Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 29 (2017) 415–419

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Journal of Oral and Maxillofacial Surgery,

Medicine, and Pathology
journal homepage: www.elsevier.com/locate/jomsmp

Original Research

Single non-contact Nd: YAG laser irradiation treatment for venous

malformations in the oral cavity
Natsumi Takamaru ∗ , Tetsuya Tamatani, Go Ohe, Yoshiko Yamamura, Keiko Kudoh,
Youji Miyamoto
Department of Oral Surgery, Subdivision of Clinical Dentistry, Division of Oral Sciences, Institute of Biomedical Sciences, Tokushima University Graduate
School, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study is to reveal a clinical evaluation of single non-contact Nd: YAG (the
Received 9 March 2017 neodymium: yttrium-aluminium-garnet laser) photocoagulation irradiation treatment of venous mal-
Received in revised form 4 May 2017 formation (VM) in the oral region.
Accepted 29 May 2017
Patients and methods: Seventeen patients with 21 VMs in the oral region who visited our hospital from
Available online 21 June 2017
2010 to 2015 were subjected. The patients consisted of six males and 11 females, ranging in age from 27
to 71 years old. The VM locations included tongue, buccal mucosa, and lip sites. Their sizes ranged from
Keywords:
4 to 24 mm along the major axis direction, and the thickness ranged from 4 to 13 mm. All patients were
Venous malformations
Nd: YAG laser
treated with single non-contact irradiation using the Nd: YAG laser under local anaesthesia.
Non-contact Results: All cases, including the patients with deep-seated lesions, healed after one-time irradiation with
the laser beam. Serious complications have not occurred in patients receiving the treatment. There was
no recurrence of VMs for at least one year after treatment.
Conclusions: Using single non-contact irradiation treatment, we obtained good results without clinical
complications. The application of the Nd: YAG laser in treatment of lesions has the advantages of no
bleeding, minimal scarring, and a short operative time. These results suggest that Nd: YAG laser treatment
by a single non-contact irradiation is effective against VMs of thicknesses 13 mm or less in the oral region.
© 2017 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽

1. Introduction composed of distensible venous channels that arise from congen-

In 1996, the International Society for the Study of Vascular
Anomalies adopted Mulliken’s nomenclature for congenital vascu-
lar lesions [1]. It divided them into two categories, haemangiomas
and vascular malformations, based on both cellular features and
biological behaviour. Vascular malformations present at birth do
not proliferate or involute and are further categorized into low-
flow (capillary, venous, lymphatic, and combined) and high-flow
(arterial and arteriovenous) malformations. Approximately 70% of
all vascular malformations are originated venously [2]. Venous
malformations (VMs) are slow-flow aberrant venous connections
夽 AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian
Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-
ogy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese
Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.
∗ Corresponding author at: Department of Oral Surgery, Subdivision of Clinical
Dentistry, Division of Oral Sciences, Institute of Biomedical Sciences, Tokushima
University Graduate School 3-18-15 Kuramoto-cho, Tokushima 770-8504, Japan.
E-mail address: takamaru@tokushima-u.ac.jp (N. Takamaru).
ital disruption of normal vein development. These lead to venous
collection with gradual expansion and intermittent thrombus for-
mation that will persist until treatment [3]. VMs consist of a
flattened endothelium exhibiting slow turnover due to the lack of
smooth muscle. These lesions may be present in the skin, mucous
membrane, or in any other organ, and the predominant sites in the
head and neck are particularly on the tongue, lips and cheeks. Most
venous malformations are asymptomatic and can be managed con-
servatively. However, large VMs causing functional discomfort or
frequent bleeding need treatment.
Thus far, many different treatment modalities for vascular
lesions have been used: surgery, laser therapy, embolization,
steroid therapy, sclerotherapy, cryosurgery, or electrodessication,
among others [4]. Sclerotherapy is widely used alone or with
surgery for the treatment for vascular lesions. It ultimately causes
endothelial disruption and coagulation, followed by an intense
initial inflammatory reaction, resulting in fibrosis of the VM and
contraction of the lesion [5]. The success of sclerotherapy is largely
dependent on the experience of the intervention radiologist and on
the extent and flow rate of the vessels. Otherwise, surgical treat-

http://dx.doi.org/10.1016/j.ajoms.2017.05.010
2212-5558/© 2017 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
416 N. Takamaru et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 29 (2017) 415–419

Table 1
Summary of characteristic of patients and treatment outcomes.

Case No. sex age site size (mm) complications recurrence

the major axis thickness bleeding swelling pain

1 female 40 tongue 24 4 − ++ + − (3 years)

tongue 6 5
2 female 63 lower lip 22 10 − ++ + − (3 years)
3 male 62 tongue 20 13 − ++ + − (1 year)
tongue 15 8
4 male 71 tongue 20 7 − ++ − −(4 years)
5 male 27 tongue 20 7 − ++ − − (3 years)
6 female 73 tongue 20 7 − ++ + − (2 years)
7 female 31 buccal mucosa 18 6 − ++ − − (3 years)
8 female 64 buccal mucosa 14 4 − − − − (1 year)
9 female 63 buccal mucosa 12 7 − + − − (4 years)
buccal mucosa 4 3
10 female 53 buccal mucosa 10 4 − ++ − − (2 years)
11 female 53 tongue 9 6 − + − − (4 years)
12 female 59 lower lip 6 − − + − − (3 years)
13 male 70 tongue 6 − − + − − (3 years)
lower lip 5 −
14 female 58 lower lip 5 4 − + − − (2 years)
15 male 63 upper lip 5 − − + − − (3 years)
16 female 63 buccal mucosa 5 − − + − − (2 years)
17 male 49 lower lip 4 4 − + − − (3 years)

ment is sometimes used for smaller vascular lesions. However,
complete surgical excision is often difficult because of either the
extent of the lesions or the recurrence of adjacent abnormal vessels
[5].
In the 1990s, the neodymium: yttrium-aluminium-garnet (Nd:
YAG) laser was proven to be an effective treatment tool, albeit
requiring observation of certain general precautions and limita-
tions [4,6–8]. Long-pulsed Nd: YAG laser has gained popularity for
the treatment of small- to medium-sized vessels. The advantage of
this laser over other shorter wavelength lasers is that the laser pen-
etrates more deeply, as weaker melanin has greater absorption. In
addition, during the longer pulse, it is more likely to heat the ves-
sels slowly and uniformly, allowing for sufficient vessel damage to
cause coagulation but avoiding vessel rupture, subsequent purpura,
and possible post-laser hyperpigmentation.
Therefore, we focused on the Nd: YAG laser treatment for vas-
cular malformations as a minimally invasive method. In this study,
we performed single non-contact beam irradiation using the Nd:
YAG laser on vascular malformations in the oral region to examine
the clinical effectiveness of the treatment.
2. Patients and methods
2.1. Patients
The subjects in this study were 17 patients with 21 VMs who
visited the Tokushima University Hospital from December 2010 to
March 2015. The clinical characteristics of the patients are shown in
Table 1. There were six males and 11 females (mean age, 56.6 years;
range, 27–71 years). Diagnosis was based on the International Soci-
ety for the Study of Vascular Anomalies (ISSVA) classification [9].
The disorders were clinically diagnosed as VM based on medical
history, age, and the findings of magnetic resonance imaging (MRI)
and ultrasonography. Thereafter, the patients were treated by pho-
tocoagulation with an Nd: YAG laser. The lesions were located at
sites including the tongue (nine sites), buccal mucosa (six sites), and
lip (six sites). The size of the lesions ranged from 4 to 24 mm along
the major axis; 13 cases (61.9%) had lesions <15 mm, and eight cases
(38.1%) had lesions 15 mm. The thicknesses of the lesions ranged
from 4 to 13 mm.
2.2. Laser and treatment procedure
A Nd: YAG laser with a 1064 nm wavelength (Ho/Nd: YAG
®
Laser VersaPulsea SelectTM , Yokneam, Israel) was used. Treatment
procedures were performed as follows. First, the outline of the
lesion was marked, and 2% lidocaine with epinephrine was injected
around the lesion. The output of the laser beam was selected at
10 W, and the irradiation distance from the tip of the optical fibre
guide to the lesion was kept at less than 10 mm without physical
contact. The lesion was irradiated with the laser beam until the sur-
face colour of the VM changed from dark purple to white. Moreover,
the spot of the laser beam was moved to irradiate the entire range
of the lesion. It took approximately 20 s to treat a 10-mm diameter
lesion.
3. Results
Treatment outcomes of the 17 cases are shown in Table 1. All
VMs were disappeared, and no patients have been free of relapsed
since the single Nd: YAG laser irradiation treatment over one year
ago. There were not significant complications during or after the
treatment. Notably, intraoperative bleeding did not occur in any of
the cases, regardless of the size, or site of the lesion. Conversely,
with respects to the degree of the postoperative swelling, slight
swelling occurred in nine cases in which the size of the major
axis was less than 12 mm. Moderate to severe swelling occurred
in eight cases in which the size of the major axis was more than
20 mm. However, the airway obstruction did not appear and the
moderate to severe swelling disappeared within seven days. Post-
operative pain occurred in four cases with VMs of relatively large
size. The degrees of pain were relatively mild in all cases, and the
pain was also disappeared within seven days. Although necrotic
tissue formed on the laser irradiated lesion in many cases, it was
replaced with normal mucosa in approximately one to two months
after the treatment. Postoperative infection and neuroparalysis did
not occurred in any of the patients.
3.1. Case 1
The patient (Case No. 3 in Table 1) was a 62-year-old male with
two superficial violet-coloured lesions in the right border of the
tongue (ϕ 20 mm and 15 mm) (Fig. 1A). The thickness of larger
 N. Takamaru et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 29 (2017) 415–419 417

Fig. 1. Case 1 (Case No.3 in Table 1).

(A) A superficial violet-coloured lesions (ϕ 20 mm and 15 mm) on the right border and dorsum of the tongue.
(B) MR imagies. (a) T1-weighted image showing that the lesion was hyperintense. (b) T2-weighted image showing that the lesion was hyperintense.
(C) The lesion became contracted and changed from dark purple to white immediately after irradiation.
(D) At three days after irradiation, some necrotic tissue was observed on the surface.
(E) Three month later, the shape and colour of the tongue appeared normal.

size VM was 13 mm. The diagnosis of VM was according to clin-
ical, MRI (Fig. 1B), and US findings. The patient had taken the
anticoagulant drug, warfarin, because of chronic atrial fibrillation.
As his prothrombin time/international normalized ratio was 2.3,
he was treated by photocoagulation with an Nd: YAG laser. After
marking the outline of the lesion and administering local anaes-
thesia, the power of the laser was set at 10 W; the lesion changed
from dark purple to white immediately after irradiation and fine
wrinkles formed on the surface of the lesion (Fig. 1C). Total irradia-
tion time was approximately 2 min. No considerable complications
were observed during the irradiation. Severe swelling occurred for a
few days after irradiation (Fig. 1D). Necrotic tissue covering the irra-
diated lesion formed, and an ulcer appeared after separation of the
necrotic tissue (Fig. 1D). There was no delay of wound healing and
no other significant complications such as paraesthesia or paraly-
sis of the tongue. Although moderate pain occurred at the wound
on the day after the operation, loxoprofen sodium was adminis-
tered and pain disappeared within seven days. One month after
treatment, the tongue recovered a normal shape and mobility, and
there were neither scar formation nor functional problems (Fig. 1E).
Four years later, the recurrence of VMs did not occur.
3.2. Case 2
The patient (Case No.7 in Table 1) was a 31-year-old female
with a superficial (18 × 16 mm) violet-coloured lesion in the left
buccal mucosa (Fig. 2A), with a 6-mm thickness as determined by
US examination. We planned to perform single irradiation treat-
ments by Nd: YAG laser under local anaesthesia. The operation was
performed similarly to Case 1. Total irradiation time was approxi-
mately 1 min. The day after treatment, slight swelling occurred in
the buccal mucosa (Fig. 2B), but the patient did not complain of
postoperative pain at all. Ulceration appeared after the necrotizing
tissue was detached, but there was no delay of wound healing. One
month after the operation, the buccal mucosa showed complete
healing without scaring and residual lesions (Fig. 2C). No recurrence
was observed three years after the treatment.
4. Discussion
We investigated a clinical evaluation of treatment for VM in the
oral region using photocoagulation with an Nd: YAG laser. These
findings demonstrated that treatment using single non-contact
irradiation could obtain good results without clinical complica-
tions.
Glade et al. had reported that Nd: YAG laser therapy could pro-
vide good control of VMs in the skin and mucosa [10]. However,
in laser treatment for vascular malformations in the oral region,
the KTP laser, as well as the Nd: YAG laser, was used in many
studies. Theoretically, the KTP laser may be the most appropriate
for photocoagulation because the wavelength (532 nm) is almost
the same as the maximum absorption wavelength of haemoglobin
418 N. Takamaru et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 29 (2017) 415–419
Fig. 2. Case 2 (Case No.7 in Table 1).
(A) A superficial violet-coloured lesion in the left buccal mucosa.
(B) At one day after the irradiation, the lesion was covered in fibrin.
(C) One month later, the surface of the buccal mucosa showed complete healing without scaring and residual lesions.
(540 nm) [6,11,12]. Moreover, non-contact irradiation with the KTP
laser exhibits a sufficient therapeutic effect for superficial lesions,
but it is not effective for deep and thick lesions without modifica-
tion because the penetration level of the KTP laser into the tissue
is shallow (∼2 mm) [11]. Conversely, the wavelength of the Nd:
YAG laser is 1064 nm, which is twice the wavelength of the KTP
laser, and it is preferentially absorbed by deoxyhaemoglobin and
oxyhaemoglobin in vessels >100 ␮m [13]. The specific absorption
could make it an excellent treatment for venous channels. Melanin
can also act as a chromophore for the Nd: YAG laser, and can
result in increased thermal damage to skin causing blistering and
ulceration. However, by using the Nd: YAG laser, good therapeutic
outcomes were achieved in all our patients, including those with
24 mm maximum major axis size or 13 mm maximum lesion thick-
ness. In many cases, submucosal remnants cannot be reached by
non-contact superficial Nd: YAG laser irradiation alone [11]. Many
studies [13,14–17] have reported the effectiveness of intralesional
photocoagulation for vascular anomalies in the oral cavity using
insertion with the tips of a Nd: YAG or KTP laser. However, all of
our cases were treated by non-contact superficial Nd: YAG laser
single irradiation without use of intralesional photocoagulation,
and we obtained good results, including the cases with 13-mm
thickness. Because the lesion became contracted in horizontal and
vertical directions, like the rapid deflation of a balloon, immediately
after irradiation, the thickness of contracted lesion became thinner,
and lesions with thickness of 7 mm or more could heal completely.
We demonstrated that VMs less than 13 mm in thickness could be
treated with single laser irradiation because the laser beam reached
deep in the lesion by shrinking the VMs.
Complications that may occur during treatment include bleed-
ing, swelling, pain, necrosis, and nerve damage, and there are some
techniques to avoid them. The fibre tip of the laser should not be
held in the same place for too long, and it should be passed slowly
over the lesion while watching for tissue shrinkage and blanching.
Moreover, photocoagulation must be performed without irradia-
tion beyond the visible extent of the lesion. The tissue sloughing,
which could lead to haemorrhage9, should not occur within the
hypervascularized area.
Slight postoperative swelling, as in Case 2, occurred in nine cases
(53%), and moderate to severe swelling, as in Case 1, occurred in
eight cases (47%); however the patient with abnormal healing was
not among the cases with postoperative swelling (Table 1). More-
over, severe swelling tended to arise in the patients with larger
sized and deeper lesions. Additionally, moderate to severe post-
operative swelling was also thought to be most likely caused by
tissue injury with longer exposure of the Nd: YAG laser. Yang et al.
[18] reported that treatments of larger-sized regions or those near
the root of tongue or oropharynx must be cautious of respiratory
tract stenosis. Moreover, pain also occurred in only four (24%) of 17
patients with VM located in the tongue and lip. Because pain might
tend to be caused by the treatment of bigger VM (Table 1), active
pain control using analgesics should be considered. Other compli-
cations, including neuroparalysis did not appear in any cases.
No recurrence of VMs have occurred at the one-year point after
the single non-contact beam irradiation treatment using the YAG
laser.
5. Conclusions
Single non-contact irradiation of the Nd: YAG laser was per-
formed for 21 venous malformations in the oral cavity. This therapy
is a simple, minimally invasive, and quick operation without the
occurrence of critical complications; therefore, it is suggested as a
very effective method for the treatment of venous malformations
less than 13 mm thick in the oral cavity.
Conflict of interest
No sources of funding were used in this work. The authors have
no conflict of interest or financial relationship to declare.
 N. Takamaru et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 29 (2017) 415–419
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