the term hemangioma incorporates heterogeneous group of clinical benign vascular lesions with similar histologic characters . though the lesion usually develops in children , older age individuals may also occasionally be affected . although there are conflicting reports regarding its gender predilection , but many clinicians observed that this lesion has higher incidences in female subjects than in male subjects . hemangiomas are classified into capillary and cavernous types on the basis of the size of vascular spaces and histology . the capillary hemangiomas have numerous proliferating small thin walled blood filled vessels composed of single layer of flattened or plump endothelial cells , surrounded by discontinuous layer of pericytes and reticular fibers . the cavernous hemangiomas on other hand consists of deep , irregular , dermal tangles of large thin walled vessels or sinusoids separated by scanty connective tissue and surrounded by discontinuous layer of endothelial cell . capillary hemangioma ( ch ) as a term has been commonly practiced to describe a large number of vasoformative tumors ( vft ) . ch exhibits both , a proliferative phase and an involution phase , where as vascular malformations are more stable and fail to regress . hemangiomas have been described to be presenting clinically as a soft tissue mass , smooth or lobulated , sessile or pedunculated and with variable size . sometimes ch may be confused with vascular appearing lesions of face or oral cavity similar to sturge - weber syndrome . most true ch involute with time , but certain small percentage does not , and may present with complication that require surgical management . although the literature suggests ch as a common soft tissue tumor of head and neck , but contrarily it is observed as a relatively rare and uncommon pathologic entity in the oral cavity . these tumors are mostly seen on face , fingers , and occasionally on oral mucosa . periodontally , these growths often appear to arise from the gingival papilla and spread laterally to involve adjacent tissues . this paper describes the case of a patient who had a growth similarly arising from gingival papilla between maxillary left first and second molars on palatal side , which was successfully managed by periodontal widman 's flap surgery , with two years uneventful follow - up for observing any recurrence . a 30-year - old female reported with a gradually increasing , painless swelling in the upper left posterior palatal region since childhood . there was history of frequent bleeding from the lesion , and difficulty in swallowing and speaking . extra - oral examination including the lymph nodes was insignificant . intra - oral examination revealed a 22.5 cm growth which was red in color with bluish hue and with slightly pale periphery , arising from the buccal attached gingiva of maxillary left first and second molar , which extended palatally [ figure 1 ] . although two surface ulcerations were noticed , probably due to trauma during mastication , the remaining entire surface was smooth with several visible small vessels . the growth was gently soft to palpate and showed blanching on application of pressure , and was pulsatile but not reducible [ figure 2 ] . intra - oral periapical radiograph of the region exhibited a horizontal pattern of bone loss due to chronic periodontitis [ figure 2 ] . carotid angiogram could not be possible because of under - privileged socio - economic status . bluish hue colored growth in the maxillary left posterior region , occupying space in the posterior region of oral cavity blanched palatal extension of the growth with heavy calculus on adjacent molars a provisional diagnosis hemangioma was laid down due to clinical appearance and characteristics of the growth . widman 's periodontal flap of maxillary left quadrant was carefully raised under local anesthesia ( posterior superior alveolar block ) and the growth was excised [ figure 3 ] . the excised growth [ figure 4 ] was sent for histo - pathological examination ( hpe ) and patient was given necessary hygiene instructions for home care of wound . satisfactory uneventful healing occurred and follow - up was done for two years to monitor any recurrence . hp section under low magnification , showing multiple vessels the excised soft tissue mass was subjected to routine processing and several sections were obtained . hpe of the sections obtained from the lesion showed numerous capillaries filled with rbc in a delicate fibrillar connective tissue which was predominantly full of proliferating endothelial cells . the connective tissue component was covered by parakeratinized stratified squamous epithelium which showed ulceration at few places . areas of ulceration were covered with fibrin meshwork and were infiltrated by rbcs and mixed inflammatory cells . correlating the microscopic features with the clinical picture , hpe confirmed the diagnosis as  capillary hemangioma  [ figures 57 ] . periodontal flap reflected and curetted micro - photograph of the capillary hemangioma , showing multiple vessels with rbcs occluding the lumen and inflammatory cells uniformly distributed in the stroma . ( h and e 100 ) higher magnification showing proliferating endothelial cells and dense distribution of plasma cells and lymphocytes . the term hemangioma has been used traditionally to describe a variety of developmental vascular anomalies , and may often be referred by terms like hamartoma , malformations , or true benign neoplasm / tumors . it is necessary to distinguish it from inflammatory growths ( reactive hyperplasia ) which have excessive proliferation of reparative tissue . the hemangiomas ( both solitary or when found with other anomalies / angiomatosis syndromes ) are true hamartomas . the hamartomas are tumor - like malformations characterized by the presence of cellular proliferation that is native to the part but that manifests growth cessation without potential for further growth . hamartomas are usually congenital and simultaneously grow along the growth of rest of the body . once they achieve their adult size , they do not extend to involve more tissue unless there is trauma , infection , edema , inflammation , or filling of new vascular channels . , extra digits ) in which excessive tissue is present in its usual histological relationship with almost no growth potential . on the other hand , true benign neoplasm / tumors have a relatively unlimited capacity for expansive growth which may continue even after the stimulus has ceased to operate . the term - vft , encompasses the hemangiomas and the vascular malformations and the difference between them are elaborated in the table 1 . in 1982 , mulliken and glowacki described classification scheme that is ubiquitously accepted [ table 2 ] . comparison of hemangiomas and vascular malformations types of hemangiomas and vascular malformations although , the etiology of vfts is unclear , a hypothesis had been postulated that the placental cells such as trophoblasts may be the cell of origin of hemangiomas , and therefore , they arise secondary to some event in utero . it has been suggested that the endothelial cells of hemangiomas are derived from a distant population of endothelial precursors carried by existing vascular pathways to a receptive environment , and its potential sources include bone marrow and placenta . a small embolic nidus of placental endothelial cells could reach fetal tissues through the permissive right - to - left fetal shunt of fetal circulation . possibly , local placental injury may predispose the shedding of cells into the fetal circulation . however , further investigations are required to confirm this hypothesis . the pathogenesis of the common capillary hemangioma involves three stages of development similar to development of any other vft . it represents an arrest in the development of mesenchymal primordia which is being nourished by an interlacing system of blood spaces without distinguishable arterial and venous channels . as the development progresses to the second stage i.e. , the retiform developmental stage , the primitive vessels penetrate deeper into the subcutaneous layers ( to muscle or bone ) and gives rise to capillary hemangiomas . as this stage ends , an arterial , venous , and capillary system is established . finally in the third stage , i.e. , the final developmental stage there is gradual replacement of the immature plexiform network of vessels by the mature vascular channels . during the early proliferative phase ch can be shown immunohistochemical expression of proliferating cell nuclear antigen and vascular endothelial growth factor ( vegf ) , localized to endothelium and pericytes , while type iv collagenase only along endothelium . all these three are required for growth and proliferation of the vessels and are reduced during involution phase . contrarily , the tissue inhibitors of metalloproteinases ( timp ) , and anti - angiogenic factors are markedly increased . a number of growth factors , including vegf , basic fibroblast growth factor ( bfgf ) , transforming growth factor - beta ( tgf - beta ) , and interleukin-6 ( il- 6 ) , have been demonstrated as regulators of angiogenesis . takahashi et al . outlined a number of cellular markers that distinguish the phases of hemangiomas ; these markers include metalloproteinase ( timp-1 ) , bfgf , proliferating cell nuclear antigen , type iv collagenase , vegf , and urokinase . lack of estradiol receptors in the stable or involuted lesions have supported this theory ; therefore , steroid treatment has become a first line of treatment for proliferating lesions . hemangiomas are common tumors of infancy , affecting as many as 12% whites , but it rarely occurs in dark - skinned individuals . hemangiomas can occur at any age , but the incidences are more among infants and children . they occur in 5 - 10% of 1-year - old children and their incidence increases to 23% in premature infants with birth weight less than 1000 grams . barette and speight observed 35 oral vascular malformations over a 48 years period at their institution . the peak incidence of central vascular malformation of the jaws is in the second decade of life . although 80% of hemangiomas occur as single lesions , about 20% of affected patients have multiple tumors . the most common location for occurrence of hemangiomas is head and neck region , and it accounts for almost 60% of all cases . despite this , intraoral hemangiomas are not common pathologic entities . furthermore , if at all ch are found , the bones , muscles , mucosa , and the skin are affected , and the most frequent site of occurrence of intraoral hemangiomas are lips , tongue , buccal mucosa , and palate . it is very rare to find hemangiomas on attached gingiva as has been observed in the present case discussed here . when found , the hemangiomas of gingiva are often covered by rugose epithelium and may be connecting to central hemangiomas / lesions . the incidence of intra - osseous hemangiomas varies from 0.5 - 1.0% of all intra - osseous neoplasms . the most commonly affected facial bones are the mandible and the maxilla , with a ratio of 2:1 reported in the study . intramuscular hemangiomas in the oral region are most commonly seen in the masseter , comprising 5% of all intramuscular hemangiomas . the location of the lesion does not generally influence its behavior , but lesions of the lip are less favorable . occasionally , ch may be accompanied by other deformities at other sites on the body . patient 's sex and size of the hemangioma does not influence the speed or the completeness of the involution . histologically , the early hemangiomas are characterized by numerous plump endothelial cells and often in distinct vascular lumina . as the lesions mature , the endothelial cells become flattened . finally , small capillary sized vascular spaces lined by single layer of endothelial cells supported by a connective tissue stroma of varying density become evident . mast cells and factor - viii- positive interstitial cells mast cells are important producer of angiogenic factors that regulate the growth of these tumors . it is identical to some cases of pyogenic granuloma  which in fact , histopathologically is a lobulated capillary hemangioma more aptly . then , a slow spontaneous involution often begins in the center of the lesion with darkening of color followed by numerous fibrous septa within the lesion . capillary hemangiomas are not common in this age group people as discussed in this our case and specifically hemangioma arising on attached gingival is extremely rare entity . clinical findings in correlation with histo - pathologic picture supported the diagnosis of capillary hemangioma . the surgical management of this case was preferred therefore widman 's periodontal flap surgery was performed . spontaneous and profuse bleeding as well as possibility of post operative recurrence , regular clinical observation of the affected site should be mandatory for certain time and for this patient follow - up for clinical evaluation of site was done for two years with satisfaction .
the capillary hemangiomas represent developmental hamartomatous lesions of vascular tissue and their growth stops after certain period of time , following which some of the hemangiomas may involute . 
 capillary hemangiomas are common tumors of infancy and adolescents . although head and neck are the most prevalent sites for origin of hemangiomas , they are very rarely observed arising on attached gingiva . 
 this paper presents a rare case report of capillary hemangioma on attached gingiva of posterior maxilla in an adult female . 
 surgical management was done by widman 's periodontal flap operation with satisfactory uneventful healing . 
 the characteristic clinical and histo - pathologic features of vascular tumors and malformations , especially capillary hemangiomas are discussed .