Central Giant Cell granuloma from Diagnosis to Management

Facing the Giant
Central Giant Cell Granuloma
Dr Saikat Saha
MDS (OMFS)
Oral & Maxillofacial Surgeon
Center for Jaw Face Neck Oral Surgery Head and Neck Reconstructive and Onco Surgery

“If you do not tame the cub today, be prepared to face the Giant Lion Tomorrow”

Let Us Now See The Giants in Play

THE CASE
MALE – 32
Swelling on the left side of the lower jaw
since 8 months that gradually grew in size.
The left lip and the chin area subsequently
felt numb. There was no associated pain.
Family History: Not relevant
Past Medical History:
He was treated elsewhere one month back.

CLINICAL PRESENTATION
ON EXTRAORAL EXAMINATION:
A Brawny hard swelling of the left body of the
mandible was noted.
The swelling was non-fluctuant.
ON INTRAORAL EXAMINATION:
A Brawny hard swelling was felt over the left
buccal cortical plate with respect to teeth
region #32, #33, #34, #35, #36 and #37.
The left lower buccal vestibule was obliterated.

RADIOGRAPHIC INTERPRETATION
Well defined radiolucent osteolytic lesion present at the left body of the mandible
with some fine wispy trabeculae. There are multiple root resorption of the teeth
on the left lower jaw. The lesion appears cystic and expansile with medullary
hollowing out, thinning of the cortical plates and approaching the lower border of
the mandible.

No significant Blood Picture
Serum Calcium and Phosphate ------- NAD

PROVISIONAL DIAGNOSIS
• AMELOBLASTOMA (UNICYSTIC)

CT - FACE & NECK
IMPRESSION
Lobulated , expansile lesion involving the 
left half of symphysis menti and body of mandible
with almost deficiency of the wall of the lesion on 
left antero-lateral aspect involving the gingivo - buccal sulcus and left mandibular canal.

FNAC was done.
Few giant cells were found in a matrix of RBCs

DIFFERENTIAL DIAGNOSIS - Based on Clinical and Radiographic features
AMELOBLASTOMA
BROWN TUMOR OF HYPERPARATHYROIDISM
ANEURYSMAL BONE CYST
TRAUMATIC BONE CYST
CHERUBISM
ODONTOGENIC MYXOMA

• It is uncommon in a younger age range, which
is most susceptible to giant cell granuloma.
• Seen in posterior mandible in contrast to giant
cell granuloma which occurs anterior to the
first molar.
• Ameloblastoma demonstrates internal, hard
curved arch like septa whereas giant cell
granuloma has lighter wispy septa.
• Ameloblastoma is usually multiloculated
AMELOBLASTOMA

Ameloblastoma is a true neoplasm of enamel organ type.
Unicentric, nonfunctional, intermittent in growth,
It is the second most common odontogenic neoplasm.
Mandible > Maxilla (molar-ramus area region.)
AMELOBLASTOMA

Clinical
Slow growing
Painless expansion
Thinning of cortical plates.
In Advanced Stages --
• Root resorption,
• Tooth mobility
• Paresthesia
AMELOBLASTOMA

Histological subtypes:
1. Follicular,
2. Plexiform
3. Acanthomatous
4. Granular
5. Desmoplastic
6. Basilar.
AMELOBLASTOMA

Image Courtesy: Journal of Pathology and Translational Medicine
https://www.jpatholtm.org/journal/Figure.php?xn=kjpathol-47-191.xml&id=
Follicular type Plexiform type Acanthomatous type Desmoplastic type
AMELOBLASTOMA

Radiographically :
•Unicystic,
•Multicystic
•Solid
•Peripheral type
Multicystic or solid type is prevalent in 86% of cases.
Unicystic ameloblastoma is of three subtypes:
1. Luminal,
2. Intraluminal
3. Mural
AMELOBLASTOMA

AMELOBLASTOMA
Image Reference : https://radiopaedia.org/articles/ameloblastoma

AMELOBLASTOMA
Tatapudi R, Samad SA, Reddy RS, Boddu NK. Prevalence of ameloblastoma: A three-year retrospective study . J Indian Acad Oral Med
Radiol [serial online] 2014 [cited 2020 Jul 11];26:145-51. Available from: http://www.jiaomr.in/text.asp?2014/26/2/145/143687
Unicystic type Spider-web type
Soap-bubble type
Honeycomb type

ECF [Ca 2+]
ECF [Ca 2+] & [Phosphate]
PTH
Vitamin D

• Parathyroid hormone (PTH) is released in response to decreased
serum Ca
 PTH increase Ca by:
causing an efflux of Ca from the bony skeleton
increased reabsorption by the kidneys.
PTH also leads to increased release of vitamin D from the kidneys,
which in turn causes increased Ca absorption from GIT.
• Conversely, PTH leads to decreased P levels due to increased
excretion by the kidneys.

• Primary HPT  one or more parathyroid glands secrete an
excessive amount of PTH, eg. parathyroid adenoma;
• Secondary HPT  increased secretion of PTH is a response
to lowered ionized calcium, typically as a result of renal
disease.
• In Tertiary HPT  secretion of PTH occurs as a result of
long-standing chronic renal disease eventually leading to
overactive parathyroid glands that become independent of
the underlying disease.
Hence, tertiary HPT is not corrected when patients receive
a renal transplant that corrects the underlying renal
etiology

• Uncontrolled HPT  BTHPT.
• Presents late in untreated disease
• Extensive bone resorption, which is replaced
by fibrovascular tissue and giant cells with
abundant deposits hemorrhage and
hemosiderin.

• Histology –
Similar to central reparative giant cell
granulomas. histologically  abnormal
calcium homeostasis in HPT.

Image Courtesy: Shetty, Akshay D., J Namitha and Leena James. “Brown Tumor of Mandible in Association with Primary Hyperparathyroidism: A Case
Report.” Journal of International Oral Health : JIOH 7 (2015): 50 - 52.

•
Treatment:
Manage underlying HPT
• Surgical treatment may be required in 
[refractory cases] / [symptomatic lesions.]

• In this current case serum calcium levels were not
elevated. Is it a Brown tumor?
 Yes
 No

Calcium is maintained within a fairly narrow range from 8.5 to 10.5 mg/dl (4.3
to 5.3 mEq/L or 2.2 to 2.7 mmol/L).
The Normal Serum calcium levels ?
A) 8.5 to 10.5 mg/dl
B) 4.3 to 5.3 mg/dl
C) 2.2 to 2.7 mg/dl
D) 15 to 20 mg/dl

• ABC is a giant cell lesion within a fibroconnective
tissue stroma with blood caverns or sinusoids and no
epithelial lining.
• A reactive lesion of bone rather than a cyst or true
neoplasm,
• it occurs in posterior segment of mandible, posterior
to molar region.
• Aspiration produces blood
ANEURYSMAL BONEC CYST

• The radiographic features are not pathognomonic
and are sometimes confusing.
• Can mimic a Neoplasm
• An associated periosteal reaction with reactive new
bone forming a peripheral sclerotic border
(difficult to differentiate from a subperiosteal
hematoma)

Cause : Exaggerated, localized, proliferative response
of vascular tissue in bone.
Diagnosis: Blood aspirate obtained and the
histopathologic findings

Image Courtesy; Sharma GH, Dabir AV, Das DA, Talreja-Kanchan PP. Bilateral aneurysmal bone cyst of the mandible: A case report. J Indian Acad Oral Med
Radiol [serial online] 2015 [cited 2020 Jul 11];27:479-83. Available from: http://www.jiaomr.in/text.asp?2015/27/3/479/170471

TRAUMATIC BONE CYST
•Rare , asymptomatic
• Intraosseous lesion
•Pseudocyst of jaws and long bones .
•It is otherwise regarded as solitary bone cyst, hemorrhagic bone cyst, simple
bone cyst, extravasation cyst or progressive bone cyst.
• Young males in 2nd decade of life.
Long Bones (90-95% in long bones) 
Symphysis and body of mandible > (75%) > humerus (65%),> femur (25%)
rare involvement of maxilla and condyle (1%).
•Cortical plate expansion are rarely noticed

• No expansion of overlying bone cortex (rare).
• No bodily movement of teeth is present.
• Aspiration is negative mostly or sometimes a
little straw colored liquid.
TRAUMATIC BONE CYST

TRAUMATIC BONE CYST
Radiograph features
Well-defined, unilocular radiolucency
+/- sclerotic margins extending between the roots of the tooth
in the affected region, providing a characteristic scalloping
feature.

TRAUMATIC BONE CYST
Reference Image: Titsinides S, Kalyvas D. Traumatic bone cyst of the jaw: a case report and review of previous studies. J Dent Health Oral Disord Ther.
2016;5(5):318‒325. DOI: 10.15406/jdhodt.2016.05.00167

TRAUMATIC BONE CYST
Reference ImageKarthik KP, Balamurugan R, SahanaPushpa T (2019) Traumatic bone cyst of anterior mandible: A surgical approach. Dent Oral
Maxillofac Res 5: DOI: 10.15761/DOMR.1000306

TRAUMATIC BONE CYST
Reference Image: https://www.rdhmag.com/patient-care/radiology/article/16407975/traumatic-bone-cyst

Histological findings:
Fibrous connective tissue + chronic inflammatory cell
infiltrate
No epithelial lining.
Treatment:
Surgical excision followed by curettage of cystic cavity.
Surgical exploration  bleeding which forms  blood clot
within the cavity  resolution and regeneration of new bone.
TRAUMATIC BONE CYST

3rd most common odontogenic tumor after ameloblastoma and odontomas.
The tumor is almost always located intraosseously,
Peripheral types have been described.
Odontogenic Myxoma

Clinical features
Benign, slow growing but locally aggressive tumor.
2nd to 4th decades.
Common site: Molar and ramus regions of the mandible.
Maxillary lesions also tend to present in the posterior quadrant.
Odontogenic Myxoma

Radiographic features
•Well circumscribed / diffuse lesions
•+/- Root displacement / resorption
•
•Missing or impacted tooth is usually a finding.
Odontogenic Myxoma

• Small lesions may have a unilocular appearance.
• Most lesions are multilocular radiolucencies with
internal bony septa.
• These septa gives the following radiologic appearances
a) Tennis- racket
b) Honey comb
c) Soap bubble
d) Step Ladder
ODONTOGENIC MYXOMA
Radiographic features

Image Reference: Manne, Rakesh Kumar, Venkata suneel Kumar, P. Venkata Sarath, Lavanya Anumula, Sridhar Mundlapudi, and Rambabu Tanikonda.
“Odontogenic Myxoma of the Mandible.” Case Reports in Dentistry. Hindawi, July 9, 2012. https://www.hindawi.com/journals/crid/2012/214704/.
ODONTOGENIC MYXOMA

Image Reference : Manne, Rakesh Kumar, Venkata suneel Kumar, P. Venkata Sarath, Lavanya Anumula, Sridhar Mundlapudi, and Rambabu Tanikonda.
“Odontogenic Myxoma of the Mandible.” Case Reports in Dentistry. Hindawi, July 9, 2012. https://www.hindawi.com/journals/crid/2012/214704/.
ODONTOGENIC MYXOMA

Image Reference: Wright, John M, and Merva Soluk Tekkesin. “Odontogenic Tumors: Where Are We in 2017 ?” Journal of Istanbul University
Faculty of Dentistry. Istanbul University Faculty of Dentisty, December 2, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750825/.
ODONTOGENIC MYXOMA

Image Reference: Jawaid, Moazzam, Sunil R. Panat, Ashish Aggarwal, Nitin Upadhayay, Nupur Aggarwal, Astha Durgvanshi and G. N. Sowmya.
“Odontogenic Myxoma of the Mandible : A Rare Case Report.” (2016).
ODONTOGENIC MYXOMA

• Histopathology
• Fine delicate stellate, fusiform and round cells in
a bland myxoid stroma
• Appear like ~~ Dental papilla.
• If more collagen
Odontogenic Myxoma
 Odontogenic Myxofibroma

Treatment and prognosis
•Resection with free margins.
•Small lesions can be treated by conservative surgery.
•Recurrence = 25% (long-term follow-up is required)
Odontogenic Myxoma

Odontogenic Myxoma is a _________________ common odontogenic tumor
after ameloblastoma?
A) 2nd Most
B) 3rd Most
C) 4th Most
D) 5th Most

Peripheral varieties of Odontogenic Myxoma are also seen.
1) True
2) False

Odontogenic Myxoma is a very fast growing tumor?.
1) True
2) False
In Odontogenic Myxoma which radiological appearance is common?.
1) Step Ladder
2) Tennis Racket
3) Honey Comb

CHERUBISM
• Inherited
• Characterized by bone degradation and
replacement by fibrous tissue at maxilla and
mandible during childhood.
• This disease tends to show variable degree of
remission or spontaneous involution after puberty;
 facial deformity.

• It is bilateral in the posterior part of mandible
and there is history of familial involvement.
• It does not cross the midline.
• Frequent in first decade especially in 2-5
years. Females>males, 2:1.
CHERUBISM

CHERUBISM
Reference Image : Fernandes Gomes M, Ferraz de Brito Penna Forte L, Hiraoka CM, Augusto Claro F, Costa Armond M. Clinical and surgical
management of an aggressive cherubism treated with autogenous bone graft and calcitonin. ISRN Dentistry. 2011 ;2011:340960. DOI:
10.5402/2011/340960.

CHERUBISM
Treatment
• Calcitonin + Autogenous Bone Grafting
Calcitonin  inhibits bone resorption  Osteoclastic cells
( inhibited)
Osteo-inductive implant material
chemotactic, mitogenic and osteogenic
potential.
Autogenous
bone & marrow grafts

What are Giant Cell Granulomas?

Bone Marrow
Chemokines
IL, Interferon etc.
Differentiate
Irritation site in
the body.
Inflamation

Benign Intraosseous Jaw Lesion
CGCG
Non Odontogenic

Still Unknown
How?
Reactive Hamartomatous Neoplastic

Fibroblasts and Multinucleated Giant Cells in a densely packed stroma

Most in children and young adults.
Age= 1st 3 decades
2:1 Female:Male
CGCG = 10% of all the Benign lesions of the jaw
CGCG is less common than the giant cell granulomas of the extremities

Mostly confined to the tooth bearing areas of the jaw
Mandible> Maxilla
More common in the anterior mandible,
Often crossing the midline and causing painless swellings
Rarely posterior jaw (ramus and the condyle)

Asymptomatic, Painless Expansion
Thinning of the cortical plates with plate perforation
Early Signs = Swelling & Premature deciduous Loose tooth
Jaw/Facial Asymmetry

Two Biologic Forms
Reactive Neoplastic
Non - Aggresive Aggressive

Giant Cells are the most prominent feature
But
The mononuclear spindle cell is the proliferating cell (in cell cycle)
Spindle Cell Originate from the mesenchyme of the marrow.
Expression of the cell cycle protein Ki-67 in CGCGs.
indicated by

Spindle Cells
(Fibroblast or Fibroblast Like)
A Belief !!!!!!
Monocytes
Cytokines
Osteoclastic
Epigenitic
Event

Radiographic Features
Central giant cell lesions present as radiolucent defects. Which may be
unilocular or multilocolar.
The lesion may vary from a 5×5mm incidental radiographic findings to a
destructive lesion greater than 10cm in size.
The radiographic findings are not specifically diagnostic.
Small unilocular lesion may be confused with periapical granuloma or
cysts.
Multilocular giant cell lesions cannot be radiographically distinguished
from ameloblastomas or other multilocular lesion.

Grossing
 Brownish to reddish friable tissue of various size.
Specimen is usually coated with fresh or coagulated blood.

Central Giant Cell lesions of the jaws are usually treated by curettage
Studies indicate a recurrence rate of about 15-20%.
Long term prognosis is good & no metastasis reported
Surgical resection in more aggressive malignant cases.
Treatment

Differential Diagnosis
Ameloblastoma
Brown tumor
Aneurysmal bone cyst
 Cherubism
 Myxoma
 Intra bony hemangioma

TREATMENT
Surgical Resection of the left partial-mandible
followed by Reconstruction using Rib Graft under
Hypotensive General Anesthesia.
The sample was sent for histopathological
analysis.

After left Hemi-Mandibulectomy

Harvesting the 5th Rib graft from the Right side

Reconstruction of the Left Hemi-mandible with
Rib graft and titanium mandible recon plate

TRAUMATIC BONE CYST
NO ROOT RESORPTION
NO BODILY MOVEMENT OF TEETH

ODONTOGENIC MYXOMA
TENNIS RACKET APPEARANCE

CHERUBISM
Bilateral involvement,
but does not cross the midline

BROWN TUMOR OF THE MANDIBLE
PEPPER POT APPEARANCE
OF THE SKULL

Controversy in the Treatment of
Central Giant Cell Granuloma
Calcitonin
Calcitonin and Interferon ,
Calcitonin/Interferon/Imatinib/Corticosteroids,
Calcitonin/Interferon/Alendronate/Sorafenib
Calcitonin/Interferon/Coritcosteroids in order to correct facial
contours or to remove a remaining lesion after stabilization with
extensive pharmacological treatment.
None of these lesions recurred in the follow-up period
Ref : Schreuder, W. & Berg, Henk & Lange, J.. (2011). Controversy in the Treatment of Central Giant Cell Granuloma: In
Search of Evidence-Based Treatment. Journal of Oral and Maxillofacial Surgery - J ORAL MAXILLOFAC SURG. 69.
10.1016/j.joms.2011.06.231.

Central Giant Cell granuloma from Diagnosis to Management

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