Central Giant Cell Granuloma (CGCG) was described by Jaffe in 1953 for the
first time as an idiopathic, non neoplastic proliferative lesion (Sholapurkar
et al., 2008; De Lange and van der Akker, 2005;
Sun et al., 2009). World Health Organization
(WHO) defined CGCG as an intra osseous lesion consisting of cellular fibrous
tissue containing multiple foci of hemorrhage, aggregations of multinucleated
giant cells and occasionally trabeculae of woven bone (Kruse-Losler
et al., 2006; Farrier et al., 2006).
Clinical behavior of CGCG varies from a slowly asymptomatic swelling to an aggressive
lesion with pain, cortical perforation and root resorption (Sun
et al., 2009; Farrier et al., 2006;
Cossio et al., 2007).
The CGCG of the jaws account for approximately 7% of all benign tumors of the
jaws (Sun et al., 2009; Kruse-Losler
et al., 2006). These lesions mainly occur in young adults with a predilection
for females (De Lange and van der Akker, 2005; Kruse-Losler
et al., 2006; Regezi, 2002; Stavropoulos
and Katz, 2003). The lesions must be differentiated from a variety of the
jaw lesions such as cysts, odontogenic tumors, fibro-osseus lesions, vascular
malformations and even malignancies (De Lange and van der
Akker, 2005; Kruse-Losler et al., 2006).
In radiography a unilocular or multilocular radiolucency is observed (Kruse-Losler
et al., 2006; Farrier et al., 2006).
As this is a slow growing lesion, borders are usually well defined. Teeth displacement,
root and lamina dura resorption of the teeth may also be observed (Farrier
et al., 2006; White and Pharoah, 2004). Small
CGCG lesions may have no radiographic pattern.
The traditional treatment of CGCG is local curettage, however, aggressive subtypes
of CGCG show a tendency to recurrence and required bone resection (Kruse-Losler
et al., 2006; Lange et al., 2007).
Recently, non surgical methods such as using systemic Calcitonin, Alpha interferon
and intra-lesionary injection of corticosteroids have emerged (Sun
et al., 2009; Farrier et al., 2006).
The purpose of this study was to analyze the clinical and radiographic features
of 18 cases of central giant cell granuloma for the first time in our province.
Increasing awareness of dental practitioners about clinical and radiographic
features of this lesion has an important role in the early diagnosis of CGCG.
MATERIALS AND METHODS
In this retrospective study, all the existing records in the archive of Oral Medicine Department of Mashhad Dental Faculty from 2005 to 2008 were reviewed and the records of CGCG cases were extracted. All cases with clinical diagnosis of CGCG were confirmed by diagnostic biopsy and histopathological examination performed by the same pathologist in Oral and Maxillofacial Pathology Department prior to definitive surgical treatment. Clinical and radiographic findings were analyzed focusing on age, gender, location of the lesions, signs and symptoms at presentation and radiographic findings. Data were analyzed using SPSS version 15 (SPSS Inc., Chicago, IL). Radiographs of these cases were examined in the Oral and Maxillofacial Radiology Department by the same radiologist again by using orthopantographs as a minimum standard. Cases of hyperparathyroidism were excluded by laboratory tests.
As it was a retrospective study focusing on archived medical records, it doesn't seem necessary to obtain permission from ethical committees to publish patient's information without their prior consents.
RESULTS AND DISCUSSION
During the period of this study, 18 patients with CGCG were diagnosed in our Department. The mean age at the time of diagnosis was 23.5 years and male to female ratio was 7 to 11.
Demographical information and location of the lesions are shown in Table 1. In 44.6% of our cases duration of the lesion was less than 2 months.
Clinical findings: The most common feature was an asymptomatic swelling
of the face or oral cavity; while pain was reported only by 3 patients. Tooth
displacement and tooth mobility was recorded in 38.9 and 44% of patients, respectively.
Hard tissue expansion was seen in 77.8% of patients (Fig. 1).
Purple discoloration of mucosal surface was reported in 27.8% of cases and in
16.7% the surface was ulcerated.
Consistency of 16 lesions was hard and in 2 cases was rubbery. Clinical symptoms of patients are shown in Table 2.
Adversity of radiographic features was observed. The most common radiographic feature was multi-locular radiolucency with septations (14 cases). Root resorption was seen in 2 cases in mandible (Fig. 2). No changes in lamina dura were noticed but cortical bone destruction was observed in 2 cases.
The CGCG primarily occurs in the jaws and facial bones, though it also may
appear in other areas of the body. It is an asymptomatic lesion and is usually
diagnosed during routine radiographic examinations or when a painless expansion
of the affected bone is realized by the patients or his/her parents.
features and location of the lesions
characteristics of lesions
Exists, -: Doesnt exist
between bone expansion and radiographic feature
between root resorption and location of the lesions
The developing lesions are usually painless and do not cause paresthesia; however,
pain has been reported in some cases (Sun et al.,
2009). The CGCG may occur at any age, but there is a predilection for younger
age groups (less than, 30 years old) (De Lange and van der
Akker, 2005; Kruse-Losler et al., 2006; Regezi,
2002). In this study, 72.2% of the lesions were found in patients younger
than 30 years, which is in accordance with published reports (Sun
et al., 2009; Kruse-Losler et al., 2006).
The CGCG occurs two times more often in mandible compared with maxilla and
women are more affected than men (De Lange and van der Akker,
2005; Kruse-Losler et al., 2006; Stavropoulos
and Katz, 2003; Gungormus and Akgul, 2003; Cohen
and Hertzanu, 1988). All of maxillary cases were located in anterior parts,
but in other studies molar and premolar areas were more affected (Sun
et al., 2009; De Lange and van der Akker, 2005).
In female patients and in patients younger than 20 years of age CGCG was more frequent in anterior parts of mandible (Table 1).
Clinical behavior of CGCG varies considerably. Asymptomatic swelling was the
most common clinical presentation in other studies (De Lange
and van der Akker, 2005; Kruse-Losler et al.,
2006) while pain and paresthesia were the most common symptoms in some other
studies (Kruse-Losler et al., 2006; Farrier
et al., 2006; Gungormus and Akgul, 2003).
In this study, asymptomatic swelling was the chief complaint of 77.7% cases and pain was present only in 16.6% of patients. None of our patients was asymptomatic (Table 2).
Perforation of cortical bone is typical sign for aggressive growth (Kruse-Losler
et al., 2006; Chuong et al., 1986)
and this finding was observed in 2 cases in our study. In one of these cases,
tooth mobility and tooth displacement was, also, present.
Tooth mobility was observed in 8 cases and 7 cases had tooth displacement (Table
2). Pain was reported in 3 patients, one of them was accompanied by swelling.
Two lesions were rubbery in consistency because of tooth mobility and displacement
caused by bone destruction (Table 2). Superficial ulceration
of the lesions with hard consistency seems to be the result of secondary trauma.
These findings were compatible with other studies (De Lange
and van der Akker, 2005; Kruse-Losler et al.,
2006; Whitaker and Waldron, 1993).
Radiographically, most of our cases were multilocular (77.7%) while, in other
studies unilocular lesions have been observed more frequently (Kruse-Losler
et al., 2006). This finding was different from many studies (De
Lange and van der Akker, 2005; Kruse-Losler et al.,
Root resorption as a sign of aggressive lesions was present in 11% of our cases
that these results were similar to other studies (De Lange
and van der Akker, 2005; Sun et al., 2009;
Lange et al., 2007).
Surgery is still the most frequently applied treatment in CGCG (Sun
et al., 2009). The extent of surgery depends on the size and localization
of the lesion and range from simple curettage to extensive resection. Treatment
strategy for our cases was surgery.
Present study showed that demographic and clinical characteristics of CGCG of the jaws in our province is similar to most earlier studies. But radiographic feature is different in some aspects. The CGCG should be considered in differential diagnosis of both unilocular and multilocular radiolucencies in the jaws.