The peripheral giant cell granuloma (PGCG) is a nonneoplastic lesion commonly caused by local irritation. This report describes a 46-year-old Caucasian male who presented with a PGCG associated with a dental implant. The dental implant was originally placed in August 2012. Ten months later, the patient presented with a well-circumscribed lesion associated with and covering the implant, at which time the lesion was excised. Four months later, due to recurrence of the lesion, a deeper and wider excisional biopsy with curettage of the adjacent bone was performed. No evidence of recurrence has been reported after 12 months of follow-up. Immunohistochemistry, using the antibody CD68, was performed to investigate the origin of the multinucleated giant cells, with their immunophenotype being similar to those of other giant cell lesions, including central giant cell granuloma, foreign-body reactions, and granulomatous reactions to infectious agents.
The peripheral giant cell granuloma (PGCG) is a nonneoplastic lesion, characterized by reactive hyperplasia in the presence of local irritation [
There is little data in the literature regarding the prevalence of reactive lesions associated with dental implants and whether they develop due to mechanical or biological irritation, with the former being associated with inappropriate implant placement and the latter with poor oral hygiene. The complications that may arise in and around implant sites are numerous and may include dehiscence, mucositis, gingival hyperplasia, and the formation of a biofilm [
This case report describes a peripheral giant cell granuloma associated with a dental implant and reviews similar cases published in the English literature.
A 46-year-old Caucasian male presented to the Department of Implant Dentistry, Faculty of Dentistry, University of São Leopoldo Mandic, Campinas, São Paulo, Brazil, in August 2012, requesting implants for aesthetic and functional purposes. Titamax Ex external hexagon implants (Neodent, Brazil) were placed in the regions of the upper left premolar and the lower left first molar, with their respective healing abutments. In June 2013, the patient presented with a lesion associated with and covering the lower left first molar implant site. Intraoral examination showed a well-circumscribed, pedunculated, painless, purple mass measuring approximately 1 cm, rubbery in consistency. Radiographically, in the lower left molar region, the presence of an implant was observed without evidence of radiographic features that would be compatible with bone involvement (Figure
Clinical photograph of the painless purple pedunculated lesion associated with the dental implant.
Panoramic radiograph showing the presence of a dental implant in the lower left molar region. Insert: increased magnification focusing on the implant in the region of the lower left molar, showing lack of radiographic features that would be compatible with bone involvement.
Photomicrograph revealing fragments of dense connective tissue, showing proliferation of ovoid and spindle-shaped cells, multinucleated giant cells, and congested blood vessels (haematoxylin and eosin stain, original magnification ×200).
In October 2013, the patient was referred to the Oral Medicine Clinic, Faculty of Dentistry, University of São Leopoldo Mandic, Campinas, São Paulo, Brazil, with a recurrence of the lesion. A deeper and wider excisional biopsy, curettage of the adjacent bone, and application of surgical cement were performed. The biopsy was once again forwarded to the Department of Oral Pathology, Faculty of Dentistry, University of São Leopoldo Mandic, Campinas, São Paulo, Brazil. The histopathological diagnosis was peripheral giant cell granuloma. The patient remains lesion-free following one year of follow-up.
The paraffin-embedded blocks from each biopsy were selected for immunohistochemical staining using the antibody CD68. Five
Immunohistochemical staining with CD68 was strongly positive for multinucleated giant cells, as shown in Figure
Immunohistochemical staining with CD68 showing strong positivity for multinucleated giant cells (original magnification ×200).
When compared with peri-implantitis, reactive lesions associated with dental implants, such as PGCG, are considered rare, with only 12 cases reported in the English literature (Table
Age, sex, site, initial presentation, time between implant placement and appearance of lesion, treatment, and outcome of cases of PGCG associated with dental implants found in the literature.
Author | Age | Sex | Site | Initial presentation | Type of implant | Time between implant and appearance of the lesion | Recurrence | Treatment |
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Hirshberg et al. [ |
31 | M | Posterior mandible | Peri-implantitis | ND | Unknown | Yes | *Curettage/excision (laser) |
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Hirshberg et al. [ |
44 | F | Posterior mandible | Peri-implantitis | ND | 6 years | Yes | *Curettage/excision and surgical removal of the implant |
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Hirshberg et al. [ |
69 | M | Anterior maxilla | Peri-implantitis | ND | 14 months | Yes | *Curettage/excision (laser) and surgical removal of the implant |
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Bischof et al. [ |
56 | F | Posterior mandible | Tender rapidly growing mass | Branemark self-tapping Mk II | 2 years | No | *Excision and curettage |
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Cloutier et al. [ |
21 | M | Posterior mandible | Exophytic mass | Rough-surfaced titanium spray implant | 6 years | No | *Excision and surgical removal of the implant |
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Olmedo et al. [ |
64 | F | Anterior maxilla | Tumor-like lesion | Branemark-like, 4.1 mm diameter and 11.5 mm length | 12 years | No | *Excision and curettage |
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Özden et al. [ |
60 | F | Posterior mandible | Exophytic mass | Straumann | 6 years | No | *Excision and curettage |
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Hernandez et al. [ |
45 | F | Posterior mandible | Bleeding mass | 3 self-tapping Branemark implants |
3 years | Yes | *Excision and curettage/surgical removal of the implant |
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Hernandez et al. [ |
36 | F | Posterior maxilla | Profuse bleeding on toothbrushing | Branemark self-tapping implant |
2 years | Yes | *Excision and curettage/surgical removal of the implant |
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Hernandez et al. [ |
62 | F | Anterior mandible | Exophytic mass | 2 self-tapped implants (Branemark system) | 3 months | No | *Excision and curettage |
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Peñarrocha-Diago et al. [ |
54 | F | Posterior mandible | Exophytic Mass | 7 Defcon Avantblast TSA surface implants | 2 years | No | *Excision and curettage |
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Galindo-Moreno et al. [ |
74 | M | NA | Exophytic mass | NA | 6 years | No | *Excision and curettage |
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Present study, 2014 | 46 | M | Posterior mandible | Painless exophytic mass | Neodent Titamax Ex |
10 months | Yes | *Excision/excision and curettage |
Dental implants aside, pyogenic granuloma is considered more common than PGCG; it is, therefore, extremely interesting that PGCG is in fact more common than pyogenic granuloma in the dental implant population. A search of the English literature (available for download) revealed 12 cases of PGCG and only five cases of pyogenic granuloma associated with dental implants [
Although the case presented in this study refers to a male patient, our review of the literature revealed that, as PGCG is not associated with dental implants, there is a female preference [
In the present review, the age range was noted to be 31–74 years, with an average age of 50.9 years, as observed by Katsikeris et al. [
PGCG has been reported as being more common in the mandible [
In the cases reviewed, a recurrence rate of 46.2% was observed, with some lesions reported as recurring five times [
Six of 13 cases recurred, three of which had initially been treated solely with curettage. Only one case was excised from the start, which also recurred. Of the seven cases that were initially excised and curetted, only two recurred. Five of the thirteen cases required surgical removal of the implant (38%).
Bischof et al. [
The presence of peri-implant metal particles has been reported as being caused by the insertion mechanics, an inadequate abutment placement, and early removal of failing implants [
In terms of treatment, it is important that any exacerbating factors, such as fractured prostheses and restorations, large or poorly adapted restorations, and dental calculus, should be removed. Other factors should also be considered, such as diastema, which can promote retention of food particles, orthodontic appliances, and dental implants. Following removal of the causal factor, the surgical excision of the lesion should be performed, associated with debridement of the adjacent bone, which is paramount for the prevention of recurrence [
Immunohistochemistry for CD68 was performed in order to confirm the origin of the multinucleated giant cells in the lesion. The literature is controversial in terms of the origin of these multinucleated giant cells, with speculation over a macrophage or osteoclast origin. Various studies have shown that multinucleated giant cells in PGCG demonstrate positivity for the immunohistochemical markers MB-1, vimentin,
In conclusion, reactive peri-implant lesions should be removed in their entirety in order to prevent recurrence and implant failure. In addition, clinical experience reveals that differences in opinions exist regarding whether the implant should also be removed during excision of the lesion; therefore, it is critical that these lesions are reported so as to arrive at a treatment consensus. Furthermore, it is paramount that histological examination is performed on all peri-implant soft tissue reactions in order to arrive at an appropriate diagnosis, as other neoplastic and nonneoplastic lesions such as pyogenic granuloma, central giant cell granuloma, the brown tumor of hyperparathyroidism, and malignancy must be excluded [
The authors declare that there is no conflict of interests regarding the publication of this paper.