This presentation will give u a brief idea of different soft tissue lesions and their diagnosis

1. DR ARAVIND B S
SECOND YEAR PG
DEPT. OF ORAL MEDICINE AND RADIOLOGY
Guided by
Dr. TATU .E. JOY
PROFESSOR AND HOD
DEPT OF ORAL MEDICINE AND RADILOGY

2. DYSTROPHIC CALCIFICATION
 CALCIFICATION IDIOPATHIC CALCIFICATION
METASTATIC CALCIFICATION
 MINERALISATION
 Soft tissue calcifications in the orofacial region are
uncommon and are usually asymptomatic in nature.

3. Classification
A .Dystrophic Calcifications
• General dystrophic calcification of the oral regions
• Calcified lymph nodes
• Dystrophic calcification in the tonsils
• Cysticercosis
• Arterial calcification
- Monckerberg's medial calcinosis (Arteriosclerosis)
- Calcified Atherosclerotic plaque
B. Idiopathic calcifications
• Sialoliths
• Phleboliths
• Laryngeal cartilage calcifications
• Rhinolith/Antrolith
C. Metastatic calcifications
• Ossification of the styloid ligament
• Osteoma cutis Myositis ossificans

4. GENERAL DYSTROPHIC CALCIFICATION OF ORAL REGIONS
 -Precipitation of calcium salts into primary sites of chronic
inflammation or dead and dying tissue.
 Associated with a high concentration of phosphatase
 Increase in local alkalinity.
 Common location -long standing chronically inflamed cyst

5. CLINICAL FEATURES
 COMMON SITES – Gingiva, tongue, lymph nodes and cheek
 COMMONLY FOUND IN DISEASES
- Tuberculosis
- Necrosis
- Atherosclerosis
-Scars And Areas Of Fatty
Degeneration
Occasionally the area Is Enlarged, ulcerated Or Palpable.

6. Radiographic features
 common sites -long standing chronically inflamed cysts.
 Appearance- varies from fine grains of radiopacities to
larger irregular radiopaque particles that rarely exceed
0.5 cm in diameter.
 One or more of the radiopacities may be seen,
homogenous or may contain punctate areas.
 The outline is usually irregular or indistinct.

7. Calcified Lymph Nodes
 Calcification occurs in lymph nodes that have been chronically
inflamed because of various diseases (usually granulomatous
disorders).
 The lymphoid tissue is replaced by hydroxyapatite, like calcium
salts nearly effacing all of the nodal architecture.
 The common disease that cause calcified lymph nodes are,
tuberculosis (scrofula or cervical tuberculous adenitis),BCG
vaccination, sarcoidosis, cat-scratch disease, lymphoma treated
with radiation therapy, fungal infections, and metastases from
distant calcifying neoplasms.

8. Clinical Features

10. Clinical Features
 The most commonly involved nodes are submandibular and
cervical nodes (superficial and deep) and less commonly the
preauricular and submental nodes.
 There are no significant signs or symptoms.
 They are most often detected as an incidental finding during
panoramic radiographic examination.
 • On palpation these nodes, which may be single or multiple or
sometimes chain of nodes, which are found to be mobile, hard,
round or oblong masses, whose outline is well contoured and
well defined.

11.  The most common site is the submandibular region,
either at or below the inferior border of the mandible
near the angle, or between the posterior border of the
ramus and cervical spine.
 The image of the calcified node may sometimes overlap
the inferior aspect of the ramus.
 The node calcification may be single, or a series of nodes
called lymph node chaining.
Radiographic Features

12.  The periphery may be well-defined, irregular and
sometimes may even have a lobulated appearance
(cauliflower like). The irregular outline helps to
differentiate lymph node calcification from other
potential soft tissue calcification in the area.
 It may have a varying degree of radiopacity, giving an
impression of a collection of spherical or irregular masses,
which may look like mass of coral.
 Occasionally the lesion may have a laminated appearance.

13. Radiographic Features
 Calcified lymph nodes located inferior to the angle of the
mandible. Prior chronic infection of the lymph nodes may result
in calcification of the nodes. A history of successfully treated
tuberculosis is often associated with this calcification. This
asymptomatic condition may involve a single node or a chain of
nodes.

14. OPG showing two calcified lymph nodes in the left cervical chain
(solid arrows).
Note also the ghost shadows of the lymph nodes on the right
premolar/canine region (open arrows)

15.  A lateral cervical radiograph shows a chain of calcified
lymph nodes.

16. Management
Usually require no treatment, but the underlying cause
should be determined in case treatment is required; as
in the case of lymphoma.

17. Dystrophic Calcification in the Tonsils
(tonsillar calculi, tonsil concretions, tonsilloliths)
 Tonsillar calculi are formed when repeated bouts of
inflammation enlarge the tonsillar crypts. Incomplete
resolution of dead bacteria and pus serve as the nidus
for dystrophic calcification.

18. Clinical Features
 Age group - 20 to 68 years of age, more in the older age group.
 Tonsilloliths are usually hard, round, white or yellow objects
projecting from the tonsillar crypts.
 The small calculi may not produce any signs or symptoms.
 In case of larger calcifications, pain, swelling, fetor oris
dysphagia and a foreign body feeling on swallowing has been
reported.
 In rare cases there may be giant tonsilloliths, which stretch the
lymphoid tissue, resulting in ulcerations and extrusion

19. Clinical Features

21. Radiographic Features
 On the panoramic film, tonsilloliths appear as single or
multiple radiopacities that overlap the mid portion of the
mandibular ramus in the region where the image of the
dorsal surface of the tongue crosses the ramus in the
palatoglossal air spaces.
 It appears as clusters of multiple small ill-defined
radiopacities. This may vary from 0.5 cm to 14.5 cm in
diameter.
 The radiopacity is of the same density as that of cortical
bone, and a little more radiopaque than cancellous bone.

22.  Digital panoramic radiography with image suggesting
multiple tonsilloliths in the lower one third of the
mandibular ramus on both sides.

23. Left side of an OPG showing the typical appearance
of tonsillar calcifications (arrowed) overlying the ramus of the
mandible

24. NOTE:- A right angled view to the panoramic field such
as a posterior skull view or an open Towne's view may
help to differentiate whether the calcification lies to the
medial aspect of the ramus.
 Management
Larger calcifications with associated symptoms should
be removed surgically.

25. Cysticercosis
 When eggs or gravid proglottids from Taenia Solium (pork
tapeworm) are ingested by human, their covering is digested
in the stomach and the larval form cysticercus cellulosae) of
the parasite is hatched. These larvae penetrate the mucosa,
enter the blood vessels and lymphatics and are distributed in
the tissues all over the body, but preferentially locate to the
brain, muscle, skin and heart. They are also found in the oral
and perioral tissues, especially the muscles of mastication.
After the larva die, they are treated as foreign bodies causing
granuloma formation, scarring and calcification, this takes
approximately 3 months. These areas in the tissues are called
cysticerci.

26. Clinical Features
 Multiple small nodules may be felt in the region of the masseter and
suprahyoid muscles and in the buccal mucosa and lip.
 Examination of the head and neck region may disclose palpable, well
circumscribed soft fluctuant swellings, which resemble a mucocele.
 Mild cases are completely asymptomatic.
 Moderate cases have symptoms that range from mild to severe
gastrointestinal upset with epigastric pain and severe nausea and
vomiting.
 Invasion of the brain may result in seizures, headaches, visual
disturbances, acute obstructive hydrocephalus, irritability and loss
of consciousness.

27. Clinical Features

28. Radiographic Features
 When alive the larva is not visible radiographically.
 They are usually found in the muscles of mastication and
facial expression, the suprahyoid muscle, and the
postcervical musculature.
 They appear as multiple, well-defined, elliptical,
homogeneous, radiopacities, which resemble grains of
rice.

29. Cysticercosis proglottids— A. Shows calcified nodules near the
inferior border of the mandible, which represents calcific
degeneration of the larval stage. B. Shows similar ovoid calcifications
of the shoulder and thoracic region

30. Radiograph of a patient with cysticercosis. Thevcalcified encysted
larvae are clearly seen in the soft tissues.
A single calcification in the area of the Whartons duct may be
easily mistaken for a sialolith on an intraoral film

31. Management
 Medical management by using an antihelmintic, in the
initial stage.
 After the larvae have settled and calcified in the oral
tissues, they are harmless.

32. Arterial Calcification
 There are two different patterns of arterial calcifications
which can be identified both radiographically and
histologically; Monckerberg's Medial Calcinosis and
Calcified Atherosclerotic Plaque.
 Monckerberg's Medial Calcinosis
(Arteriosclerosis)
 This is characterized by the fragmentation, degeneration
and eventual loss of elastic fibers followed by the
deposition of calcium within the medial coat of the vessel.

33. Clinical Features
 • Initially most patients are asymptomatic.
 Eventually they may develop cutaneous gangrene,
peripheral vascular disease and myositis due to vascular
insufficiency.
 • Patients with Sturge-Weber syndrome also develop
intracranial arterial calcifications.

34. Radiographic Features
 • Those involving the facial or the carotid artery may be
seen on the panoramic radiographs.
 • The calcific deposits in the walls of the artery outline
an image of the artery.
 • From the side, it may appear as a parallel pair of thin,
radiopaque lines, that may have a straight or tortuous
path (pipe stem or tram track appearance).
 • In cross section the involved vessels display a circular
ring like pattern.

35.  Calcification of the facial artery. It may occur in
arteriosclerosis and represents an inflammatory process.

36. Facial artery calcification

37. Management
 Evaluation of the patient for occlusive arterial disease,
and in some cases hyperparathyroidism should be
considered as medial calcinosis frequently develops as a
metastatic calcification in these patients.

38. Calcified Atherosclerotic Plaque
 This is found in the extracranial carotid vasculature and
is a major contributing source of cerebrovascular
embolic and occlusive disease.
 Dystrophic calcifications can occur in the evolution of
plaque within the intima of the involved vessel.

39. Radiographic Features
 • This first develops at the arterial bifurcation as a result of
increased endothelial damage at these sites.
 • When calcification occurs, these lesions may be visible on
the panoramic radiograph in the soft tissues of the neck
adjacent to the greater cornu of the hyoid bone and the
cervical vertebrae C3, C4 or the intervertebral space between
them.
 • The soft tissue calcifications are usually seen as
heterogeneous radiopacities, which are multiple and irregular
in shape, sharply defined from the surrounding soft tissues
and have a vertical linear distribution.

40. Digital panoramic radiography with images suggesting the
presence of atheroma on both sides.

41. Digital panoramic radiography with image suggesting the
presence of atheroma on left side.

42. Management
 The patient should be referred to the physician for
cerebrovascular and cardiovascular workup.

43. Idiopathic Calcification (or calcinosis)
 This results from deposition of calcium in normal tissue
despite normal serum calcium phosphate levels. (e.g.
chondrocalcinosis, phleboliths)
 Sialoliths (Salivary Gland Stone, Salivary Gland
Calculus)
 Sialolithiasis is the formation of calcified obstruction within
the salivary duct resulting in chronic retrograde infection
because of a decreased salivary flow.
 Sialoliths may also form in any of the major or minor salivary
glands (glandular sialolith) or their ducts (ductal sialolith),
usually only one gland is involved.

44.  Mechanical conditions contributing to the slow flow
rate and physiochemical characteristics of the gland
secretions both contribute to the formation of a nidus
and subsequent precipitation of calcium and phosphate
salts.
 Accordingly, the submandibular gland and ductal
system lie in a dependent position. The Wharton duct is
long and has an irregular tortuous course, an uphill flow
in the proximal portion and the orifice is much smaller
than the lumen. The salivary secretion of the
submandibular gland is more viscous and has higher
mineral content.

45.  The sialolith is made up of laminated layers of organic
material covered with concentric shells of calcified
material, which is crystalline in structure
(Hydroxyapatite crystals with octacalcium and
phosphate).
 The chemical composition is principally of calcium
phosphate and carbon with traces of magnesium,
potassium, chloride and ammonium.

46.  • These are common in the middle age with a slight
predilection for men.
 • The submandibular gland and the Wharton duct are
by far the most frequently involved (83% of the cases),
followed by the parotid (10%) and sublingual (7%)
glands. About half of the submandibular stones lie in
the distal portion of the Wharton's duct, 20% in the
proximal portion, and 30% in the gland.
Clinical Features

47.  • The patient may be asymptomatic, or they may history
of pain and swelling in the floor of the mouth and in the
involved gland. Intra glandular stones cause less severe
symptoms than the extra glanular or the intraductal
types.
 • The discomfort may intensify at meal times, when the
salivary flow is stimulated.

48.  • If the blockage is partial, then the pain and swelling
gradually subsides.
 • 9% of patients have recurrent sialolithiasis and 10% have
nephrolithiasis.
 • Pus may exude from the duct orifice, the surrounding soft
tissue may be inflamed, and tender, and the overlying
mucosa may ulcerate.
 • Stones in the more peripheral portion of the duct may be
palpated, if it is of sufficient size.
 • Sialolithiasis of minor salivary gland is a rare occurrence,
the most common site being buccal mucosa either near the
commissure or in the proximity to the mandibular
mucobuccal fold.

52.  The sialoliths located in the duct of the submandibular
glands are usually cylindrical. But they may vary in
shape from long cigar shapes to oval or round shapes.
 • Stones that form in the hilus of the submandibular
gland tend to be larger and more irregularly shaped.
 • The stones are homogeneously radiopaque, and show
evidence of multiple layers.
 • Less than 20% of the submandibular gland and 40% of
the parotid gland sialoliths are radiolucent because of
the low mineral content of parotid secretions.
Radiographic Features

53.  CT: also helps to detect minimally calcified sialoliths
which are not visible on plain films.
 USG: is of limited use in the diagnosis of
inflammatory and obstructive diseases, but if the
stone is large (2 mm), it will be detected as a
characteristic acoustic shadow showing echodense
spots.

54.  • A periapical film, placed in the buccal vestibule, with
reduced exposure and time and the central ray directed
through the cheek, helps to demonstrate stones in the
parotid gland duct.
 • An anteroposterior skull view, of the patient with "blow-
out" cheek , or an open-mouth lateral skull projection, helps
to demonstrate stones in the parotid duct. When producing
radiographs to detect sialoliths, the exposure time should be
reduced to about half of normal, this helps to detect stones
that are highly calcified.

55.  If non calcified stone are suspected, then Sialography; is
helpful in locating obstructions that are undetectable with
plain radiography. The contrast agent usually flows around the
sialolith, filling the duct proximal to the obstruction. The
ductal system is frequently dilated proximal to the obstruction
and infers the presence of an obstruction even when is not
visible. The contrast agent that flows around the sialolith is
more radiopaque and may obscure small sialoliths.
 Radiolucent sialoliths appear as ductal filling defects.
 Sialography should not be performed if the radiopaque stone is
shown by plain radiography to be in the distal portion of the
duct, because the procedure may displace it proximally into the
ductal system, complicating its subsequent removal.

56. Additional Imaging
 • On the periapical view, there may be superimposition of the
stone over the mandibular premolar and molar apices.
 • A standard mandibular occlusal view, using half the usual
exposure time, displays the floor of the mouth without overlap
of the mandible and is the best view for visualizing stones in
the distal portion of the Wharton's duct.
 • A lateral oblique view or a panoramic view, helps to
visualize stones in a more posterior location.

57. Radiographic Features
 Mandibular occlusal projection shows a sialolith
(salivary calculus) in the duct of the submandibular
gland (Wharton's duct).

58. Calcifications in the parotid gland

59. Sialolith with in Stensons duct of the parotid gland.
Other calcifications such as phleboliths or osteoma on
the pterygoid process can occur in the region. With the
help of a tangential zygoma projection (phleboliths) or
an axial skull film or with CT (osteoma on the pterygoid
process), the differential diagnosis can be determined

60. On periapical radiographs, the
radiopacity may be
misdiagnosed as osteosclerosis.
To differentiate an
osteosclerosis from a sialolith,
take two radiographs using
different vertical (or horizontal)
angulations of the x-ray beam.
If the radiopacity changes its
position in relation to the
adjoining teeth, as shown here,
the radiopacity is a sialolith in
the floor of the oral cavity
(Clark's rule: same lingual,
opposite buccal). Another
method to identify a
submandibular sialolith is to
take an occlusal projection.

61.  A sialolith on a panoramic radiograph may be misdiagnosed
as a calcified lymph node. In the absence of clinical signs and
symptoms it is difficult to differentiate the two types of
calcifications unless a sialogram is made.

62. A. Right side of an OPG showing a large radiopacity in
the lower premolar region (arrowed).
B. Lower 90° occlusal of the same patient showing the
opacity to be a large stone in the right submandibular
duct

63.  Sialogram showing an obstruction in the Wharton's duct
preventing the flow of the radiopaque dye into the
submandibular salivary gland. The stone (arrow) is blended
with the radiopaque dye.

64.  Digital panoramic radiography with image suggesting
a single sialolith in the right submandibular gland.

65.  Digital panoramic radiography showing a image suggesting
a calcification in the right parotid gland and in its duct.

66.  Digital panoramic radiography with image suggesting
multiple microliths in the parotid gland on both sides.

67. Differential Diagnosis
 • Gas bubble; these are more easily removed and are more
circular than sialoliths.
 • Hyoid bone; these are seen bilaterally on the panoramic film.
 • Myositis ossificans; there will be restriction of mandibular
movements.
 • Phleboliths; there will be no sialadenitis, and these are more or
less rounded and contain laminations or central dark
(radiolucent) areas.
 • Calcific submandibular lymph nodes; if there is presence of
pain then it is suggestive of a sialolith. The calcified lymph
nodes appear to be cauliflower shaped.

68.  • Chondrodystrophia calcificans congenita; this is
associated with calcifications in the neck which
resemble the submaxillary calculi in the radiographs.
 • Palatine tonsillitis; on the panoramic image it has a
similar location to parotid sialoliths, superimposed
over the ramus, but can be differentiated in that they
are typically multiple and punctate.

69. Other Causes of Obstructions
 • Mucous plugs; these are incompletely mineralized
sialoliths.
 • Strictures and Stenosis; this may be papillary or ductal
obstruction due to chronic irritation, acute trauma or
presence of intra ductal growth or tumor.
 • Foreign bodies; food particles, toothbrush bristles, tooth
picks.
 • Extra ductal causes; like muscle pressure, tumors, lymph
nodes and denture flanges.

70.  Parotid fistula; this may open into the oral cavity or on to
the exterior of the face. It may be due to trauma, rupture
of parotid abscess or complication of superficial
parotidectomy.
 Management: It is best to encourage spontaneous
discharge through the use of sialogogues or piezoelectric
extracorporeal shock wave lithotripsy or surgical removal
is indicated.

71. Pheboliths
 Intravascular thrombi, which arise secondary to venous
stagnation, may get organized or mineralized. The
mineralization begins at the core of the thrombus and
consists of crystals of apatite with calcium phosphate and
calcium carbonate. Phleboliths are calcified thrombi
found in veins, venulae, or the sinusoidal vessels of
hemangiomas (especially the cavernous type).

72. Clinical Features
 • In the head and neck region , phleboliths always indicate
the presence of a hemangioma.
 • In an adult it may be the sole residua of a childhood
hemangioma, which has long since regressed.
 • The involved soft tissue may be swollen, throbbing or
discolored by the presence of veins or a soft tissue
hemangioma, which often fluctuate in size, associated with
changes in body position or during a Valsalva maneuver.
The vascular nature may be confirmed by the presence of
blanching or change in color on applying pressure.
 Auscultation may reveal bruit in case of cavernous
hemangioma but not in the capillary type.

73. Radiographic Features
Multiple phleboliths
superimposed on the
mandibular ramus.
Phleboliths are calcified
thrombi. These calcified
masses in blood vessels
are associated with
hemangiomas found in
the cheek.

74.  Multiple phleboliths of various sizes in cavernous
hemangioma of the face. The radiograph is of the patient's
cheek.

75. Oblique lateral showing multiple phleboliths
(arrowed) associated with a hemangioma. Note the
typical target appearance of some of the calcifications

76.  Panoramic radiography with image suggesting multiple
phleboliths on the right side.

77.  • These are commonly found in hemangiomas.
 • In cross section the shape is round or oval, up to 6 mm in
diameter with a smooth periphery. If the involved blood
vessel is viewed from the side, the phlebolith may resemble
a straight or a slightly curved sausage.
 It may be homogeneously radiopaque but more commonly
has the appearance of laminations, giving phleboliths a
bull's eye or target appearance. A radiolucent center may be
seen, which may represent the remaining patent portion of
the vessel.
Radiographic Features

78. Differential Diagnosis
 • Sialolith; these usually occur singly, if multiple
sialoliths are present, they are usually oriented in a
single line, whereas phleboliths are usually multiple
and have a more random, clustered distribution, and is
usually associated with a vascular lesion.

79. Laryngeal Cartilage Calcifications
 Both the thyroid and the triticeous (means grain of wheat)
cartilages (found within the lateral thyrohyoid ligaments)
consist of hyaline cartilage, which has a tendency to calcify
or ossify with advancing age.

80. Clinical Features
 • Has no clinical features and usually is an incidental radiographic finding.
 Radiographic Features
 • The calcified cartilage is located on a lateral view within the pharyngeal air
space inferior to the greater cornu of the hyoid bone and adjacent to the
superior border of C4. The superior cornu of a calcified thyroid cartilage
appears medial to C4 and is superimposed on the prevertebral soft tissue.
 • The triticeous cartilage measures 7 to 9 mm in length and 2 to 4 mm in
width. The periphery is well defined and smooth, and only the top 2 to 3 mm
of the calcified thyroid cartilage is visible at the lower edge of a panoramic
radiograph.
 • The calcified tracheal cartilages usually present a homogeneous
radiopacity, with an occasional outer cortex.

81.  Calcification of the thyroid cartilage. It is asymptomatic.

82.  Ossified thyroid and cricoid cartilages in a 40-year-old
female patient demonstrated on a lateral cephalometric
radiograph.

84.  Digital panoramic radiography with image suggesting
triticeous cartilage on both sides (between the greater horn
of the hyoid and superior horn of the thyroid cartilage).

85. Differential Diagnosis
 • Calcified Atheromatous Plaque in the carotid bifurcation,
the calcified triticeous cartilage has a solitary nature and
an extremely uniform shape and size.
 Management: No treatment required.

86. Rhinolith/Antrolith
 Hard calcified bodies or stones that occur in the nose
(rhinoliths) or the antrum (antroliths) arise from the
deposition of mineral salts such as calcium phosphate,
calcium carbonate, and magnesium around a nidus.
 In case of a rhinolith the nidus is usually an exogenous
foreign body (coin, beads etc) whereas the nidus for an
antrolith is usually endogenous (root tip, bone fragment,
masses of stagnated mucus, etc.).

87. Clinical Features
 • The patient may be asymptomatic initially.
 • With the increase in size of the expanding mass, it
may impinge on the mucosa, producing pain,
congestion and ulceration.
 • The patient may develop a unilateral purulent
rhinorrhea, sinusitis, headache, epistaxis, nasal
obstruction, anosmia, fetor, fever and facial pain.

89. Radiographic Features
 • These stones have a variety of shapes and sizes. They have
well-defined smooth or irregular borders.
 • They may be homogeneous or heterogeneous radiopacities,
depending on the nature of the nidus and sometimes have
laminations. Occasionally the density may exceed the
surrounding bone.
 • Antroliths occur within the maxillary sinus above the floor of
the antrum and may be seen on the periapical, occlusal and
panoramic radiographs.
 • Rhinoliths are seen in the nasal fossae. A posteroanterior
skull view will help to identify the location of a rhinolith.

90.  Antrolith (stone in maxillary sinus) on the floor of the sinus.
 It is asymptomatic.

92.  A. Rhinolith in the maxillary sinus, seen on an OPG. The
rhinolith is seen located at the posterior wall of the right
maxillary sinus (arrow), B. Rhinolith in the maxillary sinus
of the same patient, seen on Waters Projection, this
projection also reveals the presence of chronic sinusitis

93. Differential Diagnosis
 • Osteoma
 • Healing odontogenic cyst
 • Mycolith
 • Root fragments; should be differentiated from antroliths
by the presence of the root anatomy and presence of a root
canal. A displaced fragment in the sinus will move when the
radiography is performed with the head in different
positions, unless it is lodged between the bone and the
sinus lining.

94. Management
 Patients should be referred to an otorhinolaryngologist for
the removal of the stone.
 Metastatic calcification results when minerals precipitate
into normal tissue as a result of higher than normal serum
calcium (e.g. hyperparathyroidism, hypercalcemia of
malignancy) or phosphate (e.g. chronic renal failure).
 Metastatic calcifications usually occur bilaterally and
symmetrically. The deposits of calcium occur in the kidney,
lung, gastric mucosa and media of blood vessels.

95. Ossification of the Styloid Ligament
 Ossification of the styloid ligament usually extends
downwards from the base of the skull and commonly occurs
bilaterally. In rare cases the ossification begins at the lesser
horn of the hyoid or in the central area of the ligament. The
associated conditions are Eagle's Syndrome, Styloid
Syndrome and Styloid Chain Ossification.

96. Clinical Features
 • Patients are more than 40 years of age and are usually
clinically symptom less.
 • It may be detected by palpation over the tonsil as a
hard pointed structure.
 • The patient may present with a complaint of a vague
nagging to intense pain in the pharynx on swallowing,
turning the head or opening the mouth, especially on
yawning.

97.  • The elongated styloid process and local scar tissue probable
cause symptoms by impinging on the glossopharyngeal nerve.
 • Similar clinical findings without a history of neck trauma
constitute stylohyoid (carotid artery) syndrome.
 – The patient may also describe attacks of otalgia, tinnitus,
temporal headache and vertigo or transient syncope.
 – The pain may be produced by mechanical irritation of
sympathetic nerve tissue in the arterial wall, producing
regional carotidynia.
 – This condition is more prevalent than Eagle's syndrome.

98. Radiographic Features
 • The styloid ligament ossification is quite common in
individuals of any age and may be detected as an incidental
feature on any panoramic radiograph.
 • In the panoramic image it is seen as a linear, long,
tapering, thin, radiopaque process that is thicker at its
base, extending forward from the region of the mastoid
process and crosses the posteroinferior aspect of the ramus
towards the hyoid bone. The hyoid bone is positioned
approximately parallel to or superimposed on the posterior
aspect of the inferior cortex of the mandible.

99.  • The ossified ligament has a more or less straight
outline, but it may sometimes show irregularity in the
outer surface. The further the radiopaque ossified
ligament extends towards the hyoid bone, the more
likely it is that it will be interrupted by radiolucent, joint
like junctions (pseudo articulations).
 • Small ossifications of the styloid ligament appear
homogeneously radiopaque. As the ossification increases
in length and girth, the outer cortex of this bone appears
as a radiopaque band at the periphery.

101.  Calcified stylohyoid ligament.

102. Patient with Eagle’s syndrome. The stylohyoid ligaments are
bilaterally calcified.

103. Differential Diagnosis
 • Temporomandibular joint dysfunction; there is no
radiographic evidence of ligament ossification.
 Management: Amputation of the stylohyoid process.

104. Osteoma Cutis
 These are sites of normal bone formation in abnormal
locations. It is a rare soft tissue calcification in the skin.
 It may develop secondary to acne of long duration. In a
scar or chronic inflammatory dermatosis.
 Histologically these are seen as areas of dense viable bone
in the dermis or subcutaneous tissue. They are
occasionally found in diffuse scleroderma, replacing the
altered collagen in the dermis and subcutaneous septa.

105. Clinical Features
 • It may occur on the face (extraoral) in the cheek and lip
region, and tongue (intraoral) where it may be called
osteoma mucosae or osseous choristoma.
 • It does not cause any visible change in the overlying skin,
except in some cases where the color may change to
yellowish white.
 • It varies in size from 0.1 mm to 5 cm in diameter, if the
lesion is large. The individual osteoma may be palpated. A
needle inserted into one of the papules usually meets with
stone like resistance.

106.  • Osteoma may be single or multiple.
 • Some patients develop numerous lesions (dozens to
hundreds)
 Usually on the face in females and on the scalp or chest
in males. This is known as multiple miliary osteoma
cutis.

108. Radiographic Features
 • An intraoral film placed between the cheek and the
alveolar bone gives accurate localization.
 • A posteroanterior skull view with the cheek blown
outward using a soft tissue technique of 60 kVp helps
localize osteomas of the skin.
 • If present in the cheek or lip region the shadow may be
superimposed over a tooth root or alveolar process, giving
the appearance of dense bone.
 • The osteoma cutis appears as smoothly outlined,
radiopaque, washer-shaped images.

109.  •The single or multiple radiopacities of various sizes.
 • It appears as a homogeneous radiopacity with a
radiolucent center that represents normal fatty marrow,
giving the lesion a dough-nut appearance radiographically.
 • Trabeculae usually develop in the marrow cavity of the
larger osteomas.
 • Lesions of calcified cystic acne resemble a snowflake
radiopacity which corresponds to the clinical location of
the scar.

111. Differential Diagnosis
 • Myositis ossificans; is of greater proportions, in some
cases causing noticeable deformity of the facial contour.
 • Calcinosis cutis
 • Osteoma mucosae; if the blown out cheek technique is
used, the lesions of osteoma cutis. appear much more
superficial than mucosal lesions.

112. Management:
 They may be removed for cosmetic reasons. The
methods used are excision, resurfacing of the skin with
erbium:YAG laser using tretinoin cream (especially in
cases of multiple miliary osteomacutis).

113. Myositis Ossificans
 In this case, the fibrous tissue and heterotopic bone form
within the interstitial tissue of the muscle and associated
tendons and ligaments. There is secondary destruction and
atrophy of the muscle as the fibrous tissue and bone
interdigitate and separate the muscle fibers. It is of two
types:
 – Localized myositis ossificans
 – Progressive myositis ossificans

114. Localized Myositis Ossificans (post-traumatic
myositis, myositis ossificans, Solitary myositis)
 This results due to acute or chronic trauma, heavy muscular
strain, muscle injury which may lead to considerable
hemorrhage into the muscle or associated tendons or fascia.
The hemorrhage organizes and undergoes progressive scarring.
 During the healing process, heterotopic bone and in some cases
cartilage is formed. There is no inflammation (the term
myositis is thus misleading).
 The fibrous tissue and bone form within the interstitial tissue of
the muscle, there is no actual ossification of the muscle fibers.

115. Clinical Features
 • It may develop at any age, in either gender, but is more common in
young men who engage in vigorous activities. The commonly
involved oral sites are, the masseter, sterno-cleidomastoid and
lateral pterygoid muscle.
 • The site of the precipitating trauma remains swollen, tender and
painful for a long time. The overlying skin may be red and inflamed.
 • If the lesion involves a muscle of mastication, opening the jaw may
be difficult.
 • After a period of 2-3 weeks the area of ossification may become
apparent, as a firm, intramuscular palpable mass, which enlarges
slowly, but eventually stops growing. The lesion may appear fixed or
may be freely movable on palpation.

117. Radiographic Features
 • A radiolucent band may be seen between the areas of
ossification and adjacent bone, and the heterotopic bone
may lie along the long axis of the muscle. The periphery is
more radiopaque than the internal structure. The shape
may vary from irregular, oval to linear streaks
(psuedotrabeculae) running in the same direction as the
normal muscle fibers.
 • The internal structure varies with time:
 – In the third or fourth week after injury, the appearance is
faintly homogeneous radiopacity.

118.  – By the second month, it is organized and appears as
delicate lacy or feathery radiopaque internal structure,
which indicate the formation of bone. This bone does not
have a normal appearing trabecular pattern.
 – Gradually the image becomes denser and better defined,
maturing fully in about 5-6 months.
 – After this the lesion may shrink.

119.  Myositis Ossificans , this could be due to trauma or
repeatedly occurring inflammatory events. In this case there
is ossification of the masseter muscle causing limited ability
to open the mouth. A. shows a section of an OPG (arrow). B.
shows the massive ossification in a tangential zygoma
projection (arrow)

120.  Ossification of muscle attachments on the mental spine; the
genioglossus muscle and the geniohyoid muscle may
become ossified where they attach to the mental spine, and
this may provide difficulties for denture wearers. This may
represent a form of myositis ossificans, which is a
heterotopic accumulation of the bone at the attachment of
the musculature

121.  Myositis ossificans involving the masseter muscle

122. Differential Diagnosis
 •Ossification of the stylohyoid ligament, dystrophic calcifications
in areas of necrosis, pathological calcifications, phleboliths. The
form and location of myositis ossifications and the presence of
psuedotrabeculae are enough to differentiate it from them.
 • Bone forming tumors; although tumors like osteogenic sarcoma
can form a linear bone. pattern, the tumor is contiguous with the
adjacent bone and signs of bone destruction are present.
 Management: Sufficient rest to the injured part, and if
necessary excision.

123. Progressive Myositis Ossificans
 This is a rare disease of unknown cause that usually affects
children before 6 years of age, and occasionally as early as
infancy.
 Progressive formation of heterotopic bone occurs within
the interstitial tissue of muscles, tendons, ligaments and
fascia, and the involved muscle atrophies.
 This condition may be inherited or may be a spontaneous
mutation affecting the mesenchyma.

124. Clinical Features
 • It usually affects children before 6 years of age, and
occasionally as early as infancy, males are more affected.
 It may affect the striated muscles including the heart
and diaphragm.
 • It starts in the muscles of the neck and upper back and
moves to the extremities.
 • It begins as a soft tissue swelling that is tender and
painful and may show redness and heat, indicating the
presence of inflammation.
 • As the acute symptoms subside, a firm mass remains in
the tissue.

125.  •Sometimes the spread of ossification is limited, in other
cases it may be very extensive; affecting, almost all the
muscles of the body, resulting in stiffness and limitation
of motion of the neck, chest, back and extremities
(especially the shoulders), which gradually increases.
 • Advanced stages of the disease result in the “petrified
man” like appearance.
 • During the third decade the process may spontaneously
arrest, however most of the patients die young during the
3rd or 4th decade, due to respiratory embarrassment or
from inanition through the involvement of the muscles of
mastication.

126. Radiographic Features
 • The radiographic appearance is similar to that of localized
myositis ossificans.
 • The heterotopic bone more commonly is oriented along the
long axis of the involved muscle, with coarser linear striae of
increased density which represent new bone formation, and
there is evidence of dense osseous replacement of the greater
part or whole of the muscle.
 • The bone that is laid down does not show normal bone
structure, and appears as a rather structure less mass of variable
density.
 • Osseous malformations of the regions of muscle attachment,
such as the mandibular condyles, may also be seen.
 • Skeleton becomes osteoporotic because of lack of function as
muscles atrophy and joints become ankylosed.

127. Differential Diagnosis
 • Rheumatoid arthritis; in the initial stage it may be
difficult but as the disease progresses specific anomalies
confirm the diagnosis.
 • Calcinosis; the deposists of amorphous calcium salts
frequently resorb, but in progressive myositis ossificans
that bone never disappears.
 Management: There is no effective treatment. The
treatment is symptomatic and supportive as per the
requirement of each case. Nodules that are traumatized
and then ulcerate should be excised.

128. References
 Shenoy N, Ahme J, Sumanth K N, Srikant N S, Rai S, Yadiyal M . Prevalence of
Laryngeal Cartilage Calcifications in Mangalore population; a Radiographic
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 Mupparapu M, Vuppalapati A. Ossification of Laryngeal Cartilages on Lateral
Cephalometric Radiographs. Angle orthod.2005;75(2):196-201
 White SC, Pharoa MJ. Oral Radiology: Principles and Interpretation. 6th ed. Saint
Louis: Mosby; 2007
 Haring JI, Jansen L. Dental radiography: principles and techniques. 2nd ed.
Philadelphia:Saunders; 2000. 569 p.
 Langland OE, Langlais RP, Preece JW. Principles of dental imaging. 2nd ed.
LippincottWilliams & Wilkins; 2002. 459 p.