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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 337-340
 

Central giant cell granuloma in a 4-year-old female child


1 Department of Pedodontics and Preventive Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
2 Department of Oral Pathology and Microbiology, Government Dental College and Research Institute, Bengaluru, Karnataka, India
3 Department of Prosthodontics, Government Dental College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication18-Sep-2015

Correspondence Address:
Dr. Srinath Krishnappa
Department of Pedodontics and Preventive Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.165711

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   Abstract 

Central giant cell granulomas (CGCG) are reddish lesions of gingiva that account for an important number of disorders frequently diagnosed in the regular dental practice. Although the majority of the lesions are nonaggressive, asymptomatic, and slow-growing, about 30% show an aggressive, progressively destructive behavior, and a tendency to recur. We present a case of aggressive CGCG of the maxilla in a 4-year-old female child managed by surgical excision. To minimize the possible cost of esthetic, functional, and psychological problems, mainly in young patients, CGCG should be diagnosed and managed at the earliest.


Keywords: Aggressive, giant cells, granuloma


How to cite this article:
Krishnappa S, Srinath S, Gopinath P, Krishnappa VS. Central giant cell granuloma in a 4-year-old female child. J Indian Soc Pedod Prev Dent 2015;33:337-40

How to cite this URL:
Krishnappa S, Srinath S, Gopinath P, Krishnappa VS. Central giant cell granuloma in a 4-year-old female child. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Jul 20];33:337-40. Available from: http://www.jisppd.com/text.asp?2015/33/4/337/165711



   Introduction Top


Reddish lesions of gingiva account for an important number of disorders frequently diagnosed in the regular dental practice, and one of the main entities representing this group is central giant cell granuloma (CGCG). Jaffe [1] (1953) was the first to distinguish CGCGs of the jawbones from other giant cell lesions of bones and originally called them "central giant cell reparative granulomas" since they were believed to be a reactive-reparative process that might heal spontaneously. [2] However, further case documentation has shown that most lesions are not reparative in nature but rather neoplastic, and that approximately 70% have the biological behavior of a nonaggressive, asymptomatic, slow-growing lesion, whereas the remaining 30% show an aggressive, progressively destructive behavior. The latter lesions are frequently associated with pain, paresthesia, expansion, rapid growth, tooth displacement, root resorption, and remarkable cortical bone destruction. [3]

Characteristic feature of CGCG is the presence of multinucleated giant cells. These are presented as clusters or in diffuse form and are commonly seen in the hemorrhagic areas.

Metaplastic bone formation may be seen and mitoses might be present abundantly. The other giant cell lesions of the jaw bones are "brown tumor" of hyperparathyroidism, aneurysmal bone cyst, and cherrubism. [2]

The conventional therapy for CGCG of the jawbones is local curettage, but a recurrence rate of up to 70% has been reported, mainly for lesions that display an aggressive biological behavior. [3],[4] Such patients need extensive surgical procedures that often result in serious mutilation of the jaws and face as well as loss of teeth and dental germs in young patients.

We present a case of aggressive CGCG that appeared as periapical radiolucency associated with left upper primary central incisor, which was diagnosed by histopathological evaluation, with a provisional diagnosis of an odontogenic cyst or a dentigerous cyst.


   Case Report Top


A 4-year-old female child reported to the department with a solitary, diffuse swelling of 4 months duration in the anterior maxilla. Oral cavity examination revealed a 2 cm × 2 cm asymptomatic swelling in the upper labial vestibular region with vestibular obliteration. The surface over the swelling appeared normal with no secondary changes. On palpation, the swelling was nontender, nonfluctuant, and firm in consistency. Bilateral cervical lymph nodes were nonpalpable. Spacing of 12-14 mm was present between the primary central incisors [Figure 1] and [Figure 2]. The patient gave a history of trauma to the upper front teeth region 4 months back, and pulpectomy was attempted for left upper primary central incisor (61).
Figure 1: Labial view of 2 cm × 2 cm asymptomatic swelling in the maxillary anterior region


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Figure 2: Occlusal view of 2 cm × 2 cm asymptomatic swelling in the maxillary anterior region


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The radiographic examination revealed a well-circumscribed, unilocular, non-corticated radiolucency, extending from the mesial aspect of 51 up to the distal aspect of 62l, and closely associated with unerupted tooth bud of permanent upper right and left central incisor. Area of radiopacity observed in proximity to the apex of 61 [Figure 3]. Root resorption was noted with respect to 61 [Figure 4].
Figure 3: Occlusal radiograph showing well-circumscribed, unilocular, noncorticated radiolucency, and extending from the mesial aspect of 51 up to the distal aspect of 62


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Figure 4: IOPAR showing root resorption of 61


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The hematological tests were within normal limits and no other systemic abnormality was observed. The lesion was excised [Figure 5] and [Figure 6] and sent for histopathological examination. Gross examination of the lesion revealed four bits of tissue, one of which was attached to the apical and lateral surfaces of the involved tooth (61), which was extracted. The three other tissue bits were of firm consistency, brownish in color. Size of the larger bit was about 0.8 cm × 0.5 cm × 0.5 cm and two smaller bits of size each 0.5 cm × 0.3 cm × 0.3 cm [Figure 7].
Figure 5: Intraoperative image before extraction of the involved tooth (61)


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Figure 6: Immediately after extraction of the involved tooth (61) and other bits of tissue


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Figure 7: Four bits of tissue, one of which was attached to the apical and lateral surfaces of the involved tooth (61)


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Decalcification was done for the extracted tooth specimen with 5% HNO 3 . Sections stained with hematoxylin and eosin revealed granulation tissue attached to the apical portion of the tooth. The connective tissue stroma consisted of numerous multinucleated giant cells that were irregular in size with varying number of nuclei (10-40) with the background of round to spindle shaped cells, proliferating endothelial cells, numerous blood capillaries, and few inflammatory cells. Reactive bone areas and scant collagen fibers were also shown in [Figure 8].
Figure 8: The connective tissue stroma consisted of numerous multinucleated giant cells


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   Discussion Top


Reddish nodular lesions affecting the gingival tissue of young patients are commonly found in dental practice. The development of nonneoplastic proliferative disorders, such as peripheral ossifying fibroma and pyogenic granuloma, which normally manifest as asymptomatic nodules in the inter papillary and gingival regions is mainly due to the lack of an adequate oral hygiene. Another important diagnostic possibility for a general practitioner facing a reddish gingival lesion is peripheral giant cell granuloma. Vascular disorders like hemangioma could also be considered in these circumstances.

CGCG is a benign bone lesion located in the maxilla and more commonly in the mandible of female patients. [5] Slight female predominance for CGCG may be explained by recent suggestions of the association between hormonal secretion and the appearance of CGCG in females.

The etiology and pathogenesis of CGCG of jawbones have not been established clearly. However, it has been suggested that it could result as a reactive granulomatous response to local changes in the blood flow to the bone or to previous trauma. [6]

The primary concern for the patients to seek health services is facial growth. In young children, the craniofacial skeleton is actively developing to include osteogenesis, exfoliation, and eruption of teeth. These processes cease in adulthood and may, therefore, predispose to CGCG formation in younger individuals. [7]

In the present case, numerous multinucleated giant cells which were irregular in size and with varying number of nuclei were found in the connective tissue stroma. Multinucleated giant cells present in the lesion have been considered as being phagocytes, foreign body cells, or osteoclasts, [8] and have been demonstrated to possess osteoclast specific characteristics, including lacunar resorption of bone, responsiveness to calcitonin, binding of osteoclast specific monoclonal antibodies, [9] and expression of tartrate-resistance acid phosphatase. [10]

The presence of numerous blood capillaries and proliferating endothelial cells in the connective tissue stroma of the present case was the characteristic feature of the lesion, and based on the light microscopic findings in CGCG that are comprised of many blood vessels, extravasated red blood cells and giant cells adjacent to blood vessel walls, it has been suggested that CGCG is part of the spectrum of mesenchymal, primary vascular jawbone tumors. [10]

Reactive bone areas were noted in the present lesion. Usually, such areas are present in the advancing front of the lesion, and the reactive bone trabeculae often "point" to the lesion with their long axis. [11]

The present case was diagnosed as CGCG of the maxilla based on the histological findings. As there was rapid growth, expansion, displacement of 51, and 61, root resorption of 61 and remarkable cortical bone destruction, the present case was considered as an aggressive type of CGCG and a decision was made to surgically excise the lesion.


   Conclusions Top


CGCGs are characterized by different cell populations that are in a state of continuous differentiation. Based on the signs and symptoms, and histological evaluation aggressive lesions should be differentiated and managed appropriately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-osseous) dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol 1953;6:159-75.  Back to cited text no. 1
[PUBMED]    
2.
Pogrel MA, Regezi JA, Harris ST, Goldring SR. Calcitonin treatment for central giant cell granulomas of the mandible: Report of two cases. J Oral Maxillofac Surg 1999;57:848-53.  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.
Kaban LB, Troulis MJ, Wilkinson MS, Ebb D, Dodson TB. Adjuvant antiangiogenic therapy for giant cell tumors of the jaws. J Oral Maxillofac Surg 2007;65:2018-24.  Back to cited text no. 4
    
5.
Sun ZJ, Cai Y, Zwahlen RA, Zheng YF, Wang SP, Zhao YF. Central giant cell granuloma of the jaws: Clinical and radiological evaluation of 22 cases. Skeletal Radiol 2009;38:903-9.  Back to cited text no. 5
    
6.
Ustündag E, Iseri M, Keskin G, Müezzinoglu B. Central giant cell granuloma. Int J Pediatr Otorhinolaryngol 2002;65:143-6.  Back to cited text no. 6
    
7.
Venkateshwarlu M, Geetha P, Radhika B. Central giant cell granuloma. Indian J Dent Adv 2010;2:134-7.  Back to cited text no. 7
    
8.
Liu B, Yu SF, Li TJ. Multinucleated giant cells in various forms of giant cell containing lesions of the jaws express features of osteoclasts. J Oral Pathol Med 2003;32:367-75.  Back to cited text no. 8
    
9.
Flanagan AM, Nui B, Tinkler SM, Horton MA, Williams DM, Chambers TJ. The multinucleate cells in giant cell granulomas of the jaw are osteoclasts. Cancer 1988;62:1139-45.  Back to cited text no. 9
    
10.
Kaban LB, Troulis MJ, Ebb D, August M, Hornicek FJ, Dodson TB. Antiangiogenic therapy with interferon alpha for giant cell lesions of the jaws. J Oral Maxillofac Surg 2002;60:1103-11.  Back to cited text no. 10
    
11.
Robinson RA. Head and Neck Pathology. Atlas for Histologic and Cytologic Diagnosis. Philadelphia PA: Lippincott Williams and Wilkins; Copyright @ 2009. p. 100-4.  Back to cited text no. 11
    


    Figures

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



 

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