Uncommon

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 Hypodontia/Oligodontia (uncommon) • 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 Hypodontia/Oligodontia (uncommon) • • • • 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 Cleidocranial dysplasia 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) • • • • Langerhans’ cell disease Factitial injury Cyclic neutropenia Malignancy (leukemia, lymphoma, neuroblastoma, rhabdomyosarcoma) • Hyper keratosis palmoplantaris and periodontoclasia in childhood (PapillonLefeuvre 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 • Langerhans’ cell disease • 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 (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 (MorquioBrailsford syndrome) • Ehlers-Danlos syndrome • Hypophosphatasia • Hypoparathyroidism • Radiation therapy during tooth development Dentin Aberrations (common) • • • • Dental caries Idiopathic internal resorption Dentinogenesis imperfecta Regional odontodysplasia Dentin Aberrations Dentin Aberrations (uncommon) • • • • • Osteogenesis imperfecta Dentin dysplasias Shell teeth of Rushton Ehlers-Danlos syndrome 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) • Idiopathic internal resorption Prematurely Closed Root Apex Prematurely Closed Root Apex • Previous trauma to tooth • Radiation therapy during tooth development • Dentinogenesis imperfecta • Osteogenesis imperfecta • Radicular dentin dysplasia 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 Dentin dysplasias Dentinogenesis imperfecta 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) • • • • • • • • Factitial injury Inostosis Malignant tumors (e.g. lymphoma) Oxalosis Hyperparathyroidism Periodontal disease Foreign body reaction Idiopathic internal resorption 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 • Compound odontoma • 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 • Langerhans’ cell disease Generalized Loss of Lamina Dura Generalized Loss of Lamina Dura (common pathlogic) • • • • Idiopathic Osteoporosis Paget’s disease of bone Leukemia Generalized Loss of Lamina Dura (uncommon pathlogic) • • • • • • • Metastatic malignancy (especially breast) Hyperparathyroidism Hypoparathyroidism 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 COMMON UNCOMMON • True ankylosis of retained primary • Trauma • Re-implantation • Obscuring condensing osteitis • Infection • Inostosis • Socket sclerosis (false ankylosis) • Obscuring idiopathic osteosclerosis Crestal Radiolucency Crestal Radiolucency (common) • • • • • Early destructive periodontal disease Hyperemic decalcification Juvenile periodontosis Factitial injury Acute necrotizing ulcerative gingivitis Crestal Radiolucency (uncommon) • Langerhans’ cell disease • Hyperkeratosis palmoplantaris and periodontoclasia in children (PapillonLefevre syndrome) • Leukemia • Local malignancy (central or peripheral) • Previous radiation therapy • Hypothuroidism (cretinism/myxedema) /continued Crestal Radiolucency (uncommon) • • • • • • • Hyperthyroidism Hyperparathyroidism Peripheral giant cell granuloma (epulis) Other epulides Cyclic neutropenia Hypophosphatasia Acrodynia /continued Crestal Radiolucency (uncommon) • • • • • 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 punchedout 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 Compound odontoma 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 nonmetallic) • 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 Periapical Radiolucency (uncommon pathologic) • Central giant cell granuloma • Langerhans’ cell disease • Lingual salivary gland depression (Stafne’s bone cavity) • Multiple myeloma • Metastatic malignancy (especially breast) /continued Periapical Radiolucency (uncommon pathologic) • Early cementoblastoma or osteoblastoma • Radicular dentin dysplasia • 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 Odontogenic keratocyst Neurofibroma or neurilemmoma Giant cell granuloma Unilocular ameloblastoma Langerhans’ cell disease Hyperparathyroidism 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 • Odontogenic myxoma • 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 Non-Cystlike Radiolucency of Bone • • • • • • • Focal osteoporotic defect Large marrow space Normal variant of tuberosity Sparse trabeculation in child Maxillary sinus Foramina Submandibular fossa /continued Non-Cystlike Radiolucency of Bone • • • • • • 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 Previous radiation therapy Leukemia Metastatic malignancy (especially breast) Langerhans’ cell disease 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 • Previous radiation therapy • 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) • Previous radiation therapy • Vitamin D deficiency syndrome • Thalassemia Generalized Rarefaction Generalized Rarefaction (common) • • • • • Osteoporosis Cortisone therapy Rheumatoid arthritis Prolonged immobilization Malignant and other cachetic diseases Generalized Rarefaction (uncommon) • • • • • • • Cushing’s syndrome Hyperparathyroidism Vitamin D deficiency syndrome 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) • • • • • • • • Hypophosphatasia Hyperphosphatasia Hypoparathyroidism Thyrotoxicosis Hypogonadism Agranulocytosis Oxalosis Previous radiation therapy Multilocular Radiolucency Multilocular Radiolucency (common unilateral) • • • • • • Aberrant normal anatomy (maxillary antrum) Ameloblastoma Odontogenic keratocyst Central giant cell granuloma Odontogenic myxoma Multilocular radicular or residual cyst Multilocular Radiolucency (uncommon unilateral) • Mucoepidermoid tumor • Aneurysmal bone cyst • Arterio-venous malformation • Central hemangioma • Ameloblastic fibroma • Calcifying odontogenic cyst • Early fibrous dysplasia • Developing odontoma • Langerhans’ cell disease 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 Odontogenic keratocyst Giant cell granuloma Multilocular large radicular or residual cyst Ameloblastoma-like Radiolucency (uncommon) • • • • • • • • Ameloblastic fibroma Traumatic (simple) bone cyst Langerhans’ cell disease Ossifying fibroma Fibrous dysplasia Calcifying odontogenic cyst Sporotrichosis Oxalosis Lucency Below Mandibular Canal Lucency Below Mandibular Canal (common) • Normal variation • Submandibular fossa • 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 Ossifying fibroma Aneurysmal bone cyst (rare) • Traumatic (simple) bone cyst • Burkitt’s lymphoma Lesions with Crenulated (Undulating) Margins Lesions with Crenulated (Undulating) Margins • • • • • • Ameloblastoma Central giant cell granuloma Odontogenic myxoma Other benign tumors Odontogenic keratocyst Botyroid lateral periodontal cyst Lytic Lesions with Wide Band-like Borders Lytic Lesions with Wide Band-like Borders (common) (uncommon) • Infected cyst • Lateral inflammatory odontogenic cyst • • • • (rare) • Osteoblastoma • Osteoid osteoma Fibrous dysplasia Giant cell tumor Aneurysmal bone cyst Ossifying fibroma Widened Mandibular Canal Widened Mandibular Canal (common) (uncommon) • • • • • Malignant tumor (primary, extension or metastasis) • Lymphoma Normal variant Neurilemmoma Neurofibroma Vascular tumor, hamartoma or malformation Scattered Bone Destruction Separated by Normal Bone Scattered Bone Destruction Separated by Normal Bone (common) (uncommon) • Acute osteomyelitis • Multiple myeloma • Squamous cell carcinoma • • • • • Actinomycosis Osteoradionecrosis Metastatic carcinoma Oxalosis Tuberculous osteomyelitis Short Linear Area of Radiolucency in Inferior Cortex Short Linear Area of Radiolucency in Inferior Cortex • Acute osteomyelitis • 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 Odontogenic myxoma Central giant cell granuloma Neurofibroma Thinned Lower Cortex (Mandible) Thinned Lower Cortex (Mandible) (common) (uncommon) • Multiple myeloma • Rheumatoid arthritis • Diseases associated with generalized rarefaction • • • • Langerhans’ cell disease Hyperparathyroidism Thalassemia Sickle cell anemia (rare) • Hemifacial atrophy (Romberg disease) • Osteogenesis imperfacta Ballooned Inferior Cortex Ballooned Inferior Cortex (common) • • • • • • • Dentigerous cyst Periostitis ossificans Large radicular or residual cyst Fibrous dysplasia Cementifying/ossifying fibroma Ameloblastoma Odontogenic myxoma Ballooned Inferior Cortex (uncommon) • • • • • • Central giant cell granuloma Neurofibroma (blister lesion) Hyperparathyroidism (Brown tumor) Hemangioma Ameloblastic fibroma Calcifying odontogenic cyst Ballooned Inferior Cortex (rare) • • • • Aneurysmal bone cyst Burkitt’s lymphoma 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 • Acute osteomyelitis Attenuation of Shadow of Follicle Wall (uncommon) • • • • • • Vitamin D deficiency syndromes Leukemia Langerhans’ cell disease Burkitt’s lymphoma Lymphosarcoma Hyperparathyroidism Attenuation of Shadow of Follicle Wall (rare) • Melanotic neuroectodermal tumor of infancy • Rhabdomyosarcoma • Neuroblastoma Discontinuity of Nasal or Antral Wall (common) (uncommon) • Apical inflammation • Projection artifact • • • • (rare) • Osteogenic sarcoma • Langerhans’ cell disease • Lymphosarcoma • Antral mucocele Osteomyelitis Odontogenic myxoma Ameloblastoma Invasive squamous cell carcinoma • Invasive salivary gland malignancy • Long-standing antritis • Previous surgery Suspected Daughter “Cysts” Suspected Daughter “Cysts” (common) (uncommon) • Odontogenic keratocyst • Ameloblastoma • Mucoepidermoid tumor (central) • Central hemangioma • Botyroid lateral periodontal cyst 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 (common) (uncommon) • Odontogenic cyst • Non-odontogenic cyst • Traumatic bone cyst • • • • • Ameloblastoma Odontogenic myxoma Hemangioma Neurofibroma Osteolytic osteogenic sarcoma • Ameloblastic fibroma • Early calcifying cyst or tumor 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 • Multiple myeloma • Metastatic carcinoma • Langerhans’ cell disease Lymphosarcoma • Leukemia • Ameloblastomas • Skip lesion of osteosarcoma • Niemann-Pick disease • Cerebroside lipoidosis (Gaucher’s disease) • Mucopolysaccharoidoses • Hyperparathyroidism Multiple Osteolytic Lesions with Punched Out Margins Multiple Osteolytic Lesions with Punched Out Margins • • • • • Multiple Myeloma Langerhans’ cell disease Metastatic carcinoma Hemangioma Burkitt’s lymphoma Radiopaque and Mixed Radiolucent/Radiopaque Lesions Periapical Mixed Lucency/Opacity Periapical Mixed Lucency/Opacity (common) • Dental crypt • Rarefying osteitis plus tooth root • Mixed rarefying sclerosing osteitis • Periapical cemental dysplasia • Foreign body (e.g. root canal filling material) (uncommon) • Cementifying/ ossifying fibroma • Cementoblastoma • Paget’s disease of bone • Complex odontoma • Compound odontoma • Calcifying odontogenic cyst Pericoronal Mixed Lucency/Opacity Pericoronal Mixed Lucency/Opacity (common) • Complex odontoma • Compound odontoma • Adenomatoid odontogenic tumor (uncommon) • Ameloblastic fibroodontoma • Calcifying odontogenic cyst • Odontogenic fibroma • Cystic odontoma • Calcifying epithelial odontogenic tumor (Pindborg tumor) 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 Cementifying/ossifying fibroma Mature complex odontoma Osteoblastic metastases Paget’s disease of bone 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 Paget’s disease of bone Ameloblastic fibro-odontoma Complex odontoma Compound odontoma Calcifying odontogenic cyst Superimposed soft tissue calcification Single Mixed Lucency/Opacity Not Necessarily Contacting Tooth (rare) • • • • • Osteoblastoma Osteoid osteoma Osteogenic sarcoma Chondrosarcoma Osteoblastic metastases 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) • Fibrous dysplasia • Paget’s disease of bone • 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 Osteogenic sarcoma Osteoblastic metastases Osteoblastoma and osteoid osteitis Melorrheostosis Myelosclerosis Healing syphilitic gumma Increased Girth of Individual Trabeculae Increased Girth of Individual Trabeculae (common) (uncommon) • Condensing osteitis (focal sclerosing osteomyelitis) • Central hemangioma • Neurofibroma • Fluorosis • Myelosclerosis • Osteoblastic metastases Granular Bone (common) (uncommon) • 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 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) • • • • • • • Cementifying/ossifying fibroma Compact osteoma Osteogenic sarcoma Chondrosarcoma Osteoblastoma Osteoid osteoma Superimposed soft tissue calcification Simulating Compound Odontoma Simulating Compound Odontoma (common) (uncommon) • • • • • • • • Compound odontoma Supernumerary teeth Complex odontoma Adenomatoid odontogenic tumor • Ameloblastic fibroodontoma Ameloblastic odontoma Distomus Teratoma Epignathion Simulating Complex Odontoma Simulating Complex Odontoma (common) • Complex odontoma • Periapical cemental dysplasia (late phase) • Florid osseous dysplasia • Compound odontoma • Condensing osteitis (uncommon) • Compact osteoma • Cementifying/ossifying fibroma • Osteogenic sarcoma • Osteochondroma • Ameloblastic odontoma • Fibrous dysplasia (late) Opacity Denser than Normal Bone Opacity Denser than Normal Bone (common) (uncommon) • 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 Osteomastosisintestinal polyposis syndrome (Gardner Sx) • Occulodento-osseous dysplasia Multiple Separate Radiopacities Multiple Separate Radiopacities (common) (uncommon) • 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 Root-like Density in Bone Root-like Density in Bone (common) (uncommon) • 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 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 (common) • Amalgam fragment • Body jewelry • Other restoratives or dental instruments • Artifact (scratched cassettes, fixer splash, panoramic ghosts, etc.) (uncommon) • • • • • Needles Shot-gun pellets Leaded glass fragments Paper in cassette Metal fragment in path of primary beam Suspected Non-Metallic Foreign Body Suspected Non-Metallic Foreign Body (common) • • • • • • • Calcified acne Carotid atherosclerosis Sialolithiasis Calcified lymph node Tooth fragment Osteosclerosis Subclinical fibrous dysplasia (uncommon) • Cysticercosis • Phlebolith • Myositis ossificans Sequestra-like density Sequestra-like density (common) • • • • Acute osteomyelitis Chronic osteomyelitis Osteoradionecrosis Osteogenic sarcoma • Also see Single Large Opacities list (uncommon) • • • • • Tuberculosis Actinomycosis Syphilis Mercury poisoning Phosphorus poisoning (“phossy” jaw) Target Lesion (Radiopacity with Peripheral Shadow Target Lesion (Radiopacity with Peripheral Shadow (common) • Retained primary root • Infection around retained tooth root • Sequestra • Periapical cemental dysplasia • Odontoma (uncommon) • Cementoblastoma • Cementifying/ossifying fibroma • Fibrous dysplasia (rare) • Brodie’s abscess • Osteoblastoma • Osteoid osteoma Excrescence with Density of Bone Excrescence with Density of Bone (common) • • • • Idiopathic Tori and exostoses Ossifying fibrous epulis Osteochondroma • Soft tissue calcifications (uncommon) • Hyperostosis • Fibrous dysplasia • Osteomatosis-intestinal polyposis syndrome (Gardner/s syndrome) • Peripheral chondroma • Chondrosarcoma 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) Osteogenic sarcoma Ewing’s sarcoma Neostosis secondary to hemodialysis Idiopathic periostitis with dysproteinemia (Goldbloom’s syndrome) • Diffuse idiopathic skeletal hyperostoses Sx New Periosteal Bone with Internal Destruction New Periosteal Bone with Internal Destruction • Chronic osteomyelitis • Tuberculous osteomyelitis • Osteogenic sarcoma New Bone Perpendicular to Original Cortex New Bone Perpendicular to Original Cortex (common) • • • • • • Sickle cell anemia Osteogenic sarcoma Chondrosarcoma Osteoblastic metastases Reticulum cell sarcoma Neuroblastoma (uncommon) • • • • • • • • • Thalassemia Spherocytosis Ewing’s sarcoma Burkitt’s lymphoa Syphilitic periostitis Meningioma Hemangioma Ossifying fibrous epulis Osteoma 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 (common) • Ameloblastoma • Central giant cell granuloma • Odontogenic myxoma • Odontogenic keratocyst • Traumatic (simple) bone cyst • Cherubism (uncommon) • Central hemangioma • Fibrous dysplasia • Chondroma Lesions with Honeycombed Internal Structure Lesions with Honeycombed Internal Structure (common) • • • • • • Odontogenic myxoma Central hemangioma Ewing’s sarcoma Aneurysmal bone cyst Ameloblastoma Central giant cell granuloma (uncommon) • Neurofibroma • Fibrous dysplasia • Osteogenic sarcoma Lesions with Wispy Internal Structure Lesions with Wispy Internal Structure • • • • Odontogenic myxoma Central giant cell granuloma Fibrous dysplasia Neurofibroma Lesions with Internal Residual Bone Lesions with Internal Residual Bone (common) • • • • Odontogenic myxoma Ameloblastoma Central hemangioma Invasive squamous cell carcinoma (uncommon) • • • • • Fibrous dysplasia Ossifying fibroma Osteochondroma Hodgkin’s disease Lymphoma Lesions with Tubular Internal Structure Lesions with Tubular Internal Structure (common) • Normal vascular channels (nutrient canals) • Central hemangioma • Arteriovenous malformation • Sturge-Weber syndrome (tram track calcifications in brain) (uncommon) • Central giant cell granuloma • Ameloblastoma • Neurofibroma Lesions with Internal Rounded Dense Radiopacities Lesions with Internal Rounded Dense Radiopacities (common) • Odontomas • Periapical cemental dysplasia • Florid osseous dysplasia • Adenomatoid odontogenic tumor • Paget’s disease of bone • Fibrous dysplasia (uncommon) • Osteogenic sarcoma • Chondrosarcoma • Chondrometaplasia 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 (common) • Breast • Prostate • Liver (uncommon) • • • • • • Lung Rectum and colon Neuroblastoma Osteogenic sarcoma Leiomyosarcoma Hodgkin’s disease 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) • Normal variation • Racial variance (Scandinavian and African) • Edentulous mandible (apparent) • Relative prognathism (e.g. retrognathic midface secondary to cleft) • Acromegaly Prognathism (uncommon) • • • • Paget’s disease of bone Pituitary giantism Hemifacial hyperplasia Lymphangioma of tongue or cystic hygroma Prognathism (rare) • Multiple nevoid multiple basal cell carcinoma syndrome (Gorlin and Goltz syndrome) • Craniometaphyseal dysplasia (Pyle’s disease) • Beckwith-Wiedemann syndrome • XXXXY syndrome • Waardenburg syndrome Retrognathism Retrognathism (common) • Normal variant • Relative to protrusion of midface • TMJ ankylosis • Juvenile rheumatoid arthritis (uncommon) • • • • Hemifacial hypoplasia Subluxation in infancy Hypopituitarism Progressive hemiatrophy • Agenesis/dysgenesis of mandible • Agnathia • Micrognathia-related Micrognathia Micrognathia (common) • Mandibulofacial dysostosis (TreacherCollins syndrome) • Gonadal dysgenesis (Turner’s syndrome) • Juvenile rheumatoid arthritis (Still’s Sx) • Cleft lip, micrognathia and glossoptosis (PierreRobin syndrome) (uncommon) • Oculoauricularvertebral dysplasia (Goldenhar’s Sx) • XX and XY Turner phenotype syndrome (Noonan’s syndrome) • Oculomandibulodyscephaly (Hallerman-Streiff Sx) • Pyknodysostosis Micrognathia (rare) • Bird-headed dwarfism • Congenital telangiectatic erythema with growth retardation (Bloom’s syndrome) • 5P - (cric du chat) syndrome • Chondrodysplasia punctata (ConradiHünermann 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 (common) • Lateral facial dysplasia • Unilateral TMJ ankylosis • Forceps delivery trauma • Radiation therapy in infancy (rare) • Central hemangioma • Neurofibroma (uncommon) • Hemifacial hypoplasia • Hemifacial atrophy (Romberg’s disease) • Partial mandibular agenesis • Linear scleroderma Enlargement of Part of Jaw (anatomically correct) Enlargement of Part of Jaw (anatomically correct) • • • • • Adjacent hemangioma Adjacent neurofibroma Fibrous dysplasia Hemifacial hyperplasia Paget’s disease of bone Obtuse Gonial Angle Obtuse Gonial Angle (common) • Normal age change • Edentulous mandible • Condylar hyperplasia contralateral condyle • Trisomy 21 • Scleroderma (systemic sclerosis) (uncommon) • Mucopolysaccharidoses I-H (Hurler’s syndrome) • Craniometaphyseal dysplasia (Pyle’s disease) • Osteopetrosis • Hemifacial hypoplasia Aberrant Gonial Angle Aberrant Gonial Angle (common) (uncommon) • Normal variant • TMJ ankylosis • Juvenile rheumatoid arthritis • Mandibulofacial dysostosis (TreacherCollins syndrome) • Scleroderma • Neurofibroma • Trisomy 21 • Marfan’s syndrome • Isolated anomaly Persistent Mandibular Midline Suture Persistent Mandibular Midline Suture (common) (uncommon) • Normal <6 months age • Cleidocranial dysplasia • Midline fracture • Mandibular midline cleft • Normal variant Absent or Diminished Coronoids Absent or Diminished Coronoids (common) (uncommon) • 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 Deviation of Chin Towards Affected Side (common) • Normal variant • Malocclusion (crossbite) • Unilateral TMJ ankylosis • Condylar hypoplasia (uncommon) • Lateral facial dysplasia • Childhood or forceps fracture of condyle • Torticollis • Hemifacial atrophy (Romberg’s disease) • Congenital unilateral facial hypoplasia • Partial mandibular agenesis Deviation of Chin Away From Affected Side (common) • • • • Normal variant Malocclusion Condylar hyperplasia Splinting reaction to TMJ pain (uncommon) • Congenital unilateral hyperplasia • Joint effusion due to trauma • Hemangioma or neurfibroma induced jaw hyperplasia • Tumor in TMJ region (benign or malignant) Deformed Mandibular Shape (common) • Condylar hyperplasia • Trauma with mal-union • Condylar ankylosis (early) • Mandibulofacial dysostosis (TreacherCollins syndrome) • Cystic hygroma • Flawed panoramic technique (uncommon) • 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 Increased Vertical Depth of Mandible (common) • Normal variant • Prognathism • Anatomic enlargement of jaw • Periostitis ossificans • Benign tumor (e.g. ameloblastoma; ossifying fibroma) (uncommon) • • • • Thalassemia Other congenital anemias Sclerosteosis Van Buchem’s disease Unilateral Failure of Condylar Development Unilateral Failure of Condylar Development (common) • 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 (uncommon) • • • • Hemifacial hypoplasia Linear scleroderma Benign tumor Local malignant tumor destruction of growth center • Metastatic malignancy Bilateral Failure of Condylar Development Bilateral Failure of Condylar Development (common) • Trauma • Mandibulofacial dysostosis (Treacher-Collins Sx) • Cleft palate, micrognathia and glossoptosis (PierreRobin) syndrome • Juvenile rheumatoid arthritis (Still’s disease) (uncommon) • • • • Congenital dwarfism Mucopolysacharidoses Childhood radiotherapy Progeria (Hutchinson-Gilford syndrome) • Oculomandibulodycephaly (Hallerman-Streiff Sx) • Agnathia or micrognathia • Cockayne’s syndrome Condylar Hyperplasia Condylar Hyperplasia (common) • True hyperplasia • Benign tumor (e.g. osteochondroma) • Influence of adjacent vascular or neural tumor • Acromegaly • Prognathism (uncommon) • Hypertrophic arthritis • Malignant tumor (e.g. chondrosarcoma) • Fibrous dysplasia • Paget’s disease of bone 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) • Oral squamous cell carcinoma • Central bone malignancy (e.g. multiple myeloma) • Metastatic carcinoma • Osteoradionecrosis (uncommon) • 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 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 Radiolucency in Condylar Head • 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) (infection) • • • • • Osteomyelitis Tonsillitis Otitis media or externa Mastoiditis Adjacent soft tissue infection • Dental abscess • Tuberculosis (traumatic) • Mandibular fracture • Forceps delivery (other) • Rheumatoid arthritis (Still’s disease) • Ankylosing spondylitis True TMJ Ankylosis (Uncommon) (infection) • • • • • • Syphilic gumma Cancrum oris (noma) Typhoid Masseter cellulitis Rheumatic fever Measles (neoplasia) • Invasive malignancy • Osteochondroma (traumatic) • Iatrogenic • Temporal muscle fibrosis • Chronic dislocation of mandible (other) • Secondary to burn • Congenital fusion of gums 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 • Scleroderma (systemic sclerosis) • Hysterical trismus • Temporal muscle fibrosis • Myositis ossificans progressiva • Torticollis • Congenital elevation of scapula Increased TMJ Space Increased TMJ Space (common) • Normal variant • Non-uniform patient positioning • Projection effect (beam angulation) • Posturing of jaw by patient • Displaced articular disk • Effusion into joint (uncommon) • • • • 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 Scleroderma (systemic sclerosis) 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) • Normal variant • Lax TMJ capsule (uncommon) • 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) 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 polyp Blocked ostia Antral polyposis Cystic fibrosis Mucocele (blocked ostia and antral expansion) • Apical dental cyst (rare) • Aspergillosis Antral Opacification (Abnormal Walls) Antral Opacification (Abnormal Walls) (common) • Radicular cyst • Other benign cyst or tumor • Fibrous dysplasia (thicker) • Antral hypoplasia (thicker) • Antral malignancy (e.g. carcinoma; lymphoma) (uncommon) • • • • • Inverted papilloma Osteomyelitis Thalassemia Agenesis of antrum Mucormycosis Antral Opacification (Breached Walls) Antral Opacification (Breached Walls) (common) • • • • Oral-antral fistula Dental abscess Antral carcinoma Oral squamous cell carcinoma • Salivary gland malignancy (uncommon) • Infectious antritis • True mucocele • Benign odontogenic tumor (ameloblastoma; myxoma, etc.) • Lymphoma or sarcoma Absent Nasal Bones • • • • Severe trauma Prior surgery Facial cleft syndromes Arhinencephaly Depressed/Absent Nasal Bones (common) • • • • • • • Facial cleft syndromes Previous surgery Previous trauma Achondroplasia Cleidocranial dysplasia Ectodermal dysplasias Congenital syphilis (uncommon) • Idiopathic hypercalcemia • Craniometaphyseal dysplasia (Pyle’s disease) • Arhinencephaly • Acrodysostosis Hypoplasia of Maxillary and Malar Bones (common) • Mandibulofacial dysostosis (TreacherCollin’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 Hypoplasia of Maxillary and Malar Bones (uncommon) • • • • Marshall syndrome Mietens-Weber syndrome Oculodento-osseous dysplasia Oculomandibulodyscephaly (HallermanStreiff syndrome) • Oral-facial-digital syndrome • Oropalatal digital syndrome • Progeria (Hutchinson-Gilford syndrome) /continued Hypoplasia of Maxillary and Malar Bones (uncommon) • • • • • • Pyknodysostosis Rubenstein-Taybi syndrome Russel-Silver syndrome Trisomy 13 Trisomy 18 Weill-Marchesani syndrome Enlarged Maxilla Enlarged Maxilla (common) • Normal variant • Relative to mandible (see “retrognathia”) • Influence of adjacent or contiguous vascular tumor • Paget’s disease of bone • Fibrous dysplasia • Osteopetrosis (uncommon) • Juvenile hypothyroidism (cretinism) • Thalassemia • Influence of adjacent or contiguous neural tumor • Craniopharyngioma Cleft Palate (common) (uncommon) • Cleft lip and palate • Isolated cleft palate (unilateral vs bilateral; anterior vs posterior; complete vs incomplete) • Arhinencephaly • Cleft palate, micrognathia and glossoptosis (PierreRobin syndrome) • Miscellaneous other craniofacial syndromes Soft Tissue Signs Copyright of Allan G. Farman 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 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) • Myositis ossificans (traumatic) • Myositis ossificans progressiva • Ehlers-Danlos syndrome • Scleroderma (systemic sclerosis) • 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 Widespread Calcification in Soft Tissues (common) • Calcinosis universalis • Hypoparathyroidism • Scleroderma (systemic sclerosis) • Multiple vascular calcifications (uncommon) • • • • • • • Gout Hyperparathyroidism Immobilization Lupus erythematosus Cysticercosis Tumoral calcinosis Idiopathic hypercalcemia • Gross metabolic bone breakdown/metastatic calcification Vascular Calcification Vascular Calcification (common) (rare) • • • • • • Monkberg’s sclerosis • Enchondromatosishemangiomata Sx (Maffuci’s syndrome) • Aneurysm • Progeria (HutchinsonGilford syndrome) • Lipodystrophy • Renal transplantation • Werner’s syndrome • Generalized calcification of infancy Carotid atherosclerosis Hemangioma Ranine varices Phleboliths Familial arteriosclerosis (uncommon) • Secondary arteriosclerosis (e.g. diabetes; Cushing’s Sx; nephrotic Sx) Solitary Large Calcified Mass Adjacent to Bone Solitary Large Calcified Mass Adjacent to Bone (uncommon) (common) • Sialolithiasis in Wharton’s duct (superimposition) • Calcified fat • Calcified hematoma • Scleroderma (systemic sclerosis) • Osteochondroma • Gout • Hyperparathyroidism • Soft tissue osteo- or chondrosarcoma • Tumoral calcinosis • Myositis ossificans • Foreign body Calcification in Lymph Nodes of Face Calcification in Lymph Nodes of Face (uncommon) (common) • Tuberculosis (active or scar) • Sarcoidosis • Idiopathic • • • • • • Histoplasmosis BCG vaccination Coccidiomycosis Filiaris Lymphoma Osteoblastic metastases Calcification in Submandibular Area Calcification in Submandibular Area (uncommon) (common) • Sialolithiasis (in duct or gland) • Root or tooth displaced in soft tissues • Calcified lymph node • Foreign body • • • • Phlebolith Calcinosis universalis Scleroderma Radiographic artifact (rare) • Chondrodystrophica calcificans congenita • Myossitis ossificans Calcification in Parotid Area Calcification in Parotid Area (common) (uncommon) • Sialolithiasis (in duct or gland) • Artifact • Phlebolith • Foreign body • Calcinosis universalis • Myossitis ossificans • Other soft tissue calcifications including metastatic calcification related to metabolic disease Sialolith Appearance Sialolith Appearance (common) • True sialolith • Film artifact • Superimposition of tooth in soft tissue or in bone • Superimposed tori, exostoses or osteosclerosis • Calcified lymph node • Foreign body (uncommon) • • • • • • • Gout Hyperparathyroidism Immobilization Lupus erythematosus Cysticercosis Tumoral calcinosis Idiopathic hypercalcemia • Gross metabolic bone breakdown/metastatic calcification Air/Gas in Soft Tissue (common) • Gas producing odontogenic infection • Surgical emphysema from air rotor or during endodontics • Projection of air in sulci in occlusal view (uncommon) • Craters of ulcerative malignancy • Crushing injury to thorax • Persistent severe coughing • Lipomatous accumulation projected over muscle 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 Stricture of Salivary Duct (common) (uncommon) • Inflammation • Sialolithiasis • Normal variant • Carcinoma • Trauma including factitial injury and surgery • Radiation therapy Increased Retropharyngeal Space (childhood) (common) • Enlarged adenoids and tonsils • Artifact • Retropharyngeal extension of upper respiratory tract disease or odontogenic infection (uncommon) • Juvenile nasopharyngeal angiofibroma • Severe chest trauma • Cretinism • Cystic hygroma or hemangioma • Foreign body impaction • Retropharyngeal goiter • Spinal lesion Increased Retropharyngeal Space (adulthood) (common) • Infections extending from upper respiratory tract • Infections extending from odontogenic causes (uncommon) • • • • • Chordoma Carcinoma Retropharyngeal goiter Zenker’s diverticulum Rheumatoid arthritis of spine Soft Tissue Mass with Underlying Bone Erosion Soft Tissue Mass with Underlying Bone Erosion • • • • • (common) 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) Soft Tissue Mass with Underlying Bone Erosion (uncommon) • • • • • • • Lymphoma in soft tissues Malignant lymph node Amyloidosis Angioma Fungal diseases Hemophilia Sarcoma in soft tissues 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 (Connective tissue) • • • • Fibromatosis* Fibrosarcoma** Fibrous histiocytoma ** Other aggressive fibrous lesions** Suspected Soft Tissue Tumor Shadow in Facial Region (Neural tissue) (Vascular) • • • • • • • • Neurofibroma * Neurilemmoma** Neurosarcoma*** Neuroblastoma** Hemangioma* Hemangiopericytoma** Angiosarcoma*** Kaposi’s sarcoma* Suspected Soft Tissue Tumor Shadow in Facial Region (Epithelial) • Oral squamous cell carcinoma* • Salivary gland tumors* • Metastatic malignancy** (male = lung; prostate; kidney; colon; rectum; liver/female = breast; lung; thyroid; kidney; colon; rectum) Suspected Soft Tissue Tumor Shadow in Facial Region (Inflammatory) • Acute (e.g. cellulitis)* • Chronic (e.g. fibroepithelial polyp)* • Condylomata/warts* • Other epulides* (Miscellaneous) • • • • • Hematoma* Aneurysms*** Mesenchymoma*** Soft tissue sarcoma*** Accessory muscle mass*** Dermatologic lesions* Part 6: Skull Signs Copyright of Allan G. Farman 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 Radiologic Signs Concerning the Skull • • • • • • • 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 Radiologic Signs Concerning the Skull • • • • • • • 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 Radiologic Signs Concerning the Skull • • • • • • • Defective cranial ossification Hair-on-end calvarial density Solitary intracranial opacity Multiple intracranial opacities Basal ganglia calcification Hypertelorism Hypotelorism /continued Radiologic Signs Concerning the Skull • • • • • 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 Hypophosphatasia 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) 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 Microcephaly (Small Skull) • • • • 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) Macrocephaly (Large Skull) • • • • • • • Hydrocephalus (including Dandy-Walker Sx) Achondroplasia or achondrogenesis Cleidocranial dysplasia Congenital anemias Craniometaphyseal dysplasia (Pyle’s disease) Diaphyseal dysplasia (Engelmann’s disease) Cerebral giantism (Soto’s syndrome) /continued Macrocephaly (Large Skull) • Familial macroencephaly • Intracranial tumor or subdural hematoma in childhood • Beckwith-Wiedmann syndrome • Mucopolysaccharidoses • Pituitary dwarfism • Russel-Silver syndrome • Apparent with certain craniostenoses Frontal Bossing Frontal Bossing • Ectodermal dysplasias • Multiple nevoid basal cell carcinoma syndrome (Gorlin and Goltz syndrome) • Achondroplasia • Cleidocranial dysplasia • Oculomandibulodyscephaly (HallermanStreiff syndrome) /continued Frontal Bossing • • • • • • • • Osteopetrosis Rubenstein-Taybi syndrome Otopalatodigital syndrome Oral-facial-digital syndrome Hemolytic anemias Healed rickets Mucopolysaccharidoses Congenital syphilis Basilar invagination Basilar invagination • • • • • • • Achondroplasia Ankylosing spondylitis Cleidocranial dysplasia Klippel-Feil anomalad Osteogenesis imperfecta Osteomalacia Paget’s disease of bone /continued Basilar invagination • • • • • • • • Langerhan’s cell disease Mucopolysaccharidoses 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 Calvarial Density Generalized Increase in Calvarial Density • 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 Calvarial Density • • • • • • • 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 Generalized Increase in Calvarial Density • • • • • • • Hyperparathyroidism Hyperphosphatasia Hypervitaminosis D Hypo/ pseudohypoparathyroidism Idiopathic Idiopathic hypercalcemia Melorrheostosis /continued Generalized Increase in Calvarial Density • • • • • • • Meningioma Microcephaly Mucopolysaccharoidoses Myelosclerosis Osteoblastic metastases Osteogenesis imperfecta Osteopetrosis /continued Generalized Increase in Calvarial Density • • • • • • • Otopalataldigital syndrome Paget’s disease of bone Sclerosteosis Secondary polycythemia Syphilitic osteitis Treated hydrocephalus Treated rickets /continued Generalized Increase in Calvarial Density • Tuberous sclerosis (BournevillePringle 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) Fibrous dysplasia 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 • Fibrous dysplasia • Lymphoma • Mastoiditis • Meningioma • Nasopharyngeal carcinoma • Osteoblastic metastases • Osteochondroma • Osteogenic sarcoma • 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 • • • • • • • Cleidocranial dysplasia Craniolacuna Hydrocephalus Hypophosphatasia Osteogenesis imperfecta Progeria (Hutchinson-Gilford Sx) Vitamin D deficiency syndromes 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 • • • • • • • • Multiple myeloma Osteomalacia Osteomyelitis Osteoporosis Paget’s disease Meningioma Osteoradionecrosis 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 Metastatic carcinoma 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 Fibrous dysplasia /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 Fibrous dysplasia 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 Osteogenic sarcoma Surgical defect Multiple Calvarial Radiolucent Defects Multiple Calvarial Radiolucent Defects • • • • • • Cerebroside lipoidosis (Gaucher’s disease) Craniolacuna Hyperparathyroidism Langerhans’ cell disease Leukemia or lymphoma Lipid reticuloendothelioses (Niemann-Pick disease) /continued Multiple Calvarial Radiolucent Defects • • • • • • • • Metastatic malignancy Multiple myeloma Osteoradionecrosis 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 • • • • • • Cushing’s syndrome Myotonic dystrophy (Steinert’s syndrome) Genetic dwarfism Hypopituitarism Juvenile hypothyroidism (cretinism) 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 • Juvenile hypothyroidism (cretinism) • Mucopolysaccharoidosis I-H (Hurler’s syndrome) • Neurofibroma • Normal variant • Pituitary tumor • Suprasellar tumor Multiple Calvarial “Wormian” Bones Multiple Calvarial “Wormian” Bones • • • • • • Cleidocranial dysplasia Hypophosphatasia Juvenile hypothyroidism (cretinism) Normal variant Osteogenesis imperfecta Oculomandibuldyscephaly (HallermannStreiff syndrome) /continued Multiple Calvarial “Wormian” Bones • • • • • • • Otopalatodigital syndrome Pachydermoperiostitis Prader-Willi syndrome Progeria (Hutchinson-Gilford syndrome) Pyknodysostosis Trisomy 21 Vitamin D deficiency syndromes Presence of Fontanelle Shadows Presence of Fontanelle Shadows • • • • • Normal in early infancy Cerebrohepatorenal syndrome Cleidocranial dysplasia Cutis laxa Dysplasia epiphysealis punctata (Conradi’s disease) • Frontonasal dysplasias • Hypophosphatasia /continues Presence of Fontanelle Shadows • Intracranial tumors • Juvenile hypothyroidism (cretinism) • Oculomandibulodyscephaly (Hallermann-Streiff syndrome) • Osteodysplasia • Osteogenesis imperfecta • Otopalatodigital syndrome • Pachydermoperiostitis /continues Presence of Fontanelle Shadows • • • • • • • Pediatric rubella infection Progeria (Hutchinson-Gilford syndrome) Pyknodysostosis Rubenstein-Taybi syndrome Russel-Silver syndrome Trigonocephaly causes Trisomy 13, trisomy 18 or trisomy 21 Defective Cranial Ossification Defective Cranial Ossification • • • • Cleidocranial dysplasia Hydrocephalus Juvenile hypothyroidism (cretinism) Langerhans’ cell disease (LettererSiewe variety) • Neurofibromatosis • Osteogenesis imperfecta • Pachydermoperiostitis /continued Defective Cranial Ossification • • • • • Prematurity Progeria (Hutchinson-Gilford Sx) Pyknodysostosis Renal osteodystrophy Vitamin D deficiency syndromes “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 Multiple myeloma Osteogenic sarcoma 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 Solitary Intracranial Opacity • • • • • • • • Ependyoma Epidermoid or dermoid cyst Foreign body (e.g. artery clip) Healed granuloma or abscess Hemangioma (sclerosing) Idiopathic Meningioma Metastatic neoplasm /continued Solitary Intracranial Opacity • • • • • • • 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) • Hyperparathyroidism • 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 • • • • Previous radiation therapy Pseudohyperparathyroidism Toxoplasmosis Tuberous sclerosis Hypertelorism (increased interorbital width) 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 (TreacherCollins syndrome) • Turner’s syndrome Hypotelorism (decreased interorbital width) 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 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 Enlargement of Superior Orbital Fissure • • • • • Neurofibroma Neurofibromatosis Normal variant Pituitary tumor Posterior orbital encephalocele Prominent Muscle Attachment Prominent Muscle Attachment • • • • • Acromegaly Normal variant Ankylosis Pseudo-ankylosis Masseteric hypertrophy

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