It relieves on taking medication but reoccur as soon as medication stops. Patient has no relevant past medical or dental history. On oral examination nothing suspicious was found. Patient had good oral hygiene. Patient was advised for OPG. OPG revealed presence of radiolucency wrt to 36 and 46. Patient complained swelling only but OPG revealed similar lesion on the other side also which was not known to patient or parents as it was asymptomatic (Figure 2).

Following the careful enucleation, the tooth with the lesion (which was attached at and around the cemento-enamel junction) was sent for the histopathological examination (Figure 5).

The report revealed presence of lymphocytes, histiocytes and multinucleated giant cells. No cyst was identified. But diagnosis was not confirmed. The result was non-specific granulomatous inflammation (Figure 6).

Patient was recalled after 6 months and no swelling or radiolucency was present. But actual cause was still unknown (Figure 8).

After 2 years of follow up, the 37 and 47 have physiologically mesially migrated at the site of extracted first  molars uneventfully (Figure 9).

CASE REPORT II

Similar case with exactly similar clinical presentation, radiographic finding, histopathological reporting and immediate recovery after similar intervention procedure irt to 46. The only difference was that this lesion was unilateral (Figures 10-14).

CASE REPORT III

Another case with exactly similar clinical presentation, radiographic finding, histopathological reporting and immediate recovery after similar intervention procedure irt to 24,25, but this time the lesion was unilateral and in maxilla (Figures 15-19).

DISCUSSION

In 1953, Jaffe [4] described an apparently reactive intraosseous lesion of the mandible and maxilla following trauma induced intraosseous hemorrhage and containing prominent giant cells. He separated giant cell lesions from long bone giant cell tumor based on differences in their histological pattern and clinical behavior [8]. Due to its reactive in nature, he gave the term reparative giant cell granuloma [9].

It is the disease of the young presenting as a painless expansible mass ranging from a slowly growing asymptomatic swelling to an aggressive lesion causing pain and bone destruction, being more common in the anterior portion of the mandibular body sometimes crossing the midline, the epicentre being anterior to the first molar region. It is an uncommon benign lesion of the jaw which accounts for <7%. Usually in this cortical plates are thinned, with sometimes perforation but gross soft tissue involvement remains limited [10].

In the present case, biopsy report revealed presence of lymphocytes, histiocytes and multinucleated giant cells. No cyst was identified. The result was non-specific granulomatous inflammation. The sign and symptoms were similar to central giant cell granuloma.

But upon enucleation, we can clearly appreciate that the lesion was attached at the cementoenamel junction, just like in dentigerous cyst, making it having mixed presentations.

CT scan showed excessive bony thinning and destruction with resorption of buccal cortical plates, showing signs of its aggressive nature.

In present case, the radiologic features of granuloma was not been clearly defined; the lesion appeared as unilocular radiolucency with ill-defined margins with varying degrees of expansion of the cortical plates. Radiographic appearance of the lesion is not pathogenomic and may be confused with that of many other lesions of the jaws [6]. Various methods have been described for the treatment of such lesion of jaws. Most often treatment used is Curettage alone or in combination with resection with or without continuity loss [11]. Surgical treatment is usually varied depending upon the anatomic location, size of lesion, clinical behavior, periosteal or nerve involvement. But in this case, perforation of cortical plates prompted us for surgical resection and removal of molars related to the lesion.

CONCLUSION

Granulomatous inflammation may manifest in the oral cavity and usually with an array of non-specific clinical findings. Thus, an extensive clinical, microscopic and laboratory evaluation may be required in order to identify the source of the granulomatous inflammation. However, if the lesions are timely identified and appropriate therapy rendered, prognosis of the condition is significantly improved. This case highlights the difficulty in diagnosing and management of the lesion. Hence, this lesion continues to develop the interest and mystify the clinicians.

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