A v malformation,ARTEIO VENOUS MALFORMATION,MALFORMATION

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AV MALFORMATION,DENTAL PRESENTATION,DENTAL SLIDES,DENTAL PPT,CASE PRESENTATION

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A v malformation,ARTEIO VENOUS MALFORMATION,MALFORMATION

  1. 1. CASE PRESENTATION Asymptomatic Intermittent Swelling on Right Side of Face
  2. 2. Chief Complaint HOPI Past Medical History Past Dental History Family history Personal history 12/05/13
  3. 3. • General physical examination • Vital physical signs • Pulse rate: 80/min • BP: 110/70mmHg 12/05/13
  4. 4. Extra Oral Examination Frontal View 12/05/13 Profile View
  5. 5. Extra Oral Examination Worms eye view 12/05/13
  6. 6. Intra Oral Examination 12/05/13
  7. 7. 12/05/13
  8. 8. Provisional Diagnosis Superficial Vascular lesion on right midfacial region 12/05/13
  9. 9. DIFFERENTIAL DIAGNOSIS A-V malformation Hemangioma Aneurysm Phlebectasias Hematoma 12/05/13
  10. 10. Intra Oral Periapical Radiographs 12/05/13
  11. 11. OPG Radiograph 12/05/13
  12. 12. PNS View 12/05/13
  13. 13. Doppler Ultrasound 12/05/13
  14. 14. Stage I Sclerotherapy 12/05/13
  15. 15. Stage II Sclerotherapy 12/05/13
  16. 16. MRI T1 12/05/13 T2
  17. 17. Carotid Angiography 12/05/13
  18. 18. Immediate Post Surgery 12/05/13
  19. 19. Excised Specimen 12/05/13
  20. 20. Histopathology • Many vascular channels diffusely dispersed in fibrous connective tissue • Presence of blood vessels in between adipose tissue and muscle bundles. • Dilated veins, few arteries showed thickened tunica intima filled with RBC’s. • Juxta positioning of arteries and veins 12/05/13 5X
  21. 21. Final Diagnosis A-V Malformation on Right Midfacial region 12/05/13
  22. 22. 15 Days Post Operative 12/05/13
  23. 23. DISCUSSION 12/05/13
  24. 24. Introduction Vascular malformations errors of vascular morphogenesis present at low incidence ie., 7% of all benign tumors, AVM accounts for 1/3 rd of all vascular malformations, > 50% AVM are present in Head and Neck region 12/05/13
  25. 25. SYNONYMS Arteriovenous aneurysms Cavernous hemangioma Central hemangioma Pulsatile hemangioma Angioma Arteriovenous shunt Arteriovenous fistula Vascular malformation Arteriovenous malformation - Ped Dent 1996;18(4):322-7 12/05/13
  26. 26. Historical Review • Hubter 1757- AV fistula • Branham 1890– correlation of PR on compression of AV fistula – Branham sign • Biberstein & Jersner 1956 –Ist – cirsoid aneurysm • Gomez 1955-1965– reviewed AVM -10 years • Brown 1973 – AVM of Orbit, Middle cranial fossa and mandible 12/05/13
  27. 27. Definitions An AVM may be defined as a condition in which arteries communicate with veins through channels other than the normal capillary network. - Oral Surg 1981; 52: 118-125 12/05/13
  28. 28. A-V Malformation/A-V hemangioma of the head and neck are poorly circumscribed, superficial lesions of adulthood, composed of closely associated – structurally abnormal arteries, veins and capillaries, with vessels present that cannot be readily categorized as arteries /veins. - Head and Neck Surgical Pathology by Benz Pilch 12/05/13
  29. 29. 12/05/13
  30. 30. Development of Vascular system • Undifferentiated capillary network stage capillary hemangiomas • Retiform development stage venous, arterial/capillary malformations • Final development stage venous and lymphatic malformations - Head 12/05/13 and neck Surgical pathology by Ben-Z Pilch
  31. 31. Classification 3rd International Workshop for study of vascular anomalies Suggested By Glowacki and Mulliken: (1982) 1. Hemangiomas 2. Vascular malformations a. Depending On hemodynamics i. Low-flow: e.g: Capillary, lymphatic & venous ii. High-flow: e.g: Arterial & AVM b. Depending on anatomy i. Capillary: e.g: Port wine stain ii. Artery : e.g : AVM with or without fistula iii. Vein : e.g: Cavernous hemangioma iv. Lymphatic: e.g: Lymphangioma v. Mixed 12/05/13
  32. 32. Classification of AVM Depending on origin 1. Congenital AVM : result of error in vascular morphogenesis. 1. Acquired AVM : can result from injury, surgery or hormonal changes such as puberty or pregnancy. Depending on situation: 1. 2. Superficial Deep - Barnes Surgical Pathology of Head and Neck 12/05/13
  33. 33. Pathogenesis Increase in size of VM is promoted by local hemodynamic factors Areas of low vascular resistance causes shunting of blood Dilatation of nutritional arteries with atrophy of their musculoelastic wall Decreased resistance Dilation and arterilization of draining veins Increased intraluminal pressure The blood shunted to the malformation causes the lesion to grow, which in turn causes increased shunting of the blood 12/05/13 - J Can Dent Assoc 2001;67(11):646-51
  34. 34. Clinical Features Vascular malformations ≈ 7% -benign tumors .02% -.05%- general population >50% - Head & Neck region Sex - ♂:♀::1:1 Race: Caucasians & whites Age – any age Site : Mandible - Am J Neuroradiology 1993;14;307-314 - Am J Roentgenol 2000; 174; 597-608 - DMFR 2006; 35; 205-08 12/05/13
  35. 35. Clinical Features Facial swelling & asymmetry Soft tissue discoloration Erythematous & spontaneously bleeding gingiva Pain Mobile teeth Hyperthermia over the lesion Visible /palpable pulsations Presence of a thrill/ bruit - JADA 1995 ( 126); 237 -240 12/05/13
  36. 36. Late symptoms Cortical plate expansion Involvement of Nose, Sinuses- nasal obstruction, epistaxis, rhinitis, sinusitis, Orbits - proptosis and diplopia. Cardiac symptoms – murmur, cardiomegaly, heart failure, - J Oral Maxillofac Surg 1991;49(7):759-63 12/05/13
  37. 37. CLINICAL DIFFERENTIAL DIAGNOSIS       12/05/13 Cavernous hemangioma Aneurysm Hematoma Phlebectasias Lymphangioma Mucocele
  38. 38. INVESTIGATIONS  Doppler ultrasound  Aspiration  Arteriography  CT scan  MRI  Digital subtraction radiography 12/05/13
  39. 39. HISTOPATHOLOGY • Juxta posed large vascular channels diffusely dispersed in fibrous connective tissue • Presence of blood vessels in between adipose tissue and muscle bundles. • Dilated veins, few arteries show thickened tunica intima, lumen filled with RBC’s 12/05/13 - Contemporary oral and maxillofacial pathology by Sapp Eversole Wysocki
  40. 40. RADIOGRAPHIC FEATURES Gelfand et al - 3 typical radiographic appearance: 1. Sunray appearance- created by trabecular bone between vessels and osteolytic lesion 2. Soap bubble /honey comb appearance with occasional punched out areas 3. Ill defined radiolucency - JOMFS 1975; 33; 4488 12/05/13
  41. 41. RADIOLOGICAL DIFFERENTIAL DIAGNOSIS Ameloblastoma Central giant cell granuloma Hyperparathyroidism Cherubism Odontogenic myxomas Aneurysmal bone cyst Metastatic tumors of bone - Differential diagnosis of Oral and maxillofacial lesions by Wood & Goaz 12/05/13
  42. 42. Low suspicion of AVM Aspiration High suspicion of AVM Arteriography: Bilateral ECA & ICA Emergent hemorrhage Surgery Non emergent Selective embolization Expose and Ligate ipsilateral ECA Surgery (less than 48 hrs after embolization) Expose Ipsilateral ECA Unable to control Control Hemorrhage Contralateral ECA ligation 12/05/13 Resect lesion
  43. 43. Treatment Sclerosing agents: Sodium Morrhuate ( 3% Sodium tetra decyl sulfate) Alkyl sulfates Urea-Quinidine Chlorohydrolactate ( Scleroserum - V) Boiling water Nitrogen Mustard 12/05/13
  44. 44. Embolization  Isobutyl-2-cyanoacryolate (glue)  Polyvinyl alcohol foam (Ivalon)  Gelatin sponge (Gelfoam)  Autologus Muscle  Metal coils  Collagen  Lyophilized Dura 12/05/13
  45. 45. Complications of Embolization Orabach et al • • • • • • Pain, febrile response Skin sloughing Thrombus formation Spasm of artery Rupture of dilated vessels Passage of embolus into a normal artery or through the lesion • Proximal arrest of the embolus - Oral Surg 1976; 42; 2-13 - Oral Surg 1982; 53; 454-457 12/05/13
  46. 46.  Surgical management: Surgery should be performed within 7 to 14 days after Embolization preferably within 24 to 48 hrs.  Curettage  Resection of mandible  Subperiosteal resection of involved segment of bone 12/05/13
  47. 47. Syndromes associated with AVM • • • • • • • 12/05/13 Rendu-Osler weber syndrome Sturge- weber syndrome Klippel-Trenaunay weber syndrome Kasabach-merritt syndrome Von Hippel –Lindau syndrome Maffucci syndrome Cowden syndrome
  48. 48. CONCLUSION “Primum non nocere” – remain dictum Some regress spontaneously whereas some become aggressive because of their unpredictable behavior, these potentially fatal lesions of jaw should be treated and managed conservatively. 12/05/13
  49. 49. thank you.... 12/05/13

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