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Case Report

Modified micro‑marsupialization in pediatric patients:

A minimally invasive technique

P. B. Rachana, Rohit Subedar Singh, Vinay V. Patil

Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Sullia, Karnataka, India

ABSTRACT
Surgical management of ranula and mucocele in the pediatric age group is challenging.
Various procedures from wide excision with scalpel to laser are associated with
few complications. Micro‑marsupialization is minimally invasive technique for the
management of ranula and mucocele, especially in pediatric age group because
it is easy to perform, efficacious, can be performed under topical anesthesia also
and lower incidence of complications. This case reports describes the modified
micro‑marsupialization for the successful management of ranula and mucocele in
pediatric age group.

Key words: Modified micro‑marsupialization, mucocele, pediatric

INTRODUCTION Various treatment modalities are studied historically from the

simple scalpel excision to wide surgical removal along with
Mucoceles  (muco meaning mucus and coele meaning sublingual gland, from laser to cryosurgery, but it tends to
cavity), by definition, are cavities filled with mucus. recur.[3] The definitive treatment is to remove the offending
It is a common oral mucosal lesion originating from sublingual gland. The surgical procedure has a high rate of
minor salivary gland. The lower labial mucosa is the morbidity with risk of injury to the submandibular duct and
most common site of involvement, but it may develop at lingual nerve. The mucosa in the floor of the mouth is often
virtually any location where minor salivary glands occur, shredded when the head of the sublingual gland is teased off
including the soft palate, retromolar region, and buccal the oral mucosa to which it is welded by the ducts of Rivinus,
mucosa.[1,2] leading to scarring and restricted mobility of the tongue.[4]

Ranula is an accumulation of saliva on the floor of the Micro‑marsupialization is a minimally invasive procedure
mouth, so named because of its nodular bluish color given by Morton and Bartley for management of ranula,
(or buccal membrane of similar color, depending on the in which the suture is passed from the lesion at its greatest
depth of the lesion) that resembles the aerated vocal sac diameter which forms the epithelized tract through which
of a frog.[2] the accumulated saliva gets drained. It is the minimally
invasive procedure which does not require extensive surgical
Address for correspondence: approach avoiding the surgical complications making it
Dr. Rohit Subedar Singh,
Department of Oral and Maxillofacial Surgery, KVG Dental popular modality in the larger lesion in pediatric age group.
College and Hospital, Sullia, Dakshin Kannada, Karnataka, India.
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DOI: How to cite this article: Rachana PB, Singh RS, Patil VV. Modified
10.4103/srmjrds.srmjrds_1_18 micro-marsupialization in pediatric patients: A minimally invasive
technique. SRM J Res Dent Sci 2018;9:83-6.

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Rachana, et al.: Modified micro‑marsupialization in pediatric patients: A minimally invasive technique

This case report presents a case of ranula occurring in floor

of mouth and mucocele in lower lip treated with modified
micro‑marsupialization in pediatric patients.

CASE REPORTS

Case 1
A 13‑year‑old girl reported with complaints of swelling
in floor of mouth and difficulty in swallowing food since
3  days. On clinical examination, the swelling was oval
shape with well‑defined margins, smooth surface, normal
pink, measuring about 1.5 cm × 1.2 cm approximately
located on the floor of mouth on the left side [Figure 1].
The clinical diagnosis of superficial ranula was made and
treated with modified micro‑marsupialization technique
described Sandrini et al.[2] The area was disinfected with Figure 1: Preoperative Case 1
0.1% iodine, and the topical local anesthetic spray applied for
3 min, and 3‑0 black braided silk suture passed superficially
in lesion mediolaterally at three points, and knots were tied.
One suture passed at the greatest diameter of the lesion
anteroposteriorly, and knot was tied  [Figure  2], and the
accumulated saliva was drained by pressing the lesion. The
sutures were removed after 15 days, and the patient was on
follow‑up recall regularly for 50 days and shown no sign of
recurrence [Figure 3].

Case 2
A 14‑year‑boy reported with a complaint of swelling on
the lower lip on the left side since 1  week with a history
of trauma to lip due to lip bite. On clinical examination,
swelling was dome‑shaped, normal pink, soft and fluctuant
with a smooth surface measuring about 1.5 cm × 1.5 cm
approximately [Figure 4]. The clinical diagnosis of mucocele
was made and planned for micro‑marsupialization with 3‑0 Figure 2: Intraoperative (modified micro‑marsupialization)
Case 1
black braided silk suture at three various points superficially
[Figure 5]. Suture was removed after 15 days, and the patient
was on follow‑up regularly for 50 days and without any sign of
recurrence and postoperative discomfort [Figure 6].

DISCUSSION

The extensive surgical procedure such as excision of the lesion

with or without sublingual gland removal,[5] marsupialization,[6]
cryosurgery,[7] laser[8] for the management of mucocele in the
pediatric age group is difficult and sometimes require sedation
and general anesthesia. Surgical removal of ranula in floor of
mouth for new surgeons, especially in pediatric age group
may be associated with the complication such as hemorrhage,
injury to the adjacent vital structure such as lingual nerve,
lingual vessels, Wharton’s duct, reduced mobility of the
tongue, scarring or the recurrence of the lesion.
Figure 3: 50 days of follow‑up (shows no recurrence of the
Micro‑marsupialization is a simple, minimally invasive lesion) S Case 1
technique can be performed by dentist in daycare outpatient
department easily.[9,10] The success of the treatment depends history of trauma, remission of the lesions, whether the lesion
on the case selection for micro‑marsupialization. The recent is superficial or deep and size of the lesion is noted carefully.
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Rachana, et al.: Modified micro‑marsupialization in pediatric patients: A minimally invasive technique

Delbem et  al.[9] performed the micro‑marsupialization

by single long 4.0 silk suture passed through the internal
part of the lesion along its widest diameter in 14 patients
in pediatric age group between 5 and 9 years. Suture was
removed after 7  days. Of 14  patients, 12  patients have
shown complete regression of the lesion. They stated
micro‑marsupialization as an alternative treatment modality
for the mucocele as compared to the conventional surgical
approach in pediatric age group.

Sandrini et al.[2] proposed modification to the conventional

technique include an increased number of sutures to increase
the quantity of new epithelialized drainage pathways, a
decreased distance between the entrance and exit of the
needle to facilitate epithelialization of the new pathways
formed by the sutures by reducing the length of the drainage
Figure 4: Preoperative Case 2
tracts, and a longer period during which the sutures are
maintained for a period of 30 days permits the formation
of a new permanent epithelialized tract along the path of
the suture. Of 7 patients in 3 patients, there was early loss
of suture and required the second attempt by modified
technique. None of the lesions has shown recurrence in
6‑month follow‑up period.

In our case, we used the modified micro‑marsupialization

technique described by Sandrini et  al.[2] in which the
multiple suture are passed through the lesion superficially
such that the distance between the entry and exit of needle
during suturing is minimal. The suture was removed after
15  days to prevent the discomfort to the patient and
secondary infection at the suture site.
Figure 5: Intraoperative (modified micro‑marsupialization)
Case 2
Both the cases were successfully treated with modified
micro‑marsupialization without any recurrence on 2‑month
follow‑up without any postoperative complication. Moreover,
the acceptance of the less invasive technique in pediatric
age group without any intra‑ or post‑operative discomfort
proves the modified micro‑marsupialization technique for
oral mucocele and ranula more efficient and popular.

T h e re c u r re n c e o f t h e l e s i o n s t re a t e d b y t h e
micro‑marsupialization is not uncommon. We think that
second attempt for modified micro‑marsupialization should
be always considered before performing the more invasive
surgical technique.

CONCLUSION

The modified micro‑marsupialization technique is a

Figure 6: 50 days of follow up (shows no recurrence of the
lesion) S Case 2
noninvasive technique, does not require extensive surgical
skill, can be done easily in pediatric age group in general
outpatient daycare setup. The success of the technique
Castro[11] indicates the micro‑marsupialization technique
depends on the selection of cases, regular follow‑up visits. We
for mucoceles with more than 1 cm and for ranulas. The recommend the modified micro‑marsupialization in selected
recurrent mucocele which is deeply located and larger in size cases of oral mucocele and ranula as an initial management,
generally shows poor outcome with micro‑marsupialization. especially in pediatric age group.
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Rachana, et al.: Modified micro‑marsupialization in pediatric patients: A minimally invasive technique

Declaration of patient consent Suggested modifications in the micro‑marsupialization technique.

J Oral Maxillofac Surg 2007;65:1436‑8.
The authors certify that they have obtained all appropriate
3. Zhao  YF, Jia  J, Jia  Y. Complications associated with surgical
patient consent forms. In the form the patient(s) has/have management of ranulas. J Oral Maxillofac Surg 2005;63:51‑4.
given his/her/their consent for his/her/their images and 4. Goodson AM, Payne KF, George K, McGurk M. Minimally invasive
other clinical information to be reported in the journal. The treatment of oral ranulae: Adaption to an old technique. Br J Oral
Maxillofac Surg 2015;53:332‑5.
patients understand that their names and initials will not
5. Yoshimura Y, Obara S, Kondoh T, Naitoh S. A comparison of
be published and due efforts will be made to conceal their three methods used for treatment of ranula. J Oral Maxillofac Surg
identity, but anonymity cannot be guaranteed. 1995;53:280‑2.
6. Baurmash  HD. Marsupialization for treatment of oral ranula:
Financial support and sponsorship A  second look at the procedure. J  Oral Maxillofac Surg
1992;50:1274‑9.
Nil. 7. Twetman S, Isaksson  S. Cryosurgical treatment of mucocele in
children. Am J Dent 1990;3:175‑6.
Conflicts of interest 8. Neumann RA, Knobler RM. Treatment of oral mucous cysts with
There are no conflicts of interest. an argon laser. Arch Dermatol 1990;126:829‑30.
9. Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus
retention phenomena in children by the micro‑marsupialization
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