Central hemangioma of the jaws

J Oral Maxillofac 47:1154-1160,

Surg

1969

Central Hemangioma

of the Jaws

YIH WEI-YUNG, DDS, MS,* MA GUANG-SHENG, DDSJ RALPH G. MERRILL, DDS, MScD,$ AND DONALD W. SPERRY, DDS§ Fifteen cases of central hemangioma of the jaws in 14 patients are reported, and considerations in diagnosis and treatment are discussed. In the management of these tumors, diagnostic considerations are of paramount importance if associated risks are to be minimized while maximizing the chances for a successful outcome. A search of the literature suggests that surgery, either alone or in combination with embolization, remains the treatment of choice for these lesions. All cases in this report were treated surgically without incident and with good results. Of special interest were two cases in which the tumor was removed from the excised mandible, which was then sterilized and used in the immediate reconstruction of the surgical defect.

Central hemangioma of the jaws is a rare lesion that occurs twice as frequently in the mandible as in the maxilla. The peak incidence is in the second decade of life. There is a sex predilection that favors females 2:l over males. The lesion is considered by Shira and Guernsey’ to be a true neoplasm that results from an initial endothelial proliferation which then goes on to differentiate into blood vessels. Others, however, believe the lesion is a hamartoma or developmental malformation.2,3 Although most remain static, some hemangiomas enlarge and become destructive. The real importance of the lesion lies in its potential to result in exsanguination, which usually follows an unrelated treatment of some type, either in the patient with a known lesion or one in whom the nature of the le-

sion is unknown. Fatal spontaneous hemorrhage also can occur. Collectively, Lindemann et al4 and Lamberg et al5 have tabulated a total of 25 cases of fatality. Clinical Findings A patient with a central hemangioma of the jaws may show little or no evidence of an intrabony lesion. The most common finding is usually a firm, nonpainful bony swelling. Such swelling may vary from the innocuous to that which produces facial asymmetry. Presenting complaints may include a subjective pulsatile sensation or throbbing discomfort, spurting type of gingival bleeding, or epistaxis. Commonly, severe hemorrhage follows dental extraction or biopsy. Paresthesia of the involved nerves is seen uncommonly. Hypermobility of teeth may be seen along with distortion of arch form malalignment of teeth, and malocclusion. Overlying soft tissues may be discolored or may show venous dilatation. Thrills and bruits, when present, usually indicate a rapidly expanding lesion or an arteriovenous fistula.

* Associate Professor, Department of Oral and Maxillofacial Surgery, The Oregon Health Sciences University, Portland; former Assistant Director, Department of Oral and Maxillofacial Surgery, Nanjing Stomatologic Hospital, Nanjing, China. t Assistant Director, Department of Oral and Maxillofacial Surgery, Nanjing Stomatologic Hospital, Nanjing, China. $ Professor and Chairman, Department of Oral and Maxillofacial Surgery, The Oregon Health Sciences University, Portland. 5 Assistant Professor, Department of Oral and Maxillofacial Surgery, The Oregon Health Sciences University, Portland. Address correspondence and reprint requests to Dr Yih: Department of Oral and Maxillofacial Surgery, Oregon Health Sciences University School of Dentistry, 611 SW Campus Dr, Portland, OR 97201. 0 1989 American geons

Association

of Oral and Maxillofacial

Radiographic Appearance The radiographic appearance is not pathognomanic. On the radiograph, hemangioma may mimic numerous other intrabony lesions. It is usually osteolytic. Multicystic osteolytic areas may give the lesion a honeycombed or soap-bubble appearance

Sur-

0278-2391/89/4711-0005$3.00/O

1154

YIH ET AL

FIGURE 1. An occlusal radiograph showing a honeycomb-like radiolucency of the maxilla (case No. 4).

(Figs 1 and 2). The trabeculae are arranged in spokelike fashion radiating outward from the center of the lesion. The periphery of the lesion appears irregular and poorly defined. Other lesions may show multiple, irregular, spotlike radiolucencies (Fig 3). The so-called sunburst or sunray appearance which has been described owes its appearance to the coarse trabeculae perpendicular to the surrounding bone. The inferior alveolar canal may appear to be widened. Cortices may be expanded, thinned out, or even eroded. Resorption of roots of adjacent teeth, displacement of teeth, or abnormal exfoliation of teeth may also be seen and indicate an expanding lesion. Diagnosis Definitive diagnosis from the clinical and radiographic findings alone may not be possible. Biopsy should be avoided because this diagnostic procedure carries with it the risk of producing uncontrollable hemorrhage. Smith6 and Castleman reported blood loss of 750 mL and 1,400 mL, respectively, during attempted biopsy. Angiography is a useful adjunct to diagnosis when the clinical and radio-

FIGURE 2. Panoramic radiograph shows honeycombed olucency of the left mandible (case No. 11).

radi-

FIGURE 3. Preoperative lateral radiograph of case No, 12, showing an irregular radiolucency with expansion of the cortex in the right mandible.

graphic findings suggest the possibility of a central hemangioma of the jaws. This procedure will demonstrate the vascular nature of the lesion and delineate its boundaries and arterial connections.8 Treatment The clinical behavior of these lesions mandates treatment, the most significant risk of which is exsanguination. A variety of modalities have been used to treat central hemangioma of the jaws. These methods include curettage, embolization, radioand therapy, 9 injection of sclerosing solutions,” resection.“” All have been reported to be successful. Ahhough selective vessel embolization has been reported either as definitive treatment12.13 or as a preoperative adjunct to occlude the vascular supply, it has not been shown to be curative, and should be used only when resection is not possible. ‘4-18 Brooks in 1930 introduced embolization as a method of treatment of a vascular lesion,” and it has been used since then as one method of treatment. His method was nonselective, it utilized the carotid system, and it relied on the increased blood flow to the lesion to carry the embolus to the desired site. Superselective angiography and embolization, introduced in 1965,20 is performed under fluoroscopic control, with the catheter being selectively advanced into the feeding vessels. It accurately permits delivery of the embolus into a specific area. Nevertheless, serious complications have occurred. Withdrawal of the catheter has resulted in reflux of the embolus into pulmonary or cerebral vessels. Hemiplegia, blindness, and complete facial paralysis have been reported.2’-24 Em-

1156

CENTRAL HEMANGIOMA

bolization also alters facial blood flow and may cause necrosis of skin or mucosa and thus complicate local flap reconstruction.25 The complex anatomy, the multiple feeding vessels, and the narrowness of the arterial lumina in the maxillofacial region may make cannulation of these vessels and selective vessel embolization difficult, and perhaps impossible. 16,26 Given the risks of significant hemorrhage and residual deformity, several authors still believe that complete resection of extracranial hemangiomas is the preferred method of treatment. 14~15q22 Indications for immediate surgical intervention have been the threat of imminent hemorrhage or a rapidly expanding lesion.27 The risk of bleeding attendant to surgery may be decreased by preoperative embolization or ligation of major feeding arteries. The aim of surgery is the complete removal of the tumor with preservation of the maximum amount of bone and soft tissue consistent with this goal. Table 1.

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Comparison of Cases This study reports 15 lesions in 14 patients (Table 1). One case, a 7-year-old Chinese girl (Table 1, case 12), had separate lesions in the maxilla and mandible, which is exceedingly rare. It is similar to the case reported by LaDow et a1.13 Nine patients were male and five were female, demonstrating a male-female predilection of 1.8: 1. Other reports’0,28 have shown the opposite. Age ranged from 7 to 45 years at the time of diagnosis. Four patients were younger than 10 years of age, suggesting the possibility of a congenital origin. Four of the 15 lesions in this study were in the maxilla. Nine of the patients were left with some residual noncontinuity defect (Table 1). All cases have been followed for a period of 1 to 13 years without evidence of recurrence. The clinical findings in the 14 cases are shown in Table 2, and the radiographic findings are described in Table 3.

Characteristics of 14 Cases of Central Hemangioma of the Jaws

Case

Sex! Age

1 2

F/l6 Ml38

2 1

3 4 5 6 7 8

F/8 Ml38 Ml25 Ml8 F/l0 M/45

6 1 2 2 2 12

9

M/10

10

Duration (mos)*

Location Mandible Maxilla

Size (cm)

Mode of Treatment

9.0 X 3.5 x 2.0 5.0 x 3.0 x 2.0

Partial mandibulectomy Curettage; ligation of ipsilateral external carotid artery Partial mandibulectomy Partial maxillectomy Hemimandibulectomy Curettage Partial mandibulectomy Curettage and ligation of ipsilateral external carotid artery Hemimandibulectomy and ligation of ipsilateral external carotid artery Partial mandibulectomy and ligation of ipsilateral external carotid artery Hemimandibulectomy and ligation of ipsilateral external carotid artery Hemimandibulectomy/autogenous bone graftt ; partial maxillectomy

No recurrence; No recurrence

NCD

No No No No No No

NCD partial defect NCD

Partial mandibulectomy/autogenous bone grafts; ipsilateral external carotid ligation Partial mandibulectomy preserving condyle, inferior and posterior borders

No recurrence

Mandible Maxilla Mandible Mandible Mandible ZygomalMax

4.0 5.0 8.0 10.0 2.5 1.5

x x x x x x

3.0 4.0 3.0 2.0 1.5 1.5

x x x x x x

2.0 3.0 3.0 2.0 1.0 1.5

1

Mandible

10.0 x 4.0 x 3.0

M/9

3

Mandible

8.0 x 4.5 x 2.0

11

M/26

84

Mandible

14.0 x 6.0 x 4.0

12

F/7

84

Mandible

8.0 x 3.0 x 2.0

13

M/l3

?

Maxilla Mandible

5.0 x 4.0 x 3.0 6.0 x 3.0 x 2.0

14

F/l

12

Mandible

12.0 x 4.0 x 3.0

Result

recurrence; recurrence; recurrence; recurrence recurrence; recurrence

NCD

No recurrence;

NCD

No recurrence;

NCD

No recurrence;

NCD

No recurrence;

partial defect

No recurrence;

NCD

Abbreviation: NCD, noncontinuity defect. *Approximate. t Tumor was removed from the resected mandible, which was then boiled in saline and used in the immediate reconstruction of the jaw. $ Same procedure used as in case No. 12, except that the resected mandible was autoclaved, rather than boiled, and was used as a crib to carry autogenous cancellous bone in the immediate reconstruction of the jaw.

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YIH ET AL

Table 2. Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Clinical Findings Gingival Bleeding

Postextraction Bleeding

Swelling and Pain

InfIammatory Growth +

+ +

+ + +

+

+

+ +

+ + t +

+

+ +

+

All 15 lesions in this series were treated surgically. Feeder vessels to all lesions were ligated, and in six cases the ipsilateral external carotid artery was also ligated in an effort to reduce the risk of bleeding. When ligated, the external carotid artery was approached along the anterior border of the sternomastoid muscle, at the level of the superior thyroid artery, where it was ligated between the lingual and superior thyroid branches. Other feeding vessels which could arise from the internal carotid, as well as the vertebral and thyrocervical systems, were identified and ligated before the lesion was entered. In some instances, it was desirable to approach the internal maxillary artery via the maxillary sinus. Any efferent vessels through which backflow could occur were occluded before the mass was separated from its nutrient vessels. Curettage alone, or in combination with external carotid artery ligation (risky and carried out only with small, slow-flowing lesions), was performed on two maxillary lesions and one mandibular lesion. Those three lesions were of the sclerosing variety,2’ and no unusual blood loss occurred. Two maxillary lesions, which did not involve the overying periosteum, were treated by hemimaxillectomy, using the standard Weber-Ferguson approach. The intact mucoperiosteum provided the framework for appositional bone growth, thus maintaining contour and producing excellent cosmetic results. Nine mandibular lesions were treated with either a partial mandibul;oectomy or hemimandibulectomy, using the inframandibular approach to the mandible. When this type of therapy was selected (Table 1, cases 2, 8, 9, 10, 11, and 13), the external carotid was approached in the manner previously described. When uninvolved with tumor, a sufficiently large mucoperiosteal pedicle was raised from the bone, following which the specimen, with adequate margins, was removed rapidly using an

Bone Expansion + +

+

+

Mobility of Teeth

+

+ +

+

+

+ + +

+ + + + + + + +

+

oscillating saw or a Gigli saw. Packing was used to help to control the resulting bleeding and make identification of remaining feeder vessels possible. These were then ligated. In seven of the nine cases, the overlying mucoperiosteum was involved and was taken with the tumor. Loss of overlying soft tissue and the desire to minimize blood loss were the reasons onfy two of the cases (Table 1, cases 12 and 13) were selected for immediate reconstruction. In those two cases, a modified immediate bone grafting technique was used. One of these cases was that of a 7-year-old Chinese girl (Table 1, case 12) with separate lesions in the maxilla and mandible, who was operated on in two sittings. The first procedure was a right hemimandibulectomy. Using the approach previously described, the tumor mass was removed with the resected mandible. The tumor was removed from the resected mandible, which was boiled in saline for 30 minutes, soaked in antibiotic solution, replaced in the wound, and wired to the distal stump. Table 3.

Case 1 2 3 4 5 6

Radiographic Appearance

Honeycombed Radiolucency

Multiple, Irregular Spotlike Radiolucencies

+ + + +

t + +

1

8 9 10 11 12 13 14

Cystic Radiolucency

+ + + + + +

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CENTRAL HEMANGIOMA

Healing by primary intention occurred. Two years later, at the time of resection of the maxillary lesion, it was noted that the nonvital bone had been replaced by vital bone with preservation of contour. The second case (Table 1, case 13) was treated in a similar manner, except that the resected mandible from which the tumor was removed was autoclaved and then used as a crib to hold cancellous bone from the iliac crest in the operative site. Because proximal and distal bone had been preserved, the crib could be wired in place, and the patient placed in maxillomandibular fixation. Portions of nonvital crib were sequestered over time, leaving an intact, vital mandible. Excellent facial contour and a functional dental occlusion remained 13 years after surgery. Discussion As stated earlier, central hemangiomas of the jaws are considered to be rare lesions. Stellmach2’ found 111 cases reported since 1900. Most articles in the literature on this rare tumor are case reports. Before 1966, 11 cases of central hemangioma of the jaws had been reported in the Chinese literature, of which three were contributed by the author of this report. 3o In 1981, another 21 cases were reported from 10 hospitals in the Peoples Republic of China.31 From 1954 to 1981, a total of 32 cases of central hemangioma of the jaws were reported in the Chinese literature. Central hemangiomas of the jaws have the potential to produce fatal exsanguination, and proper management is dependent on recognition of its varying appearances, extent, and hemodynamic features. Dental extractions performed in the patient with this lesion may surprise the unwary dentist and be terrifying for both him and his patient. An appropriate aphorism to remember is “Avoid surprises.” This means that the differential diagnosis of any undetermined osteolytic lesion of the jaws should include this lesion. Common clinical findings associated with this tumor are bleeding from the gingival crevices and expansion of the bone. Another significant, though less common finding, is erosion of the bone with perforation of the lesion into the oral cavity (Fig 4). It may present with ulceration of the surface and have an appearance that mimics the relatively inocuous pyogenic granuloma. Seven of the 14 cases in this study (50%) presented in this manner and were accompanied by purulence and bleeding. Such presentation, especially when seen in conjunction with an osteolytic radiographic appearance, can easily be confused with either a malignancy or an inflammatory process.

OF THE JAWS

FIGURE 4. Intraoral photograph of case No. 13, showing an expanding mass causing enlargement of the mandible. Note that teeth are missing in the area of the tumor.

Positive needle aspiration, though not pathognomanic, is considered a first step in diagnosis. Positive results also give the observer an estimate of the dynamics of the lesion (slow or fast flow) and certainly prepare one for the potential for serious hemorrhage. Among the radiolucent lesions of the jaws that may appear similar to the central hemangioma and which can also produce blood on needle aspiration are the aneurysmal bone cyst, central giant cell granuloma, tumor of hyperparathyroidism, myxoma, ameloblastoma, fibrous dysplasia, osteogenic sarcoma, reticulum cell sarcoma, myeloma, lymphoma, and probably others as well. Biopsy results in a definitive diagnosis, but can result in uncontrollable hemorrhage. It is, therefore, not recommended unless needle aspiration of a suspicious, potentially malignant lesion of the jaw is negative. When performing a biopsy, a very small window is created. Should profuse bleeding occur, this approach increases the chances of successfully controlling the hemorrhage by packing and pressure. Angiograms involving cannulization of the external carotid have proved to be useful to delineate the boundaries of the lesion, as well as to demonstrate its arterial connections. Interpretation of a proven vascular lesion is difficult, however, because all vascular lesions are not central hemangiomas, nor can all hemangiomas be demonstrated angiographically. Histologic variants of the lesion (slow-flowing microlistulous lesions, and sclerotic hemangioma,2’ Fig 5) may not manifest vascular features in the angiogram.18 Moreover, the angiographic appearance of intraosseous lesions is less well defined than what is seen in vascular lesions of soft tissue. Histologic findings and clinical appearance and behavior correlate well. The fast-flowing lesions (arteriovenous hemangiomas), in which bruits can be heard and thrills palpated are characterized his-

YIH ET AL

tologically by large arteries and dilated venous channels. Patients with such lesions will often complain of the subjective sensation of pulsatile, throbbing discomfort. This finding is absent in the slowflowing (cavernous or capillary) hemangiomas (Fig 6). The proximity of these lesions to dental structures exposes them to infectious processes. Infection of the lesion evokes a proliferative response in the capillaries, resulting in enlargement of the lesion. High-dose, long-term, broad-spectrum antibiotic therapy is indicated before radical treatment of the infected tumor. Unilateral ligation of the external carotid artery, as an isolated procedure, may be ineffective in reducing blood flow to the tumor. Even ligation of this artery bilaterally has been known to be ineffective, especially if the tumor is in the maxilla. Subsequent collateralization via the internal carotid can negate any possible benefit from the isolated ligation of the external carotid artery. A case in point is that of a 38-year-old Chinese man (Table 1, case 4), who had three episodes of spontaneous bleeding from a lesion of the maxilla, which presented clinically as a 1.0 x 0.8 cm granulomatous mass on the gingivae between the upper left second and third molars that resulted in blood loss which exceeded 1,600 mL. Bleeding was controlled by ligation of the external carotid artery, local pressure, and transfusion with 3 units of whole blood. Central hemangioma of the left maxilla was subsequently diagnosed. Seven days following ligation of the external carotid, spontaneous bleeding recurred. The patient was then transferred to the hospital where one of the authors (Y .W.-Y.) was a staff surgeon. Three hours after admission, bleeding started again. On this occasion, the patient lost more than 600 mL of blood and developed shock secondary to hypovolemia. Emer-

FIGURE 5. Sclerotic hemangioma of the mandible showing numerous dilated vascular channels surrounded by thickened, partially hyahnized collagen fibers. (Hematoxylin-eosin stain. Original magnification, X40.)

1159

FIGURE 6. Photomicrograph showing numerous thin-walled blood vessels, varying in size, in a fibrous stroma with an inflammatory infiltrate. (Hematoxylin-eosin stain. Original magnification, X40.)

gency surgery to control the bleeding, along with additional whole blood replacement therapy, was followed by left partial maxillectomy. Intraoperative blood loss was greater than 900 mL and was replaced with 1,300 mL of whole blood. It seems reasonable, in this case, to assume that isolated ipsilteral ligation of the external carotid artery induced the formation of a significant collateral blood supply to the tumor, which then contributed significantly to subsequent massive blood loss. If aggressive surgery is planned, massive blood loss can be expected, and plans must be made to deal with it. These preparations should obviously include blood replacement, adequate amounts of packing material, thrombin, and Gelfoam (Upjohn, Kalamazoo, MI), and placement of multiple largebore intravenous lines with the ability to infuse large volumes of blood over a short period of time. Proper anesthesia includes drugs to reduce mean arterial pressure to the 60- to 70-mm Hg range. The optimum chance for a successful outcome can be expected only if a proper preoperative evaluation is made, along with the proper regard for the risks to be undertaken. The literature suggests that the major method of treating these lesions has been surgical, whether as an isolated procedure or in combination with embolization. The defects that result from surgery can be immediately reconstructed with bone grafts, or reconstruction may be delayed. The decision is made on an individual basis. In the cases reported, there were none in the maxillary in which the tumor involved the mucoperiosteal tissues. This made it possible to close the defects primarily with mucoperiosteal flaps and thereby achieve a satisfactory facial configuration. In two of the lower jaw lesions reported, the resected mandible from which the tumor was removed was used as a crib and reimplanted to main-

1160

tain continuity of the jaw. These two different approaches provide alternative methods for achieving satisfactory cosmetic results. Blood loss attendant to harvesting bone for immediate grafting can be a consideration, which could also dictate reconstruction at a second sitting. References

CENTRAL HEMANGIOMA

formations of the mandible. Otolaryngol Head Neck Surg 91:366,1983 15. Hoey MF, Courage GR, Newton TH, et al: Management

16.

17. 18.

1. Shira RB, Guernsey LH: Central cavernous hemangioma of the mandible: Report of a case. J Oral Surg 23:636, 1965 2. Kelly DE, Terry BC, Small EW: Arteriovenous malformation of the mandible: Report of a case. J Oral Surg 35387, 1977 3. Matthew DN: Hemangiomata. Plast Reconstr Surg 41578, 1968 4. Lindemann A, Lorenz 0: Die geschwulste der mundhohle der kiefer und des gesichtes. Stuttgart, Wissenschaftliche verlagsgesellschaft MBH 81, 1950 5. Lamberg MA, Tasanen A, Jaaskelainen J: Fatality from central hemangioma of the mandible. J Oral Surg 37:378, 1979 6. Smith HW: Hemangioma of the jaws: A review of the literature and report of a case. Arch Otolaryngol70:579, 1959 7. Castleman B: Case records of the Massachusetts General Hospital weekly clinical pathological exercises: Case 42021, hemangioma of the mandible. N Engl J Med 254~70, 1956 8. Zou Z-J, Wu Y-T, Sun G-X, et al: Clinical application of angiography of oral and maxillofacial hemangioma: Clinical analysis of seventy cases. Oral Surg Oral Med Oral Path01 55:437, 1983 9. Laws IM: Pulsating hemangiomata of the jaws. Br J Oral Surg 51223, 1968 10. Clin DC: Treatment of maxillary hemangioma with a sclerosing agent. Oral Surg Oral Med Oral Path01 55:247, 1983 11. Zalesin HM, Rotskoff K, Silverman H: Central cavernous hemangioma of the mandible treated by an intraoral approach. J Oral Surg 33;877, 1973 12. Castaneda-Zuniga WR, Lehnert M, Nath PH, et al: Therapeutic embolization of facial arteriovenous tistulae. Radiology 132:599, 1979 13. LaDow CS, Tatoian JA, Lin S-R: Treatment of central hemangioma of the maxilla by embolization: Report of a case. J Oral Surg 34:622, 1976 14. Babin RW, Osbon DB, Khangure MS: Arteriovenous mal-

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30. 3 1.

of vascular malformations of the mandible and maxilla: Review and report of two cases treated by embolization and surgical obliteration. J Oral Surg 28:6%, 1970 Frame JW, Putnam G, Wake MJC, et al: Therapeutic arterial embolization of vascular lesions in the maxillofacial region. Br J Oral Maxillofac Surg 25:181, 1987 Banna M: Intraosseous vascular malformation of the mandible. Br J Radio1 51:738, 1978 Van Den Akker HP, Kuiper L, Peeters FLM: Embolization of an arteriovenous malformation of the mandible. J Oral Maxillofac Surg 45:255, 1987 Brooks B: The treatment of traumatic arteriovenous Iistula. South Med J 23: 100, 1930 Yeoman CM: Management of hemangioma involving facial, mandibular and pharyngeal structures. Br J Oral Maxillofat Surg 25: 195, 1987 Braun IF, Levy S, Hoffman JC: The use of transarterial microembolization in the management of hemangiomas of the perioral region. J Oral Maxillofac Surg 43:239, 1985 Biller HF, Krespi YP, Som PM: Combined therapy for vascular lesions of the head and neck with intraarterial embolization and surgical excision. Otolaryngol Head Neck Surg 90:37, 1982 Leikensohn JR, Epstein LI, Vasconez LO: Superselective embolization and surgery of non-involuting hemangiomas and A-V malformations. Plast Reconstr Surg 68:143, 1981 Hupp JR: Superselective angiography with digital subtraction and embolization of a maxillary hemangioma in a patient with Eisenmenger’s syndrome. J Oral Maxillofac Surg 44:910, 1986 Berenstein A, Persky MS, Cohen NL: Combined treatment of head and neck vascular masses with preoperative embolization. Laryngoscope 94:20, 1984 Bryant WM, Maul1 KI: Arteriovenous malformations of the mandible. Plast Reconstr Surg 55:690, 1975 Pierce11 MP, Waite DE, Nelson RL: Central hemangioma of the mandible: Intraoral resection and reconstruction. J Oral Surg 33:225, 1975 Lund BA, Dahlin DC: Hemangiomas of the mandible and maxilla. J Oral Surg 22:234, 1964 Stellmach R: Die knochenhemangiome des gesichtsschadels, in Gohrbandt E, Gabka J, Bemdorfer A (eds): Handbuch der Plastichen Chirurgie, vol 2. Berlin, de Gruyter, 1973 Yih W-Y: Central hemangioma of the jaws: Report of three cases. Chin J Stomatol 10:358, 1964 The Committee of Editors of Chinese Stomatology: Central hemangiomas of the jaws. Compre Rep 16:174, 1981