Triticeous cartilage: Prevalence on panoramic radiographs and diagnostic

criteria
Mansur Ahmad, BDS, PhD,a Richard Madden, DDS,b and Loscar Perez, DMD,c
Minneapolis, Minn, and San Juan, Puerto Rico
UNIVERSITY OF MINNESOTA SCHOOL OF DENTISTRY AND UNIVERSITY OF PUERTO RICO SCHOOL OF DENTISTRY

Objectives. To determine (1) the prevalence of calcified triticeous cartilage on panoramic radiographs of subjects older than
40 years of age, (2) the age and sex distribution of the subjects who have calcified triticeous cartilage, and (3) if the shape of
triticeous cartilage differs from that of calcified carotid atheroma.
Study design. In this retrospective study, triticeous cartilages were diagnosed from 847 panoramic radiographs. The shapes of
triticeous cartilages and calcified carotid atheromas were determined using SigmaScan software.
Results. Prevalence of triticeous cartilage was 5.0% in males and 12.0% in females. The prevalence was 9.3% in the 40- to
60-year-old group (n = 464) and 7.8% in the group older than 60 years (n = 383). The triticeous cartilages were oval with
smooth borders, whereas calcified carotid atheromas were mostly linear.
Conclusions. Calcified triticeous cartilage was more prevalent in females. The prevalence was not age dependent. Shape,
outline, and location of the triticeous cartilage can help in differentiating it from a carotid atheroma.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:225-30)

Triticeous (tri-tish’us) cartilages are bilateral ovoid

structures that are part of a complex of structures found
in the area of the laryngeal skeleton.1-3 The triticeous
cartilage is located centrally in the lateral thyrohyoid
ligament at the level of third and fourth cervical
vertebrae (C3-C4) (Fig 1). Clinically, the triticeous
cartilage has no known function; although recently it has
been suggested that it might help reinforce the lateral
thyrohyoid ligament.1 When calcified, the triticeous
cartilage can be readily seen on a panoramic radiograph
(Fig 2), and can be misdiagnosed as a calcification in the
carotid artery or other dystrophic calcifications of soft
tissue.
Calcification in the carotid arteries may be visualized
by a variety of imaging methods that show a view of the Fig 1. Line diagram of the cartilages and bones of the neck.
cervical region. These radiographic examinations in- Lateral thyrohyoid ligament extends from superior cornu of
clude postero-anterior skull, cephalometric, and pano- the thyroid and reaches the distal aspect of the hyoid bone.
Triticeous cartilage is located midway in this ligament and
often calcifies to the extent that it becomes visible on
This study was funded by NIH Grant No. 5T35DE07098 to L.P., who a panoramic radiograph.
was a National Research Service Award fellow.
a
Assistant Professor, Department of Diagnostic and Surgical
Sciences, University of Minnesota School of Dentistry.
b
Formerly, Clinical Assistant Professor, Department of Diagnostic ramic. Over the past 2 decades, several studies have
and Surgical Sciences, University of Minnesota School of Dentistry. shown that partially or fully calcified atherosclerotic
Currently, a resident in TMD and Orofacial Pain Program, University plaques in the region of the carotid bifurcation can be
of Minnesota School of Dentistry.
c
Formerly, dental student, University of Puerto Rico School of
detected by panoramic radiography.4-7 The prevalence
Dentistry, San Juan, Puerto Rico. Currently, a resident in general of carotid calcifications, as diagnosed on panoramic
practice, State University of New York at Stony Brook. radiographs, varies from 0.1% to 3.2% among patients
Received for publication Dec 16, 2003; returned for revision May 3, above 50 years of age. On panoramic radiographs,
2004; accepted for publication Jun 16, 2004. calcified plaques in the carotid vessel are usually located
Available online 27 September 2004.
1079-2104/$ - see front matter
postero-inferior to the angle of the mandible (Fig 3).
Ó 2005 Elsevier Inc. All rights reserved. The triticeous cartilage can be misdiagnosed as a
doi:10.1016/j.tripleo.2004.06.069 calcified carotid atheroma due to its similar location on a

225

226 Ahmad, Madden, and Perez
Fig 2. Sections of the same panoramic radiograph showing location of hyoid, thyroid, and triticeous cartilages. Panel B traces the
outline of hyoid, thyroid, and triticeous cartilages as seen on panel A. The triticeous cartilage is oval, and is located between the
greater cornu of the hyoid and superior cornu of the thyroid cartilage. The calcified triticeous cartilage has a well-defined border
with a smooth outline.
panoramic radiograph (Figs 2 and 3). Since calcified
carotid atheromas are a risk factor for stroke, clinicians
need to differentiate between a calcified triticeous
cartilage and a calcified carotid atheroma.
The objective of this study was to determine the
prevalence of calcified triticeous cartilage on panoramic
radiographs, age and sex distribution, and to identify if
the shape of the triticeous cartilages differs from that of
carotid atheromas.
MATERIALS AND METHODS
Panoramic radiographs
Panoramic radiographs (n = 847) taken on adults
40 years and older enrolled as patients in the University
of Minnesota School of Dentistry were collected
(Table I). All the patients included in this study had
provided permission for reviewing their radiographs.
Orthopantomogram 10 (Siemens Corp, Iselin, NJ) and
Panelipse (Gendex Corp, Milwaukee, Wis) panoramic
machines were used to expose the films. The sizes of the
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February 2005
panoramic films were 5 inches 3 12 inches. Films were
processed by Fischer Feline 14 Processor (Fischer
Industries, Inc, Geneva, Ill).
Observers
An oral and maxillofacial radiologist, a general dentist,
and a senior dental student interpreted all the radiographs.
Observers were calibrated by the carotid vessel calcifi-
cation training program that was used by the American
Academy of Oral and Maxillofacial Radiology.8
Interpretation
Each observer interpreted each panoramic radiograph
individually, followed by a discussion of each film among
the 3 observers. A diagnosis of triticeous cartilage was
made when all 3 observers agreed. All radiographs were
interpreted in a dimly lit room on a standard view box; hot
spot illumination and magnification were available and
used as each interpreter felt necessary.
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Volume 99, Number 2
Fig 3. Carotid calcifications (arrows) as seen on a panoramic
radiograph. Unlike a calcified triticeous cartilage, as seen in
Fig 2, large calcified carotid atheromas are roughly linear, and
often appear as 2 irregularly parallel radiopacities. The typical
location of such calcifications is adjacent to the cervical
vertebra at or below the third and fourth cervical vertebra.
For comparison with calcified carotid atheromas, we
randomly selected radiographs (n = 64) from a database
of panoramic radiographs that displayed calcifications
of carotid atheromas.9 The radiographs of the calcified
carotid atheroma database were interpreted by 2 oral
and maxillofacial radiologists and 1 general dentist,
who were calibrated by the carotid vessel calcification
training program.8 The subjects with radiographic
diagnosis of calcified carotid atheromas were not age-
or gender-matched with the subjects exhibiting calcified
triticeous cartilages.
Shape analysis
The radiographs that had demonstrated calcifi-
cation of triticeous cartilage or carotid atheromas were
Ahmad, Madden, and Perez 227
Table I. Subject characteristics
No. of subjects
Age group (yrs) Male Female
40-50 128 132
51-60 86 118
61-70 107 100
71-80 60 61
[81 22 33
TOTAL 403 444
scanned using Epson TwainPro scanning software and
an Epson 800 flatbed scanner (Epson America Inc, Long
Beach, Calif). The areas and shapes of calcifications
were measured using SigmaScan Pro software (SPSS
Science, Chicago, Ill) after manually tracing the outline
of the calcifications. The areas were expressed as square
pixels. The shape was calculated as (4p 3 Area)/
Perimeter2, and indicated how circular an object was.10
Data analysis
Data gathered were statistically analyzed using
1-way analysis of variance (ANOVA) using SPSS (SPSS
Science). Significance was considered when P \.05.
RESULTS
Of the 847 panoramic radiographs evaluated, 73
(8.6%) revealed calcification of 1 or both triticeous
cartilages. In males, the prevalence of triticeous
cartilage calcification was 5.0% (20/403 subjects). The
prevalence in females was 12.0% (53/444 subjects),
which was significantly higher compared with males
(P \.01).
In 40 to 50 year olds, calcification of the triticeous
cartilage was present in 6.5% (17/261 subjects) (Fig 4).
In 51 to 60 year olds, calcification was seen in 12.8%
(26/204 subjects), in 61 to 70 year olds 7.8% (16/206
subjects), 71 to 80 year olds 8.3% (10/121 subjects) and
81 years and older 7.3% (4/55 subjects).
Shape was determined digitally by scanning the
radiographs and calculating the shape factor (Fig 5).
Shape factor is a unitless ratio in which a perfect circle
has a shape factor of 1.00, and a line has a shape factor
approaching 0.00. The average shape factor of calcified
carotid atheroma was 0.37 6 0.15, where as the
average shape factor of calcified triticeous cartilage is
0.78 6 0.08.
The shapes of the calcified carotid atheromas varied
from circular to mostly linear (Fig 5). Small carotid
atheromas (~100 pixels) were mostly circular, while
larger carotid atheromas ([500 pixels) were roughly
rectangular or wide linear. In comparison, the shapes
of triticeous cartilages were more circular to oval,
irrespective of size. In our database, the total area of the
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228 Ahmad, Madden, and Perez February 2005

Fig 4. Calcification of triticeous cartilage in patients of different ages. Calcification of triticeous cartilage did not increase with age.
Each column is total number of patients in the respective age group, and the shaded area indicates number of patients displaying
calcified triticeous cartilage (TC).

Fig 5. Shape factor of calcified triticeous cartilages and calcified carotid atheromas in relation to area in pixels. The shape of
calcified carotid atheroma was 0.37 6 0.15, whereas the shape factor of calcified triticeous cartilage was 0.78 6 0.08. A perfect
circle has a shape factor of 1.000, and a line has a shape factor approaching 0.000. The shape factor for an equilateral triangle is
approximately 0.61, for a square 0.79, and for a pentagon 0.86.
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Volume 99, Number 2 Ahmad, Madden, and Perez 229

largest triticeous cartilage reached ~2500 pixels while

the largest carotid atheroma reached an area of ~2800
pixels. The areas of the whole panoramic films, accord-
ing to our scanning parameter, were ~1.1 million pixels.
Differentiation between triticeous cartilages and
carotid atheromas was possible based on shape and
outline of the calcifications (Fig 6). The calcified carotid
atheromas were mostly linear, with irregular margins
and appeared punctate and with areas of radiolucencies.
In contrast, the calcified triticeous cartilages were mostly
oval, with a smooth, well-defined corticated border.

DISCUSSION
This is the first report in the literature on the
prevalence of triticeous cartilages on panoramic
radiographs. A recent article identified triticeous carti-
lage on panoramic radiographs, but did not discuss
prevalence.1 Although triticeous cartilages and calci-
fied carotid atheromas locate in a similar region on
panoramic radiographs, the shape and outline help
in differentiating these 2 calcifications in the neck.
Triticeous cartilage is specifically located between the
greater cornu of the hyoid and superior cornu of the
thyroid, while the location of calcified carotid atheroma
is not restricted by hyoid or thyroid.
In a study done on cadavers of adults from India,
calcification of the triticeous cartilage is more com-
mon in females (9.5%) compared to males (7.3%).3 In
a separate cadaver study done in Nigerian adults,
calcification of the triticeous cartilage is more prevalent
in females (16.7%) compared to males (13.2%).11
However, a neck radiograph study by Hately et al12
showed a higher prevalence of calcification of the
triticeous cartilage in males (29%) compared to females
(22%). Our study showed that calcification is more
common in females. A study by O’Bannon and
Grunow13 had also shown that calcification of triticeous
cartilage is more common in females.
Hately et al12 reported the earliest incidence of
calcified triticeous cartilage at the age of 23 years.
Although our study did not examine the radiographs of
patients less than 40 years of age, we found that the
prevalence was not age dependent. A similar finding was
reported by Yerman et al,14 who showed that there was
no correlation between increased calcification of the
laryngeal cartilages with advancing age. In our study,
we found that subjects in the age range of 51 to 60 had
significantly higher prevalence of calcified triticeous
cartilage compared to other age groups. This finding is
probably due to a higher number of female subjects from
this age group in the present study (Table I).
We did not find any significant statistical difference
in sizes between carotid atheromas and triticeous car-
tilages. Thus, the difference in sizes of the calcified
Fig 6. A large calcified carotid atheroma (arrowheads) and
a calcified triticeous cartilage (arrow) appearing adjacently.
Carotid atheroma is irregularly linear, while the triticeous
cartilage is smooth oval.
carotid atheromas and calcified triticeous cartilages is
not a reliable criterion for differentiation between these
entities.
Our study showed that the shape of triticeous cartilage
is mostly well-defined oval. As the Latin word triteceus
translates to a grain of wheat, a calcified triticeous
cartilage is similarly oval grain shaped. The margins of
the triticeous cartilage were smooth, whereas large
calcified carotid atheromas had irregular margins. Our
previous study showed that calcified carotid atheromas
are mostly circular when they are small, and as the
calcifications enlarge in size, they become mostly linear
or thin rectangular.9 Our current study showed a similar
trend in the shape of carotid calcifications. Large
calcified carotid atheromas showed areas of discrete
radiolucencies, whereas calcified triticeous cartilage has
uniform radiodensity.
On a panoramic radiograph, the triticeous cartilage
can also be confirmed by its location—situated in an
imaginary line that connects the greater cornu of the
hyoid and the superior cornu of the thyroid cartilage.
This imaginary line is usually straight, but occasionally
may follow a slight curvature.

230 Ahmad, Madden, and Perez
Carter1 described the location of the triticeous
cartilage on panoramic radiographs and emphasized
the importance of correct diagnosis of calcified tri-
ticeous cartilages to avoid misdiagnosis as calcified
carotid atheromas. Our findings indicate that shape, out-
line, and location help in discriminating the triticeous
cartilage from calcification in the carotid arteries.
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Reprint requests:
Mansur Ahmad, BDS, PhD
7-536 Moos Tower
University of Minnesota School of Dentistry
515 Delaware Street SE
Minneapolis, MN 55455
ahmad005@umn.edu