|Year : 2016 | Volume
| Issue : 2 | Page : 81-84
Lymphangioma of lip treated with carbon dioxide laser
Reenesh Mechery1, Manoj Kumar2, Piyush Arora3, Nithya Dinakar4
1 Department of Periodontology, Command Military Dental Centre (Northern Command), Udhampur, Jammu and Kashmir, India
2 Department of Oral-Maxillofacial Surgery, Military Dental Centre, Chakrata, Himachal Pradesh, India
3 Department of Oral Pathology, Jodhpur Dental College, Jodhpur, Rajasthan, India
4 General Dentist, Consultant Dentist, Command Hospital, Udhampur, Jammu and Kashmir, India
|Date of Web Publication||29-Dec-2016|
Command Military Dental Centre, (Northern Command), Udhampur, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Lymphangiomas are benign hamartomas of lymphatic channels mostly present as developmental malformations arising due to sequestration of lymphatic tissues not communicating with patented lymph channel. They are generally congenital and more frequently diagnosed in childhood but rarely do they occur in adults. In head and neck region, they have a high predilection for occurrence in tongue followed by lips . This article describes a case report of lymphangioma of lip in the light of current information with clinical and histological aspect in a young patient, which was successfully treated with carbon dioxide laser.
Keywords: Carbon dioxide laser, oral lymphangiomas, vascular malformation
|How to cite this article:|
Mechery R, Kumar M, Arora P, Dinakar N. Lymphangioma of lip treated with carbon dioxide laser. J Dent Lasers 2016;10:81-4
| Introduction|| |
Redenbacher in 1828 was first to describe these vascular malformations. Even today, there is no best established definition for lymphangiomas. Some authors describe them as hamartomas, others as congenital uncommon malformations of lymphatic system and as benign vascular tumors. Lymphangiomas are described in three groups, namely, simplex (capillary), cavernous, and cystic. , Excessive secretion from lining cell or improper drainage of lymphatics causes asymptomatic, slow-growing, painless cystic mass causing severe esthetic deformities. Often they are present at or around the time of birth (60%) and constitute 25% of all benign vascular tumors of children.  The head and neck predilection of lymphangiomas is about 50%-70% with the involvement of dorsum of tongue followed by lips, buccal mucosa, soft palate, and floor of the mouth. They can either be localized or diffused and intraorally be seen superficial or deep. Superficial lesions are elevated nodules with pinkish or yellowish color or reddish and purplish color with crusting if secondary hemorrhage is associated. Deeper lesions are soft diffused masses with normal oral color. 
There are many treatment modalities for the correction of esthetic and functional impairment cased by lymphangiomas such as surgery, aspiration, incision and drainage, steroids, intralesional sclerosing agents, cryosurgery, and lasers. Over few years, carbon dioxide lasers (CO 2 ) have proven to be best for oral lesions due to its affinity with water and high absorption by oral mucosa.  CO 2 lasers have also added the advantage of coagulation of smaller blood vessels and lymphatics, thus providing a drier and cleaner surgical field, decreased postoperative pain due to neuronal thermocoagulation of nerve endings, immediate surgical field sterilization of wound surface, and minimal wound contraction and scarring. , At molecular level, also CO 2 lasers produce comparatively less amount of primary and secondary proteomic prions formed due to thermal denaturation.  The present article describes a case of lymphangioma upper lip causing severe functional and esthetic deformity in a young college going girl leading to mental agony and social stigma associated with lymphangioma which was treated successfully and esthetically corrected with CO 2 laser.
| Case Report|| |
A 20-year-old college going young girl reported to the dental clinic with chief complaint of unaesthetic crusting on lips [Figure 1]. On eliciting the history, she explained a painless reddish-maroon crusting on her upper lip noticed 1 year back. It was intermittent in growth; earlier was colorless and over the period of 3 months noted crusting due to trauma even with mild trauma. At present, the patient was distressed due to her esthetic appearance and difficulty in social interactions making her low in self-esteem. The lesion also had a maroon crusting due to trauma invariably while brushing and eating food adding to patient's difficulties. Patient had shown to a dermatologist and dental clinics for the same and was advised for oral steroids.
On examination, the superficial lesion extending approximately 3 cm along the central part of upper vermilion border of lips and extended into the mucosa approximately 1.5 cm. Areas of fresh traumatic petechiae along with healing yellowish crusting in pebbly red rough surface can be seen on upper lip. On palpation, the lesion was painless, firm, and solitary superficial spreading with bleeding on slight provocation. Routine blood and urine investigations were advised. Differential diagnosis of such entity can be hemangiomas, lymphangiomas, arterial vascular malformations, rarely neurofibromas, amyloidosis, cheilitis granulomatosa, or mucocutaneous leishmaniasis. Opinion of contrast computed tomography (CT) was sleeked from radiologist. On radiologist consent, an incisional biopsy was planned as was a superficial lesion on nonhematogenous origin. A confirmatory diagnosis of lymphangioma simplex was arrived at by histopathologic examination [Figure 2]. A complete vaporization with CO 2 laser under local anesthetic was planned maintaining complete esthetic demands of the patient.
The patient was aseptically draped, and facial skin was scrubbed with 7.5% povidone-iodine solution and the intraoral surgical site was painted with 5% povidone-iodine solution. After obtaining local anesthesia, CO 2 laser was used with continuous ultrapulse mode at a frequency of 20 Hz and duration of 450 μs to vaporize the lesion completely at three watts [Figure 3]. Postsurgical instructions, antibiotics, and analgesics were advised. No sutures and dressings were given; the area was left to heal by secondary intention [Figure 4]. The patient was kept on regular follow-up and showed no recurrence of lymphangiomas till date with esthetically appreciable outcome [Figure 5].
| Discussion|| |
Lymphangiomas are though rare in oral cavity, but even if it occurs, it constitutes 50%-70% in dorsum of the tongue. In lip region, mostly reported cases are in lower lip approximately constituting 6% of the cases. They are generally known to cause functional, psychological, and cosmetic disfigurement. , This case reports a case of upper lip lymphangioma clinically presented as pebbly vesicular lesions with crusting. These cases when due to trauma will cause secondary hemorrhages leading to reddish eruptions such as frog eggs translucides in small vesicles with a thin wall. CT angiography, ultrasonography, and magnetic resonance imaging can be a useful tool to see the extent and communication to deep-seated lymphatics. Goetsch in 1938 studied that the sequestrated lymphatic tissues formed cysts which enlarged and caused accumulation of lymph's in adjacent tissues of penetration due to endothelial sprouting. These sprouting caused adjacent tissue and muscular atrophy and fibrosis in invading tissues. 
There is no standardized classification of lymphangiomas; they are generally divided as superficial and deep lymphangiomas depending on depth and size of abnormal lymphatic channels. Based on spread into anatomical spaces in head and neck region, De Serres et al.  proposed the under mentioned classification:
Other classification which exists is based on histopathologic features as lymphangioma simplex (small thin walled), cavernous, cystic, and benign lymphangioendothelioma. Wherein, cavernous comprises dilated lymphatics with surrounding adventitia. Cystic has huge macroscopic lymphatic spaces surrounded by fibrovascular tissue and smooth muscle and benign lymphangioendothelioma appears to be dissecting through dense collagen bundles. 
- Class/Grade I - unilateral infrahyoid
- Class/Grade II - unilateral suprahyoid
- Class/Grade III - unilateral infra- and supra-hyoid
- Class/Grade IV - bilateral suprahyoid
- Class/Grade V - bilateral infra- and supra-hyoid
Lasers although in the field of dentistry have been in vogue for intraoral procedures, generally indicated for soft tissue surgeries as an alternative to scalpel. Patient acceptance, absence of bleeding, and relative ease of procedure make it psychologically patient friendly, thus making it superior to conventional mechanical approach. Over the past 10 years, CO 2 lasers are the most commonly used lasers for oral surgical procedures due to its high affinity with water and abortion by oral tissues. At wavelength of 10,600 nm, it does not have chromatic affinity, thus making the laser transformation on interaction with tissues in the presence of fluid more predictable with regard to ablation, decontamination, and hemostasis.  The aim/intention of reporting this case was to sensitize the general dentist of such occurrence and surgical management with CO 2 laser with successful predictable outcome, thus adding a new dimension and vista in patient care.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]