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RANULA SURGICAL TREATMENT BY THE

MARSUPIALIZATION TECHNIQUE 309

RANULA SURGICAL TREATMENT BY THEMARSUPIALIZATION TECHNIQUE

TRATAMENTO CIRÚRGICO DAS RÂNULASPELA TÉCNICA DE MARSUPIALIZAÇÃO

Daniel Luiz Gaertner ZORZETTO *

Clóvis MARZOLA **João Lopes TOLEDO-FILHO ***

Marcelo Rodrigues AZENHA ****

Lucas CAVALIERI-PEREIRA ****

Luciana Pastori da SILVA-ROSA ****

___________________________________________* Professor of Oral and Maxillofacial Surgery and Traummatology Specialization course and

adviser of this report.** Titular Professor of Surgery Pensioner of Dental School of Bauru – USP. Professor of Oral and

Maxillofacial Surgery and Traummatology Specialization course.*** Titular Professor of Anatomy of Dental School of Bauru – USP. Professor of Oral and

Maxillofacial Surgery and Traummatology Specialization course.**** Student of the Residence Course in Oral and Traummatology Maxillofacial Surgery by the

Brazilian School of Buco Maxillofacial Surgery and Traummatology and Base Hospitalof Bauru, São Paulo State, Brazil.





ABSTRACT

Ranula is a traumatic lesion and its origins become from therupture of one or more salivary ducts, with mucous retention or leaking in the

floor of the mouth. The aim of the present study is to demonstrate themarsupialization surgical technique in the treatment of mouth floor mucousretention. This technique permit a direct connection between the lesion and a

joint anatomical cavity, with the purpose of obtain a spontaneous reduction of thelumen e to avoid recurrent salivary duct obliteration.

RESUMO

Rânula é uma lesão de origem traumática que se origina a partir daruptura de um ou mais ductos das glândulas salivares, ocorrendo a retenção ouextravasamento de muco na região do assoalho bucal. O propósito deste trabalhoé demonstrar a técnica cirúrgica de marsupialização na resolução de um caso deretenção salivar do assoalho bucal, propiciando uma conexão direta entre acavidade da lesão e uma cavidade anatômica adjacente. Isso tudo com o objetivode se obter uma redução espontânea do tamanho do lúmen, evitando uma novaobliteração do ducto da glândula salivar.

Uniterms: Ranula; Salivary glands; Marsupialization; Retention cysts.

Unitermos: Rânula; Glândulas salivares; Marsupialização; Cistos de Retenção.

INTRODUCTION

Located in the wooden floor of the mouth, it is initially described abenign injury (BRUITT, 1875) as being a cystic tumor with viscous volume in itsinterior and, if developing from a blockage of duct of Wharton. The word ranulais derived from the Latin, meaning frog, for presenting a similarity with the wombof this animal (MANDEL, 1996 and MARZOLA, 2005). Its ethiopatogeny isthe local trauma, being able to provoke the rupture or blockage of duct of thesalivary gland attack, being occurred extravasations’ and accumulation of salivary

mucous in the interior of the conjunctive tissue in the buccal region wooden floor(REGEZI; SCIUBA, 1991 and MARZOLA, 2005). The liquid content can besituated underlying to the mucosa of the wooden floor of the mouth, above of themilohioid muscle, characterizing ranula buccal, or still to extend itself enters thenatural spaces of the muscle, allowing the mucous extravasation for the soft tissueplans supplies-hioids, resulting in deeper ranula (GOSSETT; SMITH;SULLIVAM et al ., 1999 and MARZOLA, 2005).

Different pathologies may happen the salivary glands, being thedistinguishing diagnosis of the pathological processes of inflammatory, allergic,auto-immune, neoplasic, cystic or genetic origin basic in the determination of theinjury (HEIFER; SAMPAIO; CHAMBER, 1999 and MARZOLA, 2005).Despite the clinical differential diagnosis, in many situations, to be easy being, in





determined cases only the microscopical examination can disclose the true natureof injury (LAUAND; ACETOZE; LIA et al ., 1986 and MARZOLA, 2005).

Ranulas present as characteristic sessile the base or pediculated,necessary limits and a smooth surface. They are generally asymptomatic, being

able to evolve slowly or quickly, presenting a bluish coloration if locatedsuperficially, or are of the coloration of the mucosa when found deeply in tissues(CASTRO, 1995 and MARZOLA, 2005). In accordance with its localization, inthe majority of the times is found in only one side of the buccal wooden floor,giving the false impression of bilaterality when it presents an exaggerated volume.In this situation, the displacement of the tongue can occur, causing difficulty of phonation, chew and deglutition (LAUAND; ACETOZE; LIA et al ., 1986 andMARZOLA, 2005).

An incision and draining, the excision of the injury associated ornot with the removal of the involved gland, different techniques of marsupialization, cryosurgery, radiation, the use of sclerosants solutions,

micromarsupialization, the laser therapy, beyond the injection of hydrocolloids inthe interior of the injury, are the treatment modalities proposals in literature(CARABBA, 1984; LAUAND; ACETOZE; LIA et al ., 1986; MINTZ, 1994;YOSHIMURA; OBARA; KONDOH et al ., 1995; DELBEM; CUNHA;VIEIRA et al ., 2001 and MARZOLA, 2005).

The objective of this work is to demonstrate the marsupializationtechnique as option of safe and efficient treatment in the cases of ranula,emphasizing the necessity of the postoperative accompaniment to observe apossible return of the injury.

CASE RELATEPatient with 16 years of age, feminine sort, appeared to the Clinic

of Surgery and Traumatology BMF of the Base Hospital of the HospitalAssociation of Bauru, São Paulo State, Brazil, presenting volumetric increase inthe buccal wooden floor with evolution of 28 days. It told chew difficulty andphonation, having been submitted previous the surgical procedure for incision anddraining of this same alteration of the buccal wooden floor has 14 days. It did notpresent systemic alterations and, to the clinical examination was observedunilocular volumetric increase for the left side of the buccal wooden floor,extending itself of the median line of the mandible until the region of as the molar

one. It presented necessary limits, soft consistency, smooth surface, bluishcoloration, measuring approximately 3,5 cm of diameter, the injury presented asdiagnostic a salivary retention phenomenon of the buccal wooden floor, or so thecall ranula (Figure 1).

The proposed treatment was the marsupialization of the injuryunder local anesthesia. During the surgical procedure, the membrane that coatsthe injury was breached and all mucous contained in its interior was extravasated(Figure 2).

With the aid of a shears rhomb the injury was dissected, its suturedevertides edges and then in the buccal wooden floor with the use of the wire of Poliglactina 910, scales 4-0 (Vycril, Johnson & Johnson) (Figures 3 and 4). The

tissue removed was sent to the pathology laboratory of the Base Hospital, havingconfirmed the diagnosis of ranula.





The suture points had been kept until its complete resorption(Figure 5). The patient after meets in ambulatorial accompaniment withoutsignals of return of the injury one year of the surgical procedure.

Figure 1 – Clinical aspect f the injury in the buccal wooden floor.Figure 2 – Draining of the mucous during the surgical procedure.

Figure 3 – Dissection of the injury with shears rhomb.

1

2

3





Figure 4 - Immediate postoperative aspect with the injury completely marsupializated.

Figure 5 - Fourteen days postoperative with the wire of suture in position.

DISCUSSION

Different therapeutical modalities have been proposals for thetreatment of rânula, as a simple draining of the injury with aspiration of itsmucous content, excision only of the sublingual gland for intra or extra oral view(YOSHIMURA; OBARA; KONDOH et al ., 1995), excision of ranula and thesublingual gland in one only surgical time (BRIDGER; CARTER; BRIDGER,1989), marsupialization (MARZOLA, 2005), marsupialization and fulfilling of the socket with gauze humidified in antibiotics or still hydrocolloids solutions(LEITE; FARIA; CARNEIRO, 2006), micromarsupialization (DELBEM;

CUNHA; VIEIRA,et al

., 2001), cryosurgery, radiation and injection of sclerosants solutions (CARABBA, 1984) and, the laser therapy (MINTZ, 1994).

4

5





In this case relate it was observed the age of the patient and the present type of ranula, being instituted the marsupialization technique as treatment, for presentinggood clinical results in these situations. These authors believe that the fulfilling of the socket with gauze absorbed in antibiotic solution cannot presents advantages

when comparative to the technique of the simple marsupialization for this last oneto present resulted satisfactory in the daily clinic.Fifteen (15) cases of ranula had been studied that they were

presents in patients in the age between 1 and 35 years, with bigger incidence infeminine sort individuals (9 cases or 60%) with predominance in the seconddecade of life (7 cases or 46.7%) (BEZERRA; SAMPAIO; CÂMARA, 1999).These authors had not found difference of predominance how to the side of thebuccal wooden floor competed by the injury. In the presented case, the injury waspresent of the left side of the buccal wooden floor in a patient with 20 years of age.

The characteristics of the injury found in this work resemble it the

findings presenting ranula with necessary limits, soft consistency, smooth,mucous surface thin of covering, mucous in its interior, painless to the palpation,bluish coloration and unilocular (CASTRO, 1995). The etiologies of this injuryare the frequent traumas, causing an immediate extravasation of mucous of theaffected glands, occurring its accumulation in buccal wooden floor tissues.Depending on the injured gland, the accumulation of mucous can be exaggerated,with some injuries measuring up to six centimeters of diameter (LAUAND;ACETOZE; LIA et al ., 1986). The authors of this study had carried through themarsupialization of one ranula that he presented 3,5 centimeters of diameterapproximately.

The diagnosis of rânula is clinical essentially when the injury islocated superficially, having its characteristics to be observed so that it is possiblethe accomplishment of the distinguishing diagnosis of ranula with the cyst of thebranchial crack, cyst of the paratireoids, dermoid cyst, higroma cystic, teratomaintently benign, or still duct tireoglosso cyst (MIZUNO; YAMAGUCHI, 1993and MARZOLA, 2005).

The examinations for image, as the occlusal x-ray of the mandible,the sialographics, computerized cat scan and, the ultrassonographic are describedin literature as being important in the detention of possible blockages of thesalivary ducts and, considered for the definition of the diagnosis (MARZOLA,2005).

The clinical accompaniment of the patient submitted to the excisionof ranula, independently of the used technique, always must be carried through tobe observed the presence of possible returns of the injury.

CONCLUSIONS

It can be concluded with the literature review on the subject,beyond the presentation of the clinical case that ranula:

1. It is an injury that presents different modalities of treatment.2. One safe technique is the marsupialization, of easy

accomplishment and, presenting a favorable prognostic.

3. It must have the postoperative accompaniment of the patient forthe verification of a possible return of the injury is very important.





REFERENCES *

BEZERRA, A. R.; SAMPAIO, R. K. P. L.; CÂMARA, K. Rânula- aspectosclínicos e histopatológicos de 15 casos. Rev. bras. Odontol., v. 56, n. 6, p. 298-

302, 1999.BRIDGER, A. G.; CARTER, P.; BRIDGER, G. P. Plunging ranula: literaturereview and report of three cases. Aust. N. Z. J. Surg., v. 59, p. 945-8, 1989.BRUITT, E. Vademecum Del Chirurgo: Manuale Del la Chirurgia Moderna.Milano: Ed. F. Vallardi, 1876.CARABBA, V. Sclerosing injections in surgery. Ann. Surg., v. 99, n. 4, p. 668-75,1984.CASTRO, A. L. Estomatologia. 2a ed. São Paulo: Ed. Santos, 1995.DELBEM, A. C. B.; CUNHA, R. F.; VIEIRA, A. E. M. et al., Tratamento defenômenos de retenção salivar em crianças pela técnica da micromarsupialização.

Rev. Assoc. paul. Cir. Dent., v. 55, n. 1, p. 51-4, 2001.GOSSETT, J. D.; SMITH, K. S.; SULLIVAN, S. M. et al., Sudden sublingual andsubmandibular swelling. J. oral. Maxillofac. Surg., v. 57, p. 1353-6, 1999.LAUAND, F.; ACETOZE, P. A.; LIA, R. C. C. et al. Rânula do assoalho da boca.Relato de caso. Rev. Assoc. paul. Cir. Dent ., v. 40, n. 5, p. 383-7, 1986.LEITE, A. V.; FARIA, D. L. B.; CARNEIRO, L. J. Tratamento de rânula pelamarsupialização: relato de caso. Rev. Odonto Ciência, v. 21, n. 53, p. 289-91,2006.MANDEL, L. Ranula, or, what´s in a name? N. Y. St. dent. J ., v. 62, p. 37-9, 1996.MARZOLA, C. Fundamentos de cirurgia buco maxilo facial. Bauru: Ed.Independente, 2005, 2237 p.

MINTZ, S. Carbon dioxide laser excision and vaporization of nunplungingranulas: a comparison of two treatment protocols. J. oral Maxillofac. Surg. v. 52,p. 370-2, 1994.MIZUNO, A.; YAMAGUCHI, K. The plunging ranula. Int. J. oral Maxillofac.

Surg., v. 22, p. 113-5, 1993.REGEZI, J. A.; SCIUBA, J. I. Patologia bucal: correlações clínico patológicas.

Doenças das glândulas salivares. Rio de Janeiro: Ed. Guanabara/Koogan, 1991,p. 166-8.YOSHIMURA, Y.; OBARA, S.; KONDOH, T, et al., A comparison of threemethods used for treatment of ranula. J. oral Maxillofac. Surg., v. 53, p. 280-2,1995.

______________________________________* According of the ABNT norms.

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