Focal cemento-osseous dysplasia: a case report and literature review

doi:10.4236/health.2010.28139

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Vol.2, No.8, 941-944

doi:10.4236/health.2010.28139

(2010) HEALTH

Openly accessible at/HEAL H

Focal cemento-osseous dysplasia: a case report and

literature review

Duygu Yazicioglu*, Aysegul Mine Tuzuner-Oncul, Cahit Ucok, Omur Dereci

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University, Ankara, Turkey; *Corresponding Author:

duyguaytac@gmail.com

Received 12 March 2010; revised 9 April 2010; accepted 10 April 2010.

ABSTRACT

Objective and Case Report: In this report a

female patient with the lesion diagnosed as

focal semento-osseous dysplasia by histolog-

ical and radiological examination on the left

mandibular molar region is presented and these

focal semento-osseous dysplasia lesions are

reviewed according to the literature. Conclusion:

Histological and radiographic examination is

significant for the differential diagnosis of FCOD.

Its solid nature and posterior localization ease

the differential diagnosis. The treatment includes

long term follow-up for asymptomatic lesions or

surgical excision if a dental implant rehabili-

tation is planned for the affected partial ed-

entulous region of jaw, as seen in this case.

Keywords:Oral Pathology; Focal Semento-Osseous

Dysplasia

1. INTRODUCTION

Benign fibrooseous lesions are rare diseases which are

characterized by replacement of healthy bone and con-

nective tissue that transforms to cemento-osseous tissue

[1]. Fibroosseous lesions can be classified in three cate-

gories as fibrous dysplasia, benign fibroosseous neo-

plasms and reactive lesions [2].

The term cemento-osseous dysplasia was adopted for

the WHO classification in 1992 [3]. Cement like

structures are mostly seen on jaws in all skeletal bones.

The term cemento-osseous is used because of the

difficulty in discrimination of cement and bone tissue in

lesions which produce cement, bone and connective

tissue. Cemento osseous dysplasias are non-neoplastic

lesions and related with tooth bearing areas. This term

include florid osseous dysplasia, focal cemento-osseous

dysplasia and periapical cemental dysplasia [4].

Focal cemento-osseous dysplasia is accepted as most

frequently seen fibroosseous pathology. FCOD is seen

predominantly in African-American females, with a peak

incidence in the fourth and fifth decades. FCOD can

reach 1-2 cm size in dimensions and effect edentulous

jaws and the tooth extraction sockets. It may be localized

nearby the teeth. FCOD can cause expansion of the local

bone and can be secondarily infected [2,5-7].

FCOD is mostly a fairly well defined radioluscency

with a sclerotic border or a mixed radioluscent and

radiopaque lesion. Histopathologically, FCOD is formed

by spindle cells, bone-cement like trabeculation and con-

nective tissue stroma. Histopathologic view varies due to

the stage of the lesion. In the early stage, cellular and

vascular structures are dense and surrounded by a pro-

liferated fibrous connective tissue stroma. In the osteolytic

stage cement like structures can not be seen. In the last

osteosclerotic stage the lesion reveals poor cellularity,

bone trabeculae and irregular cement like structures

making anastomosis with each other. Fibroosseous mid-

stage consists of both early and late stage characteristics

[5,8].

FCOD does not require treatment and certainly not

routine biopsy unless it is infected and symptomatic [7].

In this report a female patient with the lesion diagnosed

as FCOD by histological and radiological examination

on the left mandibular molar region is presented. His-

tologically, these cemento-osseous lesions undergo change

from normal vascular bone into woven bone in a matrix

of fibrous connective tissue. Management of the cemento-

osseous dysplasia may be difficult and not very satis-

factory. The lesion may persist for indefinite periods of

time without causing any symptoms. For the asympto-

matic patient, the best management consists of regular

recall examinations with prophylaxis and reinforcement

of good home hygiene care to control periodontal

disease and prevent tooth loss. [9].

2. CASE REPORT

Fifty two year old female patient was referred to Ankara

University, Faculty of Dentistry, Department of Oral and

D. Yazicioglu et al. / HEALTH 2 (2010) 941-944

942

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Maxillofacial Surgery for prosthetic rehabilitation of

extracted left premolar and molar teeth. The patient was

questioned for the physiological examination and there

were no recorded physiological disorder. Clinical exam-

ination revealed a complaint of a significant dull pain on

the left posterior region of the mandible and any kind of

pathologic changes on the alveolar mucosa of the same

region was not seen. The complaints of the patient such

as eating disorder and pain did not affect the comfort of

patient , but caused functional problems. In radiologic

examination, a radioopaque ill-defined lesion is observed

on the posterior left edentuolus part of the mandible. It

was decided to perform an advanced radiographic exam-

ination to evaluate the lesion. Thus, panoramic and com-

puterised tomography was performed and a 1 cm diameter

lesion was identified 2-3 mm above the mandibular

canal (Figures 1 and 2).

A surgical intervention was decided to exclude pain

and to prepare a healthy bone for dental implant re-

habilitation. The lesion was curetted in two parts. How-

ever, pathologic tissue was not easily separated from

surrounding healthy bone. The histological diagnosis

was FCOD and the examination revealed compact and

dense cement bone like structures deposited as irregular

lamellae and ill-defined borders. Based on the ob-

servation of histologic slides, the mineralised structures

did not contain a lot of cells and had a low amount of

interstisiel connective tissue. There was not any sign of

dentin or dentin like tissue and malignancy (Figures 3

and 4). Surgical site healed uneventfully in the post-

operative period. Recurrence was not observed during

the follow up period of postoperative six months before

the dental implant rehabilitation (Figure 5).

3. DISCUSSION

Cemento-osseous lesions are derived from periodontal

ligament tissues and occured by the same pathological

process. They can be classified in three groups which are

periapical cemental dysplasia, focal cemento-osseous

dysplasia and florid cementoosseous dysplasia [10]. Per-

iapical cemental dysplasia is bilateral and generally

located periapically [9]. Florid cemento-osseous dysplasia

is a dysplastic form of bone and cemental tissue and res-

tricted in jaws. In addition to this, florid osseous dy-

splasia can be classified as a diffuse form of periapical

cemental dysplasia [11]. It is crucial for the differential

diagnosis of FCOD, provided that the lesion is solid,

located posteriorly on jaws and 1-2 cm in diameter.

FCODs are cystic radioluscent lesions in the early

period. Luscent lytic areas replace with opaque areas in

time. FCOD do not usually expand the cortical layer [8].

Figure 1. FCOD lesion confirmed on CT axial section.

Figure 2. Panoramic radiography of the FCOD lesion.

Figure 3. Histopathologic image of FCOD lesion showing

loose fibrous tissue and active irregular cement-bone like tis-

sue formation. Intersticiel connective tissue exists as scattered

narrow bands (Hematoxylin-Eosin stain × 50).

D. Yazicioglu et al. / HEALTH 2 (2010) 941-944

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Figure 4. Higher magnification of histopathologic image. Note

the cellularity of connective tissue. Irregular lamellea of dense

cementum-bone like deposits can be easily seen (Hematoxylin-

Eosin stain × 200).

Figure 5. Panoramic radiography after 6 months follow-up

postoperative period.

Once they excised, recurrence is not common. However,

cystic changes may take place around the lesion [4].

FCOD was first reported as ‘localized fibro-osseous

cemental lesion’ by Waldro [2]. Later, it is renamed as

focal cemento osseous dysplasia and its unique feature was

identified by Summerlin and Tomich [5]. It is also

compared with cemento-ossifying fibroma which FCOD

resembles histopathologically [5]. The establishment of the

exact differentiation between cemento-ossifying fibroma

and FCOD was made in 1971 [7]. It is emphasized that

the surgical specimen of FCOD was in fragments on

histopathologic examination, unlike COF [12]. It is

difficult to distinguish FCOD and ossified fibroma

clinically and histopathologically. Ossified fibromas are

well-demarcated and show radioluscent feature with small

radioopaque calcifications. However, FCOD is usually

radioopaque. Ossified fibromas can be easily separated

and excised as one segment from surrounding tissues

thanks to its well-demarcated border. FCOD can not be

readily excised from healthy bone [6].It is also difficult to

distingusih FCOD and florid cemento- osseous dysplasia.

Florid cemento-osseous dysplasia may be familial with

an autosomal dominant inheritance pattern, but there are

only a few examples in the literature in which the

familial pattern has been confirmed [13,14]. In the resent

case, no familial aspects of the disease could be estab-

lished. FCOD is mostly a fairly well defined radio-

luscency with a sclerotic border or a mixed radioluscent

and radiopaque lesion. These lesions exhibit a sclerotic

appearance similar to that of other lesions on conven-

tional radiographs. Paget’s disease of the bone may also

have a cotton-wool appearance. Paget’s disease is often

polyostotic, involving other bones such as spine, femur,

skull, pelvis and sternum and produces biochemical

serum changes, such as elevated alkaline phosphate,

calcium and phosphorus levels [14].However, there there

is no recorded elevation of biochemical serum levels for

the focal cemento-osseous lesions in the literature.

FCOD lesion reveal itself with a female predilection

[15]. They are fairly well or poor defined lesions ac-

cording to some authors [5,6]. However, Okhura reported

that almost all of the cases treated were well defined [16].

It is considered that infections seem to occur after the

exposure of cemental masses by resorption of the

edentuolus alveolus or by extraction of teeth whose roots

are close to the lesions [17]. Infection of FCOD may

induce chronic sclerosis. Furthermore, it is reported that

chronic osteomyelitis could appear on radiographic

examination similar to the FCOD [17]. Waldron defined

FCOD as an abnormal reaction of bone to the injury due

to its significant presence at extraction sites. It is also

reported that FCOD lesions are localized on edentulous

posterior parts of mandible [2,16]. According to Ohkura,

radioluscent content of radiographic appearance of FCOD

is more common in younger patients whereas complete

radiopacities are more prevalent in older patients [16]. In

contrast to this opinion, some studies reveal complete

radiopacities can occur in younger patients [18].

Summerlin and Tomich recommended follow-up for

FCOD lesions for the possibility of progression to florid

cemento-osseous dysplasia [5]. FCOD lesions have

tendency to occur in the other quadrants of jaws, if a

FCOD lesion is present [19]. Although the follow-up for

D. Yazicioglu et al. / HEALTH 2 (2010) 941-944

944

FCOD is a widely accepted entity for researchers, there

is no any recommendations about the long term follow-

up of these lesions [20]. It is not known whether the

bone after the healing period will be adequate for the

osseointegrated implants after removal of the lesion [20].

Openly accessible at /HEALH

FCOD lesions have significant clinical importance due

to edentulous sites requiring osseointegrated implants,

though, it is accepted that a symptomatic FCOD need no

treatment. As an essential matter, the introduction of the

new discovered FCOD lesions is required [20].

4. CONCLUSIONS

Histological and radiographic examination is significant

for the differential diagnosis of FCOD. Its solid nature

and posterior localization ease the differential diagnosis.

The treatment includes long term follow-up for asym-

ptomatic lesions or surgical excision if a dental implant

rehabilitation is planned for the affected partial ed-

entulous region of jaw, as seen in this case.

FCOD is rarely diagnosed according to the literature.

Thus, due to the importance of FCOD, the lesion must

be included during the evaluation of intraosseous le-

sions.

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