Periapical cemento-osseous dysplasia/ Periapical cemental dysplasia
- Periapical cemento-osseous dysplasia refers to an asymptomatic set of lesions that forms around the apex of mostly mandibular, vital anterior teeth. Also rarely, the condition is seen in the anterior maxilla.
- They are asymptomatic but can be seen early in radiographs, as rounded radiolucent areas related to the apices of the teeth. These simulate periapical granulomas but related teeth are vital. Later, increasing calcification, starting centrally, causes the masses to become densely radiopaque, but all stages of development may be seen in multiple lesions
- Black women of African heritage around the age of 40 years are the most commonly affected. Rarely, men, younger individuals, or members of other races also are affected.
- It is usually an incidental radiographic finding because these lesions do not induce tooth mobility or bony expansion.
Fig. The natural radiographic course of periapical cemento-osseous dysplasia is illustrated in this series of periapical radiographs:
(a) beginning radiolucencies; (b and c) beginning and more mature radiopacities creating a more dense, irregular, mixed radiolucent-radiopaque appearance; (d and e) mature radiopacities creating a pure, well-outlined, radiopaque appearance.
During the radiolucent stage, periapical cemento-osseous dysplasia may be confused with an apical periodontal granuloma or a radicular cyst. It also may resemble a primordial odontogenic keratocyst or the early phase of an ossifying fibroma. Because four and sometimes all six anterior teeth may be involved, radiographically it also will suggest a chronic osteomyelitis. It is therefore imperative that all anterior teeth undergo pulp testing and that serial radiographs are taken over time. On rare occasions, sublingual salivary gland depressions of the lingual cortex will produce a round radiolucency superimposed over vital apices as well.
During the mixed radiolucent-radiopaque and completely radiopaque phases, the differential diagnosis will change significantly. It then will include an odontoma, a sequestrum from a case of chronic osteomyelitis, an ossifying fibroma, and an osteoblastoma. Cementoblastomas occur only in posterior teeth and therefore are not included on this differential list.
Initially, the lesions of periapical cemento-osseous dysplasia consist of vascular fibrous tissue with no capsule. Over time, an increasing quantity of mineralized tissue develops, which may take the form of rounded, cementum-like material and/or osseous trabeculae that may show osteoblastic rimming. Eventually, there is coalescence of this material with formation of a sclerotic, avascular, and acellular mass. These stages are reflected in the changing radiographic picture.
Because this phenomenon is not progressive, symptomatic, or particularly damaging, no treatment is required. In fact, it is important to avoid well-meaning treatment attempts such as root canal therapy or apicoectomy merely to improve the radiographic picture. Understanding the biology of this phenomenon, its clinical-radiographic picture, and the vitality of the associated teeth will prevent unnecessary interventions that often lead to iatrogenic complications.