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. 2023 Jan 31;12(3):1129.
doi: 10.3390/jcm12031129.

Sialendoscopy-Based Analysis of Submandibular Duct Papillae with a Proposal for Classification

Affiliations

Sialendoscopy-Based Analysis of Submandibular Duct Papillae with a Proposal for Classification

Aleksandar Aničin et al. J Clin Med. .

Abstract

Identifying a submandibular (Wharton's) duct punctum often hinders sialendoscopy; however, there is a paucity of evidence on whether the appearance of Wharton's duct papilla impacts the sialendoscopic procedure. A classification of Wharton's duct papillae based on the macroscopic appearance, size of dilatation probes, and sialendoscopic approach was proposed herein. The classification describing four main types of papillae, A, B, C, and D, was prospectively evaluated on 351 Wharton's duct papillae in 315 patients. For each papillae type, the demographic/clinical data, intraoperative complications, and time required for sialendoscope introduction were analyzed. Estuary-like papilla (type A) was commonly seen after spontaneous stone extrusion, had no intraoperative complications noted, and had the shortest time required for the sialendoscope introduction. Normal papilla (type B) was the most frequently observed papilla (48.1%), reflecting diverse underlying pathology, while difficult papilla (type C) was often associated with unfavorable anatomical variations of the mandible or floor of the mouth. Substantially closed papilla (type D) had the highest rate of intraoperative complications, namely, perforation with a false passage, and required the longest time for the sialendoscope introduction. In seven patients (2.0%), the entrance into the duct was feasible only through the fistula, while the sialendoscope introduction failed in eight patients (2.3%). In conclusion, the appearance of Wharton's duct papillae may be influenced by the underlying pathology. Based on the proposed classification, papilla typology affects the duration of sialendoscope introduction and may influence the frequency of intraoperative complications.

Keywords: Wharton’s duct; classification; ductal stenosis; salivary gland disorders; salivary gland papilla; sialadenitis; sialendoscopy; sialolithiasis.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Insertion of the dilatation probe into the orifice of submandibular duct. The figure depicts the anatomy of the mouth floor, including two submandibular duct papillae. The dilatation probe is inserted into the right orifice of Wharton’s duct.
Figure 2
Figure 2
Graphical representation of different types of Wharton’s duct papillae. In (a), easy or estuary-like papilla (type A) can be seen. (b) depicts a normal papilla (type B) with evident orifice and papilla; and (c) demonstrates a difficult papilla (type C). (d,e) depict a substantially closed papillae (subtypes DI/II and DIII, respectively). In last two figures, the orifice is barely visible. An oval-shaped fistula can be noted near the orifice in the last figure.
Figure 3
Figure 3
Sialendoscope and probes used for dilatation of papilla. (a) displays a sialendoscope (Karl Storz, Tuttlingen, Germany). In (b), dilatation probes (Marchal dilatator system, Karl Storz, Tuttlingen, Germany) with sizes in decreasing order are depicted (from size 6 to 0000).
Figure 4
Figure 4
Submandibular duct papillae. (a) displays an estuary-like papilla (type A) on the patient’s right side before inserting the dilatation probes (asterisk *). The following two figures demonstrate normal papilla (type B) in two patients. In (b), the dilatator is inserted into the papilla, while the patient’s left papilla (asterisk *) is already dilatated in (c). (d) displays a difficult papilla (type C) with the dilatator inserted. In this patient, the narrow mandibula and mandibular torus hindered the insertion of dilatation probes. (e) shows one visible papilla on the patient’s left side, while substantially closed papilla (type D) on the patient’s right side cannot be visualized.

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