CLINICAL ARTICLES
Haemangioma on the Dental Alveolar Ridge
– Report of a Case
Shiu-Yin Cho*, BDS, MDS, FRACDS, FHKAM (DS)
Man-Ching Tang†, MBBS, FRCPath, FHKAM (Pathology)
ABSTRACT Haemangioma is the most common benign oral soft tissue tumour in children. It often presents at
birth or soon after, and appears as a soft and vascular swelling in lip, tongue, or buccal mucosa. This article reports
a case of haemangioma on the dental alveolar ridge in a 10-year-old girl which does not present with the characteristic
vascular appearance.
Introduction
Haemangiomas are benign tumours characterised by the
proliferation of blood vessels 1. They are often present at
birth or appear soon after, and grow rapidly by endothelial
proliferation 2. They must be distinguished from the
arteriovenous malformation which grows by dilation of
the abnormal vessels and at the same rate as the child.
Haemangiomas, especially the congenital ones, are
probably hamartomas and are not true neoplasms 1, 3.
The majority of haemangiomas involve the head
and neck region, and more females are affected 1, 3.
Retrospective studies of oral tumours in paediatric
patients have shown that haemangiomas were the most
common benign soft tissue tumour in children 4, 5, 6. In
a survey where a broad spectrum of biopsied oral lesions
were studied, haemangioma accounted for 4.4 percent
of all oral biopsies and was the sixth most common oral
lesions in children up to 15 years of age 7. This was in
contrast to earlier studies which found less than 1 percent
of haemangiomas in oral biopsies from patients up to
19 years of age 8, 9. However, all these figures are
probably under-estimations of the true prevalence of
* Senior Dental Officer, Fanling School Dental Clinic, Department of
Health, Hong Kong
† Chief of Service, NTW Pathology Service, Hospital Authority, Hong
Kong
Correspondence:
Dr. Shiu-Yin Cho
Fanling School Dental Clinic,
2/F Fanling Health Centre,
2 Pik Fung Road, Fanling, N.T.,
Hong Kong.
Tel : (852) 2639 4678
Fax : (852) 2671 2092
e-mail : fsdc@dh.gov.hk
37
Hong Kong Dental Journal 2004; 1: 37-39
haemangiomas in children as some of the lesions may
have been left for natural involution and were not
available for biopsy.
Haemangiomas are often classified on the basis of
their histological appearance and two main types are
described: capillary and cavernous 1-3 . Capillary
haemangiomas are composed of many small capillaries
lined by a single layer of endothelial cells supported in
a connective tissue stroma of varying density. Cavernous
haemangiomas are formed by large, thin-walled vessels
or sinusoids lined with a single layer of endothelium
which are separated by thin septa of connective tissues.
Mixed haemangiomas consist of both components may
also occur 3.
Clinically haemangiomas of the oral soft tissues often
appear as soft, flat or raised lesions of the mucosa.1
They are usually deep red or bluish red in colour and
may blanch on the application of pressure. They are
seldom well circumscribed and the most common sites
of occurrence are the lip, tongue and buccal mucosa 1, 3.
This article reports a case of haemangioma on the
alveolar ridge which does not present with the
characteristic vascular appearance.
Case Report
A 10 year-old Chinese girl who complained of an oral
swelling over the alveolar ridge at the upper left premolar
region. The swelling was detected a few weeks after
exfoliation of the primary molar 64. Her medical and
dental history was unremarkable and she had been a
participant of the School Dental Care Service since she
was 6 years old. From the clinical record no oral swelling
was observed at the last routine dental examination 6
months ago. On examination, the patient was in mixed
dentition and a local soft tissue swelling of about 1cm
diameter was detected over the alveolar ridge at the
region of tooth 24. The swelling was firm, non-painful,
38
Figure 1 Periapical radiograph of the affected area.
Figure 2 Buccal view of the lesion before surgical excision.
and of colour similar to normal mucosa. The swelling
was not ulcerated or impinged by the opposing teeth.
Radiographic examination of that region did not reveal
any bony involvement and the tooth 24 had almost
attained full post-eruption height anatomically (Figure 1).
Differential diagnoses were fibrous hyperplasia,
peripheral ossifying fibroma, and peripheral giant cell
granuloma. Provisional diagnosis of fibrous hyperplasia
was made based on the history and clinical features of
the lesion. The patient was advised to use daily hot
saline mouthwash for 2 weeks to see if the lesion would
reduce in size.
The patient was reviewed 2 weeks after the initial
examination and the swelling persisted with no change
in size (Figure 2). Excisional biopsy was then performed
to remove the swelling and to confirm the diagnosis. A
narrow margin of normal mucosa was removed with
the lesion in order to ensure total removal of the lesion
and to prevent recurrence. The crown of tooth 24 was
totally exposed after the excision and haemostasis was
achieved by gauze biting. Histopathological examination
Haemangioma on the Dental Alveolar Ridge – Report of a Case
Figure 3 Photomicrograph of the lesion showing lobules of capillary-
size vessels in the subepithelial fibrous stroma (20x).
Figure 4 Buccal view of the area 1 year after excision.
of the lesion showed mucosa lined by parakeratotic
stratified squamous epithelium, with lobules of capillary-
size vessels found in the subepithelial fibrous stroma
(Figure 3). Diagnosis of capillary haemangioma was
made. The patient was reviewed 1 week, and then 3, 6,
and 12 months after the biopsy and there has been no
recurrence of the lesion (Figure 4).
Discussion
Besides haemangiomas, there are other vascular lesions
which could also be found in oral soft tissues. One
example is the pyogenic granuloma which commonly
occurs on gingival tissues. Pyogenic granuloma in the
mouth has a typical purple-red polypoid or exophytic
appearance. Microscopically it is composed of lobules
of capillary-size vessels in a fibromyxoid stroma. Most
lesions are altered by secondary inflammatory changes
and therefore have been likened to granulation tissue.
The lesion in this case did not show the typical gross or
Cho and Tang
microscopic appearance of a pyogenic granuloma. It
only contained lobules of capillary-size vessels in a
fibrous stroma without inflammation, and was therefore
a capillary haemangioma 10. The definite vascular
component in this lesion also excluded the differential
diagnosis of fibrous epulis.
Management of oral haemangiomas varies
considerably depending on the age of the patients, and
the extent and type of the lesions. The range of treatment
includes surgery 11, laser therapy 12, use of sclerosing
agents 13, and embolisation 14. Cryotherapy, compression,
and radiation therapy have also been suggested in the
past 1. Most haemangiomas in infancy should be left
alone, allowing for natural involution to occur 2 .
Exceptions to this may include psychological reasons
and lesions at eyelids affecting vision. Angiography,
computerised tomography and magnetic resonance
imaging are useful in delineating the vascular supply
and extent of the haemangiomas when their sizes are
large or when jaw bones are involved 2, 14. Management
of such extensive lesions often requires a team approach
consisting of radiologist, maxillofacial surgeon and plastic
surgeon.
The treatment carried out in the present case was
surgical excision, which had been chosen based on the
size of the lesion and the provisional diagnosis of fibrous
hyperplasia. However, this could have resulted in severe
bleeding if the lesion was a haemangioma involving
large blood vessels. If severe blood loss is anticipated,
the operation must be performed in hospital setting
where blood transfusion facilities are available. The
prognosis in this case is good as haemangiomas rarely
become malignant or recur after adequate removal 1.
The haemangioma presented in this case is considered
relatively uncommon based on its site of occurrence
and clinical characteristics. In fact, haemangiomas of
the oral soft tissues may mimic other lesions clinically,
and in some cases even histologically. Dentists should
therefore be aware of these lesions when making
diagnosis and attempts at excision of apparently innocent
lesions may result in serious bleeding.
39
Acknowledgement
The authors thank Dr Alfred C. C.Tsang for his kind
assistance in the preparation of this article.
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