|Year : 2015 | Volume
| Issue : 1 | Page : 44-47
Oral mucocele: A neoteric approach in children using CO 2 laser
Yusuf Chunawalla, Abdul Morawala, Rohan Talathi, Ajitha Nandam
Department of Pediatric and Preventive Dentistry, MA Rangoonwala College of Dental Sciences, Pune, Maharashtra, India
|Date of Web Publication||22-May-2015|
6/B Sukhada Housing Society, Chaphalkar Colony, Market Yard, Pune - 411 037, Maharashtra
Source of Support: None, Conflict of Interest: None
Mucocele is a common lesion of the oral mucosa that results from an alteration of minor salivary glands due to a mucus accumulation. Mucocele involves mucin accumulation causing limited swelling. Two histological types exist-extravasation and retention. Mucoceles can appear at any site of the oral mucosa where minor salivary glands are present. Mostly seen on lower lip, followed by floor of the mouth and buccal mucosa being the next frequent site. This paper presents a case report of mucocele using CO 2 laser.
Keywords: CO 2 laser, mucocele, obstruction, trauma
|How to cite this article:|
Chunawalla Y, Morawala A, Talathi R, Nandam A. Oral mucocele: A neoteric approach in children using CO 2 laser. J Dent Lasers 2015;9:44-7
| Introduction|| |
Mucocele (mucus is derived from muco, cavity is derived from coele) is a benign lesion of the oral cavity that results from any alteration of the minor salivary glands. It is characterized by accumulation of mucin, which is the product of the secretion of salivary glands and their ducts in the oral cavity's subepithelial tissue. Mucocele can appear either by extravasation or retention mechanism. Extravasation is a swelling of connective tissue consisting of a collection of mucus. Retention type is due to an obstruction/blockage of glandular ducts resulting in decreased secretion of saliva.,
| Etiopathogenesis|| |
Yamasoba et al. emphasized on two important etiological factors leading to the occurrence of mucocele: ,
- Trauma to the salivary gland
- Obstruction of salivary glands
- Trauma during birth.
The causes of trauma can be due to the following reasons
Obstructive causes of mucocele
- Abnormal oral habits-lip biting, lip sucking, tongue thrusting, cheek biting 
- Chronic irritation to the tissue-cigarette smoking, extreme heat 
- Accidental rupture of the gland causing chronic damage 
- lip piercings 
- Sport injuries ,
- Mechanical injury during the process of mastication where the tissue of lower lip gets caught between the maxillary and mandibular anterior 
- Accidental rupture of salivary gland 
- Adjacent teeth causing chronic damage 
- Incorrect use of pacifiers-during tooth eruption period, oral tissues become very sensitive, and children try to relieve the symptoms by biting on the pacifier with exaggerated forces leading to the development of mucocele 
- Surgical procedures in the oral cavity causing trauma to the gland 
- Trauma from oral intubation 
- Spontaneous development. 
Trauma during birth due to
- Sialolithiasis-calculi or stones 
- Benign or malignant tumors 
- Sjogren's syndrome 
- Congenital malformation, stenosis. 
- Baby sucking his or her fingers in utero or the baby passing through the birth canal 
- The use of forceps during delivery or suctioning of the baby's mouth after birth 
- These causes are mostly seen in children and young adults. Hence mucocele is mostly prevalent in second and third decade of life 
- Extravasation mucoceles appear as a result of physical trauma which results in spillage of salivary secretion into surrounding tissues and hence causing inflammation. 
Extravasation type mainly undergoes three phases
The retention mucoceles are caused by epithelial proliferation of an obstructive salivary duct, because of which there is pooling of saliva, leading to dilation of the duct and consequent swelling. 
- In the 1 st phase, inflammatory cells such as leucocytes and histiocytes are seen where there is spillage of mucus 
- In the 2 nd phase, granulomas associated with foreign body reaction appear due to the presence of histiocytes, macrophages, and giant cells. This is the resorption phase 
- The 3 rd phase includes the formation of pseudocapsule without epithelium and is therefore considered as pseudocysts. 
| Clinical Features|| |
Mucocele present as rounded, well circumscribed, soft, fluctuant bluish swellings that are moveable, asymptomatic and transparent which lasts for about 3-6 weeks. The bluish discoloration is due to vascular congestion and cyanosis of tissue above the lesion and accumulation of fluid below.  It also depends on the lesion size, proximity to surface and elasticity of the upper tissue.  The size of the lesion may vary from few millimeters to centimeters and occurs as a unilateral lesion. Patients with superficial mucoceles present small fluid-filled vesicles on the soft palate, the retromolar pad, the posterior buccal mucosa, and the lower labial mucosa. These vesicles spontaneously rupture leaving an ulcerated mucosal surface that is painful and heals within a few days. Individual may either rupture or unroof the vesicles by creating a suction pressure. 
Mucoceles are usually superficially positioned. Rarely, do they arise from deeper areas such as floor of mouth creating speech and masticatory problems. They are seen in the oral cavity in the following order: Lower labial mucosa, 83.9%; floor of mouth, 2.7%; ventral tongue, 3%; buccal mucosa, 8.3%; palate, 1.3%; and retromolar area, 0.5%. 
| Case Report|| |
An 8-year-old boy presented with a chief complaint of swelling in the lower lip [Figure 1] and [Figure 2]. A soft, bluish swelling around 2 cm × 2 cm was noticed in the inner aspect of lower lip in 32.33 region for the past 2 weeks. No reported trauma to the region was observed. The patient gave no history of fever or malaise. Final diagnosis of mucocele was made on the basis of history and clinical features.
The treatment plan consisted of removing the mucocele using a CO 2 laser. Hematoxylin pencil was used to mark the extent of the lesion for precision in laser excision. Perilesional local anesthetic agent was administered. Usual safety precautions for the operator and patient were followed. A CO 2 laser with a power of 1.5 W in a noncontact, continuous mode was used to excise the lesion along the margins [Figure 6] and [Figure 8]. A focalizing mode for sectioning and defocalizing for vaporization was required. The low power (0.5 W) was used for tissue ablation [Figure 3]. At the end of the surgery, the beam was set on a defocused mode to promote better hemostasis and the wound was allowed to heal by secondary intention [Figure 5]. The specimen obtained was immersed in 10% formalin and sent for histopathological analysis [Figure 4].  The histopathological study showed the presence of epithelium and underlying connective tissue. The overlying epithelium was parakeratotic and squamous in nature. The underlying epithelium was composed of mucous pooled cavity surrounded by compressed connective tissue. This tissue composed of chronic inflammatory cells such as lymphocytes, plasma cells, mucinophages and engorged blood vessels. A foci showed the presence of minor mucous salivary gland acini [Figure 7]. 
The patient was recalled following a week. Chlorhexidine 0.2% rinse daily was advised to maintain good postoperative oral hygiene. 
| Discussion|| |
Mucoceles are a common pathological condition seen in children, and they have a high recurrence rate. Recurrence is due to the dozens of minor salivary glands that lay just beneath the lining of the mouth, and each has a little duct that leads from the gland to the surface of the mouth. When the duct is cut, which happens due to trauma, the mucus that the gland produces collects under the mucosa. Often, the mucus deposits stretch the mucosa to the point of breaking, causing the release of the mucus and collapse of the mucocele. When the mucosa heals, however, the duct usually does not connect to the surface, thus, repeating the process. Hence to prevent recurrence, complete removal of the mucus deposit and the gland is essential. 
Conventional surgical techniques were used earlier, but they have various disadvantages such as delayed wound healing, patient experienced numbness for a longer duration, scarring and the need for sutures. , Other treatment modalities are marsupialization, micro-marsupialization, cryosurgery, laser vaporization, laser excision and also intralesional corticosteroid therapy. 
CO 2 lasers have been used in pediatric dentistry for soft tissue procedures. Benefits of laser over conventional treatment modalities include: Reducing numbers of appointments, reducing the procedural stress, improving visibility, patient comfort, good hemostasis, anti-inflammatory properties and reducing postoperative complications. CO 2 lasers produce an excellent intraoperative coagulation of blood vessels (up to 0.5 mm), lymphatics and nerve endings resulting in better vision and immediate sterilization of surgical site. ,
CO 2 laser is strongly absorbed by water, followed by hemoglobin and melanin resulting in photo thermal laser-tissue interaction. High degree of absorption of CO 2 by water allows precise cutting of tissue, via vaporization of intra and the extracellular fluid destruction of the cell membrane. The noncontact mode of laser reduces intraoperative wound contamination by tumor cells. The laser offers a protection to the surgical site through a coagulum surface, postoperatively, thus reducing the bacterial load. ,
| Conclusion|| |
The use of lasers has been an effective adjunct to conventional dental procedures. CO 2 lasers have shown superior results in terms of hemostasis, tissue ablation and decontamination of surgical field and also offer lesser working time (around 3-5 min), improves postoperative comfort of the patient with better esthetic outcome compared to the conventional methods.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]