Arteriovenous malformation of the mandible: life-threatening complications during tooth extraction JD Engel, JS Supancic and LF Davis J Am Dent Assoc 1995;126;237-242

Overview: 13 yr. old female diagnosed with an arteriovenous malformation of her lower left mandible following extraction of tooth #18.Intial finding

13 year old female presented to her general dentist with occasional bleeding assoc with tooth #18. No obvious caries and tooth was mobile and slightly supraeruptedPA #18 did not show any periapical pathosisFollowing extraction, immediate, severe, uncontrollable hemorrahage ensued - finger in the dike method of hemostasis was employed until an ambulance arrived 5 mins later

Emergency DepartmentAn arteriogram was used to determine the source of bleeding

Operating Room - Initial Surgery - Mandible SectioningVessels were embolized with special clotting coils placed in the internal maxillary artery, two in the lingual and 2 in the facial to decrease the flow by 80%The AV malformation exended to the right premolar region and the mandible was sectioned from the left condyle to the right premolarMandibular reconstruction plate with a metal condyle was contoured to fit the defect.The sectioned mandible had teeth removed and cancellous portion removed then frozen for future reconstruction

Operating Room - Second Surgery - Reconstruction Reconstruction after 6 months following sectioning- harvested cancellous bone from iliac crest bilaterally TMJ was reconstructed from the 5th right rib Graft was attached by screws to the cryopreserved mandible 1 year later, 5 x implants placed in mandible to support a removable prosthesis

Discussion:! Diff Dx for Vascular anomolies:

Hemangiomas: vascular tumor that usually appears shortly after birth and grows rapidly until the age of 6-8 months. At that time, they slowly involute and regress by adolesence

Vascular malformation: lesions present at birth that may not become clinically evident until later in life. Histologically: have a normal endothelial cell cycle and normal numbers of mast cells

High flow - arterial and AV malformationsLow flow - capillary, lymphatic and venous malformations

How would I detect an arteriovenous malformation?

Early signs/symptoms: Essentially a laundry list of bad thingsRadiographic: Typically normal appearanceHistory: The mother indicated that after extraction of her

daughter’s of primary teeth, she occasionally had blood on her pillow upon waking. Further investigation would have revealed that the bleeding was more significant than the dentist believed. The hemorrhage required the frequent changing of the entire bed linens by the mother.

Take Home: Previous extraction history is an excellent way to assess potential bleeding problems.

Mark Lit Abstract Oct 2010

Saini is a god

C[INICA[ rACJIC[-

Figure 7. raph of thep

Figure 8. The patient 22months after resectlon of theAVM.

tist with a mobile permanentmandibular molar. Inter-mittent spontaneous hemor-rhage associated with that toothwas noted by the patient andher parents, although there wasno bleeding that day. The par-ents said their physician hadmentioned the possibility of herhaving a hemangioma of theface as a small child but nofurther investigation was done.

The dentist took a periapicalradiograph of the area. Because

this radiographlooked some-what unusual,

he took a second radiograph,which was essentially the same.At that point, it was decidedthat the tooth should be extract-ed because of the severe mobil-ity. In reviewing the bleedinghistory, the patient reportedprevious extractions of primaryteeth without problems. Themother noted that the child oc-casionally had blood on herpillow on waking in themorning.A few things can be learned

from this case that may helpalert others to the possibility ofan AVM. Although reports ofhemangioma and history ofbleeding problems given by theparents can be somewhatvague, they should raise serioussuspicions and alert the clini-cian that further work-up ofthese areas might be indicated.In this case, the hemangiomawas never pursued and so noinformation was available.Further discussion of the bloodon the pillow revealed that thebleeding was more significantthan the dentist initially wasled to believe, as this necessi-tated frequent changing of theentire bed linens by thepatient's mother.

Previous extraction history isan excellent way to assess po-tential bleeding problems; how-

ever, as there was no history ofproblems in this case, thedentist was lulled into a falsesense of security. A panoramicradiograph of the mandible mayhave been helpful in distin-guishing a possible intrabonyabnormality. However, as notedpreviously, preoperative radio-graphs often appear normal inpatients with AVMs.

Finally, it should be men-tioned that even if the lesion

had been sus-E pected and con-

firmed beforethe extraction,the treatmentwould havebeen the same:

Dr. Engel w a surgical resec-chlf resident of t o the

Orla-1 lion of theOral andMaxillofecil- involved man-Surger. University .dible. How-of Nebraska Meiloalcar, at me time ever, the pro-of this o . Ho . cedure wouldnow In private.Prtl In Oew-h .have been

* done under

feesor of Surgeryend chief of Orsi and Dr. Supanoic vvs a

M~xiofscisia Surng- chief residenit of Oral

ery, Universty of and MwXiiiofacIiaNebraska Mediosi Surgery. Univerafty of

Center. 600 IL42nd Medisai

St., Ornshe sales8- Center, at the tinte ofso o. Address this case He Is n

reprint requests to In private preactce In

Dr. Dais Mels Clf

JADA, Vol. 126, February 1995 241

on October 5, 2010

jada.ada.orgD

ownloaded from

iNICAL PRACTICE

Figure 1. Preoperative perlapical radiograph of theleft mandibular molar region showing nondescriptradlolucent area.

Figure 2. Left hemimandible Immediately afterresection.

Figure 3. Mandibular reconstruction bar withcondylar prosthesis next to the resected specimen.Note that the teeth and cancellous marrowcontaining the tumor have been removed.

hemorrhage, sometype of vascular mal-formation was sus-pected immediately.The bleeding site wasquickly suctioned, thesocket was packedwith petroleum gauzeand-digital pressurewas maintained.

After the infusionof two liters of fluid,the blood pressurestabilized and thepatient was intubatedto control the airway.Blood was drawn fortype and crossmatch,and packed red bloodcell replacement wasstarted as soon as itwas available.

To determine thesource of the bleed-ing, an arteriogramwas taken of the leftexternal carotid arteryvia the left femoralartery. At this point,the hemorrhage hadbeen somewhatcontrolled by digitalpressure.

The arteriogramrevealed a very largeAVM that appearedto involve the entireleft mandibular body.Multiple feedervessels could be seen,including the left lin-gual, facial andinternal maxillaryarteries.The vessels were

then embolized withspecial "clotting"coils. Three coils wereplaced in the internalmaxillary artery, twoin the lingual andtwo in the facial-reducing the blood

flow to the area by about 80percent.

The patient was then takenimmediately to the operatingroom. The left external carotidartery was isolated with avascular loop, placed to provideproximal control.

To expose the mandible fromthe midline to the angle region,the surgeon made an incisionthat split the lip and extendeddown into the neck. A smallfissure bur was used to deter-mine the extent of resectionnecessary.

Based on the radiographs,the lesion seemed to extend tothe left parasymphysis region.However, when the pilot holeswere drilled, severe hemorrhageunder pressure squirted fromthe bone. Bone wax was packedin the holes to control thebleeding.

The involved bone extendedto the right premolar region.The mandible was sectioned inthe premolar region and the leftcondyle was disarticulated(Figure 2). A mandibular recon-struction plate with a metalcondyle was contoured to fit thedefect (Figure 3).

The teeth were removed fromthe affected bone, as was theentire cancellous portion (in-cluding the AVM). The man-dible was then frozen for futurereconstruction.

The intraoperative blood losswas estimated at 2,000 cubiccentimeters, and the patientreceived six units of packed redblood cells in addition to 5,000cc of lactated Ringer's solutionand 500 cc of albumin. Herpostoperative course wasremarkably smooth, and shewas discharged on the eighthday.

Five months later, a follow-up Doppler examination of the

238 JADA, Vol. 126, February 1995

on October 5, 2010

jada.ada.orgD

ownloaded from