although hemangioma is considered one of the most common soft tissue tumors of the head and neck , it is relatively rare in the oral cavity and uncommonly encountered by the clinicians . they may be cutaneous , involving skin , lips and deeper structures ; mucosal , involving the lining of the oral cavity ; intramuscular , involving masticator and perioral muscles ; or intra - osseous , involving mandible and/or maxilla . though previously termed angiomas  or vascular  birthmarks  , vascular anomalies are divided into two main categories : vascular tumors and vascular malformations . infantile hemangiomas comprise the majority of vascular anomalies and are considered the predominant vascular tumor type composed of rapidly proliferating endothelial cells . blood vessel architecture is incomplete and surrounded by hyperplastic cells in hemangiomas and other vascular tumors . in contrast , vascular malformations do not contain hyperplastic cells , but consist of progressively enlarging aberrant and ectatic vessels composed of a particular vascular architecture such as veins , lymphatic vessels , venules , capillaries , arteries or mixed vessel type . the latter comprises lymphangiomas or lymphatic malformations which are congenital collections of ectatic lymph vessels that form endothelial lined cystic spaces . occasionally , channels may be filled with blood , a mixed hemangiolymphangioma , an uncommon developmental anomaly with a propensity to invade underlying tissues and to recur locally , distinguishing it from the simple lymphangioma or hemangioma . although histologically it is a benign disorder , local invasion into the muscle , bone , and underlying tissue can lead to severe deformity . management of hemangiomas and the treatment of choice depend on several factors including the age of the patient and the size and extent of the lesions , as well as their clinical characteristics . an 18-year - old male patient , reported to department of oral and maxillofacial surgery , trivandrum , kerala , india , in may 2011 , with the complaint of reddish swelling over left side of the upper lip with occasional bleeding while brushing since last 3 - 4 years . patient noticed swelling over the left side of upper lip region 3 - 4 years back . patient had repeated episodes of bleeding while brushing teeth or on mechanical trauma to the lesion . patient visited private hospital , where he was kept on vitamin tablets and no other medications as history suggested by patient . the swelling was initially small papular which increased slowly to a size of 21 cm approximately in greatest dimension in last 2 years , after that there was no further change in swelling . at the time of reporting patient local examination revealed reddish multiple papular lesion over left side of buccal mucosa extending from 1 cm behind the left corner of mouth in relation to 24 , 25 of size approximately 21 cm [ figure 1 ] . there was no ulceration . on palpation the lesion was soft in consistency , non - tender , with smooth borders and was pulsatile in nature . provisional diagnosis of hemangioma left buccal mucosa was made . to rule out intracranial and bony involvement ct head and orthopantomogram ( opg ) was taken , subsequently no abnormalities has been detected [ figures 2 and 3 ] . gross specimen was soft in consistency and reddish in color and approximately of size 1.51 cm [ figure 4 ] . hematoxyline and eosine stain section shows hyperplastic stratified squamous epithelium which is extensively proliferating in to underlying moderately collagenous connective tissue stroma . there are numerous endothelail line vascular spaces through the stroma and extending in to submucosa . clinically reddish multiple papular lesion left buccal mucosa ct head with no detected abnormality hematoxyline and eosine stained section showing features of hemangiolympangioma hemangiomas are a common soft tissue tumor that often congenital or develop in the neonatal period and grow rapidly . they usually cover a large site , may be macular or raised and usually resolve progressively in childhood . they may occur in the oral and maxillofacial region including gingiva , palatal mucosa , lips , jawbone , and salivary glands . the occurrence of hemangioma with its primary location on gingival tissues seems to be extremely rare . there are many clinical features of capillary hemangioma such as asymmetry of the face , spontaneous bleeding , pain , mobility of teeth , blanching of tissue , pulsation , expansion of bone , paresthesia , early exfoliation of primary teeth , delayed eruption , root resorption , and missing teeth . hemangiomas are associated with various syndromes , rendu - osler - weber syndrome ( autosomal dominant inheritance , multiple telengiectasias , occasional gi tract involvement , occasional cns involvement ) , sturge - weber - dimitri syndrome ( non - inherited and non - familial , portwine stain , leptomeningeal angiomas ) , von hippel - lindau syndrome ( genetic transmission variable , hemangiomas of cerebellum or the retina , and cyst of the viscera ) . in present case intracranial and bony involvement is ruled out by ct head and opg . the differential diagnosis of hemangiomas includes pyogenic granuloma , chronic inflammatory gingival hyperplasia ( epulis ) , epulis granulomatosa , varicocell , talengectasia , and even with squamous cell carcinoma . this is a reactive lesion that develops rapidly , bleeds easily and is usually associated with inflammation and ulceration . clinically , it is often lobulated , pedunculated and red to purple and it may be hormone sensitive . histopathologically , hemangioma exhibits a progression from a densely cellular proliferation of endothelial cells in the early stages to a lobular mass of well - formed capillaries in the mature phase , often resembling the pyogenic granuloma without the inflammatory features . diagnosis is given according to predominant component , e.g. ; hemangiolymphangioma and/or lymphangiohemangioma , this particular terminology is also true in case of lymphangiomas . as in our case there were intermingled lymphatic channels , but predominant component was of hemangioma , so diagnosis of hemangiolymphangioma was made . precise diagnosis of the type of vascular lesion is important because it may influence treatment considerably . angiographic studies are not strictly demonstrated for diagnosis of hemangiomas , and are utilized only to define the size and the extent of the lesion . these are more complicated procedures than histopathological evaluation , have a higher morbidity , and may cause undesirable side - effects . ct and mri of these lesions have more recently been demonstrated , and have been successfully utilized for the diagnosis of hemangiomas , as for other lesions of soft tissues . in the case presented here , treatment of the hemangiolymphangioma was done by wide surgical excision and primary closure . in present case post - operative uneventful healing various treatment modalities has been advocated , e.g. ; surgical excision , for those lesions not amenable to surgery other therapy such as intralesional injection of fibrosing agents , interferon a-2b , radiation , electrocoagulation , cryosurgery , and laser therapy , embolization may be used . attempts to remove hemangiomas using surgical excision may lead to serious medical problems such as heavy bleeding . bogdan et al . aimed a study to evaluate the efficacy of the 980 nm diode laser and er : yag laser for photocoagulation treatment of oral and maxillofacial hemangioma and vascular malformations . seventy consecutive patients with either hemangioma or low - flow vascular malformations of the head and neck treated with laser photocoagulation were comprised in the study . long - term follow - up demonstrated regression of the lesion in all patients with good aesthetic results . the range of reduction in size varied between 45% and 95% and no complications or reperfusion of the lesions was noted . photocoagulation with diode laser or er : yag laser of hemangioma and vascular malformations is an effective treatment for correctly selected patients . they concluded that properly applied , these techniques can achieve reduction in size of these lesions without compromising function and cosmetics . conducted an observational retrospective study , reviewing medical records with clinical diagnosis of haemangioma between 1990 and 2006 at the children 's maxillofacial surgery service of the hospital universitario la fe , valencia . the study included 28 patients ( 19 females and 9 males ) with a mean age of 4.27 years ( range 0 - 14 years ) . the most frequent location of oral haemangioma was in the lip with 23 cases , followed by three cases in the tongue and 2 in the buccal mucosa . the mean diameter of the lesion was 1.67 cm ( range 1 - 3 cm ) . the mean duration of the lesion was 6.3 months ( range 1 month to 5 years ) . of the 28 haemangiomas , 13 were surgically removed , 2 were treated with embolization and 13 disappeared spontaneously . they have a predilection for females . they are uncommon in the oral cavity . in the oral region , plasma knife ( pk ) is a new treatment modality for excision of these lesions . pk technology provides an electrically conducting site by means of obtaining the use of controlled radiofrequency energy , and by using the intra and extracellular fluid . the active zone on the device dense kinetic energy divides , demolishes and evaporates the constructional element tissue . during this procedure , there is very little thermal damage to the surrounding tissue . because it requires no additional saline supply for the operation according to the thermal procedure pk is developed for tonsillectomy , adenoidectomy , uvulopalatopharyngoplasty , thyroidectomy and excisions of the head and neck masses . they used a 90% coagulation and 10% cut mode choice for the pk excision of the haemangioma of the tongue . this method is consequently a safe and suitable surgical choice to be applied for superficial and small sized haemangiomas of the tongue . in their case the experience that we gained from this case is that the pk surgery would be a suitable treatment modality for the localized and superficial haemangiomas of the tongue . pk can also be combined with other treatment modalities in larger lesions . in conclusion hemangiomas all suspected cases should be properly evaluated to rule out intracranial , bony and systemic involvements . patient should be followed postoperatively to rule out complication and further long - term follow - up to rule out recurrence . as in present case
hemangiomas are lesions that are not present at birth . 
 they manifest within first month of life , exhibit a rapid proliferative phase , and slowly involute to non - existent . 
 hemangiomas of the oral cavity are not common pathological entities , but the head and neck are common sites . 
 furthermore some time histologically lymphatic channels may be evident in hemangiomas , and then it will be categorized according predominant component , e.g. ; hemangiolymphangiomas or lymphangiohemangiomas , vice versa is true for lymphangiomas . 
 most true hemangiomas involute with time , but 10 - 20% of true hemnagioma in completely involute and required post- adolescent ablative treatment . in the present article we are reporting a case of hemangiolypmangiomas of left buccal mucosa in an 18-year - old male patient . 
 we have also reviewed various treatment modalities and their clinical implication .