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 cementoosseous lesions in light of four presented cases

Dagistan, Saadettin

Goregen, Mustafa

Miloglu, Özkan

Çakur, Binali

Portuguese

Portal de Peritódicos da PUCPR (Pontifícia Universidade Católica do Paraná)

Rev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49CEMENTO-OSSEOUS DYSPLASIASDisplasias cemento-ósseasSaadettin Dagistan1, Mustafa Goregen2, Binali Çakur3, Özkan Miloglu41 DDS, PhD Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatürk University.2 DDS, Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatürk University.3 DDS, PhD Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatürk University,   Erzurum, Turkey,   e-mail:  bcakur@atauni.edu.tr4 DDS, Department of Oral Diagnosis and Oral Radiology, Faculty of Dentistry, Atatürk University.AbstractCemento-osseous dysplasia is a benign condition of the jaws that may arise from the fibroblasts of theperiodontal 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 occuras a result of mild chronic trauma or traumatogenic occlusion. Cemento-osseous lesions areasymptomatic 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.ResumoA displasia cemento-óssea é uma condição benigna dos maxilares que pode originar-se defibroblastos do ligamento periodontal. São classificadas em três grupos principais: periapicais(circundam a região apical dos dentes), focal (lesões isoladas) e displasias cementárias floridas(massas escleróticas simétricas). A etiologia da condição é desconhecida, embora tenha sidosugerido que resulta de trauma crônico leve ou oclusão traumática. As lesões cemento-ósseas sãoassintomáticas e não requerem tratamento. Neste artigo, discutem-se os diferentes tipos de lesõescemento-ósseas, à luz da apresentação de quatro casos.Palavras-chave: Displasia cemento-óssea; Cementoma periapical; Cementoblastoma.4 4 Dagistan S, Goregen M, Çakur B, Miloglu Ö.Rev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49INTRODUCTIONThe classification of cemento-osseouslesions within jaws has long been a debatabletopic for pathologists and clinicians. The literaturedisplays a wide range of terminology in order todefine the similar-looking lesions (1, 2, 3). Themost recent classification of cemento-osseouslesions was released in 1992 by the World HealthOrganization based on the location of the lesionas well  as age, sex, histopathological ,radiographical and clinical characteristics. Thisclassif ication includes cemento-osseousdysplasia, cemento-ossifying fibroma and benigncementoblastoma (4).Cemento-osseous dysplasias areprobably the most common type of fibro-osseouslesions encountered in clinical practice. Thepathogenesis of the cemento-osseous dysplasiasis unknown, although they appear to representsome form of reactive or dysplastic process. Onthe basis of their clinical and radiographic features,this type is further divided into three groups:periapical, focal and florid cemento-osseousdysplasia (5).Periapical  cemento-osseous dysplas ia(PCOD) is an asymptomatic benign lesion. Theterm cementoma is often used for this condition,although, it is not a neoplasm (6). PCOD occursmost commonly in the anterior mandible ofpatients older than 30 years of age. It is morecommon in women than in men, and there is apredominance in black women (6, 7). Solitary ormultiple lesions may occur but multiple lesionsare present more frequently (8). Related teeth arealmost invariably vital (5).PCOD appears in radiographs taken forother reasons (5, 9). It displays three differentcharacteristics according to its period. In the firstperiod, which is also called osteolytic period,circular and elliptical resorption areas are seen inthe place where the lesion is located. In the secondperiod, which may also be called as cementoblasticperiod or intermediate period, small calcificationsoccur within the lesion. A mixed radiolucent andradiopaque appearance emerges. In the third period,lesions display massive calcifications. Solitarylesions may rarely widen to 10 cm in diameter, butnot widen to the cortex (5, 9).Focal cemento-osseous dysplasia (FCOD) isa benign lesion that occurs between the periapicaland florid cemento-osseous dysplasia. Althoughboth periapical and florid types represent similarfeatures, they have different clinical andradiographical characteristics. About 80 percentof cases occur in females, between 30 and 50years of age, and it is more common in white thanin black patients (10). FCOD may occur in anyarea of the jaws, although the posterior mandibleis the predominant site (6).Radiographically, the lesion may appearas completely radiolucent or completelyradiopaque. Most commonly, however, there is amixed pattern. Usually, the patient has only onelesion. Once a diagnosis has been established, notreatment is necessary (5, 6).Florid cemento-osseous dysplasia (FLCOD)has been described as a condition that usuallymanifests as multiple radiopaque cementum-likemasses distributed throughout the jaws. Thiscondition has also been classified as gigantiformcementoma, chronic sclerosing osteomyelitis andsclerosing osteitis. It occurs most often in blackwomen older than 40 years of age (1, 4, 11). Thecondition usually involves multiple quadrants(6). The process may be totally asymptomaticand, in such cases, the lesion is detected whenradiographs are taken for other purposes (12).Radiographically, the lesions appear asmultiple sclerotic masses, located in the maxillaor mandible. The diagnosis of florid cemento-osseous dysplasia is usually made on the basis ofthe characteristic radiographic appearance. Notreatment is indicated. The most commoncomplication is the development of osteomyelitisin patients who wear full or partial dentures (6).REPORT OF CASESCase IA 40-year-old female patient applied toour clinic due to lack of teeth. The patient had nosystemic disease. In the extra-oral examination,no abnormal symptoms were observed. Afterintra-oral examination, a panoramic radiographwas taken. A radiopaque lesion surrounded by aradiolucent halo was observed in the apical areaof the lower left canine (Figures 1 and 2). Thevitality test was positive. Based on the clinicalexamination and radiographic evaluation, adiagnosis of mixed period of PCOD was made.4 5Cemento-osseous dyplasiasRev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49Case IIA 32-year-old female patient applied toour clinic with wisdom teeth complaints. Thepatient had no systemic disease. In the extra-oralexamination, no abnormal symptoms wereobserved. After intra-oral examination, apanoramic radiograph was taken. A radiopaquelesion surrounded by a radiolucent halo wasobserved in the distal apical area of the lower leftfirst molar (Figures 3 and 4). The vitality test waspositive. Based on the clinical examination andradiographic evaluation, a diagnosis of FCOD ofmixed stage was made.FIGURE 1 - Radiopaque lesion surrounded by radiolucent halo in the apical area of the lowerleft canineFIGURE 2 - Radiopaque lesion in the periapical areaof the lower left canineFIGURE 3 - Radiopaque lesion surrounded by aradiolucent halo in the distal apical areaof the lower left first molar4 6Case IIIA 21-year-old male patient applied toour clinic for routine control. The patient had nosystemic disease. Upon extra-oral examination,no abnormal symptoms were observed. Afterintra-oral examination, a panoramic radiographywas taken. A radiopaque lesion surrounded by aradiolucent halo was observed in the apical areaof the lower left first premolar. Another lesionthat was totally radiopaque was observed in theapical area of the mesial root of the lower rightfirst molar (Figure 5). Vitality tests for both teethwere positive. Based on the clinical examinationand radiographic evaluation, a diagnosis of FCODof mixed and end stage, respectively, was made.FIGURE 4 - Radiopaque lesion surrounded by radiolucent halo in the distal apical area of the lowerleft first molarFIGURE 5 - Radiopaque lesion surrounded by a radiolucent halo in the apical area of the lower left firstpremolar. Another totally radiopaque lesion in the apical area of the mesial root of the lowerright first molarRev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49Dagistan S, Goregen M, Çakur B, Miloglu Ö.4 7Case IVA 47-year-old female patient applied toour clinic for a dental care. She was systemicallyhealthy and the extra-oral examination was withinnormal limits. An intraoral examination revealed apartially edentulous area and the overlying gingivaand mucosa were normal without any clinical signsof inflammation. There was no marked expansionin the mandible. A panoramic radiography wasobtained. Multiple sclerotic masses with radiolucentborders were found in the mandibula (Figures 6and 7). A diagnosis of FLCOD was made, but wasnot confirmed, as the patient declined a biopsy.FIGURE 6 - Multiple sclerotic masses with radiolucent borders in the mandibleFIGURE 7 - Radiopaque lesions confined within the alveolus in the regions of the lowerright premolarCemento-osseous dyplasiasRev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-494 8DISCUSSIONCemento-osseous dysplasias areprobably the most common types of fibro-osseouslesions encountered in clinical practice. Thepathogenesis of the cemento-osseous dysplasiasis unknown, although they appear to representsome form of reactive or dysplastic process. Onthe basis of their clinical and radiographic features,cemento-osseous dysplasias are divided into threegroups: periapical, focal and florid cemento-osseous dysplasia (5).The observations revealed that periapicaland focal cemento-osseous dysplasias share thesame histopathological and clinical characteristics(13). Although FCOD is most common seen inthe posterior mandible, PCOD is generally seenin the anterior mandible (6, 7).  Additionally,FCOD is more common in white men comparedto black men (10). The localization of lesions inour second and third cases diagnosed with FCODwas in agreement with the literature. The factthat two different stages appeared together makesthe third case more different. Particularly, thedifferential diagnosis of the lesion, located on theapical area of the right first molar, should beperformed with cementoblastoma, which has apathognomic radiographic appearance of well-defined solitary circular radiopacity with aradiolucent halo (14). However, there was noradiolucent halo in this case.Periapical cemental dysplasia is usuallydetected upon routine radiological examination(15). Although PCOD is a commonly diagnosedlesion, it may be mixed with periapical cyst,granuloma and chronic osteomyelit during thefirst phase of lesion, and the patients may bemisdirected. Therefore, vitality tests are especiallyimportant (12). Chronic sclerosing osteomyelit,ossifying/cementifying fibroma, odontoma andosteoblastoma should be considered in distinctivediagnosis at mixed and radiopaque (II. and III.period) phases (10). The etiology of the periapicalcemento-osseous dysplasia is unknown, althoughit has been suggested to occur as a result of mildchronic trauma or traumatogenic occlusion (1,5).  Familial periapical cemental dysplasia hasbeen reported previously (16).  Zegarelli et al(17) studied 230 cases and determined thatlesions occur in multiples and within the lowerjaw in 70% and 94% of cemento-osseousdysplasias, respectively. In those cases, 85% ofthe patients were females and 71% of the patientswere black. Moreover, they did not encounterany trauma or infection in related teeth. Sitepredilection of periapical cemento-osseousdysplasia is the mandibular incisors (7). Althoughlesions generally appear in multiple forms, theymay be also observed in a single form. Relatedteeth are almost invariably vital. The lesion isslow growing and usually asymptomatic (12, 18).There was no history of orofacial trauma in allsubjects. The localization of the lesion in the firstcase with the diagnosis of the PCOD was inagreement with the literature.FLCOD exhibit a sclerotic appearancesimilar to that of other lesions on conventionalradiographs. Paget’s disease of the bone may havea cotton-wool appearance (19). However, thiscondition affects the bone of the entire mandibleand shows loss of lamina dura, whereas floridcemento-osseous dysplasia is centered above theinferior alveolar canal and its cervical two thirdsare normal. Additionally, Paget’s disease is oftenpolyostotic (1, 20), while no other boneinvolvement was found in the present case.Cemento-osseous dysplasia is a conditionthat do not require treatment, but periodicobservation is advisable. Biopsy may be requiredin some cases that do not present with thecharacteristic radiographic features (21).REFERENCES1. Gonçalves M, Pispico R, Alves F, CarlosEduardo B, Lugao, Gonçalves A. Clinical,radiographic, biochemical and histologicalfindings of florid cemento-osseousdysplasia and report of  a case. Braz Dent J.2005;3:16-20.2. Young SK, Markowitz NR, Sullivan S, SealeTW, Hirschi R. Familial gigantiformcementoma: classification and presentationof a large pedigree. Oral Surg Oral MedOral Pathol. 1989;68:740-747.3. Melrose RJ, Abrams AM, Mills BG. Floridosseous dysplasia. A clinical-pathologicstudy of  thirty-four cases. Oral Surg OralMed Oral Pathol. 1976;41:62-82.Rev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49Dagistan S, Goregen M, Çakur B, Miloglu Ö.4 94. Waldron CA, Giansanti JS, Browand BC.Sclerotic cemental masses of the jaws (so-called chronic sclerosing osteomyelitis,sclerosing osteitis, multiple enostosis, andgigantiform cementoma). Oral Surg OralMed Oral Pathol. 1975;39:590-604.5. Damm N, Bouquot A. Oral and maxillo-facial pathology. Philadelphia:  W.B.Saunders Company; 1995. p. 464-465.6. Ibsen OAC, Phelan JA. Oral Pathology forthe dental Hygenist. 3rd ed. Philadelphia:W.B. Saunders Company; 2000. p. 262-265.7. Pindborg JJ, Kramer IRH, Torloni H.Histological typing of odontogenictumours, jaws cysts and allied lesions.Geneva: WHO; 1971.8. White SC, Pharoah MJ. Oral Radiologyprinciples and interpretation. 4th ed. St.Louis: The CV Mosby Company; 2000.p. 450-456.9. William GS. A textbook of  oral pathology.4th ed. Japan: W.B. Saunders Company;1984. p. 297-298.10. Galgano C, Samson J, Küffer R, LombardiT. Focal cemento-osseous dysplasiainvolving a mandibular lateral incicor casereport. Int Endod J. 2003;36:907-911.11. Miyake M, Nagahata S. Florid cemento-osseous dysplasia. report of a case. Int JOral Maxillofac Surg. 1999;28.56-57. 12. Gariba-Silva R, Sousa-Neto MD, CarvalhoJR, Saquy PC, Pecora JD. Periapicalsemental dysplasia: case report. Braz DentJ. 1999;10:55-57.13. Su L, Weathers DR, Waldron CA. Distin-guishing features of focal cemento-osseousdysplasias and cemento-ossifying fibromas.Oral Surg Oral Med Oral Pathol.1997;84:540-549.14. Pynn BR, Sands TD, Grace B. BenignCementoblastoma: a case report. J CanDent Assoc. 2001;67:260-262.15. Ogunsalu CO, Lewis A, Doonquah L.Benign fibro-osseous lesions of the jawbones in Jamaica: analysis of  32 cases OralDiseases. 2001;7:155-162.16. Thakkar NS, Horner K, Sloan P. Familialoccurrence of periapical cemental dysplasia.Virchows Arc. 1993;423:233-236.17. Zegarelli EV, Kutscher AH, Napoli N,Iurone F, Hoffman P. The cementoma - astudy of  230 patients with 435 cementomas.Oral Surg Oral Med Oral Pathol. 1964;17:19-224.18. Waldron CA. Fibro-osseous lesions of  thejaws. J Oral Maxillofac Surg. 1993;51:828-835.19. Beylouni L, Farge P, Mazoyer JF, CoudertL. Florid cemento-osseous dysplasia;Report of a case documented withcomputed tomography and 3D imaging.Oral Surg Oral Med Oral Pathol OralRadiol Endod. 1998;85:707-711.20. Ogunsalu CO, Lewis A, Doonquah L.Benign fibro-osseous lesions of the jawbones in Jamaica: analysis of  32 cases OralDiseases. 2001;7:155-162.21. Coleman H, Altini M, Kieser J, NissenbaumM. Familial florid cemento-osseous dysplasia-a case report and review of the literature. JDent Assoc S Afr. 1996; 51:766-770.Received: 01/15/2007Recebido: 15/01/2007Accepted: 02/15/2007Aceito: 15/02/2007Cemento-osseous dyplasiasRev. Clín. Pesq. Odontol. 2007 jan/abr;3(1):43-49

CEMENTO-OSSEOUS DYSPLASIAS

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CEMENTO-OSSEOUS DYSPLASIAS

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