Case Report

Arteriovenous Malformation in Mandible

Lt Col Suresh Menon*, Maj SK Roy Chowdhury+, Col Chandra Mohan, SM
#

MJAFI 2005; 61 : 295-296

Key Words: Mandible; Embolisation; Angiography

Introduction and is essential for therapy planning. A transfemoral

angiography of the left external carotid artery was performed
A rteriovenous malformations (AVM) are errors of
vascular morphogenesis that are present at birth
and become evident due to an event like trauma, surgery,
and confirmed the diagnosis of high flow AV malformation
involving the left facial, lingual and maxillary artery (Fig 2).
MRI was also done to rule out soft tissue involvement of the
infection, etc. The management of this condition in the lesion and confirm the limitation of the lesion within mandible.
maxillofacial region is difficult because of the abundant It was then decided to embolise the feeder vessels before
vascular network. One of the most common signs of surgically intervening. Embolisation of the facial, lingual and
these patients, especially in the mixed dentition period, maxillary arteries were achieved using gel foam and poly vinyl
is hyper mobility of the teeth with spontaneous alchohol and the occulusion confirmed by post embolisation
haemorrhage from the surrounding gingival sulcus [1]. angiography. Angiography of the contralateral side was also
Mandibular AVM is a potentially life-threatening done to rule out any contralateral feeding of the lesion. Two
pathology requiring radical treatment. days later the patient was to be taken up for resection of the
lesion but a preoperative angiography revealed recanalisation
Case History of the vessels filling the lesion. Embolisation was again
A 14 year old boy reported to a dental centre with a performed and the patient taken up for resection the next day.
complaint of mobility of Mandibular left 1st and 2nd molars Hemimandibulectomy was performed and during the surgery
since a couple of months. Clinical examination revealed a profuse bleeding was encountered in spite of the embolisation
good periodontal condition with mobility of the teeth in cycles performed. An immediate reconstruction using iliac
question. The buccal cortical plate was intact while the lingual graft was done (Fig 3,4). The resected specimen showed
plate revealed areas of erosion. complete erosion of the lingual plate with an abnormally wide
As there was no obvious cause for the mobility, a mandibular foramen.
diagnostic Ortho Pan Tomograph was taken. The radiograph Discussion
revealed a diffuse radiolucency of the left mandible with clear-
cut margins anteriorly in relation to the canine but with ill- Due to the potential danger to the patient in these
defined border posteriorly in the retro molar region [2]. The lesions, surgical intervention has to be the choice of
two premolars and 2nd molar also showed signs of root treatment in large lesions refractory to embolisation
resorption. The left Mandibular canal was larger than the [3]. Traditional treatment has usually involved the
right canal in size. The 3rd molar was impacted and pushed obtaining of proximal and distal vascular control by
posteriorly. transfemoral embolisation [4] followed by surgical
A CT scan of the area confirmed an osteolytic lesion with removal of the lesion, when feasible. Various other
buccal plate expansion and lingual plate thinning (Fig 1). A conservative modalities of management are also in
provisional diagnosis of dentigerous cyst ameloblastoma was vogue. Workers have used intralesional occlusion [5] as
made after reviewing all parameters. A significant clinical an adjunct to arterial embolisation or in isolation with
finding was an unusually prominent pulsation and bruit over encouraging results, especially in intra osseous
the left facial artery giving rise to a doubt, whether this was a malformations [6].
vascular lesion.
Permanent embolic obliteration of the malformation
Diagnostic Angiography requires placement of occlusive material directly into
Angiography is the corner stone of diagnosis of vascular the nidus (core) of the lesion. Even optimal placement
lesions and shows the exact angioarchitecture of the lesion of arterial embolic material may fail to fully obliterate

*
Associate Professor, Oral and Maxillofacial surgery, Armed Forces Medical College, Pune, +Classified Specialist, Oral and Maxillofacial
surgery, Army Dental Centre, #Senior Advisor, Radiodiagnosis and Interventional Vascular Radiology, Army Hospital, R&R, Delhi Cantt.
Received : 29.09.2003; Accepted : 22.01.2004
296 Menon, Chowdhury and Mohan

Fig. 1 : Coronal slice of mandible revealing osteolytic lesion left

body Fig. 2 : Angiography reveals the AV malformation with venous
filling of pterygoid plexus

Fig. 3 : Immediate reconstruction with iliac bone graft

Fig. 4 : 3D CT view of the reconstructed mandible
the nidus, allowing eventual restoration of flow to the Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002 Oct:
lesion due to arterial recanalization. Under such 94(4): 503-9.
circumstances it may be possible to obliterate the 3. Anderson JH, Grisius RJ, McKean TW. Arteriovenous
malformation and control lesional hemorrhage by malformation of the mandible. Oral Surg Oral Med Oral Pathol
occlusion of the malformation by direct percutaneous 1981 Aug: 52(2): 118-25.
mandibular puncture. 4. Kiyosue H, Mori H, Hori Y, Okahara M, Kawano K, Mizuki
Transvenous embolisation has been achieved using a H. Treatment of mandibular arteriovenous malformation by
transvenous embolization: A case report. Head Neck 1999:
variety of materials like Titanium microcoils, poly vinyl 21(6): 574-7.
alcohol and gel foam [7]. Intra lesional material aiding
5. Siu WW, Weill A, Gariepy JL, Moret J, Moret J, Marotta T.
in embolisation include sclerosing agents, n-butyle- Arteriovenous malformation of the mandible : embolization
cyanoacrylate and Ethibloc in conjuncton with/without and direct injection therapy. J Vasc Interv Radiol 2001: 12(9):
ivalon particles [8,9]. 1095-8.
In our case hemimandibulectomy was the treatment 6. Fan X, Zhang Z, Zhang C, et al. Direct-puncture embolization
of choice due to the extensive nature of the lesion. The of intraosseous arteriovenous malformation of jaws. J Oral
Maxillofac Surg 2002: 60(8): 890-6: discussion 896-7.
case report underscores the limitations of therapeutic
7. Kawano K, Mizuki H, Mori H, Yanagisawa S. Mandibular
embolization and emphasizes the need for surgical
arteriovenous malformation treated by transvenous coil
removal of larger lesions. embolization: a long term follow up with special reference to
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MJAFI, Vol. 61, No. 3, 2005