CBCT FINDINGS OF PERIAPICAL CEMENTO-OSSEOUS DYSPLASIA: A

CASE REPORT

Amir Eskandarloo and Faezeh Yousefi

Dept. Of Oral And Maxillofacial Radiology, Faculty Of Dentistry, Hamadam University Of Medical Science,

Hamadam, Iran

Imaging Sci Dent. Sep 2013; 43(3): 215–218.

INTRODUCTION

Cemento-osseous dysplasia- most common fibro-osseous lesion faced in clinical practice and affects the tooth-bearing areas of the jaws.

Three subtypes according to its clinical and radiographic features:

o Periapical,o Focal,o Florid.

Eversole R, ElMofty S. Benign fibro-osseous lesions of the craniofacial complex. A review. Head Neck Path. 2008;2:177–202.

PCOD- ”a non-neoplastic lesion affecting the periapical tissues of one or more teeth”, which therefore does not subclassify this lesion according to any defined location”

Synonyms-Cementoma/fibrocementoma/ periapical osteofibrosis/ periapical fibrous dysplasia/ periapical fibroosteoma

Benign lesion arising from undifferentiated cells of the periodontal ligament tissues.

It is a localized change in normal bone metabolism that results in components of normal cancellous bone with fibrous tissue and cementumlike material, abnormal bone or mxture of both.

FCOD- “localized fibro-osseous cemental lesions-presumably reactive in nature”

FL.COD-“When lesions with radiologic and microscopic features similar to FCOD extend to two or more quadrants of the jaw, the disease is termed.

Also called as florid osseous dysplasia, giagntiform cementoma, and familial multiple cementomas.

Eversole R, ElMofty S. Benign fibro-osseous lesions of the craniofacial complex. A review. Head Neck Path. 2008;2:177–202.

Periapical and florid types are generally most appropriately diagnosed on the basis of the clinical and radiographic features.

The focal type requires a biopsy to establish a definitive diagnosis.

Etiology and pathogenesis are unknown.

These lesions become more radiopaque with time; large calcified masses become a characteristic histologic feature.

PCOD FCOD FL.COD

• Site-At the apical aspect of vital

mandibular anterior teeth

• Mostly in black and Asians

• Women>men• >40 yrs• Vital teeth

• Enlarge slowly• Radiolographic

• Asyasymptomatic• No treatment

• At apical aspect of posterior teeth

• Whites and Caucasians

• Women> men

• Biopsy and histologic examination

• Asyasymptomatic

• No treatment

• Involves multiple quadrents of both jaws• Blacks and Asians•Women> men

•Radiolographic- mixed or radioopaque

•Well defined with sclerotic border

•Poor vasular supply

•Asymptomatic

•No treatment

Burkit’s Oral Medicine- 11th EdiWood And Goes- 2nd EdiWhite And Pharoh- 5th Edi

PERIAPICAL FOCAL FLORID

Clinical features of PCOD

PCOD occurs most commonly in the anterior mandible of patients older than 30 years of age.

There is a significant tendency toward female patients and approximately 70% of cases affect blacks.

PCOD is asymptomatic and the involved teeth are vital. It shows three different features according to its stage. First stage or osteolytic stage- circular or elliptical resorption areas are

seen in the lesion. Second stage/ cementoblastic stage/mixed stage- small calcifications are

seen within the lesion. Final or mature stage- completely radiopaque lesion.

Falace D, Cunningham C. Periapical cemental dysplasia: simultaneous occurrence in multiple maxillary and mandibular teeth.

J Endod. 1984;10:455–456.

Periapical cemento-osseous dysplasia generally does not cause cortical bone expansion or perforation.

The diagnosis of PCOD can be made on the basis of the appropriate radiological and clinical characteristics.

Commonly, no treatment is required and only regular follow-up examinations are advised. If the teeth have been removed and if considerable atrophy of the alveolar ridge has

occurred,these segments of cementum may reach the mucosal surface,much in the same way as stones become become exposed in old, worn concrete.

It sould be removed surgically when comes under denture.

• 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;87:107–114. • DiFiore P, Bowen S. Cemento-osseous dysplasia in African-American men: a report of two clinical cases. J Tenn Dent Assoc. 2010;90:26–29.

This lesion appears occasionally in radiographs taken for other reasons. Most cases of the PCOD lesions have a well-defined periphery. Often a radiolucent border of varying width is present.

Alsufyani NA, Lam EW. Cemento-osseous dysplasia of the jaw bones: key radiographic features. Dentomaxillofac Radiol. 2011;40:141–146.

Cone-beam computed tomography

(CBCT) is a new medical imaging technique that generates 3-D images at a lower cost and absorbed dose compared with conventional computed tomography (CT).

This imaging technique is based on a coneshaped X-ray beam centred on a 2-D detector that performs one rotation around the object, producing a series of 2-D images.

These images are re-constructed in 3-D using a modification of the original cone-beam algorithm developed by Feldkamp et al. in 1984.

Images of the craniofacial region are often collected with a highe resolution

than those collected with a conventional CT.

Case report

A 45-year-old Iranian woman was referred to the private clinic in the city of Hamadan for implant consultation.

Her past medical history was not notable, and there was no evidence of systemic disease and no history of trauma to the mandible.

In the extra-oral examination, no abnormal symptoms were observed. Intra-oral examination revealed normal oral mucosa, the absence of

soft tissue expansion, and teeth of a normal color. Periodontal tissues were normal. All of the teeth were asymptomatic, with no pain or tenderness on percussion or palpation. The involved teeth were vital in an electric stimulation test.

Promax3D CBCT (Planmeca OY, Helsinki, Finland). A radiolucent-radiopaque mixed lesion located on the apices of the

lower incisors.

A reformatted panoramic CBCT image

Extension- from mesial side of the right mandibular lateral incisor to the distal side of the left mandibular lateral incisor.

It was a multifocal lesion-solitary lesions were reached together and made a larger lesion.

Dimension -16.6 mm in the mesio-distal direction and 6.9 mm in the longest superior-inferior direction.

Lesion associated with left mandibular lateral incisor radiolucent, lesion on the apex of the left central incisor was mixed and the lesion associated with the right central incisor was radiopaque with a radiolucent rim.

Axial and cross-sectional images

On the axial image, two expansion and thinning areas of the buccal cortex were revealed. One of them was located at the mesial side of the right canine and the other between the left central and lateral incisors.

Discontinuity of the lingual cortex was found at the area between the two central incisors on several consecutive sectional images.

3-D reconstructed CBCT images of mandible

The frontal view shows erosion of the buccal cortex of the lesion.

The lingual view shows that the lesion erodes the lingual cortex.

Periapical radiograph

No root resorption or tooth displacement. Loss of lamina dura of involved teeth. Periodontal ligament space widening(left lateral incisor)

DISCUSSION

The term cemento-osseous dysplasia is well known and widely used. PCOD is a specific lesion within this group of conditions that usually occurs in middle-aged black women.

. Komabayashi T, Zhu Q. Cemento-osseous dysplasia in an elderly Asian male: a case report. J Oral Sci. 2011;53:117–120.

MacDonald-Jankowski DS. Florid cemento-osseous dysplasia: a

systematic review. Dentomaxillofac Radiol. 2003;32:141–149. indicated an ethnic distribution of 59%- for blacks 37%- Asians (Japanese, Chinese, and Korean), 3%- Caucasians including Indian cases, respectively, in case reports.

Zegarelli E, Kutscher A, Napoli N, Iurono F, Hoffman P. The cementoma. A study of 230 patients with 435 cementomas. Oral Surg Oral Med Oral Pathol. 1964;17:219–224

PCOD in the general population is 2-3/1000.

Differential diagnosis

Periapical abscess, granuloma, or cyst- Vitality tests

mixed stage and the radiopaque stage, chronic sclerosing osteomyelitis- asso with pain

tenderness,lymphadenopathy, mottled or smoky appearance

Cemento-ossifying fibroma- ,

Paget’s ds- multiple bone involvement, cotton ball and cotton wool appearance of bone

Odontoma- younger age, delayed eruption of permanent tooth,

No treatment with only periodic follow-up.

Differentiation

More vascular Less cellular cavernous-like vascularity Free hemorrhage R/F- Ginger root pattern of

bone trabeculae  Irregularly shaped

cementum-like masses

Less vascular More cellular storiform pattern  R/F- Thin isolated trabeculae Prominent osteoblastic

rimming

Cemento-osseous dysplasia

Cemento-osseous fibroma

Su L1, 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.

Benign fibro-osseous lesions of the craniofacial complex. A review

Roy Eversole, Lan Su, and Samir ElMofty

Head Neck Pathol. 2008;2:177–202.

Review of the literature

All of the cemento-osseous dysplasias occur in tooth-bearing areas.

Periapical cemento-osseous dysplasia has been previously referred to as cementoma, periapical cementoma, periapical cemental dysplasia, and periapical fibrous dysplasia.

PCOD is a reasonably well-defined clinical-radiological entity, predominantly involving the apical areas of vital mandibular incisors.

WHO definition of PCOD, is “a non-neoplastic lesion affecting the periapical tissues of one or more teeth”, which therefore does not subclassify this lesion according to any defined location (i.e.: anterior vrs posterior apical areas of jaws).

Subtypes of cemento-osseous dysplasia (COD)

Jong-Ki Huh1, Su-Jung Shin2Misdiagnosis of florid cemento-osseous dysplasia leading to unnecessary root canal treatment: a case report Restor Dent Endod. Aug 2013; 38(3): 160–166.

Alsufyani NA, Lam EW. Osseous (cemento-osseous) dysplasia of the jaws: clinical and radiographic analysis. J Can Dent

Assoc. 2011;77:b70

Alsufyani and Lam reviewed the clinical and radiographic characteristics of 118 patients with COD.

They showed that 71.6% of 118 patients had no cortical expansion, 76% had intact lamina dura, and 93% had a normal periodontal ligament space. None of them had mandibular cortical plate destruction.

In the radiolucent-radiopaque mixed stage and the radiopaque stage, the differential diagnosis might include chronic sclerosing osteomyelitis, cementoossifying fibroma, odontoma, cementoblastoma, and osteoblastoma

In many COD cases that have been misdiagnosed and/or mismanaged, the lesions were identified in their early stages as a periapical rarefying osteitis such as Periapical abscess, granuloma, or cyst

Vitality tests are especially important for differential diagnosis.

As PCOD is asymptomatic, treatment is usually not needed because development and maturation of the lesion is self-limiting.

Intervention may cause secondary infection of the cementum-like radiopacities, which may in turn induce osteomyelitis in these lesions.

Ariji Y, Ariji E, Higuchi Y, Kubo S, Nakayama E, Kanda S. Florid cemento-osseous dysplasia. Radiographic

study with special emphasis on computed tomography. Oral Surg Oral Med Oral Pathol. 1994;78:391–396.

High density mass in PCOD which is centered in low density area is different from findings of calcifying cystic odontogenic tumor in which calcification is observed at or near the cyst wall.

Cemento-ossifying fibroma has more obvious concentric buccolingual expansion on multiplanar CBCT image.

By using CBCT discrimination of PCOD from these lesions that exhibit similar internal calcification on conventional radiography, would be more accurate.

Conclusions This case highlights the importance of appropriate diagnosis

in cases that are difficult to diagnose, such as PCOD, in order to avoid unnecessary invasive root canal therapy.

This case was considered as no treatment with only periodic follow-up check.

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