Jc 1 cbct findings of periapical cemento-osseous dysplasia
CBCT FINDINGS OF
OSSEOUS DYSPLASIA: A
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.
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:
Eversole R, ElMofty S. Benign fibro-osseous lesions of the
craniofacial complex. A review. Head Neck Path.
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
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
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
•Mostly in black and
•At apical aspect of posterior
•Whites and Caucasians
•Biopsy and histologic
quadrents of both jaws
•Blacks and Asians
•Radiolographic- mixed or
•Well defined with
•Poor vasular supply
Burkit’s Oral Medicine- 11th Edi
Wood And Goes- 2nd Edi
White And Pharoh- 5th Edi
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
The diagnosis of PCOD can be made on the basis of the appropriate radiological and
Commonly, no treatment is required and only regular follow-up examinations are
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.
(CBCT) is a new medical imaging technique that generates 3-D images at a
lower cost and absorbed dose compared with conventional computed
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.
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
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
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.
No root resorption or tooth displacement.
Loss of lamina dura of involved teeth.
Periodontal ligament space widening(left lateral incisor)
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
PCOD in the general population is 2-3/1000.
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
No treatment with only periodic follow-up.
Ginger root pattern of bone
Thin isolated trabeculae
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.
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
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
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.
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