Vol.2, No.8, 941-944
doi:10.4236/health.2010.28139
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(2010) HEALTH
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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
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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).
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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
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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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