Periapical radiopacities/ dental implant courses

Periapical radiopacities
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

True periapical radiopacities
• Condensing or sclerosing
osteitis
• Periapical idiopathic osteo
sclerosis
• Periapical or focal
cemento osseous dysplasia
• Un erupted succedenous
teeth
• Foreign bodies
• Hyper cementosis
• Rarities
• Calcifying odontogenic
cyst
• Cemento ossifying
fibroma
• Chondroma and
chondrosarcoma
• Focal or diffuse sclerosing
osteomyelitis
• Hamartoma
• Mature cemento blastoma

False periapical radiopacities
• Anatomic structures
• Impacted teeth
,supernumerary teeth
and compound
odontomas
• Tori , exostosis,and peri
apical osteomas
• Retained root tips
• Foreign bodies
• Mucosal cysts of the
maxillary sinus
• Ectopic calcifiactions
• Sialoliths
• Rhinoliths and antroliths
• Calcified lymphnodes
• Phleboliths
• Arterial calcifications

Rarities
• Calcified acne lesions
• Calcified hematoma
• Calcifying odontogenic cyst
• Calcinosis cutis
• Cysticercosis
• Hamartomas
• Myositis ossificans

Sclerosing lesions in the jaws
• Condensing osteitis
• Idiopathic sclerosing osteitis
• Sclerosing osteomyelitis
• Hyperostotic borders
• Osteosclerosing tumour

Condensing osteitis/sclerosing osteitis
I
Sclerosis
idiopathic osteosclerosis
develops during healing process
Sclerosis
NOT BY
INFLAMMATION
INFLAMMATION
NONVITAL TOOTH
VITAL TOOTH

Sclerosing osteomyelitis / chronic osteomyelitis
Sclerosis of sequestrum/ surrounding bone
Hyperostotic border
Sclerosis
Surrounds benign osteolytic process with in the bone(cysts,
granuloma,benign tumours ,slowly expanding malignancy)
PRESSURE OF EXPANDING TUMOUR

Osteosclerosing tumour
Irregular sclerosis
Malignanciesinv.Bones(osteosarcoma,chondrosarcoma,metast
atic prostatic carcinoma) aggressive benign bone lesions
(ameloblastoma,chondroma myxoma,hemangioma)
TUMORS MAY INDUCE OSTEOBLASTIC
ACTIVITY WITH DENSE BONE FORMATION

PERIAPICAL
RADIOPACITIES
true periapical radiopacities
Two types
false periapical radiopacities
Differentiated by clark tube shift technique

True periapical radiopacities
• These are group of lesions that occur in the
immediate region of periapex and are
composed of dense bone,cartilage,hard dental
tissues,or foreign material
• Condensing /sclerosing osteitis-sclerosis of the
bone is induced by an inflammation or
infection
• In this lesion there is proliferation of bone
tissue.
• They are produced by the extension of the
inflammatory process into the periapical area.

• Chronic infection acts as irritating factor
(causing resorption of bone )and a stimulating
factor (producing dense bone.
Features
• Nonvital tooth
• No pain,swelling,drainage,or associated
lymphadenitis
• Site- apices mandibular 1stmolar
• Sex-f:m-3:2
• Age <30yrs
• 12%cases-root resorption

Condensing osteitis

Differential diagnosis
• Idiopathic osteosclerosis-vital teeth
• Hypercementosis-tooth root is seperated from
periapical bone by pdl space
• Foreign body introduced during rct-h/o rct
• Pcod/fcod-have thin uniform radiolucent rim
Age>30yrs
Management-extraction
Rct

Periapical idiopathic
osteosclerosis
• Enostosis,dense bone island,bone whorls, bone
eburnation
• It is acommon finding on full mouth radiographs of
dentulous pts over 12yrs of age
• Idiopathic-not readily apparent/understood
• Features-
• Site-mandibular 1st premolar and canine
• Sex-f=m
• Vital tooth
• No pain ,swelling,cortical change,softness, drianage,or
lymphadenitis,alv.mucosa is normal
• Size-few mm to 2cm in diameter

Periapical idiopathic
osteosclerosis

• It is round to irregular with with well defined
/ragged borders
• Occasionally they are multiple and bilateral
• Inc incidence-colrectal cancers /adenomas
• Differential Diagnosis –
• Dense trabecular pattern in alveolar bone
induced by heavy masticatory forces-sclerosis
involves entire alveolar process, diffuse outline

• Hypercementosis-club shaped appearance of
tooth root and root is seperated from adj bone
by pdl space
• Pcod/fcod- welldefined radiopacity surrounded
by radiolucent halo
• Condensing osteitis-nonvital teeth

Rarities
Metastatic
prostatic
carcinaoma
Chondrosarcoma
and
osteosarcoma-
Osteoblastoma
and
cementoblastoma
Complex
odontoma
•-by h/o primary
tumours and
increased levels of
serum acid
phosphatase levels
ragged radiolucent
areas with
radiopacities
•Previous
radiographs
•Round and
attached to root
apex
•Unerupted teeth
or in between roots
•Denser sharper
radiopacites
caused by deposits
of enamel
•Radiolucent halo

Mature pcod/fcod
• It is a reactive phenomenon that arises from
elements with in the periodontal ligament
• These lesions are sub divided into
• 2groups- 1.Mandibular incisor
region(pcod)
• 2.Premolar molar region(fcod

Mature pcod or fcod
• 3stages-early stage- radiolucent
• Intermediate stage-mixed radiolucent and
radiopaque
• Late stage-radiopaque
Features-
• Site-Lower incisors
• Sex-Females
• Age->30yrs
• Diameter<2cm
• Occasionally produces clinically expansion
• Multiple lesions

Mature pcod

Mature fcod

• Hypercementosis
• Periapical idiopathic osteosclerosis
• Condensing osteitis

rarities
Cementoblastoma Pagets and
metastatic
osteoblastic
prostatic
carcinoma
Osteosarcoma
chondrosarcoma
chondroma
Complex
odontoma
periapices of
premolars and
molars
systemic
symptoms present
ragged radiolucent
areas with
radiopacities
•Unerupted teeth
or in between roots
•Denser sharper
radiopacites
caused by deposits
of enamel

Unerupted succedenous teeth
• When the permanent crown of succedenous
teeth are completely formed and resorption
of corresponding deciduous teeth is initiated
the images of permanent tooth crowns
represent periapical radiopacities.
• Age-<12-13 yrs

Unerupted second premolar

Foreign bodies
• Radiopaque foreign bodies in the periapex
are usually root canal filling materials.
• Images produced by extruded guttapercha
,silver points,sealer or retrograde amalgam
restoration and filled root canal –periapical
radiopacities
• H/o root canal filling

Foreign bodies

hypercementosis
• Cemental hyperplasia
• Excessive formation of cementum on the
surface of the root of the tooth.
• Etiology-not known
• Associated with periapical inflammatory
conditions –pcod,systemic diseases(pagets ,
acromegaly,gigantism

features
• Asymptomatic
• Premolars , molars
• It may be confined to small region of root or
whole root .
• They may be bilateral and a generalised
form with hyperplasia of cementum on all
root surfaces may be seen.
• Vital tooth and not sensitive to percussion.

Radiographic features
• Club shaped root
• Normal pdl space and lamina dura
• In anterior teeth they appear as spherical mass
of cementum attached to root end
• Differential diagnosis
• False radiopaque images
• The projected radiopacities are not delineated
by pdl space and lamina dura
• Tube shift method

hypercementosis

• True periapical radiopacities-
• Periapical osteosclerosis,condensing osteitis,and
pcod –lie outside the shadow of pdl and lamina
dura
• Cementoblastoma
• Management-no treatment required
cementoblastoma hypercementosis
•Neoplastic condition
•Mand. Molars and premolars
•Pain and cortical expansion
•Non neoplastic condition
•Premolars
•No pain nad cortical
expansion
•Associated with local and
systemic factors

Rarities
cementoblastoma

False periapical radiopacities
• They can be categerised into
• Radiodense bodies with in the bone situated
either buccally or lingually to the apex
• Hard or soft tissue situated on the periphery
of the bone or in the adjacent soft tissue.
• They can be identified altering the angle of
the projection

Anatomical structures
• Anterior nasal spine
• Ala of the nose
• Malar process of maxilla
• External oblique ridge
• Mental protuberance
• Mylohyiod ridge and hyiod bone

Ala of nose
Mylohyiod ridge

Anatomical radiopacities
External oblique
ridge
Malar process of
maxilla
Mental
protuberance

Impacted teeth supernumarary teeth
and compound odontomas
• Radiographically they appear as periapical
radiopacities and the they can be identified
by-density and shape
• Clarks tube shift technique

Impacted
supernumerary teeth
Compound
odontomawww.indiandentalacademy.com

Tori , exostosis andperipheral
osteomas
– On radiographic examination tori , exostosis
may appear as single or multiple smoothly
contoured dense radiopaque masses
– Their shadows happen to fall in an apical area
on the radiograph shifting the tube
demonstrates these are false periapical
radiopacities

Tori

Retained root tips
• Molar regions
• It canbe identified by
• Shape of the root and its root canal, pdl
space,lamina dura
• Tube shift method

Retained root fragment

Foreign bodies
• Metal fragments ,buttons,zippers ,hooks,and
fragments of the instrument
• They appear in the radiographs as periapical
radiopacities
• h/o restorations

foreign bodies

Mucosal cyst of maxillary sinus
• It represents retention cyst in the lining
mucosa of the maxillary sinus
• Features-
• M=f
• Bilateral
• Age 3rd decade
• Asymptomatic

• On radiographs the cyst may appear as dense
dome shaped mass with with its base on the
floor of maxillary sinus
• The apices of maxillary 1st and 2nd molars may
apear to be with in the opaque image of the
cyst
• Diagnosis-location and appearance of dome
shaped radiopaque structure
• Periodic radiographic examination

Mucosal cyst of maxillary sinus

• True radiopacities-condensing osteitis
• Periapical idiopathic osteosclerosis
• Pcod
• Malignant tumour of sinus
• Fibrous dysplasia of maxillary sinus-ground
glass appearance
• Radiographic views such as panoramic,waters
,pa view identify it as a mass situated in the
maxillary sinus.

Ectopic calcifications
• Ectopic calcifications in the soft tissues
surrounding the jaw-mistaken as calcified
odontogenic cyst
• They diagnosed by –radiopacities are
surrounded by pdl space and lamina dura
• Location of these ectopic calcifications are
shown to be away from the teeth by clarks
tube shift method.

sialoliths
• These are calcareous deposits in the ducts of
minor and major salivary glands or with in
the glands
• They are thought to form from a slowly
calcifying nidus of tissue or bacterial debris

Major salivary gland sialolith
The submandibular gland is the most common site of
involvement, 80 to 90%
The parotid gland - 5 to 15%
The sublingual gland or minor salivary glands- 2 to 5%
REASONS:
• The torturous course of Wharton’s duct
• Higher calcium and phosphate levels, and
• The dependent position of the submandibular
glands,which leave them prone to stasis.

features
• Present with a history of acute, painful, and intermittent
swelling of the affected major salivary gland.
• Typically, eating will initiate the salivary gland
swelling.
• The involved gland is usually enlarged and tender
• The soft tissue surrounding the duct may show a severe
inflammatory reaction
• Complications: Acute sialadenitis,
Ductal stricture, and
Ductal dilatation

Radiographic features
R/F:
LOCATION: Submandibular gland ( 83 to 94 %)
50% lies in the distal portion of warthons duct,
20% in the proximal portion ,
30% in the gland itself
PERIPHERY & SHAPE:
Duct- cylindric & very smooth in their outline
INTERNAL STRUCTURE:
Some stones are Homogeneously RO
Others show evidence of multiple layers of calcifications

SAILOLITH IN WHARTONS DUCT

Multiple sialoliths and a sialolith of unusual size in the
submandibular duct :A case report

Hyiod bone Myositis ossifans phleboliths
Bilaterally
Shape –v shaped
Restriction of mandibualr
movements
Symptoms of sailadenitis
are absent
Calcifications in
the walls of facial
artery
Foreign bodies Avulsed toth Calcified lymph
node
-serpentine
calcified image is
diagnostic
Charecteristic shape
h/o trauma
Shape
h/o trauma
•Incidence
•Painful swelling is
not persent,old
burned out
asymptomatic
lesion.
•sialogram

• Management-
• Small sialolith-milking of duct
• Large sialolith-surgical excision

Minor salivary gland sialoliths
• They are usually solitary ,small ,painless
submucosal nodules that are fully movable
in the tissue .
• Location-buccal mucosa ,upperlip ,palate
• Age-5th -7th decade
• Rarely multiple siaoliths may be seen

• Small mucosal cysts
• Lymph nodes
• Salivary gland tumours
• Radiograph-small radiopacity if sufficient
mineral content present
• Xeroradiography-non radiopaque sialoliths
• Management- surgical excision .

Rhinoliths and antroliths
• Calcareous concretions that occur in the
nose(rhinolith) or the antrum of the
maxillary sinus(anthroliths) arise from the
deposition of nasal,lacrimal and
inflammatory mineral salts
Anthrolith Rhinolith
Endogenous Exogenous substance
Adult population Pediatric population

C/F:
Unilateral purulent rhinorrhea,Sinusitis
,Headache,Epistaxis,Anosomia fever
R/F:
The stones have variety of shapes and sizes &
the internal structure may present as
homogeneous or hetergeneous RO

Periapical radiographs demonstrating
anthrolith

Periapical condensing
osteitis
Buccal exostosis or
palatine torus
Complex odontoma
Non vital tooth
Additional films show
that mass is not
encroaching the sinus
Clinical examination Radiopacity is surrounded
by radiolucent capsule

• Conecuts
• Eyeglasses
• Ala of the nose
• inferior additional
portion of malar process fims
of the maxilla should be
taken
• Root tips in maxillary sinus-root canal present
• Fibrous dysplasia-ground glass appearance on
periapical radiograph
• Mucous retention cyst-dome shaped appearance

Calcified lymph nodes
• They occur in cervical and submaxillary
regions
• Majority-submandibular lymph nodes
• On certain radiographic views they may
appear over mandibular bones /apex of
mandibular tooth

features
• Asymptomatic
• H/o succesful treatment of tuberculosis
• Isolated nodes /several nodes/whole chain of
nodes –calcified
• Superficial nodes-palpated as bony hard ,round
or linear masses with variable mobility.
• Radiographs-single round ,oval or linear
radiopaque mass with well contoured and well
defined outline.

panoramic

• Sialoliths
• Superimposed myosistis ossificans
• Tubercular calcified lymph node must be
differentiated from histoplasmosis,bacillus
calmette –guerin vaccination,cocccidosis
Filariasis,lymphoma,metastatic calcifying
tumour and idiopathic calcifications

phleboliths
• Calcified thrombi occuring in venules ,veins,or
sinusiodal vessels of hemangiomas
• They may occurs singly or multiple
calcifications and are usually small
radiopacities ,may be round or oval and may
show concentric light and dark rings
• Differential diagnosis-
• Sialoliths ,tonsilloliths,calcified acne,myositis
ossificans and arterial calcifications

Arterial calcifications
• Calcification frequently accompanies
arteriosclerosis and facial artery may be
affected.
• Radiographic-serpentine outline and position
of the faint radiopacity are pathognomic
• This radiopaque image may cast over the body
of the mandible near the inferior borders
• Differential diagnosis- sialoliths
• Calcified lymph nodes

Arterial calcifications

rarities
Calcinosis cutis

References
• 1.Differential dignosis of oral and maxilo facial lesions-paul
w.Goaz -5th edition
• 2.Oral radiology –whiteand pharoah -5th edition
• 3.Oralpathology-shafers- 6th edition

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