Published online: 2019-09-30 The Peripheral Giant Cell Granuloma in Edentulous Patients: Report of Three Unique Cases Osman A. Etoza Ahmet Emin Demirbasa Mehmet Bulbulb Ebru Akayc ABSTRACT The peripheral giant cell granuloma (PGCG) is a rare reactive exophytic lesion taking place on the gingiva and alveolar ridge usually as a result of local irritating factors such as trauma, tooth extrac- tion, badly finished fillings, unstable dental prosthesis, plaque, calculus, chronic infections, and im- pacted food. This article presents 3 cases of PGCG that presented at the same location of the edentu- lous mandible of patients that using complete denture for over ten years. (Eur J Dent 2010;4:329-333) Key words: Peripheral giant cell granuloma; Chronic irritation; Edentulous patients; Complete denture. INTRODUCTION Giant cell granuloma lesions (peripheral and teoclastoma, or giant-cell hyperplasia. Etiologic central) are benign, non-odontogenic, moderately factors are not known, although it is thought that rare tumors of the oral cavity. They develop pe- it may be due to an irritant or aggressive factor ripherally (within gingiva) or centrally (in bone).1 such as trauma, tooth extraction, badly finished The peripheral giant cell granuloma (PGCG) is a fillings, unstable dental prosthesis, plaque, calcu- rare reactive exophytic lesion taking place on the lus, chronic infections, or impacted food.2,3 Clini- gingiva and alveolar ridge, also known as a giant- cal appearance of PGCGs can present as polyploi- cell epulis, giant-cell reparative granuloma, os- dy or nodular lesions, primarily bluish red with a smooth shiny or mamillated surface, stalky or 2,4,5 a Erciyes University, Faculty of Dentistry, Department of sessile base, small and well demarcated. Pain Oral and Maxillofacial Surgery, Kayseri, Turkey. is rare and in most cases growth of the lesion is b Gaziantep University, Faculty of Dentistry, induced by constant trauma.3 PGCGs usually origi- Department of Prosthodontics, Gaziantep, Turkey. c Erciyes University, Faculty of Medicine, Department of nate from either the periodontal ligament or mu- Pathology, Kayseri Turkey. coperiosteum. The PGCG is located in the region of the gingiva or edentulous alveolar margins, Corresponding author: Dr. Mehmet Bulbul frequently in the lower jaw.3 Histological features Gaziantep Universitesi, Dishekimligi Fakultesi, Protetik Dis Tedavisi Anabilim Dali, of PGCG reveal a non-capsulated mass of tissue Kampus, Gaziantep, Turkey. containing a large number of young connective E-mail: [email protected] tissue cells and multinucleated giant cells.4 Hem- July 2010 - Vol.4 European Journal of Dentistry 329 Peripheral giant cell granuloma orrhage, hemosiderin, inflammatory cells, and of resection of the lesion and closure of the de- newly formed bone or calcified material may also fect with a mucosal graft. Postoperative healing be seen throughout the cellular connective tis- was uneventful (Figure 2) and no sign of recur- sue.5,6 The lesion can develop at any age, though rence was observed. Histopathological examina- it is more common between the fifth and sixth de- tion of the lesion revealed rich inflammatory cell cades of life, and shows a slight female predilec- infiltration under the epithelia, a great number of tion.4-7 PGCG is a soft tissue lesion that infrequent- multinuclear giant cells between the inflamma- ly affects the underlying bone, although the latter tory cells, and epithelioid histiocytes around the may undergo superficial erosion.3,7,8 In the present inflammatory cells. Also there were many conges- report, three cases of PGCG are presented at the tive vessels, hemorrhages, and hemosiderin over same location in the mandible. the cellular connective tissue. Final diagnosis was made as PGCG. CASE REPORTS Case 1 Case 2 A 57-year-old otherwise healthy woman was A 81-year-old female patient with hypertension referred to our clinic for a gingival mass of the low- was referred to our clinic for soft swelling on the er jaw. The patient was edentulous and had been anterior mandible. The patient was edentulous and using a complete denture for more than 10 years. had been using a complete denture for about 15 The tumoral lesion was located on the edentulous years. The lesion had appeared one month before. anterior mandible, and the patient did not know The patient reported neither pain nor alteration of how long the lesion had been there. The patient the size of the mass. Clinical exploration revealed reported neither pain nor alteration of the size of a red-bluish nodule, sessile lesion located on the the mass. Clinical exploration revealed a red and anterior mandibular alveolar crest (Figure 3). The bluish nodule, sessile lesion located on the anteri- lesion measured 1x0.5 cm in size and had no ul- or mandibular alveolar crest (Figure 1). The lesion cerated surface. Radiological examination showed measured 1x0.5 cm in size and had no ulcerated no evidence of bony involvement. surface. Radiological examination revealed no evi- Treatment consisted of resection of the lesion dence of bony involvement. Treatment consisted and closure of the defect with a mucosal graft. Postoperative healing was uneventful (Figure 4). Histopathological examination confirmed the di- agnosis of PGCG (Figure 5). Through the one-year follow-up period, there were no complaints or re- currences. Case 3 A 53-year-old otherwise healthy male patient was edentulous and had been using a complete denture for more than 10 years. The patient re- Figure 1. Clinical view of the lesion of the first patient. ported a painless lesion at the anterior mandible Figure 2. Clinical view of the postoperative healing of the first patient. Figure 3. Clinical view of the lesion of the second patient. European Journal of Dentistry 330 Etoz, Demirbas, Bulbul, Akay which had grown in size in the last few months. follow-up period, there were no complaints or re- Clinical examination revealed a red-bluish nodule, currences. sessile lesion located on the anterior mandibular alveolar crest (Figure 6). The lesion measured DISCUSSION 1x0.5 cm in size and had no ulcerated surface. Peripheral giant cell granuloma (PGCG) is a Radiological exploration showed no evidence of benign hyperplastic reactive lesion which is a bony involvement. The lesion was resected and relatively uncommon lesion of the oral mucosa. the wound was closed with a mucosal graft. Post- PGCG originates from the periodontal ligament operative healing was uneventful (Figure 7). Histo- or mucoperiosteum and is usually caused by lo- pathological examination confirmed the diagnosis cal irritation or chronic trauma. The etiology of of PGCG (Figures 8 and 9). Through the one-year PGCG is unknown. Local irritation factors such as Figure 4. Clinical view of the postoperative healing of the second patient. Figure 5. Histopathological view of the lesion of the second patient (A- hematoxylin eosin X40). Figure 6. Clinical view of the lesion of the third patient. Figure 7. Clinical view of the postoperative healing of the third patient. Figure 8. Histopathological view of the lesion of the third patient (hematoxylin eosin Figure 9. Histopathological view of the lesion of the third patient (hematoxylin eosin X40). X200). July 2010 - Vol.4 European Journal of Dentistry 331 Peripheral giant cell granuloma poor dental restorations, unstable dental pros- fected site for all patients in this report was the thesis, dental extractions, plaque and calculus anterior mandible. In the literature, PGCG is more accumulation, and food retention seem to play a common in the lower jaw than in the upper jaw.4,5 significant role in the development of a PGCG.2,3,5,9- Clinically, PGCG is a smooth brown, red, or blu- 11 Histopathologic characteristics of PGCG may ish nodule, sessile or pedunculated. Radiographic be consistent with periodontal ligament or peri- examinations generally have no findings, because osteum origin.4 Histologically, PGCG is identified the lesion is a soft tissue mass. Although the etiol- as a non-encapsulated mass of tissue compiled of ogy of PGCG is unclear, in the present report the a reticular and fibrillar connective tissue stroma etiologic factor is thought to be chronic trauma, containing profuse young connective tissue cells because of unstable prosthesis. Our three patients of ovoid or fusiform shape, and multinucleated gi- have used complete dentures for numerous years. ant cells.8 The fibrocellular reaction is akin to that PGCGs generally develop either in the gingival tis- of other reactive lesions such as fibrous hyperpla- sue or in the alveolar processes of the incisor and sia and peripheral ossifying fibroma.10-12 The calci- canine region.3 Of our three cases, all were located fied material or newly formed bone may also be in the edentulous alveolar margins of the anterior seen all over the cellular connective tissue, and mandibular region. Lesion size differs from 0.5 to some of the lesions may be either woven bone or 1.5 cm in diameter, although there have been 5 cm lamellar bone produced by the mononuclear stro- size cases in the literature, in which factors such mal cells, which might be similar to latent prolif- as poor oral hygiene or xerostomia seem to play erative osteoblasts or osteoprogenitor cells.5,6,13 an important role in lesion growth.4 None of our The microscopic appearance of PGCG is distinctive cases exceeded 2 cm in size. mainly due to the large number of multinucleated In the present report, all three cases have had giant cells that are disseminated in the connective long-term use of complete dentures that might tissue stroma.4 The exact basis of the giant cells be thought of as having the possible effect of un- is still uncertain. Many opinions have been offered stable dental prostheses on PGCGs etiology. The in the literature, as osteoblasts, phagocytes, en- most preferred occlusion type for complete den- dothelial cells, and spindle cells are thought to tures is bilateral balanced occlusion (BBO).