Hindawi Publishing CorporationCase Reports in MedicineVolume 2012, Article ID 347939, 4 pagesdoi:10.1155/2012/347939

Case Report

Oral Haemangioma

Jaspreet Singh Gill,1 Sharanjeet Gill,2 Amit Bhardwaj,1 and Harpreet Singh Grover1

1 Department of Periodontics and Oral Implantology, SGT Dental College, Hospital and Research Institute,Gurgaon, Budhera, Haryana 122505, India

2 Department of Oral Pathology, Manav Rachna Dental College, Haryana, Faridabad 121004, India

Correspondence should be addressed to Jaspreet Singh Gill, drjaspreet13137@yahoo.com

Received 27 July 2011; Accepted 13 November 2011

Academic Editor: Jahn M. Nesland

Copyright © 2012 Jaspreet Singh Gill et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Vascular anomalies comprise a widely heterogeneous group of tumours and malformations. Haemangioma is the most commonbenign tumour of vascular origin of the head and neck region. The possible sites of occurrence in oral cavity are lips, tongue,buccal mucosa, and palate. Despite its benign origin and behaviour, it is always of clinical importance to the dental professionand requires appropriate management. This case study reports a rare case of capillary haemangioma on the palatal gingiva in a14-year-old female.

1. Introduction

Haemangioma are the most common benign vasoformativetumours of infancy and childhood [1, 2]. They usually aremanifested within the first month of life, exhibit a rapidproliferative phase, and slowly involute to near completeresolution. There are many ways to classify haemangiomas.According to Enzinger and Weiss, haemangiomas are broadlyclassified into capillary, cavernous, and miscellaneous formslike verrucous, venous, arteriovenous haemangiomas, and soforth [3]. Capillary haemangiomas further include juvenile,pyogenic granuloma, and epitheliod haemangioma [3]. Theterm haemangioma has been commonly misused to describea large number of vasoformative tumours [4]. However, theInternational Society for the Study of Vascular Anomalies(ISSVA) has recently provided guidelines to differentiatethese two conditions, according to the novel classificationfirst published by Mulliken et al. in 1982 [5]. Vasoformativetumours are broadly classified into two groups: haeman-gioma and vascular malformation [5]. Haemangioma ishistologically further classified into capillary and cavernousforms [6, 7]. Capillary haemangioma is composed of manysmall capillaries lines by a single layer of endothelial cellssupported in a connective tissue stroma of varying density,while cavernous haemangioma is formed by large, thin

walled vessels, or sinusoids lined by epithelial cells separatedby thin layer of connective tissue septa [8].

The majority of haemangioma involve the head and neck.However, they are rare in the oral cavity but may occuron tongue, lips, buccal mucosa, gingiva, palatal mucosa,salivary glands, alveolar ridge, and jaw bones [3, 4, 6, 9–12]. Clinically, haemangioma appears as soft mass, smoothor lobulated, and sessile or pedunculated and may vary in sizefrom a few mms to several cms [8]. They are usually deep redand may blanch on the application of pressure and if largein size, might interfere with mastication [9]. In the presentcase study, we report a rare and an unusual case of capillaryhaemangioma of the palatal mucosa.

2. Case Report

A female patient aged 14 years, reported with a chiefcomplaint of a swelling and growth on the inner side of herupper front teeth since 4-5 months. She also complains oflocalized bleeding in that area on brushing, and there wasslight pain and discomfort on eating.

Dental history revealed that she had a history of gingivalenlargement, one year back, which she had got excised.However, the growth recurred within two months aftersurgical excision. It was initially small in size, gradually

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Figure 1: Preoperative intraoral view.

increased and stabilized after 3-4 weeks till the present size.On general physical examination, it was found that thepatient was normally built for her age with no defect in gaitor stature, and there was no relevant medical history. Familyhistory was also noncontributory.

A comprehensive intraoral examination revealed a local-ized gingival mass between maxillary right central incisorand lateral incisor (11, 12) on the palatal aspect (Figure 1).It was firm, pedunculated with a distinct stalk arising fromthe interdental papillary region. The mass was bright red,erythematous and bilobulated with well-defined margins.The two distinct lobes measured about 5 cm× 4 cm and 3 cm× 2.5 cm in diameter. They were firm and rubbery in texture.No surface ulceration or secondary infection was noted.Periodontal examination revealed no clinical attachmentloss. Panoramic examination confirmed no alveolar boneloss, and a provisional diagnosis of pyogenic granuloma wasmade on the basis of history and clinical features.

The other pathologic entities that were included in thedifferential diagnosis were malignancies, trauma, and orinfection (bacterial, viral, and fungal), enlargement due todrugs. Complete blood examination, urine analysis, andan intraoral periapical radiograph with respect to 11, 12were done. The laboratory investigations of blood and urinewere within normal limits that ruled out any leukemicenlargement and diabetes mellitus. HIV, HBs, VDRL, andMantoux test were negative, ruling out any possibilityof infectious involvement. Radiographically, there was noevidence of crestal bone loss, and lamina dura was intactaround the roots of both maxillary right central and lateralincisor. Scaling was carried out under universal precautions,and later surgical excision of the lesion was done underlocal anaesthesia as a part of excisional biopsy. A thread wastied around the stalk of the pedunculated lesion and wasstretched tightly so as to reduce blood circulation to thelesion. The growth was then surgically excised along withthe stalk, and thorough curettage of the area was performed.The excised lesion was stored in 10% formalin and sentfor histopathological examination. Periodontal dressing wasapplied on the operated area, and the patient was given

Figure 2: H and E stain section at 10x magnification showingnumerous blood-filled capillaries in connective tissue stroma.

Figure 3: Postoperative view after one week.

postoperative instructions. Histopathological examinationrevealed stratified squamous epithelium which showed atro-phy, and in some areas hyperkeratosis was seen. Beneaththis, many small and large capillaries filled with bloodwere present. These vessels were lined by a single layerof endothelial cells and were supported by a connectivetissue stroma of varying density with no inflammatorycomponent (Figure 2). On the basis of clinical examinationand histopathology, a diagnosis of capillary haemangiomawas made. The patient was recalled after a week with normalhealing and various plaque control measures were reinforced(Figure 3). The patient was also reviewed 1, 3, and 6 monthsafter the biopsy, and there was no recurrence of the lesion.

3. Discussion

The confusing and misleading terminology has led toinappropriate grouping and classification of vasoformativetumours [4]. The differentiation between haemangioma andvascular malformations is made on the basis of clinicalappearance, histopathology, and biological behaviour [4].

Pathogenesis and origin of haemangioma remain incom-pletely understood. However, various theories have been

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proposed to elucidate the mechanism and pathogenesis ofhaemangioma. Aberrant and focal proliferation of endothe-lial cells results in haemangioma, although the cause behindthis remains unclear [13]. The placental theory of hae-mangioma origin has been described by North et al. [14],who studied various histology and molecular markers suchas GLUTI, Lewis Y Antigen, Merosin, CCR6, CD15, IDO,FC, and gamma Receptor II. Positive staining for GLUTI isconsidered highly specific and diagnostic for haemangioma,and it is useful for making differential diagnosis betweenhaemangioma and other vascular lesions clinically relatedto it [13]. More recently, somatic mutational events in geneinvolved in angiogenesis are related to haemangioma growth[4]. Growth factors specifically involved in angiogenesissuch as VEGF, b-TGF, and IGF are often increased duringthe proliferation phases of haemangioma growth [15, 16].Moreover, it has been noted that during the involution phaseof haemangioma, there is a decrease in angiogenic molecules(VEGF, PCNA, Type IV collagenase, Lewis V antigen, CD31), while there is increase in concentration of marker forapoptosis (T4, TUNNEL, INF, Mast cells, and TGF) [4,17, 18]. Thus, role of molecular signalling is now clear inhaemangioma development.

A variety of other lesions can resemble haemangiomain the oral cavity. The differential diagnosis includes pyo-genic granuloma, chronic inflammatory gingival hyper-plasia, epulis granulomatosa, telangiectasia, angiosarcoma,squamous cell carcinoma, and other vascular appearinglesions of face or oral cavity such as Sturge Weber Syndrome[9].

In the present case, clinical features resemble that ofpyogenic granuloma. However, the lesion did not showmicroscopic appearance of a pyogenic granuloma. It con-tained blood-filled capillaries lined by layer of endothelialcells in a connective tissue stroma without any evidence ofinflammation.

Angiosarcoma is a rare malignant tumour of vascularendothelium, and it resembles haemangioma. However, itcan be differentiated from it on the basis of histopathologicfindings as it is characterized by infiltrative proliferation ofendothelium-lined blood vessels that form an anastomosingnetwork. The endothelial cells appear hyperchromatic andatypical and often tend to pile up within vascular lamina[8].

Management of haemangioma depends on a variety offactors, and most true haemangioma requires no inter-vention. However, 10–20% requires treatment because ofthe size, exact location, stages of growth or regenera-tion, functional compromise, and behaviour. The rangeof treatment includes surgery, flash lamp pulsed laser,intralesional injection of fibrosing agent, interferon alpha-2b, and electrocoagulation while cryosurgery, compressionand radiation were used in the past [11–13, 19–22]. Eachtreatment modality has its own risk and benefits. In thepresent case, surgery was carried out on the basis of size andlocation. Moreover, the difficulty in swallowing was anotherfactor that was taken in consideration, and surgical approachwas preferred as to remove excess residual fibrofatty andredundant tissue after involution.

4. Conclusion

Haemangioma is of benign origin and behaviour, buthaemangioma in the oral cavity is of clinical importance. Itoften mimics other lesion clinically and requires appropriateclinical diagnosis and proper management.

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