Central Hemangioma: An Overview and Case Report

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:Central Hemangioma: An Overview and Case Report
Author(s): Nikhil Marwah, MDS, Archana Agnihorti BDS, Samir Dutta, MDS
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. vol 28 No 5. 460-467
Major topic: Central Hemangiomas
Minor topic(s): Differential diagnosis, treatment options, Case report
Overview of method of research: Review/Case Report

Findings:
Hemangioma is a benign tumor characterized by proliferation of blood vessels. Presentation of a central hemangioma (CH) in the maxilla or mandible is rare. The literature differs on the origin of CH. Some believe it is a reaction from endothelial proliferation, while others contend it is a hamartoma resulting from proliferation of mesoderm that differentiates and becomes vascularized. CH also may be congential in origin. However it is agreed that it is benign. Some CH exhibit large size increases and can be locally destructive. CH occurs most commonly in the mandible (usually the body, sometimes the condyle) with a male:female ratio of 1:3 with peak incidence in the second decade of life. A CH may contain fibrous CT, osseous tissue, or cavernous blood vessels. The characteristic appearance of CH is a sunburst, or soap bubble pattern.
CH is a great mimicker of other conditions. CH may be in the differential diagnosis for:
1. Osteosarcoma
2. FD
3. Central giant cell granuloma
4. Ameloblastoma
5. Multiple myelome
6. Dentigerous cyst
7. Odontogenic cyst
8. Central ateriovenous fistula (clinically)
9. Aneurysms (clinically)
10. Shunts (clinically)

Clinical Findings
A CH may show little to no evidence of any intrabony lesion. Possible symptoms are pain including referred pain to the ear, TMJ, and condyle, swelling, or throbbing, and may be present from 1 week to 10 months. Referred pain to the ear, TMJ, and condyle is possible as well.
Dental findings may include
1.Occlusal derangement
2. Displaced teeth
3. Supraeruption
4. Premature exfoliation of primary teeth
5. Early eruption of teeth.

Radiographic Appearance
Usually presents as an area of altered radiodensity, usually osteolytic, occasionally w/ central radiopaque areas and a trabecular pattern. Trabeculae are arranged as spokes of a wheel, radiating from the center to the periphery. A soap bubble, sunburst or honeycomb pattern is possible as well. Nearly any combination of lesion size, shape, location or pattern can develop, with well defined, ill defined, and scalloped margins all being possible. Due to the ambiguity of the radiographic exam of a CH, diagnosis by radiographs alone is impossible.

Histology
This is the diagnostic test for a CH. It can either be capillary, cavernous, or mixed.

Diagnosis
A biopsy is 100% necessary for proper diagnosis. However due to the vascular nature of CH, uncontrollable bleeding must be considered. Angiography is a very useful diagnostic tool, as is aspiration.

Treatment
1. Radiotherapy(500-3300 R)-Used when the lesion is inaccessible to surgery
2. Injection of sclerosing agents (Boiling H20, Na morrhuate, Na tetradecly sulfate)-Very irritating, thrombogenic
3. Surgical removal-Risky, but still used the most frequently. Sometimes surgery and embolization (occlusion of vessels feeding the lesion) are used in conjunction. The biggest concern is hemorrhaging.

Case Report
8 yo Indian boy presented with a mandibular left side swelling that had been present for 10 months. The child’s primary molar had been ext’s before the start of the swelling. It started out small, then grew for the first 5 months. The child had minor ‘tooth’ pain. The swelling was confined to the left, lateral aspect of the mandible, it was hard, nonhyperthermic, and only sensitive to deep palpation. PA’s we non descript. A panorex showed coarse trabeculations and an increased radiodensity extending from the mand. lateral incisor to the 1st molar. The tooth buds of the canine and second premolar were affected. There was a definite honeycomb appearance. Lab reports were all normal. Fine needle aspiration was done to confirm the diagnosis. The child was admitted to the hospital, declared healthy, and prepped for surgery. A submand. Incision was made from the angle of the mandible to the symphyseal area. Enbloc resection of the lesion, including 1 cm of healthy bone was performed. A nickel titanium plate was placed over the defect. Further lab tests confirmed the lesion was a CH. 8 weeks post surgery the child was healing well, and the graft was being planned.

Key points/Summary:
Diagnosis cannot be made by clinical exam and/or radiographic exam alone. The three treatment options all have their pro’s and con’s. Many factors must be taken into account before deciding which treatment is best. CH must always be considered in the DD and proper precautions must be taken in establishing the final diagnosis before any tx is initiated.

Assessment of Article: Good, thorough review of CH and it’s implications. I thought the case report was ok. Would have liked to see more pictures and radiographs and the follow up of the boy. Overall a good review.