Peripheral giant cell granuloma (giant cell epulis


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Peripheral giant cell granuloma (giant cell epulis

  2. 2. Classification of giant cells lesions of jaw <ul><li>I. Reactive disorders of bone </li></ul><ul><li>(a) Central giant cell granuloma </li></ul><ul><li>(b) Primary hyperparathyroidism </li></ul>
  3. 3. <ul><li>II. Tumors of the bone </li></ul><ul><li>Giant cell tumor (osteoclastoma) </li></ul><ul><li>Idiopathic histiocytosis </li></ul><ul><li>(Langerhans cell diseases) </li></ul><ul><li>-Letterer Siwe disease </li></ul><ul><li>-Hand-Schuller Christian syndrome </li></ul><ul><li>- Eosinophilic granuloma </li></ul>
  4. 4. <ul><li>III. Connective Tissues Hyperplasia </li></ul><ul><li>Peripheral giant cell granuloma (Giant cell epulis) </li></ul>
  5. 5. <ul><li>IV. Non-epithelialized primary bone cyst </li></ul><ul><li>Aneurysmal bone cyst </li></ul><ul><li>Solitary bone cyst (simple bone cyst, traumatic bone cyst) </li></ul>
  6. 6. <ul><li>V. Fibroosseous lesions </li></ul><ul><li>Fibrous dysplasia </li></ul><ul><li>Cherubism </li></ul>
  7. 7. <ul><li>Giant Cells Ultrastructurally -> Derived from mononuclear phagocyte system (macrophages) </li></ul><ul><li>Show features of osteoclasts </li></ul><ul><li>Immunohistochemically -> macrophages and giant cells have similar antigenic marker such as muramidase α-1 antichymotrysin.   </li></ul>
  8. 9. Giant cells
  9. 11. Peripheral Giant Cell Granuloma (Giant Cell Epulis ) Dept: of Oral medicine UDM ( Mdy:)
  10. 13. <ul><li>One of the reparative hyperplasias commonly seen in oral mucous membrane representing an exuberant reparative response. </li></ul><ul><li>It does not represent a true neoplasm but is a reactive lesion caused by local irritation or trauma. </li></ul><ul><li>Distinguishing feature of this lesion is appearance of multinucleated giant cells </li></ul>
  11. 14. <ul><li>CLINICAL AND RADIOGRAPHIC FEATURES </li></ul><ul><li>Occurs exclusively on the gingiva usually in the area between first permanent molars and incisors. </li></ul><ul><li>Red or Reddish-Blue nodular mass (sessile or pedunculated) </li></ul><ul><li>Clinical appearance is similar to the pyogenic granuloma of the gingiva (PGG -> more bluish-purple compared with bright red of a typical pyogenic granuloma). </li></ul>
  12. 15. <ul><li>Peak prevalence -> 5th and 6th decades of life. </li></ul><ul><li>♀ > ♂ (60%); Either anterior or posterior regions of gingiva or alveolar mucosa; </li></ul><ul><li>Mandible > maxilla </li></ul><ul><li>If arising from periodontal ligament or periosteum -> Bone resorption (+) </li></ul><ul><li>X-ray -> Cup-shape radiolucency (cupping resorption of underlying alveolar bone) </li></ul>
  13. 17. <ul><li>Lack of involvement of bone </li></ul>
  14. 19. <ul><li>cuff-shaped radiolucency at the entrance to the alveolus of clinically vital tooth 12. </li></ul>
  15. 20. <ul><li>Cup-shaped osseous defect at 12 teeth </li></ul>
  16. 21. <ul><li>HISTOLOGICAL FEATURES </li></ul><ul><li>Basically -> Hyperplastic granulation tissues (+) </li></ul><ul><li>Proliferation of multinucleated giant cells within a background of plump ovoid and spindle-shaped mesenchymal cells </li></ul><ul><li>Acute or chronic inflammatory cell (+) </li></ul>
  17. 22. <ul><li>Lack of mature collagen, abandance of cells </li></ul>
  18. 23. <ul><li>Peripheral giant cell granuloma arising interdentally </li></ul>
  19. 24. <ul><li>Multinucleated giant cells in peripheral giant cells granuloma </li></ul>
  20. 25. <ul><li>TREATMENT AND PROGNOSIS </li></ul><ul><li>Local surgical excision down to the underlying bone </li></ul><ul><li>The adjacent teeth should be carefully scaled to remove any source of irritation and minimize the risk of recurrence. </li></ul>
  21. 26. <ul><li>D/D OF PGG </li></ul><ul><li>Pyogenic granuloma (PGG -> more likely to cause bone resorption than pyogenic granuloma) </li></ul><ul><li>Central giant cell granuloma (Which is derived from medullary tissues of mandible and maxilla) </li></ul><ul><li>(Clinical features adequately separate these microscopically identical lesions; PGG and CGG) </li></ul>
  22. 27. <ul><li>CENTRAL GIANT CELL GRANULOMA </li></ul><ul><li>(GIANT CELL TUMOR) </li></ul><ul><li>Benign process exclusively occurs within jaw bones </li></ul>
  23. 29. <ul><li>AETIOLOGY AND PATHOGENESIS </li></ul><ul><li>Three possible causes: </li></ul><ul><li>Reparative response to intrabony haemorrhage and inflammation </li></ul><ul><li>A lesion considered to be a true neoplasm </li></ul><ul><li>Developmental anormaly closely related to A.B.C (Aneurysmal Bone Cyst) </li></ul>
  24. 30. <ul><li>CLINICAL AND RADIOGRAPHIC FEATURES </li></ul><ul><li>> 60% of cases -> occur before age 30 </li></ul><ul><li>Less frequent than PGG </li></ul><ul><li>♀ > ♂(2:1); mandible > maxilla (70%); more common in anterior portions of the jaws </li></ul>
  25. 31. <ul><li>Mandibular lesions frequently cross the midline </li></ul><ul><li>Most of the cases -> Asymptomatic </li></ul><ul><li>Minority of the cases -> Associated with pain, paraesthesia or perforation of cortical plate </li></ul>
  26. 32. <ul><li>Based on clinical and radiographic features, CGG can be divided into two categories: </li></ul><ul><li>(A) Non Aggressive lesions </li></ul><ul><li>No symptoms </li></ul><ul><li>Slow growth </li></ul><ul><li>No cortical perforation </li></ul><ul><li>(B) Aggressive lesions </li></ul><ul><li>Pain </li></ul><ul><li>Rapid growth </li></ul><ul><li>Cortical perforation and root resorption (+) </li></ul><ul><li>Marked tendency to recur after treatment. </li></ul>
  27. 34. <ul><li>X-ray = unilocular (or) multilocular radiolucency with well-demarcated presenting scalloping border </li></ul><ul><li>Radiographic finding - not diagnostic </li></ul><ul><li>(small unilocular -> Periapical granuloma </li></ul><ul><li>(or) cysts multilocular -> Amelobastomas) </li></ul>
  28. 37. <ul><li>Multilocular radiolucency with expansion of jaw bone in central giant cells granuloma </li></ul>
  29. 38. <ul><li>Expansion of occlusal projection and multilocular radiolucency across the midline in CGCG </li></ul>
  30. 39. <ul><li>RADIOLUCENCY In midline of mandible,CGCG </li></ul>
  31. 40. <ul><li>Unilocular radiolucency with well defined margin in premolar area ,CGCG </li></ul>
  32. 41. CGCG
  33. 43. <ul><li>HISTOLOGICAL FEATURES </li></ul><ul><li>Many multinucleated giant cells in background of ovoid to spindle-shaped mesenchymal cells </li></ul><ul><li>Giant cells Small and irregular in </li></ul><ul><li>shape </li></ul><ul><li>Large, round containing </li></ul><ul><li>20 (or) more nuclei </li></ul><ul><li>Connective tissue stroma Loosely </li></ul><ul><li>arranged </li></ul><ul><li> Cellular </li></ul>
  34. 45. TREATMENT AND PROGNOSIS <ul><li>Surgical management with aggressive curettage of tumor mass followed by removal of peripheral bone margin -> Good prognosis and low recurrence rate </li></ul><ul><li>15 - 20% recurrence rate (+) </li></ul>
  35. 46. <ul><li>Patients with aggressive tumors, three alternative to surgery </li></ul><ul><li>(1) Corticosteroids </li></ul><ul><li>(2) Calcitonin </li></ul><ul><li>(3) Interferon α 2A </li></ul>
  36. 47. <ul><li>(Weekly injection directly into the tumor with triamcinolone acetonide x 6 weeks -> success + +) </li></ul><ul><li>cases resistant to intralesional steroids->Salmon calcitonin (Systemic administration) </li></ul><ul><li>Intradermal Injection of calcitonin _12 months </li></ul><ul><li>These alternatives can be used for large lesions if treated surgically would result in significant deformity </li></ul>
  37. 48. <ul><li>D/D of CGG </li></ul><ul><li>Due to multilocular radiolucency, </li></ul><ul><li>Ameloblastoma </li></ul><ul><li>Odontogenic myxoma </li></ul><ul><li>Odontogenic keratocyst </li></ul><ul><li>ABC </li></ul>
  38. 49. <ul><li>Histological features of CGG is identical to brown tumor of hyperparathyroidism but no changes in blood chemistry in CGG </li></ul><ul><li>In case of hyperthyroidism </li></ul><ul><li> - ↑ Serum Ca + + </li></ul><ul><li> - ↑ Serum alkaline phosphatase </li></ul><ul><li> - ↓ Serum phosphorus value </li></ul>
  39. 50. Thank You