|Year : 2013 | Volume
| Issue : 2 | Page : 81-84
Diode laser in management of vascular malformation of lip
Reet Kamal1, Parveen Dahiya2, Rajan Gupta2, Rohit Bhardwaj2
1 Department of Oral and Maxillofacial Pathology, Himachal Pradesh Government Dental College, Shimla, India
2 Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
|Date of Web Publication||3-Jan-2014|
Department of Oral and Maxillofacial Pathology, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh - 171 005
Source of Support: None, Conflict of Interest: None
Vascular anomalies embody a myriad of blood vessels abnormalities that are thought to occur perinatally. They are broadly classified into vascular tumor or hemangioma and vascular malformation. An accurate diagnosis can be made by a detail case history, clinical presentation, ultrasonography, computerized tomography, arteriography, and histopathological examination. Due to complex nature of these vascular lesions a multidisciplinary approach is frequently necessary for their management. Herein, we present a case report of management of a vascular malformation on lower lip with diode laser. This paper also summarizes the etiopathogenesis, classification and treatment modalities of vascular malformations.
Keywords: Diode laser, hemangioma, vascular lesion, vascular malformation
|How to cite this article:|
Kamal R, Dahiya P, Gupta R, Bhardwaj R. Diode laser in management of vascular malformation of lip. J Dent Lasers 2013;7:81-4
| Introduction|| |
Vascular anomalies are among the most common congenital and neonatal dysmorphogenesis, which are separated into hemangioma and vascular malformation. These are two distinct groups of vascular lesions which are often confused with each other, and unfortunately the terms have been used interchangeably. These hemangioma and vascular malformation account for nearly 60% of all lesions in body and are still great challenges for clinicians because of their unknown etiology and difficulty in management.  Depending upon the size and location of these vascular lesions, it may affect the physiognomic aspect and may cause significant psychological distress.  A vascular malformation of maxillofacial region can give rise to a dental emergency, if lesion is inadvertently disturbed. 
These vascular lesions were often misdiagnosed and mistreated for years because of its inconsistent terminology and confusing classification. Mulliken and Glowacki's work in the field of diagnosis and treatment of vascular lesion was remarkable. In 1982, they developed a biological classification of vascular lesions encompassing physical findings, clinical behaviour and cellular kinetics.  They classify vascular lesions into hemangioma and vascular malformation [Table 1]. Hemangiomas are vascular tumors that are rarely apparent at birth, and grow rapidly during first 6 months of life and involutes with time, whereas, vascular malformation are irregular vascular networks defined by their particular blood vessel type. In contrast to hemangioma, they are present at birth, slowly growing, infiltrative and destructive. They show an increase in size as patient grow and don't regress spontaneously and blood vessels do not show endothelial proliferation. In Rome, in 1996 at an International society of study of vascular anomalies (ISSVA) meeting, the Mulliken classification was slightly modified  [Table 2].
|Table 2: Vascular anomalies. Classi fication modified by ISSVA, Rome 1996|
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Here, we report a case of vascular malformation on lower lip treated by diode laser. This paper also discussed various aspects like etiology, classification, pathogenesis and treatment modalities of vascular malformations.
| Case Report|| |
A 65 year old male patient reported to department of Oral Medicine and Radiology as an outpatient with a chief complaint of swelling in left side of lower lip. Patient gave a history of small negligible swelling on left side of lower lip since his birth (as he was told by his parents). He noticed a gradual increase in size since last three years. Initially it was not interfering with speech and mastication but now it does.
Clinical examination revealed a single, oval, well defined, non-pulsating, soft and compressible swelling roughly measuring 1 × 0.8 × 0.8 cm 3 [Figure 1]. The colour of lesion was bluish red. A careful inspection under magnifying glass revealed that few blood vessels were moving in and out of the lesion and diascopy test was positive with escape of coloration upon compressibility.
|Figure 1: Vascular malformation on lower lip; Intraoral photograph (Inset)|
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Patient was systemically healthy with normal value of blood tests like Hb, BT, CT, TLC, DLC, PTT, fasting blood sugar, SGOT and SGPT etc.
Patient's case history and clinical examination leads to a diagnosis of vascular malformation and the patient was planned for excision of the lesion with gallium aluminium Arsenide diode (GaAlAs) diode laser [Figure 2]a. The lesion was excised under local infiltration (2% lignocaine with 1:200000 adrenaline) [Figure 2]b and the tissue was sent for histopathological examination.
|Figure 2: (a) GaAlAs diode laser. (b) Excision of lesion with diode laser. (c) Photograph showing healing after 15 days|
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H and E staining of soft tissue at ×10 revealed large dilated blood sinuses with thickening of endothelial lining of blood vessels [Figure 3]. High power photomicrograph (×40) showing dilated blood sinuses engorged with Red blood cells [Figure 4]. Endothelial lining at some sites showed quiescent, while few sites showed endothelial hyperplasia. There was no salivary gland tissue seen. Deeper section showed a few muscle tissue fibers. All these histopathological features, as correlated with clinical presentation, are suggestive of vascular malformation.
|Figure 3: Low power photomicrograph showing large dilated sinuses with thickened endothelial wall. (H and E stain, ×10)|
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|Figure 4: High power photomicrograph showing dilated blood sinuses engorged with Red blood cells. (H and E stain, ×40)|
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Patient was recalled after one week for suture removal and satisfactory healing was reported after 15 days [Figure 2]c.
| Discussion|| |
Vascular malformations are structural anomalies of blood vessels without endothelial proliferation. Some reports show that males and females are equally affected whereas others indicate a female predominance by a ratio of 2:1.  It has been found that almost all the vascular malformation and nearly 40% of hemangioma require intervention.  In the present case, laser excision of lesion was done at the age of 65 years. This might be explained on the basis of slow growing nature of the lesion. Sudden increase in size in last three years might be correlated with continuous trauma to the lesion. As it has been found that trauma, pregnancy and puberty may accelerate the growth of lesion.
An accurate history and a thorough clinical examination are a key to accurate diagnosis. Radiographical advancements like computerized tomography and magnetic resonance imaging can help to clarify the extent of lesion and bony involvement.  Super-selective arteriography is essential in identifying the contributing vessels  and the histopathological examination confirms the diagnosis.
Vascular malformation arises as a result of faulty embryonic development at some stage of vasculogenesis or angiogenesis. Most vascular malformation are sporadic (not familial) and their cause is unknown. Some are inherited in mendalian autosomal dominant pattern and the causative genes are known. Molecular studies suggest that vascular malformations are caused by abnormal signaling process that regulates cellular proliferation, apoptosis, differentiation, maturation and adhesion.
A successful therapy for vascular malformation includes: Sclerosing agents and embolization with solid materials followed by surgical excision, cryosurgery, different types of lasers like Er:YAG, Nd:YAG and diode laser, and psychological support. The choice of treatment usually depends upon the phase, size, location, extent and depth of lesion. In our case we use GaAlAs diode laser with a wavelength of 810 ± 10 nm. The diameter of delivery fiber was 200 μm and it works at a power of 0.1-2.5 watts ± 20% output. The wavelength of this laser is absorbed by the hemoglobin, which leads to tissue coagulation and formation of charred layer. The diode laser leads to thermo-coagulation of blood vessels which is responsible for its haemostatic effect. The diode laser is also known for its bactericidal effect.  Moreover, post-operative pain is also less with diode laser as compared with conventional surgical therapy.
Successful treatment usually requires complete removal of the lesion to prevent its reoccurrence. Large sized vascular malformations in maxillofacial region should be treated by a multidisciplinary approach with the involvement of vascular and plastic surgeon, oral and maxillofacial surgeon, pediatrician, otolaryngologist, angioradiologist, geneticist, and psychologist.
| Conclusion|| |
It has been now clear that benign vascular lesions are a consequence of blood vessels abnormalities or endothelial proliferation and constitute some of the most difficult diagnostic and therapeutic enigmas in head and neck region. So, proper diagnosis and careful treatment planning are necessary to reduce the unwarranted risk and complications.
Diode laser in the treatment of vascular malformations offers distinctive advantages, such as the ability to cut, coagulate, ablate or vaporize target tissue elements, enabling dry-field surgery, disinfection of the tissue, reduced post-operative edema and decreased amount of scarring. These unique properties resulting in improved treatment outcome and increased patient comfort and satisfaction. But, some long term longitudinal studies, regarding treatment with diode laser, are still required to justify the superiority of diode laser over other treatment modalities.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]