Abstract
This study evaluated the performance of an upgrading of the micro-marsupialisation technique for the management of mucus extravasation or retention phenomena. This study presents a prospective case series of management of ranulas and mucoceles, with a follow-up ranging from 6 to 18 months. Data included the age and gender of patients, as well as the type, size, and site of lesions, and number of punctures. The treatment performance was evaluated according to: postoperative pain, oedema, secondary infection, clinical healing, retreatment, and recurrence of the lesions. All patients showed clinical healing of the lesions within 30 days after the micro-marsupialisation technique. None of patients presented a recurrence or required retreatment, there was no oedema or infection. No pain, or mild pain was reported by the majority of patients (58.81%). Micro-marsupialisation proved to be a simple, low cost, relatively non-invasive, painless, effective, and low recurrence technique to treat mucus extravasation or retention phenomena. Micro-marsupialisation can be recommended primarily to treat oral ranulas and selected mucoceles.
Ranulas and mucoceles are mucus extravasation phenomena which develop by means of ruptures within the salivary duct, with mucin spillage onto the sublingual glands or minor salivary glands, respectively. Mucus retention phenomena, also referred to as salivary duct cysts, occur infrequently and exhibit a true cystic epithelial lining due to ductal dilatation, as a result of saliva that cannot be adequately accommodated. Salivary duct cysts cannot be differentiated clinically from oral mucoceles and ranulas.
There are various treatments for mucus extravasation or retention phenomena, especially for ranulas. Ranulas are treated by the removal of the sublingual gland, the removal of the sublingual gland and ranula, the removal of only the ranula, marsupialisation, micro-marsupialisation, incision and drainage, the injection of OK-432, homoeopathy, or no treatment. Ranulas may be classified as oral (simple) ranula or plunging (cervical) ranula. Morton and Bartley stated that ranula can be treated by placing a silk suture in the dome of the cyst, known as the micro-marsupialisation technique, a simple technique used in the management of mucoceles, which was later modified by Sandrini et al. According to the pathophysiology of oral ranulas and mucoceles, the present study aims to illustrate an upgrading of the micro-marsupialisation technique. The goal of this study is to present a prospective case series of ranulas and mucoceles that were managed using an upgrading of this technique.
Patients and methods
This prospective case series study consists of 17 patients with a clinical diagnosis of mucocele and oral ranula. The patients were referred to the Oral Medicine Services of the School of Dentistry at Universidade Federal de Minas Gerais (UFMG) in Belo Horizonte, Brazil, from August 2009 to December 2010. Informed written consent forms were obtained from all patients. The criteria for selecting mucoceles were those of Delbem et al. These criteria included: patients who presented mucoceles, located on the lower lip or ventral surface of the tongue with a smooth surface; on the thin mucosa, with a bluish or mucosa-like colour; on a sessile base; and with a flaccid consistency appearing to contain a quantity of mucus ( Fig. 1 A ). For ranulas, only oral (simple) ranulas with a bluish or mucosa-like colour, close to the mucosa surface which appear to contain a quantity of mucus, were included in this study. For both lesions, the minimal size considered was 10 mm ( Fig. 2 A and D ). All lesions diagnosed as plunging ranulas were excluded. Patients currently using anti-inflammatory or analgesic medications were excluded from the study.
Upgraded micro-marsupialisation technique
All patients were submitted to the micro-marsupialisation technique as proposed by Morton and Bartely, and modified by Sandrini et al. with some current modifications. Topical anaesthesia (Emla ® AstraZeneca do Brasil LTDA, São Paulo, Brazil or Benzocaine 20%, DFL Indústria e Comércio S.A., Rio de Janeiro, Brazil) was performed according to Delbem et al. ( Fig. 1 B). The current modifications of the micro-marsupialisation technique were: the use of a 3.0 silk suture (Shalon ® , Shalon Fios Cirúrgicos, Goiás, Brazil) with a round cross-section needle; the mechanical enlargement of the pathways performed by a to-and-fro movement using silk sutures ( Fig. 1 C); and the clearance of total mucus by conventional suction, together with local manual discrete pressure on the inside of the lesion ( Fig. 1 D and E). The sutures were placed in the mucosa and in the dome of the lesion at a distance of 3–5 mm from each other (Figs 1 E, 2 B and E). The sutures were maintained for 30 days. All patients underwent a follow-up period of at least 6 months. The performance of the upgraded micro-marsupialisation technique was evaluated according to: postoperative pain, oedema, secondary infection, clinical healing, retreatment, and recurrence of the lesion.
Evaluation measures
Evaluation of postoperative pain and oedema was performed subjectively 1 week after the micro-marsupialisation technique had been applied. The patients were asked, in terms that could be easily understood, if the pain they felt was: 1, no pain; 2, mild pain; 3, moderate pain; 4, severe pain; or 5, unbearable pain. The patients were asked whether an oedema was present. Secondary infection was investigated by the presence or absence of local exudation and fever.
Post-micro-marsupialisation care
All patients underwent special oral hygiene care, especially as regards hot, hard, and acidic foods, during the post-micro-marsupialisation period. Oedemas and pain associated with micro-marsupialisation were also observed. Patients were instructed not to ingest any form of analgesic during the post-micro-marsupialisation period, except in case of the unbearable pain.
Results
The clinical profiles of the patients and data concerning the lesions treated with the upgraded micro-marsupialisation technique are presented in Table 1 .
| Patients | Age (years) | Gender | Type of lesion | Size (mm) | Site | Number of punctures | Complications/retreatment/recurrence | Follow-up (months) |
|---|---|---|---|---|---|---|---|---|
| 1 | 16 | F | Oral ranula | 30 | Left floor of the mouth | 5 | No | 18 |
| 2 | 12 | M | Oral ranula | 20 | Left floor of the mouth | 4 | No | 13 |
| 3 | 8 | M | Oral ranula | 30 | Left floor of the mouth | 7 | No | 12 |
| 4 | 15 | F | Oral ranula | 20 | Left floor of the mouth | 4 | No | 12 |
| 5 | 9 | F | Oral ranula | 25 | Left floor of the mouth | 6 | No | 10 |
| 6 | 30 | F | Oral ranula | 20 | Right floor of the mouth | 5 | No | 9 |
| 7 | 16 | M | Oral ranula | 10 | Middle floor of the mouth | 4 | No | 7 |
| 8 | 15 | M | Oral ranula | 20 | Right floor of the mouth | 8 | No | 7 |
| 9 | 5 | F | Oral ranula | 20 | Left floor of the mouth | 4 | No | 6 |
| 10 | 16 | F | Mucocele | 10 | Ventral surface of the tongue | 3 | No | 18 |
| 11 | 18 | M | Mucocele | 10 | Lower lip | 3 | No | 16 |
| 12 | 31 | M | Mucocele | 14 | Lower lip | 5 | No | 17 |
| 13 | 18 | F | Mucocele | 15 | Lower lip | 5 | No | 10 |
| 14 | 14 | F | Mucocele | 10 | Lower lip | 4 | No | 9 |
| 15 | 19 | M | Mucocele | 10 | Lower lip | 4 | No | 9 |
| 16 | 6 | F | Mucocele | 15 | Ventral surface of the tongue | 5 | No | 6 |
| 17 | 27 | F | Mucocele | 10 | Lower lip | 4 | No | 6 |
| Total | Mean: 16.18 years Range: 5–31 years |
58.82% F; 41.18% M Ratio F/M: 1.4/1 |
9 oral ranulas (52.94%) 8 mucoceles (47.06%) |
Mean: 20.29 mm Range: 10–30 mm |
35.29% left floor of the mouth 35.29% lower lip 11.76% right floor of the mouth 11.76% ventral surface of the tongue 5.88% middle floor of the mouth |
Mean 4.70 Range: 3–8 |
None | Mean: 10.88 Range: 6–18 |
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