Cemento-osseous dysplasia: a multi-centre analysis of surgical management

Cemento-osseous dysplasia: a multi-centre analysis of surgical management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cemento-osseous dysplasia: a multi-centre analysis of surgical management Fadi Titinchi, Naser Alturki, Jean Morkel, Salem Alkaabi, Kathryn Taylor This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5253068/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 May, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Cemento-osseous dysplasia (COD) is a fibro-osseous lesion whose management is highly controversial in the literature. Due to scarcity of comprehensive studies on its management, the aim of this study was to analyse its management and develop a treatment protocol. Methods A multi-centre retrospective cohort analysis was conducted at two tertiary referral hospitals on 124 patients diagnosed with COD from 2005–2023. Demographic, clinical, and radiological data were analysed and correlated with treatment methods. Post-operative complications such as osteomyelitis or pathological fracture were documented along with follow-up visits to evaluate the need for further treatment. Data was analysed using Student’s t-test and Fisher’s exact test. Statistical significance was set at P < 0.05 Results The patients’ ages ranged from 22–78 years (mean: 48.5 years), with majority being females (90.4%) and of African descent (95.9%). Radiopaque CODs presented significantly higher rate of symptoms compared to radiolucent or mixed lesions ( p = 0.02). The majority of incidental CODs were managed through observation (72%), while six incidental CODs underwent biopsy due to suspicion of more sinister lesions. Symptomatic lesions were mainly treated by curettage (29.7%) or local excision (48.6%), while only one symptomatic case was managed with observation and antibiotics ( p = 0.0001). Conclusion Biopsy of asymptomatic COD should only be reserved for cases with inconclusive clinico-pathological features. The decision to surgically treat COD should be based on the presence of symptoms and infection. Early curettage or excision of infected COD is the most effective approach to eradicate the disease and prevent progression into osteomyelitis. Cemento-osseous dysplasia Florid Cemento-osseous dysplasia Fibro-osseous lesions Maxilla Mandible Figures Figure 1 Figure 2 Figure 3 1. Introduction A benign fibro-osseous lesion is a non-neoplastic condition characterized by the replacement of normal bone with a fibrous connective tissue matrix that includes abnormal bone or cementum [ 1 ]. Cemento-osseous dysplasia (COD) is the most prevalent among the six primary categories of fibro-osseous lesions acknowledged in the 2022 World Health Organization (WHO) classification of head and neck tumors [ 2 ]. Although it is a non-neoplastic lesion occurring exclusively in the dento-alveolar regions of the jaws, recent study has detected pathogenic hotspot mutations in the RAS-MAPK signalling pathway in COD, including mutations in BRAF, HRAS, KRAS, NRAS, and FGFR3 [ 3 ]. The lesion is relatively common in middle aged females of African and Asian descent, with an age-adjusted prevalence rate of 5.5%. Numerous studies have reported a male to female ratio of 1:9 [ 4 , 5 ]. The exact aetiology of this lesion remains unknown, but genetic and hormonal factors have been suggested. Some authors propose that it may be a reactive lesion arising from the periodontal ligament [ 4 , 5 ]. COD is sub-classified into three different variants based on the anatomical location of the lesion and its distribution within the jaws: Periapical COD, which has a predilection for the apical region of the mandibular incisor teeth, Focal COD involving a single tooth in a quadrant, usually in the posterior mandible; and Florid COD, which is more extensive and generalized with multi-quadrant involvement and tends to be bilateral, symmetric and may involve both jaws [ 6 ]. The diagnosis of COD can often be reached based on clinical and radiographic features alone, without the need for pathological confirmation, however, the management of these lesions remains contentious due to the risks associated with biopsy, including potential complications such as osteomyelitis and injury to adjacent vital structures. Conversely, refraining from biopsy of suspicious lesions can result in misdiagnosis and disease progression [ 6 ]. In the literature, there is notable scarcity of large, detailed studies on the management of COD, particularly in regions such as Africa and Asia where the lesion is most prevalent. Additionally, conflicting evidence exists from studies conducted across Europe, America, Asia, and Africa [ 7 ]. Therefore, further investigations into the management of this relatively common fibro-osseous lesion of the jaws are warranted. The aim of this study is to analyse the management of COD and develop a treatment protocol. 2. Methods This was a multicentre retrospective descriptive cohort analysis of patients diagnosed with COD at two tertiary referral hospitals for the period from 2005 to 2023. Ethical clearance was obtained from the Biomedical Science Research Ethics Committee (reference: BM22/7/5) prior to conducting the study. Patients were included in the study if they had a confirmed diagnosis of COD based on clinico-pathological correlation. In addition, the patient’s records needed to be complete with demographic, clinical, radiographic and treatment (if any) details. Patients with inconclusive diagnosis were excluded. Data collection included patient’s age, gender, and ethnicity. The presenting clinical features including pain and infection, were documented alongside symptom history, with inclusion of incidental and asymptomatic lesions. Lesion locations within the jaws were characterised as anterior or posterior or both, notes on bilateral lesions and those present in all four quadrants. For each patient, the type of COD and its association with simple bone cyst (SBC) were recorded. The radiodensity of each lesion was recorded and correlated with symptoms and treatment received. The effects of the lesion on adjacent anatomical structures (adjacent teeth, inferior alveolar canal and/or maxillary antrum) was documented. The treatment methods employed were recorded including observation, excision, partial removal or resection. The occurrence of any complications such as osteomyelitis or pathological fracture was documented. Follow-up visits and serial post-operative radiographs were evaluated for evidence recurrences. The data collected was analysed using Student’s t-test and Fisher’s exact test to identify correlations between various clinico-pathological parameters and treatment methods. GraphPad statistical software was utilized for the analysis, which included means, standard deviations, and percentages. Statistical significance was set at p < 0.05. 3. Results A total of 141 patients were diagnosed with COD during the study period. Of these, only 124 patients met the inclusion criteria; the rest were excluded due to inconclusive diagnosis or poor-quality imaging. Notably, COD was the most prevalent of the fibro-osseous lesions in this population throughout the study period. 3.1. Clinico-pathological features The ages of patients at the time of diagnosis with COD ranged from 22 to 78 years (mean: 48.5 years). The majority of patients diagnosed with COD (76.5%) were above 40 years of age. Females constituted the most of affected individuals (90.4%), predominantly of African descent (95.9%). A significant proportion of patients with COD (61.3%) exhibited symptoms such as pain, swelling, or infection. A considerable number of cases were observed in fully edentulous patients, where COD was exposed through the gingiva/oral mucosa (39.5%). Additionally, paraesthesia of the lower lip was reported in four patients (3.2%). Seven lesions (5.6%) were associated with osteomyelitis of the mandible, and five patients presented with submandibular draining fistulas, a consequence of long-standing infected COD. The duration of reported symptoms ranged from 1 to 48 months (mean: 9.5 months) prior to presentation. The majority of symptomatic COD lesions were located in the posterior mandible (95.6%). Most CODs presented in the mandible (75.8%), predominantly in the posterior regions (75.5%). Focal COD was the most prevalent type (46.7%), followed closely by florid COD (45.1%), and lastly periapical cemental dysplasia (8.2%). Florid COD presenting in both jaws were fairly common (44.6%). On panoramic radiographs, the majority of CODs exhibited mixed density (51%). The vast majority of the lesions were well-defined (93.5%), with an irregular shape (62.1%). Most CODs did not displace adjacent anatomical structures, such as maxillary sinus or inferior alveolar canal (82.1%). Only two cases (1.6%) were associated with SBC, and one case was associated with an odontogenic keratocyst (OKC). One patient developed osteosarcoma in association with florid COD. Importantly, radiopaque COD lesions were significantly more likely to be symptomatic compared to radiolucent or mixed density lesions ( p = 0.02). However, there was no statistical correlation between the type of COD and the presence of symptoms (Table 1 ). Table 1 Analysis of different variables based on symptom presentation (n = 124). Symptomatic Total P-value Yes No Site p = 0.39 Mandible 53 41 94 (75.8%) Maxilla 4 1 5 (4%) Both jaws 17 8 25 (20.2%) Radio-density p = 0.02 Lucent 1 8 9 (7.2%) Mixed 34 29 63 (50.9%) Opaque 39 13 52 (41.9%) Type of COD p = 0.56 Periapical 2 8 10 (8.1%) Focal 35 23 58 (46.8%) Florid 37 19 56 (45.1%) 3.2. Management Symptomatic CODs were mostly managed with surgical removal, especially in cases that were secondarily infected (34.7%). When a fistula was present in association with infected COD, a fistulectomy was concurrently performed. Extensive lesions often required additional surgical debridement and sequestrectomy (Fig. 1 ), or radical resection in refractory cases. Partial removal or curettage was selectively performed for certain symptomatic lesions in order to avoid injury to adjacent anatomical structures (Fig. 2 ). Lesions were only biopsied if there was clinico-radiological concern that the lesion might mimic other sinister pathologies such as an osteosarcoma or odontogenic cyst or tumour. In the analysis of the treatment methods, most radiopaque and mixed lesions underwent excision or curettage due to the increased risk of secondary infection following exposure to the oral cavity. A large number of mixed density lesions were observed while more than half of radiolucent lesions were also observed. Despite these treatment patterns, there was no statistically significant relationship among them ( P > 0.05). In cases of infected COD, these lesions could easily be curetted from the rest of the uninvolved bone. In certain cases, due to the extensive size of COD, the lesion needed to be removed in piecemeal. The medical management protocol for infected CODs involved the administration of empiric antibiotics such as Amoxicillin/clavulanic acid (Augmentin®) or Clindamycin. The antibiotic regimen was adjusted as necessary, based on the result of the microscopy, culture and sensitivity to target cultured bacteria. Residual cavities in the jaw were packed with bismuth iodoform paraffin paste (BIPP) impregnated gauze, which was serially removed over a period of 2–3 weeks. The majority of incidentally found CODs were managed by observation and serial follow-up (72%), while six incidental CODs underwent biopsy due to clinical suspicion for other more sinister lesions. On the other hand, most symptomatic lesions were treated by curettage (29.7%) or local excision (48.6%), while only one symptomatic case was observed and treated with antibiotics (Table 2 ). These differences in management patterns were statistically significant ( p = 0.0001). Table 2 Management patterns of incidental and symptomatic CODs. Treatment method Incidental Symptomatic Total Observation 36 (29%) 1 (0.8%) 37 (29.8%) Incisional biopsy 6 (4.8%) 15 (12.2%) 21 (17%) Complete excision 6 (4.8%) 36 (29%) 42 (33.8%) Curettage 2 (1.6%) 22 (17.8%) 24 (19.4%) Total 50 (40.3%) 74 (59.7%) 124 3.3. Complications Within this sample, surgically treated lesions rarely required re-treatment due to secondary infection. The placement of BIPP impregnated gauze in the bony cavity after debridement reduced the risk of post-operative infection (Fig. 3 ). BIPP impregnated gauze also eliminated the dead space and circumvented the need for bone grafting thus reducing post-operative complications. Three cases required re-operative surgery for removal of previously treated COD (mean follow-up: 7.9 months). One case of OKC associated with COD recurred four years post enucleation, likely due to the incomplete removal of the entire cyst lining, especially in areas closely associated with the COD. One edentulous patient experienced a pathological fracture of the mandible during surgical removal of COD. Extraction of teeth in close proximity to COD lesions was the leading cause of complications, which included secondary infection of COD, osteomyelitis, and development of cutaneous fistula. 4. Discussion Cemento-osseous dysplasia is a well described disease process whereby healthy bone is replaced by sclerotic bone. It is the most prevalent of the fibro-osseous lesions presenting in the jaws. Despite being fairly common in females of African and Asian origin, there is a lack of studies in the literature on COD in African populations [ 8 ]. Therefore, this study is one of the largest and most comprehensive on the management of COD in a predominantly African population. 4.1. Clinico-pathological features Middle-aged individuals of African ancestry are the population group most commonly affected by COD. The mean ages of patients diagnosed with COD in the literature ranges from 40.6–66.5 years, with an overall mean of 52.2 years [ 5 – 7 , 9 – 14 ]. Females are significantly more likely to be affected with COD, whereas it is infrequently reported in males. This study’s findings align with these observations. The disproportionate prevalence of COD in females has been hypothesized to be due to hormonal imbalance that influence bone remodelling [ 15 ]. Generally, COD is described as an inconspicuous condition, usually detected incidentally on routine radiography. Some affected patients may present with swelling, pain and purulent discharge due to secondary infection in the bone surrounding the lesion. Studies in the literature report the presence of symptoms to range from 14.7–100% of cases [ 5 , 7 , 9 – 12 ]. In this study, 38.7% of cases were incidentally found on routine radiography. There is consensus in the literature that the mandible is by far the most affected jaw, with the majority of lesions presenting in the posterior regions of the mandible [ 6 , 7 , 9 , 10 , 13 , 14 ]. In current study’s sample, more than three quarters of CODs occurred in the mandible alone, while 20.2% occurred in both jaws. CODs occurring in the maxilla alone were uncommon. There is conflicting data in the literature regarding which subtype of COD is the most common. Some studies report focal COD as the most prevalent subtype [ 6 , 10 , 14 ], while others identify florid COD as the most common [ 5 , 7 , 9 , 11 , 13 ]. In this study, focal and florid CODs were nearly equally common, with focal COD being slightly more prevalent. MacDonald-Jankowski (16) and Pereira et al . [ 6 ] reported that all florid CODs involved the mandible, while nearly half also involving the maxilla as well. The radiological features of COD are crucial for an accurate diagnosis. The majority of studies in the literature report that COD typically appears as a mixed density lesion on radiographs [ 6 , 7 , 9 , 10 , 11 , 14 ]. However, studies focusing solely on florid COD have found that many lesions are radiopaque due to their mature nature [ 5 ]. In this study, nearly half of florid COD cases (46.4%) appeared radiopaque. There is general agreement in the literature that CODs appear as well-defined lesions on radiographs in most cases [ 10 ]. Alsufyani and Lam [ 10 ] reported that 91.5% of CODs in their sample were well-defined. Similarly, in the present study 93.5% of lesions were well-defined. Ill-defined lesions warranted further investigations using advanced imaging or biopsy to rule out more sinister conditions. In our study, the relationship of COD with adjacent anatomical structures was assessed using multiplanar CBCT/CT. Cortical bone aberration was the most commonly involved structure in most subtypes of COD, consistent with other studies [ 17 ]. Other frequently observed features included cortical bone thinning, expansion, and perforation. As previously reported, florid COD was responsible for most aberrations to the cortical bone compared to other subtypes of COD, further highlighting its aggressive nature [ 18 , 19 ]. The accuracy of diagnosis of COD based on clinical and radiological examination is vitally important in order to avoid unnecessary biopsy of asymptomatic lesions. Although arriving at an accurate diagnosis may be challenging, it is essential for appropriate management. Ideally, COD should be diagnosed based on clinical and radiographic signs, with biopsies reserved for uncertain cases [ 6 ]. In this study, most cases were accurately identified as COD (sensitivity: 83.3%), a finding similar to other authors [ 10 ]. 4.2. Management There is currently no consensus in the literature regarding when surgical treatment for COD is indicated and which method is most appropriate [ 7 ]. Generally, it is accepted that asymptomatic COD does not require surgical intervention beyond close clinical follow-up, preventive measures, and restorative methods to prevent the need for dental extraction and exposure of COD to the oral environment [ 9 , 20 ]. The findings of this study underscore the necessity of biopsy in some asymptomatic cases to rule out other conditions. A biopsy is indicated if the diagnosis based on radiographic exam is uncertain, especially for lesions in the radiolucent phase or those causing significant bone expansion. Additionally, the presence of a second pathology, such as SBC, should prompt a biopsy to confirm the diagnosis [ 6 ]. This also applies to the rare occurrence of associated osteosarcoma, as observed in one of the cases in this study [ 21 ]. When COD lesions manifest symptoms, their management becomes more challenging due to development of chronic inflammation and bacterial infection within densely mineralized tissue. It has been described that there is poor penetration of antibiotics due to lack of tissue diffusion deeming them ineffective [ 6 ]. Consequently, performing a biopsy increases the risk of developing secondary infection, and removing of such lesions in asymptomatic patients can lead to significant morbidity [ 20 ]. Surgical debridement and curettage are recognised as the most appropriate methods for managing symptomatic and infected CODs (Table 3 ). Despite the challenges associated with treating infected lesions, particularly due to the poor vascularity of the area and increased bone hardness, these surgical techniques have shown effectiveness in treating the majority of infected CODs, with a success rate of 88.9% [ 7 ]. Antibiotics play an adjuvant role by inhibiting the formation of new biofilms through the destruction of bacterial colonies before they can adhere to the necrotic bone. Table 3 Comparison of types of COD and their management in this study with other recent studies in the literature. Type of COD Treatment Author Periapical Focal Florid Observation Biopsy Curettage/Excision Olgac et al . [ 6 ] 33 (24.4%) 83 (61.5%) 19 (14.1%) None 135 (100%) N/A Pereira et al . [ 5 ] None None 82 (100%) 35 14 (34.1%) Kato et al . [ 7 ] 10.60% 27.30% 62.10% N/A N/A 59 (89.4%) Elbeshir and Alhadad [ 9 ] None None 47 (100%) 17 (47%) N/A 19 (40.4%) Alsufyani and Lam [ 10 ] 93 (78.8%) 25 (21.5%) N/A N/A N/A Benaessa et al . [ 13 ] 16 (12%) 24 (18%) 93 (69.9%) N/A N/A N/A Nam et al . [ 14 ] None 60 (96.7%) 2 (3.2%) N/A N/A N/A Decolibus et al . [ 11 ] 63 (33%) 43 (22.5%) 85 (44.5%) N/A 73 (38.2%) N/A This study 10 (8.1%) 58 (46.8%) 56 (45.1%) 27 (29.8%) 21 (17%) 66 (53.2%) *N/A: Not available. The primary prognostic indicator for the development of infected CODs in this study were identified as dental extraction and the use of removable dentures. Kato et al . [ 7 ] reported comparable predictive factors for the onset of infection within COD lesions. Chronic secondarily infected COD were found to be more easily to curettage from the underlying bone, as the osteolytic process leads to the sequestration of the necrotic lesion. In these cases, patients generally exhibit compromised wound healing, precluding the application of bone grafting. Iodoform impregnated gauze has been shown to facilitate wound healing and the formation of granulation tissue. Certain authors have suggested the utilization of local soft tissue flaps, such as buccal fat pad, to aid in wound closure. Should there be a failure to heal after a period of 3 to 4 months, secondary surgical intervention should be considered [ 12 ]. Following an extensive literature search, very few studies focused on the management of COD. This study stands out as one of the most comprehensive analysis focused on the treatment of COD. Furthermore, using findings from this study along with data available from the literature, a management protocol is proposed (Table 4 ). Table 4 Treatment protocol for Cemento-Osseous Dysplasia. Treatment method Indications Observation - Asymptomatic periapical, focal or florid COD with accurate diagnosis based on clinical and radiographic features - No exposure through oral tissues - No associated pathology with COD (such as OKC, SBC) Incisional biopsy - Clinical/radiographic diagnosis of COD is uncertain (e.g. radiolucent phase, extensive COD mimicking osteosarcoma) - Associated with another pathological lesion (OKC, SBC, osteosarcoma) - Lesion causing expansion Debridement/curettage - Symptomatic lesion closely associated with anatomical structures (inferior alveolar/mental nerve or maxillary sinus) - Lesion interferes with denture prosthesis Local excision - Symptomatic COD - Secondarily infected COD (with draining sinus/fistula or osteomyelitis) - Exposed COD through oral tissues 4.3. Complications One of the major complications associated with COD is the development of osteomyelitis, especially in the mandible, which leads to high morbidity for the patient and development of cutaneous fistulas, as seen in this sample. Elbeshir and Alhadad [ 9 ] reported that 25.5% of their Sudanese sample to have developed osteomyelitis, while Alsufyani and Lam ([0] reported an 11% prevalence. Kawai et al . [ 15 ], in a Japanese study, reported a 14.8% prevalence, whereas in this study, only 5.6% of patients developed osteomyelitis. This lower rate of osteomyelitis in this study is likely due to aggressive and early surgical intervention in infected CODs cases to prevent progression to osteomyelitis. Elbeshir and Alhadad [ 9 ] managed most COD cases in their sample with antibiotics initially, while only refractory cases were treated with surgical debridement. This approach may explain the higher prevalence of osteomyelitis in their study when compared to this one. The recurrence rate and need for surgical re-treatment of COD is another possible complication. Nam et al . [ 14 ] reported excellent outcomes following surgical removal or curettage and administration of antibiotics, with no recurrence. In the current study, three cases (2.4%) required re-treatment due to incomplete removal. The decision for incomplete removal was initially made to avoid injury to vital structures, such as the inferior alveolar nerve. Several limitations were encountered in this study, which are commonly encountered in other retrospective record-based studies. A significant number of records (approximately 12%) did not meet the study’s inclusion criteria due to missing information. For some older records, it was challenging to attain the patient’s clinical presentation due to incomplete record keeping. Given that the study was conducted over a period of 18 years and at two different hospitals, treatment methods could not be standardized, as multiple providers performed these procedures during this time period. Additionally, a significant number of patients were lost to follow-up, as many lived in rural communities far from these hospitals. In conclusion, the decision to surgically manage COD lesions should be based on clinical signs and symptoms, as well as the presence of infection or osteomyelitis. Asymptomatic cases should be monitored periodically, with an emphasis on preventative measures to avoid secondary infections. Biopsy of asymptomatic lesions should only be performed when the clinico-pathological features are inconclusive and lesion could mimic other more sinister conditions. The presence of pain, suppuration and osteolytic changes with or without bone sequestration, are indications for surgical intervention in infected COD. Despite the lack of consensus regarding treatment regime, early curettage or surgical excision of infected COD is the most successful approach to eradicate the disease process and prevent further progression into osteomyelitis. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Fadi Titinchi, Naser Alturki and Jean Morkel. Data analysis was performed by Salem Alkaabi and Kathryn Taylor. The first draft of the manuscript was written by Fadi Titinchi and Naser Alturki and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by biomedical research ethics committee of the University of the Western Cape (BM22/7/5). Consent to participate No consent was required due to the retrospective, record-based design of the study. Clinical trial number: not applicable. References Mainville GN, Turgeon DP, Kauzman A (2017) Diagnosis and management of benign fibro-osseous lesions of the jaws: a current review for the dental clinician. Oral Dis 23:440–450. https://doi.org/10.1111/odi.12531 Vered M, Wright JM (2022) Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Odontogenic and Maxillofacial Bone Tumours. Head Neck Pathol 16:63–75. https://doi.org/10.1007/s12105-021-01404-7 Haefliger S, Turek D, Andrei V, Alborelli I, Calgua B, Ameline B, Harder D, Baumhoer D (2023) Cemento-osseous dysplasia is caused by RAS-MAPK activation. Pathology 55:324–328. https://doi.org/10.1016/j.pathol.2022.10.006 Slootweg PJ, El-Naggar AK (2018) World Health Organization 4th edition of head and neck tumor classification: insight into the consequential modifications. Virchows Arch 472:311–313. https://doi.org/10.1007/s00428-018-2320-6 Pereira DL, Pires FR, Lopes MA, Carlos R, Wright JM, Patel P, van Heerden W, Uys A, Vargas PA (2016) Clinical, demographic, and radiographic analysis of 82 patients affected by florid osseous dysplasia: an international collaborative study. Oral Surg Oral Med Oral Pathol Oral Radiol 122:250–257. https://doi.org/10.1016/j.oooo.2016.04.013 Olgac V, Sinanoglu A, Selvi F, Soluk-Tekkesin M (2021) A clinicopathologic analysis of 135 cases of cemento-osseous dysplasia: To operate or not to operate? J Stomatol Oral Maxillofac Surg 122:278–282. https://doi.org/10.1016/j.jormas.2020.06.002 Kato CNAO, de Arruda JAA, Mendes PA, Neiva IM, Abreu LG, Moreno A, Silva TA, Souza LN, Mesquita RA (2020) Infected Cemento-Osseous Dysplasia: Analysis of 66 Cases and Literature Review. Head Neck Pathol 14:173–182. https://doi.org/10.1007/s12105-019-01037-x Muwazi LM, Kamulegeya A (2015) The 5-year prevalence of maxillofacial fibro-osseous lesions in Uganda. Oral Dis 21:e79–85. https://doi.org/10.1111/odi.12233 Elbeshir EI, Alhadad M (2017) Florid cemento-osseous dysplasia: analysis of 47 Sudanese cases and review of the literature. Oral Surg 10:216–221. https://doi.org/10.1111/ors.12256 Alsufyani NA, Lam EW (2011) Osseous (cemento-osseous) dysplasia of the jaws: clinical and radiographic analysis. J Can Dent Assoc 77:b70 Decolibus K, Shahrabi-Farahani S, Brar A, Rasner SD, Aguirre SE, Owosho AA (2023) Cemento-Osseous Dysplasia of the Jaw: Demographic and Clinical Analysis of 191 New Cases. Dent J (Basel) 11:138. https://doi.org/10.3390/dj11050138 Ebrahimi F, Ebrahimi F, An J (2023) Surgical Management of Infection Secondary to Cemento-osseous Dysplasia. J Craniofac Surg 34:e614–e617. https://doi.org/10.1097/SCS.0000000000009556 Benaessa MM, Mahomed F, Ngwenya SP (2019) A retrospective clinico-pathologic analysis of cemento-osseous dysplasia in a South African patient population. Afr Health Sci 19:3154–3159. https://doi.org/10.4314/ahs.v19i4.38 Nam I, Ryu J, Shin SH, Kim YD, Lee JY (2022) Cemento-osseous dysplasia: clinical presentation and symptoms. J Korean Assoc Oral Maxillofac Surg 48:79–84. https://doi.org/10.5125/jkaoms.2022.48.2.79 Kawai T, Hiranuma H, Kishino M, Jikko A, Sakuda M (1999) Cemento-osseous dysplasia of the jaws in 54 Japanese patients: a radiographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:107–114. https://doi.org/10.1016/s1079-2104(99)70303-3 MacDonald-Jankowski DS (2003) Florid cemento-osseous dysplasia: a systematic review. Dentomaxillofac Radiol 32:141–149. https://doi.org/10.1259/dmfr/32988764 Gumru B, Akkitap MP, Deveci S, Idman E (2021) A retrospective cone beam computed tomography analysis of cemento-osseous dysplasia. J Dent Sci 16:1154–1161. https://doi.org/10.1016/j.jds.2021.03.009 Cavalcanti PHP, Nascimento EHL, Pontual MLDA, Pontual ADA, Marcelos PGCL, Perez DEDC, Ramos-Perez FMM (2018) Cemento-Osseous Dysplasias: Imaging Features Based on Cone Beam Computed Tomography Scans. Braz Dent J 29:99–104. https://doi.org/10.1590/0103-6440201801621 Ito K, Hirahara N, Iizuka N, Sawada E, Okada S, Suemitsu M, Kuyama K, Kaneda T (2018) Florid Cemento-Osseous Dysplasia of Osteolytic Stage Showing Cyst-Like Findings on CT and MRI: A Case Report. Int J Oral-Med Sci 17:137–142 Aiuto R, Gucciardino F, Rapetti R, Siervo S, Bianch AE (2018) Management of symptomatic florid cemento-osseous dysplasia: Literature review and a case report. J Clin Exp Dent 10:e291–e295. https://doi.org/10.4317/jced.54577 Indermun S, Titinchi F, Alwan J, Morkel J, Nortje CJ (2024) Osteosarcoma associated with cemento-osseous dysplasia: co-incidence or two related entities? Oral Radiol 40:546–554. https://doi.org/10.1007/s11282-024-00758-2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 May, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted Editorial decision: Accepted 27 Apr, 2025 Reviews received at journal 01 Jan, 2025 Reviewers agreed at journal 13 Dec, 2024 Reviewers invited by journal 27 Oct, 2024 Editor assigned by journal 15 Oct, 2024 Submission checks completed at journal 15 Oct, 2024 First submitted to journal 12 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5253068","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366295747,"identity":"32940aa5-3d2c-4db0-9d20-a52f30a59f91","order_by":0,"name":"Fadi Titinchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBAC9gbGBoYEBoYENvYGIrXwHGNsbABr4TlAtBYGRpDxCQwSCcRqkW9uf/Bwh10en+QbM4kfDHbyDPyHH+DXwgZ0WOKZ5GI26RwzyR6GZMMGhmMGeLXYg7W0HUhsA2q5zcDAnAB0KH4tPHAtkmdAWuoTGJjZPxCpRYIHpOVwAgMbDyFbEhtnJLYlJ7bxpJX/7DE4btjGw1OAXwvz8Qcff7bZJc5vP7zZ4EdFtTw///ENeLWgAaCT2EhRPwpGwSgYBaMAOwAA1mk/J77oqjgAAAAASUVORK5CYII=","orcid":"","institution":"University of the Western Cape","correspondingAuthor":true,"prefix":"","firstName":"Fadi","middleName":"","lastName":"Titinchi","suffix":""},{"id":366295748,"identity":"5ae617e5-d3f5-4713-bf35-f4f0698b73d3","order_by":1,"name":"Naser Alturki","email":"","orcid":"","institution":"University of the Western Cape","correspondingAuthor":false,"prefix":"","firstName":"Naser","middleName":"","lastName":"Alturki","suffix":""},{"id":366295750,"identity":"bc74e948-271d-4aa1-bf62-09f3745644ed","order_by":2,"name":"Jean Morkel","email":"","orcid":"","institution":"University of the Western Cape","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"","lastName":"Morkel","suffix":""},{"id":366295751,"identity":"90133401-a00e-411d-a423-3162bfc5514e","order_by":3,"name":"Salem Alkaabi","email":"","orcid":"","institution":"Amsterdam University Medical Centers and Academic Centre for Dentistry Amsterdam, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences","correspondingAuthor":false,"prefix":"","firstName":"Salem","middleName":"","lastName":"Alkaabi","suffix":""},{"id":366295752,"identity":"659f9bc6-aa8c-4c9e-a120-9566e1b8cfd3","order_by":4,"name":"Kathryn Taylor","email":"","orcid":"","institution":"University of Central Lancashire","correspondingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"","lastName":"Taylor","suffix":""}],"badges":[],"createdAt":"2024-10-12 20:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5253068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5253068/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10006-025-01394-8","type":"published","date":"2025-05-07T15:57:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67280567,"identity":"5d14c073-bbd3-45a2-8deb-71adf8005354","added_by":"auto","created_at":"2024-10-23 08:58:17","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1297401,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a)\u003c/strong\u003e Pre and \u003cstrong\u003e(b)\u003c/strong\u003eintra-operative findings of an infected COD in the left mandible.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5253068/v1/d61ea589c8be61a684f79561.jpg"},{"id":67280568,"identity":"4c6b75cf-4af6-498a-a9fb-b19d75b7e331","added_by":"auto","created_at":"2024-10-23 08:58:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":816679,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a)\u003c/strong\u003e Pre-operative panoramic radiograph of a patient diagnosed with florid COD complaining of pain and bilateral swelling in the mandible. \u003cstrong\u003e(b)\u003c/strong\u003ePre-operative coronal and \u003cstrong\u003e(c)\u003c/strong\u003e axial CBCT images revealing expansive mixed density lesions in the bilateral mandible. \u003cstrong\u003e(d)\u003c/strong\u003e Seven months post-operative panoramic radiograph of the same patient showing good healing following excision of COD lesions from the posterior mandible.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5253068/v1/24e430754bf8fbbd76af7bea.jpg"},{"id":67280566,"identity":"274d4903-2c0c-4fb7-8cae-1cde55119d00","added_by":"auto","created_at":"2024-10-23 08:58:17","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":568619,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a)\u003c/strong\u003e Pre-operative panoramic radiograph of a patient with extensive florid COD and features of osteomyelitis in the mandible bilaterally. \u003cstrong\u003e(b)\u003c/strong\u003e Post-operative panoramic radiograph of the same patient post debridement of COD and placement of BIPP impregnated gauze.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5253068/v1/ee5f1121ca0a8f86e05b2bc2.jpg"},{"id":82537823,"identity":"0e5a7586-d281-4db3-9397-6fb7646e4c81","added_by":"auto","created_at":"2025-05-12 16:10:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3355822,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5253068/v1/8749be37-db6d-4b17-bb81-c26b7c96f16e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cemento-osseous dysplasia: a multi-centre analysis of surgical management","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eA benign fibro-osseous lesion is a non-neoplastic condition characterized by the replacement of normal bone with a fibrous connective tissue matrix that includes abnormal bone or cementum [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Cemento-osseous dysplasia (COD) is the most prevalent among the six primary categories of fibro-osseous lesions acknowledged in the 2022 World Health Organization (WHO) classification of head and neck tumors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although it is a non-neoplastic lesion occurring exclusively in the dento-alveolar regions of the jaws, recent study has detected pathogenic hotspot mutations in the RAS-MAPK signalling pathway in COD, including mutations in BRAF, HRAS, KRAS, NRAS, and FGFR3 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lesion is relatively common in middle aged females of African and Asian descent, with an age-adjusted prevalence rate of 5.5%. Numerous studies have reported a male to female ratio of 1:9 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The exact aetiology of this lesion remains unknown, but genetic and hormonal factors have been suggested. Some authors propose that it may be a reactive lesion arising from the periodontal ligament [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCOD is sub-classified into three different variants based on the anatomical location of the lesion and its distribution within the jaws: Periapical COD, which has a predilection for the apical region of the mandibular incisor teeth, Focal COD involving a single tooth in a quadrant, usually in the posterior mandible; and Florid COD, which is more extensive and generalized with multi-quadrant involvement and tends to be bilateral, symmetric and may involve both jaws [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of COD can often be reached based on clinical and radiographic features alone, without the need for pathological confirmation, however, the management of these lesions remains contentious due to the risks associated with biopsy, including potential complications such as osteomyelitis and injury to adjacent vital structures. Conversely, refraining from biopsy of suspicious lesions can result in misdiagnosis and disease progression [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the literature, there is notable scarcity of large, detailed studies on the management of COD, particularly in regions such as Africa and Asia where the lesion is most prevalent. Additionally, conflicting evidence exists from studies conducted across Europe, America, Asia, and Africa [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, further investigations into the management of this relatively common fibro-osseous lesion of the jaws are warranted. The aim of this study is to analyse the management of COD and develop a treatment protocol.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis was a multicentre retrospective descriptive cohort analysis of patients diagnosed with COD at two tertiary referral hospitals for the period from 2005 to 2023. Ethical clearance was obtained from the Biomedical Science Research Ethics Committee (reference: BM22/7/5) prior to conducting the study. Patients were included in the study if they had a confirmed diagnosis of COD based on clinico-pathological correlation. In addition, the patient\u0026rsquo;s records needed to be complete with demographic, clinical, radiographic and treatment (if any) details. Patients with inconclusive diagnosis were excluded.\u003c/p\u003e \u003cp\u003eData collection included patient\u0026rsquo;s age, gender, and ethnicity. The presenting clinical features including pain and infection, were documented alongside symptom history, with inclusion of incidental and asymptomatic lesions. Lesion locations within the jaws were characterised as anterior or posterior or both, notes on bilateral lesions and those present in all four quadrants. For each patient, the type of COD and its association with simple bone cyst (SBC) were recorded.\u003c/p\u003e \u003cp\u003eThe radiodensity of each lesion was recorded and correlated with symptoms and treatment received. The effects of the lesion on adjacent anatomical structures (adjacent teeth, inferior alveolar canal and/or maxillary antrum) was documented. The treatment methods employed were recorded including observation, excision, partial removal or resection. The occurrence of any complications such as osteomyelitis or pathological fracture was documented. Follow-up visits and serial post-operative radiographs were evaluated for evidence recurrences.\u003c/p\u003e \u003cp\u003eThe data collected was analysed using Student\u0026rsquo;s t-test and Fisher\u0026rsquo;s exact test to identify correlations between various clinico-pathological parameters and treatment methods. GraphPad statistical software was utilized for the analysis, which included means, standard deviations, and percentages. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 141 patients were diagnosed with COD during the study period. Of these, only 124 patients met the inclusion criteria; the rest were excluded due to inconclusive diagnosis or poor-quality imaging. Notably, COD was the most prevalent of the fibro-osseous lesions in this population throughout the study period.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Clinico-pathological features\u003c/h2\u003e \u003cp\u003eThe ages of patients at the time of diagnosis with COD ranged from 22 to 78 years (mean: 48.5 years). The majority of patients diagnosed with COD (76.5%) were above 40 years of age. Females constituted the most of affected individuals (90.4%), predominantly of African descent (95.9%). A significant proportion of patients with COD (61.3%) exhibited symptoms such as pain, swelling, or infection. A considerable number of cases were observed in fully edentulous patients, where COD was exposed through the gingiva/oral mucosa (39.5%). Additionally, paraesthesia of the lower lip was reported in four patients (3.2%).\u003c/p\u003e \u003cp\u003eSeven lesions (5.6%) were associated with osteomyelitis of the mandible, and five patients presented with submandibular draining fistulas, a consequence of long-standing infected COD. The duration of reported symptoms ranged from 1 to 48 months (mean: 9.5 months) prior to presentation. The majority of symptomatic COD lesions were located in the posterior mandible (95.6%).\u003c/p\u003e \u003cp\u003eMost CODs presented in the mandible (75.8%), predominantly in the posterior regions (75.5%). Focal COD was the most prevalent type (46.7%), followed closely by florid COD (45.1%), and lastly periapical cemental dysplasia (8.2%). Florid COD presenting in both jaws were fairly common (44.6%). On panoramic radiographs, the majority of CODs exhibited mixed density (51%). The vast majority of the lesions were well-defined (93.5%), with an irregular shape (62.1%).\u003c/p\u003e \u003cp\u003eMost CODs did not displace adjacent anatomical structures, such as maxillary sinus or inferior alveolar canal (82.1%). Only two cases (1.6%) were associated with SBC, and one case was associated with an odontogenic keratocyst (OKC). One patient developed osteosarcoma in association with florid COD. Importantly, radiopaque COD lesions were significantly more likely to be symptomatic compared to radiolucent or mixed density lesions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). However, there was no statistical correlation between the type of COD and the presence of symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of different variables based on symptom presentation (n\u0026thinsp;=\u0026thinsp;124).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSymptomatic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (75.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxilla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth jaws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadio-density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLucent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (50.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpaque\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (41.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of COD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriapical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlorid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Management\u003c/h2\u003e \u003cp\u003eSymptomatic CODs were mostly managed with surgical removal, especially in cases that were secondarily infected (34.7%). When a fistula was present in association with infected COD, a fistulectomy was concurrently performed. Extensive lesions often required additional surgical debridement and sequestrectomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), or radical resection in refractory cases. Partial removal or curettage was selectively performed for certain symptomatic lesions in order to avoid injury to adjacent anatomical structures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Lesions were only biopsied if there was clinico-radiological concern that the lesion might mimic other sinister pathologies such as an osteosarcoma or odontogenic cyst or tumour.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the analysis of the treatment methods, most radiopaque and mixed lesions underwent excision or curettage due to the increased risk of secondary infection following exposure to the oral cavity. A large number of mixed density lesions were observed while more than half of radiolucent lesions were also observed. Despite these treatment patterns, there was no statistically significant relationship among them (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eIn cases of infected COD, these lesions could easily be curetted from the rest of the uninvolved bone. In certain cases, due to the extensive size of COD, the lesion needed to be removed in piecemeal. The medical management protocol for infected CODs involved the administration of empiric antibiotics such as Amoxicillin/clavulanic acid (Augmentin\u0026reg;) or Clindamycin. The antibiotic regimen was adjusted as necessary, based on the result of the microscopy, culture and sensitivity to target cultured bacteria. Residual cavities in the jaw were packed with bismuth iodoform paraffin paste (BIPP) impregnated gauze, which was serially removed over a period of 2\u0026ndash;3 weeks.\u003c/p\u003e \u003cp\u003eThe majority of incidentally found CODs were managed by observation and serial follow-up (72%), while six incidental CODs underwent biopsy due to clinical suspicion for other more sinister lesions. On the other hand, most symptomatic lesions were treated by curettage (29.7%) or local excision (48.6%), while only one symptomatic case was observed and treated with antibiotics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These differences in management patterns were statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eManagement patterns of incidental and symptomatic CODs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncidental\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSymptomatic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (29.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurettage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (40.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Complications\u003c/h2\u003e \u003cp\u003eWithin this sample, surgically treated lesions rarely required re-treatment due to secondary infection. The placement of BIPP impregnated gauze in the bony cavity after debridement reduced the risk of post-operative infection (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). BIPP impregnated gauze also eliminated the dead space and circumvented the need for bone grafting thus reducing post-operative complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThree cases required re-operative surgery for removal of previously treated COD (mean follow-up: 7.9 months). One case of OKC associated with COD recurred four years post enucleation, likely due to the incomplete removal of the entire cyst lining, especially in areas closely associated with the COD. One edentulous patient experienced a pathological fracture of the mandible during surgical removal of COD. Extraction of teeth in close proximity to COD lesions was the leading cause of complications, which included secondary infection of COD, osteomyelitis, and development of cutaneous fistula.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eCemento-osseous dysplasia is a well described disease process whereby healthy bone is replaced by sclerotic bone. It is the most prevalent of the fibro-osseous lesions presenting in the jaws. Despite being fairly common in females of African and Asian origin, there is a lack of studies in the literature on COD in African populations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, this study is one of the largest and most comprehensive on the management of COD in a predominantly African population.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Clinico-pathological features\u003c/h2\u003e \u003cp\u003eMiddle-aged individuals of African ancestry are the population group most commonly affected by COD. The mean ages of patients diagnosed with COD in the literature ranges from 40.6\u0026ndash;66.5 years, with an overall mean of 52.2 years [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Females are significantly more likely to be affected with COD, whereas it is infrequently reported in males. This study\u0026rsquo;s findings align with these observations. The disproportionate prevalence of COD in females has been hypothesized to be due to hormonal imbalance that influence bone remodelling [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGenerally, COD is described as an inconspicuous condition, usually detected incidentally on routine radiography. Some affected patients may present with swelling, pain and purulent discharge due to secondary infection in the bone surrounding the lesion. Studies in the literature report the presence of symptoms to range from 14.7\u0026ndash;100% of cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this study, 38.7% of cases were incidentally found on routine radiography.\u003c/p\u003e \u003cp\u003eThere is consensus in the literature that the mandible is by far the most affected jaw, with the majority of lesions presenting in the posterior regions of the mandible [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In current study\u0026rsquo;s sample, more than three quarters of CODs occurred in the mandible alone, while 20.2% occurred in both jaws. CODs occurring in the maxilla alone were uncommon.\u003c/p\u003e \u003cp\u003eThere is conflicting data in the literature regarding which subtype of COD is the most common. Some studies report focal COD as the most prevalent subtype [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], while others identify florid COD as the most common [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this study, focal and florid CODs were nearly equally common, with focal COD being slightly more prevalent. MacDonald-Jankowski (16) and Pereira \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported that all florid CODs involved the mandible, while nearly half also involving the maxilla as well.\u003c/p\u003e \u003cp\u003eThe radiological features of COD are crucial for an accurate diagnosis. The majority of studies in the literature report that COD typically appears as a mixed density lesion on radiographs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, studies focusing solely on florid COD have found that many lesions are radiopaque due to their mature nature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this study, nearly half of florid COD cases (46.4%) appeared radiopaque.\u003c/p\u003e \u003cp\u003eThere is general agreement in the literature that CODs appear as well-defined lesions on radiographs in most cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Alsufyani and Lam [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported that 91.5% of CODs in their sample were well-defined. Similarly, in the present study 93.5% of lesions were well-defined. Ill-defined lesions warranted further investigations using advanced imaging or biopsy to rule out more sinister conditions.\u003c/p\u003e \u003cp\u003eIn our study, the relationship of COD with adjacent anatomical structures was assessed using multiplanar CBCT/CT. Cortical bone aberration was the most commonly involved structure in most subtypes of COD, consistent with other studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Other frequently observed features included cortical bone thinning, expansion, and perforation. As previously reported, florid COD was responsible for most aberrations to the cortical bone compared to other subtypes of COD, further highlighting its aggressive nature [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe accuracy of diagnosis of COD based on clinical and radiological examination is vitally important in order to avoid unnecessary biopsy of asymptomatic lesions. Although arriving at an accurate diagnosis may be challenging, it is essential for appropriate management. Ideally, COD should be diagnosed based on clinical and radiographic signs, with biopsies reserved for uncertain cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this study, most cases were accurately identified as COD (sensitivity: 83.3%), a finding similar to other authors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Management\u003c/h2\u003e \u003cp\u003eThere is currently no consensus in the literature regarding when surgical treatment for COD is indicated and which method is most appropriate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Generally, it is accepted that asymptomatic COD does not require surgical intervention beyond close clinical follow-up, preventive measures, and restorative methods to prevent the need for dental extraction and exposure of COD to the oral environment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of this study underscore the necessity of biopsy in some asymptomatic cases to rule out other conditions. A biopsy is indicated if the diagnosis based on radiographic exam is uncertain, especially for lesions in the radiolucent phase or those causing significant bone expansion. Additionally, the presence of a second pathology, such as SBC, should prompt a biopsy to confirm the diagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This also applies to the rare occurrence of associated osteosarcoma, as observed in one of the cases in this study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen COD lesions manifest symptoms, their management becomes more challenging due to development of chronic inflammation and bacterial infection within densely mineralized tissue. It has been described that there is poor penetration of antibiotics due to lack of tissue diffusion deeming them ineffective [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Consequently, performing a biopsy increases the risk of developing secondary infection, and removing of such lesions in asymptomatic patients can lead to significant morbidity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical debridement and curettage are recognised as the most appropriate methods for managing symptomatic and infected CODs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Despite the challenges associated with treating infected lesions, particularly due to the poor vascularity of the area and increased bone hardness, these surgical techniques have shown effectiveness in treating the majority of infected CODs, with a success rate of 88.9% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Antibiotics play an adjuvant role by inhibiting the formation of new biofilms through the destruction of bacterial colonies before they can adhere to the necrotic bone.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of types of COD and their management in this study with other recent studies in the literature.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eType of COD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePeriapical\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eFlorid\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eObservation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eBiopsy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCurettage/Excision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOlgac \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (24.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePereira \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e14 (34.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKato \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.30%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59 (89.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElbeshir and Alhadad [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 (40.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlsufyani and Lam [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e93 (78.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenaessa \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (69.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNam \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (96.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecolibus \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (22.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85 (44.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (29.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*N/A: Not available.\u003c/p\u003e \u003cp\u003eThe primary prognostic indicator for the development of infected CODs in this study were identified as dental extraction and the use of removable dentures. Kato \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported comparable predictive factors for the onset of infection within COD lesions. Chronic secondarily infected COD were found to be more easily to curettage from the underlying bone, as the osteolytic process leads to the sequestration of the necrotic lesion. In these cases, patients generally exhibit compromised wound healing, precluding the application of bone grafting. Iodoform impregnated gauze has been shown to facilitate wound healing and the formation of granulation tissue. Certain authors have suggested the utilization of local soft tissue flaps, such as buccal fat pad, to aid in wound closure. Should there be a failure to heal after a period of 3 to 4 months, secondary surgical intervention should be considered [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing an extensive literature search, very few studies focused on the management of COD. This study stands out as one of the most comprehensive analysis focused on the treatment of COD. Furthermore, using findings from this study along with data available from the literature, a management protocol is proposed (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment protocol for Cemento-Osseous Dysplasia.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Asymptomatic periapical, focal or florid COD with accurate diagnosis based on clinical and radiographic features\u003c/p\u003e \u003cp\u003e- No exposure through oral tissues\u003c/p\u003e\u003cp\u003e- No associated pathology with COD (such as OKC, SBC)\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Clinical/radiographic diagnosis of COD is uncertain (e.g. radiolucent phase, extensive COD mimicking osteosarcoma)\u003c/p\u003e \u003cp\u003e- Associated with another pathological lesion (OKC, SBC, osteosarcoma)\u003c/p\u003e \u003cp\u003e- Lesion causing expansion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDebridement/curettage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Symptomatic lesion closely associated with anatomical structures (inferior alveolar/mental nerve or maxillary sinus)\u003c/p\u003e \u003cp\u003e- Lesion interferes with denture prosthesis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Symptomatic COD\u003c/p\u003e \u003cp\u003e- Secondarily infected COD (with draining sinus/fistula or osteomyelitis)\u003c/p\u003e \u003cp\u003e- Exposed COD through oral tissues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Complications\u003c/h2\u003e \u003cp\u003eOne of the major complications associated with COD is the development of osteomyelitis, especially in the mandible, which leads to high morbidity for the patient and development of cutaneous fistulas, as seen in this sample. Elbeshir and Alhadad [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that 25.5% of their Sudanese sample to have developed osteomyelitis, while Alsufyani and Lam ([0] reported an 11% prevalence. Kawai \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], in a Japanese study, reported a 14.8% prevalence, whereas in this study, only 5.6% of patients developed osteomyelitis. This lower rate of osteomyelitis in this study is likely due to aggressive and early surgical intervention in infected CODs cases to prevent progression to osteomyelitis. Elbeshir and Alhadad [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] managed most COD cases in their sample with antibiotics initially, while only refractory cases were treated with surgical debridement. This approach may explain the higher prevalence of osteomyelitis in their study when compared to this one.\u003c/p\u003e \u003cp\u003eThe recurrence rate and need for surgical re-treatment of COD is another possible complication. Nam \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported excellent outcomes following surgical removal or curettage and administration of antibiotics, with no recurrence. In the current study, three cases (2.4%) required re-treatment due to incomplete removal. The decision for incomplete removal was initially made to avoid injury to vital structures, such as the inferior alveolar nerve.\u003c/p\u003e \u003cp\u003eSeveral limitations were encountered in this study, which are commonly encountered in other retrospective record-based studies. A significant number of records (approximately 12%) did not meet the study\u0026rsquo;s inclusion criteria due to missing information. For some older records, it was challenging to attain the patient\u0026rsquo;s clinical presentation due to incomplete record keeping. Given that the study was conducted over a period of 18 years and at two different hospitals, treatment methods could not be standardized, as multiple providers performed these procedures during this time period. Additionally, a significant number of patients were lost to follow-up, as many lived in rural communities far from these hospitals.\u003c/p\u003e \u003cp\u003eIn conclusion, the decision to surgically manage COD lesions should be based on clinical signs and symptoms, as well as the presence of infection or osteomyelitis. Asymptomatic cases should be monitored periodically, with an emphasis on preventative measures to avoid secondary infections. Biopsy of asymptomatic lesions should only be performed when the clinico-pathological features are inconclusive and lesion could mimic other more sinister conditions. The presence of pain, suppuration and osteolytic changes with or without bone sequestration, are indications for surgical intervention in infected COD. Despite the lack of consensus regarding treatment regime, early curettage or surgical excision of infected COD is the most successful approach to eradicate the disease process and prevent further progression into osteomyelitis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Fadi Titinchi, Naser Alturki and Jean Morkel. Data analysis was performed by Salem Alkaabi and Kathryn Taylor. The first draft of the manuscript was written by Fadi Titinchi and Naser Alturki and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by biomedical research ethics committee of the University of the Western Cape (BM22/7/5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo consent was required due to the retrospective, record-based design of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMainville GN, Turgeon DP, Kauzman A (2017) Diagnosis and management of benign fibro-osseous lesions of the jaws: a current review for the dental clinician. Oral Dis 23:440\u0026ndash;450. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/odi.12531\u003c/span\u003e\u003cspan address=\"10.1111/odi.12531\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVered M, Wright JM (2022) Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Odontogenic and Maxillofacial Bone Tumours. Head Neck Pathol 16:63\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12105-021-01404-7\u003c/span\u003e\u003cspan address=\"10.1007/s12105-021-01404-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaefliger S, Turek D, Andrei V, Alborelli I, Calgua B, Ameline B, Harder D, Baumhoer D (2023) Cemento-osseous dysplasia is caused by RAS-MAPK activation. Pathology 55:324\u0026ndash;328. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pathol.2022.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.pathol.2022.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlootweg PJ, El-Naggar AK (2018) World Health Organization 4th edition of head and neck tumor classification: insight into the consequential modifications. Virchows Arch 472:311\u0026ndash;313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00428-018-2320-6\u003c/span\u003e\u003cspan address=\"10.1007/s00428-018-2320-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira DL, Pires FR, Lopes MA, Carlos R, Wright JM, Patel P, van Heerden W, Uys A, Vargas PA (2016) Clinical, demographic, and radiographic analysis of 82 patients affected by florid osseous dysplasia: an international collaborative study. Oral Surg Oral Med Oral Pathol Oral Radiol 122:250\u0026ndash;257. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.oooo.2016.04.013\u003c/span\u003e\u003cspan address=\"10.1016/j.oooo.2016.04.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlgac V, Sinanoglu A, Selvi F, Soluk-Tekkesin M (2021) A clinicopathologic analysis of 135 cases of cemento-osseous dysplasia: To operate or not to operate? J Stomatol Oral Maxillofac Surg 122:278\u0026ndash;282. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jormas.2020.06.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jormas.2020.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKato CNAO, de Arruda JAA, Mendes PA, Neiva IM, Abreu LG, Moreno A, Silva TA, Souza LN, Mesquita RA (2020) Infected Cemento-Osseous Dysplasia: Analysis of 66 Cases and Literature Review. Head Neck Pathol 14:173\u0026ndash;182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12105-019-01037-x\u003c/span\u003e\u003cspan address=\"10.1007/s12105-019-01037-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuwazi LM, Kamulegeya A (2015) The 5-year prevalence of maxillofacial fibro-osseous lesions in Uganda. Oral Dis 21:e79\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/odi.12233\u003c/span\u003e\u003cspan address=\"10.1111/odi.12233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElbeshir EI, Alhadad M (2017) Florid cemento-osseous dysplasia: analysis of 47 Sudanese cases and review of the literature. Oral Surg 10:216\u0026ndash;221. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ors.12256\u003c/span\u003e\u003cspan address=\"10.1111/ors.12256\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsufyani NA, Lam EW (2011) Osseous (cemento-osseous) dysplasia of the jaws: clinical and radiographic analysis. J Can Dent Assoc 77:b70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDecolibus K, Shahrabi-Farahani S, Brar A, Rasner SD, Aguirre SE, Owosho AA (2023) Cemento-Osseous Dysplasia of the Jaw: Demographic and Clinical Analysis of 191 New Cases. Dent J (Basel) 11:138. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/dj11050138\u003c/span\u003e\u003cspan address=\"10.3390/dj11050138\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbrahimi F, Ebrahimi F, An J (2023) Surgical Management of Infection Secondary to Cemento-osseous Dysplasia. J Craniofac Surg 34:e614\u0026ndash;e617. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SCS.0000000000009556\u003c/span\u003e\u003cspan address=\"10.1097/SCS.0000000000009556\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenaessa MM, Mahomed F, Ngwenya SP (2019) A retrospective clinico-pathologic analysis of cemento-osseous dysplasia in a South African patient population. Afr Health Sci 19:3154\u0026ndash;3159. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4314/ahs.v19i4.38\u003c/span\u003e\u003cspan address=\"10.4314/ahs.v19i4.38\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam I, Ryu J, Shin SH, Kim YD, Lee JY (2022) Cemento-osseous dysplasia: clinical presentation and symptoms. J Korean Assoc Oral Maxillofac Surg 48:79\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5125/jkaoms.2022.48.2.79\u003c/span\u003e\u003cspan address=\"10.5125/jkaoms.2022.48.2.79\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawai T, Hiranuma H, Kishino M, Jikko A, Sakuda M (1999) Cemento-osseous dysplasia of the jaws in 54 Japanese patients: a radiographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:107\u0026ndash;114. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s1079-2104(99)70303-3\u003c/span\u003e\u003cspan address=\"10.1016/s1079-2104(99)70303-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald-Jankowski DS (2003) Florid cemento-osseous dysplasia: a systematic review. Dentomaxillofac Radiol 32:141\u0026ndash;149. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr/32988764\u003c/span\u003e\u003cspan address=\"10.1259/dmfr/32988764\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGumru B, Akkitap MP, Deveci S, Idman E (2021) A retrospective cone beam computed tomography analysis of cemento-osseous dysplasia. J Dent Sci 16:1154\u0026ndash;1161. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jds.2021.03.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jds.2021.03.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavalcanti PHP, Nascimento EHL, Pontual MLDA, Pontual ADA, Marcelos PGCL, Perez DEDC, Ramos-Perez FMM (2018) Cemento-Osseous Dysplasias: Imaging Features Based on Cone Beam Computed Tomography Scans. Braz Dent J 29:99\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/0103-6440201801621\u003c/span\u003e\u003cspan address=\"10.1590/0103-6440201801621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIto K, Hirahara N, Iizuka N, Sawada E, Okada S, Suemitsu M, Kuyama K, Kaneda T (2018) Florid Cemento-Osseous Dysplasia of Osteolytic Stage Showing Cyst-Like Findings on CT and MRI: A Case Report. Int J Oral-Med Sci 17:137\u0026ndash;142\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAiuto R, Gucciardino F, Rapetti R, Siervo S, Bianch AE (2018) Management of symptomatic florid cemento-osseous dysplasia: Literature review and a case report. J Clin Exp Dent 10:e291\u0026ndash;e295. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4317/jced.54577\u003c/span\u003e\u003cspan address=\"10.4317/jced.54577\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIndermun S, Titinchi F, Alwan J, Morkel J, Nortje CJ (2024) Osteosarcoma associated with cemento-osseous dysplasia: co-incidence or two related entities? Oral Radiol 40:546\u0026ndash;554. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11282-024-00758-2\u003c/span\u003e\u003cspan address=\"10.1007/s11282-024-00758-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cemento-osseous dysplasia, Florid Cemento-osseous dysplasia, Fibro-osseous lesions, Maxilla, Mandible","lastPublishedDoi":"10.21203/rs.3.rs-5253068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5253068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eCemento-osseous dysplasia (COD) is a fibro-osseous lesion whose management is highly controversial in the literature. Due to scarcity of comprehensive studies on its management, the aim of this study was to analyse its management and develop a treatment protocol.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA multi-centre retrospective cohort analysis was conducted at two tertiary referral hospitals on 124 patients diagnosed with COD from 2005\u0026ndash;2023. Demographic, clinical, and radiological data were analysed and correlated with treatment methods. Post-operative complications such as osteomyelitis or pathological fracture were documented along with follow-up visits to evaluate the need for further treatment. Data was analysed using Student\u0026rsquo;s t-test and Fisher\u0026rsquo;s exact test. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe patients\u0026rsquo; ages ranged from 22\u0026ndash;78 years (mean: 48.5 years), with majority being females (90.4%) and of African descent (95.9%). Radiopaque CODs presented significantly higher rate of symptoms compared to radiolucent or mixed lesions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). The majority of incidental CODs were managed through observation (72%), while six incidental CODs underwent biopsy due to suspicion of more sinister lesions. Symptomatic lesions were mainly treated by curettage (29.7%) or local excision (48.6%), while only one symptomatic case was managed with observation and antibiotics (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBiopsy of asymptomatic COD should only be reserved for cases with inconclusive clinico-pathological features. The decision to surgically treat COD should be based on the presence of symptoms and infection. Early curettage or excision of infected COD is the most effective approach to eradicate the disease and prevent progression into osteomyelitis.\u003c/p\u003e","manuscriptTitle":"Cemento-osseous dysplasia: a multi-centre analysis of surgical management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-23 08:58:12","doi":"10.21203/rs.3.rs-5253068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-27T13:04:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-01T23:04:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234968664634102474828194829093656813975","date":"2024-12-13T22:45:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-27T07:07:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-15T12:20:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-15T12:19:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2024-10-12T20:41:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"21806b83-83ab-464b-afa2-179425a6b74a","owner":[],"postedDate":"October 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:07:24+00:00","versionOfRecord":{"articleIdentity":"rs-5253068","link":"https://doi.org/10.1007/s10006-025-01394-8","journal":{"identity":"oral-and-maxillofacial-surgery","isVorOnly":false,"title":"Oral and Maxillofacial Surgery"},"publishedOn":"2025-05-07 15:57:26","publishedOnDateReadable":"May 7th, 2025"},"versionCreatedAt":"2024-10-23 08:58:12","video":"","vorDoi":"10.1007/s10006-025-01394-8","vorDoiUrl":"https://doi.org/10.1007/s10006-025-01394-8","workflowStages":[]},"version":"v1","identity":"rs-5253068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5253068","identity":"rs-5253068","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}