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ABNORMAL CALCIFICATIONS IN HEAD & NECK REGION (also odontogenic orgins)

PREPARED BY : MUNAGA RAMAKRISHNA GDCRI BALLARI

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Table of contents1.INTRODUCTION2.CLASSIFICATIONA).DYSTROPHIC CALCIFICATION• General Dystrophic calcification of oral regions• Calcified lymph nodes

• Dystrophic calcifications in Tonsils

• Cysticercosis

• Arterial calcification

-a) Monck berg's Medial calcinosis

- Atherosclerotic PlaqueB) IDIOPATHIC CALCIFICATION• Sailolith• Phleboliths• Laryngeal cartilage calcification• rhinolith or anthrolith.

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• METASTATIC CALCIFICATION• HETEROTROPIC CALCIFICATIONS

• ossification of stylohyoid ligament• osteoma cutis• myositis ossificans1. localized(or) traumatic myositis

ossificans2. Progressive myositis ossificans

• CALCIFICATIONS IN ORAL TISSUES• odontoma• calcifying epithelial odontogenic tumor• adenomatoid odontogenic tumor• pulp stones (or) pulp calcifications• dentinal sclerosis

• REFERENCES

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ABNORMAL CALCIFICATIONS

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CALCIFICATION :• It is the accumulation of calcium salts in a body tissue, It normally occurs in the formation of bone.

PATHOLOGIC CALCIFICATION: •It is the abnormal tissue deposition of calcium salts, together with smaller amounts of iron, magnesium and other mineral salts.

CAUSES:•Can be caused by vitamin k2 deficiency or by poor calcium absorption due to a high calcium/vitamin D ratio.

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• HISTOPATHOLOGICAL STAINED SECTIONS– Calcium salts appear as deeply basophilic, irregular and granularclumps.– The deposits may be intracellular, extracellular, or at both locations.– Occasionally, hetero topic bone formation (ossification) may occur.– Calcium deposits can be confirmed by special stains• Silver impregnation method of von-Kossa producing black color,• Alizarin red S that produces red staining.– Pathologic calcification is often accompanied by diffuse or granulardeposits of iron• Positive Prussian blue reaction in Perl's stain

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A .Dystrophic Calcifications • General dystrophic calcification of the oral regions • Calcified lymph nodes • Dystrophic calcification in the tonsils • Cysticercosis • Arterial calcification - Moncke berg's medial calcinosis (Arteriosclerosis) - Calcified Atherosclerotic plaque B. Idiopathic calcifications • Sailoliths • Phleboliths • Laryngeal cartilage calcifications • Rhinolith/Antrolith C. Metastatic calcifications • Ossification of the stylohyoid ligament • Osteoma cutis * Myositis ossificans -Localized(or) traumatic Myositis ossificans - Progressive myositis ossificans

CLASSIFICATION

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•Dystrophic calcification is characterized by deposition of calcium salts in dead and degenerated tissues with normal calcium metabolism and normal serum calcium levels.

• Pathogenesis:

• 2 Phases • Initiation (nucleation) • 2.Propagation – accumulation of Ca+2

phosphate salts

DYSTROPHIC CALCIFICATION

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General dystrophic calcification of the oral regions

Dystrophic calcification is the precipitation of calcium salts into primary sites of chronic inflammation or dead and dying tissue.

clinical features: Common sites: gingiva , tongue , lymph nodes, & cheek • It is usually asymptomatic • A solid mass of calcium salts sometimes can be palpatedRadiological features: Fine grains of RADIO OPACITIES to large, irregular radiopaque

particles (<0.5CM)The calcification may be homogeneous or may contain

punctuate areasIrregular or indistinct outline

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GENERAL DYSTROPHIC CALCIFICATION OF THE ORAL REGIONS

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Calcified lymph nodes

• Dystrophic calcification occurs in lymph nodes that have been chronically inflamed because of various diseases.

ARE:• Tuberculosis(scrofula or cervical tuberculous lymphadenitis)• Sarcoidosis • Rheumatoid arthritis• Systemic sclerosis• Fungal infections• Lymphoma• Metastases from distant calcifying neoplasms

CLINICAL FEATURES• Asymptomatic• Sub mandibular, superficial and deep cervical lymphnodes • NODES-bony hard , round or linear masses with variable mobility

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RADIOLOGICAL FEATURESLOCATION : • 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 (Radio Opacities seen only on the

surface of the node)• DIFFERENTIAL DIAGNOSIS Sailolith-has a smooth outline . Phlebolith- are small & multipleHisto plasmosis -firm consistencylymphoma –rubbery consistency

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Calcified lymphnodes

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CALCIFIED LYMPHNODES RADIOGRAPHICAL VIEW

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Dystrophic calcification in the tonsils

Synonyms: Tonsillar calculi, Tonsillar concretions,

& tonsilloliths• Tonsillar calculi are formed when repeated botus of inflammation enlarge the tonsillar crypts

Clinical features: • They present as hard , round , white or yellow objects projecting from the tonsillar crypts • Small calcifications are asymptomatic• Large calcifications produce pain ,swelling, foetis oris, dysphagia•Older age groups are commonly

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RADIOLOGICAL FEATURES:Location: Mid portion of the mandibular ramus

Tonsilliths frequently appear on the panoramic radiograph immediately inferior to the mandibular canal

Periphery: ill-definedInternal structure: uniformly radiopaqueDifferential diagnosis: Calcified granulomatos disease-Firm Syphilis-firm Mycosis or lymphoma –firm Radio opacity lesions such as dense bony islands

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DYSTROPHIC CALCIFICATIONS OF TONSILS

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CYSTICERCOSIS

Human ingests egg or gravid proglattids

The covering of the egg is digested

The larvae is hatched

It enters blood vessels and lymphatic'sDistributed in the tissues all over the body In tissues other than intestinal mucosa the larvae

eventually die and are treated as foreign bodies causing grannuloma formation scarring and calcification ,these areas in the tissues are called cysticeri

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•CLINICAL FEATURES•Mild cases are completely asymptomatic•Moderate to severe cases have symptoms range from mild to severe git upset •Epi-gastric pain •Severe nausea and vomiting •Seizures, headache •Visual disturbances•Irritability.

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RADIOLOGICAL FEATURES:• Location :• Muscles of mastication and facial muscles and supra hyoid muscles and post cervical musculature • Periphery and shape:• Multiple well defined elliptical Radio opacity resembling grains of rice • Internal structure: Homogeneously Radio opacity• Differential diagnosis:• Sailolith • The small size of the calcified nodules of cysticerci and their wide spread dissemination ,particularly in brain and muscle are highly suggestive of the diagnosis

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CYSTICERCOSIS

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

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CYSTICERCOSIS

Radiograph of a patient with cysticercosis. The calcified encysted larvae are clearly seen in the soft tissues.A single calcification in the area of the Wharton’s duct may beeasily mistaken for a sialolith on an intraoral film

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ARTERIAL CALCIFICATION

Two distinct type of arterial calcification can be identified both radiographically & histologically •A) Monckberg’s medial calcinosis•B) Calcified atherosclerotic plaque

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MONCKBERG’S MEDIAL CALCINOSISSynonym: Arteriosclerosis•Degeneration and eventual loss of elastic fibers followed by the deposition of the calcium within the medial coat of vessel.

Clinical features: • Initially asymptomatic • In later cases cutaneous gangrene peripheral vascular disease and myositis.• Patients with sturge -Weber syndrome also develop intracranial arterial calcification

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Radiological features: • Location : Facial artery . less commonly carotid artery • Periphery and shape: • It outline an image of the artery ,appears as a parallel pair of thin Radio opacity lines –pipe stem or tram track appearance • In cross section ,involved vessels will display a circular or ring like pattern

Differential diagnosis: • The radiographic appearance of arteriosclerosis is so distinctive as to be pathognomic of the condition • In addition hyper parathyroidsm may be considered as medial calcinosis frequently develops as a metastatic calcification in patients with this condition.

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Monckberg’s medial calcinosis

Calcification of the facial artery. It may occur in arteriosclerosis

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HISTOPATHOLOGY• The calcifications can be seen in the tunica media in the PURPLISH BLUE.• The lumen is un affected by this process.• Destruction of muscle and elastic fibers and formation of calcium

deposits.

Monckberg’s medial calcific sclerosis

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CALCIFIED ATHEROSCLEROTIC PLAQUE• Atheromatous plaque found in the extra cranial carotid

vasculature and is a major contributing source of cerebro vascular embolic and occlusive disease. • Dystrophic calcifications can occur in the evolution of plaque

within the intima of the involved vessel.RADIOGRAPHIC FEATURES:• 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.

PERIPHERY & SHAPE: multiple and irregular in shape and sharply defined from the surrounding tissues

INTERNAL STRUCTURE: heterogeneous radiopacity with radiolucent voids

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Calcified atherosclerotic plaque

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

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DIFFERENTIAL DIAGNOSIS• Calcified triticeous cartilage may be mistaken for

atheromatous plaque, although the uniform size, shape and location of calcified triticeous cartilage in the laryngeal cartilage generally aids in identification of this condition.•HISTOPATHOLOGY:•Microscopically Atherosclerotic plaques three principle components.• 1)cells including smooth muscle cells, macrophages, and other leucocytes.• 2)extracellular matrix including collagen, elastic fibers, and proteoglycans.• 3)intracellular and extra cellular lipids.• The calcification occurs in the tunica intima

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Atherosclerotic plaque

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IDIOPATHIC CALCIFICATIONS

• This results from deposition of calcium in normal tissue despite normal serum calcium phosphate levels

• Sialoliths • Phleboliths • Laryngeal cartilage calcifications • Rhinolith /Antrolith

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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 radio graphically detectable

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• 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.

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CLINICAL 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

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RADIOLOGICAL FEATURE:

LOCATION: Sub mandibular gland ( 83 to 94 %) 50% lies in the distal portion of warthon’s 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 Radio opaqueOthers show evidence of multiple layers of calcifications

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

Sialogram of the submandibular gland

SAILOLITH

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INVESTIGATIONSSubmandibular 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 RADIOGRAPH 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• Radio nuclide salivary imaging

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DIFFERENTIAL DIAGNOSIS: 1) A calcified lymph node-Incidence2) An avulsed or embedded tooth3) A phlebolith –Symptoms of sailadentitis 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.

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PHLEBOLITHS• Phleboliths are calcified thrombi found in veins, or the sinusoidal vessels of hemangiomas .

clinical features:• 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.

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RADIOLOGICAL FEATURES:Location: most commonly found in hemangiomas

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 appearance of laminations giving a bull’s eye or target appearance ;a Radio Lucent centre may be seen .

Differential Diagnosis: • Sailolith• Tonsilloliths• Arterial calcifications.•Myositis ossificans • Cysticercosis• Calcified acne – superficial lesions.

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A case report of intramuscular hemangioma presenting with multiple phleboliths

PHLEBOLITH

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

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LARYNGEAL CARTILAGE CALCIFICATIONS•A small paired triticeous cartilageous are found within the lateral thyrohyoid ligaments.

•Both the thyroid and triticeous cartilages contains hyaline cartilage which has a tendency to calcify with advancing age.

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RADIOLOGICAL FEATURES: Location: located on lateral view within the pharyngeal 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 RADIO OPAQUE

Differential diagnosis: Calcified triticeous cartilage may be confused with calcified atheromatous plaque in the carotid bifurcation .

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Laryngeal cartilage calcifications

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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).

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RHINOLITH( or) ANTROLITH• Hard calcified bodies or stones that occur in the nose

(Rhinoliths) or the antrum of the maxillary sinus (Antroliths) arise from the deposition of mineral salts such as calcium phosphate, calcium carbonate, and magnesium around a nidus

Anthrolith Rhinolith

Endogenous Exogenous substance

Adult population Pediatric population

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CLINICAL FEATURES:• Unilateral, purulent, rhinorrhea, Sinusitis ,Headache, Epistaxis,

Anosomia, fever.RADIOLOGICAL FEATURES:PERIPHERY AND SHAPE:• Stones have variety of shapes and sizes INTERNAL STRUCTURE :• may present as homogeneous or heterogeneous RADIO OPAQUEDIFFERENTIAL DIAGNOSIS:• Osteoma• Complex Odontoma• Matured cementoma• Periapical condensing osteitis • Palatine torus • Impacted teeth• Ala of the nose

RADIO LUCENT borders

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PERIAPICAL RADIOGRAPH DEMONSTRATING ANTHROLITH

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RHINOLITH

Lateral occlusal film shows a anthrolith positioned above the floorof the nose. B, Posterior-anterior skull film of the same case demonstrating that the rhinolith is positioned within the nasal fossa

ANTHROLITH

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Metastatic calcification

• It results when minerals precipitate into normal tissue as a result of higher than normal serum levels of calcium or phosphate.•When the mineral is deposited in soft tissue as organized , well

formed bone, the process is known as HETEROTOPIC OSSIFICATION.

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Heterotopic ossification:

•Ossification of the stylohyoid ligament•Osteoma cutis•Myositis ossificans a) Localized(or) traumatic myositis ossificans

b) Progressive myositis ossificans.

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OSSIFICATION OF THE STYLOHYOID LIGAMENT• Ossification of the stylohyoid ligament usually extends downward from the base of the skull and commonly occurs bilaterally • However in rare cases the ossification begins at the lesser horn of the hyoid and fewer still in a central area of the ligament.

CLINICAL FEATURES:• Symptoms related to this ossified ligament are termed EAGLE SYNDROME

CLASSIC EAGLE SYNDROME: cranial nerve impingement.

CAROTID ARTERY SYNDROME• Intense pain in pharynx during swallowing & turning head or opening the mouth especially on yawning.

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OSSIFICATION OF THE STYLOHYOID LIGAMENT

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

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Classification BASED ON LANGLAIS& ASSOCIATES (1986)• TYPE I : ELONGATED• TYPE II: PSUEDO ARTICULATED• TYPE III: SEGMENTED

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RADIOLOGICAL FEATURESLocation: The linear ossification extends forward from the region of the mastoid process and crosses the posterio inferior aspect of the ramus towards the hyoid bone

Shape: Appears as a long tapering thin Radio opaque process .• It normally varies from 0.5 to 2.5 cm in length.Internal structure: homogenously Radio opaque

DIFFERENTIAL DIAGNOSIS:•Tempero mandibular joint dysfunction.

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OSTEOMA CUTIS• Rare soft tissue ossification in the skin • 85% of the cases occur secondary to acne of long duration developing in a scar or chronic inflammatory dermatisis.

CLINICAL FEATURES: • 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 )

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OSTEOMA CUTIS

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Radiological features:• Location: cheek & lip regions•Periphery & shape: smoothly outlined RADIOPAQUE washer shaped images ,single or multiple RADIOPACITIES usually measuring 0.1 to 5cm • Internal structure: homogeneously RADIO OPAQUE but usually has a RADIO LUCENT centre ( donut appearance )

Differential diagnosis: •Myositis ossificans • Calcinosis cutis

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OSTEOMA CUTIS

Osteoma cutis seen as faint radiopaque calcification in the cheek

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histopathologyHistologically 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.

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MYOSITIS OSSIFICANS

• In myositis ossificans; fibrous tissue & heterotrophic bone form within the interstitial tissue of muscle and associated tendons and ligaments, there is Secondary destruction and atrophy of the muscle occur as the fibrous tissue and bone interdigitate and separate the muscle fibers.

Two forms: • localized (Traumatic) myositis ossificans• progressive myositis ossificans.

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Localized (traumatic)myositis ossificans

SYNONYM: post traumatic myositis ossificans, solitary myositisETIOLOGY: • acute or chronic trauma,• heavy muscular strain.• muscle injury from multiple injections.CLINICAL FEATURES: YOUNG MEN • The site of the precipitated trauma remains swollen, tender and painful.• The over lying skin may be red and inflamed.•Opening of jaw may be difficult.

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Radiographic featuresLocation: •masseter and sterno cledomastoid• The anterior 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 Radio opaque 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 • 6months- it becomes denser and more defined Differential diagnosis:• Ossification of stylohyoid ligament • Soft tissue calcifications

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MICRO DESCRIPTIONEARLY LESIONS(3 WEEKS)• Inner cellular zone resembling nodular fasciitis with short

fascicles or haphazard fibroblasts that are uniform with faint eosinophilic cytoplasm, tapering processes, vesicular or finely granular nuclei and variable nucleoli, usually numerous mitotic figures but none atypical:• Stroma is vascular, myxoid or edematous with extravasated

red blood cells, fibrin, scattered inflammatory cells and osteoclast like gaint cells.• If highly cellular, may mimic sarcoma such as osteo sarcoma• Intermediate zone has osteoblasts depositing woven bone,

and outer zone has mineralized trabaculae.LATER: Bone matures with formation of marrow and

myofibroblasts are less prominent.

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HISTOPATHOLOGY

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Traumatic myositis ossificans

Soft tissue ossification extending from the coronoid process in a superior direction, following the anatomy of the temporalis muscle

A rare isolated unilateral myositis ossificans traumatic

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PROGRESSIVE MYOSITIS OSSIFICANS• Rare hereditary disease with autosomal dominant transmission

Clinical features• Affects children before 6yrs of age • Occasionally seen in infants • Males are more affected• Progressive formation of heterotrophic bone occurs within

the interstitial 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 DIFFERENTIAL DIAGNOSIS:• Rheumatoid arthritis• calcinosis .

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MYOSITIS OSSIFICANS

Myositis ossificans seen as bilateral linear calcifications of the sternohyoid muscles

Excessive ossification temporalis and masseter

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PATHOLOGIC CALCIFICATION IN ORAL TISSUES• ODONTOMA * COMPOUND ODONTOMA * COMPLEX ODONTOMA• CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (PINDBORG TUMOR)• ADENOMATOID ODONTOGENIC TUMOR(AOT)• PULP CALCIFICATIONS OR PULP STONES• DENTINAL SCLEROSIS.

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ODONTOMA

Definition:• Odontomes are a group of common hamartomatous

odontogenic lesions with limited growth potential capable of producing normal appearing enamel, dentin, cementum and pulp etc in an unorganized fashion.

Two types :1) Complex odontome2) Compound odontome

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1)Complex odontome:• It consists of a completely disorganized and diffuse

mass of odontogenic tissue with haphazardly arranged enamel, dentin and cementum.

2)Compound odontome:• Compound odontome presents collections of numerous

small, discrete, tooth-like structures• Most odontogenic tissues in compound odontome bear

superficial anatomical resemblance to normal teeth.

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Clinical features:FREQUENCY: • Represent about 7% of all odontogenic neoplasmsAGE: • They occur in young age group, with the average age

being second decade of life.SEX:• There is no sex prediction.LOCATION:Compound : More often in the anterior maxillaComplex: More often in the posterior mandible

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CLINICAL PRESENTATION• Odontomes generally produce small, asymptomatic

lesions which are detected incidentally.• Lesions vary in size greatly.• May produce large, bony hard swellings of the jaw with,

expansions of cortical plates and displacement of regional teeth.• A tooth may be often missing from the dental arch as

the odontome can block the eruption of the tooth.

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CLINICAL PRESENTATIONCOMPUND COMPLEX

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Radiological features:• Odontomes usually produce pericoronal radiolucencies with well corticated borders.• A developing odontome may look completely radiolucent as the calcified elements do not form in the initial stages.

COMPOUND ODONTOME:• Radio graphically appear as numerous, small, miniature teeth or tooth like structures, which are projecting from a single focus.• apparently they look like “a bag of tooth” and are commonly located between the roots of the erupted permanent teeth or above the crown of an impacted tooth.

THE COMPLEX ODONTOME:• The complex odontomes radio graphically

appears as round or oval or “ sun burst like” conglomerated radio opaque mass within the jaw bone

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Radiological appearance COMPUND COMPLEX

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DIFFERENTIAL DIAGNOSIS:• Calcifying epithelial odontogenic

tumor(ceot)• Ameloblastic fibrodentinoma• Ameloblastic fibro- odontome• Osteoma• Odonto ameloblastoma• Focal sclerosing osteo myelitis.

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HISTOPATHOLOGYCOMPOUND ODONTOME:• Histologically compound odontome presents as

encapsulated mass of multiple separate denticles, embedded in a fibrous tissue stroma.• However in each one of them, there is presence of

enamel, dentin, cementum and pulp tissues ,which are in a similar fashion as seen as in a normal tooth

COMPLEX ODONTOME:• Histologically complex odontoma presents an irregularly

arranged mass of well framed enamel, dentin, cementum and pulp which is surrounded by a fibrous capsule.

• Small islands of eosinophilic stained epithelial GHOST CELLS are present.

• These may represent remnants of odontogenic epithelium that have undergone keratinization and cell death from the local anoxia.

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Histopathology COMPOUND COMPLEX

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Calcifying epithelial odontogenic tumor(ceot)SYNONYMS:• Pindborg’s tumor.ORIGIN: • The lesion arises from either the cells of the stratum

intermedium of the enamel organ or the reduced enamel epithelium or even the remnants of the dental lamina.• Difference to the ameloblastoma and ceot is calcifying

epithelial odontogenic tumor always contains some calcified materials within it’s mass, which never seen in ameloblastoma.

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CLINICAL FEATURES:INCIDENCE RATE: About 1% of all odontogenic neoplasms.Age: middle aged(40) years more affected.Sex: • no sex differentiation.Site: • The mandible is more often involved than the

maxilla.• The molar region is the most common site of

occurrence followed by premolar region.

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CLINICAL SIGNIFICANCE:Usually a slow enlarging, painless swelling of the jaw with expansion and distortion of the cortical plates.Displacement of regional teeth, with de-arrangement of occlusion and facial asymmetry.Large maxillary lesions may invade into the antrum or nasal floor and such lesions occasionally cause nasal airway obstruction, epistaxis and proptosis of the eyeball, etc.

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RADIOGRAPHICAL PRESENATATIONWell defined, multilocular( rarely unilocular) radiolucent area in the jaw.Calcifications within the tumor is a characteristic in the calcifying epithelial odontogenic tumors and radio graphically it often exhibits multiple, small, radiopaque foci varying radio density with the radiolucent zone produced.Driven snow appearance. This type x-ray of calcification within the tumor often produces a typical driven snow appearance

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HISTOPATHOLOGY• Histologically the tumor reveals SHEETS or ISLANDS of

closely packed, POLYHEDRAL EPITHELIAL CELLS in a non inflammed connective tissue stroma.• Sometimes the neoplastic cells may have a CRIBRIFORM

arrangement and they enclose areas of hyalinized stroma.• Some amount of homogenous, hyaline materials is often

deposited in between the tumor cells, which stain like “AMYLOIDS”• One of the most distinctive histological characteristics of

ceot is the presence of SEVERAL CALCIFIED BODIES OR MASSES within the lesion.• These calcified masses are hematoxyphilic in nature and are

present as concentrically laminated rings LIESEGANG RINGS in and around the degenerating tumor cells.

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Histopathology

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Differential diagnosis:

• Calcifying epithelial odontogenic cyst.• Adenomatoid odontogenic tumor.• Poorly differentiated carcinoma.• Ameloblastoma.• Ameloblastic fibro-odontoma.• Dentigerous cyst.• Central ossifying or cementifying fibroma.

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Adenomatoid odontogenic tumor(aot)

• The adenomatoid odontogenic tumor is a relatively uncommon, well circumscribed, odontogenic neoplasm characterized by the formations of multiple “duct-like” structures by the neoplastic epithelial cells.

ORIGIN:• Arises from the reduced enamel epithelium during

the pre secretory phase of enamel organ development.

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CLINICAL FEATURESAGE: • Younger age – 2nd and 3rd decade of life.SEX: • Females are more commonly affected in comparison to the

males 2:1 ratio.SITE: • Typically occurs in the maxillary anterior region, sometimes

in premolar region.• Rarely involves the angle-ramus area • 70% of cases are in erupted tooth.• CLINICAL PRESENTATION:• Slow ,enlarging, small, bony hard swelling in the

maxillary anterior region.• Displacement of the regional teeth, mild pain and

expansion of the cortical bones are usually present.• The extra osseous or peripheral tumor produces a

solitary painless, asymptomatic nodular swelling on the gingiva predominantly on facial surface.

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RADIOLOGICAL FEATURES• A well circumscribed, unilocular, radiolucent area,

which often encloses a tooth or tooth like structure.• Multiple small, radio opaque foci of varying radio

density may be present inside the lesion and finding is known as “ snow flake” calcifications.

DIFFERENTIAL DIAGNOSIS:• Dentigerous cyst• Globulo maxillary cyst• Lateral periodontal cyst• Odontome• Unicystic ameloblastoma• Ossifying (or) cementifying fibroma• Calcifying epithelial odontogenic tumor (or) cyst.

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radiographic and gross appearance

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HISTOPATHOLOGY• Reveals spindle shaped, neoplastic odontogenic epithelial

cells proliferating in multiple “duct like” patterns, within a thin but well vascularized stroma.• Each duct like structure exhibits a central space, which is

bordered on the periphery by a single layer of tall columnar cells resembling ameloblasts or pre-ameloblasts.• The lumen of the duct like structures is generally filled with

a homogenous eosinophilic coagulum.• Small foci of calcifications are often seen scattered

throughout the lesion .this indicates an abortive attempt towards formation of enamel, dentin or cementum by the tumor cells.

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histopathology

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PULP STONES OR PULP CALCIFICATIONSDEFINTION: • deposition of calcified masses within the dental pulp for no

apparent reason is called pulp calcification.• etiology: the etiology of pulp calcification is un known and it

appears to be not related to inflammation, trauma or any systemic diseases.

PATHOGENSIS:

Localized metabolic Hyalinization of the tissue

FibrosisMineralizationFormation of calcified mass in tissue

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Types of calcificationsDENTICLES: • These are small masses of tubular dentin formed within

the pulp near the furcation area of tooth.PULP STONES:• Pulp stones are nodular calcified bodies having an

organic matrix and they occur frequently in relation to the coronal pulp.

DIFFUSE LINEAR CALCIFICATIONS OF PULP:• These are amorphous unorganized, fine fibrilar strands

of calcified masses and are typically formed within the radicular and coronal pulp.

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TYPES OF PULP STONESTRUE: composed of predominantly of dentin and have

dentinal tubules. they may have a outer layer of pre dentin and are often located adjacent to the odontoblast cells.

FALSE: composed of concentric layers of calcified material with no tubular dentinal tubules.

ACCORDING TO LOCATION:FREE PULP STONES: are surrounded on all sides by pulpal

tissue and not attached to dentinal wall.ATTACHED PULP STONES: which are attached to dentinal

wall of pulpal chamber.INTERSTITIAL PULP STONES: are those where the pulp

stones have become surrounded by reactionary or secondary dentin they are called interstitial pulp stones.

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CLINICAL SIGNIFICANCE:SYMPTOMS: • Sometimes, it may cause pain from mild pulpal neuralgia to

severe excruciating pain resembling that of tic douloureux as the denticle can impinge on the nerve of the pulp.• Difficulty in root canal treatment encountered in extirpating

the pulp.RADIGRAPHIC FEATURES:APPEARANCE:• They are seen as radiopaque structures within the pulp

chamber.SHAPE: • They may be round or oval.LOCATION: • They may occur as single dense mass or several opacities.

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radiological presentation

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MICROSCOPIC EXAMINATIONTRUE STONE:• The true pulp stone has an appearance characterized

of dentin with tubules radiating out from the center and predentin around the periphery.

FALSE STONE:• The false pulp stone is characterized by concentric

layers of mineralization rather than radiating tubules as seen in true pulp stones.

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HISTOPATHOLOGYTrue pulp stones

False pulp stone

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DENTINAL SCLEROSISDEFINITION: It is the condition characterized by calcification of

the dentinal tubules of the tooth.ETIOLOGY:• Injury to dentin causes• Aging process• Abrasion or erosion of teeth.FEATURES:• The refractive indices of sclerotic dentin in which the tubules are

occluded are equalized, and such areas become transparent.• Transparent or sclerotic dentin can be observed in the teeth of

elderly people, especially in the roots.• Sclerosis reduces the permeability of the dentin and may help

prolong pulp vitality.• It appears transparent or light in transmitted light and dark in

reflected light.

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Microscopic examination • DEAD TRACTS AND BLIND TRACTS: when dentin is

damaged, odontoblastic processes die or retract leaving empty dentinal tubules.• Areas with empty dentinal tubules are called dead tracts

and appear as dark areas in ground sections of tooth.• With time, these dead tracts can become completely filled

with mineral (calcium).• This region is called blind tracts and appears white in

ground sections of tooth.• The dentin in blind tract is called sclerotic dentin.• And the phenomena is called as dentinal sclerosis

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MICROSCOPIC EXAMINATION

DENTINSCLEROSIS

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THANK YOU

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REFERENCES• ORAL RADIOLOGY: PRINCIPLES& INTERPRETATION STUART C WHITE. MICHAEL.J. PHAROAH --- 6th EDITION• BASIC PATHOLOGY AND PRACTICAL BOOK OF

PATHOLOGY BY HARSH MOHAN ---7th EDITION• MEDICAL PHYSIOLOGY : GUYTON AND HALL --- 11th EDITION.• ORAL HISTOLOGY AND EMBRYOLOGY : ORBAN’S --- 13th EDITION.• ORAL PATHOLOGY: SHAFER’S --- 6th EDITION• OTHER SOURCES: WIKIPEDIA• HD IMAGES : FROM GOOGLE