Surgery of Trismus in Oral Submucous Fibrosis by Madan Kapre & Sudhanshu Kothe

Author:Madan Kapre & Sudhanshu Kothe
Language: eng
Format: epub
Publisher: Springer Singapore, Singapore

Ananya Kothe

Email: [email protected]

Key Points

Reconstruction is best done with vascularized flaps from intraoral or extraoral sources.

Provision of an adequate flap facilitates an adequate release/excision.

Reconstruction is planned as per the grades of trismus.

Intraoperative teeth removal facilitates release as well as reconstruction.

After release or excision of affected cheek and surrounding tissues in a case of trismus, there is a need to replace mucosa. Leaving the defects raw will lead to intense fibrosis, with recurrence of trismus.

Replacing the mucosa can be done with many available tissues in and around the mouth.

Skin grafts, split thickness or full thickness, are discouraged, as they will still allow the base of the defect to contract, causing recurrence. Maintaining a skin graft inside the mouth is also fraught with problems.

Alloplastic material is not preferred, as it will not stall the process of intense scarring and recurrence. Any material, be it collagen sheet, will only mimic the epithelium for a short period of a few days and will not be of any further use.

Reconstruction can be done with intraoral tissues of tissues from the extraoral sources. Intraoral choices are mucosal flaps like mandibular mucoperiosteal flap or palatal mucoperiosteal flaps. It could also be a musculomucosal flap like the tongue flap. Flaps bring in their own blood supply and thus vascularize the bed of the defect in submucous fibrosis. Muscle flaps further enhance the vascularity of the area.

Extraoral source is the platysma flap and its variations. These flaps are sturdy, pliable, and well vascularized. They give epithelial lining to the defect and also create many planes of movement within the cheek, for supple movements. The platysma myocutaneous flap has areolar layers between the skin and muscle and the muscle and fascia under it; hence, once the flap is inset, the tissues can move between themselves to give a supple cheek.

Choice of reconstruction is dictated by the site and area of defect in the cheeks, which in turn is dictated by the grade of trismus. In grade 1 and 2, the defect may be only a linear cut, of a small defect in the posterior cheek, in the retromolar area. Reconstruction, if necessary, could be in the form of mucosal flaps or tongue flap. In grade 3 trismus, often, the defect is large and involves the posterior and mid-cheek, along with an exposed mandible due to coronoidectomy. Here, larger flaps, like the palatal flap, may be necessary. In grade 4 trismus, the entire mucosa of the cheek, and may be the palate to some extent, will be lost, and the mandible is exposed due to coronoidectomy. Here, platysma myocutaneous flap is the preferred option.

An important prerequisite for good result is an adequate release. If the surgeon releasing and excising the fibrotic tissues is assured that the defects can be covered well, using adequate flaps, there is better likelihood of adequate release. This is how a good reconstruction positively influences a good release and result.

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