Control # 209
Title: Life -Threatening Lytic lesion of the Mandible:
A Lesson Learned
eEdE# eEdE-157
Nothing To Disclose
Life-Threatening Lytic lesion of the Mandible
“A Lesson Learned”
1
Nucharin Supakul, MD
2
Juan G Tejada, MD
1. Ramathibodi Hospital, Mahidol University
Bangkok, Thailand
2. Indiana University School of Medicine,
Eskenazi Health
Indianapolis, Indiana, USA
Purpose
• To review the characteristic imaging
findings of mandibular vascular
malformations and avoid unnecessary and
risky biopsies of the mandibular lesions.
• To demonstrate interventional treatment
options for vascular lesions in the
mandible in life-threatening conditions and
also in the preoperative setting.
Introduction
Mandibular Vascular lesions are divided in 2 groups
• Hemangioma
 Failure of differentiation in the early stages of embryogenesis
 Appears in childhood and regresses over time
 Rarely associated with fatal hemorrhage
• Vascular malformation
 Disturbance in the late stage of angiogenesis (truncal stage)
and results in persistence of arteriovenous anastomosis
 Present at birth and grows over time
 Symptoms depend on hemodynamic factors
 High flow: AVM, AVF
Fatal hemorrhage
 Low flow: Lymphatic, venous, or mixed
Mandibular AVM
• Abnormal direct communication between arteries
and veins, bypassing capillary bed
• Location: Usually posterior location within the
ramus and posterior mandibular body
• Clinical presentation
 Gingival bleeding (most common)
 Massive bleeding with shock following by the
extraction of teeth (most common)
 Soft tissue mass (pulsatile/ non pulsatile), bruit, thrill
 Painful, alteration of facial morphology
 Neurosensory deficit
Imaging Findings
• Cystic radiolucent lesion
• Honeycomb (multilocular) or soap bubble
appearance
• Resorption of the adjacent bone/ dental
root teeth floating in the adjacent alveolar
osseous erosion
• Mimics odontogenic/non-odontogenic lesions
Central giant cell granuloma
Ossifying fibroma
Traumatic bone cyst
Ameloblastoma
Imaging Findings
• CT and MRI
Evaluates the extent of the lesion
Bone erosion
Involvement of major vessels
• Catheter angiogram
Gold standard in diagnosis and treatment
Super-selective arteriography of the external
carotid  evaluates collaterals and multiple
anastomoses of the Internal maxillary artery
Management
• Sclerosing agents (sodium morrhuate,alcohol,
tetracycline etc.)  ineffective most of the times
• Ligation of the external carotid  not recommended
 Numerous anastomoses (internal carotid, ophthalmic,
vertebral, cervical, and contralateral external carotid) and
collateral vessels
 Limits further angiography and future embolization
• Direct trans osseous puncture of the vascular bed and
embolization
• Embolization (Onyx, cyanoacrylate, polyvinyl alcohol
particles, Gelfoam, coils, collagen)
 Pre operative embolization in acute phase then surgery
within 48 hours to 2 weeks
 Usually multiple stages of embolization for curative results
19-MONTH-OLD FEMALE WITH
LEFT LOWER GINGIVA BLEEDING
Skull AP and Towns views were performed. No demonstrable
lytic lesion within the mandible is noted. This is an inappropriate
study to evaluate a mandibular lesion.
A
C
B
D
E
MRI and MRA of the head and neck were obtained.
A - B: Coronal T2 (A) and axial T1 fat suppression images show an expansile T1 iso/T2 hyperintense bony lesion within the leftsided mandible involving body, angle and ramus (orange arrows). Involvement of the left canine, left premolar and left 1 st molar
teeth is noted. Several flow void signals are noted, best seen on T2 images.
C - D: Post contrast T1 fat suppression in coronal (C) and axial (D) images show heterogeneous contrast enhancement and
increased signal intensity with in the left masseter and let temporalis muscles.
E - F: MIP MRA images of the head and neck vessels show enlargement of the left external carotid artery (blue arrows)
supplying this mass (pink arrow) with early draining vein to the left external jugular vein (green arrow).
F
A
B
Conventional angiogram with left external carotid artery catheterization.
A – B: There is a vascular blush of the mass (green arrow) within the left buccal/maxillary
region supplied by branches of the left internal maxillary artery (orange arrows) and left facial
artery (blue arrows) with AV shunting and venous drainage into the external jugular vein (pink
arrows).
C: Post PVA embolization via the left internal maxillary artery, superficial temporal, and left
facial arteries with nearly complete disappearance of the vascular blush.
C
7-YEAR-OLD MALE WITH RIGHT LOWER GINGIVA
MASS WITH INTERMITTENT BLEEDING FOR A MONTH.
RECENT HISTORY OF ACTIVE BLEEDING WITH SHOCK
Grossly unremarkable Panoramic radiograph of the mandible
A
C
E
B
D
F
MRI and MRA of the head and neck without and with contrast
A-B: Axial T1 fat suppression (A) and T2 fat suppression (B) images show T1/T2 hyperintense expansile lesion within the
body of the right-sided mandible (orange arrows). A few signal voids are noted.
C-D: Post contrast axial T1 fat suppression (C) and coronal T1 fat suppression (D) images show heterogeneous contrast
enhancement within this mass (orange arrows).
D-E: Contrasted MRA images show dilation of the right facial vein (blue arrow) and external carotid artery (pink arrows),
related to a feeding artery.
F: MIP image shows dilation of the right external carotid artery (pink arrow) with no visualized drain vein.
G
Conventional angiogram
with right external carotid
artery catheterization
A
B
A-B: Lateral and AP images
show abnormal vascular
blush with arterial supply
from the right facial (orange
arrows) and right internal
maxillary arteries (blue
arrows) and early draining
vein to the right external
jugular vein (pink arrow).
C-D: Post embolization
images after gelfoam and
NBCA injection show
complete occlusion of the
mandibular AVM.
C
D
12-YEAR-OLD MALE WITH
LOWER GINGIVA BLEEDING
CT head and neck with
contrast
A-B: Axial and coronal CT
without contrast at the level
of the mandible show welldefined lytic lesion within the
posterior body of the right
mandible associated with
tooth root resorption (orange
arrows).
A
B
C
D
C-D: Axial post contrast
images show avid
enhancement within this
lesion (blue arrow)
associated with enlargement
of the right external carotid
artery and right facial artery.
Findings are suggestive of
AVM.
A
C
E
B
D
F
Conventional angiogram with right external carotid artery catheterization
A-D: AP and lateral images show abnormal vascular blush with arterial supply from the right inferior
alveolar (orange arrows) and right facial arteries (blue arrows). Drainage to the right facial vein (pink
arrow) is noted. There is a large venous pouch in the right mandibular body (green arrow).
E-F: Post embolization images with NBCA demonstrate residual venous pouch (green arrow) and
vascular blush lesion. Patient was scheduled for second stage embolization within a month.
Second stage embolization with NBCA
Residual small AVM was treated with NBCA. Post embolization angiogram shows
marked decreased flow of the AVM and increased venous stagnation.
15-YEAR-OLD MALE WITH
VASCULAR MASS FOUND ON
DENTAL PROCEDURE
15-year-old boy with intra-oral vascular mass identified incidentally during a dental procedure.
A: Axial CT image shows a lytic lesion within the posterior body of the right mandible (orange arrow).
B: Axial T1 post contrast image shows an enhancing vascular mass in the right mandibular body (blue arrow).
C: Doppler US demonstrates an AVM in the right mandibular body draining into a dilated varix (green star).
D: DSA lateral image from the right external carotid artery injection shows an AVM supplied by branches of
the facial and internal maxillary arteries (pink arrow) with venous drainage predominantly to the right
external jugular vein.
E – F: Post-embolization lateral images of the right external carotid artery injection show approximately 80%
occlusion of the mandibular AVM (yellow arrow = residual AVM).
Conclusion
• Vascular malformations of the mandible are extremely rare
potentially life-threatening conditions presenting with
intractable hemorrhage after tooth extractions or biopsies.
• Occur predominantly during childhood with a variety of symptoms
including gingival bleeding, bruit, dental loosening, swelling of the
soft tissues of the face, discoloration of the skin and mucosa and
sometime neurosensory deficits.
• Think about vascular AVM in case of gingival bleeding/ lesion in the
posterior body of the mandible.
• Cross-sectional imaging especially CT and MRI with contrast
are useful imaging modalities for clarifying the extent of the
lesion, the degree of bone erosion, and involvement of major
vessels (feeding arteries and draining veins).
• Radiologist should be able to recognize the imaging patterns to
avoid risky and unnecessary biopsies and suggest prompt treatment
in case of life-threatening hemorrhage or the need for preoperative
treatment with endovascular or percutaneous embolization
References
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Radiologic-Histopathologic Review 1." Radiographics 19.5 (1999): 1107-1124.
2. Singh V, Bhardwaj PK. Arteriovenous malformation of mandible: Extracorporeal
curettage with immediate replantation technique. Natl J Maxillofac Surg. 2010 JanJun; 1(1): 45–49.
3. Kiyosue, Hiro, et al. "Treatment of mandibular arteriovenous malformation by
transvenous embolization: a case report." Head & neck 21.6 (1999): 574-577.
4. Noreau, Gaétan, Pierre-É. Landry, and Dany Morais. "Arteriovenous malformation of
the mandible: review of literature and case history." Journal-Canadian Dental
Association 67.11 (2001): 646-651.
5. A. Churojana, R. Khumtong, D. Songsaeng, C. Chongkolwatana, and S.
Suthipongcha,. Life-Threatening Arteriovenous Malformation of the
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