Other Bone Diseases

1) Central Giant Cell Granuloma

2) Langerhans Cell Histiocytosis

Fatima A.Ameer Khalil

20102050075

Central Giant Cell

Granuloma

Giant Cell is a mass formed by the union of

macrophages
The bone is replaced by vascular fibrous tissue
containing large number of multinucleated
giant cells
Neoplastic OR Reactive ?

Clinical Features:
Gradually increasing painless swelling of bone
only occurs in the jaws
the peak incidence occurs in young
adults(<20)

Imaging
Features
Location
Mn more than Mx , specifically ANT to the 1st molar
in the Mn and ANT to the cuspid in the Mx
*may occur in the POST aspect of the jaws in elderly
patient
Periphery
Margins are well defined in the Mn and ill defined
(malignant appearing borders) in the Mx without
cortication
Internal structure
Either radiolucent totally creating a uniocular
appearance OR may contain ill defined wispy
granular septa that arise at right angle from the
periphery creating a multiocular appearance

PA image of CGCG in
the ANT Mn with no
evidence of internal
structure

Lesion in the ANT MX

with a fine granular
pattern

A
panoramic
image showing
wispy ill defined
septa

B
Axial cone-beam
CT image of the
Mx showing
poorly calcified
septa

C
Coronal conebeam CT image
of the Mx
showing ill
defined septa

Effects on surrounding structures

Root displacement & resorption
Can cause thinning , expansion or perforation of cortical
plates

Occlusal view of
Mn reveals the
uneven
expansion of
cortical plate

Occlusal view of
Mn shows the
indentation of
the expansion
with a right
angle septa

Axial CT image
reveals a CGCG
in the Mn
causing
expansion &
containing two
right angled

Differential
Diagnosis
CGCG identical to all other giant cell lesions
Totally radiolucent CGCG may be similar to the simple bone
cyst , evidence of displacement & resorption of the teeth or
expansion of the cortical plate is more characteristic of CGCG
If a granular internal structure is present, ossifying fibroma
may be considered.
If the internal structure contains septa , the DD include
ameloblastoma , odntogenic myxoma and aneurysmal bone
cyst.
The presence of coarse,curved,well defined trabeculae in the
POST Mn with peak incidence occurs in an older age group are
important signs to diagnose an ameloblastoma. Whereas
CGCCs have wispy trabeculae
Odntogenic myxoma do not have the same expansion rate as
CGCG , occurs in an older age group, have sharper and
straighter septa than CGCG

management
Majority of lesions respond very well to simple
enucleation & curettage
Recurrence rate following curettage is rare 15-20%
Long term prognosis is Good
CT scans is required for large lesions & to determine
whether the adjacent ST has been involved

Langerhans cell
histiocytosis
Langerhans cell is an antigen presenting cell
(epidermis, mucosa, LNs and BM)
This disease result from the abnormal proliferation of
Langerhans cells accompanied by eosinophils without
any specific reason . In some books its considered a
tumor like condition
Clinically divided into three groups
1. Unifocal eosinphilic granuloma
- Its a (monostotic or polystotic) disease with no extra
skeletal involvement
- Occurs in children older than 2 years
2. Multifocal eosinphilic granuloma
Also called hand schuller-christion syndrome
- It involves bone and other organs
- Occurs in children older than 2 years

3. Disseminated histiocytosis
- Its a multi-organ disease that known as letterer_siewe
disease
- Lesions in bone are Rare
- Occurs mainly in infants & children under 2 years
- Its considered a malignant form of LCH and associated
with high mortality

Clinical Features
Quickly increasing Painful swelling of bone
Usually appears in the skeleton (long bones, ribs, jaws &
skull) and rarely in ST
In the jaws the disease may cause bony swelling, soft
tissue mass, gingivitis , ulceration and loosening of teeth

Imaging
Features
Location
Either solitary or multiple radiolucent lesions ,
multiple when it occurs within the alveolar
process and solitary when it occurs elsewhere in
the jaw. The POST region of Mn is the most
common site (RAMUS)
Periphery
- Margins are smooth or irrgular moderately to
well defined without cortication
- The epicenter of the lesion occurs in the midroot
region resulting in a scooped-out appearance
Panoramic image
reveals multiple
lesions of LCH
Note the scoopedout shape of Bone
destruction in the
Mn
* The floor of the

Skull lesions of
LCH showing
well defined,
punched out
lesions

2 PA films of the
same area of the Mn.
A, the earlier phase
of the disease
produces a scooped
out shape& the
epicenter of the
lesion in the midroot
area. B, one year
later bone
destruction is
extensive resulting in

Internal structure
Totally radiolucent
Effects on surrounding structures
- Extensive bone destruction that progresses in a
circular pattern and loosening of teeth that appear to be
floating in air but without displacement
- Minor root resorption
- It can destroy the outer cortical plate and extends into
ST
- May be associated with periosteal new bone formation
Panoramic image
shows the bone
around the
remaining
mandibular teeth
has been
destroyed leaving
the teeth
unsupported

A
Bone destruction
in the body of the
Mn with periosteal
reaction along the
inferior border

Condylar neck
lesion with a faint
periosteal
reaction along the
POST border of
the ramus

Axial CT image of
the lesion in B
shows the
periosteal
reaction

Differential
Diagnosis
It resembles periodontal disease & SCC
An important characteristic in differentiation BTW LCH &
periodontal disease is the epicenter of the lesion which is
occur in the midroot region in LCH while in periodontal disease
starts at the alveolar crest and extends apically
SCC usually appears as a single lesion with ill defined margins
in elderly patient. In contrast LCH can be multiple with better
defined margins in the younger age group and associated with
periosteal reaction
LCH may resemble simple bone cyst, but the alveolar crest is
maintained in simple bone cyst

managemen
t

Is guided by extent of disease

Solitary lesion is removed by surgical curettage OR
limited radiation therapy
Disseminated disease is treated with chemotherapy
Use of systemic steroids is common singly or adjunct
to chemotherapy