1953 The buccal mucosa is the most commonly involved Caniff et al, in 1986 described submucous fibrosis as a site, but any part of the oral cavity such as the soft palate, chronic progressive scarring disease of the oral cavity pterygomandibular raphe, the anterior pillars of fauces 1 and oropharynx. and even the pharynx can be involved.1 The condition is Oral submucous fibrosis is an insidious, chronic, well associated with areca nut chewing; a habit practiced disabling disease of obscure aetiology that affects the predominately in Southeast Asia and India. Worldwide, estimates of oral submucous fibrosis indicate that 2.5 million people are affected, with most cases concentrated 1 Corresponding Author: on the Indian subcontinent, especially southern India. Dr. Vikash Ranjan The rate varies from 0.2-2.3% in males and 1.2-4.5% 1,2 Associate Professor, Department Of Oral Medicine in females in Indian communities. Oral submucous And Radiology, Divya Jyoti Collge Of Dental Sciences fibrosis also has a significant mortality rate because it is And Research, Modinagar. a premalignant condition and malignant transformation 1 Email:[email protected] has been noticed in 3-7.6% of cases . Ph – 09461644833 Indian Journal of Contemporary Dentistry, January-June 2020, Vol.8, No.1 41 Oral submucous fibrosis is clinically divided into 3 given through a nasoendotreacheal tube. stages :1 Incisions were given bilaterally on the buccal mucosa Staging: Khanna and Andrade in 1995 developed a from inside corner of the mouth extending posteriorly to group classification system for the surgical management the pterygomandibular raphe or anterior faucillar pillar of trismus. depending on the location of fibrous bands present. Incisions were placed at the level of occusal plane and • Group I: Earliest stage without mouth opening avoided injury to Stenson’s duct. The wound created limitations with an interincisal distance of greater than were further freed by manipulation until no restrictions 35 mm. were felt. The interincisal opening was recorded. • Group II: Patients with an interincisal distance of The buccal pad of fat was approached via the 26-35 mm. posterosuperior margin of the created buccal defect with • Group III: Moderately advanced cases with an blunt dissection and milking phenomenon. Buccal pad interincisal distance of 15-26 mm. Fibrotic bands are of fat was teased out gently until a sufficient amount visible at the soft palate, and pterygomandibular raphe was obtained to cover the defect without tension. It was and anterior pillars of fauces are present. secured in place with horizontal mattress suture. • Group IVA: Trismus is severe, with Presterilized collagen membrane was used to an interincisal distance of less than 15 mm cover the buccal pad of fat. Prior to use the collagen and extensive fibrosis of all the oral mucosa. sheeth was washed in saline to remove the preservative • Group IVB: Disease is most advanced, with isopropyl alcohol. It was secured in placed with the premalignant and malignant changes throughout the defect margin with resorbable sutures. All the patients mucosa .1 received prophylactic antibiotics and liquid diet for 1 week by Ryle’s feeding tube. Mouth opening exercises The previous studies were conducted to evaluate the were started from 2nd postoperative day and intensive results of surgical release of fibrosis bands bilaterally exercise was continued daily with Heister’s mouth gag coverage of surgical defect with combined use of for atleast 6 months. locoregionally present buccal pad of fat and alloplastic collagen sheeth .3 Results The aims of this pilot study was to assess the efficacy A total of seven male patients with an average age of of buccal pad of fat covered with collagen membrane as a 35.71 + 8.118 years were studied who were habitual betel grafting material in the management of Oral Submucous nut chewers. The Mean maximum mouth opening of the fibrosis. patients preoperatively was 15.29 + 4.751 mm. The Mean intraoperative interincisal distance after band excision Materials and Method was 36.14+3.485 mm. one month postoperatively the average mouth opening was 33.29+3.251 mm, at 6 A total of 7 patients histologically proven cases months 30.86+2.268 mm (Table 1). of oral submucosal fibrosis seeking treatment for improvement in mouth opening were randomly selected. Uneventful healing with good epithelization was All the patients had interincisal opening of less than 25 observed in all the cases. No post-operative complication mm. The patients were operated under general anesthesia like infection, necrosis of graft were observed. Table 1 Descriptive Statistics N Minimum Maximum Mean Std. Deviation Pre Operative Mouth 7 10 24 15.29 4.751 Opening Intra Operative Mouth 7 30 40 36.14 3.485 Opening 42 Indian Journal of Contemporary Dentistry, January-June 2020, Vol.8, No.1 Cont... Table 1 Descriptive Statistics 1 Week Post Operative 7 28 36 31.43 2.760 Mouth Opening 1 Month Post Operative 7 29 38 33.29 3.251 Mouth Opening 6 Month Post Operative 7 28 35 30.86 2.268 Mouth Opening Discussion maxilla. The BFP has a constant blood supply through the small branches of the facial artery, the internal ‘Shwartz’ in 1952 first described it as “Atropica maxillary artery and the superficial temporal artery and idiopathica mucosa oris. Treatments for oral submucous vein by an abundant net of vascular anastomoses. On fibrosis are mainly symptomatic, because the aetiology average, the volume is 9.6 cc (range 8.3-11.9 cc). Defect of the disease is not fully understood and it is progressive. up to 3X5 cm can be closed with a BFP alone without Conservative treatment includes vitamins, iron compromising the blood supply. supplements; intralesional injections of hyaluronidase, placental extracts, and steroids. Submucosal injections The buccal extension and the main body of fat pad of various drugs may produce temporary symptomatic are in close proximation to the buccal defect, and may relief but can lead to aggravated fibrosis, pronounced be approached through the same incision. In addition, trismus, and increased morbidity from the mechanical the buccal fat pad pedicled flap can cover the whole injury secondary to insertion of the needle and chemical surgical defect and not only the superficial thin layer irritation from the drug.3 seen in split thickness skin graft. The pedicled BFP graft is well vascularized, and more resistant to infection than The surgical treatment commonly followed is other kinds of free graft.5 Epithelization over the buccal the release of bilateral fibrotic bands with bilateral pad of fat is evident by the 7th postoperative day and coronoidectomy. Like any other wound, raw areas in completed by the end of 4th week.3 The main limitation the oral cavity are prone to infection, contraction and of the buccal pad of fat is its limited size which requires scarring so there is a need to cover the buccal defect after additional graft for coverage of defect. Biomaterial the fibrotic bands are released.1 collagen was used to cover surgical defect and buccal A nasolabial flap has also been used by some pad of fat. surgeons and has a good survival rate, but sometimes The proposed reasons for its use are easy availability, it may be too small to cover the whole defect. It also economical, no secondary donor site morbidity and causes a visible scar on the face and requires a second uneventful healing. surgery for division. Tongue flaps are bulky and when used bilaterally causes disarticulation, dysphagia and Role of collagen in wound healing are a) stop increases the chance of aspiration. In addition, the bleeding, b) help in wound debridement by attracting tongue is involved with the disease process in 38% cases.
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