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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 91-94

Novel physiotherapy appliance in the management of oral submucous fibrosis

Department of Oral Medicine and Radiology, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India

Date of Submission07-Sep-2020
Date of Decision10-Jan-2021
Date of Acceptance10-Jan-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. G V Ramachandra Reddy
People's Dental Academy, People's Campus, Bhanpur, Bhopal, Madhya Pradesh - 462037
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_189_20

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Background: Limitation of mouth opening is one of the most common sequelae of various pathological processes leading to compromised nutritional state in addition to physical and psychological disabilities. OSMF is one such condition with severe trismus, debilitment, and an increased risk for malignancy. Methodology: This prospective clinical study describes the fabrication and use of a new functional appliance known as Shekar's appliance. Three OSMF patients were selected and enrolled in the study and appliance was fabricated. Assisted supervised oral physiotherapy session was performed with the appliance. Result: Excellent improvement in mouth opening was observed in all the three patients treated with the appliance. The mean increase in mouth opening was recorded as 8.6 mm. Conclusion: Oral physiotherapy induces tissue remodeling in OSMF to increase mouth opening.

Keywords: Mouth exercising device, oral physiotherapy, oral sub mucous fibrosis, Shekar's appliance, trismus

How to cite this article:
Ramachandra Reddy G V, Shinde CV, Khare P. Novel physiotherapy appliance in the management of oral submucous fibrosis. J Indian Acad Oral Med Radiol 2021;33:91-4

How to cite this URL:
Ramachandra Reddy G V, Shinde CV, Khare P. Novel physiotherapy appliance in the management of oral submucous fibrosis. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Apr 18];33:91-4. Available from: https://www.jiaomr.in/text.asp?2021/33/1/91/312200

   Introduction Top

Oral submucous fibrosis (OSMF) has been well established in Indian medical literature since the time of Sushruta, a renowned Indian physician who lived in the era 600 B.C. The etiopathogenesis is still obscure, many factors such as areca nut chewing, nutritional deficiency states, genetic susceptibility, autoimmunity and collagen disorders have been suggested. The basis of morbidity are reduced mouth opening, burning sensation, restricted tongue movements, and difficulty in swallowing.[1]

Various treatment modalities ranging from both conservative and surgical have been attempted with varying achievements. Nevertheless, it is noteworthy that each and every modality attempted usually after habit cessation so far only affords symptomatic improvement in the condition and some improvement in mouth opening which is transient. Furthermore, each modality vary in duration, success rates, adverse effects, relapse, and recurrence rates.

Therefore, a search for an efficient and improved management strategy still continues. The primary morbidity in OSMF is because of reduced mouth opening. Oral physiotherapy involves tissue remodelling principle to improve mouth opening. Consequently, in search of innovation and enhancement, here we present a novel oral physiotherapy method using an inventive functional appliance in the management of OSMF.[2]

   Materials and Methods Top

This prospective clinical study designed in accordance with Helsinki's guidelines was conducted in the Oral Medicine and Radiology Department of a dental school in India. After obtaining clearance from the institutional ethics committee (Ref. No. PDA/Dean/JEC/2019/100/FAC/01. Dated: 09/09/2019) clinically diagnosed cases of OSMF, falling under grade 2 and grade 3 severity as per Kerr et al.,[3] who did not have any coexisting disease or disorder of orofacial region or systemic illness which may interfere with study protocol and who have not undergone any treatment for OSMF in past, were enrolled in the study after obtaining a written informed consent. A strict tobacco cessation protocol was followed and a routine blood test was performed prior to commencement of the study and patients within normal range were only selected. After cessation of habit the patients were prescribed antioxidants, nutritional supplements followed by Intralesional injections for one month. There was mild improvement in symptoms and mouth opening. Subsequently, the novel functional appliance was fabricated for the selected cases. The mouth opening was assessed at first and every follow-up visit. The interincisal mouth opening was assessed as distance measured from mesioincisal edge of upper left central incisor to the mesioincisal edge of the lower left central incisor. The measurement was recorded in millimetres by means of a digital vernier calliper.

Fabrication of Shekar's appliance

The appliance was designed and used by Dr. S. E. Shekar, a senior Orthodontist and former Professor of Orthodontics, Government Dental College, Bangalore. The original appliance was designed, constructed, and tried for the first time in a case of unilateral bony ankylosis after surgical intervention in 1976.[2],[3],[4],[5]

This appliance has been successfully used earlier in trismus cases like bony ankylosis of TMJ (after surgical intervention), fibrous ankylosis–early stage in children (Juvenile arthritis), and post-surgical trismus. In addition it may be valuable in the treatment of OSMF, osteo-arthritis of TMJ, myositis ossificans, and hardening of facial muscles due to radiotherapy in the treatment of oral cancer.[2],[5]

The appliance consists of two acrylic plates—maxillary and mandibular in which the maxillary acrylic plate is slightly larger in size compared to mandibular acrylic plate which is prepared after taking the measurement of the arches. Arch width is measured at pre-molar and molar regions. These plates are connected on either side by the springs that are either made individually or from a single wire. These springs are made up of 0.9-1.2 mm stainless steel orthodontic wire depending upon the age of the patient and the type of trismus to be treated. The upper part of the spring is extended about 8.0 cm outward and downward to make a handle [Figure 1].[4]
Figure 1: Appliance design

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The appliance is activated by opening the coils. The distance between the maxillary and the mandibular plates can be increased by opening the side coils as per the existing amount of opening of the patient's mouth.[4]

If the maxillary (Upper) coil is opened, the appliance exerts more pressure on the posterior part of the mandible and if the mandibular (lower) coil is opened it exerts pressure more on the anterior part of the mandible or it can be made to exert pressure uniformly on the mandible depending upon the need [Figure 2].[4]
Figure 2: Mode of action of the appliance

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When the patient wears the appliance, the plates will be resting or placed over the occlusal surface of the posterior teeth; it should not touch the anteriors, especially the incisors. For this reason, the patients were made to hold the appliance in position and then asked to do the exercises by opening and closing the mouth [Figure 3]. Patients were advised to keep the muscle in a relaxed position during the exercise. Exercises can be done 3–4 times a day or more depending upon the severity. The springs were activated once in 1 or 2 weeks.[4]
Figure 3: Mouth exercise by placing the appliance inside the mouth accompanied by opening and closing of mouth

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   Results Top

This being a pilot study, three male patients were selected concordant with above listed inclusion and exclusion criteria. Assisted supervised oral physiotherapy session was performed with the appliance for 10 min and mouth opening was recorded at weekly intervals for continuous 3 months. Additionally, patients were encouraged to maintain mouth opening by using the appliance at home 3–4 times a day depending upon severity. The results were quite encouraging and are illustrated in [Table 1]. The mean increase in mouth opening was noted as 8.6 mm which was exceptionally impressive.
Table 1: Result

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After completion of study, a yearlong follow-up was done with thorough oral examination to assess overall oral health and criteria measured to reassure that the patients comply with the strict protocol of the study and found no deterioration in the condition.

   Discussion Top

Oral physiotherapy is presently utilized as an adjunctive modality in the form of mouth opening/ exercising devices in the management of OSMF.[6] It is seldom used as a primary modality in improving the mouth opening. It has the benefits of being a non-invasive technique, being less traumatic to the patient and also constricts financial requisite.[6] Mouth exercises can be performed anywhere during the day which adds to its benefit as a patient compliant procedure. To the best of our knowledge, this appliance has been studied extensively for the first time in OSMF patients. The efficacy of Shekar's appliance in OSMF patients was assessed in terms of increase in mouth opening. We attained outstanding results from this device in this pilot study and recommend it as a primary treatment modality.

The main objective of treatment in OSMF is to increase mouth opening. Few researchers concluded that physiotherapy alone can modify tissue remodelling in OSMF to increase mouth opening.[7],[8] Mouth opening/exercising devices for this purpose are usually fixed to the teeth to keep the dental arches apart.[7]

This appliance exerts force only in the areas where there is resistance. In OSMF, resistance comes from the vertical fibrous bands. When the appliance is worn, it exerts force on these bands and stretches them. The separation of the fibres' may increase the subcutaneous matrix areas for improved circulation.[9] Researches on blood flow and muscle oxygen uptake during exercise reveals an increase in blood flow and muscle oxygen uptake.[9] This can be repeated three to four times a day to ensure the steady state of increased blood flow. The duration and frequency required for the exercise can be increased, subject to the patient's normal comfort level.

A number of studies have been performed in the past to assess the effectiveness of physiotherapy for mild to moderate cases of OSMF[7],[8],[9],[10] A study on OSMF patients observed physiotherapy to be a beneficial adjunct to micronutrients.[8] Another study on OSMF accomplished significant improvement in mouth opening using physiotherapy and ultrasound therapy.[10] Oral physiotherapy also has important role in surgically treated cases of OSMF to reduce chances of scar contracture and relapse.[7]

Future long-term studies with larger sample size, increasing study criteria and also combination with other medications are few recommendations to evaluate the clinical efficacy of this appliance to reach conclusive results. Appliances should also be studied at the microscopic level to develop them as a more definitive physiotherapeutic treatment modality in the future. Limitation of this appliance is: in long-term use, fatigue may develop in the wire that may lead to breakage of the coil, in such situations, a new appliance needs to be fabricated.

   Conclusion Top

In this study, oral physiotherapy in form of Shekar's appliance yielded exceptional result in improving mouth opening in OSMF patients. Moreover, physiotherapy is independent, cost-effective, non-invasive, free of adverse effects and less traumatic, it is more preferred by the patients. Therefore, it should be employed as primary or mainline modality in the management of OSMF. However, we have planned further studies with larger sample size and increasing study criteria to strengthen the results of this preliminary report.


With special thanks to the inventor of Shekar's appliance, Dr. S.E. Shekar for providing valuable scientific information and guidance.

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

Shinde CV, Kohli S. Comprehensive insight into management of OSMF. Int J Adv Res 2018;6:413-23.  Back to cited text no. 1
Shekar SE. Oral trismus. [Internet]. 2018 [cited on 2020 Apr 15]. Available from: https://www.oraltrismus.com/about.html.  Back to cited text no. 2
Kerr AR, Warnakulasuriya S, Mighell AJ, Dietrich T, Nasser M, Rimal J, et al. A systemic review of medical interventions for oral submucous fibrosis and future research oppurtunities. Oral Dis 2011;17(Suppl 1):42-57.  Back to cited text no. 3
Shekar SE. TMJ ankylosis and physiotherapy–A review. Ind J Oral Surg 1981;1:1-6.  Back to cited text no. 4
Shekar SE. Ankylosis of TMJ & trismus: Management using a new device. Paper presented at 69th World Dental Conference of FDI; 1980 September 1; Hamberg, Germany.  Back to cited text no. 5
Asha V, Baruah N. Physiotherapy in treatment of oral submucous fibrosis related restricted mouth opening. Int Healthcare Res J 2017;1:252-7.  Back to cited text no. 6
Cox S, Zoellner H. Physiotherapeutic treatment improves oral opening in oral submucous fibrosis. J Oral Pathol Med 2009;38:220-6.  Back to cited text no. 7
Thakur N, Keluskar V, Bagewadi A, Shetti A. Effectiveness of micronutrients and physiotherapy in the management of oral submucous fibrosis. Int J Contemp Dent 2011;2:101-5.  Back to cited text no. 8
Patil PG, Patil SP. Novel mouth-exercising device for oral submucous fibrosis. J Prosthodont 2012;21:556-60.  Back to cited text no. 9
Vijayakumar M, Priya D. Physiotherapy for improving mouth opening & tongue protrusion in patients with oral submucous fibrosis (OSMF) – Case series. Int J Pharm Sci Health Care 2013;3:50-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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