Differential Outcomes of Dental Implant Osseointegration in Florid Cemento-Osseous Dysplasia: A Case Report

Abstract

A 47-year-old Asian woman presented for treatment of multiple missing teeth and generalized dental attrition requiring prosthetic rehabilitation. Her dental history revealed prolonged absence of teeth 25, 36, 35 and 46,recent extraction (tooth 24, four months prior) due to vertical root fracture. Cone-beam computed tomography (CBCT) revealed mixed-density osseous changes, including apical radiolucencies at teeth 11–23, 35–43, a well-demarcated hyperdense mass within the tooth 36 edentulous ridge surrounded by circumferential radiolucency, and diffuse radiolucent alterations throughout the mandibular alveolar bone. The findings of CBCT images were attributable to Florid cemento-osseous dysplasia (FLCOD). The patient underwent occlusal reconstruction treatment, she opted for implant restoration to address the missing teeth (implant restoration at teeth 24, 25, 36, 45, 46), and all-ceramic crowns placed on teeth 11–17, 21–23, 26–27, 35–44, 37, and 47. One year after the placement of the implant at site 36, the patient returned with clinical symptoms of the sensation of a “loose” implant. However, the remaining implants are stable and functioning normally. The failed implant at tooth 36 penetrated completely through the lesion tissue, while the successful implants were placed away from the lesion. This case report details the causes of implant failure in patients with florid cemento-osseous dysplasia (FLCOD) and the suitable restorative methods.

Introduction

Florid cemento-osseous dysplasia (FLCOD) is a rare benign non-neoplastic condition of uncertain etiology, predominantly affects the dentate regions of the jaws.^1,2 It manifests as multifocal radiopaque lesions that may mimic chronic apical periodontitis, though with vital pulpal status.^3,4

Dental implantation, a well-established technique in oral rehabilitation, has become a cornerstone of contemporary clinical dentistry for restoring dentition defects. This procedure effectively restores masticatory function while preserving adjacent dentition, prevents alveolar bone resorption, and addresses both aesthetic and functional concerns.⁵ However, its application in patients with bone dysplasia, particularly those with compromised bone vascularity, poses significant challenges to osseointegration and long-term implant success.⁶

Current management protocols generally recommend conservative observation for asymptomatic FLCOD cases.⁷ In patients with this condition requiring implantation, the lesion exhibits cementum-like deposition, with decreased vascularity increasing the risk of osseointegration failure and secondary infection. The insufficient blood supply in such lesions impairs the recruitment, migration, proliferation, and differentiation of osteogenic cells, as well as the formation of new bone and the establishment of a stable interface between bone and titanium implant surface.^8–11 Despite these concerns, clinical guidelines regarding implant feasibility in FLCOD patients remain undefined, warranting further investigation.⁷ However, some scholars have also reported successful dental implantation in FCOD lesion areas.^1,2,12

This case report presents a patient who had dental implants placed in areas of florid cemento-osseous dysplasia. Among them, four implants placed near the lesion or within small lesion areas succeeded, while the implant that penetrated entirely through the lesion tissue failed.

Case Report

A 47-year-old Asian woman presented for treatment of multiple missing teeth and generalized dental attrition requiring prosthetic rehabilitation. Her dental history revealed prolonged absence of left mandibular posterior teeth and recent extraction (four months prior) due to vertical root fracture. Secondary complaints involved thermal hypersensitivity in multiple teeth. Her medical history was non-significant. On clinical examination we found satisfactory oral hygiene with notable occlusal wear patterns: incisal edge attrition on anterior teeth, labial surface microfractures, and dentin exposure in teeth 16, 24, 27and 37. Occlusal analysis identified a Class III malocclusion of teeth 12–14 reverse overjet and 2–3mm supraeruption of teeth 14 and 15. The dentition exhibited generalized attrition, particularly a mesiodistal occlusal crack on tooth 24 that subsequently progressed to acute pulpitis, necessitating extraction one month post-presentation (Figure 1).Cone-beam computed tomography (CBCT) revealed mixed-density osseous changes, including apical radiolucencies at teeth 11–21, 35, 44, and 46, small areas of radiolucency are present in the edentulous regions of tooth 25 and teeth 46–47, a well-demarcated hyperdense mass within the edentulous regions of tooth 36 edentulous ridge surrounded by circumferential radiolucency, and diffuse radiolucent alterations throughout the mandibular alveolar bone.The edentulous site of tooth 24 shows no pathology. Quantitative CBCT analysis showed a HU value of approximately 1800 at tooth 36 and approximately 1100 at the other edentulous sites (Figure 2).

Figure 1.

Intraoral photograph of the patient’s initial diagnosis. (A) preoperative intraoral frontal photo. (B) Preoperative maxillary intraoral photo. (C) Preoperative mandibular intraoral photo.

Figure 2.

(A) CBCT image indicating the presence of FLCOD lesions. (B and C) Preoperative CBCT of the 36th tooth, The size of the lesion area at tooth 36 is approximately 10.8 mm × 13.6 mm.

Pulp vitality testing confirmed normal responses in teeth 13–23 and 35–44. After discussing with the patient about the available options the pros and cons of each option, the patient declined orthodontic intervention and consented to implant placement at sites teeth 24, 25, 45 and 46, and all-ceramic crowns placed on teeth 11–17, 21–23, 26–27, 35–44, 37, and 47 (2–2). Implants 24, 25, 45, and 46 were inserted with a torque of 30 Ncm; implant 24 (Axiom BLPX, 3.4 mm × 12 mm), implant 25 (Axiom BLPX, 4 mm × 10 mm), implant 45 (Straumann RNS, 4.1 mm × 8 mm), and implant 46 (Straumann WNSP, 4.8 mm × 10 mm) were used. For the tooth 36 edentulous span, fixed versus removable prosthetic options were discussed. The patient decided to postpone the restoration of tooth 36. Prosthodontic workflow included facebow transfer for maxillary arch registration and diagnostic wax-up fabrication. The diagnostic wax-up technique was utilized to fabricate provisional crowns, achieving a 2mm increase in anterior vertical dimension and 0.6mm posterior disclusion (Figure 3). Following six month of provisionalization with occlusal adjustments, the patient demonstrated satisfactory adaptation and requested implant therapy for tooth 36. After comprehensive risk disclosure and informed consent acquisition, preoperative protocols included prophylactic antibiotic administration 1 hour prior to surgery and chlorhexidine mouthwash preoperatively. Under aseptic conditions, a crestal approach using round bur osteotomy to a depth of 9mm enabled simultaneous bone biopsy (Figure 4). A 4.8 diameter implants with length of 10 mm (Straumann^® SPWN) was placed in the area of tooth 36 with torque of 35 N-Cm. The drill speed was 1000 RPM and the irrigation volume was 150mL/min. After confirming proper implant alignment and spacing, the healing abutment was placed, and the wound was tightly sutured. The implant penetrated through the lesion area, with the apical 1mm positioned within healthy alveolar bone. The postoperative X-ray showed proper alignment and positioning of the implant. The specimen sample was submitted to surgical pathology for final diagnosis. The submitted specimen was grayish-white and measured 0.6×0.4×0.3cm.Histopathological analysis confirmed benign fibro-osseous changes (Figure 5). Postoperatively, the patient was instructed to take antibiotics to prevent infection. At the four-month follow-up, stable osseointegration permitted provisional crown delivery on implant 36. The 12-month evaluation revealed functional occlusion without temporomandibular complications, with definitive restorations completed except for implant 36, which remained under provisional restoration for ongoing monitoring (Figure 6). After a year of the tooth 36 implant placement, the patient returned with clinical symptoms of the sensation of a “loose” implant, accompanied by radiographic evidence of circumferential peri-implant radiolucency (Figure 7). Following informed consent acquisition, the compromised implant was surgically explanted under local anesthesia with concurrent debridement of granulation tissue. Subsequent to explantation, the peri-implant defect demonstrated uneventful healing over a nine-month follow-up period (Figure 8). The following are the periapical radiographs of tooth 36 during the treatment process (Figure 9).

Figure 3.

Use the mock-up method to make temporary crowns. (A) intraoral photo of temporary crown. (B) mock-up.

Figure 4.

Surgical procedure. (A and B) implant osteotomy preparation. (C) implant placement. (D) bone core.

Figure 5.

The pathological examination result is tumor-like hyperplasia of bone tissue.

Figure 6.

Definite restoration. (A) intraoral frontal photo. (B) maxillary intraoral photo. (C) mandibular intraoral photo.

Figure 7.

Implant removal surgery.

Figure 8.

Re-examination after implant removal.

Figure 9.

Timeline of the Treatment for Tooth 36.

Discussion

Cemento-osseous dysplasia (COD) is classified into three subtypes based on lesional distribution: focal (FCOD), periapical (PCOD), and florid (FLCOD).^7,13,14 FCOD typically presents as a solitary lesion with a predilection for the posterior mandible. PCOD involves single or multiple lesions localized to the mandibular anterior region,with discernable periodontal ligament spaces. FLCOD manifests as multifocal, bilateral lesions often affecting all jaw quadrants and demonstrating heightened susceptibility to secondary infection.^3,7,15,16 All 3 presentations of COD progress through 3 stages of development. The initial osteolytic phase features periapical bone resorption replaced by fibrous connective tissue, radiographically appearing as well-defined radiolucencies mimicking periapical pathology. Subsequent cementoblastic activity induces deposition of cementoid matrices and osseous proliferation, characterized by mixed “cotton-wool” radiopacities with central calcifications—a stage observed in over 70% of clinical cases.³ Final maturation involves fusion of hypercementotic deposits with dental roots, resolution of radiolucent margins, and radiographic evidence of root hypertrophy, completing the pathological continuum. FLCOD lesions may eventually become completely radiopaque and ubiquitous throughout the mandible.³

Florid cemento-osseous dysplasia (FLCOD) is the most extensive subtype, demonstrates distinct epidemiological and radiographic profiles.^1,3,17 Predominantly affecting middle-aged women of African ancestry.^7,15 FLCOD presents as multifocal lesions spanning 2–4 jaw quadrants. Radiographic evaluation reveals polymorphic patterns: early stages demonstrate lobulated radiolucencies with peripheral encapsulation, while advanced phases exhibit coalescing radiopaque cementoid masses interspersed with residual osteolytic regions. These imaging characteristics reflect the dynamic imbalance between pathological bone resorption and aberrant mineralization processes inherent to COD progression.^{1,3,7,9,12,15,17}

Histopathological evaluation demonstrates characteristic replacement of normal osseous architecture by fibro-osseous tissue comprising three cardinal components: (1) cellular fibrous stroma with benign fibroblasts and collagenous matrix, (2) variably mineralized cementoid deposits, and (3) disorganized trabecular bone formations. This pathological triad exhibits progressive mineralization patterns ranging from immature osteoid to acellular cementum-like masses. Notably, the hypovascular nature of these lesions predisposes to ischemic necrosis and secondary infection due to compromised microcirculation.^3,4,17

Clinically, FLCOD usually does not show significant symptoms, but if infection occurs, it can lead to the formation of sequestrum. Therefore, some scholars believe FLCOD patients should avoid stimuli such as full dentures, periodontitis, tooth extraction, and implant surgery.^3,7,8 For restoration in FLCOD cases, implants generally provide better chewing efficiency and comfort, but the heat generated during the implantation process can cause necrosis of the bony tissue that surrounds the dental implant, potentially leading to sequestrum or poor osseointegration, which can result in implant failure. The low vascularity, high mineralization, and tendency for bone cavities in the lesion area can affect the success of implant surgery. Reduced blood supply is the main reason for the susceptibility to secondary infections in FLCOD, which directly compromises the biological environment required for successful osseointegration. The diminished vascularity limits the delivery of oxygen, nutrients, and osteogenic cells to the peri-implant bone, thereby impairing long-term bone remodeling and maturation around the loaded titanium implant. This physiological limitation explains the failure of the implant placed directly within the lesion, while implants distant from the lesion, with preserved vascularity and normal bone remodeling capacity, achieved successful integration. Additionally, reduced blood flow hinders the effective concentration of systemic antibiotics in these areas, making treatment more complicated.^1,3,7,8

In this case, implant 24, 25, 45 and 46, which were placed in areas distant from the lesion, are functional to the present date. This suggests that implant surgery in areas distant from the lesion may be feasible. Although the implant 36 in this case failed, no infection occurred, thanks to strict aseptic technique and adequate saline cooling during surgery. The late implant failure observed in the present case, despite initial stable osseointegration at four months, may be attributed to biomechanical overload on poorly vascularized bone during function, rather than early failure due to insufficient primary osseointegration. Removable partial dentures are cost-effective, quick to fabricate, and avoid surgical irritation, but they can mechanically irritate the soft tissue, potentially causing secondary infection. A fixed bridge may be a more reliable option for restoring missing teeth in FLCOD patients.

There has been ongoing debate regarding the possibility of implant placement in FLCOD patients. Gerlach et al reported a case in which an implant was implanted through the lesion area, after 26 months of implant function, the patient returned with clinical symptoms of pain, buccal swelling, and the sensation of a “loose” implant. They emphasized that before implant therapy, it is essential to conduct a thorough radiographic evaluation of any dental arch with suspected bony lesions to prevent implant failure.³ Shin et al reported a case in which the implant failed to osseointegrate through the lesion area, but implants placed away from the lesion were successful.⁸ Rola Shadid et al reported a case where implant placement in the FLCOD lesion area was successful with 8 years of follow-up.¹ Hila Yousefi et al also reported a successful implant case in the vicinity of the lesion area in an FLCOD patient.¹² Mlouk et al reported a case where an implant was successfully placed in an FCOD lesion area using a modified protocol. Compared to the traditional two-stage method, this case did not involve immediate implant placement after osteotomy preparation. Instead, the mucoperiosteal flap was tightly sutured for 3 weeks before implantation. At this stage, the socket was in the proliferative phase of the healing process. The newly generated healthy tissue surrounding the implant more closely resembled normal bone and was more likely to achieve osseointegration with the implant.¹⁸

Based on the above cases, we conclude that implant placement in the FLCOD lesion area should be approached with caution, with strict adherence to indications. Minimally invasive techniques should be employed, and the surgery should include adequate cooling and strict aseptic protocols to prevent the formation of sequestrum and infection. Dental implants penetrating small lesion areas demonstrate relatively higher success rates. Implant placement in areas distant from the lesion seems feasible, but long-term clinical outcomes need further follow-up and observation. In this case, a sterile environment was ensured during the surgical procedure, and copious amounts of saline solution were used for cooling, allowing the implant to achieve early osseointegration. After delayed loading resulted in osseointegration failure, the implant was removed and the site healed well, with no infection occurring during the process. The implant was all in the lesion area, which was the main reason for the failure of this case. The clinical significance of this case is a unique within-patient control: implants distant from or in small FLCOD lesions achieved successful osseointegration, while the one penetrating the lesion tissue directly failed. This self-controlled comparison offers novel and practical evidence for the ongoing debate regarding the feasibility of dental implant placement in patients with focal florid osseous dysplasia, and may help guide clinical decision-making for similar challenging cases.

There are several limitations in the present case report that should be acknowledged. First, this is a single case report, and the findings may not be generalizable to a broader population. Second, the follow-up period was relatively short, and long-term outcomes require further observation. In addition, potential individual variations in anatomy and healing capacity may also affect the final results. Future studies with a larger sample size and longer follow-up duration are needed to verify the stability and effectiveness of the treatment.

Conclusion

After reviewing the literature, we have decided that the next step in treatment for this case will be a fixed bridge restoration for tooth 36, and we have advised the patient to maintain good oral hygiene and follow up regularly.

Funding Statement

No financial support received for this work.

Ethics Statement

This study is a retrospective case report and conforms to ethical norms. In accordance with the policies of the Ethics Committee of the affiliated Yantai Stomatological Hospital, Binzhou Medical University, this retrospective study is exempt from ethical approval, including for publication, as it involves no intervention and ensures adequate privacy protection.

Informed Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Disclosure

The authors report no conflicts of interest in this work.