Posted at 01.10.2018
Reconstruction of post release intraoral Dental Submucous Fibrosis defects by Extended Naso-Labial flaps versus Platysma myocutaneous muscle flaps: A Comparative Review.
We likened post operative final result of extended Nasolabial flaps with Platysma myocutaneous muscle flaps, in the management of 20 randomly picked patients with histologically proved dental submucous fibrosis.
Patients and Methods: All patients in the study were cured by release of fibrous rings and bilateral coronoidectomy. In addition reconstruction was done in ten patients with extended nasolabial flaps (Nasolabial group) and in another ten patients with platysma myocutaneous muscle flaps (Platysma group). Inside the nasolabial group the mean preoperative interincisal oral cavity beginning was 12 mm (range 3-14 mm) and in platysma group it was 11 mm (~ 3-13 mm). Energetic post-operative physiotherapy was advised to all 20 patients and they were followed up for next 3 years. The interincisal oral cavity opening upgraded to 47 mm (~35-51 mm) in the nasolabial group and 48 mm (~ 41-52 mm) in the platysma group.
Conclusion: Both procedures were similarly effective in general management of oral submucous fibrosis in conditions of postoperative interincisal oral cavity opening. Nevertheless the facial extra-oral scars were not aesthetically acceptable in the nasolabial group, which were avoided when Platysmal myocutaneous muscle flaps were used for the reconstruction of post release dental submucous fibrosis problems.
Oral submucous fibrosis can be an insidious, long-term, disabling disease of obscure aetiology that impacts the entire oral cavity, sometimes the pharynx and hardly ever the larynx. It is characterised by blanching and tightness of oral mucosa, which in turn causes progressive limits of mouth starting and intolerance to hot and spicy food.
It is an proven precancerous condition which is seen mostly in the Indian subcontinent. Its precancerous aspect was first defined by Paymaster 1, who registered the starting point of slowly and gradually growing squamous cell carcinomas in one third of the patients. Murti et al, 2 reported the malignant transformation of dental submucous fibrosis. As the aetiology is uncertain, its treatment has essentially been symptomatic and different treatments have been defined vastly in literature with inconsistent results.
In this analysis, two techniques for the closure of post release dental submucous fibrosis defects were likened. The importance of coronoidectomy was emphasised and two local flaps were used for reconstruction. We hypothecated that the platysma myocutaneous muscle flaps would be a much better option than prolonged nasolabial flaps in conditions of unaesthetic extraoral facial marks for the management of dental submucous fibrosis. 3, 4, 5.
PATIENTS AND METHODS
Twenty consecutive patients who had been treated at the Division of Dental and Maxillofacial surgery, SDKS Tooth College and Hospital, Hingna, Nagpur (18 men and 2 women aged between 18 to 41 yrs old), were arbitrarily selected because of this retrospective study. The analysis was approved by the institutional ethics committee. No patient got preoperative interincisal starting more than 25mm.
Following aseptic safeguards, all patients were intubated using the fibreoptic bronchoscope and managed under standard anaesthesia. Incisions were made using an electrosurgical knife from the nook of the mouth area to the soft palate at the level of the linea alba avoiding problems for the Stenson's duct. The rings were cut and the interincisal starting noted. The coronoid functions were approached via the same incision and bilateral coronoidectomy or coronoidotomy was done. The maxillary and mandibular third molars were extracted.
In the nasolabial group, prolonged nasolabial flaps as identified by Borle et al 4, were brought up for grafting from the tip of nasolabial fold to the second-rate border of the mandible. The flaps were lifted bilaterally in the plane of the superficial musculo-aponeurotic system from both terminal tips to the region of the central pedicle. The diameter of the pedicle was approximately 1cm and it was distanced 1cm lateral to the area of the mouth area (Fig. 1). The flap was transposed intraorally through a small trans-buccal tunnel near the commissure of the mouth without stress. The substandard wing of the flap was sutured to the anterior edge of the defect, while the superior wing was sutured to the posterior edge of the defect. The extraoral defect was shut primarily in levels after liberal undermining of your skin in the subcutaneous airplane to avoid any tension across the suture range.
In the platysma group, a superiorly structured platysma myocutaneous muscle flap was raised as referred to by D. A Baur 5 and used for reconstruction of the intraoral defects. With the throat hyper long, the proposed skin paddle was defined on the ipsilateral throat, below the poor border of the mandible (Fig. 2). The superior incision was made first and the plane superficial to the platysma muscle was dissected carefully cephalic to the second-rate boundary of the mandible. A skin incision was then made at the substandard line of the skin paddle, with additional publicity of the platysma muscle inferiorly. The platysma muscle was transected sharply at least 1cm inferior to the border of skin paddle, and a subplatysmal airplane of dissection developed just below the inferior boundary of the mandible. In the event the cervical branch of the cosmetic nerve was to be incorporated, it was necessary to identify the nerve in the superficial layer of deep cervical fascia with careful dissection and preservation of its proximal part. Once the aircraft of dissection was completely developed, the platysma myocutaneous flap was transected vertically, anteriorly and posteriorly for its full mobilisation. The flap was then created into the oral defect by creating an correctly sized soft structure tunnel. The harvested flap was sutured to the defect, that was created by release of the fibrous bands. The donor site was easily sealed in levels, totally avoiding any unacceptable cosmetic scar tissue and obtaining by far a far greater cosmetic result (as shown in Fig. 3b).
A gentle temporomandibular joint trainer was positioned in the oral cavity post operatively for 10 times to prevent dehiscence of the flap, as result of occlusal trauma. After a latent amount of 10 days and nights, physiotherapy was started by making use of Hister's jaw exerciser to prevent contracture and relapse. The patients were instructed about the exercises and mandated to do them for another six months until they were adopted up in the Team of Oral and Maxillofacial Surgery.
We used the Student's unpaired t test for statistical research of the study.
There were 2 sets of 10 patients each, one which experienced nasolabial flaps, and the other platysma myocutaneous flaps. The variations in mouth starting were as shown in Stand 1.
All patients in nasolabial group developed extra-oral cosmetic scars, compared with none of them in the platysma group. The variations in mouth beginning before and after the surgery were almost similar in both groups (p<0. 01)
There were some complications in the nasolabial group including incomplete flap necrosis, especially at the tips, momentary widening of oral commissure, unsightly extra dental marks as shown in (Fig. 3a), subluxation of the Temporomandibular Joint, perforation of the palate and intraoral development of hair. Inside the platysma group, few patients developed temporary paraesthesia, that was noticed above the lateral cervical region, subluxation of the mandible and scars over the low neck region which were usually included in the shirt's collar and not visible extra orally on the face. There were no delayed problems in the platysma group, but 2 patients in the nasolabial group possessed a "fish mouth area" deformity, even after a year (Stand 2).
The treatment of oral submucous fibrosis is principally symptomatic, as the aetiology is not clearly understood and it is of progressive character. Conventional treatments include multi-vitamins, flat iron supplementation and intra-lesional shots of hyaluronidase, placental extracts and steroids to name a few. Submucosal shots of varied drugs may produce momentary symptomatic alleviation but can lead to aggravated fibrosis, pronounced trismus and increased morbidity from mechanical injury, secondary to the needle prick personal injury 6.
Different treatment strategies and operative interventions have been suggested by various authors with adjustable success rates. Excision of fibrous rings and propping the oral cavity available to allow extra epithelisation may cause rebound fibrosis during treatment. The discharge of fibrous rings followed by break up thickness skin area grafting leads to high recurrence rate pursuing contracture. The survival of full thickness pores and skin grafts is questionable. The usage of an island palatal flap predicated on the higher palatine artery was suggested by Khanna et al. , but has limitations including engagement of donor tissue with the limited reach of the flap, as well as the need to extract the maxillary second molar tooth, so that the flap is not under tension. 7
The bilateral tongue flap causes severe dysphagia, disarticulation, and it provides unwarranted risk of aspiration. In addition, it provides a limited amount of donor muscle as its reach is limited. The doubtful balance of tongue flaps and their dehiscence are the most frequent post operative issues caused scheduled to uncontrolled tongue movements. 8 Buccal extra fat pads may also be used to hide the flaws after excision of fibrous bands and also as their harvest is easy. However in patients with chronic disease they are likely to be atrophic. In addition, the anterior reach of buccal extra fat pads is inadequate and thus the spot anterior to the cuspids often is required to be left natural; which therefore heals by supplementary intention and succeeding fibrosis, resulting in steady relapse. 9
Bilateral radial forearm flaps are hairy, and almost half the patients need a secondary debulking procedure. Facilities for free tissue transfer aren't universally available. 10 Caniff et al 11 suggested temporal myotomy or coronoidectomy release a severe trismus triggered by the atrophic changes in the tendon of the temporalis muscle extra to the disease. If the mouth area opening was still less than 35 mm after bilateral fibrotomy, then for each and every case bilateral coronoidectomy was done, which escalates the per-operative mouth beginning.
Complications like extra oral facial marks and intraoral expansion of locks were common observation inside our study when expanded nasolabial flaps were used for reconstruction of defects. The patient's compliance had not been very good as far as facial appearance were worried in the nasolabial group. These issues are taken care of when the platysma myocutaneous flap is gathered. The strategy of platysma muscle flap however is more challenging as compared to that of extended nasolabial flap and needs to be mastered properly.
Surgical management of dental sub mucous fibrosis not only allows mouth opening but also helps the oral examinations for early on detection and timely management of malignant transformation. This comparative study of Nasolabial flaps versus Platysma myocutaneous muscle flaps for reconstruction of intraoral post release oral submucous fibrosis flaws emphasises on avoiding the extra oral cosmetic scars in the patient. The postoperative mouth area opening 3 years after surgery was similar in both the techniques, however with better cosmetic effects in the platysmal group.
We recommend the utilization of platysma muscle flap when compared with the expanded nasolabial flap for reconstruction of the intraoral problems after release of oral sub mucous fibrosis. The facial aesthetics aren't compromised in this technique. The chance of broadening of the commissure and pinched appearance of the lips are subsequently avoided. As the incision is far away from the facial skin, and situated infero-laterally on the neck of the guitar, the marks are hidden within the shirt's collar, without hampering the facial aesthetics, steering clear of an unsightly facial scar and ultimately resulting in better patient compliance and acceptance in the current conscious population.