radiologic signs for maxillofacial diagnosis copyright of allan g. farman

Radiologic Signs for Maxillofacial Diagnosis

Copyright of Allan G. Farman

www.egydental.com/vb

Warning

This web-based publication is provided solely for the immediate study needs of students enrolled at the University of Louisville for the course directed by Dr. Allan G. Farman.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, printed, photocopying, recording or otherwise without the written permission of the author.

This material is derived from ISBN 0-8016-1549-6, for which legally recorded copyright is held by Drs. Allan G. Farman,Christoffel J. Nortjé and Robert E.Wood.

Acknowledgment

The assistance in scanning of these images by Ms. Nancy L. Hunter is recognized with thanks.

Dental Signs

Dental signs

• Number of teeth• Tooth size• Tooth morphology• Tooth structure• Tooth eruption

pattern• Tooth position• Regressive changes

Large Teeth

Large Teeth

• SINGLE• Macrodontia• Connation• Fusion• Gemination• Single central incisor

short stature syndrome

• MULTIPLE• Normal variant• Adjacent to benign

vascular, lymphatic or neural tumor

• Lipomatosis• Unilateral hyperplasia• Pituitary giantism

Small Teeth

• SINGLE • MULTIPLE

Small Teeth

• SINGLE• Microdontia (e.g. peg

lateral)• Supernumerary teeth

• MULTIPLE• Normal variant• Dentinogenesis

imperfecta• Trisomy 21• Facial hypoplasia• Pituitary dwarfism• Vascular tumors

Single/Few Teeth of Altered Form

Single/Few Teeth of Altered Form(Common) • Turner’s tooth (acquired enamel hypoplasia)• Dilaceration• Taurodontism• Enamel invaginations (dens in dente)• Peg lateral incisors• Enlarged cingulum• Enamel evaginations (Leung’s premolar)• Shovel-shaped incisors

Single/Few Teeth of Altered Form(Uncommon)

• Connation (fusion and gemination)

• Concrescence

• Twinning

• Tuberculated maxillary lateral/talon cusp

• Hutchinson’s teeth and mulberry molars (congenital syphilis)

• Premolarization of canines and molarization of premolars

Single/Few Teeth of Altered Form(Rare)

• Secondary to mutilating surgery

• Secondary to radiation therapy

• Secondary to chemotherapy

Hypercementosis

Hypercementosis

• Physiologic with passive eruption

• Idiopathic

• Periodontal disease

• Paget’s disease of bone

• Acromegaly

• Benign tumor (cementoblastoma)

• Apparent in periapical cemental dysplasia

Hypodontia/Oligodontia

Hypodontia/Oligodontia(common)

• Previously extracted teeth

• Idiopathic

• Ectodermal dysplasias

• Previous radiation therapy

• Trisomy 21 (Down’s syndrome)

Hypodontia/Oligodontia(uncommon)

• Chondroectodermal dysplasia• Facial hypoplasia• Incontinentia pigmentii• Oral-facial-digital (Möhr’s) syndrome• Oculodento-osseous dysplasia• Oculomandibulodyscephaly syndrome

(Hallerman-Streiff)

/continued


• Oligodontia and primary mesodermal iris dysgenesis (Rieger’s syndrome)

• PHC syndrome (Böök’s syndrome)

• Craniofacial dysostosis (Crouzon’s Sx)

• Ehlers-Danlos syndrome

• Focal dermal hypoplasia syndrome (Goltz syndrome)

/continued


• Pyknodysostosis

• Progeria (Hutchinson-Gilford syndrome)

• Hypoparathyroidism

• Inverted Marfan’s syndrome

Hyperodontia/Supernumeraries

Hyperodontia/Supernumeraries (common)

• Idiopathic

• Cleft palate

• Compound odontoma

• Cleidocranial dysplasia

Hyperodontia/Supernumeraries (uncommon)

• Osteomatosis intestinal polyposis syndrome (Gardner’s syndrome)

• Oculomandibulodyscephaly syndrome (Hallerman-Streiff syndrome)

• Oral-facial-digital syndrome• Distomus• Achondroplasia• Ehlers-Danlos syndrome

Natal teeth

• Normal variant

• Chondro-ectodermal dysplasia (Ellis van Crevald syndrome)

Single Failure in Eruption

Failure in eruption - single(common)

• Idiopathic

• Supernumerary teeth

• Hypodontia (non-development of tooth)

• Mechanical obstruction by other tooth

• Retained primary tooth or tooth root

• Dentigerous and eruption cysts

/continued

Failure in eruption - single(common)

• Benign tumor (e.g. odontoma, ameloblastic fibroma, ameloblastic fibro-odontoma, adenomatoid odontogenic tumor)

• Odontogenic keratocyst

• Cleft palate

• Ankylosis and submersion

• Inflammation coronal to erupting tooth

• Overlying tooth with pulpotomy

Failure in eruption - single(uncommon)

• Odontogenic myxoma

• Cherubism

• Unicystic ameloblastoma

• Langerhans’ cell disease

• Ossifying fibroma

• Malignancy and radiation therapy

• Fibrous dysplasia

• Post-extraction scar

Failure in eruption - multiple

Failure in eruption - multiple(common)

• Fibromatosis gingivae

• Drug-induced gingival hyperplasia


• Condylar hypoplasia and ankylosis

• Cherubism

Failure in eruption - multiple(uncommon)

• Osteomatosis intestinal polyposis syndrome (Gardner’s syndrome)

• Acrocephalysyndactyly (Apert’s syndrome)

• Gingival hyperplasia syndromes

• Chondroectodermal dysplasia Ellis-van Crevald syndrome)

• Trisomy 21

/continued

Failure in eruption - multiple(uncommon)

• Focal dermal hypoplasia (Goltz syndrome)• Osteopetrosis• Regional odontodysplasia• Progeria ( Hutchinson-Gilford syndrome)• Pseudohypoparathyroidism• Pyknodysostosis• Juvenile hypothyroidism (cretinism)• Ectodermal dysplasias • Vitamin D deficiency syndromes

Premature Eruption

Premature Eruption (common)

• Normal variant

• Early loss of primary teeth

Premature Eruption (uncommon)

• Adjacent benign vascular or neural tumor• Underlying malignant tumor• Underlying osteomyelitis• Hyperthyroidism• Pituitary giantism• Previous radiation therapy• Hypergonadism• Cushing’s syndrome• Adrenogenital syndrome

Early Tooth Loss

Early Tooth Loss (common)

• Rampant dental caries

• Dentofacial trauma

• Juvenile periodontosis/periodontitis

Early Tooth Loss (uncommon)


• Factitial injury

• Cyclic neutropenia

• Malignancy (leukemia, lymphoma, neuroblastoma, rhabdomyosarcoma)

• Hyper keratosis palmoplantaris and periodontoclasia in childhood (Papillon- Lefeuvre syndrome)

/continued

Early Tooth Loss (uncommon)

• Radicular dentin dysplasia

• Acrodynia (pink disease)

• Other heavy metal poisoning

• Acatalasia

• Hyperparathyroidism

Early Tooth Loss (rare)

• Acro-osteolysis

• Severe Rickets

• Pituitary cachexia syndrome (Simmond’s syndrome)

• Chediak-Higashi syndrome

Displaced Teeth/Tooth Buds

Displaced Teeth/Tooth Buds (common)

• Normal variant

• Malocclusion

• Impaction

• Dentigerous cysts

• Other cysts

• Traumatic displacement

• Submergence

Displaced Teeth/Tooth Buds (uncommon)

• Cherubism• Lateral inflammatory odontogenic cyst of

the mandible (Stoneman’s cyst)• Benign giant cell tumor• Ameloblastoma and ameloblastic odontoma• Melanotic neuro-ectodermal tumor of

infancy

/continued

Displaced Teeth/Tooth Buds (uncommon)

• Other benign tumors

• Osteomyelitis including osteomyelitis of the maxilla in the newborn


• Malignant tumors (e.g. Burkitt’s lymphoma, lymphosarcoma, neuroblastoma, rhabdomyosarcoma)

Coronal Radiolucency in Tooth (common)

• Dental caries

• Radiolucent resin restorations

• Cervical burnout and Mach phenomenon

• Proximal overlap artifact

• Enamel hypoplasia

• Abrasion, attrition and erosion

• Dens in dente

Coronal Radiolucency in Tooth (uncommon)

• Idiopathic internal resorption

• External resorption

• Radiation caries

• Pulpal diverticula

• Leung’s premolar (evagination of pulp)

• Radiolucent internal enameloma

Enlarged dental pulp

Enlarged dental pulp (common)

• Rotation of anterior teeth

• Developing teeth

• Normal variant (large cornua)

• Taurodontism

• Internal resorption

• Macrodontia

• Connation (fusion and gemination)

Enlarged dental pulp (uncommon)

• Enamel evagination (Leung’s premolar)

• Vitamin D resistant Rickets

• Shell teeth of Rushton

• Hypophosphatasia

• Renal osteodystrophy

• Pulpal extension into enamel pearl

Small dental pulp

Small dental pulp (common)

• Normal variant

• Teeth in elderly (secondary dentin)

• Reactive to dentin caries

• Traumatically induced

• Dentinogenesis imperfecta

Small dental pulp (uncommon)

• Osteogenisis imperfecta

• Dentin dysplasias

Dental Enamel Aberrations

Dental Enamel Aberrations (common)

• Dental caries

• Environmental enamel hypoplasia (Turner’s tooth; neonatal disease; exanthematous fevers; nutritional deficiency; metabolic disease; drug induced; fluorosis)

• Amelogenesis imperfectas

Dental Enamel Aberrations (uncommon)

• Mucopolysacchaidoses IV (Morquio-Brailsford syndrome)

• Ehlers-Danlos syndrome• Hypophosphatasia• Hypoparathyroidism• Radiation therapy during tooth development

Dentin Aberrations (common)

• Dental caries



• Regional odontodysplasia

Dentin Aberrations

Dentin Aberrations (uncommon)

• Osteogenesis imperfecta


• Shell teeth of Rushton


• Radiation therapy during tooth development

Persistent Open Root Apex

Persistent Open Root Apex

• Normal variation

• Post-dentition supernumerary tooth

• Non-vital tooth

• Periapical pathosis (cyst; granuloma; abscess)

• Dens evaginatus (Leung’s premolar)


Prematurely Closed Root Apex

Prematurely Closed Root Apex

• Previous trauma to tooth

• Radiation therapy during tooth development




Calcified pulp tissue

Calcified pulp tissue • Pulp stone

• Normal variant for elderly

• Projection artifact (molars)

• Reaction to dentin caries or deep restoration

• Subsequent to trauma

• Calcareous degeneration

• Superimposition of enamel pearl



Fractured Tooth Appearance

• True fractured tooth

• Periodontal ligament shadow from adjacent tooth

• Overlying lip, cheek or nose line

• Bone trabecular pattern or nutrient canal

• Accessory lateral pulp canal

• Alveolar bone fracture

• Radiographic artifact (film crimp; static, etc.)

External Root Resorption

External Root Resorption(normal variants)

• Physiologic resorption (primary teeth)• Traumatic occlusion• Aberrant resorption of mesial root of lower

first molar• Normal variant (pulpotomy of primary

tooth)• Projection artifact (foreshortening)• Incomplete formation (tooth development)

External Root Resorption(common pathologic)

• Apical pathosis (cyst; granuloma; abscess)

• Iatrogenic - excessive orthodontic force

• Idiopathic - uncertain cause

• Re-implantation of avulsed tooth

• Root canal therapy

• Benign odontogenic cysts and tumors (especially dentigerous cyst, ameloblastoma and central giant cell granuloma)

External Root Resorption(uncommon pathologic)


• Inostosis

• Malignant tumors (e.g. lymphoma)

• Oxalosis


• Periodontal disease

• Foreign body reaction


Internal Tooth Resorption

Internal Tooth Resorption

• Idiopathic

• Trauma-induced

• Caries-induced

• Causes of enlarged pulps

• Pulpal diverticuli

• External resorption

• Odontomalacia

Dental calculus and look-alikes

• True dental calculus

• Restoration overhangs

• Bony ledges adjacent teeth

• Enamel pearl

Tooth-like Structures (near oral cavity)

• Avulsed tooth or tooth fragment (trauma or iatrogenic)

• Supernumerary teeth

• Cleft palate associated


• Distomus

• Epignathus

Tooth-like Structures (distant from oral cavity)

• Lithopedion

• Ovarian teratoma

• Other teratoma (e.g. intra-cranial)

Periodontal Signs

Radiologic Signs Concerning the Periodontium

• Loss of lamina dura (local)

• Loss of lamina dura (general)

• Accentuation of lamina dura

• Widened periodontal ligament space

• Ankylosis

• Crestal lucency leading to decreased alveolar bone

Localized Loss of Lamina Dura

Localized Loss of Lamina Dura(normal variations and confusing shadows)

• Apex of maxillary canine (canine fossa)

• Tooth rotation

• Maxillary premolars before maturation

• Projection over maxillary sinus

• Tongue out of roof of mouth during panoramic

• Projection over mandibular canal

• Projection over mental foramen

Localized Loss of Lamina Dura(common pathlogic)

• Inflammatory periapical pathosis (apical granuloma, cyst or abscess)

• Simple (traumatic) bone cyst

• Periapical cemental dysplasia

• Focal osteomyelitis

Localized Loss of Lamina Dura(uncommon pathlogic)

• Malignant tumor (e.g. osteogenic sarcoma)

• Fibrous histiocytoma


Generalized Loss of Lamina Dura

Generalized Loss of Lamina Dura(common pathlogic)

• Idiopathic

• Osteoporosis


• Leukemia

Generalized Loss of Lamina Dura(uncommon pathlogic)

• Metastatic malignancy (especially breast)



• Multiple myeloma

• Osteomalacia

• Rickets (including vitamin D resistant form)

• Cushing’s syndrome

/continued

Generalized Loss of Lamina Dura(uncommon pathlogic)

• Renal acidosis• Acromegaly• Oxalosis• Hypervitaminosis D• Hypovitaminosis C• Scleroderma (systemic sclerosis)• Hyperphosphatasia• Burkitt’s lymphoma• Thalassemia

Accentuation of Lamina Dura

Accentuation of Lamina Dura

• Normal variant

• Scleroderma (systemic sclerosis)

Widened PDL Space

Widened PDL Space(common)

• Projection effect• Normal finding around necks of teeth• Periodontal disease (furcation involvement)• Periapical inflammation• Traumatic occlusion• Dental trauma (avulsion or fractured root)• Jaw fracture through tooth socket• Root shadow cast over sinus• Scleroderma (systemic sclerosis)

Widened PDL Space(uncommon)

• Re-implantation of avulsed tooth

• Diabetes mellitus

• Periodontosis

• Osteomyelitis

• Malignant tumors (especially osteogenic sarcoma)

• Fibrous histiocytoma

• Cystinosis

• Actinomycotic infection

Suspision of Tooth Ankylosis

Suspision of Tooth Ankylosis

• True ankylosis of retained primary

• Trauma• Re-implantation• Obscuring condensing

osteitis

• Infection• Inostosis• Socket sclerosis (false

ankylosis)• Obscuring idiopathic

osteosclerosis

COMMON UNCOMMON

Crestal Radiolucency

Crestal Radiolucency(common)

• Early destructive periodontal disease

• Hyperemic decalcification

• Juvenile periodontosis


• Acute necrotizing ulcerative gingivitis

Crestal Radiolucency(uncommon)

• Langerhans’ cell disease• Hyperkeratosis palmoplantaris and

periodontoclasia in children (Papillon-Lefevre syndrome)

• Leukemia• Local malignancy (central or peripheral)• Previous radiation therapy• Hypothuroidism (cretinism/myxedema)

/continued


• Hyperthyroidism


• Peripheral giant cell granuloma (epulis)

• Other epulides

• Cyclic neutropenia


• Acrodynia

/continued


• Acro-osteolysis

• Self-mutilative syndromes

• Acatalasia

• Pituitary cachexia (Simmond’s disease)

• Chediak-Higashi syndrome

Jaw Structure Fine Signs

Radiolucency• Periapical radiolucency

• Pericoronal radiolucency

• Radiolucency lateral to tooth

• Solitary radiolucency (well-defined) not necessarily associated with tooth

• Solitary radiolucency with ragged borders

• Radiolucency in maxillary lateral incisor region

• Non-cyst-like radiolucency of bone /continued

Radiolucency• Rarefying osteitis

• Blurring of trabecular pattern

• Diminished number of trabeculae

• Generalized rarefaction

• Multilocular radiolucency

• Ameloblastoma-like radiolunency

• Radiolucency below mandibular canal

• Expansile jaw lesions

• Lesions\with undulating/crenulated margins/continued

Radiolucency• Lytic lesions with wide band-like borders

• Widened mandibular canal

• Scattered bone destruction separated by normal or near-normal bone

• Short linear area of radiolucency in inferior cortex of mandible

• Cyst-like radiolucency with window-like cortical breaching

• Thinned mandibular lower cortex

/continued

Radiolucency• Ballooned mandibular lower cortex

• Attenuation of shadow of follicle wall

• Discontinuity of antral or nasal wall

• Suspected daughter cysts

• External erosion of bone

• Lesion with no internal structure

• Multiple separate well-defined lucencies

• Multiple osteolytic lesions with punched-out margins

Radiopacity and Mixed Radiopacity/Radiolucency• Periapical mixed lucent/opaque

• Pericoronal mixed lucent/opaque

• Periapical homogeneous radiopacities

• Solitary mixed lucent/opaque lesion not necessarily contacting tooth

• Mixed lucent/opaque lesion of TMJ

• Sclerosing osteitis

• Increased girth of individual trabeculae

/continued

Radiopacity and Mixed Radiopacity/Radiolucency• Granular bone

• Solitary opacity not contacting teeth


• Complex odontoma

• Opacity denser than normal bone

• Multiple separate opacities

• Root-like density in bone

• Possible causes of root in bone appearance

/continued

Radiopacity and Mixed Radiopacity/Radiolucency• Suspected foreign body (metallic or non-

metallic)

• Sequestra-like density

• Target lesion (radiopacity with peripheral shadow)

• Excrescence with bone density

• Thickened mandibular lower cortex

• Laminar periosteal new bone

/continued

Radiopacity and Mixed Radiopacity/Radiolucency• New periosteal bone with internal lysis

• Sunray spiculation (new bone perpendicular to cortex)

• Lesions with internal spindly trabeculae

• Lesions with septae or pseudoseptae

• Lesions with honeycombed internal structure

• Lesions with wispy internal structure

/continued

Radiopacity and Mixed Radiopacity/Radiolucency

• Lesions with internal residual bone

• Lesions with tubular internal structure

• Lesions with internal rounded dense opacities

• Linear striations (driven snow) within jawbone

• Suspected osteoblastic metastases

Radiolucent Lesions

Periapical Radiolucency

Periapical Radiolucency (normal)

• Marrow space

• Papillae of developing teeth

• Maxillary sinus

• Incisive foramen

• Nasolacrimal canals

• Submandibular fossa

• Sublingual fossa

• Mandibular canal and mental foramen

/continued

Periapical Radiolucency (normal)

• Mental depression (chin)

• Tomographic plane (including panoramic) artifact

• Processing errors ( e.g. developer splash)

Periapical Radiolucency (common pathologic)

• Periapical cyst, granuloma or abscess

• Fibrous healing defect

• Periapical cemental dysplasia (early)

• Periodontal abscess

Periapical Radiolucency (uncommon pathologic)

• Dentigerous cyst of underlying tooth

• Traumatic (simple) bone cyst

• Other cysts

• Osteomyelitis

• Underlying benign tumor (e.g. cementifying/ossifying fibroma)

• Primary malignant tumor (e.g. leukemia)

/continued


• Central giant cell granuloma


• Lingual salivary gland depression (Stafne’s bone cavity)



/continued


• Early cementoblastoma or osteoblastoma


• Early odontomas

Pericoronal Radiolucency

Pericoronal Radiolucency (common)

• Normal dental follicle space• Dentigerous cyst• Envelopmental odontogenic

keratocyst• Adenomatoid odontogenic tumor• Early odontoma or ameloblastic

fibro-odontoma

Pericoronal Radiolucency (uncommon single)

• Ameloblastic fibroma• Ameloblastoma• Early calcifying epithelial

odontogenic tumor (Pindborg tumor)• Mucopolysaccharidoses (I-H) -

Hurler’s syndrome• Early calcifying odontogenic cyst

Pericoronal Radiolucency (multiple)

• Dental follicle spaces

• Multiple nevoid basal cell carcinoma syndrome (Gorlin and Goltz syndrome)

• Osteomastosis- intestinal polyposis syndrome (Gardner’s syndrome)

• Mucopolysaccharoidoses

• Regional odontodysplasia

Radiolucency Lateral to Tooth

Radiolucency Lateral to Tooth (common)

• Lateral periodontal abscess• Lateral periodontal cyst• Endodontic perforation• Extension of disease from adjacent

tooth

Radiolucency Lateral to Tooth (uncommon)

• Lateral canal periapical cyst


• Neurofibroma or neurilemmoma

• Giant cell granuloma

• Unilocular ameloblastoma



Well-defined solitary lucency not necessarily contacting teeth (uncommon)

• Odontogenic keratocyst• Ameloblastoma• Giant cell granuloma• Early ossifying/cementifying fibroma• Early fibrous dysplasia• Eosinophilic granuloma

/continued

Well-defined solitary lucency not necessarily contacting teeth (uncommon)

• Neurofibroma


• Central hemangioma

Well-defined solitary lucency not necessarily contacting teeth (rare)

• Aneurysmal bone cyst

• Chondrosarcoma

• Central fibroma

• Tuberculous osteomyelitis

• Hydatid cyst

• Early calcifying epithelial odontogenic tumor (Pindborg’s tumor)

Single Radiolucency with Ragged Borders

Single Radiolucency with Ragged Borders (common)

• Chronic osteitis• Osteomyelitis• Peripheral squamous cell carcinoma• Infected radicular, residual or other

cyst

Single Radiolucency with Ragged Borders (uncommon)

• Early fibrous dysplasia• Metastatic carcinoma• Malignant salivary gland tumor

involving bone• Osteolytic osteosarcoma• Multiple myeloma• Chondrosarcoma

/continued

Single Radiolucency with Ragged Borders (uncommon)

• Fibrosarcoma• Lymphosarcoma• Melanotic neuroectodermal tumor of

infancy• Leukemia or Ewing’s sarcoma • Aneurysmal bone cyst• Neurofibroma• Odontogenic myxoma

Radiolucency in Region of Maxillary Lateral Incisor

Radiolucency in Region of Maxillary Lateral Incisor (common)

• Incisive fossa/foramen

• Canine fossa

• Periapical cyst, granuloma or abscess

• Rarefying osteitis from adjacent central

• Other periapical radiolucencies

Radiolucency in Region of Maxillary Lateral Incisor (uncommon)

• Clefts• Aberrant foramina in anterior maxilla• Nasopalatine duct cyst• Odontogenic keratocyst• Depression from nasolabial cyst• Post-surgical defect

Non-Cystlike Radiolucency of Bone


• Focal osteoporotic defect

• Large marrow space

• Normal variant of tuberosity

• Sparse trabeculation in child

• Maxillary sinus

• Foramina


/continued


• Sublingual fossa

• Post-coronoid depression

• Sigmoid notch shadow

• Acute osteomyelitis

• Healing surgical defect

• Decalcification secondary to overlying inflammation

Rarefying Osteitis - Focal Osteomyelitis

Rarefying Osteitis - Focal Osteomyelitis (common)

• Foramina or dental Papilla• Antrum or nasal passage• Mandibular canal or mental foramen• Large marrow space• Periodontal abscess • Apical cyst, granuloma or abscess• Early periosteal cemental dysplasia • Healing surgical defect

Rarefying Osteitis - Focal Osteomyelitis (uncommon)

• Actinomycosis


• Leukemia



Blurring of Trabecular Pattern

Blurring of Trabecular Pattern

• Osteomyelitis

• Decalcification secondary to inflamed adjacent tissues

• Radiodontic pitfall (e.g. motion unsharpness; bend artifact)

Diminished Number of Trabeculae

Diminished Number of Trabeculae(common)

• Normal variant in children• Inflammatory disease• Osteopenic metabolic diseases

(uncommon)

• Anaplastic anemias


• Vitamin D deficiency syndrome

• Thalassemia and Sickle cell anemia

• Neurofibroma

Decreased Size of Trabeculae

Decreased Size of Trabeculae(common)

• Normal variation • Infection and inflammation• Disuse atrophy of alveolus

(uncommon)



• Thalassemia

Generalized Rarefaction

Generalized Rarefaction (common)

• Osteoporosis

• Cortisone therapy

• Rheumatoid arthritis

• Prolonged immobilization

• Malignant and other cachetic diseases

Generalized Rarefaction (uncommon)




• Acromegaly

• Pancreatitis

• Malnutrition

• Pregnancy-related changes

/continued

Generalized Rarefaction (uncommon)

• Diabetes mellitus• Scurvy• Inherited anemias• Leukemia• Langerhans’ cell disease• Multiple myeloma• Paget’s disease of bone• Osteogenesis imperfecta• Renal acidosis

Generalized Rarefaction (rare)


• Hyperphosphatasia


• Thyrotoxicosis

• Hypogonadism

• Agranulocytosis

• Oxalosis


Multilocular Radiolucency

Multilocular Radiolucency(common unilateral)

• Aberrant normal anatomy (maxillary antrum)

• Ameloblastoma




• Multilocular radicular or residual cyst

Multilocular Radiolucency(uncommon unilateral)• Mucoepidermoid tumor


• Arterio-venous malformation

• Central hemangioma

• Ameloblastic fibroma

• Calcifying odontogenic cyst

• Early fibrous dysplasia

• Developing odontoma


Multilocular Radiolucency(rare unilateral)

• Calcifying epithelial odontogenic tumor (Pindborg tumor)

• Central fibroma

• Chondroma

• Sporotrichosis

• Cerebroside lipoidosis (Gaucher’s disease)

• Oxalosis

Multilocular Radiolucency(bilateral)

• Normal variation for maxillary sinuses• Cherubism• Cerebroside lipoidosis (Gaucher’s disease)• Multiple nevoid basal cell carcinoma

syndrome (Gorlin and Goltz syndrome)• Oxalosis

Ameloblastoma-like Radiolucency- “Soap Bubble” Appearance

Ameloblastoma-like Radiolucency- “Soap Bubble” Appearance (common)

• Ameloblastoma


• Giant cell granuloma

• Multilocular large radicular or residual cyst

Ameloblastoma-like Radiolucency(uncommon)







• Sporotrichosis

• Oxalosis

Lucency Below Mandibular Canal

Lucency Below Mandibular Canal (common)



• Lingual salivary gland defect (Stafne)

(uncommon)

• Eosinophilic granuloma

• Benign tumor of salivary gland origin

• Subperiosteal neurofibroma

• Benign vascular tumor

Expansile Jaw Lesions

Expansile Jaw Lesions(common)

• Laminar periosteal new bone ( e.g. osteitis proliferans)

• Ameloblastoma• Radicular or residual cyst• Central giant cell granuloma• Dentigerous cyst• Fibrous dysplasia• Cherubism

Expansile Jaw Lesions(uncommon)

• Hemangioma

• Neurfibroma

• Osteosarcoma or lymphosarcoma



(rare)


• Burkitt’s lymphoma

Lesions with Crenulated (Undulating) Margins

Lesions with Crenulated (Undulating) Margins

• Ameloblastoma



• Other benign tumors


• Botyroid lateral periodontal cyst

Lytic Lesions with Wide Band-like Borders

Lytic Lesions with Wide Band-like Borders

• Infected cyst• Lateral inflammatory

odontogenic cyst

• Fibrous dysplasia• Giant cell tumor• Aneurysmal bone cyst• Ossifying fibroma

(common) (uncommon)

(rare)• Osteoblastoma• Osteoid osteoma

Widened Mandibular Canal

Widened Mandibular Canal

• Normal variant• Neurilemmoma• Neurofibroma• Vascular tumor,

hamartoma or malformation

• Malignant tumor (primary, extension or metastasis)

• Lymphoma

(common) (uncommon)

Scattered Bone Destruction Separated by Normal Bone

Scattered Bone Destruction Separated by Normal Bone

• Acute osteomyelitis• Multiple myeloma• Squamous cell

carcinoma

• Actinomycosis• Osteoradionecrosis• Metastatic carcinoma• Oxalosis• Tuberculous

osteomyelitis

(common) (uncommon)

Short Linear Area of Radiolucency in Inferior Cortex

Short Linear Area of Radiolucency in Inferior Cortex


• Squamous cell carcinoma extending into bone

• Other local malignant destruction (e.g osteogenic sarcoma)

Cyst-like Radiolucency with Window-like Cortical Breaching

Cyst-like Radiolucency with Window-like Cortical Breaching

• Ameloblastoma

• Large radicular or residual cyst



• Neurofibroma

Thinned Lower Cortex (Mandible)

Thinned Lower Cortex (Mandible)

• Multiple myeloma• Rheumatoid arthritis• Diseases associated

with generalized rarefaction

• Langerhans’ cell disease• Hyperparathyroidism• Thalassemia• Sickle cell anemia

(common) (uncommon)

(rare)• Hemifacial atrophy (Romberg disease) • Osteogenesis imperfacta

Ballooned Inferior Cortex

Ballooned Inferior Cortex(common)

• Dentigerous cyst

• Periostitis ossificans

• Large radicular or residual cyst


• Cementifying/ossifying fibroma

• Ameloblastoma


Ballooned Inferior Cortex(uncommon)


• Neurofibroma (blister lesion)

• Hyperparathyroidism (Brown tumor)

• Hemangioma



Ballooned Inferior Cortex(rare)



• Central fibroma

• Calcifying epithelial odontogenic tumor (Pindborg tumor)

• Osteogenic sarcoma

Attenuation of Shadow of Follicle Wall

Attenuation of Shadow of Follicle Wall (common)

• Localized infection of primary tooth

• Eruption cyst


Attenuation of Shadow of Follicle Wall (uncommon)

• Vitamin D deficiency syndromes

• Leukemia



• Lymphosarcoma


Attenuation of Shadow of Follicle Wall (rare)

• Melanotic neuroectodermal tumor of infancy

• Rhabdomyosarcoma

• Neuroblastoma

Discontinuity of Nasal or Antral Wall

• Apical inflammation• Projection artifact

• Osteomyelitis• Odontogenic myxoma• Ameloblastoma• Invasive squamous

cell carcinoma• Invasive salivary

gland malignancy• Long-standing antritis• Previous surgery

(common) (uncommon)

(rare)• Osteogenic sarcoma• Langerhans’ cell

disease• Lymphosarcoma• Antral mucocele

Suspected Daughter “Cysts”

Suspected Daughter “Cysts”


• Ameloblastoma

• Mucoepidermoid tumor (central)

• Central hemangioma• Botyroid lateral

periodontal cyst

(common) (uncommon)

External Erosion of Bone

External Erosion of Bone• Adjacent squamous cell carcinoma• Scleroderma (systemic sclerosis) • Cystic hygroma• Secondary to pulsatile vessel• Hodgkin’s disease• Eosinophilic granuloma• Adjacent malignant adjacent lymph node• Metastatic malignancy • Secondary to PVC poisoning• Idiopathic

Lesion with no Internal Structure

Lesion with no Internal Structure

• Odontogenic cyst• Non-odontogenic

cyst • Traumatic bone cyst

• Ameloblastoma• Odontogenic myxoma• Hemangioma• Neurofibroma• Osteolytic osteogenic

sarcoma• Ameloblastic fibroma• Early calcifying cyst

or tumor

(common) (uncommon)

Multiple Separate Well Defined Radiolucencies

Multiple Separate Well Defined Radiolucencies(common)

• Normal variation• Multiple periapical pathoses (cysts,

granulomas or abscesses)• Multiple nevoid basal cell carcinoma

syndrome (Gorlin and Goltz syndrome)• Early stages of periapical cemental

dysplasia

Multiple Separate Well Defined Radiolucencies(uncommon) (rare)

• Cherubism


• Metastatic carcinoma

• Langerhans’ cell disease Lymphosarcoma

• Leukemia

• Ameloblastomas

• Skip lesion of osteosarcoma

• Niemann-Pick disease

• Cerebroside lipoidosis (Gaucher’s disease)

• Mucopolysaccharoidoses


Multiple Osteolytic Lesions with Punched Out Margins

Multiple Osteolytic Lesions with Punched Out Margins

• Multiple Myeloma



• Hemangioma


Radiopaque and Mixed Radiolucent/Radiopaque

Lesions

Periapical Mixed Lucency/Opacity

Periapical Mixed Lucency/Opacity

• Dental crypt• Rarefying osteitis plus

tooth root• Mixed rarefying -

sclerosing osteitis• Periapical cemental

dysplasia• Foreign body (e.g.

root canal filling material)

• Cementifying/ ossifying fibroma

• Cementoblastoma• Paget’s disease of

bone• Complex odontoma• Compound odontoma• Calcifying

odontogenic cyst

(common) (uncommon)

Pericoronal Mixed Lucency/Opacity

Pericoronal Mixed Lucency/Opacity

• Complex odontoma• Compound odontoma• Adenomatoid

odontogenic tumor

• Ameloblastic fibro-odontoma


• Odontogenic fibroma• Cystic odontoma• Calcifying epithelial

odontogenic tumor (Pindborg tumor)

(common) (uncommon)

Periapical Radiopacity

Periapical Radiopacity(common)

• Anatomic superimpositions• Tori and exostoses• Retained roots or unerupted tooth• Radiographic artifact• Sclerosing osteitis• Mature periapical cemental dysplasia• Hypercementosis• Foreign body

Periapical Radiopacity(uncommon)

• Superimposed soft tissue calcification

• Cementoblastoma

• Osteoblastoma


• Mature complex odontoma

• Osteoblastic metastases


Single Mixed Lucency/Opacity Not Necessarily Contacting Tooth

Single Mixed Lucency/Opacity Not Necessarily Contacting Tooth(common)

• Dense bone island/osteosclerosis• Sclerosing/condensing osteitis• Osseous excrescence• Fibrous dysplasia• Periapical cemental dysplasia• Healing surgical defect• Developing odontomas• Cementifying/ossifying fibroma

Single Mixed Lucency/Opacity Not Necessarily Contacting Tooth(uncommon)

• Chronic osteomyelitis


• Ameloblastic fibro-odontoma

• Complex odontoma




Single Mixed Lucency/Opacity Not Necessarily Contacting Tooth(rare)

• Osteoblastoma

• Osteoid osteoma


• Chondrosarcoma


Mixed Lucency/Opacity in Region of Mandibular Condyle Head

Mixed Lucency/Opacity in Region of Mandibular Condyle Head• Osteochondroma• Chondrometaplasia• Osteomyelitis from middle ear• Healing traumatic injury to TMJ• Fibrous dysplasia• Ossifying fibroma• Osteoblastoma• Osteogenic sarcoma or Chondrosarcoma• Charcot’s joint

Simulating Sclerosing Osteitis

Simulating Sclerosing Osteitis(common)

• Normal variation of trabeculation

• Superimposed normal structure or tori

• Focal sclerosing osteomyelitis (condensing osteitis)

• Florid osseous dysplasia or periapical cemental dysplasia (late stage)



• Iatrogenic (orthodontic treatrment)

Simulating Sclerosing Osteitis(uncommon)

• Superimposed osteoma

• Secondary hyperparathyroidism

• Idiopathic hypercalcemia

• Superimposed submandibular gland stone (sialolithiasis)

Simulating Sclerosing Osteitis(rare)

• Osteopetrosis

• Infantile cortical hyperostosis

• Osteoradionecrosis



• Osteoblastoma and osteoid osteitis

• Melorrheostosis

• Myelosclerosis

• Healing syphilitic gumma

Increased Girth of Individual Trabeculae

Increased Girth of Individual Trabeculae

• Condensing osteitis (focal sclerosing osteomyelitis)

• Central hemangioma• Neurofibroma

• Fluorosis• Myelosclerosis• Osteoblastic metastases

(common) (uncommon)

Granular Bone

• Fibrous dysplasia• Osteomyelitis (bone

replacing sequestrum)• Post-surgical defect• Paget’s disease of

bone

• Thalassemia• Cementifying/ossifying

fibroma• Osteogenic sarcoma• Chondrosarcoma• Hodgkin’s disease• Renal osteodystrophy

recovery phase• Groundou

(common) (uncommon)

Granular Bone

Solitary Opacity Not Necessarily Contacting Tooth

Solitary Opacity Not Necessarily Contacting Tooth(common)• Anatomic superimposition• Radiodontic pitfall (fixer splash)• Osteosclerosis, exostosis or torus• Unerupted tooth or retained root• Sclerosing osteitis or socket sclerosis• Benign cemental mass• Odontoma• Foreign body

Solitary Opacity Not Necessarily Contacting Tooth(uncommon)


• Compact osteoma


• Chondrosarcoma

• Osteoblastoma

• Osteoid osteoma


Simulating Compound Odontoma

Simulating Compound Odontoma

• Compound odontoma• Supernumerary teeth• Complex odontoma• Adenomatoid

odontogenic tumor• Ameloblastic fibro-

odontoma

• Ameloblastic odontoma• Distomus• Teratoma• Epignathion

(common) (uncommon)

Simulating Complex Odontoma

Simulating Complex Odontoma

• Complex odontoma• Periapical cemental

dysplasia (late phase)• Florid osseous

dysplasia• Compound odontoma• Condensing osteitis

• Compact osteoma• Cementifying/

ossifyingfibroma• Osteogenic sarcoma• Osteochondroma• Ameloblastic odontoma• Fibrous dysplasia (late)

(common) (uncommon)

Opacity Denser than Normal Bone

Opacity Denser than Normal Bone

• Foreign body (e.g. fragment of metallic restorative material)

• Odontomas• Florid osseous

dysplasia or periapical cemental dysplasia (late phase)

• Focal sclerosing osteitis

• Osteopetrosis• Fibrous dysplasia • Pyknodysostosis• Compact osteoma• Osteogenic sarcoma• Osteomastosis-

intestinal polyposis syndrome (Gardner Sx)

• Occulodento-osseous dysplasia

(common) (uncommon)

Multiple Separate Radiopacities

Multiple Separate Radiopacities

• Tori and exostoses• Periapical cemental

dysplasia• Florid osseous dysplasia• Multiple retained roots

or impacted teeth• Multiple socket sclerosis• Osteosclerosis including

condensing osteitis

• Calcinosis cutis• Osteomatosis-intestinal

polyposis (Gardner) syndrome

• Enchondromatosis and hemongiomatosis (Maffuci syndrome)

• Gigantiform cementoma• Overlying soft tissue

calcification

(common) (uncommon)

Root-like Density in Bone

Root-like Density in Bone

• Retained root• Dense bone island

(osteosclerosis)• Coronoid

superimposition• Root displaced in soft

tissues/fascial plane• Socket sclerosis

• Antrolith• Bony spicule in antrum• Pterygoid hamulus

superimposition• Superimposed sialolith• Other soft tissue

calcification• Osteochondroma

(common) (uncommon)

Causes of Root in Bone

• Secondary to carious destruction of tooth crown

• Traumatic injury with tooth fracture

• Iatrogenic (incomplete extraction)

• Displacement of root into adjacent soft tissues or sinus (superimposition)

Suspected Metallic Foreign Body

Suspected Metallic Foreign Body

• Amalgam fragment• Body jewelry• Other restoratives or

dental instruments• Artifact (scratched

cassettes, fixer splash, panoramic ghosts, etc.)

• Needles• Shot-gun pellets• Leaded glass fragments• Paper in cassette• Metal fragment in path

of primary beam

(common) (uncommon)

Suspected Non-Metallic Foreign Body

Suspected Non-Metallic Foreign Body

• Calcified acne• Carotid atherosclerosis• Sialolithiasis• Calcified lymph node• Tooth fragment• Osteosclerosis• Subclinical fibrous

dysplasia

• Cysticercosis• Phlebolith• Myositis ossificans

(common) (uncommon)

Sequestra-like density

Sequestra-like density

• Acute osteomyelitis• Chronic osteomyelitis• Osteoradionecrosis• Osteogenic sarcoma

• Also see Single Large Opacities list

• Tuberculosis• Actinomycosis• Syphilis• Mercury poisoning• Phosphorus

poisoning (“phossy” jaw)

(common) (uncommon)

Target Lesion (Radiopacity with Peripheral Shadow

Target Lesion (Radiopacity with Peripheral Shadow

• Retained primary root• Infection around

retained tooth root• Sequestra• Periapical cemental

dysplasia• Odontoma

• Cementoblastoma• Cementifying/ossifying

fibroma• Fibrous dysplasia

(common) (uncommon)

(rare)• Brodie’s abscess• Osteoblastoma• Osteoid osteoma

Excrescence with Density of Bone

Excrescence with Density of Bone • Idiopathic• Tori and exostoses• Ossifying fibrous epulis• Osteochondroma

• Soft tissue calcifications

• Hyperostosis• Fibrous dysplasia• Osteomatosis-intestinal

polyposis syndrome (Gardner/s syndrome)

• Peripheral chondroma• Chondrosarcoma

(common) (uncommon)

Thickened Mandibular Inferior Cortex

Thickened Mandibular Inferior Cortex• Sickle cell anemia• Secondary to osteomyelitis• Fluorosis• Phosphorus poisoning• Myelosclerosis• Sclerostosis• Rarely a variant of normal

Laminar Periosteal New Bone

Laminar Periosteal New Bone(common)

• Osteomyelitis• Periostitis ossificans

(Garrè’s osteomyelitis)

Laminar Periosteal New Bone(uncommon)• Infantile cortical hyperostosis• Lateral inflammatory odontogenic cyst of

the mandible (Stoneman’s cyst)• Superficial surface injuries to face• Cervicofacial actinomycosis• Tuberculosis affecting jaw • Syphilitic periostitis• Eosinophilic granuloma

/continued

Laminar Periosteal New Bone(uncommon)

• Hypervitaminosis A or Scurvy

• Leukemia (single new layer)


• Ewing’s sarcoma

• Neostosis secondary to hemodialysis

• Idiopathic periostitis with dysproteinemia (Goldbloom’s syndrome)

• Diffuse idiopathic skeletal hyperostoses Sx

New Periosteal Bone with InternalDestruction

New Periosteal Bone with InternalDestruction

• Chronic osteomyelitis

• Tuberculous osteomyelitis


New Bone Perpendicular to Original Cortex

New Bone Perpendicular to Original Cortex • Sickle cell anemia• Osteogenic sarcoma• Chondrosarcoma• Osteoblastic metastases• Reticulum cell sarcoma• Neuroblastoma

• Thalassemia• Spherocytosis• Ewing’s sarcoma• Burkitt’s lymphoa• Syphilitic periostitis• Meningioma• Hemangioma• Ossifying fibrous epulis• Osteoma

(common) (uncommon)

Lesions with Internal Spindly Trabeculae

Lesions with Internal Spindly Trabeculae

• Odontogenic myxoma• Central hemangioma• Central giant cell granuloma (unusual) • Ameloblastoma (unusual)

Lesions with Septae or Pseudo Septae

• Ameloblastoma• Central giant cell

granuloma• Odontogenic myxoma• Odontogenic

keratocyst• Traumatic (simple)

bone cyst• Cherubism

• Central hemangioma• Fibrous dysplasia• Chondroma

(common) (uncommon)

Lesions with Honeycombed Internal Structure

Lesions with Honeycombed Internal Structure

• Odontogenic myxoma• Central hemangioma• Ewing’s sarcoma• Aneurysmal bone cyst• Ameloblastoma• Central giant cell

granuloma

• Neurofibroma• Fibrous dysplasia• Osteogenic sarcoma

(common) (uncommon)

Lesions with Wispy Internal Structure

Lesions with Wispy Internal Structure




• Neurofibroma

Lesions with Internal Residual Bone

Lesions with Internal Residual Bone

• Odontogenic myxoma• Ameloblastoma• Central hemangioma• Invasive squamous

cell carcinoma

• Fibrous dysplasia• Ossifying fibroma• Osteochondroma• Hodgkin’s disease• Lymphoma

(common) (uncommon)

Lesions with Tubular Internal Structure

Lesions with Tubular Internal Structure

• Normal vascular channels (nutrient canals)

• Central hemangioma• Arteriovenous

malformation• Sturge-Weber

syndrome (tram track calcifications in brain)


• Ameloblastoma• Neurofibroma

(common) (uncommon)

Lesions with Internal Rounded Dense Radiopacities

Lesions with Internal Rounded Dense Radiopacities

• Odontomas• Periapical cemental

dysplasia• Florid osseous dysplasia• Adenomatoid

odontogenic tumor• Paget’s disease of bone• Fibrous dysplasia

• Osteogenic sarcoma• Chondrosarcoma• Chondrometaplasia

(common) (uncommon)

Linear Striations within Jawbone

Linear Striations within Jawbone

• Normal variant (infant mandible)

• Paget’s disease of bone (driven snow appearance)

• Craniometaphyseal dysplasia (Pyle’s disease)

Suspected Osteoblastic Metastases

• Breast• Prostate• Liver

• Lung• Rectum and colon• Neuroblastoma• Osteogenic sarcoma• Leiomyosarcoma• Hodgkin’s disease

(common) (uncommon)

Jaw Structure Gross Changes

Gross Structural Changes• Prognathism or retrognathia• Micrognathia• Unilateral small jaw• Enlargement of part of jaw• Obtuse or aberrant gonial angle• Persistent mandibular midline suture• Absent coronoid(s)• Deviation of chin• Deformed mandible

/continued

Gross Structural Changes• Increased vertical depth of mandible• Unilateral or bilateral absence of condyle• Condylar hyperplasia• Suspected jaw fracture(s)• Pathologic fracture• Suspected hyoid fractures• Radiolucency in condylar neck/head• True and false TMJ ankylosis• Increased or decreased TMJ space

/continued

Gross Structural Changes• Limited or increased TMJ movement• Small or enlarged antrum• Suspected antral foreign body• Antral opacification with normal walls• Antral opacification with abnormal walls• Antral opacification with breached cortices• Absent nasal bones • Depressed nasal bridge• Hypoplasia of maxilla and zygomas• Clefts

Prognathism

Prognathism(common)


• Racial variance (Scandinavian and African)

• Edentulous mandible (apparent)

• Relative prognathism (e.g. retrognathic midface secondary to cleft)

• Acromegaly

Prognathism(uncommon)


• Pituitary giantism

• Hemifacial hyperplasia

• Lymphangioma of tongue or cystic hygroma

Prognathism(rare)

• Multiple nevoid multiple basal cell carcinoma syndrome (Gorlin and Goltz syndrome)


• Beckwith-Wiedemann syndrome• XXXXY syndrome• Waardenburg syndrome

Retrognathism

Retrognathism

• Normal variant• Relative to protrusion

of midface• TMJ ankylosis• Juvenile rheumatoid

arthritis

• Hemifacial hypoplasia• Subluxation in infancy• Hypopituitarism• Progressive

hemiatrophy• Agenesis/dysgenesis of

mandible• Agnathia• Micrognathia-related

(common) (uncommon)

Micrognathia

Micrognathia

• Mandibulofacial dysostosis (Treacher-Collins syndrome)

• Gonadal dysgenesis (Turner’s syndrome)

• Juvenile rheumatoid arthritis (Still’s Sx)

• Cleft lip, micrognathia and glossoptosis (Pierre-Robin syndrome)

• Oculoauricularvertebral dysplasia (Goldenhar’s Sx)

• XX and XY Turner phenotype syndrome (Noonan’s syndrome)

• Oculomandibulodyscephaly (Hallerman-Streiff Sx)

• Pyknodysostosis

(common) (uncommon)

Micrognathia(rare)

• Bird-headed dwarfism

• Congenital telangiectatic erythema with growth retardation (Bloom’s syndrome)

• 5P - (cric du chat) syndrome

• Chondrodysplasia punctata (Conradi-Hünermann syndrome)

• De Lange’s syndrome

• Diastrophic dwarfism

/continued

Micrognathia(rare)

• G syndrome• Cleft palate, flattened facies and multiple

congenital dislocations (Larsen’s Sx)• Long arm 21 deletion syndrome• Mesomelic dwarfism• Orofacial digital syndrome• Osteodysplasia• Progeria (Hutchinson-Gilford syndrome)

/continued

Micrognathia(rare)

• Rubinstein-Taybi syndrome

• Russell-Silver syndrome

• Short arm deletion 18 syndrome

• Smith-Lemli-Opitz syndrome

• Thrombocytopenia-absent radius syndrome

• Trisomy 13 syndrome

• Trisomy 18 syndrome

Unilateral Small Jaw

Unilateral Small Jaw

• Lateral facial dysplasia• Unilateral TMJ

ankylosis• Forceps delivery trauma• Radiation therapy in

infancy

• Hemifacial hypoplasia• Hemifacial atrophy

(Romberg’s disease)• Partial mandibular

agenesis• Linear scleroderma

(common) (uncommon)

(rare)• Central hemangioma• Neurofibroma

Enlargement of Part of Jaw (anatomically correct)

Enlargement of Part of Jaw (anatomically correct)

• Adjacent hemangioma

• Adjacent neurofibroma


• Hemifacial hyperplasia


Obtuse Gonial Angle

Obtuse Gonial Angle

• Normal age change• Edentulous mandible• Condylar hyperplasia -

contralateral condyle• Trisomy 21• Scleroderma (systemic

sclerosis)

• Mucopolysaccharidoses I-H (Hurler’s syndrome)


• Osteopetrosis• Hemifacial hypoplasia

(common) (uncommon)

Aberrant Gonial Angle

Aberrant Gonial Angle

• Normal variant• TMJ ankylosis• Juvenile rheumatoid

arthritis• Mandibulofacial

dysostosis (Treacher-Collins syndrome)

• Scleroderma• Neurofibroma• Trisomy 21

• Marfan’s syndrome• Isolated anomaly

(common) (uncommon)

Persistent Mandibular Midline Suture

Persistent Mandibular Midline Suture

• Normal <6 months age• Cleidocranial dysplasia• Midline fracture

• Mandibular midline cleft

• Normal variant

(common) (uncommon)

Absent or Diminished Coronoids

Absent or Diminished Coronoids

• Previous surgery• Panoramic radiograph -

outside focal trough• Lateral facial dysplasia• Scleroderma (systemic

sclerosis)• Radiation therapy in • childhood

• Hemifacial atrophy (Romberg’s disease)

• Local or metastatic malignancy related erosion

• Agnathia• Agenesis

(common) (uncommon)

Deviation of Chin Towards Affected Side

• Normal variant• Malocclusion (cross-

bite)• Unilateral TMJ

ankylosis• Condylar hypoplasia

• Lateral facial dysplasia• Childhood or forceps

fracture of condyle• Torticollis• Hemifacial atrophy

(Romberg’s disease)• Congenital unilateral facial

hypoplasia• Partial mandibular agenesis

(common) (uncommon)

Deviation of Chin Away From Affected Side

• Normal variant• Malocclusion • Condylar hyperplasia• Splinting reaction to

TMJ pain

• Congenital unilateral hyperplasia

• Joint effusion due to trauma

• Hemangioma or neurfibroma induced jaw hyperplasia

• Tumor in TMJ region (benign or malignant)

(common) (uncommon)

Deformed Mandibular Shape

• Condylar hyperplasia• Trauma with mal-union• Condylar ankylosis

(early)• Mandibulofacial

dysostosis (Treacher-Collins syndrome)

• Cystic hygroma• Flawed panoramic

technique

• Neurofibroma• Hemignathia• Congenital hypo- or hyperplasia

of condyle• Hemifacial atrophy (Romberg’s

disease)• Klippel-Feil anomalad• Congenital scapular elevation• Torticollis• Electrical or thermal burns• Radiation therapy in childhood

(common) (uncommon)

Increased Vertical Depth of Mandible

• Normal variant• Prognathism• Anatomic enlargement

of jaw• Periostitis ossificans• Benign tumor (e.g.

ameloblastoma; ossifying fibroma)

• Thalassemia• Other congenital anemias• Sclerosteosis• Van Buchem’s disease

(common) (uncommon)

Unilateral Failure of Condylar Development

Unilateral Failure of Condylar Development

• Early trauma (e.g. forceps delivery)

• Childhood infections around TMJ (e.g. mastoiditis; otitis media or externa; dental or skin abscess)

• Lateral facial dysplasia

• Radiation therapy in childhood

• Hemifacial hypoplasia• Linear scleroderma• Benign tumor• Local malignant tumor

destruction of growth center

• Metastatic malignancy

(common) (uncommon)

Bilateral Failure of Condylar Development

Bilateral Failure of Condylar Development

• Trauma

• Mandibulofacial dysostosis (Treacher-Collins Sx)

• Cleft palate, micrognathia and glossoptosis (Pierre-Robin) syndrome

• Juvenile rheumatoid

arthritis (Still’s disease)

• Congenital dwarfism• Mucopolysacharidoses• Childhood radiotherapy• Progeria (Hutchinson-Gilford

syndrome)• Oculomandibulodycephaly

(Hallerman-Streiff Sx)• Agnathia or micrognathia• Cockayne’s syndrome

(common) (uncommon)

Condylar Hyperplasia

Condylar Hyperplasia

• Hypertrophic arthritis• Malignant tumor (e.g.

chondrosarcoma)• Fibrous dysplasia• Paget’s disease of bone

(common) (uncommon)

• True hyperplasia• Benign tumor (e.g.

osteochondroma)• Influence of adjacent

vascular or neural tumor

• Acromegaly

• Prognathism

Multiple Jaw Fractures

Multiple Fractures

(common) (uncommon)

• Severe trauma• Child abuse• Osteogenesis

imperfecta

• Juvenile idiopathic

osteoporosis• Achondrogenesis• Osteopetrosis• Pyknodysostosis• Mucolipidoses• Metaphyseal dysplasia• Homocystinuria• Idiopathic

Suspected Jaw Fractures (common)

• True fractures• Suture lines• Vascular channels• Fistulous tracts• Symphysis menti (neonate)• Osteomyelitis with fragmentation• Pharyngeal air space shadow• Vertebral superimpositions• Base of skull superimpositions

Suspected Jaw Fractures (uncommon)

• Previous radiation therapy• Hyoid bone superimposition• Radiodontic artifact• Large sequestra• Pathologic fracture

Pathologic Fractures

Pathologic Fractures

(common) (uncommon)

• Oral squamous cell carcinoma

• Central bone malignancy (e.g. multiple myeloma)

• Metastatic carcinoma• Osteoradionecrosis

• Severe osteomyelitis• Marked alveolar

atrophy• Scleroderma (systemic

sclerosis)• Langerhans’ cell

disease

Suspected Hyoid Fracture

• Normal cartilagenous septae

• Superimposition artifact

• Severe blunt trauma

• Hanging (often suicide)

• Homicide (strangulation)

Radiolucency in Condylar Head


• Ely’s cyst of degenerative joint disease• Rheumatoid arthritis• Projection artifact (e.g. pterygoid pit;

air cells extending into zygomatic arch)• Bifid condyle• Previous trauma• Villonodular synovitis• Central giant cell granuloma

/continued


• Benign tumor (e.g. myxoma)• Primary malignancy (e.g. osteogenic

sarcoma; chondrosarcoma; synovial sarcoma; multiple myeloma; adjacent rhabdomyosarcoma; adjacent glandular carcinomas; lymphoma)

• Metastatic malignancy (e.g. hypernephroma; carcinoma from lower gastrointestinal tract)

True TMJ Ankylosis

True TMJ Ankylosis (Common)

• Osteomyelitis

• Tonsillitis

• Otitis media or externa

• Mastoiditis

• Adjacent soft tissue infection

• Dental abscess

• Tuberculosis

• Rheumatoid arthritis (Still’s disease)

• Ankylosing spondylitis

(infection) (traumatic)

(other)

• Mandibular fracture• Forceps delivery

True TMJ Ankylosis (Uncommon)

• Syphilic gumma• Cancrum oris (noma)• Typhoid• Masseter cellulitis• Rheumatic fever• Measles

• Secondary to burn• Congenital fusion of

gums

(infection) (traumatic)

(other)

• Iatrogenic• Temporal muscle fibrosis• Chronic dislocation of

mandible

(neoplasia)• Invasive malignancy• Osteochondroma

False TMJ Ankylosis

False TMJ Ankylosis

(common) (uncommon)

• Splinting due to TMJ pain• Malar fracture (fibrous or

bony union subsequent to)• Coronoid hyperplasia• Coronoid hyperplasia with

campylodactyly• Osteochondroma


• Hysterical trismus• Temporal muscle fibrosis• Myositis ossificans progressiva• Torticollis• Congenital elevation of scapula

Increased TMJ Space

Increased TMJ Space (common) (uncommon)

• Normal variant• Non-uniform patient

positioning• Projection effect (beam

angulation)• Posturing of jaw by patient• Displaced articular disk• Effusion into joint

• Hemorrhage into joint• Loose body in joint• Acute suppurative arthritis• Displacement due to fracture of

condyle or glenoid fossa• Mandibular partial agenesis• Mucopolysaccharidoses

Increased Anterior TMJ Space

• Normal variant• Beam angulation or patient position artifact• Internal derangement of TMJ• Retracted position of condyle due to dental

occlusion• Deep overbite• Overclosure of mandible (especially in

edentulous)• Rheumatoid arthritis• Absent middle ear

Decreased TMJ Space

Decreased TMJ Space

(common) (uncommon)

• Excessive vertical angulation of beam during transcranial projection

• Arthritis (any kind)• Gross disk

displacement

• Previous surgical

removal of disk• Bony or other true

ankylosis

Limited TMJ Movement

(common)

• Normal variant

• Pain reaction

• Internal derangement of joint

• True or false ankylosis

Limited TMJ Movement (uncommon)

• Scar tissue


• Fractured zygomatic arch

• Coronoid hyperplasia

• Malignancy in joint area

• Facial Paralysis

• Torticollis

• Myositis osificans progressiva

• Submucous fibrosis

• Secondary to high dose radiation

Excessive Translation of TMJ

Excessive Translation of TMJ

(common) (uncommon)

• Normal variant• Lax TMJ capsule

• Recurrent dislocations• Neurosis• Ehlers-Danlos

syndrome

Small Antrum (Normal in Shape)

Small Antrum (Normal in Shape) (uncommon)

• Hemifacial hypoplasia (congenital)• Craniometaphyseal dysplasia (Pyle’s disease)• Cleidocranial dysplasia• Craniofacial dysostosis (Crouzon’s Sx)• Other craniostenoses• Thalassemia and other congenital anemias• Hemifacial atrophy (Romberg’s disease)• Oculomandibulodyscephaly (Hallerman-Streiff

syndrome)

Suspected Antral Foreign Bodies

Suspected Antral Foreign Bodies(common) (uncommon)• Tooth root, or restoration

fragment (superimposed or real)

• Panoramic ghost shadow• Antrolith• Bony excrescence/septum• Overlying soft tissue

calcification• Pellets; bullets; shrapnel;

auto glass

• Displaced tooth• Broken dental instrument• Drainage tubes• Heavy cosmetics or

eyeglass shadow• Aspergillosis

Antral Opacification (Normal Walls)

(common) (uncommon)

• Infectious antritis• Allergic antritis• Mucous retention

phenomenon• Mucositis secondary to

dental apical pathosis or periodontitis

• Hemorrhage following trauma

Antral Opacification (Normal Walls)

• Antral polyp• Blocked ostia• Antral polyposis• Cystic fibrosis• Mucocele (blocked ostia

and antral expansion)• Apical dental cyst (rare)• Aspergillosis

Antral Opacification (Abnormal Walls)

(common) (uncommon)

• Radicular cyst• Other benign cyst or

tumor• Fibrous dysplasia

(thicker)• Antral hypoplasia

(thicker)• Antral malignancy (e.g.

carcinoma; lymphoma)

Antral Opacification (Abnormal Walls)

• Inverted papilloma• Osteomyelitis• Thalassemia• Agenesis of antrum• Mucormycosis

Antral Opacification (Breached Walls)

(common) (uncommon)

• Oral-antral fistula• Dental abscess• Antral carcinoma• Oral squamous cell

carcinoma • Salivary gland

malignancy

Antral Opacification (Breached Walls)

• Infectious antritis• True mucocele• Benign odontogenic

tumor (ameloblastoma; myxoma, etc.)

• Lymphoma or sarcoma

Absent Nasal Bones

• Severe trauma

• Prior surgery

• Facial cleft syndromes

• Arhinencephaly

(common) (uncommon)

• Facial cleft syndromes• Previous surgery• Previous trauma• Achondroplasia• Cleidocranial dysplasia• Ectodermal dysplasias• Congenital syphilis

Depressed/Absent Nasal Bones

• Idiopathic hypercalcemia• Craniometaphyseal

dysplasia (Pyle’s disease)• Arhinencephaly• Acrodysostosis

Hypoplasia of Maxillary and Malar Bones (common)

• Mandibulofacial dysostosis (Treacher-Collin’s syndrome

• Achondroplasia• Craniofacial dysostosis (Crouzon’s

syndrome)• Acrocephalysyndactyly (Apert’s

syndrome)

Hypoplasia of Maxillary and Malar Bones (uncommon)

• Bird-headed dwarfism• Congenital telangiectatic erythema with

growth retardation (Bloom’s syndrome)• Cochayne’s syndrome• De Lange syndrome• Oculoauriculovertebral dysplasia

(Goldenhar’s syndrome• Leprechaunism (Donohue’s syndrome)• Long arm 18 deletion syndrome• Long arm 21 deletion syndrome

/continued


• Marshall syndrome• Mietens-Weber syndrome• Oculodento-osseous dysplasia• Oculomandibulodyscephaly (Hallerman-

Streiff syndrome)• Oral-facial-digital syndrome• Oropalatal digital syndrome• Progeria (Hutchinson-Gilford syndrome)

/continued


• Pyknodysostosis

• Rubenstein-Taybi syndrome

• Russel-Silver syndrome

• Trisomy 13

• Trisomy 18

• Weill-Marchesani syndrome

Enlarged Maxilla

(common) (uncommon)

• Normal variant• Relative to mandible

(see “retrognathia”)• Influence of adjacent or

contiguous vascular tumor

• Paget’s disease of bone• Fibrous dysplasia• Osteopetrosis

Enlarged Maxilla

• Juvenile hypothyroidism (cretinism)

• Thalassemia• Influence of adjacent or

contiguous neural tumor• Craniopharyngioma

(common) (uncommon)

• Cleft lip and palate • Isolated cleft palate

(unilateral vs bilateral; anterior vs posterior; complete vs incomplete)

Cleft Palate

• Arhinencephaly• Cleft palate,

micrognathia and glossoptosis (Pierre-Robin syndrome)

• Miscellaneous other craniofacial syndromes

Soft Tissue Signs


Radiologic Signs Concerning Facial Soft Tissues• Calcifications of facial soft tissues

• Calcifications in muscle and subcutaneous tissues

• Widespread soft tissue calcification

• Solitary large calcified mass adjacent bone

• Lymph node calcifications

• Calcifications in submandibular gland region

/continued

Radiologic Signs Concerning Facial Soft Tissues• Calcification in parotid duct region

• Sialolithiasis

• Air in soft tissue

• Nasopharyngeal mass

• Macroglossia

• Salivary gland enlargement

• Ductal stricture on sialography

/continued

Radiologic Signs Concerning Facial Soft Tissues

• Increased retropharyngeal space (child)

• Increased retropharyngeal space (adult)

• Soft tissue mass with underlying bone involvement

• Suspected soft tissue tumor shadow

Calcification in Facial Soft Tissues

(common) (uncommon)

• Calcified acne• Calcified lymph node

(often post tuberculosis)• Phleboliths• Calcified hematoma• Calcified adipose tisssue• Non-calcification (e.g.

tooth displaced into soft tissues)

Calcification in Facial Soft Tissues

• Myositis ossificans (traumatic)

• Myositis ossificans progressiva



• Calcinosis universalis• Cysticercosis• Hypervitaminosid D

Calcifications in Muscles and Subcutaneous Tissues

Calcifications in Muscles and Subcutaneous Tissues (common)

• Dermatolysis and calcinosis• Gout• Scleroderma (systemic sclerosis)• Vascular calcifications• Rheumatoid arthritis• Healing abscess

Calcifications in Muscles and Subcutaneous Tissues (uncommon) • Hyperparathyroidism• Hypoparathyroidism• Multiple nevoid basal cell carcinoma syndrome

(Gorlin and Goltz syndrome)• Ehlers-Danlos syndrome• Idiopathic hypercalcuria• Myositis ossificans (traumatic and progressiva)

/continued

Calcifications in Muscles and Subcutaneous Tissues (uncommon)

• Paraplegia• Calcified parasites (e.g. cysticercosis)• Carbon monoxide poisoning• Fracture segment• Tumoral calcinosis• Secondary to thermal burn or frostbite• Benign or malignant soft tissue tumor• Lupus erythrematosus

Widespread Calcification in Soft Tissues

(uncommon)

• Calcinosis universalis• Hypoparathyroidism• Scleroderma (systemic

sclerosis)• Multiple vascular

calcifications

Widespread Calcification in Soft Tissues

• Gout• Hyperparathyroidism• Immobilization• Lupus erythematosus• Cysticercosis• Tumoral calcinosis• Idiopathic

hypercalcemia• Gross metabolic bone

breakdown/metastatic calcification

(common)

Vascular Calcification

(uncommon)

• Carotid atherosclerosis

• Hemangioma

• Ranine varices

• Phleboliths

• Familial arteriosclerosis

Vascular Calcification

• Monkberg’s sclerosis• Enchondromatosis-

hemangiomata Sx (Maffuci’s syndrome)

• Aneurysm• Progeria (Hutchinson-

Gilford syndrome)• Lipodystrophy• Renal transplantation• Werner’s syndrome• Generalized

calcification of infancy

(common)

• Secondary arteriosclerosis (e.g. diabetes; Cushing’s Sx; nephrotic Sx)

(rare)

Solitary Large Calcified Mass Adjacent to Bone

(uncommon)

• Sialolithiasis in Wharton’s duct (superimposition)

• Calcified fat• Calcified hematoma

Solitary Large Calcified Mass Adjacent to Bone


• Osteochondroma• Gout• Hyperparathyroidism• Soft tissue osteo- or

chondrosarcoma• Tumoral calcinosis• Myositis ossificans• Foreign body

(common)

Calcification in Lymph Nodes of Face

(uncommon)

• Tuberculosis (active or scar)

• Sarcoidosis• Idiopathic

Calcification in Lymph Nodes of Face

• Histoplasmosis• BCG vaccination• Coccidiomycosis• Filiaris• Lymphoma• Osteoblastic

metastases

(common)

Calcification in Submandibular Area

(uncommon)

• Sialolithiasis (in duct or gland)

• Root or tooth displaced in soft tissues

• Calcified lymph node• Foreign body

Calcification in Submandibular Area

• Chondrodystrophica calcificans congenita

• Myossitis ossificans

(common)

• Phlebolith• Calcinosis universalis• Scleroderma• Radiographic artifact

(rare)

Calcification in Parotid Area

(uncommon)

• Sialolithiasis (in duct or gland)

• Artifact• Phlebolith• Foreign body

Calcification in Parotid Area (common) • Calcinosis universalis

• Myossitis ossificans• Other soft tissue

calcifications including metastatic calcification related to metabolic disease

Sialolith Appearance

(uncommon)

• True sialolith• Film artifact• Superimposition of

tooth in soft tissue or in bone

• Superimposed tori, exostoses or osteosclerosis

• Calcified lymph node• Foreign body

Sialolith Appearance

• Gout• Hyperparathyroidism• Immobilization• Lupus erythematosus• Cysticercosis• Tumoral calcinosis• Idiopathic

hypercalcemia• Gross metabolic bone

breakdown/metastatic calcification

(common)

(uncommon)

• Gas producing odontogenic infection

• Surgical emphysema from air rotor or during endodontics

• Projection of air in sulci in occlusal view

Air/Gas in Soft Tissue

• Craters of ulcerative malignancy

• Crushing injury to thorax

• Persistent severe coughing

• Lipomatous accumulation projected over muscle

(common)

Nasopharyngeal Mass (common)

• Adenoids/tonsillar tissue (especially in adolescence)

• Infections

• Projection of posterior aspect of inferior turbinates

Nasopharyngeal Mass (uncommon)

• Hematoma• Malignant nasopharyngeal neoplasm

(carcinoma; lymphoma; lymphoepithelioma; multiple myeloma; chordoma)

• Benign nasopharyngeal neoplasm (juvenile angiofibroma; neurilemmoma, angioma)

• Dermoid cyst

/continued

Nasopharyngeal Mass (uncommon)

• Extension of neoplasm from sphenoid sinus• Extension of neoplasm from nasal passage• Antral-choanal polyp

(rare)• Sarcoidosis or tuberculosis• Meningioma extending from base of skull• Encephalocoele

Macroglossia (common)• Normal variant or spread following loss of teeth• Trisomy 21 (Down’s syndrome)• Acromegaly• Hamartoma (lymphangioma or hemangioma)• Neurofibroma• Edema following trauma or allergic reaction• Primary or secondary amyloidosis• Lingual thyroid

Macroglossia (uncommon)• Juvenile hypothyroidism (cretinism)• Glycogen storage disease• Angioneurotic edema• Infant of diabetic mother• Mucopolysaccharoidoses• Muscular dystrophy• Happy-puppet syndrome• Beckwith-Wiedemann syndrome

Salivary Gland Enlargement (common)

• Paramyxovirus parotitis (mumps)• Sialolithiasis• Idiopathic• Sjögren’s syndrome• Suppurative sialadenitis• Pleomorphic adenoma

Salivary Gland Enlargement (uncommon)

• Chronic alcoholism• Hormonal imbalance• Malnutrition (e.g. protein deficiency)• Mikulicz’s syndrome• Hashimoto’s disease• Tuberculosis or sarcoidosis• Benign or malignant tumors• Oncocytosis• Mucoviscoidoses

(uncommon)

• Inflammation• Sialolithiasis

Stricture of Salivary Duct

• Normal variant• Carcinoma• Trauma including

factitial injury and surgery

• Radiation therapy

(common)

(uncommon)

• Enlarged adenoids and tonsils

• Artifact• Retropharyngeal

extension of upper respiratory tract disease or odontogenic infection

Increased Retropharyngeal Space (childhood)

• Juvenile nasopharyngeal angiofibroma

• Severe chest trauma• Cretinism• Cystic hygroma or

hemangioma• Foreign body impaction• Retropharyngeal goiter• Spinal lesion

(common)

(uncommon)

• Infections extending from upper respiratory tract

• Infections extending from odontogenic causes

Increased Retropharyngeal Space (adulthood)

• Chordoma• Carcinoma• Retropharyngeal goiter• Zenker’s diverticulum• Rheumatoid arthritis of

spine

(common)

Soft Tissue Mass with Underlying Bone Erosion

Soft Tissue Mass with Underlying Bone Erosion • Oral squamous cell carcinoma• Kaposi’s sarcoma (often in AIDS)• Nasolabial cyst• Pyogenic granuloma including pregnancy epulis• Other gingival epulides and denture-induced

gingival hyperplasia• Neurofibromatosis (blister region)• Salivary gland malignancy• Metastatic malignancy (in extraction site)

(common)

Soft Tissue Mass with Underlying Bone Erosion • Lymphoma in soft tissues

• Malignant lymph node

• Amyloidosis

• Angioma

• Fungal diseases

• Hemophilia

• Sarcoma in soft tissues

(uncommon)

Suspected Soft Tissue Tumor Shadow in Facial Region • Primary soft tissue tumors casting

their own radiographic shadows are all uncommon in the oral cavity

• Key to relative frequency in next 5 charts: * = relatively common; ** = uncommon; *** = rare

Suspected Soft Tissue Tumor Shadow in Facial Region (Muscle) • Rhabdomyosarcoma**

• Leiomyoma***

• Leiomyosarcoma***

(Fat)

• Lipoma*

• Liposarcoma***

Suspected Soft Tissue Tumor Shadow in Facial Region

• Fibromatosis*

• Fibrosarcoma**

• Fibrous histiocytoma **

• Other aggressive fibrous lesions**

(Connective tissue)


• Neurofibroma *• Neurilemmoma**• Neurosarcoma***• Neuroblastoma**

(Neural tissue) (Vascular)

• Hemangioma* • Hemangiopericytoma**• Angiosarcoma***• Kaposi’s sarcoma*

Suspected Soft Tissue Tumor Shadow in Facial Region • Oral squamous cell carcinoma*

• Salivary gland tumors*

• Metastatic malignancy** (male = lung; prostate; kidney; colon; rectum; liver/female = breast; lung; thyroid; kidney; colon; rectum)

(Epithelial)


• Acute (e.g. cellulitis)*• Chronic (e.g. fibro-

epithelial polyp)*• Condylomata/warts*• Other epulides*

(Inflammatory)

• Hematoma*• Aneurysms***• Mesenchymoma***• Soft tissue sarcoma***• Accessory muscle

mass*** Dermatologic lesions*

(Miscellaneous)

Part 6: Skull Signs


Radiologic Signs Concerning the Skull

• Craniostenoses• Microcephaly and macrocephaly• Frontal bossing• Basilar invagination• Hypoplasia of skull base• Localized increase in calvarial density• Generalized increase in calvarial density

/continued


• Localized increased density of skull base• Generalized increased density of skull base• Localized thinning of calvaria• Generalized thinning of calvaria• Granular bone in skull• Erosion of inner diploe• “Button” sequestra

/continued


• Solitary calvarial radiolucency• Radiolucent skull defect in childhood• Multiple calvarial radiolucencies• Enlargement or destruction of sella• Small sella and J-shaped sella• Multiple wormian bones• Presence of fontanelle shadows

/continued


• Defective cranial ossification• Hair-on-end calvarial density• Solitary intracranial opacity• Multiple intracranial opacities• Basal ganglia calcification• Hypertelorism• Hypotelorism

/continued


• Brachycephaly

• Dolichocephaly

• Trigonocephaly

• Turricephaly and acrocephaly

• Copper-beaten appearance

Craniostenosis• Craniofacial dysostosis (Crouzon’s disease)• Acrocephalosyndactyly (Apert’s syndrome)• Acrocephalopolysyndactyly (Carpenter’s Sx)• Chotzen’s syndrome• Pfeiffer’s syndrome• Craniometaphyseal dysplasia (Pyle’s disease)

/continued

Craniostenosis

• Diaphyseal dysplasia (Engelmann’s Sx)

• Idiopathic microcephaly

• Idiopathic hypercalcemia


• Hyperthyroidism

• Hypervitaminosis D

/continued

Craniostenosis• Mandibulofacial dysostosis (Treacher-Collins

syndrome)• Mucopolysaccharidoses• Rubenstein-Taybi syndrome• Van Buchem’s disease• Trisomy 21 (Down’s syndrome)• Head binding/papoose board

Microcephaly (Small Skull)


• Craniosynostosis syndromes

• Arhinencephaly

• Cockayne’s syndrome

• Cri du chat syndrome

• De Lange syndrome

• Dysautonomia (Riley-Day syndrome)

• Focal dermal hypoplasia (Goltz syndrome)

/continued


• Hypospadias-dysphagia (G syndrome)• Homocystinuria• Idiopathic small brain and anencephaly• Incontinentia pigmentii (Bloch-Sulzberger

syndrome)• Myotonic dystrophy (Steinert’s syndrome)• Nanocephalic dwarfism (Seckel’s syndrome)

/continued

Microcephaly (Small Skull)• Pancytopenia-dysmelia (Fanconi’s Sx)

• Phenylketonuria

• Prenatal and neonatal irradiation or infection (e.g. toxoplasmosis)

• Smith-Lemli-Opitz syndrome

• Trisomy 13, trisomy 18 or trisomy 21

• Tuberous sclerosis (Bourneville-Pringle Sx)

• Normal variant

Macrocephaly (Large Skull)


• Hydrocephalus (including Dandy-Walker Sx)

• Achondroplasia or achondrogenesis


• Congenital anemias


• Diaphyseal dysplasia (Engelmann’s disease)

• Cerebral giantism (Soto’s syndrome)

/continued


• Familial macroencephaly

• Intracranial tumor or subdural hematoma in childhood

• Beckwith-Wiedmann syndrome

• Mucopolysaccharidoses

• Pituitary dwarfism


• Apparent with certain craniostenoses

Frontal Bossing

Frontal Bossing

• Ectodermal dysplasias

• Multiple nevoid basal cell carcinoma syndrome (Gorlin and Goltz syndrome)

• Achondroplasia


• Oculomandibulodyscephaly (Hallerman-Streiff syndrome)

/continued

Frontal Bossing

• Osteopetrosis


• Otopalatodigital syndrome

• Oral-facial-digital syndrome

• Hemolytic anemias

• Healed rickets


• Congenital syphilis

Basilar invagination


• Achondroplasia

• Ankylosing spondylitis


• Klippel-Feil anomalad


• Osteomalacia


/continued


• Langerhan’s cell disease


• Osteopetrosis

• Osteoporosis

• Pyknodysostosis

• Rheumatoid arthritis

• Syphilis or tuberculosis

• Trauma-induced

Hypoplasia of Skull Base

Hypoplasia of Skull Base

• Achodroplasia

• Chondroectodermal dysplasia

Localized Increase in Calvarial Density

Localized Increase in Calvarial Density

• Fibrous dysplasia• Hyperostosis frontalis interna• Calcifying epithelioma of Malherbe• Dense bone island as normal variant• Osteoblastic metastasis• Superimposed soft tissue calcification

(scalp or brain)• Late sequel after electrical burn

Generalized Increase in CalvarialDensity

Generalized Increase in CalvarialDensity• Acromegaly• Anemias (sickle cell anemia; thalassemia;

congenital spherocytosis; elliptocytosis)• Childhood cerebral atrophy• Congenital cyanotic heart disease• Chronic increased intracranial pressure• Cranial hemiatrophy

/continued

Generalized Increase in CalvarialDensity• Craniometaphyseal dysplasia (Pyle’s disease)• Craniostenoses (all causes)• Diaphyseal dysplasia (Engelmann’s disease)• Dilantin medication• Myotonic dystrophy (Steinert’s syndrome)• Fibrous dysplasia• Hyperostosis frontalis interna

/continued


• Hyperparathyroidism• Hyperphosphatasia• Hypervitaminosis D• Hypo/ pseudohypoparathyroidism • Idiopathic• Idiopathic hypercalcemia• Melorrheostosis

/continued


• Meningioma• Microcephaly• Mucopolysaccharoidoses• Myelosclerosis• Osteoblastic metastases• Osteogenesis imperfecta• Osteopetrosis

/continued


• Otopalataldigital syndrome• Paget’s disease of bone• Sclerosteosis• Secondary polycythemia• Syphilitic osteitis• Treated hydrocephalus• Treated rickets

/continued


• Tuberous sclerosis (Bourneville-Pringle syndrome)

• Van Buchem’s disease

Generalized Increase Opacification of Skull Base

Generalized Increase Opacification of Skull Base• Craniometaphyseal dysplasia (Pyle’s disease)

• Diaphyseal dysplasia (Engelmann’s disease)


• Fluorosis

• Healed vitamin D resistant rickets

• Hyperparathyroidism (following treatment)

• Hypervitaminosis D /continued

Generalized Increase Opacification of Skull Base

• Idiopathic hypercalcemia• Juvenile hypothyroidism (cretinism)• Melorrheostosis• Meningioma• Neurofibromatosis• Osteodysplasia• Paget’s disease of bone• Severe anemia

Localized Increase Opacification of Skull Base

Localized Increase Opacification of Skull Base• Acromegaly

• Chondrosarcoma

• Chordoma with calcification

• Chronic periostitis


• Lymphoma

• Mastoiditis

• Meningioma

• Nasopharyngeal carcinoma


• Osteochondroma


• Sclerosteitis

• Sphenoid sinusitis

Generalized Thinning of Calvarium

Generalized Thinning of Calvarium

• Normal variant (parietal thinning)

• Chronic subdural hematoma

• Congenital arachnoid cyst

• Leptomeningeal cyst

• Localized temporal lobe hydrocephalus

• Neurofibromatosis

• Porencephalic cyst

• Slow-growing intracranial tumor

Localized Thinning of Calvarium

Localized Thinning of Calvarium


• Craniolacuna

• Hydrocephalus



• Progeria (Hutchinson-Gilford Sx)


Granular Bone in Skull

Granular Bone in Skull

• Electrical burn

• Hereditary anemia

• Hyperparathyroidism (primary or secondary)

• Idiopathic

• Leukemia

• Long term steroids

• Metastatic carcinoma or neuroblastoma


• Osteomalacia

• Osteomyelitis

• Osteoporosis

• Paget’s disease

• Meningioma


• Syphilis

Erosion of Inner Diploe

Erosion of Inner Diploe• Arteriovenous

malformation• Chronic subdural

hematoma• Cisterna magna anomaly• Eosinophilic granuloma• Epidermoid cyst• Glioma• Hemangioma of skull• Meningioma

• Metastasis• Neoplasm of dura• Pacchionian

granulation• Porencephaly• Sinus pericranii

So-called “Button Sequestra”

So-called “Button Sequestra”

• Eosinophilic granuloma

• Hemangioma


• Osteomyelitis

• Surgical defect

• Radiation necrosis

• Syphilis

• Tuberculosis

Solitary Radiolucency in Calvarium

Solitary Radiolucency in Calvarium

• Arachnoid cyst

• Arteriovenous malformation

• Benign tumor of scalp

• Carcinoma of scalp

• Cholesteatoma

• Dermal sinus


/continued

Solitary Radiolucency in Calvarium• Fracture• Hemangioma• Hyperparathyroidism• Idiopathic• Lymphoma• Langerhan’s cell

disease• Meningocele• Metastasis

• Multiple myeloma • Neurofibromatosis• Normal variant (venous

lake)• Osteogenic sarcoma• Osteomyelitis• Post-surgical defect• Sarcoidosis, syphilis or

tuberculosis

Radiolucent Defect in Skull of Child

Radiolucent Defect in Skull of Child• Arteriovenous malformation

• Central or peripheral hemangioma

• Epidermoid cyst


• Hemophilic pseudotumor

• Langerhan’s cell disease

• Neurofibromatosis (blister lesion) /continued

Radiolucent Defect in Skull of Child

• Normal fontanelle

• Normal variant (venous lake)

• Osteomyelitis

• Metastatic neuroblastoma


• Surgical defect

Multiple Calvarial Radiolucent Defects

Multiple Calvarial Radiolucent Defects• Cerebroside lipoidosis (Gaucher’s disease)

• Craniolacuna



• Leukemia or lymphoma

• Lipid reticuloendothelioses (Niemann-Pick disease)

/continued

Multiple Calvarial Radiolucent Defects

• Metastatic malignancy



• Osteomyelitis

• Pacchionian granulations

• Normal variant (parietal foramina)

• Sarcoidosis, syphilis or tuberculosis

• Surgical defects

Enlarged or Eroded Sellae

Enlarged or Eroded Sellae• Benign tumor of base of skull• Chordoma• Craniopharyngioma• Empty sella syndrome• Enlargement of internal carotid artery• Hyperparathyroidism• Hypogonadism• Increased intracranial pressure

/continued

Enlarged or Eroded Sellae• Juvenile hypothyroidism (cretinism)• Juxtasellar or suprasellar tumors• Mucopolysaccharoidoses I-H (Hurler’s

syndrome)• Metastatic malignancy• Nasopharyngeal or sphenoid sinus neoplasm• Optic sheath tumor• Osteomyelitis

/continued

Enlarged or Eroded Sellae

• Pituitary tumor

• Rathke’s cleft cyst

• Tumor of frontal lobe of brain

Small Sella

Small Sella


• Myotonic dystrophy (Steinert’s syndrome)

• Genetic dwarfism

• Hypopituitarism


• Normal variant

/continued

Small Sella

• Post-partum pituitary necrosis (Sheehan’s syndrome)

• Prader-Willi syndrome

• Radiation therapy in childhood

• Trisomy 21

“J-Shaped” Sella

“J-Shaped” Sella

• Hydrocephalus


• Mucopolysaccharoidosis I-H (Hurler’s syndrome)

• Neurofibroma

• Normal variant

• Pituitary tumor

• Suprasellar tumor

Multiple Calvarial “Wormian” Bones





• Normal variant


• Oculomandibuldyscephaly (Hallermann-Streiff syndrome)

/continued



• Pachydermoperiostitis

• Prader-Willi syndrome


• Pyknodysostosis

• Trisomy 21


Presence of Fontanelle Shadows

Presence of Fontanelle Shadows• Normal in early infancy

• Cerebrohepatorenal syndrome


• Cutis laxa

• Dysplasia epiphysealis punctata (Conradi’s disease)

• Frontonasal dysplasias

• Hypophosphatasia /continues

Presence of Fontanelle Shadows• Intracranial tumors


• Oculomandibulodyscephaly (Hallermann-Streiff syndrome)

• Osteodysplasia




/continues

Presence of Fontanelle Shadows

• Pediatric rubella infection


• Pyknodysostosis



• Trigonocephaly causes

• Trisomy 13, trisomy 18 or trisomy 21

Defective Cranial Ossification

Defective Cranial Ossification• Cleidocranial dysplasia

• Hydrocephalus


• Langerhans’ cell disease (Letterer-Siewe variety)

• Neurofibromatosis



/continued

Defective Cranial Ossification

• Prematurity

• Progeria (Hutchinson-Gilford Sx)

• Pyknodysostosis

• Renal osteodystrophy


“Hair on End” Calvarium

“Hair on End” Calvarium• Hereditary anemias (thalassemia;

sickle cell anemia; spherocytosis; elliptocytosis)

• Congenital heart disease

• Ewing’s sarcoma

• Hemangioma

• Iron deficiency anemia

• Meningioma

/continued

“Hair on End” Calvarium

• Metastatic neuroblastoma

• Metastatic thyroid carcinoma



• Chondrosarcoma

• Polycythemia vera

Solitary Intracranial Opacity

Solitary Intracranial Opacity• Arachnoid granulation

• Arteiovenous malformation

• Atherosclerosis

• Calcified choroid plexus

• Calcified cerebral infarct

• Calcified diaphragma sella

• Calcified dura (falx; tentorium; sagittal sinus)

/continued

Solitary Intracranial Opacity• Calcified hematoma

• Calcified petroclonoid or interclinoid ligament

• Chondrosarcoma of skull base

• Craniopharyngioma

• Cysticercosis

• Encephalofacial angiomatosis (Strurge-Weber syndrome)

/continues


• Ependyoma• Epidermoid or dermoid cyst• Foreign body (e.g. artery clip)• Healed granuloma or abscess• Hemangioma (sclerosing)• Idiopathic• Meningioma• Metastatic neoplasm

/continued


• Osteochondroma• Osteoradionecrosis• Pineal gland • Pituitary adenoma• Rubella• Syphilitic gumma• Tuberous sclerosis

(Bourneville-Pringle Sx)

Multiple Intracranial Opacities

Multiple Intracranial Opacities• Aneurysm

• Atherosclerosis

• Basal ganglia calcifications

• Idiopathic

• Encephalofacial angiomatosis (Sturge-Weber syndrome)

• Healed brain abscesses

• Carbon monoxide intoxication

/continued

Multiple Intracranial Opacities• Cockayne’s syndrome

• Cytomegalo virus inclusion disease

• Encephalitis

• Hematomas

• Hepatolenticular degeneration (Wilson’s disease)


• Hypervitaminosis D

/continued

Multiple Intracranial Opacities• Lipoid proteinosis• Metastatic malignancy• Multiple nevoid basal cell carcinoma

syndrome (Gorlin and Goltz syndrome)• Multiple tumors (e.g. meningiomas)• Neurofibromatosis• Parasitic disease• Toxoplasmosis• Tuberous sclerois

Basal Ganglia Calcifications

Basal Ganglia Calcifications• Birth anoxia• Carbon monoxide poisoning• Cockayne’s syndrome• Encephalitis• Hemorrhage• Hypoparathyroidism• Idiopathic• Lead intoxication• Parkinsonism

/continued

Basal Ganglia Calcifications


• Pseudohyperparathyroidism

• Toxoplasmosis

• Tuberous sclerosis

Hypertelorism(increasedinterorbitalwidth)

Hypertelorism• Acrocephalysyndactyly (Apert’s Sx)• Anterior meningocoele• Central facial hypoplasia• Cerebral giantism (Soto’s syndrome)• Cleidocranial dysplasia• Craniostenosis causes• Cri du chat syndrome• De Lange’s syndrome• Dysplasia epiphysealis punctata

(Conradi’s syndrome)

/continued

Hypertelorism• Facial duplication• Fibrous dysplasia• Hypertelorism-hypospadias syndrome• Idiopathic• Larsen’s syndrome• Metaphyseal chondrodysplasia• Metaphyseal dysplasia• Midline dermoid or teratoma• Mulopolysaccharidoses I-H (Hurler’s Sx)

/continued

Hypertelorism• Multiple nevoid basal cell carcinoma

syndrome (Gorlin and Goltz syndrome)• Noonan’s syndrome• Orofacial digital syndrome• Osteogenesis imperfecta• Otopalatodigital syndrome• Thalassemia• Mandibulofacial dysplasia (Treacher-

Collins syndrome)• Turner’s syndrome

Hypotelorism(decreasedinterorbitalwidth)

Hypotelorism

• Arhinencephaly

• Glycogen storage disease

• Oculodento-osseous dysplasia

• Phenylketinuria

• Trigonocephaly

• Trisomy 13

• Trisomy 21

Unilateral Exophthalmos

Unilateral Exophthalmos• Craniostenosis causes• Dermoid cyst• Epidermoid• Fibrous dysplasia• Fracture with retro-orbital blood or air• Hemangioma• Hyperthyroidism• Lacrimal gland tumor• Meningioma

/continued

Unilateral Exophthalmos• Metastatic disease• Mucocele• Mucormycosis• Neurofibromatosis• Orbital meningocoele• Benign tumor (e.g. ossifying fibroma)• Osteoma of paranasal sinus• Osteomyelitis• Paget’s disease of bone

/continued

Unilateral Exophthalmos

• Primary orbital soft tissue disease• Pseudotumor of orbit• Retro-orbital abscess or cellulitis• Sinusitis

Destructive Lesions with Exophthalmos

Destructive Lesions with Exophthalmos

• Chloroma• Langerhanss cell disease• Lymphoma• Metastatic neuroblastoma• Metastatic carcinoma• Primary carcinoma• Burkitt’s lymphoma

Enlargement of Superior Orbital Fissure


• Aneurysm of internal carotid artery• Chordoma• Craniopharyngioma• Extension of orbital malignancy• Langerhans’ cell disease• Meningioma• Metastatic carcinoma to sphenoid bone• Middle cranial fossa mass

/continued


• Neurofibroma• Neurofibromatosis• Normal variant• Pituitary tumor• Posterior orbital encephalocele

Prominent Muscle Attachment

Prominent Muscle Attachment

• Acromegaly• Normal variant• Ankylosis• Pseudo-ankylosis• Masseteric hypertrophy

radiologic signs for maxillofacial diagnosis copyright of allan g. farman

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