Submandibular salivary gland dr chithra

SUBMANDIBULAR SALIVARY GLAND
Submandibular salivary gland
PRESENTED BY
Dr. CHITHRA P
Senior Lecturer
Dept of Oral Medicine & Radiology
Malabar Dental College & Research Centre, Manoor
Chekannoor Road, Mudur PO, 679578,

CONTENTS
 Introduction
 Structure of salivary glands
 Production of saliva
 Sub-mandibular salivary gland
 Development
 Anatomy
 Evaluation of gland
 History
 Physical examination
 Radiological and endoscopic examination
 Clinical aspects
 Sialolithiasis
 Conclusion Submandibular salivary gland

INTRODUCTION

 Salivary glands are exocrine glands whose
secretions flow into the oral cavity through
ducts.
Salivary
gland
Major
salivary
gland
Minor
salivary
gland
• Orban’s Oral Histology and Embryology: 12th edition

MAJOR SALIVARY GLANDS MINOR SALIVARY GLANDS
 Parotid glands
 Submandibular glands
 Sublingual glands
 Labial & buccal glands
 Glosso palatine glands
 Palatine glands
 Lingual glands

Minor salivary glands
 found throughout the oral cavity, with the
greatest density in the buccal and labial mucosa,
the posterior hard palate, and tongue base.
 They are not often observed,, in the attached
gingiva and anterior hard palatal mucosa.
 The majority of these glands are either
mucinous or seromucinous, except for the
serous Ebner’s glands on the posterior aspect of
the tongue.

 Second largest major
salivary gland situated in
the anterior part of the
digastric triangle( in the
submandibular triangle)
 Gland is about the size of a
walnut and weighs 7–16g
 Roughly J-shaped and
indented by the posterior
border of the mylohyoid
muscle which divides it into
larger part superficial to the
muscle and the small part
lying deep to the muscle.

Enveloped by a well defined capsule.
Main excretory duct called Whartons duct
open at the caruncula sublinguae, a small
papillae at the side of the lingual frenum on the
floor of the mouth.
Mixed gland with both serous and mucous
secretory units.
Intercalated ducts are shorter compared to
parotid, striated ducts are usually longer.

DEVELOPMENT OF SUBMANDIBULAR SALIVARY
GLAND

DEVELOPMENT OF SUBMANDIBULAR SALIVARY
GLAND
3 rd month
A capsule from the surrounding mesenchyme is fully developed around the
gland
10th week of intrauterine life
The epithelial bud grows into an extensively branched system of cords of
cells that are first solid but gradually develops a lumen and become ducts
6th week of intrauterine life
Small buds appear in the floor of the mouth lateral to the tongue extend
posteriorly around the mylohyoid muscle into the submandibular triangle

morphogenesis
STAGES OF
DEVELOPMENT
PREBU
D
STAGE
INITIAL
BUD
STAGE
PSEUDOGLANDU
LAR
STAGE
CANALICULAR
STAGE
TERMINAL BUD
STAGE

STAGE I : PREBUD STAGE
 Begins as a thickening of the primitive oral
cavity epithelium adjacent to the tongue

STAGE II : INITIAL BUD STAGE
 Thickening grows down into the first brachial arch
mesenchymal to form the initial submandibular bud with
continuued epithelial proliferation and down growth the SMG
primodium becomes a solid,elongated epithelial stalk
terminating in a bundle

STAGE III :PSEUDOGLANDULAR STAGE
 Primodium branches by repeated furcation in the
distal ends of successive buds to produce a bush
like structure comprised of a network of epithelial
branches and terminal epithelial buds

STAGE IV :CANALICULAR STAGE
 Epithelial cells apoptosis begins and branches
and buds hollow out to onset lumen formation.

STAGE V :TERMINAL BUD STAGE
o Well defined lumen formation
o Ductal system and presumptive acini
develops

ANATOMY OF SUBMANDIBULAR SALIVARY
GLAND

 About half the size of the parotid gland
SUPERFICIAL PART DEEP PART

SUPERFICIAL PART:
 Wedged between the body
of the mandible and the
mylohyoid muscle and
reaches superiorly to the
mylohyoid line on the
medial surface of the
mandible.
 Posterior to the free margin
of mylohyoid the mucous
membrane of mouth lies
superior to it extends to the
angle of the mandible.
 Anteriorly reaches the level
of mental foramen.

 Gland is partly enclosed between two layers of deep
cervical fascia.
 Superficial layer is attached to the inferior border of
mandible; the thinner deep layer is attached to the
mylohyoid line.
 Posteriorly, these layers fuse in the stylomandibular
ligament which separates the submandibular gland and
parotid gland

RELATIONS
RELATIONS
INFERIOR
LATERAL
MEDIAL

RELATIONS
INFERIOR SURFACE
 covered by skin
 superficial fascia,
platysma muscle,
cervical branch of
facial nerve.
 Deep fascia
 Facial veins,
submandibular lymph
nodes

LATERAL SURFACE
 submandibular fossa on
the mandible
 Insertion of medial
pterygoid
 The facial artey which
grooves the postero
surface of the gland

MEDIAL SURFACE :
 Divided into three parts
1. Anterior Part related to
mylohyoid muscles, vessels
and nerves
2. Middle Part is related to
the hyoglossus, the
styloglossus, the lingual
nerve, the submandibular
ganglion and the
hypoglossal nerve
3. The Posterior Part is
related to the styloglossus,
the stylohyoid ligament, the
ninth nerve and the wall of
the pharynx.

DEEP PART
 Small in size
 Lies deep to the myohyoid
 Superficial to the hyoglossus
and the styloglossus
 Posteriorly it is continous
with the superficial part
around the posterior border
of the mylohyoid
 Anteriorly it extends upto
the posterior end of the
sublingual gland

Submandibular duct
 Wharton’s duct
 It is thin walled and is
about 5cm long
 Emerges at the anterior
end of the deep part of the
gland and runs forward on
the hyoglossus between
the lingual and
hypoglossal nerves
 At the anterior border of
the hyoglossus, the duct is
crossed by the lingual
nerve.

Submandibular duct
 It opens on the floor of the mouth on the summit of
sublingual papilla, at the side of the frenulum of
the tongue.

Enlarged submandibular salivary ductal
openings: physiological variation
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.

BLOOD SUPPLY
 Supplied by facial artery: small glandular
branches

VENOUS DRAINAGE
 Veins drain to the common facial or lingual
vein

LYMPHATIC DRAINAGE
 Lymph passes to the submandibular
lymph node

NERVE SUPPLY
 Supplied by branches from the
submandibular ganglion
1. secretomotor fibres
2. sensory fibres from lingual nerve
3.Vasomotor sympathetic fibres from the
plexus on the facial artery.

SECRETOMOTOR PATHWAY
 Begins in the superior
salivatory nucleus
 Preganglionic fibres pass
through the sensory root
of the facial nerve, the
geniculate ganglion, facial
nerve, the chorda tympani
and the lingual nerve, to
reach the submandibular
ganglion.
 Post ganglionic fibres
emerge from the ganglion
and enter the
submandibular gland

EVALUATIONOF THE GLAND
 Symptoms indicative of salivary gland disorders are
limited in number and generally nonspecific. Patients
usually complain of swelling, pain, xerostomia, foul
taste, and sometimes sialorrhea, or excessive salivation.
 Despite the prevalence of modern technology in the
identification of salivary gland disorders a detailed
history and thorough physical examination still play
significant roles in the clinical diagnosis

HISTORY
 Attentive listening and patience is required for
subsequent diagnosis.
 The medical profile of the patient can provide helpful
clues as dysfunction of salivary glands is often
associated with certain systemic disorders such as
diabetes mellitus, arteriosclerosis, hormonal imbalances,
and neurologic disorders.
 The factors of age group and gender are also important.
 Drug history of the patient should also be considered,
for salivary function is often affected by drug usage

 A careful dietary and nutrition history should be
obtained.
 Swelling and pain during meals followed by a reduction
in symptoms after meals may indicate partial ductal
stenosis.
 History of prior radiation therapy to head and neck.

Physical examination

INITIAL INSPECTION
 Careful examination of head and neck region, both
intra and extra orally
EXTRAORAL INSPECTION
 patient should stand 3 to 4 feet away and directly
facing in front of the examiner.
 Inspect symmetry, colour, possible pulsation and
discharging of pus on both sides of the patient
 Enlargement of submandibular gland may occur on
one or both sides.

 Submandibular swelling present first medial and
inferior to the angle of mandible.
 Submandibular swelling differentiated from
lymphatic swelling as being single, larger and
smoother.
INTRAORAL INSPECTION
 Proper lighting
 Assessment of the Wharton’s duct orifice at the
root of the tongue.

INTRAORAL INSPECTION
 Proper lighting
 Assessment of the
Wharton’s duct orifice at
the root of the tongue
 Deepening off the
mucosa around the duct
with an air blower and
then pressing on the
corresponding glands
will allow the examiner
to assess the flow or lack
of flow of saliva.

PALPATION
EXTRAORAL :
 Examiner may stand in
front of the patient
 patient head is inclined
forward to maximally
expose the parotid and
submandibular gland
region.
 Observable salivary
gland swelling do not
rise with swelling
thyroid gland and
laryngeal swelling.

BIMANUAL PALPATION
 Extraorally with one
hand and intraorally with
the other hand to
examine submandibular
gland. One/two gloved
finger should be inserted
intraorally to palpate the
gland and main excretory
ducts intraorally while
using the other hand to
extraorally support the
hand and neck

BIMANUAL PALPATION
 By rolling hands over the glands both intraorally
and extraorally,subtle mass leisons can be
identified.
 In the subamandibular gland..............to gland
can often be distinguished from pathology
within the gland by using this techniques.
 Increased salivation from ductal orifice due to
pressure extraorally applied to the gland may
induce inflammation.

Differentiating between submandibular lymph
nodes and Salivary gland:
 The salivary gland can be palpated bimanually
as it extends into the floor of the mouth.
 The Lymph Nodes are only felt below the
mandible.
 Lymph nodes may be multiple and a space
separates them from the mandible.

RADIOLOGIC AND ENDOSCOPIC EXAMINATION
 Plain film radiography
 Sialography
 Ultasonography
 Computed tomography
 Magnetic Resonance Imaging
 Sialoendoscopy
 Radionuclide Salivary Imaging
Rastiger R,B sumeet,J Govindrajan ; pictorial essay; salivary gland imaging.
Indrian J Radrol imaging 2012 oct-dec

SIALOLITHIASIS
 Sialoliths are typically calcified organic masses
that form within the secretory system of major
salivary gland.
Courtesy:Saluja H, Kasat VO, Mahindra U. Giant Sialolith in the Wharton’s duct causing
sialo-oral fistula: A case report and review of literature. J Orofac Sci 2012;4:137-42..

 Most commonly occur in submandibular gland
80-90%
Due to :
1. tortous course of wharton’s duct
2. dependent position of submandibular salivary
gland that leaves them prone to stasis.
3. higher calcium and phosphates levels
4. increased mucoid nature of secretion

CLINICAL PRESENTATION
History of acute,colicky, perprandial pain and
intermittent swelling of the salivary gland.
Degree of symptoms depends on extent of
salivary duct obstruction and the presence of
secondary infection.

 Salivary gland swelling will be evident upon
eating since the stone completely/partially blocks
the flow of saliva resulting in salivary pooling
within the gland ductal system.
 If there is commencement of infection, there may
suppurative or non suppurative expressible
damage, erythema or warmth in the overlying
skin.

DIAGNOSIS:
Plain film radiographs are helpful to visualise
sialoliths
Occlusal radiograph taken at 90 degree from floor
of mouth - submandibular sialolith.
Conventional and contrast sialography
Ultrasound
Non contrast CT images
CBCT
MRI Sialography
Sialoendoscopy

Mandibular occlusal view revealing homogenous
radiopacity in the floor of the mouth on right side
Courtesy:Saluja H, Kasat VO, Mahindra U. Giant Sialolith in the Wharton’s duct causing sialo-
oral fistula: A case report and review of literature. J Orofac Sci 2012;4:137-42..

Orthopantomogram showing a well defined radiopacity in relation to lower
right second premolar and first molar
Courtesy:Saluja H, Kasat VO, Mahindra U. Giant Sialolith in the Wharton’s duct causing sialo-oral
fistula: A case report and review of literature. J Orofac Sci 2012;4:137-42..

TREATMENT
ACUTE PHASE : supportive therapy
 Standard treatment - use of analgesics,hydration,
antibiotics and antipyretics as necessary.
 Sialogogues, massage and heat applied.
 At the orifice : transorally by milking the gland
 Deeper stones : conventional surgery /
sialoendoscopy
 Extracorporeal shock wave lithotripsy

conclusion
Salivary glands are the important glands of the
oral cavity which produces saliva, an essential fluid
required for normal mastication, swallowing,
digestion and above all to maintain the normal
integrity of oral mucosa and teeth.
Proper knowledge about the normal anatomy and
functioning of the gland is necessary to diagnose if
any pathology is present. Careful histoey taking
and clinical evaluation will help in the early
diagnosis and treatment of salivary gland diseases

References
 Burket’s Oral medicine : Diagnosis and Treatment; 9th and
12th edition
 Salivary gland disorders—Myer’s, Robert( Springer)
 Cunningham’s manual of Practical Anatomy( volume III)
 B.D.Chaurasia Human Anatomy—4th edition, vol III
 Orban’s Oral Histology and Embryology: 11th and 12th edition
 Shafer’s textbook of Oral Pathology : 6th edition
 Gray's Anatomy Review Stephen W. Carmichael, Peter H.
Abrahams, Gene L. Colborn
 Jaskoll T, Melhick M. Embryonic salivary gland branching
morphogenesis. Madame Curie Bioscience Database. 2000-
2013. Landes Bioscience.
 Saluja H, Kasat VO, Mahindra U. Giant Sialolith in the
Wharton’s duct causing sialo-oral fistula: A case report and
review of literature. J Orofac Sci 2012;4:137-42.

 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.
 Rashid Al-alri, Franeirs, Marshal, new era of endoscopic
approach for sialolithiasis. Sialoendoscopy.SQUMEDJ,DEC
2010-VOL-10(3),382-387
 Adi .Y,submandibular siladenitis with medscape cons; june
25,2015
 B. RON,A guide to salivary gland disorders, medicine today
2006 7(2), 44-48
 Rastiger R,B sumeet,J Govindrajan ; pictorial essay; salivary
gland imaging. Indrian J Radrol imaging 2012 oct-dec

Thank you…………..

Submandibular salivary gland dr chithra

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