Sialolithiasis / dental implant courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

SALIVARY GLAND ANATOMY
 Salivary gland classified as
Major and minor glands.
Major gland are paired .
They are Parotid
Submandibular
Sublingual glands.

Parotid gland
 Largest salivary gland.
 Secretion is serous in nature.
 It is pyramidal in shape,the apex is towards the angle
of mandible ,the base at the external acoustic meatus.
 Anteriorly the gland extends upto the buccal pad of
fat.
 Posteriorly encircle the posterior body of mandible.

Stensons duct
 It emerges at the anterior part of gland .
 It passes horizontally across the masseter muscle ,then
pierces through the buccinator ,to turn the right angles
to reach the oral cavity.
 Stensons duct is opening is seen as a papilla in the
buccal mucosa opposite the maxillary second molar.

Submandibular gland
 Secretion is both serous and mucous in nature.
 The gland is located in the submandibular space,
extending inferiorly up to the digastric muscle
,superiorly the mylohyoid muscle ,posteriorly up to the
angle of mandible and anteriorly till the mid portion
of body of mandible.

Submandibular duct
 Whartons duct starts from the deep part of gland ,
Turn sharply at the posterior border of mylohyoid
muscle anteriorly and superiorly ,then reach the oral
cavity.
It opens at the sublingual papilla in the floor of the
mouth.
It is close association with the facial artery ,facial vein
,choda tympani ,branch of facial nerve and lingual
nerve.

Clinical consideration
 The submandibular gland and duct are placed at a
lower level to the oral cavity.it makes the gland prone
to retrograde infection by oral flora.
 The whartons duct is also wider before reaching the
papilla .This can lead to stagnation of saliva.
 The long and tortous course of the duct also leads to
stagnation of saliva.
 The sharp bend of the whartons duct at the posterior
border of mylohyoid muscle allow stasis of the saliva
favouring the formation of salivary stones.

Sublingual gland
 It secrete predominately mucous saliva.
 It is located in sublingual space .
 Bartholins duct opens through the sublingual papilla
or join with the whartons duct.

SIALOLITHIASIS
 Sialolithiasis is the formation of sialolith (salivary
calculi,salivary stones) in the salivary duct or the gland
resulting in the obstruction of the salivary flow.
 Sialolith is a calcareous substance ,which may form in
the parenchyma or the duct of minor or major salivary
gland.
 90% of the sialolith form in the submandibular gland.
 Because of these reasons:
1. Long curved whartons duct has increased
entrapment of organic debris.
2. Secretion of this gland is higher in calcium content.www.indiandentalacademy.com

 Thick in consistency .
 Position of gland increases the chances for stagnation
of saliva.
 Factors like inflammation ,local irritation or drugs can
caues stagnation of saliva leading to build up of an
inorganic nidus ,which eventually will calcify.

Sialolith
 It is a cacified mass with laminated layers of the
inorganic material .
 The sialolith is yellowish white in color,single or
mulitiple,may be round or ovoid or elongated having
the size of 2cm or more in diameter.
 The minerals are various form of calcium phosphate
like hydroxyappetite ,octacalcium phosphate .
 Calcium and phosphorous ions are deposited on the
organic nidus which may desquamates epithelial
cell,bacteria ,foreign particle or product of bacterial
decomposition.

clinical features
 Age and sex: they are usually encountered in middle
aged patients with slight prediction for men.
 Size: it usually occur s as solitary concreation in size
from few mm to several cm.
 Symptoms : many patients complain of moderately
severe pain and intermittent transient swelling during
meals ,which resolves after meals.
 As the calculus itself rarely blocks a duct completely
,the swelling subsides as salivary demand diminshes
and as saliva seeps past the partial obstruction.

 The occlusion of the duct prevents the free flow of
saliva stagnation and accumulation of saliva when
under pressure produces pain.
 Systemic sumptoms : fever and malaise may occur.
 Signs
1. Pus may excude from the duct orifice.
2. Soft tissue surrounding the duct show a severe
inflammatory reaction which may appear as
swelling,redness and tenderness.
3. No saliva is seen coming from the duct orifice.

Investigation
 Radiograph : AP view ,lateral ,lateral oblique or
occlusal view.
 Sialography : the radiograph demonstrate the presence
of salivary calculi ,which can be appropriately located
by sialography.

Sialography
 It is a specialized radiographic tecnique procedures
performed for detection of disorders of major salivary
glands .(usually parotid and submandibular gland)
 This technique is employed for examination of both
parenchymal cells and ductal abnormalities.
 It involves cannulation and filling with a radioopaque
/contrast agent to make visible on a radiograph .

Complications
 Bacterial infection of the gland may result in the
obstruction of long duration.
 Siaioangiectasis: dialatation of the gland and the duct
system can happen because of saliva.
 The retention of the saliva may result in the formation
of mucocele especially the mucous retetion
phenomenon.

Indication
 Detectio n of calculi or foreign bodies.
 Detection and diagnosis of recurrent swelling and
inflammatory process.
Contraindication
1. Patients with a known allergy or hypersensitive to
iodine compounds.
2. During the period of acute inflammation.
3. Patient scheduled for thyroid function tests.

Procedure
 Identification of location of duct orifices.
 Exploration of the duct with a lacrimal probe: in case of the
submandibular duct ,the probe should pass the
considerable floor of mouth to the level of posterior border
of mylohyoid muscle ,approximately 5cm.
 Cannulation of the duct : the duct is slightly enlarged and
the salivary cannula is inserted into the duct.
 The dye is slowly introduced into the duct.
 0.76-1 ml for parotid gland
 0.5-0.75 ml for submandibular gland
 The injection of the dye should be stopped ,if the patient
feels mild discomfort ,or if the dye is excravasated and
when the gland is full.

 At the end of final sialographic view the cannula
should be removed from duct orifice
 The patient is instructed to chew gum or suck on a
lemon or take other sialologuegues such as 1% citric
acid solution is given and then asked to rinsed the
mouth.
 The purpose for the step is to stimulate glandular
function and cause excretion of dye.
 The projection should be made again 5min after
removal of the cannula.

 Contrast sialography can be performed by either :
 Lipid soluble or oil based agents .
 These agents contains 37% iodine eg Ethiadol.
 Water soluble or water based agents
 These agents contain 28 to 38 % iodine eg hypaque
50% .hypaque 75%,renografin 60%.
 Observatio n: the salivary calculi appear as radiolucent
lesion.

Management
Conservative treatment :
1. Salivary stimulants and massage of the gland will help
to wash fine debris and also prevent further stone
formation.
2. The smaller sialolith which are located peripherally
near the ductal opening may be removed by
bimanipulation.called milking the gland.
3. Larger sialolith are surgically removed.
4. Multiple stones or gland in the gland require the
removal of gland.

Transoral sialolithiotomy of
submandibular duct
 This is done with the patient under LA in a siting
position.
 The stone is first located by radiography and
palpation.
 If the stone is small and smooth ,a suture is passed
through the floor of the mouth below the duct and
behind the stone and tied to prevent the stone from
sliding backwards.
 A towel clamp is placed through the tip and side of
tongue to obtain retraction and control.

 The gland and duct are palpated extraorally and pushed
towards the floor of mouth to fix the intraoral tissue under
tension and make the stone easier to palpate.
 When the incision is made care is given to two structures –
lingual nerve and sublingual gland.
 If the stone is posteriorly placed ,the incision is shallow
and blunt dissection is employed immediately to prevent
injury to lingual nerve.
 If the stone is anteriorly placed incision is made medial to
plica sublingualis otherwise the sublingual gland will come
between the instrument and the stone and a portion will be
transsected.

 After the mucosa is passed ,a blunt dissection is made .
 The duct is best identified at the point where the stone
is lodged.
 The opening should reveals the stone and should be
sufficient strength to permits its removal.
 The stone is removed with small forcep but large stone
has to be broken by crushing them with forceps.
 After the stone is removed ,a small aspirating cannula
may be passed towards the gland to remove any pus or
mucus plugs.

 A probe is then passed from the carruncle to the
surgical opening to ensure the patency of the anterior
end of duct.
 The wound edges are sutured at the level of mucosa
only .

Transoral sialolithiotomy of Parotid
duct
 The approach to calcification in the parotid duct is
difficult due to anatomical pecularity of parotid duct.
 A semilunar incision running from above downward in
front of caruncle.
 The caruncle,mucosal flap and duct are then retracted
medially ,the cheek is retracted laterally and free access is
gained to the most posterior segments.
 When the stone becomes accessible ,a longitudinal incision
is made in the lateral side of the duct and the stone is
delivered.
 The duct need not to be sutured ,since simply closing the
mucosal flap with deep matress suture will serve to provide
recanilization of duct.

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Sialolithiasis / dental implant courses by Indian dental academy

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