sialolithiasis in oral and maxillofacial surgery.

1. SIALOLITHIASIS
Dr ARJUN SHENOY
PG STUDENT
DEPT OF OMFS

2. INTRODUCTION
 Sialoliths are calcified structures that develop within the
salivary gland or the ductal system.
 Men > women
 Rare in children
 75% - single
 3% - bilateral
 1.2% -autopsy

3. GLAND WISE DISTRIBUTION
80-92% - submandibular gland.
6-20% - parotid.
1-2% - sublingual and the minor salivary
glands.
 Submanibular – larger & intraductal
 Parotid – multiple, within the gland

4. SUBMANDIBULAR GLAND OCCURENCE
 Abundant calcium concentration
 Alkaline Ph
 Anatomic factors
 Wharton’s duct - longest
- two sharp curves
- small punctum

5. Composition
organic Inorganic
Organic substances
MUCOPOLYSACCHARIDES
GLYCOPROTEINS
CELLULAR DEBRIS

6. INORGANIC
CALCIUM
PHOSPHATE
Fe
Cu
CALCIUM
CARBONATE
Mn

7. CHEMICAL COMPOSITION
 Chemical composition
Microcrystalline apatite (Ca5[PO4]3OH) or
Whitlockite (Ca3[PO4])
Brushite and weddellite
BRUSHITE
WEDDELLITE

8. RECENT DISCOVERIES
 Scanning electron microscopy has demonstrated oval,
elongated shapes,
 suggesting the presence of bacilli in sialoliths.
 A recent polymerase chain reaction study found bacterial
DNA, mainly belonging to the Streptococcus genus
ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003

9. PATHOGENESIS
 Multifactorial event
 Secretory disturbances & precipitation – inflammatory
process
 Specific changes in structure of organic molecules –
supportive frame formation
 Metabolic disturbances – alkalinity & precipitation

10. MICROLITHS
 Concrements detectable only microscopically
 Contain – calcium and phosphorus
hydroxyl apatite
organic secretory material
necrotic cellular residues
 Generated - autophagocytosis of organelles that are
rich in calcium.

11.  Dyschylia - Disturbed salivary secretion & change in the
composition
 Accumulation of organic substances & mineralisation of
organic matrix
Accumulation of calcium
Increase in pH
Decreases the solubility of calcium phosphates

12. PROGRESSION
 Secretory disturbances viscous secretions
 Microlith formation ductal obstruction
 Coaction of factors + participation of bacteria
sialoliths
 Dyschylia & increasing microlith formation ascent of
bacteria lead to a focal obstructive atrophy of the
acinar cells secretory disturbances
Journal of Oral Science, Vol. 45, No. 4, , 2003

13. OTHER FACTORS
 Infection
 Salivary dysfunction
 Ductal anamolies
 Foreign bodies
 Ductal epithelium metaplasia

14. SYMPTOMS
 Pain, swelling & discomfort
 Pain - meal time – severe with sour or acidic food
 Unusual taste
 Associated with infection – fever , purulent discharge &
lymphadenopathy

15. CHARACTERISTICS
 The annual growth rate - 1 mm per year
 Shape - round or irregular
 Size - 2 mm to 2 cm

16. GIANT SIALOLITH
 72 mm in length and weighing 45.8 g
 The ability of a calculus to grow and become a giant sialolith
depends mainly on the reaction of the affected duct.
Rai and Burman. Giant Submandibular Sialolith. J Oral Maxillofac Surg 2009.

17. TREATMENT MODALITIES
 Newer treatment modalities - extracorporeal short-wave
lithotripsy and sialoendoscopy are effective alternatives
to conventional surgical excision for smaller sialoliths.
 However, for giant sialoliths, transoral sialolithotomy with
sialodochoplasty or sialadenectomy remains the mainstay
of management.

18. HISTOLOGIC FEATURES
 Stratified & mineralized with metaplastic excretory duct
cells
 Concentric laminated structures
 Acini infiltrated by lymphocytes
 Dialatation of duct
 Epithelium exfoliation

19. DIAGNOSIS
 History
 Clinical examination
Bi-manual palpation
 Imaging

20. BIMANUAL

21. IMAGING
Conventional radiography
Sialography
Ultrasonography
Computed tomography (CT)
Magnetic resonance
imaging (MRI)
Sialoendoscopy
Imaging

22. Conventional radiography
 Intra oral radiographs
IOPA , Occlusal radiographs
 Extra oral radiographs
Panaromic , PA skull projection
 Intraglandular and small stones can be missed.
 20% of sialoliths are radiolucent

23. Sialography
 "Gold Standard”
 Retrograde infusion of oil or water based contrast & the
architecture of the salivary duct system is visualized radio
graphically .

24. LIMITATIONS
Advantage
detects
radiolucent
stones
Therapeutic
Disadvantage
• invasive
• bleeding &
perforations
contraindicated
• acute
infections
• allergic to
contrast

25. Ultrasonography
 Non invasive, alternative method
 Stones > 2mm detected as echo-dense spots with a
characteristic acoustic shadow.

26. MR Sialography
 Non invasive
 Acute infections
 Canulation not possible

27. COMPUTED TOMOGRAPHY
 Posterior of the duct
 Hilum of the gland
 Substance of the gland
 Radiation exposure
 Non invasive & do not require contrast media

28. SIALOENDOSCOPY
 Minimally invasive
 Diagnostic & therapeutic
 Small endoscope – light at end of flexible cannula

29. Differential diagnosis
 Phleboliths – radiolucent center
 Dystrophic calcification of lymph nodes – Cauliflower
shaped
 Palatine tonsiliths- multiple & punctate
 Haemangiomas with calcifications

30. TREATMENT
Symptomatic Surgical

31. • Opening of wharton’s duct
Trans oral
Ductotomy
( sialolithotomy)
• Deep intra glandular
• Multiple stones
• Prevent recurrence
Sialoadenectomy

32. Sialoendoscopy
 Small endoscope – optical fibres
- irrigation or working ports
 Special devices – guide wire
- balloon catheters
- metal baskets
- laser fibres
 Ductal dialation – lacrimal probe
- balloon dialator

34. Sialoendoscopy – assisted Sialolithectomy
 Large sialolith
Lithotripsy
 Fragmentation
 Types – intracorporeal
- extracorporeal

35. Intracorporeal techniques
 Mechanical fragmentation
 Intracorpreal laser lithotripsy
- Er: YAG
- Ho: YAG
 Pneumatic lithotripsy

36.  ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003

37. Extracorporeal Lithotripsy
 Shock waves – focused, multiple high intensity acoustic
pulses
 Kinetic energy – compressive & tensile forces

38. Complications
-Inability to remove
fragment
-Postoperative
infections
-Neural damage
-Intraductal
adhesion
-Subglossal scar
band formation
-Sialocele & Ranula
formation

39.  paediatric patients
 Relatively small and distal
 Bimanual careful palpation is mandatory to diagnostic
approach for children suspicious of sialolithiasis.
 These findings also suggest that intra-oral approach is
effective treatment procedure for most of sialolithiasis in
children.
Int J Pediatr Otorhinolaryngol 2007 May;71(5)

40. MIGRATING SALIVARY STONES

44. Conclusion
 Sialolithiasis is the main cause of unilateral diffuse parotid or
submandibular gland swelling.
 Mechanical obstruction of the salivary duct, causing repetitive
swelling during meals, & often complicated by bacterial
infections.
 Common in submandibular gland , 10 – 20% are radiolucent
 Newer minimally invasive diagnostic & therapeutic modalities

45. References
 Contemporary OMFS – Perterson
 Oral Radiology – principles & interpretation – White & Pharoah
 Sialoendoscopy & salivary gland sparing surgery - Oral Maxillofaccial Surg
Clin N Am 21 (2009)
 Pathogenesis & diverse histologic findings of sialolithiasis – J Oral Maxillofac
Surg 68: 2010
 Imaging the major salivary glands – British Journal of Oral & Maxillofacial
Surgery 49 (2011)
 Oral & maxillofacial pathology – Neville
 Text book of OMFS – Neelima Mallik