Laser therapy and sclerotherapy in the treatment of oral and

maxillofacial hemangioma and vascular malformations

Bogdan Criana, Mihaela Bciua, Grigore Bciub, Liana Crianb, Simion Brana, Horaiu Rotarb,
Iuliu Moldovanb, Sergiu Vcrab, Ileana Mitrea, Ioan Barbura, Andreea Magdab, Cristian Dinu*b

a
Department of Implantology and Maxillofacial Surgery, Iuliu Hatieganu University of Medicine
and Pharmacy, Cardinal Iuliu Hossu St., No. 37, 400029 Cluj Napoca, Romania
b
Department of Cranio-Maxillofacial Surgery, Iuliu Hatieganu University of Medicine and
Pharmacy, Cardinal Iuliu Hossu St., No. 37, 400029 Cluj Napoca, Romania

ABSTRACT

Hemangioma and vascular malformations in the field of oral and maxillofacial surgery is a pathology more often
found in recent years in patients. The aim of this study was to evaluate the efficacy of the laser photocoagulation
performed with a diode laser (Ga-Al-As) 980 nm wavelength in the treatment of vascular lesions which are located on
the oral and maxillofacial areas, using color Doppler ultrasonography for evaluation of the results. We also made a
comparison between laser therapy and sclerotherapy in order to establish treatment protocols and recommendations
associated with this pathology. We conducted a controlled study on a group of 92 patients (38 male and 54 female
patients, with an average age of 36 years) having low flow hemangioma and vascular malformations. Patients in this
trial received one of the methods of treatment for vascular lesions such as hemangioma and vascular malformations:
laser therapy or sclerotherapy. After laser therapy we have achieved a reduction in size of hemangioma and vascular
malformations treated with such a procedure, and the aesthetic results were favorable. No reperfusion or recanalization
of laser treated vascular lesions was observed after an average follow-up of 6 to 12 months. In case of sclerotherapy a
reduction in the size of vascular lesions was also obtained. The 980 nm diode laser has been proved to be an effective
tool in the treatment of hemangioma and vascular malformations in oral and maxillofacial area. Laser therapy in the
treatment of vascular lesions was more effective than the sclerotherapy procedure.

KEYWORDS

Hemangioma, vascular malformation, oral, maxillofacial, laser therapy, sclerotherapy, ultrasonography.

1. INTRODUCTION

Tumors and vascular malformations in the field of oral and maxillofacial areas represent an increasingly frequent
pathology encountered in small and advanced ages. Because of these tumors location especially in the visible area of the
face, they affect primarily the physiognomic function, with great impact on the patients psyche1, 2.
The establishment of an exact diagnostic, and of the extension of such tumors, as well, must be achieved before any
treatment, as the visible portions can represent just a part of these lesions. To this end, some authors have used Doppler
color imaging, magnetic resonance imaging (MRI) or color coded duplex ultrasound, in order to identify the depth of the
vascular lesions3, 4, 5, 6.

High-end Medicine Based on Laser and Biotechnologies, edited by

Darinca Carmen Todea, Adrian Gh. Podoleanu, Virgil-Florin Duma, Proc. of SPIE
Vol. 9670, 967008 2016 SPIE CCC code: 1605-7422/16/$18 doi: 10.1117/12.2185399

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 The injection of sclerosing agents and the embolisation with various solid materials, followed by surgical excision
were frequently used as treatment methods of hemangioma and vascular malformations7, 8, 9.
Even from the late 80s different types of laser were introduced for use in the management of vascular lesions such
as hemangioma or vascular malformations, in the attempt to avoid the risk of hemorrhaging associated with the
conventional surgery of some of these lesions10, 11. The application of laser techniques have been studied throughout time
and the subsequent results have encouraged the use of laser energy radiation in various ways: contact, non-contact and
interstitial 3, 4, 5. A series of studies have used Argon, Nd:YAG, and CO2 based lasers for tumor and vascular
malformation therapy, with favorable results 12, 13, 14, 15.

2. WORKING HYPOTHESIS

The purpose of this study was that of evaluating the efficacy of the photocoagulation achieved with the help of the
980 nm diode laser (Ga-Al-As) in the treatment of the vascular lesions with an oral and maxillofacial localization, using
the pre- and post-op Doppler color ultrasound for result interpretation. We have also performed a comparison between
the different treatment methods with laser therapy and scleroptherapy in order to establish certain protocols and
therapeutic recomendations associated with this pathology.

3. MATERIALS AND METHODS

We have carried out a controlled clinical study on a group of 92 patients (38 male subjects and 54 female subjects,
with an average age of 36 years) who presented low-flow hemangioma and vascular malformations with localised at the
oral and maxillofacial regions. All the patients signed an informed consent before taking part in the study. Vascular
malformations with a high flow or high impedance have not been included in this group. All vascular lesions treated
were localised in regions with high aesthetic and functional significance for the patient. We have used the Doppler color
ultrasound in order to establish an accurate diagnostic as well as obtain certain additional information concerning
vascularisation, the type of flow, the localisation and type of vascular pedicles, and the dimentions and volume of the
lesion, respectively (Figure 1).
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Figure 1. An ultrasound color Doppler image of a hemangioma.

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The patients within this clinical trial have benefited from one of the treatment modalities of the vascular lesions such
as hemangioma or vascular malformations with laser therapy or with sclerotherapy. The choice of optimal treatment
modality was made based on results obtained following the clinical examination, ultrasound, photo documentation as
well as information in the specialized literature. The photographic documentation was carried out for each particular
case, the former also serving for long term comparative evaluation (Figure 2, Figure 3).

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 Figure 2. The clinical aspect of an infantile hemangioma in the left cheek before treatment.

Figure 3. The clinical aspect of an infantile hemangioma in the left cheek after laser treatment.

3.1 The laser therapy procedure

In order to treat hemangioma and vascular malformations with a low flow, we have used a 980 nm diode (Ga-Al-As)
laser device (Ceralas D15 model, Ceramoptec, Jena, Germany). The laser parameters used during the procedure were:
continuous wave (cw), at a power ranging from 9 W to 11 W, and the energy transmitted to the tissues was on average
1000 J per surface unit (cm2). The irradiation time varied depending on the area of the surface to be treated, an area
which was calculated before every procedure, through clinical measurements corroborated with the measurements
obtained following the Doppler color ultrasounds.
Two laser irradiation techniques were used: an interstitial laser therapy technique and an irradiation technique by
means of a glass plate (Figure 4, Figure 5). The interstitial laser therapy was used mainly for hemangioma and vascular
malformations with large dimensions and deeply seated. The glass plate laser therapy was used mainly in the case of
hemangioma and vascular malformations superficially seated. The laser therapy procedures were carried out in several
treatment stages which varied from 1 to 12 sessions, at 6 week intervals between the irradiation sessions, depending on
the size of the vascular lesion, the evolution of each individual case, and the patients satisfaction concerning the
obtained result.

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 Figure 4. Interstitial laser therapy technique.

Figure 5. Laser therapy through a glass plate.

3.2 The scleroptherapy procedure

For the sclerotherapy procedure, various sclerosis-inducing agents were used, which were injected at the level of the
vascular lesions in order to produce sclerosis in the tributary blood vessels. Sclerosis inducing substances were used,
such as: ethanol, triamcinolon, bleomycin A5, polidocanol (Aetoxisclerol), ethanolamine oleate, which were
administered in accordance with the producers recommendation. The number of sclerotherapy sessions varied between
3 and 6 in our study. The sclerotherapy procedures were also carried out at 6 week intervals, these being repeated until a
favorable result was obtained, both from the point of view of the clinical aspect and the point of view of patient
satisfaction (Figure 6, Figure 7).

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 Figure 6. The clinical aspect of a vascular malformation in the right cheek before sclerotherapy treatment.

Figure 7. The clinical appearance of a vascular malformation after sclerotherapy.

Following the procedures carried out on patients taken under study, we have done a comparative analysis between
laser therapy and sclerotherapy. In the case of laser therapy and sclerotherapy, the decrease in size of the vascular
lesions, based on the laser energy quantity administered, or the sclerosis inducing agent used, as well as the modification
of the vascularization at this level have been evaluated through clinical examination, Doppler color ultrasounds and
photo documentation in all treatment stages. Based on the clinical measurements corroborated with ultrasound ones, we
have carried out the calculations of the vascular lesion areas before and after the laser therapy, and sclerotherapy
procedures respectively. The area of a vascular lesion surface was framed as geometrical shape in the area of an ellipsis,
and based on the calculus formula all the surfaces of the vascular formations were evaluated. The square standard
deviation before and after treatment was calculated. The square standard deviation was statistically evaluated by
calculating the normalized square standard deviation (in percentages), which shows us the degree of vascular lesion
reduction in the case of sclerotherapy and laser therapy usage. The evaluation of the patients take under study was
carried out at 6, respectively 12 months after treatment finalization.

4. RESULTS

Following laser therapy, we have obtained a decrease in size of the hemangiomas or vascular malformations in all
patients who have benefited from such a procedure, and the aesthetic results were favorable, the lesions remaining
visible in only 9 cases (20,45%), of the total cases treated with laser therapy. The surface regression of the lesions and
the reduction of the vascular signal measured by ultrasound varied between 45% and 95%. From a statistical point of

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 view, the normalized square standard deviation of the surface area treated through laser therapy confirms the reduction of
vascular lesions, clinically and imagistically observed (Figure 8). No re-perfusions or vascular re-canalizations at the
level of the laser treated lesions were noticed after a medium control period of 6 to 12 months. The laser
photocoagulation was well tolerated by all the patients, with no adverse or post-operative reactions presented. All
patients presented a favorable postsurgical recuperation without functional impairment of the treated area.

The histogram for the mean square deviation

35

30

20

10

04 0.5 0.8 0.7 0.8 0.9 11

Normalized mean square deviation %

Figure 8. Normalized mean square deviation when using laser therapy.

In the case of sclerotherapy, a reduction of the size of the vascular lesions was obtained, in a proportion which
varied between 23% and 72%. From an aesthetic point of view, the lesions remained visible in 5 cases (35,71%) of those
treated through sclerotherapy. Statistically, the normalized square standard deviation of the area of the surfaces which
were treated through sclerotherapy shows a diminution of the latter, but not as significant as in the case of laser therapy
(Figure 9). As in the case of laser therapy, no complications were registered and no adverse reactions were signaled
during or after the injection of the sclerosis inducing agent. The patients evolution was favorable in these cases as well,
and no local setbacks were registered at the 6 and 12 month check-ups.

The histogram for the normalized mean square deviation

0.2 0.4 0.6 0.8 1.2 ta

Normalized mean square deviation %

Figure 9. Normalized mean square deviation when using sclerotherapy.

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 5. DISCUSSION

This study reflects the clinical experience obtained along the years of usage of the 980 nm (Ga-Al-As) diode laser in
the treatment of hemangioma and vascular malformations in the oral and maxillofacial field.
The 980 nm wave length produced by the (Ga-Al-As) diode laser has a similar effect regarding tissue coagulation
with that of 1064 nm, produced by the Nd:YAG type laser, a fact confirmed by other authors as well16, 17. By using this
kind of laser, the reduction of the vascular lesion size can be obtained with interstitial or contact laser procedures.
The results of this study of interstitial or contact therapy with diode laser (Ga-Al-As) of 980 nm at the level of
vascular lesions demonstrates a high efficiency of this new therapies.
The laser assisted interstitial photocoagulation technique performed in our study is similar to other interstitial
techniques used for various body parts within the treatment of hemangioma and vascular malformations3, 4, 5. The results
of our study show that photocoagulation with the help of the diode laser produces a regression of the hemangioma and
vascular malformations in a way similar to the results of other studies which use an Nd:YAG type laser 14, 18. In our study
we have obtained a healing process without scars or perfusions at the level of hemangioma, an observation reported by
other studies which have used an diode laser (980 nm) 19, 20, 21. Other studies have shown that the intra-lesion
photocoagulation treatment done with the help of a KTP laser is efficient and safe for the treatment of vascular lesions at
the level of the oral cavity 22, 23, 24.
The use of the sclerosis inducing agents at the level of vascular lesions in the oral and maxillofacial field has led to
obtaining of some favorable results regarding the reduction in size of these lesions and of the risk of a local relapse or
functional affectation of the treated regions, in the case of the study carried out by our team. Similar results have been
obtained by other authors as well in the studies carried out for the sclerotherapy of vascular lesions in the neck and head
areas 25, 26. These results depend however very much on the sclerosis inducing agent used, the duration and mode of
administration, and the association with other therapies.
Even if the results were favorable both in the case of the laser therapy use or of the sclerotherapy, the reduction in
size of the vascular lesions was more important through the use of contact or interstitial laser as opposed to the injection
of the sclerosis inducing agent at the level of the vascular lesions. Concerning the aesthetic aspect, the latter was assessed
by patients as being far better when the laser was used, as opposed to sclerotherapy, which was confirmed by the
photodocumentation of the cases before, during, and after the treatments carried out.
The identification of the modifications in size of the vascular lesions treated was possible through Doppler-color
ultrasound, which represents to this day an important instrument for the diagnostic and postoperative evaluation of the
results. This imaging technique is recommended for pre and postoperative routine monitoring of hemangioma and
vascular malformations 27, 28, 29.

6. CONCLUSIONS

The diode laser emitting radiation with a 980 nm wavelength proved to be as efficient as other types of lasers,
such as the Nd:YAG, KTP, He-Ne or Argon one in the treatment of hemangioma and vascular malformations.
The laser therapy and sclerotherapy procedures respectively were preferred to classical surgical excisions, even if
they required more treatment sessions, due to the lower risks of complications and intra- or postoperative accidents, as
well as the setbacks or subsequent functional afflictions.
Laser therapy proved to be a more efficient procedure in the treatment of vascular lesions than sclerotherapy, by
reducing the lesions size and through a better aesthetic aspect.
Photocoagulation through laser therapy represents an effective treatment method in the case of hemangioma and
vascular malformations. In certain situations, however, it can be one of the few treatment alternatives.

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 7. ACKNOWLEDGMENTS

The clinical study presented was conducted in the Clinic of Cranio-Maxillofacial Surgery, Cluj- Napoca, with the
approval of the Ethics Committee of the "Iuliu Haieganu" University of Medicine and Pharmacy Cluj- Napoca, based on
document no. 15/24.04.2005.
The study was partially funded by POSDRU grant no. 159/1.5/S/136893 grant with title: Strategic partnership to
improve the quality of medical research in universities through doctoral and postdoctoral scholarships
DocMed.Net_2.0.

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