A 12-year-old female patient reported to the Department of Periodontics, People's College of Dental Science and Research Centre, Bhopal, with a history of swelling in the upper lip and gums since last six years. Patient gave history of trauma during playing six years back, which resulted in laceration of upper lip, for which a local doctor was consulted. This was followed by appearance of swelling in the upper lip which increased gradually in size and was constant since the last two years. Patient also gave a history of swelling and spontaneous bleeding from the gums, because of which she refrained herself from oral hygiene maintenance.
Intra oral examination showed generalized gingival hyperplasia with maxillary arch with a typical bluish purple gingiva at the interdental areas of 11 and 21; associated with grade I mobility Also, localized gingival enlargement was present in relation with mandibular incisors and canine [Figures –]. Generalized bleeding was observed at slightest provocation of gingiva. No abnormalities were detected on general systemic examination, and hematological investigations which included a coagulation profile. Orthopantomogram was also inconclusive .
Pre operative right lateral view
Periodontal treatment which was initiated with phase I therapy using hand instruments resulted in spontaneous brisk bleeding which was difficult to control. The bleeding site was suctioned and severe hemorrhage was controlled by digital pressure which took no less than 20 to 25 minutes. Because of the severe nature of hemorrhage encountered, some type of vascular abnormality was suspected and the patient was referred to physician for opinion.
Ultra sonography of the upper lip was performed which showed marked thickening of upper lip with multiple dilated vascular channels in the submucosal layer of upper lip. Dilated and enlarged arteries were seen with marked increase in systolic and diastolic flow predominantly on left side of midline. The findings were suggestive of post traumatic AVM .
Angiography is the corner stone of diagnosis of vascular lesions which helps in visualizing exact angioarchitecture of the lesion essential for treatment planning. A transfemoral angiography was performed which confirmed the diagnosis of a small high flow AV malformation measuring (approx. 16×9×12 mm) situated in the middle of upper lip . The arterial feeders were from right internal maxillary artery and venous drainage via bilateral ophthalmic vein into bilateral cavernous sinuses and partly via bilateral facial vein into bilateral jugular vein.
The patient underwent a surgery in a private clinic where the mass associated with upper lip was excised using circumferential excision and the defect was closed. The patient did not turn up for further recall and reported back after two years for periodontal treatment. Intraoral examination revealed gingival enlargement was still present, and also a recurrence of the malformation of lip was noted as the central nidus of the lesion present in the midline of the upper lip was not removed. After consultation with the physician and oral surgery department, it was decided to undertake periodontal treatment after embolization of the lesion.
Local anesthesia was administered to the patient and the osseous topography of the bone was determined using bone sounding. Gingivectomy and gingivoplasty were performed at the same time, so as to achieve the normal topography of gingiva. Bleeding points were marked using pocket marker so as to outline the course of incision. The incision was started using no. 15 scalpel blade from the distal most tooth apical to the bleeding points marking the course of the pocket and directed coronally to a point between the base of the pocket and crest of bone. The incision was beveled at 45 degree to the tooth surface, so as to recreate normal festooned patter of gingiva. The incised tissue was removed and the area was degranulated using gracey curettes. Taking into consideration the bleeding encountered and the extent of gingival enlargement, the surgery was performed sextant wise, the bleeding during the surgery was relatively less as compared to initial phase due to embolization of the lesion. The intrasurgical bleeding was controlled using pressure pack and postoperative bleeding was controlled by cold compression.
Post embolization of the vascular lesion present with the upper lip and following gingivectomy procedure, the patient was followed-up for a period of one year and no recurrence was noted [Figures –]. The final aesthetic result was acceptable by the patient.
Post operative frontal view after one year
Post operative left lateral view after one year
Post operative right lateral view after one year