134 volume 2 • issue 2 April / June 2012 • Abstract
Central giant cell granuloma (CGCG) is an intra-os-seous lesion consisting of cellular fibrosis tissue contain-ing multiple foci of hemorrhage, multinucleated giant cells and trabecules of woven bone.1 This lesion accounts for less than 7% of all benign jaw tumours.2 Jaffe3 consid-ered it as a locally reparative reaction of bone, which can be possibly due to either an inflammatory response, hemorrhage or local trauma. Females are affected more frequently than males. It occurs over a wide age range.4 It has been reported that this lesion is diagnosed during the first two decades of life in approximately 48% of cases, and 60% of cases are evident before the age of 30. It is considerably more common in the mandible than in the maxilla. Most lesions occur in the molar and premolar area, some of these extending up to the ascending ramus. The presence of giant cell granuloma in the mandibu-lar body area, the entire ramus, condyle and coronoid represents a therapeutic challenge for the oral and maxil-lofacial surgeons. The aim of this report is to describe an unusual presentation of central giant cell granuloma in-volving the mandibular body, ramus, condylar and coro-noid processes, and to discuss the differentiated diagnosis, the radiographic presentation and the man-agement of this lesion.
Keywords: giant cell granuloma, mandible, histopatho-logical examination, resection, primary reconstruction.
CASE REPORT
A 23 year-old woman from the remote village of Uttrankhand state reported to the Department of Oral and Maxillofacial Surgery at the Govern-ment Dental College, Rohtak, with a painless swelling involving the left side pre-auricular and mandibular region, having appeared approxi-mately 6 months ago. The patient had difficulty in speech and chewing, as the cheek was crushed in the interocclusal space on the left side. Clini-cal examination revealed large swelling, dif-fused, non-tender, with ill-defined margins, non-flactuant and non-compressible, restricting the mandibular movements. (Fig. I)
Fig. I.
Occlusion was disturbed as swelling had pushed the maxillary posterior teeth palatally. A pano-ramic radiography exhibited a well-defined mixed radio-opaque, radio-lucent lesion extend-ing from the left premolar region to the condylar head. (Fig. II)
Fig. II. Pre-operative orthopantomogram showing lytic lesion in the posterior part of the mandible
(left-side)
CENTRAL GIANT CELL GRANULOMA OF THE MANDIBLE:
A RARE PRESENTATION
Virendra SINGH1, Sunita MALIK2
1. Prof. PhD, Dept of M.D.S. (Oral & Maxillofacial Surgery), Head of Dept., Government Dental College, Pt. P.D. Sharma, University of health Sciences, Rohtak, Haryana, India
2. Assist Prof. Dept of M.D.S. (Oral & Maxillofacial Surgery), Government Dental College, Pt. P.D. Sharma, University of health Sciences, Rohtak, Haryana, India
Corresponding author: Sunita Malik: drsunitamalikmds@gmail.com
Case report
International Journal of Medical Dentistry 135
Based on historical, clinical and radiologic find-ings, a differential diagnosis of ameloblastoma, Pindborg’s tumor, true giant cell lesion, odon-togenic keratocyst was established. Biopsy was planned and performed for histopathological ex-amination. This gave the impression of giant cell granuloma.
A coronal computer tomography revealed an expansile, well-defined lesion, occupying the body, ramus, condyle and coronoid process. Multiple perforations were noted beyond the ossified thin borders of the lesion. Axial CT re-vealed an intrabone lesion with cortical expan-sion on the lingual and buccal sides. (Fig. III)
Fig. III. Pre-treatment CT scan axial view showing large expansile lesion
On the basis of histopathological and radiolo-gical findings, a diagnosis of aggressive central giant cell granuloma was established. Surgical resection of the left side mandible with disarti-culation was planned. Under general anesthesia, the mandible was approached by lip split and submandibular incision.
The lesion was resected with disarticulation on the left side. (Fig. IV) Primary reconstruction was done with a titanium reconstruction plate
with condylar part. (Fig. V) Finally, histopatho-logical examination confirmed the final diagno-sis of central giant cell granuloma. The patient is on follow up, but no clinical or radiographic signs of recurrence are evident.
Fig. IV. Resected Tumour Mass showing buccal cortical perforation
Fig. V. Primary reconstruction of defect with Titanium reconstruction plate.
DISCUSSION
The central giant cell granuloma appears as a painless expansile mass. The clinical behaviour of the central giant cell granuloma ranges from a slowly growing asymptomatic swelling to an aggressive lesion causing pain, local bone de-struction, root resorption or displacement of
136 volume 2 • issue 2 April / June 2012 • teeth.4 In the here presented case, the female
pa-tient was conscious about her facial asymmetry due to the painless, gradually increasing swell-ing on the left side of the mandible. The case presented in this article conforms to the reported site, sex, age and jaw. This lesion usually occurs in patients younger than 30 years, being more common in females than males, and more fre-quent in the mandible than in the maxilla. The lesion has been reported as confined to the tooth bearing area of the jaws, being more common in the anterior portion of the mandibular body.5
The radiologic features of giant cell granuloma have not been clearly defined, the lesion may appear as an either unilocular or multilocular radiolucency with well-defined or ill-defined margins with varying degrees of ex-pansion of the cortical plates. Radiographic ap-pearance of the lesion is not pathognomic and may be confused with that of many other lesions of the jaws.6
Various methods have been described for the treatment of central giant cell granuloma of the jaws. Curettage alone or in combination with resection with or without continuity loss is the treatment most frequently used. Some investi-gators has reported successful treatment, using intra-lesional injections of corticosteroids.7 As
corticosteroids inhibit osteoclasts in narrow cul-tures, under conditions of bone absorption by increased apoptosis, their use for giant cell
granuloma has been advocated.
Biophosphonates have been used to treat giant cell lesions and fibrons dysplasia in children, because of their inhibiting action of osteoclastic bone resorption. The management methods are extremely various, ranging from simple enuclea-tion to radicle resecenuclea-tion. The surgical treatment is modified according to the anatomic location,
size of lesion, clinical behaviour, periosteal or nerve involvement. However, in this case, perfo-ration of the cortical plates prompted us for sur-gical resection and primary reconstruction with titanium plates.
The present case report, describing a central giant cell granuloma of the mandible involving the body ramus condyle and cornoid processes, is rare and can be a diagnostic challenge for both oral and maxillo-facial surgeons.
References
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Virendra Singh, Sunita Malik
