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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 205-208

A simplified intraoral appliance for protecting the flap in a patient with oral submucous fibrosis

1 Department of Prosthodontics and Crown and Bridge, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu, India
2 Department of Prosthodontics, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, India
3 Department of Prosthodontics, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, India

Date of Submission11-Sep-2021
Date of Decision19-Nov-2021
Date of Acceptance21-Sep-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Sonia Abraham
Department of Prosthodontics and Crown and Bridge, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijds.ijds_120_21

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Oral submucous fibrosis (OSMF) is a chronic, debilitating premalignant condition of the oral cavity predominantly caused by betel chewing. In this condition, the sub mucosal tissues (lamina propria and deeper connective tissue) show inflammation and progressive fibrosis that results in inability to open the mouth. Surgical excision of fibrous bands is usually the treatment of choice. Postsurgical trauma to the flap during occlusion is one of the common complications that may occur in those patients. Hence, an intraoral appliance which could protect the flap is necessary. This article explains about the fabrication of an intraoral appliance in a simplified manner to protect the flap from trauma during the occlusion of a patient diagnosed with OSMF who underwent surgical excision of fibrous tissue. The appliance helped in better healing of the surgical site, avoided the trauma to the flap, comfortable and cost effective.

Keywords: Buccal mucosa, flaps intraoral appliance, oral submucous fibrosis, premalignant

How to cite this article:
Abraham S, Manoharan P S, Arivarasan N K, Prabhu K, Karthik V C, Kirubakaran A. A simplified intraoral appliance for protecting the flap in a patient with oral submucous fibrosis. Indian J Dent Sci 2022;14:205-8

How to cite this URL:
Abraham S, Manoharan P S, Arivarasan N K, Prabhu K, Karthik V C, Kirubakaran A. A simplified intraoral appliance for protecting the flap in a patient with oral submucous fibrosis. Indian J Dent Sci [serial online] 2022 [cited 2023 Nov 30];14:205-8. Available from: http://www.ijds.in/text.asp?2022/14/4/205/361193

  Introduction Top

Oral submucous fibrosis (OSMF) refers to the chronic, premalignant condition of the oral mucosa which is characterized gradually by increasing fibrosis of the oral cavity and pharynx. Schwartz was the first person who described OSMF in 1952.[1] OSMF commonly involves the buccal mucosa and rarely involves the larynx, which results in trismus. Trismus is the most common condition where an individual shows the inability to open the mouth due to various pathological processes.[2] In addition to physical and psychological disabilities, it may also lead to compromised nutritional state. OSMF commonly affects 20-40 years of age and it is more prevalent in 0.2%-0.5% general population in India. Initially, OSMF leads to inflammation followed by hypovascularity and fibrosis. OSMF in the moderate stage will be leading two trims and also progressive. It is characterized by irreversible fibrosis. Normal mouth opening ranges from 40 to 60 mm.[3],[4]

OSMF was classified by Khanna and Andrade based on maximal interincisal opening (MIO) are:

  • Stage I, early OSMF without trismus (MIO >35 mm);
  • Stage II, mild to moderate (MIO 26-35 mm);
  • Stage III, moderate to severe (MIO 15-25 mm);
  • Stage IVa, severe disease (MIO <15 mm); and
  • Stage IVb, extremely severe malignant/premalignant lesions noted intraorally
  • OSMF can be managed medically and surgically depending on stage.[5]

In trismus patients, the restriction of mouth opening varies from a few millimeters to even centimetre. Trismus in OSMF results in loss of elasticity and stiffness due to fibrosis of the lamina propria. Trismus is a common complication of dental treatment, but also it has further bearing on mastication, speech, oral hygiene, and swallowing.[6],[7],[8] Surgical intervention is mandatory for the removal of oral bands. Fibrotomy can be done for improving the mouth opening and then reconstruction can be done with suitable flaps.[9] Reconstruction can be done with skin grafts. During reconstruction procedures, sometimes, it leads to necrosis and failures of flaps because of trauma from occlusion.[8]

Some authors suggested using a soft TMJ trainer, transbuccal suturing, gauze piece application, etc., in the oral cavity which helps to prevent trauma from occlusion. All above modalities have disadvantages such as inability to speak, scar formation, drooling of saliva, inability to chew, and it will be inadequate in posterior extended.[1]

Here is an appliance which was introduced by author Borle as Borle's appliance which helps in preventing trauma from occlusion and cheek bite.

This clinical report focuses on the fabrication of an intraoral appliance named as Borle's appliance which is the modification of cheek bumper appliance using heat cure acrylic resin, buccal shield which helps in overcoming the failures during reconstruction and also helpful for healing of ulcer. It also helps to improve the inability to speak, chew, limited mouth opening, and helps in protecting the flaps.[1]

  Case Report Top

A 40-year-old female with multinodular goiter was referred from the department of general surgery for dental opinion regarding trismus. The patient was diagnosed with OSMF by the specialists in oral medicine and radiology following which she was referred to the department of prosthodontics for the management of trismus and ulcer on buccal mucosa because of trauma from occlusion during the postoperative week as a sequel to surgical treatment.

During her visit to the department of oral medicine and radiology, her chief complaint was pain in the left upper back tooth region for the past 1 week. In the history of presenting illness, the patient was apparently normal 1 week back when she experienced pain in the left upper back tooth region.

The pain was gradual in onset, aggravates on eating, and relieves at rest and also has a history of difficulty in mouth opening for the past 4 months with burning sensation and pain level 6 (according to Visual Analog Scale).[10] Her past medical history was multinodular goiter. She has undergone replacement of missing teeth 3 years back and she had the habit of chewing paan with tobacco and areca nut with stakelime for five to six times a day for 3 years. She spits it out after 10 min.

On intraoral examination, generalized thick fibrous bands are palpable on the right and left buccal mucosa; generalized tenderness present on palpation of the right and left buccal mucosa. She had restricted mouth opening and restricted tongue movement. She wears quack removable partial denture in relation to 11, 21, 22 and has dental caries in relation to 26 which is tender on percussion. Clinically on intraoral examination missing teeth in relation to 41 and 27. Generalized attrition seen and Grade III mobility in relation to 31. Generalized depapillation of the tongue and mouth opening was almost 10 mm. The patient was diagnosed as dental caries with apical periodontitis in relation to 26 and another diagnosis was OSMF which was stage IVa (MIO <15 mm)

Then medication (SM FIBRO 1-0-1, 30 days) was prescribed by the department of oral medicine and referred to the department of oral and maxillofacial surgery for the extraction of 26 and management of OSMF.

In the oral surgery department, the patient underwent surgical intervention. The patient has been reviewed after 4 months of follow-up. Since the patient has undergone treatment over a period of time, she was not able to tolerate pain due to trauma from occlusion. Hence, the patient was referred to the department of prosthodontics with mouth opening almost 10 mm after the incision was done at size 0.5 mm, and also at that time, the burning sensation and pain level 4[10] (according to Visual Analogue Scale) which was reduced compared with the first visit. Hence, an alternative treatment therapy was considered. Intraoral appliance therapy was advised for 2 months along with mouth exercise (passive stretching exercise) and the patient was instructed for follow-up after 2 months.

Intraoral appliance here was the prosthesis with extension of acrylic in the right and left side of buccal vestibule which helps to reduce cheek biting, improve healing of ulcer, and also it helps in improving mouth opening. Consent has been obtained from the participant.

Maxillary and mandibular impressions were recorded using stock trays with irreversible hydrocolloid impression material (Algitex, DPI, India). The cast was obtained using type II gypsum product (Kalabhai). Modified Adam's clasp was fabricated using stainless steel orthodontic wire in relation to 16.Wax up done [Figure 1]. Then flasking, dewaxing, packing, and curing are done. Acrylic palatal plate with buccal shield was made using heat cure acrylic resin (DPI, India) which extends bilaterally covering the buccal aspect of upper and lower posterior teeth along with modified Adam's clasp. Buccal shield was made in dimension 2 cm × 3 cm using autopolymerizing resin and it was made convex which helps the buccal mucosa away from occlusion [Figure 2].
Figure 1: Master cast with wax up

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Figure 2: Intra oral protective appliance

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Sprinkle on the technique was used for the fabrication of the appliance which covers the anterior region sulcus area and it covers the buccal area posteriorly.

Once the acrylic resin polymerization completed, the appliance was removed, cleaned, trimmed, and polished. The appliance was tried in the patient's mouth after 24 h of surgery to check for extensions; adjustments were done wherever necessary to wear/remove it comfortably by the patient without any interference and care was taken not to impinge the gingival margins [Figure 3]. The appliance was then delivered and postinsertion instructions were given.
Figure 3: Extra oral image after insertion

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The follow-up was done after 2 months. When the patient was evaluated, wound healing was satisfactory. When the mouth opening was evaluated, it was almost 13 mm.

The custom-made appliance used here offers good stability and retention. It also has adequate strength to separate the flaps and has better durability. Intraoral appliance along with mouth exercise mainly helps to increase the mouth opening, healing of ulcer, and also helps in preventing necrosis. Furthermore, it is cost-effective and easy to fabricate.

  Discussion Top

Oral function without any interference is important in each and every individual. Patients might feel pain because of trauma from occlusion during the postoperative period which may lead to psychological stress. Therefore, simplified intraoral appliance was fabricated to protect the flap from trauma and also helps in the healing process. Various treatment methods such as vestibular screen, mouth guard, soft TMJ trainer, transbuccal suturing, crib, and gauze piece application have been advocated in protecting the flap and in preventing the trauma from occlusion. All these have some disadvantages such as inability to speak, scar formation, inability to chew, scar formation, drooling of saliva, and inadequate extensions. In this case, treatment has been decided depending upon patient age, health, co-operation of the patient toward treatment and also it is depending upon severity of disease; this simplified intraoral appliance was designed. This design of the prosthesis helpful in preventing trauma from occlusion and also it has adequate strength in separating the flap. This appliance has better stability, retention, and better durability. This device can be easily fabricated and insertion can be done without any discomfort to the patient.

  Conclusion Top

The treatment of OSMF by surgical intervention often compromises the outcome and prognosis due to trauma of flap during occlusion. Proper treatment planning and designing of prosthesis which could avoid the trauma to the flap should be done for the better outcome of such patients. Different methods of prosthesis are obtained for OSMF patients. Such prosthesis should have good stability, retention, adequate strength, better durability, and are easy to fabricate. The Borle's appliance fabricated through a simplified approach suggested in this case report could be used for the better treatment outcome of surgically managed OSMF patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Yadav AO, Vanza BH, Borle RM, Joglekar KA. Custom made protective appliance for oral submucous fibrosis. J Maxillofac Oral Surg 2013;12:472-4.  Back to cited text no. 1
Chaitanya NC, Krishna Prasad CM, Priyanka Danam R, Nithika M, Suvarna C, Nancypriyanka J, et al. A new intraoral appliance for trismus in oral submucous fibrosis. Case Rep Dent 2018;2018:1039391.  Back to cited text no. 2
Dayanarayana U, Doggalli N, Patil K, Shankar J, Mahesh K, Sanjay. Non surgical approaches in treatment of OSF. IOSR J Dent Med Sci 2014;13:63-9.  Back to cited text no. 3
Kajave M, Shingote S, Mankude R, Chodankar K. An innovative prosthodontic approach in managing oral submucous fibrosis patient. SRM J Res Dent Sci 2015;6:139-43.  Back to cited text no. 4
  [Full text]  
Qayyum MU, Janjua OS, Ul Haq E, Zahra R. Nasolabial and extended nasolabial flaps for reconstruction in oral submucous fibrosis. J Korean Assoc Oral Maxillofac Surg 2018;44:191-7.  Back to cited text no. 5
Oswal C, Gandhi P, Sabane A. Prosthodontic management of surgically treatment oral submucous fibrosis using the oral screen prosthesis, IOSR J Dent Med Sci 2013;10:33-6.  Back to cited text no. 6
Mehrotra V, Garg K, Sajid Z, Sharma P. The saviors: Appliance s used for the treatment of trismus. Int J Prev Clin Dent Res 2014;1:62-7.  Back to cited text no. 7
Rawson K, Prasad RK, Nair AK, Josephine J, Oral submucous fibrosis – The Indian scenario review and report of three treated cases. J Indian Acad Oral Med Radio 2017;29:354-7.  Back to cited text no. 8
Anoop D, Anil Kumar S, Raghavan SM, Mohan S, Muhamedali M. Sectional tray approach for cheek bumper prosthesis in a patient with oral submucous fibrosis. Int J Sci Res 2018;7:1029-30.  Back to cited text no. 9
Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15 Suppl 1:S17-24.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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