Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 124-127  

Laser excision of intraoral capillary hemangioma


Department of Periodontics, SRM Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission19-Apr-2020
Date of Decision15-May-2020
Date of Acceptance02-Jun-2020
Date of Web Publication27-Jan-2021

Correspondence Address:
Sangeetha Subramanian
Department of Periodontics, SRM Dental College and Hospital, Ramapuram, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_81_20

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   Abstract 


Hemangiomas are benign tumors of the blood vessel origin. They appear as raised or flat reddish-blue lesions and are generally solitary, affecting women in younger age groups. The tumor may be slowly progressive, involving extensive portions of the superficial and deep blood vessels, and affect function, depending on the location. They are mostly common in the head and neck region but rarely in the oral cavity. This case report presents a case of capillary hemangioma in the labial mucosa of a female patient, which was diagnosed by histopathology after laser excision.

Keywords: Benign tumors, capillary hemangioma, laser excision


How to cite this article:
Subramanian S, Dalmia P, Samuel Gnana PP, Appukuttan D. Laser excision of intraoral capillary hemangioma. J Nat Sc Biol Med 2021;12:124-7

How to cite this URL:
Subramanian S, Dalmia P, Samuel Gnana PP, Appukuttan D. Laser excision of intraoral capillary hemangioma. J Nat Sc Biol Med [serial online] 2021 [cited 2021 Jun 13];12:124-7. Available from: http://www.jnsbm.org/text.asp?2021/12/1/124/307860




   Introduction Top


Hemangiomas are developmental vascular abnormalities and are rated by many as a benign origin closely resembling a normal cell belonging to an endothelial origin.[1],[2] They are widely classified by the type of blood vessels being involved into capillary and cavernous.[3] The most common type is capillary hemangioma, mostly occurring as a small localized lesion, and has less aggressive clinical behavior. However, cavernous hemangioma is the most aggressive kind-generating infiltrated lesions.[3] The pathogenesis of hemangiomas is attributed mostly to genetic and cellular factors. Imbalance in the angiogenesis, which causes an uncontrolled proliferation of vascular elements, associated with substances, such as vascular endothelial growth factor, basic fibroblast growth factor, and indoleamine 2,3-dioxygenase, which are found in large amount during proliferative stages, is believed to be the cause.[4]

Hemangiomas account for about 60%–70% lesions in the head and neck region and are seen rarely in the oral cavity, having a predilection for women and children.[5] Clinically characterized as a soft, smooth, or lobulated mass, which are sessile or pedunculated, they may be seen in any size ranging from a few millimeters to several centimeters.[2] The color usually varies from pink to red purple which occurs either spontaneously or after minor trauma. They are usually self-limiting; however, in certain scenarios, they can become symptomatic and may need therapeutic intervention, which may include surgical excision, cryotherapy, embolization, laser therapy, and corticosteroids. No gold standard treatment has been approved, till date.

Oral hemangiomas are usually seen on the gingiva and less frequently at other sites, including palate, buccal mucosa, alveolar ridge, and salivary glands.[6] The presentation of hemangioma at the labial mucosa may cause a lot of problems, being susceptible to trauma, producing cosmetic deformity, recurrent hemorrhage, and functional problems with speaking and mastication. This article describes about a 24-year-old female patient with painless swelling on the labial mucosa and its management, which was diagnosed histologically as capillary hemangioma.


   Case Report Top


A female patient aged 24 years reported to the Department of Periodontology, SRM Dental College, Ramapuram, Chennai, with a painless enlargement on the left labial mucosa in relation to canine–premolar region in the last 7 months. A comprehensive intraoral examination revealed soft tissue overgrowth [Figure 1] which was pink in color, soft in consistency, nonpulsatile on palpation, and sessile in origin arising from the labial mucosa in relation to 33–35 region. The margin of the lesion is about 3.5 cm × 2 cm in diameter with no secondary ulcerations or bleeding. Dental history revealed extraction of the tooth 34 which was done 8 months back followed by which the orthodontic management was undertaken. The oral hygiene was reasonably good. Medical history non contributory. A provisional diagnosis of fibroma was made based on the clinical resemblance and the assumption that the patient was undergoing orthodontic treatment. Differential diagnosis, Pyogenic granuloma, lipoma, peripheral giant cell granuloma. Preoperative hematological test revealed all the relevant findings to be normal. The treatment plan included was complete scaling followed by excision of the lesion using soft tissue diode laser as confirmatory diagnosis was yet to be elucidated. The lesion was excised under 2% lignocaine with 1:80,000 adrenaline under soft tissue laser of 810 nm, under the settings of 2.5 watts, contact, and pulsed mode. An excisional biopsy was thus made for histopathological examination. Layering sutures using 3-0 black silk (nonresorbable) were given postexcision for achieving primary wound closure. Analgesic ibuprofen 400 mg oral was prescribed with clear instructions to be taken only if necessary followed by other postsurgical instructions being given. The excised lesion was sent for histopathological examination after fixing in 10% neutral buffered formalin. The hematoxylin and eosin-stained soft tissue section showed lobulated cellular growth which is divided by fibrillar connective tissue being composed of loose bundles of collages fibers. They contain proliferating endothelial cells in combination with numerous well and poorly canalized blood vessels. The overlying epithelium is parakeratotic stratified type. It is sparsely infiltrated with chronic inflammatory cells, predominantly lymphocytes [Figure 2] and [Figure 3]. On the basis of clinical examination and histopathology, a confirmatory diagnosis of lobulated capillary hemangioma was made.
Figure 1: Preoperative intraoral view of the lesion

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Figure 2: Photomicrograph showing lobulated cellular growth with intervening connective tissue stroma (H and E, ×10). (A) Lobular aggregates, (B) salivary gland-acini, (C) small- and large-sized blood vessels with engorged red blood cells, (D) epithelial cells, (E) extravasated red blood cells, (F) connective tissue septa

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Figure 3: Photomicrograph showing blood vessels lined by endothelial cells and overlying epithelium is stratified squamous parakeratotic type (H and E, ×40). (A) Blood vessels, (B) densely arranged connective tissue, (C) extravasted red blood cells, (D) lining epithelium

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The patient was recalled within 10 days for suture removal, and satisfactory uneventful healing was seen to occur within 1 month. The patient is under follow-up to monitor the reoccurrence [Figure 4].
Figure 4: Six months' postoperative intraoral view

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   Discussion Top


Accurate diagnosis of the type of vascular lesion is important as it may influence the treatment planning and outcome considerably. The classification system of Mulliken and Glowacki[7] is based on cellular approach. It is simple and less confusing than older classification systems. Vascular lesions can be divided into those characterized by endothelial proliferation (hemangiomas) and those with normal endothelial turnover (vascular malformations). Although hemangioma is considered one of the most common soft tissue tumors of the head and neck, it is relatively rare in the oral cavity and uncommonly encountered by the clinicians.[8] On the basis of history given by the patient and the clinical examination, a provisional diagnosis of fibroma was made. Multitude of other lesions in the oral cavity can be resembled as hemangiomas, with the differential diagnoses comprising pyogenic granuloma (PG), chronic inflammatory gingival hyperplasia, epulis granulomatosa, telangiectasia, angiosarcoma, squamous cell carcinoma, and other vascular appearing lesions of the face or oral cavity, such as Sturge–Weber syndrome.[9] Therefore, microscopic evaluation is mandatory to come to a definitive diagnosis.

PG and hemangiomas can present a diagnostic dilemma to a clinician as they share common clinical findings with high incidence in females. Microscopically, PG is classified into two types, lobular capillary hemangioma (LCH) and non-LCH. LCH type consists of an attenuated endothelial lining surrounded by uniform proliferation of the plump to spindle cells, whereas capillary hemangioma consists of more prominent endothelial cells and an array of capillary-sized blood vessels with lobular architecture. In LCH type of PG, capillaries are frequently arranged perpendicular to the surface.[2],[10] In fibroma, dense connective tissue is more with less budding capillaries with respect to capillary hemangioma. Based on the histological findings and clinical examination, a confirmatory diagnosis of capillary hemangioma was made.

Hemangiomas are generally characterized by three stages, namely endothelial cell proliferation, rapid growth, and spontaneous involution.[8] No details are available regarding their incidence in the Indian population.[3]

The treatment of hemangiomas of the oral mucosa depends upon various factors, such as the age of the patient, the size of the lesion, extent of the lesion, the site of involvement, and the clinical features. The most common treatment modality of hemangioma is surgical excision of the lesion, with or without ligation of vessels and embolization.[3],[8],[9],[11]

Surgical management is to be carried out with caution as attempts to remove hemangiomas using surgical excision may lead to serious medical problems, such as heavy bleeding. In addition, postoperative recurrence may encounter. Recently developed treatment modalities include steroid therapy, electrosurgery, laser, cryosurgery, and sclerotherapy. Sclerotherapy is being used largely in recent times because of its ability and efficiency to preserve the surrounding tissue. Current management consists of spontaneous involution, steroid therapy, and chemotherapy.[12]

In this report, treatment option chosen was excision using soft tissue diode laser based on clinical judgment. Diode laser (810–1064 nm) has become very popular in the general dentistry because of their small size, low cost, fiber optic delivery, and ease of use. Genovese et al.[13] reviewed the use of surgical lasers in hemangioma treatment. It has been shown that the use of high-potency diode laser in the treatment of hemangioma reduces bleeding during surgery, with a consequent reduction in operating time, and promotes rapid postoperative hemostasis. It has been shown in previous reviews about its safety for use on large lesions, ease to manage with minimum postoperative problems, including potential scarring, and discomfort.


   Conclusion Top


Hemangiomas are common benign vascular growth; however, since their occurrence is a rare entity, it becomes imperative for dental professionals to evaluate them clinically and undertake all necessary investigations. It is mandatory for the dental professionals to be well versed and aware of all the clinical and treatment modalities that are associated with hemangiomas, and all necessary precautions should be taken before attempting surgical excision as the tissues may bleed profusely and unexpectedly. Capillary hemangioma often mimics PG and hence requires appropriate clinical diagnosis and proper management. Attempts to remove them using a simple surgical excision may lead to bleeding, and hence, laser excision should be always considered as an option.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Purkait SK. Essentials of Oral Pathology. Benign and Malignant Neoplasms of the Oral Cavity. JP Medical Ltd; New Delhi, India. 2011. p. 120-1.  Back to cited text no. 1
    
2.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & Maxillofacial Pathology. 2nd ed. India: Elsevier; 2002. p. 467–71.  Back to cited text no. 2
    
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Shafer WG, Hire MK, Levy BM. A textbook of oral pathology. 4th ed. Philadelphia: WB Saunders Co; 1983. pp. 154–157.  Back to cited text no. 3
    
4.
Avila ED, Molon RS, Conte Neto N, Gabrielli MA, Hochuli-Vieira E. Lip cavernous hemangioma in a young child. Braz Dent J 2010;21:370-4.  Back to cited text no. 4
    
5.
Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St. Louis: Mosby; 1995. p. 581-6.  Back to cited text no. 5
    
6.
Lanza A, Gombos F. A case of multiple oral vascular tumours: The diagnostic challenge on haemangioma still remains open. J Stomatol Investig 2008;2:67-71.  Back to cited text no. 6
    
7.
Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412-22.  Back to cited text no. 7
    
8.
Kamala KA, Ashok L, Sujatha GP. Cavernous hemangioma of the tongue: A rare case report. Contemp Clin Dent 2014;5:95-8.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Dilsiz A, Aydin T, Gursan N. Capillary hemangioma as a rare benign tumor of the oral cavity: A case report. Cases J 2009;2:8622.  Back to cited text no. 9
    
10.
Bouquot JE, Nilai H. Lesions of the oral cavity. In: Gnepp DR, editor. Diagnostic Surgical Pathology of the Head and Neck. Philadelphia: WB Saunders; 2001. pp. 141–233.  Back to cited text no. 10
    
11.
Kumari VR, Vallabhan CG, Geetha S, Nair MS, Jacob TV. Atypical presentation of capillary hemangioma in oral cavity- A case report. J Clin Diagn Res 2015;9:ZD26-8.  Back to cited text no. 11
    
12.
Mulliken JB. Cutaneous vascular anomalies. In: McCarthy JG, editor. Plastic Surgery: Tumors of Head and Neck and Skin. Vol. 5. Philadelphia, PA: W.B Saunders Company Ltd.: 1990. p. 3194-230.  Back to cited text no. 12
    
13.
Genovese WJ, dos Santos MT, Faloppa F, de Souza Merli LA. The use of surgical diode laser in oral hemangioma: A case report. Photomed Laser Surg 2010;28:147-51.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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