PMC6585231_01
(a-h) Bony hard, nontender swelling with expansion of inferior border as well as the buccal and medial aspects of the right angle region of the mandible. (i) Orthopantomogram revealed a large multilocular radiolucency, with scalloped margins and a soap bubble and honeycomb appearance in the region of the right angle of mandible, with resorption of root tips of the adjacent first molar. (j and k) A sample of tissue was obtained for histopathological examination by removing a small window of bone from the expanded buccal cortical plate and scooping out tissue from within the lesion
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F1
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 [Figure 1a-h]. The patient was in the mixed dentition stage [Figure 1g]. Orthopantomogram [Figure 1i] showed the jaws in the mixed dentition stage typical for the age of the patient. 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 [Figure 1i]. Tissue biopsy was carried out under LA, by creating a small window through the buccal cortical bone in the retromolar region [Figure 1j and k], through which a representative sample of soft tissue was excavated from within the bony lesion.
Noncontrast computed tomographic scan revealed a multiloculated expansile cystic lesion with bony septae within, measuring 2.6 cm x 2.5 cm x 3.7 cm (AP x Tr x CC) in the region of the right angle of the mandible. Overlying cortex was thinned out with breaches of its integrity at places
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F2
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].
Magnetic resonance imaging of the lesion (axial sections) showed evidence of a 3.3 cm x 2.5 cm x 3.4 cm well-defined, expansile, mild to moderately enhancing lobulated T1 hypointense and T2 iso to hyperintense lesion in the right angle of the mandible with cortical thinning and cortical breaches, causing mild compression of the submandibular gland
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F3
Magnetic resonance imaging of the lesion showed evidence of a 3.3 cm x 2.5 cm x 3.4 cm well-defined, expansile, mild to moderately enhancing lobulated T1 hypointense and T2 iso to hyperintense lesion in the right angle of the mandible with cortical thinning and cortical breaches [Figures 3 and 4], causing mild compression of the submandibular gland [Figures 4 and 5].
Magnetic resonance imaging of the lesion (coronal sections) revealing mild compression of the right submandibular gland by the expanding lesion of the right angle of the mandible
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F4
Magnetic resonance imaging of the lesion showed evidence of a 3.3 cm x 2.5 cm x 3.4 cm well-defined, expansile, mild to moderately enhancing lobulated T1 hypointense and T2 iso to hyperintense lesion in the right angle of the mandible with cortical thinning and cortical breaches [Figures 3 and 4], causing mild compression of the submandibular gland [Figures 4 and 5].
Magnetic resonance imaging of the lesion (sagittal and axial sections) revealing multiple enlarged submandibular and cervical lymph nodes, especially in the posterior triangle
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F5
Magnetic resonance imaging of the lesion showed evidence of a 3.3 cm x 2.5 cm x 3.4 cm well-defined, expansile, mild to moderately enhancing lobulated T1 hypointense and T2 iso to hyperintense lesion in the right angle of the mandible with cortical thinning and cortical breaches [Figures 3 and 4], causing mild compression of the submandibular gland [Figures 4 and 5].
Magnetic resonance angiography of the cervical vessels revealed no evidence of abnormal flow voids or abnormal draining channels, ruling out an arteriovenous malformation
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F6
Magnetic resonance angiography of the cervical vessels revealed no evidence of abnormal flow voids or abnormal draining channels [Figure 6].
(a-c) H and E section x 10 and x 20 showed unencapsulated tumor containing multiple osteoclast-type giant cells evenly scattered in a vascular stoma comprising of proliferating fibroblasts arranged in a whorled pattern. (d) H and E section x40 showing giant cells scattered in the stroma which contained areas of hemorrhage and hemosiderin deposition along with few scattered mixed inflammatory cells. No necrosis or atypia was noted
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F7
Microscopic evaluation revealed soft tissue fragments of cellular tissue along with lamellar bony trabeculae along the margins [Figure 7].
(a-d) Submandibular approach exposing the expanded and bulbous right angle of mandible. Thin shell of overlying cortical bone, nibbled using rongeurs, exposing the soft spongy, vascular tumor mass, which was carefully excavated. (e-g) Vigorous curettage followed by trimming of bony edges and peripheral ostectomy of the base of the residual defect. (h and i) Chemical cauterization of the defect using Carnoy's solution. (j) Extirpated tumor mass. (k-n) Autologous platelet-rich fibrin prepared intraoperatively and place into the bony defect before closure of operated site
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F8
Careful dissection was then carried out through the white glistening investing layer of the deep cervical fascia [Figure 8a]. The submandibular salivary gland which bulged into the operating site [Figure 8b] 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 [Figure 8c]. The mass had a soft spongy texture [Figure 8d]. The overlying expanded buccal and medial cortical plates were nibbled away carefully using rongeurs forceps [Figure 8e-g], taking care to avoid any undue pressure of force to prevent an inadvertent fracture of the already weakened mandible. This was thereafter followed by chemical cauterization of the entire tumor bed using cotton pellets soaked with Carnoy's solution [Figure 8h], to ensure prevention of future recurrence. The adjacent tissues were first protected from the caustic chemical, using layers of folded Vaseline gauze [Figure 8h]. After thorough irrigation of the area, hemostasis was ensured and all sharp margins of bone were carefully smoothened using bone files [Figure 8j]. 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 [Figure 8l-o], 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-beta (TGF-beta) to hasten soft tissue healing as well as subsequent bone fill in the defect region. Histopathological examination of the excised specimen [Figure 8k] confirmed the prior diagnosis of GCT.
(a-d) Postoperative photographs showing good healing of the operated site with esthetic positioning of the incision line and an inconspicuous resultant scar
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F9
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 [Figure 9].
(a-h) Postoperative non contrast computed tomographic revealed smooth residual margins, walls, and floor of residual bony defect
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F10
Postoperative NCCT of the region [Figure 10] revealed smooth residual margins, walls, and floor of the residual bony defect.
(a-c) Histopathological examination of excised specimen confirming the diagnosis of central giant cell granuloma
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F11
Histopathological examination of samples of tissue from the excised specimen confirmed the diagnosis of CGCG [Figure 11].