ISSN:

Printed version: 1806-7727

Electronic version: 1984-5685
RSBO. 2012 Jan-Mar;9(1):102-7

Case Report Article

Periapical cemento-osseous dysplasia:

case report
Francine Sumie Morikava1
Ligia Yumi Onuki1
Cassiano Lima Chaiben1
Maria Helena Martins Tommasi1
Iran Vieira1
Antonio Adilson Soares de Lima1

Corresponding author:
Antonio Adilson Soares de Lima
Curso de Odontologia Departamento de Estomatologia da UFPR
Rua Prefeito Lothrio Meissner, n. 632 Jardim Botnico
CEP 80170-210 Curitiba PR Brasil
E-mail: aas.lima@ufpr.br

1
School of Dentistry, Department of Stomatology, Federal University of Paran Curitiba PR Brazil.

Received for publication: April 18, 2011. Accepted for publication: June 20, 2011.

Abstract
Keywords: mandible;
tooth cementum; Introduction: Periapical cemento-osseous dysplasia is a pathologic
panoramic radiograph; entity resulting from bone and cementum reactional process which
periapical tissue. affects the periapical region of the anterior mandible. Its etiology is
not fully understood, but possibly it is related to an unusual bone
and cementum response to some local factor. Objective: The aim
of this study is to present a case of periapical cemento-osseous
dysplasia. Case report: A 50 years-old female patient sought for
dental care due to pain in the lower right premolar region. The
panoramic radiography revealed the presence of an extensive
radiolucent lesion with radiopaque areas located between the roots
of the teeth #43 and #35. Teeth presented vitality and it was not
observed any changes involving the periodontal ligament. Periapical
cemento-osseous dysplasia diagnosis was established through clinical
and radiographic features. Periapical cemento-osseous dysplasia
does not require any treatment unless complications occur. Patients
complaint of discomfort was related to occlusal imbalance and
was solved after the occlusion reestablishment. The patient was
radiographically followed-up for 12 months and the lesion exhibits
satisfactory signs of healing. Conclusion: The dentists need to be
aware of asymptomatic intra-osseous lesions affecting the anterior
region of mandible not to misconduct the diagnosis that could
compromise the patients oral health.

Introduction
Osseous dysplasia is defined as a reactional and
non-neoplasic process developing in periapical tooth
area and characterized by normal bone replacement
by fibrous tissue and metaplastic bone. This
pathological alteration can assume several clinical
forms and therefore receive different denominations
[22]. When such process occurs in the periapical
area of mandibles anterior teeth, is so-called
periapical cemento-osseous dysplasia. However,
other terms have been used for this pathological
entity, such as: cementums periapical dysplasia,
periapical cemental dysplasia, focal cemento-
osseous dysplasia, periapical osseous dysplasia,
and periapical cementoma [14, 21, 23].
According to the classification proposed by
Eversole et al. [6], among the large spectrum of
osseous lesions, there is a group of entities so-
called cemento-osseous dysplasias comprising focal
cemento-osseous dysplasia and florid cemento-
osseous dysplasia. For this authors, periapical
cemento-osseous dysplasia or focal cemento-
osseous dysplasia are two different terms for the
same reactive lesion. However, the World Health
Organizations most recent tumor classification
says that periapical cemento-osseous dysplasia is
a condition related to osseous lesions [2].
The etiology and pathogenesis of this entity
are still unknown. On the other hand, clinical and
histological evidences show this condition has a
histogenetic origin derived from the periodontal
ligament [29].
Periapical cemento-osseous dysplasia exhibits a
predilection for melanoderm women, at mid-age (40-
50 age-range) and rarely below 20 years-old [4, 27].
Mandibles periapical area is the most common site
of appearance; frequently multiple sites are affected
(root apex of two or more teeth). A radiographic
study performed by Su et al. [27] revealed that the
lesions mean size is about 1.8 cm, ranging from
0.2 to 11 cm. Additionally, although the lesions are
close to the tooth apex, the periodontal ligament
remains clearly visible in radiographs [9].
Periapical cemento-osseous dysplasia is a self-
limiting problem because the osseous cortex is
not expanded and progressive growth is rare. Its
prevalence is difficult to be determined because
it is an asymptomatic lesion and there is not the
need of a biopsy to prove the diagnosis [14]. In
1934, Stafne conducted a radiographic study in a
sample of 10,000 patients and found a prevalence
of 0.24%. Neville et al. [15] observed a prevalence
of 5.9% of periapical cemento-osseous dysplasia in
RSBO. 2012 Jan-Mar;9(1):102-7 103
Black women. Vicci & Capelozza [30] determined
the occurrence of tooth and osseous lesions by
using the image of panoramic radiographs. This
study revealed the prevalence of periapical cemento-
osseous dysplasia was 1.8%. In 2008, Pereira et
al. [18] performed a similar study and found a
prevalence of 1% for this disease.
Periapical cemento-osseous dysplasia has a
natural evolutional path in which changes in the
pathologys features are noted. Traditionally, this
evolution can be divided into three stages: osteolytic,
cementoblastic and mature. However, Langlais et al.
[11] believed that there would be two additional stages:
a more early osteoporotic stage in all cases and a
later florid stage in some cases. The replacement of
osseous tissue by fibrous tissue is characterized by a
radiolucent image at the tooth apexes, indicating the
osteolytic stage of its development. As the condition
progresses, the radiolucent lesion assumes a mixed
pattern due to an increase of the cementoblastic
activity leading to cementum spicules deposition.
These aspects characterized the cementoblastic stage
of the development. At the mature stage, periapical
cemento-osseous dysplasia is a solid opaque mass,
frequently surrounded by a radiolucent halo, due
to its complete maturation. This process can take
months or years to occur [14].
Due to t he nature a nd evolut ion of t his
lesion, no treatment is necessary. Because the
teeth remain vital, tooth extraction or endodontic
treatment should not be performed On the other
hand, regular following-up examinations are
recommended comprising dental prophylaxis and
oral hygiene instruction reinforcement to prevent
periodontal disease and caries lesions which can
lead to tooth loss [16]. The aim of this study is
to describe a case of a patient diagnosed with
periapical cemento-osseous dysplasia based on the
clinical and radiographical findings.
Case report
A 50-year-old, melanoderm patient sought for
the Semiology Clinics of the School of Dentistry of
Federal University of Parana due to a complain of
discomfort at the area of tooth #44, #45, and #46,
where implants had been installed two years ago.
During clinical examination, it could be noted
the presence of caries lesions, gingival retraction,
periodontal pocket at tooth #17 and a nodular
lesion in lower lip whose diagnosis was fibrous
hyperplasia. This lesion underwent an excisional
biopsy and the anatomic-pathological examination
confirmed the diagnosis.
 Morikava et al.
104 Periapical cemento-osseous dysplasia: case report
To evaluate the origin of the patients discomfort,
oral examination, panoramic and periapical
radiographs of the region were done. The radiographs
revealed that the area where the implants had been
installed did not show any significant alteration.
Therefore, the patient was referred to the Periodontics
Clinics for a more detailed assessment. Because
no radiographic alteration involving the implants
was seen, patients periodontium and occlusion
was checked. Periodontal examination did not
find any contributory finding, but the occlusion
examination revealed a premature contact in the
prosthesis installed on the implant at the area of
tooth #45. Patients occlusion was reestablished
through weariness with burs and polishing of the
amalgam restoration in the antagonist tooth. The
anterior teeth and the implants were submitted to
root scaling, planing and polishing. Additionally,
patient was instructed to improve her oral hygiene.
At the following appointment, one week later, patient
reported that her discomfort had stopped.
Notwithstanding, during the analysis of the
pa nora mic radiographic, it was observed a n
extensive lesion of radiolucent aspect comprising
areas of radiopacity within it, which was located
at t he a rea close to t he lower i ncisors a nd
Figure 1 Extensive lesion at the mandibles anterior area in the panoramic radiographic
canine teeth (figure 1). Periapical radiographs
were executed and showed that the lamina dura
surrounding the apical area of the involved teeth
was preserved (figure 2).
The patient was not aware about the presence
of intra-osseous lesions and did not feel any
discomfort in the area. The physical examination
of the mucosa revealed that there was not any
volume increase and that the periodontal tissues
were normal (figure 3). All teeth in this area
were submitted to thermal test, which responded
positively demonstrating that tooth vitality was
preserved. Vertical percussion test was also
conducted, and the patient did not report any
discomfort. The diagnosis of periapical cemento-
osseous dysplasia was established based on the
lack of symptomatology and on the clinical and
radiographic aspects of the lesion (melanoderm
patient, 50 years-old, female, painless lesion
involving several lower incisors). Because the
lesions were asymptomatic and already exhibited
signs of repair, biopsy was not considered. The
only procedure executed was periodic radiographic
following-up. One year clinical and radiographical
following-up examination showed satisfactory signs
of lesion evolution.

Figure 2 Radiolucent aspect of the lesion with
radiopaque areas maintaining the lamina dura
Figure 3 Chin area and oral mucosa with normal
aspect
Discussion
Periapical cemento-osseous dysplasia is an
asymptomatic clinical condition occurring exclusively
in the mandibles anterior area and whose etiology
remains inconclusive. Literature has presented
several clinical cases and in some of them due to
RSBO. 2012 Jan-Mar;9(1):102-7 105
misdiagnosis a satisfactory result was not achieved
[3, 5, 7, 8, 10, 12, 19, 20, 24, 25, 26, 31].
In this present case report, a 50-year-old
melanoderm female patient sought for dental
treatment because of a discomfort in the bicuspid
area where there were osseointegrated implants.
During the patients examination, a routine panoramic
radiograph was executed and revealed the presence
of a lesion with mixed radiographic aspect. Periapical
cemento-osseous dysplasia at its cementoblastic stage
demonstrated a radiolucent-radiopaque mixed pattern
with a well defined radiolucent halo surrounding
the radiopacity areas [6]. The cases of periapical
cemento-osseous dysplasia are often detected
through routine radiographic examinations [17].
Although periapical cemento-osseous dysplasia is a
lesion easily diagnosed, it can be mistaken by other
alterations occurring at the area closer to tooth
apexes, such as: apical periodontal cyst, periapical
granuloma and chronic osteomyelitis. This could
occur during periapical cemento-osseous dysplasia
evolution first stages, and the case could be misled.
Differential diagnosis of periapical cemento-osseous
dysplasia at its cementoblastic stage includes chronic
sclerosing osteomyelitis, ossifying/cementing fibroma,
odontoma, and osteoblastoma [7]. In this context,
the cases clinical and radiographic features are
fundamental at the moment of establishing the
definitive diagnosis.
The radiographic image may be erroneously
interpreted as an infection of endodontic origin. In
these cases, tests evaluating pulp tissue vitality are
important to elucidate any clinical confusion [8]. In
this case report, the radiographic image was very
suggestive of periapical cemento-osseous dysplasia.
However, even then, we opted to perform vitality
cold/hot and vertical percussion tests.
The key points for this disease diagnosis,
according to Brannon & Fowler [4] are:
Predilection for mid-age Black women;
One or more circumscribed lesions (0.5 cm or
shorter) at the periapical area of vital teeth;
Painless non-expansive lesion located usually at
mandibles anterior area;
Radiographic characteristics can be radiolucency of
mixed density (radiolucent with opacities), or opaque
with a narrow radiolucent margin;
Cellular fibrous stroma with lamellar osseous
tissue and/or oval calcifications.
The case here described fulfills almost all
the characteristics of the diagnosis suggested by
Brannon & Fowler [4]. The lesion occurred in a
mid-age Black woman presenting a non-expansive
extensive painless intra-osseous lesion localized at
the mandibles anterior area. The radiographic aspect
 Morikava et al.
106 Periapical cemento-osseous dysplasia: case report
observed in the radiographs revealed that the lesion
was large, of mixed density, and it seemed a result
of the union of several lesions affecting the incisors
and canine teeth.
It is a consensus t hat t he execut ion of
invasive procedures, such as tooth extraction and
biopsy for histopathological analysis in periapical
cemento-osseous dysplasia patients is extremely
contraindicated. Such procedures may cause the
inoculation of bacteria into the lesions and begin
a serious infection. Additionally, because blood
vessels are not capable of penetrating into the thick
cortical margins surrounding the lesions, the use of
antimicrobial therapy is not effective [20]. Therefore,
since patient did not report any discomfort at the
lesion area, radiographic follow-up of the case was
conducted. Patient returned 12 months later and
the lesion still preserved its radiolucent aspect with
increase of internal radiopacity.
Because periapical cemento-osseous dysplasia
approach is the clinical and radiographic following-
up, biopsies are not executed. This contributes to
some extent that further histopathological studies
be limited. At macroscopic examination, stained
fragments coming from periapical cemento-osseous
dysplasia are of brownish color and friable aspect [28].
The histomorphological findings of periapical, focal
and florid dysplasias are essentially undistinguishable
and show a spectrum of progressive features
depending on, especially, the stage of the lesions
development. At the initial stages, the lesions are
represented by a fibrous non-encapsulated conjunctive
tissue exhibiting numerous blood vessels of small
caliber and lack of inflammatory cells [4]. The
case here described, due to its radiographic aspect,
probably was at cementoblastic stage, which is
characterized by a variable amount of mineralized
tissue comprising immature bone trabeculae and
round drops of a tissue similar to cementum. These
structures of tissue similar to cementum may fuse
to each other and produce larger aggregates with
rounded contours accounting for increasing the
radiopacity degree within the lesions [11].
Periapical cemento-osseous dysplasias are
probably the most common fibro-osseous lesions
found in clinical practice. Its pathogenesis remains
unknown, although it can represent a reactive or
dysplastic process. The dentist must be aware of
the appearance of these lesions in clinical practice
and have enough knowledge to determine the proper
diagnosis, avoiding therefore inappropriate approaches
which can compromise the patients health.
The patient searched for treatment due to her
discomfort in an edentulous area where implants
had been installed about one year ago. Pain or
discomfort may be one of the first signs of implants
failure, usually with its mobility [13]. Additionally,
persistent discomfort could occur prior to any
radiographic chance to be detected [32]. A fractured
or loosen implant should be the first hypothesis
when a patient complaint about discomfort or that
the implant is loosen. According to the American
Academy of Periodontics [1], periodical evaluation
after implant installation should follow the following
factors: a) presence of plaque or calculus; b) clinical
aspect of the periimplantar tissue; c) the implants
and surrounding structures radiographic aspect;
d) occlusal status and the prosthesis and implants
stability; e) probing depth and the presence of
exsudate or bleeding to probe; f) the function and
the patients comfort.
This case reports patient underwent a clinical and
radiographic examination which identified a possible
relation of the reported sensibility to an occlusal
imbalance. Once the occlusion adjustment was
performed, patient returned without complaints.
Conclusion
Intra-osseous lesion misdiagnosis found in
routine examinations is common. Periapical cemento-
osseous dysplasia is a condition with particular
characteristics and whose diagnosis is based on the
cases clinical and radiographic information.
References
1. American Academy of Periodontology. Position
paper. Dental implants in periodontal therapy.
J
Periodontol. 2000;71(12):1934-42.
2. Barnes L, Eveson JW, Reichart P, Sidransky
D. Gentica e patologia dos tumores de cabea e
pescoo. So Paulo: Santos; 2009.
3. Bittencourt S, Meira AL, Ferreira OS, Tunes
U, Ribeiro E, Casati MZ. Displasia cementria
periapical relato de caso. Rev Inst Cinc Sade.
2007;25(3):319-21.
4. Brannon RB, Fowler CB. Benign fibro-osseous
lesions: a review of current concepts. Adv Anat
Pathol. 2001;8(3):126-43.
5. Ceclia MS, Favieri A, Aroeira R. Displasia
cementria periapical, conseqncia de diagnstico
incorreto: relato de caso. RBO. 2000;57(1):10-1.
6. Eversole R, Su L, ElMofty S. Benign fibro-osseous
lesions of the craniofacial complex a review. Head
and Neck Pathol. 2008;2:177-202.
7. Galgano C, Samson J, Kuffer R, Lombardi T. Focal
cemento-osseous dysplasia involving a mandibular
lateral incisor. Int Endod J. 2003;36(12):907-11.

8. Gariba-Silva R, Sousa-Neto MD, Carvalho Jr JR,
Saquy PC, Pecora JD. Periapical cemental dysplasia:
case report. Braz Dent J. 1999;10(1):55-7.
9. Kawai T, Hiranuma H, Kishino M, Jikko A,
Sakuda M. Cemento-osseous dysplasia of the jaws
in 54 Japanese patients: a radiographic study. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
1999;87(1):107-14.
10. Komabayashi T, Zhu Q. Cemento-osseous
dysplasia in an elderly Asian male: a case report. J
Oral Sci. 2011;53(1):117-20.
11. Langlais RP, Langland OE, Nortj CJ. Diagnostic
imaging of the jaws. Malver: Williams & Wilkins;
1995. p. 540-6.
12. Leal RM, Santiago Mde O, Silveira FF, Nunes
E, Capistrano HM. Periapical
cemental dysplasia
in twin sisters: a case report. Quintessence
Int.
2009;40(10):e89-92.
13. Lekholm U, van Steenberghe D, Herrmann
I. Osseointegrated implants in the treatment of
partially edentulous jaws: a prospective 5-year
multicenter study. Int J Oral Maxillofac Implants.
1994;9:627-35.
14. Melrose RJ. The clinicopathologic spectrum of
cemento-osseous dysplasia. Oral Maxillofacial Surg
Clinical North Amer. 1997;9(4):643-53.
15. Neville BW, Albenesius RJ, Charleston SC.
The prevalence of benign fibro-osseous lesions
of periodontal ligament origin in black women:
a radiographic survey. Oral Surg Oral Med Oral
Pathol. 1986;62(3):340-4.
16. Neville BW, Damm DD, Allen CM, Bouquot
JE. Patologia
oral e maxilofacial. Rio de Janeiro:
Guanabara Koogan; 2004. p. 534-8.
17. Ogunsalu CO, Lewis A, Doonquah L. Benign fibro-
osseous lesions of the jaw bones in Jamaica: analysis
of 32 cases. Oral Diseases. 2001;7:155-62.
18. Pereira RM, Ribeiro EDP, Bittencourt S. Displasia
cementria periapical: estudo de prevalncia. Innov
Implant J Biomater Esthet. 2008;3(5):43-6.
19. Pippi R, Della Rocca C, Sfasciotti GL.
Periapical
cemental (fibrous) dysplasia. Clinical, radiographic
and pathologic aspects in 7 reported cases. Minerva
Stomatol. 2004;53(4):135-41.
20. Sethusa MPS, Khan MI. The orthodontic
management of a patient presenting with cemento-
osseous dysplasia. SADJ. 2009;64(3):120-4.
RSBO. 2012 Jan-Mar;9(1):102-7 107
21. Slootweg PJ. Bone diseases of the jaws. Int J
Dent. 2010;2010:1-7.
22. Slootweg PJ. Displasias sseas. Gentica e
patologia dos tumores de cabea e pescoo. So
Paulo: Santos; 2009. p. 323.
23. Slootweg PJ. Lesions of the jaws. Histopathology.
2009;54(4):401-18.
24. Smeele LE, Baart JA, Van der Waal I. Unusual
behavior of periapical cementous dysplasia. Br J
Oral Maxillofac Surg. 1991;29(1):58-60.
25. Smith S, Patel K, Hoskinson AE. Periapical
cemental dysplasia: a case of misdiagnosis.
Br Dent
J. 1998;185:122-3.
26. Studart-Soares EC, Scortegana A, Azoubel E,
Pezzi LPG, Santana Filho M. Leses fibro-sseas:
displasia cemento-ssea periapical X displasia
cemento-ssea florida. R Fac Odontol Porto Alegre.
1998;39(2):26-30.
27. Su L, Weathers DR, Waldron CA. Distinguishing
features of focal cemento-osseous dysplasia
and cemento-ossifying fibromas. II. A clinical
and radiologic spectrum of 316 cases. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
1997;84(5):540-9.
28. Su L, Weathers DR, Waldron CA. Distinguishing
features of focal cemento-osseous dysplasias
and cemento-ossifying fibromas: I. A pathologic
spectrum of 316 cases. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 1997;84(3):301-9.
29. Summerlin DJ, Tomich CE. Focal cemento-
osseous dysplasia: a clinicopathologic study
of 221 cases. Oral Surg Oral Med Oral Pathol.
1994;78(5):611-20.
30. Vicci JG, Capelozza ALA. Incidncia de leses
dentrias e sseas evidenciadas atravs de radiografia
panormica. FOL/UNIMEP.
2002;14(2):43-6.
31. Wilcox LR, Walton RE. Case of mistaken
identity: periapical cemental dysplasia in an
endodontically treated tooth. Endod Dent Traumatol.
1989;5(6):298-301.
32. Worthingon P, Bolender CL, Taylor TD. The
Swedish system of osseointegrated implants:
problems and complications encountered during a
4-year trial period. Int J Oral Maxillofac
Implants.
1987;2:77-84.
 CEMENTO-OSSEOUS DYSPLASIAS

Displasias cemento-sseas

Saadettin Dagistan1, Mustafa Goregen2, Binali akur3, zkan Miloglu4

1
DDS, PhD Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatrk University.
2
DDS, Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatrk University.
3
DDS, PhD Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatrk University,
Erzurum, Turkey, e-mail: bcakur@atauni.edu.tr
4
DDS, Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatrk University.

Abstract
Cemento-osseous dysplasia is a benign condition of the jaws that may arise from the fibroblasts of the
periodontal ligaments. Cemento-osseous dysplasias are further classified into three main groups: periapical
(surrounds the apical region of teeth), focal (single lesion) and florid (sclerotic symmetrical masses)
cemental dysplasias. The etiology of the condition is unknown, although it has been suggested to occur
as a result of mild chronic trauma or traumatogenic occlusion. Cemento-osseous lesions are
asymptomatic and no treatment is required. In this article, we discuss these different types of cemento-
osseous lesions in light of four presented cases.

Keywords: Cemento-osseous dysplasia; Periapical cementoma; Cementoblastoma.

Resumo
A displasia cemento-ssea uma condio benigna dos maxilares que pode originar-se de
fibroblastos do ligamento periodontal. So classificadas em trs grupos principais: periapicais
(circundam a regio apical dos dentes), focal (leses isoladas) e displasias cementrias floridas
(massas esclerticas simtricas). A etiologia da condio desconhecida, embora tenha sido
sugerido que resulta de trauma crnico leve ou ocluso traumtica. As leses cemento-sseas so
assintomticas e no requerem tratamento. Neste artigo, discutem-se os diferentes tipos de leses
cemento-sseas, luz da apresentao de quatro casos.

Palavras-chave: Displasia cemento-ssea; Cementoma periapical; Cementoblastoma.

Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49

44 Dagistan S, Goregen M, akur B, Miloglu .
INTRODUCTION
The classification of cemento-osseous
lesions within jaws has long been a debatable
topic for pathologists and clinicians. The literature
displays a wide range of terminology in order to
define the similar-looking lesions (1, 2, 3). The
most recent classification of cemento-osseous
lesions was released in 1992 by the World Health
Organization based on the location of the lesion
as well as age, sex, histopathological,
radiographical and clinical characteristics. This
classification includes cemento-osseous
dysplasia, cemento-ossifying fibroma and benign
cementoblastoma (4).
Cemento-osseous dysplasias are
probably the most common type of fibro-osseous
lesions encountered in clinical practice. The
pathogenesis of the cemento-osseous dysplasias
is unknown, although they appear to represent
some form of reactive or dysplastic process. On
the basis of their clinical and radiographic features,
this type is further divided into three groups:
periapical, focal and florid cemento-osseous
dysplasia (5).
Periapical cemento-osseous dysplasia
(PCOD) is an asymptomatic benign lesion. The
term cementoma is often used for this condition,
although, it is not a neoplasm (6). PCOD occurs
most commonly in the anterior mandible of
patients older than 30 years of age. It is more
common in women than in men, and there is a
predominance in black women (6, 7). Solitary or
multiple lesions may occur but multiple lesions
are present more frequently (8). Related teeth are
almost invariably vital (5).
PCOD appears in radiographs taken for
other reasons (5, 9). It displays three different
characteristics according to its period. In the first
period, which is also called osteolytic period,
circular and elliptical resorption areas are seen in
the place where the lesion is located. In the second
period, which may also be called as cementoblastic
period or intermediate period, small calcifications
occur within the lesion. A mixed radiolucent and
radiopaque appearance emerges. In the third period,
lesions display massive calcifications. Solitary
lesions may rarely widen to 10 cm in diameter, but
not widen to the cortex (5, 9).
Focal cemento-osseous dysplasia (FCOD) is
a benign lesion that occurs between the periapical
Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49
and florid cemento-osseous dysplasia. Although
both periapical and florid types represent similar
features, they have different clinical and
radiographical characteristics. About 80 percent
of cases occur in females, between 30 and 50
years of age, and it is more common in white than
in black patients (10). FCOD may occur in any
area of the jaws, although the posterior mandible
is the predominant site (6).
Radiographically, the lesion may appear
as completely radiolucent or completely
radiopaque. Most commonly, however, there is a
mixed pattern. Usually, the patient has only one
lesion. Once a diagnosis has been established, no
treatment is necessary (5, 6).
Florid cemento-osseous dysplasia (FLCOD)
has been described as a condition that usually
manifests as multiple radiopaque cementum-like
masses distributed throughout the jaws. This
condition has also been classified as gigantiform
cementoma, chronic sclerosing osteomyelitis and
sclerosing osteitis. It occurs most often in black
women older than 40 years of age (1, 4, 11). The
condition usually involves multiple quadrants
(6). The process may be totally asymptomatic
and, in such cases, the lesion is detected when
radiographs are taken for other purposes (12).
Radiographically, the lesions appear as
multiple sclerotic masses, located in the maxilla
or mandible. The diagnosis of florid cemento-
osseous dysplasia is usually made on the basis of
the characteristic radiographic appearance. No
treatment is indicated. The most common
complication is the development of osteomyelitis
in patients who wear full or partial dentures (6).
REPORT OF CASES
Case I
A 40-year-old female patient applied to
our clinic due to lack of teeth. The patient had no
systemic disease. In the extra-oral examination,
no abnormal symptoms were observed. After
intra-oral examination, a panoramic radiograph
was taken. A radiopaque lesion surrounded by a
radiolucent halo was observed in the apical area
of the lower left canine (Figures 1 and 2). The
vitality test was positive. Based on the clinical
examination and radiographic evaluation, a
diagnosis of mixed period of PCOD was made.
 Cemento-osseous dyplasias 45

FIGURE 1 - Radiopaque lesion surrounded by radiolucent halo in the apical area of the lower
left canine

examination, no abnormal symptoms were

observed. After intra-oral examination, a
panoramic radiograph was taken. A radiopaque
lesion surrounded by a radiolucent halo was
observed in the distal apical area of the lower left
first molar (Figures 3 and 4). The vitality test was
positive. Based on the clinical examination and
radiographic evaluation, a diagnosis of FCOD of
mixed stage was made.

FIGURE 2 - Radiopaque lesion in the periapical area

of the lower left canine

Case II
FIGURE 3 - Radiopaque lesion surrounded by a
A 32-year-old female patient applied to
radiolucent halo in the distal apical area
our clinic with wisdom teeth complaints. The of the lower left first molar
patient had no systemic disease. In the extra-oral

Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49

46 Dagistan S, Goregen M, akur B, Miloglu .

FIGURE 4 - Radiopaque lesion surrounded by radiolucent halo in the distal apical area of the lower
left first molar

Case III radiolucent halo was observed in the apical area

A 21-year-old male patient applied to
our clinic for routine control. The patient had no
systemic disease. Upon extra-oral examination,
no abnormal symptoms were observed. After
intra-oral examination, a panoramic radiography
was taken. A radiopaque lesion surrounded by a
of the lower left first premolar. Another lesion
that was totally radiopaque was observed in the
apical area of the mesial root of the lower right
first molar (Figure 5). Vitality tests for both teeth
were positive. Based on the clinical examination
and radiographic evaluation, a diagnosis of FCOD
of mixed and end stage, respectively, was made.

FIGURE 5 - Radiopaque lesion surrounded by a radiolucent halo in the apical area of the lower left first
premolar. Another totally radiopaque lesion in the apical area of the mesial root of the lower
right first molar

Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49

 Cemento-osseous dyplasias 47

Case IV and mucosa were normal without any clinical signs

A 47-year-old female patient applied to
our clinic for a dental care. She was systemically
healthy and the extra-oral examination was within
normal limits. An intraoral examination revealed a
partially edentulous area and the overlying gingiva
of inflammation. There was no marked expansion
in the mandible. A panoramic radiography was
obtained. Multiple sclerotic masses with radiolucent
borders were found in the mandibula (Figures 6
and 7). A diagnosis of FLCOD was made, but was
not confirmed, as the patient declined a biopsy.

FIGURE 6 - Multiple sclerotic masses with radiolucent borders in the mandible

FIGURE 7 - Radiopaque lesions confined within the alveolus in the regions of the lower
right premolar

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48 Dagistan S, Goregen M, akur B, Miloglu .
DISCUSSION
Cemento-osseous dysplasias are
probably the most common types of fibro-osseous
lesions encountered in clinical practice. The
pathogenesis of the cemento-osseous dysplasias
is unknown, although they appear to represent
some form of reactive or dysplastic process. On
the basis of their clinical and radiographic features,
cemento-osseous dysplasias are divided into three
groups: periapical, focal and florid cemento-
osseous dysplasia (5).
The observations revealed that periapical
and focal cemento-osseous dysplasias share the
same histopathological and clinical characteristics
(13). Although FCOD is most common seen in
the posterior mandible, PCOD is generally seen
in the anterior mandible (6, 7). Additionally,
FCOD is more common in white men compared
to black men (10). The localization of lesions in
our second and third cases diagnosed with FCOD
was in agreement with the literature. The fact
that two different stages appeared together makes
the third case more different. Particularly, the
differential diagnosis of the lesion, located on the
apical area of the right first molar, should be
performed with cementoblastoma, which has a
pathognomic radiographic appearance of well-
defined solitary circular radiopacity with a
radiolucent halo (14). However, there was no
radiolucent halo in this case.
Periapical cemental dysplasia is usually
detected upon routine radiological examination
(15). Although PCOD is a commonly diagnosed
lesion, it may be mixed with periapical cyst,
granuloma and chronic osteomyelit during the
first phase of lesion, and the patients may be
misdirected. Therefore, vitality tests are especially
important (12). Chronic sclerosing osteomyelit,
ossifying/cementifying fibroma, odontoma and
osteoblastoma should be considered in distinctive
diagnosis at mixed and radiopaque (II. and III.
period) phases (10). The etiology of the periapical
cemento-osseous dysplasia is unknown, although
it has been suggested to occur as a result of mild
chronic trauma or traumatogenic occlusion (1,
5). Familial periapical cemental dysplasia has
been reported previously (16). Zegarelli et al
(17) studied 230 cases and determined that
lesions occur in multiples and within the lower
jaw in 70% and 94% of cemento-osseous
Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49
dysplasias, respectively. In those cases, 85% of
the patients were females and 71% of the patients
were black. Moreover, they did not encounter
any trauma or infection in related teeth. Site
predilection of periapical cemento-osseous
dysplasia is the mandibular incisors (7). Although
lesions generally appear in multiple forms, they
may be also observed in a single form. Related
teeth are almost invariably vital. The lesion is
slow growing and usually asymptomatic (12, 18).
There was no history of orofacial trauma in all
subjects. The localization of the lesion in the first
case with the diagnosis of the PCOD was in
agreement with the literature.
FLCOD exhibit a sclerotic appearance
similar to that of other lesions on conventional
radiographs. Pagets disease of the bone may have
a cotton-wool appearance (19). However, this
condition affects the bone of the entire mandible
and shows loss of lamina dura, whereas florid
cemento-osseous dysplasia is centered above the
inferior alveolar canal and its cervical two thirds
are normal. Additionally, Pagets disease is often
polyostotic (1, 20), while no other bone
involvement was found in the present case.
Cemento-osseous dysplasia is a condition
that do not require treatment, but periodic
observation is advisable. Biopsy may be required
in some cases that do not present with the
characteristic radiographic features (21).
REFERENCES
1. Gonalves M, Pispico R, Alves F, Carlos
Eduardo B, Lugao, Gonalves A. Clinical,
radiographic, biochemical and histological
findings of florid cemento-osseous
dysplasia and report of a case. Braz Dent J.
2005;3:16-20.
2. Young SK, Markowitz NR, Sullivan S, Seale
TW, Hirschi R. Familial gigantifor m
cementoma: classification and presentation
of a large pedigree. Oral Surg Oral Med
Oral Pathol. 1989;68:740-747.
3. Melrose RJ, Abrams AM, Mills BG. Florid
osseous dysplasia. A clinical-pathologic
study of thirty-four cases. Oral Surg Oral
Med Oral Pathol. 1976;41:62-82.
 Cemento-osseous dyplasias 49

4. Waldron CA, Giansanti JS, Browand BC. 16. Thakkar NS, Horner K, Sloan P. Familial
Sclerotic cemental masses of the jaws (so- occurrence of periapical cemental dysplasia.
called chronic sclerosing osteomyelitis, Virchows Arc. 1993;423:233-236.
sclerosing osteitis, multiple enostosis, and
gigantiform cementoma). Oral Surg Oral 17. Zegarelli EV, Kutscher AH, Napoli N,
Med Oral Pathol. 1975;39:590-604. Iurone F, Hoffman P. The cementoma - a
study of 230 patients with 435 cementomas.
5. Damm N, Bouquot A. Oral and maxillo- Oral Surg Oral Med Oral Pathol. 1964;
facial patholog y. Philadelphia: W.B. 17:19-224.
Saunders Company; 1995. p. 464-465.
18. Waldron CA. Fibro-osseous lesions of the
6. Ibsen OAC, Phelan JA. Oral Pathology for jaws. J Oral Maxillofac Surg. 1993;51:828-
the dental Hygenist. 3rd ed. Philadelphia: 835.
W.B. Saunders Company; 2000. p. 262-265.
19. Beylouni L, Farge P, Mazoyer JF, Coudert
7. Pindborg JJ, Kramer IRH, Torloni H. L. Florid cemento-osseous dysplasia;
Histological typing of odontogenic Report of a case documented with
tumours, jaws cysts and allied lesions. computed tomography and 3D imaging.
Geneva: WHO; 1971. Oral Surg Oral Med Oral Pathol Oral
8. White SC, Pharoah MJ. Oral Radiology Radiol Endod. 1998;85:707-711.
principles and interpretation. 4 th ed. St. 20. Ogunsalu CO, Lewis A, Doonquah L.
Louis: The CV Mosby Company; 2000. Benign fibro-osseous lesions of the jaw
p. 450-456. bones in Jamaica: analysis of 32 cases Oral
9. William GS. A textbook of oral pathology. Diseases. 2001;7:155-162.
4 th ed. Japan: W.B. Saunders Company;
1984. p. 297-298. 21. Coleman H, Altini M, Kieser J, Nissenbaum
M. Familial florid cemento-osseous dysplasia-
10. Galgano C, Samson J, Kffer R, Lombardi a case report and review of the literature. J
T. Focal cemento-osseous dysplasia Dent Assoc S Afr. 1996; 51:766-770.
involving a mandibular lateral incicor case
report. Int Endod J. 2003;36:907-911.
11. Miyake M, Nagahata S. Florid cemento- Received: 01/15/2007
osseous dysplasia. report of a case. Int J Recebido: 15/01/2007
Oral Maxillofac Surg. 1999;28.56-57.
Accepted: 02/15/2007
12. Gariba-Silva R, Sousa-Neto MD, Carvalho Aceito: 15/02/2007
JR, Saquy PC, Pecora JD. Periapical
semental dysplasia: case report. Braz Dent
J. 1999;10:55-57.
13. Su L, Weathers DR, Waldron CA. Distin-
guishing features of focal cemento-osseous
dysplasias and cemento-ossifying fibromas.
Oral Surg Oral Med Oral Pathol.
1997;84:540-549.
14. Pynn BR, Sands TD, Grace B. Benign
Cementoblastoma: a case report. J Can
Dent Assoc. 2001;67:260-262.
15. Ogunsalu CO, Lewis A, Doonquah L.
Benign fibro-osseous lesions of the jaw
bones in Jamaica: analysis of 32 cases Oral
Diseases. 2001;7:155-162.

Rev. Cln. Pesq. Odontol. 2007 jan/abr;3(1):43-49