Case Report

Complex Therapeutic Process due to Diagnostic Error in the Periapical Fibro-Osseous Lesion of Mandibular First Molar. A Case Report with Successful Implant Placement

Won-Bae Park1,2, Gazelle Jean Crasto4, Richard Y Hong4, Ji-Young Han3, Philip Kang4*

1Department of Periodontology, School of Dentistry, Kyung Hee University; Seoul 02447, Korea

2Private Practice in Periodontics and Implant Dentistry, Seoul 02771, Korea

3Department of Periodontology, Division of Dentistry, Hanyang University, College of Medicine, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea

4Division of Periodontics, Section of Oral, Diagnostic and Rehabilitation Sciences Columbia University College of Dental Medicine, #PH7E-110, 630 W. 168 St., New York, NY 10032, USA

*Corresponding author: Philip Kang, Division of Periodontics, Section of Oral, Diagnostic and Rehabilitation Sciences Columbia University College of Dental Medicine, #PH7E-110, 630 W. 168 St., New York, NY 10032, USA

Received Date: 05 May 2023

Accepted Date: 09 May 2023

Published Date: 12 May 2023

Citation: Park W, Crasto GJ, Hong RY, Han J, Kang P (2023) Complex Therapeutic Process due to Diagnostic Error in the Periapical Fibro-Osseous Lesion of Mandibular First Molar. A Case Report with Successful Implant Placement. Ann Case Report. 8: 1305.


Cemento-osseous dysplasia (COD) present radiographically as radiolucent lesions that are frequently misdiagnosed as endodontic lesions. The following case report involves a 42-year-old female that was treated for a molar endodontic lesion. The typically benign lesion, post endodontic therapy caused pain and chewing discomfort. The tooth was extracted a year later and biopsy samples confirmed the initial lesion was focal cemento osseous dysplasia (FCOD). The site was rehabilitated with dental implants and supplemented with bone graft material. The histological evidence of the extraction site revealed osteoporotic large bony marrow spaces with an inflammatory cell infiltrate, supplemented with cells of hematopoietic origin. Typically, sites that have abnormal bone quality, with confirmed diagnosis of cemento-osseous dysplasia are not considered ideal sites to receive implant placements. The present case report demonstrates a sequence of events for the management of FCOD in the posterior mandible with successful implant and bone graft treatment. Typically asymptomatic, FCOD benign lesions are not ideal candidates for implant placement, the following case reports depicts favorable outcomes in terms of osteointegration of the dental implant and subsequent oral rehabilitation for improved function.

Keywords: Dental Implant; Fibro-Osseous Lesion; Focal Cemento-Osseous Dysplasia; Periapical Lesion


Implant osseointegration is dependent on the dynamics of the bony tissue during both initial placement and subsequent healing. Specifically, placing implants in areas of high bone density, which is associated with increased mineral content, may result in compression necrosis [1], while areas of low bone density may compromise implant stability [2]. Similarly, dysplastic bone observed in fibro-osseous lesions presents a challenge for implant rehabilitation. The quality of available bone, in terms of structural presentations, vascular support, dense inflammatory infiltrate and the lack of cellular components directly impacts the process of osseointegration of dental implants. Cemento-osseous dysplasia (COD) is a benign fibro-osseous lesion derived from fibroblasts of periodontal ligament cells in the tooth-bearing region of the jaw [3-5]. The early osteolytic stage of COD consists of well-defined and well-vascularized fibrous tissue [6], which translates to decreased bone density often misdiagnosed in radiographs as periapical lesions of endodontic origin [5]. These lesions are observed to progress to radiopaque presentations as the bone density increases significant [7,8]. Among different classifications of COD, focal cemento-osseous dysplasia (FCOD) involves a single site, often associated with a tooth in the posterior mandible [4,9]. FCOD does not warrant any treatment [12,13]. However, early or intermediate stage FCOD are often misdiagnosed as periapical granuloma or abscess, subsequently receiving endodontic treatment. Various clinical reports document dental treatments that have led to detrimental effects due to misdiagnosis of FCOD [5,14]. The purpose of this case report is to document a sequence of events, from misdiagnosis of FCOD to successful implant rehabilitation treatment in the management of the fibro-osseous lesion in the mandibular first molar.

Case Presentation

A 42-year old female non-smoker, presents with no known systemic disease or medication regiment. Patient presented to a private dental clinic, exhibiting symptoms of pain and discomfort associated with severe tooth mobility in the mandibular right posterior region. Radiographic evaluation demonstrated alveolar bone resorption around the mandibular right first molar and periapical radiolucent lesion around distal root apex located above the mandibular canal (Figure 1a, b). The CBCT sections of the distal root demonstrate a radiopaque lesion with a radiolucent rim (Figure 1c, d). Based on the radiographic findings, the lesion was identified and diagnosed as FCOD. The patient subsequently was referred out to an endodontist for an ailing tooth on another quadrant. The endodontist incorrectly identified, diagnosed, and treated the mandibular right first molar that was previously diagnosed as FCOD. Post-treatment, the patient reported back with persistent chewing discomfort, mobility, and pain. At this time, an apicoectomy and excisional biopsy of the periapical lesion were performed by an oral surgeon. The lesion was diagnosed as fibrous dysplasia from the histological examination of the biopsy specimen. The patient then returned to our private clinic after a one year healing period. The patient continued to report functional problems with regards to food consumption, mainly from the persistent mobility in the right mandibular molars. Patient wanted to replace the teeth with implant-supported restorations. Risks and benefits of the extraction and implant treatment were clearly outlined and discussed with the patient in detail. Another set of panoramic radiograph and CBCT were acquired for implant treatment planning purposes (Figure 2a, b). The right mandibular first molar that received the apicoectomy presented with no visible abnormalities in the area of the previous fibro-osseous lesion (Figure 2c, d).


Figure 1: (a) A radiolucent periapical lesion was observed in the distal root of tooth #30 on a preoperative panoramic radiography; (b) In the sagittal image of CBCT, unilocular mixed radiolucent and radiopaque image with well-defined border was observed within the lesions. The lesion extended to the upper part of the mandibular canal; (c, d) In the coronal image of CBCT, a calcified mass was surrounded with radiolucent rim. Radiologically, the periapical lesion was suggested to be focal cemento-osseous dysplasia (FCOD).