This case report describes CBCT findings of periapical cemento-osseous dysplasia (PCOD) in a 45-year-old woman. CBCT imaging revealed a mixed radiolucent-radiopaque lesion extending from the right lateral incisor to the left lateral incisor. Axial and cross-sectional CBCT images showed expansion and thinning of the buccal cortex in two areas. 3D reconstructed images showed erosion of the buccal and lingual cortices. Based on the radiographic and clinical features, PCOD was diagnosed and no treatment was required, only periodic follow-up. CBCT provided improved visualization of the lesion compared to conventional radiography for diagnosis.

1. 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.

2. 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.

3.  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.

4.  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.

5.  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.

6. 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 Edi
Wood And Goes- 2nd Edi
White And Pharoh- 5th Edi

7. PERIAPICAL FOCAL FLORID

8. 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.

9.  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.

10.  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.

11.  (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.

12. 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.

13. 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.

14. 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.

15. 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.

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

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

22.  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).

23. 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.

24. 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.

25.  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.

26. 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.

27. 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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