Does Salivary Duct Repositioning Prevent Complications After Tumor Resection or Salivary Gland Surgery? Akiko Sakakibara, DDS, PhD,* Tsutomu Minamikawa, DDS, PhD,y Kazunobu Hashikawa, MD, PhD,z Shunsuke Sakakibara, MD, PhD,x Takumi Hasegawa, DDS, PhD,k Masaya Akashi, DDS, PhD,{ Shungo Furudoi, DDS, PhD,# and Takahide Komori, DDS, PhD** Purpose:
Tissue that is resected for the treatment of oral tumors often includes salivary gland ducts. At their institution, the authors conserve and transfer as much of the salivary duct as possible during these procedures to avoid obstructive complications. Differentiating these obstructive complications from a metastatic node can be challenging and can confound subsequent oncologic management. This study compared and examined the effectiveness of salivary duct repositioning in decreasing the incidence of obstructive complications.
Materials and Methods:
Cases of oromandibular disease treated with salivary duct resection at Kobe University Graduate School of Medicine from 2008 to 2013 were retrospectively analyzed. Thirty-two cases (25 patients) of Wharton duct resection and 31 cases (31 patients) of Stensen duct resection were included. The incidence of complications after salivary duct repositioning, duct ligation, and retention of the sublingual gland around the Wharton duct was compared.
Results:
Wharton ducts were repositioned in 30 cases and ligated in 2 cases. Complications, including oral swelling at the Wharton duct, were observed in 5 cases of repositioning and 2 cases of ligation. Stensen ducts were repositioned in 9 cases and ligated in 22 cases. The only complication reported was a single case of salivary fistula after ligation.
Conclusions: Salivary duct repositioning is performed to prevent blockage of physiologic salivary discharge. Complications were more frequently associated with Wharton ducts than with Stensen ducts because of the unique physiologic and anatomic characteristics of the Wharton duct. Repositioning of the salivary duct is a suitable method for preventing complications associated with the Wharton duct. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:1003-1007, 2015
The excretory duct of a major salivary gland is often resected during treatment of salivary calculi or oral tumors. If a salivary duct is not repositioned, then the patient might develop swelling or pain, and complications after resection of a malignant tumor can
be misdiagnosed as tumor recurrence. However, few reports have discussed the association between salivary duct repositioning and the incidence of complications, and, in particular, none have addressed the complications associated with repositioning of the
Received from the Kobe University Graduate School of Medicine,
**Professor, Department of Oral and Maxillofacial Surgery.
Kobe, Japan.
Address correspondence and reprint requests to Dr A. Sakakibara:
*Intern Doctor, Department of Oral and Maxillofacial Surgery.
Department of Oral and Maxillofacial Surgery, Kobe University Grad-
yLecturer, Department of Oral and Maxillofacial Surgery.
uate School of Medicine, Kobe 650-0017, Japan; e-mail: oguni@med.
zAssociate Professor, Department of Plastic Surgery.
kobe-u.ac.jp
xProject Research Associate, Department of Plastic Surgery. kResearch Associate, Department of Oral and Maxillofacial
Received August 23 2014 Accepted December 2 2014 Ó 2015 American Association of Oral and Maxillofacial Surgeons
Surgery. {Research Associate, Department of Oral and Maxillofacial Surgery.
0278-2391/14/01796-0 http://dx.doi.org/10.1016/j.joms.2014.12.006
#Associate Professor, Department of Oral and Maxillofacial Surgery.
1003
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SALIVARY DUCT REPOSITIONING AND COMPLICATIONS
FIGURE 1. Representative salivary duct procedures in the study population. A, Transfer of a Stensen duct to penetrate the flaps. B, Transfer of a Wharton duct to the space between the flap and closed oral mucosa. (Fig 1 continued on next page.) Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
Stensen duct. At their institution, the authors typically conserve and transfer as much of a duct as possible when an excretory duct is included in the resection region. However, they occasionally ligate the duct when repositioning is challenging. This study examined the complications associated with salivary duct repositioning.
Materials and Methods The Declaration of Helsinki guidelines on medical protocol and ethics were followed. This was a retrospective study and thus raised no ethical concerns related to the study protocol; the study was exempted
by the ethical committees of Kobe University Graduate School of Medicine (Kobe, Japan). Written informed consent was obtained from the participant, next of kin, or caregiver in pediatric patients for inclusion of the patient’s clinical records in the study. The decision to reposition or ligate the salivary duct was based on the size of the tumor to be resected. Relevant information was provided on the procedure, and written consent was obtained from each patient or caregiver on the potential need to reposition the salivary duct; the final decision to ligate or reposition the duct was made by the surgeon. In all cases, the duct within the resection margin was excised. In addition, duct repositioning was designed to avoid increasing the
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SAKAKIBARA ET AL
FIGURE 1 (cont’d). C, Transfer of a Stensen duct to penetrate the artificial dermis. The orifice in each panel is indicated by a circle. Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
risk of tumor recurrence. Medical records were anonymized before analysis. If consent had not been obtained, then the record was excluded from the study. The data of 63 ducts in 55 patients who underwent major salivary gland excretory duct resection (Wharton duct, 32; Stensen duct, 31) from 2008 to 2013 at Kobe University Hospital were retrospectively analyzed. The cases included typical repositioning, repositioning that penetrated the flaps or the artificial dermis, and repositioning to the space between the flap and oral mucosa. Representative cases of each procedure are shown in Figure 1.
Table 1. PRIMARY DISEASES AND DISTRIBUTION OF STENSEN DUCT RESECTION AND WHARTON DUCT RESECTION IN PATIENTS UNDERGOING SALIVARY GLAND SURGERY
Resected Salivary Duct Stensen duct
Wharton duct
Primary Disease Buccal mucosa cancer Mandibular cancer Maxillary cancer Oral floor cancer Oral floor cancer Tongue cancer Plunging ranula Mandibular cancer Sialolithiasis
Cases, n (%)
Total, N (%)
24 (77.4)
31 (100)
4 (12.9) 2 (6.5) 1 (3.2) 23 (71.9) 4 (12.5) 3 (9.3) 2 (6.3) 1 (3.1)
32 (100)
Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
The frequency of repositioning procedures and the incidence of complications after repositioning, such as mucus retention, swelling, and pain, were measured. Furthermore, the authors statistically analyzed whether complications were caused by the sublingual gland being retained around the Wharton duct.
Results The Wharton duct cases included 22 (69%) cases of oral floor cancer, and the Stensen duct cases included 24 (77%) cases of buccal mucosa cancer (Table 1). In the Stensen duct group, there were 9 (29%) repositioning cases and 22 (71%) ligation cases. Only 1 case in the ligation-treated Stensen duct group showed complications; this case of parotid gland fistula resolved with adjuvant radiotherapy for cancer. The complication was attributed to resection of the parotid gland lower pole during neck dissection, rather than Table 2. STATISTICAL SIGNIFICANCE OF RELATIONS BETWEEN THE COMPLICATION RATE AND STENSEN DUCT LIGATION, WHARTON DUCT LIGATION, OR SUBLINGUAL GLAND PRESERVATION
Risk Factor for Complications
c2 Value
P Value
Stensen duct ligation Wharton duct ligation Sublingual gland preservation
0.423 7.619 1.200
.709 .042* .272
* Statistically significant (P < .05 by the Fisher exact test). Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
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SALIVARY DUCT REPOSITIONING AND COMPLICATIONS
FIGURE 2. Computed tomogram of a patient with right parotid atrophy (arrows). The patient underwent resection of a buccal mucosa carcinoma and Stensen duct ligation. Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
to the duct ligation. Statistical analysis using the Fisher exact test showed no statistical correlation between Stensen duct repositioning and the likelihood of complications (Table 2). Parotid atrophy was confirmed using computed tomography or magnetic resonance imaging in 15 of 16 cases (Fig 2); in 6 cases, the presence of parotid atrophy could not be determined because enhanced images were not obtained or the resection site was excessively large. In the Wharton duct group, there were 30 (94%) repositioning cases and 2 (6%) ligation cases. Among the 32 Wharton duct cases, 7 (22%; 5 repositioning cases and 2 ligation cases) developed complications approximately 1 month after reconstruction (mean, 31 days; range, 4 to 110 days). Statistical analysis using the Fisher exact test showed that Wharton duct ligation was statistically correlated with an increased risk of complications (Table 2). The sublingual gland was preserved in 22 cases and resected in 10 cases. Preserving the sublingual gland did not exert a statistically meaningful effect on the
risk of complications, which were observed in 10% of cases (1 of 10) in which the gland was preserved and in 27% of cases (6 of 22) requiring sublingual gland resection.
Discussion Ducts are frequently repositioned during excision of malignant tumors involving resection of major salivary gland ducts. Duct transfer is used to minimize obstruction of physiologic salivary discharge. If duct ligation is performed or if salivary duct transfer is not performed correctly, then obstruction and stenosis of the duct can cause inflammation and swelling of the salivary gland. In the long term, occlusion of an excretory duct causes the associated glandular tissue to degenerate into fat and connective tissue, which decreases the secretory capacity of the salivary gland.1,2 In addition, duct complications that arise after malignant tumor resection cannot be readily distinguished from tumor recurrence and cervical lymph node metastasis.3
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SAKAKIBARA ET AL
However, few reports have investigated the incidence rate of complications associated with salivary duct repositioning, and reports on Stensen duct repositioning are extremely rare. The present study showed a lower rate of complications with Stensen duct ligation than with Wharton duct ligation. When irradiated, serous glands undergo atrophy more readily than do mucous glands. The radiation affects the bloodstream and decreases circulation, resulting in salivary gland degeneration.4 Similarly, when the Stensen duct is obstructed within the parotid gland, which is a pure serous gland, salivary gland atrophy occurs early. Previous work has shown that completely obstructed parotid glands undergo rapid, progressive, and severe atrophy that results in an absolute loss of more than 85% of the gland within 2 weeks.5 Parotid atrophy was detected using computed tomography or magnetic resonance imaging in cases that required Stensen duct ligation. When the Stensen duct is ligated and salivary extrusion is disturbed, parotid gland atrophy occurs early; this helps offset obstructive complications involving the Stensen duct. The present study showed a higher rate of complications with procedures involving the Wharton duct than those involving the Stensen duct, and complications, such as mucus extravasation from the sublingual glands, were observed with Wharton duct repositioning or ligation. In addition, in procedures involving the Wharton duct, retention of the sublingual gland had no statistical effect on the risk of complications, and repositioning of the duct was associated with fewer complications than was ligation. These findings might be explained by the following anatomic characteristics of the Wharton duct. There are 8 to 20 excretory ducts within the sublingual gland. Some of the small sublingual ducts (Rivinus ducts) join the Wharton duct directly; others open separately in the mouth at the plica sublingualis, and at least 1 duct forms the major sublingual duct, also known as the large sublingual duct or Bartholin duct, which opens into the Wharton duct.6-9 When a primary excretory duct that functions as a Wharton duct is occluded, the saliva drains through the smaller sublingual ducts. The smaller diameter of these tubes alters salivary discharge, which can lead to complications, such as ranula, when the smaller sublingual ducts are damaged.
Resection of the sublingual gland includes the section of the Wharton duct distal to the sublingual gland and the small sublingual ducts within the resection site. Complications are typically not associated with sublingual gland resection,10 because the salivary duct is repositioned so that physiologic salivary discharge is unhindered. The submandibular gland does not contain small submandibular ducts; thus, repositioning the remaining Wharton duct could decrease complications. In this study, Wharton ducts were repositioned in 30 of 32 cases because ligation was expected to increase the risk of complications. Thus, salivary duct repositioning, particularly Wharton duct repositioning, can lower the likelihood of obstructive complications. Salivary duct repositioning is performed to enable physiologic saliva drainage. Complications are more likely in procedures involving the Wharton duct than the Stensen duct because of the anatomic and physiologic characteristics of the ducts. Duct repositioning is considered 1 strategy in preventing complications of the Wharton duct.
References 1. Yoshimura Y, Morishita T, Sugihara T: Salivary gland function after sialolithiasis: Scintigraphic examination of submandibular glands with 99mTc-pertechnetate. J Oral Maxillofac Surg 47: 704, 1996 2. Isacsson G, Ahlner B, Lundquist PG: Chronic sialadenitis of the submandibular gland. A retrospective study of 108 cases. Arch Otorhinolaryngol 232:91, 1981 3. Ord RA, Lee VE: Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 54:1075, 1996 4. Cotrim AP, Sowers A, Mitchell JB, et al: Prevention of irradiationinduced salivary hypofunction by microvessel protection in mouse salivary glands. Mol Ther 15:2101, 2007 5. Scott J, Liu P, Smith PM: Morphological and functional characteristics of acinar atrophy and recovery in the duct-ligated parotid gland of the rat. J Dent Res 78:1711, 1999 6. Leppi TJ: Gross anatomical relationships between primate submandibular and sublingual salivary glands. J Dent Res 46: 359, 1967 7. Harrison JD: Modern management and pathophysiology of ranula: Literature review. Head Neck 32:1310, 2010 8. Nanci A: Ten Cate’s Oral Histology. New York, NY, Elsevier Press, 2013, pp 255 9. Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck. New York, NY, Elsevier Press, 2012, pp 156 10. Shehata EA, Hassan HS: Surgical treatment of ranula: Comparison between marsupialization and sublingual sialadenectomy in pediatric patients. Ann Pediatr Surg 4:89, 2008
Tissue that is resected for the treatment of oral tumors often includes salivary gland ducts. At their institution, the authors conserve and transfer as much of the salivary duct as possible during these procedures to avoid obstructive complications. Differentiating these obstructive complications from a metastatic node can be challenging and can confound subsequent oncologic management. This study compared and examined the effectiveness of salivary duct repositioning in decreasing the incidence of obstructive complications.
Materials and Methods:
Cases of oromandibular disease treated with salivary duct resection at Kobe University Graduate School of Medicine from 2008 to 2013 were retrospectively analyzed. Thirty-two cases (25 patients) of Wharton duct resection and 31 cases (31 patients) of Stensen duct resection were included. The incidence of complications after salivary duct repositioning, duct ligation, and retention of the sublingual gland around the Wharton duct was compared.
Results:
Wharton ducts were repositioned in 30 cases and ligated in 2 cases. Complications, including oral swelling at the Wharton duct, were observed in 5 cases of repositioning and 2 cases of ligation. Stensen ducts were repositioned in 9 cases and ligated in 22 cases. The only complication reported was a single case of salivary fistula after ligation.
Conclusions: Salivary duct repositioning is performed to prevent blockage of physiologic salivary discharge. Complications were more frequently associated with Wharton ducts than with Stensen ducts because of the unique physiologic and anatomic characteristics of the Wharton duct. Repositioning of the salivary duct is a suitable method for preventing complications associated with the Wharton duct. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:1003-1007, 2015
The excretory duct of a major salivary gland is often resected during treatment of salivary calculi or oral tumors. If a salivary duct is not repositioned, then the patient might develop swelling or pain, and complications after resection of a malignant tumor can
be misdiagnosed as tumor recurrence. However, few reports have discussed the association between salivary duct repositioning and the incidence of complications, and, in particular, none have addressed the complications associated with repositioning of the
Received from the Kobe University Graduate School of Medicine,
**Professor, Department of Oral and Maxillofacial Surgery.
Kobe, Japan.
Address correspondence and reprint requests to Dr A. Sakakibara:
*Intern Doctor, Department of Oral and Maxillofacial Surgery.
Department of Oral and Maxillofacial Surgery, Kobe University Grad-
yLecturer, Department of Oral and Maxillofacial Surgery.
uate School of Medicine, Kobe 650-0017, Japan; e-mail: oguni@med.
zAssociate Professor, Department of Plastic Surgery.
kobe-u.ac.jp
xProject Research Associate, Department of Plastic Surgery. kResearch Associate, Department of Oral and Maxillofacial
Received August 23 2014 Accepted December 2 2014 Ó 2015 American Association of Oral and Maxillofacial Surgeons
Surgery. {Research Associate, Department of Oral and Maxillofacial Surgery.
0278-2391/14/01796-0 http://dx.doi.org/10.1016/j.joms.2014.12.006
#Associate Professor, Department of Oral and Maxillofacial Surgery.
1003
1004
SALIVARY DUCT REPOSITIONING AND COMPLICATIONS
FIGURE 1. Representative salivary duct procedures in the study population. A, Transfer of a Stensen duct to penetrate the flaps. B, Transfer of a Wharton duct to the space between the flap and closed oral mucosa. (Fig 1 continued on next page.) Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
Stensen duct. At their institution, the authors typically conserve and transfer as much of a duct as possible when an excretory duct is included in the resection region. However, they occasionally ligate the duct when repositioning is challenging. This study examined the complications associated with salivary duct repositioning.
Materials and Methods The Declaration of Helsinki guidelines on medical protocol and ethics were followed. This was a retrospective study and thus raised no ethical concerns related to the study protocol; the study was exempted
by the ethical committees of Kobe University Graduate School of Medicine (Kobe, Japan). Written informed consent was obtained from the participant, next of kin, or caregiver in pediatric patients for inclusion of the patient’s clinical records in the study. The decision to reposition or ligate the salivary duct was based on the size of the tumor to be resected. Relevant information was provided on the procedure, and written consent was obtained from each patient or caregiver on the potential need to reposition the salivary duct; the final decision to ligate or reposition the duct was made by the surgeon. In all cases, the duct within the resection margin was excised. In addition, duct repositioning was designed to avoid increasing the
1005
SAKAKIBARA ET AL
FIGURE 1 (cont’d). C, Transfer of a Stensen duct to penetrate the artificial dermis. The orifice in each panel is indicated by a circle. Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
risk of tumor recurrence. Medical records were anonymized before analysis. If consent had not been obtained, then the record was excluded from the study. The data of 63 ducts in 55 patients who underwent major salivary gland excretory duct resection (Wharton duct, 32; Stensen duct, 31) from 2008 to 2013 at Kobe University Hospital were retrospectively analyzed. The cases included typical repositioning, repositioning that penetrated the flaps or the artificial dermis, and repositioning to the space between the flap and oral mucosa. Representative cases of each procedure are shown in Figure 1.
Table 1. PRIMARY DISEASES AND DISTRIBUTION OF STENSEN DUCT RESECTION AND WHARTON DUCT RESECTION IN PATIENTS UNDERGOING SALIVARY GLAND SURGERY
Resected Salivary Duct Stensen duct
Wharton duct
Primary Disease Buccal mucosa cancer Mandibular cancer Maxillary cancer Oral floor cancer Oral floor cancer Tongue cancer Plunging ranula Mandibular cancer Sialolithiasis
Cases, n (%)
Total, N (%)
24 (77.4)
31 (100)
4 (12.9) 2 (6.5) 1 (3.2) 23 (71.9) 4 (12.5) 3 (9.3) 2 (6.3) 1 (3.1)
32 (100)
Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
The frequency of repositioning procedures and the incidence of complications after repositioning, such as mucus retention, swelling, and pain, were measured. Furthermore, the authors statistically analyzed whether complications were caused by the sublingual gland being retained around the Wharton duct.
Results The Wharton duct cases included 22 (69%) cases of oral floor cancer, and the Stensen duct cases included 24 (77%) cases of buccal mucosa cancer (Table 1). In the Stensen duct group, there were 9 (29%) repositioning cases and 22 (71%) ligation cases. Only 1 case in the ligation-treated Stensen duct group showed complications; this case of parotid gland fistula resolved with adjuvant radiotherapy for cancer. The complication was attributed to resection of the parotid gland lower pole during neck dissection, rather than Table 2. STATISTICAL SIGNIFICANCE OF RELATIONS BETWEEN THE COMPLICATION RATE AND STENSEN DUCT LIGATION, WHARTON DUCT LIGATION, OR SUBLINGUAL GLAND PRESERVATION
Risk Factor for Complications
c2 Value
P Value
Stensen duct ligation Wharton duct ligation Sublingual gland preservation
0.423 7.619 1.200
.709 .042* .272
* Statistically significant (P < .05 by the Fisher exact test). Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
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SALIVARY DUCT REPOSITIONING AND COMPLICATIONS
FIGURE 2. Computed tomogram of a patient with right parotid atrophy (arrows). The patient underwent resection of a buccal mucosa carcinoma and Stensen duct ligation. Sakakibara et al. Salivary Duct Repositioning and Complications. J Oral Maxillofac Surg 2015.
to the duct ligation. Statistical analysis using the Fisher exact test showed no statistical correlation between Stensen duct repositioning and the likelihood of complications (Table 2). Parotid atrophy was confirmed using computed tomography or magnetic resonance imaging in 15 of 16 cases (Fig 2); in 6 cases, the presence of parotid atrophy could not be determined because enhanced images were not obtained or the resection site was excessively large. In the Wharton duct group, there were 30 (94%) repositioning cases and 2 (6%) ligation cases. Among the 32 Wharton duct cases, 7 (22%; 5 repositioning cases and 2 ligation cases) developed complications approximately 1 month after reconstruction (mean, 31 days; range, 4 to 110 days). Statistical analysis using the Fisher exact test showed that Wharton duct ligation was statistically correlated with an increased risk of complications (Table 2). The sublingual gland was preserved in 22 cases and resected in 10 cases. Preserving the sublingual gland did not exert a statistically meaningful effect on the
risk of complications, which were observed in 10% of cases (1 of 10) in which the gland was preserved and in 27% of cases (6 of 22) requiring sublingual gland resection.
Discussion Ducts are frequently repositioned during excision of malignant tumors involving resection of major salivary gland ducts. Duct transfer is used to minimize obstruction of physiologic salivary discharge. If duct ligation is performed or if salivary duct transfer is not performed correctly, then obstruction and stenosis of the duct can cause inflammation and swelling of the salivary gland. In the long term, occlusion of an excretory duct causes the associated glandular tissue to degenerate into fat and connective tissue, which decreases the secretory capacity of the salivary gland.1,2 In addition, duct complications that arise after malignant tumor resection cannot be readily distinguished from tumor recurrence and cervical lymph node metastasis.3
1007
SAKAKIBARA ET AL
However, few reports have investigated the incidence rate of complications associated with salivary duct repositioning, and reports on Stensen duct repositioning are extremely rare. The present study showed a lower rate of complications with Stensen duct ligation than with Wharton duct ligation. When irradiated, serous glands undergo atrophy more readily than do mucous glands. The radiation affects the bloodstream and decreases circulation, resulting in salivary gland degeneration.4 Similarly, when the Stensen duct is obstructed within the parotid gland, which is a pure serous gland, salivary gland atrophy occurs early. Previous work has shown that completely obstructed parotid glands undergo rapid, progressive, and severe atrophy that results in an absolute loss of more than 85% of the gland within 2 weeks.5 Parotid atrophy was detected using computed tomography or magnetic resonance imaging in cases that required Stensen duct ligation. When the Stensen duct is ligated and salivary extrusion is disturbed, parotid gland atrophy occurs early; this helps offset obstructive complications involving the Stensen duct. The present study showed a higher rate of complications with procedures involving the Wharton duct than those involving the Stensen duct, and complications, such as mucus extravasation from the sublingual glands, were observed with Wharton duct repositioning or ligation. In addition, in procedures involving the Wharton duct, retention of the sublingual gland had no statistical effect on the risk of complications, and repositioning of the duct was associated with fewer complications than was ligation. These findings might be explained by the following anatomic characteristics of the Wharton duct. There are 8 to 20 excretory ducts within the sublingual gland. Some of the small sublingual ducts (Rivinus ducts) join the Wharton duct directly; others open separately in the mouth at the plica sublingualis, and at least 1 duct forms the major sublingual duct, also known as the large sublingual duct or Bartholin duct, which opens into the Wharton duct.6-9 When a primary excretory duct that functions as a Wharton duct is occluded, the saliva drains through the smaller sublingual ducts. The smaller diameter of these tubes alters salivary discharge, which can lead to complications, such as ranula, when the smaller sublingual ducts are damaged.
Resection of the sublingual gland includes the section of the Wharton duct distal to the sublingual gland and the small sublingual ducts within the resection site. Complications are typically not associated with sublingual gland resection,10 because the salivary duct is repositioned so that physiologic salivary discharge is unhindered. The submandibular gland does not contain small submandibular ducts; thus, repositioning the remaining Wharton duct could decrease complications. In this study, Wharton ducts were repositioned in 30 of 32 cases because ligation was expected to increase the risk of complications. Thus, salivary duct repositioning, particularly Wharton duct repositioning, can lower the likelihood of obstructive complications. Salivary duct repositioning is performed to enable physiologic saliva drainage. Complications are more likely in procedures involving the Wharton duct than the Stensen duct because of the anatomic and physiologic characteristics of the ducts. Duct repositioning is considered 1 strategy in preventing complications of the Wharton duct.
References 1. Yoshimura Y, Morishita T, Sugihara T: Salivary gland function after sialolithiasis: Scintigraphic examination of submandibular glands with 99mTc-pertechnetate. J Oral Maxillofac Surg 47: 704, 1996 2. Isacsson G, Ahlner B, Lundquist PG: Chronic sialadenitis of the submandibular gland. A retrospective study of 108 cases. Arch Otorhinolaryngol 232:91, 1981 3. Ord RA, Lee VE: Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 54:1075, 1996 4. Cotrim AP, Sowers A, Mitchell JB, et al: Prevention of irradiationinduced salivary hypofunction by microvessel protection in mouse salivary glands. Mol Ther 15:2101, 2007 5. Scott J, Liu P, Smith PM: Morphological and functional characteristics of acinar atrophy and recovery in the duct-ligated parotid gland of the rat. J Dent Res 78:1711, 1999 6. Leppi TJ: Gross anatomical relationships between primate submandibular and sublingual salivary glands. J Dent Res 46: 359, 1967 7. Harrison JD: Modern management and pathophysiology of ranula: Literature review. Head Neck 32:1310, 2010 8. Nanci A: Ten Cate’s Oral Histology. New York, NY, Elsevier Press, 2013, pp 255 9. Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck. New York, NY, Elsevier Press, 2012, pp 156 10. Shehata EA, Hassan HS: Surgical treatment of ranula: Comparison between marsupialization and sublingual sialadenectomy in pediatric patients. Ann Pediatr Surg 4:89, 2008
