Management of oral vascular malformation-Review of

literature

Dr. Huda Moutaz Ismael BDS-MSc

Dr. Mais Raad Kanger Dr. Mais majed Rahman

College of dentistry /University of BaghdadDepartment of oral & maxillofacial surgery

Introduction

• Vascular malformations (VMs): are developmental abnormalities of the vascular system. They should be differentiated from vascular tumors or hemangiomas, because they have different causes, growth patterns, treatments, and outcomes. (1)

• There is a primary distinction between a vascular tumor, which grows by cellular hyperplasia, and a vascular malformation, which represents a localized defect in vascular morphogenesis. (2)

Clinical differences between hemangioma and (VMs)

Picture available at: http://www.slideshare.net/Dravneet1/vascular-malformations (3)

Classification of (VMs)Vascular malformation can be categorized based on

their

Histological features hemodynamic features

Classification of Vascular Malformations

• Simple lesions (Low-flow)• Capillary (port-wine stain)• Venous• Lymphatic (lymphangioma)

• High-flow• Arterial

• Combined lesions• Ateriovenous• Lymphovenous

• Other combinations (4)

Lymphangioma

Classification of (VM)

• Current classifications of vascular abnormalities can help the practitioner to establish the correct diagnosis.

• Accurate diagnosis is essential because treatments vary according to the nature of the lesion.(5)

Radioraphical assessment Clinical assessment

Diagnosis of (VMs)

Histopathological examination

Laboratory examinations

Clinical assessmentAn accurate history and a thorough physical

examination are key to accurate diagnosis

Radiographical assessment of oral vascular lesions 1-Magnetic resonance imaging (MRI)

(8)

Radiographical assessment of oral vascular lesions

2-Angiography

Pic available at (9)

3-CT Scan (computed tomography)

4- Doppler ultrasound

Indications for treatment of the (OVMs)

Esthetic and functional problems Vascular malformations in the oral cavity cause

discomfort and potentially serious clinical problems. Tongue lesions can cause problems such as recurrent hemorrhage, biting of the lesion, pain, and difficulty with speaking, swallowing, mastication or deglutition.(12)

Clinical Hints in management of oral vascular malformation (OVM)

Based on the massive research reports , the following

principles must be followed in management of vascular

anomalies in oral and maxillofacial regions:

The targeted management should be depended on the correct recognition of the two

types of lesions, hemangiomas and vascular malformations.

For example, steroids are effective for proliferating hemangiomas, but non effective

for involuted hemangioma and vascular malformations, therefore, correct

differential diagnosis is critical to appropriate, individualized treatment. (13)

The choice of different treatment modalities is dependent on the phases, size, location, extent and depth of the lesions.

Small to middle sized venous malformations can be successfully treated by intralesional injection of Bleomycin A5, laser therapy or surgery, whereas combined sclerotherapy and/or surgery are the treatment of choice for larger venous malformations. Arteriovenous malformations can be treated by embolization with or without surgery. (13)

Treatment Options for (VMs)

1-Laser treatment 2-Ultrasound guided intralesional treatment of (VMs) 3-Surgery 4-sclerotherapy 5-Electrochemical therapy (ECHT) 6-Electric copper needle embolization 7-Embolization 8-Liquid nitrogen cryotherapy. (14)

Laser treatment Laser therapy is a mainstay of management of mucosal vascular

malformations nowadays with different wavelengths, different irradiation

parameters and application procedures.

They can be used in photocoagulation, vaporization or excision

procedures. The most used lasers are neodymium–yttrium–aluminum–

garnet (Nd:YAG) laser (1064 nm), potassium–titanium–phosphate (KTP)

laser (532 nm), diode laser (800–980 nm), pulsed dye lasers (585 and 595

nm), argon laser (514 nm) and carbon dioxide (CO2) laser (10,600 nm).

They have been found to be safe and effective in the treatment of

vascular anomalies (15)

The laser advantages Elimination of vascular lesion without significant hemorrhage Disinfection of the surgical wound No need for sutures less scaring, and less post-operative complications in

comparison with conventional surgery. (16,17)

The laser disadvantages Potential risks of laser therapy include: Thermal injuries to nerves Skin scarring due to laser treatments of superficial lesions. (18)

During the operation while performing the incision some fume were released from vaporization of epithelium with a burning smell, which can provoke stress and hurt in the patient, and for relief of this complication, it is necessary to operate with a powerful air evacuator, and to offer a block by temporary dam

Venous malformation on the tongue before and after a session of Nd:YAG laser treatment (fluence, 200J/cm2; pulse duration, 35ms; spot diameter, 3mm). Pictures available at (19)

Venous malformation on the tongue before and after a session of Nd:YAG laser treatment (fluence, 200J/cm2; pulse duration, 30ms; spot diameter, 3mm). Picture available at (19)

The laser can be used in different techniques: the traditional excisional biopsy (EB), and two less invasive techniques, the transmucosal thermocoagulation (TMT) and the intralesional photocoagulation (ILP). (20)

Transmucosal thermocoagulation (TMT)

• The TMT is based on the laser irradiation without contact of the fiber with the tissue. The preferable distance from the lesion surface is about 2-3mm. Energy must be applied with a scanning movement without keeping the fiber fixed on the same point for more than 5-10 seconds to avoid irreversible thermal effects

• During the treatment the lesion becomes lighter and smaller. This effect is called “forced dehydration” and it is due to the high absorption of laser energy by the blood into the lesion. (20)

Thin glass put over the lesion (TMT technique).Available at :http://www.medicinaoral.com/pubmed/medoralv18_i2_p279.pdf

Advantages TMT is really helpful if patients are affected by

systemic pathologies such as factor VIII of coagulation deficiency. In these cases there is no bleeding

safe and quick treatment permits a good resolution of the pathology without any risk, during and after the treatment

ILP & Ultrasound guided ILP (intralesional treatment of vascular malformation)

• Intralesional photocoagulation (ILP) technique using a laser is described for treatment of deep venous malformations in the oral cavity.

• The photocoagulation of the lesion was obtained by introducing the optical fiber inside the lesion, the laser power used is between 2 and 3 Watts in Continuous Wave (CW), with a continuous movement within the lesion.

• Alternatively, the mucosa may be perforated with an intravascular catheter of 14-18 gauge, and then introduce the fiber inside the lesion through this catheter. (21)

Intralesional photocoagulation performed by angio-catheter and KTP laser optical fiber positioned inside. (21)

A flexible laser fiber with diameter of 200 μm was introduced into the lesion via a 22-gauge needle, and the laser fiber was advanced in radial direction as photocoagulation proceeded within the tissueAvailable at http://www.tmj.ro/article.php?art=351563853712856

ILP Advantages: 1- ILP, often used for wide and deeper lesions that cannot be treated with Transmucosal Thermophotocoagulation (TMT). 2- It can be overall considered a safe technique. However, bleeding risk during this technique, can be reduced by using an ultrasound-guided intralesional laser treatment, as suggested by Miyazaki et al. in 2013. (21)

ILP Disadvantages: 1- The main risk related to the technique is that it is a “blind” procedure and has a risk of unintended destruction of surrounding normal tissue, so a great attention must be dedicated to the exact extent of the lesion to minimize the risk of peripheral tissues damages.

2- A higher risk of bleeding, especially due to the fiber penetration into the lesion.(20)

Surgical treatment• Surgical excision is usually considered to be the

definitive treatment for both superficial and deeper lesions.

• During operation, special care should be taken to preserve the facial and hypoglossal nerve in these cases and perform careful dissection with nerve monitoring and thorough hemostasis.

• Compound lesions should be initially treated with a laser to remove the superficial component and then followed with surgical resection or sclerotherapy for the deep component. (22)

The aim of surgery • The aim of surgery is to remove the malformations for

improvement of the contour and preserve the involved organs as much as possible for better function (22)

The disadvantages of surgery1- Attempts to excise large venous malformations usually cause significant morbidity and also cause significant scar formation. Therefore, surgical excision should be used for lesions that do not involve significant muscle groups or bones and should only be performed by an experienced surgeon2- Despite successful removal in many cases, most lesions recur after surgery. (22)

A) clinical picture of a vascular lesion in the cheek involving the BFP B) The vascular mass was removed as excisional biopsy through intraoral approach(23)

Sclerotherapy Sclerotherapy consists of the direct intralesional

injection of a sclerosing agent that causes the destruction of endothelial surfaces with subsequent thrombosis, leading to intimal fibrosis and obliteration of the vessel lumen .

This procedure has been largely and successfully used for the treatment of symptomatic venous malformations and can be considered the treatment of choice for small and middle-sized superficial and deep venous malformations of the oromaxillofacial and cervical regions. (24)

The sclerosants commonly used are 5% sodium morrhuate, pingyangmycin (PYM), anhydrous ethanol and lauromacrogol, bleomycin.

monoetanolamine

Clinical picture of the patient showing facial asymmetry as result of right zygomatic swelling; B) Intraoral view shows bluish mass extending to the soft palate when the patient presented to the clinic for the first time; C) Intraoral photograph of the same patient 18 months after first presentation. The lesion increased in size, bled easily and appeared darkens with bad oral hygiene and heavy calculus at the right side of the jaw.(25)

A) The catheter loaded with ethanol in place during injection; B) Contrast medium is injected into the lesion and an X-ray is taken to make sure that the catheter is within the lesion itself; C) An angiogram shows ethanol injection within the lesion(25)

A) Postoperative picture of the lesion one and B) three months following injection. (25)

Complication of sclerotherapy• Complications of sclerotherapy include allergic

reactions, cutaneous or mucosal necrosis, and sensory nerve or motor nerve injuries such as facial paralysis. These complications occur more often after injection of absolute ethanol and sodium morrhuate but seldom PYM injection (26, 27).

Electrochemical therapy (EDHT) Electrochemical therapy (EChT) is a new alternative for the

treatment of patients with symptomatic low-flow venous malformations who are not good surgical or sclerotherapy candidates or failed to sclerotherapy and/or surgery (28)

Mechanisms of treatment • The primary mechanisms of treatment is creating local

changes in the pH of the tissues surrounding the electrodes, and also creating toxic products such as chlorine and hydrogen ions from chemical reactions in the vicinity of the electrodes, causing electrolysis of the tissues, which are more susceptible to direct current than normal tissues. The pH change (12 in the area around the negative electrodes and 1—2 in the area around the positive electrodes) depolarizes and destroys the endothelial cell membranes, resulting in thrombosis, fibrosis and regression of the lesions (28)

Electrochemical therapeutic apparatus and electrodes: ZAY-B electrochemical therapeutic instrument and platinum electrodes made in China.

Figure 22: M. 32 y. Huge vascular lesion in tongue. The tongue dropped out of mouth and had a malfunction (Photo 1). 1 year after EChT. Well function of tongue recovered (Photo 2).Available at: http://www.hindawi.com/archive/2013/858319/fig22/

Electric copper needle embolization

• Electric copper needle embolization is another option for the treatment of venous malformations. When properly applied in selected patients, satisfactory results could be achieved.(Dissociation of copper ion and agglutination of red blood cells are the essential mechanisms in electrothrombosis with copper needle. A 4—6 V galvanic current lasting for 15—20 minutes is usually used for safe and effectivetreatmen (29)

Embolization of Vascular Malformations

• Embolization is defined as the "therapeutic introduction of various substances into the circulation to occlude vessels, either to arrest or prevent hemorrhaging; to devitalize a structure, tumor, or organ by occluding its blood supply; or to reduce blood flow to an arteriovenous malformation. (30)

Intraosseous AVM of mandible in a 16-year-old female who presented with massive bleeding per gum status post external carotid artery ligation. A) Axial CT scan revealing osteolytic appearance of the malformation. B) Left internal carotid angiogram exhibiting reconstitution of the internal maxillary artery from anastomosis of ILT with consequence supply to the AVM via inferior alveolar artery. C) Recruitment of the external carotid system from anastomosis of vertebral artery too. D) Frontal and E) Lateral projection during NBCA embolization via direct transosseous puncture. F) Left internal carotid angiography and G) Left vertebral angiography immediate post embolization demonstrating complete obliteration of the malformation.(31)

Embolization may have 3 therapeutic goals:

1.Anadjunctive goal (eg, preoperative, adjunct to chemotherapy or radiation therapy)2.Acurative goal (eg, definitive treatment such as that performed in cases of aneurysms, arteriovenous fistulae [AVFs], arteriovenous malformations [AVMs], and traumatic bleeding)3. A palliative goal (eg, relieving symptoms, such as those of a large AVM, which cannot be cured by using embolotherapy alone) (32)

Embolisation Agents:

• Polyvinyl Alcohol Foam Particles (PVA)• Embospheres• Gelfoam• NBCA –Histoacryl (Glue)• OnyxTM Liquid Embolic System• Coils.

• Balloons. (33)

NBCA –Histoacryl (Glue)

.

Gelfoam

OnyxTM Liquid Embolic System

Embospheres

Coils

Disadvantages of embolization • The risk of embolization material reaching cranial

cavity via external and internal carotid arteries • The need for an experienced radiologist in order to

perform this procedure. (34)

Cryotherapy • Cryotherapy is derived from the greek word“kryos”

means frost hence cryosurgery is local destruction of tissue by freezing

• Any biological tissue subjected to temperature below -20 degree centigrade will undergo cryogenic coagulation and necrosis, nothing is excised; rather, the lesion is frozen and the resultant necrotic tissue is allowed to slough spontaneously. (35)

• Cryotherapy used in the treatment of oral vascular malformations: The lesion resolves completely without scar in most cases. Two freeze thaw cycle for 1 ½ minute each is given.

Application of liquid nitrogen via the utilization of the large contact tip to the lesion. (37)

Cryotherapy

Necrotic and sloughing area at the postoperative first week

Cryotherapy advantages:

• Minimal general disturbance to the patient, particularly well accepted by the elderly. • Low complication rate. • Reasonably predictable volume of tissue destruction. Particularly suited to extensive superficial lesions. • May be used as an adjunct to surgery and/or radiotherapy in palliative tumor control. • Cryosurgery is a very safe, easy to perform, and relatively inexpensive technique for treating various oral lesions in an out-patient clinic.(36)

Cryotherapy disadvantages & complications:

• Vesicle formation • Exposure of bone if probe applied to areas with thin mucoperiosteal surfaces such as mucosa over lingual aspect of mandible. • Peripheral nerve fibers may be painful following moderate freezing of adjacent structures, possibly due to the action of cellular breakdown products. • The late complications are appearance of pseudoepitheliomatous hyperplasia, post-surgical infection, fever, and pyogenic granuloma. (35)

Complication of oral vascular malformation

Complications of oral vasoformative tumors can be divided into 2 general types: • 1-complications related to the disease

process: • include hemorrhage, high-output states, infection,

function problems (eg, airway, vision, hearing), thrombocytopenia, and ulceration. Ulceration is the most common complication of capillary hemangiomas and typically occurs centrally in large lesions. It may result in scarring and does not hasten resolution of the lesion. Ulceration may become secondarily infected and is readily treated with local wound care. Bleeding is one of the most common reasons that patients with oral hemangiomas and vascular malformations seek care. (38)

2-complication from treatment: • A-With the 2 medical treatments, steroids and interferons,

the complications are the well-known adverse effects of the

drugs. No special complications are related to the treatment

of vasoformative tumors, other than nonresponse to

treatment

• B-With embolotherapy, complications can range from minor

to life threatening. Complications are often related to

specific kinds of embolizing devices and techniques.

• C-Complications related to sclerotherapy include the

following: skin necrosis (4%), temporary myoglobinuria

(2%), and airway compromise (1%). (38)

Conclusion

Conclusion Treatment of vasoformative tumors represents a challenge

because the morbidity can range from minor bleeding and swelling to life-threatening hemorrhage and airway embarrassment. Treatment of oral vascular depends on the proliferative nature and the extent of the lesions and on the functional impairment, usually hemorrhage and airway problems. For limited lesions, treatment for cosmetic reasons may be an acceptable risk-benefit decision.

It is important that these lesions be correctly diagnosed. Not only will AVMs that are misdiagnosed as hemangiomas and treated as such fail to respond to medical treatment with pharmacologic agents, error in surgical management of such lesions may also result in treatment failure and loss of angioaccess for proper management of the lesion in the future. (51)

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