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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 83-86

Modified micro-marsupialization in pediatric patients: A minimally invasive technique


Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Sullia, Karnataka, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Rohit Subedar Singh
Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Sullia, Dakshin Kannada, Karnataka
India
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DOI: 10.4103/srmjrds.srmjrds_1_18

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  Abstract 

Surgical management of ranula and mucocele in the pediatric age group is challenging. Various procedures from wide excision with scalpel to laser are associated with few complications. Micro-marsupialization is minimally invasive technique for the management of ranula and mucocele, especially in pediatric age group because it is easy to perform, efficacious, can be performed under topical anesthesia also and lower incidence of complications. This case reports describes the modified micro-marsupialization for the successful management of ranula and mucocele in pediatric age group.

Keywords: Modified micro-marsupialization, mucocele, pediatric


How to cite this article:
Rachana P B, Singh RS, Patil VV. Modified micro-marsupialization in pediatric patients: A minimally invasive technique. SRM J Res Dent Sci 2018;9:83-6

How to cite this URL:
Rachana P B, Singh RS, Patil VV. Modified micro-marsupialization in pediatric patients: A minimally invasive technique. SRM J Res Dent Sci [serial online] 2018 [cited 2021 Apr 15];9:83-6. Available from: https://www.srmjrds.in/text.asp?2018/9/2/83/234586


  Introduction Top


Mucoceles (muco meaning mucus and coele meaning cavity), by definition, are cavities filled with mucus. It is a common oral mucosal lesion originating from minor salivary gland. The lower labial mucosa is the most common site of involvement, but it may develop at virtually any location where minor salivary glands occur, including the soft palate, retromolar region, and buccal mucosa.[1],[2]

Ranula is an accumulation of saliva on the floor of the mouth, so named because of its nodular bluish color (or buccal membrane of similar color, depending on the depth of the lesion) that resembles the aerated vocal sac of a frog.[2]

Various treatment modalities are studied historically from the simple scalpel excision to wide surgical removal along with sublingual gland, from laser to cryosurgery, but it tends to recur.[3] The definitive treatment is to remove the offending sublingual gland. The surgical procedure has a high rate of morbidity with risk of injury to the submandibular duct and lingual nerve. The mucosa in the floor of the mouth is often shredded when the head of the sublingual gland is teased off the oral mucosa to which it is welded by the ducts of Rivinus, leading to scarring and restricted mobility of the tongue.[4]

Micro-marsupialization is a minimally invasive procedure given by Morton and Bartley for management of ranula, in which the suture is passed from the lesion at its greatest diameter which forms the epithelized tract through which the accumulated saliva gets drained. It is the minimally invasive procedure which does not require extensive surgical approach avoiding the surgical complications making it popular modality in the larger lesion in pediatric age group.

This case report presents a case of ranula occurring in floor of mouth and mucocele in lower lip treated with modified micro-marsupialization in pediatric patients.


  Case Reports Top


Case 1

A 13-year-old girl reported with complaints of swelling in floor of mouth and difficulty in swallowing food since 3 days. On clinical examination, the swelling was oval shape with well-defined margins, smooth surface, normal pink, measuring about 1.5 cm × 1.2 cm approximately located on the floor of mouth on the left side [Figure 1]. The clinical diagnosis of superficial ranula was made and treated with modified micro-marsupialization technique described Sandrini et al.[2] The area was disinfected with 0.1% iodine, and the topical local anesthetic spray applied for 3 min, and 3-0 black braided silk suture passed superficially in lesion mediolaterally at three points, and knots were tied. One suture passed at the greatest diameter of the lesion anteroposteriorly, and knot was tied [Figure 2], and the accumulated saliva was drained by pressing the lesion. The sutures were removed after 15 days, and the patient was on follow-up recall regularly for 50 days and shown no sign of recurrence [Figure 3].
Figure 1: Preoperative Case 1

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Figure 2: Intraoperative (modified micro-marsupialization) Case 1

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Figure 3: 50 days of follow-up (shows no recurrence of the lesion) S Case 1

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Case 2

A 14-year-boy reported with a complaint of swelling on the lower lip on the left side since 1 week with a history of trauma to lip due to lip bite. On clinical examination, swelling was dome-shaped, normal pink, soft and fluctuant with a smooth surface measuring about 1.5 cm × 1.5 cm approximately [Figure 4]. The clinical diagnosis of mucocele was made and planned for micro-marsupialization with 3-0 black braided silk suture at three various points superficially [Figure 5]. Suture was removed after 15 days, and the patient was on follow-up regularly for 50 days and without any sign of recurrence and postoperative discomfort [Figure 6].
Figure 4: Preoperative Case 2

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Figure 5: Intraoperative (modified micro-marsupialization) Case 2

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Figure 6: 50 days of follow up (shows no recurrence of the lesion) S Case 2

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  Discussion Top


The extensive surgical procedure such as excision of the lesion with or without sublingual gland removal,[5] marsupialization,[6] cryosurgery,[7] laser [8] for the management of mucocele in the pediatric age group is difficult and sometimes require sedation and general anesthesia. Surgical removal of ranula in floor of mouth for new surgeons, especially in pediatric age group may be associated with the complication such as hemorrhage, injury to the adjacent vital structure such as lingual nerve, lingual vessels, Wharton's duct, reduced mobility of the tongue, scarring or the recurrence of the lesion.

Micro-marsupialization is a simple, minimally invasive technique can be performed by dentist in daycare outpatient department easily.[9],[10] The success of the treatment depends on the case selection for micro-marsupialization. The recent history of trauma, remission of the lesions, whether the lesion is superficial or deep and size of the lesion is noted carefully. Castro [11] indicates the micro-marsupialization technique for mucoceles with more than 1 cm and for ranulas. The recurrent mucocele which is deeply located and larger in size generally shows poor outcome with micro-marsupialization.

Delbem et al.[9] performed the micro-marsupialization by single long 4.0 silk suture passed through the internal part of the lesion along its widest diameter in 14 patients in pediatric age group between 5 and 9 years. Suture was removed after 7 days. Of 14 patients, 12 patients have shown complete regression of the lesion. They stated micro-marsupialization as an alternative treatment modality for the mucocele as compared to the conventional surgical approach in pediatric age group.

Sandrini et al.[2] proposed modification to the conventional technique include an increased number of sutures to increase the quantity of new epithelialized drainage pathways, a decreased distance between the entrance and exit of the needle to facilitate epithelialization of the new pathways formed by the sutures by reducing the length of the drainage tracts, and a longer period during which the sutures are maintained for a period of 30 days permits the formation of a new permanent epithelialized tract along the path of the suture. Of 7 patients in 3 patients, there was early loss of suture and required the second attempt by modified technique. None of the lesions has shown recurrence in 6-month follow-up period.

In our case, we used the modified micro-marsupialization technique described by Sandrini et al.[2] in which the multiple suture are passed through the lesion superficially such that the distance between the entry and exit of needle during suturing is minimal. The suture was removed after 15 days to prevent the discomfort to the patient and secondary infection at the suture site.

Both the cases were successfully treated with modified micro-marsupialization without any recurrence on 2-month follow-up without any postoperative complication. Moreover, the acceptance of the less invasive technique in pediatric age group without any intra- or post-operative discomfort proves the modified micro-marsupialization technique for oral mucocele and ranula more efficient and popular.

The recurrence of the lesions treated by the micro-marsupialization is not uncommon. We think that second attempt for modified micro-marsupialization should be always considered before performing the more invasive surgical technique.


  Conclusion Top


The modified micro-marsupialization technique is a noninvasive technique, does not require extensive surgical skill, can be done easily in pediatric age group in general outpatient daycare setup. The success of the technique depends on the selection of cases, regular follow-up visits. We recommend the modified micro-marsupialization in selected cases of oral mucocele and ranula as an initial management, especially in pediatric age group.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Seifert G, Miehlke A, Haubrich J, Chilla R. Diseases of the Salivary Glands. Stuttgarg: Georg Thieme Verlag; 1986. p. 91-100.  Back to cited text no. 1
    
2.
Sandrini FA, Sant'ana-Filho M, Rados PV. Ranula management: Suggested modifications in the micro-marsupialization technique. J Oral Maxillofac Surg 2007;65:1436-8.  Back to cited text no. 2
    
3.
Zhao YF, Jia J, Jia Y. Complications associated with surgical management of ranulas. J Oral Maxillofac Surg 2005;63:51-4.  Back to cited text no. 3
[PUBMED]    
4.
Goodson AM, Payne KF, George K, McGurk M. Minimally invasive treatment of oral ranulae: Adaption to an old technique. Br J Oral Maxillofac Surg 2015;53:332-5.  Back to cited text no. 4
[PUBMED]    
5.
Yoshimura Y, Obara S, Kondoh T, Naitoh S. A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg 1995;53:280-2.  Back to cited text no. 5
[PUBMED]    
6.
Baurmash HD. Marsupialization for treatment of oral ranula: A second look at the procedure. J Oral Maxillofac Surg 1992;50:1274-9.  Back to cited text no. 6
[PUBMED]    
7.
Twetman S, Isaksson S. Cryosurgical treatment of mucocele in children. Am J Dent 1990;3:175-6.  Back to cited text no. 7
[PUBMED]    
8.
Neumann RA, Knobler RM. Treatment of oral mucous cysts with an argon laser. Arch Dermatol 1990;126:829-30.  Back to cited text no. 8
[PUBMED]    
9.
Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus retention phenomena in children by the micro-marsupialization technique: Case reports. Pediatr Dent 2000;22:155-8.  Back to cited text no. 9
[PUBMED]    
10.
Harrison JD. Modern management and pathophysiology of ranula: Literature review. Head Neck 2010;32:1310-20.  Back to cited text no. 10
[PUBMED]    
11.
Castro AL. Glândulas salivares. In: Estomatologia. 2nd ed. São Paulo: Santos; 1995. p. 152-4.  Back to cited text no. 11
    


    Figures

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


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