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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 142-148

Micro-marsupialization as a conservative therapeutic approach for management of pediatric oral mucoceles


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt
2 Department of Pediatric Dentistry, Faculty of Dentistry, Kafrelsheikh University, Kafr el-Sheikh, Egypt
3 Department of Oral Medicine, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission27-Apr-2019
Date of Acceptance29-Aug-2019
Date of Web Publication14-Jan-2020

Correspondence Address:
Emad F. Essa
Department of Oral and Maxillofacial, Faculty of Dentistry, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_21_19

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  Abstract 

Background: Alteration of minor salivary glands due to a mucous accumulation is known as mucocele. It is considered to be a common oral mucosa lesion in pediatric and adolescents. The invasive conventional surgical technique, including surgical excision of the mucocele with the affected minor salivary gland, is not preferred especially in large lesion and in pediatric patients.
Objective: This research aims to study the efficacy of micro-marsupialization as a new conservative technique for management of oral mucoceles in pediatric patients.
Patients and methods: A prospective study was carried out using the clinical records of patients under 12 years old. The patient's age was ranged between 6 and 12 years old with a mean of 9.83 years. Twelve patients were included; they were suffering from mucocele and were treated using conservative micro-marsupialization as a solo treatment via draining the mucus out of the mucoceles to reduce its size and allowing subsequent healing. All children were recalled for clinical evaluation after 1 week, 1, and 3 months.
Patients and methods: Out of the 12 children, seven (58.3%) children were complaining of lower lip mucoceles with 100% success, while the other five (41.7%) children were complaining of oral ranula, the micro-marsupialization technique showed 80% of successful results plus one recurrent case after 1 month of the technique that was treated by conventional marsupialization with packing.
Results: Micro-marsupialization has proved to be a simple technique, the best choice management for pediatric mucoceles. It is rapid to perform, noninvasive, painless, requires only surface anesthesia, effective, low recurrence, well-tolerated by children, and can be easily performed by dental general practitioner in daycare outpatient departments safely.

Keywords: micro.marsuiaplization, minor salivary gland, pediatric mucocele, ranula


How to cite this article:
Essa EF, Beltagy TM, El Mekaky YM. Micro-marsupialization as a conservative therapeutic approach for management of pediatric oral mucoceles. Tanta Dent J 2019;16:142-8

How to cite this URL:
Essa EF, Beltagy TM, El Mekaky YM. Micro-marsupialization as a conservative therapeutic approach for management of pediatric oral mucoceles. Tanta Dent J [serial online] 2019 [cited 2020 Sep 24];16:142-8. Available from: http://www.tmj.eg.net/text.asp?2019/16/3/142/275934


  Introduction Top


Mucocele is a mucous accumulation resulting from an alteration of minor salivary glands. This accumulation involves mucin secretion causing limited swelling [1]. The two crucial etiological factors in mucoceles are trauma and obstruction of salivary gland ducts [2]. The rank of mucoceles among the most common oral lesions is 17th with the incidence of ∼2.5 lesions per 1000 individuals and it represent the second most popular benign soft tissue lesion that affecting the oral cavity [3].

Mucoceles often arise within a few days after minor trauma. It can persist unchanged for months unless treated [4]. Mucocele appears as an asymptomatic pink or bluish nodule but it causes discomfort and creates trouble especially in children, the size may vary from 1 mm to several centimeters [5].

Although the lower labial mucosa is the most affected site, it may affect the cheek, tongue, palate, and floor of the mouth and there is no sex predilection [6].

Mucocele is derived from Latin words 'muco' and 'coele,' meaning mucus and cavity, respectively. It can appear as either one of two types: the extravasation type and the retention type. Extravasation results from a broken salivary glands duct and the consequent accumulation into the soft tissues around this minor salivary gland. Retention appears due to blockage of the minor salivary gland ducts with retention of glandular secretion [7]. A mucocele, in the floor of the mouth in relation to the sublingual gland, is known as ranula. Its name is derived from the Latin word 'Rana' which means 'Frog'. The swelling looks like a frog's translucent underbelly or air sacs [8].

Different techniques have been described for the management of mucoceles[4] including conventional surgical removal of the lesion [9], cryosurgery [10], intralesional corticosteroid injection [11], marsupialization, micro-marsupialization [12], and laser ablation [13]. Concerning treatment, it must be taken into account that the typical minor salivary gland mucoceles rarely resolve on by their own, that is, surgical removal is required in most cases. Surgical excision is carried out when the lesions are multiple, recurrent or cause patient discomfort [14].

The conventional treatment of mucoceles requires surgical excision by electrosurgery or scalpel, which included the associated overlying mucosa and glandular tissue down to the muscle layer [15]. Special care is required during surgical excision to avoid damaging the other glands or ducts with the suture needle, as this may become a cause of recurrence [3].

Regarding ranula possible treatment modalities includes, simple and modified marsupialisation, enucleation of the lesion, and enucleation with gland removal which is the widely accepted radical and definitive treatment, marsupialization is still used as an alternative to conservative surgical treatment in cases of giant intraoral ranula, reducing the risk of surgical morbidity, and presenting low rates of recurrence. While its technique should be performed with care [16], so marsupialization with packing could be the initial treatment, but in case of recurrence, partial or total excision of the sublingual gland should be done [17].

Prognosis of the mucocele is favorable. However, most of the described management options are either invasive or requires expensive equipment [18]. Thus, there was a need for assessment of an alternative method for the management of mucoceles which is neither expensive nor invasive. Therefore, the aim of this study was designed to determine the effectiveness of the micro-marsupialization technique in particular as an alternative less invasive therapeutic method for management of pediatric mucoceles.


  Patients and Methods Top


Patients and study design

This prospective noncontrolled (one study group) clinical study was carried out on 12 children patients of both sexes aged 6–12 years old (mean: 9.83 years). They were selected from the three Outpatient Clinics of Oral and Maxillofacial Surgery and Oral Medicine (Faculty of Dentistry, Tanta University) as well as from Pedodontic Department, Faculty of Dentistry, Kafrelsheikh.

Ethical approval of this study was obtained from the Research Ethics Committee, Faculty of Dentistry, Tanta and Kfrelsheikh Universities where the study was conducted.

All children's parents participating in this study were informed about the importance of the study, thoroughly acquainted with the objective and procedures of the research, informed and written consents were obtained from them. In addition, ascents were obtained from the children above 8 years old. Handicapped and uncooperative children, children having any systemic diseases, and the parents/children who are not willing to return for follow-up visits were excluded from the study.

The following data were collected: age, sex, site and size of the lesion, color, consistency, etiologic factor, duration of mucoceles development and recurrence postoperatively. The treatment plan for the selected cases was modified marsupialization (micro-marsupialization).

Intervention protocol

Detailed medical history was taken and the following data were recorded: age, sex, site and size of the lesion, evolution of lesion and recurrence postoperatively. The treatment plan for the selected cases was a modified technique of marsupialization (micro-marsupialization).

Technique of micro-marsupialization

The technique in this study was done by one operator. All children were complaining and principally diagnosed as having oral mucoceles or ranula based on the following clinical features: site of the lesion, past history of oral trauma, rapid onset, variations in size, consistency, and bluish color as shown in [Figure 1].
Figure:1 (a): Lip mucocele. (b) Ranula.

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All children underwent micro-marsupialization according to the following method: the size of each lesion was measured using Vernier digital caliper (IOS, USA) with an accuracy of ±0.02 mm and repeatability of ±0.01 mm. Then the area was disinfected with Betadine 7.5% solution (povidone iodine 7.5%; PanaxPharma, PharmaCare, Cairo, Egypt), and a Lignocaine10% [lidocaine 10% spray Arab Drug Co. (ADCO), Cairo, Egypt] surface anesthesia was applied over the entire oral mucosa related to the mucocele and ranula for ∼1 min.

The overlying oral mucosa was penetrated from one edge of the mucocele using a 3–0 silk suture material, then the suture thread passed through the widest diameter of mucocele away from the underlying tissue and get out from the other edge as shown in [Figure 2].
Figure:2 Passing the suture through the widest diameter of the lesion.

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A surgical knot was made, leaving a space between the knot and the lesion. Finally, a compression of the mucocele was done for the evacuation of the accumulated secretion around the suture as shown in [Figure 3].
Figure:3 (a) Two surgical knot with a space for lip mucocele. (b) Three knots for ranula.

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For postoperative care, the children and/or their parents were instructed for regular use of 0.5% chlorhexidine gel (Heliopolis, Cairo, Egypt) and 0.2% chlorhexidine mouth rinse to avoid secondary infection. The suture materials were removed after 7–10 days which was enough time for disappearance of the lesion. All children were followed up clinically after 1 week, 1, and 3 months and were instructed to return for further clinical evaluation in case of recurrence.

Statistical analysis

In this study, a convenient total sample of 12 patients was recruited as in the former study of Giradd and Saifi [18].

All collected data were tabulated and statistically analyzed using descriptive statistics. Mean and SD were calculated for quantitative data. Statistical analysis of data was performed using SPSS software version 25.0 (IBM Corp., Illinois, Chicago, USA).


  Results Top


A total of 12 children aged from 6 to 12 years old with a mean of 9.83 ± 1.89 years were treated from minor salivary gland mucoceles and oral ranula using a modified technique of marsupialization (micro-marsupialization). Eight (66.7%) children were girls and four (33.3%) children were boys. Regarding the site of the mucoceles seven (58.3%) cases were at the lower lip and five (41.7%) cases were at the floor of the mouth (ranula; [Table 1] and [Table 2]).
Table 1 Distribution of patients in micro-marsupialization technique in oral mucocele

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Table 2 Distribution of data in micro-marsupialization technique by percent

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The size of the mucoceles was measured by digital calliper that ranged from 0.5 to 2 cm, measuring on average 1 cm.

Out of the 12 cases treated by micro-marsupialization, seven mucoceles at the lower lip had a 100% success rate after 10 days and no recurrence was detected during the 3 months of follow-up period as shown in [Figure 4] and [Figure 5].{Figure 4}
Figure:5 (a) One month postoperative showing full regression without recurrence. (b) Three months postoperative showing full regression without recurrence.

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The other five ranula had 80% success (four cases) and only one case had a recurrence after the removal of the suture as shown in [Figure 6].
Figure:6 Recurrent ranula after stitch removal (left side).

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This study shows that, regarding the overall recurrence rates, 12 mucoceles were micro-marsupialized from both the lower lip and floor of the mouth. Only a case (8.3%) of ranula showed a recurrence ([Table 1] and [Table 2]).

For the recurrent ranula, it was managed by marsupialization and packing till complete regression. No postoperative complications were observed.


  Discussion Top


Mucoceles are mucus containing cysts of salivary glands with relatively rapid onset and fluctuating sizes. They are commonly present in the oral cavity but also can be encountered in the gall bladder, appendix, and lacrimal sac. The oral trauma is the main predisposing factors such as lip biting, cheek biting, piercings, and accidental rupture of salivary gland. The dilation of the duct is secondary to its obstruction caused by dense mucosa or a sialolith is another etiologic factor [11].

Although there are many articles that discussed mucoceles and its management in dental and maxillofacial journals, few of them focused on children [6]. The incidence of mucoceles in the general population is about 0.4–0.8% [19]. Mucoceles is still considered as a common oral lesion in children, as about 11–21% of all pediatric oral biopsies showed mucoceles [20].

Concerning the location of the mucocele in the oral cavity, most investigators consider the lower lip to be the most frequently affected location 40–80% of all cases [21]. This ratio was in agreement with the results of this study as we found that 58.3% of cases were at the lower lip.

Diagnosis of mucoceles in this study is mainly based on the past history of trauma and clinical manifestation such as well circumscribed lesion, rapid onset, specific site, and soft, fluctuant, and transparent bluish swelling. They are usually asymptomatic, but the large one causing discomfort and difficulty in chewing and speaking for children [22].

The typical location of these mucoceles is in the lower lip because this site is more susceptible to accidental trauma and suction habits [23]. Moreover, as regarding the size of the mucoceles, the previous studies reported a variation between 0.2 mm and 2 cm in diameter [24]; this was in coincidence with our own results as the mean size was 1 cm.

The color of mucoceles ranged from blue to the normal color of oral mucosa. The blue color arises from tissue vascular congestion, cyanosis associated with the stretched overlying tissue and the translucency of the accumulated fluid beneath. The color variation depends on the lesion size, the elasticity of the overlying mucosa and its proximity to surface mucosa[12],[21]. In this study, around 33% of the patients had bluish lesions, and almost all of them were more than 1 cm in size. This finding is in accordance with the finding of Giradd and Saifi [18].

The literature describes different options for management of mucoceles, including cryosurgery, intralesional corticosteroid injection [11], marsupialization, micro-marsupialization of the mucoceles [12], conventional surgical removal and laser ablation [13]. Although surgical intervention is a widely used technique, it has several drawbacks such as damage to adjacent ducts, invasive, disfigurement of lip with further development of satellite lesions [25].

Furthermore, the extensive surgical technique for management of oral mucocele in the pediatric age group is difficult and sometimes need sedation and general anesthesia. Surgical removal of ranula in the floor of mouth for new surgeons, especially in pediatric age group, may be associated with complications such as hemorrhage, injury to the adjacent vital structure such as lingual nerve and vessels, and Wharton's duct causing limited tongue movement, scarring or lesion recurrence [26]. Therefore, the aim of this study was to determine the effectiveness of the micro-marsupialization technique in particular as an alternative less invasive therapeutic method for management of pediatric mucoceles.

Some authors recommend an initial cryosurgical approach [10], or intralesional injection of corticosteroids [11]. However, the number of relapses associated with these techniques is very high, and most cases as a result, require re-intervention in the form of conventional surgery to ensure complete removal of the mucoceles.

Regardless of the chosen technique, it is important to reach the muscle layer during treatment [15]. As all managements are therefore invasive, they are not always tolerated by the children or their parents. If the surgical approach is used, the adjacent minor salivary glands must be removed. Care should be taken to avoid the injury to any marginal glands and ducts, otherwise it may lead to reoccurrence of the lesion [27].

On the other hand, Delbem et al.[12] propose micro-marsupialization as a technique which consists of draining the accumulated saliva and creating new epithelialized tracts along the path of the sutures as an ideal treatment alternative for mucoceles in children, since the technique is simple, rapid, and offers satisfactory good results. This is the least traumatic of all the described management options, and involves passing the mucoceles along its maximum diameter with suture thread that is left in place for at least 7–10 days [5].

Micro-marsupialization is a minimally invasive technique in pediatric age group without any intraoperative or postoperative discomfort, and all cases in our research were carried out under topical surface anesthesia only. The required time was ∼ 2 min, with no tissue damage. It appears to be a suitable technique for children who cannot tolerate long or invasive procedures and also a suitable technique for general dental practitioner. These results are confirmed by the study of Amaral et al.[28] and Sagari et al.[29] who reported the same findings.

In the technique of this study, the multiple suture are passed superficially through the lesion to decrease the distance between the entrance and exit of the needle and increase the quantity of new epithelialized drainage pathways formed by the sutures [30].

The suture in this study was removed after 7 days to prevent the patient discomfort and to avoid the secondary infection at the site of suture [25]. This agree with Delbem et al.[12] and Giradd and Saifi[24] who performed the micro-marsupialization in pediatric age group and remove the suture at the same time similar to our study.

Our results showed the full regression of 91.6% mucoceles that had been diagnosed while 8.4% showed recurrence of ranula and need a second intervention for treatment, this was coincide with the results of Piazzetta et al.[31]who had 85% of regression of mucoceles.

In addition, the failure case in this study is confirmed by the explanation of Castro[32] who demonstrated that the larger size and deeply located mucoceles generally shows poor clinical outcome with micro-marsupialization technique. Therefore, the success rate depends upon the selection of cases for micro-marsupialization; the remission of the lesions, recent history of trauma, whether the lesion is superficial or deep, and the size of the lesion is noted carefully.

Finally, although micro-marsupialization is a simple, zero side effect, no bleeding, and rapid technique with credible good results in the management of pediatric mucoceles, still we should take care when selecting this technique as it does not enable a biopsy to be taken, and the diagnosis remains based up on clinical features. Further, it should be carefully used in areas as palatal or buccal mucosa as lesions in these areas may be misdiagnosed as mucoceles while it may be minor salivary gland tumors.


  Conclusion Top


Micro-marsupialization is an adequate good alternative nonsurgical technique which can be performed in a short span of time, economical, cosmetic and performed effortlessly. It is a relatively simple, repeatable, cost-effective and potentially curative technique easily acceptable by the child, and also easily carried out in routine dental practice.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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