florid cemento - osseous dysplasia ( fcod ) refers to a group of fibro - osseous lesions , 
 which are exuberant , multiquadrant and arise from the tooth - bearing area of the jaws 
 .
fcod is a benign jaw lesion and is 
 discovered most frequently in the mandible of middle - aged black female .
it usually presents a multiple radiopaque 
 bone / cemetum - like masses distributed throughout the jaw .
fcod lesions have a striking tendency towards bilateral , often quite symmetrical , 
 location , and it is not unusual to find extensive lesions in all 4 posterior 
 ( molar - premolar region ) quadrants of the jaw .
the word " florid " was introduced to describe the wide 
 spread , extensive manifestations of the disease in multiple quadrants of the jaws 
 .
the various synonyms used are 
 multiple enostoses , multiple cemento - ossifying fibromas , multiple periapical 
 osteofibromatosis , florid cement - osseous dysplasia and gigantiform cementom . in 2005 ,
world health organization 
 subdivided cemento - osseous dysplasias ( cods ) into periapical , florid and other cods 
 .
the definite diagnosis of these 3 
 diseases can not be reached by clinical ground , but only by histopathologic 
 examination .
although , the disease may be 
 totally asymptomatic , some patients present with pain , swelling , purulent discharge 
 and sequestrum formation .
rare reports of 
 its association with simple bone cysts ( sbc ) are present usually when the cases 
 reported are symptomatic .
melrose and co - workers   were the first to observe this association in their series of 34 
 cases , where 14 patients had concurrent , biopsy - proven simple bone cyst .
fcod is not 
 associated with any other extragnathic abnormalities and there are no abnormalities 
 in blood chemistry of patients .
most benign fibro - osseous lesions of jaws are asymptomatic and slowly progressing 
 . those benign fibro - osseous lesions 
 that present as an atypical radiographic appearance require a detailed clinical , 
 radiographic and laboratory workup to arrive at a diagnosis . for the asymptomatic patient ,
the best management consists 
 of regular recall examinations with prophylaxis and reinforcement of good home 
 hygiene care to control periodontal disease and prevent tooth loss .
the case presented here highlights a rare combination of fcod co - existing with a 
 multilocular radiolucency .
computed tomography ( ct ) , because of its ability to give 
 three - dimensional axial , sagittal , and frontal views , is useful in the evaluation of 
 these lesions .
this paper presents the case of a patient , who was diagnosed with 
 fcod on the basis of clinical and radiographic findings .
we hereby report one rare case of 
 co - occurrence of florid cemento - osseous dysplasia with simple bone cyst presenting 
 with symptoms of pain and swelling in the jaw .
41 year old female patient reported to the department of oral and maxillofacial 
 radiology , ab shetty memorial institute of dental sciences , nitte university , 
 deralakatte , mangalore , karnataka , india , with a complaint of pain in the right 
 posterior region of the mandible since 4 days .
the pain radiated to the right side 
 of the face , and was continuous in nature .
patient gave a history of extraction of a 
 tooth in the same region 2 years ago .
tooth was extracted due to decay , after which 
 timely healing did not occur and was associated with mild intermittent pain .
extraoral examination revealed single diffuse smooth swelling on the right side of 
 the jaw , approximately 1 x 1 cm in size , with normal overlying skin ( figure 1 ) .
right submandibular lymph nodes were tender on 
 palpation . clinical photograph of the patient showing swelling on the right side of the 
 cheek ( white arrow ) .
normal response was seen in all the teeth , when electric pulp testing was carried 
 out .
superiorly , it extended 0.5 cm from the crest of the edentulous alveolar ridge and 
 presented with scalloped border , with incomplete septa running into the radiolucency 
 ( figure 3 ) .
the inferior and anterior 
 extent of the radiolucency were not clear , hence an opg was suggested .
intraoral periapical radiograph showing well defined radiolucency with 
 scalloped border ( white arrows ) .
orthopantomography revealed well defined radiolucency in the body of mandible on the 
 right side , measuring approximately 3 x 4 cm .
it was present in the region of teeth 
 # 46 , # 47 and # 48 involving the periapical area of # 45 anteriorly , up to the anterior 
 border of the ramus posteriorly .
the radiolucent area extended superiorly up to 0.5 
 cm from the edentulous alveolar crest and 0.5 cm above the lower border of the 
 mandible .
multiple mixed 
 radio - opacities were present around the periapical region of all mandibular teeth 
 above the level of the mandibular canal .
the radiolucency was also observed at the 
 periapices of teeth # 18 , # 12 , # 26 and # 28 in the maxilla suggestive of a 
 fibro - osseous lesion .
the radio opacities presented with a radiolucent halo around 
 them ( figure 4 ) .
mandibular occlusal view of 
 the same region revealed expansion of the buccal and lingual cortical plates with 
 presence of multiple internal loculations ( figure 
 5 ) .
orthopantamogram showing multilocular radiolucency on the right body of the 
 mandible ( white arrow ) and multiple radio opacities in all the quadrants of 
 both jaws ( yellow arrows ) .
mandibular occlusal radiograph showing cortical expansion and internal 
 loculations ( encircled in yellow ) .
based on these radiological findings , lists of differential diagnoses for the 
 radiolucenct , as well as radio - opaque areas were made .
for the multilocular 
 radiolucency ameloblastoma , odontogenic keratocyst , simple bone cysts were enlisted 
 and for the diffuse radioopaque lesion , diffuse sclerosing osteomyelitis , florid 
 cemento - osseous dysplasia , paget 's disease were enlisted as differential 
 diagnoses . to determine the boundaries of the lesion preoperatively ,
it revealed , a well defined expansile osteolytic lesion measuring 
 approximately 1.7 x 2.3 x 2.7 cm in size in the right body of the mandible at the 
 level of the molar teeth . there is a narrow zone of transition ( figure 6 ) .
ct section showing a well defined expansile osteolytic lesion in the right 
 body of the mandible ( yellow arrow ) .
multiple patchy well defined hyperdense lesions with hypodense rim were observed in 
 the body of mandible located above the level of mandibular canal , between the 
 inter - radicular and inter - dental areas of maxilla and mandible ( figure 7 and figure 8) . 

the ct scan findings were consistent with florid cemento - osseous dysplasia - stage 
 iii ( mature stage ) .
coronal ct section showing multiple patchy well defined hyperdense lesions 
 with hypodense rim were observed above the level of mandibular canal ( yellow 
 arrow ) .
sagittal ct section showing multiple patchy well defined hyperdense lesions 
 with hypodense rim ( yellow arrows ) .
surgical exploration of the multilocular lesion showed connective tissue that was 
 tightly adherent to the surrounding bone and was devoid of epithelium .
the area was 
 thoroughly cleaned with curette and the adjacent bony areas were sent for 
 histopathological examination .
internal titanium plate fixation was done to the 
 lower border of the mandible to avoid pathologic fracture due to thinning of the 
 cortex ( figure 9 ) .
histological examination of the tissue lining the bony cavity revealed presence of 
 fibrocellular connective tissue with osteoid areas as well as mineral deposition 
 within them .
the connective tissue shows spindle shaped fibroblasts and collagen 
 fibres . blood vessels and chronic inflammatory cells in the form of lymphocytes were 
 additionally identified ( figure 10 ) .
hematoxylin and eosin stained histopathological section ( original 
 magnification x10 ) of periapical bone and buccal cortex in the region of 
 teeth # 45 and # 46 showing immature bone with osteocytes .
histopathological examination of stained slides of periapical bone and buccal cortex 
 in the region of teeth # 45 and # 46 shows immature bone with osteocytes .
hematoxylin and eosin stained histopathological section ( original 
 magnification x40 ) of cavity lining showing fibrocellular connective tissue 
 with osteiod areas within them ( black arrow ) .
based on these histopathological , as well as supporting clinico - radiological findings 
 a confirmative diagnosis of florid cemento - osseous dysplasia co - occurring with 
 simple bone cyst was made .
fcod is the most common pathologic condition of the jaws that occurs as radiopacities 
 in multiple quadrants of the tooth - bearing regions of the jaws .
this disorder is strictly localized to the 
 tooth bearing areas and not associated with any other skeletal disease . however , the etiopathogenesis is not 
 clear .
waldron et al .   have proposed that 
 reactive or dysplastic changes in the periodontal ligament might be a cause for the 
 disease .
this condition has also been classified by various authors as sclerosing 
 osteomyelitis , sclerosing osteitis , sclerotic cemental masses , gigantiform 
 cementoma , and various other terms .
fcod is a benign fibro - osseous lesion in which mature bone is replaced with a woven 
 bone in a matrix of fibrous connective tissue .
fcod is a rare disease entity especially in the indian population ; only 2% cases have 
 been reported among the indians in the literature .
these lesions are most commonly seen in middle - aged black women , 
 although it may also occur in caucasians and asians .
clinically , these lesions are often asymptomatic and may present as an incidental 
 radiological findings .
symptoms 
 such as dull pain or drainage are almost always associated with exposure of 
 sclerotic calcified masses in the oral cavity .
no such features were seen in our 
 case . this may occur as a result of progressive alveolar atrophy under a denture or 
 after extraction of teeth in the affected area .
the patient presented herein , underwent tooth extraction 2 years 
 ago after which the healing did not occur .
occasionally patients may also present 
 with complaint of intermittent , poorly localized pain in the affected bone , 
 especially when a simple bone cyst has developed within the lesion .
progressive increase in the bulk of the lesion was seen in case 
 report presented by miyake and nagahata . 

waldron suggested that periapical 
 cemento - osseous dysplasia and focal cemento - osseous dysplasia may also develop into 
 florid cemento - osseous dysplasia .
a simple bone cyst can be found in association with benign fibro - osseous lesions such 
 as cemento - osseous dysplasia and fibrous dysplasia .
some reports have described an association between solitary bone 
 cysts and fibro - osseous lesions including fibrous dysplasia and cemento - osseous 
 dysplasias .
venous obstruction and blockage 
 of interstitial fluid drainage , in these areas of rapidly growing and remodelling 
 cancellous bone , may lead to formation of the simple bone cysts . in our case ,
an elective surgical procedure including biopsy was not 
 performed , because of the risk of secondary infection .
secondary infection occurs in 
 such lesions due to abundant cementum formation and poor vascularity .
radiographically , fcod is characterized by extensive sclerotic areas , often involving 
 the posterior quadrants of the mandible and maxilla in a symmetric fashion .
fcod is a diffuse form characterised by 
 multiple periapical lesions involving one or both the jaws .
it occurs around the 
 root apices of vital tooth in middle - aged women with a predilection for mandibular 
 incisors . in the early stage
, it appears as a well defined radiolucent lesion , which 
 gradually becomes totally radiopaque with a thin lucent rim in the mature stages 
 .
asymptomatic lesions do not require intervention because , complete resection of the 
 lesion would be impractical as it usually occupies most of the mandible and maxilla 
 .
when surgical intervention is 
 indicated , a remodelling resection is recommended for aesthetic reasons .
histopathologically , fcod is composed of a 
 proliferating fibrous connective tissue stroma containing foci of cementum along 
 with the presence of osteoid or bone .
, large sclerotic masses are formed that are hypocellular and 
 extremely dense with small marrow spaces and few haversian systems .
the simple bone cysts that occur without any association with cemento - osseous 
 dysplasia tend to heal better after surgery than those associated with 
 cemento - osseous dysplasia .
the 
 histological features of simple bone cysts are mostly non - specific , and when a 
 tissue is submitted from this lesion , a microscopic examination will reveal only a 
 strip of fibrous connective tissue , occasionally with an associated rim of bone 
 .
expansion of the buccal and lingual cortical plates is not observed in fcod unless 
 associated with cystic changes . a 
 similar finding supported our case . as differential diagnosis
we can include paget 's disease which would present 
 radiologically with cotton - wool appearance and diffuse sclerosing osteomyelitis 
 which can also be a complication associated with fcod .
paget 's disease is also 
 characterized by deformities of multiple bones and produces biochemical serum 
 changes , such as elevated alkaline phosphate levels .
regular follow - up during six month was maintained and patient reported to be 
 asymptomatic after the surgery .
the management of florid cemento - osseous dysplasia may not be satisfactory , since the 
 disease process may run for a very long time without any symptoms .
when patients are 
 asymptomatic , optimum oral hygiene has to be maintained to avoid tooth loss and 
 periodontal disease .
elective intraoral procedures have to be avoided due to the 
 associated risk of infection or subsequent osteomyelitis and fracture . when the 
 patient is symptomatic secondary to a tooth pain , the tooth may be managed 
 endodontically by avoiding extractions .
since our patient will require 
 frequent scans during the follow - ups , imaging modalities with lesser radiation doses 
 have to be employed .
the treatment options should be easily available and accessible , 
 affordable to the masses without hampering the aesthetics and function of the 
 patient .
 abstractbackgroundthe purpose of this report is to present a rare case of co - occurrence of 
 florid cemento - osseous dysplasia with simple bone cyst in a middle aged 
 asian woman . 
 most of the reported cases are isolated cases of simple bone 
 cyst or florid cemento - osseous dysplasia , but co - occurrence of these two 
 entities is extremely rare.methodsthe authors report a 41 year old female patient with co - occurrence of 
 mandibular florid cemento - osseous dysplasia with simple bone cyst . 
 a 
 thorough clinical and radiological examination was carried out.resultsit was diagnosed mandibular cyst with possible co - occurrence of florid 
 cemento - osseous dysplasia . 
 surgical exploration of the multilocular lesion 
 was applied . since , the patient was symptomatic at the time of presentation 
 utmost caution was taken during the surgical procedure as florid 
 cemento - osseous dysplasia 
 is associated with hypo - vascularity of the 
 affected bone . 
 based on histopathological , as well as supporting 
 clinico - radiological findings a confirmative diagnosis of florid 
 cemento - osseous dysplasia co - occurring with simple bone cyst was made . 
 
 patient was followed - up for a period of six months and was reported to be 
 asymptomatic.conclusionstimely diagnosis and well planned treatment is important to obtain a good 
 prognosis when a rare co - occurrence of two or more bone lesions affects the 
 jaws . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS