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RANULA SURGICAL TREATMENT BY THE MARSUPIALIZATION TECHNIQUE TRATAMENTO CIRRGICO DAS RNULAS PELA TCNICA DE MARSUPIALIZAO

Daniel Luiz Gaertner ZORZETTO * Clvis MARZOLA ** Joo Lopes TOLEDO-FILHO *** Marcelo Rodrigues AZENHA **** Lucas CAVALIERI-PEREIRA **** Luciana Pastori da SILVA-ROSA ****

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* 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 Hospital of Bauru, So Paulo State, Brazil.

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ABSTRACT
Ranula is a traumatic lesion and its origins become from the rupture 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 the marsupialization surgical technique in the treatment of mouth floor mucous retention. This technique permit a direct connection between the lesion and a joint anatomical cavity, with the purpose of obtain a spontaneous reduction of the lumen e to avoid recurrent salivary duct obliteration.

RESUMO
Rnula uma leso de origem traumtica que se origina a partir da ruptura de um ou mais ductos das glndulas salivares, ocorrendo a reteno ou extravasamento de muco na regio do assoalho bucal. O propsito deste trabalho demonstrar a tcnica cirrgica de marsupializao na resoluo de um caso de reteno salivar do assoalho bucal, propiciando uma conexo direta entre a cavidade da leso e uma cavidade anatmica adjacente. Isso tudo com o objetivo de se obter uma reduo espontnea do tamanho do lmen, evitando uma nova obliterao do ducto da glndula salivar. Uniterms: Ranula; Salivary glands; Marsupialization; Retention cysts. Unitermos: Rnula; Glndulas salivares; Marsupializao; Cistos de Reteno.

INTRODUCTION
Located in the wooden floor of the mouth, it is initially described a benign injury (BRUITT, 1875) as being a cystic tumor with viscous volume in its interior and, if developing from a blockage of duct of Wharton. The word ranula is derived from the Latin, meaning frog, for presenting a similarity with the womb of this animal (MANDEL, 1996 and MARZOLA, 2005). Its ethiopatogeny is the local trauma, being able to provoke the rupture or blockage of duct of the salivary 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 be situated underlying to the mucosa of the wooden floor of the mouth, above of the milohioid muscle, characterizing ranula buccal, or still to extend itself enters the natural spaces of the muscle, allowing the mucous extravasation for the soft tissue plans supplies-hioids, resulting in deeper ranula (GOSSETT; SMITH; SULLIVAM et al., 1999 and MARZOLA, 2005). Different pathologies may happen the salivary glands, being the distinguishing diagnosis of the pathological processes of inflammatory, allergic, auto-immune, neoplasic, cystic or genetic origin basic in the determination of the injury (HEIFER; SAMPAIO; CHAMBER, 1999 and MARZOLA, 2005). Despite the clinical differential diagnosis, in many situations, to be easy being, in

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determined cases only the microscopical examination can disclose the true nature of 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 located superficially, or are of the coloration of the mucosa when found deeply in tissues (CASTRO, 1995 and MARZOLA, 2005). In accordance with its localization, in the 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 and MARZOLA, 2005). An incision and draining, the excision of the injury associated or not 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 in the 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 marsupialization technique as option of safe and efficient treatment in the cases of ranula, emphasizing the necessity of the postoperative accompaniment to observe a possible return of the injury.

CASE RELATE
Patient with 16 years of age, feminine sort, appeared to the Clinic of Surgery and Traumatology BMF of the Base Hospital of the Hospital Association of Bauru, So Paulo State, Brazil, presenting volumetric increase in the buccal wooden floor with evolution of 28 days. It told chew difficulty and phonation, having been submitted previous the surgical procedure for incision and draining of this same alteration of the buccal wooden floor has 14 days. It did not present systemic alterations and, to the clinical examination was observed unilocular 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, bluish coloration, measuring approximately 3,5 cm of diameter, the injury presented as diagnostic a salivary retention phenomenon of the buccal wooden floor, or so the call ranula (Figure 1). The proposed treatment was the marsupialization of the injury under local anesthesia. During the surgical procedure, the membrane that coats the 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 sutured evertides 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, having confirmed the diagnosis of ranula.

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The suture points had been kept until its complete resorption (Figure 5). The patient after meets in ambulatorial accompaniment without signals 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.

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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 the treatment of rnula, as a simple draining of the injury with aspiration of its mucous content, excision only of the sublingual gland for intra or extra oral view (YOSHIMURA; OBARA; KONDOH et al., 1995), excision of ranula and the sublingual 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).

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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 presenting good 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 one to 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 in feminine sort individuals (9 cases or 60%) with predominance in the second decade of life (7 cases or 46.7%) (BEZERRA; SAMPAIO; CMARA, 1999). These authors had not found difference of predominance how to the side of the buccal wooden floor competed by the injury. In the presented case, the injury was present 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 injury are the frequent traumas, causing an immediate extravasation of mucous of the affected 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 the marsupialization of one ranula that he presented 3,5 centimeters of diameter approximately. The diagnosis of rnula is clinical essentially when the injury is located superficially, having its characteristics to be observed so that it is possible the accomplishment of the distinguishing diagnosis of ranula with the cyst of the branchial crack, cyst of the paratireoids, dermoid cyst, higroma cystic, teratoma intently benign, or still duct tireoglosso cyst (MIZUNO; YAMAGUCHI, 1993 and MARZOLA, 2005). The examinations for image, as the occlusal x-ray of the mandible, the sialographics, computerized cat scan and, the ultrassonographic are described in literature as being important in the detention of possible blockages of the salivary ducts and, considered for the definition of the diagnosis (MARZOLA, 2005). The clinical accompaniment of the patient submitted to the excision of ranula, independently of the used technique, always must be carried through to be 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 for the verification of a possible return of the injury is very important.

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REFERENCES *
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* According of the ABNT norms.

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