8/4/2019 leses centrais de clulas gigantes 3

1/4

Central giant cell granulomaReport of a case

The central giant cell granuloma IS a tumor that has great potential for the displacem ent of teethand the development of a facial deformity. Although its cause and behavior are still matters fordiscu ssion , its early diagn osis and treatment are a priority. We describe a patient with a largebenign central giant cell granuloma of the anterior mand ible. The clinica l, radiographic, andhistolog ic appearance, as well as the appropriate treatment. are discu ssed in light of the currentliterature.(OH.U SI KC. OK.\I Mm OH\I t\irio~. lW3;75:2X6-Y1

T e central giant cell granuloma (CGCG) i> ;Icommon reactive nonneoplastic lesion of the jaw. I~.lalfe first used the term giant cell reparative gran-uloma in 1953 to distinguish this lesion of the j;lMfrom the giant cell tumor. a histologically similar Ic-sion of the long bones.J Although once believed to beseparate entities. it is now thought that these repre-sent the same disease process. and only manifestthemselves differently b> the site of occurrcncc andthe age of the patient. The CGCG is typically foundin persons under the age of 30 (75%) and has ;I prc-dilection for women (64:; ).. The preferred site forthe occurrence of CGCG is in the facial bones. hutreports, of other sites including the temporal. eth-moid, and sphenoid bones do c.xi\t.CASEREPORT

.1\ 1-kbear-old Ilkp;lnic male came to the CJniverGty 01Texas Health Science center for routine dental procedure\.The patients mother \vas particularI> interested in an orth-odontic consultation for his mandibular anterior teeth thathad shifted. tvaluatiun revealed ;I retained left primar!cusp id. and the nxlndibular anterior incisor teeth ucre se-vcrcly inclined to the patients left. 4 large. la bial vcstibu-lar swelling was noted from the rnesial aspec t of the left

permanent Iirht hlcus pid to the distal aspec t 01 the rightpermanent lateral in&or. The swelling \\us hard to palpa-tion. cons istent with bone. and U;IS covered with normalI~UCOS;I. tressure did not elicit any exudate or any tender--ness . and there D;I~ no presence of paresthesia. There \\;I\minimal swell ing of the l ingual aspect of the mandible. and~11 other tissue s of the oral cavity \lere \+ithin normal lim-it\

Kadlographh or the patient Included LI panoramic viev.ouclusal wa4. croswxtional tomogram5. and axial con-lputed torrqraph~ (Fig. I ). Thes e revealed ;I large. ~~\cll-L:ircurnscrihed. unilocular radiolucenq that mcasu rcd 5WI X 4 cnt in !/it midline olthe mand ible (Fig. 3). The le.-Gon exknded lrom the mes i~l root surface (II the left per-manen lirst hiLucpid to the mes ial root suriacc of the rightpermanent cu\pid. Th e \ertic:tl extension \\;I\ from thenccka 01 the mandibular anterior teeth to the inferior cor-IC\ 01 ihc rnxntiihic. with no rexu-ption 01 the roots 01 !hclccth noted. Modcr:ite hucc al expansion *;I\ presenl. ~$1111\r\eri: th~nn~ns 01 the cortical plate. W ithin the radiolwcent> appeared ;I radiopaque structure consiste nt with the~mpacttzd cro\\ n and p;rrti:ll root oithe m;tndihul:lr left per--m~nen~ ~uspld ho other calcifica tions \+ithin the lumen 01the IWOII \\crc inotcxi.

On the baGa of the clinic al and radiographIc irndings, i hctliiterential diagn& s included dentigerouj c!xt. odonto=c-iiic keratocybt. (GC(; . aneury-smal hone c) \t. amcloh las-toma. and ame loblastic libroma

8/4/2019 leses centrais de clulas gigantes 3

2/4

ORAL SURGERY ORAI MEDICINE ORAL P~rw~.oc;vVolume 7.5. Number 3 Potter and Tiner 287

Fig. 1. Panoramic radiograph reveals large, circular, well-defined radiolucent lesion of anterior mandibleImpacted mandibular lef t cuspid is observed projecting into lesion.

Fig. 2. Preoperative axial computerized tomograph shows well-circumscribed, unilocular, lo\n, densitysymphysis lesion.

mixed with a. yellowish substance. Using a handpiece, alarge window was made and the spongy, vascular lesion wasremoved by thorough curettage and sent for histologic ex-amination. The impacted mandibular lef t cuspid was theneasily removed. After irrigation with saline solution andpacking the bony defect with a thrombin-soaked absorbablegelatin sponge (Gelfoam), the flap was repositioned and SLI-tured.

The gross specimen consisted of a grayish-pink mass oftissue that measured 3.3 cm X 3.3 cm X 1.6 cm. The lesionwas well circumscribed, with a rubbery consis tency. Mul-tiple sections showed numerous benign giant cells within acellular hbrovascular stroma, consistent with the histologicpicture o f CGCG (Fig. 3).

The patient was followed closely fo r a period of 2 years

and the postoperative course was uneventful with noevidence of recurrence (Fig. 4).DISCUSSION

The CGCG typicall y appears as a multilocular, ra-diolucent lesion that occurs in the tooth-bearing areasof the jaws previously occupied by the deciduousteeth. Although the lesion is usually located in closeproximity to the teeth, some cases of CGCG havebeen reported in the edentulous patient. , These le-sions commonly occur in the mandible (675,) as op-posed to the maxilla (3 1 %I), with a predilection for theanterior segment. In the mandibular anterior regions,these lesions will cross the midline. The CGCG occurs

8/4/2019 leses centrais de clulas gigantes 3

3/4

most frequently in the young, with Ihc greukxtoccurrence between the ages of IO and I9 years. LX-sions that occur in persons over the age of 49 arc e\.-tremety uncommon.

The clinica l and radiographic presentation of IhcCGCG often includes an asymptomatic swelling thatreaches a sufficient size that the patient begins to no-tice the deformity. Although on occasion the init ialfinding will be made after routine radiographic cx-amination. it is more common for the CGCG to

achieve significant hi/e before it is diapnoscd. Ex-pansion of the cortex is seen with the larger lesions.but perforation should be considered rare. Withincreasing sire of the lesion, facial deformity and dis-placement of the teeth wilt be seen. and casts of toothresorption have been reported.x. I The CGCG wiltappear as ;I radiotucency with some degree of corti-cation of the margins being present. The smaller te-sions will appear radiographically as unitocular, andwith increasing si/e, the appearance of wispy bon!

8/4/2019 leses centrais de clulas gigantes 3

4/4

@\I. SLR(oFK\ OK,\1 MI I~ICIUI . OR, , l . P4Tt iOl .OG\Volume 75, Number :

septae becomes a prominent feature. Because of therecurrent nature of the CGCG, radiographic fol-low-up should be continued unt il evidence of bony re-generation is apparent.

Histologically, the CGCG appears with a uniformstroma that consists of spindle-shaped fibroblasts.Within this stroma, mult inucleated giant cells wi!lusually be found accumulating around numerousvascular channels and in areas of hemorrhage. Thepresence of the giant cells is variable and can at timesbe found to be evenly distributed throughout the con-nective tissue stroma. Less aggressive CGCG tend tohave smaller giant cells with fewer numbers ofnuclei.. -3 Attempts to predict the degree of ag-gressiveness of CGCG suggest that there is no signif-icant correlat ion between the giant cells and the ag-gressive behavior. I2 nor is there any way of predict ingtheir nature.j The histologic presentation of CGCGis identical to the Brown tumor of hyperparathyroid-ism. A complete medical work-up and radiographicexamination for mul tiple lesions is always indicated.

Treatment of the CGCG consists of thoroughcurettage of the affected area. Although 10% to 15%of these lesions do recur, the locally aggressive giantcel l lesions have a higher rate of recurrence. Inhighly aggressive lesions of significant sire, en blocresection should be considered. In rare cases whencomplete removal is not possible because of the loca-tion of the lesion, radiation therapy may be used inconjunction with the surgical procedure. However,caution must be exercised because of the potential forsarcomatous transformation.7. jREFERENCES

I. Auclair I. Cuenin P, Kratochvil F. Slater L, Ellis G. A clin-ical and histomorphologic comparison of the central giant ccl1granuloma and lhr giant cell tumo r. OR41 SI KG ORAl MFIIOKZI l\rl1ol 198X:66:197-208.

2.3.

4.

5

6.

7.

8.

9.

IO

II

I2

I3I4

IS

Potter and Tiller 289Bondi R, Urso C, Santucci B, Santucci M. Giant cell lesion ofthe jaw : case report. Tum ori 1988;74:479-X4.Cassalty M, Greenberg A. Kopp W. Bilateral giant cell gran-ulomata of the mandible: report of case. J Am Dent Assoc1988;l 17:731-3.

Jaffe H. Giant cell reparative granuloma. traumatic bone cys t.and fibrous (fibro-osseous) dysplasia ofjaw bones. OK \I SI,K(;OR~I Mw OKAL PATHOL 1953;6:159-75.Stimson P. McDaniel R. Trau matic bone cyst. aneurysmalbone cys t, and central giant cell granuloma-pathogeneticallqrelated 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 mimic king anintracranial tumo r: case report and review of the literature.Surg Neurol 1990;33:52-6.Tesluk H, Senders C. Dubln A. Case report 562: giant cell re-parative granuloma of the temporal boric. Skeletal Radio11989;18:599-602.Cohen M, Hertzanu Y . Radiologic features. including thoseseen with computed tomograp hy. of the giant cell granulomaof the jaws. OR,\I SL KC; ORAL MFD OWI P\III~I 1988 :65:2X5-61.Marshall M, DeBoom G. Enlarging soft tissue ma \\ involvingthe mandibular left alveolar ridge. J Am Dent Acsoc 1988;I 16:707-9.Cohen M. Grossman .E, Thomp son S. Features of the centralgiant cell granuloma of the jaws xenografted in nude mice.OKAI S~JKG ORAL Mm OKAL P~ TH OI 1988;66:209-17.High A. Mathews A. The importance of radiography inass&sing the behaviour of an aggressive giant cell lesion of theia&s. Dentom axillofiac Radio1 1989;18:36-X.&kurdt A. Pogrel M, Kaban L, Chew K. Mayall B. Centralgiant cell granulomas of the jaw s: nuclear DNA anctlqsis usingimage cytome try. Int J Oral Maxillofac Surg 1989;18:3-6.llorner K. Central giant cell granuloma of the jaw \: a clmico-radiological study. Cln Radio1 1989:40:622 -h.Chuong R, Kaban L , Kozakewich H, Perez-Ataydc A. Centralgiant cell lesions of the jaw s: a clinicopathologic study. J OralMaxillofac Surg 19X6:44:708-13.Smith P. Marrogi A, Delfino J. Multifocal central giant celllesions of the maxillofacial skeleton: a case rcpor?. .I OralMaxillofac Surg 1990:4X:300-5.

B.D. Tiner. DDS. MDUniversity of Texas Health Science CenterDepartment of Oral and Maxillofacial Surgeq7703 Floyd Curl DriveSan Antonio. TX 78284-790X