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Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2015) xxxxxx

Anterograde excision of a sublingual gland: new surgical

technique for the treatment of ranulas
Zhigang Liu , Bin Wang 1
Oral and Maxillofacial Surgery Department, Sanming First Hospital of Fujian Medical University, 29 Liedong Street, Sanming, Fujian, 365000, China

Accepted 19 December 2015

Abstract

Whartons duct is dissected in a retrograde direction from the orifice of the duct to the hilum of the submandibular gland when the gland is
being excised conventionally. Here we describe an anterograde technique, in which Whartons duct is dissected in an anterograde direction
from the hilum of the submandibular gland to the orifice of the duct. This prospective clinical study included 50 consecutive patients with
ranulas who had anterograde excision of the sublingual gland between May 2012 and January 2015. The intraoral incision was similar to that
for conventional excision. Whartons duct and other important anatomical structures located in the space behind the sublingual gland were
all identified at the beginning of the procedure, followed by anterograde dissection of Whartons duct. After the glandular tissue lateral to the
duct had been incised completely, the duct was exposed and the gland cut into two parts. Finally, the two parts were removed, and the ranula
ruptured. The patients were followed up was from 6 months-2 years. There were no complications. Anterograde excision of the sublingual
gland is based on the anatomy, and this reduces the risk of complications after removal of a ranula.
2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: sublingual gland excision; ranula; Anterograde; retrograde

Introduction is the technique usually used in conventional excision of the

sublingual gland, and the anterograde approach has not to our
Ranulas are mucoceles that develop as a result of mucous knowledge been described.
extravasation from the sublingual gland, and are classified
into oral and plunging ranulas depending on the site.
Techniques for their treatment vary, and there is a lack of
consensus about the most appropriate, but some authors think Patients and methods
that transoral excision of the ipsilateral sublingual gland with
evacuation of the ranula results in the lowest morbidity.14 We prospectively studied 50 consecutive patients with ranula
To date, retrograde dissection of Whartons duct, from the who were treated by anterograde excision of the sublingual
orifice of the duct to the hilum of the submandibular gland, gland between May 2012 and January 2015 at Sanming First
Hospital, Sanming, Fujian, China.
All oral ranulas presented as fluctuant, unilateral, bluish,
Corresponding author. Oral and Maxillofacial Surgery Department, San-
soft tissue masses confined to the floor of the mouth. All
ming First Hospital, 29 Liedong Street, Sanming, Fujian, 365000, China. plunging ranulas presented as submandibular masses with a
Tel.: +8615259899319.
E-mail addresses: lzg8273@hotmail.com (Z. Liu),
tail-sign, or diagnosis of plunging ranula, on preoperative
15280592770@139.com (B. Wang). computed tomography (CT). Diagnosis was established by
1 Tel.: +8615280592770. fine-needle aspiration and the finding of mucus with a high
http://dx.doi.org/10.1016/j.bjoms.2015.12.017
0266-4356/ 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Liu Z, Wang B. Anterograde excision of a sublingual gland: new surgical technique for the treatment
of ranulas. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.12.017
YBJOM-4734; No. of Pages 4
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2 Z. Liu, B. Wang / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxxxxx
Figure 1. Before anterograde excision of the sublingual gland the important
anatomical structures and the first crossing point of Whartons duct (WD)
and the lingual nerve (LN) were identified in the space behind the sublingual
gland (G). B=branches of the sublingual artery and vein, SLG=sublingual
ganglion, and R=ranula.
amylase activity in each case. Patients with bilateral ranulas
were excluded, as were those who had previously been treated
for ranula. Data collected included the patients age and sex,
and the site and type of ranula.
Surgical technique
All operations were done by the first and second authors.
With the patient under general anaesthesia and nasotracheal
intubation, a linear incision is made 1 cm medial to, and
parallel to, the ipsilateral mandible, and extended from the
orifice of Whartons duct to the lingual side of the retromolar
region. To control bleeding the site is infiltrated with a
solution of lignocaine and epinephrine. The mucosa is then
incised, and blunt dissection and mosquito haemostats used
to expose the lateral aspect of the sublingual gland. The
posterior part of the gland is gripped with an Allis clamp
and constant traction exerted in an anterior, superior, and
medial direction by the assistant, which exposes the loose
areolar tissue behind the gland. Smooth, blunt dissection is
used in the loose areolar tissue to identify Whartons duct,
the main trunk of the lingual nerve, the branches of the
sublingual artery and vein, the relations of the lingual nerve
and Whartons duct, and the sublingual ganglion split from
the main trunk of the lingual nerve (Figs. 12). Branches
from this ganglion are mainly distributed in the sublingual
gland.5 The sublingual ganglion and the branches of the
sublingual artery and vein are ligated and divided as close
as possible to the posterior surface of the gland.
The lingual nerve courses laterally to medially, cross-
ing Whartons duct first by passing below the nerve then
by crossing it medially.6 To prevent damage to the lingual
nerve, therefore, anterograde dissection of Whartons duct
is started between the posterior surface of the gland and the
first crossing point of Whartons duct and the lingual nerve.
It then continues anteriorly to create a tunnel lateral to Whar-
tons duct. After the glandular tissue lateral to the tunnel had
Please cite this article in press as: Liu Z, Wang B. Anterograde excision of a sublingual gland: new surgical technique for the treatment
of ranulas. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.12.017
Figure 2. Branches of the sublingual artery and vein (B) run anteriorly and
then enter the posterior part of the gland (G).
Figure 3. After the glandular tissue lateral to the tunnel has been incised
completely without loss of blood, Whartons duct (WD) is exposed and the
gland cut into two parts: superior (SP) and inferior (IP). LN=lingual nerve
and R=ranula.
been incised completely without bleeding, Whartons duct is
exposed and the gland cut into two parts: superior and infe-
rior. The two parts are then opened laterally with Allis clamps
or mosquito haemostats to expose the medial aspect of the
gland, and give a wider surgical field to visualise and protect
Whartons duct and the lingual nerve (Fig. 3).
The medial aspect and the inferior aspect of the inferior
part are dissected meticulously with Metzenbaum scissors
in direct contact with the surface of the gland under direct
vision, avoiding injury to Whartons duct, the lingual nerve,
and the vessels, which are ligated and divided when encoun-
tered within the surgical field. The inferior part of the gland is
then removed anteriorly. The superior part of the gland is then
removed posteriorly (Fig. 4). Bartholins duct is identified,
ligated, and divided. The ranula is ruptured without excision
and mucus drained naturally and suctioned. Finally, the sur-
gical field is irrigated and inspected, followed by meticulous
haemostasis. The incised mucosa is loosely sutured back, and
a drain inserted through the incision.
Cefazolin sodium 1.0 g every 12 hours was given on
admission and continued until the third postoperative day.
Patients were recommended to take a liquid diet for 1 week.
The drain was removed after 12 days, and patients were
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Z. Liu, B. Wang / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxxxxx 3

yielding the lowest recurrence and complication rates for both

oral and plunging ranulas is removal of the ipsilateral sub-
lingual gland with evacuation of the ranula. and Attempts
to excise the ranula in conjunction with the sublingual gland
likely places the lingual nerve and submandibular duct at
even more risk due to more invasive dissection.1 Davison
et al. concluded that: Excision of the pseudocyst is prob-
ably unnecessary and places surrounding structures at risk
of damage.10 We imagine, therefore, that the complications
caused by excision of the ranula must be associated with dif-
ferent sizes or types of ranula, or both. We found that evacua-
tion of the ranula without excision caused no complications.
Excision is usually through a transoral approach, though
Figure 4. The excised superior part (SP) and inferior part (IP). for plunging ranula a transcervical approach may be pre-
ferred. Hidaka et al. stated that plunging ranulas were best
Table 1
Characteristics of the 50 patients. Data are number of patients except where
managed with a transoral approach to remove the sublingual
otherwise stated. gland,11 and Huang et al. agreed because of the high suc-
Variable
cess rate (94.4%) and few complications.3 Removal of the
ranula through a transcervical approach can result in many
Sex:
Male 20
complications.12 We used only a transoral approach.
Female 30 Patel et al. reported few complications with conventional
Mean (SD) age (years) 26 (10) sublingual gland excision, which included recurrence (1%)
Range 9-53 and hyperaesthesia of the tongue (2%).1 We retrospectively
Affected side: reviewed the records of 54 such patients who had had con-
Right 27
Left 23
ventional excision of the sublingual gland between July 2008
Type of ranula: and April 2012 at our hospital, and the complications were
Oral 36 recurrence (1.9%), hyperaesthesia of the tongue (11.1%),
Plunging 14 and bleeding or haematoma (1.9%). However, there were no
Complications 0 complications in this study.
During anterograde excision of the sublingual gland we
usually discharged 35 days postoperatively. Sutures were noted that the space behind the gland itself contained impor-
removed on the seventh day. Patients were followed up for 6 tant anatomical structures, including Whartons duct, the
months -2 years. main trunk of the lingual nerve, the branches of the sub-
lingual artery and vein, and the sublingual ganglion, together
with the first crossing point of Whartons duct and the lingual
Results nerve, which was large. Indeed, Pogrel et al. reported that the
average nerve diameter was 3.62 mm (range, 2.5 to 4.5 mm;
Characteristics of the patients and results are shown in SD = 1.00 mm).13 The sublingual ganglion and the branches
Table 1. of the sublingual artery and vein also ran anteriorly, and then
entered the posterior part of the gland (Figs. 12).
We developed anterograde excision of the sublingual
Discussion gland based on these anatomical characteristics, and so it
has the advantage of reducing the risk of complications in
Ranulas are mucoceles that develop as a result of mucous the operative treatment of ranulas.
extravasation from the sublingual gland, and a ranula is clas- At the beginning of the operation we identify these impor-
sified as oral or plunging, depending on its site. Bhaskar tant anatomical structures, together with the first crossing
et al. concluded that a ranula was produced by extravasa- point of Whartons duct and the lingual nerve, quickly and
tion of saliva from a damaged salivary duct and was not without bleeding. Whartons duct and the main trunk of the
lined by epithelium.7 Harrison investigated the pathogene- lingual nerve can therefore be protected, and the sublingual
sis histopathologically, and concluded that ranulas arose from ganglion and the branches of the sublingual artery and vein
the sublingual glands and mechanical trauma to a duct of Riv- ligated and divided. For this reason, the subsequent steps of
inus seemed to be the usual cause of both oral and plunging the procedure anteriorly will be safer and easier.
ranulas.8 The sublingual gland is cut into two parts during antero-
The techniques for the treatment of ranulas vary,1,9 and grade dissection of Whartons duct (Fig. 3), because it is not
there is still a lack of consensus about the most appropriate. necessary for the sublingual gland to be removed en bloc, as
However, Patel et al. concluded that: the definitive treatment the sublingual gland and the ranula are not a tumour. There

Please cite this article in press as: Liu Z, Wang B. Anterograde excision of a sublingual gland: new surgical technique for the treatment
of ranulas. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.12.017
YBJOM-4734; No. of Pages 4
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4 Z. Liu, B. Wang / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxxxxx
is no risk of injury to the lingual nerve during anterograde
dissection of Whartons duct, because at this point the lingual
nerve is inferior or medial to the duct, not lateral. The medial
aspect of the gland, Whartons duct, and the lingual nerve are
therefore exposed directly, a wider surgical field is provided,
and a cleaner plane of dissection is achievable without bleed-
ing. The medial aspect of the gland can be dissected under
direct vision, and further dissection of the lingual nerve is not
necessary, so the risk of injury will be reduced.
Cutting the sublingual gland into two parts during retro-
grade dissection of Whartons duct is not a viable alternative
to conventional excision of the sublingual gland, because
some important anatomical structures, together with the first
crossing point of Whartons duct and the lingual nerve, have
not first been identified. This will increase the risk of acci-
dentally damaging the anatomical structures, particularly the
lingual nerve.
Ranula is not a common condition, and the relatively small
size of our series is one of its disadvantages. More impor-
tantly, only patients with ranula are suitable for anterograde
excision of the sublingual gland because the gland is cut into
two parts during anterograde dissection of Whartons duct.
For a patient with a tumour, this invasive procedure could
increase the risk of recurrence or metastasis.
We conclude that anterograde excision of the sublingual
gland is a new technique for the treatment of ranulas that is
based on its anatomical characteristics, and so has the advan-
tage of reducing the risk of postoperative complications.
Conict of Interest
We have no conflict of interest.
Please cite this article in press as: Liu Z, Wang B. Anterograde excision of a sublingual gland: new surgical technique for the treatment
of ranulas. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.12.017
Ethics statement/conrmation of patients permission
The local hospital ethics committee approved the protocol.
Figures 14 are published with the patients permission.
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