Focal cemento-osseous dysplasia of maxillary posterior region

Sanyog Pathak; Abishek Balani; Sonalika Wanjari Ghate; Anand S Tegginamani; HS Vanishree

doi:10.4103/2348-1471.184734

CASE REPORT

Year : 2016 | Volume : 4 | Issue : 2 | Page : 50-53

Focal cemento-osseous dysplasia of maxillary posterior region

Sanyog Pathak¹, Abishek Balani², Sonalika Wanjari Ghate³, Anand S Tegginamani⁴, HS Vanishree⁵
¹ Department of Oral and Maxillofacial Surgery, Hitkarni Dental College and Hospital, Jabalpur, Madhya Pradesh, India
² Department of Oral and Maxillofacial Surgery, New Horizon Dental College, Bilaspur, Chhattisgarh, India
³ Department of Oral Pathology, Hitkarni Dental College and Hospital, Jabalpur, Madhya Pradesh, India
⁴ Department of Oral Pathology, Faculty of Dentistry, SEGi University, Kota Damansara, Petaling Jaya, Selangor, Malaysia
⁵ Department of Paediatric Dentistry, Faculty of Dentistry, SEGi University, Kota Damansara, Petaling Jaya, Selangor, Malaysia

Date of Web Publication

27-Jun-2016

Correspondence Address:
Anand S Tegginamani
Faculty of Dentistry, SEGi University, Kota Damansara, 47810, Petaling Jaya, Selangor
Malaysia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2348-1471.184734

Abstract

Keywords: Benign fibro-osseous lesions, cemento-osseous dysplasia, etiopathogenesis, maxillary molar region, World Health Organization

How to cite this article:
Pathak S, Balani A, Ghate SW, Tegginamani AS, Vanishree H S. Focal cemento-osseous dysplasia of maxillary posterior region. Dent Med Res 2016;4:50-3

How to cite this URL:
Pathak S, Balani A, Ghate SW, Tegginamani AS, Vanishree H S. Focal cemento-osseous dysplasia of maxillary posterior region. Dent Med Res [serial online] 2016 [cited 2022 May 20];4:50-3. Available from: https://www.dmrjournal.org/text.asp?2016/4/2/50/184734

Introduction

Benign fibro-osseous lesion of the craniofacial complex is a broader term representing various diseases that are characterized by replacement of normal bone with hypercellular fibroblastic stroma with varying amount of pathologic ossifications and calcifications. The definitive diagnosis can rarely be established based on imaging and histopathologic features alone. Instead a thorough clinicopathologic evaluation is mandatory. Eversole et al.^[1] classified them as neoplasms, developmental dysplastic lesions, and inflammatory/reactive processes. The treatment and prognosis varies from the lesion to lesion hence it is important to establish a definitive diagnosis.

Cemento-osseous dysplasia (COD) occurs in the tooth-bearing region of the jaws. It belongs to a benign group of fibro-osseous lesion manifesting in a localized site as periapical COD and focal COD (FocCOD) whereas multifocal involvement is termed as florid COD. ^[2] FocCOD is of uncertain etiopathogenesis, with reactive and dysplastic processes as the suggested underlying mechanisms. The radiographic appearance varies according to the stage of development and thus overlaps a wide range of intrabony pathologies. A careful histopathologic examination with meticulus clinical correlation only can lead to a definitive diagnosis; we present an unusual case of FocCOD in a 22 years old female.

Case report

A 22-year-old female reported with the chief complaint of swelling with the left side of the face and hard palate since last 1 year. The swelling was slowly progressive in nature. There was no relevant medical/family history. Extraorally, there was diffuse swelling of the left side of the face with the molar region. Intraorally it was more obvious on the palatal side as compared to buccal one, from the first premolar to third molar region [Figure 1]. Swelling was nontender and hard on palpation with normal color of overlying mucosa and skin. No involvement of local or regional lymph nodes was seen. Computed tomography scan of the lesion showed hyperdense mass [Figure 2] in relation to the left side of maxilla involving posterior teeth, with buccal and palatal cortical plate expansion and without infiltrating sinus or nasal floor, blood investigations were in normal limits. On the basis of above-mentioned findings, a diagnosis of osteoma/ossifying fibroma was made, and excision of the lesion was planned. The patient was taken under general anesthesia with all necessary precautions and protocaols. Buccal and palatal flaps were raised, and the lesion was removed along with involved teeth from the first premolar to the third molar with the help of chisel and mallet. There was no involvement of maxillary sinus or nasal floor seen after removal. Primary closure of flaps was carried out and the patient was extubated uneventfully. Recovery phase was satisfactory, and there was no recurrence seen 2 years postoperative. The excised specimen was subjected for histopathological evaluation. Microscopically, H and E stained sections showed irregular, thick, interconnected trabaculae of cementum/bone like mineralized material in a fibro-cellular, vascular connective tissue [Figure 3]. Noticeably, periodontal ligament was intact. There was no direct attachment of pathologic tissue to root cementum [Figure 4].

Figure 1: Swelling was nontender and hard on palpation with normal color of overlying mucosa

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Figure 2: Computed tomography scan of the lesion showed hyperdense mass

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Figure 3: Thick, interconnected trabaculae of cemento-osseous material in a fibrocellular stroma

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Figure 4: Dense sclerotic calcified cementum-like masses in close approximation with periodontal ligament

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Discussion

The term FocCOD as recommended by Summerlin and Tomich, ^[3] is presumably a reactive lesion affecting tooth bearing regions of posterior jaws especially the extraction sites. ^[4] It represents a dysplastic process in which multiple focal areas of bone and marrow is replaced by cellular connective tissue lesion with limited growth potential, attaining a fixed size which thereafter undergoes maturation process resulting in the formation of multiple dense calcified masses. Theses masses may later fuse. ^[5] The location of the lesion in close approximation to periodontal ligament and histopathologic similarity with the associated structure suggests an origin from periodontal ligament. However, some investigators believe it to be an extraligamentary bone remodeling that may be triggered by local factors or hormonal imbalance. ^[4]

FocCOD usually discovered accidentally during routine examination usually it is symptomless or rarely manifest as pain and swelling. ^[6] Kawai et al. noted signs and symptoms of pain, gingival swelling, purulent discharge, tenderness, or delayed wound healing after extraction. ^[7] Commonly seen in a middle-aged individual of Asian, East Asian, and African ethnicity but can occur in all ages and all ethnic groups, the mandible is commonly affected than the maxilla. ^[8] The present case was unusual due to the involvement of maxillary posterior region in a young female which presented as bony enlargement.

Radiographic presentation of the lesion depends upon the stage of evolution. Three stages have been defined as an early radiolucent stage, mixed radiolucent-radiopaque stage, and lastly completely opaque lesion. ^[9] The periphery usually is well-defined with a radiolucent rim either partially or completely, but lesions with scleotic borders also are reported. ^[3] The internal radio-opacities are described as discrete irregular to ovoid/globular cementum-like masses which undergoes fusion with substantial radio-opacification as the lesion matures. ^[10] These lesions are considered to be nonexpansile, but cases with cortical plate expansion are also reported. ^[11]

Histopathology of all the fibro-osseous lesions has an overlapping feature with some variations in the histologic pattern. This pattern consists of cellular spindle cell stroma with varying amounts of mineralization. ^[12] The form of mineralization may vary from woven bone to mature lamellar bone or small globules of osteoid. Such globular, concentric mineralization is also called as cementicles. Cementum has similar chemical composition as a bone in its relationship of type I collagen to calcium hydroxyapetite crystals. Hence, based on routine hematoxylin and eosin staining it is not possible to differentiate between these two tissues. However, when the lesion is not associated with the tooth root as in normal Cementum, the use of term "cementicles" is warranted. ^[12] The microscopic picture of FocCOD also varies according to the stage of evolution. In an early stage which corresponds to radioluscency on radiograph shows vascular stroma with scattered osteoid trabaculae. The stroma becomes more fibrotic and increased the proportion of osteoid trabaculae as the lesion matures. In the late stage, which corresponds to the radiopaque presentation, FocCOD shows very little fibrotic stroma with thick curvilinear trabaculae ("ginger-root" pattern) or irregularly shaped cementum-like masses. ^[1] The histopathology of the present case was in lieu with a mature FocCOD [Figure 4].

The most important lesion which needs to be differentiated from FocCOD is ossifying (cemento-ossifying) fibroma (COF) which is a true neoplasm with a significant growth potential. FocCOD especially end stage and COF resemble each other radiographically as well as histologically. A well-defined lesion with a radiolucent rim representing the fibrous capsule and surgical finding of easy separation from the surrounding healthy bone are important diagnostic clues for COF. In the present case, there was only partial separation of lesional bone from surrounding bone and surgical removal of the lesion was with great difficulty.

Management of this lesion depends upon its size. Smaller asymptomatic lesion needs no treatment. The Larger lesion may require surgery to prevent further destruction. ^[12] Cases have been reported where FocCOD has progressed to florid COD. Thus follow-up is recommended. ^[3],[9] An association of FocCOD with simple bone cyst and increased risk of FocCOD in East Asians and Africans makes follow-up mandatory in the present case. ^[10] There is always a potential for complications such as osteomyelitis to arise because of secondary infection from exposure through extraction sites, bone loss from periodontal disease, or implant placement. ^[6] Extraction from the lesional sites should be avoided as cases have been reported with poor socket healing and sequestrum formation following extraction of teeth closely associated with the cemental masses. ^[13] In the present case, the lesion was completely excised as it was progressively enlarging, with the expansion of the involved bone causing significant discomfort to the patient.

Conclusion

An unusual case of expansile FocCOD in the maxillary posterior region is presented in a young female patient. The presenting features favor the diagnosis of ossifying fibroma which is a true neoplastic process. Radiographic and histopathological correlation is of utmost importance for the definitive diagnosis. FocCOD is benign, slow growing, self-limiting, an asymptomatic lesion which usually require no treatment. There is always a risk of secondary infection when there is communication with the oral cavity, hence extraction if possible should be avoided. Association with simple bone cyst and recurrences are well documented. Thus, regular follow-up both clinically and radiographically is mandatory. Treatment should be tailored according to the case presentation. Expansile symptomatic lesions, cases requiring prosthesis are clear-cut indication for surgical removal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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