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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 145-148

Central giant cell granuloma: A case report and review


1 Department of Oral Medicine and Radiology, Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
3 Department of Oral Pathology, Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India

Date of Submission08-May-2015
Date of Acceptance22-Oct-2017
Date of Web Publication9-Nov-2017

Correspondence Address:
Krishnaveni Buduru
Department of Oral Medicine and Radiology, Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_100_15

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   Abstract 

Central giant cell granuloma (CGCG) is a benign intra-osseous lesion of unknown etiology, and occurs in jaws. Clinically and radiographically difference between its nature - aggressive and non-aggressive can be made. It is characterized histologically by cellular fibrous tissue containing multiple foci of hemorrhage, aggregations of multinucleated giant cells, and occasionally, trabeculae of woven bone. Histologically, identical lesions occur in patients with known genetic defects such as cherubism, Noonan syndrome, or neurofibromatosis type I. It has an increased predilection for mandible and females in younger age group. Surgical curettage or resection is the most common therapy in aggressive lesions. The drawback is undesirable damage to the jaw or teeth, tooth germs, and frequent recurrences. Non-aggressive tumors respond well to such treatments. We are presenting a case of an aggressive type of CGCG of mandible in a young patient, who presented with massive swelling associated with loss of teeth in just 6 months duration.

Keywords: Central giant cell granuloma, mandible, resection


How to cite this article:
Buduru K, Podduturi SR, Vankudoth DS, Prakash J. Central giant cell granuloma: A case report and review. J Indian Acad Oral Med Radiol 2017;29:145-8

How to cite this URL:
Buduru K, Podduturi SR, Vankudoth DS, Prakash J. Central giant cell granuloma: A case report and review. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2019 Nov 17];29:145-8. Available from: http://www.jiaomr.in/text.asp?2017/29/2/145/217901


   Introduction Top


Central giant cell granuloma (CGCG) of the jaw is a benign osteolytic lesion. It may exhibit aggressive biologic behavior, characterized by localized swelling, pain, rapid growth, bony expansion, cortical perforation, tooth displacement, and root resorption.[1],[2] It has been defined by the World Health Organization as an intraosseous lesion consisting of cellular fibrous tissue containing multiple foci of hemorrhage, aggregations of multinucleated giant cells, and occasionally, trabeculae of woven bone.[3] CGCG, first described by Jaffe in 1953, is a benign lesion that usually occurs in the mandible and the maxilla. The origin is unknown, but genetic abnormalities are implicated. The most commonly used therapy is surgical curettage but other treatment options have also been recommended.


   Case Report Top


A 16-year-old male patient reported with the complaint of pain and swelling in the lower left back tooth region for the past two months. Swelling started as a small one that gradually reached the present size. Associated pain was severe, intermittent, aggravated on eating food, temporarily relieved on medication. The patient had a history of mobility of the teeth and parasthesia over the affected area. Patient underwent extraction of teeth from that region due to mobility. Also, there was history of trauma to the left side of mandible with a cricket ball, six months back. On general physical examination, patient was conscious and cooperative with no significant medical history.

On extra oral examination, a diffuse swelling was seen on the left side of mandible measuring 4 × 4 cm in diameter extending anteroposteriorly 2 cm from symphysis region to the angle of mandible and superoinferiorly from the corner of the mouth to the inferior border of mandible, which was tender and firm in consistency [Figure 1]. Intraorally, growth measuring 3 × 2 cm extending anteroposteriorly from 33 region to 36 and buccolingually obliterating the buccal and lingual sulci with associated missing premolars and mobility of 31, 32, 33, 36, 37 [Figure 2] and [Figure 3].
Figure 1: Lower facial asymmetry as a result of left side mandible enlargement

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Figure 2: Visible intraoral swelling, obliteration of buccal sulcus and lingual extension of tumor with missing teeth

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Figure 3: Intraoral view of swelling

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Routine blood investigation showed normal hematological values and normal serum levels of calcium, phosphorous, and alkaline phosphotase. Fine needle aspiration cytology (FNAC) was negative indicating the solid lesion. Mandibular cross-sectional occlusal radiograph showed a well-defined multilocular radiolucency in the premolar and molar region measuring roughly 4 × 4 cm in size, with fine wispy trabeculae radiating from center to the periphery and associated with both lingual and buccal cortical expansion [Figure 4]. Orthopantomogram revealed well-defined multilocular radiolucency on the left body of the mandible extending from the mesial aspect of 41 to the distal aspect of 37 measuring 4 × 4 cm in size, showing fine wispy trabeculae, root resorption of 36, and distal displacement of 33 with thinning of inferior border of mandible [Figure 5].
Figure 4: Occlusal view showing multilocular radiolucency of left body of mandible associated with missing premolars

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Figure 5: Orthopantomogram showing multilocular radiolucency extending from 41 to 37, displacing 33 with thinning of inferior border of mandible

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Based on history, clinical and radiological findings provisional diagnosis of “central giant cell granuloma of mandible” was given. Various differential diagnoses were suggested. Ameloblastoma was ruled out based on patient's age and site of lesion. Brown's tumor of hyper parathyroidism was excluded as serum picture was normal. Cherubism was ruled out as the lesion is unilateral in appearance with no genetic predisposition. Aneurysmal bone cyst was ruled out by negative aspiration. AOT was ruled out based on the more posterior location, size, and radiographic appearance.

Incisional biopsy confirmed CGCG with histopathological features of fibrocellular connective tissue with fibroblasts, numerous giant cells, and moderate chronic inflammatory cell infiltrate mostly lymphocytes. Management was done by segmental resection of the affected part of the mandible [Figure 6] with safe margins followed by reconstruction using titanium reconstruction plate. Bone reconstruction was done by autogenous block graft harvested from iliac crest [Figure 7]. The resected mandible was sent for histopathological examination, which reconfirmed clinical diagnosis of CGCG. The case is under follow up for a period of one year without any evidence of recurrence.
Figure 6: Resected specimen

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Figure 7: Intra operative image showing reconstruction using autogenous graft and reconstruction plate

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   Discussion Top


CGCG was first described by Jaffe in 1953 as a giant-cell reparative granuloma of the jaw bones.[4] It was hypothesized that the lesion is not a true neoplasm but merely the result of a local reparative reaction. CGCG appears as a painless expansile mass. The clinical behavior of the CGCG ranges from a slowly growing asymptomatic swelling to an aggressive lesion that manifests with pain, local destruction of bone, root resorption, or displacement of teeth.[5] Lesion usually occurs in patients younger than 30 years, is more common in females than males, and is more common in mandible than maxilla. The lesion has been reported to be confined to the tooth-bearing area of the jaws and is more common in anterior portion of the mandibular body.[6]

The radiologic features of giant cell granuloma have not been clearly defined; the lesion may appear as unilocular or multilocular radiolucency with well-defined or ill-defined margins with varying degrees of expansion of the cortical plates. Radiographic appearance of the lesion is not pathognomic and may be confused with that of many other lesion of the jaws.[7]

Various methods have been described for the treatment of CGCG of the jaws. Curettage alone or in combination with resection with or without continuity loss is the treatment modality most often used.[8] Some investigators have reported successful treatment, using intralesional injections of corticosteroids as a non-surgical management.[9] The use of calcitonin may have some merit in the treatment of aggressive lesions in the form of subcutaneous injection or nasal spray [10] and alpha-interferon -2a (IFN-α 2-a) injections had varying success. Surgical treatment is modified depending upon the anatomic location, size of lesion, clinical behavior, periosteal or nerve involvement. But in this case, perforation of cortical plates prompted us for surgical resection and primary reconstruction with autogenous bone graft and titanium plate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
de Lange J, Rosenberg AJ, van den Akker RK, Koole R, Wirds JJ, van den berg H. Treatment of central giant cell granuloma of the jaw with calcitonin. Int J Oral Maxillofac Surg 1999;28:372-6.  Back to cited text no. 1
    
2.
Waldron CA. Bone pathology. In: Neville BW, Damm DD, Allen CN, Bouquot JE, editors. Oral and Maxillofacial pathology. 2nd ed. Philadelphia: Saunders; 2002. p. 544-7.  Back to cited text no. 2
    
3.
Kramer, Pindborg JJ, Shear M. Histological typing of odontogenic tumours. 2nd ed. Berlin: Springer-Verlag; 1991. p. 31.  Back to cited text no. 3
    
4.
Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-osseous) dysplasia of the jaw bones. Oral Surg Oral Med Oral Pathol 1953;6:159-75.  Back to cited text no. 4
[PUBMED]    
5.
Austin LT, Dahlin CD, Royer QR. Central giant cell granuloma and related condition affecting the jaw bone. Oral Surg Oral Med Oral Pathol 1955;12:1259.  Back to cited text no. 5
    
6.
Abu-El-Naaj, Ardekiam L, Leberman R, Peled M. Central giant cell granuloma of the mandibular condyle: A rare presentation. J Oral Maxillofac Sur 2002;50:939-41.  Back to cited text no. 6
    
7.
Chuong R, Kaban LB, Kozakewich H, Perez-Atyade A. Central giant cell lesions of the jaws. A clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13.  Back to cited text no. 7
    
8.
Shafer WG, Hine MB, Levy BM. A Text Book of Oral pathology. 4th ed. Philadelphia: Saunders; 1983. p. 146-9.  Back to cited text no. 8
    
9.
Kermer C, Millesi W, Watzue IM. Local injections of corticosteroids of central giant cell granuloma. A case report. Int J Oral Maxillofac Surg 1994;23:366-8.  Back to cited text no. 9
    
10.
Harris M. Central giant cell granulomas of the jaws regions regress with calcitonin therapy. Br J Oral Maxillofac Surg 1993;31:89-94.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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