Familial florid cemento-osseous dysplasia: a report of three cases and review of the literature

Cemento-Osseous Dysplasia in a Female Bronze Age Skeleton (North Caucasus)

PURPOSE

The earliest known case of cemento-osseous dysplasia could be detected in a Bronze Age skeleton, dating back 4500 years ago in the region of the North Caucasus. Although the soft tissue was missing, sufficient diagnosis could be achieved by using different methods that prove the existence of fibro-osseous processes already in prehistory. Skeletal remains provide a direct view of such changes which cannot be obtained from a living patient without compromising.

METHODS

A skeleton of a 30-40-year-old female individual from the burial mound of Budyonnovsk 10 (including 19 individuals) in Southern Russia was investigated using macroscopic, radiographic, and microscopic methods.

RESULTS

In the mandible, destruction of the labial wall of the alveoli 32 and 31 is already visible macroscopically. At the base of the lesion, the original bone is replaced by fine porous bone including small dense particles: plain radiography and computed tomography evidence localized processes to the periapical areas of all lower incisors. The lesions are mainly radiolucent, only the particles in alveolus 32 have a radiopaque appearance. Microscopy shows woven bone as filling of the lesions and additional hypocellular materials in alveolus 32, which can best be explained as cementum-like structures.

CONCLUSIONS

The lesion´s location in the periapical areas of the lower incisors, the woven bone, and cementum-like structures fit the diagnosis of periapical cemento-osseous dysplasia. The presence of a second individual with focal cemento-osseous dysplasia in this burial mound is an interesting co-occurrence that requires further genetic analysis.

LIMITATIONS

The diagnosis is solely based on the skeletal remains, soft tissue components are missing.

SUGGESTIONS FOR FURTHER RESEARCH

Genetic analyses are planned to detect the underlying mutation for the two individuals.

The Occurrence and Outcomes of Cemento-Osseous Dysplasias (COD) in the Jaw Bones of the Population of Lower Silesia, Poland

Background: Cemento-osseous dysplasias (CODs) are rare lesions of the jawbone. Their occurrence, localization, type, size, and shape can vary between cases. This fibro-osseous lesion is typically found in the jaw near tooth-bearing areas and is often asymptomatic, discovered incidentally, and may be associated with the periapical region of the teeth. In rare cases, COD can lead to secondary bone osteomyelitis. Currently, there is limited information in the literature on the occurrence and characteristics of COD. This paper's main aim was to focus on the authors' COD experience in the lower Silesian area. Methods: A retrospective evaluation of radiographies (RTG-Panx, cone-beam computed tomography (CBCT)) was conducted on patients treated, diagnosed, or consulted by the authors. A statistical correlation analysis was made to establish any relationship within the gathered data. Results: COD is predominantly an incidental finding in the mandibular bone near tooth apices. It is most commonly diagnosed in females. Both CBCT and panoramic radiographies are generally sufficient for diagnosing the lesion. COD rarely requires treatment. Conclusions: COD lesions are mostly discovered incidentally during routine radiographies or cone-beam computed tomography (CBCT) scans. In most cases, clinical and radiological monitoring is sufficient, along with evaluating the teeth's response to cold stimuli and assessing the surrounding bone structures. Biopsies or tooth extractions are seldom necessary. When oral hygiene is well-maintained and no periapical inflammation is present, COD lesions typically remain asymptomatic.

Periapical cemento-osseous dysplasia masquerading as asymptomatic chronic apical periodontitis in a Chinese woman: A case report

Key Clinical Message

Cemento-osseous dysplasia (COD) belongs to a group of fibrous osseous disorders that can masquerade as periapical inflammatory conditions in the jawbones. We present a rare case of COD occurring in a patient who also had periapical periodontitis concurrently. When faced with a patient exhibiting no symptoms, diagnosis may be challenging.

Abstract

COD is a fibrous osseous disorder similar to periapical chronic inflammatory conditions and other cysts in the jaw bones on the radiograph. There is a rare case of COD occurring in a 49-year-old Chinese woman who also had chronic periapical periodontitis concurrently. The lesions were incidentally discovered in the mandibular anterior tooth region during the patient's imaging examination. The patient exhibited no symptoms, and diagnosing the conditions may be challenging due to the confusingly similar radiological features that present as a radiolucent lesion in the periapical region. The final diagnosis was made through pulp vitality tests, cone beam computed tomography (CBCT), and clinical examinations. The COD was recommended for annual follow-up. Root canal therapy has been performed for chronic apical periodontitis. According to the diagnostic process of COD, a thorough history check, multiple clinical examinations, and imaging studies should be emphasized to prevent misdiagnosis and avoid unnecessary or inappropriate therapies. The patient was followed up for 6 years. The recovery of chronic apical periodontitis in tooth #31 and the transformation of osteolytic and osteogenesis of COD had been observed in CBCT.

Clinical, CBCT and Histological Analysis of a Florid Cemento-Osseous Dysplasia with Co-Occurrence of Simple Bone Cyst in the Mandible: A Case Report

Cemento-osseous dysplasia (COD) is classified, by the World Health Organization as a benign fibro-osseous lesion related to the tooth and periapical area of the jaws and is considered as a benign reactive process appearing from the apical periodontium in close relation with the apices of teeth. Usually, it is asymptomatic, discovered accidentally, and affecting particularly middle-aged African women. There are four subtypes distinguished of the lesion: periapical (PCOD), focal (FCOD), florid (FLCOD) and familial florid cemento-osseous dysplasia (FFLCOD). Pseudocysts found in the jaws go by various names, including solitary bone cyst, traumatic bone cyst, or simple bone cyst (SBC). These two pathologies have been reported separately; however, their co-occurrence remains rare and the first case of FLCOD with co-occurrence of SBC was reported by Melrose et al. in 1976 and later a few cases been reported in the literature. The aim of this report is to describe a case of a 46-year-old oriental female diagnosed with FLCOD with co-occurrence of SBC. Under local analgesia, a surgical exploration of the cyst was performed. In addition, a biopsy with a trephine was done in the region of missing right first mandibular molar. Based on the patient clinical, radiographic, and histological findings, a diagnosis of FLCOD was made in co-occurrence with a mandibular SBC. An examination of another female family member unveils a distinctive case, and the familial factor has been ruled out. No further treatment was planned and only follow-up was suggested.

Radiological follow-up of cemento-osseous dysplasia on cone-beam computed tomography

This study investigated the natural course of cemento-osseous dysplasia (COD) on cone-beam computed tomography (CBCT). Retrospectively, 104 CBCT scans from 36 patients (mean age, 44.5 years; 33 female and three male) with mandibular COD (10 florid, seven focal, 19 periapical) were included, based upon clinico-radiological features, without complications such as infection and related surgery. Changes in maximum diameter and morphology (lytic, mixed lytic-sclerotic, sclerotic) were evaluated in 83 lesions, with a mean follow-up of 28.3 months. The occurrence of a diameter increase was assessed by time-to-event analysis; interreader agreement for diameter and morphological evaluation by intraclass correlation coefficient and weighted κ statistics, respectively. Fifteen of 83 (18.1%) lesions (eight florid, one focal, six periapical) in 10 patients increased in diameter; 12 of 83 (14.5%) lesions (five florid, seven periapical) in 11 patients changed morphologically. The median period until a diameter increase was longest (120 months) for periapical COD, and shortest (66 months) for florid COD (p = 0.023). There was high reader agreement (ICC = 0.891; weighted κ = 0.901). In conclusion, CBCT is an effective tool with which to follow-up COD. If any, the natural progress in uncomplicated COD is prolonged, which underlines its non-surgical character and aids in its long-term management.

Imaging of Fibro-osseous Lesions and Other Bone Conditions of the Jaws

This review directs the focus on the imaging features of various fibro-osseous lesions and other bone lesions that can be of similar presentation. Broad diagnosis of "fibrous osseous lesion" may culminate in improper treatment and management. Radiographic discriminating factors between these entities are highlighted and summarized to improve the diagnostic process when encountering these lesions.

Imaging Characteristics of Embedded Tooth-Associated Cemento-Osseous Dysplasia by Retrospective Study

BACKGROUND

Since there are many differential diagnoses for cemento-osseous dysplasia (COD), it is very difficult for dentists to avoid misdiagnosis. In particular, if COD is related to an embedded tooth, differential diagnosis is difficult. However, there have been no reports on the characteristics of the imaging findings of COD associated with embedded teeth. The aim of the present study was to investigate the occurrence and imaging characteristics of cemento-osseous dysplasia (COD) associated with embedded teeth, in order to appropriately diagnose COD with embedded teeth.

METHODS

The radiographs with or without histological findings of 225 patients with COD were retrospectively analyzed. A retrospective search through the picture archiving and communication system (PACS) of the Division of Oral and Maxillofacial Radiology of Kyushu Dental University Hospital was performed to identify patients with COD between 2011 and 2022.

RESULTS

Fifteen COD-associated embedded mandibular third molars were identified in 13 patients. All 13 patients were asymptomatic. On imaging, COD associated with embedded mandibular third molars appeared as masses that included calcifications around the apex of the tooth. On panoramic tomography, COD showed inconspicuous internal calcification similar to that of odontogenic cysts or simple bone cysts, especially in patients with COD only around the mandibular third molar region. Those with prominent calcification resembled cemento-ossifying fibroma, calcifying epithelial odontogenic tumor, calcifying odontogenic cyst, adenomatoid odontogenic tumor, and so on, as categories of masses that include calcifications on panoramic tomography and computed tomography.

CONCLUSIONS

The current investigation is the first to report and analyze the imaging characteristics of COD associated with embedded teeth. It is important to consider the differences between COD and other cystic lesions on panoramic tomography, and the differences between COD and masses that include calcifications on CT.

Microvascularized Fibular Bone Grafting for the Treatment of Mandibular Expansive Osseous Dysplasia - A Case Report

Rationale

Osseous dysplasia (OD) is a benign fibro-osseous lesion classified as periapical, focal or florid with some rare cases being diagnosed as expansive OD.

Patient Concerns

A 43-year-old female presented with gross mandible expansion and tooth displacement.

Diagnosis

Imaging scans revealed an expansive lesion in the anterior mandible, with varying opacity in the central region, and other smaller lesions in the region of teeth #37 and #47, consistent with expansive OD.

Treatment

Surgical resection followed by immediate reconstruction of the mandibular defect using a microvascularized fibular graft.

Outcomes

The patient had a 4-year follow-up, with adequate mandibular bone continuity, mastication, swallowing, and speaking ability reestablished.

Take-away Lessons

Immediate reconstruction after large surgical resection is required as tissues retract over time, hampering late reconstructions. Microvascularized fibular graft aims at adequate and functional rehabilitation with osseointegrated implants and long-term follow-up is needed as florid OD may evolve into expansive OD.

[The new WHO classification of jaw tumours]

Maxillofacial tumours cover a broad spectrum of lesions, including neoplasms, hamartomatous changes and developmental disorders. Since the beginning of 2022, a beta version of the 5th edition of the WHO classification for head and neck tumours has been available online, and a print version is expected to be published in mid-2023. From a conceptual point of view, little has been changed compared to the 4th edition; the sort order of lesions is more rigorously arranged according to benign and malignant behaviour and identical tumour types are no longer described redundantly in different chapters depending on their location. The diagnostic criteria are now summarized as "essential" and "desirable", and in addition to the clinical features, imaging is now also incorporated, providing an interdisciplinary approach to the classification. A few new entities are included for the first time. This article gives an overview of the main changes introduced in the new WHO classification with a special emphasis on fibro-osseous lesions of the craniofacial skeleton.

Multifocal periapical cemental dysplasia in periodontal Ehlers-Danlos syndrome combined with leukoencephalopathy in the mutation of c.890G > a, G297D [pEDS]

Periodontal Ehlers-Danlos syndrome (pEDS) is a rare disorder caused by heterozygous mutations in complement 1 subunit genes C1R and C1S. To date, 148 cases have been described in the literature.We describe a case of a suspected de novo-mutation of pEDS with generalized Periapical cemental dysplasia (PCD) and cerebral leukoencephalopathy.

Cone beam computed tomography analysis of mandibular inferior cortical thickness and bone texture in cemento-osseous dysplasia

OBJECTIVE

This study compared mandibular cortical thickness (CTh) and fractal dimension (FD) in patients with cemento-osseous dysplasia (COD) and controls, as measured with cone beam computed tomography.

STUDY DESIGN

In total, 28 female patients with COD and 28 age-matched controls were selected retrospectively. Inferior cross-sectional CTh was measured at the symphysis (sCTh), anterior (aCTh), mental foramen (mfCTh), molar (mCTh), and posterior (pCTh) regions. The alternate measurement of mean CTh of the volume including buccal, lingual, and inferior cortices between the mental foramina (alternate CTh) was measured in ImageJ. FD was calculated in cortical and trabecular bone. Data were analyzed for significance of differences in CTh and FD between patient groups and for correlation of inferior and alternate CTh measurements.

RESULTS

Inferior CTh values were lower overall in the patients with COD than in the controls (P = .01), specifically at sCTh, mCTh, and pCTh (P ≤ .042). Alternate CTh was also significantly lower in the COD group (P = .005). There was a significant correlation between inferior and alternate CTh measurements (r = 0.636, P < .001). No significant differences were observed in cortical or trabecular FD between groups (P ≥ .072).

CONCLUSIONS

Female patients with COD had significantly lower inferior and alternate CTh than healthy controls. Both groups had similar cortical and trabecular bone textures.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Odontogenic and Maxillofacial Bone Tumours

The 5^th edition of the World Health Organization (WHO) Classification of Head and Neck Tumours (2022) comes out only five years after the previous edition, however it presents important updates that run in parallel with the rapid progression involving the increasingly sophisticated molecular investigation and its interpretation, some of which already have therapy-related impact. This manuscript provides an overview of the leading changes introduced in the classification of Odontogenic and Maxillofacial Bone Tumours that encompasses cysts of the jaws, odontogenic tumours, giant cell lesions and bone cysts, and bone and cartilage tumours. This is the first edition that Essential and Desirable Diagnostic Features were added for each entity, so that the most important clinical, microscopic and/or radiologic features were encapsulated and briefly highlighted. Surgical ciliated cyst was added to the group of odontogenic cysts, adenoid ameloblastoma was a newly recognized benign epithelial odontogenic tumour, and segmental odontomaxillary dysplasia was introduced in the group of fibro-osseous tumours and dysplasia. In addition, rhabdomyosarcoma with TFCP2 rearrangement, was introduced into the group of malignant jawbone tumours. The unique genetic aberrations distinguish it from other types of rhabdomyosarcomas. On the other hand, melanotic neuroectodermal tumour of infancy and osteoid osteoma were deleted from the benign bone and cartilageneous tumours, as was the hematolymphoid tumour of solitary plasmacytoma of bone. We systematically reviewed each entity in this chapter and provided important updated findings for selected topics that can further aid in the diagnostic process for challenging cases, broaden insights on the logic of the present classification, and finally, emphasize the potential that some of the molecular results may have in the near future to set new treatment approaches.

Multiple periapical dysplasias analyzed by cone-beam-computer tomography and 99Tcm-Scintigraphy

Periapical cemental dysplasia (PCD) is considered a non-neoplastic proliferation of fibrous tissues and cementum-like hard tissues, usually occurring in the periapical regions of teeth. PCD is characterized by the presence of vital pulp and is often accidentally discovered during a general radiographic survey. PCD may arise from the tissue of odontogenic origin or occur as a reactive process in the periapical tissue. Multilocular occurrences in both jaws are rare. However, we encountered a case of multiple PCDs by orthopantomography, which showed different degrees of maturation in the mandible and maxilla by osteodensitometric detection via cone-beam computed tomography (CB-CT) validated by Tc-99m bone-scintigraphy (BS). Biopsies confirmed the radiological results. CB-CT osteodensitometry allows for the categorization and assessment of different stages of PCD maturation from beginning to florid, detection of remittent osseous changes, and evaluation in the clinical follow-up. When using the local cortical bone as a reference value of 100%, periapical dysplasias show density values of 75% in the mandible and 80% in the maxilla. Early classification of PCD is possible with CB-CT osteodensitometry.

[Clinical and imaging characteristics of familial gigantiform cementoma. A review of the literature]

Familial gigantiform cementoma (FGC) is a rare benign fibro-cementum lesion, which follows an autosomal dominant inheritance pattern and presents during childhood. It is limited to the bones of the face, with a predilection for the jaw, is fast growing and painless and expands considerably over time. It is considered among the seven disorders that affect the physiognomy of the craniofacial skeleton. Radiographically, FGC occurs in three stages of maturation similar to bone dysplasia, being radiolucent, mixed and radiopaque and is described as a mixed lobular well delimited mass, which can occur in both maxillae, causing expansion of the buccal and palatal / lingual bone cortices. displacement and retention of teeth. The aim of this study was to perform a review of the literature to identify the clinical, radiographic and histopathological characteristics of FGC in the jaws and describe the imaging tools that are useful for the diagnosis and follow-up of this lesion.