Soft tissue calcifications and ossifications / oral surgery courses

Soft tissue calcification & ossification
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Deposition of calcium salts in tissues other than osteoid or
enamel is called pathologic or heterotrophic calcification
Two distinct types of pathologic calcification are recognised:
• Dystrophic calcification
• Metastatic calcification
Dystrophic calcification :characterized by deposition of salts in
dead or degenerated tissues with normal calcium metabolism
and normal serum calcium levels.
Metastatic calcification: Occurs in normal tissues and is
associated with dearranged calcium metabolism and
hypercalcaemia

Heterotopic ossification
When the mineral is deposited in soft tissue as
organised ,well formed bone the process is called
heterotopic ossification

Dystrophic calcification
• General dystrophic calcification of the oral region
• Calcified lymphnodes
• Dystrophic calcification in the tonsils
• Cysticercosis
• Arterial calcification –Arteriosclerosis
Calcified atherosclerotic plaque
Idiopathic calcification:
• Sailolith
• Phlebolith
• Laryngeal cartilage calcification
• Rhinolith /anthrolith

Metastatic calcification:
• Ossification of the stylohyoid ligament
• Osteoma cuts
• Myositis ossificans-Localized (traumatic)myosistis ossificans
Progressive myositis ossificans

General dystrophic calcification
of the oral regions
Dystrophic calcification is the precipitation of calcium salts
into primary sites of chronic inflamation or dead and dying
tissue.
C/F:
Common sites: gingiva , tongue , lymphnodes, & cheek
• It is usually asymptomatic
• A solid mass of calcium salts sometimes can be palpated
R/F:
Fine grains of RO to large, irregular radiopaque particles
(<.5CM)
The calcification may be homogeneous or may contain
punctate areas
Irregular or indistinct outline

Calcified lymph nodes
Dystrophic calcification occurs in lymphnodes that have
been chronically inflamed because of various diseases.
Tuberculosis(scrofula or cervical tuberculous adenitis)
Sarcoidosis
Catscratch disease
Rhematoid arthritis
Systemic sclerosis
Lymphoma
Fungal infections
Metastases from distant calcifying neoplasams

C/F:
• Asymptomatic
• Submandibular , superficial and deep cervical lymphnodes
• NODES-bony hard , round or linear masses with variable
mobility

R/F:
Location :
Submandibular
calcification may affect a single node or linear series of nodes in a
phenomenon known as lymph node “chaining”
Periphery:
Well defined , irregular occasionally having lobulated appearance
(cauliflower)
Internal structure:
Without any pattern but may vary in the degree of radiopacity
Egg shell calcification (RO seen only on the surface of the node)

Differential diagnosis
• Sailolith-has a smooth outline .
• Phlebolith- are small & multiple
• Histoplasmosis-firm consistency
• lymphoma –rubbery consistency

Calcified lymphnodeswww.indiandentalacademy.com

Dystrophic calcification in the
tonsils
Synonyms: Tonsillar calculi, Tonsillar concretions,
& tonsilloliths
• Tonsillar calculi are formed when repeated botus of
inflammation enlarge the tonsillar crypts
C/F:
They present as hard , round , white or yellow objects projecting
from the tonsillar crypts
Small calcifications are asymptamatic
Large calcifications produce pain ,swelling, foetis oris, dysphagia
Older age groups are commonly

R/F:
Location: Mid portion of the mandibular ramus
Tonsilliths frequently appear on the panoromic radiograph
immedeatly inferior to the mandibular canal
Periphery: ill-defined
Internal structure: uniformly radiopaque
D/D:
Calcified granulomatous disease-Firn
Syphillis-firm
Mycosis or lymphoma –firm
RO lesions such as dense bony islands

Dystrophic calcification
of tonsils

cysticercosis
Human ingests egg or gravid proglattidss
The covering of the egg is digested
The larvae is hatched
It enters blood vessels and lymphatics
Distributed in the tissues all over the body
In tissues other than intestinal mucosa the larvae eventually die and
are treated as foreign bodies causing granuloma formatin scarring
and calcification ,these areas in the tissues are called cysticerci

C/F:
Mild cases are completely asymptomatic
Moderate to severe cases have symptoms range from mild to
severe GIT UPSET
Epigastric pain
Severe nausea and vomiting
Seizures,headache
Visual disturbances
Irritability

R/F:
Location : Muscles of mastication and facial muscles and
suprahyoid muscles and post cervical musculature
Periphery and shape: Multiple well defined elliptical
RO resembling grains of rice
Internal structure: Homogeneously RO
D/d: Sailolith
The small size of the calicified nodules of cysticerci and their
wide spread dissemination ,particularly in brain and muscle
are higly suggestive of the diagnosis

Arterial calcification
Two distict type of arterial calcification can be
identified both radiographically & histologically
• Monckeberg’s medial calcinosis
• Calcified atherosclerotic plaque

Monckberg’s medial calcinosis
Synonym: Arteriosclerosis
Degeneration and eventual loss of elastic fibers followed by
the deposition of the calcium within the medial coat of
vessel.
C/F:
• Intially asymptomatic
• In later cases cutaneous gangrene peripheral vascular
disease and myositis.
• Patients with sturge -weber syndrome also develop
intracranial arterial calcification

R/F:
Location : Facial artery .
less comonly carotid artery
Periphery and shape:
It outline an image of the artery ,appears as a parallel pair of thin
RO lines –pipe strem or tram track appereance
In cross section ,involved vessels will display a circular or ring
like pattern
D/D:
The radiographic appereance of arteriosclerosis is so distinctve as
to be pathognomic of the condition

ARTERIOSCLEROSIS

Calcified atherosclerotic plaque
• Dystrophic calcification can occur in the atherosclerotic
plaque over a period of time
R/F:
LOCATION: It develops at arterial bifurcation , when
calcification has occurred these lesions may be visible in the
panoramic radiography in the soft tissues of the neck eighter
superior or inferior to the greater cornu of the hyoid bone
PERIPHERY & SHAPE: multiple and irregular in shape and
sharply defined from the surrounding tissues
INTERNAL STRUCTURE: heterogeneous radiopacity with
radiolucent voids

sialolith
Sialolith are calcified deposits in the ducts of the major salivary
glands or within the glands themselves
• Etiology: It is believed that a nidus of salivary organic material
becomes calcified and gradually forms a sialolith
• The structure of sialoliths is crystalline

• 50% of parotid gland sialoliths and 20% of submandibular gland
sialoliths are poorly calcified. This is clinically significant because
such sialoliths are not radiographically detectable
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.

C/F:
• 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

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

Occlusal view demonstrates a calcified
deposit in Wharton’s duct.

SAILOLITH IN WHARTONS DUCT

Sialogram of the submandibular gland

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

Investigations
Submandibular duct:
• Periapical view
• Standard mandibular Occlusal view using half exposure time –
Distal part of Wharton's duct
• Lateral oblique or panoramic view –post part of duct
Parotid gland:
Periapical R placed in the buccal vestibule & the central x-ray
directed through cheek
AP. skull view
Lateral skull projection.
If non calcified stones are suspected SAILOGRAPHY is helpful
CT scan
MRI
Radionucleide salivary imaging

D/D:
1) A calcified lymph node-Incidence
2) An avulsed or embedded tooth
3) A phlebolith –Symptoms of sailadenitis are absent
4) Calcification in the facial Artery-serpentine calcified
image is diagnostic
5) Myositis ossificans-Restricted mandibular movement
6) An anatomic structure such as hyoid bone-The
shape is significant & it is bilateral

phleboliths
Phleboliths are calcified thrombi found in veins, or the sinusoidal
vessels of hemangiomas
C/F:
In head and neck , phlebolith nearly always signals the presence of
a hemangioma
Or it may be the sole residua of a childhood hemangioma
The involved soft tissue may be swollen,throbbing or discolored by
the presence of veins or a soft tissue hemangioma

R/F:
Periphery & shape: In cross section the shape is round or oval
with a smooth periphery
Internal structure: It may be homogeneously radiopaque but
more commonlY has the appeareance of laminations giving a
bull’s eye or target appeareance ;a RL centre may be seen .
D/D:
Sailolith
Tonsilloliths
Arterial calcifications.
Myositis ossificans
Cysticercosis
Calcified acne – The are superficial lesions

Phlebolith

A case report of intramuscular hemangioma presenting
with multiple phleboliths

Laryngeal cartilage
calcifications
A small paired triticeous cartilageous are found within the
lateral thyrohyoid ligaments
Both the thyroid and triticeous catilages contains hyaline
cartilage which has a tendency to calcify with advancing
age

R/F:
Location: located on lateral view within the pharygeal air space
inferior to greater cornu of hyoid bone and adjacent to
superior border of c4
Periphery and shape:
It is well defined & smooth
Internal structure:
homogeneous RO
D/D:
Calcified atheromatous plaque in the carotid bifurcation

Laryngeal cartilage
calcifications

Rhinolith or anthrolith
Calcareous concretions that occur in the nose(rhinolith) or
the antrum of the maxillary sinus(anthroliths) arise from
the deposition of nasal,lacrimal and inflamatory 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
D/D:
Osteoma
Complex Odontoma
Matured cementoma
Periapical condensing osteitis
Palatine torus
Impacted teeth
Ala of the nose
RL borders

Periapical radiographs demonstrating
anthrolith
Occlusal radiograph
deomstrating anthrolith

OSSIFICATION OF THE
STYLOHYOID LIGAMENT
Ossification of the stylohyoid ligament usually extends
downward from the base of the skull and commonly
occurs bilaterally
C/F:
Symptoms related to this ossified ligament are termed eagle
sndrome
Classic eagle syndrome: cranial nerve impingement
Carotid artery syndrome
Intense pain in pharynx during swallowing & turnign head
or opening the mouth especially on yawning

OSSIFICATION OF THE STYLOHYOID
LIGAMENT

R/F:
Location: The linear ossification extends forward from the
region of the mastoid process and crosses the
posteroinferio aspect of the ramus towards the hyoid bone
Shape: Appears as a long tapering thin RO process .
It normally varies from 0.5 to 2.5 cm in length.
Internal structure: homogeneuously RO
D/D:Tmj dysfunction
MANAGEMENT : NO TREATMENT IS REQUIRED

OSTEOMA CUTIS
Rare soft tissue ossification in the skin
85% of the cases occur secondary to acne of long duration
developing ina scar or chronic inflamatory dermatosis
C/F: face is the most common site
tongue is the most intra oral common site (osteoma
mucosae or osseous choristoma)
Some patients develop numerous lesions (multiple miliary
osteoma cutis )

R/G:
Location: cheek & lip regions
Periphery & shape: smoothly outlined RO washer shaped images
,single or mutliple RO usually measuring 0.1 to 5cm
Internal structure: homogeneously RO but usally has a Rl centre
( donut appereance )
D/d:
Myositis ossificans
Calcinosis cutis

Osteoma cutis

MYOSITIS OSSIFICANS
In myositis ossificans;fibrous tissue & heterotopic bone form
within the interstitial tissue of muscle and associated
tendons and ligaments
Secondary destruction and atrophy of the muscle occur
2 forms: localized and progressive

Localized (trumatic)myositis ossificans
Synonym: postraumatic myositis ossificans
solitary myositis
Etiology: acute or chronic trauma.heavy muscular strain
muscle injury from multiple injections
C/F: YOUNG MEN
• The site of the precipitated trauma remains swollen
,tender and painful
• The overylying skin may be red and inflamed
• Opening of jaw may be difficult

Radiographic features
• Location: masseter and sternocledomastoid
the ant attachment of temporalis as well as the medial
pterygoid muscles are at high risk of injury on administration
of mandibular block
Periphery and shape: periphery is more RO than the internal
structure
shape irregular oval – linear streaks (pseudotrabeculae)
Internal structure: 3rd or 4th week-faint RO
2months-a delicate or feathery internal structure develop
6moths- it becomes denser and more defined

D/D:
Ossification of stylohyoid ligament
Soft tissue calcifications

Trumatic myositis ossificans

Progressive myositis ossificans
Rare heriditary disease with autosomal dominant
transmission
Affects children before 6yrs of age
Occasionally seen in infants
Males
Progressve formation of heterotrophic bone occurs within
the interstetial tissue of muscles tendons ligaments and
fascia

• Stiffness & limitations of the motion of the neck , chest ,back
& extremities
• In advanced stages disease result in petrified man
D/D:
Rheumatiod arthritis
calcinosis

Myositis ossificans
Myositis ossificans seen as bilateral linear calcifications
of the sternohyoid muscels

Excessive ossification temporalis and
masseter

References :
• Principles & interpretation of oral radiology
6th edition;stuartc.white,michael j.pharoah
• Normank.wood.paul w.goaz-differential
diagnosis of oral and maxillofacial lesions-
5th edition

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