Intraosseous Hemangioma of the mandibular ramus

PURPOSE: Intraosseous vascular lesions are rare conditions, comprising only 0.5% to 1% of all intraosseous tumors. They mainly occur in the second decade of life especially in women. The mandible is a quite rare location (the most common locations are the vertebral column and skull). According to the World Health Organization, hemangiomas are benign vasoformative neoplasms of endothelial origin. However, the origin of central hemangioma is debatable. Some authors believe that it is a true neoplasm, whereas others state it is a hamartomatous lesion. The patient may be completely symptom-free or may present discomfort, pulsatile bleeding and mobile teeth. Derangement of the arch form or accelerated dental exfoliation may be observed in the childhood. Most frequently radiographic finding is an unilocular or a multilocular radiolucent image with honeycombs or soap bubble appearance. Differential diagnosis includes neoplasms such as ameloblastoma, cystic lesions such as residual cyst, keratocyst and fibro-osseous lesions such as fibrous dysplasia. Wide surgical excision remains the gold standard although there are some therapeutic alternatives. We present a very rare case of intraosseous mandibular ramus hemangioma. MATERIALS AND METHODS: A 64-year-old female patient came to the Maxillofacial Surgery Operative Unit of the University of L’Aquila because of a radiolucent image observed randomly on the panoramic radiography and involving all the left mandibular ramus. Anamnestic and clinical data excluded pathologies such odontogenic cystes (the left inferior third molar was absent because extracted but it was not impacted or with follicular lesion). CT performed pre-operatively showed the lesion as a wide osteolytic and homogenous area with regular limits. It was very important to the surgical planning because axial, panorex and dental reconstructions described in detail the large osteolysis of the all internal cortex of the left ramus and therefore also near the delicate neurovascular mandibular structures (lingual nerve, inferior alveolar nerve and vessels). An intraoral transcortical complete excision was performed. The histological examination revealed a mesenchymal tumor with numerous capillaries and dilated vessels immunohistochemically being positive for CD31, but not for D2-40. In addition, there was a remarkable increase of osteoclasts that sometimes exhibited Howship's lacunae. The tumor was diagnosed as “ Intraosseous hemangioma with bone degradation”. The follow-up at two years show no recurrence and the complete reconstruction of bone without using filler. Histological findings suggest further investigated whether there could be an association between angiogenesis and osteoclastogenesis as a central pathway leading to centrifuge bone destruction in the case of intraosseous hemangiomas.