[Downloaded free from http://www.ijdr.in on Tuesday, August 27, 2013, IP: 125.16.60.178] || Click here to download free Android application for this journal
Original Research
Excision of oral mucocele by different wavelength lasers Umberto Romeo, Gaspare Palaia, Gianluca Tenore, Alessandro Del Vecchio, Samir Nammour1
Department of Oral and
Maxillofacial Sciences,
“Sapienza” University of Rome,
Rome, Italy, 1Department of
Dental Sciences, Faculty of
Medicine, University of Liege,
Liege, Belgium
Received
: 24-03-10
Review completed : 20-05-10
Accepted
: 06-07-10
ABSTRACT
Background: Mucocele is a common benign neoplasm of oral soft tissues and the most common
after fibroma. It generally occurs in the lower lip and its treatment includes excision of cyst and
the responsible salivary gland, in order to prevent recurrences.
Aims: To evaluate the capability of three different lasers in performing the excision of labial
mucocele with two different techniques.
Materials and Methods: In the presented cases, excision was performed using two different
techniques (circumferential incision technique and mucosal preservation technique) and three
different laser wavelengths (Er,Cr:YSGG 2780 nm, diode 808 nm, and KTP 532 nm).
Results: All the tested lasers, regardless of wavelength, showed many advantages (bloodless
surgical field, no postoperative pain, relative speed, and easy execution). The most useful
surgical technique depends on clinical features of the lesion.
Conclusion: Tested lasers, with both techniques, are helpful in the management of labial
mucocele.
Key words: Circumferential incision technique, laser, mucocele, mucosal preservation technique Mucoceles are the most common of the benign soft tissue
masses present in the oral cavity, after irritation fibroma.[1]
Mucoceles, by definition, are cavities filled with mucus. The
mechanisms for mucus cavity development are extravasation
or retention. Extravasation is the leakage of fluid from the
ducts or acini of salivary glands in the surrounding tissues
(mucus extravasation cyst), while the much less common
retention phenomenon occurs as a result of a narrowed
ductal opening due generally to inflammatory causes or
salivary calculus that cannot adequately accommodate the
exit of the produced saliva, leading to ductal dilation and
surface swelling (mucus retention cyst).[1]
The extravasation mucocele, or extraductal mucus cyst, was
described for the first time by Hamperl in 1932, with the
name ‘mucus granuloma’ (Schleimgranulom).[2] It represents
the most frequent swelling of the lower lip in the first two
Address for correspondence:
Prof. Romeo Umberto
E-mail: [email protected]
Access this article online
Quick Response Code:
Website:
www.ijdr.in
PMID:
***
DOI:
10.4103/0970-9290.116685
211
decades of life and has a peak occurrence between the second
and third decade.[3] According to Jones and Franklin,[4]
mucous extravasation phenomenon is the most frequently
diagnosed salivary gland pathology in children, occurring
mainly in the lower lip (77.9%), tongue (9.9%), and mouth
floor (5.7%).
The retention mucocele, or sialocyst, is more rare than the
first one. It occurs more commonly on the upper lip than
the lower lip.[3] It is more frequent in adults, after the age of
40, with an incidence peak between the seventh and eighth
decade of life.[4]
The two forms are clinically similar. Mucocele appears as
a solitary circular painless swelling, fluctuant to palpation
since the mucus content, painless, with diameter ranging
from a few millimetres to a few centimetres,[5] and is of
normal pink or bluish colour. When occurring on the lower
lip, it affects mainly the canine area, the most susceptible
to trauma.[1] It can also involve other minor salivary glands
such as Blandin–Nuhn glands or the oral floor (ranulae).[1]
If surgical excision is not performed, particularly in the
extravasation type, it is possible to observe a cyclical increase
and decrease in size, as a result of the rupture of the cyst
and subsequent new production of mucin.
The differential diagnosis should be placed with the fibroma,
angioma, lipoma, and benign salivary gland neoplasm and
others rare diseases such as acinic cell carcinoma.[6]
Indian Journal of Dental Research, 24(2), 2013
[Downloaded free from http://www.ijdr.in on Tuesday, August 27, 2013, IP: 125.16.60.178] || Click here to download free Android application for this journal
Romeo, et al.
Laser treatment of oral mucocele
Histologically, in the extravasation form, the accumulation
of saliva induces an acute foreign body reaction, with the
recall, in the affected area, of macrophages and neutrophils;
thereafter, these cells are replaced by granulation tissue of
fibroblasts,[7] which defines a pseudocapsule. Due to the
absence of a clear epithelial layer, extravasation mucocele
may be considered a false cyst or pseudocyst.[3] By contrast,
retention mucocele can be considered a true cyst, due to the
presence of an epithelial layer of ductal origin, of cylindrical
or flat cells.[3,7]
The therapy, in both types of mucocele, is surgical and
consists of excision of the cyst and the responsible minor
salivary gland, to prevent any possible recurrence.[1,8]
Two surgical procedures are described in its management,
the Circumferential Incision Technique (CIT) in superficial
localizations and the Mucosal Preservation Technique
(MPT) in deep-seated lesions.[1,9]
The aim of the study was to evaluate the capabilities of
three different wavelengths in the surgical excision of oral
extravasation mucocele through two different surgical
techniques.
MATERIALS AND METHODS
Three extravasation mucoceles were treated in the
Department of Oral and Maxillofacial Sciences of Sapienza
University of Rome.
Surgical treatments were performed by three different lasers:
Erbium, Chromium-doped Yttrium Scandium Gallium
Garnet (Er,Cr:YSGG), Potassium-Titanyl-Phosphate (KTP)
and Diode laser.
Small and superficial lesions were treated by CIT, while in
larger and deeper lesions, MPT was adopted.
Case 1
A 14-year-old boy presented with fluctuant, painless,
bluish swelling in the lower lip, about 0.5 cm in diameter
[Figure 1]. A trauma preceded the onset of the mass. Story
and appearance suggested the hypothesis of mucocele. It
was decided to perform an excision by Er,Cr:YSGG laser
2780 nm (Waterlase®, Biolase, USA) by MPT.
After local anesthesia, a longitudinal laser incision was
performed, at 2 Watt, 10% air, 10% water, 35 J/cm2, with a
600-μm fiber. The cyst was exposed [Figure 2] with a roundshaped instrument, and then the lesion was completely
excised by laser at 1.5 Watt, 10% air, 10% water, 26 J/cm2
[Figure 3]. A 4/0 resorbable suture was applied to protect a
critical area often exposed to traumas.
No complications occurred in the post-operative period;
healing was excellent [Figure 4].
Indian Journal of Dental Research, 24(2), 2013
The histological examination confirmed clinical diagnosis.
Case 2
A 13-year-old boy presented with pedunculate pink lesion
of 0.5 cm in diameter, with multiple recurrences after
traumas [Figure 5]. The patient also reported the habit of
biting the lower lip.
Because of poor dimensions, the CIT by Diode laser 808 nm
(Laser Innovation 30W®, Italy) was adopted.
In local anesthesia, the lesion was clamped and excised
circumferentially, with a 320-μm fiber at 2 Watt,
Ton=100 ms, Toff=100 ms, 248 J/cm2 [Figure 6]. No bleeding
was observed and no suture was applied [Figure 7]. Healing
was completed in three weeks [Figure 8].
Histology confirmed the clinical diagnosis of extravasation
mucocele.
Case 3
A 12-year-old boy presented with lower lip swelling, of
1 cm in diameter [Figure 9]. The lesion, covered by normal
mucosa, was fluctuant, neither painful nor bleeding, and
was noticed about 2 months ago. The size of the lesion
suggested the MPT by KTP laser 532 nm (SmartLite®,
DEKA, Italy).
In local anesthesia, a longitudinal incision was performed
at 1.5 Watt, Ton=100 ms, Toff=100 ms, 212 J/cm2 and with a
300-μm fiber [Figure 10]. Using a round-shaped instrument
the lesion was exposed [Figure 11], and then excised at
1 Watt, Ton=100 ms, Toff=100 ms, 141 J/cm2 [Figure 12].
A 4/0 resorbable suture was applied to protect the surgical
wound.
The post-operative period was comfortable [Figure 13].
Histology confirmed clinical diagnosis.
RESULTS
All the cases are successfully treated, without any
recurrence. Er,Cr:YSGG 2780 nm, Diode 808 nm and KTP
532 nm showed good effectiveness when both techniques
were adopted. Surgery was relatively quick and atraumatic,
and no complications occurred in the intra- or postoperative
period. The use of laser did not impede the histological
diagnosis.
DISCUSSION
Mucocele is a common oral pathology, especially in young
patients. It is generally determined by a traumatic event
that can cause the rupture of a excretory duct of salivary
gland and it usually appears as a solitary painless swelling,
fluctuant to palpation, in canine-bicuspid areas, with a
normal pink or bluish colour, the latter depending from
212
[Downloaded free from http://www.ijdr.in on Tuesday, August 27, 2013, IP: 125.16.60.178] || Click here to download free Android application for this journal
Romeo, et al.
Laser treatment of oral mucocele
Figure 1: Incision by Er,Cr:YSGG laser of a lower lip mucocele of a
young boy
Figure 3: Surgical excision by laser at 1.5 Watt, 10% air, 10% water,
26 J/cm2
Figure 2: Exposed mucosal cyst
Figure 4: Complete healing at 3 weeks, without any scars
Figure 5: Esophitic pink lesion on the lower lip
Figure 6: Surgical excision using a Diode laser 808 nm at 2 Watt,
Ton=100 ms, Toff=100 ms, 248 J/cm2
Figure 7: Immediate postoperative control; no suture was applied
Figure 8: Control at 3 weeks; healing was excellent
213
Indian Journal of Dental Research, 24(2), 2013
[Downloaded free from http://www.ijdr.in on Tuesday, August 27, 2013, IP: 125.16.60.178] || Click here to download free Android application for this journal
Laser treatment of oral mucocele
Figure 9: Lower lip swelling in a 12-year-old boy
Figure 11: Exposed cyst
Romeo, et al.
Figure 10: Linear incision using KTP laser 532 nm at 1.5 Watt,
Ton=100 ms, Toff=100 ms, 212 J/cm2
Figure 12: Surgical excision completed at 1 Watt, Ton=100 ms,
Toff=100 ms, 141 J/cm2
gland responsible for the mucocele, in order to avoid
undesired recurrences.
Different surgical techniques have been described,
depending generally on the lesion’s clinical features. In
traditional scalpel surgery, Baurmash[1] proposed complete
excision for small lesions and unroofing procedure for large
mucoceles.
Figure 13: Complete healing at 3 weeks without any complications
tissue cyanosis and vascular congestion associated with the
stretched overlying tissue and the translucent character of
the accumulated fluid beneath.[1]
After an appropriate differential diagnosis with other
pathological forms (e.g., fibroma, lipoma, angioma, salivary
neoplasms), surgical excision represents the only treatment
for this disease. In fact, if surgical excision is not performed,
particularly in the extravasation type, it is possible to observe
a cyclical increase and decrease in the size of the lesion, as
a result of the breakage of the cyst and new production of
mucin.
Surgical excision must include the cyst, generally wellcoated by a fibrous capsule, together with the minor salivary
Indian Journal of Dental Research, 24(2), 2013
Kopp and St-Hilaire proposed the MPT[9] surgical technique
that consists of a linear incision of the mucosa on the
top of the lesion, until it is identified; the lesion is then
incised, decompressed and excised, together with the whole
pathologic glandular tissue.
Vaporization by CO2 laser was suggested by Huang et al.,[10]
but this technique was questioned since it does not allow
histological examination of the lesion.
Our recent studies[11,12] revealed that Erbium, KTP, and
Diode lasers were ideal devices for oral soft tissues biopsy
with poor thermal damage permitting a correct histological
diagnosis. Er,Cr:YSGG is a solid-state laser with a wavelength
of 2780 nm, with great affinity to water molecule. It has a
fixed frequency of 20 Hz and also the possibility to perform
air or water cooling. Its cutting hydrokinetic action allows
working effectively on hydrated tissues without any thermal
214
[Downloaded free from http://www.ijdr.in on Tuesday, August 27, 2013, IP: 125.16.60.178] || Click here to download free Android application for this journal
Romeo, et al.
Laser treatment of oral mucocele
damage. Its physical characteristics make it effective on all
tissues of the oral cavity, both hard (bone, tooth) and soft
ones. This device, however, has no hemostatic capacity, so
it must be used cautiously in vascular lesions (eg, angioma).
Diode laser 808 nm is a semiconductor device emitting
an infrared radiation, with good affinity with oxidized
hemoglobin and melanin. It may work in continuous or
interrupted mode, through optical fibres of varied diameter.
This is an excellent surgical laser for dentistry because it can
cut all oral vascularised soft tissues. Moreover, by using such
kind of laser, a bloodless surgical field can be easily obtained.
The KTP, also called Nd:YAG double frequency laser, is a
solid state device, whose wavelength is obtained by halving
the radiation produced by a Nd:YAG laser (1064 nm), by
means of Potassium (K) Titanium (T) Phosphate (P) mirrors.
The resulting radiation (wavelength, 532 nm) is green and
has a higher affinity for oxidized hemoglobin if compared
with all other dental lasers. For this reason, KTP laser can
work using low power energy and influences, reducing
thermal damages to target tissues.[11,13] Like diode laser,
even more so, KTP laser can operate in bloodless field,
with considerable advantages in the surgical management
of many clinical diseases. KTP laser can work either in
continuous or interrupted mode.
In this study, excision of the lesions was performed by these
lasers adopting both CIT and MPT surgical techniques.
In the Erbium and KTP cases, due to the large size of lesions,
MPT was chosen. This procedure prevents damages to deep
anatomical structures of the lower lip, as the lower labial
artery and superficial branches of mental nerve allows to
see the responsible salivary gland at the base of the surgical
site and its complete removal without loss of mucosal tissue.
Tissue preservation is important in the lower lip since it is
an aesthetic region. Only in the case treated by diode laser,
CIT was preferred to remove the lesion, as it was small and
pedunculate.
All tested devices showed advantages. In particular, KTP
and diode lasers offered the best bleeding control and
a high cutting activity, due to their higher affinity for
hemoglobin,[11-13] whereas in the case of Er,Cr:YSGG, a
precise and atraumatic cut was obtained, mainly in the
first incision, according to other studies.[13,14] With all
215
wavelengths, no scars or postoperative pain were observed,
and histological diagnosis was made. No adverse side effects
to laser surgery were emphasized in the presented cases.
In conclusion, laser surgery, regardless of wavelengths,
can be considered helpful in oral mucocele management,
offering technical and clinical advantages. However, it is
important to choose the correct surgical technique according
to the clinical features of the lesions.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Baurmash HD. Mucoceles and Ranulas. J Oral Maxillofac Surg
2003;61:369-37.
Seifert G, Donath K, von Gumberz C. Mucoceles of the minor salivary
glands. Extravasation mucoceles (mucus granulomas) and retention
mucoceles (mucus retention cysts). HNO 1981;29:179-91.
Mustapha I, Boucree S. Mucocele of the upper lip: Case report of an
uncommon presentation and its differential diagnosis. J Can Den Ass
2004;70:318-21.
Jones AV, Franklin CD. An analysis of oral and maxillofacial
pathology found in children over 30-year period. Int J Paediatr Dent
2006;16:19- 30.
Boneu-Bonet F, Vidal-Homs E, Maizcurrana-Tornil A, GonzálezLagunas J. Submaxillary gland mucocele: Presentation of a case. Med
Oral Patol Oral Cir Bucal 2005;10:180-4.
Cho JH, Yoon SY, Bae EY, Lee CN, Lee JD, Cho SH. Acinic cell carcinoma on
the lower lip resembling a mucocele. Clin Exp Dermatol 2005;30:490-3.
Regezi JA, Sciubba JJ. Salivary gland diseases. In: Oral pathology: Clinical
pathologic manifestations. 1st ed. Philadelphia (PA): W.B. Saunders Co;
1989. p. 225-83.
Cunha RF, De M, Carvalho P, Guimaraes CM, Macedo CM surgical
treatment of mucocele in an 11 month-old baby: A case report. J Clin
Pediatr Dent 2002;26:203-6.
Kopp WK, St-Hilaire H. Mucosal preservation in the treatment of
mucocele with CO2 laser. J Oral Maxillofac Surg 2004;62:1559-61.
Huang IY, Chen CM, Kao YH, Worthington P. Treatment of mucocele
of the lower lip with carbon dioxide laser. J Oral Maxillofac Surg
2007;65:855-8.
Romeo U, Palaia G, Del Vecchio A, Tenore G, Gutknecht N, De Luca M.
Effects of KTP laser on oral soft tissues. In vitro study. Lasers Med Sci
2010;25:539-43.
Romeo U, Libotte F, Palaia G, Del Vecchio A, Tenore G, Visca P et al.
Histological in vitro evaluation of the effects of Er:YAG laser on oral
soft tissues. Lasers Med Sci 2012 Jul;27:749-53.
Romeo U, Palaia G, Botti R, Leone V, Rocca JP, Polimeni A. Non surgical
periodontal therapy assisted by potassium-titanyl-phosphate laser
assisted: A pilot study. Lasers Med Sci 2010;25:891-9.
Rizoiu IM, Eversole LS, Klimmel AI. Effects of an erbium, chromium:
yttrium, scandium, gallium, garnet laser on mucocutanous soft tissues.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:386-95.
How to cite this article: Romeo U, Palaia G, Tenore G, Vecchio AD, Nammour
S. Excision of oral mucocele by different wavelength lasers. Indian J Dent
Res 2013;24:211-5.
Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Dental Research, 24(2), 2013