[Downloaded free from http://www.jdas.in on Sunday, February 2, 2020, IP: 103.24.125.

69]

Case Report

Florid Cemento‑osseous Dysplasia: A Series of Case Reports

Preeti Arwind Jha, Ashwini Ashok Pai, Nikhil Diwan, Rashmi Sapkal
Department of Oral Medicine and Radiology, M.A. Rangoonwala Dental College and Research Centre, Pune, Maharashtra, India

Abstract
Florid cemento‑osseous dysplasia (FCOD) is a fibro‑osseous lesion that affects jaw bones of middle‑aged women affecting two or more
quadrants of the jaw. The disease is known to be periodontal ligament in origin which is asymptomatic, characterized by multiple, confluent,
and nonexpansile radio‑opacities, often with circumferential radiolucency. This case report describes two cases diagnosed with FCOD on the
basis of radiographic findings which includes intraoral periapical radiograph, orthopantomograph as well as cone‑beam computed tomography
images.

Keywords: Cementum, cone‑beam computed tomography, fibro‑osseous lesion, florid cemento‑osseous dysplasia, periodontal ligament

Introduction Case Reports

The word “florid” was introduced to describe the widespread, Case 1
extensive manifestations of the disease in the jaws.[1,2] It was A 45‑year‑old female patient came to the Department of Oral
described by Melrose et  al. for the first time in 1976.[3,4] It Diagnosis and Radiology with pain in the lower right back
is a benign, fibro‑osseous, and multifocal dysplastic lesion region of jaw for the past 1 month. On general examination,
of the jaw which includes cellular fibrous connective tissue no abnormality was detected, and there was no history of
with bone‑like and cementum‑like tissues. [5,6] This was systemic illness. On intraoral examination, teeth 36 and
previously known as gigantiform cementoma, multiple 37 were carious and tender on palpation. The gingiva and
cement‑ossifying fibroma, sclerosing osteitis, multiple surrounding mucosa were normal with no clinical signs of
enostosis, and sclerotic cemental masses of the jaws.[5,4] It has inflammation and suppuration.
an unknown etiology having a tendency to occur bilaterally.
An intraoral periapical radiograph of 36 and 37 was taken which
Mostly seen in middle‑aged black woman.[7,8] Clinically,
showed well‑defined irregular shaped sclerotic masses beyond
these lesions are often asymptomatic and may present as
the roots of 36 and 37 [Figure 1]. To evaluate the extension
incidental radiological findings. Radiographically, florid
and site of the sclerotic masses, orthopantomograph (OPG)
cemento‑osseous dysplasia  (FCOD) appears as dense,
was taken. OPG revealed well‑defined multiple, lobulated
lobulated masses, surrounded by a radiolucent rim seen in
radio‑opacities surrounded by radiolucent rim bilaterally
all conventional radiographs but to differentiate it from other
in the mandibular posterior region which may mimic it as
lesions, such as Paget’s disease, fibrous dysplasia, and chronic
cotton wool appearance [Figure 2]. For further information
diffuse sclerosing osteomyelitis which have similar features
and relation of the sclerotic masses with the surrounding
with FCOD, cone‑beam computed tomography (CBCT) has
area three‑dimensional (3D) CBCT scan was taken. In
become useful in evaluating these lesions due to its ability to
give axial, sagittal, and coronal views. They are often confined
within the alveolar bone.[5,3] Address for correspondence: Dr. Ashwini Ashok Pai,
Department of Oral Medicine and Radiology, M.A. Rangoonwala
This paper reports two cases of 45‑ and 59‑year‑old females Dental College and Research Centre, 2309‑B, K.B. Hidayatullah Road,
Azam Campus, Pune ‑ 411 041, Maharashtra, India.
having classic radiographic features in mandible posterior E‑mail: [email protected]
region bilaterally.

Access this article online This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
Quick Response Code: tweak, and build upon the work non‑commercially, as long as the author is credited
Website: and the new creations are licensed under the identical terms.
www.jdas.in
For reprints contact: [email protected]

DOI: How to cite this article: Jha PA, Pai AA, Diwan N, Sapkal R. Florid
10.4103/jdas.jdas_8_17 cemento-osseous dysplasia: A series of case reports. J Dent Allied Sci
2017;6:101-4.

© 2017 Journal of Dental and Allied Sciences | Published by Wolters Kluwer - Medknow 101
[Downloaded free from http://www.jdas.in on Sunday, February 2, 2020, IP: 103.24.125.69]

Jha, et al.: Florid cemento‑osseous dysplasia

cross‑sectional CBCT images, a clear thin radiolucent rim were carried out and was found within normal limits in both
was seen surrounding the multiple sclerotic radiopaque patients.
masses [Figure 3] and the axial section showed buccal and
Biopsy was not done in both the cases as they were diagnosed
lingual cortical plate expansion bilaterally [Figure 4].Teeth
on the basis of characteristic features of radiographs. [1,3]
36 and 37 were endodontically treated.
Patients were being followed up for the past 6 months. Both
Case 2 the patients were asymptomatic.
A 59‑year‑old female patient admitted to the department with
pain in upper and lower left back region of the jaw for the Discussion
past 15  days. On general examination, no abnormality was
FCOD is a set of radiolucent‑radiopaque periapical and
detected, and there was no history of systemic illness. On
interradicular nonneoplastic, reactive fibro‑osseous lesions
intraoral examination, there was generalized attrition of the
involving alveolar areas of the mandible bilaterally and
teeth, tooth 37 was tender on percussion.
sometimes the maxilla and seen to have a typical female gender
Intra‑oral periapical radiograph of 36 and 37 was taken which predilection affecting black women in fourth to fifth decades
showed the loss of enamel and dentin with 37. The periapical with a mean age of 42 years. It is basically an extended form
region showed dense radio‑opaque sclerotic masses in the of periapical cemento‑osseous dysplasia.[5,9] FCODs are most
region of 36.37 and 38 [Figure  5]. OPG was taken which often painless and detected through routine radiographs[5,10,11]
revealed multiple, well defined, irregular shaped radio‑opacities Their presence is not usually associated with expansion, but
seen bilaterally in mandible posterior region. The radio‑opaque rare cases may show mild expansion.[5,12]
masses was surrounded by the thin radiolucent the rim in the
Etiopathogenesis is not clear. Waldron et al. have proposed
same region [Figure  6]. For further detailed examination,
that reactive or dysplastic changes in the periodontal ligament
3D CBCT scan was taken in which cross‑sectional images
might be a cause for the disease. These lesions are characterized
showed the well‑defined sclerotic masses surrounded by thin
radiolucent rim [Figure 7] and also axial sections showed the
buccal expansion [Figure 8]. Later tooth 37 was endodontically
treated. Serum alkaline phosphatase, calcium, and phosphorus

Figure 2: Orthopantomograph revealed well defined multiple, lobulated

radio opacities (red arrow) surrounding by radiolucent rim (yellow arrow)
which may mimic it as cotton wool appearance

Figure 1: Intraoral periapical radiograph showing well-defined radiopaque

sclerotic masses (red arrow) in the periapical area of 36 and 37

Figure 3: Cross-sectional cone-beam computed tomography images of

left mandibular molar region showing well-defined sclerotic masses (red Figure 4: Axial sections showed buccal and lingual cortical plate
arrow) surrounded by thin radiolucent rim (yellow arrow) expansion (red and yellow arrow simultaneously)

102 Journal of Dental and Allied Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2017
[Downloaded free from http://www.jdas.in on Sunday, February 2, 2020, IP: 103.24.125.69]

Jha, et al.: Florid cemento‑osseous dysplasia

Figure 6: Orthopantomograph revealed well‑defined multiple, lobulated

radio opacities (red arrow) surrounding by radiolucent rim (yellow arrow)
seen on both the quadrants of mandible

Figure 5: Intraoral periapical radiograph showing well-defined irregular

shaped sclerotic masses (red arrow) surrounding radiolucent rim (yellow
arrow) in the region of 36 and 38 and also over the roots of 37

Figure 8: Axial sections showed buccal cor tical plate expansion

Figure 7: Cross-sectional cone beam computed tomography images (red arrow)
of left mandibular molar region showing well-defined sclerotic masses
(red arrow) surrounded by tin radiolucent rim (yellow arrow) cortical bones which helps to differentiate FCOD from lesions
that exhibit a similar sclerotic appearance on conventional
by replacement of bone by connective tissue matrix, the matrix radiographs.[16]
displaying varying degrees of mineralization in the form of
woven bone or cementum‑like round basophilic a cellular The differential diagnosis of FCOD is odontoma, ameloblastic
structures.[7,13,14] The affected area undergoes changes from fibro‑odontoma, osteoid osteoma, osteoblastoma, calcifying
vascular bone into acellular cementum‑like lesion. Clinically, epithelial odontogenic tumor  (CEOT), ossifying fibroma,
FCOD is asymptomatic but sometimes there may be localized fibrous dysplasia, Paget’s disease, and chronic diffuse sclerosing
expansion of the cortical plates or symptoms of dull aching osteomyelitis. Odontoma and ameloblastic fibro‑odontoma
pain or drainage. A systematic review on FCOD conducted generally occur in children and are in association with impacted
showed only three Indian patients (<2%) identified from the teeth. Osteoid osteoma and osteoblastoma occur during the
whole series that combined most of the cases reported around second decade of life. The dull and nocturnal pain that FCOD
the world.[14] The incidence of familial involvement has also lacks is the major symptom associated with osteoid osteoma
and osteoblastoma.[8] CEOT, ossifying fibroma, and fibrous
been reported, but the mode of transmission is not clear.[1]
dysplasia are benign, slow growing expansile lesions while
The radiographic appearance of FCOD depends on the FCOD rarely shows bone expansion. FCOD has no other
degree of maturation of the lesion. The lesion may appear skeletal changes, skin tumors, and dental anomalies thus can
as radiolucent, mixed, or lobulated dense radiopaque masses be differentiated from Gardner’s syndrome. Paget’s disease
with radiolucent halo, usually located in tooth‑bearing areas. is polyostotic and shows raised alkaline phosphatase levels
Most of the times, these lesions are diagnosed incidentally which are not a consistent feature of FCOD. Chronic diffuse
on routine radiographic examination.[15] Other than a routine osteomyelitis is not confined to tooth bearing areas. It is a
radiographs, axial and cross‑sectional 3D CBCT images clearly primary inflammatory condition of the mandible with cyclic
show the location and extent of the lesion, expansion of the episodes of unilateral pain and swelling. The affected region

Journal of Dental and Allied Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2017 103
[Downloaded free from http://www.jdas.in on Sunday, February 2, 2020, IP: 103.24.125.69]

Jha, et al.: Florid cemento‑osseous dysplasia

of the mandible exhibits a diffuse opacity with poorly defined Conflicts of interest
borders.[1,17,18] There are no conflicts of interest.
As such, biopsy is not required in such cases as this is diagnosed
radiographically.[1,3] It is not normally justified to surgically References
remove these lesions, as the surgery involved can be extensive. 1. Mangala  M, Ramesh  DN, Surekha  PS, Santosh  P. Florid
Instead, follow up and recontouring are recommended when cemento‑osseous dysplasia: Review and report of two cases. Indian J
Dent Res 2006;17:131‑4.
cortical expansion occurs.[17] Surgery leads to the lack of 2. Brown KE. Fabrication of ear prosthesis. J Prosthet Dent 1969;21:670‑6.
vascularity of the lesion and increased the risk of osteomyelitis. 3. Das BK, Das SN, Gupta A, Nayak S. Florid cemento‑osseous dysplasia.
The affected area undergoes changes from normal vascular bone J Oral Maxillofac Pathol 2013;17:150.
into an avascular cementum‑like lesion. Furthermore, complete 4. Wakasa  T, Kawai  N, Aiga  H, Kishi  K. Management of florid
cemento‑osseous dysplasia of the mandible producing solitary bone
removal of necrotic tissue may result in a large discontinuity cyst: Report of a case. J Oral Maxillofac Surg 2002;60:832‑5.
defect. However, in lesions causing pain and disturbance, surgery 5. Sentürk MF, Kestane  R, Yakar  EN, Keskin A. Florid cementoosseous
and the risks it entails might be necessary for adequate treatment. dysplasia: A rare case report. Case Rep Dent 2013;2013:946583.
However, recontouring should be the treatment of choice where 6. Beylouni I, Farge P, Mazoyer JF, Coudert JL. Florid cemento‑osseous
dysplasia: Report of a case documented with computed tomography
there are only cortical expansion and mucosal perforation due and 3D imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
to the cement osseous lesions. In asymptomatic patients line of 1998;85:707‑11.
treatment is they should be kept under observation, and regular 7. Melrose RJ, Abrams AM, Mills BG. Florid osseous dysplasia. A clinical
pathologic study of thirty four cases. Oral Surg Oral Med Oral Pathol
radiological follow‑up should be made.
1976;41:62‑82.
8. Damm  DD, Fantasia  JE. Multifocal mixed radiolucencies. Florid
Conclusion cemento‑osseous dysplasia. Gen Dent 2001;49:461‑538.
9. Minhas G, Hodge T, Gill DS. Orthodontic treatment and cemento‑osseous
Normally, a diagnosis of cemento‑osseous dysplasia in the dysplasia: A case report. J Orthod 2008;35:90‑5.
jaws is made by clinical findings, radiographic features, 10. Said‑al‑Naief NA, Surwillo E. Florid osseous dysplasia of the mandible:
Report of a case. Compend Contin Educ Dent 1999;20:1017‑22.
and histology. However, FCOD is a condition in which the 11. Marx RE, Stern D. Oral and Maxillofacial Pathology: A Rationale for
diagnosis relies on radiology and clinical findings alone. This Diagnosis and Treatment. London, UK: Quintessence; 2004.
condition being asymptomatic requires no treatment, but 12. Waldron CA. Fibro‑osseous lesions of the jaws. J Oral Maxillofac Surg
regular follow‑up is needed. 1985;43:249‑62.
13. Singer SR, Mupparapu M, Rinaggio J. Florid cemento‑osseous dysplasia
Acknowledgment and chronic diffuse osteomyelitis. Report of a simultaneous presentation
and review of the literature. J Am Dent Assoc 2005;136:927‑31.
• This research was supported by, Department of Oral 14. Oikarinen  K, Altonen  M, Happonen  RP. Gigantiform cementoma
Medicine and Radiology, M.A. Rangoonwala Dental affecting a Caucasian family. Br J Oral Maxillofac Surg
College and Research centre (MARDC), Pune, India. We 1991;29:194‑7.
thank our Head of the Department of Oral medicine and 15. Kim  JH, Song  BC, Kim  SH, Park  YS. Clinical, radiographic and
histological findings of florid cemento‑osseous dysplasia: A case report.
Radiology (OMDR) Imaging Sci Dent 2011;41:139‑42.
• Dr.  R. Krishna Kumar for his expertise that greatly 16. Yildirim  E, Baglar  S, Ciftci  ME, Ozcan  E. Florid cemento‑osseous
improved the research dysplasia: A rare case report evaluated with cone‑beam computed
• We thank our colleagues from Department of OMDR, tomography. J Oral Maxillofac Pathol 2016;20:329.
17. Bencharit  S, Schardt‑Sacco  D, Zuniga  JR, Minsley  GE. Surgical
MARDC who provided insight and expertise that greatly and prosthodontic rehabilitation for a patient with aggressive florid
assisted the research. cemento‑osseous dysplasia: A clinical report. J Prosthet Dent
2003;90:220‑4.
18. Ariji  Y, Ariji  E, Higuchi  Y, Kubo  S, Nakayama  E, Kanda  S. Florid
Financial support and sponsorship cemento‑osseous dysplasia. Radiographic study with special
From the department staffs and all the other postgraduate emphasis on computed tomography. Oral Surg Oral Med Oral Pathol
students. 1994;78:391‑6.

104 Journal of Dental and Allied Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2017