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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 111-114

Central giant cell granuloma in a 10-year-old pediatric patient - A rare entity in posterior mandible with CBCT findings: A case report


1 Department of Oral Medicine and Radiology, Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu, India
3 Department of Oral and Maxillofacial Surgery, Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu, India

Date of Submission08-Oct-2020
Date of Decision21-Jan-2021
Date of Acceptance08-Feb-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Kandasamy Murugan
Reader, Department of Oral Medicine and Radiology, Rajas Dental College and Hospital, Kavalkinaru Jn., Tirunelveli - 627 105, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_206_20

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   Abstract 


Central giant cell granuloma (CGCG) of bone constitutes about 7% of all benign lesions of the jawbones. CGCG, as described by Jaffe in 1953, is an idiopathic non-neoplastic proliferative lesion. The mandible anterior to the first molar is the frequently affected site, and has a tendency to cross the midline. Though CGCG is a benign reactive osseous lesion, it has been classified into two types based on its clinic-radiologic features into a slow growing asymptomatic, nonaggressive lesion, and an aggressive type encountered in younger patients which is painful and grows rapidly into a large size, perforating the cortex causing root resorption, and has a tendency to recur. We report a rare case of aggressive CGCG with massive destruction in molar region and angle of mandible.

Keywords: Aggressive type, central giant cell granuloma, CBCT, posterior mandible


How to cite this article:
Jose D, Murugan K, Sathiasekar AC, Kumar D. Central giant cell granuloma in a 10-year-old pediatric patient - A rare entity in posterior mandible with CBCT findings: A case report. J Indian Acad Oral Med Radiol 2021;33:111-4

How to cite this URL:
Jose D, Murugan K, Sathiasekar AC, Kumar D. Central giant cell granuloma in a 10-year-old pediatric patient - A rare entity in posterior mandible with CBCT findings: A case report. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Apr 13];33:111-4. Available from: https://www.jiaomr.in/text.asp?2021/33/1/111/312205




   Introduction Top


Central giant cell granuloma (CGCG) of bone constitutes about 7% of all benign lesions of the jawbones.[1] CGCG, as described by Jaffe in 1953 is an idiopathic non-neoplastic proliferative lesion.[2],[3] According to World Health Organization 1992 class, CGCG is defined as “an intraosseous lesion consisting of more or less fibrous tissue containing multiple foci of hemorrhage, aggregates of multinucleated giant cells, some amount of trabeculae of woven bone forming within the septa of more mature fibrous tissue that may traverse the lesion.”[4] The mandible anterior to the first molar is the frequently affected site, and has a tendency to cross the midline.[5] We report a rare case of aggressive CGCG in molar region and angle of mandible.


   Patient Information Top


A 10-year-old female patient came to the department of Oral Medicine and Radiology with the chief complaint of painful swelling in the right lower one third of the face for the past 15 days. Swelling was sudden in onset and progressed without any remission to attain the present size associated with pain which was sudden in onset, intermittent in nature, dull aching pain with moderate intensity, aggravates during mastication and upon touch, with no relieving factors. No history of trauma [Figure 1].
Figure 1: Time line of History

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   Clinical Findings Top


The patient's general examination revealed no abnormality. Vital signs were normal, moderately built and nourished. On extra oral examination, A single diffuse swelling seen in right lower one third of the face of size 5x3 cm extends anterioposteriorly 3 cm from the corner of mouth to angle of mandible, superioinferiorly from line joining corner of mouth to tragus of ear to 2 cm below the inferior border of mandible. The skin over the swelling appears normal [Figure 2]. No sinus opening. On Palpation all the inspectory findings were confirmed swelling was warm, and the size measuring approximately about 6x5 cm,firm to hard in consistency and seem to arise from deeper tissue, skin and the overlying soft tissue are movable. Single right submandibular lymphnode was palpable which was roughly oval in shape,s ize measuring approximately 1 × 0.5 cm, firm to hard in consistency and tender.
Figure 2: (a)Profile showing the extraoral swelling. (b)Intraoral swelling with teeth indentation overit

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On intraoral examination, a diffuse vestibular swelling measuring about 4 × 3 cm was seen in the region of 46,47 and retromolar area. Teeth indentation seen over the mucosa of right reteromolar region. The crown structure of 46,47 appeared intact with no carious lesion [Figure 2]. On palpation it was tender, hard in consistency. There was a prominent smooth buccal and very minimal lingual cortical expansion and thinning of cortical plate felt. The teeth in region of swelling were displaced occlusally causing anterior open bite but were not mobile.


   Diagnostic Assessment Top


Based on the history and clinical examination, a provisional diagnosis of benign odontogenic tumor was considered. A clinical differential diagnosis of ameloblastoma, CGCG, Browns tumor of hyperparathyroidism, aneurysmal bone cyst were listed.

Intraoral periapical radiograph of 46,47 region, mandibular right lateral occlusal radiograph and Orthopantamograph (OPG) showed ill-defined radiolucency of size more than 1 cm seen distal to 46 region, external root resorption in distal root of 47 and bicortical expansion distal to 46 was evident [Figure 3]. CBCT scan revealed a multilocular hypodense lesion appears like soap bubble with thin wispy septa. There was bicortical expansion and thinning of inferior border of the mandible extending from distal to 46 to the ramus of the mandible [Figure 4]. Radiographic differential diagnosis considered were ameloblastoma, CGCG, Browns tumor of hyperparathyroidism.
Figure 3: (a) OPG shows ill defined radiolucency seen distal to 46 region and root resorption seen in 47 (b) Incisional biopsy was done (c) On histopathological examination shows large number of multinucleated giant cells, Areas of haemorrhage and Mixed inflammatory cell infiltrate

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Figure 4: CBCT {Axial view, coronal view, sagittal view} shows multilocular hypodense lesion with bicortical expansion and 3D reconstruction glossy bone view shows massive destruction of posterior mandible and root resorption in 47 region

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Incisional biopsy was done under local anesthesia in left buccal vestibule in relation to 47 region. Histopathological examination revealed non-keratinized squamous epithelium with fibroblasts, macrophages, and multinucleated giant cells in a collagenous stroma suggestive of a giant cell lesion [Figure 3]. Because CGCG and brown tumor of hyperparathyroidism are histologically indistinguishable biochemical investigations was done which revealed serum calcium (9 mg/dL), serum phosphorous (4.5 mg/dL), and parathyroid hormone assay (40 pg/mL), to be within normal limits. Based on the clinical, radiographical, biochemical, and histopathologic findings, a final diagnosis of aggressive CGCG was given.


   Therapeutic Intervention Top


Enucleation of the lesion was done leaving intact lower border and part of the lesional tissue was sent for the histopathological examination.


   Follow-up and Outcomes Top


The postoperative histopathological examination showed areas of non-keratinized squamous epithelium with multinucleated giant cells . Follow-up of the patient was done after 3 months and 1 year and no recurrence was noted [Figure 5].
Figure 5: Postoperative CBCT images after 3 months

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   Discussion Top


CGCG, as described by Jaffe in 1953 is an idiopathic non-neoplastic proliferative lesion.[1.2] The term reparative giant cell granuloma was at one time widely accepted as CGCG was considered primarily to be a local reparative reaction of bone, possibly to intramedullary hemorrhage or trauma. The incidence of CGCG in the general population is estimated to be 0.0001% with 60% of cases occurring before the age of 30.[3] CGCG is more prevalent in anterior than the posterior jaws, often crossing the midline (50%), and the mandible is commonly affected than the maxilla.[4],[5] However, our patient was a young female, who presented with a lesion in the posterior mandible distal to the molars and she did not recollect any history of trauma.

CGCG had been classified into two types based on its clinic-radiologic features. They may present as slow growing asymptomatic, nonaggressive type, or an aggressive type that grows rapidly, frequently painful, perforating the cortex, causing root resorption, with a tendency to reccur. The rate of recurrence is as high as 13–49%.[6] Our patient also presented with the aggressive type, however no recurrence was noted till 1 year.

The clinical and radiological differential diagnosis[7] of the present case is shown in [Table 1] and [Table 2], respectively. Surgical treatment may include enucleation, curettage, peripheral osteotomy, and en bloc resection.[8] Our patient was treated with enucleation so as to preserve the inferior border of the mandible. Nonsurgical treatments indicated include intralesional injections of steroids, calcitonin, and bisphosphonates, which inhibit osteoclastic activity and alpha interferons due to its anti-angiogenic effects.[9] These were not tried in the present case, as the clinical course appeared to be aggressive, necessitating removal.
Table 1: Clinical differential diagnosis of CGCG

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Table 2: Radiological differential diagnosis of CGCG

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   Patient Perspective Top


There were no adverse effects or complications that affected their quality of life from the perspective of the patient.


   Conclusion Top


CGCGs are benign, but occasionally aggressive lesions can develop in the jaws. Huge, irregular, intraoral swellings need proper history taking, thorough examination with relevant hematological, biochemical, serological, and histopathological investigations for proper diagnosis as they mimic other pathological conditions. Aggressive lesions may need surgical resection along with curettage. Use of INF-alpha and intralesional corticosteroid therapy are the latest therapeutic approaches available at this time.

Declaration of patient consent

We, being authors of this case report, certify that we have obtained all appropriate patient consent forms. In the way, 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.
Chavva S, Dhawalraj C, Badam RK, Chaitanya NC. Aggressive central giant cell granuloma: A rare case report. J Indian Acad Oral Med Radiol 2017;29:220-2.  Back to cited text no. 1
  [Full text]  
2.
Amar AS, Keerthilatha PM, Auswaf A. Central giant cell granuloma of the anterior maxilla. Indian J Dent Res 2008;19:78-82.  Back to cited text no. 2
    
3.
Kamble KA, Guddad SS, Guddad SS, Lingappa A. Central giant cell granuloma: A case report with review of literature. J Indian Acad Oral Med Radiol 2016;28:98-101.  Back to cited text no. 3
  [Full text]  
4.
Singh G, Thakur A, Sadiq H, Gupta P. Central giant cell granuloma: A case report with diagnostic dilemma. Int J Stud Res 2015;5:11-4.  Back to cited text no. 4
  [Full text]  
5.
Hosur MB, Puranik RS, Vanaki SS, Puranik SR, Ingaleshwar PS. Clinicopathological profile of central giant cell granulomas: An institutional experience and study of immunohistochemistry expression of p63 in central giant cell granuloma. J Pathol 2018;22:173-9.  Back to cited text no. 5
    
6.
Baskaran P, Gopal M, Rastogi V, Misra SR. Aggressive central giant cell granuloma of the mandible, a diagnostic dilemma. J Oral Maxillofac Radiol 2015;3:88-91.  Back to cited text no. 6
  [Full text]  
7.
Kaffe I, Ardekian L, Taicher S, Littner MM, Buchner A. Radiologic features of central giant cell granuloma of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:720-6.  Back to cited text no. 7
    
8.
Pogrel AM. The diagnosis and management of giant cell lesions of the jaws. Ann Maxillofac Surg 2012;2:102-6.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
da Silva NG, Carreira AS, Pedreira EN, Tuji FM, Ortega KL, de Jesus Viana Pinheiro J. Treatment of central giant cell lesions using bisphosphonates with intralesional corticosteroid injections. Head Face Med 2012;8:23.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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