ArticlePDF Available

Abstract and Figures

Central giant cell granuloma (central giant cell granuloma) is an uncommon benign bony lesion that occurs in the mandible and maxilla and accounts for approximately 7% of all benign tumours of the jaws [1]. The World Health Organization (WHO) has defined central giant cell granuloma as an intraosseous lesion consisting of cellular fibrous tissue that contains multiple foci of haemorrhage, aggregations of multinucleated giant cells and occasional trabeculae of woven bone [2]. Central giant cell granuloma occurs predominantly in children or young adults, with approximately 75%of cases presenting before 30 years of age although presentation can occur at any age [3]. Females are affected more frequently than males, with a ratio of 2:1
Content may be subject to copyright.
Central Giant Cell Granuloma
Nilotpol Kashyap1,*, Manisha Upadhyay2, Rupam Tripathi3, Pallavi Pawar4, Ranjeet Kumar Prasad Sah5, Rupesh Kumar Mandal6
1Professor and Head, Department of Pedodontics and Preventive Dentistry, Universal College of Medical Sciences, Bhairahawa, Nepal
2Lecturer, Department of Pedodontics and Preventive Dentistry, Universal College of Medical Sciences, Bhairahawa, Nepal
3Lecturer, Department of Conservative Dentistry and Endodontics, Universal College of Medical Sciences, Bhairahawa, Nepal
4Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Pacific Institute of Dental Sciences, Udaipur, India
5Intern, Universal College of Medical Sciences, Bhairahawa, Nepal
6Intern, Universal College of Medical Sciences, Bhairahawa, Nepal
*Corresponding Author : Dr. Nilotpol Kashyap, Professor and Head, Department of Pedodontics and Preventive Dentistry, Universal College of
Medical Sciences, Bhairahawa, Nepal, Tel: +977 9811596307; E-mail: nilkash9365@gmail.com
Received date : April 26, 2019; Accepted date : June 07, 2019; Published date: June 07, 2019
Citation: Kashyap N, Upadhyay M, Tripathi R, Pawar P, Sah RKP, et al. (2019) Central Giant Cell Granuloma. J Dent Oral Maxillofac Surg 2(2):
dx.doi: 10.31579/2643-6612/010
Copyright : © 2019 Kashyap N. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Introduction
Central giant cell granuloma (central giant cell granuloma) is an
uncommon benign bony lesion that occurs in the mandible and maxilla
and accounts for approximately 7% of all benign tumours of the jaws
[1]. The World Health Organization (WHO) has defined central giant
cell granuloma as an intraosseous lesion consisting of cellular fibrous
tissue that contains multiple foci of haemorrhage, aggregations of
multinucleated giant cells and occasional trabeculae of woven bone
[2]. Central giant cell granuloma occurs predominantly in children or
young adults, with approximately 75%of cases presenting before 30
years of age although presentation can occur at any age [3]. Females
are affected more frequently than males, with a ratio of 2:1 [4].
The clinical behaviour of central giant cell granuloma ranges from a
slow growing asymptomatic swelling to an aggressive lesion that
presents pain, local bone destruction, root resorption or tooth
displacement [5].
Clinical Relevance
Chuong et al. [6] outlined the criteria that can be used to classify a
lesion as aggressive or non-aggressive. Aggressive lesions are
characterized by one or more of the following features: pain,
paraesthesia, root resorption, rapid growth, cortical perforation, and a
high recurrence rate after surgical curettage. Different authors have
classified central giant cell granuloma into two types, based on clinical
and radiographic features [5].
Aggressive lesions are mostly found in younger patients.
Histologically there is no strict criterion to differentiate between
aggressive and non-aggressive lesions, however the number and
volume of giant cells versus other components of the lesion might give
an indication on its clinical behaviour [7].
Surgery is considered the traditional treatment and it is still the most
accepted one, however in literature not all authors agree on the type of
surgery which should be performed. Excision via curettage has been
associated with a low rate of recurrence for what concerns small
lesions. In case of recurrences, curettage plus peripheral osteotomy
and bone resection should be performed instead [7]. Unal et al.
proposed obtaining safety margins by means of microdrilling of the
surgical field with a diamond burr [8]. Although en bloc resection is
the treatment which provides the lowest recurrence rate, only a few
single case reports describe the use of this technique followed by
reconstruction with iliac crest graft [7].
Non-surgical treatments (alpha interferon [a-IFN], calcitonin,
corticosteroids) have been described and their benefits may be worthy
of consideration.
As pointed out by de Lange medical therapy success rates are still not
reaching those of surgery in controlling the lesions and additional surgery
is undoubtedly needed whenever medical therapy fails [9].
Case Report
An 8 year old boy reported to the Department of Pedodontics and
Preventive Dentistry, Rungta College of Dental Sciences & Research,
Bhilai, Chhattisgarh with a chief complaint of swelling in upper front
region of the mouth for the last 20 days, with a history of sudden increase
in size since one week. Associated with swelling there was no history of
pain or bleeding. On intra oral examination, a 1.5 × 1.5 cm, well defined
oval, reddish pink, soft, non-tender, extending toward the palatal surface
between the two central incisors. Diastema was present with respect to
teeth 11 and 21. There was no associated lymphadenopathy. [Figure 1
showing preoperative view of patient; Figures 2a and 2b Showing the
central giant cell granuloma].
Figure 1: Showing preoperative view of patient.
Figure 2a and 2b: Showing the central giant cell granuloma.
Auctores Publishing Volue2-010 www.auctoresonline.org
Page - 01
Open Access
Case Report
Journal of Dentistry and Oral-Maxillofacial Surgery
Nilotpol Kashyap
AUCTORES
Globalize Your research
J Dent Oral Maxillofac Surg
No systemic abnormalities were detected. Hematological reports were
noncontributory. A decision was thus made to excise the lesion. The
growth was excised under local anesthesia with a cold scalpel. Care
was taken to remove the entire base and the excised lesion was stored
in 10% formalin and sent for histopathological examination. [Figure 3:
Showing excisional biopsy].
Figure 3: Showing excisional biopsy.
The histopathological section showed well encapsulated lobulated
mass, numerous giant cells and hyperparakeratinized stratified
squamous epithelium. The presence of these features was suggestive
of central giant cell granuloma. The lesion reoccurs during 2nd week
and 3rd month follow-up period and was retreated. The lesion did not
reoccur during the 1-week and 6-month follow-up period. (Figures 4a
and 4b Showing histopathological view); (Figures 5a-5e Showing
retreatment of the recurrent central giant cell granuloma), (Figure 6
Showing postoperative view after retreatment).
Figure 4a and 4b: Showing histopathological view.
Figure 5a-5e: Showing retreatment of the recurrent central giant cell
granuloma.
Auctores Publishing Volue2-010 www.auctoresonline.org
Page - 02
J Dent Oral Maxillofac Surg
Figure 6: Showing postoperative view after retreatment.
Table 1: Results: surgical therapy
Background
Various authors proposed excision via curettage and the overall
recurrence rate has been reported to range from 16% to 49% [3,6]. A
higher incidence of recurrence was found in aggressive central giant
cell granulomas and in younger patients, especially males. According
to Eisenbud et al., in case of recurrence curettage plus peripheral
ostectomy and bone resection should be performed [20]. Unal et al.
proposed to obtain safety margins by means of microdrillingof the
surgical field with a diamond burr [8]. However Eisenbudet al. [20]
indicate that surgical curettage with peripheral osteotomy is still not
the safest treatment for central giant cell granulomas, especially in
aggressive lesions. En bloc resection might provide the greatest
certainty of a cure: in a study of 18 patients with aggressive central
giant cell granuloma, treatment consisted of en bloc surgical resection
with a 5 mm margin of healthy tissue and only 1 patient had a
recurrence [21].
In growing patients, aggressive surgical approaches are not a suitable
solution for central giant cell granulomas. More conservative surgery
is instead the only applicable strategy for subjects with deciduous
dentition. In general destructive surgery (en bloc surgical resection
with 5 mm margins) seems to be the safest option for the control of
recurrences but it may result in facial deformities which are obviously
of great concern.
Conflict of Interest: None
References
1. Austin LT, Dahlin CD, Royer RQ (1959) Giant cell reparative
granuloma and related conditions affecting the jawbones. Oral
Surg Oral Med Oral Pathol 12: 1285-1295.
2. Barnes L, Eveson JW, Reichart P, Sidransky D (2005) Pathology
and genetics of head and neck tumours. In: Kleihues P, Sobin
LH, World Health Organization classification of tumours. Lyon,
France: IARC Press.
3. Whitaker SB, WaldronCA (1993) Central giant cell lesions of the
jaws. A clinical, radiologic, and histopathologic study. Oral Surg
Oral Med Oral Pathol 75(2): 199-208.
4. de Lange J, van Rijn RR, van den Berg H, van den Akker HP (2008)
Regression of central giant cell granuloma by a combination of
imatinib and interferon: a case report. Br J Oral Maxillofac Surg
47(1): 59-61.
5. Stavropoulos F, Katz J (2003) Central giant cell granulomas: a
systematic review of the radiographic characteristics with the
addition of 20 new cases. Dentomaxillofac Radiol 31(6): 213-217.
6. Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A (1986)
Central giant cell lesions of the jaws: a clinicopathologic study. J
Oral Maxillofac Surg 44(9): 708-713.
7. Tosco P, Tanteri G, Iaquinta C, Fasolis M, Roccia F, et al. (2009)
Surgical treatment and reconstruction for central giant cell granuloma
of the jaws: A review of 18 cases. J Craniomaxillofac Surg 37(7):
380-387.
8. Unal M, Karaback T, Vayisoglu Y, Bagis HE, Pata YS, et al. (2006)
Central giant cell reparative granuloma of the mandible caused by a
molar tooth extraction: special reference to the maneuver of drilling
the surgical field. Int J Pediatr Otorhinolaryngol 70(4): 745-748.
9. de Lange J, van den Akker HP, van den Berg H (2007) 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
104(5): 603-615.
10. Vered M, Buchner A, Dayan D (2006) Giant cell granuloma of the
jaw bones the proliferative vascular lesion? Immunohistochemical
study with vascular endothelial growth factor and basic fibroblast
growth factor. J Oral Pathol Med 35(10): 613-619.
11. Kaban LB, Troulis MJ, Ebb D, August M, Hornicek FJ, et al. (2002)
Antiangiogenic therapy with interferon alpha for giant cell lesions of
the jaws. J Oral Maxillofac Surg 60(10): 1103-1111.
Author
No.
Aggressive/ non-
aggressive
treatment
Follow-up
Overall recurrence
rate
Chuong (1986) [6]
17
8/9
Curettage, radiation
therapy in 4 patients
24-380 months
41.0%
Eisenbud (1988) [20]
37
--
Curettage and
resection
2-16 years
11.0%
Whitaker (1993) [3]
47
26/21
Curettage
Mean 48 months
49.0%
Bataineh (2002) [21]
18
18/18
Resection
1-9 years
5.6%
Kruse-Losler (2006) [22]
26
10/16
Curettage and
resection
9 months to 12 years
11.5%
Tosco (2008) [7]
18
11/7
Resection (.5 mm)
Mean 68 months
0%
Auctores Publishing Volue2-010 www.auctoresonline.org
Page - 03
J Dent Oral Maxillofac Surg
12. Kaffe I, Ardekian L, Taicher S, Littner MM, Buchner A (1996)
Radiologic features of central giant cell granuloma of the jaws.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81(6): 720-
726.
13. Jacoway JR, Howell FV, Terry BC (1988) Central giant cell
granulomadan alternative to surgical therapy. Oral Surg Oral
Med Oral Pathol 66: 572.
14. Flanagan AM, Nui B, Tinkler SM, Horton MA, Williams DM
(1988) The multinucleate cells in giant cell granulomas of the jaw
are osteoclasts. Cancer 62(6): 1139-1145.
15. Nickolson GC, Horton MA, Sexton PM, Mosely JM, Kemp BE,
et al (1987) Calcitonin receptors of human osteoclastoma. Horm
Metab Res 19: 585-589.
16. Harris M (1993) Central giant cell granulomas of the jaws regress
with calcitonin therapy. Br J Oral Maxillofac Surg 31(2): 89-94.
17. Kaban LB, Mulliken JB, Ezekowitz RA, Ebb D, Smith PS, et al.
(1999) Antiangiogenic therapy of a recurrent giant cell tumor of
the mandible with interferon alfa-2a. Pediatrics 103(6): 1145-
1149.
18. Borges HO, Machado RA, Vidor MM, Beltrao RG, Heitz C, et al.
(2008) Calcitonin: a non-invasive giant cells therapy. Int J Pediatr
Otorhinolaryngol 72(7): 959-963.
19. Terry BC, Jacoway JR (1994) Management of central giant cell
lesions: an alternative to surgical therapy. Oral Maxillofac Surg Clin
N Am 6: 579-601.
20. Eisenbud L, Stern M, Rothberg M, Sachs SA (1988) Central giant
cell granuloma of the jaws: experiences in the management of
thirtyseven cases. J Oral Maxillofac Surg 46(5): 376-384.
21. BatainehAB, Al-Khateeb T, Rawashded MA (2002) The surgical
treatment of central giant cell granuloma of the mandible. J Oral
Maxillofac Surg 60(7): 756-761.
22. Kruse-Losler B, Diallo R, Gaertner C, Mischke KL, Joos U, et al.
(2006) Central giant cell granuloma of the jaws: a clinical, radiologic,
and histopathologic study of 26 cases. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 101(3): 346-354.
Auctores Publishing Volue2-010 www.auctoresonline.org
Page - 04
ResearchGate has not been able to resolve any citations for this publication.
Article
The giant cell granuloma of jaw is a well-vascularised lesion comprising a mononuclear cell infiltrate with a large number of giant cells. It has been suggested that the lesion is reparative in nature, rather than neoplastic, and that the giant cells are phagocytes accumulating in chronic reparative granulation tissue. However, the nature of the multinucleate giant cells never has been established. One possibility is that the constituent giant cells are osteoclasts. The authors assessed expression by the giant cells of several osteoclast-specific characteristics: excavation of bone; motility inhibition by calcitonin (CT); and binding of osteoclast specific monoclonal antibodies. Two tumors were disaggregated and incubated on slices of cortical bone in the presence and absence of CT. Both tumors were found to excavate bone, a function unique to osteoclasts. The giant cells also were responsive to CT, resulting in cytoplasmic quiescence and inhibition of bone resorption. Two osteoclast-specific monoclonal antibodies bound all the giant cells in one central and six peripheral tumors examined immunohistochemically. These results provide strong evidence for the osteoclastic nature of the giant cells. The presence of alkaline phosphatase-positive cells forming woven bone in giant cell granulomas suggests that osteoblasts are present in the lesion. As cells of osteoblastic lineage are known to regulate osteoclastic function, it may be that osteoblasts account for the characteristic infiltration of osteoclasts into giant cell granulomas of jaws, either as part of a reparative response by reactive osteoblasts or as an infiltrate induced by osteoblasts of aberrant function, as suggested for giant cell tumors of bone.
Article
Osteoclast-rich cultures were prepared by disaggregation of osteoclastomas (giant cell tumour of bone) and settlement onto glass or plastic surfaces. Autoradiography using [125I]-salmon calcitonin ([125I]-sCT) revealed specific binding only to multinucleate giant cells (osteoclasts) and a minor population of mononuclear cells. [125I]-sCT competitive binding studies indicated a Kd of 5 x 10(-10) M and receptor number of approximately 1 million sites/osteoclast. sCT treatment resulted in a dose-dependent rise in cAMP (EC50 10(-10) M). Homogenates of an osteoclastoma also demonstrated specific binding of [125I]-sCT. Chemical cross-linking of a labelled synthetic sCT derivative. [125I]-[Arg11,18,Lys14]-sCT, using disuccinimidyl suberate, resulted in labelling of a receptor component of approximate Mr 85-90,000. The multinucleate giant cells (osteoclasts) of human osteoclastomas possess large number of CT receptors which exhibit the same binding kinetics and apparent Mr as those of other CT target cells.
Article
This report reviews experiences in the management of 37 cases of central giant cell granuloma of the jaws. The statistical analysis includes location, age, sex, size on initial presentation, and other variables relating to incidence and distribution. The technique of curettage or curettage with peripheral ostectomy was used in all cases treated surgically, resulting in no evidence of disease in 21 out of 23 cases followed postoperatively for 2 or more years. Radiation therapy was curative in one instance. Preoperative endodontic therapy for teeth in the field of surgery has proved to be advantageous. The pathogenesis of the giant cell granuloma of the jaws is discussed.
Article
Aggressive central giant cell granulomas may be eliminated by administering human calcitonin 0.5 mg (100 iu) deep subcutaneously for 1 year. This avoids the need for mutilating surgery or radiotherapy in growing children. Aggressive recurrent peripheral lesions (the giant cell epulis) can also be treated by excision after calcitonin therapy. These giant cell granulomas should be redefined as osteoclast granulomas, and the aneurysmal bone cyst, the cystic osteoclast granuloma. However the stimulus for the disturbance in the osteo progenitor spindle cell needs to be defined.
Article
The radiologic features of central giant cell granuloma (CGCG) have not been clearly defined, and conflicting descriptions appear in the literature. This study analyzes the radiologic and clinical features of 80 cases of CGCG. In nearly 50% of the cases the lesion is located in the posterior area of the jaws, that is, the molar, ramus, and tuberosity, and not in the deciduous teeth-bearing area as was accepted in the past. Only 51% of CGCGs are multilocular, and the frequency of these lesions is significantly higher in the mandible than in the maxilla. The correlation between the lesion's size and its locularity is statistically significant, and larger lesions assume a multilocular appearance. Only 6% of the lesions crossed the midline of the jaws, a feature that was considered in the past as typical for CGCG.
Article
We report a 5-year-old girl with a large rapidly growing giant cell tumor of the mandible that recurred 2 months after the first surgical excision and 3 months after a second resection. An angiogenic protein, (bFGF), was abnormally elevated in her urine. The patient was treated with interferon alfa-2a for 1 year because this agent inhibits angiogenesis by suppressing bFGF overexpression in infantile hemangiomas and in other human tumors. During this time the bone tumor regressed and disappeared, the urinary bFGF fell to normal levels, and the mandible regenerated. She has remained tumor-free and has been off therapy for 3 years at this writing. This first successful use of interferon alfa-2a to treat a mandibular tumor in a child demonstrates: 1) low grade tumors that overexpress bFGF may respond to interferon alfa-2a, in a manner similar to life-threatening infantile hemangiomas; 2) antiangiogenic therapy, given without interruption for 1 year, was safe and effective in this patient; and 3) treatment may be continued for 1 year without the development of drug resistance.
Article
The objective of this study was to report and evaluate our experience in the surgical treatment of mandibular central giant cell granuloma by resection without continuity defect and peripheral ostectomy. A retrospective analysis was conducted of patients with central giant cell granuloma of the mandible who were treated between 1991 and 2000, in the Oral and Maxillofacial Surgery Unit at Jordan University of Science and Technology. A uniform surgical technique was used in all cases. The compact bone composed of the lower border of the mandible and/or posterior border of the ascending ramus, together with the nutrient periosteum attached to it, was preserved. All soft tissues in contact with or overlying the lesion and a margin of cancellous bone related to the lesion were excised. All patients were reviewed annually for a follow-up period of 1 to 9 years (mean, 3.9 years). Eighteen patients with central giant cell granuloma were included, (9 males and 9 females). Their age ranged from 10 to 46 years, with 89% younger than 40 years. Five (28%) lesions were in the incisor-canine region, 2 (11%) were confined to the premolar region, 4 (22%) were in the premolar-molar region, and 7 (39%) were in the molar-ramus region. All patients had aggressive central giant cell granulomas with pain, tooth mobility, and rapidly enlarging swelling. The initial diameter of lesions ranged from 2.7 to 10 cm. During the follow-up period, there was 1 case of recurrence, 2 (11%) patients had permanent lower lip paraesthesia, and no patient had obvious facial deformity. Our results suggest that resection without a continuity defect and peripheral ostectomy is a satisfactory method in the treatment of central giant cell granuloma of the mandible, with no or a very low recurrence rate and favorable postoperative function.
Article
The clinical behavior of central giant cell granuloma (CGCG) of the jaws is variable and difficult to predict. Clinical data and follow-up information of 26 patients with CGCG were analyzed. Histologic features were correlated with the clinical course of the disease. In 16 patients the CGCGs were asymptomatic; 10 lesions presented with aggressive growth, pain, massive swelling, root resorption, cortical perforation, and/or recurrence. These patients were younger and the lesions were larger than in the nonaggressive group. The histomorphometric analysis proved a significant increase in large giant cells, fractional surface area, and mitotic activity in aggressive CGCG lesions. Immunohistologic investigation (Ki-67 and p53 stain) revealed no significant differences. After surgical treatment, 3 patients with aggressive lesions developed a recurrence. The data show that clinical and histomorphometric features may be reliable indicators for the differentiation between aggressive and nonaggressive CGCG. This should be accounted for to improve the individual planning of the treatment and follow-up.