Central giant cell granuloma

Journal club
Presenter: Dr. Shilpa Kokate
Surgical treatment and reconstruction
for central giant cell granuloma of the
jaws: A review of 18 cases

• P.Tosco , G. Tanteri, C. Iaquinta, M. Fasolis, F.

Roccia, S. Berrone, P.Garzino-Demo

• Journal of Cranio-Maxillofacial Surgery (2009)

37, 380- 387
INTRODUCTION
• WHO - CGCG 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
• predominantly in children or young adults ( 75%)
• Females : males = 2:1
• Maxilla - anterior region
• Mandible - equally distributed anteriorly and
posteriorly
• Clinical behavior of CGCG - aggressive or non-
aggressive (Chuong et al., 1986)

6 criteria : pain,
rate of growth
swelling,
tooth root resorption
cortical perforation
recurrences
• Non-surgical treatments - alpha interferon [α-IFN],
calcitonin, corticosteroids
• Surgery - traditional treatment and it is still the most
accepted one
Aim of this study
• To evaluate recurrences in patients treated with
surgery alone
• To compare these preliminary results with those
found in the literature regarding medical therapy
MATERIALS AND METHODS
• Between 1998 and 2004 - 18 cases of CGCG were
surgically treated under general anaesthesia, at the
Department of Oral and Maxillofacial Surgery,
University of Turin Hospital, Italy

• Patients who had previously undergone medical

therapy & elevated serum calcium, phosphorus and
alkaline phosphatase (hyperparathyroidism ) were
excluded from the study
• Patients’ data were analysed in terms of age,
gender, anatomic location, clinical and
radiographic features, type of surgery,
reconstruction and follow-up period
 RESULTS
• Patients- 3 males and 15 females. ages - 7 to 80 years
• Location- 12 mandibular lesion, 6 in maxillary lesions
No patient had multiple lesions.

• Clinical features- expansion of the buccal plate in both the maxilla

and mandible
• partial obliteration of the buccal vestibule

• 4 pt. - pain, tooth mobility, and a rapidly enlarging facial swelling.

• 3 pt - Paraesthesia
• 3 pt - painful swelling
• 1 pt. - perforation of the cortical plate both vestibularly and buccally,
a painful swelling of the face, anaesthesia of the alveolar nerve, tooth
mobility, partial obliteration of the buccal vestibule and perforation of
the overlying mucosa
Radiographic features

• 5 pt.- CGCG in edentulous areas,

• 13 pt. - teeth involved with the lesions

• Chuong’s criteria- 11 aggressive & 7 non-

aggressive cases
 Type of treatment
• All patients were operated under general anaesthesia
• Mandible- 8 pt - through an intraoral approach and en bloc resection with at least a 5
mm margin
• mandibular continuity was conserved
• 1 pt.- submental approach and an en bloc resection of the CGCG - at the mental
symphysis.
• involved teeth were preserved
• 2 pts.- total resection of the bone

• inferior alveolar nerve was preserved.

• periosteum was minimally sacrificed.
• Immediate reconstruction was carried out for all the above cases with iliac crest bone
graft

• 1 pt - subtotal mandibulectomy
• reconstruction with a fibula free flap
• Maxilla – 5 cases – resection beyond 5 mm from
the lesion
• reconstruction of the bony gap an autogenous
iliac crest bone graft
• 1 case - reconstruction was performed with a
temporal myofascial flap (TMF).

• Average hospitalization time was 8 days

Follow-up
• followed annually with clinical and radiographic
examinations for periods ranging from 2 to 10
years (mean 65 months).
• No recurrences
• No pathological fractures occurred.
• After 4 months- prosthetic rehabilitation
 DISCUSSION
• Jaffe - ‘‘giant cell reparative granuloma’’
• Shafer et al., 1983; Neville et al., 1995 - destructive rather than
reparative

• Jaffe, 1953; Austin et al., 1959; Chuong et al., 1986 - an inflammatory

lesion, a reactive lesion, a true tumour, or an endocrine lesion

• Collins, 2000; Kaban et al., 2002 - mesenchymal proliferative vascular

primary jaw lesions

• Vered et al., 2006 - low mean microvascular volume (MVV) of

Vascular Endothelial Growth Factor (VEGF)- and Basic Fibroblast
Growth Factor (bFGF)-positive blood vessels implies little angiogenic
activity, which contradicts the description of CGCG as a true
proliferative vascular lesion
Different therapeutical options for
CGCG treatment.
• Jacoway et al. (1988) were the first to report on
treatment with corticosteroids
• MOA - Extracellular production of bone-
resorption-mediating lysosomal proteases by
giant cells is inhibited by steroids which also
induce apoptosis of the osteoclast-like cells.
• complete resolution in 3 out of 4 patients,
 First author No. Administration and dose Effect Follow-up

Triamcinolone 10 mg/ml and marcain

16— 36
Terry (1994) 4 0.5%, 1:1, 2 ml per 2 cm of the lesion, Complete remission in all patients
months
once a week for 6 weeks

Triamcinolone 10 mg/ml and lidocaine

Rajeevan (1998) 1 0.5%, 1:1, 2 ml per 2 cm of the lesion, Complete remission 10 months
once a week for 6 weeks

Triamcinolone 40 mg/ml and marcain

Khafif (2000) 1 Complete calcification of the lesion 24 months
0.5%, 1:1, once a week for 6 weeks

Triamcinolone 10 mg/ml and

Complete remission after two
Kurtz (2001) 1 marcain 0.5%, 1:1, 2 ml per 2 cm 18 months
treatment sessions
of the lesion, once a week for 6 weeks

Triamcinolone 10 mg/ml and

marcain 0.5% , 1:1, 6 ml variable Variable from considerable
Carlos (2002) 4 2—7 years
number of injections (3—20). Additional regression to complete remission
surgery in 2 patients
calcitonin therapy
• Immunohistochemical study demonstrated that
giant cells in CGCGs- osteoclasts through
osteoclast-specific monoclonal antibodies
staining
• giant cells in CGCG express calcitonin receptors
• directly inhibit giant cells
 Human
First author No. Administration and dose Duration Effect Follow-up
/salmon

Complete remission with

Injection, 100 IU/day/nasal
Harris (1993) 4 h/s 12—14 months additional surgery in 2 14—72 months
spray 200 IU/day
patients

Injection, 50—100 IU/day/nasal

de Lange (1999) 4 h 12—15 months Complete remission 7—36 months
spray 200 IU/day

O'Regan (2001) 1 h Injection, 100 IU/day 15 months Partial remission 30 months

Pogrel (2003) 9 s Injection, 100 IU/day 19 — 27 months Complete remission 26—50 months

Dominguez 3 s Nasal spray, 100 IU/day 12 — 19 months Complete remission 12 months

Cuadrado (2004)

Beck-Mannagetta 1 s Nasal spray, 100 IU/day 13 months Complete remission 62 months

(2004) with additional surgery

No response-partial
de Lange (2006) 14 s Nasal spray, 200 IU/day 12—15 months 6 months
remission

Partial response with

Vered (2007) 5 s Nasal spray 200—400 IU/day 13 — 14 months 10—24 months
additional surgery

Subcutaneous 100 IU/day and

Borges (2008) 4 s 6— 28 months Partial remission ?
nasal spray 200 IU/day
α-IFN
• angiogenic potential and as a mediator in
differentiation from mesenchymal cells to
osteoblasts thus leading to an increase in bone
apposition
First author No. Administration and dose Duration Effect Follow-up

Collins (2000) 1 Injection 1 x 106 IU/day 9 months Complete remission > 3 months

Injection 2.3 x 106—3.106 Complete remission with 12— 72

Kaban (2002) 8 6—8.4 months
IU/day curettage months

Busaidy (2002) 5 ? 2 months Partial remission —

Goldman Injection 1.51 x 106—9.106

1 8 months Partial remission with 4 months
(2005) IU/day

curettage
Injection 3 x 106—9.106 IU/day

de Lange
2 10—14 months Partial remission > 6 months
(2006)

Partial-complete
Kaban (2006) 16 Injection 3 x 106 IU/day >6 months > 3 months
remission with curettage

de Lange
1 Injection 180 |µg weekly 9 months Partial remission —
Surgery
• traditional treatment
• range from large (en bloc resection) to more
conservative approaches (curettage )
 Overall
Aggressive /non-
First author No. Treatment Follow-up recurrence
aggressive
rate

Chuong (1986) 17 8/9 Curettage, radiation 24—380 months 41.0%

therapy in 4 patients

Curettage and
Eisenbud (1988) 37 ? 2—16 years 11.0%
resection

Whitaker (1993) 47 26/21 Curettage Mean 48 months 49.0%

Bataineh (2002) 18 18/18 Resection 1 — 9 years 5.6%

de Lange (2005) 80 16/64 Curettage 0—10 years 26.3%

Kruse-Losler Curettage and

26 10/16 9 months to 12 years 11.5%
(2006) resection

Tosco (2008) 18 11/7 Resection (> 5 mm) Mean 68 months 0%

CONCLUSIONS
• En bloc resection - greatest certainty of a cure
• soft tissues and periosteum are preserved, and
only the bony component is excised, then it is
possible to reconstruct the surgical defect with
autogenous bone grafts.
• prosthetic rehabilitation via implants can be
safely performed.
Review of literature
Clinical and radiological features of
central giant-cell lesions of the jaw

• J. Lange, and H. P. Akker

Oral Surg Oral Med Oral Pathol Oral Radiol

Endod 2005;99:464-70
• Aim - to evaluate the clinical and radiological
features of central giant-cell lesions that were
diagnosed in The Netherlands between January
1, 1990, and January 1, 1995.
• Results - 83 patients (89 lesions).
• 16 – Aggressive , 3 - Multiple lesions
• recurrence rate - 26.3%
• Conclusion - Surgical curettage is not an
effective therapy for CGCGs in young people who
show aggressive signs and symptoms. Calcitonin
therapy could prove to be a good presurgical
treatment modality.
GIANT CELL GRANULOMA OF THE
MAXILLA - CASE REPORT

• U. H. Uzbek, I. Mushtaq

• J Ayub Med Coll Abbottabad 2007; 19(3):

93- 95
 Swelling of the left cheek The mass involving anterior
part of maxilla and alveolar ridge

Partial maxillectomy-gingival sulcus approach.

Entire tumoral mass was
removed along with portions of invaded bone and
corresponding teeth.

multinucleated giant cells and spindle cells

which have oval and fusiform nuclei.
The Surgical Treatment of Central
Giant Cell Granuloma of the Mandible

• A. B. Bataineh, T. Al-Khateeb, M. A.Rawashdeh

• J Oral Maxillofac Surg 60:756-761, 2002

• Methods – 18 pts. treated between 1991 and
2000, in the Oral and Maxillofacial Surgery Unit
at Jordan University of Science and Technology.
• 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.
• Results – 18 pts - 9 males and 9 females
• 5 - incisor-canine region, 2 - premolar region,
4 - premolar-molar region, 7 - molar-ramus region
All pts . Aggressive CGCG
lesion - 2.7 to 10 cm
Recurrence – 1 pts

• Conclusion: resection without a continuity defect

and peripheral osteoctomy is a satisfactory method
in the treatment of central giant cell granuloma of
the mandible
Recurrent central giant cell granuloma
in the mandible: Surgical treatment and
dental implant restoration
• P. I. Cossío , R. M. Fuentes , A. C. Carranza,
D. T. Lagares , J. L. Pérez

• Med Oral Patol Oral Cir Bucal 2007;12:E229-32.

uniloculated appearance and poorly defined borders of the lesion
adjacent to the image of extraction of the left second molar tooth.
curettage of the lesion followed by removal of the
peripheral bony margins through a retromolar approach

osteolysis of the mandible with loss of

bone in medial cortex.
• lesion was removed en bloc with a bony security
margin of 0.5 cm
• autogenous particulated bone harvested from the
mandibular ramus of the left side +bioactive glass + 50
cc of venous blood was processed using double
centrifugation technique

two years later showing a well-healed and

diseased-free mandible.
• Restoration - with a composite bone graft that
consisted of autogenous bone, xenograft, and
autologous platelet-rich plasma (PRP)
• restoration - implant-supported prosthesis.
Advanced giant cell reparative granuloma of
the mandible: radiological features
and surgical treatment
• E. DE CORSO, M. POLITI , M.R. MARCHESE,
T. PIRRONTI, R. RICCI, G. PALUDETTI

• ACTA OTORHINOLARYNGOL ITAL 26, 168-

172, 2006
Conclusion
• Considering the high rate of recurrences after
• curettage, En bloc resection provides the
greatest certainty of a cure although morbidity is
undoubtedly high
Thank you