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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 26  |  Issue : 3  |  Page : 306-309

Enlarged submandibular salivary ductal openings: A new physiological variation


1 Department of Oral Medicine and Radiology, Government Dental College, Raipur, Chhattisgarh, India
2 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
3 Department of Oral Medicine and Radiology, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India
4 Department of Prosthodontics, JSS Dental College and Hospital, Mysore, Karnataka, India

Date of Submission27-Jul-2014
Date of Acceptance06-Nov-2014
Date of Web Publication19-Nov-2014

Correspondence Address:
Pinakapani Ramakrishna
Department of Oral Medicine and Radiology, Government Dental College, Rajbandha Maidan, Raipur - 492 001, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.145014

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   Abstract 

Developmental anomalies of the salivary glands are rare. These include aplasia of glands, atresia of ducts, accessory or ectopic glands, and a variety of cysts. Through this case report we are presenting a unique case of bilateral, enlarged, Wharton's ductal openings that have not been documented yet.

Keywords: Sublingual salivary gland, submandibular salivary gland, Wharton′s duct


How to cite this article:
Ramakrishna P, Chaitanya NC, Yellarthi PK, Nagaraj C. Enlarged submandibular salivary ductal openings: A new physiological variation . J Indian Acad Oral Med Radiol 2014;26:306-9

How to cite this URL:
Ramakrishna P, Chaitanya NC, Yellarthi PK, Nagaraj C. Enlarged submandibular salivary ductal openings: A new physiological variation . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2019 Apr 18];26:306-9. Available from: http://www.jiaomr.in/text.asp?2014/26/3/306/145014


   Introduction Top


Salivary glands are compound, tubuloacinar, merocrine, exocrine glands, the ducts of which open into the oral cavity. [1] The main developmental anomalies of the salivary glands are aplasia of the glands, atresia of the ducts, accessory or ectopic glands, and a variety of cysts. [2] Aplasia of one or more glands, which is rare, has been reported in literature. Salivary gland aplasia may be found in some congenital syndromes. [3] Duct atresia is less infrequent and may affect the submandibular duct, causing occasional cyst formation. [2] Ectopic salivary tissue can be found in the developmental areas of the first and second branchial arches, which include the lateral part of the neck, pharynx or middle ear, and in the lymph nodes or extranodal lymphoid tissue, particularly in the parotid and surrounding area. [2] It may also be found in rare sites within the head and neck region, such as the gingiva and the brain. Such ectopic salivary tissue without an excretory duct can cause salivary fistulas. [2] We are reporting a unique case of enlarged submandibular salivary gland openings in the oral cavity that have not been, to the best of our knowledge, documented yet.


   Case Report Top


A 24-year-old male patient reported to our Outpatient Department with a chief complaint of generalized discoloration of teeth. His medical and dental history was noncontributory. His general physical examination did not reveal any abnormality. His routine clinical examination revealed generalized extrinsic stains and mild calculus deposits on the teeth. Furthermore, on examination, unusually large bilateral submandibular salivary gland ductal openings were present, well-patent and measuring roughly 3 mm (right side) and 4 mm (left side) in their greatest dimension [Figure 1]. The sublingual caruncles were absent bilaterally. There were no visible signs of inflammation, infection or ductal obstruction. On palpation, the findings were within normal limits. No variation in salivary quality or quantity was observed. The patient was made aware of his clinical findings and was further interviewed for any signs and symptoms associated with salivary gland functioning. The patient did not report any prior history of trauma, pain or swelling in the orofacial region, especially in the submandibular region, nor did he report any symptom of oral dryness, difficulty in speech, mastication, swallowing, or other associated functions. The unstimulated whole salivary collection using the spitting method over five minutes was 1.4 mL (0.28 mL/minute). The obtained saliva was slightly cloudy in appearance with a pH of 6.8 and specific gravity of 1.01. Findings of the blood and serum biochemistry were within normal limits.
Figure 1: Intraoral view showing, well-patent bilaterally enlarged Wharton's ductal openings and absence of sublingual caruncles

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The patient's mandibular cross-sectional occlusal [Figure 2] and panoramic [Figure 3] radiograph revealed no abnormality. An ultrasound examination (Make: Siemens; Linear probe: 7-14 MHz) showed normal ductal morphology with no pathological findings [Figure 4], [Figure 5], [Figure 6], [Figure 7]. As sialography was not advisable in the absence of any pathological findings affecting the salivary glands, it was not carried out. A diagnosis of enlarged bilateral submandibular salivary ductal opening (physiological variation) was made.
Figure 2: Mandibular occlusal radiograph (cross-sectional) showing absence of salivary gland or duct abnormality

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Figure 3: Panoramic radiograph showing absence of salivary gland or duct abnormality

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Figure 4: Ultrasonography examination of the right submandibular salivary gland

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Figure 5: Ultrasonography examination of the right Wharton's duct

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Figure 6: Ultrasonography examination of the left submandibular salivary gland

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Figure 7: Ultrasonography examination of the left Wharton's duct

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   Discussion Top


The submandibular glands are the second largest major salivary glands weighing 7-16 g each. Each gland, on either side, is located in the submandibular triangle. The gland predominantly produces mucous secretion that is carried by its duct - 'The submandibular duct'. The duct after exiting the gland courses deep to the lingual nerve, medial to the sublingual gland. Between the hyoglossus and mylohyoid muscles, on the genoiglossus muscle, it ultimately forms - The 'Wharton's duct'. Measuring 4-5 cm in length, it courses itself anteriorly, superior to the hypoglossal nerve, while being inferior to the lingual nerve. The largest among the entire sublingual salivary ducts (the duct of Bartholin), joins the Wharton's duct, to drain through the sublingual papillae, also called the caruncula sublingualis, near the midline of the floor of the mouth on each side of the lingual frenum. [4]

The submandibular gland begins to develop at six weeks of embryonic life and the sublingual and minor salivary glands at eight to twelve weeks. Individual salivary glands arise as a proliferation of the oral epithelial cells, forming a focal thickening (bud) that grows into the underlyling ectomesenchyme. Clefts develop in the bud, forming two or more new buds; continuation of this process, called 'branching morphogenesis', produces successive generations of buds and a hierarchical ramification of the gland. [5],[6] The process of branching morphogenesis requires interactions between the epithelium and mesenchyme. Several factors that control the location of the branch points and overall structure of the gland have been identified. Signaling molecules, including members of the fibroblast growth factor protein family, sonic hedgehog, transforming growth factor β, and their receptors, play a major role in the development of the branches. The differential contraction of the actin filaments at the basal and apical ends of the epithelial cells is thought to provide a physical mechanism underlying the cleft formation, and deposition of extracellular matrix components within the clefts apparently serve to stabilize them. Finally, the specific mesenchyme associated with salivary glands has been shown to provide the optimum environment for gland development. [6]

The development of lumen within the branched epithelium generally occurs first at the distal end of the main cord, and finally in the central portion of the main cord. The lumina form within the ducts before they develop within the terminal buds. Some studies have suggested that lumen formation may involve apoptosis of the centrally located cells in the cell cords, but further research is required to definitively establish a role for cell death in this process. [6],[7] The cells of the secretory end pieces and ducts attain maturity during the last two months of gestation. The gland continues to grow postnatally - With the volume proportion of the acinar tissue increasing and the volume proportion of the ducts, connective tissue, and vascular elements decreasing - Up to two years of age. [1]

We consider the present case as a physiological variation rather than a pathological one. The probable reason, as seen in the present case, might be a developmental anomaly, wherein the duct of Bartholin has joined the Wharton's duct at its most proximal end. This could be one of the reasons for the absence of a sublingual caruncle in our case. As discussed previously, various signaling molecules, influencing the differential contraction of the actin filaments, might have altered the physical mechanism underlying cleft formation during gland development in our case. Exfoliation or dislodgement of a sialolith from the ductal orifice is not a rare entity. [8] An enlarged ductal opening could be a sequel of such an episode. However, in the present case the patient does not report any such experience. The presence of such wide ductal openings located in the floor of the mouth could lead to foreign body entry into the ductal system, causing a partial or total obstruction of salivary secretion. Such variations can also favor a retrograde spread of the oral microflora leading to glandular infection and inflammation, a consequence of which might be glandular destruction.


   Conclusion Top


Developmental disturbances of salivary glands are rare. We are reporting a case of bilaterally enlarged Wharton's ductal openings, which appears to be more of a physiological variation rather than a pathological one.

 
   References Top

1.Berkovitz BK, Holland GR, Moxham BJ. Oral Anatomy, Histology and Embryology: Salivary Glands. 4 th ed. Edinburgh, New York: Mosby Elsevier; 2009. p. 260-1.  Back to cited text no. 1
    
2.Lamey PJ, Lewis MA. Oral medicine in practice: Salivary gland disease. Br Dent J 1990;168:237-43.  Back to cited text no. 2
    
3.Pham Dang N, Picard M, Mondié JM, Barthélémy I. Complete congenital agenesis of all major salivary glands: A case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e23-7.  Back to cited text no. 3
    
4.Holmberg KV, Hoffman MP. Anatomy, biogenesis and regeneration of salivary glands. Monogr Oral Sci 2014;24:1-13.  Back to cited text no. 4
    
5.Patel VN, Rebustini IT, Hoffman MP. Salivary gland branching morphogenesis. Differentiation 2006;74:349-64.  Back to cited text no. 5
    
6.Sakai T. Epithelial branching morphogenesis of salivary gland: Exploration of new functional regulators. J Med Invest 2009;(Suppl):234-8.  Back to cited text no. 6
    
7.Varner VD, Nelson CM. Cellular and physical mechanisms of branching morphogenesis. Development 2014;141:2750-9.  Back to cited text no. 7
    
8.Singhal A, Singhal P, Ram R, Gupta R. Self-exfoliation of large submandibular stone-report of two cases. Contemp Clin Dent 2012;3(Suppl2):S185-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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