RadiopaqueLesions

1. Radiopaque Lesions And
Their
Interpretation
By: Maryam Arbab
House Officer
Dept Of Radiology

2. CONTENTS
Radiopacity definition
Anatomic radiopacities of jaws
Classification of lesions
 Abnormalities of the teeth
 Conditions of variable radiopacity affecting bone
• Developmental
• Inflammatory
• Tumors- Odontogenic
Non odontogenic

3. Definition
Normal radiopacity may be defined as the
radiographic image of the normal anatomic
structures of sufficient density, thickness or
both to appear light or white on radiographs

4. Anatomic Radiopacities Of Jaws
• Radiopacities common to both jaws:
• Teeth
• Bone
• Cancellous bone
• Cortical plates
• Lamina dura
• Alveolar process

7. Radiopacities Peculiar To Maxilla
• The commonly seen radiopacities of maxilla from
anterior region to posterior region
1. Nasal septum and boundaries of the nasal
fossae:
• The nasal septum may be seen on films of the
central incisors.
• It is positioned superiorly to the apices of these
teeth.
• Appear as a wide vertical radiopaque shadow and
frequently deviates slightly from the midline.

8. • Nasal fossae are lined with compact cortical bone
• There floors may be seen extending bilaterally
from the inferior limit of the septum
• They appear as linear radiopacities that curve
superiorly when the lateral walls of the fossae are
approached
2. Anterior nasal spine:
• It’s a projection of the maxilla at the lower
borders of the nasal fossae
• It is seen as a small white, v-shaped, opaque
shadow below the nasal septum

9. Nasal
Septum

10. 3. Walls and floor of the maxillary sinus:
• Walls of maxillary sinus appear as white lines on
the radiographs of the maxillary teeth
• Outline of sinus extends from area of canine to
the tuberosity
• Floor of the sinus lies above the apices of
maxillary teeth but varies widely as to extent and
contour
• It is scalloped as it dips between roots to varying
depths or it may be smoothly curved or flat
especially in the edentulous jaws.

12. 4. Zygomatic process of maxilla and zygomatic
bone:
• It is seen as U shaped radiopaque shadow
above the roots of max. 1st molar.
• The inferior border of the zygomatic bone
may appear on the superior aspect of
maxillary molar as a dense, more or less
horizontal extending from the zygomatic
process posteriorly .

14. 5. Maxillary tuberosity:
• It’s a rounded projection of cancellous bone outlined
by a thin layer of compact bone.
• Cancellous bone may extend into the tuberosity
causing this structure to appear on radiograph as a thin
shell of cortical bone.
6. Pterygoid plates and pterygoid hamulus:
• Lateral pterygoid plate is wider than the medial plate
and rarely seen on radiographs of max. 3rd molar
region.
• Pterygoid hamular process varies in length, thickness
and density, and its tips may be seen lying above or
below the level of alveolar crest on periapical films.

16. 7. Coronoid process:
• It’s a mandibular structure that often appears
on radiographs of max.3rd molar region.
• Is cone shaped with its apex pointing upward
and forward with varying contours and
positions.
• Sometime it’s radiopaque shadow has been
mistaken for a root fragment in the maxilla.

18. Radiopacities Peculiar To Mandible
1. External oblique ridge:
• It’s a continuation of anterior border of ramus clearly
seen as radiopaque line passing across the molar
region
2. Mylohyoid ridge:
• It originates on the medial portion of ramus over the
lingual surface of mandible
• It is clearly seen in its posterior portion crossing
retromolar and molar region inferior to and running
approx. parallel to the external oblique ridge

20. 3. Mental ridge:
• The term mental ridge is a misnomer
• Two bilateral radiopaque lines occasionally run
anteriorly and superiorly from low in the premolar
area toward the midline where they meet.
4. Genial tubercles:

21. Classification
Common lesions that present variable radiopacities in
the jaws:
Abnormalities of the teeth
• Unerupted and misplaced teeth including
supernumeraries
• Odontomes- Compound
- Complex
• Root remnants
• Hypercementosis

22. Conditions Of Variable
Radiopacities Affecting The Bone
• Developmental: exostoses including tori-
mandibular or palatal
• Inflammatory: 1. Low grade chronic infection
2. Sclerosing osteitis
3. Osteomyelitis
• Tumors:
A: Odontogenic: CEOT
AOT
Calcifying cystic odontogenic tumors
Cementoblastoma
Odontomes- Compound
Complex

23. B: Non odontogenic- Benign: Osteoma
Chondroma
Malignant: Osteosarcoma
Osteogenic sec.
metastasis
• Bone related lesions
• Osseous dysplasias: Periapical osseous dysplasia
Focal osseous dysplasia
Florid osseous dysplasia
Familial gigantiform
Cementoma

24. • Other lesions: Ossifying fibroma
Fibrous dysplasia
• Bone diseases: Paget’s disease of bone
Osteopetrosis
Superimposed Soft Tissue Calcifications:
• Salivary calculi
• Calcified lymph nodes
• Calcified lymph nodes
• Phleboliths
• Calcified acne scars
Foreign Bodies:
• Infra-bony
• Within the soft tissues
• On or overlying the skin

25. Typical Radiographic Features Of
Abnormalities Of The Teeth
Unerupted or misplaced teeth including
supernumeraries

26. Odontomes
It’s a benign tumour of
odontogenic origin.
Specifically, it’s a dental
hamartoma.

28. 1. Compound odontome
• This odontome is made up of several small tooth
like denticles.
• The miniature tooth shapes are of dental tissue
radiodensity,with surrounding radiolucent line.
2. Complex odontome
• This odontome is made up of an irregular
confused mass of dental tissue bearing no
resemblance in shape to a tooth.
• The enamal content provides the dense
radiopacity suggestive of dental tissue and the
mass is surrounded by radiolucent line.

29. Root Remnants
• Deciduous and permanent root remnants
remaining in the alveolar bone, following
attempted extraction, are common.
• The site shape and density make radiographic
identification relatively simple.
• Additional diagnostic feature include the
surrounding radiolucent line of periodontal
ligament shadow and sometime evidence of
root canal.

31. HYPERCEMENTOSIS
• Also known as “excessive formation of
cementum on the surface of root of the
tooth”.
• Etiology unknown but sometimes assoc. with
development of periapical inflammatory
conditions, pcod, systemic diseases such as
paget’s disease acromegaly or gigantism.

33. Features:
• Completely asymptomatic.
• Premolars and molars are affected.
• Can be confined to small region of root or
whole root may be involved.
• In multi-rooted teeth one or two or all roots
may show hypercementosis.
• Teeth are usually vital and not sensitive to
percussion.

34. Differential Diagnosis:
• Condensing osteitis.
• Periapical idiopathic osteosclerosis.
• Developmental anomalies such as fused roots
and dilaceration.
Management
• Do not require special treatment.

35. • Tori and Exostosis
• Situated in the periphery of jaws and vary greatly
in size shape and location.
• They are slow growing benign bony
protuberences.
• Appear symmetrically as nodular or bosselated
lesion that have smooth contours and covered
with normal mucosa.
• Hard on palpation and are attached by a broad
bony base to the underlying jaw.
• Growth occurs mainly in 1st 30 years of life.
• Common in females.
Developmental Condition

36. • Specific exostosis develop in
particular sites and are often
bilateral.
1. Torus mandibularis- Lingual
aspects of the mandible, in
premolar/molar region.
2. Torus palatinus- Either side of
the midline towards the
posterior part of the hard
palate.

38. Inflammatory Condition
• Condensing or Sclerosing osteitis
1) It is a sclerosing of bone induced by an
inflammation or infection that occur pulpo apical
lesion.
2) In this proliferation of bone tissue occurs
(opposite from rarefying osteitis in which bone
resorption occurs).
3) Highly concentrated products of infection are
thought to act as irritants and produce resorption
where as diluted irritants induce bone
proliferation as seen in this case.

39. Features:
• Almost invariably painless and do
not produce expansion of the
cortex.
• Covering mucosa is normal in
appearance.
• Sinuses are not present.
• Approx.85% of this occurs the
mandible of whites, 1st molar is
the predominant site.
• In blacks approx. 71.6% of focal
bony sclerotic area are in
mandible.
• Female to male ratio is 3:2 ,
majrity found in mandible.
• 50% cases are under 30 yrs of age.

40. • Pulps of involved teeth are non-vital although
the sclerosing may have commenced before
the complete pulp become non-vital.
• If carious molars are treated with IPC some of
these lesions disappear and pulps remain
vital.
• Radiographic images may vary greatly in
number size shape contours and discreteness
of margins.
• Since the process is low grade there is usually
no pain, swelling, drainage, or associated
lymph adenitis.

41. Differential diagnosis:
• Periapical idiopathic osteosclerosis.
• Periapical cementoosseous dysplasia (PCOD).
• Focal cementooseous dysplasia (FCOD).
• Hypercementosis.
Management
• Extraction of affected tooth or root canal
treatment.

42. PERIAPICAL IDIOPATHIC
OSTEOSCLEROSIS
• Relatively common finding on full mouth
radiographs of dentulous patients over 12
years of age.
• It second most frequently seen periapical
radiopacity.
• Term idiopathic means the cause of the lesion
is not readily apparent or understood.

44. Features:
• Mostly located in the peri apex of mand. 1st
premolar and canine.
• Female : male ratio is 2:1
• More often in black females.
• Associated teeth are invariably healthy, have vital
pulps, and are asymptomatic.
• No associated pain, cortical change, softness,
expansion, drainage or lymphadenitis.
• Overlying alveolar mucosa appears normal.
• Its radiopacity vary from few mm. to 2cm in
diameter.

45. • Shape may range from round to very irregular
or sometimes triangular configuration is
observed.
• Degree of density may vary from slight
accentuation of the trabecular pattern to a
dense homogenous radiopaque mass.
• Borders may b well defined or vague and well
contoured or ragged.
Differential Diagnosis:
Hypercementosis, abnormally dense alv. Bone
induced by heavy occlusal stress.

46. Management
• Endodontic treatment or extraction

47. TUMORS
1. Calcifying Epithelial Odontogenic
Tumor
• Also known as CEOT or Pindborg tumor.
• Defined by WHO as a locally invasive epithelial
odontogenic neoplasm, characterized histologically by
amyloid material that may become calcified.
• Age: 20-60 yrs old adults.
• Frequency: rare- approx. 1% of all odontogenic
tumours.
• Site: molar/premolar region of mandible
maxilla occasionally.

48. • Shape: unilocular or multilocular
usually round
often associated with impacted tooth
especially 38 48
• Outline: variable definition , frequently
scalloped, variable cortication
• Radiodensity: radiolucent in early stages, then
numerous scattered radiopacities usually become
evident within the lesion, often most prominent
around the crown of any associated unerupted tooth.
- this appearance is sometimes described as DRIVEN
SNOW
• Effects: adjacent teeth sometime displaced or
resorbed.
Expansion of cortical bone

50. 2. Ameloblastic Fibro-odontoma
• These are rare, unilocular or
multilocular odontogenic tumors.
• Resemble closely ameloblastic
fibromas.
• Also affects children.
• However they are often associ.
With an unerupted tooth.
• Usually contain enamel, dentin
either as multiple, small opacities
or as a solid mass.

51. 3. Adenomatoid Odontogenic Tumor
• Described by WHO as being composed of
epithelium embedded in a mature connective
tissue stroma and characterized by slow but
progressive growth.
• Age: variable but 90% develop before age of 30
with most diagnosed in 2nd decade of life.
• Frequency: rare-approx.2-7% of all
odontogenic tumours.
• Site: anterior maxilla-incisor/canine region
occasionally anterior mandible.

53. • Shape: Unilocular, usually round or oval
often surrounds an entire unerupted
tooth
• Outline: Smooth and well defined
well corticated
• Radiodensity: Initially radiolucent, but small
opacities (snowflakes) within
central radiolucency may be
seen peripherally as the lesion
matures.
• Effects: Adjacent teeth displaced, rarely resorbed.
• Assoc. tooth is often unerupted.
• Buccal/palatal expansion.

54. 4. Calcifying Cystic Odontogenic
Tumour (Calcifying Odontogenic Cyst)
• Also known as gorlin’s cyst.
• WHO described it as benign cystic neoplasm of
odontogenic origin characterized
histopathologically by ameloblastoma like
epithelium with ghost cells that may calcify.
• Age: Variable reported in patients between 5 to
92 yrs of age
• Frequency: Rare
• Site: Mandible or maxilla-anterior or premolar
region 1/3rd assoc. with unerupted tooth or
odontome.

55. • Size: Usually small upto 4cm in dia.
• Shape: Variable but usually
unilocular.
• Outline: Smooth well defined well
corticated.
• Radiodensity: Initially radiolucent
but in more advanced stages contains
a variable amount of calcified
radiopaque material of tooth like
density.
• Effects:Adjacent teeth usually
displaced, causing root divergence, or
resorbed.
- bony expansion

56. 5. Cementoblastoma
• Classified by WHO as an
odontogenic tumour which is
characterized by the formation of
cementum-like tissue in cementum
with the root of a tooth.
• Age: Reported in patients b/w 8
and 44 yrs old with mean age 20.
• Frequency: rare
• Site: Apex of mandibular 1st
permanent molar, occasionally
premolars. Exceptionally assoc.
with the primary dentition
• Size:Variable,but upto2-3cm in
dia.

57. • Shape: Round or irregular, sometimes sometimes
described as resembling a golf ball attached to tooth
root
• Outline: Well defined
• Radiodensity: Radiopaque but often surrounded
by a thin radiolucent line owing to an outer zone of
osteoid
- often surrounded by a diffuse area of sclerotic bone
• Effects: Attached to the tooth root which is usually
obscured as a result of resorption and fusion to the
tooth
-if large may cause localized expansion of the cortical
plates.

58. 6. Osteoma ( Benign )
• Osteoma of the jaws may be located in the medullary
bone (enosteal osteoma) or arise on the surface of the
bone as a pedunculated mass (periosteal osteoma) .
• Usually detected in young adults and are typically
asymptomatic, solitary lesions.
• Multiple jaw osteomas are a feature of rare inherited
condition Gardner’s syndrome.
• They are of two types
1. Compact- consisting of dense lamellae of bone
2. Cancellous-consisting of trabeculae of bone

60. 7. Osteosarcoma ( Malignant )
• Rare, rapidly destructive, malignant tumour of bone
from a radiological viewpoint, there are three main
types:
• Osteolytic: No neoplastic bone formation.
• Osteogenic/osteosclerotic: Neoplastic
osteoid and bone formed.
• Mixed lytic and sclerotic patches of neoplastic bone
formed.
• Early features: Non specific, poorly defined
radiolucent area around one or more teeth.
• Widening of periodontal ligament space.

61. • Later features
• Osteolytic lesion
• Unilocular, ragged area of radiolucency.
• Poorly defined, moth eaten outline.
• So called spiking resorption and/or loosening of
assoc.teeth.
 Osteogenic and mixed lesion
• Poorly defined radiolucent area.
• Variable internal radiopacity with obliteration of the normal
trabular pattern.
• Perforation and expansion of the cortical margins by
stretching the periosteum, producing the classical, but
sunray or sunburst appearance.

63. Thank You!