Arterio-Venous

Malformation of Mandible –
Case Report and an Unique
Surgical Approach
- Dr. Senthil Ramasamy
- Sir J.J. Group of Hospitals and GGMC, Mumbai
Introduction
Arterio-Venous malformation
• Progressive ectasia of abnormal vessels
• Grows proportionally with the child

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Hemangioma
• Endothelial hyperplasia and cellular proliferation
• Appear in early infancy
• Grow rapidly during the first months of life
• Slowly involute over 5 or 6 years
Salient Features
• Mandibular AVM is a very rare phenomenon

• Can present with swelling, tooth ache and bleeding gums

• Can sometimes have torrential bleeding after tooth extraction

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AVM rarely occurs in In the maxilla-facial
50% of which occurs in
visceral organs and skeleton, mandible is
maxilla-facial skeleton
bones the least likely site
Case
• 13 year girl
• Presented with
• Swelling and tenderness in the right side of mandible
• Gradually progressing over 1 year
• Bleeding of gums on minor trauma
• Multiple dental procedures done previously

On careful Further invertigations

Had torrential examination – - OPG
bleeding in one such
Pulsatile swelling - CT
tooth extraction
Palpable bruit - Selective Angiogram
Investigations Super selective
Angiography
Facial, Lingual and Internal
Maxillary artery

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CT Angio
- Typical moth eaten appearance
- Dilated Inferior Alveolar Canal and the Mental
Foramen
- Root resorption of the molar teeth
-Thinning of the lingual cortex of the mandible

OPG
- Radiolucency in the body of the right side of mandible
 OPG

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Our Management Plan

Repeat MRA
after 6 weeks
48 hours later

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- Exploration
Super Selective and excision of
Embolization of the swelling
Facial, Lingual
and Internal
Maxillary artery
CT Scan images
• Involving the inner cortex
• Adequate bone thickness of the outer cortex

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PRE EMBOLISATION

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POST EMBOLISATION

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 Our Operative Plan

Lip Split incision extending
down in the submental and
submandibular area till the
angle of mandible
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- Designed a step osteotomy in the right parasymphyseal region
preserving the Mental Nerve
- Predrilled a 2mm plate across the site of osteotomy
 Operative Plan

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Lesion

Exposing the lingual cortex of the

mandible
After the osteotomy the Making easier to access the
mandible is rotated outwards lesion
Intra-operative findings

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 INTRAOP

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Discussion
• Although 50 % of vascular lesions occur in the head and neck, Mandibular AVMs are
very uncommon

• Usually Second decade

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• Female preponderance

• Lesions become apparent as it grows in size along with the age

 Classical Symptoms
-Painful swelling -Discolouration of
-Loose teeth the mucosa -Asymmetry of the
face
-Tooth migration -Gingival bleeding

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-Catastrophic
-Local pulsation
haemorrhage after
-Noticeable bruit
tooth extraction
 Rare but a possibility
• First investigation when in doubt
• Ill-defined radiolucency, soap bubble or sunray
OPG appearance

• Definitive investigation
• Gives all anatomical details, extent and helps in

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CT operative planning

• Gold standard
Selective • Identify feeder vessels and their embolization
angiogram

Can avoid a Catastrophe

 Ligation of • Significant Collateral circulation
external • Prevents embolization in future
• Not preferred
carotid

Super-selective • Initial treatment of choice

• Success rate of 70%

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angiographic • Complications (e.g. Occlusion of pulmonary and cerebral
vessels)
embolization • chances of recurrence of the disease

Surgical • Preferred 48 hours after embolization of feeder vessel

excision • Reduce the recurrence rate.

Surgical Management post Embolization
Excision with preservation of the not involved
cortex
Wide Resection with Free Fibula Flap

• Significant morbidity • Reduced morbidity

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• Comparable results with Free Fibula
• Not a fool proof technique – Graft
Reported cases of recurrence • To be considered especially if only
one cortex is involved

• Obviating the need for mandibular

reconstruction
Technique – Flipping the Mandible
Great exposure to inner cortex

Predrilling of plate prevents change in occlusion

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Prevents breaking of the outer cortex to access the lesion

However, this approach depends on the lesion’s size, accessibility

and anatomic contiguity to the important structures
 Thank you

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