CLINICIAN'S CORNER

Skeletal and soft-tissue incidental findings

on cone-beam computed tomography images
Sevin Barghan,a Sotirios Tetradis,b and Jeanne M. Nervinac
Los Angeles, Calif, and Ann Arbor, Mich

Cone-beam computed tomography provides orthodontists with 3-dimensional images of the craniofacial region
and valuable information for diagnosis and treatment planning of craniofacial or dental anomalies. However,
a narrow focus on the skeletal and dental contributions to malocclusion can cause failure to identify skeletal
or soft-tissue pathologies of the craniofacial structures unrelated to the orthodontic concerns. Two cases are
presented that demonstrate skeletal and soft-tissue anomalies identified as incidental findings on cone-beam
computed tomography scans of asymptomatic orthodontics patients. One patient was diagnosed with
craniofacial fibrous dysplasia; the other had an intrahemispheric lipoma. Their cone-beam computed
tomography images are presented, along with a literature review on their pathologies. (Am J Orthod
Dentofacial Orthop 2013;143:888-92)

C
one-beam computed tomography (CBCT) ex-
pands the imaging options for clinicians by
providing volumetric information unobtainable
with standard radiographs. This option is especially
valuable in orthodontics, in which diagnosis is made in
3 planes of space.1 Along with the increased power to
accurately diagnose malocclusion in 3 dimensions,
CBCT imposes on clinicians an obligation to evaluate
the entire imaged volume for pathology.2-4 Thus,
clinicians using CBCT for diagnosis must have a strong
knowledge of normal head and neck anatomy.
Although CBCT is most useful for imaging
skeletal structures, soft tissues are also imaged, albeit
at a lower contrast resolution.5 Orthodontists focused
on diagnosing the skeletal and dental contributions to
malocclusion might fail to recognize abnormalities in
craniofacial structures captured in the CBCT images. Fig 1. Lateral cephalogram of 12-year-old Hispanic girl sug-
To highlight the need to evaluate both the mineralized gesting sphenoid opacification anterior to the sella turcica.
and soft-tissue components of CBCT images, we present
2 cases of incidental findings in the initial CBCT
radiographs taken of orthodontics patients.
a
Postdoctoral fellow, Section of Oral and Maxillofacial Radiology, School of Den-
tistry, University of California, Los Angeles.
b
Professor and chair, Section of Oral and Maxillofacial Radiology, School of Den-
PATIENT 1: FIBROUS DYSPLASIA
tistry, University of California, Los Angeles. A 12-year-old Hispanic girl came to the orthodontic
c
Assistant professor, Department of Orthodontics and Pediatric Dentistry, School
of Dentistry, University of Michigan, Ann Arbor. clinic at the University of California at Los Angeles for
The authors report no commercial, proprietary, or financial interest in the screening. Her past medical history was significant for
products or companies described in this article. a lymphoma on the left side of the neck at age 3.5 years;
Reprint requests to: Jeanne M. Nervina, University of Michigan School of
Dentistry, 1011 N University Ave, Dentistry 2158, Ann Arbor, MI 48109; it was surgically excised with no recurrence. The clinical ex-
e-mail, jnervina@umich.edu. amination showed a mild overbite and a slight asymmetry
Submitted, January 2012; revised and accepted, March 2012. of the face. The patient was referred to the university's Oral
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists. and Maxillofacial Radiology Clinic for panoramic, lateral
http://dx.doi.org/10.1016/j.ajodo.2012.03.037 cephalometric, and CBCT examinations.
888
Barghan, Tetradis, and Nervina 889

Fig 2. CBCT images of the patient in Figure 1, confirming the sclerotic changes and defining the extent
to the right lesser wing of the sphenoid and frontal bones (arrows) in A, the axial plane; B, the coronal
plane; and C, the sagittal plane.

Fig 3. Medical computed tomography images of the patient in Figure 1, demonstrating the sclerotic
changes to the right lesser wing of the sphenoid and frontal bones in A, the axial plane; B, the coronal
plane; and C, the sagittal plane. D, There was no reduction in the diameter of the right optic nerve root
foramen or the superior orbital fissure.

The lateral cephalograph was initially seen as normal,
although in retrospect sphenoid opacification anterior to
the sella turcica could be identified (Fig 1). The CBCT im-
ages showed expansion and loss of cortication and tra-
becular architecture of the right frontal bone that
extended to the lesser wing of the sphenoid. These
changes, along with the ground-glass or homogeneous
sclerotic appearance of this region, were consistent
with fibrous dysplasia (Fig 2).
The patient was referred for medical computed
tomography and magnetic resonance imaging (MRI) of
the brain. Consistent with the CBCT findings, the
medical computed tomography image showed fibrous
dysplastic changes of the roof of the right orbital fossa
and the superior margin of the greater wing of the
sphenoid. There was no reduction in the diameter of
the right optic nerve root foramen or the superior orbital
fissure (Fig 3).
MRI scans of the brain and orbits with contrast were
carried out to assess the optic nerve canal. There were
hyperostotic changes to the roof of the right orbit and
lesser wing of the sphenoid bone. There was no obvious
compromise to the optic nerve as it transited the canal,
and the brain was normal (Fig 4). (Because of the fixed
orthodontic appliances, substantial phase artifacts
obscured the tail of the orbital fossa.)

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890
Fig 4. MRI images of A, the brain; B and C, the optic nerve of the patient in Figure 1, showing bony
changes but no significant pathology in the brain.
Fig 5. Unremarkable lateral cephalogram of the 16-year-
old white boy.
The patient was referred to an ophthalmologist to
complete the evaluation. Since the lesion was
asymptomatic and growing slowly, no treatment was
indicated. Radiographic follow-up in 6 months was
recommended. A CBCT scan was done to assess the
progression of the lesion. No significant changes were
observed between the 2 examinations. The patient is
followed annually with CBCT imaging to monitor the
progression of her disease.
PATIENT 2: INTRAHEMISPHERIC LIPOMA
A 16-year-old white boy came to the same orthodon-
tic clinic for screening. His medical history was
unremarkable. Panoramic and lateral cephalometric
June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Barghan, Tetradis, and Nervina
radiographs, full-mouth series, and CBCT scans were
obtained.
The bones of the skull, face, soft tissues, airway, and
paranasal sinuses were unremarkable on the lateral
cephalometric radiograph (Fig 5). However, the CBCT
examination showed a well-defined uniform radiolu-
cency measuring approximately 9 3 17 mm in the right
side of the temporal lobe of the brain (Fig 6).
An MRI scan of the brain was recommended for
better evaluation of the area. It showed a well-defined
bright, water-saturated T1 signal in the right inferior
and lateral aspect of the right temporal fissure just bor-
dering the anterior and inferior margins of the sylvian
fissure (Fig 7, A and B). The fat-saturated T2 image
(Fig 7, C) showed a complete loss of the signal. These
findings were consistent with lipoma in the right tempo-
ral lobe.
Although lipoma has a benign course and, in this
patient, required no intervention at the time of initial
diagnosis, an annual follow-up MRI examination was
recommended to confirm the lack of its growth.
DISCUSSION
As with all radiographs, CBCT images taken of ortho-
dontic patients must be thoroughly evaluated for
diseases.6 Incidental findings appear on approximately
25% of CBCT images.7 As demonstrated here, incidental
findings of both skeletal and soft-tissue diseases can be
detected on CBCT scans. Thus, it is imperative that the
entire imaged volume is examined for pathologies or
anatomic variants in patients.
In the cases presented here, the need for medical
referral was warranted because of the nature of the
abnormalities observed. Fibrous dysplasia results from
a mutation in the guanine nucleotide-binding protein,
Barghan, Tetradis, and Nervina 891

Fig 6. CBCT examination of the patient in Figure 5, showing a radiolucent lesion in the right anterior
temporal lobe of the brain in A, the axial plane; B, the coronal plane; and C, the sagittal plane.

Fig 7. A, Axial; B, sagittal water-saturated T1-weighted; and C, axial fat-saturated T2-weighted MRI
images of the patient show the lipid-rich lesion in the temporal lobe.

a-stimulating activity polypeptide I (GNAS-1) gene, and
is characterized by fibrous replacement of mineralized
bone.8,9 Fibrous dysplasia has a clinical spectrum and
can be monostotic or polyostotic; the latter is part of
the McCune-Albright syndrome with or without
precocious puberty, or the McCune-Albright syndrome
with other endocrine disorders.10 Bone pain, deformities,
and fractures caused by a weakened bone structure are
common clinical features. If fibrous dysplasia is
suspected in an orthodontic patient, medical referral is
required for a definitive diagnosis, which requires
a bone biopsy or genetic screening for the GNAS-1
mutation. The prognosis depends on where in the
fibrous dysplasia spectrum the patient falls and the
extent of skeletal involvement. Monostotic patients
have the best long-term prognosis, whereas McCune-
Albright patients have the poorest prognosis. In all
fibrous dysplasia cases, extensive fibrous replacement re-
duces the long-term prognosis. Treatment involves phar-
maceutical agents, beginning with mild pain relievers
and bisphosphonates to reduce bone resorption. Nutri-
tional supplementation with calcium, vitamin D, and
phosphorous is also used to promote mineralization. Sur-
gery to correct the skeletal deformity is also warranted.
Fibrous dysplasia accounts for 5% to 7% of all bone
tumors.11 Unlike fibrous dysplasia, intracranial lipomas
are quite rare, with an incidence of less than 0.1%.12
Most intracranial lipomas are located near the corpus
callosum and are usually asymptomatic, although the
patient might have chronic headaches, convulsions,
psychomotor deficits, or cranial nerve dysfunction.12
Surgical removal is rarely indicated since these tumors

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892
are usually not lethal and the surgical risks outweigh
nontreatment.12
These 2 patients demonstrate that both skeletal and
soft-tissue pathologies can be detected with CBCT imag-
ing. Clinicians using these images for their patients must
be alert to any possible lesions throughout the
craniofacial region. This is particularly important in the
evaluation of orthodontic patients when large field-of-
view volumetric scans that image most of the patient's
skull are used. Incidental findings occur in approxi-
mately 25% of CBCT images, and not all of them have
associated symptoms.7 As with conventional cephalo-
metric and panoramic radiographs,13 CBCT scans should
first be considered skull images and interpreted by
a specialist familiar with the anatomy, normal variants,
and anomalies of the craniofacial structures.4,6,14
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