Central giant cell granuloma

Report of a case

The central giant cell granuloma IS a tumor that has great potential for the displacement of teeth and the development of a facial deformity. Although its cause and behavior are still matters for discussion, its early diagnosis and treatment are a priority. We describe a patient with a large benign central giant cell granuloma of the anterior mandible. The clinical, radiographic, and histologic appearance, as well as the appropriate treatment. are discussed in light of the current literature. (OH.U SI KC. OK.\I Mm OH\I t\irio~. lW3;75:2X6-Y1

he central giant cell granuloma (CGCG) i> ;I common reactive nonneoplastic lesion of the jaw. I~ .lalfe first used the term giant cell reparative granuloma in 1953 to distinguish this lesion of the j;lM from the giant cell tumor. a histologically similar Icsion of the long bones.J Although once believed to be separate entities. it is now thought that these represent the same disease process. and only manifest themselves differently b> the site of occurrcncc and the age of the patient. The CGCG is typically found in persons under the age of 30 (75%) and has ;I prcdilection for women (64:; ).. The preferred site for the occurrence of CGCG is in the facial bones. hut reports, of other sites including the temporal. ethmoid, and sphenoid bones do c.xi\t.
CASEREPORT

permanent Iirht hlcuspid to the distal aspect 01 the right permanent lateral in&or. The swelling \\us hard to palpation. consistent with bone. and U;IS covered with normal I~UCOS;I. tressure did not elicit any exudate or any tender-ness. and there D;I~ no presence of paresthesia. There \\;I\ minimal swelling of the lingual aspect of the mandible. and ~11 other tissues of the oral cavity \lere \+ithin normal limit\ Kadlographh or the patient Included LI panoramic viev.

ouclusal wa4. croswxtional

lputed torrqraph~ (Fig. L:ircurnscrihed. unilocular WI X 4 cnt in !/it midline

tomogram5.

and axial con-

I ). These revealed ;I large. ~~\cllradiolucenq that mcasurcd 5 olthe mandible (Fig. 3). The le.-

Science center for routine dental procedure\. The patients mother \vas particularI> interested in an orthodontic consultation for his mandibular anterior teeth that
had shifted. tvaluatiun revealed ;I retained left cuspid. and the nxlndibular anterior incisor teeth vcrcly inclined to the patients left. 4 large. labial lar swelling was noted from the rnesial aspect of primar! ucre sevcstibuthe left

.1\ 1-kbear-old Texas Health

Ilkp;lnic

male

came

to the CJniverGty

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Gon exknded lrom the mesi~l root surface (II the left permanen lirst hiLucpid to the mesial root suriacc of the right permanent cu\pid. The \ertic:tl extension \\;I\ from the nccka 01 the mandibular anterior teeth to the inferior corIC\ 01 ihc rnxntiihic. with no rexu-ption 01 the roots 01 !hc lccth noted. Modcr:ite huccal expansion *;I\ presenl. ~$1111 \r\eri: th~nn~ns 01 the cortical plate. Within the radiolw cent> appeared ;I radiopaque structure consistent with the ~mpacttzd cro\\ n and p;rrti:ll root oithe m;tndihul:lr left per-m~nen~ ~uspld ho other calcifications \+ithin the lumen 01 the IWOII \\crc inotcxi. On the baGa of the clinical and radiographIc irndings, i hc tliiterential diagn&s included dentigerouj c!xt. odonto=ciiic keratocybt. (GC(; . aneury-smal hone c) \t. amclohlastoma. and ameloblastic libroma

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Fig. 1. Panoramic
Impacted mandibular

radiograph reveals large, circular, well-defined radiolucent left cuspid is observed projecting into lesion.

lesion

of anterior

mandible

Fig. 2. Preoperative symphysis lesion.

axial computerized

tomograph

shows

well-circumscribed,

unilocular,

lo\n, density

mixed with a. yellowish substance. Using a handpiece, a large window was made and the spongy, vascular lesion was removed by thorough curettage and sent for histologic examination. The impacted mandibular left cuspid was then easily removed. After irrigation with saline solution and packing the bony defect with a thrombin-soaked absorbable gelatin sponge (Gelfoam), the flap was repositioned and SLItured. The gross specimen consisted of a grayish-pink mass of tissue that measured 3.3 cm X 3.3 cm X 1.6 cm. The lesion was well circumscribed, with a rubbery consistency. Multiple sections showed numerous benign giant cells within a cellular hbrovascular stroma, consistent with the histologic picture of CGCG (Fig. 3). The patient was followed closely for a period of 2 years

and the postoperative course was uneventful evidence of recurrence (Fig. 4).

with

no

DISCUSSION
The CGCG typically appears as a multilocular, radiolucent lesion that occurs in the tooth-bearing areas of the jaws previously occupied by the deciduous teeth. Although the lesion is usually located in close proximity to the teeth, some cases of CGCG have been reported in the edentulous patient., These lesions commonly occur in the mandible (675,) as opposed to the maxilla (3 1 %I), with a predilection for the anterior segment. In the mandibular anterior regions, these lesions will cross the midline. The CGCG occurs

most frequently in the young, with Ihc greukxt occurrence between the ages of IO and I9 years. LXsions that occur in persons over the age of 49 arc e\.tremety uncommon. The clinical and radiographic presentation of Ihc CGCG often includes an asymptomatic swelling that reaches a sufficient size that the patient begins to notice the deformity. Although on occasion the initial finding will be made after routine radiographic cxamination. it is more common for the CGCG to

achieve significant hi/e before it is diapnoscd. Expansion of the cortex is seen with the larger lesions. but perforation should be considered rare. With increasing sire of the lesion, facial deformity and displacement of the teeth wilt be seen. and casts of tooth resorption have been reported.x. I The CGCG wilt appear as ;I radiotucency with some degree of cortication of the margins being present. The smaller tesions will appear radiographically as unitocular, and with increasing si/e, the appearance of wispy bon!

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septae becomes a prominent feature. Because of the recurrent nature of the CGCG, radiographic follow-up should be continued until evidence of bony regeneration is apparent. Histologically, the CGCG appears with a uniform stroma that consists of spindle-shaped fibroblasts. Within this stroma, multinucleated giant cells wi!l usually be found accumulating around numerous vascular channels and in areas of hemorrhage. The presence of the giant cells is variable and can at times be found to be evenly distributed throughout the connective tissue stroma. Less aggressive CGCG tend to have smaller giant cells with fewer numbers of nuclei.. -3 Attempts to predict the degree of aggressiveness of CGCG suggest that there is no significant correlation between the giant cells and the aggressive behavior. I2 nor is there any way of predicting their nature.j The histologic presentation of CGCG is identical to the Brown tumor of hyperparathyroidism. A complete medical work-up and radiographic examination for multiple lesions is always indicated. Treatment of the CGCG consists of thorough curettage of the affected area. Although 10% to 15% of these lesions do recur, the locally aggressive giant cell lesions have a higher rate of recurrence. In highly aggressive lesions of significant sire, en bloc resection should be considered. In rare cases when complete removal is not possible because of the location of the lesion, radiation therapy may be used in conjunction with the surgical procedure. However, caution must be exercised because of the potential for sarcomatous transformation.7. j
REFERENCES
I. Auclair ical and granuloma
OKZI

4.

6.

7.

8.

Bondi R, Urso C, Santucci B, Santucci M. Giant cell lesion of the jaw: case report. Tumori 1988;74:479-X4. Cassalty M, Greenberg A. Kopp W. Bilateral giant cell granulomata of the mandible: report of case. J Am Dent Assoc 1988;l 17:731-3. Jaffe H. Giant cell reparative granuloma. traumatic bone cyst. and fibrous (fibro-osseous) dysplasia ofjaw bones. OK\I SI,K(; OR~I Mw OKAL PATHOL 1953;6:159-75. Stimson P. McDaniel R. Traumatic bone cyst. aneurysmal bone cyst, and central giant cell granuloma-pathogeneticallq related lesions? J Endod 1989;15:164-7. Ciappetta P, Salvati M. Bernardi C. Raw A, Dilorenro N. Giant cell reparative granuloma of the skull base mimicking an intracranial tumor: case report and review of the literature. Surg Neurol 1990;33:52-6. Tesluk H, Senders C. Dublin A. Case report 562: giant cell reparative granuloma of the temporal boric. Skeletal Radio1 1989;18:599-602. Cohen M, Hertzanu Y. Radiologic features. including those seen with computed tomography. of the giant cell granuloma of the jaws. OR,\I SL KC; ORAL MFD OWI P\III~I 1988:

65:2X5-61.
M, DeBoom G. Enlarging soft tissue ma\\ involving 9. Marshall the mandibular left alveolar ridge. J Am Dent Acsoc 1988; I 16:707-9. IO Cohen M. Grossman .E, Thompson S. Features of the central giant cell granuloma of the jaws xenografted in nude mice. OKAI S~JKG ORAL Mm OKAL P~THOI 1988;66:209-17. II High A. Mathews A. The importance of radiography in ass&sing the behaviour of an aggressive giant cell lesion of the ia&s. Dentomaxillofiac Radio1 1989;18:36-X. I2 &kurdt A. Pogrel M, Kaban L, Chew K. Mayall B. Central giant cell granulomas of the jaws: nuclear DNA anctlqsis using image cytometry. Int J Oral Maxillofac Surg 1989;18:3-6. I3 llorner K. Central giant cell granuloma of the jaw\: a clmicoradiological study. Clin Radio1 1989:40:622-h. R, Kaban L, Kozakewich H, Perez-Ataydc A. Central I4 Chuong giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg 19X6:44:708-13. P. Marrogi A, Delfino J. Multifocal central giant cell IS Smith lesions of the maxillofacial skeleton: a case rcpor?. .I Oral Maxillofac Surg 1990:4X:300-5.

I. Cuenin P, Kratochvil F. Slater L, Ellis G. A clinhistomorphologic comparison of the central giant ccl1 and lhr giant cell tumor. OR41 SI KG ORAl MFII l\rl1ol 198X:66:197-208.

B.D. Tiner. DDS. MD University of Texas Health Science Department of Oral and Maxillofacial 7703 Floyd Curl Drive San Antonio. TX 78284-790X

Center Surgeq