DOI: 10.1111/j.1365-263X.2011.01198.x
Micro-marsupialization as an alternative treatment for
mucocele in pediatric dentistry
CLETO M. PIAZZETTA1, CASSIUS TORRES-PEREIRA2 & JOSE´ M. AMENA´BAR2
1
2
Post-Graduate Program in Dentistry, Oral Medicine Department, Federal University of Parana´, Curitiba, PR, Brazil, and
Oral Medicine Department, Federal University of Parana´, Curitiba, PR, Brazil
International Journal of Paediatric Dentistry 2012; 22:
318–323
Background. Mucocele is a common oral lesion in
children and adolescents. Different techniques
have been described for the treatment; however,
all of them are invasive.
Aim. This work studied the efficacy of micro-marsupialization for the treatment for mucoceles in
paediatric patients.
Design. A retrospective review was performed
using the clinical records of patients aged between 0
and 18 years with a clinical diagnosis of mucocele.
The following data were obtained: age, gender,
location and size of the lesion, duration of mucocele
development, and type of treatment and its results.
Introduction
Mucocele is a common oral mucosal lesion
that originates from the minor salivary glands
and occurs more frequently in children and
adolescents1–4. The term mucocele describes
the accumulation of mucus within a salivary
gland5, and they are commonly subdivided
into two types: (i) a mucus extravasation cyst,
which is generally regarded as being a result
of trauma, such as lip biting; and (ii) a mucus
retention cyst, which results from the obstruction of the duct of a minor or accessory salivary gland5–11.
The clinical features of mucoceles have
been well-documented. They usually appear
as an asymptomatic vesicle or bulla with a
pink or bluish colour, and their size may vary
from 1 mm to several centimetres10,12. The
lower labial mucosa is the most frequently
Correspondence to:
J. M. Amena´bar, Av. Lotha´rio Meissner 632, Jardim
Botaˆnico, CEP: 80210-170, Curitiba-Parana´, Brazil.
E-mail: [email protected]
318
Results. The mean age of the patients was
11.1 ± 3.95 years. Mucoceles were found in the
lower lip (83.7%), buccal mucosa (11.6%), and
tongue (4.7%). From the overall cohort of 86
cases, 33 were treated by micro-marsupialization,
of which five developed a recurrence that required
surgical excision. The other 53 cases were treated
by surgical excision, and three of these had recurrent disease. No statistically significant difference
was found between the treatment methods.
Conclusions. Micro-marsupialization can be used
to treat mucoceles in paediatric dentistry. It is simpler to perform, minimally invasive, requires no
local infiltration of anaesthesia, has a lower postoperative complications rate, and is well-tolerated
by patients.
affected site, but mucoceles can also develop
also in the cheek, tongue, palate, and floor of
mouth, where it is called ranula5,8,12–15. A
variant of the extravasation mucocele is a
superficial mucocele, which is found in the
soft palate and retromolar region. These are
isolated or multiple and usually present in
the form of vesicles that rupture easily, forming a superficial ulceration7,14,15.
Mucoceles often arise within a few days after
minor trauma, but then plateau in size. They
can persist unchanged for months unless treated. Different techniques have been described
for the treatment for mucoceles6,16–19, but they
usually require surgical excision5,20. Therefore,
the aim of this article was to demonstrate
the feasibility of the technique of micromarsupialization in the treatment for mucoceles and its use as an alternative therapeutic
approach for paediatric patients in particular.
Material and methods
A retrospective study was performed on the
records of 86 patients aged from 0 to 18 years
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd
Micro-marsupialization as a treatment for mucocele
old with a clinical diagnosis of mucocele, who
were treated between 1994 and 2009 at the
Oral Medicine Unit of the Universidade Federal do Parana´, Brazil. The work was approved
by the Ethics Committee of the University.
The patients fell into two groups according
to the initial treatment that was performed.
Micro-marsupialization was performed in 33
cases according to the following technique:
the area was disinfected with a povidone
iodine 0.1 solution; a topical anaesthetic
(benzocaine 20%) was applied over the entire
lesion for approximately 3 min, and a 3.0 silk
suture was passed through the internal part
of the lesion along its widest diameter
(Fig. 1). The suture thread was then passed
through the lesion and a surgical knot was
made, leaving a space between the knot and
the lesion (Figs 2 and 3). The mucoceles were
then compressed, and the accumulated saliva
extravasated around the suture (Fig. 4). To
prevent a secondary infection at the site of
the suture, the patient applied 0.5% chlorhexidine gel postoperatively. The sutures were
removed after 7 days. The conventional surgical technique was carried out in the other 53
cases under local infiltrative anaesthesia with
a scalpel. The excision included the associated
overlying mucosa and glandular tissue down
319
Fig. 2. Making the surgical knot and leaving a space
between it and the lesion.
Fig. 3. Clinical aspect of lesion after micro-marsupialization.
Fig. 1. Silk suture passed through the mucocele.
to the muscle layer. The sutures were
removed after seven postoperative days.
From the records, the following data were
obtained: age, gender, site and size of the
lesion (maximum diameter), duration of
lesion development (from first appearance to
diagnosis), follow-up time after treatment,
and outcomes. The data between groups were
analysed by chi-square tests.
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd
320
C. M. Piazzetta, C. Torres-Pereira & J. M. Amena´bar
Table 1. Comparison of the two treatment groups.
Variables
Fig. 4. Compression of the mucocele and extravasation of
accumulated saliva.
Gender
Male
Female
Age (years)
0–6
7–12
13–18
Size (cm)
<0.5
0.6–1.0
>1.0
Site
Lower lip
Tongue
Buccal mucosa
Duration of lesion
<30
31–90
91–180
181–365
>366
Recurrence
Micro-marsupialization
(n = 33)
Excision
(n = 53)
n (%)
n (%)
P
15 (45.46)
18 (54.54)
27 (50.94)
26 (49.06)
0.662
5 (15.15)
17 (51.52)
11 (33.33)
5 (9.43)
26 (49.06)
22 (41.50)
0.622
8 (24.24)
15 (45.46)
10 (30.30)
31 (58.49)
18 (33.96)
4 (7.55)
0.002
44 (83.02)
8 (15.09)
1 (1.89)
0.157
11
23
11
5
3
3
0.144
28 (84.84)
2 (6.06)
3 (9.10)
development (days)
14 (42.42)
11 (33.33)
2 (6.06)
4 (12.12)
2 (6.06)
5 (15.15)
(20.75)
(43.40)
(20.75)
(9.43)
(5.67)
(5.67)
0.141
Results
Of the 86 patients included in this study, 42
were boys and 44 were girls. The mean age
was 11.1 ± 3.95 years. There were 10 cases
(11.6%) in the 0–6 years age group, 43 cases
(50.0%) in the 7–12 years age group, and 33
cases (38.4%) in the 13–18 years age group.
The mean size of the lesion was 0.71 ± 0.21
mm; 39 lesions (45.3%) were <0.5 cm, 33
mucoceles (38.4%) were between 0.6 and
1.0 cm, and 14 cases (16.3%) were >1.0 cm.
Seventy-two lesions (83.7%) were located in
the lower lip, whereas 10 cases were located
on the ventral surface of the tongue, and four
mucoceles were in the buccal mucosa. The
patients were examined 1 week after the
treatment to remove the sutures; some were
examined again after 15 or 30 days depending on the kind of treatment. All of them
were told to return for the further examination if healing was not complete or if there
was any suggestion of recurrence.
From the 33 cases treated by micro-marsupialization, 25 had a full regression of the
lesion after 7 days and three had full regression after 15 days. In the other five cases, the
lesions reappeared and surgical excision of
the mucocele was needed. In the group treated with surgical excision, three of the 53
patients treated developed a recurrence and
required a second surgical excision. According
to the chi-square test analyses, the rate of
recurrence was not statistically different
between the treatment methods.
It was also observed that mucoceles that
had been present for <90 days had a greater
chance of being resolved after micro-marsupialization than mucoceles that had been present for more than 90 days. Data from the 86
cases are presented in Table 1, and the characteristics of the recurrent cases are presented
in Table 2.
Discussion
Mucoceles can be treated by surgical excision,
electrosurgery, cryosurgery, laser vaporization, or laser surgery6,16–19. Regardless of the
chosen technique, it is important to reach the
muscle layer during treatment18; as all treatments are therefore invasive, they are not
always tolerated by the children or their
parents.
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd
Micro-marsupialization as a treatment for mucocele
Table 2. Comparison of the recurrence cases in the two
treatment groups.
Variables
Recurrence in
micro-marsupialization
(n = 5)
Recurrence in
excision (n = 3)
n (%)
n (%)
Gender
Male
2 (40.00)
Female
3 (60.00)
Age (years)
0–6
0 (0.00)
7–12
2 (40.00)
13–18
3 (60.00)
Size (cm)
<0.5
1 (20.00)
0.6–1.0
2 (40.00)
>1.0
2 (40.00)
Site
Lower lip
4 (80.00)
Tongue
0 (0.00)
Buccal mucosa
1 (20.00)
Duration of lesion development (days)
<30
0 (0.00)
31–90
0 (0.00)
91–180
0 (0.00)
181–365
3 (60.00)
>366
2 (40.00)
1 (33.33)
2 (66.67)
1 (33.33)
0 (0.00)
2 (66.67)
2 (66.67)
1 (33.33)
0 (0.00)
2 (66.67)
1 (33.33)
0 (0.00)
0
1
1
1
0
(0.00)
(33.33)
(33.33)
(33.33)
(0.00)
Marsupialization is a surgical technique that
involves incising into a cyst and suturing the
edges of the subsequent slit to form a continuous surface from the exterior to the interior of
the cyst20. Micro-marsupialization consists in
draining the accumulated saliva and creating a
new epithelialized tracts along the path of the
sutures6,10,21,22. It is a minimally invasive technique, and most cases can be carried out under
topical anaesthesia alone6,21. The required procedure time is brief (approximately 3 min),
there is practically no tissue damage or inflammation, and it appears to be a particularly suitable technique for children who cannot
tolerate long or invasive procedures6,21.
Although micro-marsupialization has been
described in the literature since 2000, mainly
for the treatment for ranulas22, its use in the
treatment for other mucoceles has been limited to single case reports or small series of
patients6,10,21. In this retrospective study, 33
mucoceles of a 15-years cohort of 86 patients
in total were treated with micro-marsupialization. This technique was chosen according to
patient age, physical and emotional states,
and resistance to or fear of infiltrative anaes-
321
thesia and ⁄ or invasive procedures. The size
and duration of the lesion were not considered in this choice. In two cases, the sutures
broke down within 7 days. In these cases,
micro-marsupialization was repeated and the
new suture remained in the place for the necessary 7 days to create a new epithelialized
tract.
In this study, full resolution of the mucocele was observed in almost 85% of the
patients (28 cases). There were five recurrent
mucoceles, and these were successfully treated by formal surgical resection. The clinical
features of these five mucoceles were painless
fibrous round masses, which were nonulcerated and had the same colour as the surrounding mucosa with white areas on their
surface. Micro-marsupialization may not have
been successful as these clinical characteristics
indicate a mucocele deep in the mucosa6,23.
Our results showed the full regression of all
25 mucoceles that had been diagnosed within
90 days of their appearance. According to this
finding, micro-marsupialization appears to me
more likely to be successful if the lesion is
treated within 90 days. Berti et al.21 affirmed
that a recently developed mucocele would
have a thinner covering mucosa, and so the
success of micro-marsupialization could be
expected in these cases.
Based on the physiological characteristics of
epithelial tissue, Sandrini et al.24 suggested
that sutures should be maintained for 30 days
after micro-marsupialization. The authors
claimed this longer period would be sufficient
to allow the development of several new permanently epithelialized tracts along the path
of the sutures. We disagree with this conclusion, mainly owing to the difficulty that some
patients, especially children, would have in
keeping the suture in place. The sutures
would be more likely to cause discomfort and
secondary infections as a result of suboptimal
oral hygiene in paediatric patients if left for a
long period. In this study, the sutures were
maintained for 7 days in all of the cases, and
in 25 of them, the lesion had full regression
in that time.
Although micro-marsupialization showed
good results in the treatment for most mucocele in this series, some precautions must be
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd
322
C. M. Piazzetta, C. Torres-Pereira & J. M. Amena´bar
taken when selecting this technique. Micromarsupialization does not enable a biopsy to
be conducted, and the diagnosis remains
exclusively clinical. Furthermore, it should be
carefully used in palatal or buccal lesions, as
minor salivary gland tumours are often
located in those areas and can be wrongly
diagnosed as mucoceles.
Conclusion
This study suggests that micro-marsupialization could be a treatment option for children
and adolescents with mucoceles. It is simpler
to perform, minimally invasive, requires no
local infiltration of anaesthesia, has a lower
postoperative complications rate, and is welltolerated by patients.
What this paper adds
d Micro-marsupialization is often used to treat ranulas
but not mucocele.
d Micro-marsupialization have a high successful rate in
mucocele
d A treatment option for mucoceles that was not discuss
previously in the literature.
Why this paper is important to paediatric dentists
d The technique has simple application, it is a minimal
invasive procedure, and it is well accepted by paediatric patients.
d This technique can be use as a successful alternative
treatment for mucocele in children and adolescents.
Conflict of interest
The authors declare no conflict of interest.
References
1 Chen YK, Lin LM, Huang HC, Lin CC, Yan YH. A
retrospective study of oral and maxillofacial biopsy
lesions in a pediatric population from southern
Taiwan. Pediatr Dent 1998; 20: 404–410.
2 Maia DM, Merly F, Castro WH, Gomez RS. A survey
of oral biopsies in Brasilian pediatric patients. ASDC
J Dent Child 2000; 67: 128–131.
3 Sousa FB, Etges A, Correˆa L, Mesquita RA, de Arau´jo
NS. Pediatric oral lesions: a 15-years review from Sa˜o
Paulo-Brazil. J Clin Pediatr Dent 2002; 26: 413–418.
4 Jones AV, Franklin CD. An analysis of oral and
maxillofacial pathology found in children over a 30year period. Int J Paediatr Dent 2006; 16: 19–30.
5 Baurmash HD. Mucoceles and ranulas. J Maxillofac
Oral Surg 2003; 61: 369–378.
6 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: 155–180.
7 Porter SR, Scully C, Kainth B, Ward-Booth P.
Multiple salivary mucoceles in a young boy. Int J
Paediatr Dent 1998; 8: 149–151.
8 Regezi SA, Sciubba JJ, Jordan RC, Abrahams PH.
Oral Pathology: Clinical Pathologic Correlation, 4th edn.
St. Louis: W. B. Saunders, 2003: 195–201.
9 Esmeili T, Lozada-Nur F, Esptein J. Common benign
oral soft tissue masses. Dent Clin North Am 2005; 49:
223–240.
10 Stuani AS, Stuani AS, Santos BM, Paula e Silva
FWG, Borsato MC, Queiroz AM. Treatment of
mucocele for micromarsupialization technique: case
report. Revista de Odontologia da Universidade Cidade de
Sa˜o Paulo 2008; 20: 307–310.
11 Mı´nguez-Martinez I, Bonet-Coloma C, Ata-AliMahmud J, Carrillo-Garcı´a C, Pen˜arrocha-Diago M,
Pen˜arrocha-Diago
M.
Clinical
characteristics,
treatment, and evolution of 89 Mucoceles in
children. J Oral Maxillofac Surg 2010; 68: 2468–2471.
12 Neville B, Damn DD, Allen CM, Bouquot JJ. Oral &
Maxilofacial Pathology, 2nd edn. Philadelphia: W. B.
Saunders, 2002: 389–392.
13 Harrison JD. Salivary mucoceles. Oral Surg Oral Med
Oral Pathol 1975; 39: 268–278.
14 Bermejo A, Aguires JM, Lopez P, Saez MR.
Superficial mucocele: report of 4 cases. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1999; 88:
469–472.
15 Mandel L. Multiple superficial oral mucoceles: case
report. J Oral Maxillofac Surg 2001; 59: 928–930.
16 Garofalo S, Briganti V, Cavallaro S et al. Nickel
gluconate-mercurius heel-potentised swine organ
preparations: a new therapeutical approach for the
primary treatment of pediatric ranula and intraoral
mucocele. Int J Pediatr Otorhinolaryngol 2007; 71:
247–255.
17 Roh JL, Kim HS. Primary treatment of pediatric
plunging ranula with nonsurgical sclerotheraphy
using
OK-432
(Pinivanil).
Int
J
Pediatr
Otorhinolaryngol 2008; 72: 1405–1410.
18 Huang IY, Chen CM, Kao YH, Worthington P.
Treatment of mucocele of the lower lip with carbon
dioxide laser. J Oral Maxillofac Surg 2007; 65: 855–
858.
19 Boj JR, Point C, Espada E, Hernandez M, Espanya
A. Lower lip mucocele treated with an erbium laser.
Pediatr Dent 2009; 31: 249–252.
20 Pandt RT, Park AH. Management of pediatric
ranula. J Otolaryngol Head Neck Surg 2002; 127: 115–
118.
21 Berti AS, Santos JAR, Dirschnabel AJ, Sousa PHC.
Micromarsupializac¸a˜o: Relato de dois casos clı´nico.
Rev Port Estomatol Cir Maxilofac 2006; 47: 151–155.
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd
Micro-marsupialization as a treatment for mucocele
22 Harrison
JD.
Modern
management
and
pathophysiology of raˆnula: literature review. Head
Neck 2010; 32: 1310–1320.
23 Kaiser KM, Silva ALT, Rosa TF, Pereira MA.
Mucocele of the lower lip mucosa. RGO 2008; 56:
85–88.
323
24 Sandrini FA, Sant’ana-Filho M, Rados PV. Ranula
management: suggested modifications in the micromarsupialization technique. J Maxillofac Oral Surg
2007; 65: 1436–1438.
2011 The Authors
International Journal of Paediatric Dentistry 2011 BSPD, IAPD and Blackwell Publishing Ltd