Efficacy of coronoidotomy as an adjunct to fibrotomy in advanced cases of oral submucous fibrosis: A prospective cross-sectional study

Sohel Shrivastav; Nitin D Bhola; Rajanikanth Kambala; Anendd Jadhav; Pawan Hingnikar; Tanuj Patil

doi:10.4103/jdmimsu.jdmimsu_125_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 15 | Issue : 2 | Page : 247-250

Efficacy of coronoidotomy as an adjunct to fibrotomy in advanced cases of oral submucous fibrosis: A prospective cross-sectional study

Sohel Shrivastav, Nitin D Bhola, Rajanikanth Kambala, Anendd Jadhav, Pawan Hingnikar, Tanuj Patil
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission	16-Apr-2020
Date of Decision	22-Apr-2020
Date of Acceptance	10-May-2020
Date of Web Publication	21-Dec-2020

Correspondence Address:
Dr. Pawan Hingnikar
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_125_20

Abstract

Aim: To evaluate the effectiveness of Coronoidotomy as an adjunctive procedure to Fibrotomy in terms of improvement in intraoperative mouth opening during surgical management of Oral Submucous Fibrosis. Subjects and Method: 30 patients clinically diagnosed with OSMF (Grade IVa) underwent surgical intervention comprising of Bilateral Fibrotomy and Coronoidotomy. The inter-incisal distances were measured following Bilateral fibrotomy, Unilateral Coronoidotomy and Bilateral Coronoidotomy and compared. We evaluated the percent improvement in the inter-incisal distance after Unilateral and Bilateral Coronoidotomy compared to fibrotomy as well as the associated complications of coronoidotomy. Results: We found a striking improvement of 76.68% after performing Bilateral Coronoidotomy in comparison to fibrotomy. Furthermore, there was a mean increase of 34.56 ± 5.96 mm when compared to baseline pre-operative mean value (5.46 ± 4.04 mm). All the comparisons were statistically significant (P = 0.0001). Conclusion: Coronoidotomy is an effective adjunctive procedure to fibrotomy in terms of improvement in the intraoperative mouth opening in advanced cases of OSMF.

Keywords: Coronoidotomy, fibrotomy, oral submucous fibrosis

How to cite this article:
Shrivastav S, Bhola ND, Kambala R, Jadhav A, Hingnikar P, Patil T. Efficacy of coronoidotomy as an adjunct to fibrotomy in advanced cases of oral submucous fibrosis: A prospective cross-sectional study. J Datta Meghe Inst Med Sci Univ 2020;15:247-50

How to cite this URL:
Shrivastav S, Bhola ND, Kambala R, Jadhav A, Hingnikar P, Patil T. Efficacy of coronoidotomy as an adjunct to fibrotomy in advanced cases of oral submucous fibrosis: A prospective cross-sectional study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 23];15:247-50. Available from: http://www.journaldmims.com/text.asp?2020/15/2/247/304237

Introduction

Management of oral submucous fibrosis (OSMF) mainly revolves around alleviating the signs and symptoms causing discomfort to the patient, namely, intolerance to spices, burning sensation in the mouth, depapillation of the tongue, stiffness of the oral mucosa, alteration in salivation, ulceration/stomatitis, remission and relapses of the vesicle formation, blanching, pigmentation of the oral mucosa, progressive difficulty in opening the mouth, referred pain in the temporomandibular region, and difficulty in phonation and malignant transformation.^[1] Moreover in advanced cases, in addition to clinical findings, there is subsequent muscle degeneration leading to fibrosis and scarring of the temporalis muscle. The temporalis muscle, with its attachment to the coronoid process, induces a restraining effect owing to fibrotic changes in the muscle leading to elongation of the coronoid process, further enhancing the limitation in mouth opening.^[2]

The severity of the disease defines the treatment modality opted to achieve restoration of mouth opening and functions. Advanced cases of OSMF do not respond to conventional medicinal treatment and/or physiotherapy, thence surgical intervention becomes mandatory.^[3] The complete release of the thick fibrotic tissue (i.e., Fibrotomy) intraoperatively is the first step essential for increasing the mouth opening and forms the basis of surgical intervention. However, one cannot achieve the desired mouth opening intraoperatively in every case with fibrotomy alone as the severity and extent of disease differ from person-to-person. Hence, coronoidotomy, coronoidectomy, and temporalis muscle myotomy have been described in the literature as adjunctive procedures to fibrotomy to enhance the mouth opening.

Out of these adjunctive modalities, coronoidotomy is hypothesized to have an upper hand as there is the release of the temporalis muscle pull without causing severe damage to the muscle.^[4] However, there are conflicting schools of thought regarding the utilization of these adjunctive procedures in terms of unnecessary additional trauma and associated complications , namely, reduced mandibular excursion, iatrogenic muscle damage, hematoma formation, risk of damaging local vascular supply, and the unknown fate of the coronoid process after coronoidotomy.

In the light of the above-mentioned thoughts, we found it prudent to undertake a study to assess the effectiveness of coronoidotomy as an adjunctive procedure to fibrotomy in terms of improvement in the intraoperative mouth opening.

Methodology

The present prospective observational study was conducted during the period of September 2016–May 2019 at the Acharya Vinoba Bhave Rural Hospital, Wardha. The study was performed in accordance with the Helsinki declaration and its later amendments or comparable ethical standards and institutional ethical guidelines prescribed by the Central Ethics Committee on Human Research of Datta Meghe Institute of Medical Sciences.

A total of 41 patients with a clinical diagnosis of OSMF were evaluated. Patients with maximal interincisal Distance (IID) <15 mm (Grade IVa)^[3] were included in the study irrespective of age, gender, religion, socioeconomic status, and site of involvement. Patients exhibiting coexistent malignant lesions were excluded from the study.

After obtaining written informed consent, patients were posted for the surgery under general anesthesia. Fibrotomy and coronoidotomy were performed as a standard surgical protocol in all patients. Preoperative and intraoperative maximal IID was recorded using a digital caliper. Fergusson's mouth gag was used intraoperatively for obtaining maximal IID after each step, i.e., bilateral fibrotomy (BF), unilateral coronoidotomy (UC), and bilateral coronoidotomy (BC) and recorded using a digital caliper. After achieving adequate passive IID reconstruction of the defect done with Biwinged Nasolabial/Buccal Fat Pad/Submental island/platysmal flap, depending on the extent of defect created. Active mouth opening was started after the 4^th postoperative day using Hister's jaw exerciser 4–5 times a day.

Statistical analysis was done using descriptive and inferential statistics using Student's paired t-test, one-way ANOVA, and multiple comparisons: Tukey test. The software used in the analysis was SPSS 22.0 version (Chicago, Illinois, USA) and P < 0.05 is considered as the level of significance.

Ethical Approval

Ethical approval for this study (DMIMS(DU)/IEC/2017-18/2255) was provided by the Ethical Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) on 20/4/2017.

Observations and Results

Out of 41 patients, a total of 30 patients fulfilling the inclusion criteria were included in the study. The mean age of the study population was 32.30 ± 8.92 (range 21–60 years). About 53.33% population (n = 16) belonged to the age group of 21–30 years. Majority of the patients, i.e., 76.67% were males (n = 23), whereas 23.33% were females (n = 7). The mean preoperative mouth opening was 5.46 ± 4.04 mm [Table 1]. BC was routinely performed in all cases after the bilateral release of fibrous bands. IIDs were calculated by digital caliper after active traction by Ferguson's mouth gag following BF, UC, and BC.

Table 1: Comparison of interincisal mouth opening (mm) with baseline (preoperative interincisal distance)

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The mean IIDs achieved after BF, UC and BC were 22.65 ± 4.72 mm, 29.89 ± 4.53 mm, and 40.02 ± 4.36 mm, respectively [Table 1]. The values were compared with preoperative IID and found to be statistically significant (P = 0.0001). The mean increase in IID after performing BF, UC, and BC was 17.19 ± 5.05 mm, 24.43 ± 5.24 mm, and 34.56 ± 5.96 mm, respectively, as compared to the mean preoperative IID and found to be statistically significant (P = 0.0001) [Table 2]. The basis of our study was to highlight the mean percent increase in IID after performing Unilateral and BC and comparing the values achieved with BF. We found a striking improvement of 31.96% (7.24 ± 1.17 mm) after UC and 76.68% (17.36 ± 1.17 mm) after BC [Table 3]. Furthermore, in comparison of UC and BC, there was an improvement of 32.43% (10.12 ± 1.17 mm). All these comparative increments were statistically significant (P = 0.0001). No complications associated with coronoid process resection were observed. However, we observed dislocation of the mandible in 20% cases (n = 6), which required unilateral or bilateral eminectomy.

Table 2: Comparison of interincisal distance intraoperatively by one-way ANOVA

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Table 3: Comparison of increase in percentage in inter-incisal distance intraoperatively

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Discussion

Overactivity of the masticatory muscles in habitual areca nut chewers results in severe glycogen depletion. This increased muscle activity in conjunction with the reduced blood supply, owing to fibrotic changes of connective tissue, lead to muscle degeneration, fibrosis, and scarring.^[5] The temporalis muscle undergoes degeneration in a similar fashion leading to fibrosis and scarring. This results in elongation of the coronoid process, thereby, influencing further limitation in mouth opening.^[2] Hence, it is essential to release the restraining effect imposed on the coronoid to improve the intraoperative mouth opening as well as facilitate aggressive postoperative mouth opening exercises.

Kamath^[4] conducted a systematic review to collate and analyze from world literature the different modalities utilized in the surgical management of OSMF. However, the conclusion could not be drawn regarding a definite protocol for the adoption of a particular treatment mode since the severity and chronicity of the disease differs from person-–to-person.

The role of coronoidotomy or coronoidectomy and its adjunctive role to fibrotomy has been questioned time and again pertaining to unnecessary additional trauma and suspected postoperative complications related to degenerated muscle pull and elevation of the jaw, disfiguring deviation of the mandible, and other surgical barriers. Over the years, although coronoidotomy/coronoidectomy has been utilized as an adjunct, a strong consensus is still required for its inclusion as a protocol in every case. In earlier times, Canniff et al.,^[6] had recommended “temporal myotomy or coronoidectomy to release severe trismus caused by the atrophic changes in the tendon of temporalis muscle secondary to the disease.” Subsequently Khanna and Andrade,^[3] Borle et al.,^[7] Bande et al.,^[8] Gupta et al.,^[2] Chan et al.^[9] performed studies that further supported the claim that coronoidotomy/coronoidectomy must be routinely performed along with fibrotomy to facilitate aggressive postoperative rehabilitation for relapse free, long-term results.

In contrast, Soh and Muthusekhar.^[10] and Arakeri et al.^[11] believed in avoiding unnecessary trauma in performing these additional procedures if a desirable mouth opening of 35 mm could be achieved with fibrotomy alone. Thakur et al.^[12] disregarded the utilization of coronoidectomy or myotomy by stating that these adjunctive procedures might not alter the underlying juxtaepithelial mucosal changes. Rai et al.^[13] stated that there were no specific indications for performing coronoidectomy or coronoidotomy, and there was no impact on the postoperative mouth opening by either of the procedures.

Hence, it is essential to establish a designated protocol, especially where the cases have reached an advanced stage. In our study, performing coronoidotomy provided us with excellent results considering the preoperative mouth opening that the patient exhibited at the first visit. We achieved a mean increase of 34.56 ± 5.96 mm after coronoidotomy (40.02 ± 4.36 mm) in comparison to mean preoperative values (5.46 ± 4.04 mm). Furthermore, we found a striking improvement of 76.68% (17.36 ± 1.17 mm) after performing coronoidotomy in comparison to fibrotomy (22.65 ± 4.72 mm).

A parallel study by Chang et al.^[5] resulted in a mean increase of 13 mm after performing 22 coronoidotomies and 27 mm on comparison with preoperative IID. Gupta et al.^[2] achieved the increment of 20.2 mm and 34.40 mm, respectively, by performing five bilateral coronoidectomies. While Kothari et al.^[14] achieved the increment of 31.7 mm after ten coronoidectomies.

These results show that there is no significant difference in the IID achieved after coronoidotomy/coronoidectomy. Both modalities were equally efficient and comparable on the basis of treatment outcome. Hence, the selection of treatment modality completely lies in the hands of the operating surgeon, the difference of choice being less iatrogenic damage to the temporalis muscle during coronoidotomy. Another important aspect to note is that the preoperative MO in all these studies were 13.5 mm,^[5] 14.4 mm,^[2] and 14.7 mm,^[14] respectively, while our study included more advanced cases with a mean mouth opening of 5.46 ± 4.04 mm. Considering the severity dealt with, the 76.68% increment achieved in our study after coronoidotomy was more than satisfactory for the patient, provided the patient maintained a regular follow-up and consistent mouth opening exercises.

All six cases of temporomandibular joint (TMJ) dislocations underwent eminectomy in the same setting. Intraoperative dislocation can be mainly attributed to glenoid fossa changes due to severe fibrosis. As a result, eminectomy can also be included in the protocol for the management of advanced cases of OSMF.

Conclusion

We conclude that BC is a highly effective adjunctive procedure to fibrotomy with minimal associated complications and must be routinely utilized in advanced cases of OSMF for achieving desired outcomes. In chronic cases, where there is TMJ dislocation eminectomy can also be included as a treatment protocol. However, periodic follow-up, patient counseling and physiotherapy are important criteria which define the true prognosis of the treatment and prevent postoperative relapse.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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