Radiologic features, including those seen

with computed tomography, of central

giant cell granuloma of the jaws
Mark A. Cohen, BSc., M.Dent.,
Johannesburg, South Africa
UNIVERSITY

OF THE

F.F.D.(S.A.),*

and Yancu Hertzanu,

M.D.,**

WITWATERSRAND

The radiologic
features
of 16 cases of central
giant cell granuloma
of the jaws were studied.
Three cases,
two involving
the maxilla and one involving
an extensive
lesion in the mandible,
were further
investigated
with the use of computed
tomography.
In the mandible,
the radiologic
features
varied from ill-defined
destructive
lesions to a well-defined,
multilocular
appearance.
One of the most consistent
features
found
was splaying
of the roots of teeth adjacent
to the lesion. The features
as seen with computed
tomography
are reported
in detail and are of benefit in the surgical
management
of maxillary
lesions and large
mandibular
(CAL

SURC

lesions.
ORAL MED ORAL

PATHOL

1988;65:255-61)

he central giant cell granuloma (CGCG) of the

jaws is a relatively uncommon pathologic process,
accounting for less than 7% of all benign jaw lesions.
The lesion was considered by Jaffe2 to be a local
reparative reaction of bone, possibly to intramedullary hemorrhage or trauma. Hence, the term reparative giant cell granuloma was at one time widely
accepted. The word reparative has subsequently been
deleted since the lesion represents essentially a
destructive process.
Clinically, the CGCG usually occurs in patients
under the age of 30 years, occurs more often in
females than in males, and is more common in the
mandible than in the maxilla. In most series, the
lesion has been reported as being confined to the
tooth-bearing areas of the jaws.3s4
The radiologic appearance of the CGCG is variable (Figs. 1,2, and 3). Usually the lesion appears as
a unilocular or multilocular radiolucency; it may be
well defined or ill defined and shows variable expansion and destruction of the cortical plates. The
radiologic appearance of the lesion is not pathogno*Formerly, Division of Maxillofacial and Oral Surgery, Department of Surgery, and Department of Oral Pathology, University
of the Witwatersrand. Presently, Division of Oral and Maxillofacial Surgery, College of Dentistry, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada.
**Formerly Department of Diagnostic Radiology, University of
the Witwatersrand; presently, Department of Diagnostic Radiology, Soroka Medical Centre, Beersheba, Israel.

Fig. 1. Central giant cell granulomawith multiloculated

soap bubble appearance.

manic and may be confused with that of many other

lesions of jaws.5*6 Because of the well-documented
varying radiologic appearance of the lesion, an
attempt was made in a series of 16 cases to characterize any of the distinctive radiologic features of the
CGCG. In addition, three CGCGs in the series were
examined with computed tomography (CT), and the
value of this modality in diagnosis and treatment is
discussed.
PATIENTS

AND METHODS

The radiographs and clinical details of 16 cases of

CGCG of the jaws were obtained from the files of the
255

256

Cohen and Hertzanu

Oral
February

Surg
1988

Fig. 4. Site distribution and extent of 16casesof central

giant cell granulomasof jaws.
Fig. 2. Radiographof central giant cell granulomawith
unilocularradiolucentappearanceandsplayingof rootsof
adjacentteeth.

of the lesions varied from those of less than 1 cm to

large lesions occupying an entire hemimandible.
Only three lesions were present in the maxilla. The
site distribution and the extent of lesions are shown
in Fig. 4.
RA434OL004C

Fig. 3. Occlusal radiograph of ill-defined mandibular

lesionwith buccal expansionand loculation.

Departments of Oral Pathology and Maxillofacial

and Oral Surgery at the University of the Witwatersrand. CT had been used with three of the patients.
The clinical features noted were age, gender, race,
site and extent of the lesion. Features noted on the
radiographs included the definition of the radiolucency, whether the margin was corticated, and the
effect of the lesion on the roots of the teeth, i.e.,
displacement and resorption. Unilocularity and multilocularity of the lesions were also noted.
RESULTS

The ages of the patients ranged from 7 to 63 years,

with the majority of patients (seven) in the second
decade. There were seven male and nine female
patients with a white-to-black ratio of 9:7. The size

FEATURES

All cases of CGCG appeared as radiolucencies,

50% of which were multilocular.
The remaining
cases had a unilocular appearance. The majority of
lesions (nine) were well defined, while seven
appeared as ill-defined radiolucencies. Eleven lesions
showed cortication of bone at the periphery of the
lesion, while eight lesions (50%) had scalloped margins. Displacement and divergence of the apices of
the roots were present in ten cases, and root resorption was seen in three cases. In two of the cases, the
patients were edentulous. The radiologic features are
summarized in Table I. The features of the lesions as
seen on CT are described in the individual case
reports.
CASE REPORTS
CASE 1

A 13-year-old white boy was referred becauseof a

slow-growing,pamlessmassin the left maxilla. It wasfirst
noticed by his parents 1 year previously and had been
steadily increasingin size. On examination, the patient
exhibited a facial asymmetry that included fifling out of
the left nasolabialfold with lifting of the ala of the noseon
that side. The skin wasof normal color and texture, and
motor andsensorynerve functionswereintact. Intraorally,
the lesion had causedmarked palatal expansion,which
extendedacrossthe midlineand posteriorly to the level of
the molar teeth. There was also mild expansioninto the
buccal sulcusover the left incisor and canine teeth, The
masswasfirm and rubbery, with no evidenceof fluctuation. The mucosaoverlying the lesionwasnormal.
A panoramicradiograph(Fig. 5) showedan ill-defined
radiolucent lesion of the right maxilla. A degree of

Radiologc

Volume 65
Number 2

features of CGCG of jaws

257

I. Radiologic features of 16 cases of central

giant cell granuloma of the jaws

Table

Fe&we

Multilocularity
Unilocularity
Scalloped margin
Smooth margin
Well defined
Poorly defined
Divergence of roots
Root resorption

No. of cases

8
8
8
8
9
I
10
3

50
50
50
50
56
44
71
21

splaying of the roots of the lateral incisorand canineteeth

Fig. 5. Panoramic radiograph showing an ill-defined

radiolucencyof the left maxilla (arrows).

wasvisible.A tomogram(Fig. 6) showeda massinvolving

the left maxilla and extendinginto the nasalfossa.Axial
and coronalCT (Fig. 7) showeda well-definedmasswith a
corticated margin. Calcified trabeculae were present
throughout the lesion.The massoccupiedthe horizontal
plate of the palatine bonewith someexpansioninto the
maxillary sinus and the nasal fossa. The differential
diagnosisincludedbenignfibro-osseous
lesionand CGCG.
Biochemicalanalysisincludedserumalkalinephosphatase
and serum calcium levels, both of which were within
normal limits. An incisionalbiopsy wasperformed,and a
histopathologicdiagnosisof CGCG was returned. With
the patient undergeneralanesthesia,
the lesionwasenucleated. Recoverywasuneventful, with no signof recurrence
after 4 yearsof follow-up.
CASE 2

A 62-year-oldblack womanwasreferred for the investigation and managementof a large tumor of the right side
of the mandible. The patient had a 4-year history of a
slow-growing,nontender massof the right side of her
face.
Her main reasonfor seekinghelpwasthat the masswas
interfering with mastication.On examination,an obvious
swellingof the right sideof the mandibleextendingfrom
just belowthe zygomatic arch to the inferior borderof the
mandible was present.The skin over the lesion was of
normal color and texture, and motor and sensorynerve
functionswereintact. The patient experiencedmild limitation of mandibular opening. Intraoral examination
revealed a large mass,which occupied the entire right
mandibular buccal sulcusand which extended over the
mandibularalveolusto the lingual side.The masswasfirm
and nontender and exhibited areasof ulceration on its
surface.All mandibularteeth posteriorto the right canine
had beenpreviouslyextracted.
A panoramic radiograph (Fig. 8) showeda relatively
ill-defined,destructive lesionof the right mandible,which
extendedfrom the area of the right canineto the neck of
the mandibularcondyle. An incisionalbiospyof the mass
returned a diagnosisof CGCG of the jaw. Biochemical
investigation excluded hyperparathyroidism. Computed
axial and coronal tomograms(Fig. 9) showeda large,

6. Case1. Tomographiccut demonstratingpalatal

expansionand extensionof the massinto the nasalfossa.

Fig.

soft-tissuemasson the buccal and lingual sidesof the

mandible. Extension of the massinto the floor of the
mouth and displacementof the tonguewere clearly seen.
Destructionof the buccaland lingual cortical platesof the
mandibleby the masswas evident. The condylar process
wasessentiallyuninvolvedby the lesion.With the patient
undergeneralanesthesia,
the lesionwasresectedfrom the
midline of the mandible to the condylar process.The
mandibularfragmentswere splintedby meansof a previously constructedwire splint. The patients recovery was
uneventful,andshewasdischargedwith an appointmentto
return 4 weekslater for bonegrafting. She failed to return
and hassincebeenlost to follow-up.
CASE 3
A lo-year-old black girl was referred becauseof a
painless,bony hard swellingof the right maxilla. It was
first noticed by her parents4 monthsbeforethe consultation and since then had slowly increasedin size. The
swellingextendedfrom just below the right infraorbital
marginto the nasolabialfold area,which wasfilled out and

258

Cohen and Hertzanu

Oral Surg
February

1988

Fig. 7. Case1. Coronal(top) and axial (bottom) CT scans.The lesionis well corticated with extensioninto
the palatine boneand nasalfossa.Bony trabeculaeare clearly seenwithin the lesion.

Fig. 8. Case 2. Panoramic radiograph showing a

destructivelesionof the left sideof the mandiblewith a
large soft tissueshadow.

obliteratedby the mass.Slight lifting of the right ala of the

nosewas evident. The overlying skin was mobile and of
normal color and texture. All motor and sensorynerve
functionswere intact. There wasno extensionof the mass
into the nasalvestibule.

Intraoral examination revealed a relatively healthy

mouth with teeth in the mixed-deniition phase.It was
noteworthy that the right maxillary first premolar had
eruptedadjacentto the lateral incisortooth. There wasno
signof the cuspidtooth in the mouth. This wasin contrast
to the left side, where the deciduouscuspid was still
present.A well-defined,bony hard massextendedbuccally
from the midlineto the right maxillary first molarareaand
obliterated the buccal sulcus.The mucosaoverlying the
masswasof normalcolor and texture. Palatal swellingwas
not evident. The panoramic radiograph showedan illdefined radiolucencyof the right maxilla extending from
the lateral incisorto the seconddeciduousmolartooth. The
uneruptedcuspidtooth on that sidewasdisplacedmedially
toward the midline. An intraoral occlusal radiograph
showedan ill-definedlesionof the right maxilla adjacentto
an uneruptedcuspidtooth (Fig. 10). Definite splayingof
the rootsof the lateral incisortooth and first premolarwas
evident. An incisionalbiopsyspecimenshowedthe typical
histologic featuresof CGCG. Biochemicalinvestigations
were all within normal limits. Axial and coronal CT was
carried out (Fig. 10). This showeda trabeculatedlesion,
which extendedfrom the right maxillary alveolusinto the
maxillary sinus.There wasno associatedsoft-tissuemass,
although expansion of the buccal cortical plate was
marked.
With the patient under general anesthesia,the lesion
enucleatedeasily with the useof a buccal approach.The

Volume 65
Number 2

9. Case
bucally and in

Fig.

Radiologic

features of CGCG of jaws

259

tissue mass

Fig. 10. Case3. Intraoral occlusalradiograph(top right) showingan ill-defined loculated lesionof the
maxilla with splayingof the roots of the secondcuspidand first premolarteeth. CoronalCT scan(top left)
showsextensionof the lesion from the alveolusinto the maxillary sinus.The axial CT scans(bottom)
demonstratetrabeculation of the lesion,buccal expansion,and extensioninto the nasalfossa.

impactedcuspid tooth was removed.A nasalantrostomy

wasperformed,and healingwasuneventful. After 2 years
of follow-up, there has beenno sign of recurrence.
DISCUSSION

From the study of 16 cases of CGCG, it is clear

that the radiologic features of the lesion are variable.

Half of the lesions studied had a multilocular

appearance, while half were unilocular. Furthermore, this feature did not depend on the site or extent
of the lesion. One of the most consistent features
found was significant divergence of the roots of teeth
adjacent to the lesion. This occurred in 10 of 14
lesions (two lesions were in edentulous mandibles).

260 Cohen and Hertzanu

Root resorption however, was, an uncommon feature

(three cases). It has been suggested that two distinct
radiologic appearances of CGCG of the jaws exist.6
One variety appears as a unilocular radiolucency,
while the other type is multilocular with fine trabeculae coursing through the radiolucency. The present
study supports these findings.
The site distributions of the lesions in this series
varied markedly from that of Waldron and Shafer.l
All of their cases occurred in the tooth-bearing areas
of the jaws, and, in fact, few were situated in the
molar regions. In the present series, five lesions
(31%) extended into the ascending ramus of the
mandible, with two lesions involving the condylar
process. This feature has been reported previously
but appears to be rare.aE Four of the lesions in this
report were extensive lesions that involved virtually
an entire hemimandible.
The literature appears to be confused with respect
to the terminology and exact nature of the central
giant cell lesion of the jaws. Although the term
granuloma is still widely used to describe the lesion,
others have recognized its neoplastic potential and
refer to the lesion as giant cell tumor.9 Indeed, it
has been extensively shown that the lesion is destructive, rather than reparative. Confusion arises as the
term tumor equates the lesion in the jaws with the
giant cell tumor of long bones. The long bone lesion
has a propensity for recurrence after conservative
management and often displays malignant behavior
with metastasis. However, metastasis from jaw
lesions is extremely rare, although recurrence after
curettage has been reported.8, I* I2 Attempts to distinguish the jaw lesion from the long bone lesion
histologically have met with some success. Significant differences in the size and the number of the
nuclei of the giant cells between jaw lesions and long
bone lesions have been described.13 With the use of
stereologic techniques, differences in nuclear numerical density and absolute cell volumes have also been
reported. I4 These features, however, remain inconclusive for the prediction of behavior. Shklar and
Meyer9 have presented a series of cases with the
features of a neoplasm and suggest that these lesions
be referred to as giant cell tumors. Their observations are based on radiologic and histologic criteria,
as well as the clinical behavior of the lesion. On this
basis, the authors dispute earlier2 theories that the
giant cell tumor is extremely rare in the jaws, but
they conclude that until larger series of lesions have
been studied, the distinction between tumor and
granuloma remains unclear.
CT is now a well-established technique used for
examining lesions of the head and neck, particularly

Oral Surg
February 1988

malignant tumors. Only recently, however, have the

advantages of CT over conventional radiography
been demonstrated in the diagnosis of benign lesions
of the jaws.15.17 CT is superior to conventional
radiography in that it clearly demonstrates the
soft-tissue mass of a lesion, extension into adjacent
structures, and bony destruction. This is clearly
shown by cases 1 and 3 in this article. In case 1, the
lesion was poorly defined on conventional radiographs; however, extension of the lesion to the
palatine bone and into the nasal fossa was clearly
seen on CT. Furthermore, trabeculations running
through the lesion were visualized. Similarly, in case
3, extension of the mass into the maxillary sinus and
expansion of the buccal cortical plate of the maxilla
were superiorly visualized in both the axial and
coronal planes. Case 2 is an example of an extensive,
destructive tumor, the extent of which was poorly
visualized on plane mandibular
radiographs. CT
clearly demonstrated the soft-tissue mass with extension into the floor of the mouth and buccal areas.
Furthermore, preservation of the condylar process is
evident on the coronal scan, an important feature in
surgical management. Two fairly recent publications8.9 have mentioned the CT features of several
giant cell lesions of the maxilla; however, the present
article probably constitutes the first detailed description in the literature of the CT features of CGCG of
the jaws.
Although simple curettage is effective treatment
for the majority of CGCGs of the jaws, extensive
lesions such as that demonstrated in case 2 must be
treated by resection. In these cases, as well as in
maxillary lesions in which the tumor mass may lie
adjacent to several important structures, CT is
invaluable to surgical planning and management.
We are grateful to Dr H. Kola for permission to use case
2 in this article.
REFERENCES

1. Austin Jr LT. Dahlin DC, Royer RQ. Giant cell reparative

granuloma and related conditions affecting the jawbones.
ORAL SURGORAL MED ORAL PATHOL 1959;12:1285-95.
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cyst, and fibrous (fibro-osseus) dysplasia of the jawbones.
ORAL SURGORAL MED ORAL PATHOL 1953;6:159-75.
3. Waldron CA, Shafer WC. The central giant cell reparative
granuloma of the jaws. Am J Clin Path01 1966;45:437-47.
4. Lucas RB. Pathology of tumors of the oral tissues. 4th ed.
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5. Shafer WC. Hine MK. Levv BM. A textbook of oral
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I. Shensa DR, Nasseri S. Central giant cell granuloma of the
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8. Tasanen A, Konow L, Nordling S. Central giant-cell lesion in

Radiologic features of CGCG of jaws

Volume 65
Number 2
the mandibular condyle. Report of a case. ORAL SURC ORAL
MED ORAL PATHOL 1978;45:532-9.

9. Sbklar G, Meyer I. Giant-cell tumors of the mandible and

maxilla. ORAL SURC ORAL MED ORAL PATHOL 1961;14:80921.

10. Mintz GA, Abrams AM, Carlsen CD, Melrose RJ, Fister
HW. Primarv malignant giant cell tumor of mandible. ORAL
SURG ORAL T&D ORAL P~HOL

1981;51:164-71.

11. Guralinick WC, Donoff RB. Central giant cell granuloma. Br

J Oral Surg 1972;9:200-7.
12. Davis GB, Tideman H. Multiple recurrent central giant cell
granulomas of the jaws. Case report. J Maxillofac Surg
1977;5:12?-9.
13. Abrams B, Shear M. A histological comparison of the giant
cells in the central giant cell granuloma of the jaws and the
giant cell tumor of long bone. J Oral Path01 1974;3:217-23.
14. Franklin CD, Craig GT, Smith CJ. Quantitative analysis of
histologic parameters in giant cell lesions of the jaws and long
bones. Histopathology 1979;3:51 l-22.
15. Mendelsohn DB, Hertzanu Y, Cohen M, Lello G. Computed
tomography of craniofacial fibrous dysplasia. J CAT 1984;
8:1062-5.

261

16. Hertzanu Y, Cohen M, Mendelsohn DB. Nasopalatine duct

cyst. Clin Radio1 1985;36:153-8.
17. Cohen MA, Hertzanu Y, Mendelsohn DB. The value of
computed tomography in the diagnosis and treatment of
mandibular ameloblastoma. J Oral Maxillofac Surg
1985;43:796-801.
18. Som PM, Lawson W, Cohen BAC. Giant-cell lesions of the
facial bones. Radiology 1983;147:129-34.
19. Rhea JT, Weber AL. Giant-cell granuloma of the sinuses.
Radiology 1983;143:135-7.
Reprint

requests

to:

Dr Mark A. Cohen
College of Dentistry
University of Saskatchewan
Saskatoon
Sask
S7N OWO
Canada