Management of central giant cell granulomas of the jaws: An unusual case report with critical appraisal of existing literature
An 8-year-old female child was brought by her parents with the complaints of a slowly enlarging, painless swelling on the right side of her face in the region of the lower jaw. It had been first noticed 8 months ago which had slowly increased in size and prominence lately over the past month.
On examination, a roughly spherical, smooth, bulbous, bony hard, and nontender swelling was noted in the right angle region of the mandible with expansion of both the inferior border as well as the medial aspect/surface. The skin overlying the swelling appeared normal, with no visible pulsations or secondary changes. On palpation, the swelling was bony hard in consistency, nontender, noncompressible, and nonpulsatile. No paresthesia was noted. The expansion of the inferior border in the angle region was significant, extending onto the medial aspect. Mouth opening was unrestricted, and temporomandibular joint and condylar movements were bilaterally synchronous, full, and free. There was no regional lymphadenopathy noted. Intraorally, there was appreciable expansion of the buccal cortical plate in the molar and retromolar regions as well as the lowermost aspect of the ascending ramus. “Egg shell crackling” could not be elicited. There was no disturbance of the dental arches or of the occlusion, and no displacement of teeth was noted in the region. The patient was in the mixed dentition stage . The oral mucosa showed no breach, secondary changes, or sinus opening and was of the normal coral pink color and appearance.
Orthopantomogram showed the jaws in the mixed dentition stage typical for the age of the patient. It revealed a large multilocular radiolucency, with scalloped margins and a soap bubble and honeycomb appearance in the region of the right angle of the mandible, extending anteriorly up to the root tips of the adjacent first molar, which showed evidence of resorption. Posteriorly, the multilocular lesion extended posterior to the developing second molar tooth bud and its follicle, past the angle region of the mandible. There was noted diverging and expanding margins of the lesion, with cortical thinning as well as sclerotic margins at places. There was seen a pronounced expansion along the inferior border of the mandible in the angle region, causing its eccentric ballooning with periosteal new bone formation . Thin radiopaque septae separated the locules. Fine bony trabeculations in the lesion give a typical “soap bubble appearance.”
Noncontrast computed tomographic (NCCT) scan was carried out, and 5-mm contiguous, axial sections were obtained for the maxillofacial region without administration of iodinated contrast [Figure 2]. It revealed a multiloculated expansile cystic lesion with bony septae within, measuring 2.6 cm × 2.5 cm × 3.7 cm (AP × Tr × CC) in the region of the right angle of the mandible. The overlying cortex was thinned out with breaches of its integrity at places. No calcific foci were noted within the matrix of the lesion. The findings led to the differential diagnosis of an aneurysmal bone cyst, odontogenic myxoma, CGCG, or an arteriovenous malformation.
After routine workup, the child was taken up for surgery under general anesthesia. Enucleation of the lesion followed by aggressive curettage and peripheral ostectomy, through a retromandibular cum submandibular approach was planned.
The incision line was marked 1 cm below the expanded inferior border of the angle region of the mandible and infiltrated with 1: 80,000 adrenaline and 2% lignocaine. The incision was made through the skin and subcutaneous tissue, which was then carefully undermined in all directions to permit ease of retraction and suturing later on. The platysma muscle was sharply incised from one end of the incision to the other. Careful dissection was then carried out through the white glistening investing layer of the deep cervical fascia. The marginal mandibular nerve was identified and retracted superiorly; the facial vessels were cut and ligated. The submandibular salivary gland which bulged into the operating site was carefully retracted inferiorly using a malleable retractor. The inferior border of the mandible was visualized, which was covered by periosteum anterior to the premasseteric notch and by the avascular portion of the pterygomasseteric sling posterior to the premasseteric notch in the angle region, both of which were incised sharply and stripped from the underlying bone, exposing the tumor mass. The mass was covered by a thin shell of bone which was perforated in several areas, exposing the tumor mass within. Once the almost eggshell thin areas of overlying bone were nibbled away with rongeur forceps, the tumor mass was exposed to view. It appeared chocolatey brown in color, interspersed with hemorrhagic areas welling up with blood. The mass had a soft spongy texture.
The soft, friable, and vascular tumor mass was enucleated, by scooping it out from the bony cavity underneath. The overlying expanded buccal and medial cortical plates were nibbled away carefully using rongeurs forceps, taking care to avoid any undue pressure of force to prevent an inadvertent fracture of the already weakened mandible. After complete enucleation of the tumorous tissue, vigorous curettage of the residual bony cavity was carried out, followed by peripheral ostectomy using vulcanite trimmers. The oozing from inferior alveolar canal in the far end of the angle was controlled using bone wax. This was thereafter followed by chemical cauterization of the entire tumor bed using cotton pellets soaked with Carnoy's solution, to ensure prevention of future recurrence. The adjacent tissues were first protected from the caustic chemical, using layers of folded Vaseline gauze. After thorough irrigation of the area, hemostasis was ensured and all sharp margins of bone were carefully smoothened using bone files. 15 ml of blood was drawn from the patient, and autologous platelet-rich fibrin (PRF) was prepared using a tabletop centrifuge. This was placed within the bony defect, which would help in two ways, first by eliminating the dead space and second by providing a host of growth factors such as platelet-derived growth factor (PDGF), insulin-like growth factor, vascular endothelial growth factor (VEGF), and transforming growth factor-β (TGF-β) to hasten soft tissue healing as well as subsequent bone fill in the defect region. This was followed by layerwise closure using resorbable Vicryl sutures for the deeper layers and interrupted Prolene sutures for the skin. An extraoral pressure dressing was applied to prevent formation of a hematoma. Histopathological examination of the excised specimen confirmed the prior diagnosis of GCT.
The postoperative recovery of the patient was smooth and uneventful. The mild postoperative pain and edema were controlled with analgesic anti-inflammatory drugs, and the patient was placed on intravenous broad-spectrum antibiotics for 5 days. There were no neurological deficits related to the marginal mandibular nerve. There was noted a mild numbness of the right half of the chin and lip, resulting presumably from the removal of the segment of the inferior alveolar nerve involved within the tumor, thus rendering the mental branch nonconductive. Careful placement of the incision line at the time of surgery in the submandibular neck crease had resulted in a fairly inconspicuous and hidden resultant scar . Postoperative NCCT of the region revealed smooth residual margins, walls, and floor of the residual bony defect. Histopathological examination of samples of tissue from the excised specimen confirmed the diagnosis of CGCG .
The patient was followed up for 1 year, and there was no clinical or radiographic evidence of recurrence of the lesion.
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Fig.2 : Submandibular approach exposing the expanded and bulbous right angle of mandible. Thin shell of overlying cortical bone, nibbled using rongeurs.
Fig.3 : Magnetic resonance angiography of the cervical vessels revealed no evidence of abnormal flow voids or abnormal draining channels
Fig.4 : Magnetic resonance imaging of the lesion (sagittal and axial sections) revealing multiple enlarged submandibular and cervical lymph nodes
Fig.5 : Magnetic resonance imaging of the lesion (coronal sections) revealing mild compression of the right submandibular gland
Fig.9 : Postoperative photographs showing good healing of the operated site with esthetic positioning of the incision line