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Oral & Maxillofacial Pathology Journal [ OMPJ ] Vol. 2 No. 2 Jul-Dec -2011 ISSN 0976 - 1225

FLORID CEMENTO-OSSEOUS DYSPLASIA AN UNUSUAL ENTITY

A CASE REPORT

1 2 2 3Vandana Shah Nishit Soni B.S Manjunatha Swati Kumar

1 2 3Professor Reader Senior Lecturer, Department of Oral Pathology,

KM Shah Dental College & Hospital, Gujarat,India

Corresponding Author : Vandana Shah, Professor & Incharge,Department of Oral Pathology, SumandeepVidyapeeth, KM Shah Dental College & Hospital, Piparia Post, Waghodia Road, Vadodara, Gujarat.E mail [email protected]

Abstract

Florid cemento-osseous dysplasia (FLCOD) is a rare, but well recognized condition that

characteristically affects the jaws of middle aged women. It usually manifests radiographically as a diffuse,lobulated and irregularly shaped radio-opacities distributed throughout the alveolar processes which areusually bilaterally symmetrical. This condition has been classified as sclerosing osteitis, multipleenostoses, diffuse chronic osteomyelitis and gigantiform cementoma. The lesion is usually benign andrequires no treatment unless cosmetically concerning or becomes symptomatic. For the asymptomaticpatient the best management consists of regular recall examination with prophylaxis and maintenance ofgood oral hygiene According to the recent review of literature in 2006, only five patients of floridcemento-osseous dysplasia from India have been reported (less than 2%). Here we present such a rarecase occurring in a 37 year old female who came with a swelling and dull pain in the lower right back teethregion since 1 and 1/2 years. Radiographically, it showed mixed radiolucent / radio-opaque mass in bothright and left premolar to molar region.

Key Words: Fibro-Osseous Lesions; Florid Cemento Osseous Dysplasia.

IntroductionCase Report

The term fibroosseous lesion (FOL) is ageneric designation of a group of jaw disorders A 37-year-old female patient presented to KMcharacterized by replacement of bone by benign Shah Dental College & Hospital, Vadodara,

1 with a complaint of swelling and dull pain inconnective tissue matrix . The classification oflower right back teeth region since 1 and cemento-osseous lesions of the jaws has longyears. On extra-oral examination facialbeen a matter of discussion for pathologists andasymmetry was noted on lower right side of theclinicians. A review of the literature shows aface (Figure 1). Overlying skin was normal withwide range of terminologies used to describe

2 st no change in color, temperature andwhat seem to be similar lesions . In 1 Edition ofconsistency. Intraoral examination revealed aWo rld Hea l th Organ iza t ion (WHO)localized swelling measuring about 2 X 1.5 cmclassification of Odontogenic tumors 1971,extending from distal margin of right secondFLCOD was categorized under the Neoplasmspremolar anteriorly to mesial margin of right& other tumors related to odontogenic

3 third molar posteriorly. The mandibularapparatus . The current classification ofvestibule was obliterated. On palpation, thecementomatous lesions, released in 1992 by theswelling was hard in consistency. TeethWHO includes FLCOD under cemento associated with the lesion were vital and theosseous dysplasia of the Neoplasms and other

1,3 overlying gingiva and mucosa were normal.lesions related to bone . This paper describesOrtho pantomogram was taken andsuch a rare case diagnosed on the basis of

showed multiple sclerotic masses bilaterally inclinical, radiographic and histological findings.

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162Florid Cemento-osseous Dysplasia An Unusual Entity A Case Report


tooth bearing areas of posterior mandible inrelation to premolar and molar regions.Irregularly shaped radio opacities weredistributed diffusely throughout the alveolar

process enmeshed in poorly defined zones ofdecreased radio density. The borders of thelesion were indistinct and blended into theaffected surrounding bone (Figure 2). Occlusal

view showed no buccal or lingual cortical plateexpansion (Figure 3). Posterior Anterior view ofthe skull showed mixed radio opaque and radiolucent areas on both sides of mandible. The leftside of mandible was asymptomatic andapparently normal on clinical examination.

Surgical recontouring of the lesion onthe right side was done for esthetic reasons.Multiple soft and hard tissue bits of varyingsizes were received.

Microscopically, the H (hematoxylin)and E (eosin) stained sections showedfragments of soft and hard tissues. The softtissue composed of cellular mesenchymal tissue

with spindle shaped fibroblasts intermingled inthick bundles of collagen fibers and numeroussmall blood vessels. The hard tissue contained

mixture of lamellar bone and globular shapedacellular, basophilic cementum like structures(Figure 4). Bony trabeculae were thickcurvilinear resembling ginger root pattern(Figure 5). Few hemorrhagic areas were seen inclose association with bony trabeculae. Adiagnosis of florid cemento-osseous dysplasia

was given.

Fig 1: Clinical photograph

Fig 2: Ortho Panto-mograph showing multiple RO-RL

masses in premolar and molar region ofposterior mandible of left side

Fig4: Photomicrograph showing cementummasses and bony trabeculae in fibrousconnective tissue [ H &E ]

Fig 5: Photomicrograph showing ginger rootpattern of bony trabeculae [ H& E, 40X ]

Discussion

Cemento-osseous dysplasias are agroup of disorders known to originate fromperiodontal ligament tissues and involve,essentially, the same pathological process. Theyare usually classified, depending on their extentand radiographic appearances, into three maingroups: periapical (surrounds the periapical

region of teeth and are bilateral), florid

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12(sclerotic symmetrical masses) and focal (single symptomatic. Treatment of FLCOD withlesion) cemental dysplasias. Florid cemento- complete resection of the lesion would beosseous dysplasia clearly appears to be a form of impractical because it usually occupies most ofbone and cemental dysplasia that is limited to the mandible and maxilla. When surgical

4

jaws. intervention is indicated, a remodelling5Florid cemento-osseous dysplasia was resection is recommended for esthetic reasons .2

first described by Melrose et al. in 1976 . Thiscondition has been interpreted as a dysplastic C h r o n i c d i f f u s e s c l e r o s i n glesion or developmental anomaly arising in osteomyelitis may resemble FLCOD, whichtooth-bearing areas. appears as a single, poorly delineated opaque

segment of the mandible. Clinically it involvesFLCOD is more commonly seen in the body of the mandible from the alveolus to

middle-aged black women, although it also may the inferior border and may extend into the2,5 ramus. FLCOD may be familial with anoccur in Caucasians and Asians. In some cases,

5 autosomal dominant inheritance pattern, buta familial trend can be observed. These lesionsthere are only a few examples in the literature in

have a striking tendency toward bilateral 5which the familial pattern has been confirmed .symmetrical location, and it is not unusual tofind extensive lesions in all four posterior

Only five Indian patients of florid(molar-premolar region) quadrants of the jaws.cemento-osseous dysplasia have been reportedThe radiographic appearance can vary from(less than 2%), according to the recent review ofareas of radiolucency to mixed lesions and to

12,13opaque masses. Over the time the lesions tend recent literature. This makes the occurrence

6,7 of FCOD a relatively rare phenomenon. In theto become increasingly radio opaque .present case, no familial aspects of the diseaseFLCOD blends with adjacent bone and

were reported.therefore pathologists often receive multiple8

curetted fragments . The lesions can be foundFlorid cemento-osseous dysplasia is ain multiple quadrants in both the maxilla and

6,9 self limiting disease restricted to alveolarmandible . FLCOD is occasionally expansile9 processes. It is a distinct entity representing anand patients may experience pain rarely .

exuberant variant of cemento-osseous dysplasianormally seen in multiple quadrants of both theHistopathologically, FLCOD consistsjaws. Normally, a diagnosis of florid cemento-of dense, sclerotic masses that have beenosseous dysplasia in the jaws is made by clinicalinterpreted either as cementum or bone which

4findings, radiographic features and histology.are anastomosing and layers of cementum-like

These lesions have to be included in thecalcifications embedded in a fibro cellular2,5 differential diagnosis of mixed radiolucent radiobackground.

opaque lesions of the jaws.

Management of FLCOD may be

Many lesions that occur in the jaw havedifficult and not very satisfactory. When a similar radiographical appearance and it issymptomatic, there may be pain alone or inoften difficult to differentiate among them.association with sinus tracks with minimal

10 Differential diagnosis is crucial especially whenpurulent drainage. Although in most situationsthere are coincidental findings like odontogenicthe lesion is not treated, treatment is requiredinfections or chronic diffuse osteomyelitis,when infection of the lesion occurs. For theneoplasia, bone dysplasia that can cause changesasymptomatic patient the best managementin the mandible with similar radiographicconsists of regular recall examination withcharacteristics. Hence we must consider all theprophylaxis and maintenance of good oral

11 available diagnostic information, thehygiene. Extensive surgical resection andradiographic characteristics which wouldsaucerization are proposed treatment optionscontribute significantly to the diagnosis.

when lesions become extensive and

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Braz Dent J.

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Conflict of Interest - None declared

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