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Micro-marsupialization as an alternative treatment for

mucocele in pediatric dentistry
CLETO M. PIAZZETTA
1
, CASSIUS TORRES-PEREIRA
2
& JOSE
´
M. AMENA
´
BAR
2
1
Post-Graduate Program in Dentistry, Oral Medicine Department, Federal University of Parana´ , Curitiba, PR, Brazil, and
2
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-mar-
supialization 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.
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 recur-
rent 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 sim-
pler to perform, minimally invasive, requires no
local infiltration of anaesthesia, has a lower post-
operative complications rate, and is well-tolerated
by patients.
Introduction
Mucocele is a common oral mucosal lesion
that originates from the minor salivary glands
and occurs more frequently in children and
adolescents
1–4
. The term mucocele describes
the accumulation of mucus within a salivary
gland
5
, 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 obstruc-
tion of the duct of a minor or accessory sali-
vary gland
5–11
.
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 centimetres
10,12
. The
lower labial mucosa is the most frequently
affected site, but mucoceles can also develop
also in the cheek, tongue, palate, and floor of
mouth, where it is called ranula
5,8,12–15
. 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, form-
ing a superficial ulceration
7,14,15
.
Mucoceles often arise within a few days after
minor trauma, but then plateau in size. They
can persist unchanged for months unless trea-
ted. Different techniques have been described
for the treatment for mucoceles
6,16–19
, but they
usually require surgical excision
5,20
. Therefore,
the aim of this article was to demonstrate
the feasibility of the technique of micro-
marsupialization in the treatment for mucoce-
les 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
Correspondence to:
J. M. Amena´ bar, Av. Lotha´ rio Meissner 632, Jardim
Botaˆ nico, CEP: 80210-170, Curitiba-Parana´ , Brazil.
E-mail: jamenaba@ufpr.br
Ó 2011 The Authors
318 International Journal of Paediatric Dentistry Ó 2011 BSPD, IAPD and Blackwell Publishing Ltd
DOI: 10.1111/j.1365-263X.2011.01198.x
old with a clinical diagnosis of mucocele, who
were treated between 1994 and 2009 at the
Oral Medicine Unit of the Universidade Fed-
eral 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% chlorh-
exidine gel postoperatively. The sutures were
removed after 7 days. The conventional surgi-
cal 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
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. Fig. 1. Silk suture passed through the mucocele.
Fig. 2. Making the surgical knot and leaving a space
between it and the lesion.
Fig. 3. Clinical aspect of lesion after micro-marsupialization.
Micro-marsupialization as a treatment for mucocele 319
Ó 2011 The Authors
International Journal of Paediatric Dentistry Ó 2011 BSPD, IAPD and Blackwell Publishing Ltd
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 depend-
ing on the kind of treatment. All of them
were told to return for the further examina-
tion if healing was not complete or if there
was any suggestion of recurrence.
From the 33 cases treated by micro-marsup-
ialization, 25 had a full regression of the
lesion after 7 days and three had full regres-
sion after 15 days. In the other five cases, the
lesions reappeared and surgical excision of
the mucocele was needed. In the group trea-
ted 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-marsupi-
alization than mucoceles that had been pres-
ent for more than 90 days. Data from the 86
cases are presented in Table 1, and the char-
acteristics of the recurrent cases are presented
in Table 2.
Discussion
Mucoceles can be treated by surgical excision,
electrosurgery, cryosurgery, laser vaporiza-
tion, or laser surgery
6,16–19
. Regardless of the
chosen technique, it is important to reach the
muscle layer during treatment
18
; as all treat-
ments are therefore invasive, they are not
always tolerated by the children or their
parents.
Fig. 4. Compression of the mucocele and extravasation of
accumulated saliva.
Table 1. Comparison of the two treatment groups.
Micro-marsupialization
(n = 33)
Excision
(n = 53)
Variables n (%) n (%) P
Gender
Male 15 (45.46) 27 (50.94) 0.662
Female 18 (54.54) 26 (49.06)
Age (years)
0–6 5 (15.15) 5 (9.43) 0.622
7–12 17 (51.52) 26 (49.06)
13–18 11 (33.33) 22 (41.50)
Size (cm)
<0.5 8 (24.24) 31 (58.49) 0.002
0.6–1.0 15 (45.46) 18 (33.96)
>1.0 10 (30.30) 4 (7.55)
Site
Lower lip 28 (84.84) 44 (83.02) 0.157
Tongue 2 (6.06) 8 (15.09)
Buccal mucosa 3 (9.10) 1 (1.89)
Duration of lesion development (days)
<30 14 (42.42) 11 (20.75) 0.144
31–90 11 (33.33) 23 (43.40)
91–180 2 (6.06) 11 (20.75)
181–365 4 (12.12) 5 (9.43)
>366 2 (6.06) 3 (5.67)
Recurrence 5 (15.15) 3 (5.67) 0.141
320 C. M. Piazzetta, C. Torres-Pereira & J. M. Amena´ bar
Ó 2011 The Authors
International Journal of Paediatric Dentistry Ó 2011 BSPD, IAPD and Blackwell Publishing Ltd
Marsupialization is a surgical technique that
involves incising into a cyst and suturing the
edges of the subsequent slit to form a continu-
ous surface from the exterior to the interior of
the cyst
20
. Micro-marsupialization consists in
draining the accumulated saliva and creating a
new epithelialized tracts along the path of the
sutures
6,10,21,22
. It is a minimally invasive tech-
nique, and most cases can be carried out under
topical anaesthesia alone
6,21
. The required pro-
cedure time is brief (approximately 3 min),
there is practically no tissue damage or inflam-
mation, and it appears to be a particularly suit-
able technique for children who cannot
tolerate long or invasive procedures
6,21
.
Although micro-marsupialization has been
described in the literature since 2000, mainly
for the treatment for ranulas
22
, its use in the
treatment for other mucoceles has been lim-
ited to single case reports or small series of
patients
6,10,21
. In this retrospective study, 33
mucoceles of a 15-years cohort of 86 patients
in total were treated with micro-marsupializa-
tion. This technique was chosen according to
patient age, physical and emotional states,
and resistance to or fear of infiltrative anaes-
thesia and⁄ or invasive procedures. The size
and duration of the lesion were not consid-
ered 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 nec-
essary 7 days to create a new epithelialized
tract.
In this study, full resolution of the muco-
cele was observed in almost 85% of the
patients (28 cases). There were five recurrent
mucoceles, and these were successfully trea-
ted by formal surgical resection. The clinical
features of these five mucoceles were painless
fibrous round masses, which were nonulcer-
ated and had the same colour as the sur-
rounding mucosa with white areas on their
surface. Micro-marsupialization may not have
been successful as these clinical characteristics
indicate a mucocele deep in the mucosa
6,23
.
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 per-
manently epithelialized tracts along the path
of the sutures. We disagree with this conclu-
sion, 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 muco-
cele in this series, some precautions must be
Table 2. Comparison of the recurrence cases in the two
treatment groups.
Recurrence in
micro-marsupialization
(n = 5)
Recurrence in
excision (n = 3)
Variables n (%) n (%)
Gender
Male 2 (40.00) 1 (33.33)
Female 3 (60.00) 2 (66.67)
Age (years)
0–6 0 (0.00) 1 (33.33)
7–12 2 (40.00) 0 (0.00)
13–18 3 (60.00) 2 (66.67)
Size (cm)
<0.5 1 (20.00) 2 (66.67)
0.6–1.0 2 (40.00) 1 (33.33)
>1.0 2 (40.00) 0 (0.00)
Site
Lower lip 4 (80.00) 2 (66.67)
Tongue 0 (0.00) 1 (33.33)
Buccal mucosa 1 (20.00) 0 (0.00)
Duration of lesion development (days)
<30 0 (0.00) 0 (0.00)
31–90 0 (0.00) 1 (33.33)
91–180 0 (0.00) 1 (33.33)
181–365 3 (60.00) 1 (33.33)
>366 2 (40.00) 0 (0.00)
Micro-marsupialization as a treatment for mucocele 321
Ó 2011 The Authors
International Journal of Paediatric Dentistry Ó 2011 BSPD, IAPD and Blackwell Publishing Ltd
taken when selecting this technique. Micro-
marsupialization 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-marsupializa-
tion 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 well-
tolerated 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 paediat-
ric 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.
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