Arteriovenous malformation of the jaws: a black hole for the GDP – a case report

A 3-year-old Caucasian female presented to the Maxillofacial Department with a three-week history of swelling of the left cheek. On examination there was a bony hard swelling buccal to the lower left second primary molar (LLE) with inflamed gingiva. The mother reported occasional bleeding gums in the lower left quadrant for one year but had routine dental examinations.

An orthopantomogram (OPG) (Figure 1) showed three discrete radiolucent areas in the left mandible. On examination under anaesthesia there was no evidence of a vascular blush in the oral mucosa. Enucleation of the possible cyst was attempted and, on entering the cavity, bright red arterial bleeding was encountered, resulting in a loss of 150 ml of blood. The haemorrhage was arrested by packing the cavity with Surgicel® and the patient was haemodynamically stable. This raised the suspicion of AVM of the mandible.

The patient had a catheter angiogram (Figures 2 and 3) and embolization (Figure 4). Onyx, a liquid embolic agent, was injected and the inferior dental artery was selectively embolized. At the termination of the procedure, filling of the arteriovenous malformation was no longer visualized. The patient was discharged but presented with a couple of episodes of minor bleeding from the surgical site, which settled down with tranexamic acid mouthwash. A post-operative MRI scan was taken after three months showing successful embolization of the AVM (Figure 5).