Introduction

Mucocele is the most common benign pathology of the minor salivary glands and occurs due to rupture or obstruction of the salivary ducts^¹. It is asymptomatic^¹, well-defined, soft on palpation^², with a sessile or pedicled base and variable color and size that depend on the depth, elasticity of the tissue and location³. More common on the lower lip⁴ and in children and young adults, without sex predilection^¹.

Treatment techniques vary between surgical excision, marsupialization, micromarsupialization, cryosurgery and steroid injection^², all of which are unfeasible for outpatient care in babies, as these patients are unable to cooperate and require procedures with reduction of pain and clinical time.

The objective of this study is to present a simplified technique for treating pedicled mucoceles in babies, providing better trans and postoperative conditions.

Case report

Male patient, four months old, referred to the Children's Specialties Clinic of the State University of Londrina (UEL), for diagnosis and treatment of a nodular lesion present since birth and located on the inner mucosa of the lower lip. According to the mother, there was an increase in the size of the lesion and greater manipulation of the region by the baby, indicating discomfort, but without reports of pain.

On intraoral physical examination, a pedunculated nodule was observed,

with a smooth surface, soft to palpation, measuring approximately 2mm x 1mm (height x width) and a mucous-like color, consistent with the characteristics of a primary mucocele lesion (Figure 1). Considering the patient's age and the fact that they lived in a small town far from the university, the Ligature technique was chosen in a single session and in an outpatient setting. After obtaining the consent form, the procedure was carried out.

The patient was stabilized on a dental table and the technique was started: 1st) disinfection of the area with 0.12% chlorhexidine digluconate; 2nd) isolation of the region with the aid of gauze; 3rd) application of the ophthalmic anesthetic Tetracaine Hydrochloride 1% and Phenylephrine Hydrochloride 0.1% (Allergan®) with a cotton swab (Figure 2); 4°) creation of the tie at the base of the lesion with 5-0 silk suture thread, (Figure 3). 5°) Post-operative hygiene and follow- up instructions.

Due to the Covid-19 pandemic period, post-operative monitoring was carried out through tele monitoring with daily images and videos of the patient's oral cavity. On the first day, a reduction in the size of the mucocele was observed, but with the same clinical characteristics of color and shape. On the second day, the lesion appeared whitish-yellow, indicating reduced blood circulation in the region (Figure 4). On the third day, the injury had its complete remission. After a week, a satisfactory scarring appearance was observed in the region (Figure 5).

Figure 1 Initial state of the lesion located in the inner region of the lower lip. 

Figure 2 The region being anesthetized with topical ophthalmic anesthetic with the aid of a cotton swab. 

Figure 3 Ligature with silk suture placed at the base of the lesion. 

Figure 4 Appearance of the lesion on the second day of photo monitoring, with altered color ranging from mucous-like to whitish-yellow 

Figure 5 Final appearance of the inner mucosal tissue of the healed lower lip after 1 week of the procedure. 

Discussion

When we refer to the treatment of these injuries in babies, it is necessary to think about techniques suitable for this age group, as they do not have the ability to cooperate with dental treatment, even with simplified techniques, such as micromarsupialization. Some techniques are difficult to perform because they require anesthetic infiltration and mucosal suturing. Furthermore, when using more invasive techniques, good hygiene of the operated site is essential to avoid postoperative infections, which is not always maintained by those responsible.

The Ligature technique, proposed by Children's Specialties Clinic of the State University of Londrina (UEL), consists of tying around the pedicled base of the lesion in order to block the blood supply and enable the lesion's remission process. It has the advantage of being able to be performed in an outpatient setting, quickly and practically, bringing patients greater collaboration and less discomfort during the procedure. It is an alternative treatment for mucoceles, indicated mainly for primary lesions, free of ulcerations, pedicle base, smooth surface, well defined, and may be bluish or translucent in color and soft on palpation.

Babies have a considerable prevalence of developing this type of lesion due to some oral habits during this period of life, such as biting and/or sucking their lips and cheeks and the frequent habit of pushing their tongue^². In these cases, the Ligature technique becomes a relevant procedure in the area of pediatric dentistry, as patients generally have fears regarding the treatment and do not have the collaborative capacity like adults, due to the lack of psychological maturity and prior conditioning in most cases times^5,6.

With surgical excision as the gold standard procedure for the treatment of mucoceles, some disadvantages can be observed, firstly because it is a more traumatic technique for children, due to the use of infiltrative anesthesia and scalpel⁷, in addition to the longer healing time and discomfort. However, in cases where there is frequent trauma or secondary mucoceles, the recommendation is to surgically remove the glands associated concomitantly with the injury^8,9.

It is worth noting that both micromarsupialization10 and the Ligature technique are procedures that provide greater comfort to patients, making dental care more productive and less traumatic when compared to the conventional technique, as they are quick and easy to perform, do not require infiltrative anesthesia, have a good prognosis and low recurrence rate. However, the necessary period of sutures permanence used in micromarsupialization can cause discomfort and a greater probability of secondary infections^7,9, problems that the Ligature technique does not cause due to its greater ease postoperative control and shorter treatment time.

Monitoring the case is a key factor in a good prognosis, regardless of the type of procedure chosen. The studies by Delbem¹⁰; Piazetta¹¹ and Sagari⁷, demonstrated that during the follow-up period of 55 cases after micromarsupialization, 8 presented recurrence while of the 60 cases that opted for surgical excision, only 3 relapsed. In the present study, the Ligature technique did not show recurrence after 6 months of follow-up.

Conclusion

Considering the innovation of the Ligature technique and because it is not mentioned in the literature, this study sought to demonstrate that it is possible to develop problem-solving techniques through simpler means that meet the needs of the patient, who has particularities due to lack of knowledge, psychological development when compared to adults.