Surgical technique for the treatment of high-flow arteriovenous malformations of the mandible

Intraosseous resection of mandibular arteriovenous malformations: A mandible sparing multi-disciplinary case series

Mandibular arteriovenous malformations (AVMs) are high flow vascular malformations that can cause pain, hypertrophy, deformity, malocclusion, jaw asymmetry, bone destruction, tooth loss, and severe bleeding [1]. Although general principles apply, the rarity of mandibular AVMs limits definitive agreement on the best course of treatment. Current treatment options include embolization, sclerotherapy, surgical resection, or some combination of techniques [2]. [3]. An alternative multidisciplinary technique of embolization with mandibular-sparing resection is presented. This technique aims to mitigate bleeding with effective removal of the AVM, while preserving mandibular form, function, dentition, and occlusion.

Comprehensive Treatment of Upper Lip Arteriovenous Malformation

Arteriovenous malformations are uncommon congenital disorders in vascular development. They frequently involve craniofacial structures and result in a morphogenic abnormality with ominous arteriovenous shunting. We present a huge AVM of the upper lip in an 18-year-old patient who was successfully treated by the combination method of presurgical endovascular embolization and complete resection of the lesion. Subsequent surgical defect in upper lip, which involved more than two-third of the lip length, was reconstructed via Webster's modification of cheek advancement flap.

Percutaneous sclerotherapy of arteriovenous malformations of the face using fibrin glue combined with OK-432 and bleomycin after embolisation

Congenital arteriovenous malformations (AVM) in the maxillofacial region are rare, but potentially life-threatening, vascular lesions. Here we review our experience of 13 patients with AVM of the facial soft tissues who were treated using percutaneous sclerotherapy with fibrin glue combined with OK-432 and bleomycin after embolisation. The mean (range) follow-up was 27 (14-58) months. Three of the lesions were completely controlled, eight were nearly completely controlled, and the other two were partly controlled. Our experience is that percutaneous sclerotherapy of arteriovenous malformations of the face using fibrin glue combined with OK-432 and bleomycin after embolisation is safe and effective.

Gingival bleeding of a high-flow mandibular arteriovenous malformation in a child with 8-year follow-up

Intraosseous arteriovenous malformations (AVMs) in the head and neck region are uncommon. There are several types and they can have a wide range of clinical presentations. Depending on the blood flow through the AVM, the treatment may be challenging for the attending team and may lead to life-threatening hemorrhages. A clinical case report is presented. A 9-year-old girl, seen for gingival bleeding during oral hygiene, was found to have a high-flow AVM located within and around the mandible. Two-stage treatment consisted of intra-arterial embolization followed by intraoral injection of a sclerosing agent 8 weeks later. At the 8-year follow-up, imaging study showed no evidence of recurrent lesion inside or outside the bone. The final outcome is a correct occlusion with a symmetric facial result. This case shows that conservative treatment may be the first treatment option mostly in children. Arteriography and transcortical injection were enough to control the AVM.

Comprehensive treatment and rehabilitation of a patient with maxillary arteriovenous malformation

Arteriovenous malformations (AVMs) of the maxilla are rare and potentially life-threatening conditions that can pose a therapeutic dilemma. We reported the first case of maxillary AVM in a 15-year-old girl who was treated by marginal hemimaxillectomy including overlying palatal mucosa and immediate replantation of the segment after removing the AVM tissues and teeth and covering by a full-thickness pedicled temporal muscle flap rotated into the mouth. Then, this preserved bone underwent distraction osteogenesis and dental implant rehabilitation successfully. This method was previously used for the definitive treatment of mandibular AVMs, and in this case, we applied this method for the first time in maxillary AVMs. In conclusion, this surgical method may be considered as a safe, convenient, and effective treatment and reconstructive modality for such vascular malformations in the maxilla and restores function and symmetry of the jaws while obviating the need for bone harvesting and future major reconstructive operations.

New bone formation after ligation of the external carotid artery and resection of a large aneurysmal bone cyst of the mandible with reconstruction: a case report

The aneurysmal bone cyst (ABC) is a benign cystic and expanding osteolytic lesion consisting of bone-filled spaces of variable size, separated by connective tissue containing trabeculae of bone or osteoid tissue and osteoclast giant cells. Radiographic findings may vary from unicystic or moth-eaten radiolucencies to extensive multilocular lesions with bilateral expansion and destruction of mandibular cortices. Treatment modalities include curettage (with reported recurrences) and resection with immediate reconstruction. The main arterial and feeder vessels may be embolized to prevent profuse intraoperative blood loss and achieve a bloodless surgical field. Failed embolization may necessitate ligation of the external carotid artery of the affected side.

Case report: Combined transarterial and direct approaches for embolization of a large mandibular arteriovenous malformation

Arteriovenous malformations (AVMs) that involve the mandible are difficult lesions to treat, with traditional options being surgery and embolization. This article describes a large mandibular AVM that was treated with embolization using transarterial as well as direct puncture approaches. Follow-up imaging showed thrombosis of the vascular spaces of the malformation. There were no complications. The patient is doing well and is on follow-up.

Face skin necrosis following embolization for arteriovenous malformations: a case report

INTRODUCTION

Arteriovenous malformations (AVMs) are rare in the oral and maxillofacial regions.

DISCUSSION

AVMs may induce severe complications such as uncontrollable bleeding. Superselective intra-arterial embolization is an effective method for this bleeding that is refractory to conservative treatment. Arterial embolization may cause ischemic complications. We report the case of a patient who developed face skin necrosis following bilateral facial artery embolization.

A multidisciplinary approach to treating maxillofacial arteriovenous malformations in children

OBJECTIVE

Congenital arteriovenous malformations (AVMs) in the maxillofacial region are rare, potentially life-threatening, vascular lesions. This study reviewed our experience with a multidisciplinary approach to treating maxillofacial AVMs in children.

STUDY DESIGN

Thirteen patients (10 boys and 3 girls) with AVMs involving the facial soft tissues or jaws were treated using a multidisciplinary approach that included: 1) superselective intra-arterial embolization (SIAE); 2) bone wax packing (BWP) of the bone cavity and curettage; and 3) compartmentalization and sclerotherapy.

RESULTS

The mean follow-up was 13.5 months, with a range of 6-22 months. The following outcomes were obtained: 9 lesions (69.2%) were completely involuted, 3 lesions (23.1%) were mostly involuted, and 1 lesion (7.7%) was partially involuted. The rates of completely and mostly involuted AVMs involving the jaws treated using SIAE, BWP, and curettage were 80% and 20%, respectively. The rates of completely, mostly, and partially involuted AVMs involving soft tissues treated by compartmentalization and sclerotherapy were 60%, 30%, and 10%, respectively.

CONCLUSION

SIAE was reliable for controlling bleeding and as adjunctive treatment for maxillofacial AVMs in children. SIAE followed by BWP of the bone cavity and curettage was a simple, safe, and effective method for treating AVMs of the jaws; SIAE followed by compartmentalization and the injection of OK-432 and pingyangmycin was a reliable alternative treatment for AVMs of the soft tissues in the maxillofacial region.

Treatment of arteriovenous malformations: assessment of 2 techniques--transmandibular curettage versus resection and immediate replantation

PURPOSE

This study evaluates 2 surgical methods used at our center for the treatment of mandibular arteriovenous malformations (AVMs): resection with immediate replantation and curettage via proximal transmandibular osteotomy.

PATIENTS AND METHODS

Patients with AVMs of the mandible who were treated during a 17-year period between 1992 and 2008 at our department were assessed. Two surgical techniques were used for treatment: 1) resection of the segment, curettage of the intrabony lesion, extraction of involved teeth, and immediate replantation and 2) proximal osteotomy curettage of the lesion within the bone and extraction of involved teeth. In the replantation group the resected segment of the mandible was replanted after the contents were scraped out and the involved teeth removed. In contrast, in the proximal osteotomy group this was done without removal of the bone segment. In both techniques the cortical bone of the mandible was maintained. However, in the transmandibular curettage group the periosteum was not entirely stripped off because curettage was done via proximal osteotomy without removal of the segment. The entire intrabony lesion and a margin of cancellous bone related to the lesion were excised in both groups. The bone was fixed with titanium plates in all cases. All patients were followed up annually for a period of 1 to 17 years (mean, 9.5 years).

RESULTS

We treated 12 patients with mandibular AVMs (2 male and 10 female patients). Their ages ranged from 7 to 17 years. Preoperative angiography showed high-flow central vascular lesions in all patients. Of the lesions, 7 (58%) were treated via resection with immediate replantation and 5 (42%) were treated via transmandibular curettage. Embolization was performed in 4 cases 48 hours before surgery. However, blood loss was not significantly decreased by embolization. The lesions were categorized as multilocular (58.3%) or unicystic (41.7%) based on the radiographic findings and were located in the mandibular body (66.7%) or ramus (33.3%). Blood loss averaged 1.60 L in the group undergoing resection and immediate replantation and 1.30 L in the transmandibular curettage group. During the follow-up period, no recurrences were encountered in either group via clinical, radiographic, or computed tomography scan assessment, and none of the patients had facial deformities develop.

CONCLUSIONS

The results suggest that transmandibular curettage via proximal osteotomy without complete resection is an effective less invasive method with which to treat AVMs of the mandible provided that the lesion is small, is confined within the bone, and has not invaded the soft tissues. Less blood loss, preservation of the bone, more favorable postoperative esthetics, and better function are among the advantages of this technique. In more extensive cases and those involving both hard and soft tissues, resection with immediate replantation is recommended. Both techniques obviated the need for bone graft reconstruction. This technique is better than resection and discarding of the segment.

Arteriovenous fistula of the mandible simulating an odontogenic cyst. A case report

SUMMARY

We describe a rare case of mandibular highflow arteriovenous malformation (AVM) mimicking an odontogenic cyst in a young man. The diagnosis of mandibular AVM was made by CT angiography and confirmed by digital subtraction angiography. CT scan showed the extent of mandibular bone alteration and a double enlarged mandibular canal on the same side. An AVM containing a large aneurysm was demonstrated by CT angiography.The mandibular AVM was successfully treated by endovascular therapy with Guglielmi detachable coils. On panoramic radiogram, mandibular AVMs can appear as cystic lesions without pathognomonic features. Several benign and malignant tumours of this anatomical region must be considered in the differential diagnosis.We emphasize the radiological sign of double enlarged mandibular canal and the diagnostic role of CT, particularly CT angiography, to discriminate a mandibular AVM from neoplastic entities of this region, sparing the risks of a needle biopsy.

Comprehensive Treatment of Arteriovenous Malformations in the Oral and Maxillofacial Region

PURPOSE

Arteriovenous malformations (AVMs) in the oral and maxillofacial region are rare but potentially life-threatening vascular lesions. We report our experience in treating these lesions in the oral and maxillofacial region.

PATIENTS AND METHODS

Superselective intra-arterial embolization (SIAE), sclerotherapy, bone wax packing of bone cavity and curettage, radiotherapy, and surgical resection were used alone or in combination in 28 patients with AVMs in the oral and maxillofacial region. Among them there are 13 cases involving the soft tissue, 11 cases involving bone, and 4 cases involving both the soft tissue and bone.

RESULTS

Follow-up ranged from 3 to 60 months (median, 22 months) after comprehensive treatment. The rates of improvement and cure were 89.3% and 60.7%, respectively. Sclerotherapy in 6 cases of AVMs was ineffective. The rates of improvement and cure in AVMs involving soft tissue treated by surgical resection were 23.1% and 84.6%, respectively. The rates of cure for AVMs involving the jaws treated by SIAE, bone wax packing, curettage, and partial bone resection alone or in combination was 100%.

CONCLUSION

Three cases of AVMs involving both soft tissue and bone treated with SIAE and radiotherapy as well as surgical resection were cured. SIAE was an adjunctive treatment for the AVMs of soft tissue and jaws and for controlling bleeding. Surgical resection was an important treatment modality for AVMs. Bone wax packing of bone cavity and curettage was a simple, safe, and effective method for the treatment of AVMs of the jaws. Radiotherapy and sclerotherapy may not be effective methods for AVMs involving the soft tissue.

Maxillofacial rehabilitation of a large facial defect resulting from an arteriovenous malformation utilizing a two-piece prosthesis

Large facial defects involving the oral cavity can be difficult to restore prosthetically because of a lack of anatomic undercuts, limited means of retention, mobility of soft tissue margins, and the weight of the prosthesis. Use of skin adhesives may be precluded because of the presence of persistent moisture and saliva. The maxillofacial rehabilitation, including the design and fabrication of a 2-piece silicone prosthesis retained by the teeth, of a patient with a large facial defect as a result of treatment for an arteriovenous malformation is described. The pathogenesis and therapeutic alternatives for arteriovenous malformations is also discussed.

Direct-puncture embolization of intraosseous arteriovenous malformation of jaws

PURPOSE

Our goal was to report our experience with direct-puncture embolization of intraosseous arteriovenous malformations (AVMs).

PATIENTS AND METHODS

Three cases of AVM in the mandible and 2 cases of AVM in the maxilla comprised this study group. The patients were embolized with fiber coils through direct puncture, and the coils were placed directly into the center of the intraosseous lesion, in some cases in conjunction with polyvinyl alcohol foam and N-butyl-2-cyanoacrylate through vascular access.

RESULTS

The acute arterial bleeding was controllable in 3 patients. The other 2 patients had pericoronal oozing bleeding and a warm soft pulsative mass on the left face, respectively; their symptoms and signs improved greatly. The pericoronal oozing of blood in all patients disappeared during a 3- to 13-month follow-up, and new bone formation was found on the follow-up radiography.

CONCLUSIONS

The embolization of the AVM of jaws by direct percutaneous puncture in conjunction with endovascular therapy is effective and safe, but longer follow-up is required to determine the true efficacy of this method of treatment.