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Facts about ranulas
Facts about ranulas Background.—Ranulas have a bluish appearance that has been compared to a frog’s belly. These lesions develop as a result of extravasation of mucus after the sublingual gland has experienced trauma or when the ducts are obstructed. Treatment for ranulas has included excision, marsupialization, excision of the sublingual gland and drainage of the lesion, and excision of the lesion and the sublingual gland. However, recurrence is common, and smaller oral lesions may recur as larger plunging (cervical) ranula. The features of the 3 clinical categories of ranula were outlined, along with the results of surgical management.
Results.—Patients ranged in age from 3 months to 80 years, but ranulas were found most often in patients ages 10
to 19. The 3 clinical patterns were represented fairly equally. Female subjects were affected slightly more often (56.47% vs 45.53% for male subjects), but plunging ranulas were distinctly more common among male patients. The difference in incidence between oral and plunging ranulas was statistically significant. The left side was involved in 324 cysts and the right side in 256. Plunging ranulas were noted most often on the right side, with highly significant differences in the occurrence of oral and plunging ranulas and significant differences between the occurrence of oral and mixed ranulas by side. Nine bilateral ranulas were identified. Oral ranulas typically consisted of a gradually enlarging round or oval, fluctuant swelling of the floor of the mouth (Fig 2) that was painless. Large oral lesions crossed the midline and caused deviation of the tongue. In 13 cases intermittent swelling of the submandibular gland was noted on the same side when the patient ate. Most ranulas lasted a few days to 3 weeks, but some were present for months or years before the patient sought treatment. More patients who had plunging ranulas had them for more than 6 months, with a highly significant difference in this aspect compared to oral and mixed ranulas. After aspiration of the ranulas, 19 patients experi-
Fig 2.—Clinical photograph of oral ranula presented as an oval swelling of the right floor of mouth. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Fig 3.—Plunging ranula showing the swelling in the right submandibular region without evidence of intraoral involvement. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Methods.—The clinical and pathologic records of 580 ranulas in 571 Chinese patients were reviewed retrospectively. The 3 categories of ranula used were oral ranula, plunging ranula, and mixed ranula, based on the sites of the primary swelling. Data included patient’s age at presentation, gender, history of onset, sites of swelling, surgical approaches, histologic results, and outcome of treatment.
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Fig 5.—Recurrent plunging ranula. A, Recurrence occurred after excision of the lesion via the left submandibular approach 8 months ago. B, Multiple-cystic lesion under the platysmal muscle.The cyst connected with the deep portion of the sublingual gland by a ductlike structure. No recurrence 5 years after excision of the ranula and the sublingual gland. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Fig 4.—Mixed ranula originating from the right sublingual gland in 13-year-old boy, showing obvious swelling of floor of mouth crossing midline (A) with involvement of the submental and right submandibular regions (B). (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
enced pain and rapidly increased swelling. In 24 ranulas, spontaneous drainage was reported, but none of these disappeared completely. In 17 cases, patients recalled trauma related to the development of the cyst.
142 Dental Abstracts
Intraoral lesions were blue and fluctuant. The color of plunging lesions was the same as the normal mucosa or skin, and these ranulas were typically soft, painless, nonmobile swellings in the neck (Fig 3). Mixed ranulas had swellings both intraorally and extraorally, with the cervical lesions found later than the intraoral ones (Fig 4). It was not difficult to diagnose most of the oral and mixed ranulas, but some confusion was found with the plunging lesions, which were mistaken for lymphatic malformations, venous malformations, or a thyroglossal tract cyst. Histologically, no differences existed between oral, plunging, and mixed ranulas. A total of 606 surgical procedures were done, with 580 performed for primary lesions and 26 for recurrent cysts. Most procedures were done through the mucosa of the floor of the mouth, but for 58 plunging or mixed ranulas,
access was through a submandibular incision. With this approach, a thin-walled cyst intimately involved with the anterior part of the submandibular gland was noted when the platysma muscle was first elevated, but further dissection revealed a connection to the sublingual gland (Fig 5). Recurrences developed in 21 cases. A significantly higher recurrence rate accompanied treatment by simple excision (57.69%) or marsupialization (66.67%) than treatment by excision of the sublingual gland or removal of both gland and ranula (1.20%). A relationship was noted between method of surgical procedure and recurrence rates. For 5 cases with a second recurrence, simultaneous removal of the lesion and sublingual gland in a third operation produced a cure. Discussion.—Some of the clinical features of the plunging ranulas differed from those of the oral or mixed ranulas, but all were essentially the same from a histologic standpoint. Recurrence rates of ranulas are closely related to the methods of the surgical procedure but show no link
to either swelling patterns or surgical approaches. Cure was achieved most often in cases where the sublingual gland was removed along with intraoral excision of the ranula without respect for the clinical pattern of the ranula.
Clinical Significance.—Ranulas occur in 3 forms: oral, mixed, and plunging. Their intimate relationship with the submandibular gland warrants removal of the gland if recurrence is to be avoided.
Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004 Reprints available from Y-F Zhao, Dept of Oral and Maxillofacial Surgery, College & Hosp of Stomatology, Wuhan Univ, 237 LuoYu Rd, Wuhan, People’s Republic of China 430079; e-mail: yifang @public.wh.hb.cn
Oral and Maxillofacial Surgery Few complications with coronectomy Background.—In coronectomy the crown of a tooth is removed but the root is left. This procedure is generally done to avoid damaging the inferior alveolar nerve. However, the follicle or follicle remnants can act like a deep periodontal pocket and become a site of infection (Fig 1).
The likelihood that infection of the retained root and transected pulp will develop was explored. Methods.—Fifty-two patients were evaluated retrospectively. All had undergone operations during a 10-year
Fig 1.—A, The problem—a 27-year-old patient with clinical signs and symptoms of purulent infection related to #17 despite a lack of radiographic signs of infection. Infection of #17 was confirmed at surgery. B, The solution—immediate postop view. (Reprinted by permission of the publisher from O’Riordan BC: Coronectomy [intentional partial odontectomy of lower third molars]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:274-280, 2004. Copyright 2004 by Elsevier.)
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Results.—Patients ranged in age from 3 months to 80 years, but ranulas were found most often in patients ages 10
to 19. The 3 clinical patterns were represented fairly equally. Female subjects were affected slightly more often (56.47% vs 45.53% for male subjects), but plunging ranulas were distinctly more common among male patients. The difference in incidence between oral and plunging ranulas was statistically significant. The left side was involved in 324 cysts and the right side in 256. Plunging ranulas were noted most often on the right side, with highly significant differences in the occurrence of oral and plunging ranulas and significant differences between the occurrence of oral and mixed ranulas by side. Nine bilateral ranulas were identified. Oral ranulas typically consisted of a gradually enlarging round or oval, fluctuant swelling of the floor of the mouth (Fig 2) that was painless. Large oral lesions crossed the midline and caused deviation of the tongue. In 13 cases intermittent swelling of the submandibular gland was noted on the same side when the patient ate. Most ranulas lasted a few days to 3 weeks, but some were present for months or years before the patient sought treatment. More patients who had plunging ranulas had them for more than 6 months, with a highly significant difference in this aspect compared to oral and mixed ranulas. After aspiration of the ranulas, 19 patients experi-
Fig 2.—Clinical photograph of oral ranula presented as an oval swelling of the right floor of mouth. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Fig 3.—Plunging ranula showing the swelling in the right submandibular region without evidence of intraoral involvement. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Methods.—The clinical and pathologic records of 580 ranulas in 571 Chinese patients were reviewed retrospectively. The 3 categories of ranula used were oral ranula, plunging ranula, and mixed ranula, based on the sites of the primary swelling. Data included patient’s age at presentation, gender, history of onset, sites of swelling, surgical approaches, histologic results, and outcome of treatment.
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Fig 5.—Recurrent plunging ranula. A, Recurrence occurred after excision of the lesion via the left submandibular approach 8 months ago. B, Multiple-cystic lesion under the platysmal muscle.The cyst connected with the deep portion of the sublingual gland by a ductlike structure. No recurrence 5 years after excision of the ranula and the sublingual gland. (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
Fig 4.—Mixed ranula originating from the right sublingual gland in 13-year-old boy, showing obvious swelling of floor of mouth crossing midline (A) with involvement of the submental and right submandibular regions (B). (Reprinted by permission of the publisher from Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004. Copyright 2004 by Elsevier.)
enced pain and rapidly increased swelling. In 24 ranulas, spontaneous drainage was reported, but none of these disappeared completely. In 17 cases, patients recalled trauma related to the development of the cyst.
142 Dental Abstracts
Intraoral lesions were blue and fluctuant. The color of plunging lesions was the same as the normal mucosa or skin, and these ranulas were typically soft, painless, nonmobile swellings in the neck (Fig 3). Mixed ranulas had swellings both intraorally and extraorally, with the cervical lesions found later than the intraoral ones (Fig 4). It was not difficult to diagnose most of the oral and mixed ranulas, but some confusion was found with the plunging lesions, which were mistaken for lymphatic malformations, venous malformations, or a thyroglossal tract cyst. Histologically, no differences existed between oral, plunging, and mixed ranulas. A total of 606 surgical procedures were done, with 580 performed for primary lesions and 26 for recurrent cysts. Most procedures were done through the mucosa of the floor of the mouth, but for 58 plunging or mixed ranulas,
access was through a submandibular incision. With this approach, a thin-walled cyst intimately involved with the anterior part of the submandibular gland was noted when the platysma muscle was first elevated, but further dissection revealed a connection to the sublingual gland (Fig 5). Recurrences developed in 21 cases. A significantly higher recurrence rate accompanied treatment by simple excision (57.69%) or marsupialization (66.67%) than treatment by excision of the sublingual gland or removal of both gland and ranula (1.20%). A relationship was noted between method of surgical procedure and recurrence rates. For 5 cases with a second recurrence, simultaneous removal of the lesion and sublingual gland in a third operation produced a cure. Discussion.—Some of the clinical features of the plunging ranulas differed from those of the oral or mixed ranulas, but all were essentially the same from a histologic standpoint. Recurrence rates of ranulas are closely related to the methods of the surgical procedure but show no link
to either swelling patterns or surgical approaches. Cure was achieved most often in cases where the sublingual gland was removed along with intraoral excision of the ranula without respect for the clinical pattern of the ranula.
Clinical Significance.—Ranulas occur in 3 forms: oral, mixed, and plunging. Their intimate relationship with the submandibular gland warrants removal of the gland if recurrence is to be avoided.
Zhao Y-F, Jia Y, Chen X-M, et al: Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:281-287, 2004 Reprints available from Y-F Zhao, Dept of Oral and Maxillofacial Surgery, College & Hosp of Stomatology, Wuhan Univ, 237 LuoYu Rd, Wuhan, People’s Republic of China 430079; e-mail: yifang @public.wh.hb.cn
Oral and Maxillofacial Surgery Few complications with coronectomy Background.—In coronectomy the crown of a tooth is removed but the root is left. This procedure is generally done to avoid damaging the inferior alveolar nerve. However, the follicle or follicle remnants can act like a deep periodontal pocket and become a site of infection (Fig 1).
The likelihood that infection of the retained root and transected pulp will develop was explored. Methods.—Fifty-two patients were evaluated retrospectively. All had undergone operations during a 10-year
Fig 1.—A, The problem—a 27-year-old patient with clinical signs and symptoms of purulent infection related to #17 despite a lack of radiographic signs of infection. Infection of #17 was confirmed at surgery. B, The solution—immediate postop view. (Reprinted by permission of the publisher from O’Riordan BC: Coronectomy [intentional partial odontectomy of lower third molars]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:274-280, 2004. Copyright 2004 by Elsevier.)
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