Reparative giant cell granuloma of the maxilla
A 23-year-old female reported with complaints of a slowly expanding swelling of right cheek and upper jaw, pain in right upper teeth, and painful watering of the right eye of 2-3 months duration.\nHer dental history revealed that she had pain in 16 about 1½ year back and got root canal treatment done for it by a local general dentist and was apparently asymptomatic for the next 6 months. There was no history of trauma. Then she had intermittent pain in the same tooth and antibiotics were given. Later she developed a swelling on right cheek and felt severe pain so the tooth 16 was extracted by the same dentist about 3 months back. As the pain and swelling did not subside even after extraction, incisional biopsy was performed twice from the region of 16 both from the socket and vestibule by oral and maxillofacial surgeons. It was histologically diagnosed as nonspecific inflammatory lesion.\nOn examination, extraorally a swelling measuring about 4 × 5 cm with diffuse borders was seen on right cheek extending from the corner of the mouth, nose, to lower eyelid. On palpation, the swelling was firm to hard in consistency with moderate tenderness []. Skin over the swelling was reddened and compromised facial nerve function on right side on smiling was also observed. Obliteration of right nasolabial fold and mild edema over right lower eyelid was noticed. Right eye showed no change in visualacquity and eyeball movements.\nThe intraoral examination revealed a purplish discoloration with expansile mass in the right upper vestibular region extending from 13 to 17 with complete obliteration of the vestibule []. Oroantral fistula resulted after the earlier biopsies in the regions of 14, 15, and 16. There was no caries in the associated teeth but were periodontally compromised: 14, 15, and 17 showed grade II mobility and 13 and 18 exhibited grade I mobility. Significant palatal expansion in the molar region was also observed. Aspiration was negative and the lesion was found to be bleeding actively on slightest provocation.\nOPG showed a radiolucent lesion with ill-defined borders in the regions of 15 to 17. CT scan revealed a soft tissue mass completely obliterating the right vestibule, cheek, and extending on to maxilla and maxillary antrum with thinning and destruction of parts of the antral walls []. The mass extended inferiorly into the body of the maxilla up to alveolus, involving the teeth. Medially, it almost obliterated the posterior and inferior third of the right maxillary antrum []. Superiorly, it extended up to the floor of the orbit and laterally into the body of the zygoma. Posteriorly, it reached the lateral and medial pterygoid plates, infratemporal fossa, and lower portion of the temporal space []. CT also showed evidence of weakness []. 3D reconstruction CT shows perforation of anterolateral surface of the maxilla and uninvolved right orbital floor [].\nKeeping in mind the clinical and radiological features, it was thought that the lesion could not be a nonspecific inflammatory one but it could be a benign tumor. Therefore, a biopsy was done to obtain more deeper tissue and to have an idea about the exact nature of the lesion, and it was histologically revealed as a giant cell granuloma [].\nWith this provisional diagnosis, an incisional biopsy was performed under general anesthesia, and the histopathological examination confirmed it as RGCG [].\nThe patient was advised routine and special blood investigations to rule out hyperparathyroidism. Complete excision of the tumor mass along with partial maxillectomy to gain access to the infratemporal region was planned. Partial maxillectomy was carried out through a Weber-Fergusson incision under general anesthesia [Figures and ]. Palatal mucosa was separated from the bony segment and greater palatine artery ligated. Entire tumor mass was removed along with portions of invaded bone and corresponding teeth. Pressure resorption of the alveolus with exposure of the roots of the teeth was observed intraoperatively.\nA careful and thorough curettage of the residual bony cavity was performed []. The defect was reconstructed with full-thickness skin graft harvested from right thigh region [Figures and ]. The graft was secured by interrupted sutures. Postoperatively nasogastric feeding was maintained for 10 days. The postoperative course was uncomplicated and the patient was discharged on postoperative day 10. The patient was regularly observed at follow-up visits and the wound healing was uneventful []. Patient recovered well and was followed up for 1 year. She is asymptomatic and no recurrence is evident till date.