Behnia Hossein, Ghodoosi Iraj, Motamedi Mohammad Hosein Kalantar, Khojasteh Arash, Masjedi Ahmad
Department of Oral and Maxillofacial Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
J Oral Maxillofac Surg. 2008 Dec;66(12):2557-65. doi: 10.1016/j.joms.2008.06.056.
This study evaluates 2 surgical methods used at our center for the treatment of mandibular arteriovenous malformations (AVMs): resection with immediate replantation and curettage via proximal transmandibular osteotomy.
Patients with AVMs of the mandible who were treated during a 17-year period between 1992 and 2008 at our department were assessed. Two surgical techniques were used for treatment: 1) resection of the segment, curettage of the intrabony lesion, extraction of involved teeth, and immediate replantation and 2) proximal osteotomy curettage of the lesion within the bone and extraction of involved teeth. In the replantation group the resected segment of the mandible was replanted after the contents were scraped out and the involved teeth removed. In contrast, in the proximal osteotomy group this was done without removal of the bone segment. In both techniques the cortical bone of the mandible was maintained. However, in the transmandibular curettage group the periosteum was not entirely stripped off because curettage was done via proximal osteotomy without removal of the segment. The entire intrabony lesion and a margin of cancellous bone related to the lesion were excised in both groups. The bone was fixed with titanium plates in all cases. All patients were followed up annually for a period of 1 to 17 years (mean, 9.5 years).
We treated 12 patients with mandibular AVMs (2 male and 10 female patients). Their ages ranged from 7 to 17 years. Preoperative angiography showed high-flow central vascular lesions in all patients. Of the lesions, 7 (58%) were treated via resection with immediate replantation and 5 (42%) were treated via transmandibular curettage. Embolization was performed in 4 cases 48 hours before surgery. However, blood loss was not significantly decreased by embolization. The lesions were categorized as multilocular (58.3%) or unicystic (41.7%) based on the radiographic findings and were located in the mandibular body (66.7%) or ramus (33.3%). Blood loss averaged 1.60 L in the group undergoing resection and immediate replantation and 1.30 L in the transmandibular curettage group. During the follow-up period, no recurrences were encountered in either group via clinical, radiographic, or computed tomography scan assessment, and none of the patients had facial deformities develop.
The results suggest that transmandibular curettage via proximal osteotomy without complete resection is an effective less invasive method with which to treat AVMs of the mandible provided that the lesion is small, is confined within the bone, and has not invaded the soft tissues. Less blood loss, preservation of the bone, more favorable postoperative esthetics, and better function are among the advantages of this technique. In more extensive cases and those involving both hard and soft tissues, resection with immediate replantation is recommended. Both techniques obviated the need for bone graft reconstruction. This technique is better than resection and discarding of the segment.
本研究评估了我院治疗下颌骨动静脉畸形（AVM）的两种手术方法：切除并即刻再植术以及经下颌骨近端截骨刮除术。
对1992年至2008年期间在我院接受治疗的下颌骨AVM患者进行评估。采用两种手术技术进行治疗：1）切除病变节段，刮除骨内病变，拔除受累牙齿，然后即刻再植；2）经下颌骨近端截骨刮除骨内病变并拔除受累牙齿。在再植组中，刮除下颌骨切除节段的内容物并拔除受累牙齿后进行再植。相比之下，在近端截骨组中，不切除骨段进行上述操作。两种技术均保留了下颌骨的皮质骨。然而，在下颌骨刮除组中，由于通过近端截骨进行刮除而未切除骨段，骨膜未完全剥离。两组均切除整个骨内病变及与病变相关的松质骨边缘。所有病例均用钛板固定骨。所有患者每年随访1至17年（平均9.5年）。
我们共治疗了12例下颌骨AVM患者（2例男性，10例女性）。年龄范围为7至17岁。术前血管造影显示所有患者均为高流量中心性血管病变。其中7例（58%）采用切除并即刻再植术治疗，5例（42%）采用经下颌骨刮除术治疗。4例在手术前48小时进行了栓塞。然而，栓塞并未显著减少出血量。根据影像学表现，病变分为多房性（58.3%）或单囊性（41.7%），位于下颌体部（66.7%）或下颌支（33.3%）。切除并即刻再植组平均失血量为1.60 L，经下颌骨刮除组为1.30 L。在随访期间，两组通过临床、影像学或计算机断层扫描评估均未发现复发，且所有患者均未出现面部畸形。
结果表明，对于病变较小、局限于骨内且未侵犯软组织的下颌骨AVM，经下颌骨近端截骨不完全切除的刮除术是一种有效的微创治疗方法。该技术具有失血量少、保留骨组织、术后美观度更佳以及功能恢复更好等优点。对于病变范围更广以及累及软硬组织的病例，建议采用切除并即刻再植术。两种技术均无需进行骨移植重建。该技术优于切除并丢弃骨段的方法。
