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SURGICAL MANAGEMENT OF SUBMANDIBULAR GLAND SIALOLITHIASIS: A CASE

REPORT
Yohan E. Marpaung1, Benny S. Latief2, Dwi Ariawan3

Trainee, Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Universitas Indonesia
Lecturer, Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Universitas Indonesia
3
Lecturer, Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Universitas Indonesia
1
2

Email: johan.edward.m@gmail.com

Abstract
Background:
Sialolithiasis is a salivary gland disease that often occurs, approximately 1.2% in population.
This condition raised due to obstruction in salivary duct with male and female ratio 1.04:1, and
age varied from 25 years to 50 years. 80%-90% sialolithiasis raised in submandibular duct, 6%
in parotid duct, 2% in sublingual duct and 2% in minor salivary duct.
Objective
To report surgical management of submandibular sialolithiasis
Case report
Female, 32 years old, came to oral and maxillofacial surgery department, CiptoMangunkusumo
General Hospital with chief complaint swelling at floor of mouth since 3 months ago. From
anamnesis patient felt pain below her tongue and the pain increased while consuming sour food
and beverages. She also complained green yellowish fluid aroused from her tongue floor. From
radiologic examination (occlusal) concluded that there is a sialolith at left submandibular duct.
Subsequently oral antibiotics spiramycin 3x500mg given and afterwards surgical management
performed to remove the sialolith.
Conclusion
Sialolithiasis is one of the most common disease in submandibular gland. There is several
modalities to treat the disease. In this case report, surgical management is chosen to overcome
the condition. The recurrence rates of this method wereas low as 1.9%.

Introduction
Sialolithiasis is a salivary gland disease that often occurs, approximately 1.2% in
population. This condition arose due to obstruction in salivary duct with male and female ratio

1.04:1, and age varied from 25 years to 50 years. 80%-90% sialolithiasis occur in submandibular
duct, 6% in parotid duct, 2% in sublingual duct and 2% in minor salivary duct.1
The presence of this disease is recognized by obstacles in the salivary gland system. The
obstacle arose from hard material such as sialolith or calculus. The most common clinical
symptom related to this condition are pain, swelling and infection at the salivary gland and the
ductal system.2
2 main factors related to high incidence rate sialolithiasis in submandibular gland are the
characteristic of saliva produced by submandibular gland. Secretion of submandibular gland will
produce saliva with highly mucin consistency, organic products, phosphatase enzyme, calcium,
alkali pH, phosphate and carbon dioxide. In the other hand, the anatomy factor is also give
influence the high incidence rate. Wharton ducts has unique characteristic, it has long and
curvaceous pathway, higher orifice position than the ductal system, and the ductus diameter is
smaller than its lumen.1
As a therapy, sialolithiasis can be cured by surgical approach, known as sialolithectomy
method. Sialolithectomy is widely performed due to the simplicity, safety and efficiency. The
recurrence rate of sialolithiasis treated with this method is as low as 1.9%.3
Objective
To report surgical management of submandibular sialolithiasis

Case report
Female, 32 years old referred from other hospital with chief complaint swelling at her
mouth floor 3 weeks before. From anamnesis, patient admitted that she felt pain just below her
tongue, especially while consuming sourish food. She also complained green-yellowish fluid that
sometime exudates below her tongue. She avowed that she had had fever shortly after the fluid
exudates but fever was reduced after she consume over the counter antipyretic drug. She denied
any trauma to the surrounding area.
From visual examination there is no abnormality and palpation confirmed that the
condition is within normal limit. There is no regional lymph node enlargement (fig. 1).

Intra orally there are swelling at floor of mouth in 3x2x2 cm size, hard consistency, easily
move, ill fitting border and smooth surface. The color of the swelling is slightly reddish in
comparation to the adjacent soft tissue (fig. 2)
.
From anamnesis and clinical examination, temporary diagnosis is made as sialodenitis
from suspected obstacle at salivary gland system (sialolith). As confirmation procedure, plain
radiographic in occlusal mode is made. From occlusal radiograph there is rarefaction as
radiopaque appearance at left side (fig. 3).
By the confirmation from this examination, working diagnosis is made as sialolithiasis at
salivary gland canal. As treatment, spiramycin oral 3X500 mg started to eradicate bacteria that
produce infection. Shortly after the infection reduced, sialolithectomy performed.
Sialolithectomy was performed in general anesthesia. First patient is laid in supine
position. Thereafter the mouth is opened and hold using Denhardt mouth gag. Tounge retraced
and fixated using 3/0 silk. (fig 4.1). Subsequently the sialolith position is identified and using
methylen blue ink the location is drawn (fig 4.2). Afterwards vasoconstrictor applied to the area.
Incision was done using #15 blade to the mucosa and sub mucosa. And then blunt dissection
performed until submandibular salivary duct identified. Thereafter just above the sialolith,
another incision was made and then the sialolith removed in single piece (fig 4.3). As closure,
canal edge is fixated to the adjacent soft tissue, shortly mucosa and submucosa is stitched using
absorbable material, vicryl 4/0 (fig 4.4).

Post operative, patient discharged 1 day after. After 7 days she came to do control and the
condition is good. There are no infection, nor sensory disturbance or functional disturbance (Fig.
5).

Discussion
One of the most common diseases in the submandibular gland system is stone at salivary
gland duct. Incidence rate of stone at submandibular gland system is 80% which is higher than
other salivary gland system. 20% occurred at parotid gland system, and the rest is sublingualis
and minor salivary gland. Salivary stone mostly contain calcium phosphate, less magnesium,
ammonium and carbonate. Salivary gland stone may also formed from organic matrix, mixed
from carbohydrate and amino acid. Stone is easily occurred at submandibular system due to
several conditions such as alkali salivary secretion, high calcium and phosphate concentration,
and mucoid product. Other factor that gave influence is submandibular gland canal is long and
the flow is not depending on the gravity. Usually stone in the submandibular gland system
occurred in the duct, this is different from stone in the parotid gland that occurred more often
inside hillum or parenchym.4
The etiology of the stone can be divided into 2 main theories, first is nidus theory and
second retrograde theory. In nidus theory, conditions such as abnormal calcium metabolism,
dehidration, salivary flow decrease, alteration in saliva pH due to oropharyngeal infection and
solubility crystalloid change from mineral salt deposition will form a nidus that subsequently
covered by organic and inorganic material. Finally this mixed turn into a mass. Calcification
degree of this mass is different in every cases therefore 15-20% sialolith will not be visible as
radiopaque rarefaction in plain radiographic examination.5
In retrograde theory that introduced by Marchal in 2001, stone occurred due to salivary
gland ductal system which is resemble to sphincter system at 3 cm first. This system has
responsibility to the retrograde migration of materials inside oral cavity. The hypothesis of

retrograde theory is supported by Teymoortash. Teymoortash did his research using PCR
(polymerase chain reaction) and he found that bacterias in the salivary gland stone constitute the
same bacterias in the gingival plaque.6
Clinical symptoms as patient chief complain usually is intermittent swelling with pain.
Pain is worsening due to sourish food or beverages. In manual palpation, stone position can be
perceived.4
Treatment of sialolithiasis has several modalities, conservative and surgical. In the
conservative method, drugs such as antibiotics, anti inflamation and analgesics is given. The
purpose of this method is to reduce infection, inflammation and pain. Other conservative method
done by giving heat treatment so the duct is dilated, therefore the saliva flowed and reduce
obstacles. Sour food and beverages occasionally used as treatment too due to its ability to
stimulate saliva secretion. By increasing the salivary secretion, the flow increase and push the
obstacle from the canal. Unfortunately conservative methods is not always working, This method
succeed if the stone is located near the orifice or the stone size is small.4
Surgical method is considered as the most common treatment chosen to treat sialolithiasis
due to high successful rate. Surgical method can be done with open method (sialolitectomy) or
sialoendoscopy. Due to the complicated tools and technology, sialoendoscopy as treatment
choice is not as popular as open method. Open method (sialolitectomy) is widely used because
this method is safe, easy and has low recurrence rate, as low as 1.9%.3

Conclusion
Sialolithiasis is one of the most common diseases in submandibular salivary gland. There is
several modalities to treat the disease. One of the modalities is by open surgical method
(sialolitectomy). In this case report, sialolitectomy is chosen to overcome the condition. The
recurrence rates of this method were as low as 1.9%. This method is easy, reliable and efficient.

References
1. Graney DO, Jacobs JR, Kern RC. Salivary Glands. In: Cumming CJ, editor. .Otolaryngology Head and
Neck Surgery. 3rd ed. Mosby; 1999. p.1220.
2. Rahnama M, Jastrzebska-Kamrogiewicz I, Jamrogieicz R, Krochmalska E. Modern
Treatment Method of Sialolithiasis. 2012. Curr. Issues Pharm. Med. Sci 25 (4); 353-56.
3. Park JH, Kim JW, Lee S. Long-term Study of Sialodochoplasty for Preventing Submandibular Sialolithiasis
Recurrence. Clinical and Experiment Otorhinolaryngology 2012; 5 (1): 34-38.

4. Su YX, Liao GQ, Zheng GS, Liu H, Liang Y, Ou D. Sialoendoscopically assisted open
sialolithectomy for removal of large submandibular hilar calculi. J Oral Maxillofac Surg
2010; 68:68-73.
5. Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modern management of
obstructive salivary diseases. Acta Otorhinolaryngologica Italica 2007; 27 (4): 16172.
6. Teymoortash A, Wollstein A C , Lippert B M , Peldszus R: Werner J A : Bacteria and
pathogenesis of human salivary calculus. Acta Oto-Laryngol. 2004. 122: 210-214 .
7. Laskin DM, Abubaker AO. Decision Making in Oral and Maxillofacial Surgery. 2007.
Chicago-Quintessece. 202-3.

Pictures

Figure 1. Extra oral clinical appearance.

Figure 2. Intra oral appearance.

Figure 3. Occlusal x-ray.

Figure 4. Surgical therapy.


Figure 4. Surgical therapy.

Figure 5. Condition in control day