Radiopacities not necessarily contacting teeth/ dental implant courses

SOLITARY RADIOPACITIES NOT
NECESSARILY CONTACTING TEETH
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

True intrabony radiopacities
Tori,exostosis and peripheral osteomas
Unerupted,impacted and supernumerary teeth
Retained roots
Idiopathic osteosclerosis
Condensing or sclerosing osteitis
Mature focal cementoosseous dysplasia
Fibrous dysplasia
Focal sclerosing osteomyelitis
Diffuse sclerosing osteomylitis
Proliferative periostitis
Mature odontoma
Ossifying subperiosteal hematoma

Rarities
Cementifying & ossifying fibroma
Chondroma & chondrosarcoma
Mature osteoblastoma
Metastatic osteoblastic carcinoma
Osteoblastoma
Osteochondroma
Osteogenic sarcoma

Projected radiopacities
 Anatomic structures
 Foreign biopsy
 PathologY soft tissue
masses
 Ectopic calcifications
sailolith of major n minor
salivary glands
Rhiolith anthrolith
Calcified lymphnodes
Tonsilloliths
Phlebolith
Arterial calcification
Rarites
 calcified acne lesion
 Calcified hematoma
 Calcinosis cutis
 Cysticercosis
 Hemartoma
 Myositis ossificans
 Peripheral fibroma with
calcification
 Pilomatricoma
 Tumoral calcinosiswww.indiandentalacademy.com

Tori ,exostosis and peripheral osteomas
o Tori and exostosis are peripheral benign slow growing
bony protruberance of the jaws
o They appear symmetrically as nodular lesions that have
smooth contour and are covered by normal mucosa
o The well-defined RO shadows of these bony
protruberances are projected over the images of tooth
roots
o Females

DEPENDING ON LOCATION
Torus Palatinus
The shadow is best seen when it is
projected through that of the
maxillary antrum in an occlusal iopa

Torus Mandibularis

BUCCAL EXOSTOSIS

Differential diagnosis
o Cementossifying fibroma-Thin Rl rim surrounds lesion
o Osteogenic sarcoma
o Small chondrosarcoma
o Sub periosteal hematoma
Diagnosis:-
CORRELATING THE CLINICAL FINDINGS OF A SMOOTH
NODULAR PROTRUBERANCE WITH R/G FINDINGS OF A
SMOOTHLY CONTOURED RO

UNERUPTED IMPACTED AND SUPERNUMERARY
TEETH
These are next most common solitary RO after tori, exostosis
Lower 3rd molars upper 3rd molars, canines,premolars and
supernumerary teeth
DIAGNOSIS: OUTLINE OF THE TOOTH,RL PULPCHAMBER
PERIODONTAL LIGAMENT & FOLLICULAR SPACE

IMPACTED TEETH & SUPERNUMERARY
TEETH

Retained roots
Retained roots are a common findings in edentulous regions of jaws
Majority of retained roots are asymptamatic
Unaltered their identification is easy
Rootcanals obliteration ,peripheral resorption condensing osteitis
DIAGNOSIS: HOMOGENEOUS QUALTIY OF THE ROOT TIPS
SHADOW

Retained root tips

An area of bony sclerosis is termed idiopathic osteosclerosis if its
cause cannot be readily explained
c/f:
Painless & donot produce expansion of the cortex.
Covering mucosa is normal in appereance.
85% occur in mandible – first molar region. Alveolus, between the
roots ,just below the crest of the ridge
These sclerotic areas may remain unchanged or may partially resolve
or may completely resolve.

R/G:
Number: solitary but may be multiple
Size may vary from few mm to 2 or 3 cm
Shape: irregular to round
Prominent accentuation of the normal trabecular pattern in milder
cases to a dense,homogeneous radiopacity in more pronounced
case
Margins: smoothly contoured or ragged and well defined
The radiodensity of the lesion may tend to blend with that of the
adjacent normal bone

Condensing or sclerosing osteitis
Condensing or sclerosing osteitis is a sclerosis of bone induced by
an inflamation or infection.
Sclerosis is brought about by the deposition of new bone along the
existing trebecular –APPOSITIONAL BONE DEPOSITION
c/f:
Female predominance
Non vital pulp
Low grade infection –no pain, swelling, drainage or associated
lymphadenitis www.indiandentalacademy.com

The lesion vary greatly in size and shape
Margins: welldefined or poorly defined or may graduall trail off into
normal bone
Location: between teeth ,just below the crest ,near the apex or in
the body of the bone deep to the apex
In most instances CO is adjacent to an area of rarefying osteitis.
Small lesions are usually cupped around the apex

Condensing osteitis in edentulous area

Fcod
Retained roots
Unerupted tooth
Mature complex odontome
Osteoblastic malignant tumor - h/o primay tumor,pain,swelling n
parastesia
Focal sclerosing osteomyeltitis - tender swelling with intermittent
drainage through sinus
Tori, exostoses, peripheral osteomas-clinical examination
Sclerosing osteomyelitis
Shape, density& rl
border

Enostosis (whorl) – greater the distance from the tooth apex
margins –well defined
absence of any signs & symptoms
Pagets disease – woolly appereance
A submaxillary salivary calculus.
Osteopetrosis .
Secondary hyperparathyroidism.

MATURE FCOD
FCOD & PCOD that develops from the cells of pdl
c/f:
When these mature lesions occur without apparent relation to the
teeth then they have the follwing features
1. At the apices of vital teeth & edentulous region
2. They may be solitary or multiple.the mature lesions are
uniformly RO with RL border
3. Bone peripheral to the RL rim may show scleortic or groud
glass appereance
4. On histologic examinaion it is entirely composed of varying
proportions of dense cementum and bone

Oblique lateral showing relatively late-stage focal
cemento-osseous dysplasia in the region of the /6 extraction site
(arrowed). An appreciable amount of internal calcification is evident

Mature FCOD

FIBROUS DYSPLASIA
Synonyms- Fibrocystic diseae, Osteitis fibrosa, Focal osteitis fibrosa,
fibrosseous dystrophy
• Fibrous dysplasia is considered a hamartomatous fibrosseous
lesion which is not of periodontal origin
osteolytic stage
mixed osteolytic & osteoblastic
osteoblastic

M=f
Mandible-canine,premolar,molar areas; the ramus and symphysis
Maxilla – molar&premolar region n maxillary sinus
Painless expansion of jaw bone
Expansion is usually fusiforn ,firm, smoothly contoured and covered
by normal mucosa
Teeth in the region remain firm

Radiographically
Predominance of bone
1. Stippled(orange peel appeareance)
2. Groundglass appereance-adults
3. Dense structureless homogeneous density-maxilla
The margins of the abnormal bone blends with normal bone
Inferior cortical margin is maintained but when lost gives an
impression of thumb print –RIBBON LIKE CORTEX
DIAGNOSIS: A SOLITARY FUSIFORM ENLARGMENT WITH GROUND GLASS
APPEREANCE APPERING IN JAW OF YOUNG INDIVIDUAL

ORANGE PEEL APPEREANCE OF FIBROUS
DYSPLASIA

Fibrous dysplasia

DIFFERENTIAL DIAGNOSIS
Pagets disease.
Hyperparathyroidism.
Diffuse sclerosing osteomyelitis - symptoms
Mature cementossifying fibroma
Calcifying post surgical defect

Synonym: Periostitis ossificans, Garreys osteomyelitis
This condition is characterised by the formation of new bone
on the periphery of the cortex
The formation of a new bone is a response for inner surface
of periosteum to stimulation by a low grade infection that
has spread through the bone and penetrated the cortex
Periapical odontogenic is a frequent cause of proliferative
periostitis of the jaws

For this lesion to develop ,the following pecular combination of
circumstances must occur
1. The periosteum must possess a high potential for osteoblastic
activity
2. A chronic infection must be present
3. Balance b/w host resistance and virulance of organism

c/f:
Children
Male predominance
Pain , nontender swelling-inferior border or other peripheris of
mandible
Infected mandibular 1st molar is the most common etiological factor
Facial asymmetry
The swelling is characterstically cinvex varying in length and depth
of the bone deposits

Radiographically
o Smoothly contoured convex bony shadow can be extending form
the preserved cortex of the jaw
o the space between this new ,thin shell of bone and the cortex
may be quite RL without bOny trabeculation
o Later an alternating light and dark laminated appereance may be
seen
o When the whole lesion is mineralized the lesion may completely
appear as RO
In most of the cases adjacent normal bone is seen but some times
oseosclerotic osteomyeltitis changes may be seen

D/D:-
Ewings sarcoma -sun ray pattern,moth eaten type of destruction
rapid unrestricted growth - parastesia
Fibrous dysplasia-ground glass appereance
Osteogenic sarcoma- irregular & sunburst appereance
Infantile cortical hyperostosis-generalized expansion of several
bones
Hemartoma h/o trauma mottled appereance ,RO is not uniform
Calus of a healing fracture –h/o trauma ,fracture line
Tori exostosis ,peripheral osteoma –nodular

Proliferative periostitis resulting from inflammatory lesions. Note
the multiple layers of new bone, resulting in an onion-skin appearance.

PROLIFERATIVE PERIOSTITIS

 It is a developmental anamoly of tooth tissue like teeth
 The tumor is made up of 3 calcified dental tissues ,these are laid
down in a disorganised irregular mass without normal
morphologic relationship of tissue to another
c/f: 1st and 2nd permanent mandibular molars
prevents eruption of permanent teeth

RADIOGRAPHICALLY
 Mature lesion - appears as homogeneously dense RO mass
surrounded by Rl halo which is well defined and has a smooth
outer periphery
 Earlier lesion –irregular radiodense pattern (cotton wool
appereance)

DIFFERENTIAL DIAGNOSIS:
PCOD over 30 yrs of age
FCOD situated deep in the bone

Diffuse sclerosing osteomyelitis
It is an uncommon disease that affects a broad area of the body of
the mandible
Etiology – not clearly known
chronic infection of bacteria wth low low virulence
expression of chronic recurrent multifocal osteomyelitis

CLINICAL FEATURES:-
40 yrs
Female prediliction
Recurrent pain
Swelling of inferior aspect of the cheek
Trismus
Cyclic episodes of swelling
During excerbations ,sub febrile temperature and eleveated
sedementation rates,cervical lymphadenipathy

RADIOGRAPHIC FEATUTES
Limited to half of the mandible
Molar angle and ramus region
Osteolytic areas may predominate initially (symptamatic)
Dense diffuse bony sclerosis predominates and rl components
deminishes
ENDOSTEAL SCLEROSIS may be so dense and cortex looses
definition
Sub periosteal bone & external cortical erosion

Differetial diagnosis:-
Florid cemento osseous dysplasia-circular RO with RL
border
Pagets disease-multiple bones
Osteopetrosis-multiple bones
Fibrous dysplasia-painless
Dysosteosclerosis

DIFFUSE SCLEROSING OSTEOMYELITIS

Focal sclerosing osteomyelitis
It is a reaction to a low grade infection
c/f:
Tenderness
Pain local swelling
Regionla lymphaneditis
Draining sinus
The borders of RO lesion may be ragged or smooth or well
defined or vague

Differential diagnosis
Osteoblastic or sclerosing malignancy
Condensing osteitis
Fibrous dysplasia
FCOD

Ossifying subperiosteal hematoma
In early cases they appear as mixed RO & RL lesion but as
ossification is completed it becomes dense RO smoothly
contoured convex expansion on the periphery of bone

Sailolith

SAILOLITH IN WHARTONS DUCT

Anthrolith

phlebolith

Dystrophic calcification of tonsil

Foreign bodies

Trumatic myositis ossificans

Calcified cervical lymphnode

ARTIFACT

Genial tubercle

CONCLUSION
Solitary radiopacity
surrounded by RL halo
Pcod
Fcod
Unerupted teeth
supernumerary teeth
Impacted teeth
Mature odontomes
Retained root tips
Cementossifying fibroma
Florid cementosseous
dysplasia
Projected radiopacities
Sailolith
Anthrolith
Rhinolith
Phlebolith
Calcified lymphnodes
Tonsiloliths
Calcinosis cutis
Fibrous dysplasia
Condensing osteitis
Tori. Exostosis.
Focalsclerosing oseomyeltis
Diffuse sclerosing
osteomyeltis
Proliferative osteitis
clarks tube shift technique

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

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