A Comparative Evaluation between the Use of Buccal Pad of Fat and Bovine Collagen Membrane in the Management of Oral Submucous Fibrosis.

PURPOSE: This study is intended to assess and compare the effectiveness of BFP and BCM as reconstruction materials in treating oral submucous fibrosis (OSMF).
MATERIALS AND METHODS: This study comprised twenty patients of 20 and 60 years who were clinically diagnosed with OSMF. All patients were subjected to fibrotomy with reconstruction under general anesthesia. In all the patients, following fibrotomy reconstruction was done using the buccal pad of fat on the left and with the collagen membrane on the right. The temporal muscle insertions were released, and coronoidectomy was performed as and when required. Any third molars if present were removed. All patients were feeded for 7 days by Ryle's tube and were on intravenous antibiotics for 5 days. Clinical evaluation was done at periodic intervals of 7, 30, 90, and 180 days postoperatively for mouth opening, burning, pain on mouth opening, and recurrence.
RESULTS: The mean age of patients was 27.3 years. A 12 mm was mean preoperative mouth opening. Intraoperative mouth opening was 37 mm in all the patients and maintained at 36 mm at the 6th-month postoperative period. No significant difference was observed between both sides pertaining to pain on maximal mouth opening, burning sensation, or postoperative infection. However, there was a significant difference in the time taken for epithelization on both sides.
CONCLUSION: The results of this study reveal that both Buccal Pad of Fat (BPF) and BCM are viable reconstruction options, but BFP as a reconstruction material exhibited prompt epithelization with the lowest wound contracture. Copyright:

INTRODUCTION

Oral submucous fibrosis (OSMF) is a chronic disease with higher chances of malignant transformation.[1] Literature reveals that the malignant transformation rate for OSMF ranges between 7% and 30%.[2] Although numerous etiological factors have been advocated in the literature, the precise role of these factors in the initiation and spread of this condition is still uncertain since it is encountered even in individuals with none of the etiological factors.[3] Hence, the need to meticulously choose the treatment options is essential. Numerous treatment options have been proposed by previous studies but literature shows that termination of habit would have a substantial effect on the improvement of the symptoms of OSMF.[4] OSMF treatment initiates by fibrotomy to facilitate mouth opening. Therefore, medical interventions are employed to suppress the inflammatory response.[5] Different local and distant flaps are used in surgical management.[6] The surgical defect following fibrotomy can also be resurfaced with allografts. Previous studies have shown BPF and BCM as viable options.[7] Both of these have been tried in the past with varies success.

MATERIALS AND METHODS

A comparative study comprised twenty patients belonging to the age group of 20 and 60 years with a mean age of 27.3 years and reported to our unit between the period of June 2017 and September 2019 was planned. Khanna and Andrade's grading of OSMF was used.[8] Diagnostic criteria were the history of the patients, habits of the patients, and the clinical examination. Following screening of the patients based on the inclusion and exclusion criteria, the preoperative mouth opening was measured and noted. Orthopantomograph was taken preoperatively to assess coronoid processes and the position of third molars bilaterally. Institutional ethical clearance was obtained and the patient written consents were taken for surgery. Only patients with < 20 mm of mouth opening necessitating surgical intervention according to Khanna and Andrade's grading and who are fit for surgical interventions under general anesthesia (GA) were included in the study. All the procedures were planned for GA using fiberoptic nasotracheal intubation. In all the patients following fibrotomy, reconstruction was done with the buccal pad of fat on the left side and with the collagen membrane on the right side as shown in Figure 1. The cuts made from the corner of the mouth. The mouth was opened actively with the use of a Heister jaw opener till there is no restriction. Based on the preoperative Orthopantomogram (OPG), if the coronoid processes were elongated, then they were approached through the same surgical wound. The temporal muscle insertions were released and coronoidectomy was performed using burs, chisels, and mallet. Any third molars if present were removed. Following this, an active mouth opening of 35–40 mm was achieved as shown in Figure 2. Later, an incision was made in the maxillary vestibule on the left side and buccal pad fat was used. On the right side, the surgical defect was only cover with the use of a bovine collagen membrane. Ryle's tube was placed and then the patient was extubated. Thorough intraoral irrigation was done twice daily using saline and 5% povidone-iodine in the immediate postoperative phase. Bolster pack was removed after 7 days. Active physiotherapy was started using wooden sticks from the 3rd postoperative day. Patients were evaluated clinically at periodic intervals of 7, 30, 90, and 180 days postoperatively for mouth opening, burning, pain on mouth opening, and recurrence.

Figure 1

Intraoperative view. (a) BPF on the left side following fibrotomy. (b) BCM on the right side following fibrotomy

Figure 2

Mouth opening. (a) Preoperative mouth opening. (b) Intraoperative mouth opening

RESULTS

This is a comparative study comprising twenty patients belonging to 20 and 60 years with a mean age of 27.3 years. Our results show that the fibrosis predominantly involved buccal mucosa and the retromolar pad. All patients had a 5 mm to 18 mm mouth opening postoperative with a mean of 12 mm. On the 7th day, it was 30 mm and post 90 days it was 36 mm [Figures 3 and 4]. BFP and BCM as a reconstruction material exhibited prompt epithelization as shown in Figures 5 and 6. Pain on maximal mouth opening was insignificant on both the sides.

Figure 3

Mouth opening. (a) Third month postoperative mouth opening. (b) Sixth month postoperative mouth opening

Figure 4

Graph showing the mean mouth opening

Figure 5

First week postoperative view. (a) Healing of BPF on the left side following fibrotomy. (b) Healing of BCM on the right side following fibrotomy

Figure 6

First month postoperative view. (a) Healing of BPF on the left side following fibrotomy. (b) Healing of BCM on the right side following fibrotomy

DISCUSSION

Ever since the time of Sushruta, Oral submucous fibrous is considered to be a wellknown clinical entity. Schwartz first termed it in the contemporary literature.[9] Previous studies have stated that this enduring, progressive precancerous condition is frequently encountered in the South Asian region.[10] The results of this study show that the fibrous bands were typically encountered in the buccal mucosa, retromolar trigone, and the labial mucosa. Our findings are in accordance with previous studies when compare to patients age.[310] Although numerous etiological factors have been advocated in the literature, the precise role of these factors in the initiation and spread of this condition is still uncertain since it is encountered even in individuals with none of the etiological factors.[2] Hence, the need to meticulously choose the treatment options is essential. The etiological factor noticed is all the patients included in this study were areca nut chewing which would produce free radicals leading to local immunosuppression.[10] At the outset, surgical management of OSMF was intended to surgical remove the fibrotic bands that lead to trismus. However, the results of these surgical interventions resulted in additional scarring and worsening of the trismus. Therefore, the concept of grafting the raw area following the removal of the fibrous bands with the aid of onlay graft or local flaps became inevitable.[11] This study involved the comparison of the clinical effectiveness of using BFP and collagen in reconstruction following fibrotomy in OSMF. It was observed that the bulk of BFP in all our cases was found to be sufficient and it retained its location as an interposition material in the postoperative period.[12] The results of this study revealed that there was a reduction of pain on maximal mouth opening with the advancement of time on both the sides of the patients suggestive of appropriate healing on both the sides. These findings are in accordance with previous studies.[12] It was observed that the healing of BFP was reliable and the results of our study are comparable to previous studies.[13] A mean duration of 4.5 weeks was required for the epithelization of the BPF which was in accordance with previous studies which stated that BPF epithelized in 4–6 weeks. Literature reveals that BFP has a persistent rich vascular anastomosis with a decent volume ranging between 8.3 and 11.9 cc that can be used in 3 cm × 5 cm defects.[913] Previous studies have used BPF for the closure of oroantral communication.[14] In addition to this, the ease in harvesting the BFP coupled with not causing any visible scar at the donor site and its anatomic proximity to the recipient site facilitating prompt grafting. Hence, BFP can be efficaciously employed for the reconstruction following fibrotomy in OSMF.[13] With regards to BCM, it was observed that at the end of the 4th week, majority of the patients encountered decent epithelization and the results of our study are comparable to previous studies which advocated that collagen epithelizes in approximately 4–5 weeks.[15] It was also observed that the grafted area regained its normal texture in about 4 weeks time. There was improvement in the mouth opening, pain-free maximal mouth opening observed in patients on both the side with relatively prompt epithelization, and less wound contracture on the BFP side. However, it was noticed in this study that the mean operating time on the BCM side was relatively more than on the BPF side. This was in accordance with previous studies.[8] It was observed that none of the patients had any adverse reaction to the BCM substantiating that BCM is a safe biological dressing material which is in accordance with previous studies.[16] BCM exhibits a fibrin collagen interaction resulting in the initial adherence to the underlying tissues. With time, BCM sloughs off.[16] In this study, prophylactic extraction third molar if the present was done in order to avoid injury to the BPF/BCM in the retromolar area. In clinical scenarios where the adequate mouth was not achieved intraoperatively or when the coronoid process was considerable elongated, bilateral temporalis myotomy, and coronoidectomy were performed based on previous studies.[17] Our study concludes that BFP is good as a pedicled graft while BCM is a safe biological dressing material facilitating epithelization. Previous studies reveal that patients who do not cooperate for aggressive physiotherapy are much more prone to relapse.[18]

CONCLUSION

The results of this study reveal that both BPF and BCM are viable reconstruction options. There were insignificant differences in the postoperative mouth opening and pain in both the sides but BFP as a reconstruction material exhibited prompt epithelization with lowest wound contracture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.