• Users Online: 131
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 55-58

An Unusual Case of Maxillary Central Giant Cell Granuloma


Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai, Maharashtra, India

Date of Web Publication27-Jun-2016

Correspondence Address:
Ruchika Kapoor
Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai - 400 008, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2393-8692.184741

Rights and Permissions
  Abstract 

Central giant cell granuloma, formerly known as giant cell reparative granuloma, is considered as a reactive lesion to an unknown stimulus or a neoplastic lesion. The lesion mainly affects young adults and commonly involves mandible more than maxilla. When present in the maxilla, it is usually seen anterior to cuspids, but in this case, it was the posterior maxilla which was involved making it an unusual site for its occurrence. This case report describes a 20-year-old female patient presenting with a chief complaint of swelling of the left side of the face for 1-year. Depending on the clinical features and radiographic findings, a diagnosis of giant cell granuloma was made, which was surgically excised.

Keywords: Giant cells, hyperparathyroidism, maxilla


How to cite this article:
Kapoor R, Karjodkar FR, Sansare K, Dora AC. An Unusual Case of Maxillary Central Giant Cell Granuloma. Indian J Oral Health Res 2016;2:55-8

How to cite this URL:
Kapoor R, Karjodkar FR, Sansare K, Dora AC. An Unusual Case of Maxillary Central Giant Cell Granuloma. Indian J Oral Health Res [serial online] 2016 [cited 2019 Aug 22];2:55-8. Available from: http://www.ijohr.org/text.asp?2016/2/1/55/184741


  Introduction Top


Jaffe originally coined the term "giant cell reparative granuloma." According to him, the lesion was a response to intraosseous hemorrhage resulting from jaw trauma. [1] Other researchers prefer the term "giant cell granuloma" to describe this lesion, noting the inconsistent history of trauma and lack of significant elements of reparative terms. Thus, the word "reparative" was omitted. [2]

Central giant cell granuloma (CGCG) is a bony lesion mainly affecting adolescents and young adults, preferably younger than 20 years. The etiology of the lesion is still debatable. Some considered it to be a reactive lesion to an unknown stimulus and some considered it to be a neoplastic lesion. The lesion is more often located in the mandible. [1] The presenting symptom in majority of the cases is painless swelling. Although the histologic appearance of the lesion is benign, some maxillary lesions may have malignant characteristics.


  Case report Top


A 20-year-old female patient presented to the department of oral medicine and radiology with a chief complaint of swelling on the left side of the face for 1 year as shown in [Figure 1], which was insidious on onset and started as a swelling in the upper left posterior palatal region, which gradually increased to involve the entire palate and the left side of the face.
Figure 1: Profile photograph shows diffuse swelling of the left side of the face

Click here to view


On extraoral examination, the face was grossly asymmetrical. Swelling was present on the left side of the face which extended superoinferiorly from the left infraorbital region to 1 cm above the left inferior border of the mandible and mediolaterally from the left lateral nasal process to approximately 3 cm in front of the tragus. The nasolabial fold and philtrum were obliterated. The swelling had well-defined margins on palpation with firm consistency, and was nontender and compressible. The temperature over the swelling was normal. Cervical lymph nodes were not palpable.

On intraoral examination, a firm swelling was noted involving the entire hard and soft palate extending from the mesial aspect of the maxillary right central incisor to the distal aspect of the maxillary left second molar causing obliteration of the left vestibule as shown in [Figure 2]. Overlying mucosa was slightly purplish at the posterior palatal region. Teeth number 21, 22, 23, 24, 25, 26, and 27 were Grade II mobile and extruded with spacing as shown in [Figure 3].
Figure 2: Swelling involving the entire hard and soft palate

Click here to view
Figure 3: Swelling and obliteration of the left side vestibule

Click here to view


Panoramic radiograph revealed a well-defined expansile lesion within the left maxilla extending mediolaterally from the mesial aspect of 13 to the distal aspect of 27 and superoinferiorly from the floor of the left orbit to the crest of the maxillary alveolar bone. Displacement, extrusion, and root resorption were seen in teeth 11, 21, 22, 23, 24, 25, 26, and 27. Root of 13 was distally tilted. Borders of the left maxillary sinus were not traceable [Figure 4].
Figure 4: Panoramic radiograph showing well-defined expansile lesion involving the left maxilla with displacement of teeth, root resorption, and obliteration of sinus

Click here to view


Computed tomography revealed partial cortication with expansion of the bone. Perforation was present at the lateral and inferior aspects of the left maxilla. Internal structure had wispy septae. Obliteration of the left maxillary sinus was noted [Figure 5].
Figure 5: Coronal computed tomography scan shows partial cortication, expansion with perforation of the left maxillary sinus

Click here to view


Serum calcium, phosphorous, alkaline phosphatase, and parathyroid hormone (PTH) levels were within normal limits. Brown tumor of hyperparathyroidism was excluded on the basis of age and laboratory investigations.

Based on clinical features, radiographic findings, and serum levels, a diagnosis of giant cell lesion was made.

Excision of tumor with free fibula flap reconstruction was done, and the patient is kept on follow-up for any recurrence [Figure 6] and [Figure 7].
Figure 6: Postoperative facial profile

Click here to view
Figure 7: Postoperative panoramic radiograph of the patient showing graft placement and bony plates

Click here to view


Histopathological examination revealed numerous multinucleated giant cells with a background of plump proliferating mesenchymal cells with extravasated red blood cells favoring aggressive giant cell lesion as shown in [Figure 8].
Figure 8: High power histopathological picture of giant cell lesion

Click here to view



  Discussion Top


CGCG, formerly known as giant cell reparative granuloma, is considered as reactive lesion to an unknown stimulus. The lesion mainly affects young adults and involves mandible more than maxilla.

The most common presenting sign is painless swelling. The overlying mucosa appears normal unless traumatized. The lesion predominately involves the region anterior to the first molar in the mandible and anterior to cuspids in the maxilla. The lesion sometimes crosses the midline. When present in the maxilla, it is usually seen anterior to cuspids, but in this case, it was the posterior maxilla which was involved, making it an unusual site for its occurrence.

Although considered as benign reactive osseous lesion, CGCG has been classified into two types based on its clinicoradiologic features as nonaggressive lesion which is usually asymptomatic and slow growing, and an aggressive type which is most of the times painful, grows rapidly into a large size, perforating the cortex causing root resorption, and has a tendency to recur. [2],[3] The radiographic appearance of the lesion can be unilocular or multilocular. As the lesion grows slowly, it usually produces well-defined margins. In certain cases, there is no evidence of cortication and may have ill-defined margins, especially in the maxilla as was seen in this case. Small lesion may not show any evidence of internal structure. Large lesion may have ill-defined wispy septa. Septa arising at the right angle from the periphery of the lesion with small indentation of the expanded cortical plate at the origin of the septa make the diagnosis of CGCG most likely. As the radiographic findings are not pathognomonic of the disease, the final diagnosis depends on the histopathology.

The differential diagnosis of CGCG includes brown tumor of primary hyperparathyroidism, aneurysmal bone cyst, ameloblastoma, and odontogenic myxoma. Ameloblastoma and odontogenic myxoma are found in older age group. PTH levels, alkaline phosphatase, and serum calcium levels need to be checked to rule out the brown tumor of primary hyperparathyroidism, which is increased in hyperparathyroidism. Ameloblastoma has coarse, curved, well-defined trabeculae and odontogenic myxoma has sharp and straight septae and do not expand to such an extent as seen in this case.

Treatment of CGCG includes curettage and resection of the jaw. [4]

Alternative therapies such as intralesional injections of corticosteroids, subcutaneous administration of calcitonin, or interferon alpha have also been tried with variable success rates. [5],[6] Aggressive lesion curettage for young patients is not an effective treatment for aggressive lesions; en bloc resection is the treatment of choice. Even though radical resection is an effective modality for aggressive lesions, it leads to functional disturbances. [7],[8]

Follow-up at regular interval is mandatory to rule out any occurrence. Recurrences are rare and are more common in the maxilla. [9],[10]

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.
Motamedi MH, Eshghyar N, Jafari SM, Lassemi E, Navi F, Abbas FM, et al. Peripheral and central giant cell granulomas of the jaws: A demographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e39-43.  Back to cited text no. 1
    
2.
Whitaker SB, Waldron CA. Central giant cell lesions of the jaws. A clinical, radiologic, and histopathologic study. Oral Surg Oral Med Oral Pathol 1993;75:199-208.  Back to cited text no. 2
    
3.
Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: A clinicopathologic study. J Oral Maxillofac Surg 1986;44:708-13.  Back to cited text no. 3
[PUBMED]    
4.
de Lange J, van den Akker HP, van den Berg H. Central giant cell granuloma of the jaw: A review of the literature with emphasis on therapy options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:603-15.  Back to cited text no. 4
    
5.
Adornato MC, Paticoff KA. Intralesional corticosteroid injection for treatment of central giant-cell granuloma. J Am Dent Assoc 2001;132:186-90.  Back to cited text no. 5
    
6.
Pogrel MA. Calcitonin therapy for central giant cell granuloma. J Oral Maxillofac Surg 2003;61:649-53.  Back to cited text no. 6
    
7.
Eisenbud L, Stern M, Rothberg M, Sachs SA. Central giant cell granuloma of the jaws: Experiences in the management of thirty-seven cases. J Oral Maxillofac Surg 1988;46:376-84.  Back to cited text no. 7
    
8.
Roberts J, Shores C, Rose AS. Surgical treatment is warranted in aggressive central giant cell granuloma: A report of 2 cases. Ear Nose Throat J 2009;88:E8-13.  Back to cited text no. 8
    
9.
Stavropoulos F, Katz J. Central giant cell granulomas: A systematic review of the radiographic characteristics with the addition of 20 new cases. Dentomaxillofac Radiol 2002;31:213-7.  Back to cited text no. 9
    
10.
White SC, Pharoah MJ. Oral Radiology: Principles and Interpretation. 6 th ed. Missouri: Mosby; 2009. p. 442-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed1233    
    Printed77    
    Emailed0    
    PDF Downloaded73    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]