in 1952 , schwartz coined the term  atrophica idiopathica mucosa oris  to describe an oral fibrosing disease he discovered in 5 indian women from kenya . worldwide , estimates of oral submucous fibrosis indicate that 2.5 million people are affected , with most cases being concentrated on the indian subcontinent , especially eastern and southern india . oral submucous fibrosis is widely prevalent in all age groups and across all socioeconomic strata in india . a sharp increase in the incidence of oral submucous fibrosis is noted after pan parag came into the market , and the incidence continues to increase . the majority of patients present with an intolerance to spicy food , rigidity of lip , tongue , and palate leading to varying degrees of limitation of opening of the mouth and tongue movements [ 3 , 4 ] . the management of oral submucous fibrosis can be dealt with two broad categories : medical and surgical . the medical management includes multiphase injections of hyaluronidase , hydrocortisone , placental extract , triamcinolone plus vitamin , and iron supplements . the medical management has been extensively reported in the review literature by kerr et al . . the surgical treatment is the method of choice in patients with marked limitation of mouth opening . the following surgical modalities have been used : release of fibrous bands and covering of the raw areas with split thickness skin grafting , bilateral nasolabial flaps , palatal island flaps , tongue flaps , temporalis myotomy , and coronoidectomy . the buccal fat pad is a supple and lobulated mass , easily accessible , and mobilized . the buccal fat pad is mainly used to cover defects in the posterior maxilla , the buccal region , the hard palate , the soft palate , and the retromolar and pterygomandibular regions after tumor resections and oroantral communications after tooth extractions [ 8 , 9 ] . so , the aim of this study is to evaluate the use of  buccal fat pad as an interpositioning material in surgical management of oral submucous fibrosis . a series of 8 cases with proven oral submucous fibrosis , with mouth opening less than 20  mm , from 2007 to 2009 involving the buccal mucosa were treated surgically in the department of oral and maxillofacial surgery , college of dental surgery , saveetha university , chennai . pedicled buccal fat pad was used as an interpositioning material to cover the raw areas in the oral cavity after incision and release of fibrous bands . a detailed personal history with special reference to the tobacco habits was obtained from each patient . the preoperative interincisal distance was measured in every case with maximal mouth opening ( figures 1 and 2 ) . the horizontal incision was placed along the occlusal plane with the surgical knife on the buccal mucosa away from stenson 's duct orifice . the incision was placed posteriorly to the pterygomandibular raphe or anterior pillar of fauces and at the anterior most point to the corner of the mouth . the mouth was then forced to open with the mouth gag to an acceptable range of approximately 35  mm . the coronoid process was approached from the wounds created or another incision placed along the external oblique ridge of the mandible . the mouth was opened and the intraoperative opening was measured between upper and lower incisors . a mouth opening of 3035  mm the buccal fat pad was approached on the posterior superior margin of the created buccal defect ( figure 3 ) , that is , posterior to the zygomatic buttress . after blunt dissection , through the sub mucosa the buccal fat pad was mobilised gently until a significant amount was obtained to cover the defect without tension . this was done by using small artery forceps and gently letting out the buccal fat pad to the raw area . the buccal fat pad was secured in place by horizontal mattress sutures or simple interrupted sutures with 3/0 vicryl . the buccal fat pad covered the buccal defects posteriorly to the soft palate and anteriorly to the corners of the mouth ( figures 4 and 5 ) . in selected cases where the mouth opening was severely restricted operatively , ryle 's tube was kept intraoperatively for feeding . the patients were instructed to use 10  ml of hexidine mouth rinse at 8 hourly . mouth opening exercises were started postoperatively after 36 hours using fergusson 's mouth gag or wooden spatulas . the frequency of the exercises was carried out at 1520 times thrice daily for at least 1 month for all patients . patients were asked for the status of signs and symptoms and a thorough clinical examination was done . the status of mouth opening was noted . the results were found to be satisfactory in all patients as shown in tables 1 and 2 . in 8 patients , the range of preoperative mouth opening was 318  mm ( mean 14  mm ) ( tables 1 and 2 ) . as the result of the successful surgical procedure , the size of the intraoperative mouth opening was ranged from 2538  mm ( mean 33.25  mm ) . the patients were discharged 57 days after the operation ( figures 6 , 7 , and 8) . the range of the mouth opening at this time was 2536  mm ( mean 30.63  mm ) . one patient ( case 5 ) failed to exercise several times daily and finally experienced a significant relapse . the postoperative mouth opening after a follow - up period of 6 months was 1835  mm ( mean 30  mm ) ( figures 9 and 10 ) . the preoperative mouth opening was compared with intra- and each postoperative mouth opening using students t - test and found to be statistically significant ( p < 0.001 ( 99.9% sig ) ) . oral submucous fibrosis as an insidious chronic disease affecting any part of the oral cavity and sometimes pharynx , although occasionally preceded by andor associated with vesicle formation , is always associated with juxtaepithelial inflammatory reaction followed by fibroelastic changes in the lamina propria , with epithelial atrophy leading to stiffness of the oral mucosa causing trismus and difficulty in eating . most convincing evidence is derived from case - control studies   that estimated the odds ratios for areca nut use among oral submucous cases and a defined dose - dependant relationship between areca nut and the causation of the disease . both frequency and duration of chewing were important for the development of oral submucous fibrosis . the commercially freeze - dried products such as pan masala , guthka , and mawa ( areca and lime ) have high concentrations of areca nut per chew and cause oral submucous fibrosis more rapidly than self - prepared conventional betel quid which contains smaller amounts of areca nut . early on , the histopathology   consists mostly of chronic inflammatory cells with an eosinophilic component infiltrating the subepithelial connective tissues . older lesions demonstrate a reduced vascularity , reduced numbers of inflammatory cells , and dense bundles and sheets of collagen deposited immediately beneath the epithelium . the diffuse hyalinization of subepithelial stroma usually extends into the submucosal tissues , typically replacing the fatty and fibro vascular tissues . so the basic aim of the treatment modality has been relieving the symptoms which hamper function in the form of trismus , difficulty in mastication , deglutition , and speech . the medical management has been extensively reported in the review literature by kerr et al . . they concluded with low - grade evidence to support recommendations for the nonsurgical management of oral submucous fibrosis . the buccal fat pad is a supple and lobulated mass , easily accessible , and mobilized . anatomically , the buccal fat pad is described as consisting of a central body and 4 extensions [ 8 , 9 ] : buccal , pterygoid , pterygopalatine , superficial , and deep temporal . the main body is situated deeply along the posterior maxilla and upper fibers of the buccinator . the buccal extension lies superficially within the cheek and is mainly responsible for cheek fullness . the blood supply of the buccal fat pad comes from 3 sources : maxillary artery ( buccal and temporal branches ) , superficial temporal artery , and transverse facial artery . it is often encountered accidentally during maxillary orthognathic operations and there have been reports in children of spontaneous or traumatic herniation of buccal fat pad . the easy mobilisation of the buccal fat pad and its excellent blood supply and minimal donor site morbidity makes it an ideal flap . the main advantages of buccal fat pad are ease of harvesting , simplicity , versatility , low rate of complications , as well as quick surgical technique . the operation can be performed in one incision , affecting neither appearance nor function of the area . it has been used as pedicled graft in facial augmentation procedures , for the repair of persistent oroantral fistulas after dental extractions and in the reconstruction of small and medium size maxillary defects after resection of a tumor . r. m. borle and s. r. borle   reported that skin graft was used to cover the defect after excision of fibrotic bands caused contracture during healing . the incidence of shrinkage , contracture , and rejection of the graft was found to be very high . the other limitation of split thickness skin graft is the morbidity associated with the donor site . tongue flaps have been used to cover the buccal defects but were found to be bulky . bilateral radial forearm flap has been used for the resection of buccal defects in oral submucous fibrosis . the buccal fat pad by virtue of its anatomic position and excellent blood supply , the ease with which it can be accessed and mobilized , without any donor site morbidity , proved to be a logical , convenient , and reliable interpositioning material . the procedure considering the anatomic proximity of the donor and recipient site is not a lengthy one . the graft can be approached through the same buccal incision which was used to release the fibrotic bands . should it fail , the consequences are not serious , as other options are open . the volume of buccal fat pad was found to be adequate in all cases , and it maintained its position as an interpositioning material postoperatively , similar to the findings of yeh   and sharma et al . . compared the surgical treatment modalities in 100 patients using buccal fat pad , tongue flap , nasolabial flap , and split thickness graft and concluded that buccal fat pad graft was superior to all the other surgical procedures and that can be done even under local anaesthesia as a day care procedure . postoperative healing was uneventful with no evidence of infection in all cases . in our study , the postoperative mouth opening range was 2536  mm ( mean 30.63  mm ) . involvement in the physiologic functions like suppleness and elasticity of the buccal mucosa was seen on clinical examination . symptoms such as burning sensation and intolerance to spices were eliminated in all the patients . this study showed the transferred buccal fat pad tissue was replaced by connective tissue postoperatively . all cases with more than 6 months follow - up were studied to correlate degree of mouth opening . considering the favorable results of this study with the advantages offered , buccal fat pad seems to be an appropriate interpositional graft in the surgical management of oral submucous fibrosis .
purpose of the study . 
 this study was to evaluate the use of buccal fat pad as an interpositioning material in surgical management of oral sub mucous fibrosis . 
 materials and methods . a series of 8 cases with proven oral sub mucous fibrosis , with mouth opening less than 20  mm , involving the buccal mucosa were treated surgically in the department of oral and maxillofacial surgery , college of dental surgery , saveetha university , chennai . 
 pedicled buccal fat pad was used as an interpositioning material to cover the raw areas in the oral cavity after incision and release of fibrous bands . results . in 8 patients , 
 the range of pre operative mouth opening was 318  mm ( mean 14  mm ) . 
 as the result of the successful surgical procedure , the size of the intra operative mouth opening was ranged from 2538  mm ( mean 33.25  mm ) . 
 the patients were discharged 57 days after the operation . 
 the range of the mouth opening at this time was 2536  mm ( mean 30.63  mm ) . 
 the results were evaluated using student 's t test and found to be statistically significant . 
 the pedicled grafts took up uneventfull .