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原文題目(出處)： Central hemangioma—A case report and review of literature 原文作者姓名： Sharadindu M. Kotrashetti, Sarvesh B. Urolagin∗, Tejraj P. Kale,
Shridhar D. Baliga
通訊作者學校： Department of Oral & Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Nehru Nagar, Belgaum, Karnataka 590010, India 報告者姓名(組別)： 羅竣元(Intern B 組)
報告日期： 2011/10/11 內文：
1. Introduction
Vascular lesions of the maxillofacial region are classified as either: (i) hemangiomas or (ii) vascular malformations.
Hemangiomas are the most common cutaneous tumor of infancy and demonstrate rapid growth followed by a slow spontaneous involution or regression within five to seven years. Vascular malformations enlarge proportionately with the growth of the child and do not undergo spontaneous involution
Vascular malformations can be subdivided based on blood flow rate: slow flow” (capillary, venous, lymphatic or mixed) versus “fast flow” (arteriole, arteriovenous, fistulae or shunt) subtypes.
It mainly occurs in the vertebral column. Mandible is a very infrequent location although possible.
The female:male ratio is 2:1 and the peak of incidence is between the second and fifth decades of life [2,3].
2. Case history
An 18-year-old female patient reported with a complaint of swelling in the lower right side of the jaw since one and half years
Swelling was slowly increasing in size, which was of cosmetic concern to the young female
Clinical examination revealed approximately 2 cm×1.5 cm, diffused swelling on the right lower side of the face.
Skin over the swelling was normal and no neurological deficit was noted.
Intra oral examination showed vestibular swelling at number 44, 45 and 46 teeth region, which was hard on palpation. Swelling was hard on palpation and no pulsations or bruits were noted.
Slight mobility of number 45 tooth was noted, otherwise all other teeth were clinically normal.
Diagnostic panoramic radiograph revealed ill defined radiolucent area at the periapical region of premolar teeth
3. Diagnostic angiography
There was evidence of bony perforation both buccal and lingual side suggesting feeder vessels.
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Three dimensional reconstructed (3D) images of angiography showed unusually small facial artery with the branches entering the mandible (Fig. 2b). These branches were identified as supplying the lesion.
4. Treatment
Crevicular incision was made on the right side of the mandible. Mucoperiosteal flap was raised on both buccal and lingual side, ligating and cauterising the feeder vessels.
A bony window was made on the buccal cortex at the periapical area of lower right third molar region to reach the mandibular canal.
Mental neurovascular bundle seen emerging from the lesion was clamped and ligated.
Deroofing of the lesion was done from the buccal aspect.
Second premolar was extracted as it was left with no bone support.
5. Histopathology
Confirmed by histopathological study with evidence of proliferating endothelial cells forming small to large blood vessels
6. Discussion
The literature suggests that the lesion may present at any age, but was most commonly discovered in the second decade of life.
The most frequent location of hemangioma is the molar premolar region
There was ill defined radiolucency in the premolar region.
It is important to emphasise that some radiographic patterns, such as the spoke-like and sunray
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appearance, frequently described in other studies and textbooks, are actually extremely rare
Therapeutic alternatives include: surgery, curettage and embolization
Histologically, hemangioma can be divided into three groups: cavernous, is the most frequent one and is located in the mandible, capillary and mixed.
In the proliferative phase, the lesion is highly cellular and contains plump proliferating endothelial cells and pericytes, with a high mitotic activity and numerous mast cells. Vascular channels are not prominent.
In the involutive phase, the endothelial cells are flattened, the cell turnover is normal and there are few mast cells. Vascular channels filled with blood cells predominate, and the lesion is eventually replaced by fibrofatty tissue.
Complete cure by arterial embolization is difficult.
The direct transosseous puncture of the vascular bed has been proposed. This procedure controls the acute hemorrhagic phase, but does not eliminate the risk of a recurrence.
The newer technique, transmandibular curettage via proximal osteotomy without complete resection, however, is a less invasive but effective method to treat small intraosseous vascular lesions of the mandible that have not invaded the soft tissues. Less blood loss, preservation of the bone and periosteum, more favorable postoperative esthetics and better function are among the advantages of this technique when indicated. Azzolini et al. [30] presented an exclusively intraoral treatment by extracting the teeth and then cleaning the underlying cavity through the alveolar process and packing the mandible with oxidized cellulose after superselective intra-arterial embolization (SIAE). The technique reported consists of SIAE and piecemeal removal of the lesion through burred holes made in the cortex. Bone wax packing (BWP) of bone cavities was used to control hemorrhage of the lesions in emergency and carried out curettage 2 months later. This technique is reported as simple and safe. Bone tissue, dental embryo, erupted tooth, and lower alveolar nerve may be preserved in most cases. It reduces morbidity by maintaining the continuity of the mandible
Number 45 tooth was extracted. So, we employed the newer technique, transmandibular curettage via proximal osteotomy without complete resection.
Preservation of continuity of jaw bone, more favorable postoperative esthetics and better function.
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