I Came in Her Mouth Again and Again and Again
Natl J Maxillofac Surg. 2010 January-Jun; i(1): 86–xc.
Unusual causes of reduced mouth opening and information technology'due south suitable surgical management: Our experience
Sunil Kumar Gupta
Section of Oral and Maxillofacial Surgery, IDST Dental College, Modinagar, India
Amar S. Rana
Department of Oral and Maxillofacial Surgery, IDST Dental College, Modinagar, India
Deepak Gupta
Department of Oral and Maxillofacial Surgery, IDST Dental Higher, Modinagar, India
Gaurav Jain
Department of Oral and Maxillofacial Surgery, IDST Dental College, Modinagar, India
Puneet Kalra
Department of Oral and Maxillofacial Surgery, IDST Dental College, Modinagar, India
Abstract
Reduced mouth opening is a common clinical problem and many individuals feel information technology at least once in his or her life and nigh dental practitioners come across patients with restricted mouth opening quite frequently. Information technology can occur due to a variety of underlying conditions which may involve complex factors. Hence, it is essential for the clinician to thoroughly investigate and examine these cases for proper diagnosis and its appropriate management.
Keywords: Reduced mouth opening, ankylosis, caustic soda
INTRODUCTION
The problem of reduced mouth opening is caused past variety of reasons. This particular clinical condition cannot exist attributed to whatsoever particular disease or condition, every bit information technology may exist a symptom of number of conditions. In healthy individuals mouth opening is effectually thirty-50mm. Simply when the rima oris opening is express to a maximum of 20mm the individual is said to accept a reduced mouth opening or trismus.
Nosotros are presenting five cases of reduced oral cavity opening, with unusual etiological factors like caustic soda ingestion, oral sub-mucous fibrosis, space infection, temporomandibular joint ankylosis and zygomatic arch fracture and their surgical management.
CASE REPORTS
Case one (Caustic soda ingestion)
A 28-year-old lady, reported with reduced month opening and near nil tongue movement, following caustic soda ingestion accidentally four years back. The chemical injury was express to lips and oral cavity, only esophagus was spared and had not been injured because she spit out the caustic soda without swallowing. On exam, facial appearance was normal, but her mouth opening was reduced to 1 cm and tongue was totally fixed to the flooring of the mouth [Figure one]. Vertical and round fibrous bands were present on buccal mucosa bilaterally extending from corner of mouth to tooth region. The treatment done was incision of contracted scar tissue on both sides of buccal mucosa extending from commissure to 3rd molar, followed by submucosal dissection. The same procedure was done on the other side for release of contracture and mouth opening of around iii.5 cm was achieved. This was followed past release of tongue adhesion from inductive to base of operations of the tongue. Divide skin graft was taken from left thigh and was placed on the ventral surface of the natural language and on buccal mucosa bilaterally [Figures 2–4].[1]
Preoperative photo (complete adhesion of natural language to floor of the rima oris and ane cm oral fissure opening)
Intraoperative photograph of pare graft placed at buccal mucosa after excision of gristly bands
Postoperative photograph with improved oral fissure opening
Intraoperative photograph of skin graft placed at ventral surface of the natural language later on releasing tongue adhesion with the floor of the mouth
Case ii (Oral submucous fibrosis)
A 45-year-old female patient reported with complaint of reduced mouth opening. She had a history of eating pan for last twenty years. She had quit the habit 2 years dorsum due to minimal mouth opening. She had consulted at various centers and had taken every possible medicinal treatment during the last 10-year period. But to her agony, her mouth opening did not improve. In the due course of fourth dimension, she had to take anti-depressants, which is yet going on. On examination, the mouth opening was just 13 mm and posterior teeth were impinging on buccal mucosa [Figure 5]. Because she had already taken all medicinal treatments including intralesional corticosteroid injections, we were left with merely i choice and that was of surgery. The handling washed was release of bilateral fibrous bands, bilateral coronoidotomy, and reconstruction with buccal pad of fat. She underwent vigorous physiotherapy and had been advised to do so for a longer period of time [Figure vi].[2]
Case 3 (Sub masseteric space infection)
A 45-year-erstwhile male patient of rural region reported to the Department of Oral and Maxillofacial Surgery with the mutter of pain in lower back molar since i month, which aggravated ten days back with marked swelling at the bending of mandible and reduced mouth opening [Effigy 7]. At the time of reporting, the patient had severe trismus (nil rima oris opening) with chill and fever and he was looking very ill. The patient was given intravenous fluids to rehydrate and intravenous antibiotics were started. After examination and investigation, submasseteric space abscess was the final diagnosis. Incision and drainage was done. Extraoral incision was done [Figure viii] to bleed the pus, then forceful mouth opening was done and carious exposed cleaved 3rd molar was extracted. A corrugated rubber drain was put on for the next 48 hours. The patient took effectually one calendar month to get normal subsequently taking a course of antibiotics and musculus relaxant.[3]
Intraoperative photograph
Case iv (TMJ ankylosis)
A 14-yr-old male patient reported with complaint of inability to open the mouth. The patient had history of fall from roof 1 year back and gradually mouth opening was reduced to zilch [Effigy 9]. He had scar mark over chin with no facial asymmetry. There was no condylar movement bilaterally. Orthopantomogram (OPG) and computed tomography (CT) revealed bilateral bony wedlock between condyle and glenoid fossa. All the investigations were within normal limits. Bilateral gap arthroplasty along with bilateral coronoidectomy was washed and 45 mm oral fissure opening was achieved [Effigy ten].[4]
Case 5 (Zygomatic arch fracture)
A twenty-year-onetime female patient reported with primary complaint of reduced oral fissure opening and an observable low over right temple region. The patient had history of set on twenty days back. Submentovertex view revealed V-shaped zygomatic curvation fracture [Figure xi] and this causing hindrance in opening the rima oris. Gillie'south temporal fossa approach[3] was used to reduce the fracture [Figure 12]. No fixation was required as the fracture was displaced around vertical centrality.[v]
RESULTS
We had done the treatment of the reported cases of trismus according to the underlying cause. All of them had favorable outcome and the patients are very much satisfied.
DISCUSSION
Cases of caustic soda ingestion and subsequent surgery have been rarely reported in the literature. Many grafting materials are tried in the reconstruction.[1] Skin graft was also used by many surgeons in the past, only was not considered as a popular pick of graft cloth in such situations, because of dehiscence and further loss of the peel graft and thereby relapses, just in our case skin graft was taken up very well. Fifty-fifty later 1 year of the surgery, no complication has been reported. In this particular case, tongue was totally fixed to the floor of the oral cavity (no movement). Releasing the tongue from the floor and placement of pare graft at the ventral side of the tongue produced an excellent result with sufficient mobility of the tongue.
OSMF is nevertheless a condition present very commonly particularly in developing countries due to known reasons of chewing tobacco, pan, etc. Various medicinal and surgical treatments are beingness recommended and performed, depending on the severity and elapsing of the disease.[2] Our case was diagnosed as OSMF ten years back and she was given all the possible medicinal treatments including intralesional corticosteroid injection merely the patient was not relieved of the disease. When she came to united states, we proposed the surgical choice and did bilateral resection of the bands, coronoidotomy and reconstruction using buccal pad fat graft, followed by vigorous physiotherapy. Though it was a tough decision for the patient to be ready for this kind of surgery, she gave the consent and the result of buccal pad graft is besides very encouraging.
Space infections can crusade trismus; timely intervention in the form of incision and drainage is the key in such a state of affairs.
Patients of temporomandibular ankylosis have trismus and limited mouth opening ranging from zero to a few centimeters. The first goal was to achieve adequate mouth opening and the 2nd goal was to maintain this by the physiotherapy. We got excellent result by osteoarthroplasty.
Zygomatic arch fracture, if depressed, restricts the motion of coronoid process and tin can crusade temporary trismus which tin be but corrected by elevating the arch. Sometimes, the zygomatic arch/bone unite with the coronoid procedure (malunited fracture). Patients become in a trismus which tin can be corrected past refracturing the curvation and the coronoid process and achieving the rima oris opening.
Although cases of trismus status come to clinician not quite oft and it seems that these cases are sometimes difficult to diagnose, if we take proper history and exercise thorough clinical examination and investigations, one can treat these cases very efficiently.
Nosotros encountered a few cases of trismus with varied etiologies. But each one of them had undergone the treatment according to the underlying cause.
CONCLUSION
We would like to say that although the cases of trismus condition seems to be difficult initially, by proper diagnosis and planning we can provide advisable treatment to the patients with a good prognosis. Pare grafts are nonetheless a skillful reconstructive option for the soft tissues and buccal fatty pad is also a very good option for oral and maxillofacial cases because of its proximity.
Footnotes
Source of Support: Nada.
Conflict of Interest: None declared.
REFERENCES
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304171/
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