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Table of Contents
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 46-48

Cemento-ossifying fibroma: A diagnostic dilemma

1 Department of Oral Pathololgy, Sri Sankara Dental College Varkala, Kerala, India
2 Oral and Maxillofacial Surgeon, Al Salam International Hospital, Kuwait, India
3 Oral and Maxillofacial Pathologist, Trivandrum, India
4 Oral and Maxillofacial Pathologist, Kannur Dental College, Anjarakandy, Kerala, India

Date of Submission11-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication29-Mar-2021

Correspondence Address:
Dr. Roopan Prakash
Department of Oral Pathololgy, Sri Sankara Dental College Varkala, Lotus, cra k1, Charachira Road, YMR Junction, Kowdiar PO Thiruvananthapuram 695003, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJO.INJO_3_21

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Cemento-ossifying fibroma (COF) is a controversial term because of its terminology and its diagnosis. The COF is odontogenic in origin, although it is a central neoplasm of the bone and involves the periodontium. Most COFs exhibit slow and expansile growth in the jaws and are benign in origin. The lesion is encapsulated with mixed radiodensities. The COF is characterized by the replacement of normal bone by fibrous tissue and varying amounts of osteoid and cementum-like material. The definitive diagnosis of such lesions requires clinical, radiological, and histopathological observations. The treatment of choice is surgical resection, and recurrence is uncommon. We report a case of COF in the left mandibular premolar region and discuss how to confirm the diagnosis.

Keywords: Cemento-ossifying fibroma, cementum, periodontium

How to cite this article:
Prakash R, Shahid S M, Raj H, Anil K S. Cemento-ossifying fibroma: A diagnostic dilemma. Int J Oral Care Res 2021;9:46-8

How to cite this URL:
Prakash R, Shahid S M, Raj H, Anil K S. Cemento-ossifying fibroma: A diagnostic dilemma. Int J Oral Care Res [serial online] 2021 [cited 2021 Aug 6];9:46-8. Available from: https://www.ijocr.org/text.asp?2021/9/1/46/312535

  Introduction Top

The COF is a benign tumor of the oral cavity, and it consists of highly cellular, fibrous tissue with varying amounts of osteoid and cementum-like material, which resembles the bone, the cementum, or both. It is most commonly seen between the third and fourth decades of life[1] and is more frequent in women than in men.[2]

The periodontal membrane is a layer of fibrous connective tissue surrounding the roots of teeth. It contains multipotent cells that are capable of forming cementum, bone, and fibrous tissue.[1] Radiographically, they appear as well-defined unilocular or multilocular intraosseous masses. The lesion is invariably encapsulated and of mixed radiolucent densities.[3]

These benign fibro-osseous lesions can occur in any part of the facial skeleton, though 70% of the lesions in the head and neck region is seen the mandible.[4] There are many fibro-osseous and odontogenic entities that mimic it clinically, macroscopically, and radiologically. Although the line of treatment for most of these lesions is similar, it is important to differentiate them histologically as they have distinct features.[5]

These lesions grow slowly and are unnoticed by the patient until swelling of the face becomes clearly visible; in a few cases, the tumor may grow rapidly and cause symptoms.[6] Although central COFs of the mandible are common, they are more frequent in women than in men. The aim of this article is to report a case of COF in a male patient and how to distinguish the lesion from other fibro-osseous lesions through clinical, radiological, and histopathological examination.

  Case Presentation Top

We report a case of a South India man with swelling of the left mandibular region since eight months who reported to our hospital [Figure 1]. We advised a patient orthopantomogram, and it revealed a radiolucent multilocular sclerotic lesion expanding from regions 33 to 36. The patient was advised a CT scan, and it revealed a focal mildly expansile sclerotic lesion 8.5 × 8.2 mm seen in relation to the left edentulous first premolar teeth location. Rest of the mandible and maxillary alveolar process appeared normal. Bilateral parotid glands and submandibular glands were normal. No significant lymph nodes were visualized in the neck; bilateral nasal bones, crista galli, and bilateral cribriform plates were intact; and bilateral orbits and its contents were normal. Zygoma and zygomatic arch were normal, bilateral temporomandibular joint functions were normal, and there was no history of dislocation. The visualized skull bones and vertebrae were normal. The adjacent teeth tested positive for vitality. The patient experienced no pain because of the swelling. Based on the CT scan report, a mildly expansile, sclerotic periapical lesion in relation to the left edentulous first premolar region was made [Figure 2]. Provisional diagnosis of cemento-osseous dysplasia, odontoma, and condensing osteitis was made after radiological examination.
Figure 1: Intraoral examination showing swelling of the left mandibular region

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Figure 2: Orthopantomogram and computerised tomography images revealing multilocular sclerotic lesion

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The general dentist at the hospital referred the case to an oral pathologist, and a biopsy was done. The soft tissue specimen was hard in consistency, and the specimen was grayish brown in color measuring 0.5 × 0.5 × 0.2cm. The histopathological examination revealed stratified squamous epithelium with underlying connective tissue composed of bundles of collagen fibers; basophilic masses of cementum-like material were seen. Focally, there was ossification in the cementum areas lined by osteoblasts. From the histopathological examination, a final diagnosis of the COF of the mandible was made [Figure 3]. Complete surgical excision of the tumor was done by an oral and maxillofacial surgeon [Figure 4].
Figure 3: Histopathological examination of the lesion showing cementum like material in fibrous connective tissue stroma

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Figure 4: Complete surgical excision of the lesion

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  Discussion Top

These benign fibro-osseous lesions can arise from any part of the facial skeleton and skull, with more than 70% of cases arising in the head and the neck region and principally in the jaws. Various classifications were proposed to classify these lesions, The origin of COF is not clearly understood; in most of the cases reported in the literature, a history of trauma was found that was not seen in our case. A few authors have considered that these lesions had either reactive or developmental origin, from the periodontal membrane that contains multi-potential cells, which, under certain pathologic conditions, are capable of producing tumors that are composed of cementum, lamellar bone, or fibrous tissue.[7]

The World Health Organization (WHO) classifies COF as a fibro-osseous neoplasm included among the non-odontogenic tumors derived from the mesenchymal blast cells of the periodontal ligament, with a potential for fibrous tissue, cement and bone, or a combination of such elements. However, there is controversy over such an origin, since tumors of similar histology have been reported in the bone lacking periodontal ligament and they are not located in the maxillary region, such as ethmoid bone, frontal bone, or even long bones of the body.[8]

This emphasizes the need for a histopathological examination of the biopsy specimen for an accurate diagnosis because of the difficulty in diagnosing COF based only on clinical observations. Treatment of COF consists of removal of etiological factors, scaling adjacent teeth, and aggressive surgical excision. Some authors have suggested excision of the involved periodontal ligament and periosteum to minimize the possibility of recurrence of incompletely removed lesions.[9]

Today, COF is widely accepted because both osseous and cemental tissues are seen commonly in a single lesion. The people who are affected are mostly females when they reach their third and fourth decades of life, although in the present case the middle aged are affected. The histopathology of juvenile ossifying fibroma often shows a psammomatoid pattern present as concentric lamellae. Inadequate surgical treatment may cause recurrence of the lesion, although recurrence is rare; therefore, a proper diagnosis and treatment plan are required to achieve good results in the management of this tumor.[10]

  Conclusion Top

The diagnosis of COF is a very difficult process, as it requires a clinical, radiological, and histopathological examination to rule out other fibro-osseous lesions and odontogenic tumors. Surgical resection of such tumors will provide good prognosis and aesthetic results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/ have given his/ her/ their consent for his/ her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sarwar HG, Jindal MK, Ahmad SS Cemento-ossifying fibroma—A rare case. J Indian Soc Pedod Prev Dent 2008;26:128-31.  Back to cited text no. 1
Aburas S, Bandura P, Al-Ibraheem A, Berger S, Meier M, Turhani D A large maxillary cemento-ossifying fibroma superimposed with solitary bone cyst documented over 18 years: A case report. Int J Surg Case Rep 2020;68:257-62.  Back to cited text no. 2
More C, Thakkar K, Asrani M Cemento-ossifying fibroma. Indian J Dent Res 2011;22:352-5.  Back to cited text no. 3
Ram R, Singhal A, Singhal P Cemento-ossifying fibroma. Contemp Clin Dent 2012;3:83-5.  Back to cited text no. 4
Dewan HS, Dewan SK, Bahl S, Parekh PT. Cemento-ossifying fibroma of mandible mimicking complex composite odontome.BMJ Case Rep 2016;2016:bcr2016216053.  Back to cited text no. 5
Katti G, Khan MM, Chaubey SS, Amena M. Cemento-ossifying fibroma of the jaw.BMJ Case Rep 2016;2016:bcr2015214327.  Back to cited text no. 6
Sridevi U, Jain A, Turagam N, Prasad MD Cemento-ossifying fibroma: A case report. Adv Cancer Prev2016;1:1-4.  Back to cited text no. 7
Silvestre-Rangil J, Silvestre FJ, Requeni-Bernal J Cemento-ossifying fibroma of the mandible: Presentation of a case and review of the literature. J Clin Exp Dent 2011;3:e66-9.  Back to cited text no. 8
Guru SR, Singh SS, Guru RC Peripheral cemento-ossifying fibroma: A report of two cases. J Health Sci Res 2016;7:71-5.  Back to cited text no. 9
Rani A, Kalra N, Poswal R, Sharma S Cemento-ossifying fibroma: Report of a case and emphasis on its diagnosis. Indian J Multidiscip Dent 2017;7:140-3.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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